NCLEX Questions & Explanations (PT 2)

The nurse provides discharge instructions to a client who was hospitalized for deep venous thrombosis (DVT) that is now resolved. Which of the following instructions should the nurse include to prevent the reoccurrence of DVT? Select all that apply.

Educational objective: Discharge teaching for a client with resolved deep vein thrombosis includes interventions to prevent reoccurrence (eg, take in adequate fluids, elevate the extremities, exercise regularly, change positions frequently, stop smoking). - Clients do not need to avoid traveling in a car or airplane. However, during extended travel (>4 hours), clients must use preventive measures (eg, wear compression stockings, exercise calf and foot muscles frequently, walk every hour).

The nurse is providing safety teaching to the adult child of a client with Alzheimer disease who is forgetful and wanders. Which of the following responses by the adult child demonstrates correct understanding of the teaching? Select all that apply.

Educational outcome: All medications should be out of the client's reach or locked away. A confused person may not remember the day of the week and take more or less medication than prescribed.

The nurse is interviewing a non-English-speaking client. Which best practices will the nurse use when working with a professional medical interpreter for clients of limited English proficiency? Select all that apply.

Educational outcome: When working with an interpreter, the nurse should apply the following best practices to maximize communication and understanding with the client: Address the client directly in the first person Speak in short sentences, pausing to allow the interpreter to spea. Ask only one question at a time Avoid complex issues, idioms, jokes, and medical jargon Hold a pre-conference with the medical interpreter to review the goals of the interview. Use a qualified professional interpreter whenever possible The nurse should be mindful of any gender preferences to ensure the client is comfortable speaking with the interpreter

The nurse is caring for assigned clients. The nurse should recognize the client at highest risk for developing pulmonary embolism is the client who

Educational Outcome: A client who had a cesarean birth 6 hours ago is at highest risk for PE due to: Abdominal surgery (endothelial damage) Engorged pelvic vessels from pregnancy (venous stasis, hypercoagulability of blood) Inactivity/immobility ≥6 hours related to positioning during surgery and the immediate with epidural anesthesia (venous stasis) Postpartum state (hypercoagulability of blood)

The registered nurse is developing a nursing care plan for a client who has just undergone surgery for treatment of ulcerative colitis with the creation of a permanent ileostomy. What is the priority outcome for this client?

Educational Outcome: A client who has undergone ostomy surgery must become independent in self-care. This requires adaptation to a significant alteration in body image and dealing with a number of psychosocial issues that are associated with a change in appearance and the loss of bowel control. It is not uncommon for a client to cope with this loss by refusing to look at or participate in the care of the stoma. Nursing interventions for this client will include: Supportive counseling and assistance in psychosocial adjustment Teaching and facilitating self-care Providing information about the reason for the surgery, prognosis, potential complications, and community resources

A client receiving total parenteral nutrition complains of nausea, abdominal pain, and excessive thirst. What is the best action for the nurse to take?

Educational Outcome: A complication of total parenteral nutrition (TPN) is hyperglycemia, as evidenced by excessive thirst, increased urination, abdominal pain, headache, fatigue, and blurred vision. The development of hyperglycemia is related to the following: Excessive dextrose infusion A low tolerance for dextrose in critically ill clients due to the inflammatory response and the resulting production of counterregulatory hormones High infusion rate Administration of medications such as steroids Infection Interventions to resolve TPN-associated hyperglycemia include reducing the amount of carbohydrate in the TPN solution, slowing down the infusion rate, and administering subcutaneous insulin.

A client comes to the emergency department after being assaulted. Imaging studies show a simple fracture of the mandible. The nurse assesses edema of the face and jaw, drooling, and bleeding in the mouth; the client rates pain as a 9 out of 10. What is the priority nursing intervention?

Educational Outcome: A direct blow to the face or a motor vehicle collision is usually the cause of mandibular fracture. The client drools due to inability to close the mouth from edema and misalignment of the jaw. Structural damage, excessive saliva, and bleeding with pooled blood in the mouth can compromise the airway. Therefore, the priority nursing intervention is to suction the mouth and oropharynx to maintain airway patency.

A client with a history of diverticular disease is being discharged after an episode of acute diverticulitis. Which instructions should be included in the discharge teaching plan to reduce the risk of future episodes? Select all that apply.

Educational Outcome: A low-residue diet, which avoids all high-fiber foods, may be used in treating acute diverticulitis. However, after symptoms have resolved, a high-fiber diet is resumed to prevent future episodes.

The nurse is preparing to insert a peripheral venous access device for a client who has an order for an infusion of IV fluids. Which of the following veins would be most appropriate for the nurse to select?

Educational Outcome: A peripheral venous access device (VAD) is a hollow tube approximately 1 inch (2.54 cm) in length that is used to administer IV fluids directly into the client's vein. The ideal placement for a peripheral VAD is a palpable, straight vein on the distal part of the client's nondominant arm where the tip of the catheter is located far from joints that flex. Bending the arm can move the VAD, causing irritation at the insertion site, which can result in phlebitis, infiltration, and infection. Therefore, veins located in the dorsal surface of the forearm (ie, cephalic vein) are least prone to complications -- Veins in the antecubital space (ie, medial cubital vein) are most commonly used in emergency situations due to size and ease of VAD insertion but are prone to complications (ie, dislodgement) because of placement in the bend of the elbow.

Which client should the nurse assess first after receiving the hand-off morning report? Click the exhibit button for additional client information.

Educational Outcome: A peripherally inserted central catheter (PICC) is inserted via the basilic or cephalic veins into the superior vena cava. The nurse should measure and document the external length of the PICC during dressing changes. A change in the length of the external portion of the catheter can indicate migration of the tip of the catheter from its original position. The nurse should hold IV fluids and medications, secure the PICC to prevent further movement, and notify the health care provider for x-ray evaluation of catheter tip placement.

The nurse is assessing a client during a routine physical examination. Which of the following findings would be most important to report to the health care provider?

Educational Outcome: Acanthosis nigricans is a skin disorder characterized by the presence of symmetric, hyperpigmented velvety plaques located in flexural and intertriginous regions of skin (axilla, neck). Skin tags (acrochordons) are commonly seen in regions affected by acanthosis nigricans. Recognition of these skin disorders is important due to their association with insulin resistance. The client should be referred to the health care provider to be evaluated for diabetes mellitus and/or metabolic syndrome

The nurse is talking with a client who has chronic kidney disease and is receiving peritoneal dialysis. Which of the following statements by the client would require follow-up?

Educational Outcome: Anuria (ie, no urinary output) is an expected finding with chronic kidney disease and indicates the need for PD. The dialysate drainage amount should be greater than that of the dialysate infused due to the removal of waste products and excess fluid from the body. Peritonitis is commonly caused by touch contamination of the peritoneal dialysis catheter. Sterile technique (eg, wearing a surgical mask) should be followed when connecting and disconnecting the catheter.

The nurse is caring for assigned clients with central venous access devices (CVADs). The nurse should recognize that the client at highest risk for developing a central line-associated bloodstream infection is the client with a CVAD in the

Educational Outcome: Appropriate site selection for a CVAD (eg, avoidance of the femoral vein, when possible) reduces the risk for CLABSIs. Femoral CVADs bring a high risk for infection due to their strong susceptibility to contamination by urine or feces; in addition, they are difficult to cover with an occlusive dressing

The nurse is talking with a client who is scheduled for cardiac catheterization. Which of the following findings would be essential to follow up? Select all that apply.

Educational Outcome: Cardiac catheterization involves injection of IV iodinated contrast to assess for obstructed coronary arteries. Potential complications of IV iodinated contrast include: Allergic reaction: Clients with a previous allergic reaction to iodinated contrast may require premedication (eg, corticosteroids, antihistamines) to prevent reaction or an alternative contrast medium Lactic acidosis: When administered to clients taking metformin, IV iodinated contrast can cause an accumulation of metformin in the bloodstream, which can result in lactic acidosis. Therefore, health care providers may discontinue metformin 24-48 hours before administration of contrast and restart the medication after 48 hours, when stable renal function is confirmed Contrast-induced nephropathy: Iodinated contrast can cause acute kidney injury in clients with renal impairment (eg, elevated serum creatinine). Therefore, clients with renal impairment should not receive iodinated contrast unless absolutely necessary

A nurse is caring for a client diagnosed with rheumatoid arthritis (RA). Which assessment finding does the nurse expect to assess?

Educational Outcome: Characteristic features of RA include the following: Symmetrical pain and swelling that initially affects the small joints of the hands and feet Morning joint stiffness that lasts from 60 minutes to several hours Elevated ESR and rheumatoid factor levels

The nurse is assisting a client who has a chest tube back to bed when the drainage system is knocked over, cracks, and the tube is disconnected from the drainage system. Which of the following actions should the nurse take?

Educational Outcome: Chest tubes are inserted into the pleural cavity to drain air, blood, or other fluids. They are sutured in place and connected to a drainage system. If the drainage system breaks or if the chest tube is disconnected and cannot be immediately reattached or is contaminated, the distal end of the chest tube should be submerged 1-2 inches (2.5-5.1 cm) in a bottle of sterile water. This creates a water seal and prevents air from entering the pleural space while a new drainage system is established Unless prescribed by the health care provider (HCP), chest tubes should not be clamped because it raises intrapleural pressure and can lead to tension pneumothorax. Clamping briefly is acceptable when checking for an air leak or when changing the drainage system.

The nurse has been made aware of laboratory test results for assigned clients. Which of the following test results would require immediate follow-up? Click the exhibit button for additional client information.

Educational Outcome: Clients with heart failure are expected to have elevated b-type natriuretic peptide (BNP) levels (>100 pg/mL [100 ng/L]). The nurse should compare BNP levels with those from the previous day.

The nurse is evaluating a parent's understanding of home care management for a 2-week-old client after initial cast placement for treatment of congenital clubfoot. Which of the following statements by the parent indicate a correct understanding? Select all that apply.

Educational Outcome: Clubfoot (ie, talipes equinovarus) is a congenital bone deformity and soft tissue contracture manifested by one or both feet being turned inward. The health care provider typically begins management of the deformity soon after birth by manipulation and stretching of the affected foot and placing a long-leg cast. Weekly recasting over 5-8 weeks (ie, Ponseti method) is necessary to gradually reposition the foot. To maintain the correction after successful casting, the client commonly wears custom shoes secured to a bar brace. To prevent recurrence, long-term follow-up continues until the child attains skeletal maturity. The nurse should teach parents about cast care, which includes monitoring the client's circulation (eg, toes pink and warm) and keeping the cast dry during diapering and bathing to prevent skin irritation or infection

A client is diagnosed with a small thoracic aortic aneurysm during a routine chest x-ray and follows up 6 months later with the health care provider (HCP). Which assessment data is most important for the nurse to report to the HCP?

Educational Outcome: Difficulty swallowing is the most important symptom to report to the HCP. A thoracic aortic aneurysm can put pressure on the esophagus and cause dysphagia. The development of this symptom may indicate that the aneurysm has increased in size and may need further diagnostic evaluation and treatm

The nurse is caring for a client who sustained a fracture of the femur 24 hours ago. Which of the following actions would be a priority for the nurse to take to reduce the client's risk for fat emboli?

Educational Outcome: Early stabilization of the injury to repair long bone (eg, femur, humerus, radius, ulna, tibia, fibula) fractures is recommended to reduce further injury to soft tissue. The nurse should minimize movement of the injured extremity to reduce the risk of dislodging fat globules into the bloodstream

The nurse is caring for a 6-month-old client who has a new tracheostomy. Which of the following findings would indicate that the client's airway requires suctioning? Select all that apply.

Educational Outcome: Findings that indicate a need for suctioning include: Adventitious breath sounds (eg, rhonchi, wheezes, crackles) Altered mental status (eg, irritability, lethargy) Decreased oxygen saturation Increased heart rate Increased respiratory rate Increased work of breathing (eg, flared nostrils, use of accessory muscles) Pallor, mottling, or cyanosis of the skin

The nurse is caring for a client who had a gastrojejunostomy and is reporting episodes of nausea, dizziness, and sweating that occur shortly after eating. Which of the following actions should the nurse take?

Educational Outcome: Gastrojejunostomy (ie, Billroth II procedure) removes part of the stomach and shortens the upper gastrointestinal tract. After a partial gastrectomy, many clients experience dumping syndrome, which occurs when rapid gastric emptying causes a fluid shift into the small intestine. Symptoms include dizziness, sweating, nausea, abdominal cramping, tachycardia, and diarrhea shortly after meal consumption. To reduce the occurrence of symptoms, clients should recline after eating meals to slow the emptying of gastric contents.

The unlicensed assistive personnel (UAP) assists a client with cirrhosis who underwent paracentesis 4 hours ago. The UAP reports to the nurse that the client was lightheaded and unsteady while ambulating to the chair. Which action should the nurse implement first?

Educational Outcome: Hypovolemia is an associated complication related to intravascular fluid shifts that occur during and post-procedure and also to high volume peritoneal fluid removal (>5 L). The nurse should first validate the presence of light-headedness and unsteady gait, monitor vital signs, and assess for manifestations of hypovolemia (eg, orthostatic hypotension, tachycardia, reduced pulse volume, decreased urine output), as decreased circulating volume can lead to hemodynamic instability. Post-paracentesis vital signs are frequently monitored for the first 4 hours to assess for complications (eg, hypotension, bleeding). The nurse can ask the UAP to take another set of vital signs, but this should not be the nurse's first intervention.

A client is being discharged after having a coronary artery bypass grafting (CABG) x 5. The client asks questions about the care of chest and leg incisions. Which instructions should the registered nurse include? Select all that apply.

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

The nurse is caring for a client with age-related macular degeneration. Which of the following menu selections by the client would be appropriate?

Educational Outcome: Increasing dietary intake of lutein, an antioxidant found in leafy, dark green vegetables (eg, spinach, kale, broccoli), can slow the progression of vision loss in AMD. In addition, vitamin C (eg, strawberries) and vitamin E (eg, avocado) can also help slow disease progression. Therefore, the most appropriate meal choice is a spinach salad, avocado, and strawberries

The clinic nurse receives multiple phone calls regarding client status. Which call should the nurse return first?

Educational Outcome: Infectious mononucleosis is caused by the Epstein-Barr virus. Spleen rupture is a serious complication of infectious mononucleosis that can occur spontaneously and present with sudden onset of left upper quadrant abdominal pain. The 16-year-old client should be taken to the emergency department for close monitoring of hemoglobin levels, supportive care to prevent hemorrhagic shock, and possible surgery.

The nurse is preparing to administer a scheduled vaccine to a pediatric client with hemophilia. Which of the following actions should the nurse take? Select all that apply.

Educational Outcome: Interventions to reduce the risk for bleeding with the administration of vaccines include: Applying firm, continuous pressure and/or ice at the site for 5 minutes Using the smallest bore and shortest needle length indicated when administering the vaccine Limiting the number of injections per extremity Scheduling vaccine administration soon after factor VIII administration

The nurse is assessing a 4-hour-old newborn. Which of the following findings would require follow-up?

Educational Outcome: Pathologic jaundice appears within 24 hours of birth and results from a rapid rise in bilirubin caused by hemolysis (eg, ABO incompatibility or Rh alloimmunization), excessive bruising, or polycythemia (ie, high concentration of RBCs). Bilirubin is a by-product of RBC destruction that is yellow tinged; excessive levels of bilirubin are highly toxic to neurons and can cause permanent brain damage (ie, kernicterus). If jaundice (ie, yellow-tinged skin) is noted within 24 hours of birth, immediate follow-up is required (eg, measure bilirubin level, initiate phototherapy)

The nurse is performing a routine physical assessment of a 2-year-old client. The parent expresses concern that the client has been eating less than the client did as an infant. Which of the following actions would be most appropriate for the nurse to take?

Educational Outcome: Physiologic anorexia (ie, decreased nutritional need and appetite) occurs when the very high metabolic demands of infancy slow down to keep pace with moderate growth during toddlerhood. During this phase, toddlers are increasingly picky about their food choices and eating schedules. Parents sometimes fear the child is not consuming enough calories, but over several days intake usually meets nutritional and energy needs. The nurse should teach parents that physiologic anorexia is an expected finding in toddlers

The nurse is planning discharge teaching for a client newly diagnosed with polycythemia vera. Which of the following actions will the nurse include in the teaching? Select all that apply.

Educational Outcome: Polycythemia vera (PV) is a chronic disorder of the bone marrow in which too many RBCs, WBCs, and platelets are produced. Clients with PV are at risk of developing blood clots due to increased blood volume and viscosity. Typical laboratory values seen in clients with PV include increased hemoglobin and/or hematocrit. Discharge instructions to reduce symptoms and prevent complications in clients with polycythemia vera include: Elevating legs and feet while sitting Wearing support stockings Increasing fluid intake during exercise and hot weather Reporting signs of deep vein thrombosis (eg, swelling and tenderness in the legs) Increasing the intake of iron-containing foods and supplements can further increase hemoglobin production and is not recommended. Clients with PV need periodic phlebotomy to remove excess blood. Itching is a common and frustrating symptom of PV. Reducing water temperature, using starch baths, and patting the skin dry rather than rubbing vigorously are beneficial.

The nurse is caring for a pediatric client with cystic fibrosis. Which of the following complications should the nurse recognize the client is at risk for developing? Select all that apply.

Educational Outcome: Potential complications of CF include: Infertility due to thickened reproductive secretions (eg, seminal fluid, cervical mucus) that cause blockage (eg, mucus plug) of the vas deferens in men or the cervix in women Diabetes mellitus due to pancreatic injury, which leads to insufficient insulin production (ie, alterations in blood glucose) Insufficient weight gain for height and age (ie, ≤10th percentile on a growth chart); this is common in clients with CF due to malabsorption of nutrients in the gastrointestinal tract Frequent respiratory infections secondary to retained bronchial secretions that permit the accumulation of debris and bacteria in the airway

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

Educational Outcome: Priority interventions for active or suspected air embolism are as follows: -Clamp the catheter to prevent more air from embolizing into the venous circulation. -Place the client in Trendelenburg position on the left side, causing any existing air to rise and become trapped in the right atrium. -Administer oxygen if necessary to relieve dyspnea. -Notify the HCP or call an RRT to provide further resuscitation measures. -Stay with the client to provide reassurance and monitoring as the air trapped in the right atrium is slowly absorbed into the bloodstream over the course of a few hours.

The nurse is caring for a client with hearing loss who received new hearing aids for both ears 1 month ago.

Educational Outcome: Proper use and care of hearing aids are essential for the success of hearing aid therapy and are associated with improved client outcomes. To adjust to new hearing aids, clients can wear them for a short time (eg, 20 min) before gradually increasing the length of wear. Findings that require follow-up and additional teaching include: Pulling the ear down and back to insert the hearing aid: The client should pull the ear up and back before insertion. In addition, the client should ensure that the volume is off prior to insertion. Turning up the volume if a whistling sound is heard: A high-pitched whistling sound can indicate that the hearing aid volume is too high. The client should turn the volume down to eliminate the whistling sound. Washing the hearing aid with a wet washcloth: The hearing aid should be cleaned with alcohol wipes or a soft cloth and should not be immersed in water, which can damage the electrical components. High heat (eg, hair dryers, heat lamps) should also be avoided while wearing hearing aids.

The nurse is talking with a client who reports daily fatigue and recent weight gain despite eating less. The nurse should ask if the client is also experiencing which of the following symptoms? Select all that apply.

Educational Outcome: Regardless of etiology, decreased levels of thyroid hormones result in a slower metabolic rate that affects the entire body. Features of hypothyroidism commonly include vague symptoms such as fatigue and weight gain. Because of the insidious nature of the symptoms, months or years may pass before some clients receive a proper diagnosis. The nurse should thoroughly assess clients with suspected hypothyroidism for common clinical manifestations, including: Cold intolerance and hypothermia related to a declining core body temperature Constipation caused by a decrease in gastrointestinal motility that slows peristalsis and delays gastric emptying Menstrual irregularities (eg, menorrhagia, anovulation) caused by a decrease in circulating sex hormones that occurs in response to lower thyroid hormone levels

A client is 48 hours post abdominal aneurysm repair. Which assessment by the nurse is cause for greatest concern?

Educational Outcome: Renal perfusion status is monitored closely in a client who has had abdominal aneurysm repair. Hypotension, dehydration, prolonged aortic clamping during surgery, blood loss, or embolization can lead to decreased renal perfusion and potential kidney injury. The nurse should routinely monitor the client's blood urea nitrogen (BUN) and creatinine levels as well as urine output. Urine output should be at least 30 mL/hr. This client should have an output of at least 120 mL of urine in a 4-hour period.

The nurse is screening clients for those at risk for developing pelvic inflammatory disease (PID). Which of the following factors would increase a client's risk for developing PID? Select all that apply.

Educational Outcome: Risk factors for PID include: Multiple sexual partners and inconsistent use of barrier contraceptives (eg, condoms) because sexually transmitted infections (STIs) are often asymptomatic

The nurse is screening clients for those at risk for developing aortic dissection. Which of the following factors would increase a client's risk for developing aortic dissection? Select all that apply.

Educational Outcome: Risk factors for aortic dissection include: Cocaine use, because it can cause a sudden and drastic increase in blood pressure (BP) Hypertension, which causes increased pressure on the aorta that can lead to tears in the inner lining; it is especially common in clients who suddenly stop taking antihypertensive medications, which causes a rapid increase in BP Underlying structural abnormalities of the aorta (eg, Marfan syndrome), which increase the risk of aortic injury and tears

The nurse is caring for a client at 32 weeks gestation who reports occasional sharp, right-sided groin pain that occurs when the client changes positions. Which of the following statements would be appropriate for the nurse to make?

Educational Outcome: Round ligaments provide support for pelvic structures and must stretch and lengthen as the uterus grows during pregnancy. Each round ligament is attached on either side of the uterus from the uterine fundus (ie, top of the uterus) to the labia majora, which can cause sharp, unilateral abdominal pain that characteristically radiates to the groin. Round ligament pain is a benign discomfort of pregnancy and occurs more frequently with walking and sudden changes in movement. The nurse should encourage clients to utilize heating pads, change positions slowly, and bring both knees in toward the chest to reduce strain on the ligament Pain associated with preterm labor is characterized by regular contractions, persistent lower back ache, or uterine cramping, not unilateral pain that mostly occurs with movement.

The nurse is assessing a client with scleroderma. Which of the following findings would be a priority to follow up?

Educational Outcome: Scleroderma is an overproduction of collagen that causes tightening and hardening of the skin and connective tissue. This progressive disease has no cure, and treatment is aimed at managing complications. Renal crisis is a life-threatening complication of scleroderma that causes malignant hypertension due to narrowing of the vessels that provide blood to the kidneys. Early recognition and treatment of renal crisis are needed to prevent acute organ failure and even death

The nurse is reviewing discharge teaching for a client who had surgical repair of a retinal detachment. Which of the following instructions are appropriate for the nurse to include in the teaching? Select all that apply.

Educational Outcome: Surgical repair involves rebinding the choroid and retina. After repair, interventions focus on promoting retinal reattachment. Postoperative teaching should include: Avoiding activities that increase intraocular pressure (eg, rubbing the eye, straining) Reporting sudden pain, flashes of light, vision loss, or bleeding, which may indicate detachment or infection, to the health care provider Avoiding focused activities (eg, reading, writing, sewing), which can cause rapid eye movements and increase the risk for detachment Wearing an eye patch or shield as directed to prevent rubbing/scratching of the eye and minimize eye movement Ensuring appropriate positioning as instructed by the surgeon because clients may receive intravitreal oil or gas, which holds the retina in a specific position to allow healing

The nurse is talking with a client who has cellulitis of the left lower leg. Which of the following statements by the client would require follow-up?

Educational Outcome: The client should elevate the affected extremity to promote lymphatic drainage. Flat or dependent positioning may worsen edema, which delays recovery and contributes to pain - Warm compresses can be applied to the affected area to reduce discomfort and promote blood flow

The public health nurse is providing directly observed therapy (DOT) for a client with active pulmonary tuberculosis. The nurse understands that DOT requires

Educational Outcome: The duration of standard treatment for tuberculosis is long, typically over the course of months, which makes it difficult for many clients to adhere to the treatment regimen. Directly observed therapy (DOT) is an effective treatment strategy that increases compliance with the treatment regimen to prevent reinfection and development of multidrug-resistant tuberculosis. DOT requires providing the client all antitubercular medications and watching the client swallow each dose for at least the first 2 months of therapy, preferably longer, in a designated area (eg, clinic, home, school, workplace)

The nurse is preparing to discharge a client with asthma who has a new prescription for a high-dose inhaled corticosteroid. The nurse is informed that the medication will be unavailable at the client's pharmacy for 2 days. Which of the following actions should the nurse take?

Educational Outcome: The nurse should collaborate with a case manager and advocate for safe, effective discharge planning by ensuring the client has the equipment, supplies, or medications needed to transition into the home environment. In this case, the safest option is to delay discharge until the medication is available

A nurse is caring for a client with blindness due to diabetic retinopathy. Which interventions should the nurse implement for this client? Select all that apply.

Educational Outcome: The nurse should create a therapeutic and safe environment for the client who is blind while fostering as much independence as possible. Nursing interventions include the following: Offer the client an elbow for guidance while walking slightly ahead and describing the environment Announce room entry and exit to orient and avoid startling the client Describe the location of items (eg, food, hygiene supplies) using a clock-face orientation so the client can find them easily Instruct the client to use a cane with the dominant hand and to sweep areas in front from side to side for orientation. Orient the client to the room and maintain this orientation for safety.

A nurse is caring for a client who developed paralytic ileus after a stroke. The client reports nausea, abdominal discomfort, and distension; bowel sounds are absent. Which prescription does the nurse question?

Educational Outcome: To prevent further abdominal distension and resulting nausea, the client should remain NPO. Nasogastric tube to wall suction may be necessary to decompress the stomach. IV fluid and electrolyte replacement (eg, normal saline) may be necessary to correct losses that occur from nasogastric suction. Nausea can be treated with prescribed antiemetics (eg, ondansetron, promethazine). The client should not take medications by mouth (due to NPO status), and opioid medications should be avoided as they prolong paralytic ileus. Instead, non-opioid IV analgesics (eg, ketorolac, ibuprofen, acetaminophen) should be administered as prescribed if the client is in pain.

The nurse is reviewing laboratory data for a client admitted to the emergency department with chest pain. Which serum value requires immediate action by the nurse? Click the exhibit button for additional client information.

Educational Outcome: Troponin is a highly specific cardiac marker for the detection of MI. It has greater sensitivity and specificity for myocardial injury than creatine kinase (CK) MB. Serum levels of troponin increase 4-6 hours after the onset of MI, peak at 10-24 hours, and return to baseline after 10-14 days. A troponin T value of 0.7 ng/mL (0.7 mcg/L) indicates cardiac muscle damage and should be the priority and immediate focus of the nurse (Option 4). Normal values: troponin I <0.03 ng/mL (<0.03 mcg/L); troponin T <0.1 ng/mL (<0.1 mcg/L).

The nurse is screening clients for those at risk for developing oral cancer. Which of the following factors would increase a client's risk for developing oral cancer? Select all that apply.

Educational Outcome: Ultraviolet light exposure to the lips (eg, regular use of tanning beds), which causes proliferation and mutation of cancerous cells

The nurse reinforces teaching about self-management strategies for a client with urge incontinence. Which of the following statements indicate that teaching has been effective? Select all that apply.

Educational Outcome: Urge incontinence (UI), also known as overactive bladder, occurs when the bladder contracts randomly, causing a strong, sudden urge to urinate that is followed by urine leakage. UI may occur without cause or may result from spinal cord injury and impairment of the bladder (eg, interstitial cystitis) or neurological system (eg, Parkinson disease, stroke). Interventions for clients with UI include: Loss of excess weight to reduce pressure on the pelvic floor Anticholinergic medications (eg, oxybutynin, tolterodine) to decrease bladder spasms. Dry mouth (xerostomia) is a frequent adverse effect Avoidance of bladder irritants (eg, artificial sweeteners, caffeine, citrus juices, alcohol, carbonated drinks, nicotine) Pelvic floor exercises (eg, Kegel) to strengthen the muscles and help prevent urinary leakage Bladder training (eg, voiding every 2 hours while awake) and gradually lengthening intervals between voiding

The nurse is answering questions at a hospital-sponsored health fair. What actions should the nurse encourage to help prevent contracting the West Nile virus? Select all that apply.

Educational Outcome: West Nile virus is a mosquito-borne disease (encephalitis) that occurs mainly during the summer months, especially during humid weather. Prevention focuses on avoiding mosquitoes and using an insect repellent. Prevention also includes wearing long sleeves, long pants, and light colors and avoiding outdoor activities at dawn and dusk when mosquitoes are most active

The nurse is observing a client who had a left total knee replacement using a cane to descend stairs. It would demonstrate correct technique if the client descends the stairs by placing the

Educational Outcome: When descending stairs, the client should: Lead with the cane. Bring the affected leg down next. Finally, step down with the unaffected leg When ascending stairs, the client should: Step up with the unaffected leg first. Move the cane next, while bearing weight on the unaffected leg. Finally, move the affected leg. To remember the order, the client can use the mnemonic, "up with the good and down with the bad." The cane always moves before the affected leg.

The nurse is talking with the parents of a 7-year-old client with newly diagnosed type 1 diabetes mellitus. Which of the following statements by the parents would indicate effective coping?

Educational Outcome: When providing teaching, the nurse should emphasize that, with planning and preparation, diabetes mellitus can be well managed and that the client can resume regular day-to-day activities and have an independent life

The nurse is caring for a 28-year-old client.

Educational Outcome: Monitoring for abdominal distension, which may indicate toxic megacolon, a complication of CDI that occurs when severe mucosal inflammation leads to smooth muscle paralysis. Peristalsis halts, and the inflamed colon expands with gas and stool, leading to life-threatening colonic perforation.

The clinic nurse is teaching a client about the advance directive form that needs to be completed. Which statement indicates that the client understands the information?

Educational objective: An advance directive is placed in the client's medical record and copies are given to health care proxies. Two witnesses are required for completion of the advance directive, but they should not be the health care proxies listed in the document.

The nurse plans teaching for an adolescent client being discharged home with a Boston brace for treatment of scoliosis. Which instruction will the nurse include in the discharge teaching plan?

Educational objective: Clients wearing a brace during treatment for scoliosis must perform proper skin care, wear a cotton t-shirt under the brace, and understand the importance of wearing the brace as prescribed to slow curvature progression. Psychosocial issues (eg, body image, socialization) should also be addressed to promote compliance.

The nurse is reviewing dietary teaching with a client who has chronic kidney disease. Which of the following statements by the client would indicate a correct understanding of the teaching? Select all that apply.

Educational objective: Clients with chronic kidney disease are at risk for fluid overload and electrolyte disturbances caused by decreased renal function. Dietary modifications include drinking water instead of soft drinks or cola to limit phosphorus intake and using fresh herbs instead of table salt to limit sodium intake. Clients should avoid foods high in potassium (eg, salt substitutes, raisins, bran, peanut butter), sodium (eg, saltines), and phosphorus (eg, milk).

The clinic nurse is interviewing the parents of a 6-month-old client about the infant's diet. Which statement by the parents is most concerning?

Educational objective: Clostridium botulinum spores in honey can colonize an infant's (age <12 months) immature gastrointestinal system and release a toxin that causes botulism, a rare but potentially life-threatening illness.

The nurse is calculating the intake and output for a client who had a transurethral prostatectomy and is receiving continuous bladder irrigation at 175 mL/hr. The nurse empties 2300 mL of urine from the urinary drainage bag at the end of the 8-hour shift. How many mL should the nurse document as the client's net urine output for the shift? Record your answer using a whole number.

Educational objective: Continuous bladder irrigation is commonly used to prevent bladder obstruction by blood clots after a prostatectomy. To calculate the net urine output in a client with continuous bladder irrigation, the nurse should subtract the total amount of irrigating solution infused from the total amount of catheter output.

A hospitalized client with a history of obstructive sleep apnea sleeps while wearing a full-face mask with continuous positive airway pressure. Oxygen saturation drops to 85% during the night. What is the nurse's first action?

Educational objective: Continuous positive airway pressure is prescribed for clients with obstructive sleep apnea to prevent the structures of the pharynx and tongue from collapsing backward and obstructing the airway. If the client experiences a sudden decrease in oxygen saturation, the nurse should first check the tightness of the straps and mask.

The nurse is assisting the health care provider (HCP) with a client's chest tube removal. Just as the HCP prepares to pull the chest tube, what instructions should the nurse give the client?

Educational objective: During chest tube removal, the client should be instructed to take a deep breath, hold it, and bear down (Valsalva maneuver) to prevent air from reentering the pleural space and possibly causing a pneumothorax. The site is covered with a sterile airtight petroleum jelly gauze dressing. A post-procedure chest x-ray is needed.

The nurse is caring for a client with liver cirrhosis who was admitted for cellulitis of the leg. Which assessments would the nurse perform to determine if the client's condition has progressed to hepatic encephalopathy? Select all that apply.

Educational objective: HE manifests with sleep disturbances, altered mental status, and lethargy. Asterixis and elevated ammonia are characteristic of HE.

A football player is brought to the emergency department after a helmet-to-helmet collision without loss of consciousness or signs of external trauma. Which clinical finding warrants immediate intervention?

Educational objective: Retinal detachment is a separation of the retina from the posterior wall of the eye, and may result from blunt-force trauma. If not promptly recognized and treated, permanent blindness may occur. Signs of detachment include lightning flashes or floaters and a curtain-like or gnats/hairnet/cobweb effect throughout the field of vision.

A nurse is evaluating an acutely ill client with suspected meningitis. The nurse should take what action first?

Educational objective: The client with suspected bacterial meningitis should be placed on droplet precaution isolation until the causative agent has been identified and appropriate treatment is initiated. - Although assessment is a priority and meningeal signs should be checked, the nurse can only safely perform these assessments once droplet precautions are in place.

A student nurse is preparing to administer the hepatitis B vaccine to a newborn. Which statement by the student nurse requires the preceptor to provide further teaching?

Educational objective: The preferred site for intramuscular (IM) injection in newborns is the vastus lateralis muscle in the anterolateral portion of the middle thigh. A 1-mL syringe should be used, and medication dosages should be calculated to two decimal places. A ⅝-inch, 22- to 25-gauge needle is appropriate for IM injection in a newborn.

The nurse is reviewing new orders for a client with chronic kidney disease. The nurse should clarify the order for

Educational objective:Clients with chronic kidney disease (CKD) have decreased glomerular filtration, resulting in retention of fluid and electrolytes (eg, potassium, magnesium, sodium, phosphorus). Nurses caring for clients with CKD should clarify orders for electrolyte-containing products or medications. - Due to impaired renal electrolyte excretion, the administration of electrolyte-containing products or medications (eg, magnesium hydroxide, potassium chloride) may result in a rapid, life-threatening increase in serum electrolyte levels.

The nurse is talking with the parent of a 15-month-old client who is scheduled to receive the varicella vaccine. Which of the following statements would be appropriate for the nurse to make? Select all that apply.

Educational objective:The varicella vaccine provides protection against the varicella-zoster virus and may cause mild adverse reactions, including low-grade fevers, swelling and erythema at the injection site, irritability, and a rash that may appear up to 1 month after the injection. A second dose of the vaccine is required to reach optimal immunity.

The nurse is caring for a client who has been receiving mechanical ventilation for 4 days. During multidisciplinary morning rounds, the health care provider questions the development of a ventilator-associated pneumonia (VAP). Which of the following manifestations does the nurse assess as the best indicator of VAP?

Educational outcome: Characteristic clinical manifestations of VAP include purulent sputum, positive sputum culture, leukocytosis (WBC >10,000 mm3), elevated temperature (>100.4 F [38 C]), and new or progressive pulmonary infiltrates suggestive of pneumonia on chest x-ray

The nurse teaches a client diagnosed with iron deficiency anemia about iron-rich foods. Which meal selection by the client indicates the teaching has been effective?

Educational outcome: Foods rich in iron include: Meats (eg, beef, lamb, liver, chicken, pork) Shellfish (eg, oysters, clams, shrimp) Eggs, green leafy vegetables, dried fruits, dried beans, brown rice, and oatmeal

The nurse is teaching the parent of a 5-year-old client with newly diagnosed absence seizure disorder. Which of the following statements by the parent would indicate a correct understanding of the teaching?

Educational outcome: Absence seizures are brief generalized seizures (lasting <20 seconds) that occur in children age 5-8. During these episodes, which are often mistaken for inattention, clients maintain postural tone but are unresponsive to vocal or tactile stimulation. Symptoms of impaired consciousness (eg, motionless, blank stare) occur suddenly and are followed by an abrupt return to full consciousness

The nurse is caring for an assigned team of clients. Which client is the priority for the nurse at this time?

Educational outcome: 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.

The nurse in the emergency department is caring for a 12-year-old client.

Educational outcome: Applying cold compresses is not indicated because cold constricts the blood vessels, worsens the pain, and may result in tissue injury in clients experiencing acute painful episodes. Warm compresses cause vasodilation and can help relieve pain for the client with sickle cell disease experiencing an episode of acute pain.

The nurse is assessing a client with chronic peripheral venous insufficiency. Which of the following findings would be consistent with the condition? Select all that apply.

Educational outcome: CVI may lead to venous ulcers, which are typically diffuse and boggy with irregular borders and often occur over the medial malleolus. Arterial ulcers are typically dry and rounded, with well-demarcated borders or a "punched out" appearance, and often occur on the toes.

The nurse is planning care for a client who developed toxic epidermal necrolysis while receiving lamotrigine. Which of the following interventions should the nurse include in the client's plan of care? Select all that apply.

Educational outcome: Care of a client with TEN is similar to that of a burn patient. Nursing interventions include: Applying sterile, moist dressings to areas of open skin because clients with TEN often experience epidermal shedding (ie, skin detachment) on the face, trunk, and palms Ensuring the causative medication (ie, lamotrigine) is discontinued to prevent further progression of symptoms Providing cotton blankets and maintaining a warm room temperature to prevent hypothermia Administering lubricating eye drops or ointment to relieve dryness and prevent corneal abrasion and keratoconjunctivitis

The nurse is reviewing the plan of care for a 4-year-old client who will receive daily dressing changes for an infected leg wound. Which of the following interventions should the nurse include in the plan of care for a preschool-age child? Select all that apply.

Educational outcome: During preprocedural education, the nurse should: Promote a sense of security and reduce fear by allowing the parents to stay with the child during the procedure Address misconceptions related to preoperational thinking (ie, state that the procedure is not punishment for misbehavior) Foster initiative by encouraging the child to ask questions, voice concerns, and participate during dressing changes Enhance the child's learning ability and confirm the child's understanding of the procedure by allowing the child to imitate the procedure using a doll or toy equipment Peer support from other clients undergoing similar procedures is a coping technique that is more appropriate for adolescents.

The nurse is assessing a client an hour after a left lung lobectomy. The client is awake, alert, and oriented, and reports pain of 6 on a 0-10 scale. Pulse oximetry is 92% on 4 L oxygen via nasal cannula. The chest tube is set to continuous water seal suction at -20 cm H2O. The collection chamber has accumulated 320 mL of frank red drainage in the last hour. What is the priority nursing action?

Educational outcome: Following lung surgery, a chest tube is inserted into the pleural space to create a negative vacuum to re-inflate the lung and prevent air from re-entering the space. A client with a chest tube should be assessed for signs of air/fluid in the chest (eg, diminished breath sounds), excessive drainage (>100 mL/hr), pain, and infection at the drainage site. The collection chamber should be inspected every hour for the first 8 hours following surgery, then every 8 hours until it is removed. Excess drainage of frank red blood is indicative of hemorrhage and must be managed immediately. The priority action is to contact the health care provider for further management.

The nurse is teaching a client who has acute pyelonephritis. Which of the following information should the nurse include? Select all that apply.

Educational outcome: Home management for a client with acute pyelonephritis includes: Drinking at least 2 L of fluids each day to avoid dehydration and help flush bacteria out of the urinary tract Urinating as soon as the urge is felt because delaying urination enhances the bacteria's ability to proliferate in stagnant urine Managing symptoms (eg, administering antipyretics [eg, acetaminophen] for fever) Recognizing signs and symptoms of unresolved or reoccurring infection (eg, persistent flank pain) that may require additional intervention (eg, barriers for medication adherence, additional urine culture and sensitivity)

A nurse preparing to insert a peripheral IV catheter dons clean gloves, applies a tourniquet to the client's arm, and immediately identifies a site for venipuncture. Place in order the remaining steps that the nurse should take. All options must be used.

Educational outcome: Steps to promote safety and reduce infection risk when initiating IV therapy include the following: Perform hand hygiene using Centers for Disease Control and Prevention guidelines Prepare equipment: Open IV tray, prime tubing with prescribed IV solution for infusion, set IV pump if indicated, prepare tape, and open the over-the-needle catheter (ONC) with safety device Don clean (non-sterile) gloves Identify a possible venipuncture site Apply a tourniquet, ensuring it is tight enough to impede venous return but not tight enough to occlude the artery Select a venipuncture site after palpating the vein. Ask the client to open and close the hand several times to promote vein distension. The tourniquet may need to be released temporarily to restore blood flow and prevent trauma from extended application. Clean the site with chlorhexidine, alcohol, or povidone iodine. Use friction and clean per facility protocol, either back and forth or in a circular motion from insertion site to outward area (clean to dirty direction). Stretch the skin taut using the nondominant hand to stabilize the vein

The nurse employed in a woman's health care clinic would be most concerned about which client statement?

Educational outcome: The nurse would be most concerned about the client who describes symptoms of inflammatory breast cancer. In this aggressive form of cancer, breast lymph channels are blocked by cancer cells, creating breast tissue that becomes red, warm, and has an orange peel (peau d'orange), pitting appearance on the skin surface. The nurse would be most concerned about this client and make an immediate referral to the health care provider for examination and evaluation. Other info: Clients usually describe lumps related to fibroadenoma, a benign breast disorder, as small, round, painless, mobile lumps with no breast tissue retraction or discharge. - Clients usually describe fibrocystic breast nodules as soft, movable nodules that change size at various times during the menstrual cycle. Fibrocystic breast changes are a common benign breast disorder.

The nurse is talking with a client who has viral rhinitis. Which of the following statements by the client would require follow-up?

Educational outcome: Treatment is supportive including saline nasal sprays, antihistamines, decongestants, mild analgesics, and saltwater gargles. Antibiotics are not indicated to treat viral rhinitis but may be necessary if a bacterial complication develops (eg, sinusitis, otitis media, tonsillitis)

The nurse is reviewing discharge teaching with the parent of a pediatric client with acute myelogenous leukemia who was admitted with varicella-zoster virus. The client has multiple lesions that have not crusted. Which of the following information should the nurse include? Select all that apply.

Educational outcome: Varicella-zoster virus infection (chickenpox) is characterized by lesions that begin as a maculopapular rash, progress to weeping vesicular lesions, and typically crust over within approximately one week. The lesions are often pruritic and/or painful, and clients frequently have an accompanying fever. In most cases, treatment is supportive and includes: Cool oatmeal baths, calamine lotion, and antihistamines (eg, diphenhydramine) to relieve itching Acetaminophen as needed for fever or pain Clients who are immunocompromised (eg, clients with acute myelogenous leukemia) are at risk for severe varicella (eg, disseminated, pneumonia) and require aggressive therapy, including an antiviral agent (eg, acyclovir). Antiviral therapy should be continued until all the lesions have crusted over Varicella-zoster virus is spread via airborne and contact transmission. Clients are most infectious in the days leading up to the rash and continue to be infectious until the entire rash reaches the crusting stage

The nurse is talking with the parent of a newborn with developmental dysplasia of the hip who has a new prescription for a Pavlik harness. Which of the following statements by the parent would be essential to follow up?

Educational Outcome: Instructions for the use of a Pavlik harness should include dressing the client in clothing and socks under the harness to protect the skin, and applying the client's diaper under the harness straps to keep the harness clean and dry A Pavlik harness is worn until the hip joint becomes stable, typically about 3 to 5 months.

The nurse is caring for a client with type A aortic dissection. Which of the following actions should the nurse take? Select all that apply.

Educational Outcome: Interventions for a client with type A (ascending) aortic dissection include: Administering an IV beta blocker (eg, esmolol) to decrease blood pressure (BP) and heart rate, which reduces pressure inside the aorta and risk for aortic rupture Initiating continuous cardiac monitoring to help identify complications of aortic dissection (ie, aortic rupture, cardiac tamponade) Preparing the client for emergency surgery, because type A dissections, which occur in the ascending aorta, can rapidly become life-threatening Administering opioid analgesics (eg, morphine) to reduce pain and decrease heart rate and myocardial oxygen demand

The nurse is caring for a 58-year-old client.

Educational Outcome: Interventions indicated for clients with SBO include: Inserting a nasogastric tube for gastrointestinal decompression to reduce abdominal distension and improve intestinal blood flow Administering IV antiemetics to prevent further fluid and electrolyte imbalance from vomiting Preparing the client for abdominal CT scan to determine the size and location of intestinal obstruction Administering IV fluids to improve fluid volume status In clients with SBO, bowel rest (ie, NPO status) with gastric decompression is prescribed; therefore, a soft diet is not indicated. Stimulant laxatives increase intestinal motility and are not indicated for clients with intestinal obstruction due to the risk for bowel perforation.

A postoperative client with obesity and diabetes mellitus has an abdominal incision and is at risk for poor wound healing. Which interventions should the nurse include in the plan of care to promote wound healing and prevent dehiscence? Select all that apply.

Educational Outcome: Interventions to prevent abdominal wound dehiscence include: Administering stool softeners (eg, docusate) to prevent straining and constipation from postoperative immobility and opioid pain medications Administering antiemetics (eg, ondansetron) as needed for nausea to prevent straining that can occur with vomiting Applying an abdominal binder to provide hemostasis, support the incision, and reduce mechanical stress on the wound when coughing and moving Monitoring blood sugar to maintain tight glycemic control (<140 mg/dL [7.8 mmol/L] fasting glucose; <180 mg/dL [10 mmol/L] random glucose) to decrease infection risk and promote wound healing Splinting the abdomen by holding a pillow or folded blanket against the wound for support when coughing and moving

The unit educator is performing skill validations with unit staff. Which of the following actions by the staff nurses demonstrate a correct understanding of parenteral medication administration? Select all that apply.

Educational Outcome: Intradermal Administer injections at a 5- to 15-degree angle to reduce risk of injection into subcutaneous tissue (Option 2). Apply firm pressure to the injection site to reduce bleeding. Massaging the site introduces medication into deeper tissues and should be avoided. Subcutaneous Administer injections at 90 degrees if 2 in (5 cm) of subcutaneous tissue can be grasped or at 45 degrees if only 1 in (2.5 cm) can be grasped. Intramuscular Acceptable sites include the deltoid, vastus lateralis, and ventrogluteal. The ventrogluteal is preferred as fewer large blood vessels and nerves are present. Position the client supine, prone, or side-lying with the knee and hip flexed when administering ventrogluteal injections. Flexing the knee and hip reduces muscle tension, improves access, and promotes client comfort.

The charge nurse observes a student nurse administering a tuberculin skin test using the intradermal route. Which action by the student nurse requires intervention and additional teaching from the charge nurse?

Educational Outcome: Intradermal injections deliver a small amount of medication (0.1 mL) into the dermal layer of the skin, just under the epidermis. This parenteral route is used to perform allergy testing and tuberculosis (TB) screening. The correct procedure for administering a TB intradermal injection is: Choose an appropriate 1-mL tuberculin syringe (ie, 25- to 27-gauge, ¼- to ⅝-inch) and then don clean gloves. Position the forearm to face upward and cleanse a site that is a hands width above the wrist. Place the nondominant hand 1 inch below the insertion site and pull the skin downward so that it is taut. Insert the needle almost parallel to the skin at a 5- to 15-degree angle with the bevel up. Advance the tip of the needle through the epidermis into the dermis; the outline of the bevel should be visible under the skin. Verify that the medication will be injected into the dermis nject medication slowly while raising a small wheal (bleb) on the skin. Remove the needle and do not rub the area. Circle the area with a pen to assess for redness and induration (according to institution policy)

The nurse is reviewing laboratory test results for a 13-month-old client who is irritable, fatigued, and pale. The parent reports that the client consumes approximately 1100 mL of cow's milk daily. The nurse should expect that the client will have

Educational Outcome: Iron deficiency anemia (IDA) is a common nutritional disorder in children. Common causes of IDA include premature birth, insufficient dietary intake of iron, delayed introduction of solid foods, and consumption of cow's milk before age 1. Toddlers (ie, age 1-3) who consume excessive amounts of cow's milk (>700 mL per day) may develop IDA due to the exclusion of iron-rich foods in favor of cow's milk, a poor source of available iron. Clients with IDA may initially be asymptomatic. As IDA progresses, irritability, fatigue, shortness of breath, tachycardia, dizziness, pallor, and fissures at the corners of the mouth can occur. A decreased hemoglobin level is expected because insufficient levels of iron impair the production of hemoglobin

The nurse is teaching the parent of a pediatric client with Kawasaki disease. Which of the following information should the nurse include? Select all that apply.

Educational Outcome: Irritability can last up to 2 months after treatment due to inflammation and joint pain - Temporary arthritis (eg, joint pain, swelling) may persist for several weeks. Additional NSAIDs should be avoided because the client is already receiving aspirin therapy, which is typically continued until inflammatory markers normalize. Instead, acetaminophen can be administered for discomfort.

The nurse is caring for a client with irritable bowel syndrome. Which of the following menu selections would be appropriate to offer the client?

Educational Outcome: Irritable bowel syndrome (IBS) is a chronic bowel condition characterized by abdominal discomfort, diarrhea, and/or constipation. The exact cause of IBS is unknown, but there may be environmental, psychosocial, and genetic components. IBS is diagnosed by ruling out other gastrointestinal-related disorders (eg, food allergies, intestinal parasites). There is no cure for IBS, but clients can improve symptoms by making dietary modifications, including slowly increasing dietary fiber and avoiding triggering foods. Foods that are generally well tolerated include low-fat proteins (eg, baked chicken) and those with high dietary fiber (eg, rice) (Option 3). Clients with IBS should restrict gas-producing foods (eg, beans, broccoli) as well as those that irritate the gastrointestinal tract (eg, caffeinated beverages, alcohol, high-fat foods). Instead, clients should consume foods low in fermentable oligo-, di-, and monosaccharides and polyols (FODMAPs) (eg, wheat, dairy, high-fructose corn syrup).

The nurse is admitting a client with heart failure-related fluid overload. Which action should the nurse complete first?

Educational Outcome: It is appropriate for this client to have continuous cardiac monitoring that can alert staff to life-threatening rhythms (eg, ventricular tachycardia) if they occur. However, the client's respiratory status should be assessed first. - ABCS!!!!!

A client is 1-day postoperative abdominoplasty and is discharged to go home with a Jackson-Pratt (JP) closed-wound system drain in place. The nurse teaches the client how to care for the drain and empty the collection bulb. Which statement indicates that the client needs further instruction?

Educational Outcome: It is common for clients to be discharged with a JP closed-wound surgical drain in place after abdominal and breast reconstruction surgery. The purpose of the drain is to prevent fluid buildup in a closed space, which can put tension on the suture line and compromise the integrity of the incision, increase the risk for infection, and decrease wound healing. The general procedure for emptying the drainage device includes the following steps in order: Perform hand hygiene as asepsis must be maintained to prevent the transmission of microorganisms even though there is less chance of bacteria entering the wound using a closed-wound drainage device (eg, JP, Hemovac) than an open-drain device (eg, Penrose) Pull the plug on the bulb to open the device and pour the drainage into a small, calibrated container (eg, plastic water cup, urine specimen container) as this facilitates recording accurate drainage output Empty the device every 4-12 hours unless it is 1/2 to 2/3 full before then because as the small capacity bulb (100 mL) fills, the amount of negative pressure in the bulb decreases Compress the empty bulb by squeezing it from side-to-side with 1 or 2 hands until it is totally collapsed. Although the reservoir can be collapsed by pressing the bottom towards the top, compressing the sides of the reservoir (bulb) is recommended as it is more effective in establishing negative pressure Clean the spout on the bulb with alcohol and replace the plug when it is totally collapsed to restore negative pressure

The nurse is caring for a 4-year-old client with Kawasaki disease. Which of the following actions should the nurse take? Select all that apply.

Educational Outcome: Kawasaki disease (KD) is an inflammatory condition of unknown origin that causes systemic vasculitis (ie, blood vessel inflammation, especially the coronary arteries) in children. Clinical manifestations of KD include high fevers unresponsive to antipyretics, conjunctivitis, strawberry tongue, swollen and cracked lips, and erythema of the hands and feet with skin peeling. Treatment consists of administering IV immunoglobulin and aspirin to improve vasculitis, reduce fever, and decrease the risk for coronary complications (Options 1 and 3). Aspirin is generally not recommended in children due to the risk for Reye syndrome; however, the benefit of preventing coronary artery aneurysm outweighs the risk. Additional nursing interventions include: Encouraging a soft food/liquid diet as tolerated due to discomfort caused by mucositis Initiating continuous cardiac monitoring to assess for dysrhythmias indicating cardiac complications (eg, cardiogenic shock related to heart failure [HF]) Preparing the client for an echocardiogram to visualize cardiac structures and evaluate for coronary artery enlargement and aneurysm

A client with multidrug-resistant tuberculosis (MDR-TB) has a 1-month follow up visit after beginning medication therapy. The client states, "I've had really bad nausea and fatigue, but because my cough has already improved, I knew it would be alright to stop taking the medications." The nurse identifies which priority nursing diagnosis (ND) in this client's care plan?

Educational Outcome: Knowledge deficit is the lack of adequate information required for health recovery, maintenance, and promotion. The priority ND is knowledge deficit of the prescribed therapeutic regimen manifested by the client's verbalization of nonadherence to the prescribed MDR-TB therapy. Medication to treat MDR-TB usually must be taken for 6 to 9 months. The length of the treatment regiment, the cost and amount of medications that must be taken, and the unpleasant side effects all contribute to clients becoming nonadherent with treatment. If clients do not properly complete the entire medication regimen, they risk reactivating the MDR-TB disease, increasing the bacteria's drug-resistance, and spreading the disease to others. The medications cannot be discontinued until therapy is complete.

The nurse is planning care for a client who has lactational mastitis. Which of the following interventions should the nurse include in the client's plan of care? Select all that apply.

Educational Outcome: Lactational mastitis is infection and inflammation of breast tissue that may result from inadequate milk duct drainage or poor breastfeeding technique (eg, shallow latch) that can cause damage to the nipple. Bacteria can enter the nipple, especially if it is damaged, and proliferate within the stagnant milk in the breast. Interventions indicated for clients with lactational mastitis include: Administering antibiotics Relieving pain and inflammation with analgesics compatible with breastfeeding (eg, acetaminophen, NSAIDs) Applying warm compresses and massaging the breast to facilitate complete emptying Encouraging adequate rest, nutrition, and hydration (ie, increasing daily fluid intake) Clients should be encouraged to wear soft/supportive bras, rather than tight compression or underwired bras that restrict the breast tissue and impede healing. Discontinuing breastfeeding until symptoms resolve is not indicated. Instead, the client should continue breastfeeding frequently (ie, every 2-3 hours) to ensure adequate milk drainage and to relieve milk duct obstruction. The newborn can safely breastfeed from the infected breast.

The nurse is precepting a new graduate nurse (GN) who is administering a prefilled enoxaparin injection to an obese client. Which action by the GN indicates the need for further education from the nurse preceptor?

Educational Outcome: Low-molecular-weight heparins (LMWHs) (eg, enoxaparin, dalteparin) are anticoagulants commonly used for prevention and treatment of deep venous thrombosis and pulmonary embolism. LMWH is administered subcutaneously and is often available in a prefilled syringe, which contains an air bubble to ensure delivery of the entire dose. During injection, the air bubble follows the medication out of the syringe, ensuring that no medication is left behind. The nurse should not expel the air bubble prior to administration as this could result in an incomplete dose and medication error After subcutaneous anticoagulant injection, the client should not rub the injection site as this increases bruising and the risk for hematoma. A 90-degree angle is appropriate for a subcutaneous injection in an obese client. In general, subcutaneous injections are administered at a 90-degree angle if 2 in (5 cm) of tissue can be grasped or a 45-degree angle if only 1 in (2.5 cm) of tissue can be grasped (when patients are very thin)

The nurse is assessing a client with suspected aortic dissection. Which of the following findings would support a diagnosis of aortic dissection? Select all that apply.

Educational Outcome: Manifestations of aortic dissection include: Diaphoresis Sudden onset of severe chest pain that may be described as "tearing," "ripping," or "worst ever" A significant difference in systolic blood pressure between the right and left arms if the subclavian artery, which supplies blood to the upper extremities, is involved Abdominal or back pain A widening aorta on chest imaging (eg, CT scan with contrast, transesophageal echocardiogram) Restlessness/anxiety

The nurse is caring for assigned clients. The nurse should first assess the client who had a

Educational Outcome: Manifestations of decreased gastrointestinal motility (eg, nausea, vomiting) may occur during recovery from cholecystectomy secondary to bowel manipulation, anesthesia, and opioid analgesia use. In the immediate postoperative period, the client has an increased risk for aspiration due to a decreased level of consciousness (eg, drowsiness) from anesthesia. Therefore, the nurse should first place the client who is drowsy and reporting nausea in a side-lying position to prevent aspiration if vomiting occurs Other info: - Pain is an expected postoperative finding of laminectomy (ie, removal of vertebral lamina) and should be managed with analgesic medications.

During assessment of a client who underwent a coronary artery bypass graft 10 hours ago, the nurse notes that the amount of drainage from the mediastinal chest tube has decreased from 100 mL to 20 mL over the last hour. Which of the following nursing actions is appropriate?

Educational Outcome: Mediastinal chest tubes are used to drain air or fluid from the mediastinal space and/or pericardial cavity (ie, after cardiac surgery). Obstruction (eg, clot) of the chest tube will result in excess fluid buildup in the pericardium, leading to inhibited cardiac contractility and eventual diagnosis of cardiac tamponade. Cardiac tamponade is a life-threatening form of obstructive shock marked by decreased cardiac output and eventually obstructive cardiac arrest if untreated. If chest tube drainage is markedly decreased, the nurse should quickly assess for signs of cardiac tamponade and if no such signs are present should troubleshoot other possible causes of chest tube occlusion.

The nurse has attended a staff education program about various types of diets. The nurse recognizes that which diet would place a client at the highest risk for megaloblastic anemia?

Educational Outcome: Megaloblastic anemia (ie, enlarged and dysfunctional RBCs) is caused by vitamin B12 or folic acid deficiency. Vitamin B12 is formed by microorganisms and found only in animal-based foods; some plant-based foods may contain minimal amounts of vitamin B12 only if they accidentally contain animal particles. Other natural sources of vitamin B12 include meat, fish, poultry, eggs, and milk; some breads and cereals, as well as some nutritional yeasts, may be fortified with vitamin B12. Vegans are strict vegetarians; they exclude all animal products, including eggs and milk products, from the diet. They also may avoid foods that are processed or not organically grown, thereby eliminating potentially fortified food sources of vitamin B12. Therefore, individuals who consume a vegan diet are at risk for vitamin B12 deficiency and ultimately megaloblastic anemia

The nurse completes a neurological examination on a client who has suffered a stroke to determine if damage has occurred to any of the cranial nerves. The nurse understands that damage has occurred to cranial nerve IX based on which assessment finding?

Educational Outcome: Mnemonic: On Old Olympus's Towering Top, AFinn And German Viewed Some Hops - Cranial nerves IX and X work together to create movement of the pharynx and tongue. An absent gag reflex, asymmetrical uvular and palate movement, or a change in voice quality indicates damage.

A client calls the primary care clinic reporting diarrhea for 4 days and a low grade fever. What instruction is most important for the nurse to give to the client?

Educational Outcome: Most bouts of diarrhea are self-limiting and last ≤48 hours. Clients experiencing diarrhea that lasts >48 hours or accompanied by fever or bloody stools should be evaluated by a health care provider (HCP). Causes may include infectious agents, dietary intolerances, malabsorption syndromes, medication side effects, or laxative overuse. The HCP will need to assess for dehydration and electrolyte imbalances and identify underlying causes of the diarrhea that may require further treatment (eg, Clostridium difficile).

A client involved in a motor vehicle collision reports severe pelvic and right heel pain. While waiting for imaging, the nurse assesses the client. Which finding should the nurse report to the health care provider immediately?

Educational Outcome: Motor vehicle collisions and motorcycle crashes, followed by falls, are the most common mechanisms for pelvic fractures. The pelvis contains several large vascular structures (eg, internal and external iliac veins and arteries) and abdominal and pelvic organs (eg, small bowel, sigmoid colon, bladder, urethra, uterus, prostate). Therefore, when caring for a client with a fractured pelvis, in addition to pain, the nurse should assess for internal hemorrhage (eg, abdominal distension, vital signs, hematocrit, hemoglobin), paralytic ileus (eg, bowel sounds), neurovascular deficits (eg, extremity circulation, sensation, movement), and abdominal and genitourinary organ injuries (eg, hematuria, urine output <0.5 mL/kg/hr). Abdominal distension could be due to serious intra-abdominal bleeding or injury to the bowel or urinary structures. Absent bowel sounds can indicate the presence of a paralytic ileus related to the trauma and/or a retroperitoneal hematoma; these should be reported to the health care provider (HCP)

The nurse is caring for a client who had an anterior wall myocardial infarction 24 hours ago. Which finding is most concerning at this time?

Educational Outcome: Myocardial infarction (MI) can affect the pumping ability of the left ventricle, putting the client at risk for heart failure and cardiogenic shock. The development of pulmonary congestion, auscultation of a new S3 heart tone, crackles on lung auscultation, or jugular venous distension can signal heart failure and should be immediately reported to the health care provider Other info but related: During MI, clients may experience nausea and vomiting resulting from stimulation of the vomiting center by severe pain or from vasovagal reflexes initiated from the area of the infarction. This finding does not take priority over the S3 heart tone. Dysrhythmias are a common complication after MI due to ventricular irritability. Premature ventricular contractions are not significant if they occur infrequently. The nurse should further assess the client's potassium level and assess the apical-radial pulse for the presence of a pulse deficit. An increase in temperature following an MI is usually due to a systemic inflammatory process caused by myocardial cell death. The elevation may last as long as a week. This finding is not as significant as a new S3 heart tone.

The nurse in the emergency department is caring for a client with hypothyroidism who has a decreased level of consciousness. Which of the following actions should the nurse take first? Click on the exhibit button for additional client information.

Educational Outcome: Myxedema coma is a life-threatening complication of hypothyroidism characterized by a decreased level of consciousness (eg, lethargy, stupor, coma), hypothermia, bradycardia, and hypotension. Hypoventilation can also occur as a result of respiratory muscle fatigue and mechanical obstruction by an edematous tongue. The nurse should first provide respiratory support (eg, manual ventilation with a bag-valve-mask resuscitator) and prepare for endotracheal intubation due to signs of respiratory failure (eg, slow or shallow breathing, low oxygen saturation) from hypoventilation and altered mental status. Clients with myxedema coma require thyroid hormone replacement with IV levothyroxine to correct the hypothyroid state but only after the client's respiratory status is addressed. Improvement in clinical status may not occur for up to a week after initiation of hormone replacement.

The nurse is screening clients for those at risk of developing nephrolithiasis. Which of the following factors would increase a client's risk of developing nephrolithiasis? Select all that apply.

Educational Outcome: Nephrolithiasis (ie, kidney stones or renal calculi) occurs when salt and mineral deposits form concretions in the kidney and travel through the genitourinary system. Kidney stones can obstruct the ureters, leading to hematuria (ie, blood in the urine), flank and/or abdominal pain, and nausea/vomiting. Risk factors for developing nephrolithiasis include: Gout, which increases the amount of uric acid in the kidneys (uric acid stones). Frequent urinary tract infections, which lead to the development of struvite stones Dehydration, which increases the concentration of solutes in the kidneys Hyperparathyroidism and hypercalcemia, which increase the amount of calcium in the kidneys (calcium phosphate stones) A family history of nephrolithiasis

The nurse is caring for a newborn with spina bifida cystica. The nurse should recognize that the client is at risk for which of the following complications? Select all that apply.

Educational Outcome: Newborns with spina bifida cystica are at increased risk for: Altered lower extremity sensitivity and mobility, which can lead to skin breakdown and increases the risk for infection Hydrocephalus secondary to a Chiari II malformation, which occurs when the NTD displaces the brain downward, blocking the outward flow of cerebral spinal fluid Neurogenic bladder, which often results in urinary retention and requires frequent catheterizations, increasing the risk for urinary tract infections

The nurse is talking with the parent of a 22-month-old client. The parent states, "I am worried about my child's thumb-sucking and its effects on tooth alignment." Which of the following responses would be appropriate for the nurse to make? Select all that apply.

Educational Outcome: Nonnutritive sucking (eg, pacifiers, thumb-sucking) serves as a self-soothing mechanism for children and is an important natural reflex for coping. The peak age for a child to engage in thumb-sucking is age 18 to 20 months. According to the American Academy of Pediatrics, the behavior does not contribute to malocclusion or dental misalignment unless it persists beyond age 4 approximately or when permanent teeth erupt. The nurse should reassure the mother of a 22-month-old client and provide anticipatory guidance for when thumb-sucking requires intervention. Helpful tips for breaking the habit of thumb-sucking include: Avoiding negative reinforcement of the behavior (eg, minimize attention given to the child when actively sucking the thumb) Offering a security item (eg, blanket, stuffed animal) to help the child with self-soothing instead of the thumb-sucking behavior Using a positive reinforcement strategy (eg, sticker chart, reward system) when the child avoids sucking the thumb Thumb-sucking at age 12 months does not pose an increased risk of malocclusion or dental misalignment; however, if the behavior persists beyond the eruption of permanent teeth, it will affect the child's dentition.

The nurse is caring for a client with type 1 diabetes mellitus who is obtunded and responding only to painful stimuli. A STAT blood sample reveals a blood glucose level of 38 mg/dL (2.11 mmol/L). Which initial action by the nurse is best?

Educational Outcome: Nurses caring for clients with hypoglycemia and altered mental status or dysphagia should immediately administer 1 mg glucagon IM into the deltoid muscle. Glucagon signals the liver to convert glycogen to glucose, making glucose rapidly available; IV glucose replacement (eg, 50% dextrose) may also be administered. These medications quickly correct hypoglycemia and prevent further neurologic decline. The nurse should retest the glucose level every 15 minutes and repeat treatment if necessary

The nurse is planning care for a client who has cellulitis of the right foot. Which of the following interventions should the nurse include in the client's plan of care? Select all that apply.

Educational Outcome: Nursing interventions include: Avoiding prolonged exposure to moist/soiled linens (eg, frequent linen changes), which can cause tissue damage and spread the infection to other areas Applying warm compresses to reduce pain and promote blood flow Marking and dating the area of inflammation to monitor for worsening infection Antibiotic therapy to treat the bacterial infection Flat or dependent positioning and engaging in weight-bearing activities (eg, frequent ambulation) may worsen edema, which delays recovery and worsens pain. Instead, the client should elevate the affected extremity to promote lymphatic drainage and minimize weight-bearing activities.

The house supervisor has notified the charge nurse on the intensive care unit (ICU) that a bed is needed for an admission from the emergency department. All ICU beds are currently full. Which client should the charge nurse consider as most appropriate for transfer out of the ICU?

Educational Outcome: Occasional premature ventricular contractions (PVCs) are common dysrhythmias that may be precipitated by several factors, including electrolyte imbalances (eg, potassium), stimulants (eg, caffeine, nicotine), and stress. Occasional PVCs typically do not cause hemodynamic instability. The client who is stable one day post extubation can be safely transferred to a telemetry or medical-surgical unit, where the occasional PVCs may be further investigated and treated - Complete heart block (ie, third-degree atrioventricular block) requires temporary pacing followed by permanent pacemaker insertion. This client, who is at risk for severe bradycardia and hemodynamic instability, should not be transferred.

The emergency nurse is admitting a 12-year-old client who reports palpitations. Which action should the nurse anticipate? Click the exhibit button for additional information.

Educational Outcome: Once an ECG confirms SVT, the nurse should anticipate nonpharmacological interventions (ie, vagal maneuvers) to convert SVT to sinus rhythm if the client is stable. Placing an ice bag to the client's face and instructing the client to hold their breath while bearing down (Valsalva) are vagal maneuvers that can slow electrical conduction through the heart's atrioventricular node . If these maneuvers are ineffective, or if the client becomes unstable, administration of adenosine or synchronized cardioversion is indicated.

Which statement is most important to emphasize when teaching a 40-year-old female client newly diagnosed with fibrocystic breast changes?

Educational Outcome: 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) 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). 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. 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.

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

Educational Outcome: One-on-one supervision provided by a trained staff member who stays with the client at all times can promote safety while reducing or eliminating the use of restraints on a client who is confused and agitated. Frequent reassurance, touch, and verbal orientation (regarding name, location, time, and the client's situation) can lessen disruptive behaviors. Placing a large clock and calendar within the client's visibility would also help. Ideally, the client will be placed in a room near the nursing station. However, the client with delirium and agitation will also require ongoing supervision to minimize harm to self or others.

The nurse is caring for a 13-year-old client in the emergency department.

Educational Outcome: Osteomyelitis is a bone infection that occurs in pediatric clients due to hematogenous spread of bacteria through the bloodstream into the well-vascularized metaphysis of long bones (eg, tibia). Inflammation compromises skeletal blood flow, forcing the infectious exudate into cortical and periosteal bone, causing necrosis. Eventually, the areas of dead bone separate from living bone, forming sequestra. Manifestations include fever, pain, erythema, and swelling at the affected site. Without treatment, sepsis can develop. The nurse should obtain a specimen for blood culture and sensitivity to determine the causative pathogen (typically Staphylococcus aureus) and administer antibiotics

A 1-year-old child who goes to day care is recovering from an episode of otitis media. Which intervention is most important for the nurse to recommend to the parents in order to prevent recurrence?

Educational Outcome: Otitis media (OM) is the inflammation or infection of the middle ear resulting from dysfunction of the eustachian tube. OM typically occurs in infants and children under age 2, sometimes following a respiratory tract infection. The eustachian tubes in infants and young children are short, straight, and fairly horizontal, which results in ineffective drainage and protection from respiratory secretions. Infants with exposure to tobacco smoke are at risk for OM due to the resulting respiratory inflammation. OM risk is also higher with activities such as using a pacifier or drinking from a bottle when lying down as these allow fluid to pool in the mouth and then reach the eustachian tubes. Key preventive measures include eliminating exposure to smoke, obtaining routine immunizations to prevent infection, and reducing or eliminating use of a pacifier after age 6 months.

A 6-month-old client has been diagnosed with cystic fibrosis. Which of the following would be appropriate for the registered nurse to teach to the parents?

Educational Outcome: Over time, airways develop chronic colonization and frequent respiratory infections result. Bronchial hygiene therapy, such as manual chest physiotherapy, is used. For physiotherapy, various positions are used, and this should be performed before meals to avoid a full stomach and resultant regurgitation or vomiting

The nurse is preparing teaching for a client with Parkinson disease. Which of the following techniques are appropriate when communicating with a client with Parkinson disease? Select all that apply.

Educational Outcome: PD causes both physical (eg, bradykinesia, tremor) and neurological (eg, mood alterations, dementia) symptoms. Because of these alterations, accommodations are often needed when nurses provide client teaching, including: Teaching and encouraging the client to speak slowly, enunciate words, and pause to take deep breaths because speech disturbances are common in PD and may lead to frustration if misunderstandings occur Identifying and promoting the client's strengths during teaching because cognitive and physical alterations in PD can negatively affect body image and lead to depression Identifying times of day when the client functions optimally and scheduling teaching/activities during these periods, often late morning Ensuring that teaching occurs at times without rushing or interruptions because several factors in clients with PD (eg, fatigue, depression, cognitive impairment) may impair the ability to process teaching quickly

A nurse is caring for a client who is meeting with the palliative care team. After the meeting, the client's family asks for clarification about palliative care. Which statements about palliative care are accurate? Select all that apply.

Educational Outcome: Palliative care is a model of treatment that involves managing symptoms, providing psychosocial support, coordinating care, and assisting with decision making to relieve suffering and improve quality of life for clients and families facing serious illnesses. An interdisciplinary palliative assessment team often includes nursing staff, chaplains, social workers, therapists, and nutritionists who work together on a comprehensive treatment plan. This model of care has been found to decrease unnecessary medical interventions and reduce depressive symptoms. Families of clients who receive palliative care interventions also experience lower rates of prolonged grief and post-traumatic stress disorder. Palliative care is not limited to the last 6 months of life and can begin immediately after diagnosis of terminal disease (eg, advanced heart failure or cancer). The main difference between palliative care and hospice is that clients receiving palliative care can receive concurrent curative treatment. Hospice care is only started once the client decides to forego curative treatment.

The nurse is teaching the parents of an 8-year-old client with newly diagnosed pediculosis capitis. Which of the following information should the nurse include? Select all that apply.

Educational Outcome: Pediculosis capitis (ie, head lice) is a contagious parasitic infestation in which a female louse lays eggs (nits) on the hair shaft, close to the scalp. Head lice are most common in school-aged children and are spread by direct contact with infested individuals or personal items. The treatment of head lice involves applying pediculicide shampoo (usually permethrin 1% cream) to the hair. The pediculicide usually kills only adult lice, so a nit comb (ie, a fine-tooth comb) should be used daily to remove nits ). A second treatment in 7-10 days may be necessary to kill newly hatched lice. Parents should also: Soak all brushes, combs, and hair accessories in a lice-killing solution or hot water for 10 minutes Vacuum all carpets, mattresses, and upholstered furniture frequently Wash the client's bedding and clothing in hot water and dry it on the hottest dryer setting Seal nonwashable items in a plastic bag for 2 weeks It is not necessary to dispose of hats, h

The nurse is preparing to administer medications to a newly admitted client who is scheduled for hip arthroplasty. Which of the following medications would be a priority for the nurse to administer? Click the exhibit button for additional client information.

Educational Outcome: Perioperative glycemic management (ie, insulin administration) is a priority due to increased secretion of cortisol during surgery (eg, hip arthroplasty). Impaired glycemic control and acute hyperglycemia are associated with poor outcomes, including impaired postoperative wound healing, perioperative complications, and hyperosmolar hyperglycemic syndrome

A nurse in an urgent care center triages multiple clients. Which client should the nurse assess first?

Educational Outcome: Peritonsillar, or retropharyngeal, abscess is a serious complication that can result from tonsillitis or pharyngitis. The presenting features of peritonsillar abscess, in addition to fever, include a "hot potato" (muffled) voice, trismus (inability to open the mouth), pooling of saliva (drooling), and deviation of the uvula to one side. The abscess can progress to life-threatening airway obstruction (eg, dysphagia, stridor, restlessness). The nurse should immediately assess the client with symptoms of peritonsillar abscess and monitor for signs of airway obstruction Other info: - Symptoms of acute sinusitis include severe facial pain, nasal congestion with purulent nasal drainage, and fever. In most cases, the etiology is viral but can be complicated by secondary bacterial infection. This client likely requires antibiotics and supportive care but is not the priority - Acute otitis media (ie, infection of the middle ear) may develop secondary to rhinitis (eg, common cold, seasonal allergies) due to inflammation of the Eustachian tube. This client with otitis media will likely require antibiotics and pain management but is not the priority.

The nurse is planning care for a 3-year-old client who has pertussis. Which of the following interventions should the nurse include in the client's plan of care? Select all that apply.

Educational Outcome: Pertussis (whooping cough) is caused by the highly contagious bacterium Bordetella pertussis, which is spread through close human contact, coughing, and sneezing. Once attached to cilia in the client's upper respiratory tract, this bacterium releases a toxin that causes irritation and swelling. To prevent transmission, the nurse should implement standard (universal) and droplet precautions Pertussis is characterized by a violent, spasmodic cough and a distinctive high-pitched "whooping" sound heard during inhalation. Coughing may continue until the client expectorates a thick mucus plug or vomits (posttussive emesis). Therefore, the nurse should closely monitor for airway obstruction (eg, cyanosis) during coughing episodes, place clients on the side if vomiting, and suction the airway and provide oxygen as needed Treatment consists of antibiotics and other supportive measures (eg, humidified oxygen, oral fluids). Small amounts of oral fluids help loosen mucus so it can be expectorated - Cough suppressants interfere with the expectoration of mucus plugs that develop in the airway and are not recommended for pertussis because they are usually ineffective. Other info: Airborne precautions (ie, negative pressure isolation room) are appropriate for clients with Measles, Tuberculosis, and Varicella-zoster infections (mnemonic - airing MTV).

The nurse is assessing a client who has cellulitis of the left lower leg. Which of the following findings would be consistent with the condition? Select all that apply.

Educational Outcome: Petechiae are reddish, pinpoint spots that occur due to bleeding from capillaries just beneath the skin. Petechiae are associated with a blood vessel injury or bleeding disorders (eg, disseminated intravascular coagulation) and are not a manifestation of cellulitis.

The nurse in a long-term care facility is caring for a client with major depressive disorder who is reporting difficulty sleeping. The client gets up during the night, paces the hallway, wrings the hands, and appears teary. Which of the following actions should the nurse take? Select all that apply.

Educational Outcome: Pharmacological agents may be used to treat insomnia; however, long-term treatment with medication alone is not the best approach. Nonpharmacological strategies for improving sleep hygiene include: Receiving at least 20 minutes of natural sunlight each day, ideally in the morning, to improve sleep patterns Decreasing environmental stimuli; making sure the bedroom is dark, cool, and quiet Participating in a relaxing activity before bedtime (eg, warm bath, reading, listening to soft music) Avoiding heavy meals or large amounts of fluids at bedtime Drinking a cup of warm milk or eating a small amount of carbohydrates before bedtime, which promotes comfort and relaxation to aid sleepiness

The clinic nurse cares for a 4-year-old who has been diagnosed with a pinworm infection. Which client symptom supports this diagnosis?

Educational Outcome: Pinworms (ie, enterobiasis) are very common in childhood and easily transmitted when microscopic pinworm eggs, which can be found on contaminated food, drink, toys, and linens, are inhaled or swallowed. Once ingested, the eggs hatch in the intestines. During the night, the female pinworm lays thousands of microscopic eggs in the skin folds 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 antiparasitic medications

The nurse is observing a group of 4-year-old clients playing. The nurse would most likely expect to observe the clients playing

Educational Outcome: Play is an integral part of a child's mastery of emotional, social, and physical development. Preschoolers (age 3-5) enjoy associative play: They engage in similar activities or play with the same or similar items, but the play is unorganized and without specific goals or rules. Magical thinking is present in this stage of development and commonly includes make-believe play (eg, imaginary friends, dress-up clothes). During solitary play, children play alone while focusing on their own activities but also enjoy interactions with familiar people (eg, parents) or objects (eg, favorite toy). This type of play is most common in infants (age <12 months). Cooperative play involves children playing with one another with a specific goal (eg, sports, building a block castle), often within a rigid set of rules. Older preschool-aged children may begin learning how to cooperatively play together, but cooperative play is more common in school-aged children During parallel play, children play next to each other and are happy to be in the presence of peers, but they do not play directly with one another. Parallel play is more common in toddlers (age 1-3).

The nurse assesses a client with fever and productive cough for the last 10 days. Which findings support the presence of pneumonia? Select all that apply.

Educational Outcome: Pneumonia is an acute infection of the lungs. Findings in a client with pneumonia include: Crackles - Fine or coarse crackling sounds caused by air passing through alveoli and small airways obstructed with mucus Fever, chills, productive cough, dyspnea, and pleuritic chest pain Increased vocal/tactile fremitus - Transmission of palpable vibrations (fremitus) is increased when transmitted through consolidated versus normal lung tissue. Bronchial breath sounds in peripheral lung fields - High-pitched, harsh sounds conducted through consolidated lung tissue, which are abnormal when heard in an area distant from where normally heard (ie, trachea); this finding can be an early sign of pneumonia. Unequal chest expansion - Decreased expansion of affected lung on palpation Dullness - Percussion of medium-pitched sounds over consolidated lung tissue (pneumonia) or fluid-filled space (eg, pleural effusion, a complication of pneumonia) Other info: Hyperresonance is percussed over a hyperinflated lung (eg, asthma, emphysema) or air in the pleural space (eg, pneumothorax).

The nurse assesses a client with left-sided pneumonia who has an intermittent, productive cough with copious amounts of thick, yellow sputum. Which of the following interventions help to facilitate secretion removal? Select all that apply.

Educational Outcome: Pneumonia is an inflammatory reaction in the lungs, often due to infection, that causes alveoli to fill with cellular debris and thick, purulent exudate (ie, consolidation), which may cause impaired ventilation and oxygenation. Interventions to facilitate secretion removal in clients with pneumonia include: Performing chest physiotherapy (percussion, vibration, postural drainage) to loosen and break up thickened secretions Assisting the client to perform huff coughing, which raises secretions from the lower to the upper airway for expectoration - Side-lying positioning is utilized in hypoxic clients with unilateral pneumonia to increase perfusion to the healthy lung by gravity and improve oxygenation by positioning the client with the unaffected (good) side down. However, side-lying position alone does not improve secretion clearance

A parent calls the nursing triage line during the evening. The parent says that a 7-year-old was found playing in an area with poison ivy and asks what to do. Which is the most important instruction to give the parent?

Educational Outcome: Poison ivy can cause a contact dermatitis rash in those who are sensitive to the oily resin found on the leaves, stems, and roots of the plant. About 50% of people who come in contact with the plant develop a rash. It is often linear in appearance where the plant brushed against the skin. The rash develops 12-48 hours after exposure and can last for several weeks. The severity of the rash depends on the amount of resin on the skin. It is most important to first thoroughly wash the area to remove the resin and prevent its spread to other areas of the body.

The nurse is caring for a hospitalized client with an acute exacerbation of heart failure. The client receives digoxin 0.5 mg PO once daily, furosemide 40 mg PO twice daily, and potassium chloride (KCl) 20 mEq PO twice daily. The client's child reports that the client has trouble swallowing the large KCl pill. The client's potassium level is 3.7 mEq/L (3.7 mmol/L). What action should the nurse take first?

Educational Outcome: Potassium chloride (KCl) is commonly prescribed to correct or prevent hypokalemia. Oral KCl is available in extended-release tablets, capsules, dissolvable packets, and effervescent tablets, and as an oral liquid. If a client has difficulty swallowing large pills, the nurse should consult the pharmacist to see if other forms of KCl are currently available and to determine if the medication is safe to crush. If a more appropriate form (eg, liquid) is available, the nurse would then discuss that change in route with the health care provider and obtain an updated prescription. -Some pills or capsules are sustained-release formulations, and crushing may alter the release of the drug and cause an overdose of the medication. The nurse should consult the pharmacist before altering the form of the drug. -The use of a loop diuretic, such as furosemide, is a common cause of potassium depletion. Holding the KCl dose may cause the client's potassium level to fall below normal (<3.5 mEq/L [3.5 mmol/L]), which can potentiate digoxin toxicity (eg, cardiac dysrhythmias, gastrointestinal upset). - Tucking the chin to the chest during swallowing is a technique used to prevent aspiration. This most likely will not help the client swallow the large pill.

The nurse has attended a staff education program about postpartum psychosis (PPP). Which of the following statements by the nurse would require follow-up?

Educational Outcome: Potential triggers/risk factors for PPP include the rapid drop in estrogen and progesterone levels after birth, sleep deprivation, discontinuing psychiatric medication during pregnancy, and a history of bipolar disorder.

The nurse is screening clients for those at risk for developing a pressure injury. At highest risk for developing a pressure injury is the client

Educational Outcome: Pressure injuries develop from external pressure compressing capillaries and underlying soft tissue, or from friction and shearing forces. The nurse should assess every client's risk for pressure injuries using a standardized assessment tool (eg, Braden scale) on admission and at least once daily during hospitalization. Risk factors for pressure injuries include immobility, impaired sensation (eg, quadriplegia), increased skin moisture, and fever (ie, elevated temperature) or infection. This client has four risk factors and therefore is at highest risk for developing a pressure injury - Braden scale

The primary care provider's office nurse must return telephone calls concerning 4 clients. Which client has the most emergent situation and requires an immediate call back?

Educational Outcome: Priapism is a prolonged, painful erection (>2 hours) caused by trapping of blood in the penile vasculature that can lead to erectile tissue hypoxia and necrosis. The condition is usually idiopathic, secondary to prescription medications (eg, sildenafil, trazodone) or a preexisting medical condition (eg, sickle cell disease, cocaine use). The nurse should return this call first as the condition is a medical emergency that can result in permanent erectile dysfunction; it requires urgent treatment in the emergency department.

The client recently admitted to the assisted living center has impaired vision related to primary open-angle glaucoma. Select the graphic that best illustrates the effects of glaucoma on the client's vision.

Educational Outcome: Primary open-angle glaucoma (POAG) is an eye condition characterized by an increase in intraocular pressure and gradual loss of peripheral vision (ie, tunnel vision). The signs/symptoms of POAG develop slowly and include painless impairment of peripheral vision with normal central vision, difficulty with vision in dim lighting, increased sensitivity to glare, and halos observed around bright lights. POAG can lead to blindness if left untreated.

The nurse is caring for a 76-year-old male in the emergency department.

Educational Outcome: Prostate cancer can cause similar manifestations to BPH due to prostate enlargement. However, clients with prostate cancer would likely have prostate nodules, induration (eg, hardening), or asymmetry on digital rectal examination with elevated prostate-specific antigen levels. Treatment includes surgery and/or brachytherapy. The radioactive seeds remain in the client's prostate even when they stop emitting radiation.

An 8-month-old infant with congenital pulmonic stenosis is scheduled for a femorally inserted balloon angioplasty in the cardiac catheterization laboratory. Which finding should the nurse report to the health care provider that could possibly delay the procedure?

Educational Outcome: Pulmonic stenosis causes increased pressure in the right side of the heart as the ventricle tries to push blood through the narrowed opening of the pulmonary artery to the lungs. In severe pulmonic stenosis, higher pressure in the right side of the heart causes unoxygenated blood to travel to the left side through the foramen ovale (or other congenital defect) and into the systemic circulation, leading to chronic hypoxia and cyanosis and requiring repair (interventional catheterization or surgery). The presence of severe diaper rash should be reported to the health care provider (HCP). This could delay the procedure if the rash is in the groin area where access is planned for a femorally inserted arterial cannula. Yeast or bacteria may be present on the rash which could be introduced into the bloodstream with the arterial stick. Children should be NPO for ≥4-6 hours before the procedure. Younger children and infants may have a shorter period of NPO status and

The nurse is caring for assigned clients. The nurse should first assess the client with

Educational Outcome: Purpura refers to reddish-purple patches on the skin caused by bleeding underneath the skin. These patches do not lighten when pressed (Option 3). Further assessment must be completed to evaluate for the presence of acute or chronic clotting disorders (eg, disseminated intravascular coagulation, thrombocytopenia). - A soft, distinct liver edge that is even with the bottom of the right rib cage or right costal margin is a normal finding. An abnormal finding would be a boggy liver edge below the rib cage (ie, hepatomegaly).

The nurse is monitoring a client following a radiofrequency catheter ablation. The nurse notes that the P waves are not associated with the QRS complexes on the cardiac monitor. Which intervention is most appropriate at this time? Click on the exhibit button for additional information.

Educational Outcome: Radiofrequency ablation is performed through transvenous cardiac catheterization to ablate (ie, burn) electrical pathways causing supraventricular or ventricular tachydysrhythmias. Ablation performed near the atrioventricular (AV) node can damage conduction, causing varying degrees of AV block. Third-degree AV block, or complete heart block, occurs when electrical conduction from the atria to the ventricles is blocked, causing decreased cardiac output (eg, dizziness, syncope, mental status changes, heart failure, hypotension, bradycardia). On ECG, third-degree AV block presents as a regular rate and rhythm with disassociated P waves and QRS complexes. This type of AV block requires temporary or permanent pacing to restore electrical conduction and hemodynamic stability

The nurse is preparing to transfer a client from the bed to the chair for the first time. The client has generalized weakness and is unable to follow instructions. Which would be the most appropriate method for the nurse to use to transfer this client safely?

Educational Outcome: Recommended bed-to-chair transfer method Full weight bearing: -Independent; no assistance required -1-person standby assistance or observation for clients who are uncooperative or at high risk for falls Partial weight bearing -1-person assist stand & pivot transfer with gait belt or motorized assist device if cooperative -2-person assist with full-body sling if client is uncooperative None -Motorized assist device if client is cooperative & has upper body strength -2-person assist with full-body sling if client is uncooperative &/or has no upper body strength -Client should use as much of his or her own strength as possible. -Use assistive devices when lifting >35 lb (15.9 kg) of client's body

The nurse is caring for a client who has not eaten for 8 days and is undergoing nutritional rehabilitation via oral and enteral feedings. Which of the following findings would indicate that the client is developing refeeding syndrome? Click the exhibit button for additional client information.

Educational Outcome: Refeeding syndrome is a potentially lethal complication of nutritional replenishment in significantly malnourished clients and can occur with oral, enteral, or parenteral feedings. After a period of starvation, carbohydrate-rich nutrition (glucose) stimulates insulin production along with a shift of electrolytes from the blood into tissue cells for anabolism. The key signs of refeeding syndrome are rapid declines in phosphate, potassium, and/or magnesium (mnemonic - PPM). Other findings may include fluid overload, sodium retention, hyperglycemia, and thiamine deficiency. Actions to prevent refeeding syndrome include the following: Obtaining baseline electrolytes Initiating nutrition support cautiously with hypocaloric feedings Closely monitoring electrolytes Increasing caloric intake gradually

The nurse reviews discharge teaching about residual limb care for a client who had a lower limb amputation. Which of the following instructions should the nurse include? Select all that apply.

Educational Outcome: Residual limb care following an above-knee amputation (AKA) or a below-knee amputation (BKA) is an important component of rehabilitation and focuses on maintaining skin integrity, controlling pain, preventing infection, and restoring mobility. It is also important for the nurse to consider that the client may experience grief due to disturbed body image. The nurse should include the following residual limb care instructions when discharging a client after an AKA or BKA: Clean the limb by washing it daily with soap and warm water. Thoroughly dry after washing to prevent skin maceration Thoroughly inspect the limb for signs of infection (eg, redness) and areas that may be at risk for infection (eg, irritation, skin breakdown) Keep limb socks, wraps, and appliances/prostheses clean and dry Perform daily range-of-motion exercises to improve muscle strength and mobility. Hip flexion contractures are a common complication during the recovery process. Nurses should teach clients to lie prone several times each day and to avoid sitting in a chair for ≥1 hour Clients should be taught to avoid applying potential irritants (eg, alcohol, lotion, powder) to the residual limb, unless prescribed by the health care provider. This reduces the risk of skin breakdown and infection.

The nurse has taught a client with heart failure who has had multiple admissions to treat exacerbations. Which of the following statements by the client would require follow-up?

Educational Outcome: Restricting sodium intake (<3 g/day) decreases circulating fluid volume and prevents excess strain on the heart. Understanding how to read nutritional labels and avoiding foods high in sodium (eg, frozen meals, canned foods, restaurant foods, processed meats and snacks) can help prevent future exacerbations. The nurse should encourage the client to prepare meals using fresh ingredients to limit the amount of added sodium rather than substituting frozen meals for restaurant foods

The nurse has attended a staff education program about cerebral palsy. Which of the following should the nurse recognize as risk factors for cerebral palsy? Select all that apply.

Educational Outcome: Risk factors for CP include: Brain injury from fetal asphyxiation during delivery, infantile infection (eg, meningitis), or trauma Perinatal complications such as premature birth, low birth weight, and stroke Maternal factors such as advanced age, chronic conditions (eg, hyperthyroidism), and recreational substance or alcohol use Complicated delivery (eg, prolonged rupture of membranes, preeclampsia, abnormal fetal presentation [eg, breech])

The nurse has provided instructions about home care management to the parents of a child diagnosed with rotavirus infection. Which of the following statements by the parents indicate that the teaching has been effective? Select all that apply.

Educational Outcome: Rotavirus is a contagious virus and the leading cause of diarrhea in children age <5; it is also the cause of many nosocomial infections each year. Rotavirus is spread via the fecal-oral route. Because the virus is stable in the environment, transmission to a human host can occur via contact with objects (eg, toys, diapers), food, and hands. Meticulous handwashing and proper diaper disposal prevent spreading the virus. Symptoms include foul-smelling, watery diarrhea that lasts 5-7 days and is often accompanied by fever and vomiting. Vaccination is available and must be given before the child is age 8 months. Because the virus can easily lead to dehydration, parents should be taught the symptoms of dehydration (eg, lack of tears, extremely fussy or sleepy, decreased urination, dry mucous membranes). Oral rehydration solutions should be used to combat dehydration

The nurse is caring for a 10-year-old client who has a fracture of the right ulnar. The client is reporting severe pain 30 minutes after receiving IV morphine. It would be a priority for the nurse to

Educational Outcome: Severe pain is expected after a fracture; however, pain that is disproportionate to the injury or unrelieved by analgesics is an early symptom of CS. The nurse should immediately check and compare bilateral pulse quality and capillary refill and assess for other signs of CS (eg, paresthesia, pallor, coolness, swelling, paralysis) - The nurse can provide additional pain relief after assessing for signs of impaired tissue perfusion related to CS

The nurse is screening clients for those at risk for developing osteomyelitis. Which of the following factors would increase a client's risk for developing osteomyelitis? Select all that apply.

Educational Outcome: Sickle cell disease causes splenic dysfunction, which decreases the client's defense against pathogens and increases the risk for infection. Clients are particularly susceptible to osteomyelitis in areas of bone with infarction or necrosis due to hyperviscosity of sickled RBCs - Diabetes insipidus (DI) is caused by inadequate secretion or impaired renal use of antidiuretic hormone. Clients with diabetes mellitus, not DI, are at increased risk for osteomyelitis because diabetic foot ulcers can spread infection to the bone.

The nurse assesses a client 5 minutes after initiating a blood transfusion. The client has shortness of breath, itching, and chills. The nurse immediately turns off the transfusion and disconnects the tubing at the catheter hub. What action should the nurse take next?

Educational Outcome: Signs of a transfusion reaction include chills, fever, low back pain, flushing, and itching. Nursing interventions include: Stop transfusion immediately and disconnect tubing at the catheter hub. Maintain IV access with normal saline, using new tubing to prevent hypotension and vascular collapse. Notify health care provider (HCP) and blood bank. Monitor vital signs. Recheck labels, numbers, and the client's blood type. Treat client's symptoms according to the HCP's prescription. Collect blood and urine specimens to evaluate for hemolysis. Return blood and tubing set to the blood bank for additional testing. Complete necessary facility paperwork to document the reaction. Other info: The HCP will likely prescribe IV medications (eg, vasopressors, antihistamines, corticosteroids) to treat the transfusion reaction, so a patent IV is critical. Mislabeling blood and administering the wrong blood type are the most common causes of a transfusion reaction.

A clinic nurse examines a client with a tentative diagnosis of primary Sjögren's syndrome. Which finding observed by the nurse would most likely be associated with this syndrome?

Educational Outcome: Sjögren's syndrome is an autoimmune condition. It causes inflammation of the exocrine glands (eg, lacrimal, salivary), resulting in decreased production of tears and saliva and leading to dry eyes (xerophthalmia) and dry mouth (xerostomia). Treatment with over-the-counter, preservative-free artificial tears can relieve eye dryness, burning, itching, irritation, pain, and a gritty sensation in the eyes. Wearing goggles can protect the eyes from outdoor wind and dust. Dry mouth is treated with artificial saliva. Using a room humidifier and not sitting in front of fans and air vents can also help

During the admission assessment of a client with a small-bowel obstruction, the nurse anticipates which clinical manifestations? Select all that apply.

Educational Outcome: Small-bowel obstruction can have mechanical or non-mechanical causes. Mechanical obstruction is commonly caused by obstruction of the bowel resulting from surgical adhesions, hernias, intussusception, or tumors. Paralytic ileus, a non-mechanical obstruction, may occur after abdominal surgery or narcotic use. When a small-bowel obstruction develops, fluid and gas collect proximal to the obstruction, producing rapid onset of nausea and vomiting colicky intermittent abdominal pain , and abdominal distension. The nurse should recognize symptoms of bowel obstruction quickly as delay could lead to vascular compromise, bowel ischemia, or perforation. Nursing management of an obstruction includes placing the client on NPO status, inserting a nasogastric tube, administering prescribed IV fluids, and instituting pain control measures. Symptoms of a large-bowel obstruction differ slightly from small-bowel obstruction and include gradual onset of symptoms, cramping abdominal pain, abdominal distension, absolute constipation, and lack of flatus. Constipation and decreased flatus resulting from small-bowel obstruction would occur later, as the stool and gas in the large colon would be expelled for a few days.

The nurse provides instruction to a community group about lung cancer prevention, health promotion, and smoking cessation. Which statement made by a member of the group indicates the need for further instruction?

Educational Outcome: Smoking is responsible for 80%-90% of all lung cancers. Although the risk is greater among smokers, former smokers and nonsmokers can develop lung cancer as well. Risk factors include secondhand smoke, air pollution, genetic predisposition, and exposure to radon, asbestos, and chemicals in the workplace. Smoking cessation is the best way to prevent lung cancer. Nicotine replacement therapy (eg, patches, gum, inhalers, lozenges) is effective in helping smokers quit by reducing cravings. Although users receive a low dose of nicotine, they do not receive the other toxins that cigarettes include. The best way to reduce the risk of lung cancer is to avoid both firsthand and secondhand smoke. Smoke from someone else's burning cigarette contains the same carcinogens as those found in mainstream smoke and creates a health risk to those inhaling it. Exposure to high levels of radon can cause lung cancer. Radon levels must be tested before a home can be sold.

The nurse is caring for a client who has a Clostridioides difficile infection. Which of the following infection control precautions should the nurse implement? Select all that apply.

Educational Outcome: Soap and water should be used to cleanse the hands because C difficile spores have shown resistance to alcohol-based sanitizers. Surgical masks (ie, face masks) must be worn as personal protective equipment if an organism is spread via droplets. However, masks are not required for preventing the spread of a contact-transmissible infection such as C difficile.

The nurse prepares to insert a large-bore nasogastric tube for gastric decompression. After obtaining equipment, the nurse identifies the client, performs hand hygiene, applies clean gloves, assesses nares, and selects a naris. Place the remaining steps in the correct order. All options must be used.

Educational Outcome: Steps for inserting a nasogastric tube for gastric decompression include the following: Perform hand hygiene and apply clean gloves (no need for sterile gloves) Place client in high Fowler's position Assess nares and oral cavity and select naris Measure and mark the tube Curve 4-6" tube around index finger and release Lubricate end of tube with water-soluble jelly Instruct client to extend neck back slightly Gently insert tube just past nasopharynx, aiming tip downward Rotate tube slightly if resistance is met, allowing rest periods for client Continue insertion until just above oropharynx Ask client to flex head forward and swallow small sips of water (or dry if NPO) Advance tube to marked point Verify tube placement and anchor - use agency policy and procedure to verify placement by anchoring tube in place and obtaining an abdominal x-ray. Aspirating gastric contents and testing the pH may also give an indication of placement (pH should be 5.5 or below). Auscultation of inserted air is acceptable for confirming tube placement initially, but is not definitive as it is not an evidence-based method. Nothing may be administered through the tube until x-ray confirmation is obtained, or this may cause aspiration.

A client is transferred from the post-anesthesia recovery unit to the surgical unit following an open cholecystectomy. Which interventions are most important for the nurse to perform to prevent postoperative pneumonia? Select all that apply.

Educational Outcome: Strategies to prevent postoperative pneumonia include the following: Adequate pain control is a priority so that the client can move, deep breathe, and cough more effectively and comfortably. Opioids are effective for relieving postoperative pain, but because they depress respirations and the cough reflex, assessing the client's response to the medication and level of sedation is important. Ambulate within 8 hours after surgery, if possible. Mobilization/early ambulation decreases atelectasis and hypoventilation, and promotes coughing, deep breathing, and lung expansion. Usually, it can be initiated within 4-8 hours after surgery. Coughing with splinting every hour. Splinting of the incision and adequate pain management are useful for promoting an effective cough (huff, cascade) that clears the airway of secretions. Deep breathing and use of the incentive spirometer every hour. Deep breathing in conjunction with the use of the incentive spirometer promotes ventilation and oxygenation. It opens the pores of Kohn that permit air from well-ventilated alveoli to move into collapsed alveoli, and it helps to prevent/decrease atelectasis and hypoventilation caused by the effects of anesthesia, analgesia, and pain. Place in Fowler's position. Elevating the head of the bed 45-60 degrees helps to promote oxygenation and prevent aspiration. Turn and reposition the client at least every 2 hours. Swab mouth with chlorhexidine swabs every 12 hours. Mouth care prevents ventilator-associated and postoperative pneumonia. Use hand hygiene (all personnel) to decrease transmission of microorganisms.

The nurse is caring for a client who is receiving enteral feedings after sustaining severe burns to the face. Which of the following statements by the nurse would indicate a correct understanding of why the client is receiving enteral feedings instead of parenteral nutrition?

Educational Outcome: Stress ulcers (ie, Curling ulcers) of the gastrointestinal tract are a common complication in clients who are critically ill (eg, sepsis, shock, burns). Decreased perfusion causes blood to be shunted away from the gut to the more vital organs, increasing the risk for stress ulcers. Clients with a functional gastrointestinal tract are candidates for enteral nutrition. Enteral feedings (eg, nasogastric tube, percutaneous endoscopic gastrostomy tube) help preserve gut integrity, limit movement of bacteria from the intestines into the bloodstream, and prevent stress ulcers Nasal and oral tubes used for enteral nutrition may remain in place for approximately 4 weeks prior to surgical placement of gastrostomy and jejunostomy tubes, which can be used for an extended time. Parenteral nutrition may also be administered long term via a central venous access device. Caloric and metabolic needs can usually be met adequately with enteral feedings or parenteral nutrition. Multiple enteral and parenteral formulas are available to meet individual client needs. If metabolic demands are not being met using enteral feedings alone, parenteral nutrition can be added.

The nurse plans care for a client with surgically wired jaw fixation after a mandibular fracture. Which intervention should the nurse prioritize?

Educational Outcome: Surgical immobilization of the jaw uses metal wiring and/or a fixation device to fix the upper and lower jaws together to promote healing and proper bone alignment after a mandibular fracture or malocclusion repair. The wiring or device prevents the mouth from opening and greatly increases the risk for aspiration or airway obstruction. When caring for clients with jaw fixation, nurses must keep wire cutters available, typically secured to the head of the bed, to free the jaw by cutting the wires in case of a medical emergency (eg, vomiting, respiratory distress, airway obstruction) The nurse should find an appropriate nonverbal communication method (eg, dry-erase board, pen and paper, alphabet board) to use with the client to allow communication, but this does not take priority. The client should receive frequent oral hygiene with 0.9% sodium chloride or water to prevent infection and assist with healing, but reducing infection risk does not take priority over maintaining airway patency. Pain management is important

The nurse has been made aware of laboratory test results for a client who is experiencing an acute exacerbation of systemic lupus erythematosus. Which of the following test results would require immediate follow-up? Click the exhibit button for additional information.

Educational Outcome: Systemic lupus erythematosus (SLE) is an autoimmune disorder that is characterized by alternating periods of exacerbation (ie, flare) and remission that causes deposition of immunocomplexes (eg, antigen-antibody complexes) in various organs. Kidney injury (eg, lupus nephritis) occurs in approximately half of clients with SLE due to vascular inflammation. The client's elevated serum creatinine level indicates impaired renal function and requires immediate follow-up to preserve kidney function and prevent irreversible kidney damage Antinuclear antibody titer (ANA) testing is positive in nearly all clients with SLE. Positive ANA titer does not require immediate follow-up because the client has already been diagnosed with SLE. Laboratory abnormalities associated with SLE include elevated inflammatory markers (eg, C-reactive protein, erythrocyte sedimentation rate [ESR]). Elevated ESR is expected during an acute exacerbation. Anemia (ie, decreased hemoglobin level), mild leukopenia, and thrombocytopenia are expected findings with SLE and do not require immediate follow-up.

A nurse is teaching a client with a surgically repaired undescended testis about testicular self-examination (TSE). Which instructions should be included in the teaching? Select all that apply.

Educational Outcome: Testicular cancer is the most common form of cancer in men age 15-35. When diagnosed early, it is highly curable. Clients at high risk for developing a tumor (eg, history of undescended testis) are encouraged to perform a monthly TSE. Client instructions for a TSE include: Perform TSE monthly on the same day (easy to remember) Perform TSE while taking a warm shower or bath as warm temperatures will relax the scrotal tissue and make the testis hang lower in the scrotum Use both hands to feel each testis separately Palpate each testicle gently, using the thumb and first 2 fingers Check that the testicle is normally egg-shaped and movable with a smooth surface The clinical findings that should be reported to the health care provider include: Painless, hardened lump on testes Scrotal swelling or heaviness Dull ache in pelvis or scrotum It is normal for one testicle to be slightly larger or hang lower than the other. Some people may also confuse epididymis (small coiled tube) as a small lump at the beginning. These do not need to be reported.

A client was struck on the head by a baseball bat during a robbery attempt. The nurse gives this report to the oncoming nurse at shift change and conveys that the client's current Glasgow Coma Scale (GCS) score is a "10." Which client assessment is most important for the reporting nurse to include?

Educational Outcome: The GCS quantifies the level of consciousness in a client with acute brain injury by measuring eye opening (alertness), verbal response (orientation), and motor response (eg, obeying a command, frontal lobe function). The maximum score on the GCS is 15 and the lowest is 3. If a client is trending for deterioration, this should always be noted in neurological assessments. A numerical decline of a single number in 1 hour is significant. A criticism of the GCS score is that it is not that precise.

While caring for a client in skeletal traction, which tasks can the registered nurse (RN) delegate to experienced unlicensed assistive personnel (UAP) to help prevent immobility hazards? Select all that apply.

Educational Outcome: The UAP changes the linens from the top to the bottom of the bed with assistance; clients are instructed to lift themselves using the overhead trapeze. This approach maintains immobilization of the injured extremity. Logrolling the client will require multiple staff members, including one person to stabilize weights.

The clinic nurse educator is developing a teaching plan about the Valsalva maneuver. The nurse should instruct which of the following clients to avoid the Valsalva maneuver? Select all that apply.

Educational Outcome: The Valsalva maneuver involves holding the breath while bearing down and contracting the abdominal muscles (eg, straining during defecation). The Valsalva maneuver simulates the vasovagal response, causing bradycardia, decreased cardiac output, and hypotension, and provokes dysrhythmias. This maneuver facilitates voiding, equalizes ear pressure, treats supraventricular tachycardia, and is an adjunctive technique to avoid an air embolism when a line (eg, central venous access device) or drain is removed. The following clients should avoid performing the Valsalva maneuver: Clients with glaucoma or recent eye surgery (eg, cataract surgery) because straining increases intraocular pressure Clients unable to hemodynamically compensate due to certain heart conditions (eg, heart failure, myocardial infarction) . When the client relaxes, blood flow rapidly returns to the heart. If the heart is unable to compensate for the blood flow increase, fatal complications can occur. Clients recently diagnosed with increased intracranial pressure, stroke, or a head injury . Straining increases intraabdominal and intrathoracic pressure, which raises the intracranial pressure. Clients with portal hypertension related to cirrhosis . Straining should be avoided due to the risk of variceal bleeding induced by increased pressure.

A client with a T4 spinal cord injury has a severe throbbing headache and appears flushed and diaphoretic. Which priority interventions should the nurse perform?

Educational Outcome: The client should have the head of the bed elevated 45 degrees or high Fowler's to lower blood pressure. The Sims' position is flat and side-lying. - No need for pain meds as Headaches associated with autonomic dysreflexia are typically due to severe hypertension and often resolve after blood pressure has been treated.

The nurse is teaching a client with pelvic inflammatory disease who has a new prescription for oral antibiotics. Which of the following statements by the client would indicate a correct understanding of the teaching? Select all that apply.

Educational Outcome: The client should return to the outpatient care facility for reevaluation in 48 to 72 hours to monitor for worsening of the infection, which may require hospitalization and IV antibiotics

A major disaster involving hundreds of victims has occurred, and an emergency nurse is sent to assist with field triage. Which client should the nurse prioritize for transport to the hospital?

Educational Outcome: The client with flail chest (ie, paradoxical chest movement during respiration) from multiple fractured ribs is at risk for respiratory failure from impaired ventilation. In addition, mobile fractured ribs may puncture the pleura or vessels, causing hemothorax and/or pneumothorax at any time. Therefore, this client would be classified as emergent due to airway compromise, which requires immediate treatment

The nurse is inserting an indwelling urinary catheter for a female client. Which of the following actions should the nurse take? Select all that apply.

Educational Outcome: The correct procedure for indwelling urinary catheter insertion for a female client is as follows: Position the client supine with knees flexed and hips slightly externally rotated Perform hand hygiene and open a sterile catheterization kit. Apply sterile gloves and place the sterile drapes underneath the client's buttocks Remove the protective covering from the catheter, lubricate the catheter tip, and pour antiseptic solution over the cotton swabs while maintaining sterility. Use the nondominant hand to gently spread the labia. The nondominant hand is now contaminated Use the dominant (ie, sterile) hand to cleanse from the clitoris toward the anus using a new antiseptic-soaked cotton swab for each swipe to avoid transferring bacteria between areas. Cleanse the labia majora first, then the labia minora, and lastly the urinary meatus (Option 3) Use the dominant hand to advance the catheter 2-3 in (5-7.5 cm) or until urine return is visualized in the tubing; and then advance it an additional 1-2 in (2.5-5 cm) before inflating the balloon.

The registered nurse (RN) and licensed practical nurse (LPN) are caring for a client with an established colostomy. Which nursing actions may the RN delegate to the LPN? Select all that apply.

Educational Outcome: The following actions related to ostomy care are generally within the LPN scope of practice: Provide ostomy care and observe for skin breakdown Perform specific assessments (eg, bowel sounds, stoma color) Monitor drainage characteristics (eg, color, amount) Reinforce education Irrigate an established ostomy Document observations and interventions (Option 1) The RN may delegate specific assessments to the LPN. The LPN focuses on data collection and determining normal versus abnormal findings. For example, the LPN may determine that a client's colostomy stoma is an abnormal color whereas the RN synthesizes assessment findings (eg, color, temperature, capillary refill) to determine the quality of tissue perfusion.

The nurse is screening clients for those at risk for developing bladder cancer. The nurse should recognize that the client at highest risk for developing bladder cancer is a

Educational Outcome: The greatest risk factors for bladder cancer include tobacco use and industrial carcinogenic exposures such as paint, rubber, and textiles . Male clients have a greater risk due to urinary tract anatomy and age-related prostate enlargement. - Diets high in fatty, red meats increase the risk for colon cancer due to increased bile and anaerobic bacteria in the bowel. Alcohol use is also a risk factor for colon cancer.

The nurse is screening clients for those at risk for developing umbilical cord prolapse. The nurse should recognize the client at highest risk for developing umbilical cord prolapse is the client at

Educational Outcome: The highest risk factor for umbilical cord prolapse is lack of fetal engagement in the maternal pelvis when ROM occurs. A client at preterm gestation (ie, <37 weeks) with a bulging amniotic sac at a high fetal station (eg, −3 station) is at highest risk because a fetus at 26 weeks gestation is small and unlikely to be engaged in the maternal pelvis when ROM occurs

A nurse in the neonatal intensive care unit discovers a cyanotic newborn with excessive frothy mucus in the mouth. What should be the nurse's first action?

Educational Outcome: The initial nursing action for a client experiencing cyanosis and excess oral secretions is suctioning the mouth (ie, oropharynx) to clear the airway (Option 4). Excessive frothy mucus and cyanosis in a newborn could be due to esophageal atresia (EA) and tracheoesophageal fistula (TEF). If EA/TEF is suspected, the infant should be kept supine with the head elevated at least 30 degrees to prevent aspiration. A nasogastric tube should be inserted and connected to continuous or intermittent suction until surgical repair. Oxygen cannot be delivered to the lungs if secretions obstruct the airway. Therefore, suctioning is a priority. This infant is aspirating and in immediate distress, which should be addressed without delay. After suctioning the excess saliva and ensuring a clear airway, the nurse may perform further assessments.

The nurse is screening clients for those at risk of developing acute pancreatitis. Which of the following factors would increase a client's risk of developing acute pancreatitis? Select all that apply.

Educational Outcome: The most common causes of pancreatitis are obstructive biliary tract disease (eg, untreated cholelithiasis [ie, gallstones]) and alcohol use disorder. Other causes include pancreatic injury caused by abdominal trauma, certain medications such as thiazide diuretics [ie, hydrochlorothiazide]), hypertriglyceridemia, and medical procedures that can irritate the pancreas (eg, endoscopic retrograde cholangiopancreatography)

The emergency department nurse assesses an elderly client who was just admitted with a fractured hip after a fall. Which assessment findings would the nurse most likely expect? Select all that apply.

Educational Outcome: The most common clinical manifestations of hip fractures include: Ecchymosis and tenderness over the thigh and hip - occur from bleeding into the surrounding tissue as the femur is very vascular and a fracture can result in significant blood loss (>1000 mL) Groin and hip pain with weight bearing Muscle spasm in the injured area - occurs as the muscles surrounding the fracture contract to try to protect and stabilize the injured area Shortening of the affected extremity - occurs because the fracture can reduce the length of the bone and the muscles above the fracture line pull the extremity upward (Option 5) Abduction or adduction of the affected extremity depending on location and mechanism of injury.

A client with Alzheimer disease is found wandering in the middle of the street at 3 AM and is returned home by police. The community health nurse teaches the client's family members about measures to keep the client safe at home. What is the most important strategy for the nurse to include in the instruction to prevent wandering?

Educational Outcome: The most effective strategy to prevent wandering outside of the home is to make modifications that secure the environment. A preventive method to create a safe and secure environment for clients with AD is to install a door sensor to alert family members if the client leaves the home. Other interventions include providing an enclosed, safe area for wandering and maintaining a structured schedule to reduce confusion

The nurse is preparing to administer an IM vaccine to a 6-month-old client. Which of the following needle lengths and injection sites would be appropriate for the nurse to use?

Educational Outcome: The needle length and injection site for IM injections are dependent on a client's age and muscle mass. Selecting the most appropriate needle length and injection site ensures immunization success and minimizes local reactions to vaccine components. When administering IM injections, the appropriate needle length for newborns (age <1 month) is ⅝ inch (16 mm) and ⅝ (16 mm) to 1 inch (25 mm) for infants (age 1-12 months) and children. The vastus lateralis muscle in the anterolateral middle portion of the thigh is the preferred IM injection site for newborns and infants (Option 2). Other info: A 3⁄8-inch (9-mm) needle is too short to penetrate the muscle, and the infant's ventrogluteal muscle does not have enough muscle mass for use. The muscle should be big enough to absorb the amount of vaccine injected and to avoid blood vessels and nerves. The dorsogluteal muscle is not recommended for IM injections due to the risk of injuring the sciatic nerve. A 1½-inch (38-mm) needle is typically used for older children and adults with sufficient muscle mass. The deltoid muscle is used in children age >3 and adults

The nurse receives report on 4 clients. Which client should the nurse assess first?

Educational Outcome: The nurse caring for a client after thyroidectomy must closely monitor for and immediately report any clinical manifestations of thyrotoxicosis (eg, fever, anxiety, tachycardia), particularly in clients with hyperthyroidism because thyroid hormones may remain elevated, or increase, for several days postoperatively

The nurse is caring for a newborn with suspected hypertrophic pyloric stenosis. Which of the following actions should the nurse take? Select all that apply.

Educational Outcome: The nurse caring for a client with hypertrophic pyloric stenosis should: Record strict intake and output (eg, weigh all wet diapers) and monitor for signs of dehydration (eg, sunken fontanels, dry mucous membranes, decreased urinary output) Prepare the client for an abdominal ultrasound to confirm pyloric stenosis and determine the need for surgical treatment (ie, pyloromyotomy) Monitor serum electrolytes because the client is at risk for hypokalemia due to severe vomiting The nurse should ensure the client is NPO and receiving IV fluids for hydration in preparation for surgical repair.

The medical-surgical nurse cares for a group of clients. Which client situations would prompt the nurse to notify the health care provider during the middle of the night? Select all that apply. Click the exhibit button for additional client information.

Educational Outcome: The nurse contacts the health care provider (HCP) for certain circumstances, regardless of the time of day. An emergent call is warranted if a client: Falls Deteriorates significantly or dies Has critical laboratory results Needs a prescription that requires clarification Leaves against medical advice or runs away Refuses key treatments in a relevant period The HCP should be called after the initiation of hospital protocols (eg, stroke, code blue) and after a concerning assessment finding (eg, significant change in vital signs, unilateral drift, change in level of consciousness, signs of trauma after a fall

The nurse is providing care to a 66-year-old client in the medical-surgical unit.

Educational Outcome: The nurse should allow the family to be present during postmortem care, which includes: Positioning the client (eg, straightening the body and limbs) and gently closing the client's eyes because it is difficult to reposition the client once rigor mortis (stiffening of the body after death) occurs. Notifying the organ and tissue donation organization because only specially trained personnel (ie, transplant coordinator) handle organ donation requests. Cleansing the body, placing a pad under the perineum, and changing the bed linens and gown. Removing all medical equipment (eg, tubes, drains, peripheral IV catheter, urinary catheter) because an autopsy is not indicated. It is critical that the nurse leave body identification tags on the client for transportation to the morgue and/or funeral home. The nurse should keep the surgical incision (eg, abdominal staples) intact to prevent any signs of trauma to the body (eg, open wound).

After making initial rounds on all the assigned clients by 8:00 AM, which client should the nurse care for first?

Educational Outcome: The nurse should care for the client with adenocarcinoma scheduled for a lobectomy at 9:00 AM first. Not being able to sleep the night before surgery is a common manifestation of anxiety and fear; these emotions can negatively affect recovery. For this reason, it is important to identify and listen to the client's concerns (eg, diagnosis of cancer, fear of death, pain, anesthesia), teach the client about what to expect following surgery (eg, pain control, tubes, intensive care environment), and provide emotional support to help alleviate the fear and anxiety. The nurse can provide for the physical preparation of the client and complete the preoperative checklist as well.

The nurse is reviewing new orders for an older adult client who is experiencing a severe exacerbation of chronic obstructive pulmonary disease. The nurse should clarify the order for

Educational Outcome: The nurse should clarify the order for morphine because older adult clients and those with respiratory conditions such as COPD are at risk for increased sensitivity and may require lower doses to prevent severe respiratory depression - Oxygen should be titrated to the minimum amount necessary to maintain an oxygen saturation of 88%-92%. A Venturi mask is the best choice for clients with COPD because the adapter allows precise control of the fraction of inspired oxygen that the client receives.

A client who is 24 hours postoperative bowel resection is receiving IV opioids PRN for severe pain. The nurse reviews the health care provider's prescription to discontinue the continuous IV normal saline. What is the nurse's most appropriate action?

Educational Outcome: The nurse should discontinue the IV infusion of normal saline and apply a saline lock to maintain IV access while preventing clotting. The prescription of the health care provider (HCP) to lock the IV catheter is implied, as the client is currently receiving PRN IV opioids . A saline lock is sufficient to maintain the line patency and allows greater mobility than a continuous infusion. The client is only 24 hours postoperative abdominal surgery, so IV access is necessary to administer medications (eg, antibiotics, analgesics, antiemetics). The HCP's prescription specifies discontinuing IV fluids but not removing the IV catheter or slowing the infusion to a keep-vein-open (KVO) rate. Also, the nurse would need to clarify a KVO prescription with the HCP for a precise rate.

The nurse is caring for a client who had a laparoscopic cholecystectomy 6 hours ago. The client has not urinated since surgery. Which of the following actions should the nurse take? Select all that apply.

Educational Outcome: The nurse should promote spontaneous voiding and use invasive methods only if non invasive ones fail. For a client who has not voided 6 hours after surgery, appropriate interventions include: Assisting the client to ambulate to the bathroom because ambulation, normal body position, and privacy promote spontaneous urination Encouraging oral fluid intake to stimulate adequate urine production Performing a bladder scan, which can be used noninvasively to assess the volume of urine in the bladder Turning on the water in the bathroom sink or pouring warm water over the perineum, which can stimulate the urge to void spontaneously Urinary catheterization is prescribed if the client has significant urine in the bladder assessed via bladder scan and is unable to void voluntarily. However, indwelling urinary catheters increase the risk for UTI and should be avoided if possible.

A nurse is caring for 4 clients. Which prescription by the health care provider would the nurse question and seek further clarification before administering? Click the exhibit button for additional client information.

Educational Outcome: The nurse should question the administration of a hypotonic IV solution (ie, 0.45% sodium chloride) to replace gastrointestinal tract fluid losses as this would create a concentration gradient and shift fluid out of the intravascular compartment into the interstitial tissue and cells, worsening the client's fluid volume deficit. Isotonic IV solutions (eg, 0.9% sodium chloride, lactated Ringer's) have the same osmolality as plasma and are administered to expand intravascular fluid volume. These solutions replace fluid losses commonly associated with vomiting and diarrhea, burns, and traumatic injury. Anaphylaxis causes increased capillary permeability, leaking intravascular fluid into free spaces; this places the client at risk for hypotension. Therefore, isotonic solutions should be given to such clients. Extreme hyperglycemia in a client with diabetic ketoacidosis results in osmotic diuresis and dehydration. The immediate initial treatment is IV fluid resuscitation with isotonic 0.9% sodium chloride to replace fluid losses, stabilize vital signs, reestablish urine output, and dilute the serum glucose concentration before initiating insulin therapy.

The nurse is caring for a client who is in labor and experiencing umbilical cord prolapse. Which of the following actions should the nurse take?

Educational Outcome: The nurse should relieve cord compression by lifting the presenting fetal part off the cord until an emergency cesarean birth is performed. The nurse can also position the client into the knee-chest position to aid with relieving compression

A 3-month-old infant is treated in the emergency department for a spiral femur fracture. The parent reports that the infant sustained the injury after rolling off the bed. What is the priority nursing action?

Educational Outcome: The parent's account of this injury is inconsistent with the developmental milestones of a 3-month-old, because the muscles required for rolling over do not develop until age 6 months. Additionally, spiral femur fractures indicate that pressure was applied to the leg in opposite directions (torsion), which is an unlikely accidental injury in a nonambulatory child. Fractures in young children, especially nonambulatory, are always concerning and suspicious of child abuse. The nurse's priority is to report suspected child maltreatment to the appropriate authorities following facility protocol as required by law in the United States and Canada . However, the nurse should also be aware of cultural health practices (eg, cupping, coining) and physiologic conditions (eg, hemophilia, congenital dermal melanocytosis) mimicking maltreatment. After reporting suspected maltreatment, the nurse should facilitate a complete physical evaluation (eg, skeletal survey, growth/development comparisons, radiographic studies, neurologic examination)

A client with chronic heart failure calls the clinic to report a weight gain of 3 lb (1.4 kg) over the last 2 days. Which information is most important for the nurse to ask this client?

Educational Outcome: The priority for the nurse on the phone is to ascertain if the client is experiencing any physiological symptoms such as shortness of breath, coughing, or edema . These could indicate fluid overload. This information can help the nurse direct the client to come in for further assessment, follow a protocol to make changes in medications/dosages, or restrict fluids.

The nurse is caring for a client with acute cholecystitis who has vomited multiple times in the past hour. Which of the following actions would be a priority for the nurse to take?

Educational Outcome: The priority intervention for a client with cholecystitis who is vomiting is maintaining NPO status to prevent additional gallbladder stimulation and bile secretion and to prepare for potential surgery Anticholinergics may be prescribed to decrease gastrointestinal secretions and prevent smooth muscle spasms which can cause abdominal cramping and pain. Promethazine is an H1 (ie, histamine) receptor antagonist that is used for treatment of nausea and vomiting. Administering it in suppository form ensures that the client absorbs the medication in the event of vomiting. Insertion of a nasogastric tube connected to low-intermittent suction provides gastric decompression, alleviates nausea and vomiting, and promotes bowel rest.

The nurse in the emergency department is caring for a client with new-onset right-sided weakness and slurred speech. Which of the following actions should the nurse take first?

Educational Outcome: The priority nursing action is to ensure airway patency. The nurse should determine the time of symptom onset after the client's airway is secured. It is vital to determine the time of symptom onset because treatment is time sensitive (eg, thrombolytics must be administered 3 to 4.5 hr from the onset of symptoms). A CT scan of the head is required to rule out hemorrhagic stroke and to determine the location and extent of the injury. Thrombolytics are used only in ischemic strokes, so the CT scan must be completed to confirm the type of stroke before administering any medications. The nurse should insert a large-bore peripheral venous access device for rapid infusion of thrombolytics and other medications and IV fluids as needed.

The nurse is evaluating how well a client with chronic obstructive pulmonary disease understands the discharge teaching. Which statements made by the client indicate an understanding of the pursed-lip breathing technique? Select all that apply.

Educational Outcome: The pursed-lip breathing technique helps to decrease shortness of breath by preventing airway collapse, promoting carbon dioxide elimination, and reducing air trapping in clients with chronic obstructive pulmonary disease (COPD). Clients with COPD are taught to use this technique when experiencing dyspnea as it increases ventilation and decreases work of breathing. Regular practice (eg, 5-10 minutes 4 times daily) enables the client to do pursed lip breathing when short of breath, without conscious effect. Clients are taught the following steps: Relax the neck and shoulders Inhale for 2 seconds through the nose with the mouth closed Exhale for 4 seconds through pursed lips. If unable to exhale for this long, exhale twice as long as inhaling

The health care provider suspects a rotator cuff injury in a client who is an avid tennis player. The nurse would most likely assess which of the following?

Educational Outcome: The rotator cuff is a group of 4 shoulder muscles and tendons that attach to the humeral head. It allows for rotation of the arm. A partial or full thickness rotator cuff tear can occur gradually over time as a result of aging, repetitive use, or an injury to the shoulder. It can also occur as a result of a sports injury involving repetitive overhead arm motion (eg, swimming, tennis, baseball, weight lifting). Characteristic symptoms of rotator cuff injury usually include shoulder pain and weakness. Severe pain when the arm is abducted between 60 and 120 degrees (painful arc) is characteristic. Restriction of active and passive ranges of motion of the shoulder (complete stiffness) is seen with frozen shoulder. Pain and paresthesia over the first 3½ fingers suggest carpal tunnel syndrome. Tenderness over the lateral epicondyle is seen with tennis elbow.

The nurse is talking with the parent of a 4-year-old client who received the varicella vaccine 48 hours ago. The parent reports the client has discomfort, redness, and three vesicles at the injection site. Which of the following responses would be appropriate for the nurse to make?

Educational Outcome: The varicella vaccine is administered to prevent infection by varicella-zoster virus, commonly known as chickenpox. Adverse effects of the vaccine include low-grade fever, discomfort, redness, swelling, and a few vesicles at the injection site. Symptoms are usually self-limited and resolve within a few days to a week. If needed, a cool compress can be applied over the injection site to decrease discomfort

The nurse is assessing a client with suspected viral rhinitis. Which of the following findings would support a diagnosis of viral rhinitis? Select all that apply.

Educational Outcome: The virus invades the upper respiratory tract and initiates an inflammatory response causing: Cough and sore throat that is exacerbated by mucus draining down the back of the throat Headache due to sinus pressure Nasal congestion, rhinorrhea, and sneezing due to inflammation of the mucous membranes Low-grade fever Malaise

The nurse is caring for several clients in a gynecology clinic. Which of the following clients are at increased risk for developing breast cancer? Select all that apply.

Educational Outcome: Therefore, the nurse should recognize factors that increase a client's risk for developing breast cancer, including: Having a first-degree, biological relative (eg, mother, sister) with a history of breast cancer, particularly if the relative was diagnosed at a young age (ie, age <45) Inheriting a mutation of breast cancer 1 or 2 (BRCA1,BRCA2) genes, which can affect the body's ability to suppress breast tumor growth Gaining excessive weight in the postmenopausal years because fat cells store estrogen, which can stimulate growth of malignant breast tissue Using menopausal hormone therapy (eg, estrogen and progestin pills) for >5 years because it can stimulate tumor growth in estrogen-sensitive tissues (eg, breast) and age ≥50

The office nurse for an orthopedic health care provider receives 4 telephone messages. Which client does the nurse call back first?

Educational Outcome: This client is most likely using the crutches incorrectly or they are not fitted correctly. Pressure on the ulna or radial nerves can lead to numbness and tingling of the fingers and hand weakness. This symptom needs intervention, but it is not potentially life-threatening. Pain and swelling are to be expected with an anterior cruciate ligament injury and are treated with RICE (rest, ice, compression, elevation) for 24-48 hours. Pain and a feeling of tightness can indicate an effusion that may require aspiration, but the condition is not potentially life-threatening.

The nurse is caring for a 29-year-old client in the emergency department.

Educational Outcome: Thrombotic thrombocytopenic purpura (TTP) is a platelet disorder characterized by the formation of microthrombi in small blood vessels (eg, arterioles, capillaries). Clients with TTP typically develop thrombocytopenia (ie, bleeding, petechial rash, purpura) caused by increased platelet consumption, hemolytic anemia (eg, jaundice, pallor) due to RBC destruction while they pass through microthrombi, and end-organ damage due to microthrombi formation (ie, neurologic manifestations [confusion, seizures], renal insufficiency [decreased urine output, fluid overload]). TTP most often occurs in young adults and is often idiopathic but may be triggered by infections (eg, HIV), malignancy, or medications; if known, the underlying cause must be treated. TTP is life-threatening and requires emergency treatment with plasmapheresis (ie, plasma exchange). Plasmapheresis removes components in the blood that cause microthrombi formation and supplies plasma enzymes that help reverse platelet aggregation. Plasmapheresis is performed daily until blood counts improve and symptoms resolve.

The nurse is caring for a 50-year-old client in the medical-surgical unit.

Educational Outcome: Thyroidectomy, partial or complete surgical removal of the thyroid, is often performed to treat hyperthyroidism or thyroid cancer. Complications result primarily from local wound complications (eg, hemorrhage) or surgical injury to the nearby structures (eg, parathyroid gland, laryngeal nerves). Nursing care following a thyroidectomy includes: Monitoring for dysphagia (ie, difficulty swallowing) or frequent swallowing, which can be a sign of local hemorrhage Assessing for inspiratory stridor and new or worsening changes in voice strength and quality (eg, hoarseness), which may indicate laryngeal nerve damage or excessive neck swelling that can lead to tracheal compression and respiratory arrest Assessing for and immediately reporting signs of hypocalcemia (eg, facial or extremity tingling/numbness, Trousseau and Chvostek signs), which can be caused by damage to the parathyroid gland during surgery Keeping emergency airway equipment (eg, tracheostomy kit, suction, oxygen) available at the bedside in case the client develops respiratory distress Maintaining the client in the semi-Fowler position to reduce swelling and the risk for respiratory distress

A 14-year-old is seen in the sexually transmitted disease (STD) outpatient department and diagnosed with gonorrhea. The client tells the nurse of having sexual relations with only a 19-year-old partner. What is the best response by the nurse?

Educational Outcome: To avoid re-infection with gonorrhea, it is essential that the client's partner be tested and treated. During the visit, the nurse should counsel the client about the importance of partner evaluation and treatment and the likely recurrence of the infection if the partner refuses to be treated. The client should avoid sexual relations until treatment is completed and the client and partner no longer have symptoms. A 19-year-old having sexual relations with a 14-year-old is considered statutory rape and is reportable to child protective services or local law enforcement. However, it is most important in this situation to ensure that the client and partner receive appropriate testing and effective treatment. If the client is told that the two are going to be reported to the local authorities, there is a high probability that the client will leave the clinic without being treated and the partner will never come in.

A client is able to partially bear weight and follow the nurse's instructions. Which would be the most appropriate method for the nurse to use to safely transfer this client?

Educational Outcome: To determine the most appropriate method to safely transfer a client for the first time, the nurse should assess: Whether the client can bear weight Whether the client is cooperative If the client is cooperative and able to partially bear weight, a safe transfer requires a 1-person stand and pivot technique with a gait belt or powered stand-assist lift.. If the client can fully bear weight and is cooperative, the client will not require an assisted transfer. However, a caregiver should stand by during the first transfer for safety or for assistance This method would be appropriate for a client who has no weight-bearing ability but can follow instructions and has enough upper body strength to use a motorized stand-assist lift. If the nurse determines that the client cannot be safely transferred with assistance from 1 caregiver, a 2-person stand and pivot transfer may be performed. However, the nurse should first encourage the client to use as much own strength as possible.

The nurse is caring for a newborn who has hyperbilirubinemia and is receiving phototherapy. Which of the following actions should the nurse take? Select all that apply.

Educational Outcome: To prevent complications during phototherapy, the nurse should: Reposition the newborn every 2 hours to ensure equal skin exposure and prevent skin breakdown. Remove all clothing to fully expose the newborn's skin during phototherapy because the amount of skin exposed to the light directly affects treatment efficacy; however, the skin of the genital area is prone to excoriation and should be protected with a diaper. Apply an eye shield to prevent retinal injury from light exposure; the newborn's eyes should be closed prior to applying the shield to prevent corneal abrasion. Avoid application of lotions or creams because they can cause burns by absorbing heat. Closely monitor the infant's temperature because continuous light exposure can cause overheating. - The newborn should be removed from the phototherapy unit during feedings to facilitate skin-to-skin contact and bonding with the parents. - The nurse should monitor the newborn's urine and stool output because bowel movements should become more frequent as more bilirubin is excreted, which indicates the effectiveness of phototherapy.

The nurse provides discharge teaching to a client who had total hip replacement 4 days ago. Which client statement indicates that additional teaching is necessary?

Educational Outcome: To prevent hip prosthesis dislocation following hip arthroplasty, a client must not force the hip into >90 degrees of flexion. Clients should use a chair with armrests and a high firm seat and proceed to place the hands on the armrests for support while lowering themselves onto the seat and when rising from it. Bending forward when getting into a chair creates excessive hip flexion (>90 degrees) and must be avoided. The client performs leg exercises 2-3 times a day to help strengthen the muscles surrounding the hip and continues them for several months after discharge. These include isometric quadriceps and gluteal setting, leg raises, and abduction exercises from the supine and standing positions. The client must not twist from the waist, reach across the affected extremity, or bend forward >90 degrees when dressing or putting on slippers, shoes, and socks. The client is instructed to use assistive equipment when getting dressed, such as a reacher/grabber, sock puller, or a long-handled shoehorn. The client should use a toilet riser or a bedside commode chair with arms to prevent excessive hip flexion when getting on and off the toilet seat.

The nurse in the emergency department is caring for a client who is experiencing torsades de pointes. Which of the following medications should the nurse recognize is used to treat this cardiac dysrhythmia?

Educational Outcome: Torsades de pointes (ie, "twisting of the points") is a polymorphic ventricular tachycardia characterized by QRS complexes that change size and shape in a characteristic twisting pattern. Electrolyte imbalances (eg, hypomagnesemia) and some medications (eg, amiodarone, amitriptyline, ondansetron) cause a prolonged QT interval, which precedes torsades de pointes. Torsades de pointes requires immediate intervention because the heart is no longer pumping effectively, which lowers cardiac output and can progress to ventricular fibrillation and cardiac arrest. The first-line treatment is IV magnesium.Treatment may also include cardioversion and discontinuation of QT-prolonging medications.

The nurse is preparing to suction a client who has a tracheostomy tube. Which of the following actions should the nurse take? Select all that apply.

Educational Outcome: Tracheostomy suctioning is performed to remove pulmonary secretions and maintain airway patency in clients who are unable to clear secretions independently. Tracheostomy suctioning is important for promoting gas exchange and preventing alveolar collapse, but inappropriate technique increases the client's risk for complications (eg, pneumonia, hypoxemia) or tracheal injury. To reduce the risk of complications and injury during suctioning, the nurse should: Preoxygenate with 100% oxygen and allow for reoxygenation periods between suction passes Use strict sterile technique throughout suctioning Suction only while withdrawing the catheter from the tracheostomy tube Limit suctioning to ≤10 seconds on each suction pass

The nurse is planning care for a 2-year-old client with newly diagnosed pertussis. Which of the following interventions should the nurse include in the client's plan of care? Select all that apply.

Educational Outcome: Treatment of pertussis includes antibiotics (eg, azithromycin) and supportive measures (eg, humidified oxygen, oral fluids) To prevent transmission, the nurse should implement both standard and droplet precautions and encourage the prophylactic treatment of household contacts . The nurse must notify the local health agency because pertussis is a reportable condition; public health officials should monitor outbreaks closely to identify epidemiologic trends

The nurse has taught the parent of a pediatric client with sickle cell disease. Which of the following statements by the parent would require follow-up?

Educational Outcome: Vasoocclusive crisis can cause complications, including cardiovascular events (eg, stroke, myocardial infarction), pulmonary complications, damage to the kidneys and liver, and bone necrosis. The nurse should follow up with the parent because weakness of the hands and legs may indicate a stroke - The parent should avoid bringing the client to high elevations (eg, camping or hiking in the mountains) because reduced atmospheric oxygen increases the risk for hypoxia.

The nurse is caring for assigned clients. The nurse should first assess the client with

Educational Outcome: Venous leg ulcers result from chronic venous insufficiency and can be associated with large amounts of serous or serosanguineous drainage. The saturated dressing will need to be changed, but this can safely be delayed.

A nurse in the intensive care unit is interpreting a client's cardiac rhythm. Which rhythm should the nurse document? Click on the exhibit button for more information.

Educational Outcome: Ventricular paced rhythms are seen in clients with ventricular pacemakers. Ventricular pacemakers typically have one lead placed in the right ventricle. The pacer spike just before the QRS complex signals electrical stimulation of the ventricle by the pacemaker lead (Option 3). The pacemaker lead depolarizes the right ventricle first, and electricity travels across the heart to depolarize the left ventricle. This atypical electrical pathway distorts and widens the QRS complex. The T wave can be seen immediately after the wide QRS complex. Implanted permanent pacemakers are often placed in clients with symptomatic bradycardia or heart block. Demand pacemakers are the most common type of implanted permanent pacemaker. The demand pacemaker sends an electrical impulse (pacer spike) only if the pacemaker does not sense an intrinsic heartbeat occurring at the programmed threshold rate -Atrial flutter is characterized by recurring, regular, sawtooth-shaped flutter waves from an impulse originating within the atria. -Ventricular bigeminy is a rhythm in which every other heartbeat is a premature ventricular contraction. -Ventricular tachycardia is characterized by wide QRS complexes occurring at a rate of 150-250/min from an impulse originating within the ventricle. This rhythm may or may not produce a pulse.

The nurse in the outpatient care facility is caring for a client with viral rhinitis. Which of the following actions should the nurse take? Select all that apply.

Educational Outcome: Viral rhinitis (ie, common cold) is a highly infectious, mild upper respiratory infection, most commonly caused by rhinovirus. The virus invades the upper respiratory tract and initiates an inflammatory response, leading to nasal congestion, sore throat, cough, headache, low-grade fever, and malaise. Viral rhinitis is self-limited and typically resolves within 1 to 2 weeks. Supportive measures for management of viral rhinitis include: Saline nasal sprays and hydration to thin and loosen mucus Saltwater gargles to manage sore throat Mild analgesics (eg, acetaminophen) to reduce headaches and generalized body aches Viral rhinitis is transmitted via large droplets emitted while breathing, talking, sneezing, or coughing or by direct hand contact. Airborne precautions (eg, N95 respirator mask) are used for viruses that are transmitted via very small airborne droplets (eg, tuberculosis), not viral rhinitis.

The nurse in the outpatient clinic is talking with a client who sustained a distal fracture of the humerus and had a cast applied 2 days ago. Which of the following statements by the client would be a priority to follow up?

Educational Outcome: Volkmann contractures are associated with distal humerus fractures and occur as a result of compartment syndrome. Swelling of antecubital tissue causes pressure within the muscle compartment, restricting arterial blood flow. The resulting ischemia leads to tissue damage, wrist contractures, and an inability to extend the fingers. A Volkmann contracture is a medical emergency that can cause permanent damage to the extremity if left untreated. Any restrictive cast or splint should be removed immediately, and the health care provider (HCP) must be notified for possible surgical intervention (eg, fasciotomy).

A client with multiple sclerosis is voicing concerns to the nurse about incoordination when walking. Which of the following instructions by the nurse would be most appropriate at this time?

Educational Outcome: Walking with the feet apart increases the support base, improving steadiness and gait. Assistive devices, such as a cane or walker, are usually required as demyelination of the nerve fibers progresses. Range-of-motion, strengthening, and stretching exercises help limit spasticity and contractures in clients with MS. Fatigue is a common symptom with MS. Rather than increasing the duration, clients should balance exercise with rest. Clients should also exercise when the weather is cool and stay hydrated; dehydration and extremes in temperature cause symptom exacerbation. Wheelchairs are advised only if exercise and gait training are not successful as clients should maintain mobility and independence as long as possible.

The nurse is caring for a client with a chest tube to evacuate a hemopneumothorax after a motor vehicle accident. The drainage has been consistently 25-50 mL/hr for the majority of the shift. However, over the past 2 hours there has been no drainage. Which actions should the nurse take? Select all that apply.

Educational Outcome: When chest drainage stops abruptly, the nurse must perform assessments and interventions to ascertain if this is an expected finding. Auscultating breath sounds helps the nurse detect whether breath sounds are audible in all lung fields, potentially indicating that the lung has re-expanded and there is no more drainage. Other interventions to facilitate drainage include having the client cough and deep breathe and repositioning the client. If a client has been in one position for a prolonged period, drainage may accumulate and a position change may facilitate improved drainage.

While reviewing prenatal records with a client and her partner, the nurse notes documentation in the medical record indicating that the client is a G2P0. However, the client denies a previous pregnancy. Which action by the nurse is appropriate?

Educational Outcome: When reviewing obstetric history, the GTPAL notation system gives the health care provider information about a client's past pregnancies. This notation may be shortened to gravida (ie, number of previous pregnancies) and para (ie, number of births after 20 weeks). For example, a G2P0 indicates 1 prior pregnancy ending before 20 weeks and 1 current pregnancy. The nurse should be cautious of discussing obstetric history with a client in front of the partner or family and not assume that others have knowledge of the client's past pregnancies. If there is a discrepancy between what the client discloses in the interview and the medical record, the information should be clarified when the client is alone to maintain confidentiality

An elderly client with osteoporosis falls onto an out-stretched hand and injures the wrist. The client has severe wrist edema, deformity, and pain rated a 10 on a pain scale of 0-10. What should be the nurse's first action?

Educational Outcome: While the client is undergoing evaluation by the health care provider (HCP) in the emergency department (ED), nursing interventions should include: Performing a neurovascular assessment (eg, pulse, temperature, color, capillary refill, sensation, movement). This is the priority nursing action as neurovascular insufficiency related to swelling (eg, compartment syndrome) or arterial/nerve damage by the bone fragments is associated with a Colles' fracture. If neurovascular status is compromised, urgent reduction of the fracture is indicated. Administering analgesia to promote comfort. Applying an ice pack to the wrist to help reduce edema and inflammation. Elevating the extremity on a pillow above heart level to reduce edema. Instructing the client to move the fingers to reduce edema, increase venous return, and help improve range of motion.

The nurse is talking with the parents of a 2-year-old client about nutritional choices to promote growth and development. The family observes a strict vegan diet. Which of the following information should the nurse include? Select all that apply.

Educational Outcome: With careful monitoring of nutritional intake, a vegan diet can be appropriate for clients of all ages. Pediatric clients who consume a vegan diet are at increased risk for nutritional deficiencies (eg, calcium, vitamin D, iron, vitamin B12) due to their rapid growth and development. Parents of pediatric clients who adhere to a vegan diet should receive information about: Calcium: Children who follow a vegan diet should consume nondairy, calcium-rich or calcium-fortified foods (eg, green, leafy vegetables, calcium-fortified soy milk, calcium-fortified cereal) following a vegan diet can obtain vitamin D from exposure to sunlight as well as from mushrooms and fortified, plant-based milks Vitamin C: Iron absorption is improved when iron and vitamin C are consumed together - Vitamin B12 is found only in foods from animal sources, such as meat, eggs, and dairy. The nurse should teach the parents about the importance of vitamin B12-fortified foods, including meat substitutes, milk alternatives, fortified nutritional yeasts, and/or oral B12 supplements.

The nurse is planning care for a client immediately following a thyroidectomy. Which of the following nursing actions are appropriate to include in the plan of care? Select all that apply.

Educational Outcome: thyroidectomy involves partial or complete removal of the thyroid, often to treat hyperthyroidism or thyroid cancer. Clients undergoing thyroidectomy require close monitoring because they are at increased risk for airway compromise due to potential neck swelling, hypocalcemia, and nerve damage. Nursing care following thyroidectomy focuses on promoting client recovery and monitoring for and preventing complications, and includes: Assessing for and immediately reporting signs of hypocalcemia (eg, facial or extremity numbness or tingling, stridor, Trousseau and Chvostek signs, which may occur from parathyroid gland trauma during surgery Keeping emergency airway equipment (eg, tracheostomy kit, suction, oxygen) at the bedside in case respiratory distress develops Maintaining the client in semi-Fowler position, which promotes drainage of surgical site edema around the neck and reduces the risk of respiratory distress Assessing for stridor and new or worsening changes in voice strength and quality (eg, hoarseness, whispering), which may indicate laryngeal nerve damage that can result in respiratory arrest

The nurse is assessing a client with suspected posttraumatic stress disorder (PTSD). Which of the following findings would support a diagnosis of PTSD? Select all that apply.

Educational Outcomes: Intrusive thoughts, including flashbacks or nightmares of the traumatic events

The nurse is talking about nutrition with the parent of a 1-year-old client. Which of the following statements by the parent would require follow-up?

Educational objective : Early childhood caries (ECC) can occur when a child is given a bottle containing high-carbohydrate fluid such as milk at night. To prevent tooth decay, the nurse should discourage parents from giving a bottle of milk to an infant or toddler at night. Intake of fruit juice should also be limited due to the similar risk for ECC.

The nurse is assessing a client with suspected hypovolemic shock. Which of the following findings would support a diagnosis of hypovolemic shock?

Educational objective: Clinical manifestations of hypovolemic shock are associated with inadequate perfusion and include urine output <0.5 mL/kg/hr, changes in mental status, hypotension, and tachycardia. Other info: A mean arterial pressure (MAP) of >60-65 mm Hg is necessary to perfuse the vital organs (eg, brain, coronary arteries, kidneys). Hypovolemic shock is associated with a low MAP.

The nurse is reviewing telephone messages from clients who were previously seen at the facility. The nurse should first telephone the client who had

Educational objective: A bowel or stoma obstruction is urgent and requires immediate medical attention. Signs of obstruction may include nausea, vomiting, abdominal pain, and bloating. If left untreated, bowel obstruction can lead to electrolyte disturbances, dehydration, bowel perforation and infection (eg, peritonitis), and/or tissue necrosis. - Other info: Constipation (eg, no bowel movement in 4 days) is common after an appendectomy due to opioid usage and decreased peristalsis from bowel manipulation. Interventions to relieve constipation (eg, increasing fluids and activity) should be initiated, but this may be safely delayed.

A client sustained a concussion after falling off a ladder. What are essential instructions for the nurse to provide when the client is discharged from the hospital? Select all that apply.

Educational objective: A client sent home with a head injury requires the presence of a responsible adult. This person should observe for the signs/symptoms of increased intracranial pressure including change in level of consciousness, projectile vomiting, motor alteration (eg, ataxia), ipsilateral pupil dilation, and seizures.

The nurse is observing a staff member caring for a newborn with a myelomeningocele. The nurse should intervene if the staff member is observed

Educational objective: A myelomeningocele is a neural tube defect resulting in a herniated sac that contains the meninges, spinal cord, nerve roots, and spinal fluid. The nurse should place the newborn in the prone position and apply a moist, sterile dressing over the sac. The use of diapers and rectal temperature measurement should be avoided.

The nurse is caring for a 56-year-old client in the emergency department.

Educational objective: An aortic dissection is a tear in the inner lining of the aorta that causes severe, sharp chest or back pain that is abrupt in onset and often described as "tearing." Management includes administering IV opioids and beta blockers and monitoring for aortic rupture (eg, muffled heart sounds, narrowed pulse pressure).

What is the priority when caring for a 6-month-old diagnosed with atopic dermatitis?

Educational objective: Atopic dermatitis (eczema) is a chronic skin disorder manifested in infants by pruritus, dry skin, and red, crusted, scaly lesions. The priority management is to prevent scratching as this would promote formation of new lesions and predispose to secondary infections.

The home health nurse is visiting a client discharged 2 days ago after a coronary artery bypass graft. The client reports fatigue and palpitations, and the nurse connects the client to a portable heart monitor. The nurse recognizes the displayed rhythm as which type? Click on the exhibit button for additional information.

Educational objective: Atrial fibrillation on ECG is characterized by an irregular rhythm with fibrillatory waves instead of P waves. Treatment includes rate control and anticoagulation.

The nurse gathers a health history from a 58-year-old male client with acute urinary retention. Which of the following questions should the nurse ask to aid in assessing for benign prostatic hyperplasia? Select all that apply.

Educational objective: Benign prostatic hyperplasia (BPH) occurs with increasing age (usually in men age >50) and is often undiagnosed until voiding difficulties and abnormalities are observed. Typical BPH symptoms include acute urinary retention, voiding urgency, incomplete emptying, straining to void, weak urinary stream, urinary frequency, and nocturia.

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

Educational objective: Carpal tunnel syndrome (CTS) is pain and paresthesia of the hand caused by compression of a median nerve within the carpal tunnel of the wrist. Clients with CTS are taught to wear wrist immobilization splints, particularly at night, to prevent wrist flexion and subsequent nerve compression to reduce symptoms. - Instructing clients to perform repetitive hand exercises or wear elastic compression hose could worsen symptoms of CTS by increasing median nerve compression. - Although educating clients to avoid tobacco and caffeinated products is appropriate to improve general health, avoidance of such substances does not impact symptoms of CTS.

The nurse is screening clients for those at risk for developing cervical cancer. The nurse should recommend a Pap test for the

Educational objective: Cervical cancer screening (Pap testing) in the United States is initiated at age 21 and repeated every 3 years until age 65. If both Pap and human papillomavirus tests (cotesting) are negative in clients age 30-65, testing may be performed every 5 years. In Canada, guidelines advise regular Pap testing every 3 years for clients age 25-69.

The nurse is caring for a client who had a lumbar puncture 30 minutes ago and is reporting a severe headache. Which of the following factors may have contributed to the client's headache?

Educational objective: Clients may develop a headache following lumbar puncture if cerebrospinal fluid leaks into the surrounding tissues. To prevent headaches from developing or worsening, clients should remain on bed rest in a supine position for a prescribed length of time following the procedure.

The nurse is preparing to discharge a client who is stable following a head injury. Which statement by the client indicates a need for further discharge instructions?

Educational objective: Clients should avoid opioid pain medications and CNS depressants (eg, alcohol) when recovering from a head injury. They should also avoid driving, using heavy machinery, playing contact sports, or taking hot baths for 1-2 days.

The nurse receives report on 4 clients. Which client should the nurse see first?

Educational objective: Clients with a history of chronic hypertension should immediately be assessed for hypertensive encephalopathy (ie, emergency syndrome caused by hypertensive crisis) if signs of increased intracranial pressure (eg, epistaxis, visual impairment, confusion) are present.

A speeding driver sustained a closed-head injury in an acceleration/deceleration accident from striking a tree front end first. Based on the coup-contrecoup phenomenon, which assessments are most likely to be affected related to the involved areas of the brain?

Educational objective: Coup-contrecoup injuries usually affect the frontal and occipital lobes. The frontal lobe controls executive function, memory, speech, and motor skills. The occipital lobe processes vision.

The nurse is assessing a newborn with suspected developmental dysplasia of the hip (DDH). Which of the following findings would support a diagnosis of DDH?

Educational objective: Developmental dysplasia of the hip (DDH) is a hip abnormality that ranges from mild dysplasia of the hip joint to full dislocation of the femoral head. Asymmetrical or extra gluteal or inguinal folds are one of the most notable manifestations of DDH in newborns.

The clinic nurse is caring for several clients during well-child visits. The nurse should recognize which client as being the most at risk for anemia?

Educational objective: During gestation, the amount of iron a fetus stores is dependent on the length of gestation. Infants born at preterm gestation have lower iron stores at birth and are at an increased risk for iron-deficiency anemia. Iron supplementation (eg, oral iron drops, iron-fortified formula) is usually needed by preterm infants at an earlier age (2-3 months).

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

Educational objective: Ebola is an extremely contagious viral disease with a high mortality rate. Infected clients require extensive infection precautions, including an airborne isolation room, strict personal protective equipment use, restriction of visitors, and a log of individuals who enter and exit the room.

The nurse assesses a client diagnosed with chronic kidney disease who had an internal arteriovenous fistula performed on the left arm yesterday. Which assessment finding would require immediate follow-up?

Educational objective: Following placement of an arteriovenous fistula, it is imperative to monitor for signs of potential clotting of the fistula such as absence of a bruit or thrill, decreased capillary refill, and numbness or tingling of the extremity.

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

Educational objective: Following thoracentesis, the nurse should monitor for signs of pneumothorax, including level of alertness, respiratory rate, respiratory effort, oxygen saturation, and lung sounds.

The nurse is caring for a 65-year-old client who had an acute myocardial infarction 3 days ago and is reporting tenderness and warmth of the left calf. Which of the following actions would be a priority for the nurse to take?

Educational objective: For a client with suspected deep venous thrombosis, the nurse should perform a complete neurovascular assessment of the client's extremities, including assessment of color, edema, temperature, pulses, and capillary refill.

The nurse is assisting with cardioversion for a client with supraventricular tachycardia who has become hemodynamically unstable. It would be a priority for the nurse to

Educational objective: For performing cardioversion, the synchronize button must be activated prior to delivering the shock. The synchronize function allows the unit to sense the client's rhythm and avoid delivering a shock during the T wave that could cause the client to experience a more lethal dysrhythmia.

The nurse on the pediatric unit is caring for assigned clients. The nurse should first assess the client with

Educational objective: Foreign body aspiration can be life threatening. Battery ingestion can quickly cause corrosive damage to the esophagus and intestines, resulting in perforation, peritonitis, sepsis, and even death. Other info: Osteogenesis imperfecta (ie, brittle bone disease) is a rare genetic condition that can cause blue scleras. Bisphosphonates (eg, alendronate) are used to increase bone density, thus reducing the risk for fractures. These are expected findings; therefore, care of this client can be safely delayed.

The nurse is performing an initial assessment on a client in hypertensive crisis. What is the nurse's priority assessment? Click on the exhibit button for additional information

Educational objective: Hypertensive crisis is a life-threatening medical emergency characterized by severely elevated blood pressure (systolic ≥180 mm Hg and/or diastolic ≥120 mm Hg). The client may have symptoms of hypertensive encephalopathy, including severe headache, confusion, nausea/vomiting, and seizure. Hypertensive crisis poses a high risk for end-organ damage (eg, hemorrhagic stroke, kidney injury, heart failure, papilledema). The nurse should prioritize neurological assessment (eg, level of consciousness [LOC], cranial nerves) as decreased LOC may indicate onset of hemorrhagic stroke, which requires immediate surgical intervention. Treatment for hypertensive crisis typically includes IV nitrates or antihypertensives (eg, nitroprusside, labetalol, nicardipine) and continuous monitoring (eg, blood pressure, telemetry, urine output) in a critical care setting.

The nurse is preparing to administer an IV infusion of nitroprusside to a newly admitted client who is experiencing a hypertensive crisis and has a blood pressure of 250/145 mm Hg. The nurse should recognize that it is a priority to

Educational objective: Hypertensive crisis is a medical emergency characterized by severely elevated blood pressure (BP). Initially, the priority is to lower the mean arterial pressure (MAP) by 25% or less, or to maintain a MAP of 110-115 mm Hg. Lowering BP too quickly may cause decreased organ perfusion and damage.

The nurse is caring for a client with diabetes mellitus. The client is alert and oriented but appears shaky and pale. The client's capillary blood glucose level is 50 mg/dL (2.8 mmol/L). Which of the following actions should the nurse take next? Click the exhibit button for additional client information.

Educational objective: Hypoglycemia occurs when a client's blood glucose level falls below 70 mg/dL (3.9 mmol/L). Clients who are experiencing hypoglycemia and are conscious should receive 15 g of a simple carbohydrate to quickly increase the blood glucose level.

The nurse is inserting an indwelling urinary catheter for a female client. After inserting and advancing the catheter, the nurse notes no return of urine. Which of the following actions should the nurse take?

Educational objective: If no urine is returned from indwelling urinary catheter insertion in a female client, it likely has been inserted into the vagina as opposed to the urethra. The nurse can leave the original catheter in place as a landmark and reinsert a new sterile catheter above the original position.

A nurse in the emergency department cares for 4 clients with orthopedic injuries. Which client should the nurse assess first?

Educational objective: Joint dislocations may constitute an orthopedic emergency. Because articular tissues, blood vessels, and nerves are stretched and compressed, neurovascular compromise may occur. Prolonged disruption of the vasculature and nerves may cause permanent injury and even loss of the distal extremity.

A new graduate nurse is preparing to administer the following analgesics to clients with postoperative pain. Which situation would require intervention by the precepting nurse?

Educational objective: Ketorolac, a nonsteroidal anti-inflammatory drug, is used for short-term (≤5 days) pain relief due to risk of bleeding, gastrointestinal ulcers, and kidney injury. Intramuscular (IM) injections (using Z-track method) should be given deep into a large muscle due to burning and discomfort. A 1- to 1½-in (2.5- to 3.8-cm) needle is used to reach the proper muscle space.

The nurse is preparing a client for a magnetic resonance cholangiopancreatography. Which statements by the client would require the nurse to obtain further assessment data? Select all that apply.

Educational objective: Magnetic resonance cholangiopancreatography uses MRI to visualize the biliary and hepatic ductal system. Contraindications, including pregnancy, the presence of certain metal implants, and an allergy to gadolinium (ie, noniodine contrast agent), should be assessed before the procedure.

The nurse is caring for a client with a mandibular fracture whose jaw is wired together. While the nurse is in the room, the client begins to choke on oral secretions. Which of the following actions would be a priority for the nurse to take?

Educational objective: Maintaining a patent airway is the priority for a client with a mandibular fracture whose jaw is wired together. If choking occurs, the nurse should suction the mouth along the gum line to clear secretions. If suctioning is ineffective and the client develops respiratory distress, cutting the wires may be necessary.

The nurse is talking with the parent of a 1-day-old female client who has a small amount of blood-tinged, mucoid vaginal drainage. Which of the following statements would be most appropriate for the nurse to make?

Educational objective: Mammary gland enlargement, nonpurulent vaginal discharge (leukorrhea), and pseudomenstruation are benign transient findings commonly seen in female newborns. They are physiologic responses to transplacental maternal estrogen exposure.

A nurse is assessing a 58-year-old client with blurred vision and reduced visual fields. Which manifestation is of most concern to the nurse?

Educational objective: Manifestations of acute angle-closure glaucoma include sudden onset of severe eye pain, reduced central vision, blurred vision, ocular redness, and report of seeing halos around lights. This condition requires immediate medical intervention to reduce IOP and prevent permanent blindness.

A client with type 1 diabetes is prescribed NPH insulin before breakfast and dinner. Although the client reports feeling well, the 6 AM blood glucose level has averaged 60 mg/dL (3.3 mmol/L) over the past week. Which of the following actions is appropriate for the nurse to recommend to the client? Click the exhibit button for additional information.

Educational objective: NPH insulin is an intermediate-acting insulin that peaks in 4-12 hours. In asymptomatic clients, the best intervention to prevent low blood glucose levels related to an evening dose of NPH is to consume a bedtime snack of protein and complex carbohydrates.

Raw carrot sticks are hard and pose a choking risk. Parents should serve carrots and other hard vegetables grated or cooked.

Educational objective: Nasal drainage following a head injury could indicate a basilar skull fracture and cerebrospinal fluid (CSF) rhinorrhea (a CSF leak through the nose). Nasogastric tube insertion is contraindicated when a basilar skull fracture is confirmed or suspected.

A client is brought to the emergency department due to loss of consciousness after binge drinking at a college party and then taking alprazolam. Pulse oximetry shows 87% on room air. Which findings would the nurse expect to assess on an arterial blood gas?

Educational objective: Over-sedation, sleep apnea, anesthesia, drug overdose, progressive neuromuscular disease, and chronic obstructive pulmonary disease depress the respiratory center; this leads to alveolar hypoventilation, secondary to carbon dioxide retention, and respiratory acidosis.

A nurse is making a home visit when a fire starts in the client's kitchen trash can. The client has a fire extinguisher. The nurse should take which actions to properly operate the fire extinguisher? Select all that apply.

Educational objective: PASS is a mnemonic to help people remember the steps used in operating a fire extinguisher: P - Pull the pin; A - Aim the spray at the base of the fire; S - Squeeze the handle; and S - Sweep the spray.

A client with chest pain is diagnosed with acute pericarditis by the health care provider. The nurse explains that the pain will improve with which of the following?

Educational objective: Pericarditis is characterized by typical pleuritic chest pain that is sharp. It is aggravated during inspiration and coughing. Pain is typically relieved by sitting up and leaning forward. Treatment includes a combination of NSAIDs or aspirin plus colchicine.

The nurse is assessing a client with pertussis. Which of the following findings would be consistent with the condition?

Educational objective: Pertussis (whooping cough) is caused by the highly contagious bacterium Bordetella pertussis, which is spread through close human contact, coughing, and sneezing. Pertussis is characterized by a violent, spasmodic cough and a distinctive high-pitched "whooping" sound heard during inhalation.

The nurse is talking with a client who has phenylketonuria (PKU) and plans to become pregnant. Which of the following statements by the client would require follow-up?

Educational objective: Phenylketonuria (PKU) is an inherited metabolic disease that results from a deficiency or absence of an enzyme needed to metabolize phenylalanine, an amino acid that is present in proteins. A low-phenylalanine diet before and during pregnancy is essential in the treatment of PKU. If the newborn is also diagnosed with PKU, the nurse should teach the client to provide the infant with special formulas that are low in phenylalanine. PKU is a genetically inherited autosomal recessive trait. Genetic counseling should be completed prior to conception as parents may not realize they are carriers of a recessive gene. Adequate observation of newborn feeding is important in order to obtain accurate results as PKU cannot be detected if the newborn has not been exposed to phenylalanine via breastmilk or formula.

The nurse in the outpatient clinic is assessing assigned clients. The client who is most likely experiencing postpartum psychosis is the client who is

Educational objective: Postpartum psychosis is a rare psychiatric emergency that typically occurs within the first 2 weeks after childbirth. Clients experience manifestations of depression and/or mania, severe insomnia, agitation, disorganized behavior, and psychotic symptoms (eg, delusions, hallucinations). - PPP is most often seen in clients with bipolar disorder or in those who are later diagnosed with bipolar disorder. Clients experience manifestations of depression and/or mania (eg, increased energy levels), severe insomnia, agitation, disorganized behavior, and psychotic symptoms (eg, delusions, hallucinations)

Which statements made by the client demonstrate a correct understanding of the home care of an ascending colostomy? Select all that apply.

Educational objective: Proper care of the ostomy and pouching device in clients with a colostomy includes ensuring sufficient fluid intake, preventing gas and odor, and clarifying enteric-coated medications. - Stool produced in the ascending and transverse colon is semiliquid, which eliminates the need for irrigation. Irrigation to promote a bowel regimen may be useful for descending or sigmoid colostomies because the stool is more solid.

The nurse is screening clients for those at risk for developing bladder cancer. The nurse should recognize the client at highest risk for developing bladder cancer is a client who has

Educational objective: Routine screenings are essential to promote early diagnosis and treatment for bladder cancer. The greatest risk factor for bladder cancer is a history of cigarette smoking or other tobacco use.

The nurse is providing teaching to the parent of a 6-year-old client with scabies. Which of the following information should the nurse include? Select all that apply.

Educational objective: Scabies is easily spread through skin-to-skin contact. Clients with scabies and all persons in close contact should receive treatment with a scabicide cream applied to all skin surfaces, avoiding contact with the eyes. Potentially infested belongings should be washed and dried on the hottest dryer setting or sealed in plastic bags for at least 3 days.

The nurse is caring for a client who is experiencing status epilepticus and does not have a peripheral venous access device. Which of the following actions should the nurse take first?

Educational objective: Status epilepticus is a life-threatening emergency in which a client has a seizure for ≥5 minutes without recovering, which can lead to death from anoxia and/or hypoglycemia. Benzodiazepines (eg, rectal diazepam, IV lorazepam) depress the central nervous system and help stop seizure activity.

The nurse receives handoff of care report on four clients. Which client should the nurse assess first? Click the exhibit button for additional client information.

Educational objective: Systemic inflammatory response syndrome (SIRS) is a pathophysiologic response to inflammatory cytokine release from the inflammatory cascade (eg, trauma, tissue ischemia, infection [ie, sepsis]) that may rapidly progress to hemodynamic instability, respiratory failure, and multiorgan dysfunction. Clinical manifestations of SIRS include fever or hypothermia, tachypnea or low PaCO2, tachycardia, and leukocytosis or leukopenia.

The nurse is caring for an adult client who is being admitted with partial thickness burns to the anterior surface of the right leg and the anterior and posterior torso. The client weighs 90 kg. The total body surface area burned is calculated using the rule of nines. How many mL of IV fluid should the client receive in the first 24 hours? Record your answer using a whole number. Click the exhibit button for additional information.

Educational objective: The Parkland formula (4 mL/kg/percent of total body surface area burned [%TBSA]) is used to calculate the amount of IV fluid required for a client during the initial 24 hours after a burn injury. Half of the calculated volume is administered within the first 8 hours. - Multiplies by percentage (example: X 45; if percent is 45%)

Which client assignment is most appropriate for the nurse on an orthopedic unit to assign to a float nurse from a general medical unit?

Educational objective: The nurse on the orthopedic unit, who is giving client assignments to a float nurse, must consider how to best meet the needs of the clients safely. The most appropriate assignment is a stable client, who requires basic pain, peripheral, and neurovascular assessments, which should be familiar to a float nurse from a general medical unit.

The nurse is assessing for the presence of jugular venous distension (JVD) on a newly admitted client with a history of heart failure. Which is the best position for the nurse to place the client in when observing for JVD?

Educational objective: The nurse should position the client with the head of the bed at a 30- to 45-degree angle to assess for the presence of JVD.

The clinic nurse performs assessments on four infants. The nurse should alert the health care provider to see which client first?

Educational objective: The presence of sunset eyes (sclera visible above the iris) is a late sign of increased intracranial pressure and a priority to report to the health care provider. Other info: Eight wet diapers in 24 hours is within the normal range (6-10 diapers/day or approximately 1 diaper every 4 hours), indicating that the infant is likely producing >1 mL/kg/hr urine output and is not dehydrated, despite vomiting.

The nurse is reinforcing teaching to the caregiver of a child diagnosed with ringworm on the abdomen. Which statement by the caregiver indicates a need for further teaching?

Educational objective: Tinea corporis (ringworm of the body) is a highly contagious fungal infection on the superficial keratin layers of the skin, hair, and/or nails. The infection is spread via contact with infected animals, humans, or by touching an infected object. Initial treatment includes topical antifungal creams.

A nurse is teaching the parent of a 6-year-old with a urinary tract infection (UTI) how to avoid repeat infections. Which statements by the parent indicate that the teaching has been effective? Select all that apply.

Educational objective: Urinary stasis, constipation, and infrequent voiding are contributing factors to UTIs. The child should be encouraged to drink fluids and avoid holding in urine. Tight clothing and synthetic fabrics (eg, spandex, nylon, Lycra) should be avoided; cotton underwear is recommended. Scented soaps, bubble baths, and antibacterial soaps should not be used for bathing a child (the tub should be filled with water only), and the hair should be washed last.

During a home visit, the community health nurse observes bruises in various stages of healing on the extremities and torso of an elderly client. The client explains that the bruises are from bumping into furniture and the wall in the wheelchair. What is the priority nursing action?

Educational objective: When elder abuse is suspected, the nurse needs to perform further assessment to validate and confirm any initial findings and to determine the extent of the abuse and/or neglect. Areas of assessment for elder abuse include the client's general hygiene, clothing, nutritional and hydration status, presence of other injuries, inappropriate medication administration, signs of depression, and other statements suggesting neglect.

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

Educational objective: When performing phlebotomy for a laboratory specimen, allow the cleansed area to air dry, do not use the veins on the ventral side of wrist, position the tourniquet for no more than 1 minute at a time, and invert the tube gently 5-10 times to mix the solution with blood. Insertion in an artery will cause pulsation; if this happens, immediately remove the needle and apply pressure for 5 minutes. - The veins on the ventral aspect of the wrist are located near nerves, resulting in painful venipuncture and a higher risk of nerve injury. There is also an increased risk of arterial access on the ventral aspect of the wrist, and so this site should be avoided.

The graduate nurse (GN) is reinforcing education on sitting on and standing up from a chair to a client with crutches. Which instruction by the GN would cause the supervising nurse to intervene?

Educational objective: When standing or sitting in a chair, clients with crutches should hold both crutches in the hand on the affected side and hold the armrest with the other hand for support. Clients should touch the back of the unaffected leg to the chair before sitting, and should move to the chair edge and rise up with the unaffected leg to stand.

The home-health nurse is observing a client who is using newly prescribed crutches. The nurse should intervene if the client is observed

Educational objective: To ascend the stairs with the modified three-point crutch gait, the client should proceed as follows: stand in a tripod position and place one's body weight on both crutches, place the unaffected leg on the first step, bend the knee of the unaffected leg while shifting body weight to the unaffected leg, and then move the affected leg and both crutches to the step.

The nurse is caring for a 71-year-old client in the primary care clinic.

Educational objective:Age-related macular degeneration is a progressive condition of the eye that can cause loss of the central field of vision without loss of peripheral vision. Smoking cessation and increasing intake of leafy, dark green vegetables can increase lutein levels in the macula and slow progression of the condition.

The home health nurse teaches a client with dysphagia some strategies to help limit repeated hospitalizations for aspiration pneumonia. Which client statement indicates a need for further teaching?

Educational objective:Dysphagia increases the risk for aspiration. The nurse should teach clients with dysphagia about following proper swallowing techniques (ie, chin slightly downward when swallowing), sitting upright for at least 30-40 minutes after meals, swallowing twice before taking another bite of food, and avoiding over-the-counter cold medications when sick. - Clients at risk for aspiration pneumonia should avoid over-the-counter cold medications due to anticholinergic properties, which can cause decreased saliva (ie, xerostomia) production, and dry mouth. Saliva is a lubricant that helps bind food together to facilitate swallowing.

The nurse is caring for a 73-year-old client in the emergency department.

Educational objective:Early treatment for clients with sepsis is critical to prevent progression to septic shock and death. Initial management includes IV fluid resuscitation to restore intravascular volume, blood cultures to identify the pathogen, and broad-spectrum antibiotics to treat the infection. These interventions should be performed within 1 hour of suspecting sepsis for maximal benefit. - Vasopressors (eg, norepinephrine) may be initiated if the client does not respond to IV fluid resuscitation. However, this is not indicated yet.

The nurse is planning age-appropriate diversional activities for a 14-year-old client who had surgery and will be hospitalized for several weeks. Which of the following would be the most appropriate diversional activity to suggest for the client?

Educational objective:Friends play a significant role in the adolescent's quest for identity and provide a source of support, belonging, and understanding. Interacting with friends during recuperation after surgery is important to help counteract feelings of loneliness and isolation.

A client with advanced osteoarthritis is admitted for right total knee arthroplasty. Which characteristic manifestations does the nurse expect to assess in this client? Select all that apply.

Educational objective:Osteoarthritis is a degenerative disorder of the synovial joints that leads to progressive erosion of the articular (joint) cartilage. Clinical manifestations include pain exacerbated by weight-bearing, crepitus, morning stiffness subsiding within 30 minutes, decreased joint mobility and range of motion, and atrophy of supporting muscles. Osteoarthritis (OA) is a degenerative disorder of the synovial joints (eg, knee, hip, fingers) that causes progressive erosion of the articular (joint) cartilage and bone beneath the cartilage. As the degenerative process continues, bone spurs (osteophytes), calcifications, and ulcerations develop within the joint space, and the "cushion" between the ends of the bones breaks down.

The clinic nurse is reviewing self-care management of acne vulgaris with an adolescent client. Which client statement indicates a need for further instruction?

Educational outcome : Treatment includes topical and oral medications such as tretinoin (Retin-A), benzoyl peroxide, isotretinoin (Accutane), and oral contraceptives. Antibacterial soaps are harsh and ineffective, increase the pH of the skin, and can dry the skin . The client should instead gently wash the face with a mild facial cleanser. Additional self-care measures include: Using noncomedogenic skin care products (ie, products that do not clog pores) to avoid creating new lesions Maintaining a healthy lifestyle (eg, moderate exercise, balanced diet, adequate sleep) to reduce stress and promote healing Refraining from squeezing, picking, and vigorously scrubbing lesions to prevent additional inflammation and worsening the acne

A client with mitral valve prolapse (MVP) has been experiencing occasional palpitations, lightheadedness, and dizziness. The health care provider prescribes a beta blocker. What additional teaching should the nurse include for this client?

Educational outcome: Clients with MVP may have palpitations, dizziness, and lightheadedness. Chest pain can occur but its etiology is unknown in this client population. It may be a result of abnormal tension on the papillary muscles. Chest pain that occurs in MVP does not typically respond to antianginal treatment such as nitrates. Beta blockers may be prescribed for palpitations and chest pain. Client teaching for MVP includes the following: Adopt healthy eating habits and avoid caffeine as it is a stimulant and may exacerbate symptoms (Option 3) Check ingredients of over-the-counter medications or diet pills for stimulants such as caffeine or ephedrine as they can exacerbate symptoms Reduce stress and avoid alcohol use -There is no need for a medical alert bracelet. MVP is usually a benign condition.

The nurse is caring for a 6-year-old who is postoperative open right tibial fracture reduction with cast placement. Which finding requires priority action?

Educational outcome: If pain is not relieved (especially with passive range of motion) by prescribed pain medication or is out of proportion to the injury, the nurse should notify the health care provider (HCP). Permanent damage to the circulatory and nervous systems (compartment syndrome) can occur if this is not addressed immediately

The post-anesthesia care unit nurse receives report on a client after abdominal surgery. What sounds would the nurse expect to hear when auscultating the bowel?

Educational outcome: - Borborygmi sounds are loud, gurgling sounds suggesting increased peristalsis. Potential disease processes resulting in borborygmi include gastroenteritis, diarrhea, and the early phases of mechanical obstruction. High-pitched, gurgling sounds signify normal bowel sounds and are unlikely to be heard immediately following abdominal surgery.

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

Educational outcome: A 10-mL syringe is generally preferred for flushing the lumen of a CVC (Option 3). The smaller the syringe, the greater the amount of pressure per square inch exerted during injection, increasing the risk for damage to the CVC. The "push-pause" method involves slowly injecting normal saline into the CVC catheter and stopping for any resistance. Injecting against resistance can damage the CVC, which may result in complications, including embolism and malfunction. The nurse should always consult the specific manufacturer guidelines and facility policy when caring for a CVC. A smaller syringe (eg, 1 mL, 3 mL) creates more pressure, which increases the risk for damage to the CVC. A 30-mL syringe is unnecessarily large to flush a CVC.

Treatment includes administration of pancreatic enzymes immediately before or with meals and snacks to aid with the digestion and absorption of nutrients

Educational outcome: A client overhearing report through a privacy curtain is inadvertent communication and is not considered a violation - Calling a client by the first and last names in the waiting room is not a violation as long as no other pertinent information is given.

The nurse is caring for a client with cirrhosis who has ascites, peripheral edema, shortness of breath, fatigue, and generalized discomfort. Which of the following actions should the nurse take? Select all that apply.

Educational outcome: A client with ascites often experiences discomfort due to pressure of the fluid on the surrounding organs. Shortness of breath occurs due to the upward pressure exerted by the abdominal ascites on the diaphragm, which restricts lung expansion. Meticulous skin care is a priority due to the increased susceptibility of skin breakdown from edema, ascites, and pruritus. The nurse should provide a specialty mattress (eg, alternating air pressure mattress) and implement a turning schedule of every 2 hours. Clients with ascites experience fatigue and activity intolerance and bed rest is often indicated. Clients should be allowed to rest and increase activity as tolerated and as their condition improves.

The nurse is caring for a client after a lumbar puncture (spinal tap). Which client assessment is most concerning and requires a nursing response?

Educational outcome: A lumbar puncture involves removing a sample of cerebrospinal fluid through a needle inserted between vertebrae. Elevated intracranial pressure is a contraindication to performing a lumbar puncture. The client is placed in the fetal position or sitting and leaning over a table. Continued leaking fluid indicates that the site did not seal off and a blood patch (autologous blood into the epidural space) is required. Fluids are encouraged to help replace the cerebrospinal fluid. The client should lie flat for at least 4 hours. The prone or supine position is recommended to help prevent a headache. Up to 5%-30% of clients have the common complication of headache. It is thought to be a result of leakage of fluid through the dural puncture site. The symptom is treated and is normally self-limiting.

The nurse is caring for assigned clients. The nurse should recognize that the client at highest risk for developing acute otitis externa is the

Educational outcome: Acute otitis externa is inflammation or infection of the outer ear canal, frequently caused by Pseudomonas or Staphylococcus bacteria. Use of in-ear headphones increases the risk of acute otitis externa because it can irritate and damage the ear canal, allowing bacteria to enter the skin Additional risk factors include prolonged exposure to water (eg, swimming, environmental humidity), allergies, chronic dermatitis, and insufficient cerumen. Clients may experience pain exacerbated by pulling on the pinna or tragus, pruritus, purulent drainage, edema of the outer ear, and temporary conductive hearing loss. Treatment includes analgesics, ear debridement, and antibiotic or steroid otic drops. Clients should be encouraged to avoid inserting objects into the ear to prevent recurrence. Inflammation from a recent upper respiratory infection or secondhand smoke exposure can obstruct the eustachian tubes, increasing the risk for acute otitis media, not acute otitis externa.

The health care provider (HCP) explains the risks and benefits of a procedure to the client through an interpreter. The HCP leaves after asking the nurse to witness the client's signature on the consent. The interpreter and client now have a lengthy discussion in the foreign language. The nurse should take which action at this time?

Educational outcome: An interpreter's job is to literally translate the words/concepts spoken (as much as possible). The role does not include personally editorializing or embellishing with advice beyond what the health care provider (HCP) said. It is important to find out if there was any discussion related to the procedure or if the follow-up conversation was about other topics (eg, social). The nurse needs to obtain feedback to be certain that the client understands about the procedure and had no additional questions that the interpreter personally answered. The nurse can ask the client additional questions using this interpreter or use a different interpreter/a language line. After the nurse is satisfied that no additional information was provided and the client understands what the client is signing, the nurse (as the hospital employee) should then witness the signature. The nurse should indicate that an interpreter was used in the process.

The nurse is caring for a client who has a radial arterial catheter for continuous invasive blood pressure monitoring. Which of the following locations would indicate correct placement of the transducer at the phlebostatic axis?

Educational outcome: An invasive arterial blood pressure (BP) monitoring system is a closed system that provides continuous BP monitoring via a catheter in the radial or femoral artery. The transducer should be placed at the phlebostatic axis, which is located at the intersection of the fourth intercostal space and midaxillary line and is the anatomic reference point for the right atria. Placement of the transducer below the phlebostatic axis results in falsely high readings, while placement above the phlebostatic axis results in falsely low readings.

The nurse is assessing a client with aortic stenosis. Which of the following findings would be consistent with the condition?

Educational outcome: Aortic stenosis is a narrowing of the aortic valve, which obstructs blood flow from the left ventricle to the aorta. As stenosis progresses, the heart cannot compensate and ejects a smaller fraction of blood volume from the left ventricle during systole. This decreased ejection fraction results in a narrowed pulse pressure (ie, the difference between systolic and diastolic blood pressures), ejection systolic murmur over the aortic area, and weak, thready peripheral pulses. With exertion, the volume of blood pumped to the brain and other parts of the body is insufficient to meet metabolic demands, resulting in exertional dyspnea, anginal chest pain, and syncope

A nurse is caring for a client 2 days after surgical creation of an arteriovenous fistula in the forearm. Which finding should the nurse report immediately to the health care provider?

Educational outcome: Arterial steal syndrome is an AVF complication that occurs when the anastomosed vein "steals" too much arterial blood, causing distal extremity ischemia. Symptoms occur distal to the AVF, including skin pallor, pain, numbness, tingling, diminished pulses, and poor capillary refill. Without prompt intervention, ischemia may lead to limb necrosis (Option 3).

A client with terminal cancer is prescribed fentanyl patches for pain management while receiving hospice care at home. Which instructions related to this medication should the nurse provide? Select all that apply.

Educational outcome: Fentanyl, a potent opioid analgesic, is administered IV to treat acute pain and as a transdermal patch (Duragesic) dosed in mcg/hr to treat chronic pain. When given via transdermal patch, fentanyl is absorbed systemically through the skin to provide continuous analgesia. Patches are replaced every 72 hours, and the used patch must be removed before applying a new one - The site should be clean, with little hair. Unlike transdermal patches, topical analgesic patches (eg, lidocaine, capsicum) deliver drug locally and are placed near the site of pain. - Used patches must be folded and discarded immediately, as some medication remains in a used patch. Opioid medications must be stored and disposed of securely (eg, flushed down the toilet, discarded in a sharps container) as accidental exposure is potentially fatal for children, pets, and caregivers

A client is seen in the ambulatory care center for treatment of a second episode of acute gout. Which lifestyle modifications would help prevent future exacerbations? Select all that apply.

Educational outcome: Gout is an inflammatory condition caused by ineffective metabolism of purines, which causes uric acid accumulation in the blood. Uric acid crystals typically form in the joints. Kidney stones can also develop, increasing the risk of kidney damage. Clients with medical risk factors (eg, obesity, hypertension, dyslipidemia, insulin resistance) and other lifestyle factors (eg, poor diet, alcohol consumption, sedentary lifestyle) have increased risk for future gout attacks. Improvements in uric acid control are often seen when weight loss is accompanied by dietary modifications. Suggested modifications include: Increasing fluid intake (2 L/day) to help eliminate excess uric acid Implementing a low-purine diet, particularly avoiding organ meats (eg, liver, kidney, brain) and certain seafood (eg, sardines, shellfish) Limiting alcohol intake, especially beer Following a healthy, low-fat diet, as excess dietary fats impair urinary excretion of urates

The nurse is assessing a 6-year-old client who is experiencing diarrhea caused by Escherichia coli infection. Which of the following findings would be a priority to follow up?

Educational outcome: Hemolytic uremic syndrome (HUS) is a life-threatening complication of Escherichia coli diarrhea. HUS is characterized by RBC hemolysis, acute kidney injury, and thrombocytopenia (ie, low platelet count). Clinical manifestations of thrombocytopenia include petechiae and purpura. Additional signs and symptoms of HUS include fatigue, pallor, and bruising. Blood-streaked stools, dehydration, and fever are expected findings of E coli diarrhea that are treated with fluid and electrolyte replacement. However, the priority is the onset of possible HUS (ie, petechiae on the trunk). Resuming the client's normal diet is encouraged as it shortens the duration and severity of diarrhea. The BRAT (Bananas, Rice, Applesauce, Toast) diet is not recommended as it does not provide sufficient protein or energy. Fruit juices are not recommended for a client experiencing acute diarrhea due to their high sugar (ie, osmolality) and low electrolyte content.

The nurse has been made aware of assigned client situations. Which of the following clients would require follow-up? Select all that apply.

Educational outcome: Hydromorphone is an opioid medication used to treat pain. Pain relief may cause reduced blood pressure. Opioids may also cause histamine release, which may lead to vasodilation and hypotension.

A clinic nurse receives messages on 4 clients. Which client should the nurse call back first?

Educational outcome: Hypertensive encephalopathy is a type of hypertensive crisis characterized by nausea, vomiting, and headache . Treatment is urgent (ie, within 1 hour) to prevent damage to the heart, kidney, and brain. The client should check blood pressure at home, if possible, and then proceed to the emergency department for further assessment and treatment (eg, titration of antihypertensive medication). Other info: Celiac disease is an autoimmune disorder that interferes with the digestion of gluten. Diarrhea and foul-smelling stools are expected findings for this client, especially if noncompliant with a gluten-free diet.

A nurse prepares a client for knee arthroscopy requiring general anesthesia. Which actions should the nurse complete? Select all that apply.

Educational outcome: If an IV line has not been started, an 18-gauge catheter is preferred. However, if a functioning IV line is already present, a 20-gauge is acceptable. Blood products, if needed during surgery, can be transfused through a 20-gauge catheter if necessary.

In the intensive care unit, the nurse cares for a client admitted with a head injury who develops syndrome of inappropriate antidiuretic hormone. Which data should the nurse expect with the onset of this condition? Select all that apply.

Educational outcome: Low serum osmolality means: A result lower than the normal range means you could have one of these conditions: Hyponatremia (too little sodium) Overhydration (too much fluid retained in the body)

The nurse is assessing a client with suspected pelvic inflammatory disease (PID). Which of the following findings would support a diagnosis of PID? Select all that apply.

Educational outcome: Manifestations of PID include fever, lower abdominal pain, purulent cervical discharge, painful intercourse, and spotting after intercourse. Hematuria (ie, blood in the urine) is associated with urinary tract infection and various kidney disorders (eg, kidney stones, glomerulonephritis), not PID.

The nurse is reinforcing teaching about ulcer prevention with a client newly diagnosed with peptic ulcer disease. Which of the following client statements indicate appropriate understanding of teaching? Select all that apply.

Educational outcome: Meal timing: Eating multiple small meals throughout the day or eating shortly before sleeping may actually worsen PUD by increasing stomach acid secretion.

A client is admitted to the hospital for evaluation of suspected pulmonary tuberculosis (TB). The nurse assesses for which characteristic presenting signs and symptoms associated with TB disease? Select all that apply.

Educational outcome: Mycobacterium tuberculosis is a gram-positive, acid-fast bacillus that is transmitted through the airborne route. TB is usually (85%) pulmonary but can also be extrapulmonary (eg, meninges, genitourinary, bone and joints, gastrointestinal). TB, regardless of location, commonly presents with constitutional symptoms, including: Low-grade fever Night sweats Anorexia and weight loss Fatigue Additional symptoms depend on the location of the infection. Pulmonary tuberculosis typically includes: Cough Purulent or blood-tinged sputum Shortness of breath Dyspnea and hemoptysis are typically seen in the late stages. The classic manifestations of TB can be absent in immunocompromised clients and the elderly. Dysuria is a symptom of extrapulmonary genitourinary TB. Jaundice can be present in disseminated TB with liver involvement. It can also be a side effect associated with drugs used to treat pulmonary TB (eg, isoniazid). Back pain indicates spinal TB.

The nurse is caring for a client with pertussis. The nurse should recognize that pertussis is a

Educational outcome: Once attached to cilia in the client's upper respiratory tract, the bacterium releases a toxin that causes irritation and swelling

The nurse is teaching a client with newly diagnosed osteomalacia. Which of the following statements by the client would require follow-up? Select all that apply.

Educational outcome: Osteomalacia is a reversible bone disorder caused by vitamin D deficiency and is characterized by weak, soft, and painful bones that can easily fracture or become deformed. In vitamin D deficiency, calcium and phosphorus cannot be absorbed from the gastrointestinal tract and are unavailable for the calcification of bone tissue. Vitamin D deficiency is also associated with an increased risk for falls, especially in older adults, due to muscle weakness. Clients should be taught to increase their intake of foods high in calcium (eg, leafy green vegetables, dairy) and phosphorus (eg, organ meats, nuts, fish, poultry, whole grains) . Exposure to sunlight is also recommended because it synthesizes vitamin D in the body. Clients should be encouraged to participate in moderate physical activity to promote bone strength and health Clients should increase their intake of vitamin D through the consumption of vitamin D-fortified foods such as milk and cereals. Over-the-counter or prescription supplemental vitamin D is also recommended. Clients should use assistive devices such as canes and walkers when ambulating to help prevent falls and injuries.

One unit of packed RBCs (PRBCs) is prescribed for a client experiencing complications of sickle cell anemia. Which of the following actions by the nurse are appropriate? Select all that apply. Click the exhibit button for additional client information.

Educational outcome: Packed RBCs (PRBCs) are a component of whole blood commonly transfused to increase blood volume and improve oxygen delivery in clients experiencing anemia or acute blood loss. Appropriate actions for safe blood product transfusion include: Ensuring compatibility with the client's blood type. Clients with AB blood can receive A, B, AB, or O blood (ie, "universal recipient"). While Rh-negative clients can only receive Rh-negative blood, Rh-positive clients can safely receive Rh-positive and Rh-negative blood. Therefore, a client with AB-positive blood can safely receive A-negative blood Using Y-type blood administration tubing that has a micron filter to remove clots. Blood products should be administered with 0.9% sodium chloride; all other fluid solutions can cause hemolysis or clotting of blood cells Ensuring that the correct blood product is always given to the correct client by verifying at least two client identifiers (eg, name, date of birth) and the blood product with a second nurse before administration

The charge nurse is observing the nurse apply a condom catheter for a client who is uncircumcised. The charge nurse should intervene if the nurse

Educational outcome: Paraphimosis occurs when the uncircumcised male foreskin cannot be returned (reduced) to its original position, after being pulled back (retracted) behind the glans penis, resulting in pain, progressive swelling of the foreskin, and impaired lymph and blood flow. Paraphimosis can occur when the foreskin is in the retracted position for an extended period (eg, under a condom catheter sheath). Before applying a condom catheter, the nurse should ensure the client's foreskin is fully reduced (not retracted) to avoid impairing circulation and causing permanent damage to the glans penis . If the condom catheter is not self-adhesive, elastic adhesive may be used to secure the device to the penis, and should be applied in a spiral, not circular, manner to prevent restricting circulation. - A 1- to 2-inch (2.5- to 5-cm) space should be left between the tip of the penis and the end of the condom to prevent penile irritation and pooling of urine in the condom.

The nurse is caring for a client who had a percutaneous nephrolithotripsy 3 hours ago. The nurse notes that the nephrostomy tube has drained 0 mL since the procedure, and the client is reporting flank discomfort and nausea. Which of the following actions would be most appropriate for the nurse to take?

Educational outcome: Percutaneous nephrolithotripsy involves the insertion of a nephroscope through the skin into the pelvis of the kidney to break up and remove kidney stones (ie, renal calculi) that are too large to remove with other methods. A temporary percutaneous nephrostomy tube may be placed to prevent postoperative obstruction by stone fragments and to promote healing. Flank discomfort/pain, nausea, and no drainage from the nephrostomy tube may indicate obstruction of urine flow that can lead to kidney injury. Gentle irrigation of the nephrostomy tube with a small volume of sterile saline (as prescribed or per protocol) using aseptic technique is the most appropriate intervention

The nurse is caring for a 45-year-old female client in the clinic.

Educational outcome: Perimenopause is the transitional phase preceding menopause when ovarian function declines, and estrogen levels decrease. Symptoms include amenorrhea, emotional lability, vasomotor symptoms (eg, hot flashes, sweating), urogenital changes, and decreased bone density. -Management of perimenopause includes hormone therapy and promoting bone health (eg, vitamin D and calcium supplementation, performing weight-bearing exercise). Contraindications to hormone therapy include history of thromboembolic events (eg, deep vein thrombosis, ischemic stroke); estrogen therapy increases the risk for blood clot formation.

The nurse is assessing a 6-year-old client who has tonsillitis. Which of the following findings would require immediate follow-up?

Educational outcome: Peritonsillar or retropharyngeal abscess is a complication of tonsillitis that occurs when an abscess (ie, collection of pus) forms near the tonsil. Manifestations include throat pain, fever, muffled voice, uvula deviation to one side, and trismus (ie, inability to open the mouth due to a tonic contraction of the muscles used for chewing). A peritonsillar abscess can lead to life-threatening airway obstruction and is a medical emergency. The nurse should immediately report a muffled voice to the health care provider and monitor for signs of obstruction (eg, excessive drooling, stridor) . Surgical intervention (eg, tonsillectomy, incision and drainage) is often required. Other info: The most common bacterial cause of tonsillitis is group A beta-hemolytic Streptococcus, which can also cause scarlet fever. Manifestations include a fine, sandpaper-like rash, strawberry tongue (ie, red, swollen tongue), and fever. Streptococcal infections can be effectively trea

The nurse has just received report. Which client should the nurse assess first?

Educational outcome: Post-procedure care of a client who has undergone heart catheterization should focus on evaluating hemodynamics - blood pressure, heart rate, strength of the distal pulses, color, and temperature of extremities. The client should be also assessed several times per hour for active bleeding, hematoma, or pseudoaneurysm formation at the incision. The first hour after cardiac catheterization requires assessment every 15 minutes. Any report of back or flank pain should be assessed for possible retroperitoneal bleeding as back pain, tachycardia, and hypotension may be the only indication of internal bleeding. More than a liter of blood can pool behind the peritoneum in the pelvis undetected, and it may take up to 12 hours before a significant drop in hematocrit can be measured. Internal bleeding after cardiac catheterization is particularly dangerous due to frequent use of anticoagulant prescriptions in these clients.

The community health nurse provides an education program about risk factors for prostate cancer. Which of the following statements by program attendees indicate that teaching has been effective? Select all that apply.

Educational outcome: Prostate cancer is a slow-growing malignancy that is highly curable when treated early. Groups with higher incidence rates include Black males, those with a first-degree relative with prostate cancer, and those age >50. Clients can lower their risk for prostate cancer by reducing intake of red meat, animal fat, high-fat dairy products, and refined carbohydrates. Groups with higher incidence rates of prostate cancer include Black men, those who have a first-degree relative with prostate cancer, and those age >50 Clients can lower their risk for prostate cancer by: Reducing intake of red meat, animal fat, and high-fat dairy products Decreasing intake of refined carbohydrates Maintaining a healthy weight

The nurse is teaching skin care guidelines to a client who is receiving external radiation therapy. Which of the following statements by the client would indicate a correct understanding of the teaching? Select all that apply.

Educational outcome: Radiation therapy (ie, internal, external) is a targeted therapy that uses high-energy beams to break up DNA within cancer cells, ultimately leading to cell death. Radiation therapy has been shown to reduce tumor size and treat certain cancers; however, clients should be made aware of the adverse effects of external radiation therapy, including radiation dermatitis (local skin irritation/inflammation). Skin care interventions focus on preventing infection and promoting healing of the affected skin. Key guidelines for skin care during external radiation therapy include: Protect the skin from sun during and after treatment (eg, avoid sun exposure, wear long sleeves/pants when outside, use a sunscreen that is SPF 30 or higher) Cleanse the skin daily using lukewarm water and mild soap Protect the skin from infection and trauma (eg, wearing soft, loose-fitting clothing, avoid scratching Clients should avoid extremes in skin temperature (eg, heating pads, ice packs) and maintain a cool, humid environment when possible. Infection is prevented by avoiding any rubbing, scratching, or scrubbing and only using creams or lotions approved by the healthcare provider.

A client diagnosed with head and neck cancer has developed mouth sores related to external radiation therapy. Which of the following oral hygiene practices does the nurse include while educating the client about the condition? Select all that apply.

Educational outcome: Radiation therapy damages both healthy and malignant (cancerous) cells. Damage caused by radiation to the head and neck results in inflammation and ulceration of healthy mucosal epithelial known as oral mucositis (ie, stomatitis). The pain caused by oral mucositis, along with complications affecting the oral mucosa secondary to radiation and chemotherapy (eg, dry mouth, loss of taste, painful swallowing), can lead to decreased oral hygiene, impaired nutrition, and increased risk for infection. Oral hygiene practices that minimize oral mucositis and promote comfort include: Using water-soluble lubricating agents to moisten mouth tissues Using a soft-bristle toothbrush to decrease gum irritation Cleansing the mouth with saline or baking soda solution after meals and at bedtime to promote oral health Avoiding hot liquids and spicy/acidic foods, which can cause oral discomfort Removing dentures between meals to minimize gum irritation and soaking them in an antimicrobial solution to reduce pathogens Applying prescribed viscous lidocaine hydrochloride to alleviate oral pain Clients with mucositis should avoid rinsing with antiseptic mouthwashes with alcohol because they are irritating to mucous membranes.

The graduate nurse (GN) is providing education to a 30-year-old female client who is being evaluated for hyperthyroidism with a radioactive iodine uptake (RAIU) test. Which statement by the GN requires the nurse preceptor to intervene?

Educational outcome: Radioactive iodine uptake (RAIU) test involves administering a low dose of oral RAI to measure via imaging the amount of iodine that the client's thyroid absorbs. The thyroid gland is the only body tissue that absorbs iodine; therefore, measuring iodine absorption helps diagnose hyperfunctioning thyroid disorders (eg, Graves disease, nodular thyroid disease). For hyperthyroidism, RAIU is increased compared to RAIU in a normal functioning thyroid, which indicates a positive test. Only a trace amount of RAI is used in the test; therefore, isolation after the scan is unnecessary. In contrast, RAI treatment for thyroid cancer uses a high dose and does require some isolation.

The nurse is screening clients for those at risk for developing gastroenteritis. Which of the following clients are at risk for developing gastroenteritis? Select all that apply.

Educational outcome: Risk factors for gastroenteritis include: Attending day care, which increases risk for norovirus, one of the most common causes of gastroenteritis Interacting with animals (eg, reptiles) that may carry salmonella Consuming undercooked meat because bacteria in the meat may cause foodborne illness Lacking vaccination against common gastrointestinal illnesses (eg, rotavirus)

The nurse is caring for a client receiving mechanical ventilation (MV). Which of the following actions by the nurse requires follow-up by the charge nurse?

Educational outcome: Risks associated with suctioning include hypoxemia, micro atelectasis, and cardiac dysrhythmias. Suctioning removes secretions and oxygen. To minimize both the amount of oxygen removed and mucosal trauma, suction is applied when removing the catheter from the artificial airway, not while inserting it - It is appropriate to suction the client when the high-pressure alarm on the MV sounds, oxygen saturation drops, rhonchi are auscultated, and secretions are audible or visible. These manifestations can indicate excessive secretions impairing airway patency

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

Educational outcome: Routine care includes sterile dressing changes every 48 hours with a gauze dressing or 7 days with a transparent semipermeable dressing (biopatch) as well as immediately if dressing is loose/torn, soiled, or damp. The line should be flushed before and after medication administration and per facility protocol (Option 1). Blood pressure and venipuncture should not be performed on the affected arm as compression of the vein can alter its integrity. All infusing medications (except vasopressors) must be paused before drawing blood from the PICC to prevent false interpretation of the client's serum levels Dressings that no longer occlude the insertion site must be changed immediately. Loose corners may be temporarily reinforced with tape.

The nurse is planning teaching for a client newly diagnosed with Sjögren's syndrome. Which measures will the nurse include in the teaching plan? Select all that apply.

Educational outcome: Sjögren's syndrome is a chronic autoimmune disorder in which moisture-producing exocrine glands of the body are attacked by white blood cells. The most commonly affected glands are the salivary and lacrimal glands, leading to dry eyes (xerophthalmia) and dry mouth (xerostomia). Dryness in these areas can lead to corneal ulcerations, dental caries, and oral thrush. Other areas that can be affected and their symptoms include: Skin - dry skin and rashes Throat and bronchi - chronic dry cough Vagina - vaginal dryness and painful intercourse Treatment is focused on alleviating symptoms as there is currently no cure for Sjögren's syndrome. Over-the-counter or prescribed drops are used to relieve itching, burning, dryness, and gritty sensation in the eyes. Wearing goggles may offer further protection from drying caused by the wind. Dry mouth is treated with sugarless gum and candy or artificial saliva. Regular dental appointments to prevent dental caries are recommend

The nurse is caring for a client with chronic obstructive pulmonary disease. Which of the following would be the most appropriate oxygen delivery device to use for this client? Click the exhibit button for additional client information.

Educational outcome: Supplemental oxygen should be titrated to the minimum amount necessary to maintain an oxygen saturation of 88%-92%. A Venturi mask is the most appropriate choice for clients with COPD because the adapter allows precise control of the fraction of inspired oxygen (FiO2) that the client will receive. A partial nonrebreather mask delivers a very high FiO2 and is not indicated for clients with COPD due to the risk of overoxygenation. A simple face mask is not indicated for clients with COPD because the FiO2 fluctuates based on the client's respiratory pattern. In addition, CO2 rebreathing may reoccur, worsening hypercapnia. Oxygen-conserving cannulas use a reservoir to conserve oxygen and are typically indicated for long-term use. Although much less oxygen is used, this device is not indicated for clients with COPD because the FiO2 fluctuates based on the client's respiratory pattern.

The nurse is caring for a client who has a single-chamber atrial pacemaker. Which of the following findings would the nurse expect to observe on the client's electrocardiogram strip?

Educational outcome: The cardiac conduction cycle can be visualized on an electrocardiogram (ECG). The P wave represents atrial depolarization and the QRS complex represents ventricular depolarization. Therefore, the ECG of a client with a single-chamber atrial pacemaker should display a pacemaker spike before the P wave, indicating electrical stimulation of the atria by the pacemaker lead. The P wave may appear normal or somewhat distorted following the spike

The nurse is caring for a client recovering from a subtotal thyroidectomy to treat hyperthyroidism. Which assessment finding would require the nurse to immediately notify the health care provider?

Educational outcome: The nurse caring for a client after a subtotal thyroidectomy must closely monitor for and immediately report any clinical manifestations of thyrotoxicosis (eg, fever, chills, tachycardia) ( After surgery, thyroid hormone levels can remain elevated for several days and may even increase from intraoperative thyroid gland manipulation. Without treatment, thyrotoxicosis can rapidly progress to lethal complications (eg, hyperthermia, ventricular tachycardia). Expected postsurgical findings (eg, pain, small volume incisional bleeding) do not require notification unless the findings are unresolved by interventions (eg, pain medicine) or if they are excessive (eg, continuous or large volume bleeding). Postoperative sore throat is expected due to irritation from the endotracheal tube used during surgery. However, the nurse should monitor for hoarseness or noisy breathing, which may indicate laryngeal stridor and airway compromise.

The nurse is preparing to suction the lungs of a client who has a tracheostomy. Select, in the correct order, the steps the nurse should take. All options must be used.

Educational outcome: When performing tracheostomy suctioning, the nurse should take the following steps in this order: Place the client in the semi-Fowler position, if not contraindicated, to promote lung expansion and oxygenation. Preoxygenate with 100% oxygen (ie, hyperoxygenate) to prevent hypoxemia and microatelectasis. Alternately, if the client is breathing room air independently, ask the client to take 3 or 4 deep breaths. Gently insert the catheter the length of the airway without applying suction to prevent mucosal tissue damage. The distance can be premeasured (0.4-0.8 in [1-2 cm] past the distal end of the tube). Apply intermittent suction while rotating the suction catheter during withdrawal to prevent mucosal tissue damage. Limit suction time to 5-10 seconds with each suction pass to prevent mucosal tissue damage and limit hypoxia. Flush the catheter with normal saline and allow the client to rest for 2-3 minutes. Repeat steps 1 through 4 once or twice more if needed to clear secretions.

The nurse is preparing to admit a client with endometrial cancer to the oncology unit for brachytherapy via a sealed cervical implant. Which of the following interventions are appropriate to include in the plan of care for this client? Select all that apply.

Educational outcome: those with temporary brachytherapy (eg, sealed cervical radium implants) require safety precautions because the client emits radiation while the source is in place and poses a risk of exposure to others. The plan of care for a client with temporary brachytherapy implants should include the following interventions: Use appropriate shielding (eg, place client in a lead room, use lead shields and apron) to limit exposure Limit each person's time of exposure to the client (eg, cluster care, 30 minutes per shift) Assign all staff members involved in the client's care their own dosimeter badge to measure radiation exposure, and instruct them to wear it during every shift Instruct the client to remain on bed rest, and use caution when repositioning to avoid device dislodgement Maximize distance from the client (eg, 6 ft [1.8 m] is recommended)

The nurse is caring for a client who received extracorporeal shock wave lithotripsy with ureteral stent placement for treatment of a kidney stone. Which discharge instructions provided by the nurse are appropriate? Select all that apply.

Extracorporeal shock wave lithotripsy (ESWL) is a noninvasive procedure that uses high-energy acoustic shock waves to break up kidney stones into small fragments that can be excreted in the urine. The procedure is typically performed in an outpatient setting under general anesthesia. Temporary ureteral stents are often placed during the procedure to facilitate the passage of the stone fragments and prevent occlusion of the ureter. Stents are typically removed in 1-2 weeks. After an ESWL procedure, the client should be instructed to: Increase fluid intake to help flush out the kidney stone fragments Expect some bruising and pain of the back and/or flank of the affected side. Analgesics may be required (Option 5). Expect to see blood in the urine (hematuria). Urine color should progress from bright red to pink-tinged during the first several hours. Hematuria is concerning if the urine remains bright red for a prolonged period (eg, >24 hours) Report any symptoms of infection (eg, fever, chills) to the health care provider Ambulation is encouraged after ESWL to facilitate passage of the stone fragments.

A nurse preparing to insert a peripheral IV catheter dons clean gloves, applies a tourniquet to the client's arm, and immediately identifies a site for venipuncture. Place in order the remaining steps that the nurse should take. All options must be used. pt 2

Insert the IV ONC bevel up at a 10- to 30-degree angle and watch for blood backflow as the catheter enters the vein lumen, advancing ¼ inch into the vein to release the stylet. On visualization of blood return, lower the ONC almost parallel with the skin and thread the plastic cannula completely into the vein to the insertion site. Never reinsert the stylet after it is loosened. Use the push-tab safety device to advance the catheter. Apply firm but gentle pressure about 1¼ inch above the catheter tip, release the tourniquet, and retract the stylet from the ONC On removal, guide the protective guard over the stylet for safety and feel for a click as the device is locked. Never try to recap a stylet. Attach a sterile connection of primed IV tubing to the hub of the catheter and stabilize the catheter with tape and dressing using sterile technique. Dispose of the stylet in the sharps container.

The nurse is talking with a client who has irritable bowel syndrome about recommended dietary modifications. Which of the following menu selections by the client would demonstrate a correct understanding of the recommended dietary modifications?

Irritable bowel syndrome (IBS) is a chronic bowel condition characterized by abdominal discomfort, diarrhea, and/or constipation. The exact cause of IBS is not known, but there may be environmental, psychosocial, and genetic components. IBS is diagnosed by ruling out other gastrointestinal-related disorders (eg, lactose intolerance, food allergies, intestinal parasites). There is no cure for IBS, but clients can improve symptoms by making dietary modifications, including slowly increasing dietary fiber (eg, fruits, vegetables) and avoiding triggering foods (eg, caffeine, alcohol, high-fat foods). Foods that are generally well tolerated include low-fat proteins (eg, roasted chicken) and those with high dietary fiber (eg, sweet potatoes).Clients should limit gas-producing foods (eg, banana, beans, broccoli) as well as those that irritate the gastrointestinal tract (eg, caffeine, alcohol, high-fat foods). A diet low in fermentable oligo-, di-, and monosaccharides and polyols (FODMAPs) (eg, wheat, dairy, high-fructose corn syrup) is recommended.

he nurse is reviewing recommended dietary modifications with the parents of a 6-month-old client with phenylketonuria. Which of the following information should the nurse include? Select all that apply.

Phenylketonuria (PKU) is one of a few genetic inborn errors of metabolism. Individuals with PKU have a phenylalanine hydroxylase (PAH) enzyme deficiency. PAH enzyme is required for converting the amino acid phenylalanine into the amino acid tyrosine. As unconverted phenylalanine accumulates; irreversible neurologic damage can occur. A low-phenylalanine diet is essential in the treatment of PKU Phenylalanine cannot be entirely eliminated from the diet because it is an essential amino acid and necessary for normal development. The diet must meet nutritional needs while maintaining safe phenylalanine levels (2-6 mg/dL [120-360 µmol/L] for clients age <12). Other management strategies for clients with PKU include: Eliminating high-phenylalanine foods (eg, meats, eggs, milk) from the diet Feeding infants specially prepared formulas that are low in phenylalanine Encouraging consumption of natural foods low in phenylalanine (ie, most fruits and vegetables)

The nurse is caring for a 10-month-old client who has developed supraventricular tachycardia. The infant is alert and irritable. Which of the following actions would be a priority for the nurse take? Click the exhibit button for additional client information.

Supraventricular tachycardia (SVT) is the most common tachyarrhythmia in infants and children. Heart rate is usually >220/min with no variation in rate with activity, and the client typically has nonspecific symptoms, including pallor, irritability, and poor feeding. Prompt intervention is required because untreated SVT can lead to life-threatening heart failure. If the client is stable, nonpharmacological interventions to convert SVT to sinus rhythm should be attempted first. An ice pack can be applied to the face to stimulate a vagal response in clients who are too young to understand instructions for vagal stimulation (eg, bearing down, blowing through a closed straw). If these attempts are unsuccessful, adenosine may be administered for pharmacological cardioversion. - Antiarrhythmics (eg, propranolol, digoxin, amiodarone) are prescribed for sustained or recurrent SVT. However, amiodarone is not a first choice due to the risk for life-threatening toxicities. - Synchronized cardioversion can be used to treat SVT if less invasive methods are unsuccessful or if the client is hemodynamically unstable (eg, hypotension, tachypnea, mottled skin).

The nurse is caring for a newborn after a scheduled cesarean birth. Which of the following findings would be consistent with a complication of cesarean birth?

Transient tachypnea of the newborn (TTN) occurs in response to retained fluid in the lungs as the newborn transitions to extrauterine life. Newborns who are born via cesarean birth are at increased risk for TTN because they do not experience the same lung changes associated with vaginal birth, including: Increased catecholamine signals during labor that stimulate fluid resorption Thoracic compression that facilitates clearance of fluid from the lungs Manifestations of TTN include a sustained elevated respiratory rate (>60/min) and signs of respiratory distress (eg, grunting, nasal flaring) . TTN usually resolves over 1-3 days as the remaining fluid is resorbed

The nurse has taught a group of parents about varicella infection. Which of the following statements by a parent would indicate a correct understanding of the teaching?

Varicella (chickenpox) is a highly contagious infection caused by the varicella-zoster virus (VZV). Clinical manifestations include elevated temperature, malaise, and a maculopapular, pruritic rash that progresses to weeping vesicular lesions. The virus is spread via airborne droplets or by direct contact with lesions. Chickenpox is most contagious in the 24 hours leading up to rash onset (ie, prodromal period) and continues to be contagious until the entire rash has crusted over. During the prodromal period, clients may be asymptomatic or have vague symptoms such as low-grade fever, cough, and fatigue The incubation period for VZV infection is defined as the time between exposure to the virus and onset of first symptoms. The average incubation period is 2-3 weeks, not days. The rash associated with VZV spreads centripetally (toward the center of the body), mainly on the head and trunk rather than the hands and feet.

The nurse is teaching a client who is scheduled for a cardiac pharmacologic stress test in 2 days. Which of the following information should the nurse include? Select all that apply.

A cardiac pharmacologic stress test uses vasodilators (eg, adenosine, dipyridamole) to simulate exercise when clients are unable to tolerate continuous physical activity or when their target heart rate is not achieved through exercise alone. These medications produce vasodilation of the coronary arteries in clients with suspected coronary heart disease. Preprocedure instructions include: Avoid smoking cigarettes on the day of the test because nicotine is a stimulant Expect to experience transient nausea and/or flushing as vasodilators are injected In addition, report symptoms such as chest pain and/or dyspnea during the test. Note that a peripheral venous access device will be inserted prior to the test to administer vasodilators and other medications as necessary - Clients should avoid caffeine and decaffeinated beverages before the test because these products may contain trace amounts of caffeine.

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

According to the CDC, an occlusive dressing should be changed every 7 days. The nurse should check the institution's protocol for frequency of dressing changes. The distal port of a triple lumen CVC is the largest lumen (tube) and should be used for CVP (right atrium pressure) monitoring. The distal end of the CVC is in reverse as regards the client; therefore, the distal end is at the tip of the catheter in the superior vena cava vein, closest to the right atrium of the heart. Educational objective: Most CVCs require intravenous heparin flushes to maintain patency and prevent clotting. Single-dose vials of 2-3 mL of 10 units/mL or 100 units/mL are the standard of care. A dose of 1000-10,000 units is given for cases of thromboembolism.

The nurse is caring for a client who experienced a strong electrical shock when plugging in an electric charger. Which of the following actions would be a priority for the nurse to take?

An electrical injury refers to any trauma sustained from electricity, either from intense heat or from the electrical current itself. The extent of an electrical injury varies depending on the intensity of the electrical current, tissue resistance, and the duration of exposure. When a client sustains an electrical injury, the nurse should prioritize checking the client's pulse and respiratory effort (eg, dyspnea, alterations in respirations) because an electrical shock can lead to a disruption of normal cardiac conduction, resulting in life-threatening cardiac dysrhythmias (eg, ventricular fibrillation) and respiratory or cardiac arrest

The nurse is caring for a 67-year-old client.

Appropriate interventions for a client with Clostridioides difficile infection (CDI) include: Measuring orthostatic pulse and blood pressure to assess fluid volume status. When a client stands, the body normally vasoconstricts to preserve blood pressure. However, when a client is dehydrated, the body is already maximally vasoconstricted, and there is no other compensatory mechanism to adjust to the position change. Implementing contact precautions (eg, disposable gown, gloves, single-use equipment) to prevent transmission of C difficile. Soap and water, rather than alcohol-based hand sanitizers, should be used to cleanse hands because C difficile spores have shown resistance to alcohol-based cleansers. Frequently assessing the abdomen for distension and guarding, which may indicate colonic perforation. Toxic megacolon is a complication of CDI that occurs when severe mucosal inflammation leads to smooth muscle paralysis within the colon. Peristalsis halts, and the inflamed colon expands with gas and stool, potentially leading to life-threatening colonic perforation. Inserting a rectal tube is not appropriate because rectal tubes can cause skin/mucosal breakdown, decrease the response of the anal sphincter, and lead to infection. Administering antidiarrheal agents is not appropriate. Antidiarrheal agents (eg, loperamide) slow peristalsis and allow spores/bacteria to remain inside the colon, worsening the infection. - Fecal microbiota transplantation (FMT) may be necessary for recurrent CDIs. FMT involves transplanting components of donor stool into the colon of a client with recurrent CDIs. The healthy stool restores the client's depleted intestinal microbiome and inhibits the cycle of recurrent infections.

The nurse is teaching a client about breast self-examination. Which of the following statements by the client would indicate a correct understanding of the teaching? Select all that apply.

Breast self-examination (BSE) is a manual and visual examination of the breasts by the client to detect changes in breast tissue that may be related to breast cancer. Clients at higher risk for breast cancer (eg, positive BRCA1 or BRCA2 gene, family history) should perform BSE once a month using these techniques: Inspect breast size and symmetry and look for changes in shape or skin color while in front of a mirror Perform the examination at the end of the menstrual cycle when hormonal fluctuations in breast tissue reach a minimal level; hormonal fluctuations can cause benign breast changes (eg, cysts, tenderness) Assess the nipple for changes (ie, new-onset inversion, skin dimpling) and check for discharge by gently squeezing the nipple Lie flat when palpating the breast; feeling for changes is easier when the breast tissue flattens over the chest Palpate one breast at a time with the finger pads of the opposite hand to assess for lumps and masses. Skin dimpling or retraction can indicate distortion caused by an underlying mass and should be reported.

The nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse take? Select all that apply.

Cleansing enemas are solutions instilled rectally to promote peristalsis and evacuate the colon of feces. Enemas are commonly administered for constipation relief or in preparation for endoscopic procedures (eg, colonoscopy). Appropriate actions when administering a cleansing enema to an adult client include: Inspecting the abdomen for distension and auscultating bowel sounds prior to administration (Option 4) Asking the client to lie on the left side with the right knee flexed to allow gravity to facilitate flow of the enema solution into the lower portion of the intestine Inserting the lubricated tip of the tubing 3-4 inches (7.5-10 cm) into the rectum. Lubrication promotes comfort and prevents damage to the rectal mucosa. Insertion that is too deep can lead to bowel perforation. Encouraging the client to retain the enema for as long as possible to promote maximum effectiveness before assisting the client to a bedside commode for defecation The nurse should unclamp the tubing slowly and gradually elevate the solution bag 12 inches (30 cm) above the anus to instill the solution via gravity. Instillation should occur slowly to reduce cramping.

The nurse is assessing a client who had abdominal surgery 5 days ago. The nurse notes that the surgical incision edges are separated, and a loop of bowel is protruding through the incision. Which of the following actions should the nurse take? Select all that apply.

Educational OutcomWhen an abdominal wound evisceration occurs, the nurse should: Remain calm and stay with the client. Have a staff member notify the surgeon immediately (. Instruct the client not to cough or strain. Cover the area with sterile, saline-moistened gauze to protect the exposed organs and reduce the risk for infection (Option 3). Obtain vital signs to detect signs of potential shock (eg, hypotension, tachycardia). Place the client in the low Fowler position (ie, head of bed at 15-20 degrees) with the knees slightly flexed to decrease intraabdominal pressure and avoid further evisceration. Document interventions and the appearance of the wound and eviscerated organ (eg, color, drainage). If circulation is interrupted, the protruding organs can become ischemic (dusky) or necrotic (black).e:

The nurse is assessing a newborn with suspected hypospadias. Which of the following findings would support a diagnosis of hypospadias?

Educational Outcome Hypospadias is a congenital defect in which the urethral opening (ie, meatus) develops on the underside of the penis, caused by a failure of the urethral folds to fuse in utero. Surgical repair involves using the foreskin to reroute and reconstruct the urethra. The condition is typically corrected at age 6 to 12 months by surgically redirecting the urethra to the tip of the penis In general, the foreskin adheres to the glans penis and is not fully retractable until approximately age 3 to 5 if the client remains uncircumcised. Palpating the testicles in the inguinal canal indicates undescended testes (ie, cryptorchidism) in which one or both testes fail to descend into the scrotum. Bladder exstrophy is a congenital disorder in which the bladder and urinary mucosa develop outside of the abdominal wall due to incomplete fusion of the wall in utero. The exposed bladder cannot store or excrete urine normally, placing the client at risk for severe infection and skin breakdown.

The nurse is caring for a client with infective endocarditis. Which of the following complications should the nurse recognize the client is at risk for developing? Select all that apply.

Educational Outcome : Additional complications of IE are associated with vegetative emboli that travel to various parts of the body and cause tissue ischemia or infection, including: Ischemic stroke Glomerulonephritis Pulmonary embolism Vertebral osteomyelitis

The nurse is preparing to administer medications to assigned clients. The nurse should first administer

Educational Outcome : Sepsis occurs when an infectious organism enters the bloodstream and triggers an exaggerated immune response. Initial management includes IV fluid resuscitation, obtaining blood cultures, and antibiotic therapy. The goal is to administer broad-spectrum antibiotics as soon as possible (within 1 hour) if sepsis is suspected. Once the pathogen is identified, antibiotic therapy is targeted to the specific pathogen. Failure to treat early sepsis can lead to septic shock and multiple organ dysfunction syndrome

The nurse is caring for clients on a busy medical-surgical unit. Which client would be priority to assess first?

Educational Outcome : Clients with sepsis are at risk for developing disseminated intravascular coagulation (DIC), a condition that initially causes clotting within the microvessels. Platelets and clotting factors are consumed in clotting and become unavailable for body use, leading to bleeding complications. The initial clotting also disrupts blood flow to extremities and organs. Signs of DIC include frank external bleeding (eg, venipuncture site bleeding), signs of internal bleeding (petechiae, ecchymosis, hematuria, hematemesis, and bloody stools), and respiratory distress (eg, bleeding/clotting into lungs). Signs of DIC need immediate assessment and emergency intervention. Rapid replacement of clotting factors (fresh frozen plasma), platelets, and blood is needed to save the client from death.

The nurse is caring for a client who has a double-lumen nasogastric tube (NGT) that is connected to intermittent suction. It would require follow-up if the nurse

Educational Outcome: A nasogastric tube (NGT) is a device inserted into the stomach via the nasal passage to administer medications and enteral feedings or to aspirate stomach contents. Double-lumen NGTs are often used for gastric decompression. The larger lumen is attached to suction, and the smaller lumen (air vent) is open to the atmosphere. The air vent must remain open to provide a continuous flow of atmospheric air through the drainage tube at its distal end, preventing excessive suction and damage to the gastric mucosa

The nurse is caring for a client with acute decompensated heart failure who has tachypnea and pink, frothy sputum. After initiating oxygen therapy for the client, the nurse should next administer

Educational Outcome: After initiating oxygen therapy, the nurse should administer loop diuretics (eg, furosemide), which increase fluid excretion and urine output. As fluid volume decreases, pulmonary congestion improves, thereby improving oxygen exchange and reducing work of breathing Digoxin improves cardiac output by increasing myocardial contractility and decreasing heart rate. It may be prescribed for long-term management of HF but will not acutely improve pulmonary edema (furosemide will)

The nurse is talking with a client who had cataract surgery 2 hours ago. Which of the following statements by the client would require follow-up?

Educational Outcome: After lens implantation, vision may remain blurry for several hours before improving over the next several days. Clients should immediately notify the surgeon if vision acutely worsens because it may indicate a medical emergency, including retinal detachment or postoperative bacterial endophthalmitis

The nurse is caring for a client with syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following interventions should the nurse include in the plan of care? Select all that apply.

Educational Outcome: Appropriate nursing interventions for a client with SIADH include: Implementing seizure precautions because hyponatremia increases the risk for seizures. The nurse should also perform frequent neurological checks because water retention in the brain can lead to cerebral edema, resulting in changes in the client's behavior or level of consciousness Monitoring daily weights to determine fluid volume status. The client should be placed on fluid restriction (typically <800 mL/day) to counteract the increased water retention and prevent fluid volume overload (eg, bounding pulses, crackling in lungs, jugular venous distension) Monitoring serum osmolality because dilutional hyponatremia may result in low serum osmolality

The home health nurse visits a client with hypertension whose blood pressure has been well controlled on oral valsartan 320 mg daily. The client's blood pressure is 190/88 mm Hg, significantly higher than it was 2 weeks ago. The client reports a cold, a stuffy nose, and sneezing for 3 days. Which question is most appropriate for the nurse to ask?

Educational Outcome: Clients with hypertension should be instructed not to take potentially high-risk over-the-counter (OTC) medications such as high-sodium antacids, appetite suppressants, and cold and sinus preparations. It is appropriate to ask a client with hypertension about taking OTC cold medications as many cold and sinus medications contain phenylephrine or pseudoephedrine. These sympathomimetic decongestants activate alpha-1 adrenergic receptors, producing vasoconstriction. The resulting decreased nasal blood flow relieves nasal congestion. These agents have both oral and topical forms. With systemic absorption, these agents can cause dangerous hypertensive crisis

The nurse is teaching a client with newly diagnosed lactase deficiency about dietary management. Which statements by the client indicate a correct understanding of this condition? Select all that apply.

Educational Outcome: Clients with lactase deficiency (lactose intolerance) experience varying degrees of gastrointestinal symptoms after ingesting milk products, including flatulence, diarrhea, bloating, and cramping. This is due to a deficiency of the enzyme lactase, which is required for digestion of lactose. Treatment includes restricting lactose-containing foods in the diet. These clients may also take lactase enzyme replacements (eg, Lactaid) to decrease symptoms. Supplementation of calcium and vitamin D is recommended due to insufficient intake of fortified milk Milk and ice cream contain the highest amounts of lactose and should be restricted depending on the client's individual tolerance. Some dairy products, including aged cheeses and live-culture yogurts, contain little to no lactose and can be tolerated by most clients with lactase deficiency Lactase deficiency is not an immune reaction (allergy) to milk products. Rather, the gastrointestinal symptoms are due to a deficiency of the enzyme lactase and the resultant inability to digest lactose.

The nurse is assessing a client with suspected postpartum depression. Which of the following findings would support a diagnosis of postpartum depression? Select all that apply.

Educational Outcome: Clinical features of PPD include: Irritability, persistent sadness, and spontaneous episodes of sobbing (Option 1) Sleep disturbances (eg, insomnia, hypersomnolence) (Option 2) Appetite changes (eg, eating more or less than usual) and food cravings (Option 4) Lack of interest in the newborn and feelings of inadequacy as a parent (Option 5) Thoughts of harming self and/or the newborn

The nurse is assessing a client who has a suspected Clostridioides difficile infection (CDI). Which of the following findings would support a diagnosis of CDI? Select all that apply.

Educational Outcome: Clostridioides difficile is a gram-positive, anaerobic bacterium that causes widespread inflammation of the colon. C difficile is transmitted to susceptible individuals primarily via the fecal-oral route and requires contact precautions to prevent transmission. Risk factors include age >65, recent hospitalization, use of proton pump inhibitors or immunosuppressants, and recent antibiotic therapy. Antibiotic therapy (especially broad spectrum) can disrupt intestinal flora, increasing the risk for C difficile proliferation. Manifestations of C difficile infection (CDI) include abdominal pain/cramping, nausea, and profuse, watery diarrhea (usually nonbloody). The systemic inflammatory response causes a fever and leukocytosis. Clients with a CDI may develop hypotension, rather than hypertension, secondary to fluid volume loss.

The nurse is teaching a client who has a new prescription for a combined oral contraceptive (COC). Which of the following information should the nurse include?

Educational Outcome: Combined oral contraceptives (COCs) are pills containing estrogen and progestin that are used to prevent pregnancy by inhibiting ovulation, thickening cervical mucus, reducing tubal motility, and changing the endometrial lining. COCs are a reliable method of contraception and improve menstrual regularity while reducing menstrual pain. Common side effects include breast tenderness and nausea due to the increase in estrogen; these typically resolve spontaneously

The nurse is talking with a client with gastroesophageal reflux disease (GERD). Which of the following statements by the client would indicate a correct understanding of complications associated with GERD? Select all that apply.

Educational Outcome: Complications of GERD occur due to reflux of gastric contents and irritation of the esophageal mucosa and include: Esophageal ulcers, resulting in gastrointestinal bleeding or perforation Scar tissue formation, which can cause food to become stuck in the esophagus (eg, due to esophageal stricture or cancer [eg, Barrett esophagus]) Worsening of chronic respiratory conditions (eg, asthma) Treatment of GERD includes dietary and lifestyle modifications (eg, avoiding food triggers, smoking cessation) and medications (eg, antacids, H2 receptor agonists, proton pump inhibitors) to reduce stomach acid and promote esophageal healing.

The nurse is caring for an ambulatory client who has a new order for continuous cardiac monitoring via a portable unit. It would require follow-up if the nurse

Educational Outcome: Continuous cardiac monitoring may be accomplished via a portable unit (eg, Holter monitor) that can be carried in a pocket to allow for client mobility. The electrodes are placed on the client's torso, avoiding irritated skin, scars, or implantable devices (eg, pacemakers). The electrodes are not placed on the limbs because movement (eg, ambulation) causes artifact on the monitor For a 12-lead ECG, the leads are placed on the limbs because the test is completed within a few minutes while the client is stationary. The nurse should verify that gel is present and moist on the back of each electrode to ensure appropriate conduction; the gel should not be dry and should not be removed. For clarity of recording, the skin should be clean, dry, and free of lotion. Hair can be clipped for better contact with skin if necessary. Shaving should be avoided because it can cause nicks in the skin, increasing the risk for infection.

The nurse is teaching a client who had a partial laryngectomy and sustained damage to the ninth cranial nerve. Which of the following information should the nurse include?

Educational Outcome: Cranial nerve IX (glossopharyngeal) affects the gag reflex, ability to swallow, phonation, and taste. Clients who have had a partial laryngectomy should be assessed for the ability to swallow safely and effectively. Clients may be taught the supraglottic swallow technique that allows them to voluntarily close the vocal cords to prevent aspiration (Option 4). Clients are taught to: Inhale deeply. Hold the breath tightly to close the vocal cords. Place food in the mouth and swallow while continuing to hold the breath. Clear the throat to dispel any remaining food from the vocal cords. Swallow a second time before breathing.

The nurse is positioning clients before and after scheduled procedures. Follow-up would be required if the nurse places a client in which position?

Educational Outcome: Femoral cardiac catheterization is a procedure in which a large catheter is inserted through a sheath in a femoral vessel and threaded to coronary vessels to diagnose and treat cardiac disorders. Insertion of the sheath involves a large incision and dilation of the femoral vessel, which greatly increases the risk for rapid, life-threatening hemorrhage after device removal. Immediately following cardiac catheterization, the head of the bed should remain ≤30 degrees to prevent hip flexion which could disrupt clot formation at the insertion site and initiate bleeding. Fowler position places the client's head >30 degrees which is contraindicated If bleeding occurs, apply direct pressure over the arterial puncture site. After a liver biopsy, clients should be placed in the right side-lying position for ≥2 hours to promote direct internal pressure to the liver, which minimizes bleeding. Sims position (ie, left side-lying position with the right hip and knee flexed) is optimal for enema administration. Before lumbar puncture, clients should be placed in the side-lying fetal position or hunched seated position to separate the vertebrae. After the procedure, clients should remain supine to minimize the risk for postprocedure headache from loss of cerebrospinal fluid.

The nurse is assessing a client with suspected peripheral artery disease. Which of the following statements by the client would be consistent with the condition?

Educational Outcome: In clients with PAD, elevating the legs further impairs arterial blood flow and distal perfusion, which increases pain Clients with PAD should lower the legs to promote blood flow and decrease pain from tissue ischemia.

The nurse is assessing a client with suspected gastroesophageal reflux disease (GERD). Which of the following findings would support a diagnosis of GERD? Select all that apply.

Educational Outcome: Manifestations of GERD occur due to reflux of acidic gastric contents and irritation of the esophageal mucosa, exacerbated by increases in intrabdominal pressure (eg, bending, stooping, eating) or lying down. Manifestations include: Respiratory symptoms (eg, cough, wheezing, dyspnea) (Option 1) Heartburn and/or epigastric pain Nausea and indigestion Dysphagia Hoarseness

The nurse is assessing a client who has osteomyelitis of the right lower extremity. Which of the following findings would be consistent with the condition? Select all that apply.

Educational Outcome: Osteoarthritis can cause generalized, chronic joint inflammation and pain. However, pain associated with osteomyelitis is typically localized to the affected extremity.

The nurse is caring for a 30-year-old client.

Educational Outcome: Pericarditis -Administering nonsteroidal anti-inflammatory drugs (NSAIDs) (eg, ibuprofen) with colchicine to decrease inflammation -Monitoring for signs of bleeding (eg, melena) due to NSAID use

The emergency department nurse is caring for multiple adult clients who were involved in a motor vehicle collision. The nurse should prioritize care for the client with

Educational Outcome: Prioritization of care: First-level priority concerns: Airway Breathing Circulation & cardiac (become first priority in cardiac arrest, hemorrhage) Vital signs Second-level priority concerns: Altered mental status Acute pain Untreated medical concerns (eg, hyperglycemiain a client with diabetes mellitus) Chronic pain Acute elimination issues Abnormal laboratory results Risk for infection, safety

The nurse is teaching a client who has a new prescription for a progestin-only oral contraceptive. Which of the following information should the nurse include?

Educational Outcome: Progestin-only oral contraceptives work by thickening cervical mucus (ie, hindering sperm motility), thinning the endometrium (ie, hindering implantation), and preventing ovulation. Cervical mucus changes last approximately 24 hours, so the client must take the medication at the same time every day for it to be effective. If the medication is missed or taken late, a barrier method (eg, condom) is advised until the medication is taken correctly for at least 2 days - An additional dose should be taken if diarrhea or vomiting occurs within 3 hours of the last dose due to the risk for impaired absorption.

The nurse is caring for a client with plaque psoriasis. Which of the following statements would be appropriate for the nurse to make? Select all that apply.

Educational Outcome: Psoriasis is a chronic autoimmune disease that causes a rapid turnover of epidermal cells. The goal of therapy is to slow epidermal turnover, heal plaque-like lesions, and control exacerbations. The nurse should include the following in the teaching: Stress management (eg, relaxation, breathing exercises, yoga) and avoidance of triggers for psoriasis, including infection, medications (eg, lithium, propranolol), and alcohol, can reduce exacerbations Characteristic silver-white plaques on reddened skin may be found bilaterally on the elbows, knees, scalp, lower back, and/or buttocks during exacerbations While there is no current cure for psoriasis, the nurse can prepare the client for lifelong management of symptoms and ways to minimize exacerbations Topical therapy (eg, corticosteroids, fragrance-free moisturizers) should be applied to reduce skin irritation and minimize itching Ultraviolet (UV) light exposure (eg, sunlight, phototherapy) can improve psoriasis by slowing epidermal turnover and decreasing exacerbations. In clients receiving phototherapy, care should be taken to prevent overexposure.

The nurse is removing skin staples from a client's surgical incision. Which of the following actions should the nurse take? Select all that apply.

Educational Outcome: Steps for staple removal include: Checking the incision for and reporting signs of poor healing or infection to the HCP. Cleansing the incision with a prescribed solution (eg, 0.9% sodium chloride, antimicrobial swabs) before and after the procedure to reduce the risk for infection Placing the lower tip of the staple remover under the center of the staple and squeezing the handles, which causes the staple to be removed from the skin Initially removing every other staple while checking for wound separation. If the wound remains closed, the remaining staples can be removed Documenting the number of staples removed and the condition of the incision Staple removal may cause minor discomfort (eg, pulling/stinging sensation) but should not cause pain.

The nurse is teaching a client who has vasovagal syncope. Which of the following statements by the client would require follow-up?

Educational Outcome: Syncope is a quick-resolving (typically <1 min) loss of consciousness that results from decreased perfusion to the brain. Vasovagal syncope occurs due to an alteration in the autonomic drive. A trigger (eg, strong emotions, Valsalva maneuvers, vagus nerve stimulation) causes increased parasympathetic and decreased sympathetic tone. This results in vasodilation, hypotension, and bradycardia, which reduce perfusion to the brain and cause syncope. Clients with vasovagal syncope should avoid triggers to reduce the risk for recurrent episodes. Isometric exercises (eg, lifting weights) are associated with the Valsalva maneuver and can stimulate the vagus nerve to produce bradycardia and hypotension Isotonic exercises (eg, walking, swimming, bicycling) are safer options. - It is appropriate to avoid activities associated with vagus nerve stimulation, including rubbing the eyelids (eg, increased ocular pressure), gagging, and straining during bowel movements.

The nurse is caring for a client with a pneumothorax who has a chest tube attached to a closed-chest drainage system. Which of the following findings would require follow-up? Select all that apply.

Educational Outcome: The nurse is caring for a client with a pneumothorax who has a chest tube attached to a closed-chest drainage system. Which of the following findings would require follow-up? Select all that apply.

An elderly client tells the nurse "I have experienced leg pain for several weeks when I walk to the mailbox each afternoon, but it goes away once I stop walking." What is the priority assessment the nurse should perform?

Educational Outcome: The nurse should first check for the adequacy of blood flow to the lower extremities by palpating for the presence of posterior tibial and dorsalis pedis pulses and their quality. Poor circulation to the extremities can place the client at increased risk for development of arterial ulcers and infection. The quality of circulation to the extremities will guide the treatment plan for this client; management will include risk factor modification for cardiovascular disease, drug therapy, and possibly surgical revascularization.

The nurse is conducting a pain assessment on a client with dysuria. Which pain description is most likely associated with pyelonephritis?

Educational Outcome: Urinary tract infections (UTIs) can occur in the kidneys (pyelonephritis), bladder (cystitis), and/or urethra (urethritis). Pyelonephritis (inflammation of the kidney parenchyma) causes flank pain that is experienced in the back at the costovertebral angle (the angle between the lower ribs and adjacent vertebrae) and may spread toward the umbilicus. Cystitis alone does not cause nausea/vomiting or chills. Presence of these, fever, and signs and symptoms of a lower UTI (dysuria, urgency, and frequency) indicate pyelonephritis. -The client with a distended bladder experiences constant pain increased by any pressure over the bladder. Bladder distension is found through palpation (firmness, pain, urgency) and percussion (dullness) over the suprapubic area. -Bladder and urethral pain is usually dull and continuous and may be experienced as spasms. The detrusor muscle of the bladder may spasm if cystitis is present. - Renal colic pain (in response to renal calculi) is excruciating, sharp, and stabbing; the client would be tossing in the bed unable to find a comfortable position. Pain radiates down to the groin area as the stone travels down the ureter.

The nurse is teaching a class on nutrition and feeding practices for young children. What should the nurse recommend as the best snack for a toddler?

Educational Outcome: When choosing foods for a toddler (age 1-3 years), parents should consider the following factors: Safety: Small, hard, sticky, or slippery foods (eg, hot dogs, whole grapes, nuts, raw carrot sticks, popcorn, peanut butter, hard candy, fruit snacks) pose a choking risk and should not be offered. Nutrient density: Foods should contain valuable nutrients (eg, protein, vitamins) rather than just "empty calories" (eg, sugars). Potential for foodborne illness: Children are at a higher risk for developing food-related infections, especially if given raw, unpasteurized foods (eg, partially cooked eggs, raw fish, raw bean sprouts). Healthy snacks for a toddler include pieces of cheese, whole-wheat crackers, banana slices, yogurt, cooked vegetables, and cottage cheese with thinly sliced fruit - Raw carrot sticks are hard and pose a choking risk. Parents should serve carrots and other hard vegetables grated or cooked.

nurse is admitting a 4-year-old diagnosed with Wilms tumor. The child is scheduled for a right nephrectomy in the morning. Which action is a priority in the preoperative care plan?

Educational Outcome: Wilms tumor (nephroblastoma) is a kidney tumor that usually occurs in children age <5. Most often it involves only one kidney, and the prognosis is good if the tumor has not metastasized. Wilms tumor is usually diagnosed after caregivers observe an unusual contour in the child's abdomen. Once the diagnosis is suspected or confirmed, the abdomen should not be palpated, as this can disrupt the encapsulated tumor. It is important to post the sign "DO NOT PALPATE ABDOMEN" at the bedside. It is also essential that the child be handled carefully during bathing.

The nurse is observing a staff member care for a client who has partial-thickness burns covering 35% of the total body surface area, including the genital area. It would require follow-up if the staff member is observed

Educational Outcome: the nurse should insert two large-bore IVs (eg, 14- to 18-gauge) that are indicated to handle large and rapid volumes of fluids; a single 22-gauge IV is not appropriate for a client who is in severe trauma

Four children are brought to the emergency department. Which child should be assessed first?

Educational Outcome: Clear, colorless fluid draining from the nose or ears after head trauma is suspicious for cerebrospinal fluid (CSF) leakage. When the drainage is clear, dextrose testing can be used to determine if the drainage is CSF. However, the presence of blood would make this test unreliable as blood also contains glucose. This child is at risk for intracerebral bleeding and meningitis. Vascular compromise may occur with even minimal head trauma; therefore, the nurse should evaluate any changes in level of consciousness and temperature as well as assess the head and neck for subcutaneous bleeding. The nurse should anticipate a CT scan of the head and neck and prophylactic antibiotics. Iron ingestion is the major concern with vitamin toxicity in children. However, children's formulations contain minimal or no iron. As a result, ingestion of an unknown quantity is unlikely to cause

The nurse is caring for a 35-year-old client.

Educational Outcome: Compartment syndrome: The nurse should prepare to remove the cast and prepare the client for emergency fasciotomy (ie, surgical incision through the skin and fascia) to release pressure and restore perfusion. Expected outcomes include improved perfusion (eg, capillary refill <2 sec) and active range of motion in the affected fingers. Other info: Sanguineous (ie, bloody) discharge from the cranial laceration is expected.

The registered nurse (RN) is providing discharge instructions to a client who has had coronary artery bypass grafting (CABG). Which teaching is correct? Select all that apply.

Educational Outcome: Encourage a daily shower as a bath could introduce microorganisms into the surgical incision sites. Surgical incisions are washed gently with mild soap and water and patted dry. The incisions should not be soaked or have lotions or creams applied as this could introduce pathogens Clarify no driving for 4-6 weeks or until the HCP approves. If the client is able to walk 1 block or climb 2 flights of stairs without symptoms (eg, chest pain, shortness of breath, fatigue), it is usually safe to resume sexual activity (Option 1).

The nurse is caring for a newborn with hypertrophic pyloric stenosis. The nurse should recognize that the newborn is at risk for developing

Educational Outcome: Hypertrophic pyloric stenosis is thickening of the pylorus muscle that blocks the passage of gastric contents into the intestines, resulting in postprandial projectile vomiting. Emesis is nonbilious because gastric contents (eg, breastmilk, formula) are unable to reach the intestines. Clinical manifestations include irritability, persistent hunger despite regular feedings, and decreased stool formation. Clients with pyloric stenosis are at increased risk for dehydration (eg, sunken anterior fontanel, decreased urine output, dry mucous membranes) and malnutrition, which can progress to failure to thrive, due to persistent vomiting Other info: Intussusception is characterized by telescoping of a proximal segment of the intestine into an adjacent distal segment, leading to bowel obstruction, inflammation, and edema. Worsening obstruction can lead to life-threatening intestinal perforation and peritonitis.

The nurse is screening pregnant clients for risk factors. The nurse should recognize the client at risk for having a newborn with spina bifida is the client who

Educational Outcome: Risk factors for spina bifida include: Teratogenic medication use (eg, valproic acid) (Option 1) Previous delivery of a newborn with an NTD Diabetes mellitus Inadequate maternal folic acid intake (eg, prenatal vitamins) Obesity (ie, BMI ≥30.00 kg/m2)

The nurse is talking with a client who has Raynaud disease. Which of the following information should the nurse include? Select all that apply.

Educational Outcome: - Avoiding vasoconstrictive agents, including nicotine, caffeine, and certain cold medications (eg, nasal decongestants), which may cause or worsen vasospasm -Taking calcium channel blockers as prescribed to relax arteriole smooth muscle and prevent recurrent flares

The nurse is providing education to a 32-year-old female client diagnosed with human papillomavirus (HPV). Which client statement indicates a need for further instruction?

Educational Outcome: - Clients with HPV need to have annual Papanicolaou tests as the virus increases the risk of cervical cell changes (ie, dysplasia) and subsequent risk of cervical cancer.

The nurse is caring for a client with a hemothorax who has a chest tube attached to a closed-chest drainage system. The nurse notes 60 mL of dark red drainage in the collection chamber over the past hour. Which of the following actions should the nurse take?

Educational Outcome: - Dark red drainage of 60 mL/hr is an expected finding for a client with a hemothorax because accumulated blood is draining from the pleural cavity. Chest tube drainage amounts (eg, mL/hr) and quality should be monitored and recorded in the client's medical record - Chest tube drainage of >100 mL/hr or sudden changes in quality (eg, serous to sanguineous) should be reported to the health care provider. The nurse should also monitor for additional signs of bleeding (eg, hypotension, tachycardia, cool and pale skin). - Hemoglobin and hematocrit levels are indicated if active bleeding is suspected. Drainage of 60 mL/hr is not indicative of active bleeding.

During assessment of a client with cholelithiasis and acute cholecystitis, which of the following findings should the nurse expect during the health history and physical examination? Select all that apply.

Educational Outcome: - It is not dietary protein but foods with significant fat content (eg, cheese, avocado, fried foods) that signal the gallbladder to contract, emptying bile into the small intestine to help digestion.

The nurse has taught a client with myasthenia gravis. Which of the following statements by the client would indicate a correct understanding of the teaching? Select all that apply.

Educational Outcome: - Notifying the health care provider to discuss management and associated risks if planning to become pregnant because pregnancy and childbirth can precipitate myasthenic crisis - Eating soft foods to help conserve energy and prevent choking and aspiration

The nurse is caring for assigned clients. The nurse should first assess the client who had

Educational Outcome: - Phrenic nerve irritation from carbon dioxide used during surgery can cause referred pain to the right shoulder following a laparoscopic cholecystectomy. The nurse should place the client in Sims position and encourage deep breathing, but this may be safely delayed. - A small amount of pink serosanguineous drainage at the tracheostomy site is a normal finding. This client is not the priority; however, the nurse should notify the health care provider if excessive bleeding occurs.

The nurse receives report on 4 clients. Which client should the nurse assess first?

Educational Outcome: - altered mental status and not following commands is at risk for aspiration and airway compromise from vomiting. This client should be assessed first; the client needs to be placed in the lateral position with head elevated and may need emergent intubation if airway cannot be protected. - Clients with ankylosing spondylitis often take nonsteroidal anti-inflammatory drugs to control back pain and are at risk of developing gastric ulcers. They can cause melena (black stools). The client needs further assessment of orthostatic vital signs and hemoglobin level. Other info: - Clients receiving hemodialysis are at risk for bloodstream infections. Blood cultures need to be obtained from a client with a bloodstream infection, and antibiotics would then be administered.

The nurse is caring for a client who has cerebral edema. Which of the following therapies should the nurse recognize as appropriate for the treatment of cerebral edema? Select all that apply.

Educational Outcome: -Appropriate treatment for cerebral edema includes: -Sedation with propofol to reduce anxiety and agitation, which can increase ICP

The nurse is caring for a debilitated client with a percutaneous endoscopic gastrostomy (PEG) tube that was inserted 3 days ago for the long-term administration of enteral feedings and medications. While the nurse is preparing to administer the feeding, the tube becomes dislodged. What is the most appropriate intervention?

Educational Outcome: A PEG is a minimally invasive procedure performed under conscious sedation. Using endoscopy, a gastrostomy tube is inserted through the esophagus into the stomach and then pulled through an incision made in the abdominal wall. To keep it secured, the PEG tube has an outer bumper and an inner balloon or bumper. The tube's tract begins to mature in 1-2 weeks and is not fully established until 4-6 weeks. It begins to close within hours of tube dislodgement. The nurse should notify the health care provider who placed the PEG tube as early dislodgement (ie, <7 days from placement) requires either surgical or endoscopic replacement The insertion of a Foley catheter or immediate reinsertion of the PEG tube should not be attempted because the tube's tract is only 3 days old (immature). A reinserted tube could be placed inadvertently into the peritoneal cavity, leading to serious consequences such as peritonitis and sepsis. Therefore, these are not the most appropriate interventions.

The nurse is talking with a client who is scheduled for a barium enema in 4 days. Which of the following statements by the client would require follow-up?

Educational Outcome: A barium enema, or lower gastrointestinal series, uses fluoroscopy to visualize the colon outlined by contrast (ie, barium) to detect polyps, ulcers, tumors, and diverticula. This procedure is contraindicated for clients with acute diverticulitis because it may rupture inflamed diverticula and cause subsequent peritonitis. Before the procedure, clients should complete a prescribed bowel preparation. During the procedure, barium is instilled, and a series of images are obtained. Retained barium can cause constipation and fecal impaction. After the procedure, fluids and laxatives or suppositories should be used to help clients expel the barium and avoid fecal impaction Clients may experience chalky white stool for up to 72 hours after the procedure as barium is expelled from the body. Instillation of the barium can cause abdominal cramping and an urge to defecate. Before the procedure, clients must complete a prescribed bowel preparation to ensure the colon is clear of stool. Preparation varies and may include dietary restrictions, cathartics, and enemas.

The nurse is caring for a client who has a suspected hiatal hernia. The nurse should expect the client to receive an order for

Educational Outcome: A barium swallow (ie, esophagram) is a diagnostic test used to identify a hiatal hernia. An opaque contrast medium (ie, barium) is swallowed while imaging (eg, x-ray) is simultaneously obtained. Imaging visualizes structures of the upper gastrointestinal (GI) tract (eg, diaphragm, esophagus) and can identify the presence of a hiatal hernia A colonoscopy uses an endoscope to visualize the large intestines and screen for abnormalities of the lower GI tract (eg, cancer, diverticulosis). It does not visualize the stomach. pH testing of the esophagus can detect the presence of acid (ie, gastric contents) in the normally alkaline esophagus. pH testing is used to diagnose gastroesophageal reflux disease. An upper GI biopsy tests tissue for ulcers, infections, or tumors, not a hiatal hernia.

The nurse is auscultating a client's carotid artery and notes a bruit. Which of the following actions should the nurse take? Select all that apply.

Educational Outcome: A bruit is an abnormal sound caused by turbulent blood flow through an artery. It is commonly described as a swooshing or blowing sound. A carotid bruit is often associated with atherosclerotic disease because fatty deposits in arterial walls impair blood flow through the arterial lumen. If untreated, atherosclerosis and subsequent arterial occlusion can lead to a life-threatening cerebrovascular or cardiovascular event (eg, ischemic stroke). If a carotid bruit is identified, the nurse should notify the health care provider immediately and assess for signs of decreased blood flow to the brain, including: Visual disturbances or dizziness Palpable thrill over the carotid artery due to arterial occlusion Weak or absent temporal pulses

The nurse is caring for a client in the immediate postoperative period following a carotid endarterectomy. The client is drowsy with slurred speech. Which assessment finding would cause the nurse to notify the healthcare provider immediately?

Educational Outcome: A carotid endarterectomy is a surgical procedure performed to remove plaque from the carotid artery to improve cerebral perfusion. The nurse must closely assess for signs of new or worsening alterations in neurologic status, as surgical manipulation of arteries and blood flow increases the risk of stroke. Monitoring the client's neurologic status postoperatively can be challenging, as the effects of anesthesia degrade the neurologic examination. Nurses should use the FAST acronym to assess for stroke: Facial drooping: Numbness or droopiness on one side of the face Arm weakness: Weakness or drifting of one arm when raised to shoulder level. Speech difficulties: Slurring of words, incomprehensible speech, inability to understand others Time: Notation of the time of symptom onset, which is critical for guiding treatment Other info: Diminished gag reflex is common after anesthesia and endotracheal tube removal. The gag reflex should return as the client awakens. Individuals recovering from anesthesia may have alterations in mood or affect (eg, agitation, anxiety, tearfulness) that will resolve as anesthesia wears off. Drowsiness and somnolence during purposeful interactions (ie, following commands) are expected after anesthesia.

The nurse is caring for a 71-year-old client with age-related macular degeneration.

Educational Outcome: A consistent intake of leafy, dark green vegetables indicates that teaching was not effective. Clients should increase dietary intake of leafy, dark green vegetables (eg, spinach, kale, broccoli), which contain lutein, an antioxidant that can slow progression of AMD.

The nurse is caring for a client in the postanesthesia care unit following a gastroduodenostomy. Which of the following nursing interventions are appropriate? Select all that apply.

Educational Outcome: A gastroduodenostomy (Billroth I) involves removing the distal two-thirds of the stomach with anastomosis of the remaining stomach to the duodenum. Following partial gastrectomy, clients should remain NPO until bowel sounds return. Once tolerated, consumption of small, frequent meals will help prevent the occurrence of dumping syndrome (ie, rapid emptying of stomach contents into the small intestine). Postoperative clients are at risk for developing venous thromboembolism (VTE) due to reduced mobility levels and require VTE prophylaxis (eg, sequential compression devices, compression hose). Clients are also at risk for hypoventilation and respiratory compromise due to sedation, pain, and immobility. Encourage clients to turn, cough, and deep breathe while splinting the surgical site to prevent development of atelectasis - Clients may have a nasogastric tube postoperatively for gastric decompression. Clogged nasogastric tubes should be reported to the surgeon. Attempting to manipulate or flush the device may disrupt the surgical site, causing hemorrhage or gastric perforation.

The nurse cares for a client scheduled for a percutaneous left kidney biopsy as an outpatient. Which intervention should the nurse include in the client's post-procedure care plan?

Educational Outcome: A kidney biopsy involves obtaining a tissue sample for pathological evaluation to determine the cause of certain kidney diseases (eg, nephritis, transplant rejection). The kidney has extensive vasculature (similar to the liver); therefore, bleeding from the biopsy site is the major complication following a percutaneous kidney biopsy. Before the procedure, the client must give informed consent and discontinue all anticoagulants (eg, heparin, warfarin, rivaroxaban) and antiplatelet agents (eg, aspirin, clopidogrel, nonsteroidal anti-inflammatory drugs) for at least one week. The client should be typed and crossmatched for blood (although the need for a transfusion is rare). Blood pressure should be well-controlled. After the procedure, the nurse should monitor vital signs at least every 15 minutes for the first hour as tachycardia, tachypnea, and hypotension can indicate blood loss. The nurse should also assess the puncture site dressing for bleeding. Blood urea nitrogen (BUN) and creatinine levels would not change significantly within 30-60 minutes. These are usually measured once every 24 hours and rarely every 12 hours. Insertion of an indwelling urinary catheter is not necessary to perform a kidney biopsy and is not part of the usual protocol. Post-procedure, the client should be positioned on the affected (left) side for 30-60 minutes to provide pressure and help prevent bleeding. The client is usually placed in the prone position during the procedure to facilitate access to the kidney.

The nurse is observing client care situations. Which of the following situations would require an order for physical restraints? Select all that apply.

Educational Outcome: A physical restraint is a device used to limit movement to prevent injury to self or others. Protective devices used temporarily during routine procedures are not considered restraints and do not require an order. Restraints should be used only after less invasive methods have failed and must be discontinued as soon as it is safe to do so. A belt restraint is applied at the waist and tied using a quick-release knot. It can be used to protect a confused client who is on bed rest. Although the client can turn, it is considered a restraint because it restricts mobility. Soft limb restraints (eg, wrist, ankle) immobilize 1 or more extremities. Following a procedure requiring sedation, clients may require restraints to protect them from disrupting a surgical site or medical device until they are alert enough to follow instructions An orthopedic leg immobilizer used to restrict movement and maintain a client's extremity in proper alignment is prescribed for therapeutic purposes and is not considered a restraint. A mummy restraint involves swaddling an infant for temporary immobilization during a routine procedure and is not considered a physical restraint. The use of raised, padded side rails during a seizure protects a client from injury; it is not considered a restraint.

The nurse is screening clients for those at risk for developing a pleural effusion. Which of the following factors would increase a client's risk for developing a pleural effusion? Select all that apply.

Educational Outcome: A pleural effusion is a collection of excess fluid in the pleural space. Excess fluid compresses lung tissue, which prevents the lung from expanding fully and results in decreased lung volume, atelectasis, and ineffective gas exchange. Conditions that increase the risk for a pleural effusion include: Infection (eg, tuberculosis, pneumonia) because inflammation increases capillary permeability, causing fluid to move from the capillaries into the pleural space Pleural malignancy (eg, lung adenocarcinoma) because cancer cells can block lymphatic drainage, causing fluid to accumulate within the pleural space Heart failure because fluid retention increases hydrostatic pressure (ie, pressure exerted by the fluid in the capillary), which causes fluid to move from the capillaries into the pleural space

A client who was discharged following a prostatectomy performed 6 days ago calls the clinic and reports passing some small blood clots and experiencing a decreased urinary stream. What is the nurse's best response?

Educational Outcome: A prostatectomy uses either minimally invasive or open surgical techniques to remove all or part of the prostate gland for clients with related disorders (eg, cancer, benign prostatic hyperplasia). For up to 36 hours after surgery, small blood clots may occur, although they should not impair the urine stream. Consistent passage of clots after this time could indicate a postoperative complication. Signs of such complications (eg, reduced urine stream, persistent bleeding/blood clots, urinary retention, fever, dysuria) after discharge should be evaluated by the health care provider for further treatment The presence of blood clots 6 days after surgery is not normal and may indicate bleeding from the prostatic fossa. This client requires further evaluation. Clients should avoid the Valsalva maneuver for up to 8 weeks after prostatectomy because the exerted pressure may injure the healing tissue, causing hematuria. Maintaining adequate fluid intake helps prevent blood clot formation. However, this client is reporting blood clots with a decreased urinary stream and needs further evaluation.

The nurse completes the preoperative assessment for a client scheduled for a total knee replacement today. Which information should the nurse report to the health care provider (HCP) as soon as possible before the surgery?

Educational Outcome: A recent/current infection is a contraindication to total joint replacement surgery as a wound infection is more likely to occur in a client with a preexisting infection. The nurse should report the new onset of burning on urination to the HCP.

The nurse is preparing to administer a rectal suppository to a client with constipation. Which of the following actions should the nurse take? Select all that apply.

Educational Outcome: A suppository, commonly used to treat constipation, is inserted rectally, where it is absorbed into the bloodstream through the rectal mucosa. Correct administration of a suppository includes: Inserting the suppository into the anus and guiding it through the internal sphincter and along the rectal wall, making sure to avoid placement into stool. Maintaining contact with the rectal wall ensures systemic absorption Assisting the client into the Sims position, having the client flex the upper leg, and draping for privacy (Option 3). Applying lubricant to the tapered end of the suppository Asking the client to remain in a side-lying position for 5 minutes after insertion to promote retention of the suppository In adults, the suppository should be inserted 4 inches (10.2 cm) into the anus, beyond the internal sphincter.

The nurse enters the room of a client who had a tracheostomy created 2 months ago. The nurse notes that the client is in respiratory distress and the tracheostomy tube is lying on the bed next to the client. Which of the following actions should the nurse take?

Educational Outcome: A tracheostomy tube is an artificial airway inserted into the trachea through the neck. Accidental decannulation or dislodgment of a tracheostomy tube is a medical emergency that often results in respiratory distress. If accidental decannulation of a mature tracheostomy (ie, >7 days after insertion) occurs, the nurse should attempt to open the stoma with a curved hemostat and insert a new tracheostomy tube with an obturator (Option 2). The obturator is then removed to allow air to flow through the tube. An obturator and new tracheostomy tube should be kept at the bedside for clients with a tracheostomy. Covering the stoma with a sterile, occlusive dressing (eg, petroleum gauze, foam tape) and ventilating with a bag-valve mask over the mouth and nose are indicated for immature tracheostomies (ie, <7 days after insertion). Reinsertion of the tube is preferred for clients with a mature tracheostomy.

The nurse is caring for a 66-year-old client in the emergency department.

Educational Outcome: Accidental needlestick injuries are most often caused by improper use of the needle safety device (ie, attempting to recap the needle) or improper needle disposal (ie, not using biohazard sharps container). Needlestick injuries can facilitate transmission of bloodborne pathogens (eg, HIV, hepatitis C virus). Needlestick injuries should be reported immediately. If a health care worker is exposed to HIV via blood (eg, needlestick injury), they should immediately wash the site with soap and water. Other indicated interventions include: Screening the client for additional bloodborne pathogens (eg, hepatitis B virus, hepatitis C virus) that could have been transmitted to the health care worker Anticipating initiation of postexposure prophylaxis with antiretroviral therapy as soon as possible. Oral antibiotics are not indicated because HIV is a viral infection. Squeezing the wound tissue is not indicated. Instead, the nurse should allow blood to drain freely from the needlestick injury site. Replacing the cap on used needles is not indicated because this increases the risk of needlestick injuries. The nurse should engage the needle safety device (eg, retract stylet after IV catheter insertion) if present and use a biohazard sharps container to safely dispose of the needle.

The nurse is caring for 4 clients requiring IV fluid therapy. For which client should the nurse anticipate the need for isotonic crystalloid administration? Click the exhibit button for additional client information.

Educational Outcome: Acute gastroenteritis is associated with nausea, vomiting, and diarrhea, placing the client at risk for dehydration and sodium loss. Clients with gastroenteritis are encouraged to increase fluid intake but may require IV fluid therapy. Isotonic crystalloid fluids (eg, 0.9% sodium chloride, lactated Ringer solution) are the treatment of choice due to the similarity in concentration with plasma and ability to increase extracellular fluid (ECF) without moving into the intracellular space. In addition, isotonic fluids may increase sodium levels in clients experiencing excess sodium loss (eg, vomiting, diarrhea) - The client with a serum sodium of 112 mEq/L (112 mmol/L) is dangerously hyponatremic and at risk for further neurological decline. A hypertonic solution (eg, 3% sodium chloride) is the most appropriate choice to rapidly correct sodium deficits

The nurse is caring for a client who is receiving a transfusion of packed RBCs and is exhibiting signs of an acute hemolytic transfusion reaction. Which of the following actions should the nurse take? Select all that apply.

Educational Outcome: Acute hemolytic transfusion reaction (AHTR) is usually caused by the transfusion of mismatched blood (ie, ABO incompatibility) and occurs when host antibodies attack donor blood antigens (ie, type II hypersensitivity reaction). Manifestations include fever with chills, flank/back pain, dark red urine (ie, hemoglobinuria), tachycardia, and hypotension shortly following a transfusion. If AHTR is suspected, the nurse should: Discontinue the transfusion immediately and disconnect the tubing from the client to prevent additional incompatible blood from reaching the client Infuse 0.9% sodium chloride through new IV tubing; aggressive hydration is required for hemodynamic stabilization and prevention of kidney injury Monitor hourly intake and output because hemolysis can cause renal tubule obstruction and lead to acute kidney failure

The nurse is caring for a 5-year-old client in the emergency department.

Educational Outcome: Acute lymphoblastic leukemia (ALL) is a hematologic cancer caused by the rapid growth and overcrowding of leukemic cells (ie, immature WBCs) in the bone marrow, resulting in pancytopenia from suppression of other bone marrow components (eg, RBCs, WBCs, platelets). Clinical manifestations include fatigue, fever, bleeding, bruising, bone and joint pain, and weight loss. Interventions for clients with suspected ALL include: Preparing the client for bone marrow aspiration and monitoring biopsy results to confirm the diagnosis. Hypercellular bone marrow (ie, excess number of cells) with lymphoblasts is diagnostic of ALL. Transfusing blood products that are leukocyte-reduced and irradiated (ie, removal and inactivation of donor WBCs) to reduce the risk of complications (eg, transfusion reactions, transmission of viruses, transfusion-associated graft-versus-host disease). Monitoring complete blood counts to evaluate the client's response to treatment.

The nurse is caring for an 8-year-old client with acute otitis externa.

Educational Outcome: Acute otitis externa is inflammation or infection of the outer ear canal, frequently caused by Pseudomonas or Staphylococcus bacteria. Risk factors include prolonged exposure to water (eg, swimming), allergies, chronic dermatitis, insufficient cerumen, and irritation to the ear (eg, cleaning with cotton swabs). Clients may experience pain exacerbated with jaw movement, pruritus, purulent drainage, edema of the outer ear, and temporary conductive hearing loss. Interventions that are indicated for a client with acute otitis externa include: Administering otic drops that contain antibiotics (eg, fluoroquinolones, neomycin), antimicrobial agents (eg, acetic acid), or steroids (eg, hydrocortisone) to treat the infection and decrease inflammation Instructing the client to keep the ear dry and allow the ears to drain after contact with water to prevent recurrence Administering analgesics to manage pain Implementing ear irrigation to clean the ear canal of debris or cerumen Oral antibiotics may be used to treat acute otitis media but are not indicated for acute otitis externa. Instead, antibiotic otic drops are used to treat the infection locally. Tympanoplasty (ie, surgical repair of a perforated tympanic membrane) is not indicated for acute otitis externa because the tympanic membrane is not affected. Advising the client to stay home from school for the next week is not indicated because acute otitis externa is not contagious.

The nurse is caring for an 8-month-old client with suspected acute otitis media. Which of the following findings would be consistent with the condition? Select all that apply.

Educational Outcome: Acute otitis media (AOM) is caused by a blocked eustachian tube, which leads to buildup of purulent fluid and inflammation in the middle ear. It is one of the most common illnesses seen during childhood, occurring more often during the winter and typically after a viral respiratory infection. Children who recently began school, attend daycare, or live in a home with multiple family members are more likely to present with AOM. Manifestations of AOM include fever, inner ear pressure, ear pain, red and bulging tympanic membranes, and purulent drainage Children who are unable to verbally communicate pain may present as irritable/restless, moving the head from side to side, or pulling on the affected ear to try and relieve the pain Parents may also report a decrease in their child's oral intake or refusal to eat since chewing increases pain within the ear . Retracted tympanic membranes occur when there is negative pressure in the middle ear, which can occur with a blocked eustachian tube or as a complication of chronic infection. In AOM, the tympanic membrane will appear red and bulging due to purulent fluid build-up.

The nurse is assessing a 2-year-old client with acute otitis media. Which of the following actions would be appropriate for the nurse to take? Select all that apply.

Educational Outcome: Acute otitis media is caused by a blocked eustachian tube, which leads to a buildup of purulent fluid and inflammation in the middle ear. Manifestations include a red and bulging tympanic membrane, inner ear pressure (which can rupture the tympanic membrane if not treated), pain, and fever . Clients also may have rhinorrhea, nausea, or vomiting. The nurse should obtain assistance in restraining the client's arms and head during otoscopic examination to prevent injury to the ear canal if the client moves suddenly . The nurse should insert the speculum only as far as the outer cartilaginous part of the external auditory canal. Advancing the speculum into the bony interior part causes pain and could damage the tympanic membrane. When assessing a toddler (age 1-3), the nurse should use the otoscope last because it often distresses clients in this age group, especially when pain is present . Children age <3 have a more horizontal external auditory canal than older children and adults. The nurse should pull the pinna down and back in infants and toddlers.

The nurse receives the handoff of care report on four clients. Which client should the nurse see first?

Educational Outcome: Acute respiratory failure (ARF) is a life-threatening impairment of the lungs' ability to oxygenate blood and excrete carbon dioxide (CO2). ARF may occur from exacerbation of chronic (eg, chronic obstructive pulmonary disease, asthma) or acute (eg, pneumonia, pulmonary edema) illnesses. Nurses assessing for signs of ARF should consider both respiratory and neurological manifestations. Altered mental status (eg, confusion, agitation, somnolence) is a common and often overlooked symptom that may occur because of the brain's sensitivity to inadequate oxygenation and alterations in acid-base balance from retained CO2. Additional signs and symptoms may include paresthesias, dyspnea, tachypnea, and hypoxemia.

The nurse is talking with a client who has suspected acute rheumatic fever. Which of the following questions would be most important for the nurse to ask the client?

Educational Outcome: Acute rheumatic fever (ARF) is an inflammatory condition that occurs several weeks following untreated group A Streptococcus (GAS) infection (ie, strep throat). GAS infection triggers an autoimmune response, causing inflammation to multiple body systems (eg, cardiovascular, central nervous system, skin, musculoskeletal). Manifestations include fever, joint pain, erythematous rash, carditis, and involuntary jerking movements of the arms and legs.

The nurse plans discharge teaching for a client with active herpes lesions who has a new prescription for oral acyclovir and topical lidocaine. What information will the nurse include in the teaching plan?

Educational Outcome: Acyclovir (Zovirax), famciclovir, and valacyclovir are commonly used to treat herpes infection as they shorten the duration and severity of active lesions. Genital herpes is a sexually transmitted infection caused by a herpes simplex virus and is highly contagious, especially when lesions are active. It remains dormant in the body even when active lesions are healed. There is no cure for genital herpes; treatment is aimed at relieving symptoms and preventing the spread of infection. Touching the lesions and then rubbing or scratching another part of the body can spread the infection. Therefore, gloves should be used when applying topical antiviral or analgesic (eg, lidocaine) medications. Herpetic lesions should be kept clean and dry. They can be cleansed with warm water and soap or other solutions. Bandages are not applied to the lesions.

The nurse is assessing an older adult client and suspects the client may be experiencing elder mistreatment. Which of the following findings would be consistent with elder mistreatment? Select all that apply.

Educational Outcome: Additional manifestations include: Malnutrition, dehydration, or poor hygiene (eg, soiled clothing, matted hair) related to neglect Atypical abrasions, lacerations, or contusions (ie, irregular shape, various stages of healing) due to physical abuse Unfilled medication prescriptions, missed appointments, or unpaid expenses related to financial exploitation

The triage nurse receives a phone call from the parent of a child who has just spilled boiling water on the arm. Which of the following instructions by the nurse are appropriate for initial burn management? Select all that apply.

Educational Outcome: Administer acetaminophen or ibuprofen for pain control Briefly run cool or lukewarm water over the burn to relieve pain and stop the burning process. Avoid directly applying ice or using cold water, which may decrease oxygenation and increase tissue damage Lightly cover the burn area with a nonadhesive bandage to minimize infection risk Quickly remove clothing and jewelry around the burn area to avoid constriction during the initial edematous phase. A health care provider will remove any clothing that is stuck to the burn

The nurse is caring for a client who had an endoscopic procedure yesterday to stop upper gastrointestinal bleeding and who started a clear liquid diet today. Which of the following foods would be appropriate to offer to this client? Select all that apply.

Educational Outcome: After a client recovering from gastrointestinal surgery demonstrates adequate bowel function (eg, return of bowel sounds, passing flatus), dietary intake starts with consuming ice chips. If ice chips are tolerated (ie, free of nausea and vomiting), the postoperative diet progresses to clear liquids, full liquids, soft diet, and then regular diet. Apple juice, chicken broth, and unsweetened tea are appropriate food choices for a client on a clear liquid diet Clear liquids should be introduced slowly and in small amounts to minimize the risk of further gastrointestinal irritation, nausea, and vomiting. Fruit juices with red coloring (eg, cranberry, pomegranate) should not be given to clients with recent gastrointestinal bleeding. If a client vomits, the vomitus may appear red and falsely lead the nurse to believe that the client is bleeding. Red dye-containing foods (eg, red gelatin, cherry popsicles) should also be avoided.

A client diagnosed with end-stage renal disease comes to the dialysis clinic for treatment. Which actions should the nurse take to prepare the client for hemodialysis? Select all that apply.

Educational Outcome: After the client is connected to the dialysis machine, IV heparin is added to the blood from the client to prevent clotting that can occur when blood contacts a foreign substance. Giving subcutaneous heparin prior to initiation is not necessary

The nurse assesses a client with a history of cystic fibrosis who is being admitted due to a pulmonary exacerbation. Which assessment finding requires immediate action by the nurse?

Educational Outcome: Although impaired digestion and absorption cause frequent steatorrhea (fatty stool) episodes, clients with CF can develop distal intestinal obstruction syndrome (DIOS) from dehydrated, thickened mucus and stool. DIOS causes constipation and abdominal discomfort that can be resolved by rehydrating the stool (eg, polyethylene glycol).

The nurse is assessing a client with advanced amyotrophic lateral sclerosis. Which of the following assessment findings does the nurse expect? Select all that apply.

Educational Outcome: Amyotrophic lateral sclerosis (ALS, Lou Gehrig disease) is a debilitating neurodegenerative disease with no cure. ALS causes progressive degeneration of motor neurons in the brain and spinal cord. Physical symptoms include fatigue, progressive muscle weakness, twitching and muscle spasms, difficulty swallowing, difficulty speaking, and respiratory failure . Most clients survive only 3-5 years after the diagnosis as there is no cure. Treatment focuses on symptom management. Interventions include: Respiratory support with noninvasive positive pressure (eg, bilevel positive airway pressure [BiPAP]) or invasive mechanical ventilation (eg, via tracheostomy) Feeding tube for enteral nutrition Medications to decrease symptoms (eg, spasms, uncontrolled secretions, dyspnea) Mobility assistive devices (eg, walker, wheelchair) Communication assistive devices (eg, alphabet boards, specialized computers) Constipation due to decreased mobility is more common in ALS.

A licensed practical nurse is discussing assessment findings for several older adult clients with the registered nurse (RN). Which client is priority for the RN to assess?

Educational Outcome: An S3 sound is made when blood from the atrium is pumped into a noncompliant ventricle. S3 is heard after S2 (ventricular gallop). It may present as a normal finding in young adults. However, a new S3 in older adults is a significant finding as it may indicate development of volume overload or heart failure. These conditions require prompt intervention as they may rapidly progress to life-threatening events (eg, respiratory compromise, cardiogenic shock). This client may be receiving excessive IV fluids that are causing volume overload Other info: Repeated high gastric residual volumes (>250 mL) in clients receiving enteral feedings may indicate delayed stomach emptying and require adjustment to prevent nausea, vomiting, or abdominal distension

The nurse in the outpatient clinic is speaking with a client diagnosed with cerebral arteriovenous malformation. Which statement would be a priority for the nurse to report to the health care provider?

Educational Outcome: An arteriovenous malformation (AVM) is a tangle of veins and arteries that is believed to form during embryonic development. The tangled vessels do not have a capillary bed, causing them to become weak and dilated. AVMs are usually found in the brain and can cause seizures, headaches, and neurologic deficits. Treatment depends on the location of the AVM, but blood pressure control is crucial. Clients with AVMs are at high risk for having an intracranial bleed as the veins can easily rupture because they lack a muscular layer around their lumen. Any neurologic changes, sudden severe headache, nausea, and vomiting should be evaluated immediately as these are usually the first symptoms of a hemorrhage Other info The report of dyspnea may prompt further evaluation depending on the type of exercise performed, but it is not the priority. Clients with AVMs should be discouraged from engaging in heavy exercise as it increases blood pressure. Clients with AVMs should

The nurse is caring for a client who has just returned from external fixation device placement for stabilization of a fractured femur. Which of the following interventions are appropriate to include in the client's plan of care? Select all that apply.

Educational Outcome: An external fixator is a device used to stabilize broken bones; metal pins are placed through the tissue into the bone and connect to a frame outside the skin. The nurse should monitor clients with external fixation closely for signs of neurovascular compromise and pin site infection, which can lead to osteomyelitis. When caring for clients with external fixation, the nurse can help prevent infection and maintain extremity and device integrity by: Assessing the pin sites regularly for new, increased, and/or purulent drainage and checking the skin surrounding the pins for erythema, warmth, pain, or breakdown Assessing for signs of compartment syndrome (eg, decreased pulses, coolness, pain, numbness) Performing pin site care with a sterile cleaning solution (eg, chlorhexidine, sterile normal saline) and gauze Monitoring pins and device for loosening and reporting to the health care provider (HCP) if they are loose The nurse should promote early mobilization for clients with external fixation devices. Some clients may begin walking with physical therapy the day after surgery.

A client comes to the emergency department for the second time with shortness of breath and substernal pressure that radiates to the jaw. The nurse understands that angina pectoris may be precipitated by which of these factors? Select all that apply.

Educational Outcome: Angina pectoris is defined as chest pain brought on by myocardial ischemia (decreased blood flow to the heart muscle). Any factor that increases oxygen demand or decreases oxygen supply to cardiac muscle may cause angina, including the following: Physical exertion (eg, exercise, sexual activity): Increases heart rate and reduces diastole (time of maximum blood flow to the myocardium) Intense emotion (eg, anxiety, fear): Initiates the sympathetic nervous system and increases cardiac workload Temperature extremes: Usually cold exposure and hypothermia (vasoconstriction); occasionally hyperthermia (vasodilation and blood pooling) Tobacco use and second-hand smoke inhalation: Replaces oxygen with carbon monoxide; nicotine causes vasoconstriction and catecholamine release Stimulants (eg, cocaine, amphetamines): Increase heart rate and cause vasoconstriction Coronary artery narrowing (eg, atherosclerosis, coronary artery spasm): Decreases blood flow to myocardium

A client with aortic stenosis is scheduled for surgery in 2 weeks. The client reports episodes of angina and passing out twice at home. Which would be the best response by the nurse to explain the appropriate activity for this client at this time?

Educational Outcome: Aortic stenosis is the narrowing of the orifice between the left ventricle and aorta. Many clients with aortic stenosis are asymptomatic. Symptoms usually develop with exertion as the left ventricle cannot pump enough blood to meet the body's demands due to aortic obstruction (stenosis). These include dyspnea, angina, and, in severe cases, syncope (reduced blood flow to the brain). Clients usually do not experience symptoms at rest.

The nurse is teaching the parent of a 12-month-old client who had surgical repair of hypospadias 2 days ago. Which of the following statements by the parent would indicate correct understanding of the teaching? Select all that apply.

Educational Outcome: Appropriate postoperative care includes: Avoiding straddle toys (eg, toy rocking horse, bicycle) and strenuous activity until cleared by the surgeon Anticipating and treating bladder spasms with antispasmodic/anticholinergic medication (eg, oxybutynin) until the urinary catheter is removed Increasing oral fluid intake to maintain adequate urinary output and to counteract constipation from anticholinergics Administering pain medication and antibiotics as prescribed Placement of a temporary urinary diversion catheter is often used to support the patency and positioning of the new urethra. The catheter typically remains in place for 5 to 10 days following the revision procedure; it is not intended to remain in place longer.

The nurse is caring for a client with bacterial meningitis, identified as Neisseria meningitidis who has a stage 4 pressure injury. What personal protective equipment is most appropriate for the nurse to wear when performing a dressing change? Select all that apply.

Educational Outcome: Bacterial meningitis (eg, Neisseria meningitidis) and many respiratory illnesses (eg, influenza) are transmitted through large droplets of secretions spread into the air by coughing, sneezing, or talking. These droplets can land on surfaces up to 6 feet (1.8 meters) away from the client. Droplet precautions for routine care (eg, medication administration) require the use of a surgical mask, as the highest risk of transmission is through inhalation of droplets. Wearing a face shield, gown, and gloves is required if there is a risk of splash or contact with body fluids from procedural client care (eg, suctioning, wound care). Dedicated medical equipment (eg, stethoscope, blood pressure cuff) should remain in the room to limit spread of infection.

Which group of food selections would be appropriate for a client on a full liquid diet 3 days after bariatric surgery?

Educational Outcome: Bariatric surgery (eg, gastric banding, sleeve gastrectomy) reduces stomach capacity. A client's postoperative diet is restricted to foods low in simple carbohydrates and high in protein. After gastric surgery, consumption of simple carbohydrates can lead to dumping syndrome (ie, cramping, diarrhea). Initially, clients can consume only small meals of clear liquids. They may advance to full liquids, as tolerated (generally 24-48 hr after surgery), and progress to solid foods as the gastrointestinal tract heals. Small, frequent meals are recommended to avoid overstretching of the gastric pouch and to prevent nausea, vomiting, and regurgitation. The best food choices for a bariatric full liquid diet are cream soups, refined cooked cereal, sugar-free drinks, low-sugar protein shakes, and dairy foods. Fruit juices and puddings are high in sugar and not acceptable for a bariatric full liquid diet. Mashed potatoes are appropriate for soft diets. Ice cream is high in sugar and not acceptable for a bariatric full liquid diet. Eggs are appropriate for soft diets. Yogurt is high in sugar and not appropriate for a bariatric full liquid diet. Peanut butter is appropriate for soft diets.

A client underwent a transurethral resection of the prostate (TURP) today and has a 3-way Foley urinary catheter with continuous bladder irrigation (CBI). The client reports lower abdominal pain rated as an 8 on a scale of 0-10. What action should the nurse carry out first?

Educational Outcome: Blood and mucus can obstruct the Foley catheter if the CBI is not infused at a sufficient rate. Bladder pain will result from distention if the flow is obstructed. The nurse should ensure that there is adequate urinary drainage and no blockage from blood clots before treating the pain. If the urinary flow is obstructed, manual irrigation with sterile normal saline should be performed until there are no clots or the urine is clear/pink. Belladonna-opium suppositories or antispasmodics (eg, oxybutynin) are used for bladder spasms, an expected complication of the TURP procedure. Clients should be instructed not to urinate around the catheter as this would increase bladder pressure and spasms. Narcotics can be used for postoperative pain. If the urinary flow is adequate, a description of the pain would help to determine whether to give the client a narcotic or an antispasmodic. Before treating the resulting pain, the possibility of a physiological etiology for procedure-related pain (eg, blockage of urinary flow from blood clots) should be ruled out first. Large intestine peristalsis does not usually return for at least 24 hours. Intestinal pain is usually related to the presence of flatus. It is too soon for this to be the primary cause. An etiology related to the procedure should be ruled out first.

The nurse is assessing a client with cervical cancer. Which of the following findings would be consistent with the condition?

Educational Outcome: Bluish discoloration of the vagina and cervix (ie, Chadwick sign) is associated with pregnancy and is caused by an increase in vascularity.

The nurse is caring for a client with liver cirrhosis. Which of the following assessment findings would warrant immediate follow up?

Educational Outcome: Bright red, blood-streaked stool indicates hemorrhoids or rectal bleeding. Further evaluation of hemorrhoids can be safely delayed. Decreased bile flow into the intestine due to biliary tract obstruction (eg, cholelithiasis) produces a light gray "clay-colored" stool. This finding requires further evaluation but is not life-threatening. Small, dry, hard stool indicates constipation. Inactivity, decreased peristalsis, inadequate fiber intake, decreased fluid intake, and some medications (eg, anticholinergics, opioid analgesics) may contribute to constipation.

The nurse is assessing a client who has primary adrenal insufficiency (Addison disease). Which of the following findings is consistent with the condition?

Educational Outcome: Bronze hyperpigmentation of the skin in sun-exposed areas is caused by an increase in adrenocorticotropic hormone by the pituitary gland in response to low cortisol (ie, glucocorticoid) levels. Clients with Addison disease may also have vitiligo, or patchy/blotchy skin, which is usually present when the etiology of the disease is an autoimmune problem. The immune cells are thought to destroy melanocytes which produce melanin (or brown pigment), resulting in a patchy appearance.

A nurse is screening clients at a community health event. Which of the following client statements should the nurse recognize as a warning sign of cancer? Select all that apply.

Educational Outcome: Cancer is a growth of abnormal cells that can cause organ dysfunction and spread throughout the body (ie, metastasize). It is often difficult to identify early because some clients are asymptomatic or have only vague symptoms. However, nurses have an important role in early detection screening and should assess clients for, and immediately report, general warning signs of cancer using the mnemonic - CAUTION: C - Change in bowel or bladder habits A - A sore that does not heal U - Unusual bleeding or discharge from a body orifice T - Thickening or a lump in the breast or elsewhere I - Indigestion or difficulty swallowing that does not go away O - Obvious change in a wart or mole N - Nagging cough or hoarseness

The nurse in the emergency department is assessing a client who is reporting headache, nausea, and dizziness after being stranded at home without electricity during a winter storm. Which of the following questions would be most important for the nurse to ask the client?

Educational Outcome: Carbon monoxide (CO) is a colorless, odorless gas produced by burning fuel (eg, oil, kerosene, coal, wood) in a poorly ventilated setting. CO toxicity (poisoning) is most often associated with smoke inhalation from structure fires but is also generated by furnaces/water heaters fueled by natural gas or oil, coal or wood stoves, fireplaces, and engine exhaust. Clients with CO toxicity often have nonspecific symptoms (eg, headache, nausea, dizziness) and the diagnosis can be missed. It is important to assess for possible CO exposure to initiate appropriate emergency care and prevent hypoxic neurologic impairment. To help identify elevated CO levels in the home, the nurse can ask about the following: Similar symptoms in other family members or an illness in an indoor pet that developed at the same time. Fuel-burning heating/cooking appliances; the risk for CO toxicity increases in the fall and winter due to increased use of heat sources in an enclosed space

The nurse educator is completing a staff education conference about prenatal carrier screening. Which statement by a participant indicates a correct understanding of the genetic inheritance for cystic fibrosis?

Educational Outcome: Carrier screening offers clients who are unaffected by a genetic disorder the option to discover whether they possess an abnormal gene (ie, are carriers) that may affect health outcomes of future offspring. This type of genetic testing is frequently offered preconceptionally/prenatally to guide pregnancy decision-making. Cystic fibrosis follows an autosomal recessive inheritance pattern, meaning that offspring must receive two abnormal genes (one from each parent) to be affected with the disorder Other disorders following this inheritance pattern include phenylketonuria, Tay-Sachs disease, and sickle cell disease.

A client arrives at the clinic for a follow-up after an emergency department visit the night before. The client sustained an ulnar fracture, and a fiberglass cast was applied. Which of the following teachings related to cast care should the nurse reinforce? Select all that apply.

Educational Outcome: Casts (eg, fiberglass, plaster) are applied to immobilize fractured extremities during healing. Instructions for cast care include: Report foul odors or hot areas (hot spots) in the cast, which may indicate infection. Avoid getting the cast wet, which may damage the cast and cause skin irritation/infection. Elevate the affected extremity above heart level for the first 48 hours to reduce edema. Regularly perform isometric and range of motion exercises to prevent muscle atrophy. - The client should never insert objects inside the cast due to the risk of tissue injury and infection. Directing air inside the cast with a hair dryer on the cool setting may help relieve itching

The nurse is teaching clients at a community health fair about cataracts. Which of the following information should the nurse include? Select all that apply.

Educational Outcome: Cataracts occur when the normally clear ocular lens becomes opaque (ie, cloudy/white) and impairs visual acuity Cataracts most commonly develop due to age-related cellular changes in the eye; however, multiple environmental and personal risk factors (eg, ultraviolet light exposure, eye trauma, smoking) may cause or accelerate their development. When teaching clients about cataracts, the nurse should include the following information: Cataracts are generally painless, so new or worsening eye pain should be immediately evaluated to determine if a serious eye disorder (eg, glaucoma) has developed Cataracts may gradually increase lens cloudiness and cause blindness if left untreated Surgical replacement of the affected lens is the only curative treatment After cataract surgery, the health care provider may prescribe eye drops (eg, antibiotic drops, corticosteroid drops); however, unlike clients with increased intraocular pressure (ie, glaucoma), those with cataracts do not require long-term eye drop use, regardless of surgical intervention.

The nurse reviews a prescription to insert an indwelling urinary catheter in a hospitalized client. Which rationale for indwelling urinary catheter insertion is most appropriate?

Educational Outcome: Catheter-associated urinary tract infections are prevalent in hospital settings. Only indwelling urinary catheters should be used when appropriate. Appropriate uses include the following: Clients with urinary obstruction or retention, or a need for strict intake and output in critically ill clients Perioperative use for surgical procedures such as urologic surgery or prolonged surgeries, or when large doses of fluid or diuretics are given during surgery During prolonged immobilization when bedrest is essential To improve end-of-life comfort To facilitate healing of an open perineal or sacral wound in incontinent clients Inappropriate uses include the following: Convenience or replacement for nursing care when the client is elderly, confused, incontinent, or voids frequently For obtaining a urine culture when the client can follow instructions and void voluntarily Postoperatively for prolonged periods when other appropriate indications are not present

The nurse is screening clients for those at risk of developing syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should recognize that the client at highest risk for developing SIADH is a client with

Educational Outcome: Causes of SIADH include central nervous system disorders (eg, stroke, infection), medications (eg, selective serotonin reuptake inhibitors), and surgery. In addition, certain cancers (eg, small cell lung cancer) can produce and secrete ADH, leading to SIADH

The nurse is caring for an 18-month-old client who was born prematurely and has decreased muscle tone and delayed gross motor skills. The nurse should expect the client will receive an order for

Educational Outcome: Cerebral palsy (CP) is a neuromuscular disorder characterized by impaired posture and movement that results from brain injury before or after birth (up to age 2). Clients with CP commonly experience alterations in communication, behavior, and musculoskeletal integrity (eg, decreased muscle tone, delayed motor skills). Clients with risk factors for CP (eg, premature birth, brain injury) should be closely monitored to facilitate early implementation of supportive therapies (eg, physical therapy). CP is diagnosed based on client history, neurological examination findings, and neuroimaging (ie, MRI of the brain) A muscle biopsy can be used to diagnose muscular dystrophy (MD). However, clients with MD typically reach initial motor developmental milestones and lose function gradually as the disease progresses. - Although the client's symptoms could be indicative of brain cancer, a whole-body PET scan is typically performed after an MRI of the brain to evaluate for tumor metastasis. In addition, the client's history (eg, premature birth) is more concerning for CP.

The nurse is caring for a 4-year-old client with cystic fibrosis who uses a high-frequency chest wall oscillation (HFCWO) vest for chest physiotherapy. After reinforcing education with the client's parents, which statement by a parent requires further teaching?

Educational Outcome: Chest physiotherapy (CPT) describes techniques of airway clearance, which is an important component of treatment for clients with cystic fibrosis that loosens and drains thick respiratory secretions. CPT can be performed by percussing (ie, clapping) the chest with a cupped hand or by wearing an inflatable high-frequency chest wall oscillation (HFCWO) vest. The HFCWO vest inflates and deflates rapidly, causing vibration over the chest wall and mobilizing secretions into the large airways that the child can expectorate. The HFCWO vest's rapid vibrations may induce nausea and vomiting in some clients. Therefore, the client should avoid meals and snacks 1 hour before, during, or 2 hours following CPT to prevent gastrointestinal upset . The nurse may suggest other more appropriate ways to ensure compliance with CPT, such as allowing the child to watch a favorite television show or reading the child a story while wearing the HFCWO vest. Nebulized bronchodilators are often given before or during CPT treatments to open the airways and mobilize secretions. CPT can be administered using various methods, including percussion (ie, clapping) of the chest wall with cupped hands. CPT should be performed at least twice a day, and more often if needed.

The nurse is talking with the parent of a 5-year-old client about how to share details of the client's adoption. Which of the following thought processes would be consistent with the expected cognitive development of the client?

Educational Outcome: Children age 2-7 are in Piaget's preoperational stage of cognitive development. Children in the preoperational stage are developmentally capable of understanding adoption on a basic level; however, it may be difficult for them to understand the concept of having another family. At age 5, children may be unable to fully understand cause and effect (ie, poor causality) and therefore ascribe inappropriate causes to phenomena (eg, scraped knee was caused by earlier misbehavior). Children in the preoperational stage who are adopted may believe they are responsible for being adopted and can develop separation anxiety and a fear of abandonment

A client diagnosed with cirrhosis is experiencing pruritus. Which strategies are appropriate for the nurse to teach the client to promote comfort and skin integrity? Select all that apply.

Educational Outcome: Cholestyramine is a bile acid sequestrant used to block the reabsorption of bile acid in the intestine, thereby decreasing itching. It should be taken at least 1 hour after other medications because it can affect the absorption of many medication. Teaching for clients with pruritus secondary to cirrhosis includes the promotion of skin integrity. The nurse should encourage the client to cut nails short and use knuckles to alleviate itching when necessary. In addition, clients should implement measures to promote moisturization to soothe irritated skin Wool gloves and constricting garments (eg, tight stockings) can be irritating to itchy skin due to constant friction. Clients should be instructed to wear cotton gloves and loose, long-sleeved clothing, particularly during sleep.

The nurse is caring for a pediatric client with acute rheumatic fever who has developed chorea. The nurse should expect the client to have

Educational Outcome: Chorea is a manifestation of ARF characterized by involuntary jerking movements of the arms and legs. It may also affect the face, causing speech difficulty. Physical activity and grasping objects are often difficult for clients with chorea and increase the client's risk for injuries (eg, falls). The nurse should assist with activities of daily living as needed and encourage simple, age-appropriate activities that can be done while the client is resting in bed

The nurse is caring for a 68-year-old male client.

Educational Outcome: Chronic obstructive pulmonary disease (COPD) is a progressive, irreversible lower respiratory tract condition characterized by air trapping due to alveolar enlargement and/or airway obstruction due to inflammation and increased sputum production. Clinical manifestations include dyspnea, wheezing, chronic cough, barrel chest, fatigue, and extremity clubbing. An exacerbation of COPD occurs when symptoms acutely worsen beyond the client's baseline, often triggered by infection. Interventions for clients with a COPD exacerbation include: Collecting an expectorated sputum sample to test for an underlying respiratory infection. Requesting a prescription for an inhaled short-acting beta-adrenergic agonist (eg, albuterol) to open the airways and improve ventilation. Monitoring for changes in level of consciousness (eg, confusion, somnolence) because air trapping can lead to elevated carbon dioxide gas levels and narcosis. Monitoring the client's forced expiratory volume (ie, volume of air exhaled in one breath) to evaluate the degree of airway narrowing.

The nurse is teaching the parents of a newborn who had a circumcision using a plastic ring device 1 hour ago. Which of the following information should the nurse include?

Educational Outcome: Circumcision, the surgical removal of the foreskin from the penis, can be completed using the clamp method or plastic ring device. When the plastic ring device is used, a plastic rim is fitted over the glans penis, and a suture is tightly secured around the rim and foreskin. Following hemostasis, the excess foreskin is removed, leaving the plastic ring and suture in place until healing is complete. The nurse should teach the parents to monitor for signs of infection and keep the site clean by gently cleaning the penis with warm water during diaper changes to remove urine and stool - Removing the plastic ring device prematurely may result in circumcision site bleeding and impaired healing. The plastic rim and suture fall off independently once healing is complete (~1 week) - Applying petroleum jelly to the glans penis promotes healing and prevents wound adhesion after a clamp method circumcision. Petroleum jelly should not be applied to newborns after plastic ring device circumcision because it may cause premature detachment of the plastic rim

Clients at risk for aspiration pneumonia should avoid over-the-counter cold medications due to anticholinergic properties, which can cause decreased saliva (ie, xerostomia) production, and dry mouth. Saliva is a lubricant that helps bind food together to facilitate swallowing.

Educational Outcome: Client and family education is important for those with heart failure to prevent/minimize exacerbations, decrease symptoms, prevent target organ damage, and improve quality of life. The use of any nonsteroidal anti-inflammatory drugs (NSAIDS) is contraindicated as they contribute to sodium retention, and therefore fluid retention

The nurse is teaching a client diagnosed with Raynaud phenomenon about ways to prevent recurrent episodes. Which instructions should the nurse include? Select all that apply.

Educational Outcome: Client teaching regarding prevention of vasospasms includes: Wear gloves when handling cold objects. Dress in warm layers, particularly in cold weather. Avoid extremes and abrupt changes in temperature. Avoid vasoconstricting drugs (eg, cocaine, amphetamines, ergotamine, pseudoephedrine). Avoid excessive caffeine intake. Refrain from use of tobacco products. Implement stress management strategies (eg, yoga, tai chi) (Option 3).

The nurse has taught a client with myasthenia gravis. Which of the following statements by the client would require follow-up?

Educational Outcome: Clients should avoid factors that aggravate symptoms and may lead to myasthenic crisis, an exacerbation of MG due to disease progression caused by a deficiency in anticholinesterase. These factors include vigorous physical activity, emotional stress, respiratory infections, and temperature extremes (eg, sauna)

The nurse provides discharge instructions to a 67-year-old client with chronic bronchitis who was hospitalized for community-acquired pneumonia. Which instructions should be included in the discharge teaching plan? Select all that apply.

Educational Outcome: Clients should be taught to understand that symptoms of pneumonia (eg, cough, sputum production, shortness of breath, fatigue, and activity intolerance) remain after discharge even though the bacteria are no longer present and will dissipate over a 2-4 week period, depending on current health status and preexisting conditions. Discharge teaching includes the following instructions: Avoid the use of over-the-counter cough suppressant medicines. Unless prescribed by the HCP, cough suppressants are avoided as they impair secretion clearance, especially in clients with chronic bronchitis. Schedule a follow-up with the HCP and chest x-ray. Follow-up is needed at about 2 weeks after completion of antibiotic therapy. X-ray may be needed at a later time in certain high-risk clients to make sure the pneumonia is resolved with no underlying cancer. Use a cool mist humidifier in your bedroom at night. Humidifiers keep mucus membranes moist, maintain effectiveness of the mucociliary escalator, and facilitate expectoration of mucus. A warm bath also loosens the secretions. Continue using the incentive spirometer at home. Deep breathing and coughing promote lung expansion, ventilation, oxygenation, and airway clearance. Drink 1-2 liters of water a day, if not contraindicated, to help thin secretions and facilitate mobilization. Limit caffeine and alcohol as they can dry mucus membranes due to diuretic effects. Notify the HCP of any increase in symptoms (eg, shortness of breath, cough, sputum production, chest pain, fever, confusion). Avoid all tobacco products and second-hand smoke as these irritate the airways and impair mucociliary clearance and oxygenation. Eat a balanced diet, increase activity slowly over about 2 weeks, and take rest periods when needed to help maintain resistance to infection.

The nurse is caring for a client with newly diagnosed sickle cell disease.

Educational Outcome: Clients with SCD have chronic anemia due to the destruction and shortened lifespan of RBCs. Folic acid supplementation stimulates erythropoiesis (ie, RBC production) that is required to maintain an adequate number of RBCs. Ferrous sulfate is used to increase the hemoglobin level in clients with iron deficiency anemia. Clients with SCD have excess stores of iron from the release of iron when RBCs hemolyze and require multivitamins without iron.

The nurse is caring for a client who sustained a cervical spinal cord injury 1 hour ago and is paralyzed in all four extremities. Which of the following actions would be a priority for the nurse to take?

Educational Outcome: Clients with a cervical spinal cord injury (ie, injury at C1-C8) often have significant alterations in respiratory function because many respiratory muscles are innervated by nerve roots from the cervical spine. The degree of respiratory impairment depends on the level of spinal cord injury. Clients with a high cervical spinal cord injury (ie, above C3) are at risk for paralysis of the diaphragm because the diaphragm is innervated by cervical nerve roots from C3-C5. In the immediate period following a cervical spinal cord injury, the nurse should prioritize frequent, focused respiratory assessments. Signs of respiratory muscle paralysis (eg, shallow respirations, tachypnea) require emergency interventions (eg, intubation) to prevent respiratory arrest

The nurse is caring for a client who has acute pancreatitis. Which of the following assessment findings is most concerning? Click the exhibit button for additional client information.

Educational Outcome: Clients with acute pancreatitis are at risk for pancreatic abscess development. This mainly results from secondary infection of pancreatic pseudocysts or pancreatic necrosis. High fever, leukocytosis, and increasing abdominal pain may indicate abscess formation . The abscess must be treated promptly to prevent sepsis. The health care provider should be notified immediately as antibiotic therapy and immediate surgical management may be required. - Elevated blood glucose is an expected finding in clients with pancreatitis. Elevated blood glucose is associated with pancreatic dysfunction and may necessitate insulin administration, but this is not the most concerning finding. (even levels above 250)

The nurse is teaching the parent of a 2-year-old client who has acute streptococcal pharyngitis. Which of the following statements by the parent would indicate a correct understanding of the teaching? Select all that apply.

Educational Outcome: Clients with acute streptococcal pharyngitis may have difficulty eating due to pain with swallowing. Soft, not solid, foods and cool liquids should be offered to maintain adequate hydration . The full course of antibiotics must be completed to prevent reinfection and antibiotic resistance Toothbrushes should be replaced 24 hours after starting antibiotic therapy because bristles can harbor bacteria and cause reinfection Clients with streptococcal pharyngitis are considered no longer contagious and may return to daycare or school after completing 24 hours of antibiotic therapy and are afebrile. Warm salt water gargles can be offered to older clients but are a choking hazard for toddlers. Liquid preparations of acetaminophen or ibuprofen are preferred and may be given to help decrease discomfort and fever.

The nurse has taught a client with chronic obstructive pulmonary disease how to perform the huff cough technique. Select, in the correct order, the steps the client should take. All options must be used.

Educational Outcome: Clients with chronic obstructive pulmonary disease (COPD) often develop ineffective coughing patterns due to weakened muscles and narrowed airways prone to collapse under increased pressure. Therefore, clients with COPD are unable to cough effectively and require additional teaching to effectively expectorate secretions and prevent overexertion. Huff coughing is a series of low-pressure coughs using the following steps: Sit upright in a chair with the feet spread shoulder-width apart and lean forward with shoulders relaxed, forearms supported on the thighs or pillows, head and knees slightly flexed, and feet touching the floor Perform a slow, deep inhalation through the mouth or nose using the diaphragm Hold the breath for 2-3 seconds, keeping the throat open, and then perform a quick, forceful exhalation, creating an audible huff sound Repeat the huff once or twice more to expectorate any mucus, avoiding a normal cough Rest for 5-10 regular breaths and repeat as necessary until all mucus is cleared (Option 1).

The nurse is feeding a client who experienced a right-sided stroke and has dysphagia and hemianopsia. Which of the following actions would be appropriate for the nurse to take? Select all that apply.

Educational Outcome: Clients with dysphagia are at risk for aspiration and aspiration pneumonia. Dietary modifications and swallowing rehabilitation measures can reduce the risk of aspiration in clients who can tolerate oral feedings. Specific interventions include: Modifying food consistency (pureed, mechanically altered, soft) Placing food on the stronger side of the mouth to aid in bolus formation (Option 4) Thickening liquids Having the client sit upright at a 90-degree angle (Option 5) Tilting the chin down slightly to assist with laryngeal elevation and closure of the epiglottis Some clients who have experienced a stroke have a visual impairment such as hemianopsia; in this condition, a person sees only a portion of the visual field from each eye. A client who had a right-sided stroke may have left-sided hemianopsia. Having the client turn the head during a meal will help the client see everything on the plate - Controlling liquid intake through a straw is more difficult than drinking straight from a cup or glass and may cause choking.

The nurse is teaching about cervical cancer prevention at a women's health conference. Which of the following factors should be taught as risks for cervical cancer? Select all that apply.

Educational Outcome: Clients with weakened immunity (eg, HIV infection, immunosuppressive therapy) may have an impaired ability to clear HPV, which increases the risk for cervical cancer due to persistent infection

The nurse is caring for a 75-year-old client.

Educational Outcome: Clinical manifestations of DIC include external bleeding (eg, gums, nose, IV sites), internal bleeding (eg petechiae, ecchymosis), and organ damage from clot formation (ie, respiratory distress, renal insufficiency). Associated laboratory findings include decreased platelet count and fibrinogen level with prolonged clotting times (ie, PT, PTT). Care is supportive and focuses on treating the underlying cause. Anticipated interventions include: Initiating vasopressors (ie, norepinephrine infusion) to increase blood pressure and restore tissue perfusion Monitoring coagulation studies (eg, PT/PTT, fibrinogen, platelets) to assess the severity of DIC and evaluate the effectiveness of interventions Transfusing fresh frozen plasma and platelets for clients with severe bleeding to replace clotting factors and reduce blood loss

The nurse is caring for a client who has a suspected Clostridioides difficile infection. Which of the following actions should the nurse take? Select all that apply.

Educational Outcome: Clostridioides difficile is a gram-positive, anaerobic bacterium that causes widespread inflammation of the colon with profuse, watery diarrhea (usually nonbloody), abdominal pain and cramping, fever, and nausea. Antibiotic use (especially broad spectrum) can disrupt intestinal flora, increasing the risk for C difficile infection (CDI). Nursing interventions for clients with CDI include: Monitoring input and output because clients with CDI have persistent diarrhea (ie, at least three diarrheal episodes in 24 hr), increasing the risk for severe dehydration and hypovolemic shock Obtaining a stool specimen to test and confirm presence of C difficile Implementing contact precautions (eg, disposable gown and gloves, dedicated medical equipment, private room) to prevent transmission because C difficile spores can survive on surfaces for several months Administering antibiotics (eg, vancomycin, fidaxomicin) to treat the infection The presence of stool on the skin can lead to impaired skin integrity, urinary tract infection, and contamination of wounds. Skin barrier creams (eg, petrolatum, zinc oxide) should be used to protect perianal or perineal skin from breakdown, and stool should be removed promptly from the skin.

The nurse is talking with a group of clients about serotonin syndrome. Which of the following statements by a client would indicate an increased risk for developing serotonin syndrome? Select all that apply.

Educational Outcome: Combinations of medications that should be avoided due to the risk for serotonin syndrome include: St. John wort, an herbal supplement that mimics the action of SSRIs by increasing available serotonin in the brain, and an SSRI (eg, fluoxetine). Tramadol, an analgesic medication with serotonergic activity, and an SSRI (eg, sertraline). In addition, MAOIs enhance the serotonergic effects of SSRIs. Starting an SSRI (eg, citalopram) 1 day after stopping an MAOI (eg, phenelzine) does not provide an adequate break between medications. An adequate break when switching medications (ie, 2 weeks) is necessary to decrease the risk for serotonin syndrome. Lithium is a mood-stabilizing agent commonly prescribed for bipolar disorder. Lithium does not increase the risk for serotonin syndrome. Concurrent use of a stimulant (eg, methylphenidate) with a benzodiazepine (eg, alprazolam) does not increase the risk for developing serotonin syndrome.

The emergency department nurse cares for 5 clients. Which of the clients below are at risk for developing metabolic acidosis? Select all that apply.

Educational Outcome: Common causes of metabolic acidosis include: GI bicarbonate losses (eg, diarrhea) (Option 2) Ketoacidosis (eg, diabetes, alcoholism, starvation) Lactic acidosis (eg, sepsis, hypoperfusion) (Option 4) Renal failure (eg, hemodialysis with inaccessible arteriovenous shunt) (Option 5) Salicylate toxicity

The nurse is caring for a client who is experiencing perimenopause and asks about complementary and alternative therapies for hot flashes. Which of the following supplements should the nurse recommend to the client?

Educational Outcome: Complementary and alternative therapies that may be beneficial in relieving hot flashes include: Black cohosh: This herb may work by producing estrogen-like effects. However, black cohosh should be used cautiously in clients with liver dysfunction or estrogen-dependent cancers Soy products, wild yams, and red clover: These contain phytoestrogens that may stimulate estrogen receptors. These products should be avoided in clients with a history of breast, ovarian, or endometrial cancer. Peppermint oil may help relieve nausea and vomiting but is not an effective therapy for hot flashes. Echinacea may boost immune system function but is not an effective therapy for hot flashes. Ginger is anti-inflammatory that may reduce menstrual cramping but is not an effective therapy for hot flashes.

The nurse is caring for a client with posttraumatic stress disorder (PTSD). Which of the following findings should the nurse recognize as complications of PTSD? Select all that apply.

Educational Outcome: Complications of PTSD include: Substance use disorders (eg, alcohol use disorder, recreational substance use) (Option 1) Impaired intimate relationships (Option 2) Somatic complaints (eg, pain symptoms) (Option 3) Major depressive disorder (eg, depressed mood, loss of interest in usual activities) (Option 5)

The nurse is assessing a client with suspected umbilical cord prolapse. Which of the following findings would support a diagnosis of umbilical cord prolapse? Select all that apply.

Educational Outcome: Compression of the umbilical cord between the maternal pelvis and fetal presenting part causes a vagal response in the fetus, leading to fetal heart rate (FHR) abnormalities (eg, variable/prolonged FHR decelerations, bradycardia)

The nurse is caring for a 78-year-old client with a urinary tract infection (UTI). Which assessment finding would be most concerning and require immediate follow-up by the nurse?

Educational Outcome: Confusion is a common clinical manifestation of urinary tract infections in the elderly but still should be cause for concern and requires follow-up to rule out other possible causes. Confusion is not a normal finding in the elderly adult client. Some causes of confusion in the elderly include dehydration, lack of blood flow to the brain (stroke), decreased ability to metabolize medications, and concurrent infections.' Presbyopia is the decrease in ability to see objects close up. This is common in clients over age 40.

When monitoring an infant with a left-to-right-sided heart shunt, which findings would the nurse expect during the physical assessment? Select all that apply.

Educational Outcome: Congenital heart defects that cause blood to shunt from the higher pressure left side of the heart to the lower pressure right side (eg, patent ductus arteriosus, atrial septal defect, ventricular septal defect) increase pulmonary blood flow. Left-to-right shunting results in pulmonary congestion, causing increased work of breathing and decreased lung compliance. Compensatory mechanisms (eg, tachycardia, diaphoresis) result from sympathetic stimulation. Clinical manifestations of acyanotic defects may include: Tachypnea Tachycardia, even at rest Diaphoresis during feeding or exertion Heart murmur or extra heart sounds Signs of congestive heart failure Increased metabolic rate with poor weight gain

The nurse is observing a staff member caring for a client who has cellulitis of the right lower leg. There is clear fluid seeping from the affected area. The nurse should intervene if the staff member is observed

Educational Outcome: Daily marking and dating of reddened areas assists with monitoring improvement or worsening of the condition. Redness that progresses past the marked areas indicates worsening of the condition and should be reported to the health care provider. - The nurse should ensure that the affected extremity is elevated to reduce edema

The home health nurse has reviewed the most recent laboratory test results for a client with chronic kidney disease. Which of the following would be an appropriate afternoon snack to recommend for the client? Click on the exhibit button for additional information.

Educational Outcome: Dairy products (eg, milk, yogurt) and certain fruits (eg, bananas, oranges) are high in potassium and phosphorus. Recommended foods for a client with CKD include oatmeal and apple slices, which are low in sodium, potassium, and phosphorus (Option 3). (Options 1, 2, and 4) Avocados are high in potassium; chips may be high in sodium. Milk and pudding are dairy products that are high in phosphorus and potassium.

The nurse is screening newborns for those at risk for developing developmental dysplasia of the hip (DDH). Which of the following factors would increase a newborn's risk for DDH?

Educational Outcome: Developmental dysplasia of the hip (DDH) is a hip abnormality that ranges from mild dysplasia of the hip joint to full dislocation of the femoral head that may be present at birth or develop during the first few years of life. The exact cause of DDH is not known, but there are several risk factors. Clients should be swaddled with the hips bent up (flexion) and out (abduction), allowing room for hip movement and normal hip development. Tightly swaddling the lower extremities adducts and extends the hips and causes the femur head to become dislocated out of the acetabulum Large for gestational age and macrosomia (ie, birth weight > 8 lb 13 oz [4000 g]), not low birth weight, are associated with an increased risk for DDH. Breech presentation is when the fetal buttocks or feet present, causing the hips to be abnormally positioned, thereby increasing the risk for DDH. Cephalic presentation is the ideal position for birth and is not associated with DDH.

The nurse is caring for an elderly client who has type 2 diabetes mellitus and has just been diagnosed with diabetic retinopathy. Which statement by the client requires the most immediate action by the nurse?

Educational Outcome: Diabetic retinopathy occurs due to microvascular damage to the retina resulting from chronic hyperglycemia (eg, diabetes mellitus). Diabetic retinopathy can lead to retinal detachment - Decreased vibrancy of colors is a sign of diabetic retinopathy but does not indicate retinal detachment; therefore, it is not an emergency

The nurse is talking with a client with chronic obstructive pulmonary disease who is reporting recent weight loss. The client states that bloating, exhaustion, and dyspnea make eating difficult. Which of the following responses would be appropriate for the nurse to make? Select all that apply.

Educational Outcome: Drink fluids between meals, rather than before or during, to prevent stomach distension and decrease pressure on the diaphragm while eating - Although exercise (eg, walking) can help stimulate appetite, clients with COPD should refrain from exercise for at least 1 hour before and 1 hour after eating because it increases oxygen demand and fatigue.

The nurse is caring for a group of clients. Which finding requires immediate action by the nurse?

Educational Outcome: During IV therapy, the nurse should monitor the site to assess for patency and signs of infection (eg, redness, drainage, edema, discomfort, warmth, coolness, hardness). Infiltration is a complication that occurs when solution infuses into the surrounding tissues of the infusion site. Interventions include: Discontinuing the IV line immediately and starting a new IV, preferably on the opposite extremity Continuing to monitor the infiltration site for swelling or other abnormalities (eg, redness, warmth, coolness) Elevating the affected extremity to decrease swelling Notifying the health care provider if severe complications (eg, cellulitis, tissue necrosis, nerve damage) develop Applying a cold or warm, moist compress based on the solution infiltrated. Heat is avoided when extravasation of a vesicant (ie, drug capable of causing tissue necrosis) occurs. Other info: -Peripheral IV sites should be changed no more frequently than every 72-96 hours unless complications develop. This client's IV line will likely be discontinued at discharge and is not the highest priority.

The nurse assesses a client during the dwell time of a peritoneal dialysis cycle. Which assessment would require immediate intervention?

Educational Outcome: During peritoneal dialysis, dialysate is infused into the abdominal cavity and the tubing is then clamped to allow the fluid to dwell for a specified period. After the dwell time, the catheter is unclamped and the fluid drains out via gravity. During the installation and dwell portions of the cycle, clients are monitored closely for indications of respiratory distress (eg, difficulty breathing, rapid respirations, crackles) that can result from instilling the dialysate too rapidly, overfilling of the abdomen, or fluid entering the thoracic cavity . Crackles can also occur if over time there is more dialysate infused than is removed (fluid gain). Clients receive peritoneal dialysis due to chronic kidney failure. The client's blood pressure is likely elevated secondary to the renal failure. This

When admitting a client who had an anterior wall ST-elevation myocardial infarction to the cardiac stepdown unit, which intervention should the nurse perform first?

Educational Outcome: Dysrhythmias are the most frequent complication following myocardial infarction (MI). Ventricular fibrillation is the most common of these dysrhythmias and is regularly the cause of sudden cardiac death in clients with MI. The nurse should attach the cardiac monitor to the client before performing any other interventions. If ventricular tachycardia or premature ventricular contractions (PVCs) are observed, the client should be treated quickly (with antidysrhythmic drugs) as these rhythms usually precede ventricular fibrillation; early identification and treatment are imperative to improve outcomes. ST segment should also be monitored as reinfarction may occur; the client may or may not have the usual MI-related symptoms (eg, chest pain, shortness of breath, vomiting).

The nurse is caring for a 50-year-old client in the clinic. The client's annual physical examination revealed a hemoglobin value of 10 g/dL (100 g/L) compared to 13 g/dL (130 g/L) a year ago. What should be the nurse's initial action?

Educational Outcome: Early signs of colorectal cancer are usually nonspecific and include fatigue, weight loss, anemia, and occult gastrointestinal bleeding. Clients should have regular screening colonoscopy for colon cancer starting at age 45 if their risk is average or earlier if their risk is high. Colorectal screening can also include fecal occult blood test or fecal immunochemical test annually. New-onset anemia should be taken seriously at this client's age, and colon cancer must be ruled out. The etiology of anemia must be determined prior to recommending treatment. The cause of anemia must be determined before recommendations can be provided for iron deficiency. There are many causes of anemia (including pernicious anemia) in older adults that involve deficiencies in vitamin B12, not iron.

The nurse is caring for assigned clients. The nurse should first assess the client who had

Educational Outcome: Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure in which an endoscope is passed through the mouth into the duodenum to assess the pancreatic and biliary ducts. Using fluoroscopy with contrast media, the ducts can be visualized and treatments, including removal of obstructions, dilation of strictures, and biopsies, can be performed. Perforation or irritation of these areas during the procedure can cause acute pancreatitis, a potentially life-threatening complication of ERCP. Signs and symptoms include acute epigastric or left upper quadrant pain, often radiating to the back, and a rapid rise in pancreatic enzymes (eg, amylase, lipase) The barium contrast solution used during the procedure may make the client's stool white for up to 3 days. The nurse should encourage fluids, if appropriate, to assist in expulsion of the contrast medium. Abdominal cramps can occur after a colonoscopy due to air insufflation during the procedure. Burning with urination and blood in the urine (eg, pink tinge) are typical after a cystoscopy. The nurse should instruct the client to report bright red blood or clots.

The nurse has taught the parent of a school-aged client with erythema infectiosum (Fifth disease). Which of the following statements by the parent would require follow-up?

Educational Outcome: Erythema infectiosum (Fifth disease) is a viral illness of childhood caused by the human parvovirus B19, which affects mainly school-aged children. The initial symptoms are nonspecific and include fever, headache, diarrhea, lethargy, and itching. The client then develops a distinctive red, slapped face rash that appears on the cheeks; once the rash appears, the client is no longer contagious. Following development of the rash on the face, a maculopapular rash develops on the trunk, extremities, hands, and feet. Clients typically recover within 7 to 10 days; however, the rash may remain for up to 3 weeks. Anti-inflammatory and antipyretic agents (eg, ibuprofen, acetaminophen) may be administered to relieve fever, joint pain, and itching. Clients should be taught to cover the mouth and nose when coughing or sneezing because the virus spreads via respiratory secretions.

A newborn is being evaluated for possible esophageal atresia with tracheoesophageal fistula. Which finding is the nurse most likely to observe?

Educational Outcome: Esophageal atresia (EA) and tracheoesophageal fistula (TEF) consist of a variety of congenital malformations that occur when the esophagus and trachea do not properly separate or develop. 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 with surgery. Clinical manifestations of EA/TEF include frothy saliva, coughing, choking, and drooling. Clients may also develop apnea and cyanosis during feeding (Option 1). Aspiration is the greatest risk for clients with EA/TEF, and newborns who demonstrate signs of the condition are immediately placed on nothing by mouth (NPO) status.

Place the nursing actions for performing a renal system physical assessment in the correct order. All options must be used.

Educational Outcome: Examination of the urinary system requires an abdominal assessment. Therefore, assessment techniques must be reordered to optimize the examination. The steps for a renal system assessment are: Empty the bladder to avoid discomfort during percussion and palpation and to provide a clean-catch sample (if prescribed) Inspect the abdomen and lower back for color, contour, symmetry, distension, and movements (eg, visible peristalsis). Inspection is always done first during physical examination . The nurse should auscultate immediately after inspection as percussion or palpation may increase bowel motility and interfere with sound transmission during auscultation. Listen for renal artery bruits in the right and left upper abdominal quadrants . Percuss for kidney borders, costovertebral angle tenderness, and bladder distension. A dull percussion sound indicates solid structures or fluid-filled cavities (eg, distended bladder). Palpate for bladder distension, masses, and tenderness. A distended bladder may be palpated at any point from the symphysis pubis to the umbilicus and is felt as a firm, rounded organ. A normal kidney is not usually palpable; a palpable kidney may indicate hydronephrosis or polycystic kidney disease . Document all renal assessment findings immediately after the examination .

The nurse is planning care for a client with Graves disease who is experiencing exophthalmos. Which of the following interventions should the nurse include in the client's plan of care? Select all that apply.

Educational Outcome: Exophthalmos is a complication of Graves disease. It is defined as a protrusion of the eyeballs caused by increased orbital tissue expansion (eg, connective, adipose, muscular) and can be irreversible. The exposed cornea is at risk for dryness, injury, and infection. Nursing care for a client with exophthalmos includes: Using artificial tears or other similar products to moisten the eyes and prevent corneal drying (which causes abrasions/ulcers) Taping the client's eyelids shut during sleep if they do not close on their own Maintaining the head of the bed in a raised position to facilitate fluid drainage from the periorbital area Administering prescribed corticosteroids to reduce periorbital swelling Client teaching includes: Making regular visits to an ophthalmologist to measure eyeball protrusion and evaluate the condition Using dark glasses to decrease glare and prevent external irritants and infection Restricting dietary sodium intake to decrease periorbital edema The client should perform intraocular muscle exercises (turning the eyes using complete range of motion) to maintain flexibility.

The nurse is screening clients for those at risk for developing a hiatal hernia. Which of the following factors would increase a client's risk for developing a hiatal hernia? Select all that apply.

Educational Outcome: Factors that increase pressure within the abdominal cavity or weaken muscles within in the diaphragm contribute to the formation of hiatal hernias, including: Obesity (eg, BMI > 30.00 kg/m2) (Option 1) Frequent heavy lifting (Option 2) Advanced age (Option 4) Pregnancy (Option 5) Tumors - Hiatal hernias occur more often in clients of the female

The nurse is reviewing the medical record of a 4-year-old client with failure to thrive. Which of the following risk factors likely contribute to the client's condition? Select all that apply.

Educational Outcome: Failure to thrive (FTT) describes a client with poor growth due to inadequate caloric intake, inadequate food absorption, or excess caloric expenditure. In children, a weight that is <80% of ideal weight for height, weight that is below the 3rd to 5th percentile on growth charts, or persistent decrease in growth over time on growth charts support the diagnosis of FTT. Causes of FTT are typically multifactorial but may be related to certain medical conditions (eg, low birth weight, prematurity, congenital anomalies) or influenced by psychosocial risk factors, including: Domestic violence in the home and/or history of child neglect or abuse Caregiver or child with negative attitudes toward food (eg, fear of obesity, anorexia, food restriction) Poverty or food insecurity (which is the greatest risk factor) ( Disordered feeding behaviors (eg, unstructured mealtimes)

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

Educational Outcome: Family or personal history of skin cancer (Option 1) Celtic ancestry traits (eg, light skin, red or blond hair, blue or green eyes, many freckles) Aging Atypical or high number of moles because some skin cancers develop from pre-existing moles Immunosuppression (eg, immunosuppressant medications, HIV), which lowers the body's ability to defend against cancerous mutations Ultraviolet light exposure (eg, chronic sun exposure, outdoor occupation, tanning bed use, history of severe sunburns)

The health care provider suspects fat embolism syndrome in a client who has a long bone fracture in the right lower extremity. Which of the following assessment findings does the nurse expect to support this diagnosis? Select all that apply.

Educational Outcome: Fat embolism syndrome (FES) is a rare, life-threatening complication related to bone fractures, typically of the pelvis or long bones. FES occurs when fat globules travel through the bloodstream and obstruct small blood vessels, causing impaired circulation and ischemia. The lungs, brain, and skin are most often affected, leading to acute respiratory distress and neurologic impairment. Clinical manifestations of FES include: Neurologic changes (eg, altered mental status, confusion, restlessness) due to cerebral embolism and hypoxemia (Option 1) Respiratory distress (eg, dyspnea, tachypnea, hypoxemia) after a fat embolus travels through the pulmonary circulation and lodges in a pulmonary capillary, leading to impaired gas exchange and acute respiratory failure, similar to a pulmonary embolism Petechial rash (ie, pin-sized purplish spots that do not blanch with pressure), which appears on the neck, chest, and axilla due to microvascular occlusion; this defining characteristic differentiates a fat embolus from a pulmonary embolism Increasing pressure and paresthesia (eg, numbness, tingling, burning) of the affected extremity are assessment findings indicative of compartment syndrome, not FES.

The nurse is planning a staff education program about fetal alcohol syndrome (FAS). Which of the following should the nurse include as clinical manifestations of FAS? Select all that apply.

Educational Outcome: Fetal alcohol spectrum disorder (FASD) refers to a group of disorders caused by prenatal alcohol exposure that can result in permanent physical, developmental, and cognitive abnormalities. Fetal alcohol syndrome (FAS) is the most severe form of FASD, with manifestations throughout the lifespan that include: Microcephaly (ie, small head circumference) at birth 3 hallmark facial anomalies (eg, smooth philtrum, short palpebral fissures, thin upper lip) Impaired fine and gross motor development (eg, poor handwriting, coordination deficits) Difficulty feeding during infancy due to a weak suck reflex Poor social skills (eg, lack of social cues, social withdrawal) Hyperactivity, learning disabilities, and difficulty regulating emotions

The nurse is reinforcing discharge instructions with a client following a partial gastrectomy. Which of the following instructions should the nurse include to prevent dumping syndrome? Select all that apply.

Educational Outcome: Following 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. The symptoms usually diminish over time. Recommendations to delay gastric emptying include: Consume meals high in fat, protein, and fiber, which take more time to digest and remain in the stomach longer than carbohydrates . These foods also help meet the body's energy needs. Avoid consuming fluids with meals because this causes stomach contents to pass faster into the jejunum, which worsens symptoms. Fluid intake should occur up to 30 minutes before or after meals. Slowly consume small, frequent meals to reduce the amount of food in the stomach. Avoid meals high in simple carbohydrates (eg, sugar, syrup) because these may trigger symptoms when the carbohydrates break down into simple sugars. Avoid sitting up after a meal because gravity increases gastric emptying. Instead, lying down after meals is encouraged

A client is being discharged home after an open radical prostatectomy. Which statement indicates a need for further teaching?

Educational Outcome: Following open radical prostatectomy, any rectal interventions such as suppositories or enemas must be avoided to prevent stress on the suture lines and problems with healing in the surgical area. The client should not strain when having a bowel movement for these reasons. Therefore, interventions to prevent constipation are an important part of postoperative care and discharge teaching. Prevention of constipation is particularly important while the client remains on opioid analgesics, which can cause constipation

The nurse is caring for a client who sustained a traumatic brain injury during a fall. Which of the following findings would require follow-up? Select all that apply.

Educational Outcome: Following traumatic brain injury (TBI), clients should be closely monitored for signs of increased intracranial pressure (ICP). Increased ICP results from cerebral swelling or hematoma formation caused by shearing forces during trauma. If left untreated, ICP will continue to increase, which may decrease cerebral perfusion and cause cerebrovascular ischemia, cranial nerve compression, seizure, coma, and death. An acute alteration in level of consciousness (eg, increased drowsiness) is the earliest sign of increased ICP Cranial nerve functions will become impaired as ICP increases, as evidenced by fixed or dilated pupils (cranial nerve III). Brainstem and motor cortex impairment may also be suspected if muscle flaccidity or posturing (eg, decerebrate, decorticate) is present. Projectile vomiting is an urgent sign of increased ICP.A classic but late sign of increased ICP, and one that is often fatal, is Cushing triad (eg, widening pulse pressure, bradycardia, and hypertension). Acute amnesia (ie, loss of memory), pertaining to the events shortly before and after the injury, is common and not an urgent finding.

The nurse preparing an educational seminar on sexually transmitted infections for female college students should advise that which 2 infections are leading causes of pelvic inflammatory disease and infertility?

Educational Outcome: Gonorrhea and chlamydia can lead to pelvic inflammatory disease (PID) and infertility. They are referred to as "silent infections" because many affected women show no symptoms. Infections of the fallopian tubes and uterus can lead to permanent damage and infertility. The Centers for Disease Control and Prevention recommend annual chlamydia and gonorrhea screening for all sexually active females age <25 and older females with risk factors. Both chlamydia and gonorrhea are treatable.

The nurse is caring for a 45-year-old client in the emergency department.

Educational Outcome: Guillain-Barré syndrome (GBS) usually follows a respiratory or gastrointestinal infection (eg, gastroenteritis) that triggers an immune response, resulting in peripheral nerve inflammation. - Guillain-Barré syndrome is characterized by ascending, symmetric muscle paralysis and areflexia that can eventually progress to involve the thorax and cranial nerves. The nurse should monitor for autonomic dysfunction (eg, blood pressure variability, urinary retention, ileus), difficulty swallowing, and signs of impending respiratory failure (eg, dyspnea, shallow respirations).

The nurse is caring for a client who is receiving hemodialysis. The client reports dyspnea, chest pain, and severe anxiety. Which of the following actions should the nurse take first?

Educational Outcome: Hemodialysis (ie, renal replacement therapy) involves filtering blood in a closed system outside the body for the treatment of chronic kidney disease. Blood is passed through a semipermeable membrane with dialysis solution (ie, dialysate), which creates an osmotic gradient that filters blood, removes excess fluid and waste (ie, urea), and corrects electrolyte imbalances. Air embolism is a life-threatening complication of hemodialysis that occurs when air enters the blood stream through the hemodialysis catheter. The air embolism displaces blood in the pulmonary vessels, causing dyspnea, chest pain, severe anxiety, changes in sensorium, hypotension, and reduced oxygen saturation. The nurse should immediately clamp the access tubing to prevent additional air from entering circulation and should apply oxygen to relieve dyspnea

The nurse has taught a female client who has genital warts caused by human papillomavirus (HPV) infection. Which of the following statements by the client would indicate a correct understanding of the teaching? Select all that apply.

Educational Outcome: High-risk HPV strains (eg, types 16 and 18) increase the risk for oral, anogenital, and cervical cancers.

A community mental health nurse is a member of a mobile crisis team providing services to victims of a category 4 hurricane. Of these strategies, which would be the priority action for the team to utilize in reaching those who need mental health services?

Educational Outcome: However, finding and reaching potential clients and family members in the aftermath of a disaster can be challenging because: Clients may not know where or how to seek help Clients may be afraid or unable to leave their homes Telephone services and other lines of communication may be disrupted Potential clients may leave their homes and go to shelters or alternate housing Transportation may be severely limited It is essential to coordinate outreach efforts to maximize resources and avoid duplication of services and/or inefficiency in providing services. The mobile crisis team's priority action is to check in with the local command center, then to assist in planning outreach strategies with other community agencies, and receive assignments.

The nurse is assessing a client with suspected kidney disease who is scheduled for a kidney biopsy today. Which of the following findings may cause the procedure to be delayed?

Educational Outcome: Hypertension increases renal arterial pressure, which increases the risk for postprocedure bleeding. Therefore, blood pressure must be lowered and well controlled (goal: <140/90 mm Hg) before performing a kidney biopsy Other info: A decreased calcium level can be expected in a client with suspected kidney disease because damaged kidneys are less able to convert vitamin D3 into its active form, which leads to reduced intestinal absorption of calcium.

The nurse is assessing a newborn with hypertrophic pyloric stenosis. Which of the following findings would be consistent with the condition?

Educational Outcome: Hypertrophic pyloric stenosis is thickening of the pylorus muscle that blocks the passage of gastric contents into the intestines, resulting in postprandial (ie, after meals) projectile vomiting . Emesis is nonbilious because gastric contents (eg, breastmilk, formula) are unable to reach the intestines. Without intervention (ie, pyloromyotomy, fluid resuscitation), vomiting can lead to hypovolemia, alterations in electrolytes (eg, hypokalemia), and acid-base imbalances (eg, metabolic alkalosis). Clinical manifestations of hypertrophic pyloric stenosis include: irritability from persistent hunger despite regular feedings dehydration failure to thrive/malnutrition decreased stool formation a palpable, olive-shaped epigastric mass over the pyloric sphincter Congenital aganglionic megacolon (ie, Hirschsprung disease) is a disorder in which sections of the bowel are not properly innervated, resulting in constipation and obstruction in the distal rectosigmoid segment of the colon. Manifestations include increasing abdominal girth.

The nurse prepares to assess a newly admitted client with alcohol use disorder whose laboratory report shows a decreased magnesium level. Which assessment finding does the nurse anticipate?

Educational Outcome: Hypomagnesemia, a low blood magnesium level (normal 1.3-2.1 mEq/L [0.65-1.05 mmol/L]), is associated with alcohol use disorder due to poor absorption, inadequate nutritional intake, and increased losses via the gastrointestinal and renal systems. It is associated with 2 major issues: Ventricular dysrhythmias (eg, torsades de pointes): This is the most serious concern (priority). Neuromuscular excitability: Manifestations of low magnesium, similar to those found in hypocalcemia and demonstrated by neuromuscular excitability, include tremors, hyperactive reflexes, positive Trousseau and Chvostek signs, and seizures. Other info: Hypokalemia results in muscle weakness/paralysis and soft, flaccid muscles. Paralytic ileus (abdominal distension, decreased bowel sounds) is also common with hypokalemia. However, the most serious complication is cardiac arrhythmias.

The nurse is assessing a client with liver disease who has a decreased serum albumin level. Which of the following findings is associated with a decreased serum albumin level?

Educational Outcome: In clients with liver cirrhosis, albumin synthesis is decreased due to altered hepatic function. Decreased serum albumin (ie, hypoalbuminemia) leads to decreased oncotic pressure, causing fluid to shift from the vascular space into the interstitial space, which results in pitting edema and ascites Jaundice (ie, yellowing of the sclera/skin), easy bruising, and loss of body hair are manifestations of liver disease, not hypoalbuminemia. Jaundice occurs when excessive unconjugated bilirubin, a product of RBC breakdown, accumulates in the blood. Easy bruising is caused by the liver's inability to produce prothrombin and other clotting factors. Loss of body hair is due to altered hormone metabolism.

The nurse is reviewing laboratory test results for a client with severe chronic obstructive pulmonary disease. The nurse should anticipate that the test results will indicate

Educational Outcome: Ineffective gas exchange in clients with COPD causes hypoxemia (ie, low blood oxygen level). To compensate, the body produces more RBCs to carry needed oxygen to the cells. An elevated RBC count indicates polycythemia

The nurse in the outpatient clinic is talking with a client with newly diagnosed influenza. The client asks, "How many days do I need to avoid contact with others?" Which of the following responses would be most appropriate for the nurse to make?

Educational Outcome: Influenza is a contagious viral infection that affects the respiratory tract. Symptoms include fever, chills, severe muscle aches, headache, cough, sore throat, nasal congestion, and malaise. Treatment includes rest, humidified air, and antipyretics/analgesics. The incubation period for the influenza virus is 1-4 days. The period of highest transmission usually occurs 1 day before symptoms begin and continues for at least 5-7 days after the illness stage begins

The charge nurse must transfer multiple clients from the critical care unit to make beds available after a mass casualty event. Which of the following clients could the charge nurse appropriately transfer to the medical-surgical unit? Select all that apply.

A client who had a stroke 5 days ago and now has a residual sequela (eg, dysarthria [impaired speech])

The nurse is observing a staff member administer nasal drops to a client. It would require follow-up if the staff member is observed

Administration of medication using nasal drops is indicated to directly treat mucosa in sinus conditions (eg, infection, congestion). Appropriate administration of nasal drops includes: Confirming which sinus cavity (eg, sphenoid, maxillary) requires treatment Positioning the client supine with the head tilted back Holding the dropper approximately ½ inch (1 cm) above the client's nares, avoiding contact with the inside of the nose to prevent bacterial contamination of the dropper Instructing the client to remain supine for 1-5 minutes to allow medication absorption

The nurse is teaching the parent of a pediatric client who has atopic dermatitis. Which of the following statements by the parent would indicate a correct understanding of the teaching?

Educational Outcome: The primary goals of management are to alleviate pruritus and keep the skin hydrated to reduce scratching. High environmental temperatures can cause further dryness of the skin; time spent

The nurse is teaching a client with newly diagnosed interstitial cystitis. Which of the following information should the nurse include? Select all that apply.

Appropriate self-care measures for clients with IC include: Avoiding tobacco products along with carbonated and caffeinated beverages (eg, coffee, tea); they may irritate the bladder and worsen exacerbations Practicing stress-reduction techniques (eg, relaxation breathing) to manage current exacerbations and reduce future occurrences - Foods and drinks high in vitamin C (eg, citrus fruits) are bladder irritants and should be avoided by clients with IC to prevent exacerbations.

The nurse is preparing to administer a tuberculin skin test (TST) to a client. Which of the following statements by the client would require follow-up prior to administering the TST?

Clients who have previously tested positive for TB will likely test positive in the future and there is usually no need to repeat the test - Clients who receive a live attenuated measles, mumps, and rubella vaccine should wait 1 month before receiving a TST because of the risk for a false-negative test.

The nurse in the outpatient care facility is caring for a 6-year-old client.

Educational Outcome: Atopic dermatitis (AD) (ie, eczema) is a noncontagious, chronic skin condition characterized by pruritic, dry, erythematous, scaly skin often in the bilateral antecubital spaces and behind the knees. - Monitoring for signs of secondary infection (eg, fever, honey-colored crusts)

A 62-year-old client is scheduled for open abdominal aneurysm repair. What key assessment should be made by the nurse preoperatively?

Educational Outcome: Comparison of blood pressures in each arm may be helpful in an assessment of an upper aortic dissection or congenital aortic coarctation, but not in assessing an abdominal aortic aneurysm.

The nurse is caring for a client who had abdominal surgery 4 days ago and reports sudden abdominal pain after coughing. The nurse notes the finding shown below. Which of the following actions should the nurse take first?

Evisceration is a medical emergency that occurs when a wound opens (ie, dehiscence) and internal organs protrude through the wound. This occurs mostly in clients at risk for impaired wound healing (eg, diabetes mellitus, obesity, malnutrition). The priority nursing action for a client with evisceration involves placing saline-soaked sterile gauze over the protruding organs to prevent drying out of the organs, impaired perfusion, infection, or potential shock until surgical intervention is performed

The nurse is caring for a client who is experiencing an acute stroke and is receiving thrombolytic therapy. The client develops tachycardia and vomits a large amount of bright red blood. Which of the following actions should the nurse take first?

If the client has signs of hemorrhage, the nurse should notify the health care provider (HCP) or rapid response team immediately to ensure prompt treatment and aggressive supportive care. Thrombolytics do not have evidence-based reversal agents. - If uncontrolled bleeding occurs, obtaining blood count levels (eg, hemoglobin, hematocrit), initiating a blood transfusion, and administering an IV fluid bolus will likely be necessary.

The nurse is caring for a client who is receiving an intravenous infusion of antibiotics via a peripheral venous access device (VAD). The client suddenly becomes anxious, diaphoretic, and is wheezing. Which of the following actions should the nurse take? Select all that apply.

Management of anaphylaxis includes: Immediately stopping the antibiotic infusion to prevent additional exposure to the allergen and priming new IV tubing with 0.9% sodium chloride to correct hypotension and maintain peripheral venous access device (VAD) patency Activating the rapid response team Applying oxygen and administering IM epinephrine to prevent further release of inflammatory mediators and to reverse bronchoconstriction.

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

Occasional premature ventricular contractions (PVCs) in the normal heart are not significant. PVCs in the client with coronary artery disease or myocardial infarction indicate ventricular irritability and may lead to life-threatening dysrhythmia such as ventricular tachycardia

The nurse in the pediatric clinic is reviewing telephone messages from parents of clients previously seen at the facility. The nurse should first telephone the parent of the

Osteosarcoma is a bone cancer that most commonly occurs during periods of rapid skeletal growth (eg, adolescence) in the metaphysis of long bones (eg, femur) near the growth plate. It is frequently not detected before metastasis occurs because manifestations are often vague and attributed to growing pains or injury. The nurse should prioritize contacting the parents of the client with suspected osteosarcoma because immediate intervention is required to prevent complications (eg, amputation). The nurse should prepare the client for imaging (eg, MRI) and potential tissue biopsy to confirm the diagnosis prior to initiating treatment (eg, surgery, chemotherapy).

The nurse is planning care for a client who has a pheochromocytoma and is scheduled for an adrenalectomy. Which of the following interventions should the nurse include in the client's plan of care?

Pheochromocytoma is a rare but serious type of neuroendocrine tumor, usually of the adrenal gland, that releases large amounts of catecholamines (eg, epinephrine, norepinephrine, dopamine). This increase in catecholamines causes a sympathetic nervous response (eg, hypertension, tachycardia, diaphoresis) and increased metabolic rate (eg, weight loss, hyperglycemia). Physical manipulation of the tumor (eg, blunt trauma, increased intraabdominal pressure) may result in a sudden surge in catecholamine release, causing life-threatening hypertension, organ damage, and cardiac arrest. Therefore, the nurse should avoid deep palpation of the abdomen and use other assessment techniques (eg, inspection, auscultation)

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

Risk for esophageal cancer Squamous cell carcinoma Alcohol use Tobacco smoking N-nitroso-containing foods Underlying esophageal disease (achalasia, prior injury) Adenocarcinoma Barrett esophagus Gastroesophageal reflux disease Obesity Tobacco use Obesity (which allows stomach acid to flow upward into the esophagus due to increased abdominal pressure) and uncontrolled gastroesophageal reflux disease contribute to the development of Barrett esophagus; they are both closely linked with esophageal cancer

The nurse in the emergency department is caring for assigned clients. The nurse should first assess the client who

Vomiting with an NGT in place increases the risk for airway obstruction from aspiration of gastric contents. Vomiting may indicate possible tube obstruction, improper placement, or insufficient suction. The nurse should collaborate with the health care provider to verify correct NGT placement, irrigate or aspirate the blockage, or increase suction strength or frequency.

The nurse is caring for a client who has increased intracranial pressure. Which of the following actions should the nurse take? Select all that apply.

Turning the client with slow, gentle movements to avoid increases in ICP

The nurse is preparing to administer morphine IV push to a client via a peripheral venous access device (VAD). Which of the following actions should the nurse take? Select all that apply.

When administering IV push medication through a peripheral venous access device (VAD) the nurse should: Observe the IV site for swelling and pain that may indicate the catheter tip is no longer correctly in the vein (ie, infiltration) Clean the IV access port with an alcohol pad before administration to decrease the risk for bacterial contamination Remain with the client for several minutes after administration to evaluate for efficacy and monitor for adverse effects Verify medication compatibility with the primary infusing IV fluid before administration to prevent medication interactions

The nurse is caring for an 86-year-old female client in the clinic.

(Incorrect) Clinical manifestations of chronic obstructive pulmonary disease (COPD) include dyspnea, chronic cough, sputum production, and wheezing. Lung function can be measured with forced vital capacity (ie, total air released during forcible exhalation). Pursed lip breathing helps open the airways and reduces dyspnea in clients with COPD.

The nurse is caring for a 12-month-old client. Which of the following findings would require follow-up?

- A child's posterior fontanelle fuses by 2 months and the anterior fontanelle fuses between 12 and 18 months. - A child's length increases by approximately 50% during the first year of life. - By 1 year, a child should be able to pull to stand and may walk with assistance. A child should begin to walk independently by 15 months.

The nurse is caring for a client with suspected amphetamine/dextroamphetamine intoxication. Which of the following findings would be consistent with amphetamine/dextroamphetamine intoxication? Select all that apply.

Amphetamine/dextroamphetamine is a central nervous system (CNS) stimulant indicated for attention deficit hyperactivity disorder and narcolepsy. CNS stimulants work by inhibiting the reuptake of the neurotransmitters norepinephrine and dopamine. CNS stimulants can be highly addictive due to their pleasurable effects (eg, euphoria, elation), increased energy, alertness, and feelings of increased mental responsiveness. Manifestations of stimulant intoxication include: -Decreased appetite that can result in unintentional weight loss caused by appetite suppression and increased metabolism Psychotic symptoms (eg, paranoid delusions, suspiciousness, hallucinations) related to excess dopamine release Manifestations of CNS excitation (eg, anxiety, restlessness, agitation, insomnia) Elevated body temperature and diaphoresis

The nurse is caring for a client who has cutaneous anthrax after exposure to an infected animal. Which of the following actions should the nurse take?

Anthrax is a bacterial infection caused by Bacillus anthracis spores that can be found in soil. Spores can enter the body through cuts in the skin, via inhalation, or by way of the digestive system. The infection can be systemic or confined to the skin (ie, cutaneous). Cutaneous anthrax is most often contracted when bacteria enter the skin during contact with an infected animal. Small, itchy blisters resembling insect bites appear that develop into painless areas of ulceration and eschar. Clients should be assessed for medication allergies, including antibiotics, prior to starting treatment (eg, ciprofloxacin, doxycycline

The nurse is caring for assigned clients. The nurse should first check the client who

Bilateral fixed and dilated pupils (eg, 9 mm) are indicative of life-threatening brain herniation, which occurs when a rapid increase in ICP causes portions of the brain to protrude into adjacent structures. The nurse should immediately notify the health care provider and prioritize interventions to reduce ICP (eg, elevate the head of the bed, administer osmotic agents, prepare the client for surgery)

The nurse is caring for a client with cervical cancer who has a sealed radiation implant. Which of the following actions should the nurse take? Select all that apply.

Brachytherapy is an internal radiation treatment that is ingested, injected into a cavity, or implanted (eg, capsules, wires) directly in or near a tumor. Temporary brachytherapy (eg, cervical implant) emits radiation within a 6-ft (1.8-m) radius of the implant. Therefore, the nurse should follow the safety guideline of ALARA (As Low As Reasonably Achievable) when caring for the client, which includes: Preparing the client's meal tray before entering the room to minimize the amount of time exposed to radiation Placing frequently used items within the client's reach to facilitate self-care Maintaining a safe distance from clients when providing care and teaching visitors to limit close contact with the client

The nurse is talking with a client with chronic kidney disease about recommended dietary modifications. Which of the following statements by the client would indicate a correct understanding of the recommended dietary modifications? Select all that apply.

Clients with CKD often require dietary modifications to prevent complications (eg, fluid overload, electrolyte disturbances), including: Reducing sodium intake (eg, processed deli meats); consuming less salt helps decrease fluid retention and prevent excessive thirst . Counting foods that liquefy at room temperature (eg, gelatin, popsicles) toward total fluid intake; clients with CKD are often instructed to restrict fluid intake due to risk of volume overload . A high-protein diet can cause uremia from increased protein breakdown and further damage the kidneys. A low-protein diet is also not recommended due to the risk of malnutrition. Recommended protein intake is specific to each client and the treatment plan. -Clients with CKD should avoid eating potassium-rich foods (eg, bananas, oranges) to reduce the risk of hyperkalemia from impaired potassium excretion in the kidneys. -Clients with CKD are encouraged to reduce sodium intake. However, salt substitutes are primarily made from potassium chloride and can contribute to hyperkalemia. Clients should be encouraged to use salt-free spices and f

The nurse is caring for a client receiving peritoneal dialysis. Which findings are essential for the nurse to report to the health care provider? Select all that apply.

During peritoneal dialysis (PD), a catheter is placed into the peritoneal cavity to infuse dialysate (dialysis fluid); the tubing is then clamped to allow the fluid to dwell for a specified period. After the dwell time, the catheter is unclamped and the fluid (effluent) drains out via gravity. Cloudy outflow (effluent), tachycardia, and low-grade fever are signs of peritonitis, an infection of the peritoneal cavity and a major concern with PD. Bloody fluid can indicate intestinal perforation or that the client may be menstruating. Brown effluent can indicate fecal contamination from perforation. All these findings need to be reported to the health care provider.

The nurse is assessing a client with suspected hepatitis. Which of the following questions would be important for the nurse to ask the client? Select all that apply.

Educational Outcome: Black, tarry stool (ie, melena) is an expected finding with gastrointestinal bleeding (from the digested blood) and can occur in clients with gastric or esophageal varices. Pale stools are typically associated with hepatitis.

The nurse is caring for a client at risk for aspiration pneumonia due to a stroke. What nursing actions help prevent this potential complication during hospitalization? Select all that apply.

Educational Outcome: Encourage clients to facilitate swallowing by flexing the neck (chin to chest)

The nurse is caring for a 55-year-old female client in the clinic.

Educational Outcome: Pessaries are not expected for clients with UI. Pessaries (eg, intravaginal support devices) are used to support the pelvic floor and relieve pressure on the bladder for clients with stress incontinence related to pelvic organ prolapse.

The nurse is observing a staff member caring for a client who has a pulmonary embolism. The nurse should intervene if the staff member is observed

Educational outcome: Interventions focus on restoring and/or maintaining pulmonary circulation, ventilation, and gas exchange. The nurse should place the client in the high Fowler position, rather than the supine position, to encourage chest expansion. In addition, the nurse should provide supplemental oxygen titrated to maintain SpO2 ≥90%.

The nurse is preparing to irrigate the wound of a 7-year-old client who sustained a laceration while on a playground. Which of the following actions should the nurse take? Select all that apply.

Educational outcome: Wound irrigation is performed to flush out debris and bacteria to ensure proper wound healing. This is important for wounds obtained in an outdoor environment (eg, playground) because contamination with soil or dirt greatly increases the risk for infection. To perform wound irrigation, the nurse should: Administer analgesia 30-60 minutes before the procedure to decrease client discomfort during the procedure Fill a 30- to 60-mL sterile irrigation syringe with the prescribed irrigation solution. Attach an 18- or 19-gauge needle to the syringe and hold it 1 inch (2.5 cm) above the wound. Use continuous pressure to flush the wound, repeating until the drainage is clear Dry the surrounding wound area to prevent skin breakdown and irritation.

The nurse is caring for assigned clients. The nurse should first assess the client who has

Incontinence-associated dermatitis (IAD) is a type of moisture-associated skin damage caused by continued exposure to urine or feces. IAD is characterized by skin inflammation or erosion that presents with a diffuse red rash with or without lesions (eg, papules, pustules, vesicles) in the perineal, perianal, buttocks, or inner thigh areas. IAD is associated with the development of a pressure injury and an increased risk for infection. Therefore, it is a priority to ensure that the area of dermatitis remains clean, dry, and protected from moisture

The nurse is working in a busy emergency department and is assigned 4 clients. Which client should the nurse see first?

Other info: Hemorrhagic cystitis (eg, bladder inflammation) is a well-known complication of cyclophosphamide (immunosuppressant and chemotherapy agent). The client is instructed to drink plenty of fluids. This client may need IV hydration and other preventive measures (eg, mesna therapy). Bleeding is usually minimal and occasionally requires a blood transfusion, but is rarely life threatening.

The nurse is caring for a client with acute bronchitis who is receiving oxygen at 5 L/min via nasal cannula. Which of the following actions should the nurse take? Click the exhibit button for additional client information.

Oxygen delivery via nasal cannula is typically tolerated well at a low flow rate (eg, 1-4 L/min) for a short time. However, higher flow rates (eg, 5-6 L/min) or prolonged use can dry the mucous membranes, causing discomfort and irritation (eg, dried blood).\ A client with dementia may have difficulty communicating discomfort and/or may not remember the necessity of supplemental oxygen. The nurse should attach humidification (eg, sterile water) to the oxygen-delivery system because adding moisture can increase comfort and adherence

The nurse in the emergency department is caring for a client who has a muffled voice and is reporting a sore throat and difficulty swallowing. Which of the following actions should the nurse take? Select all that apply. Click the exhibit button for additional client information.

Peritonsillar abscess is a complication of tonsillitis that occurs when a collection of pus (ie, abscess) forms near the tonsil. Manifestations of a peritonsillar abscess include throat pain, fever, muffled voice, and trismus (ie, inability to open the mouth). Clients may also experience unilateral tonsillar swelling and uvular deviation. Without prompt treatment, peritonsillar abscess can lead to life-threatening airway obstruction. Therefore, the nurse should immediately report signs of peritonsillar abscess to the health care provider and monitor for symptoms of airway obstruction (eg, drooling, stridor). Additional interventions include: Initiating IV antibiotics to treat the causative infection Ensuring oral suctioning is available to prevent aspiration of secretions Placing an emergency airway kit at the bedside due to the risk of airway obstruction Administering IV corticosteroids to decrease tonsillar swelling Preparing client for possible surgical intervention (eg, tonsillectomy, needle aspiration)

The nurse is teaching a client who is postpartum about the measles, mumps, and rubella (MMR) vaccine. Which of the following information should the nurse include? Select all that apply.

Prior to administration, the nurse should include the following in client teaching: The client should prevent pregnancy for at least 4 weeks following administration due to potential teratogenic effects. It is safe to continue breastfeeding because the MMR vaccine is not communicable via breast milk

The nurse is screening clients for those at risk for developing sepsis. The nurse should recognize that the client at highest risk for developing sepsis is the

Sepsis is a systemic inflammatory response in which large amounts of cytokines are released in response to infection. Overwhelming release of inflammatory cytokines triggers vasodilation and capillary leakage, leading to hypotension and impaired end-organ perfusion that can lead to multisystem organ damage and death. Risk factors for sepsis include: Hospitalization due to the risk for nosocomial and antibiotic resistance infections Advanced age (ie, age >65 years) Bacteremia (ie, presence of bacteria in the blood stream) Immunosuppression due to the decreased ability to fight infection Invasive devices (eg, large bore catheters) that are prone to infection Wounds (eg, pressure injuries, fissures, surgical sites)

Several 12-month-old infants are brought to the clinic for routine immunizations. Which situation would be most important for the nurse to clarify with the provider before administering the vaccination?

Severely immunocompromised children (eg, corticosteroid therapy, chemotherapy, AIDS) generally should not receive live vaccines (eg, varicella-zoster vaccine, measles-mumps-rubella, rotavirus, yellow fever) . Passive immunization may be the only option for children with severe immunosuppression or those unable to mount an antibody immune response. Common misperceptions of contraindications to immunization: Penicillin allergy Mild illness (with or without an elevated temperature) Mild site reactions (eg, swelling, erythema, soreness) Recent infection exposure Current course of antibiotics

The nurse provides education for caregivers of a client with Alzheimer disease. Which instructions should the nurse include? Select all that apply.

Strategies for caring for clients with Alzheimer disease address progressive memory loss and declining ability to communicate, think clearly, and perform activities of daily living. Caregivers should also learn to manage clients' problematic behavior and mood swings. Therapeutic guidelines include: Use distraction and redirection (eg, going for a walk) to manage agitation Speak slowly and use simple words and yes-or-no questions. Do not try to rationalize with the client. Use visual cues when giving directions. Interact with the client as an adult, even as the client regresses to childlike affect and behavior; respect client dignity by avoiding use of pet names (eg, "honey," "sweetie," "darling") Break down complex activities into steps with simple instructions. Decrease the client's anxiety by limiting the number of choices

The nurse is assisting during a scheduled cardioversion for a client who is experiencing supraventricular tachycardia. It would require follow-up if the nurse

Synchronized cardioversion is a procedure used to convert tachydysrhythmias (eg, supraventricular tachycardia) with a pulse to stable cardiac rhythms via transcutaneous electrical shock. The synchronizer feature of a defibrillator ensures the shock is delivered only during ventricular depolarization (ie, the R wave of the QRS complex). The nurse must ensure that the synchronizer switch is turned on during cardioversion. Disabling or failing to enable the synchronizer feature may result in delivery of a potentially lethal, asynchronous shock to the client Accidentally delivering shocks during the T wave, when heart ventricles are repolarizing, would cause R-on-T phenomenon, which frequently results in a lethal dysrhythmia (eg, ventricular fibrillation).

The nurse is caring for a client who is receiving total parenteral nutrition (TPN). It would require follow-up if the nurse

Total parenteral nutrition (TPN) is a sterile mixture of micro- and macronutrients for IV infusion given to clients when enteral nutrition (ie, through the gastrointestinal tract) is inappropriate or cannot be tolerated. The nurse should infuse TPN via central venous access devices only, as the concentrated solution may cause phlebitis if given through a peripheral vein. Administering TPN as a piggyback infusion is not appropriate because TPN must be infused through a dedicated IV tubing to minimize the risk for infection - Filters are appropriate to use during TPN infusion to remove particulate matter, precipitates, or microorganisms. - The nurse should record daily weights and intake and output to ensure the client is receiving adequate nutrition and not developing fluid volume overload. - Glucose (dextrose) is a primary component of TPN solutions; therefore, the nurse should monitor blood glucose every 4 to 6 hours and assess for symptoms of hyperglycemia.

The nurse is caring for a client who had a transsphenoidal hypophysectomy and developed diabetes insipidus. Which of the following findings would the nurse expect to observe? Select all that apply.

Transsphenoidal hypophysectomy is the surgical removal of the pituitary gland, an endocrine gland that produces, stores, and excretes hormones (eg, antidiuretic hormone [ADH], growth hormone, adrenocorticotropic hormone). Clients undergoing hypophysectomies are at risk for developing neurogenic diabetes insipidus (DI), a metabolic disorder of low ADH levels. ADH promotes water reabsorption in the kidneys. Therefore, loss of circulating ADH results in massive diuresis of dilute urine. Clinical manifestations associated with DI include: Polydipsia (ie, increased/excessive thirst) Polyuria (ie, increased urine output) Increased serum osmolality (ie, water-electrolyte balance in the blood) due to dehydration from polyuria Clients with DI experience hypernatremia (ie, increased serum sodium level) due to free water loss in the urine.

The nurse is reconstituting methylprednisolone sodium succinate for IM injection. Place in order the steps that the nurse should perform to appropriately prepare the medication. All options must be used.

When reconstituting a powdered medication for parenteral administration, the nurse should: Perform hand hygiene and don clean gloves prior to handling medication. This is a universal practice for aseptic handling of any medication. Cleanse the vial top with alcohol and let it dry to prevent possible microbial contamination. Withdraw an amount of air from the vial equal to the prescribed amount of diluent to create negative pressure that will be equalized when the diluent is injected into the vial. The medication manufacturer will specify the needed amount and type of diluent Inject the appropriate diluent (eg, sterile saline, sterile water) into the vial. The diluent reconstitutes the medication by dissolving the powder Roll the vial between the palms of the hands to gently mix the solution. Avoid shaking the vial as bubbles may develop, making withdrawal of the reconstituted medication difficult Withdraw the reconstituted medication from the vial into a sterile syringe for administration Verify the dosage by checking the prepared medication against the medication administration record and medication label. Label the syringe with the medication name and dosage to prevent medication errors at the bedside.

The nurse is teaching a client who has immune thrombocytopenic purpura. Which of the following information should the nurse include? Select all that apply.

Educational Outcome: Clients with ITP should avoid tattoos or piercings and using tweezers to groom eyebrows or body hair due to low platelet count and increased risk for bleeding.

The nurse in the postanesthesia care unit is caring for an unconscious client who had a surgical procedure with general anesthesia and has an oxygen saturation level of 88%. Which of the following actions should the nurse take first?

Educational Out: Clients who receive general anesthesia are at increased risk for acute airway obstruction because the tongue may fall back and occlude the airway due to muscular flaccidity. The head tilt and chin lift is a maneuver used to open the airway and can be performed quickly. If a postoperative client displays signs of airway obstruction (eg, low oxygen saturation), the nurse should first perform a head tilt-chin lift maneuver to clear the obstruct oncome: - The nurse should perform other interventions before administering the medication because it can result in inadequate pain management.

The nurse is assessing a client with a brain tumor who has developed diabetes insipidus. Which of the following findings would the nurse expect? Select all that apply.

Educational Outcome: The decreased presence of circulating ADH signals the body to diurese, leading to: High serum osmolality (>295 mOsm/kg [>295 mmol/kg]) and hypernatremia (sodium >145 mEq/L [>145 mmol/L])

The nurse is teaching a client about the use of a diaphragm for contraception. Which of the following statements by the client would indicate a correct understanding of the teaching? Select all that apply.

Proper use of diaphragm contraception includes: Inspecting the diaphragm for holes, cracks, or tears prior to each use to ensure its effectiveness for blocking sperm Keeping the diaphragm in place for ≥6 hours after sexual intercourse to allow time for the spermicide to work Rechecking the size of the diaphragm following significant weight fluctuations (eg, weight gain or loss of ≥10.0 lb [4.5 kg]), gynecologic surgery, or pregnancy Inserting additional spermicide into the vagina before every episode of sexual intercourse Avoiding use of the diaphragm during menstruation due to the risk for toxic shock syndrome

A client with chronic kidney disease has an arteriovenous fistula placed in the left wrist for hemodialysis. Which of the following statements indicate that the client understands how to care for the fistula properly? Select all that apply.

Educational outcome: Check the function of the vascular access several times per day by feeling for vibration (thrill) to assess for AVF patency

The nurse is preparing to change the wound dressing for a client who is receiving negative pressure wound therapy. Which of the following actions should the nurse take? Select all that apply.

Educational objective: When changing a negative pressure wound therapy dressing, the nurse should administer analgesics, apply a skin protectant to intact skin around the wound, cut the foam dressing to the shape and size of the wound, ensure the prescribed pressure is applied, and verify that the occlusive dressing is free of air leaks.

The charge nurse is planning assignments for the day. Which clients will require the nursing staff to institute contact precautions? Select all that apply.

Educational outcome: Infections caused by methicillin-resistant Staphylococcus aureus(MRSA), C difficile, vancomycin-resistant Enterococcus (VRE), and scabies require contact precautions to be used

The nurse receives morning report on 4 clients who were admitted 24 hours earlier for injuries incurred in motor vehicle collisions. Which client should the nurse assess first?

Educational Outcome: A lung contusion (bruised lung) caused by blunt force can occur when an individual's chest hits a car steering wheel. This injury is potentially life-threatening because bleeding into the lung and alveolar collapse can lead to acute respiratory distress syndrome. Clients should be monitored for 24-48 hours as symptoms (eg, dyspnea, tachypnea, tachycardia) are usually absent initially but develop as the bruise worsens. Inspiratory chest pain can lead to hypoventilation, and an oxygen saturation of 90% (normal: 95%-100%) indicates hypoxemia. Therefore, the nurse should assess this client with lung contusion first and then notify the health care provider as immediate interventions to decrease the work of breathing and improve gas exchange (eg, supplemental oxygen, medications, ventilatory support) may be necessary.

The nurse is caring for a client diagnosed with a deep venous thrombosis 1 day ago. Which action by the client would require an immediate intervention by the nurse?

Educational objective:Interventions for deep venous thrombosis (DVT) include anticoagulants, warm compresses, limb elevation while in bed, and early ambulation. Clients with DVT are at risk for developing a pulmonary embolism (PE). Massaging the site of thrombosis can cause the clot to become dislodged and result in life-threatening PE.

The nurse on the orthopedic unit is observing staff members caring for assigned clients. The nurse should intervene if a staff member is observed

Educational outcome: To prevent hip flexion contractures following an above-the-knee amputation, a client's residual limb should not be elevated, especially after 24 hours. Instead, the client should wear a figure eight compression bandage at all times to control edema until the residual limb is healed (Option 4). Hip flexion contractures can also be avoided by placing the client in the prone position with the hip in extension for 30 minutes 3 or 4 times daily. Other info: A halo external fixation device is used to stabilize a cervical or high thoracic fracture when there is no damage to the spinal cord, thereby allowing the client to ambulate.

Which actions are appropriate for the registered nurse to delegate to an experienced licensed practical nurse? Select all that apply.

Educational objective: Under the direction of a registered nurse (RN), the licensed practical nurse can perform higher-level skills within the scope of practice defined by the state. Appropriate tasks include administering routine medications for expected needs, monitoring RN findings, and performing focused assessments (eg, breath sounds, bowel sounds, neurovascular status).

Which of the following observations by the charge nurse would require immediate follow-up?

Educational Outcome: To maintain gravity flow, the drainage bag should be hung below the level of the bladder. Impaired urine flow can lead to urinary retention and distension of the bladder. The nurse should immediately follow-up if the drainage bag is hung above the level of the bladder (eg, wheelchair handle) because this will impede urine flow - Fluid intake of 3000 mL/day should be encouraged in clients after surgery involving the urinary system. Increased fluid intake ensures the maintenance of a high urinary output, reducing the risk for infection and calculi. Dilute urine is less irritating to the skin surrounding the stoma site.

A nurse is completing discharge teaching to the parent of a child who had a tonsillectomy 2 hours ago. Which finding should be reported as a priority?

Educational objective: Postoperative bleeding is a primary concern after a tonsillectomy because the surgical site is not easily visualized and is vulnerable to irritation and trauma from swallowing and coughing. The nurse should observe for signs of postoperative bleeding (eg, frequent, increased swallowing).

A client with throat cancer receives radiation therapy to the head and neck. Which of the following strategies are appropriate to decrease the adverse effects associated with radiation therapy? Select all that apply.

Educational outcome: Using artificial saliva to manage xerostomia and the production of thick saliva due to altered salivary gland function

The nurse teaches a parent how to administer an oral liquid medication to a 2-month-old client. The nurse knows that the parent understands the teaching when the parent does which of the following?

Educational objective:The extrusion reflex and a decreased gag reflex in infants less than 4 months old increase the risk for choking and aspiration. Instilling the medication using a syringe at the back of the cheek decreases the risk for choking and ensures that the correct amount of medication is consumed.

The nurse on a pediatric unit is caring for a preschooler who exhibits separation anxiety when the parents go to work. Which interventions should the nurse implement? Select all that apply.

Educational objective:Toddlers and preschool-age children experience separation anxiety in response to the stress of illness and hospitalization. Key nursing interventions to alleviate separation anxiety include encouraging the presence of favorite items, establishing a daily routine, providing opportunities for play, facilitating phone calls with the parents, and providing support when the child is upset.

The nurse is caring for a client who experienced an ischemic stroke and is not a candidate for thrombolytic therapy. The client has a blood pressure (BP) of 240/124 mm Hg and is receiving IV nicardipine. Which of the following actions would be most important for the nurse to take?

Educational outcome Calcium channel blockers (eg, nicardipine) can be used to correct extreme hypertension. However, BP should be gradually lowered (eg, lowered 15% over 24 hours) to maintain cerebral perfusion. Therefore, it is most important that the nurse maintains a systolic BP ≥170 mm Hg to preserve brain function

An experienced nurse precepts a graduate nurse in the intensive care unit while caring for a client with a right subclavian triple-lumen central venous catheter (CVC). Which statement by the graduate nurse indicates understanding of the CVC?

Educational Outcome: A central line or central venous catheter (CVC) is inserted by the health care provider in a "central" vein (eg, subclavian, internal jugular, femoral) and is used to administer fluids, medications, and parenteral nutrition and for hemodynamic monitoring. Proper hand hygiene should be performed when caring for a CVC to prevent infection, and nonsterile gloves should be worn to protect the nurse from blood or body fluids at the port site as one or more lumens are often used to draw blood. The Centers for Disease Control and Prevention recommend that catheter hubs always be handled aseptically to prevent catheter-associated infections. The hubs should be disinfected with a hospital-approved antiseptic (eg, 70% alcohol sterile pads; > 0.5% chlorhexidine with alcohol; 10% povidone-iodine). CVCs may have multiple lumens. These are used to administer incompatible drugs simultaneously, for blood draws, and for hemodynamic monitoring.

A nurse is preparing a presentation about behavioral modifications to support weight loss for clients at an obesity clinic. Which of the following points should the nurse include in the teaching plan? Select all that apply.

Educational outcome: Developing health goals unrelated to weight (eg, climbing stairs without shortness of breath) to measure progress regardless of current weight