NCLEX-RN Test 1 NGN

After addressing a group of female high school students about sexual health and hygiene, the nurse recognizes that teaching about human papillomavirus (HPV) and genital warts has been effective when hearing which of the following client statements? Select all that apply.

1. "A person's genital warts may come back again, even after receiving treatment." 3."Infection with HPV increases my risk of cervical cancer." 4."Since I am sexually active, I should receive the HPV vaccine series. Treatment for genital warts (eg, topical podophyllin, cryotherapy) is usually effective but does not prevent warts from recurring (Option 1). High-risk HPV strains (eg, types 16 and 18) increase the risk of oral, genital, and cervical cancers (Option 3).The HPV vaccine helps prevent several HPV strains and is most effective if received before initiation of sexual activity. Clients who are already sexually active may still benefit from HPV vaccination (Option 4). (Option 2) Because HPV infection in females age <21 rarely progresses to malignancy, most clinical organizations recommend initiation of cervical cancer screening (eg, Pap testing) at age 21, regardless of sexual history. Subsequently, overdiagnosis and treatment (eg, cervical excision procedures) leading to negative future reproductive outcomes (eg, preterm birth) are minimized.

The nurse precepting a graduate nurse (GN) reviews age-related changes that increase older adult clients' risk for respiratory infections. Which of the following statements by the GN indicate a correct understanding? Select all that apply.

1. "The ability to cough forcefully decreases." 2. "The chest wall may become less flexible (chest wall stiffening)." 3. "The immune system response is diminished." 4. "The mucous membranes become drier." 5. "The number and motility of cilia decrease." Older adults experience expected, age-related physiologic changes, several of which increase their risk for respiratory illnesses and infection. With aging, mucus becomes thicker and more difficult to clear because the mucous membranes produce and secrete less mucus. Costal cartilage becomes calcified, reducing lung compliance and expansion (Option 2). The respiratory muscles become weaker and the cough is less forceful (Option 1). The number of respiratory cilia is decreased, and they become less effective in their brushing motion (Option 5). All these changes reduce the body's ability to clear mucus and pathogens. The immune system of older adults is also diminished as the function and quality of lymphocytes (ie, T cells, B cells) are altered and respiratory defenses (eg, mucus clearance) are impaired (Option 3). The older adult's dry mucous membranes are also more vulnerable to respiratory pathogens and infection (Option 4).

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

1. Client who had an emergency appendectomy 48 hours ago and is reporting hearing waves and seeing fish swimming through the walls - Hallucinations represent a serious safety risk to the client and others because these may compel clients to engage in behaviors or activities that trigger self-injury or violence toward others (eg, command hallucinations). Hallucinations experienced by clients without a psychiatric illness may indicate withdrawal from alcohol or narcotics, which can be life-threatening without prompt intervention. Nurses should promptly assess clients with new or worsening hallucinations

The client is attempting to remove a newly inserted peripheral IV. Which of the following interventions are appropriate at this time? Select all that apply.

2.Ask the unlicensed assistive personnel to stay with the client until a sitter is available 3.Play the client's favorite music and look at family photos together 4.Reassure the client that this is a safe environment 5.Reinforce the IV insertion site dressing with gauze Clients with moderate-stage Alzheimer disease (AD) may develop disruptive behaviors as they become unable to communicate their needs. When a client with AD is agitated or aggressive, the nurse should assess for and resolve causes of discomfort, provide distraction, and reassure the client. The nurse should secure lines, tubes, and drains and obtain a sitter if needed to maintain safety.

The charge nurse is making client assignments for the oncoming shift. Which client assignment is most appropriate for a nurse who is 10 weeks pregnant?

3. Client with a methicillin-resistant Staphylococcus aureus wound infection Health care workers (HCWs) who are pregnant do not carry a high risk for contracting methicillin-resistant Staphylococcus aureus (MRSA) as long as appropriate infection precautions (ie, contact precautions) are in place (Option 3). Even if the HCW who is pregnant were to contract MRSA, there are few known harmful effects to the fetus. Because TORCH infections (Toxoplasmosis, Other [eg, syphilis], Rubella, Cytomegalovirus, Herpes simplex virus) can cause fetal abnormalities, HCWs who are pregnant should not be assigned clients with these infections. Clients receiving brachytherapy have radioactive implants placed in a body cavity. To safely care for these clients, HCWs limit/cluster client time and keep a distance of at least 6 ft (1.8 m) unless wearing lead shielding for direct care. If possible, HCWs who are pregnant should not care for these clients because fetal radiation exposure is teratogenic.

A client with type 1 diabetes mellitus has prescriptions for NPH insulin and regular insulin. At 0730, the client's blood glucose level is 322 mg/dL (17.9 mmol/L), and the breakfast tray has arrived. What action should the nurse take? Click the exhibit button for additional information.

4. Administer 37 units of insulin: 25 units of NPH mixed with 12 units of regular insulin in the same syringe, drawing up the regular insulin first Intermediate-acting insulins (NPH) can be safely mixed with short-acting (regular) and rapid-acting (eg, lispro, aspart) insulins in one syringe. Regular insulin should be drawn into the syringe before intermediate-acting insulin to avoid cross-contaminating multidose vials (mnemonic - RN: Regular before NPH). To prepare the mixed dose: Inject 25 units of air into the NPH insulin vial without inverting the vial or passing the needle into the solution. Inject 12 units of air into the regular insulin vial and withdraw the dose, leaving no air bubbles. Draw 25 units of NPH insulin, totaling 37 units in one syringe. Any overdraw of NPH into the syringe will necessitate wasting the entire quantity.

The nurse in an ambulatory surgery center triages telephone messages from clients. Which client should the nurse call back first?

4. Client who underwent placement of an arteriovenous graft who reports a temperature of 100.9 F (38.3 C) - Arteriovenous (AV) graft placement involves surgical connection of an artery and a vein using a synthetic material to graft a hemodialysis access site. Postoperative infection of an AV graft may cause thrombosis, graft failure, or systemic infection. Fever in a postoperative client may indicate infection of the graft site, which warrants immediate notification of the health care provider (HCP); this client may require antibiotics and surgical removal of the graft (Option 4).

The nurse assists with medication reconciliation for a client visiting the clinic for a follow-up appointment. Which medication reported by the client requires further investigation? Click the exhibit button for additional information.

4. 200 mg of celecoxib PO once daily NSAIDs (eg, naproxen, ibuprofen, celecoxib) are used for their analgesic, antipyretic, and anti-inflammatory properties. However, they increase the risk of thrombotic events (eg, myocardial infarction [MI], stroke), especially in clients with cardiovascular disease (eg, coronary artery disease). The nurse should investigate why a client with a history of cardiovascular disease is taking an NSAID and alert the health care provider of its use (Option 4).

After listening to the parents' reports and seeing the following pediatric clients, the nurse knows that which client demonstrates signs of abuse that may necessitate mandatory reporting?

4. 5-year-old whose x-ray reveals 1 new and 2 healed humerus fractures after falling from a tree Signs of abuse may include: Shaken baby syndrome (ie, irritability or lethargy, poor feeding, emesis, seizures) Burns in the shape of household items (eg, iron, spatula), from cigarettes, or from immersion in scalding liquid Repeated injuries in varied stages of healing (eg, bruises, burns, fractures) (Option 4) Injuries to genitalia Lapsed time between the injury and the time when care is sought Inconsistency between the injury and the caregiver's explanation of the injury (eg, client's developmental age, mechanism of injury)

The nurse is preparing to administer acetaminophen to a 4-year-old client weighing 43 lb. Based on the prescription, what is the volume of medication in milliliters (mL) that the child should receive with each dose? Click on the exhibit button for more information. Record your answer using a whole number.

9 ml

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address the condition, and 2 parameters the nurse should monitor to assess the client's progress.

Potential condition: Pancreatitis Actions to take: Administer opioid analgesics, Administer 0.9% sodium chloride Parameters to monitor: pain level, blood glucose level Pancreatitis (ie, inflammation of the pancreas) is characterized by severe pain after eating due to the release of pancreatic enzymes (eg, lipase) in and around the pancreas, causing inflammation and autodigestion of pancreatic tissue. Pain is usually located in the epigastric area and/or left upper abdomen and may be partially relieved by leaning forward, which decreases abdominal tension. Serum lipase levels can rise to >3 times the normal upper limit. Alcohol use, gallstones, and markedly elevated serum triglycerides are the common causes. Management includes: - Administering IV pain medications (eg, opioid analgesics) and monitoring the client's pain level - Administering IV fluids (eg, 0.9% sodium chloride) to prevent hypovolemia due to dehydration and third spacing - Monitoring blood glucose levels because pancreatic damage and inflammation can impair insulin release, leading to hyperglycemia

PQRST wave (ECG)

see diagram

cardiac tamponade wrap up

acute compression of the heart caused by fluid accumulation in the pericardial cavity

Which of the following statements by the nurse are appropriate? Select all that apply.

1. "Have you considered joining a caregiver support group?" 3. "Let's talk about services that can help you care for your spouse." Nurses play an important role in recognizing caregiver distress and assisting caregivers in accessing services (eg, respite care, adult day centers, in-home services) that reduce their burden and provide time for the caregiver's own self-care. Acknowledging the caregiver's distress and offering services such as a caregiver support group provide reassurance and offer the caregiver a safe space to discuss challenges of caregiving with others who can relate and understand Relating with the client (eg, "I understand what you are going through. I am here for you") is NOT appropriate or therapeutic because only the caregiver can understand what they are experiencing.

The nurse is teaching the client's spouse about managing worsening symptoms during the evening and night. Which of the following statements by the spouse indicate a correct understanding of the teaching?

1. "I can verbally redirect my spouse when my spouse refuses care." 2."I should avoid offering my spouse caffeine in the afternoon." 4. "I will keep the lights on and the blinds open during the day." Clients with Alzheimer disease may experience neuropsychiatric symptoms (eg, agitation, aggression, delusions, hallucinations) as the disease progresses. Many clients experience worsening of these symptoms during the late afternoon and evening (eg, sundowning). The nurse should teach the caregiver about techniques to reduce distress and manage symptoms of sundowning, including: Verbally redirecting the client when the client refuses care. Redirection shifts the client's attention from a distressing situation and eases their anxiety and frustration (Option 1). Promoting a normal daytime/nighttime cycle by restricting caffeine later in the day, and increasing daytime exposure to light (eg, keeping lights on/blinds open) encourages a normal circadian rhythm (Options 2 and 4).

The nurse is reinforcing education about lifestyle choices to help reduce symptoms for a client with gastroesophageal reflux disease. Which of the following statements by the client indicate a correct understanding? Select all that apply.

1. "I have switched from coffee to decaffeinated herbal tea in the mornings." 2."I plan to join a smoking-cessation program. "4."I prop myself up on a couple of pillows when I go to sleep." 5."I will switch to low-fat dairy products and avoid high-fat foods." Gastroesophageal reflux disease (GERD) occurs when chronic reflux of stomach contents causes inflammation of the esophageal mucosa. The lower esophageal sphincter normally prevents stomach contents from entering the esophagus. Factors that decrease the tone of the lower esophageal sphincter (eg, caffeine, alcohol), delay gastric emptying (eg, fatty foods), or increase gastric pressure (eg, large meals) can precipitate GERD.

The nurses on a medical-surgical unit maintain a public social media page. Which of the following social media posts written by a nurse breaches client confidentiality? Select all that apply.

1. "I private-messaged everyone a cute story about our sweet client with dementia." 2. "It breaks my heart that our paraplegic client was so neglected by her husband." 4. "The client in room 5 is positive for influenza, so please remember your flu vaccines!" 5. "Wash your hands well if you had room 4 this week! Cultures are positive for Clostridioides difficile."

The client's chest tube is reinserted and connected to a new water seal drainage system. Which of the following observations require follow-up with the health care provider? Select all that apply.

1. 150 mL sanguineous output 1 hour after chest tube reinsertion - The presence of excess blood (>100 mL/hr of sanguineous output) in the collection chamber indicates possible hemorrhage from the stab wound or a complication of chest tube insertion (eg, lung rupture) ( 2. Continuous bubbling in the water seal chamber --> indicates an air leak Intermittent bubbling (eg, during expiration) is expected in the water seal chamber until the pneumothorax is resolved; however, continuous bubbling indicates an air leak. Continuous, gentle bubbling is expected in the suction control chamber, which maintains and controls suction to the chest drainage system Diminished breath sounds on the affected side, tidaling, and pleuritic pain are expected findings.

The nurse is preparing to administer insulin at 1700 to a client with type 1 diabetes mellitus whose blood glucose level was 245 mg/dL (13.6 mmol/L) at 1645. During what time frame is the client at highest risk for hypoglycemia? Click the exhibit button for additional information.

1. 1730-2000 Rapid-acting insulins (eg, aspart, lispro) peak quickly, often within 30 minutes to 3 hours of administration. Therefore, the client who receives insulin lispro at 1700 is at highest risk for hypoglycemia from 1730-2000 (Option 1). Insulin glargine is a long-acting insulin that does not have a peak effect. ONSET: 15 MINS PEAK: 30 MINS DURATION: 3 HOURS Insulin NPH, an intermediate-acting insulin, takes peak effect in 4-12 hours. Clients who receive insulin NPH at 1700 are most at risk for hypoglycemia from 2100-0500

A client comes to the emergency department with crushing substernal chest pain. Which of the following interventions should the nurse anticipate? Select all that apply.

1. Administer IV pain medication 2. Check blood pressure and heart rate 3.Obtain a 12-lead ECG 4.Obtain blood specimens The nurse needs to quickly identify the signs and symptoms of myocardial infarction and initiate interventions to preserve cardiac muscle. The nurse should also recognize that female and older clients may have nonspecific symptoms (eg, fatigue, indigestion, shortness of breath). Initial interventions in the emergency management of chest pain include: Insert 2 large-bore IV lines and administer prescribed medications (eg, nitroglycerin, analgesic) (Option 1). The nurse should also anticipate a prescription for an antiplatelet agent (eg, aspirin) if the client has not already received a dose. Assess airway, breathing, circulation (eg, vital signs, heart and lung sounds), and pain (Option 2). Obtain diagnostics (eg, 12-lead ECG, chest x-ray, blood specimens for cardiac markers and electrolytes) (Options 3 and 4). Administer oxygen if required (eg, capillary oxygen saturation [SpO2] <90%, dyspnea). Initiate continuous cardiac monitoring. Prepare client for additional therapy (eg, percutaneous coronary intervention, fibrinolytics). Unless contraindicated, the client should be placed in an upright, seated position because upright positioning improves ventilation and reduces pressure on the heart.

A nurse reviews the plan of care for a client who has increased intracranial pressure. Which of the following nursing actions should be included? Select all that apply.

1. Administer a stool softener - Administering stool softeners to prevent straining when defecating (Option 1). Straining and coughing increase intrathoracic and intraabdominal pressure, which increases ICP. 2. Dim the lights when not providing care -Keeping the client in a calm environment with minimal noise and disturbances (eg, dimmed lights, limited visitors) (Option 2). 4. Maintain the body in the midline position at 30 degrees - Keeping the head and body midline and avoiding extreme hip or neck flexion because it impedes venous drainage (Option 4). 5. Perform oral suctioning only when necessary - Suctioning only when needed to maintain the airway and for no more than 2 passes lasting ≤10 seconds per pass (Option 5) Treating fever aggressively (eg, acetaminophen) but keeping the client from shivering to reduce metabolic demands. Frequently monitoring arterial blood gases to prevent hypercapnia, which can increase ICP by causing cerebral vasodilation For clients with increased ICP, elevating the head of the bed is preferred over using pillows, which may flex the neck, decrease venous drainage, and increase ICP.

A 2-month-old infant is admitted with respiratory syncytial virus and bronchiolitis. Which of the following interventions should the nurse anticipate?

1. Administer antipyretics 2.Initiate IV fluids 4.Maintain isolation precautions 5.Suction as needed Administering antipyretics to reduce fever and provide comfort (Option 1). Initiating IV fluids to correct dehydration due to fever, tachypnea, or poor oral intake (Option 2). Maintaining contact isolation; droplet precautions are added if within 3 ft (0.91 m) of the client, depending on the facility policy (Option 4). Providing supplemental oxygen and suctioning to support oxygen exchange and clear the airway (Option 5).

A client with a history of a seizure disorder has a seizure while sitting in a chair. Which nursing interventions are appropriate for a client experiencing a seizure?

1. Administer oxygen as needed if client becomes cyanotic - Administer oxygen as needed in response to signs of hypoxia (eg, cyanosis, pallor) (Option 1). 3.Move the client from the chair to the floor to prevent a fall - Assist seated or standing clients to lie down (left lateral) while protecting the head, and position the client on the side to maintain a patent airway and prevent aspiration 4.Record the duration of seizure activity for documentation - Record and document the time and duration of the seizure Loosen restrictive clothing and clear the area near the client (eg, furniture corners, sharp or hard objects) to prevent injury.

The nurse is caring for a client who had an anterior wall myocardial infarction 2 days ago. The telemetry technician notifies the nurse at 8:30 AM that the client is in ventricular trigeminy. What is the nurse's priority intervention?

1. Administer potassium supplement In ventricular trigeminy, premature ventricular contractions (PVCs) occur every third heartbeat. Myocardial injury (eg, myocardial infarction) predisposes the client to ectopy (eg, PVCs), which increases the client's risk for lethal dysrhythmias (eg, ventricular tachycardia). PVCs are caused and/or exacerbated by hypoxia, electrolyte imbalances, emotional stress, stimulants, fever, and exercise. This client's morning laboratory results show hypokalemia (potassium <3.5 mEq/L [3.5 mmol/L]); therefore, the priority is treatment of the underlying cause of the ectopy by administering the prescribed potassium replacement (Option 1). Health care providers (HCPs) often prescribe electrolyte replacement algorithms to clients at risk for electrolyte imbalances (eg, myocardial injury, receiving diuretics) unless a contraindication exists (eg, serum creatinine >1.5 mg/dL [133 µmol/L], anuric, weight <99.2 lb [45 kg]).

A nurse is teaching an inservice regarding prevention of venous thromboembolism. Which nursing interventions should be included in the teaching?

1. Administer scheduled anticoagulants 2. Apply sequential compression devices 4. Have clients ambulate regularly as tolerated 5. Instruct clients to point and flex the feet in bed Venous thromboembolism (VTE) occurs when a thrombus (eg, deep vein thrombosis) forms and embolizes into the bloodstream (eg, pulmonary embolism). VTE prophylaxis should be implemented in all hospitalized clients. Measures include: Administration of anticoagulants (eg, enoxaparin), usually prescribed in clients with a moderate or high risk of VTE (eg, postsurgical) unless contraindicated (eg, active bleeding) (Option 1) Application of compression devices or antiembolism stockings to limit venous stasis (Option 2) Frequent ambulation, 4-6 times daily as tolerated, to improve circulation and promote venous return (Option 4) Foot and leg exercises (eg, extend and flex the feet and knees) to promote venous return by activating calf muscles (Option 5) Elevating the legs while in bed promotes venous return by gravity. However, the nurse should ensure that any pillows used to elevate the legs do not place pressure directly behind the knees, as pressure on the posterior knees compresses leg veins. Clients should also avoid crossing the legs to prevent pressure on the back of the knees.

A new nurse is providing hospice care for a terminally ill client who reports dyspnea. Which intervention would cause the charge nurse to intervene?

1. Administering oxygen via a nonrebreather mask Dyspnea (ie, air hunger) is a common symptom in terminally ill clients. Initial interventions focus on decreasing respiratory effort and the perception of dyspnea, as well as relieving anxiety. Nonrebreather masks are used to deliver high concentrations of oxygen in emergency situations. They require a tight face seal, which may be uncomfortable and can cause claustrophobia and increased anxiety. High-flow oxygen can paradoxically decrease respiratory drive and cause carbon dioxide retention, further worsening the perception of dyspnea. Application of a nonrebreather by a new nurse requires intervention for a client receiving hospice care (Option 1). Administering opioids (eg, morphine, fentanyl) to help relieve dyspnea/decrease respiratory effort, placing a fan in the room to improve airflow near the client to decrease the perception of dyspnea, and assisting with relaxation strategies (eg, music, guided imagery) are all appropriate interventions. The nurse can providing low-flow oxygen by nasal cannula, which may provide psychological comfort and ease feelings of apprehension, allow for frequent periods of rest to minimize exhaustion and dyspnea, and administer anxiolytics (eg, lorazepam) for anxiety associated with dyspnea.

A client is in cardiac arrest, and resuscitation efforts are in progress when the client's spouse arrives. The client's spouse insists on coming into the room. How should the nurse respond?

1. Allow the spouse into the room and provide a chair. Allowing family to be present during resuscitative efforts and invasive procedures can help the family process and cope with the client's condition, alleviate fears and anxiety, and facilitate the grieving process if the expected outcome is poor. The nurse should permit the client's spouse to enter the room and provide a location to observe (out of the care team's way) and another nurse should explain the treatment measures that are occurring (Option 1)

A nurse is reading a client's tuberculin skin test 48 hours after placement and notes an 11-mm area of induration. The client emigrated from Nigeria 1 year ago and reports no symptoms. Which of the following actions would be appropriate by the nurse?

1. Ask the client about a history of bacille Calmette-Guérin vaccination 5. Obtain a prescription for a chest x-ray from the health care provider If a client's tuberculin skin test (TST) is positive, the nurse should: Ask clients who emigrated from high-prevalence countries if they have received the bacille Calmette-Guérin (BCG) vaccine. It is commonly administered to children in high-prevalence countries but causes false-positive PPD tests (Option 1). Interferon-gamma release assay testing is preferred in BCG-vaccinated clients because it does not produce false-positive results. Obtain a prescription for a chest x-ray to differentiate latent TB from active disease in asymptomatic clients (Option 5) PPD test is positive because there is an induration >10 mm and the client emigrated from a high-prevalence country <5 years ago. There is no indication to repeat the TST. Airborne precautions NOT droplet

The nurse is caring for an African American client with disseminated intravascular coagulation. Which locations are best to assess for the presence of petechiae?

1. Buccal mucosae and conjunctivae of the eyes Petechiae are reddish or purple pinpoints on the skin that occur due to bleeding from capillaries. Petechiae usually occur due to blood vessel injury or bleeding disorders (eg, thrombocytopenia, disseminated intravascular coagulation). Petechiae and similar skin conditions are often challenging to detect in dark-skinned clients as dark pigmentation makes it difficult to assess skin color changes. In dark-skinned clients, petechiae can best be assessed in the conjunctivae of the eyes and the buccal mucosae. The palms of the hands and soles of the feet are ideal locations for assessing other skin color changes that may occur in dark-skinned clients, such as jaundice (ie, yellowing of the skin due to increased bilirubin in the blood). However, these are not ideal locations to assess for petechiae in a dark-skinned client.

Which of the following situations would be classified as an adverse event, requiring the nurse to complete an incident report?

1. Cerebrospinal fluid sample is sent to the laboratory labeled as a urine sample 3. Nurse fails to report a potassium of 6.5 mEq/L (6.5 mmol/L) to the health care provider 4. Postpartum client after epidural anesthesia falls while ambulating to the bathroom 5.Provider prescribes 5000 units of heparin; nurse gives 1 mL (10,000 units/mL) of heparin An incident/adverse event is an unforeseen or unintended outcome that results in harm, or has the potential to cause harm, which may or may not have been preventable. Examples of client incidents include falls, mislabeled laboratory specimens, and medication administration errors (Options 1, 4, and 5). Communication errors may also be classified as adverse events because the omission or miscommunication of critical information may result in harm, incomplete treatment, or inadequate follow-up (Option 3). Other incident types involving health care staff may include needlestick injuries or confidentiality breaches of protected health information.

The health care provider has explained the risks and benefits of a planned surgical procedure and asks the nurse to witness the client's signature on the consent form. Which situation would cause the nurse to question the client's understanding of their surgical procedure?

1. Client asks whether a blood transfusion will be required during surgery - To provide informed consent, a client must be a mentally competent adult; understand the explained procedure, risks, benefits, and alternatives; and sign voluntarily without coercion. Before witnessing a client's signature, the nurse should ensure that the client meets these criteria. A client question regarding the need for a blood transfusion during surgery indicates an incomplete understanding of risk and would invalidate the signature (Option 1). The client can provide informed consent only after the effects of sedating medications have worn off. The duration of action for hydrocodone is 4-6 hours; a client who received a dose 12 hours ago would no longer be impaired from the medication.

Click to highlight below the 2 findings that are a safety concern.

1. Clients may forget to take medications due to cognitive decline, limited hand mobility, and sensory alterations. This can be problematic because older adults often have various health conditions and take multiple medications. Clients can have difficulty remembering familiar faces and the surrounding environment; they will often become disoriented (eg, wandering and lost in the neighborhood). This becomes a safety risk because they are unable to find their way back home and can become lost for long periods of time. Becoming more withdrawn indicates the client may be feeling depressed. The nurse should assess for other symptoms of depression (eg, hopelessness, loss of pleasure); however, this finding does not pose an immediate safety concern.

The nurse suspects the client is experiencing cardiac tamponade and measures the client's blood pressure. Which finding does the nurse expect?

1. Decrease in systolic blood pressure during inspiration Signs of cardiac tamponade include tachycardia, muffled heart tones, jugular vein distension, and an abnormal decrease in systolic blood pressure (>10 mm Hg) with inspiration (ie, pulsus paradoxus) A significant difference in blood pressure between the upper and lower extremities is caused by coarctation of the aorta. A widened pulse pressure (ie, significant difference between systolic and diastolic blood pressure) is seen when there is a large volume of blood to pump from the ventricles (eg, aortic regurgitation, hyperthyroidism).

The nurse conducts a developmental assessment of a 4-year-old child. Which of the following tasks does the nurse anticipate that the child will perform successfully?

1. Draw a circle 4. Use a spoon and fork 5. Walk up and down the stairs Preschool-age children begin to master more gross motor activities while rapidly increasing their fine motor abilities. The preschooler age 4 should have the fine motor skills to manipulate small tools (eg, scissors, pencil) and therefore be able to draw simple shapes (eg, circle, square) and perform more self-care activities (eg, eating with a spoon and fork) (Options 1 and 4). The gross motor skills and balance of a child age 4 improve, allowing for more independent, complex movements (eg, walking up and down stairs) (Option 5). It is normal for preschool-age children to be unable to sit quietly for longer than 15 minutes at a time. Jump rope: age 5

The nurse is planning care for a client with a fractured femur who was placed in balanced suspension skeletal traction 2 hours ago. Which of the following interventions should the nurse include? Select all that apply

1. Encourage intake of at least 2 L of fluid per day to prevent constipation 2. Ensure that the weights hang freely and do not touch the ground 3. Monitor skin integrity and signs of infection at the pin insertion sites 4.Perform frequent neurovascular checks on the affected extremity (especially in the first 24 hours) Inspecting the rope for fraying and ensuring its correct position in the pulley track Ensuring proper alignment of the client and the pulley system to facilitate union of the fractured bone

The nurse witnesses the collapse of a child while outdoors. The child is not breathing and has a pulse of 50/min. The nurse calls emergency services and initiates rescue breathing. After 2 minutes of rescue breaths, the child is still not breathing and is pale with a pulse of 30/min. What is the nurse's next action?

1. Initiate chest compressions Rescue breathing is performed at a rate of 1 breath every 2-3 seconds. If the pulse remains <60/min and there are signs of poor perfusion (skin pallor), the nurse should initiate chest compressions and reassess the pulse every 2 minutes

The nurse is caring for an adult client who is in soft wrist restraints. Which of the following nursing actions should be included in the plan of care? SATA

1. Offer fluids, nutrition, and toileting every 2 hours and as needed 2.Perform neurovascular assessment every hour 4.Release restraints to perform range of motion exercises every 2 hours Clients in physical restraints must be regularly assessed to prevent skin breakdown, neurovascular deficits, and other safety concerns. Facilities may determine the frequency of client monitoring; however, general guidelines include: - Offering fluids, nutrition, and toileting every 2 hours and as needed (Option 1) - Performing hourly neurovascular checks (eg, pulses, color, skin temperature, sensation, movement) (Option 2) - Briefly releasing restraints for skin integrity assessment and range of motion exercises every 2 hours (Option 4) Restraints should be a last resort and discontinued as soon as possible. The nurse should regularly reassess (eg, every hour) the client's continued need for restraints.

The nurse suspects that the client is withdrawing from ________ and should anticipate _______

1. Opioids (downer so in withdrawal everything goes UP!) 2. Administering buprenorphrine Opioid withdrawal occurs 4-48 hours after a client with a physiologic dependence to opioids (eg, heroin, oxycodone) suddenly discontinues or drastically reduces opioid intake. When opioids are stopped after chronic use, the loss of their usual inhibitory effect leads to a sudden increase in norepinephrine. This results in withdrawal symptoms, which commonly include sleep disturbances, gastrointestinal disturbances (eg, nausea, vomiting, diarrhea), abdominal pain, dilated pupils, lacrimation (ie, watery eyes), and piloerection (ie, goosebumps). Treatment includes opioid agonist medications (eg, buprenorphine, low-dose methadone) that provide steady activation of opioid receptors to maintain physiologic dependence. These medications prevent withdrawal symptoms, diminish cravings, and reduce the euphoric effects of opioid misuse. Replacement of recreational opioids with these agents is associated with decreased incidence of relapse, drug overdose, and death.

The nurse caring for a male client prepares to insert an indwelling urinary catheter. The nurse assesses for allergies, explains the procedure to the client, and asks unlicensed assistive personnel to perform perineal care while equipment is gathered. Place in order the steps the nurse should take when inserting the urinary catheter. All options must be used.

1. Perform hand hygiene and open sterile urinary catheterization kit 2. Apply sterile gloves and place fenestrated drape with shiny side down 3. Use nondominant hand to grasp penis below glans 4. Use dominant hand to cleanse meatus with cotton balls or swab sticks 5. Use dominant hand to insert catheter until urine return is observed 6. Advance catheter to tubing bifurcation and inflate balloon

The nurse understands the client is most likely experiencing __________ and should anticipate _____________

1. Pericarditis 2. A 12-lead ECG Pericarditis results from local inflammation and typically occurs <4 days following a myocardial infarction. If pericarditis is suspected, the nurse should anticipate a 12-lead ECG for diagnosis. ECG findings consistent with pericarditis include diffuse ST-segment elevation and PR-segment depression.

The student nurse assists in caring for a client who is scheduled for electroconvulsive therapy for the treatment of depression. Which statement by the student indicates a need for further teaching?

2. "Because this client has a mental illness, the agent with medical power of attorney should sign the informed consent document." Informed consent is required for ECT. Clients who have mental illness can give or withhold consent unless they have been deemed incompetent through legal proceedings (Option 2). The client is also deemed incompetent if inebriated, psychotic, delirious, or under the influence of mind-altering medication. Guidelines for determining competency to give consent apply to all clients, with or without mental illness. ECT FOR MOOD DISORDERS (DEPRESSION, BIPOLAR) OR SCHIZO Prior to ECT, clients should be NPO for 6-8 hours and receive both a short-acting anesthesia and a muscle relaxant as well as a bite block.

The nurse is teaching about constipation prevention to a client. Which of the following client statements indicate appropriate understanding of the teaching? Select all that apply.

2. "Having a routine for bowel movements is important, but I should not wait if I feel the urge." 4. I should try to eat more fruits and vegetables every day." 5."Increasing my daily exercise level may help keep my bowel movements regular." Constipation is a symptom of many disease processes, procedures, and medications. To prevent constipation, educate the client to increase daily fiber intake, drink 2-3 L of NONCAFFEINATED fluids daily, increase daily activity levels, and initiate a bowel regimen (avoiding delay of defecation, defecating at the same time each day). Clients should avoid caffeinated beverages, which promote diuresis and dehydration and may lead to constipation.

The clinic nurse is assessing a client who is being treated for depression and suicidal ideation. Which client statement best indicates that the client is not currently at risk for suicide?

2. "I plan to attend my grandchild's graduation next month" Clients receiving treatment for depression and suicidal ideation must be carefully monitored for indications of increasing suicidal intent. During a client interview, the nurse should assess: - Access to psychiatric medications - Availability of help during a crisis (counselor, family) - Future goals and plans - Home and environment risks - Overall affect and level of energy - Possible access to weapons Clients who articulate long-term personal goals and family milestones are less likely to attempt death by suicide

The nurse is caring for a pediatric client with osteomyelitis. Prior to the nurse administering IV antibiotics, the client's parent states, "We don't believe in antibiotics. Healing comes from within, and medications are toxic to that process." What is the nurse's priority response?

2. "Please tell me your understanding of your child's condition." IV antibiotics are necessary for treating osteomyelitis (infection of the bone); without them, the client is at risk for potentially life-threatening complications (eg, sepsis). Parental refusal of necessary medication for a minor creates an ethical dilemma. The nurse's first response should be a parental baseline knowledge assessment of the client's condition by using open-ended questions. With education and proper understanding of the condition, the parent may consent to the necessary treatment (Option 2).

The nurse prepares to administer potassium chloride to a client through a peripherally inserted IV line. Which of the following are appropriate nursing interventions related to administration of this medication?

2. Assess IV site frequently 3. Assess renal function laboratory results and urine output 4. Place client on cardiac monitor 5. Verify that IV pump infusion is not >10 mEq/hr (10 mmol/hr) Potassium chloride (KCl) is commonly prescribed to correct or prevent hypokalemia. The normal range for serum potassium is 3.5-5.0 mEq/L (3.5-5.0 mmol/L). Potassium is commonly lost through diarrhea, vomiting, and diuretic use. Appropriate nursing interventions when administering KCl IV should include Frequent monitoring of the IV insertion site for extravasation to prevent tissue necrosis because Potassium is a vesicant (Option 2). Frequent monitoring of renal function laboratory results (eg, blood urea nitrogen, creatinine) and urine output as clients with impaired renal function are unable to excrete potassium and other electrolytes effectively, potentially leading to toxicity (Option 3). Cardiac monitoring during therapy because changes in potassium levels can cause cardiac rhythm disturbances, and rapid infusion can cause cardiac arrest (Option 4). Maintaining a KCl maximum infusion rate of 10 mEq/hr (10 mmol/hr) and the maximum concentration of 40 mEq/L (40 mmol/L). Higher rates and concentrations require a central venous catheter (Option 5) KCl is never administered by IV push or as a fluid bolus. KCl is always diluted and given via infusion pump.

The nurse administers an intermittent bolus enteral feeding to a client via nasogastric tube. Which of the following actions by the nurse are appropriate? Select all that apply.

2. Assess the tube placement marking at the naris insertion site - Check the tube placement marking at the naris insertion site. Displacement of the marking indicates that the tube may have been partially withdrawn (Option 2). 3. Auscultate the client's bowel sounds prior to feeding - Assess bowel function (eg, auscultate bowel sounds, measure gastric residual) to evaluate feeding tolerance (Option 3). 4. Keep the client's head of the bed elevated at 45 degrees -Elevate the head of the bed to 30-45 degrees (and keep it elevated 30-60 min afterward) to minimize aspiration risk (Option 4). 5. Slow the feeding rate if the client develops abdominal cramping -During administration of intermittent enteral feedings, the feeding rate should be slowed if abdominal cramping develops. This may occur if feeding is administered too quickly or the formula is cold (Option 5). Confirm tube placement (eg, radiology report, gastric aspirate pH) to ensure that the tip is correctly placed in the stomach or small intestine. Flush tube with 30 mL of water (and again after feedings) to prevent clogging. Aspirated gastric residual volume (GRV) should be returned to the stomach because repeatedly discarding aspirate may cause hypokalemia and metabolic alkalosis.

A client is at 28 weeks gestation with suspected preeclampsia. Which of the following signs/symptoms indicate that the client has developed this syndrome? Select all that apply.

2. Epigastric pain 4. Headaches and blurry vision 5. Proteinuria Preeclampsia is a multisystem disorder that can occur during pregnancy and is defined as new-onset hypertension and proteinuria or signs of end-organ damage. Cerebral symptoms (eg, headache, visual changes) from severe hypertension and/or epigastric pain secondary to decreased liver perfusion and hepatic damage can occur. Pregnancy causes an intravascular volume expansion larger than the rise in the number of red blood cells, resulting in hemodilution.

The nurse auscultates the lung sounds of a client with shortness of breath. Then, the nurse notifies the health care provider about the adventitious sounds heard. Which medication prescription should the nurse anticipate? Listen to the audio clip. (Headphones are required for best audio quality.)

2. Bumetanide Coarse crackles = presence of fluid or mucus in lower respiratory tract -< pulmonary edema/fibrosis --> loop diuretic Coarse crackles (loud, low-pitched bubbling) are heard primarily during inspiration and are not cleared by coughing. The sound is similar to that of Velcro being pulled apart. Coarse crackles may be confused with fine crackles (eg, atelectasis), which have a high-pitched, popping sound. Coarse crackles are present when fluid or mucus collects in the lower respiratory tract (eg, pulmonary edema, pulmonary fibrosis). During heart failure, the left ventricle fails to eject enough blood, causing increased pressure in the pulmonary vasculature. As a result, fluid leaks into the alveoli (pulmonary edema). Loop diuretics (eg, bumetanide, furosemide) treat pulmonary edema by reducing intravascular fluid volume through significant increase of fluid excretion by the kidneys Clients with asthma or chronic obstructive pulmonary disease (eg, emphysema) develop wheezing due to bronchospasm. Bronchodilators (eg, albuterol, ipratropium) and systemic corticosteroids (eg, methylprednisolone) may be prescribed to these clients upper respiratory infections or chronic bronchitis ==> guaifensin to loosen and improve the expectoration of mucus

The health care provider (HCP) prepares to place a fetal scalp electrode (FSE) to monitor the fetus of a laboring client. Which information is most important for the nurse to communicate to the HCP before FSE placement?

2. Client is HIV positive FSE placement involves inserting a small, sharp electrode directly into the fetal scalp or presenting part (ie, buttocks if breech). The nurse should notify the health care provider about the client's cervical dilation and membrane status because the cervix should be dilated ≥2-3 cm and the membranes ruptured before placing the FSE. FSE placement should be avoided, if possible, in the presence of bloodborne infections (eg, hepatitis B, HIV) because the risk of fetal infection is increased by the small puncture (Option 2).

The nurse in the cardiac intensive care unit receives report on 4 clients. Which client should the nurse assess first?

2. Client who underwent coronary artery stent placement via femoral approach 3 hours ago and is reporting severe back pain A client who undergoes percutaneous coronary intervention (PCI) and intracoronary stent placement using the femoral approach is at increased risk for retroperitoneal hemorrhage. Administration of antithrombotic drugs before, during, and after PCI can exacerbate potentially life-threatening bleeding from the femoral artery. Hypotension, back pain, flank ecchymosis (eg, Grey Turner sign), hematoma formation, and diminished distal pulses can be early signs of bleeding into the retroperitoneal space and require immediate intervention (eg, notify health care provider, serial complete blood count, CT scan of the abdomen)

An elderly client with chronic kidney disease is admitted with urosepsis. Based on the admitting diagnosis and laboratory results, which prescriptions would the nurse question? Select all that apply. Click on the exhibit button for additional information.

2. Continue home dose of valsartan -Chronic kidney disease impairs the excretion of excess potassium and can potentiate hyperkalemia, which can lead to life-threatening arrhythmias (eg, ventricular fibrillation). ACE inhibitors (eg, lisinopril, ramipril) or angiotensin II receptor blockers (eg, valsartan, losartan, irbesartan) can be used to manage hypertension secondary to renal disease; however, these drugs can worsen hyperkalemia 3. Obtain CT scan of abdomen with contrast - Clients with chronic kidney disease and elevated creatinine are unable to excrete the iodinated contrast administered for CT scans. Toxic effects from the contrast can occur; therefore, this prescription should be clarified before the scan. Urosepsis is a type of bloodstream infection that originates from the urinary tract. The initial treatment of sepsis focuses on the management or prevention of septic shock, mainly by administering boluses of isotonic IV fluids (fluid resuscitation) and IV broad-spectrum antibiotics (Option 1). Blood and urine cultures are obtained, ideally before the first dose of antibiotics (Option 4). Continuous vital sign and cardiac telemetry monitoring are initiated as hyperkalemia (high potassium of 6.5) and sepsis cause cardiovascular disturbances (eg, dysrhythmias and hypotension, respectively)

While the nurse and unlicensed assistive personnel are turning an intubated and heavily sedated client during a bath, the client coughs and expels the endotracheal tube. What is the priority nursing action?

2. Deliver rescue breathing with a bag-valve-mask attached to 100% oxygen If a client is accidentally extubated, the nurse should remain with the client, protect the airway using the head-tilt chin-lift or the jaw-thrust maneuver if spinal injury is suspected, and deliver breaths using a bag-valve-mask with 100% oxygen until reintubation is achieved (Option 2). Code blue should only be initiated if cardiac arrest occurs

A nurse is caring for a client admitted with unstable angina. After 5 minutes on an IV nitroglycerin infusion, the client reports improving chest pain but a new dull, throbbing headache. What is the appropriate nursing action?

2. Document the finding and administer prescribed acetaminophen Nitroglycerin is an antianginal medication that causes potent vasodilation (both coronary and systemic) and is used in the treatment of acute coronary syndrome (eg, unstable angina, myocardial infarction). Vasodilation relieves chest pain by decreasing venous return to the heart, resulting in decreased preload (ie, decreased oxygen demand). IV nitroglycerin administration requires continuous cardiac monitoring and frequent blood pressure assessment (ie, every 15 minutes for the first hour). Headache is an expected adverse effect from vasodilation of cranial vessels and should decrease with continuing nitroglycerin therapy. As long as the client does not have severe hypotension (eg, systolic blood pressure <90 mm Hg), the finding can be documented and the headache treated with aspirin or acetaminophen (Option 2). If the headache becomes severe or persistent despite acetaminophen, the health care provider (HCP) may temporarily decrease the dosage. The nurse should not arbitrarily stop the infusion or decrease the rate.

During the discharge process, the nurse observes a new parent placing a newborn into a car seat in the vehicle. Which action by the parent requires the nurse to intervene?

2. Dresses the newborn in a sleep sack before securing the harness - The car seat's harness should be secured snugly at or below the shoulders, at the hips, and between the legs. The harness fits securely when the newborn is dressed in lightweight clothing. Tucking blankets between the newborn and the harness or dressing the newborn in bulky coats or a sleep sack reduces the car seat's effectiveness (Option 2). (Option 1) The car seat should be placed in the back seat and in the center (away from the doors), if possible. This protects the child from airbag deployment as well as collisions to the vehicle's sides.

The pediatric nurse plans a home visit for a 2-year-old who will soon be discharged with home health care. Which condition presents the most concern as a safety hazard in the child's home environment?

2. House is heated by a wood-burning stove An open wood-burning stove is a fire hazard that may cause physiologic damage from smoke inhalation or burns (Option 2). The nurse should investigate the family's access to other utilities and determine whether the stove is the home's only source of heat. Houses built before 1978 have a high probability of containing lead-based paint.

The nurse is performing a medication reconciliation during a clinic visit with a client recently prescribed lithium. Which of the client's home medications is the priority to clarify with the health care provider?

2. Hydrochlorothiazide Lithium is a mood stabilizer most often used to treat bipolar affective disorders. Lithium has a very narrow therapeutic index (0.8-1.2 mEq/L [0.8-1.2 mmol/L]) that should be closely monitored; it also has the potential for many drug interactions. Several medications can cause increased lithium levels, including thiazide diuretics (eg, hydrochlorothiazide), nonsteroidal anti-inflammatory drugs, and antidepressants. Thiazide diuretics have demonstrated the greatest potential to increase lithium concentrations, with a possible 25%-40% increase in concentrations (Option 2). The nurse should assess the client for signs and symptoms of lithium toxicity and report the findings to the health care provider.

The registered nurse supervises a licensed practical nurse (LPN) and unlicensed assistive personnel (UAP) caring for clients receiving brachytherapy. Which action would require the nurse to intervene?

2. LPN who, when caring for a client with a radium implant, turns away from the client while wearing a lead apron Brachytherapy is an internal radiation treatment that is ingested, injected into a cavity or bloodstream, or implanted (eg, seeds, capsules, wires). Brachytherapy emits radiation in or near a tumor to treat certain malignancies. When caring for clients undergoing brachytherapy, nurses should maintain specific precautions to ensure safety, including: Limit the time of exposure (eg, 30 min/day). Cluster care and wear a designated (ie, not shared with anyone else) dosimeter badge. Maximize distance from the source; 6 feet (1.8 m) is recommended. Use shielding (eg, lead apron, portable lead shields) appropriately. Lead aprons typically shield the front of the body; turning the back to the client is a risk for exposure (Option 2). Pregnant women and children should not be exposed to clients undergoing brachytherapy. Body fluids are generally not radioactive. Dressings, bed linens, and trash must remain in the client's room until the implant is removed.

The nurse in the public health clinic is caring for a client with pubic lice. Which of the following statements should the nurse include in the education? Select all that apply.

2. Remove nits from pubic hair with a fine-toothed nit comb." 3."Sexual partners should also receive treatment." 4."Wash clothes and linens with hot water." 5."Wash pubic hair with lice treatment shampoo." Pediculosis pubis (ie, "crabs") is an infestation of pubic lice. Clients with pubic lice should be given the following instructions: Use lice treatment shampoo (1% permethrin) or rinse on pubic and body hair to kill lice (Option 5) After treatment, remove nits with a fine-toothed nit comb, fingernails, or tweezers (Option 2) Wash and dry clothes, towels, and bedding with hot water and highest-heat dryer setting (Option 4) Sexual partners should also receive pubic lice treatment (Option 3)

The nurse cares for a client with an established ascending colostomy. Which statement made by the client indicates that further teaching is required?

3. "I change the appliance and bag every other day" -Peristomal skin irritation may also occur if the ostomy appliance is removed and changed too frequently. The appliance should be changed every 5-10 days (Option 3). The ostomy bag is emptied when one-third full. The client with a colostomy is encouraged to drink plenty of fluids to prevent dehydration (the semiliquid consistency of stool from an ascending colostomy results in increased fluid loss) and decrease intake of gas-forming foods (beans, onions, broccoli).

he charge nurse is educating a new nurse on IV start technique for a 6-year-old with autism spectrum disorder. Which statement by the new nurse indicates that further teaching is required?

3. "I will hold the child's hand as a soothing measure. Children with autism spectrum disorder (ASD) respond well to brief, concrete, and developmentally appropriate communication (i.e. pictures). The nurse can ease anxiety during procedures by involving caregivers and reducing stimulation. Physical touch and eye contact may activate a stress response in children with ASD.

A nurse in the cardiac intensive care unit assesses a client with diabetes mellitus who underwent a percutaneous coronary intervention with stent placement via the left femoral artery 3 hours ago. Which assessment finding requires priority notification of the health care provider?

3. Angina rated as 4 on a pain scale of 0-10 Percutaneous coronary intervention (PCI) with stent placement is performed to improve coronary artery patency and increase cardiac perfusion. A balloon and stent are inserted via a catheter through a large artery (eg, femoral artery) and threaded toward the blocked coronary artery. The balloon expands the stent against the arterial wall, compressing plaque and improving patency. The stent remains in the client after the balloon and catheter are removed. Potential complications of PCI include thrombosis, stent occlusion, bleeding/hematoma, and limb ischemia. The nurse should immediately notify the health care provider of postprocedure angina, which indicates possible thrombosis or stent occlusion; necessary prescriptions (eg, nitroglycerin, second PCI) should be obtained and promptly initiated (Option 3). Increased blood glucose must be treated but is not a priority over stent occlusion.. This client's 1+ pulses are not a concern because they are bilateral, not unilateral. Most clients with diabetes mellitus and coronary artery disease may also have baseline peripheral artery disease.

Four pediatric clients are brought to the emergency department at the same time. Which client should be seen first?

3. Child with bruising behind the ears after a football injury Bruising behind the ear (eg, Battle sign) following head trauma may indicate a basilar skull fracture (Option 3). Because of their close proximity to the brainstem, basilar skull fractures pose a risk of serious intracranial injury, which is the most common cause of traumatic death in children. Other signs include blood behind the tympanic membrane, periorbital hematomas (ie, raccoon eyes), and cerebrospinal fluid leakage from the nose or ears. This client requires cervical spine immobilization, close neurologic monitoring, and support of airway, breathing, and circulation. Vomiting with oral intake may indicate infection (viral or bacterial). Most serious abdominal processes (eg, obstruction, intussusception, appendicitis) also have abdominal pain. This client may require IV fluids and antiemetics but is not a priority.

The charger nurse is responsible for making room assignments multiple clients. Which pari of client assignments to a shared room is appropriate?

3. Client who had a bowel resection 1 day ago and client with asthma exacerbation. When making room assignments, it is important to remember that a client with an active or suspected infection should not be paired with a client who has a fresh surgical wound or is immunocompromised. A client having an asthma exacerbation does not have an infection and is not at risk for spreading infection to a client who had a recent bowel resection surgery.

A nurse receives change-of-shift report on four clients. Which client should the nurse assess first?

3. Client with a bowel resection receiving total parenteral nutrition who had 4800 mL of urine output over the past 12 hours Total parenteral nutrition (TPN) is an IV nutrition feeding that may be prescribed to clients with dysfunction of the gastrointestinal tract (eg, short bowel). Glucose (dextrose) is a primary component of TPN solutions; therefore, the nurse should monitor blood glucose and assess for symptoms of hyperglycemia (eg, polydipsia, polyuria, headaches, blurred vision). A urine output of 4800 mL over the past 12 hours (ie, 400 mL/hr) may indicate hyperglycemia (Option 3). Symptomatic clients should be assessed and treated immediately because hyperglycemia can lead to seizures, coma, or death.

The nurse is assisting the client with repositioning in bed when the chest tube becomes dislodged from the client's chest. Which action should the nurse perform first?

3. Cover the insertion site with the palm of a gloved hand If a chest tube is accidentally dislodged from the client's chest, the priority is to cover the insertion site to prevent atmospheric air from entering the pleural space. Ideally, a dry, sterile gauze dressing is placed over the site and taped on three sides; this allows intrapleural air to escape and prevents development of a tension pneumothorax. However, if the nurse does not have immediate access to sterile gauze, the priority is to place the palm of a clean, gloved hand firmly over the site until a dressing can be obtained

The nurse cares for a client with a terminal disease who created a do not attempt resuscitation (DNAR) directive. The client stops breathing and loses their pulse. The client's adult child states, "Please, do whatever you can to save them!" Which intervention is appropriate?

3. Explain the client's resuscitation directive to the client's child Clients can create a do not attempt resuscitation (DNAR) directive instructing that CPR and other life-saving measures be withheld. With an advance directive in place, the client's wishes should be followed, even if they conflict with the wishes of loved ones

Which 3 findings are most important for the nurse to report to the health care provider?

3. Heart Sounds - Heart sounds: A grating, squeaky sound heard over the left chest wall during S1 or S2 can indicate pericardial friction rub, which occurs when inflamed surfaces of the heart rub against each other. The nurse should have the client lean forward and auscultate at the end of expiration to differentiate between pericardial friction rub and pleural friction rub (caused by inflamed lung tissue) 4. Pain Assessment -New-onset chest pain that worsens with deep breathing may indicate reinfarction or pulmonary embolism 5. Temperature -An elevated temperature (ie, ≥100.4 F [38 C]) within the first 3 postoperative days is a sign of an inflammatory process. Follow-up is required to determine whether it is related to nosocomial infection, post-MI complications (eg, pericarditis), or a noninfectious etiology (eg, pulmonary embolism) ( Acute-onset pain stimulates the sympathetic nervous system and can cause a subsequent elevation in blood pressure. The client's blood pressure is only mildly elevated and is not most concerning at this time.

The staff nurse caring for a client with a history of substance use disorder approaches the charge nurse and says, "My client is constantly requesting pain medicine. I had to administer normal saline instead of morphine because it is too early for another dose of morphine." Which action by the charge nurse is the priority at this time?

3. Instruct the nurse to notify the health care provider about the lack of pain relief Administration of a placebo (a substance with no therapeutic effect) outside of a consented research trial is unethical and deceitful. When faced with an ethical dilemma, the nurse should address the client's needs prior to reporting or documenting the unethical behavior. Clients with a history of substance use disorder and increased opioid tolerance often require a higher-dose analgesic or stronger opioid (eg, hydromorphone) to achieve pain relief. The priority action by the charge nurse is to instruct the staff nurse to contact the health care provider to discuss the client's frequent requests for morphine to alleviate uncontrolled pain

The nurse is planning care for a client with bipolar disorder and acute mania who is being admitted involuntarily after attempting to run across a five-lane highway. Which intervention is the priority to include in the care plan?

3. Offer high-calorie snacks the client can eat while on the move and during tasks When caring for a client with mania, the nurse should prioritize physiological needs over psychological or self-fulfillment needs. The nurse can address imbalanced nutrition in a manic client by providing high-calorie snacks and finger foods that the client can carry and eat without having to sit down. Bipolar disorder is characterized by alternating episodes of depression and mania. Manic clients demonstrate hyperactivity and distractibility and may refuse to sit still long enough to drink or eat, placing them at risk for inadequate nutritional intake.

A pregnant client at 38 weeks gestation is admitted to the labor and delivery unit reporting contractions, severe abdominal pain, and dark vaginal bleeding. What is the nurse's priority action?

3. Palpate the abdomen and apply a fetal heart rate monitor Placental abruption (abruptio placentae) occurs when the placenta prematurely detaches from the uterine wall. This life-threatening complication can interrupt fetal oxygen supply and cause maternal hemorrhage. Associated symptoms may include frequent contractions, abdominal pain, dark red vaginal bleeding, uterine tenderness, and elevated uterine resting tone. Priorities include assessment of maternal vital signs, palpation of the abdomen/uterus, and continuous fetal heart rate monitoring If monitoring indicates fetal distress and/or maternal hemodynamic compromise, the health care team will prepare for emergency cesarean birth.

The nurse is preparing to teach a 15-year-old primigravid client at 16 weeks gestation during an initial prenatal visit. Which information would be a priority for the nurse to include

3. Stress the importance of consistent prenatal care - Adolescents have an increased risk for complications during pregnancy (eg, low birth weight, preterm birth, preeclampsia, anemia). They may have a self-focused outlook on life and may not consider the consequences of their actions, which may negatively affect their health and that of the fetus. The primary goal of the first prenatal visit is to establish rapport and emphasize the importance of consistent prenatal care so that complications can be prevented or detected early (Option 3).

A student nurse is accompanying the charge nurse when conducting daily rounds. Which personal protective measure by the charge nurse does the student nurse question?

3. Wears 2 pairs of gloves when emptying the urinary catheter collection bag of a client who is HIV positive The best way for health care workers to protect themselves against possible HIV transmission is to consistently follow standard (universal) precautions with all clients, regardless of HIV status. HIV is transmitted through contact with blood, breast milk, semen, and vaginal secretions. No extra precautions are needed for routine care of clients that are HIV positive because the virus is not spread through casual contact, droplets, or aerosolized particles. Some nurses have the common misconception that double-gloving reduces the risk of contracting HIV. Appropriate use of a single pair of clean gloves provides a barrier between the nurse's hands and the client's blood and body fluids (Option 3). In compliance with standard precautions, situations in which blood or body fluids may splash or be sprayed (eg, suctioning, irrigation) require additional personal protective equipment (eg, face shield, gown) as necessary.

The nurse on the antepartum unit is performing shift assessments of several clients that are pregnant. Which client assessment is the priority to report to the health care provider?

4. Client with preeclampsia with 3+ reflexes and 2 beats of clonus Clients with preeclampsia are at risk for developing preeclampsia-associated seizure activity (eg, eclampsia) due to increased central nervous system irritability. The presence of neurologic manifestations (eg, hyperreflexia, clonus) may indicate worsening preeclampsia and can precede seizure activity (Option 4). This client is at the most immediate risk of harm and is the priority to report to the health care provider. Clients with gestational diabetes mellitus are more susceptible to infection (eg, urinary tract infection, vaginal yeast infection). Although the client's report of dysuria may indicate a urinary tract infection, the assessment findings do not indicate immediate risk

A client arrives in the emergency department with right-sided paralysis and slurred speech. The nurse understands that the client cannot receive thrombolytic therapy due to which reason?

4. Client's symptoms started 12 hours earlier Thrombolytic therapy (ie, t-PA) is used to dissolve blood clots and restore perfusion in clients with ischemic stroke. The nurse should assess for contraindications to t-PA due to the risk for hemorrhage. Clients have a 3- to 4.5-hour window from onset of symptoms to receive t-PA to achieve full effectiveness of thrombolytic therapy Recent major surgery within the past 14 days is a contraindication because t-PA dissolves all clots in the body and may therefore disrupt the surgical site. -To receive t-PA, clients must have a systolic blood pressure (BP) ≤185 mm Hg and diastolic BP ≤110 mm Hg. In addition, BP should be maintained at ≤180/105 mm Hg throughout the administration of thrombolytic therapy and 24 hours thereafter - Loss of the gag reflex and other major functions would most likely make the client a candidate for thrombolytics due to proof of deficits from stroke. Other contraindications include hemorrhagic stroke and stroke or head trauma within the past 3 months.

The nurse accidentally administers orally dissolving mirtazapine (an atypical antidepressant and is used primarily for the treatment of a major depressive disorder. Mirtazapine is in a group of tetracyclic antidepressants (TeCA).) through a client's percutaneous endoscopic gastrostomy tube instead of the prescribed sublingual route. After assessing the client for adverse reactions, what is the nurse's priority action?

4. Notify the prescribing health care provider Orally dissolving mirtazapine is an antidepressant specifically formulated for mucous membrane absorption, allowing quick entry into the bloodstream. Crushing and administering this medication through a percutaneous endoscopic gastrostomy tube is a wrong-route medication error. If medication errors occur, the priority is client safety. The nurse should first assess for adverse effects and stabilize the client's condition, if needed. The nurse should then immediately notify the health care provider (HCP) of the error and assessment findings (Option 4). The HCP may prescribe new interventions to prevent or reduce harm to the client. After implementing new prescriptions, the nurse should notify both the client and nurse manager about the error and complete an incident report.

The nurse is caring for a client with a central venous catheter (CVC) who reports feeling nauseated and chilled. The nurse notes that the CVC insertion site is red and inflamed and that the client has a temperature of 102 F (38.8 C). Which new prescription from the health care provider should the nurse implement first?

4. Obtain blood cultures and discontinue the central venous catheter In response to a possible CRBSI (central-line related bloodstream infection), the CVC should be removed as soon as possible to prevent continued exposure to the infection source. Blood cultures should be obtained before initiating antibiotic therapy, as antibiotics may contaminate the sample and prevent identification of the infectious organism (Option 4).

The nurse is reviewing new laboratory results for a client with an exacerbation of chronic obstructive pulmonary disease. The client's serum pH is 7.39. Which result is a priority for the nurse to report to the health care provider?

4. PaO2 of 52 mm Hg (6.92 kPa) Chronic obstructive pulmonary disease (COPD) is a progressive respiratory disease caused by alveolar destruction and loss of lung elasticity, resulting in impaired gas exchange. Because clients with COPD usually maintain a state of compensated respiratory acidosis, the urge to breathe becomes unresponsive to increasing levels of carbon dioxide gas (CO2). Instead, low oxygen levels promote respiratory efforts (ie, hypoxic drive) in clients with COPD Manifestations of COPD exacerbation (eg, tachypnea, wheezing) may progress to respiratory failure without treatment. Whereas a slight decrease in PaO2 (normal: 80-100 mm Hg [10.6-13.3 kPa]) may be an expected finding for a client with COPD, PaO2 <60 mm Hg (7.98 kPa) indicates severe hypoxia requiring immediate reporting to the health care provider (Option 4). Compensated respiratory acidosis occurs when renal resorption of HCO3− increases, causing elevated serum HCO3− (normal: 21-28 mEq/L [21-28 mmol/L]) secondary to chronic CO2 retention (ie, PaCO2 >45 mm Hg [5.99 kPa]), which helps normalize serum pH (ie, normal arterial pH: 7.35-7.45).

The nurse is reviewing the medical history of a client who has sustained a right tibia/fibula fracture from a fall. The nurse identifies which finding as most likely to hinder healing?

4. Peripheral arterial disease Bone healing depends on multiple factors, including nutrition, adequate circulation, and age. A client with peripheral arterial disease has decreased perfusion to the extremities due to atherosclerotic changes in the arteries. Without adequate perfusion, the bone is not supplied with the oxygen and nutrients required for healing

The nurse on an inpatient mental health unit is caring for a client with paranoid delusions who is refusing to eat. The client states that all the food and drinks have been poisoned. Which intervention by the nurse is appropriate?

4. Provide the client food in unopened single-serving packages - Management of paranoia focuses on building trust with and grounding the client in reality. When the client believes food has been poisoned, the nurse can build trust and promote adequate nutrition by offering unopened, individually packaged food

A client is receiving packed RBCs intravenously through a double-lumen peripherally inserted central catheter (PICC) line. During the transfusion, the nurse receives a new prescription to begin intravenous piggyback (IVPB) amphotericin B. What is the nurse's best action?

4. Wait 1 hour after blood transfusion finishes administering amphotericin B Amphotericin B is an antifungal medication used to treat systemic fungal infections. It is commonly associated with severe adverse effects, including hypotension, fever, chills, and nephrotoxicity. Due to the similarity between the adverse effects of amphotericin B and the symptoms of a blood transfusion reaction (eg, chills, fever, hypotension, kidney injury), the nurse's best action is to complete the blood transfusion and allow one hour of observation before initiating amphotericin B (Option 4). This enables the nurse to distinguish between transfusion-related reactions and adverse effects from amphotericin B.

A nurse is caring for a client at 37 weeks gestation who is undergoing a contraction stress test. Which fetal strip should the nurse associate with a negative contraction stress test?

A contraction stress test (CST) evaluates fetal well-being under stress by identifying uteroplacental insufficiency. Uterine blood flow is decreased during uterine contractions, which stresses the fetus during labor. Contractions are stimulated using either oxytocin administration or nipple stimulation. A fetal tracing is evaluated until 3 uterine contractions, each lasting 40-60 seconds, are captured within 10 minutes. A negative test has no late or variable decelerations and is associated with good fetal outcomes (Option 2). A positive test includes late decelerations with ≥50% contractions. A suspicious or equivocal test includes variable or prolonged decelerations or late decelerations with <50% contractions.

For each finding below, click to specify if the finding is consistent with the disease process of an acute myocardial infarction, pericarditis, or pulmonary embolism. Each finding may support more than one disease proces

Acute Myocardial Infarction: ST-segment elevation on ECG - Acute myocardial infarction (MI) occurs when at least one of the coronary arteries becomes occluded. An MI can cause ECG changes such as ST-segment elevation (STEMI), depending on the extent of coronary artery occlusion and myocardial wall infarction. Manifestations include ischemic chest pain (ie, angina) that radiates to the back, left arm, or jaw; nausea; and diaphoresis. The chest pain, however, is not relieved by leaning forward or worsened with deep breathing. A pericardial friction rub (ie, grating, squeaky sound auscultated over the chest wall) does not occur with MI. Pericarditis (swelling and irritation/inflammation of the thin, saclike tissue surrounding the heart (pericardium) caused by viral infections but occur following recent MI and surgery. ST-segment elevation on ECG, pain that worsens with deep breathing, chest pain relieved by leaning forward, grating squeaky sound auscultated over the chest wall -Pericarditis is characterized by pleuritic chest pain (sharp, worsens with deep breathing) that is typically relieved by sitting up and leaning forward. This position relieves pressure on the inflamed pericardium, especially during lung inflation. Manifestations include pericardial friction rub (ie, grating, squeaky sound auscultated over the chest wall) and ST-segment elevation on ECG due to inflammation of the pericardium. Pulmonary embolism: pain that worsens with deep breathing, - PE an occlusion of a pulmonary artery by material (eg, blood clot) that has traveled through the bloodstream (ie, embolized). Clients with PE typically experience sudden pleuritic chest pain that worsens with deep breathing due to pulmonary infarction and surrounding inflammation; the pain is not relieved by leaning forward. Additional findings include dyspnea and

For each characteristic below, click to specify if the characteristic is consistent with the disease process of Alzheimer disease or delirium.

Alzheimer Disease: irreversible, hallucinations, speech changes (word-finding difficulties_ Delirium: acute onset, hallucinations, speech changes Alzheimer disease is an irreversible, progressive form of dementia. Speech changes, and memory and social skills slowly decline as the disease progresses, while hallucinations tend to appear later in the course of the disease. Delirium is an acute, reversible, alteration in mental state involving a reduced or fluctuating level of consciousness, speech changes, and hallucinations.

The nurse in the emergency department is assessing telemetry strips for assigned clients. Which client tracing is a priority for the nurse to assess?

An ST-segment elevation myocardial infarction (STEMI) occurs when at least one of the coronary arteries is completely occluded. The ST segment is the portion of the ECG between the QRS complex and the T wave. Prompt treatment (eg, percutaneous coronary intervention, thrombolytics) is needed to restore myocardial oxygen supply and limit myocardial damage (Option 3).

Math: The nurse is preparing to administer a continuous dopamine infusion at 5 mcg/kg/min. The client weighs 187 lb and the available medication contains 400 mg of dopamine in 250 mL of D5W. At what rate in milliliters per hour (mL/hr) should the nurse program the infusion pump?

Answer: 16 Dopamine is an inotrope and vasopressor used to treat distributive shock and maintain cardiac output. To calculate the dopamine infusion rate in milliliters per hour, the nurse should first identify the prescribed dose (eg, 5 mcg/kg/min) and available medication (eg, 400 mg/250 mL) and then convert to milliliters per hour (eg, 16 mL/hr).

An emergency pericardiocentesis is performed to treat cardiac tamponade. The nurse understands that _________ indicates that the procedure was effective.

Answer: An increase in blood pressure A pericardiocentesis is the emergency treatment for cardiac tamponade. Pericardiocentesis involves percutaneous needle aspiration to drain the fluid accumulating in the pericardium, which relieves elevated intrapericardial pressures and restores hemodynamic stability. An increase in blood pressure indicates that the procedure was effective at relieving compression on the heart and restoring cardiac function.

The nurse is reinforcing education with a client with Marfan syndrome (Marfan syndrome is a genetic disorder that causes people to have unusually long arms, legs and fingers) who is recovering from an aortic root repair and mechanical aortic valve replacement via sternotomy and is prescribed warfarin. Which of the following client statements indicate a correct understanding of the teaching?

Aortic root repair with mechanical heart valve replacement is a procedure often performed for clients with Marfan syndrome a connective tissue disorder that increases the risk for aortic rupture. Clients with mechanical valve replacement via sternotomy require education on lifestyle changes and prevention of complications, including: 2. "I will have to have my spouse lift and carry heavy objects for me for several months." - Avoiding heavy lifting (ie, objects over 10 lb [4.5 kg]) for 3-6 months after surgery to prevent disruption of the sternotomy sutures/wires and allow the breastbone to heal 3."I will need to take prescribed warfarin for the rest of my life." - Maintaining lifelong anticoagulant therapy (eg, warfarin, apixaban) after a mechanical valve replacement to prevent thromboembolic events (eg, stroke) and valve thrombosis 4."If I gain more than 5 lb (2.3 kg) in 1 week, I will need to tell my health care provider." - Reporting signs and symptoms of heart failure (eg, weight gain >5 lb [2.3 kg] in 1 week) immediately which may indicate valve failure 5."My usual razor blades will need to be replaced with an electric shaver." - Initiating bleeding precautions (eg, using an electric shaver) because anticoagulant therapy increases the risk of uncontrolled bleeding

The nurse is reinforcing discharge teaching for a client who is experiencing age-related hearing loss. Which of the following actions should the nurse implement? Select all that apply.

Clients who have presbycusis (ie, age-associated hearing loss) require accommodations to promote engagement in care and ensure understanding of teaching. Nursing interventions should focus on facilitating effective and inclusive communication with clients to maintain their safety, including: 1. Encourage the client to repeat back teaching - Encouraging the client to repeat back instructions (ie, closed-loop communication) (Option 1). If the client is unable to repeat them back, provide further clarification with an alternative approach. 2. Ensure adequate lighting in the client's room - Sitting directly in front of the client in a well-lit room so all visual cues, such as facial expressions and hand gestures, can be seen 4. Sit directly in front of the client while speaking - Sitting directly in front of the client in a well-lit room so all visual cues, such as facial expressions and hand gestures, can be seen 5. Use printed materials with pictures and illustrations - Using printed materials with visuals, such as pictures and illustrations, or acting out demonstrations to supplement verbal instructions

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress

Condition most likely experiencing: hypoglycemia Actions to take: obtain a capillary blood glucose level, administer glucose gel PO Parameter to monitor: seizures, mental status Rapid-acting insulins (eg, lispro) are administered at mealtimes to prevent postprandial hyperglycemia. When administered without food, rapid-acting insulins can cause hypoglycemia (ie, glucose level <70 mg/dL [3.9 mmol/L]). Manifestations of hypoglycemia include confusion, lethargy, tremors, and diaphoresis. If hypoglycemia is suspected, the nurse should immediately obtain a blood glucose level. Treatment includes fast-acting oral carbohydrates (eg, glucose gel, tablets, fruit juices) or dextrose IV if the client is unable to swallow (eg, unconsciousness). Clients with severe hypoglycemia are at risk for mental status changes (eg, loss of consciousness) and seizures.

intrapartum fetal monitoring

Fetal monitoring gives a clear picture of the FHR, and is the strongest indicator of how the fetus is tolerating the labor process Done to evaluate how fetus tolerates labor & to identify possible hypoxic insult to fetus during labor Fetal monitoring has two components: -the woman's contractions -looking at how the fetus is tolerating labor by identifying changes in the fetal heart rate. Fetal monitoring may be internal or external Fetal monitoring may be continuous or intermittent

Which intervention does the nurse anticipate next?

WRONG 4. Chest tube insertion A tension pneumothorax is life-threatening and requires immediate chest tube placement to decompress the pleural space, promote reexpansion of the compressed lung, relieve compression of the heart and great vessels, and restore hemodynamic stability. The chest tube should be connected to a water seal drainage system and suction, which promotes evacuation of air and reestablishment of negative pressure in the pleural cavity. The water seal acts as a one-way valve, allowing air to exit the pleural space but not enter it

For each finding below, click to specify if the finding is consistent with the disease process of hemothorax or tension pneumothorax. Each finding may support more than one disease process.

Hemothorax: results from the accumulation of blood loss in the pleural cavity --> loss of intravascular blood vlolume: tachycardia, hypotension, unilateral diminished breath sounds Pneumothorax is characterized by air inside the pleural space, which disrupts the negative pressure that maintains lung expansion, causing the lung to collapse either partially or completely. Tension pneumothorax develops if air enters but cannot escape the pleural space --> this trapping compresses the heart and great vessels and displaces the midline structures (trachea) to the opposite side. Tension pneumothorax: tachycardia, hypotension, subcutaneous emphysema/crepitus on palpitation (air gets into the tissue under the skin), unilateral diminished breath sounds (also tracheal deviation, hyperresonance to percussion) Endoctracheal intubation would worsen the existing pneumothorax by delivering positive pressure ventilation, which would increase intrathoracic pressure ==> compress the heart and great vessels and lead to cardiac arrest.

The client has been diagnosed with acute pericarditis. For each potential intervention, click to specify if the intervention is indicated or not indicated for the care of the client.

Indicated: Administer Colchicine, administer high-dose aspirin - Administering colchicine, which is commonly used to reduce inflammation in clients with gout and has been effective in reducing symptoms associated with pericarditis. In addition, colchicine use may decrease the risk of recurrent pericarditis. Administering NSAIDs (eg, high-dose aspirin) to reduce inflammation. Not indicated: administer nitroglycerin, maintain supine positioning, encourage frequent use of an incentive spirometer - Nitroglycerin is used in clients with acute angina to dilate coronary blood vessels and improve blood flow to the myocardium. This is not indicated for a client with pericarditis. - The nurse should position the client sitting up with support to lean forward to reduce the pressure on the inflamed parietal pericardium. Supine positioning often worsens the pain and is not indicated. Incentive spirometer (IS) use helps prevent atelectasis (partial or complete collapse of the lung or lobe/alveoli) by eliciting deep breathing and coughing. However, in a client with acute pericarditis, IS use can worsen pain from the inflamed pericardium rubbing against the heart and increase anxiety; therefore, frequent use is not indicated.

Complete the following sentence by choosing from the list of options. The nurse suspects the client's condition is caused by

Neurodegenerative changes in the brain Alzheimer disease (AD) is caused by neurodegenerative changes in the brain. As individuals age, some develop insoluble amyloid plaques in the brain tissue. Amyloid plaques cause an inflammatory response that leads to cell damage and neuron death in surrounding areas. In clients with AD, more plaques are apparent, especially in areas of the brain that are essential for memory and cognitive function (eg, hippocampus). Ultimately, plaques will involve other areas of the brain, including the parts responsible for language and reasoning (eg, cerebral cortex). In addition to excess amyloid plaques, clients with AD also have abnormal accumulations of twisted protein (tau) that collect inside nerve cells and cause neuronal death. The brain will eventually shrink by the final stage of the disease.

The nurse is preparing to don sterile gloves before suctioning a client's tracheostomy. Place the steps of donning sterile gloves in the correct order

The nondominant hand is used to apply the glove of the dominant hand first. Using the dominant hand to apply the second glove improves dexterity and decreases the risk of contamination of the gloved dominant hand. 1. Perform hand hygiene and remove the outer glove package (Place the inner glove package on a clean, dry surface) 2. Open the inner glove package by folding back the edges 3. Use the nondominant fingers to grasp the edge of the cuff of the dominant glove (touch only the inside surface of the glove) 4. Pull the glove over the dominant hand 5. Use the dominant fingers to grasp the cuff of the nondominant glove 4. Pull the glove over the nondominant hand

Findings that require further investigation in a client with penetrating stab wounds to the neck, chest, and/or abdomen include:

Unilateral chest wall expansion (one side of the chest expands more than the other) and diminished breath sounds, which indicate the presence of air (eg, open pneumothorax) or fluid in the pleural space (eg, hemothorax, pleural effusion) Vital sign instability (eg, tachycardia, hypotension, tachypnea, hypoxemia) and signs of poor perfusion (eg, skin pallor), which are concerning for hemorrhage and respiratory compromise

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

Urge incontinence (UI), also known as overactive bladder, occurs when the bladder contracts randomly, causing a strong, sudden urge to urinate followed by urine leakage. UI may occur without cause or may result from neurological system dysfunction (eg, Parkinson disease, stroke) or spinal cord injury. Interventions for clients with UI include: 2. "I have an appointment with a nutritionist to help me manage my diet so that I can lose my excess weight." - Losing excess weight to reduce pressure on the pelvic floor (Option 2) 3. "I joined a smoking cessation support group at the community center." - Avoiding dietary bladder irritants (eg, caffeine, nicotine, artificial sweeteners, citrus juices, alcohol, carbonated drinks) (Option 3) 4."I plan to do my daily Kegel exercises when I am riding the train to and from work." - Performing pelvic floor exercises (eg, Kegel) to strengthen the pelvic muscles and help prevent urinary leakage (Option 4) 5."I will make sure to urinate every 2 hours to reduce urgency and have fewer accidents." - Using bladder training, such as voiding every 2 hours while awake and gradually lengthening the intervals between voiding (Option 5) Taking anticholinergic medications (eg, tolterodine, oxybutynin), which reduce bladder spasms

The nurse helps a client with end-stage renal disease and a serum potassium level of 5.2 mEq/L (5.2 mmol/L) to plan menu choices. Which items would be best to include in the meal plan?

WRONG 2. Grilled chicken sandwich on white bread, applesauce Clients with end-stage renal disease are unable to excrete potassium; therefore, the nurse should teach them to choose foods low in potassium to maintain normal serum potassium levels (3.5-5.0 mEq/L [3.5-5.0 mmol/L]). Grilled chicken sandwich on white bread and applesauce are low in potassium These clients should avoid foods high in potassium (eg, green leafy and cruciferous vegetables; legumes; melons; bananas; strawberries; milk and milk products; most beef, fish, and shellfish; and whole grains) to maintain normal serum potassium levels

There has been a major disaster involving a manufacturing plant explosion. The emergency department nurse is sent to triage victims. Which client should the nurse send to the hospital first?

WRONG 3. Client with a broken, protruding right tibia and gray, pulseless foot When prioritizing clients for treatment, emergent needs should be managed first, followed by urgent and then nonurgent. The client with an open fracture and impaired distal perfusion (eg, absent distal pulses, capillary refill >3 sec) has an emergent need for care as limb loss may occur without rapid intervention A large, open head wound and a Glasgow Coma Scale score of 3 is indicative of severe neurological trauma. This client has a poor prognosis regardless of treatment (expectant) and would be the lowest priority.

When the nurse provides education about starting risperidone, which statement by the client's parent indicates a need for further teaching?

WRONG 4. It is normal for the client to become shaky and restless when agitated." Second-generation (atypical) antipsychotic medications (eg, risperidone/Risperidal, quetiapine/Seroquel, olanzapine/Zyprexa) are used to treat schizophrenia, bipolar disorder, and other mental health disorders. One of the main adverse effects the nurse should recognize with second-generation antipsychotic medications is extrapyramidal symptoms (EPSs). EPSs include manifestations of akathisia (ie, restlessness, fidgeting), parkinsonism (eg, tremors, shuffling gait), and tardive dyskinesia (eg, lip smacking, facial grimacing). These symptoms are important to monitor because they may be easily mistaken for agitation or negative schizophrenic symptoms (eg, pacing, rocking) (Option 4). The health care provider may prescribe anticholinergics (eg, benztropine/Cogentin, diphenhydramine/Benadryl) or benzodiazepines to treat EPSs. The nurse should teach that the sedating effects of second-generation antipsychotic medications (eg, drowsiness, hypersomnia [ie, excessive daytime sleepiness]) are common.

When caring for a client with ulcerative colitis, which of the following nursing activities are appropriate for the registered nurse to delegate to the licensed practical nurse? Select all that apply.

WRONG 1. Administer a prescribed suppository 2. Monitor for a change in bowel sounds 3. Remind the client to track daily weights Ulcerative colitis (UC) is a chronic disease characterized by inflammation and ulcerations in the large intestines, resulting in urgent, frequent, bloody diarrhea; abdominal pain; fever; and fatigue. Frequent diarrhea may cause weight loss and electrolyte imbalances; therefore, the client should be taught to measure daily weights.

Based on the nursing assessment progress notes, what is the correct staging of the client's pressure injury? Click on the exhibit button for additional information.

WRONG 2. Stage 2: Stage 2 pressure injuries have partial-thickness skin loss (abrasion, blister, or shallow crater). The skin blisters or forms an open sore, and the area around the sore may be red and irritated. (shallow, open ulcer, red-pink wound with no sloughing and possible intact or ruptured blister) Stage 1: Intact skin with nonblanchable redness Stage 2: Partial-thickness skin loss (abrasion, blister, or shallow crater) involving the dermis or epidermis; the wound bed is red or pink and may be shiny or dry Stage 3: Full-thickness skin loss; subcutaneous fat is visible but not tendon, muscle, or bone; tunneling may be present Stage 4: Full-thickness skin loss with visible tendon, muscle, or bone; slough or eschar (scabbing, dead tissue) may be present; undermining and tunneling may be present Pressure injuries are described as "unstageable" if the base is covered by necrotic tissue or eschar