Practice 2

In the emergency department, a pediatric client is placed on mechanical ventilation by means of an endotracheal tube. Several hours later, the nurse enters the room and finds the client in respiratory distress. It is most important for the nurse to take which of these actions? 1. Assess the client for intercostal retractions [19%] 2. Assess the client's blood pressure in both arms [1%] 3. Auscultate the client's lung sounds [70%] 4. Observe the color of the client's fingernail beds [7%]

A client experiencing respiratory distress while receiving mechanical ventilation should be assessed for proper ventilation first. The nurse needs to determine if the mechanical ventilation equipment is still properly placed in the trachea. An endotracheal tube (ET) can become displaced with movement. By assessing the client's lung sounds, the nurse can quickly determine if ET placement has been compromised (Option 3). Airway is the priority for this client. By auscultating the client's lung sounds, the nurse can determine if the client has an open airway. (Option 1) This is an assessment of the client's breathing, which is not the priority at this time. (Option 2) This is an assessment of the client's circulation, which is not the priority at this time. (Option 4) This is an assessment of the client's circulation, which is not the priority at this time.

The client with narcissistic personality disorder often behaves in grandiose and entitled ways, believes that he/she is perfect, and relies on constant reinforcement and admiration from people perceived as ideal. What is the best explanation for these clinical characteristics? 1. The client is attempting to maintain self-esteem [46%] 2. The client is experiencing delusions of grandeur [47%] 3. The client is feeling threatened [4%] 4. The client is trying to prevent a panic attack [1%]

A client with narcissistic personality disorder (NPD) exhibits a recurrent pattern of grandiosity, need for admiration, and lack of empathy. Clients with NPD may project a picture of superiority, uniqueness, and independence that hides their true sense of emptiness. From a psychodynamic perspective, individuals with NPD have a fragile and damaged ego resulting from a childhood environment that fostered a sense of inferiority, poor self-esteem, and severe self-criticism. Narcissistic characteristics develop as a way to regulate self-esteem and protect the ego from further psychic injury. (Option 2) Delusions of grandeur are experienced by clients with a psychotic disorder; NPD is a personality disorder. (Option 3) Clients with NPD may feel threatened if criticized or if others do not meet their emotional demands. However, this is not the best explanation of the clinical characteristics associated with NPD. (Option 4) Panic attacks are characteristic of clients with an anxiety disorder, not NPD.

The nurse assesses a client who is 2 days postoperative breast reconstruction surgery. The client has 2 closed-suction Jackson Pratt bulb drains in place. There is approximately 10 mL of serosanguineous fluid in each one. One hour later, the nurse notices the bulbs are full of bright red drainage and measures a total output of 200 mL. What is the nurse's priority action? 1. Notify the health care provider (HCP) [79%] 2. Open the collection bulb to release excessive negative pressure [9%] 3. Record the amount in the output record as wound drainage [6%] 4. Reposition the client on the right side [4%]

A closed-wound drainage system device (eg, Jackson-Pratt, Hemovac) consists of fenestrated drainage tubing connected to a flexible, vacuum (self-suction) reservoir unit. The distal end lies within the wound and can be sutured to the skin. It is usually inserted near the surgical site through a small puncture wound rather than in the surgical incision. The purpose of the drain is to prevent fluid buildup (eg, blood, serous fluid) in a closed space. Although it depends on the client and type of surgical procedure, about 80-120 mL of serosanguineous or sanguineous drainage per hour during the first 24 hours after surgery can be expected. The priority action is to notify the HCP due to the change in type and amount of drainage after the first 24 hours following surgery. Excessive bleeding and fluid collection into the closed space following breast reconstruction can greatly affect the integrity of the surgical incision, the tissue reconstruction, and wound healing (Option 1). (Option 2) Opening the bulb does not release excessive negative pressure. It would release all negative pressure, drainage would cease, and even more fluid would collect in the closed space, compromising the integrity of the incision even further. (Option 3) Recording the amount of wound drainage on the output record is an appropriate intervention. However, it is not the priority action. (Option 4) Although repositioning the client could affect the amount of drainage, it is not likely as drainage is maintained by negative pressure, not gravity.

A client comes to the emergency department after being assaulted. Imaging studies show a simple fracture of the mandible. The nurse assesses edema of the face and jaw, drooling, and bleeding in the mouth; the client rates pain as a 9 out of 10. What is the priority nursing intervention? 1. Administer nasal oxygen at 3 L/min [7%] 2. Administer opioids for pain [11%] 3. Apply ice pack to face for 20 minutes each hour [4%] 4. Suction the mouth and oropharynx [76%]

A direct blow to the face or a motor vehicle collision is usually the cause of mandibular fracture. The client drools due to inability to close the mouth from edema and misalignment of the jaw. Structural damage, excessive saliva, and bleeding with pooled blood in the mouth can compromise the airway. Therefore, the priority nursing intervention is to suction the mouth and oropharynx to maintain airway patency. (Options 1, 2, and 3) Administration of nasal oxygen to facilitate breathing, administration of opioids to control pain, and application of ice to reduce edema and help reduce pain are all appropriate interventions for this client. However, these are not the priority interventions as the greatest threat to the client's survival is airway occlusion.

A clinic nurse is caring for a client who has hypertension and is prescribed hydrochlorothiazide, lisinopril, and clonidine. The current blood pressure reading is 190/102 mm Hg, and the client reports a headache that has lasted several days. Which question is most important for the nurse to ask next? 1. "Have you noticed any abnormal swelling in your legs?" [8%] 2. "How are you currently taking your blood pressure medications?" [70%] 3. "How has your stress level been the past few weeks?" [2%] 4. "What over-the-counter medications have you taken today?" [18%]

A major problem in the long-term management of hypertension is poor adherence to the treatment plan, often due to unpleasant side effects (eg, fatigue, dizziness, reduced libido, erectile dysfunction) and medication cost. This problem can worsen if a client must take multiple medications. Determining whether a client is taking medications as prescribed is a priority, as sudden or abrupt discontinuation of antihypertensive medications can cause rebound hypertension and possibly hypertensive crisis (eg, blurred vision, dizziness, severe headache, shortness of breath) (Option 2). (Option 1) The nurse should assess for peripheral edema, which may indicate heart failure. However, this can be done after assessing medication adherence. (Options 3 and 4) Stress can elevate blood pressure. Some over-the-counter medications (eg, decongestants, NSAIDs) can also increase blood pressure. However, poor adherence to prescribed medications is the number one cause of uncontrolled hypertension. The nurse should ask about all other medications the client has taken and the client's stress level after confirming that the prescribed blood pressure medications are being taken correctly.

A client is admitted to the medical surgical floor with a hemoglobin level of 5.0 g/dL (50 g/L). The nurse should anticipate which findings? Select all that apply. 1. Coarse crackles 2. Dyspnea 3. Pallor 4. Respiratory depression 5. Tachycardia

A normal hemoglobin level for an adult male is 13.2-17.3 g/dL (132-173 g/L) and female is 11.7-15.5 g/dL (117-155 g/L). A client with severe anemia will have tachycardia, which will maintain cardiac output. The cardiovascular system must increase the heart rate and stroke volume to achieve adequate perfusion. Shortness of breath (dyspnea) may occur due to an insufficient number of red blood cells. The respiratory system must increase the respiratory rate to maintain adequate levels of oxygen and carbon dioxide. Pallor (pale complexion) occurs from reduced blood flow to the skin. (Option 1) Coarse crackles occur with fluid overload but not with anemia. (Option 4) Respiratory depression does not occur with anemia. Respiratory depression may occur post-administration of a narcotic or during oversedation.

The nurse on the neurotrauma unit receives report on 4 clients. Which client should the nurse assess first? 1. Client in neurogenic shock from a spinal cord injury, with pulse of 56/min, blood pressure of 120/60 mm Hg, and warm and pink skin [4%] 2. Client with a concussion from closed-head injury due to a fall, Glasgow Coma Scale score of 15, headache, and memory loss [3%] 3. Client with a subdural hematoma, pulse of 48/min, blood pressure of 190/90 mm Hg, and a pupil that reacts slowly to light [78%] 4. Client with central diabetes insipidus from a head injury, hypernatremia, and urine output of 210 mL/hr [13%]

A subdural hematoma is caused by bleeding into the subdural space and is the result of blunt force head trauma. It is life-threatening, as increased pressure from the hematoma on the brain can lead to decreased cerebral perfusion and herniation (mid-line shift). Assessing for signs of increased intracranial pressure, including change in level of consciousness, Cushing triad (hypertension, bradycardia, and irregular respirations), ipsilateral pupil dilation, headache, and vomiting, is critical as surgery to evacuate the hematoma and relieve the pressure may be necessary. (Option 1) Manifestations of neurogenic shock include hypotension and bradycardia. Although the client has bradycardia and requires monitoring, the client is normotensive and has normal skin color and temperature, which indicate adequate perfusion. (Option 2) Headache, transient change in level of consciousness, and inability to remember the injury (retrograde amnesia) are expected manifestations of a concussion. The Glasgow Coma Scale score of 15 (range: 3-15) indicates complete orientation. (Option 4) Central diabetes insipidus results from head trauma. Damage to the hypothalamus or pituitary gland leads to decreased antidiuretic hormone secretion, resulting in increased serum osmolality (>295 mOsmol/kg [295 mmol/kg]). Treatment is necessary, but polyuria (>200 mL/hr) and hypernatremia (sodium >145 mEq/L [145 mmol/L]) due to dehydration are expected manifestations

A nurse is discussing discharge education with a client after his fifth hospitalization for pulmonary edema caused by his congestive heart failure. Which of the following statements indicates that further teaching is required? 1. "I should supplement my potassium intake." [19%] 2. "I should weigh myself daily." [2%] 3. "Moderate exercise may be helpful in my condition." [3%] 4. "Potato chips are an acceptable snack in moderation." [74%]

The client is likely dealing with some level of denial regarding his diagnosis of congestive heart failure. Glossing over the importance of salt avoidance is missing an important opportunity to help them avoid further hospitalizations for the same condition. (Option 1) Adding potassium to a diet, especially when substituting it for sodium, can decrease blood pressure and fluid retention. Some diuretics, such as furosemide (Lasix), may also cause low levels of potassium. (Option 2) Tracking the level of fluid retention with daily weigh-ins is the easiest way for clients and health care providers to monitor the effects of medication on congestive heart failure. (Option 3) Physical activity is very important in preserving cardiac function.

An African American client comes to the clinic for a follow-up visit 2 months after starting enalapril for hypertension. Which client statement should be reported to the health care provider immediately? 1. "Is there anything I can take for my dry, hacking cough?" [18%] 2. "My blood pressure this morning was 158/84 mm Hg." [4%] 3. "Sometimes I feel somewhat dizzy when I stand up." [5%] 4. "Will you look at my tongue? It feels thicker than normal." [72%]

Angioedema is swelling that usually affects areas of the face (lips, tongue), larynx, extremities, gastrointestinal tract, and genitalia. The swelling often starts in the face and can quickly become life-threatening as it progresses to the airways. Angioedema is an adverse effect of ACE inhibitors (eg, enalapril, lisinopril, captopril) and occurs more commonly in African American clients. Unlike other typical drug allergies, this side effect can occur any time after starting the medication. The nurse should immediately report angioedema to the health care provider and carefully monitor the client (Option 4). (Option 1) A persistent, dry, hacking cough is a common side effect of ACE inhibitors. It is not life-threatening, but the medication should be discontinued or changed to resolve the cough. (Option 2) The nurse should review the client's blood pressure readings over the past month since starting enalapril. The client may need a dosage change or an additional medication. This should be reported but is not the priority in this situation. (Option 3) Occasional dizziness upon rising (ie, orthostatic hypotension) is a common side effect of most antihypertensives. The client should be taught to rise slowly and sit on the side of the bed for a few minutes before standing up.

The nurse prepares to admit a client with worsening cirrhosis who is on the waiting list for a liver transplant. Based on the client's electronic health record, the nurse anticipates which assessment findings? Select all that apply. Click on the exhibit button for additional information. 1. Ascites 2. Bruising 3. Constipation 4. Itching 5. Lethargy

Cirrhosis of the liver occurs when chronic liver disease (eg, hepatitis C infection) causes scar tissue and nodules, which can decrease liver function and lead to liver failure. Clients with end-stage liver disease may experience exacerbations requiring hospitalization and acute intervention. Numerous laboratory abnormalities occur in the setting of liver failure and correlate with assessment findings (eg, high serum ammonia resulting in hepatic encephalopathy) (Options 1, 2, 4, and 5). (Option 3) Lactulose, an osmotic laxative, decreases serum ammonia levels by causing ammonia to be excreted through stool. The desired therapeutic effect is the production of 2 or 3 soft bowel movements each day; therefore, clients receiving lactulose should not exhibit constipation.

A client comes to the emergency department and reports headache, nausea, and shortness of breath after being stranded at home without electricity due to severe winter weather. While collecting a history, which question is most important for the nurse to ask? 1. "Are you up to date with your annual flu shot and other vaccinations?" [20%] 2. "Have you had difficulty eating or drinking in the last few days?" [22%] 3. "How have you been keeping your house warm during this weather?" [47%] 4. "Is there anything that you have found that relieves your symptoms?" [10%]

Carbon monoxide (CO) is a colorless, odorless gas produced by burning fuel (eg, oil, kerosene, coal, wood) in a poorly ventilated setting. CO toxicity (poisoning) is most often associated with smoke inhalation from structure fires, but is also generated by furnaces/hot water heaters fueled by natural gas or oil, coal or wood stoves, fireplaces, and engine exhaust. Clients with CO toxicity often have nonspecific symptoms, and the diagnosis can be missed. It is important to assess for possible CO exposure to initiate appropriate emergency care and prevent hypoxic neurologic impairment. To help identify elevated CO levels in the home, the nurse can ask about the following: Similar symptoms in other family members, or an illness in an indoor pet that developed at the same time Fuel-burning heating/cooking appliances; risk of CO toxicity increases in the fall and winter due to increased used of heat sources in an enclosed space (Option 3) (Options 1, 2, and 4) It is important to reconcile the client's vaccinations, obtain a nutritional history, and explore the nature of the client's symptoms, but it is essential to rule out the possibility of CO toxicity given the circumstances of this client's illness.

A nurse is precepting a new graduate nurse who is caring for a client with a paralytic ileus and a Salem sump tube attached to continuous suction. The preceptor should intervene when the graduate nurse performs which interventions? Select all that apply. 1. Checks for residual every 4 hours 2. Places client in semi-Fowler's position 3. Plugs the air vent if gastric content refluxes 4. Provides mouth care every 4 hours 5. Turns off suction when auscultating bowel sounds

Continuous suction can be applied to decompress the stomach if a double lumen Salem sump tube is in place. The larger lumen is attached to suction and the smaller lumen (within the larger one) is open to the atmosphere. Checking for residual volume is not an appropriate intervention because the Salem sump is attached to continuous suction for decompression and is not being used to administer enteral feeding (Option 1). The air vent (blue pigtail) must remain open as it provides a continuous flow of atmospheric air through the drainage tube at its distal end (to prevent excessive suction force). This prevents damage to the gastric mucosa. If gastric content refluxes, 10-20 mL of air can be injected into the air vent. However, the air vent is kept above the level of the client's stomach to prevent reflux (Option 3). General interventions to maintain gastric suction using a Salem sump tube include: Place the client in semi-Fowler's position to help keep the tube from lying against the stomach wall; this is done to help prevent gastric reflux (Option 2). Provide mouth care every 4 hours as this helps to maintain moisture of oral mucosa and promote client comfort (Option 4). Turn off suction briefly during auscultation as the suction sound can be mistaken for bowel sounds (Option 5). Inspect the drainage system for patency (eg, tubing kink or blockage). Educational objective:General interventions to maintain gastric suction when using a Salem sump tube include: Maintaining client in semi-Fowler's position Accurate assessment of bowel sounds Keeping the air vent (blue pigtail) open and above the level of the client's stomach Providing mouth care every 4 hours to maintain moisture of oral mucosa and promote comfort Inspecting the drainage system for patency

In the intensive care unit, the nurse cares for a client who develops diabetes insipidus (DI) 2 days after pituitary adenoma removal via hypophysectomy. Which intervention should the nurse implement? 1. Administer desmopressin [65%] 2. Assess fasting blood glucose [16%] 3. Institute fluid restriction [14%] 4. Place the client in the Trendelenburg position [3%]

Diabetes insipidus (DI) is a condition that occurs due to insufficient production/suppression of antidiuretic hormone (ADH). Neurogenic DI is a type of DI that results from impaired ADH secretion, transport, or synthesis. It sometimes occurs after manipulation of the pituitary or other parts of the brain during surgery, brain tumors, head injury, or central nervous system infections. DI is characterized by polydipsia (increased thirst) and polyuria (increased urine output) with low urine specific gravity (dilute urine). As a result, fluids should be replaced orally/intravenously to prevent dehydration (Option 3). ADH release is impaired in neurogenic DI. As a result, ADH replacement with vasopressin (Pitressin) can be used to treat DI. However, it also has vasoconstrictive properties. Therefore, desmopressin (DDAVP), an analog without vasopressor activity, is the preferred therapy. Clients on this treatment should be monitored for urine output, urine specific gravity, and serum sodium (to avoid hyponatremia due to excess DDAVP). (Option 2) DI is not associated with low/high blood glucose and should not be confused with diabetes mellitus (DM) as both DI and DM involve symptoms of excessive urination (polyuria). (Option 4) The Trendelenburg position (body laid flat and supine with feet higher than the head by at least 15-30 degrees) is contraindicated in most neurological conditions.

The nurse is providing teaching about contraception to a group of clients. Which statement by the nurse is appropriate to include? 1. "Backup contraception is required for the first 3 months after initiation of oral contraceptives." [35%] 2. "Diaphragm contraceptive devices, when used with spermicide, also provide protection from HIV infection." [4%] 3. "Over-the-counter emergency contraceptives should be taken within 3 days of unprotected intercourse." [51%] 4. "Use of an intrauterine device should be avoided in sexually active adolescent clients." [8%]

Emergency contraception (EC) prevents pregnancy after unprotected intercourse. Over-the-counter EC pills (eg, high-dose levonorgestrel [Plan B One-Step]) should be taken within 3 days (72 hr) of unprotected sexual intercourse (Option 3). If taken after 3 days, levonorgestrel will not harm an established pregnancy but may be less effective. Copper intrauterine device (IUD) insertion and oral ulipristal (eg, Ella) require a prescription and offer EC for up to 5 days (120 hr) after unprotected intercourse. (Option 1) Backup contraception is required for 7 days after starting oral contraceptives; however, it is not required if the pill pack is started on the first day of menses. (Option 2) Diaphragms are flexible latex or silicone devices that cover the cervix and create a barrier against sperm. Spermicide (eg, nonoxynol 9) is applied to the rim of the device to increase effectiveness. Neither provides reliable protection against sexually transmitted infections (STIs), and spermicide may increase the risk of HIV transmission. (Option 4) Adolescents are appropriate candidates for IUD placement, which provides long-term contraception, and its effectiveness is not dependent on actions at the time of coitus. STI prevention (eg, condoms) and screening is important for all sexually active adolescents, especially those using IUDs.

The nurse is reinforcing education to a client with a venous thromboembolism who is prescribed rivaroxaban. Which statement by the client indicates the medication teaching has been effective? 1. "I need to continue to avoid eating spinach and kale." [6%] 2. "I probably will have some weakness in my legs when I take this medicine." [2%] 3. "I should avoid taking aspirin while receiving this medication." [66%] 4. "I will have to get blood drawn routinely to check my clotting levels." [23%]

Factor Xa inhibitors (eg, rivaroxaban [Xarelto], edoxaban, apixaban) are anticoagulants used to prevent and treat venous thromboembolism. Factor Xa inhibitors are being prescribed more frequently than other oral anticoagulants (eg, warfarin), as they have a lower risk of bleeding and require less ongoing monitoring (eg, PT/INR). Clients prescribed rivaroxaban should be educated to avoid taking over-the-counter medications or supplements that increase bleeding risk, such as NSAIDs (eg, aspirin), garlic, and ginger. The combined effects of rivaroxaban and other anticoagulants may greatly increase the risk of uncontrolled bleeding (eg, epidural, intracranial, gastrointestinal) and hemorrhage (Option 3). (Option 1) Unlike warfarin, factor Xa inhibitors are not affected by vitamin K, which is found in many green, leafy vegetables (eg, spinach, kale). (Option 2) Anticoagulants, particularly factor Xa inhibitors, increase the risk for spontaneous intracranial bleeding or formation of epidural hematomas. Clients taking factor Xa inhibitors should be instructed to immediately contact their health care provider for symptoms of neurological impairment (eg, extremity weakness, altered sensation, numbness). (Option 4) Routine monitoring of clotting times (eg, PT/INR, PTT) is unnecessary for clients prescribed factor Xa inhibitors.

The nurse administers lactulose to a client diagnosed with cirrhosis and hepatic encephalopathy. Which nursing action is inappropriate when administering this medication? 1. Assess mental status and orientation [9%] 2. Give on an empty stomach for rapid effect [22%] 3. Hold if 3 soft stools occur in a day [33%] 4. Mix with fruit juice to improve flavor [35%]

Hepatic encephalopathy is a reversible neurological complication of cirrhosis caused primarily by increased ammonia levels in the blood. Normally, ammonia created in the intestines is converted to urea in the liver and excreted in the kidneys. However, in the presence of liver damage, blood is shunted around the liver portal system and ammonia is able to cross the blood-brain barrier, leading to neurological dysfunction (Option 1). Lactulose is the most common treatment for hepatic encephalopathy. Lactulose is not digested or absorbed until it reaches the large intestines where it is metabolized, producing an acidic environment and a hyperosmotic effect (laxative). In this acidic environment, ammonia (NH3) is converted to ammonium (NH4+) and excreted rapidly. Lactulose can be given orally with water, juice, or milk (to improve flavor) or it can be administered via enema (Option 4). For faster results, it can be administered on an empty stomach (Option 2). The desired therapeutic effect of lactulose is the production of 2-3 soft bowel movements each day; therefore, the dose is titrated until the therapeutic effect is achieved. This therapeutic dose should not be held but instead should be maintained until the desired outcomes are reached (improved mental status, decreased ammonia levels) (Option 3). The client's electrolyte levels should be closely monitored during therapy as lactulose is a laxative that can cause dehydration, hypernatremia, and hypokalemia.

A client is receiving IV potassium. The IV pump displays an occlusion alarm. The tubing is free of occlusions, and the IV flushes easily without symptoms of infiltration. Which action should the nurse take next? 1. Discard potassium and document administration of a partial dose [2%] 2. Exchange the IV pump with a different one [86%] 3. Insert a new IV catheter in a different location [6%] 4. Remove the pump and administer medication by gravity drip [4%]

IV infusion pumps display an occlusion alarm when IV solution cannot be infused due to pressure in the line. Common causes of occlusion include clamped or kinked IV tubing, clotting in the IV catheter, and kinking in the IV catheter with extremity movement (eg, elbow, wrist). The nurse should assess the tubing and IV site and flush the IV catheter to check patency. In the absence of identifiable occlusion, an alarming IV pump should be exchanged for a different one (Option 2). Malfunctioning equipment may harm the client and should be removed from the care area. The malfunctioning equipment is labeled as out of service and is sent for maintenance. (Option 1) An IV pump alarm does not indicate that a medication is no longer needed. The nurse should replace a malfunctioning pump and restart the medication. (Option 3) An IV catheter that has no symptoms of occlusion (ie, resistance to flushing) or infiltration (eg, swelling, coolness, pain) does not need to be replaced. (Option 4) IV pump infusion is more accurate than gravity drip. IV pumps are required when administering high-risk IV medications (eg, heparin, insulin, potassium). IV potassium should never be administered by gravity as it may cause lethal arrhythmias if administered too quickly.

Prior to hospital discharge, the nurse discusses sexuality after childbirth with a client who had an uncomplicated vaginal birth with no perineal lacerations. Which client statement requires further teaching? 1. "I should avoid resuming sexual intercourse until after my vaginal bleeding has stopped." [17%] 2. "I should expect vaginal dryness and use water-soluble lubricants, especially if I'm breastfeeding." [25%] 3. "I will begin using condoms to prevent pregnancy once menses returns." [38%] 4. "I will try to feed my baby before my partner and I engage in sexual activity." [19%]

Initiating an open discussion about sexual activity after childbirth allows the nurse to provide anticipatory guidance and recognize individual client concerns (eg, discomfort, fatigue, fear, body image). The nurse should plan to reinforce the use of contraception because many clients resume sexual activity before their postpartum checkup (4-6 weeks after birth), when contraception methods are usually prescribed. Ovulation may occur as early as 4 weeks after birth and before resumption of menses, especially in clients who formula feed. Clients should be encouraged to use a barrier contraceptive such as condoms to prevent pregnancy until another form of birth control can be prescribed (Option 3). (Option 1) Sexual activity may be resumed once lacerations/episiotomy are healed, and vaginal bleeding has stopped. For clients with no birth complications, risk of infection or bleeding is low at ≥2 weeks postpartum. (Option 2) Sexual arousal takes more time for most postpartum clients due to hormonal changes. Lactating clients may especially experience symptoms of estrogen deficiency (eg, vaginal dryness). Vaginal lubrication is recommended to increase comfort. (Option 4) Sexual activity may be inhibited by the couple's sense of responsibility for newborn needs. In addition, sexual arousal may stimulate leakage of breast milk. Feeding the newborn before sexual activity helps alleviate these concerns/distractions.

A client is started on lisinopril therapy. Which assessment finding requires immediate action? 1. Blood pressure 129/80 mm Hg [2%] 2. Heart rate 100/min [7%] 3. Serum creatinine 2.5 mg/dL (221 µmol/L) [85%] 4. Serum potassium 3.5 mEq/L (3.5 mmol/L) [4%]

The dosage of angiotensin-converting enzyme (ACE) inhibitors (eg, lisinopril, enalapril, ramipril) should be adjusted for clients with renal impairment. A serum creatinine of 2.5 mg/dL (221 µmol/L ) indicates renal impairment (normal 0.6-1.3 mg/dL [53-115 µmol/L]). The nurse should notify the health care provider so that the dosage can be decreased or held. (Options 1, 2, and 4) The client's blood pressure, heart rate, and serum potassium (normal 3.5-5.0 mEq/L [3.5-5.0 mmol/L]) are within normal limits. They do not require immediate action. Hyperkalemia and hypotension are contraindications for giving ACE inhibitors.

The nurse is planning care for a child being admitted with Kawasaki disease and should give priority to which nursing intervention? 1. Apply cool compresses to the skin of the hands and feet [10%] 2. Monitor for a gallop heart rhythm and decreased urine output [60%] 3. Prepare a quiet, non-stimulating, and restful environment [21%] 4. Provide soft foods and liberal amounts of clear liquids [7%]

Kawasaki disease (KD) is a childhood condition that causes inflammation of arterial walls (vasculitis). The coronary arteries are affected in KD, and some children develop coronary aneurysms. The etiology of KD is unknown; there are no diagnostic tests to confirm the disease, and it is not contagious. KD has 3 phases: Acute - sudden onset of high fever that does not respond to antibiotics or antipyretics. The child becomes very irritable and develops swollen red feet and hands. The lips become swollen and cracked, and the tongue can also become red (strawberry tongue). Subacute - skin begins to peel from the hands and feet. The child remains very irritable. Convalescent - symptoms disappear slowly. The child's temperament returns to normal. Initial treatment consists of IV gamma globulin (IVIG) and aspirin. IVIG creates high plasma oncotic pressure, and signs of fluid overload and pulmonary edema develop if it is given in large quantities. Therefore, the child should be monitored for symptoms of heart failure (eg, decreased urinary output, additional heart sounds, tachycardia, difficulty breathing). (Option 1) During the acute phase (swollen hands and feet), skin discomfort can be eased with cool compresses and lotions. No treatment is needed in the subacute phase (skin peeling), but the new skin might be very tender. (Option 3) The child will be very irritable during the acute phase of KD. A non-stimulating, quiet environment will help to promote rest. After a KD episode, it is important for parents to understand that their child's irritability may last for up to 2 months and that follow-up appointments for cardiac evaluation are important. (Option 4) During the acute phase (painful swollen lips and tongue), the child should be given soft foods and clear liquids as these are tolerated best.

A nurse educator is developing materials for a hospital-wide campaign about zero tolerance for lateral violence and bullying among staff. Which actions will the nurse educator include in teaching about what staff members should do if they experience workplace violence? Select all that apply. 1. Document the interactions with the bully 2. Ignore the bully's comments, remarks, and allegations 3. Observe interactions between the bully and other colleagues 4. Report the violent incidents to the hospital administrator 5. Tell the bully you will not tolerate the unprofessional behavior

Lateral violence (also known as horizontal violence) can be defined as acts of aggression carried out by a co-worker against another co-worker and designed to control, diminish, or devalue a colleague. These behaviors usually take the form of verbal abuse such as name-calling, unwarranted criticism, intimidation, and blaming. However, other acts, such as refusing to help someone, sabotage, exclusion, and unfair assignments, also fall under the category of lateral violence. Violence in the workplace should not be tolerated or ignored by either staff or management. Actions that staff members can take if they become victims of lateral violence include: Documenting and keeping a file of all incidents (Option 1) Reporting the incidents to the immediate supervisor Letting the bully know that the behavior will not be tolerated (Option 5) Observing interactions between the bully and other colleagues (may validate the victim's experiences and serve as a source of support) (Option 3) Seek support from within the facility or from an external source (Option 2) Ignoring acts of lateral violence will perpetuate the bullying. (Option 4) The chain of command should be followed when reporting incidents of lateral violence. If the immediate supervisor takes no action, the employee can move up the chain.

The nurse is caring for a new mother whose infant has been diagnosed with Down syndrome. The client says to the nurse, "I'm so worried. My husband is so devastated that he won't even look at the baby." What is the best response by the nurse? 1. "Both of you will benefit from supportive counseling." [7%] 2. "How are you feeling about your baby?" [73%] 3. "I will have the doctor speak to your husband." [0%] 4. "Why do you think your husband feels this way?" [18%]

Learning that their newborn has a genetic disorder (eg, Down syndrome) is an overwhelming experience for most parents. They may initially react with shock, disbelief, and/or denial. Once they accept the diagnosis, parents may be filled with uncertainty and doubt and experience an array of emotions, including guilt, depression, and anger about the presumed loss of their perfect child. When helping the family cope with the crisis, the nurse needs to keep the lines of communication open and offer support. The nurse should use open-ended therapeutic communication techniques that encourage the family members to verbalize what they are feeling or experiencing (Option 2). (Option 1) This is a true statement; supportive counseling is usually beneficial to new parents of children with disabilities. The nurse can refer clients to family support groups or even make the initial phone call for them. However, the nurse should first encourage the parents to express how they are feeling. (Option 3) This is not the best response. The nurse has a role and responsibility to offer support to clients experiencing a crisis. (Option 4) This is accusatory and nontherapeutic. The nurse should avoid asking "why" questions when attempting to gain more information.

The nurse in the outpatient clinic is reviewing phone messages. Which client should the nurse call back first? 1. Client post kidney transplant who reports white spots in the oral cavity [37%] 2. Client with a history of mitral valve regurgitation who reports fatigue [25%] 3. Client with erythema and purulent drainage at the site of a spider bite [26%] 4. Client with hypertension who reports a cold and nasal congestion [10%]

Mitral valve regurgitation is the result of a disrupted papillary muscle(s) or ruptured chordae tendineae, allowing a backflow of blood from the left ventricle through the mitral valve into the left atrium. This backflow can lead to dilation of the left atrium, reduced cardiac output, and pulmonary edema. Clients are often asymptomatic but are instructed to report any new symptoms indicative of heart failure (eg, dyspnea, orthopnea, weight gain, cough, fatigue). This client should be assessed first due to possible heart failure, which would require immediate intervention. (Option 1) Kidney transplant recipients are on an immunosuppressant regimen to prevent rejection of the transplanted organ, which can leave them susceptible to infections such as candidiasis (thrush) of the oral cavity. (Option 3) The client with a spider bite is displaying signs and symptoms of infection, and further assessment is required to evaluate for conditions such as cellulitis. This client should be called second. (Option 4) Clients with hypertension who develop sinus or nasal congestion have limited options for symptom relief. Decongestants containing a vasoconstrictor (eg, pseudoephedrine) can exacerbate hypertension.

A registered nurse (RN), licensed practical nurse (LPN), and unlicensed assistive personnel are working on the unit. A client who is about to be discharged home with tube feedings needs care. Which responsibilities should the RN delegate to the LPN? Select all that apply. 1. Cleaning the skin surrounding the gastrostomy tube stoma 2. Crushing and administering metoprolol through the gastrostomy tube 3. Programming the feeding pump to administer a prescribed bolus feeding 4. Teaching the client about home enteral feeding and gastrostomy tube care 5. Weighing the client using the bed scale

Most routine nursing tasks in a stable client can be delegated to a licensed practical nurse (LPN). Routine ostomy care is an appropriate task for delegation to an LPN. The LPN may administer bolus or continuous tube feedings to a stable client. In addition, most medication administration is suitable for delegation to an LPN. However, advanced medication administration (eg, IV medications) must be performed by a registered nurse (RN) (Options 1, 2, and 3). (Option 4) Client education, nursing assessment, and advanced medication administration should always be performed by an RN. Procedural nursing tasks in an unstable client are also an RN responsibility. (Option 5) Routine activities of daily living (eg, positioning) are generally suitable to be delegated to unlicensed assistive personnel (UAP). Obtaining the client's weight may be delegated to UAP.

A client with massive trauma and possible spinal cord injury is admitted to the emergency department following a dirt bike accident. Which clinical manifestation does the nurse assess to help best confirm a diagnosis of neurogenic shock? 1. Apical heart rate 48/min [36%] 2. Blood pressure 186/92 mm Hg [19%] 3. Cool, clammy skin [40%] 4. Temperature 100 F (37.7 C) tympanic [2%]

Neurogenic shock belongs to the group of distributive (vasodilatory) shock. It affects the vasomotor center in the medulla and causes a disruption in the sympathetic nervous system (SNS); the parasympathetic nervous system (PNS) remains intact. The imbalance of activity between the SNS and PNS results in massive vasodilation and pooling of blood in the venous circulation, causing hypotension and bradycardia, the characteristic manifestations of neurogenic shock. (Option 2) Hypotension, not hypertension, is characteristic of neurogenic shock. (Option 3) Warm, dry skin is more likely to be present in neurogenic shock; cool, clammy skin is not a characteristic manifestation. (Option 4) Although thermoregulation may be impaired (poikilothermia) in neurogenic shock, a low-grade temperature of 100 F (37.7 C) is not a characteristic manifestation.

The nurse reinforces teaching with clients in the community health clinic about risk factors for oral cancer. Which client statement indicates the need for further teaching? 1. "I will drink in moderation with just a few alcoholic drinks a day." [64%] 2. "I will enroll in a smoking cessation program next week." [2%] 3. "I will go to the dentist next week to get my dentures refitted." [4%] 4. "I will stop sunbathing and going to the tanning bed immediately." [28%]

Oral cancer refers to cancers of the lips, tongue, mouth, pharynx (ie, throat), and larynx (ie, vocal cords). The most common type of oral cancer is squamous cell carcinoma, which initially presents as a nonhealing lesion or ulcer. Other symptoms of oral cancer include mucosal thickening, difficulty swallowing, mouth bleeding, sore spots, leukoplakia (ie, white patch), and changes in salivation. Modifiable risk factors include: Chronic alcohol and/or tobacco use (Options 1 and 2) Poor oral hygiene habits Chronic irritation to the mucosa (eg, chipped teeth, improperly fitted dental appliances) (Option 3) Excessive exposure to ultraviolet light (Option 4) In addition, unprotected sexual activity (eg, oral sex, multiple partners) increases the risk for sexually transmitted infections in the oral cavity (eg, human papillomavirus virus), which can cause oral cancer.

A client diagnosed with head and neck cancer has developed mouth sores related to external radiation therapy. The nurse teaches the client to use which of the following oral hygiene practices? Select all that apply. 1. Apply a water-soluble lubricating agent to moisturize mouth tissues 2. Brush teeth with a soft-bristle toothbrush 3. Cleanse the mouth with normal saline after meals and at bedtime 4. Do not drink hot liquids or eat foods that are spicy or acidic 5. Rinse with alcohol-based antiseptic mouthwash to decrease mouth odor 6. Use palifermin as prescribed to alleviate oral pain

Oral mucositis, inflammation or ulceration of the oral mucosa, results from chemotherapy or radiation therapy. Oral hygiene practices that minimize oral mucositis and promote comfort include the following: Cleansing the mouth with normal saline after meals and at bedtime to promote oral health Use of a soft-bristle toothbrush to decrease gum irritation Application of prescribed viscous lidocaine HCl (Xylocaine) to alleviate oral pain Use of water-soluble lubricating agents to moisten mouth tissues that may become dry due to therapy Avoidance of hot liquids and spicy/acidic foods, which can cause oral discomfort (Option 5) Clients with mucositis should avoid antiseptic mouthwashes with alcohol as they are irritating to mucous membranes. (Option 6) Administration of palifermin (Kepivance), a recombinant human keratinocyte growth factor, prevents oral mucositis in clients diagnosed with hematologic malignancies. However, it does not help with pain. Viscous lidocaine HCl (Xylocaine) alleviates the oral pain caused by mucositis.

A nurse is preparing to administer oxytocin to induce labor in a pregnant client at term gestation. Which of the following nursing actions are appropriate during oxytocin infusion? Select all that apply. 1. Administer oxytocin through the primary IV line 2. Assess the uterine contraction pattern 3. Initiate continuous fetal heart rate monitoring 4. Place IV oxytocin on an electronic infusion pump 5. Titrate oxytocin to achieve cervical dilation of 1 cm every 2 hours

Oxytocin is a high-alert medication commonly used for labor induction or augmentation. It should be administered via an electronic infusion pump (Option 4), which decreases medication errors, provides for accurate dosing, and prevents maternal hypotension associated with rapid oxytocin bolus. The nurse should evaluate and document the fetal heart rate and uterine contraction pattern every 15 minutes during the first stage of labor and every 5 minutes during the second stage (Option 2). Continuous electronic fetal heart rate monitoring, not intermittent auscultation, is necessary (Option 3). The nurse should also monitor maternal intake and output to identify fluid retention, which precedes water intoxication, a potential adverse reaction of oxytocin administration causing dilutional hyponatremia, convulsions, and death. (Option 1) Oxytocin is administered through a secondary IV line connected to a main IV line (ie, isotonic fluid) via the port closest to the client (ie, proximal port). This helps prevent an inadvertent oxytocin bolus and allows for rapid discontinuation of infusion. (Option 5) Oxytocin is not titrated according to cervical dilation, which cannot be assessed continuously and varies among clients. Instead, oxytocin is initiated at the lowest possible dose and titrated until contractions are 2-3 minutes apart and last for 80-90 seconds. The infusion is decreased/discontinued if uterine tachysystole (ie, >5 contractions in 10 minutes) or fetal distress occurs.

Which discharge teaching instructions should the nurse provide to the parents of a 2-year-old with group A streptococcal pharyngitis? Select all that apply. 1. Complete all the antibiotics even if your child is feeling better 2. Cool liquids and soft diet are recommended 3. Keep your child home from daycare for at least a week 4. Replace your child's toothbrush 24 hours after starting antibiotics 5. Throat lozenges may soothe your child's sore throat

Pharyngitis caused by group A β-hemolytic Streptococcus is a contagious bacterial throat infection that can lead to renal (glomerulonephritis) or cardiac complications (rheumatic fever) if not treated. Children may refuse to eat due to pain. A soft diet and cool liquids (ice chips) should be offered rather than solid foods (Option 2). It is important to complete the full course of antibiotics to prevent reinfection and complications (Option 1). Toothbrushes should be replaced 24 hours after starting antibiotics; the bristles can harbor the bacteria and reinfection may occur (Option 4). Young children may have minor cold symptoms and still be infected. The health care provider should test siblings age <3. (Option 3) Children with streptococcal pharyngitis may return to school or daycare after they have completed 24 hours of antibiotics and are afebrile. (Option 5) Throat lozenges can be given to older children but are a choking hazard in younger children. Acetaminophen or ibuprofen (liquid preparations) should be given for pain.

A client diagnosed with end-stage renal disease comes to the dialysis clinic for treatment. Which actions should the nurse take to prepare the client for hemodialysis? Select all that apply. 1. Administer subcutaneous heparin to decrease clotting during dialysis 2. Administer the client's morning doses of carvedilol and lisinopril 3. Check the client's medical records to determine the last post-dialysis weight 4. Obtain a set of client vital signs and the client's current weight 5. Palpate the fistula in the client's arm for a thrill and auscultate for a bruit

Prior to dialysis treatment, the nurse should assess the client's fluid status (weight, blood pressure, peripheral edema, lung and heart sounds), vascular access (arteriovenous fistula, arteriovenous grafts), and vital signs (Option 4). The amount of fluid removed (ultrafiltration) is determined by calculating the difference between the last post-dialysis weight and the client's current pre-dialysis weight (Option 3). After the client is connected to the dialysis machine, IV heparin is added to the blood from the client to prevent clotting that can occur when blood contacts a foreign substance. Giving subcutaneous heparin prior to initiation is not necessary (Option 1). (Option 2) During dialysis, excess fluid is removed, making the client prone to hypotension. In addition, medications are removed from the blood during hemodialysis, making them ineffective. Many medications that are taken once daily can be held until after the dialysis treatment to prevent their removal. If blood pressure medications are given prior to dialysis, the client can develop hypotension during the dialysis and then uncontrolled hypertension (decreased drug concentrations). (Option 5) Arteriovenous fistulas are created by anastomosing an artery to a vein; a thrill can be felt when palpating the fistula, and a bruit can be heard during auscultation when the fistula is functioning properly.

The parents of a hospitalized preschooler are concerned because their toilet-trained child has started wetting the bed. Which response by the nurse is most helpful? 1. "Discipline your child by taking away playroom privileges." [0%] 2. "It is normal for your child to regress while hospitalized." [91%] 3. "Restricting fluids at nighttime will solve this problem." [6%] 4. "Your child is acting out due to the hospitalization." [2%]

Regression during hospitalization is a normal response to the stress of an unfamiliar environment, the fear and pain of invasive procedures, and the change in a child's normal routine. Toilet-trained children may start bed-wetting, and children who gave up the bottle or pacifier may ask for it. It is important for the nurse to explain that this behavior is completely normal and that the child will gain back previous milestones after discharge. (Option 1) Firm discipline would be counterproductive at this time. Punishment by restricting playtime would create more stress for the child. (Option 3) Limiting fluids at nighttime, voiding before bedtime, and involving the child in planning (eg, changing wet linens) are all appropriate interventions for enuresis. However, the first step is to reassure the parents and then teach them therapeutic interventions. (Option 4) Misbehaving is not an unusual behavior for a preschooler. Acting out would not be due exclusively to the hospitalization.

A client diagnosed with septic shock has an upward-trending glucose level (180-225 mg/dL [10.0-12.5 mmol/L]) requiring control with insulin. The client's spouse asks why insulin is needed as the client is not a diabetic. What is the most appropriate response by the nurse? 1. "It is common for critically ill clients to develop type II diabetes. We give insulin to keep the glucose level under control (<140 mg/dL [7.8 mmol/L])." [3%] 2. "The client was diabetic before, but you just didn't know it. We give insulin to keep the glucose level in the normal range (70-110 mg/dL [3.9-6.1 mmol/L])." [1%] 3. "The increase in glucose is a normal response to stress by the body. We give insulin to keep the level at 140-180 mg/dL (7.8-10.0 mmol/L)." [40%] 4. "This increase is common in critically ill clients and affects their ability to fight off infection. We give insulin to keep the glucose level in the normal range (70-110 mg/dL [3.9-6.1 mmol/L])." [55%]

Stress-induced hyperglycemia (gluconeogenesis) can occur in hospitalized clients in relation to surgery, trauma, acute illness, and infection. Hyperglycemia (glucose level >140 mg/dL [7.8 mmol/L]) affects both diabetic and non-diabetic hospitalized clients, especially those who are critically ill. Approximately 80% of clients in the intensive care unit who develop hyperglycemia have no history of diabetes before admission. Hyperglycemia is associated with increased risk of complications (eg, health care-associated infection, increased length of stay, acute kidney injury). To minimize complications and avoid hypoglycemia, the recommended glucose target range for critically ill clients is 140-180 mg/dL [7.8-10.0 mmol/L]. For non-critically ill clients, <140 mg/dL [7.8 mmol/L] fasting and <180 mg/dL [10.0 mmol/L] random blood glucose are recommended. (Option 1) Hospital hyperglycemia is not a direct cause of type II diabetes mellitus. In the non-diabetic client, the glucose level usually returns to normal after resolution of the disease process and/or discontinuation of steroid medications. A target glucose range of <140 mg/dL [7.8 mmol/L) is not recommended for this client. (Option 2) The prevalence of diabetes in hospitalized clients is high (about 1 in 4) and may be an undiagnosed pre-existing condition. A normal-range glucose level (70-110 mg/dL [3.9-6.1 mmol/L]) is not the recommended target range in this client due to the risk of hypoglycemia (with aggressive control) and worse outcomes. (Option 4) Although hyperglycemia does affect the ability to fight infection, 70-110 mg/dL [3.9-6.1 mmol/L] is not the recommended target range for this client.

The registered nurse (RN) delegates to the unlicensed assistive personnel (UAP) the ambulation of a client. The RN observes the UAP placing the client's Foley bag on the IV pole at the level of the client's chest during the ambulation down the length of the hallway. What action should the RN take initially? 1. Discuss the need for UAP inservice education with the nurse manager [0%] 2. Give praise to the UAP for encouraging the client to walk the entire hall [0%] 3. Immediately lower the bag and speak privately to the UAP [97%] 4. Let the UAP complete assigned tasks and speak to the UAP at the end of the shift [1%]

The Foley bag is too high and needs to be lowered. When observing a provider making an error, the RN should immediately intervene to stop any potential harm to the client. It is important to timely correct a staff member who is making a mistake to help ensure that the error is not repeated. Correction of staff should always be done privately, not in front of the client. (Option 1) Future inservice education is not a timely solution to this immediate need. It is appropriate to carry out teaching first rather than initiate disciplinary actions. According to the Federal Drug Administration's (FDA's) mandate, as no serious harm was caused, the incident does not need to be reported. (Option 2) The most important issue needing intervention is the improper positioning (too high) of the Foley catheter bag. Positive reinforcement for appropriate actions can also be included (and is beneficial), but the error should first be corrected to prevent harm. (Option 4) It is important to attend to the error right away to help ensure that the UAP does not repeat it. Letting this UAP complete assigned tasks first does not immediately deal with the incorrect position of the Foley bag and may not effectively teach (aid retention of) the correct positioning to the UAP.

The nurse is educating the parents of a 6-month-old about introducing solid foods into the infant's diet. Which parental statement indicates a need for further teaching? 1. "I can introduce soft finger foods before my child has teeth." [9%] 2. "I can offer a variety of foods within the first week of introducing solids." [80%] 3. "I can prepare rice cereal with formula, breast milk, or water." [7%] 4. "I can save money by preparing baby food at home instead of buying it." [2%]

The introduction of solid foods generally occurs at age 4-6 months. When introducing new foods, parents should allow several (eg, 4-7) days between each new food to observe for any reactions to a specific food. Allergic responses often worsen with subsequent exposure, so it is a priority to identify food allergies early (Option 2). (Option 1) At age 6-8 months, an infant can try pureed fruits and vegetables, followed by simple finger foods (eg, teething crackers, small pieces of fruit or cooked vegetables, cheese). These foods help children develop motor skills and learn to chew, even before they have teeth. (Option 3) Parents should start introducing solids with an iron-fortified infant cereal (eg, rice, oatmeal) mixed with breast milk, formula, or water. (Option 4) Mashed soft fruits or cooked vegetables made at home are less expensive than commercially prepared baby food.

A parent calls the after-hours triage nurse about a 3-year-old who is sick with the flu. Which report by the parent would necessitate intervention by the nurse? 1. Acetaminophen being given every 4 hours for fever [17%] 2. Bismuth subsalicylate being used for nausea [52%] 3. Ibuprofen being given every 6 hours for body aches [20%] 4. Popsicles and gelatin desserts being used for hydration [10%]

The nurse should tell the parent to discontinue the use of bismuth subsalicylate (Pepto-Bismol) as it contains a salicylate (same class as aspirin) and could possibly cause Reye syndrome. Reye syndrome can develop in children with a recent viral illness such as varicella or influenza. It can cause acute encephalopathy and hepatic dysfunction. Children with viral infections should not be given aspirin or products containing salicylates. (Options 1 and 3) Acetaminophen and ibuprofen are being used appropriately. (Option 4) Sufficient fluids are important to maintain hydration in the child with influenza. Water and fluids should be offered frequently; popsicles and gelatin desserts (eg, Jell-O) provide a palatable means of getting children to ingest fluids.

The nurse observes a nursing student performing chest compressions on an adult client. Which technique indicates that the student understands how to provide high-quality chest compressions during cardiopulmonary resuscitation? 1. Compressing the chest to a depth of at least 2 in (5 cm) [62%] 2. Pausing after each set of 15 compressions to allow for 2 rescue breaths [8%] 3. Placing the heel of the hand on the upper half of the client's sternum [10%] 4. Providing compressions at a rate of at least 80-100/min [18%]

The primary goal of cardiopulmonary resuscitation (CPR) is adequate perfusion to the brain and vital organs. High-quality chest compressions for adults are at least 2 in (5 cm) deep to adequately pump blood but no more than 2.4 in (6 cm) deep to prevent unnecessary client injury (Option 1). The chest should recoil completely after each compression to allow complete refilling of the heart chambers, which promotes effective perfusion. (Option 2) Interruption of compressions should be minimized; at least 60% (preferably more) of the total resuscitation time should be made up of compressions. For adults (and in single-rescuer CPR for any age), a cycle of 30 compressions followed by 2 rescue breaths provides the best outcome. If the client has an advanced airway, continuous compressions and 10 breaths/min should be provided. (Option 3) Correct hand placement is in the center of the chest, on the lower half of the sternum (breastbone). Hand placement on the upper half of the sternum does not provide adequate perfusion. (Option 4) Studies have shown better client outcomes due to improved perfusion with a compression rate of 100-120/min.

A 55-year-old client on a medical-surgical unit has just received a diagnosis of pancreatic cancer. The client says to the nurse, "Is this disease going to kill me?" What is the best response by the nurse? 1. "Hearing this diagnosis must have been difficult for you. What are your thoughts?" [95%] 2. "We will do everything possible to prevent that from happening." [3%] 3. "Well, we're all going to die sometime." [0%] 4. "You should concentrate on getting better rather than thinking about death." [1%]

The stress of receiving a life-threatening diagnosis often causes clients to feel very vulnerable. There is a tendency to keep feelings and concerns closed off; clients may not be able to express how distressed they feel or find the right words to express feelings and concerns. In asking, "Is this disease going to kill me?," the client is most likely not looking for a direct "yes" or "no" answer. This would immediately close off the conversation and create a missed opportunity for a meaningful engagement and communication with the nurse. It is more likely that this question is being asked to provide an opening for further discussion about the meaning of this devastating diagnosis as well as the client's thoughts and feelings. The nurse can facilitate a sense of trust, connection, and collaboration by the following: Providing empathy - acknowledging the distressing nature of the diagnosis Providing situations (eg, broad opening for discussion) in which the client can share thoughts and feelings in a safe environment Active listening - being very attentive to what the client is saying and trying to understand what the client is thinking and feeling Focusing - going beyond words and explanations to attain new awareness of a client's concerns Communicating effectively will assist the client in coping with difficult situations, reducing stress, and developing approaches for making necessary life changes (Option 2) This response attempts to give reassurance but does not address the client's thoughts and concerns. (Option 3) This is a very trite response and will close down any opportunity for further discussion. (Option 4) This response gives advice to the client and is non-therapeutic; it does not acknowledge the client's current concerns.

The oncology nurse is caring for a client with tumor lysis syndrome. Which prescription should the nurse question? 1. Allopurinol 200 mg PO every 24 hours [22%] 2. Normal saline IV at 150 mL/hr continuous [10%] 3. Sevelamer 800 mg PO 3 times daily with meals [25%] 4. Spironolactone 25 mg PO every 12 hours [41%]

Tumor lysis syndrome (TLS), an oncologic emergency, occurs when cancer treatment successfully kills cancer cells, resulting in the release of intracellular components (eg, potassium, phosphate, nucleic acids). Clients with TLS develop significant imbalances of serum electrolytes and metabolites. TLS may result in the following life-threatening conditions: Hyperkalemia (>5.0 mEq/L [5.0 mmol/L]) that can cause lethal dysrhythmias Large amounts of nucleic acids (normally converted to uric acid and excreted by the kidneys) that can overwhelm the kidneys and cause hyperuricemia and acute kidney injury (AKI) from uric acid crystal formation Hyperphosphatemia (>4.4 mg/dL [1.42 mmol/L]) that can cause AKI and dysrhythmias Hypocalcemia (<8.6 mg/dL [2.15 mmol/L]) that can cause tetany and cardiac dysrhythmias Potassium-sparing medications (eg, spironolactone) can worsen hyperkalemia (Option 4). Loop or osmotic diuretics may be prescribed to increase urine output and lower serum potassium. Sodium polystyrene sulfonate (Kayexalate) also helps to reduce potassium. (Options 1 and 2) Hypouricemic agents (eg, allopurinol) prevent the formation of uric acid, and aggressive fluid hydration (eg, IV normal saline) flushes out the kidneys to avoid the accumulation of toxins. Hydration therapy also dilutes serum potassium, lowering the risk for lethal dysrhythmias. (Option 3) Health care providers often prescribe mealtime phosphate binders (eg, sevelamer, lanthanum carbonate, calcium acetate) to prevent absorption of additional nutritional phosphorus.

A client is admitted to the hospital for severe headaches. The client has a history of increased intracranial pressure (ICP), which has required lumbar punctures to relieve the pressure by draining cerebrospinal fluid. The client suddenly vomits and states, "That's weird, I didn't even feel nauseated." Which action by the nurse is the most appropriate? 1. Document the amount of emesis [6%] 2. Lower the head of the bed [14%] 3. Notify the health care provider (HCP) [75%] 4. Offer anti-nausea medication [3%]

Unexpected and projectile vomiting without nausea can be a sign of increased ICP, especially in the client with a history of increased ICP. The unexpected vomiting is related to pressure changes in the cranium. The vomiting can be associated with headache and gets worse with lowered head position. The most appropriate action is to obtain a full set of vital signs and contact the HCP immediately. (Option 1) Documentation is important, but it is not the priority action. (Option 2) The head of the bed should be raised, not lowered, for clients with suspected increased ICP. Raising the head of the bed to 30 degrees helps to drain the cerebrospinal fluid via the valve system without lowering the cerebral blood pressure. (Option 4) The vomiting is caused not by nausea but by pressure changes in the cranium. Anti-nausea medications are often not effective. Decreasing intracranial pressure will help the vomiting.

The nurse caring for multiple clients who underwent renal system diagnostic testing should report which post-procedure finding to the health care provider? 1. 150 mL residual urine on bladder scan [50%] 2. Burning sensation when voiding after cystoscopy [22%] 3. Increased urinary output after arteriogram [14%] 4. Less than 10,000 organisms/mL on urine culture [12%]

Various diagnostic tests, including bladder scans, urine cultures, cystoscopy, renal arteriograms, and renal scans, assess the renal system. It is necessary to understand the purpose and procedures for each examination when evaluating complications arising from these assessments. Portable ultrasonic bladder scanners are used at the bedside to determine the amount of residual urine in the bladder. Amounts >100 mL should be reported as the client may be experiencing urinary retention (Option 1). (Option 2) A cystoscope is inserted through the urethra to directly visualize the bladder wall and urethra. Irritation of the urethral and bladder lining from the insertion and manipulation of the cystoscope may cause a slight burning sensation with voiding for a day or two. (Option 3) Renal arteriogram is a radiologic test performed to visualize renal blood vessels to detect abnormalities (renal artery stenosis or aneurysm). A contrast medium is injected into the femoral artery; therefore, the client should be taught to increase fluid intake after the procedure to flush the dye from the body. Increased output is an expected finding. (Option 4) Urine is sterile, but the urethra contains bacteria and a few white blood cells. Less than 10,000 organisms/mL is a normal value for urine culture. Values >10,000 organisms/mL indicate urinary tract infection (UTI).