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The most recent laboratory results for a 12-month-old who is HIV-positive show a CD4 lymphocyte count of 500/mm3 and a CD4 lymphocyte percentage of 10%. The nurse anticipates administering which immunizations? Select all that apply.

1,2,4 Routine immunization is particularly beneficial to children who are HIV-positive as they are more susceptible to preventable diseases due to a compromised immune system. The standard vaccine schedule for a 12-month-old includes Hib, PCV (PVC13), MMR, varicella, and Hep A. HIV-positive children who are asymptomatic and not extremely immunocompromised can receive the appropriate age-specific immunizations as recommended. However, live vaccine preparations (eg, MMR, varicella) are contraindicated in the presence of marked immunosuppression, as determined by CD4 lymphocyte percentages and/or counts (Options 3 and 5). An individual with a CD4 lymphocyte percentage <15% is considered to be severely immunocompromised. Low CD4 lymphocyte counts vary slightly by age due to the normal occurrence of elevated CD4 counts during infancy and early childhood. Low CD4 counts are defined as <750/mm3 for infants 12 months or younger, <500/mm3 for children between age 1-5 years, and <200/mm3 for children age >5 years and adults. Educational objective: Children who are HIV-positive and not severely immunocompromised can receive routine childhood immunizations. Children with severe immunosuppression as indicated by CD4 lymphocyte counts and/or percentages should not receive any live vaccines, including MMR and varicella.

The nurse admits a client to the unit who reports taking high doses of aspirin to ease the pain of chronic headaches. The nurse should monitor for which adverse effects? Select all that apply. 1. black tarry stools 2. bradycardia 3. bruising 4. hypertension 5. ringing in the ears

1,3,5 Aspirin is a nonsteroidal anti-inflammatory drug (NSAID). NSAIDs can cause gastrointestinal (GI) bleeding by decreasing the production of prostaglandins, which protect the lining of the stomach and intestines from digestive acids. NSAIDs (especially aspirin) also decrease platelet aggregation and thereby inhibit blood clotting. Coffee-ground emesis and black tarry stools (melena) are signs of GI bleeding. Bruising can occur due to the decreased platelet aggregation. Tinnitus (ringing in the ears) is the earliest sign of aspirin toxicity. (Options 2 and 4) An NSAID overdose will cause tachycardia (not bradycardia) and hypotension (not hypertension). However, tachycardia and hypotension occur later, secondary to blood loss and dehydration due to nausea and vomiting (common side effects). Educational objective: Aspirin and other NSAIDs inhibit platelet aggregation, resulting in GI bleeding complications. They also promote development of gastric ulcers with long-term use. Tinnitus (ringing in the ears) is the earliest sign of aspirin toxicity.

A hospitalized client with thyrotoxicosis receives atenolol 50 mg PO daily. Which statement by the nurse accurately reinforces the client's understanding of this medication's purpose?

2 Beta-adrenergic blockers (atenolol, metoprolol, and propranolol) are used to relieve some of the symptoms of thyrotoxicosis (thyroid storm), a complication of hyperthyroidism in which excessive thyroid hormones are released into the circulation. Beta blockers block the effects of the sympathetic nervous system and treat symptoms such as tachycardia, hypertension, irritability, tremors, and nervousness in hyperthyroidism. (Option 1) Atenolol is not iodine based. Iodine is used to treat thyrotoxicosis or to prepare the client for a thyroidectomy. In large doses, iodine quickly blocks the release of T4 and T3 from the gland within hours. In addition, iodine decreases thyroid gland vascularity and is helpful when preparing the client for a thyroidectomy. (Option 3) Atenolol does not contain radioactive iodine, the primary treatment for hyperthyroidism. It damages or destroys the thyroid tissue, therefore limiting thyroid secretion and eventually making the client hypothyroid. (Option 4) Propylthiouracil and methimazole (Tapazole) are first-line antithyroid drugs used to inhibit thyroid hormone synthesis. Educational objective: Beta-adrenergic blockers (atenolol, metoprolol, and propranolol) are given to relieve some of the symptoms of thyrotoxicosis. They block the effects of the sympathetic nervous system and treat symptoms such as tachycardia, hypertension, irritability, tremors, and nervousness in hyperthyroidism.

A client with a nasogastric tube is prescribed intermittent bolus enteral feedings with routine gastric residual checks. Which of the following actions by the nurse are appropriate? Select all that apply.

2,3,4 When administering bolus enteral feedings, the nurse should elevate the head of the bed to 30-45 degrees (semi-Fowler position) and keep it elevated for 30-60 minutes afterwards to decrease aspiration risk (Option 3). Many institutions require the nurse to hold feeding if the client must remain supine (eg, diagnostic tests). Feeding tubes should be flushed before and after feedings to keep the tube patent (Option 2). Gastric residual volumes (GRVs) are traditionally checked every 4 hours with continuous feeding or before each bolus feeding. Per facility policy, enteral feedings may be held for high GRV (eg, >500 mL) to reduce aspiration risk. Low GRV indicates that the client is tolerating feedings well (Option 4). Some facilities no longer routinely check GRVs because recent evidence shows that the procedure may not truly indicate aspiration risk and actually impairs calorie delivery. Regardless of GRV checks, the nurse should closely monitor clients for symptoms of intolerance (eg, abdominal distension, nausea/vomiting), which may indicate that feedings should be held or reduced in volume. (Option 1) Aspirated GRV should be returned to the stomach. If acidic gastric juices are repeatedly discarded, there is risk for hypokalemia and metabolic alkalosis. (Option 5) Gastric pH should be acidic (pH ≤5). A pH ≥6 requires x-ray confirmation of tube placement. Newly inserted nasogastric tubes also require x-ray confirmation before feedings are initiated. Educational objective: When administering bolus enteral feedings, the nurse should place the client in semi-Fowler position, check gastric residual volumes (GRVs) as prescribed, verify acidic pH ≤5, return aspirated GRV to the stomach, and flush the tube before and after feedings.

The nurse reinforces teaching about methotrexate to a 28-year-old client with rheumatoid arthritis. Which client statement indicates the need for further instruction regarding this drug?

3 Methotrexate (Rheumatrex) is classified as an antineoplastic immunosuppressant drug used to treat various malignancies and as a nonbiologic disease-modifying antirheumatic drug (DMARD) used to treat rheumatoid arthritis and psoriasis. The client's statement about getting an eye checkup every 6 months indicates that further teaching is necessary. Eye examinations every 6 months are not indicated for clients on methotrexate (Option 3), whereas they are recommended for those who are prescribed hydroxychloroquine (Plaquenil), a nonbiological antimalarial DMARD that can cause retinal damage. (Option 1) Methotrexate is an immunosuppressant and can cause bone marrow suppression. Clients are at risk for infection and should avoid crowded places and contact with individuals who have known infections. Clients on methotrexate should receive the recommended killed (inactivated) vaccines (eg, influenza, pneumococcal), but live vaccines (eg, herpes zoster) are contraindicated. (Option 2) Methotrexate is teratogenic and can cause congenital abnormalities and fetal death; therefore, clients should not become pregnant while taking this drug and wait at least 3 months after it is discontinued to conceive. (Option 4) Methotrexate is hepatotoxic; clients on this medication should avoid drinking alcohol as alcohol use increases the risk for hepatotoxicity. Educational objective: Methotrexate is a disease-modifying antirheumatic drug used to treat rheumatoid arthritis. The major adverse effects associated with methotrexate include bone marrow suppression, hepatotoxicity, congenital abnormalities, and fetal death.

The home health hospice nurse visits a client who is newly prescribed extended-release oxycodone 40 mg orally, scheduled every 12 hours to treat severe chronic cancer pain. Which information is most important to reinforce to the client's caregiver?

1 Extended-release oxycodone (Oxycontin) is a long-acting opioid agonist prescribed to manage severe chronic pain when nonopioids and immediate-release opioids (eg, immediate-release oxycodone, hydrocodone) are inadequate. The nurse should teach the client's caregiver to administer extended-release oxycodone as scheduled, even if the client does not report pain. Administration twice daily is necessary to maintain a therapeutic level and provide continuous relief as the duration of the analgesic effect is 12 hours. (Option 2) Immediate-release opioids and nonopioids are coadministered with long-acting opioids for relief of breakthrough pain. Respiratory status should be monitored; however, clients who receive long-term therapy become opioid tolerant and are less likely to experience adverse effects. Because the goal of hospice care is comfort, this client should be relieved of breakthrough pain regardless of respiratory status. (Option 3) The dose and frequency cannot be changed without a prescription. Also, breakthrough pain is best treated with short-acting opioids. (Option 4) Long-term opioid therapy leads to drug tolerance and physical dependence; higher doses are eventually required for therapeutic effect. In the dying client, it is not appropriate to taper the dose. Rather, it should be titrated upward for effective pain relief. Educational objective: Long-acting controlled-release opioid drugs for chronic pain require regularly scheduled dosing to maintain a therapeutic drug level. Immediate-release opioids may be required for breakthrough pain. Long-term opioid use leads to tolerance and physical dependence; higher doses are eventually required for therapeutic effect.

The postoperative client on hydromorphone becomes hypoxic, and naloxone is administered per protocol. What is most important for the nurse to consider in the follow-up care of this client?

1 Hydromorphone duration of action is 3-4 hours. The effects of naloxone (Narcan) start to wane at 20-40 minutes after administration, and its duration of action is approximately 90 minutes. Therefore, depending on the hydromorphone dose, its duration of action can continue beyond the duration of the naloxone. Repeat naloxone doses may be necessary. (Option 2) Documentation is essential, but client care is more important than paperwork. (Option 3) Naloxone will reverse the effects of the narcotic in the body and, as long as it is in the body, will reverse the effects of any additional narcotic administered. This client will need a different class of analgesic at this time. However, adequate respiration/oxygenation as the naloxone wears off is more important. (Option 4) Naloxone is the reversal agent for narcotics, and a drug-drug interaction is not a concern. Educational objective: The half-life of naloxone (Narcan) is shorter than most narcotics. When naloxone is used to reverse the effects of narcotics, the nurse must monitor the client to ensure that the client does not fall again into excessive sedation and/or respiratory depression.

A client diagnosed with heart failure has an 8-hour urine output of 200 mL. What is the nurse's first action? 1. auscultate the clients breath sounds 2. encourage the client to increase fluid intake 3. report the findings to the supervising registered nurse 4. start an IV line for diuretic administration

1 Urine output of <30 mL/hr may indicate low vascular volume (dehydration, blood loss), decreased renal perfusion (low cardiac output), intrinsic kidney injury, or urine outflow obstruction (enlarged prostate, kinked Foley catheter). Given this client's heart failure, low urine output is likely due to decreased cardiac function and buildup of fluid in the lungs. The nurse should assess the lung sounds for crackles and report to the supervising registered nurse (RN) and the health care provider (HCP), who can prescribe loop diuretics. (Option 2) The client with heart failure is at risk for fluid overload. Fluids should not be encouraged before consulting with the HCP to determine the cause of decreased urine output. If this client is dehydrated, fluids should be encouraged. (Options 3 and 4) The nurse should always assess the client first and then report to the supervising RN and HCP. A diuretic may be prescribed by the HCP if crackles and dyspnea are present. Educational objective: Decreased urine output of <30 mL/hr could be due to low vascular volume (dehydration, blood loss), decreased renal perfusion (low cardiac output), intrinsic kidney injury, or urine outflow obstruction (enlarged prostate, kinked Foley catheter). The nurse should always assess the client first and then report to the supervising registered nurse and health care provider.

Which statement made by the client demonstrates a correct understanding of the home care of an ascending colostomy? 1. "I will avoid eating foods such as broccoli and cauliflower" 2. "I will empty the pouch when it is one half full of stool" 3. "I will irrigate the colostomy to promote regular bowel movements" 4. "I will restrict my fluid to 2,000 milliliters of fluid a day"

1 A colostomy is a surgical procedure that creates an opening (stoma) in the abdominal wall for the passage of stool to bypass an obstructed or diseased portion of the colon. Stool drains through the intestinal stoma into a pouch device secured to the skin. Colostomies can be performed on any part of the colon (ascending, transverse, descending, and sigmoid). Depending on the location of the colostomy, characteristics of the stool will vary, with the stool becoming more solid as it passes through the colon. Proper care of the stoma and pouch appliance that should be taught to the client or caregiver includes the following: Ensure sufficient fluid intake (at least 3,000 mL/day unless contraindicated) to prevent dehydration; identify times to increase fluid requirements (hot weather, increased perspiration, diarrhea) (Option 4). Identify and eliminate foods that cause gas and odor (broccoli, cauliflower, dried beans, brussels sprouts) (Option 1). Empty the pouch when it becomes one-third full to prevent leaks due to increasing pouch weight (Option 2). (Option 3) Stool produced in the ascending and transverse colon is semiliquid, which eliminates the need for irrigation. Irrigation to promote a bowel regimen may be useful for descending or sigmoid colostomies as the stool is more formed. Educational objective: The stool changes from liquid to more solid as it passes through the colon. Proper care of the ostomy and pouching device in clients with a colostomy includes ensuring sufficient fluid intake, preventing gas and odor, and changing the pouching system when it becomes one-third full to prevent leaks.

The clinic nurse is preparing to administer an allergy immunotherapy injection to a client recently initiated on the therapy. Which statement by the client indicates a need for further teaching?

1 Allergy immunotherapy injections (allergy shots) trigger an increase in the body's production of specific immunoglobulins to reduce the client's allergy symptoms when exposed to specific allergens (eg, pollen, cat dander, dust mite). Small doses of the allergen(s) are injected subcutaneously on a client-specific schedule. Rarely, allergy shots may induce an immediate and potentially fatal anaphylactic reaction. The client must remain at the facility for 30 minutes after an injection so the nurse can monitor for severe systemic reactions (eg, respiratory failure, tongue and throat swelling) (Option 1). (Option 2) For the first few months, allergy shots are typically given every week, with a dose increase at every injection until the target maintenance dose is reached. The maintenance dose is then given every few weeks for 3-5 years. (Option 3) Although rare, the client may have a mild, systemic allergic reaction (eg, hives, itching, facial swelling, mild asthma) up to 24 hours after an allergy shot. The occurrence of any systemic reaction should be reported to the health care provider as the next dose increase may need to be delayed. (Option 4) It is common to have a localized reaction to an allergy shot. The nurse should reinforce teaching that some redness and swelling at the injection site is expected and not life-threatening. Educational objective: A client receiving an allergy shot is at risk for anaphylaxis immediately after the injection, so the client must remain at the facility and be monitored for 30 minutes after the injection.

The postoperative client on hydromorphone becomes hypoxic, and naloxone is administered per protocol. What is most important for the nurse to consider in the follow-up care of this client?

The nurse reviews the chart of a client who gave birth 4 hours ago. Which contributing factor indicates that the client has an increased risk of postpartum hemorrhage?

1 Postpartum hemorrhage (PPH) is usually defined as maternal blood loss of >500 mL after a vaginal birth or >1000 mL after a cesarean birth. Uterine atony, characterized by a soft, "boggy," and poorly contracted uterus, is the most common cause of early PPH (occurring ≤24 hours after birth). Delayed PPH (>24 hours after birth) usually results from retained placental fragments associated with a long third stage of labor (ie, time from birth of baby to expulsion of placenta, lasting >30 minutes). Risk factors for PPH include: History of PPH in prior pregnancy Uterine distension due to: Multiple gestation Polyhydramnios (ie, excessive amniotic fluid) Macrosomic infant (≥8 lb 13 oz [4000 g]) (Option 1) Uterine fatigue (labor lasting >24 hours) High parity Use of certain medications: Magnesium sulfate Prolonged use of oxytocin during labor Inhaled anesthesia (ie, general anesthesia) (Option 2) Natural, unmedicated labor and birth reduces the chance of PPH. (Option 3) Labor lasting <24 hours does not increase the risk for PPH. (Option 4) A third stage of labor lasting <30 minutes does not increase the risk for PPH. Educational objective: Postpartum hemorrhage is defined as maternal blood loss of >500 mL after a vaginal birth or >1000 mL after a cesarean birth. Uterine atony (ie, "boggy" uterus) is the most common cause of early postpartum hemorrhage (occurring ≤24 hours after birth). Risk factors include uterine distension, uterine fatigue, high parity, and certain medications.

A woman who had a cesarean delivery 5 hours ago now appears anxious and reports shortness of breath. The practical nurse should assess for which priority problem before notifying the registered nurse?

1 Pregnancy is a hypercoagulable state that provides protection from hemorrhage during childbirth but increases risk of thrombus formation. Deep venous thrombosis (DVT) refers to the development of a thrombus (blood clot) in a deep vein, commonly in the pelvis, thigh, or calf. Redness, tenderness, or warmth in the calf area should be reported to the registered nurse as these findings may indicate DVT. If DVT goes unrecognized and untreated, the thrombus can become dislodged and travel to the lungs, resulting in a pulmonary embolus (PE). Warning signs of a PE include sudden anxiety and shortness of breath. (Option 2) A temperature of up to 100.4 F (37.7 C) is common during the first 24 hours after childbirth and resolves spontaneously. Fever after 24 hours is concerning and should be reported. (Option 3) An elevated white blood cell count is expected during the immediate postpartum period. (Option 4) Incisional discomfort is expected after cesarean delivery. Educational objective: The hypercoagulable state during pregnancy increases the risk for thrombus formation. The practical nurse should report any signs of deep venous thrombosis (eg, redness, swelling, warmth in the calf area) or pulmonary embolus (eg, anxiety, shortness of breath) to the registered nurse. Elevated white blood cell count and temperature are expected findings during the first 24 hours after childbirth.

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 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. Educational objective: For high-quality adult cardiopulmonary resuscitation, compressions should be in the center of the chest; at a rate of 100-120/min; and at least 2 in (5 cm) but no more than 2.4 in (6 cm) deep for adequate perfusion without unnecessary client injury. Compression interruption should be minimized (eg, 30 compressions to 2 rescue breaths).

The clinic nurse evaluates a client's response to levothyroxine after 8 weeks of treatment. What therapeutic responses to the medication should the nurse expect? Select all that apply.

1,2,3 The client's therapeutic response to levothyroxine (Synthroid) is evaluated by resolution of hypothyroidism symptoms. The expected response includes improved well-being with elevated mood (Option 2), higher energy levels (Option 3), and a heart rate that is within normal limits (Option 1). The nurse should consult the health care provider if the heart rate is >100/min, or if the client reports chest pain, nervousness, or tremors; this may indicate that the dose is higher than necessary. Pharmacological therapy manages the symptoms of hypothyroidism, but it takes up to 8 weeks after initiation to see the full therapeutic effect. (Option 4) In hypothyroidism, the skin is cool, pale, and rough (due to dryness). These characteristics result from decreased blood flow. A therapeutic response to levothyroxine would be skin that is normal. (Option 5) The client experiencing a therapeutic response to levothyroxine would experience weight loss due to the increased metabolic rate. However, the client with untreated hypothyroidism would experience weight gain. Educational objective: The expected therapeutic response to levothyroxine (Synthroid) includes an increased sense of well-being with elevated mood, greater energy levels, and a heart rate within normal limits. It takes up to 8 weeks to see the full effect of pharmacological therapy.

The nurse is reinforcing home care education to a client newly diagnosed with von Willebrand disease. Which of the following client statements demonstrate correct understanding of the education? Select all that apply. 1.":I can use a humidifier to help prevent nosebleeds" 2. "I need to avoid contact sports such as soccer or hockey" 3. "i should use a soft toothbrush and electric razor" 4. "I will call my health care provider if in soak a menstrual pad in an hour" 5. "I will take naproxen to decrease pain and inflammation if I am injured"

1,2,3,4 Von Willebrand disease is a genetic bleeding disorder caused by a deficiency of von Willebrand factor (vWF), which plays an important role in coagulation. Intranasal desmopressin or topical therapies (eg, thrombin) may be prescribed to stop minor bleeding, whereas major bleeding may require replacement of vWF. Clients should wear medical identification bracelets in case of emergency. Client teaching includes: Notify the health care provider of signs of bleeding (eg, severe joint pain or swelling, headache [especially after injury], blood in urine/stool, uncontrollable nosebleed) Use a humidifier or nasal spray to keep the mucosa moist, reducing the risk of nosebleeds (Option 1) Avoid aspirin and NSAIDs Avoid activities with a higher risk for injury (eg, contact sports) (Option 2) Avoid gum injury (eg, use soft-bristled toothbrush, perform gentle flossing) and use an electric razor for shaving to minimize bleeding potential (Option 3) Report heavy menstrual bleeding (eg, soaking a pad in <3 hours) (Option 4) (Option 5) Clients should avoid medications that can exacerbate bleeding, including aspirin and NSAIDs (eg, ibuprofen, naproxen, ketorolac). Clients can instead use rest, ice, compression, and elevation (RICE), as well as acetaminophen, to help with pain and inflammation. Educational objective: In von Willebrand disease, a genetic bleeding disorder, a deficiency in von Willebrand factor prevents effective coagulation. Clients can decrease bleeding risk by avoiding high-risk activities (eg, contact sports) and NSAIDs, keeping nasal mucosa moist, and maintaining gum integrity (eg, soft-bristled toothbrush).

The nurse identifies which of the following clients as being at high risk for developing colorectal cancer? Select all that apply. 1. client who consumes a diet high in red meat and low in fiber 2. client is morbidly obese 3. client with a 15 year history of ulcerative colitis 4. client with a 40 year history of cigarette smoking 5. client with a family history of colorectal cancer

1,2,3,4,5 Colorectal cancer is the third most common cancer and the second leading cause of cancer deaths; it affects both genders equally. Various risk factors for colorectal cancer include: Personal or family (first-degree relative) history of colorectal cancer or polyps (Option 5) Personal history of inflammatory bowel disease, Crohn disease, or ulcerative colitis (Option 3) History of hereditary nonpolyposis colorectal cancer (Lynch syndrome) Lifestyle factors such as a diet high in red meat and saturated fat and low in fiber, obesity (eg, body mass index >30 kg/m2), cigarette smoking, and alcohol consumption (Options 1, 2, and 4) Educational objective: Medical risk factors for colorectal cancer include a personal or family (first-degree relative) history of colorectal cancer or polyps and personal history of inflammatory bowel disease. Lifestyle risk factors include a diet high in red meat and saturated fat and low in fiber, obesity, cigarette smoking, and alcohol consumption.

The nurse is teaching about the importance of dietary fiber at a community health fair. Which health benefits of consuming a fiber-rich diet should the nurse include in the teaching plan? Select all that apply. 1.helps prevent colorectal cancer 2. improves glycemic control 3. promotes weight loss 4. reduces risk of vascular disease 5. regulates bowel movements

1,2,3,4,5 Dietary fiber is composed of indigestible complex carbohydrates that absorb and retain water, which increases stool bulk and makes stool softer and easier to pass. Consuming a diet high in fiber-rich foods (eg, fruits, vegetables, legumes, whole grains) improves stool elimination, which helps prevent constipation and decreases the risk of colorectal cancer (Options 1 and 5). Fiber-rich foods tend to have a low glycemic load (less sugar per serving) and are nutrient dense, yet they have lower caloric density. Clients may also experience increased satiety as fiber absorbs water and produces fullness. This may help reduce caloric intake, improve blood glucose control, and promote weight loss (Options 2 and 3). Fiber binds to cholesterol in the intestines, which reduces serum cholesterol levels by decreasing the amount of dietary cholesterol that enters the bloodstream. Decreasing serum cholesterol levels helps reduce vascular plaque buildup and atherosclerosis. A high intake of fiber-rich foods directly correlates with a reduced risk of vascular diseases, including coronary artery disease and stroke (Option 4). Educational objective: Dietary fiber increases stool bulk and makes stool softer and easier to pass. A fiber-rich diet helps prevent constipation; decreases risk of colorectal cancer; promotes weight loss; improves blood glucose control; and decreases serum cholesterol levels, which reduces the risk of coronary artery disease and stroke.

The nurse cares for a client who is neutropenic and has open, weeping herpes zoster lesions on the left upper chest. Which of the following infection control measures by the nurse are appropriate? Select all that apply.

1,2,3,4,5 Herpes zoster (shingles) is caused by the varicella-zoster virus, which causes chickenpox. Symptoms include fever, malaise, and painful, itchy, fluid-filled blisters. The rash is often localized to areas of skin that are innervated by one or two adjacent spinal nerves (dermatomal distribution). Clients with shingles who are immunocompromised (eg, neutropenic) and/or have a disseminated rash (ie, widespread; over multiple dermatomes) must be cared for using standard precautions (eg, hand hygiene) in addition to airborne (ie, N95 respirator mask, negative-pressure room) and contact (eg, gloves, gown) precautions (Options 1, 2, 4, and 5). Clients who are neutropenic have an impaired immune system and should avoid fresh flowers, unwashed fruits and vegetables, and uncooked meats because they may carry bacteria and/or mold (Option 3).

The nurse is reinforcing education to a client prescribed methadone for management of chronic pain. Which of the following client statements indicate a correct understanding? Select all that apply.

1,2,4,5 Methadone is a long-acting opioid medication used for chronic pain management and for treatment of opioid addiction. The client receiving methadone should: Avoid alcohol and other central nervous system depressants to prevent respiratory depression (Option 1). Learn to use—and train family members to use—a naloxone auto-injector in case of oversedation and respiratory depression (Option 4). Rise slowly to a standing position because orthostatic hypotension can occur (Option 2). Have ECGs before starting, 1 month after starting, and annually while on the medication, because methadone can cause QT-interval prolongation and lethal arrhythmias (eg, torsades de pointes) (Option 5). Increase intake of water and fiber to avoid constipation. Avoid abrupt discontinuation as this can cause withdrawal symptoms. (Option 3) Methadone has a long half-life, and the drug remains active in the system after its effects wear off. Clients can easily overdose if they take additional tablets. The client should contact the health care provider if additional pain relief is required.

The nurse is reinforcing education to a client prescribed methadone for management of chronic pain. Which of the following client statements indicate a correct understanding? Select all that apply. 1. "I should not consume alcohol while taking this medication" 2. "I will stand up slowly when getting out of a bed or a chair" 3. "If my pain is not managed with one tablet, I can take an additional tablet" 4. "My family should learn to use the naloxone auto injector incase i am oversedated" 5. "This medication can cause problems with my heart, so I will need regular checkups"

The nurse is caring for a postoperative client who is unresponsive to painful stimuli and is given naloxone. Within 5 minutes, the client can be roused and responds to verbal commands. One hour later, the client is again difficult to rouse, with minimal response to physical stimuli. Which actions does the nurse anticipate? Select all that apply.

1,2,5 A client in the postoperative period who is unresponsive to painful stimuli is likely still under the effects of opioid medications used during anesthesia. Naloxone (Narcan), an opioid antagonist, will temporarily reverse the effects of any opioid medications. However, the half-life of naloxone is shorter than that of most opioid medications (ie, the effect typically wears off in 1-2 hours), and a second dose may be required. The nurse should make frequent observations of the client's respiratory rate and administer prescribed oxygen for respiratory support (Options 1 and 5). The registered nurse should be notified to fully assess the client and to administer a second dose of naloxone as prescribed (either a one-time dose or continuous drip) (Option 2). (Option 3) A postoperative client will likely still need pain medication due to the trauma from surgery. Pain should be managed with nonopioids (eg, acetaminophen, nonsteroidal anti-inflammatory drugs) if needed. (Option 4) An overly sedated client is not an indication for a rapid response team. Although this intervention is unlikely to cause harm to the client, it is not necessary and may result in overuse of personnel resources. Educational objective: Naloxone is usually prescribed as needed in postoperative clients for over-sedation related to opioid use. The nurse should monitor clients who are given naloxone with the understanding that the opioid antagonist has a shorter half-life than that of most of the opioids it is meant to counteract. As a result, a second dose of naloxone may be necessary.

The nurse admits a client to the unit who reports taking high doses of aspirin to ease the pain of chronic headaches. The nurse should monitor for which adverse effects? Select all that apply.

In the intensive care unit, the nurse cares for a client admitted with a head injury who develops syndrome of inappropriate antidiuretic hormone. Which data should the nurse expect with the onset of this condition? Select all that apply. 1. decreased serum osmolality 2. high serum osmolality 3. high urine specific gravity 4. increased urine output 5. low serum sodium

1,3,5 Syndrome of inappropriate antidiuretic hormone (SIADH) is potential complication of head injury. In SIADH, the extra ADH leads to excessive water absorption by the kidneys. Low serum osmolality and low serum sodium are the result of increased total body water (dilution). As ADH is secreted and water is retained, urine output is decreased and concentrated, resulting in a high specific gravity. (Options 2 and 4) Increased urine output is associated with diabetes insipidus (DI). In DI, ADH is suppressed, causing polyuria, severe dehydration, and high serum osmolality if the client is unable to drink enough to maintain a fluid balance. Educational objective: Syndrome of inappropriate antidiuretic hormone (SIADH) is a condition that results in increased ADH. Too much ADH causes increased total body water, resulting in a low serum osmolality and low serum sodium. As ADH is secreted and water is retained, urine output is decreased and concentrated, resulting in a high specific gravity.

The registered nurse and practical nurse are conducting a workshop on contraceptive methods for a group of outpatient clients. Which instructions should the nurses include when discussing combined estrogen-progestin oral contraceptives? Select all that apply.

1,3,5 The use of hormonal contraception (ie, estrogen with or without progestin) places women at a 2- to 4-fold increased risk for developing blood clots due to resulting hypercoagulability. Hormone levels vary among contraceptives, and higher levels of hormone content correlate to an increased risk of adverse thrombotic events (eg, stroke, myocardial infarction). Clients who are prescribed oral contraceptive pills (OCPs) containing estrogen should be educated on potential warning signs (eg, chest pain, vision loss, severe leg pain) (Options 1 and 5). In addition, clients should be instructed not to smoke while taking combined OCPs due to an increased risk of blood clots (Option 3). (Option 2) Irregular bleeding and spotting between menses are common side effects of combined OCPs. These side effects may be bothersome but are not serious and may improve within 3 months of initiation. If the client cannot tolerate side effects, a different OCP may be considered. (Option 4) Clients should be counseled that breast tenderness is a common side effect of combined OCPs and does not warrant emergent reporting to the health care provider. Educational objective: Clients who are prescribed oral estrogen contraceptives (with or without progestin) have an increased risk for developing blood clots. Clients should be educated on warning signs to report to the health care provider (eg, severe leg pain, vision loss) versus common side effects (eg, breast tenderness, spotting).

The nurse is caring for a client with community-acquired pneumonia. When collecting client data, the nurse should anticipate which findings? Select all that apply. 1. crackles 2. high pitched wheezing 3. hyperresonance 4. pleuritic chest pain 5. productive cough

1,4,5 Pneumonia is an acute infection of the lung. Findings in a client with pneumonia include the following: Fever, chills, productive cough, dyspnea, and pleuritic chest pain (Options 4 and 5) Bronchial breath sounds in peripheral lung fields: High-pitched, harsh sounds (ie, bronchial sounds) are considered abnormal when heard in areas other than the trachea. Such sounds can indicate conduction through consolidated lung tissue and be an early sign of pneumonia. Crackles: Coarse inspiratory crackles on auscultation are discontinuous, adventitious low-pitched sounds caused by air passing through airways that are intermittently obstructed with mucus (Option 1). Increased vocal/tactile fremitus: Transmission of palpable vibrations (fremitus) is increased when transmitted through consolidated versus normal lung tissue. Unequal chest expansion: Decreased expansion of affected lung is noted on palpation. Dullness: Percussion of medium-pitched sounds occurs over consolidated lung tissue (pneumonia) or a fluid-filled space (ie, pleural effusion, a complication of pneumonia). (Option 2) High-pitched wheezing is auscultated when air is forced through a narrowed airway; wheezing is a finding in clients with asthma and anaphylactic allergic reactions. (Option 3) Hyperresonance is percussed over a hyperinflated lung (eg, asthma, emphysema) or air in the pleural space (pneumothorax). Educational objective: Clinical findings in a client with pneumonia include fever, productive cough, dyspnea, and pleuritic chest pain. Auscultation of the lungs reveals bronchial breath sounds and crackles. Additional findings include dullness to percussion and increased tactile fremitus.

The health care provider has just prescribed tetracycline for an adolescent with acne vulgaris. The client takes oral contraceptive pills. The nurse should reinforce teaching about which topics? Select all that apply

1,4,5 The following should be taught to clients taking tetracyclines (eg, tetracycline, doxycycline, minocycline): Take on an empty stomach - for optimum absorption, tetracyclines should be taken 1 hour before or 2 hours after meals (Option 3) Avoid antacids or dairy products - tetracyclines should not be taken with iron supplements, antacids, or dairy products as they bind with the drug and decrease its absorption (Option 1) Take with a full glass of water - tetracyclines can cause pill-induced esophagitis and gastritis; the risk can be reduced by taking with a full glass of water and remaining upright after pill ingestion Photosensitivity - severe sunburn can occur with tetracycline. The client should use sunblock (Option 5). Medications such as tetracycline and rifampin can decrease the effectiveness of oral contraceptives; additional contraceptive techniques will be needed (Option 4). (Option 2) Tetracycline taken at bedtime has been associated with esophageal irritation and stricture development as it increases reflux of the gastric contents into the esophagus. This can be prevented by taking the medicine with plenty of water and during the day when upright. Educational objective: Tetracyclines should be taken 1 hour before or 2 hours after meals with plenty of water. They should not be taken with dairy products or within 2 hours of taking antacids. Clients should use sunblock due to photosensitivity and plan to use additional contraceptive techniques.

The nurse reinforces teaching about strategies to prevent community-acquired pneumonia. Which statement made by the client indicates the need for further instruction? 1. "I got the flu vaccine, and it can help to prevent pneumonia" 2. "I got the one time pneumonia shot, so I wont need it again" 3. "I stopped smoking a year ago, so that should help me a lot" 4. "I'll try to avoid going to the mall during the winter months"

2 A once-in-a-lifetime pneumococcal vaccination is ineffective for preventing community-acquired pneumonia (CAP). The current guidelines for pneumococcal vaccination state that all adults age ≥65 should receive 2 pneumococcal vaccinations: PCV13, or 13-valent pneumococcal conjugate vaccine (Prevnar 13) followed by PPSV23, or 23-valent pneumococcal polysaccharide vaccine (Pneumovax 23) ≥1 year apart. In addition, pneumococcal pneumonia revaccination (PPSV23) is recommended after 5 years for clients who are immunocompromised, those with a splenectomy, and those who are age ≥65 if the first dose was given before this age. (Option 1) CAP often follows a viral illness; therefore, annual influenza vaccination is an effective prevention strategy for CAP. (Option 3) Smoking cessation is an effective prevention strategy for CAP. Smoking or exposure to secondhand smoke is a significant risk factor associated with pneumococcal infections, especially in individuals age ≥65. (Option 4) Effective prevention strategies for CAP include using proper cough etiquette, practicing respiratory and hand hygiene, and avoiding crowds and contact with individuals with viral respiratory illnesses. Educational objective: Effective prevention strategies for CAP include smoking cessation, vaccination for influenza and pneumococcal pneumonia, avoidance of contact with individuals with viral respiratory illnesses, respiratory and hand hygiene practices, and use of proper cough etiquette.

An adult diagnosed with celiac disease 3 weeks ago was placed on a gluten-free diet. The client returns for ambulatory care follow-up, reports continuation of symptoms, and does not seem to be responding to therapy. Which is the best response by the nurse? 1. "it should take about 6-8 weeks before your symptoms improve" 2. "Tell me what you had to eat yesterday?" 3. "We will refer you to a dietitian" 4. "You must not be following your diet"

2 The most common reason that clients with celiac disease do not respond to a gluten-free diet is that they have not completely eliminated gluten from their food intake. This client's recent intake must be assessed to determine if the client ate foods containing gluten. (Option 1) Most clients experience dramatic relief of gastrointestinal symptoms within a few days of eliminating gluten from their diet. (Option 3) Referral to a dietitian is an appropriate intervention. However, the nurse must first explore why the client is not responding to therapy. (Option 4) This is a non therapeutic response that "blames" the client for symptoms. Furthermore, this conclusion cannot be reached without an assessment of the client's intake. Educational objective: When a client with celiac disease does not experience symptom relief after being on a gluten-free diet, it is most important for the nurse to assess the underlying cause. The most common reason for persistent symptoms is failure to follow the strict gluten-free diet.

A 2-year-old at an outpatient clinic stops breathing and does not have a pulse. CPR is initiated. When the automated external defibrillator (AED) arrives, the nurse notes that it has only adult AED pads. What is the appropriate action at this time?

2 An automated external defibrillator (AED) should be used as soon as it is available. Pediatric AED pads or a pediatric dose attenuator should be used for children age birth to 8 years if available. Standard adult pads can be used as long as they do not overlap or touch. If adult AED pads are used, one should be placed on the chest and the other on the back ("sandwiching the heart"). (Option 1) If an AED is available, it should be placed on the client as soon as possible. Research shows that survival rates increase when CPR and defibrillation occur within 3-5 minutes of arrest. (Option 3) Standard placement of adult AED pads on a 2-year-old would cause the pads to touch or overlap. Touching or overlapping of pads allows the shock to move directly from one pad to the other without traveling through the heart. (Option 4) Both AED pads are necessary for the defibrillator to work effectively. Educational objective: An automated external defibrillator (AED) should be used as soon as it is available. Adult AED pads can be used on a pediatric client if pediatric pads are unavailable. One pad is placed on the chest and the other is placed on the back ("sandwiching the heart").

The nurse is caring for a client with an exacerbation of chronic obstructive pulmonary disease and pneumonia. The nurse notes that the client has become disoriented and restless and becomes concerned that the client may have impaired oxygenation due to poor secretion clearance. Which is the nurse's priority action? 1. administer lorazepam 1 mg IM 2. administer oxygen using a venturi mask 3. maintain IV normal saline infusion at prescribed rate of 125 ml/hr 4. place the head of the bed in semi-fowler position

2 Chronic obstructive pulmonary disease (COPD) is a progressive, inflammatory lung disease that causes hypersecretion of mucus and airway structure changes that reduce expiratory airflow and impair oxygen and carbon dioxide (CO2) exchange. Clients with COPD have chronic hypoxia and hypercarbia, which alters the sensitivity of chemical receptors in the brain and causes breathing to be triggered by low oxygen levels (ie, hypoxic drive) rather than high CO2 levels. Clients with COPD who develop symptomatic hypoxia (eg, altered mental status, restlessness, respiratory distress) require prompt administration of supplemental oxygen to prevent progression to respiratory failure and arrest (Option 2). Controlled-flow devices (eg, venturi mask) are preferred as they allow delivery of precise oxygen levels, reducing the risk of delivering too much oxygen and suppressing the respiratory drive. (Option 1) Anxiety and restlessness in clients with COPD often relate to worsening hypoxia. If the client remains anxious after resolving hypoxia, low-dose anxiolytic medications (eg, lorazepam) may be used. (Options 3 and 4) Administering fluids and elevating the head of the bed (eg, semi-Fowler position) promote mobilization of secretions and improve work of breathing. However, clients with symptomatic hypoxia require immediate interventions (eg, supplemental oxygen) first. Educational objective: Clients with chronic obstructive pulmonary disease who develop symptomatic hypoxia (eg, altered mentation, restlessness) require prompt oxygen administration with a controlled-flow device (eg, venturi mask) to prevent respiratory failure and arrest.

A client with fibromyalgia refuses to take the prescribed drug duloxetine. When the nurse asks, why, the client responds, "Because I'm not depressed!" What is the nurse's most appropriate response?

2 Fibromyalgia (FM) results from abnormal central nervous system pain transmission and processing. It is characterized by chronic, bilateral musculoskeletal axial pain (above and below the waist), multiple tender points, fatigue, and sleep/cognitive disturbances. Duloxetine (Cymbalta) is a serotonin-norepinephrine reuptake inhibitor that has both antidepressant and pain-relieving effects. It is used to relieve chronic pain that interferes with normal sleep patterns in clients with FM. With the restoration of normal sleep patterns, fatigue often improves as well (Option 2). Other effective drugs to treat the chronic pain associated with FM include pregabalin and amitriptyline (Elavil), an older tricyclic antidepressant drug. (Option 1) Although depression often accompanies chronic pain, duloxetine can be prescribed specifically to treat the chronic pain associated with FM. (Option 3) Duloxetine is prescribed for major depressive disorder and to relieve pain associated with diabetic neuropathy and FM. It is not given to relieve the adverse effects of other drugs. (Option 4) A client has the right to refuse any drug. However, the nurse should first explain the purpose of the drug to the client before notifying the HCP. Educational objective: Medications such as duloxetine, pregabalin, and amitriptyline have neuropathic pain-relieving effects. They are commonly used for treating pain associated with diabetic neuropathy and FM. Duloxetine is particularly effective for treating both depression and pain.

The nurse cares for a client with type 2 diabetes mellitus and hemoglobin A1C results of 8% at an outpatient health clinic. Which statement by the nurse will best address these results? 1. "it is important for us to review the signs and symptoms of a hypoglycemic reaction" 2. "lets review your diet, exercise, and medication regimen over the past 2-3 months" 3. "please describe what you have eaten in the past 24-48 hours" 4. "you should fast for at least 8 hours prior to your morning blood work"

2 Hemoglobin A1C is a diagnostic test used to measure the percentage of glycosylated hemoglobin in the blood. A normal hemoglobin A1C is 4%-6% in clients without diabetes; the goal is to keep the level <7% in clients with diabetes. The A1C test measures blood glucose control over a period of 2-3 months; higher measurements indicate higher glycemic levels. High levels may indicate poor adherence to the recommended diet and exercise plan or ineffective antihyperglycemic medication regimen. It is important for the nurse to review the diet, exercise, and medication plan with the client who has a high hemoglobin A1C. (Option 1) Although it is important to review signs and symptoms of hypoglycemia with all clients with diabetes, this statement does not address the elevated hemoglobin A1C. (Option 3) A diet recall of the last 24-48 hours will not give the nurse adequate information on possible causes of an elevated hemoglobin A1C as this test measures glycemic control over 2-3 months. (Option 4) A hemoglobin A1C may be tested when the client is not fasting. Educational objective: Hemoglobin A1C is a diagnostic test used to measure the percentage of glycosylated hemoglobin in the blood over a period of 2-3 months. A normal hemoglobin A1C is 4%-6% in clients without diabetes; the goal is to keep the level <7% in clients with diabetes.

The nurse is caring for a client with hypothyroidism who has become lethargic and difficult to rouse. Which action is the priority? Click on the exhibit button for additional information. EXHIBIT: Vital signs Temperature 95.0 F (35.0 C) Blood pressure 90/50 mm Hg Heart rate 50/min Respirations 6/min O2 saturation or SpO2 83% 1. administer scheduled oral levothyroxine 2. manually ventilate the client with a bag valve mask 3. place a warming blanket on the client 4. review clients serum thyroid laboratory results

2 Myxedema coma refers to a state of severe hypothyroidism causing decreased level of consciousness (eg, lethargy, stupor) that may progress to a comatose state. Myxedema coma is characterized by hypothermia, bradycardia, hypotension, and hypoventilation. Hypoventilation may occur as a result of respiratory depression, respiratory muscle fatigue, and mechanical obstruction by an edematous tongue. Clients with signs of respiratory failure (eg, slow or shallow breathing, low oxygen saturation) will require emergent endotracheal intubation and mechanical ventilation. The nurse should provide respiratory support (eg, ventilation with a bag-valve-mask) and prepare to assist with intubation. (Option 1) Oral medications should never be administered to clients with a decreased level of consciousness due to risk for aspiration. Clients with myxedema coma require thyroid hormone replacement with IV levothyroxine to correct the hypothyroid state. (Option 3) A warming blanket should be placed on the client to treat hypothermia; however, respiratory support is the priority. (Option 4) A serum thyroid panel (eg, T3, T4) is required to confirm hypothyroidism and should be monitored during treatment; however, the nurse should ensure that the client is stable before reviewing laboratory values. Educational objective: Myxedema coma is a state of severe hypothyroidism and decreased level of consciousness that may progress to coma and respiratory failure. The nurse should provide respiratory support (eg, ventilation with a bag-valve-mask) and prepare to assist with intubation.

A client is taking morphine sulfate for acute pain. The client stands, is immediately "lightheaded," and calls for the nurse. What is the nurse's priority action?

2 Opioids, including morphine sulfate, dilate peripheral blood vessels and can cause hypotension. The side effect is not as noticeable when the client is lying down; however, once the client attempts to stand, it can cause orthostatic hypotension. It is more common in clients who have some underlying volume depletion (eg, opioid-induced nausea/vomiting). Due to the safety risk, clients must be taught to rise slowly from a sitting to a standing position. The nurse should first assist the client to sit if the client feels lightheaded in a standing position. Safety is the client's priority. If orthostasis is evident, fluid bolus may be needed and should be communicated to the health care provider. (Options 1 and 4) Assessing the client's orthostatic vital signs and recommending bed rest until the lightheadedness resolves are important but not first-priority actions. (Option 3) Walking with the client is not recommended when the client is symptomatic on standing. Educational objective: Client safety is the priority action in any situation. The nurse should assist the client to a safe position prior to proceeding with other interventions.

During a routine office visit, the nurse documents the list of current medications of a client with a history of hypertension. Which statement by the client would cause the most concern?

2 Over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen can cause cardiovascular side effects, including heart attack, stroke, high blood pressure, and heart failure from fluid retention. These drugs also decrease the effectiveness of diuretics and other blood pressure medications. The risks can be even higher in the client who already has cardiovascular disease or takes NSAIDs routinely or for a long time. In addition, long-term use of NSAIDs is associated with peptic ulcers and chronic kidney disease. These clients should use NSAIDs cautiously, at the lowest dose necessary and for a short time. The nurse should notify the health care provider that this client is routinely taking ibuprofen. (Option 1) Taking docusate sodium occasionally for constipation is appropriate. (Option 3) Hydrochlorothiazide is a weak diuretic and is commonly used to treat hypertension. (Option 4) Omeprazole for heartburn is appropriate for this client. Educational objective: NSAIDs may cause heart attack, stroke, high blood pressure, and possible heart failure after long-term use. NSAIDs decrease the effectiveness of diuretic and blood pressure medications. Long-term use is also associated with chronic kidney disease and peptic ulcers.

A client with cancer pain is prescribed oxycodone. Which information is most essential to reinforce in order to help prevent long-term complications?

2 Oxycodone is a morphine-like opioid medication. Opioid medications bind to opioid receptors in the intestine, which slows peristalsis and increases water absorption, leading to constipation. Constipation is an almost universally expected side effect from opioid medications. Clients will not develop tolerance to this side effect. Although clients with idiopathic chronic constipation are not commonly advised to take laxatives, opioid-induced constipation is treated with simultaneous use of senna (stimulant) and docusate (stool softener). (Options 1 and 3) Opioids cause the release of histamine, a vasodilator, which is responsible for pruritus and flushing. Opioids can also cause peripheral vasodilation and nervous system depression; both can lead to hypotension. These develop in some clients when the treatment is initiated but usually resolve over time. Antihistamines (eg, diphenhydramine) can prevent the pruritus. Lifestyle changes (eg, rising slowly from a seated position) and adequate hydration can prevent hypotension. (Option 4) Opioids stimulate the opioid receptors in the gastrointestinal tract and the chemoreceptor trigger zone in the brain, producing nausea. This is also not seen with long-term use. Antiemetics (eg, ondansetron) can be helpful. Educational objective: Constipation is an expected long-term side effect of opioid use; clients will not develop tolerance to this side effect. It is important to teach aggressive preventive measures (eg, defecate when the urge is felt, drink 2-3 L of fluid/day, high-fiber diet, exercise) and simultaneous use of a stool softener and a stimulant.

A client is admitted to the postpartum floor after a vaginal birth. Which finding indicates the need for immediate intervention?

2 Persistent headache and blurred vision could indicate postpartum preeclampsia. The majority of clients with preeclampsia develop symptoms before birth; however, a small percentage do not develop the complication until several days after birth. This potentially serious condition can rapidly worsen, leading to seizures and death if left untreated. Additional signs and symptoms may include high blood pressure, proteinuria, and edema (Option 2). (Option 1) In the immediate postpartum period, lochia should be assessed frequently to monitor for postpartum hemorrhage. Soaking a perineal pad in ≤1 hour would indicate excessive bleeding that requires urgent intervention. (Option 3) Red or painful nipples in a breastfeeding client may be the result of incorrect latch and/or improper breastfeeding technique. The nurse should observe the client while breastfeeding, identify any problems with the newborn's latch, and obtain additional assessment from a lactation consultant, if appropriate. (Option 4) Strong- or foul-smelling vaginal discharge may represent an infection (eg, endometritis). This assessment finding indicates the need for further evaluation but is not immediately life-threatening. Educational objective: Preeclampsia can develop in the postpartum period several days after birth. Clients in the postpartum period with signs and symptoms of preeclampsia (eg, edema, persistent headache, vision changes, elevated blood pressure) should be evaluated and treated immediately.

The nurse and unlicensed assistive personnel (UAP) are performing rounds on their clients. The nurse notes that a 2-hour post vaginal delivery client has saturated the peripad with rubra drainage. What should the nurse do next?

2 Saturating a peripad in 1-2 hours could indicate hemorrhage, a life-threatening condition. The nurse should assess the client's fundus and, if it is boggy, massage it. The nurse should also assess the client's vital signs and should never leave the client alone. (Option 1) The nurse can delegate changing the peripad to the UAP; however, it is not the priority at this time. (Option 3) Determining the client's hemoglobin and hematocrit levels will help determine the amount of blood that has been lost, but it is not the priority for this client. (Option 4) The nurse cannot delegate changing IV fluid rates to the UAP as this is beyond the scope of practice. Educational objective: Postpartum hemorrhage is a potentially life-threatening condition that should be addressed immediately. The nurse should first assess the fundus and massage it if boggy.

A client reports 7 of 10 on the pain scale at 2300 and asks if it is too soon to receive "another pain pill." The nurse reviews the medication administration record. Which intervention should the nurse implement? Click on the exhibit button for additional information. EXHIBIT: Vital signs Temperature 99.2 F (37.3 C) Blood pressure 134/89 mm Hg Heart rate 98/min Respirations 19/min O2 saturation (SpO2) 99% Sedation Awake, alert Medication administration record Allergies: None PRN Medications Administration History Acetaminophen 650 mg: 0900 1 suppository rectally every 6 hours as needed for fever Hydrocodone 5 mg/acetaminophen 325 mg: 0300 (2 tablets) 2 tablets orally every 4 hours as needed for moderate pain 0700 (2 tablets) 1100 (2 tablets) 1500 (2 tablets) 1900 (2 tablets) Ondansetron 4 mg: 0900 IV every 4 hours as needed for nausea 1300

2 The nurse must be aware of the amount of acetaminophen a client receives from all sources (eg, suppository for fever, oral medication for pain). If the client regularly receives more than one acetaminophen product, the nurse should alert the health care provider (HCP) and pharmacist. The safest action is for the HCP to suspend additional acetaminophen products until the client no longer regularly receives acetaminophen. The nurse should communicate the administration history during the hand-off report so that the nurses on subsequent shifts are aware and the client is not harmed by hepatotoxicity from acetaminophen overdose. On review of the medication administration record, the nurse should hold the requested dose of hydrocodone/acetaminophen as it would exceed the 24-hour limit of 4 g. To address the client's pain, the nurse should ask the HCP for an analgesic without acetaminophen (eg, hydrocodone/ibuprofen, oxycodone). The nurse should also report the earlier administration of acetaminophen via rectal suppository to the HCP. (Options 1 and 3) The medication should be held. In addition, the nurse cannot change the dose without a prescription from the HCP. (Option 4) Vital signs and sedation level do not show that naloxone is indicated at this time. If the client's respirations are ≤12/min, the nurse should hold the medication and contact the HCP. Educational objective: The nurse should closely monitor the medication administration record of clients receiving acetaminophen to ensure that the total 24-hour dose from all sources does not exceed 4 g. Hepatotoxicity may develop with >4 g/day.

A client reports 7 of 10 on the pain scale at 2300 and asks if it is too soon to receive "another pain pill." The nurse reviews the medication administration record. Which intervention should the nurse implement? Click on the exhibit button for additional information. EXHIBIT: Vital signs Temperature 99.2 F (37.3 C) Blood pressure 134/89 mm Hg Heart rate 98/min Respirations 19/min O2 saturation (SpO2) 99% Sedation Awake, alert Medication administration record: Allergies: None ---PRN Medications Administration History *Acetaminophen 650 mg: 0900 1 suppository rectally every 6 hours as needed for fever *Hydrocodone 5 mg/acetaminophen 325 mg: 0300 (2 tablets) *2 tablets orally every 4 hours as needed for moderate pain 0700 (2 tablets) 1100 (2 tablets) 1500 (2 tablets) 1900 (2 tablets) *Ondansetron 4 mg: 0900 IV every 4 hours as needed for nausea 1300 1. administer the hydrocodone/acetaminophen as prescribed 2. call the health care provider to request a prescription for a different analgesic 3. decrease the dose of hydrocodone/acetaminophen from 2 tablets to 1 4. prepare to administer naloxone

The practical nurse is conducting a hospital admission history and assessment in collaboration with the registered nurse. The client reports taking the herb black cohosh (Actaea racemosa) daily. What is the best nursing response?

2 The nurse should follow up regarding the quantity of the herb and how it is used. Black cohosh is used by some clients for menopausal hot flashes. The main side effects are thickening of the uterine lining and potential liver toxicity. Herbs can cause harmful reactions when taken in combination with other drugs. It is most important to determine that an herb does not interfere with other medications. Herbal therapy is usually stopped 2-3 weeks before any surgery. (Option 1) The client may be experiencing menopausal symptoms, but the nurse's priority is to determine whether black cohosh interferes or interacts with other prescribed medications. (Option 3) Herbs are not routinely continued during a short hospitalization, especially when they are used for comfort and symptomatic relief. (Option 4) There is no established contraindication to the client continuing to take the herb. Some herbs, such as those starting with the letter g (eg, garlic, ginger, Ginkgo biloba, ginseng) lead to an increased bleeding risk. St. John's wort interferes with the metabolism of other drugs. It is important to know about potential interactions and the necessary response (eg, delay surgery, change medication or dosing). Educational objective: The nurse should contact the pharmacy to determine possible drug-drug interaction in a client using herbal therapy.

The nurse is preparing medications scheduled at 8 AM for a client with type 1 diabetes mellitus. After reviewing the client's prescriptions and morning laboratory results, which action by the nurse is most appropriate? Click on the exhibit button for additional information. EXHIBIT: Medication administration record Allergies: None Medications Time Insulin NPH: 75 units subcutaneously, twice daily 0800 & 2000 Insulin lispro: Sliding scale dosing, before meals and at bedtime 0800, 1130, 1730, 2100 Laboratory results Serum glucose 328 mg/dL (18.20 mmol/L) Serum sodium 141 mEq/L (141 mmol/L) Serum potassium 3.0 mEq/L (3.0 mmol/L)

2 Type 1 diabetes mellitus is an endocrine disorder characterized by the absence of insulin production in the pancreas, causing hyperglycemia and intracellular energy deficits. Clients with type 1 diabetes mellitus require regular administration of insulin to prevent hyperglycemia and provide energy to the cells. Insulin shifts glucose and potassium from the intravascular to the intracellular space. This shift of potassium into cells may cause or worsen hypokalemia (<3.5 mEq/L [3.5 mmol/L]) and place the client at risk for life-threatening dysrhythmias (eg, ventricular tachycardia, ventricular fibrillation). The nurse should notify the health care provider (HCP) before administering insulin to clients with hypokalemia, as supplemental potassium may be required to prevent cardiac dysrhythmias (Option 2). (Option 1) The nurse should notify the HCP of the client's hypokalemia before administering insulin, as such administration may worsen the hypokalemia and result in potentially fatal cardiac dysrhythmias. Once supplemental potassium is administered, insulin should be administered to address the client's hyperglycemia and prevent diabetic ketoacidosis. (Options 3 and 4) Assessing for ketonuria and rechecking the client's blood glucose are appropriate but do not address the potentially life-threatening hypokalemia caused by insulin administration. These checks can occur after potassium has been replaced. Educational objective: Clients with diabetes mellitus receiving insulin therapy should be monitored for electrolyte shifts, especially of potassium. The nurse should clarify the prescription for insulin with the health care provider if the client is hypokalemic and should seek a prescription for supplemental potassium before giving more insulin.

The clinic nurse reinforces teaching to a client with systemic lupus erythematosus. Which instructions will the nurse include? Select all that apply.

2,3,4 Systemic lupus erythematosus (SLE) is an autoimmune disorder (the body's immune system erroneously attacks body tissues) that results in inflammation and damage to many body parts. Symptoms vary widely among affected individuals, but most experience painful/swollen joints, extreme fatigue, skin rashes, and kidney problems. The symptoms typically appear for periods of time (called flares) alternating with periods of remission. There is no cure for SLE, but it can be treated with immunosuppressants (eg, corticosteroids) or immunomodulators (eg, hydroxychloroquine). Pneumonia and annual influenza vaccinations are recommended for those with SLE as they are more susceptible to infections. These individuals should avoid contact with sick people and report fever to their health care provider (Options 1 and 4). Both physical and emotional stress can exacerbate SLE. Therefore, clients should follow a healthy lifestyle (eg, 7-8 hours of sleep, no smoking). Balanced exercise with alternating periods of rest is recommended (Option 2). Sunlight is known to worsen the rash of SLE and should be avoided when possible (especially between 10 AM-4 PM); protective clothing and sunscreen application are recommended during periods of sun exposure (Option 3). (Option 5) The rash of SLE should be cleansed only with mild soap. Harsh soap and chemicals should be avoided. The rash is not due to bacterial infection. Educational objective: Clients with SLE should be advised to avoid harsh sunlight and ultraviolet light exposure as well as harsh soaps and chemicals. These clients often receive corticosteroids and are susceptible to infection; therefore, annual influenza vaccination (eg, killed vaccines) is important.

A nurse is reinforcing teaching to a breastfeeding client who has been diagnosed with mastitis of the right breast. Which instructions should be included? Select all that apply.

2,4 Mastitis is a common infection in postpartum women due to multiple risk factors leading to inadequate milk duct drainage (eg, poor latch). Bacteria are transmitted from the infant's nasopharynx or the mother's skin through the nipple and multiply in stagnant milk. Staphylococcus aureus is the most common offending organism. Symptoms of mastitis include fever, breast pain, and focal inflammation (redness, edema). In addition to antistaphylococcal antibiotics (dicloxacillin or cephalexin) and analgesics (eg, ibuprofen), treatment of lactational mastitis requires effective and frequent milk drainage. Milk ducts are most efficiently drained by direct breastfeeding while ensuring a proper latch. Adequate rest and increased oral fluid intake are also recommended. (Options 1 and 3) Breastfeeding should be continued every 2-3 hours to relieve milk duct obstruction. Mothers should be reassured that the infant can feed safely from the infected breast as the newborn is already colonized with the mother's skin flora. (Option 5) Underwire bras (tight bras) are not recommended with breastfeeding or mastitis as milk flow is impeded, worsening engorgement. Soft cup bras are recommended for support and to encourage milk flow. Educational objective: Treatment of lactational mastitis includes antibiotic therapy, breast support, adequate hydration, analgesics, and frequent (every 2-3 hours) continued breastfeeding.

The nurse is reinforcing instructions to a client scheduled for cardiac pharmacologic nuclear stress testing. Which client statements indicate appropriate understanding? 1. "I can smoke 1 cigarette the day of the test so that I wont have withdrawals" 2. "I should eat a healthy breakfast the morning of the test to avoid nausea" 3. "I should stop drinking coffee 24 hours before the procedure" 4. "I should take my usual dose of insulin the day of the test"

3 A pharmacologic nuclear stress test uses vasodilators (eg, adenosine, dipyridamole) to simulate exercise when clients are unable to tolerate continuous physical activity or when their target heart rate is not achieved through exercise alone. These drugs produce vasodilation of the coronary arteries in clients with suspected coronary heart disease. A radioactive dye is injected to allow a special camera to produce images of the heart. Based on these images, the health care provider (HCP) can determine whether there is adequate coronary perfusion. Preprocedure client instructions include: Do not eat, drink, or smoke on the day of the test (NPO for at least 4 hours) (Options 1 and 2). Avoid caffeine (including decaffeinated products) 24 hours before the test (Option 3). If insulin/pills are prescribed for clients with diabetes, consult the HCP about appropriate dosage on the day of the test. Hypoglycemia can result if the medicine is taken without food (Option 4). Some medications can interfere with test results by masking angina. Do not take certain cardiac medications (eg, nitrates, dipyridamole, beta blockers) unless the HCP directs otherwise or unless needed to treat chest discomfort on the day of the test. Educational objective: Clients scheduled for cardiac nuclear pharmacologic stress testing should not eat, drink, or smoke on the day of the test; they should avoid caffeinated products for 24 hours before the test and avoid taking certain cardiac medications (eg, nitrates, beta blockers) unless otherwise instructed by the health care provider.

The nurse is caring for a postpartum client who states, "I am nervous about how my 2-year-old son will adapt to being a big brother." Which advice is appropriate for the nurse to give the client?

3 Integrating new family members is important for parents and siblings after the birth of a newborn. Toddlers do not fully grasp the concept of becoming a sibling but are aware of competition for their parents' time. To assist with postpartum sibling adaptation, recommend that the mother's arms are free and ready to receive the toddler during the first hospital visit (Option 3). This action may lessen the toddler's perception of the newborn as a rival and reaffirms a sense of security within the family. Other strategies include: Providing the older sibling with a gift "from the newborn" Encouraging family members to show attention to each child Giving siblings special clothing indicating their new role (eg, "big brother") (Option 1) Exploring the newborn usually begins with visual examination; the first touch is generally to the head and face. Supervised exploration and touching are appropriate and encourage acquaintance with the newborn. (Option 2) Introduction of new tasks (eg, potty training) should be delayed until the sibling has adjusted to changes in family structure. Maintaining the toddler's daily routine helps with adjustment. (Option 4) The bonding process takes time and shared experiences. The toddler should not be forced to spend time with the newborn until ready. Educational objective: Integrating new family members is an important step for parents and siblings after the birth of a newborn. Recommend that the mother's arms be free to embrace the toddler during the first hospital visit to positively reinforce the toddler's sense of security.

The nurse obtains a health history from a client who states, "I skip dinner most nights to lose weight. I don't want to get low blood sugar, so I don't take my evening dose of metformin when I skip dinner." Which response by the nurse is appropriate?

3 Metformin is an oral antidiabetic medication used to manage hyperglycemia in clients with type 2 diabetes. Metformin increases the sensitivity of insulin receptors in cells and reduces glucose production by the liver. These actions increase the efficacy of insulin present in the body and prevent large rises in blood glucose after meals. Because metformin does not stimulate insulin secretion by the pancreas, the risk of hypoglycemia is minimal (Option 3). Although skipping meals would cause a drop in blood glucose, metformin would not cause further hypoglycemia. (Option 1) Investigating the effect that skipping meals and medication has on the client's blood glucose levels may imply affirmation of the incorrect action. The nurse should provide education about the drug action and appropriate means of weight loss. (Option 2) Instructing the client to alter the frequency or dose of prescribed medication is outside of the nurse's scope of practice. Alterations to treatment plans require the prescriptive authority of a health care provider. (Option 4) Skipping meals to lose weight is not a healthy weight-loss strategy as it causes cellular energy deficits and may lead to hypoglycemia. Educating the client to take medications as prescribed remains the priority. Furthermore, "Why" questions are not appropriate forms of therapeutic communication. Educational objective: Metformin is an oral antidiabetic medication that increases insulin sensitivity and inhibits liver glucose production. Metformin does not increase insulin secretion, so the risk of hypoglycemia is minimal even when meals are skipped.

The nurse reinforces teaching about methotrexate to a client with rheumatoid arthritis. It is most important to address which topic regarding this drug?

3 Methotrexate (Rheumatrex) is classified as an antineoplastic, immunosuppressant drug used to treat various malignancies and as a nonbiologic disease-modifying antirheumatic drug (DMARD) used to treat rheumatoid arthritis and psoriasis. Methotrexate can cause bone marrow suppression resulting in anemia, leukopenia, and thrombocytopenia. Leukopenia and its immunosuppressant effects can increase susceptibility to infection. Clients should be educated about obtaining routine killed (inactivated) vaccines (eg, influenza, pneumococcal) and avoiding crowds and persons with known infections. Live vaccines (eg, herpes zoster) are contraindicated in clients receiving immunosuppressants, such as methotrexate. Alcohol should be avoided in clients taking methotrexate as it is hepatotoxic and drinking alcohol increases the client's risk for hepatotoxicity. (Option 1) Regular eye examinations every 6 months are indicated for clients prescribed the nonbiological DMARD antimalarial hydroxychloroquine (Plaquenil) as it can cause retinal damage. Ethambutol, used to treat tuberculosis, also requires frequent eye examinations. (Options 2 and 4) Photosensitivity (common with tetracycline, thiazide diuretics, and sulfonamides) and nephrotoxicity (common with aminoglycosides, vancomycin, and nonsteroidal anti-inflammatory drugs) can occur, but immunosuppression is more likely and potentially fatal. Educational objective: Methotrexate is a nonbiologic disease-modifying antirheumatic drug used to treat rheumatoid arthritis. The major adverse effects associated with its use include bone marrow suppression, hepatotoxicity, and gastrointestinal irritation.

The practical nurse on the neurosurgery step-down unit is assisting the registered nurse in the care of a stable client with a closed-head injury who is 1 day post craniotomy. The practical nurse prepares to administer the 7:00 AM medications and reviews the client's medication administration record. Which prescription prompts the practical nurse to contact the prescribing health care provider for clarification? Click on the exhibit button for additional information. EXHIBIT: Medication administration record Allergies: None Medications Time Gabapentin: 300 mg orally, every 8 hours 0700, 1500, and 2300 Hydrocodone/acetaminophen: (5 mg/325 mg) orally, every 4 hours Every 4 hours prn Acetaminophen: 1,000 mg IV, every 6 hours 0600, 1200, 1800, and 2400 Phenytoin: 100 mg orally, every 12 hours 0700 and 1900 1. acetaminophen 1,000 mg IV, every 6 hours 2. gabapentin 300 mg orally, every 8 hours 3. hydrocodone/acetaminophen (5mg/325 mg) orally every 4 hours prn 4. phenytoin 100 mg orally, every 12 hours

3 The recommended dose for acetaminophen should not exceed 4 g in 24 hours as excessive intake can lead to liver injury. The nurse should contact the health care provider (HCP) to question the prescription for the prn opioid analgesic hydrocodone/acetaminophen (5 mg/325 mg) (Vicodin). This client is already receiving acetaminophen 1,000 mg IV every 6 hours (4,000 mg). If the client needed and received the maximum possible dosage of 6 tablets of hydrocodone/acetaminophen (5 mg/325 mg), the total dose of acetaminophen (4,000 mg + 1,950 mg [6 tablets] = 5,950 mg) would exceed the recommended daily dosage. (Option 1) Acetaminophen (Tylenol) is an antipyretic and nonopioid analgesic. The HCP may prescribe this drug to manage mild to moderate pain and fever in the initial postoperative period. Its antipyretic effects can mask fever in clients medicated for postoperative pain. The nurse would not question this prescription. (Option 2) Gabapentin (Neurontin) is an analgesic adjunct and anticonvulsant drug prescribed to promote comfort and decrease the incidence of seizures. The nurse would not question this prescription. (Option 4) Phenytoin (Dilantin) is an anticonvulsant prescribed to prevent and/or treat post-traumatic seizure activity in clients following a head injury. The nurse would not question this prescription. Educational objective: Taking higher than recommended doses of acetaminophen can lead to hepatotoxicity. The nurse should monitor the total amount of acetaminophen administered to a client in a 24-hour period, including the amount combined with opioid drugs (eg, hydrocodone/acetaminophen [Vicodin]). The nurse would notify the health care provider if the combined dose exceeds the recommended dosage of 4 g in 24 hours.

Which group of food selections would be the best choice for a client advancing to a full liquid diet 3 days after bariatric surgery? 1. apple juice, mashed potatoes, chocolate pudding 2. chicken broth, low fat cheese omelet, strawberry ice cream 3. creamy wheat cereal, blended cream of chicken coup, protein shake 4. low fat vanilla yogurt, smooth peanut butter, vegetable juice

3 Bariatric surgery (eg, gastric banding, sleeve gastrectomy) reduces stomach capacity. A client's bariatric postoperative diet is restricted to foods that are low in simple carbohydrates and high in nutrients (eg, protein, fiber). After gastric surgery, consumption of simple carbohydrates can lead to dumping syndrome (ie, cramping, diarrhea). The client will tolerate only small meals of clear liquids at first, advance to full liquids 24-48 hours after surgery, and then progress gradually to solid foods as the gastrointestinal tract heals. Small, frequent meals are recommended to avoid overstretching of the pouch and to prevent nausea, vomiting, and regurgitation. The best food choices for a bariatric full liquid diet are cream soups, refined cooked cereals, sugar-free drinks, and low-sugar protein shakes and dairy foods (Option 3). (Option 1) Fruit juices and puddings are high in sugar and not acceptable for a bariatric full liquid diet. Mashed potatoes are considered appropriate for a soft diet. (Option 2) Ice cream is high in sugar and not acceptable for a bariatric full liquid diet. Eggs are appropriate for a soft diet. (Option 4) Yogurt is high in sugar and not appropriate for a bariatric full liquid diet. Peanut butter and vegetable juice are appropriate for a soft diet. Educational objective: Clients recovering from bariatric surgery are given small, frequent meals to prevent nausea, vomiting, and regurgitation related to overstretching of the stomach. The bariatric postoperative diet is restricted to foods that are high in nutrients (eg, protein, fiber) and low in simple carbohydrates to prevent dumping syndrome.

A client receives an injection of botulinum toxin type A for facial and neck rejuvenation. The nurse should monitor for which complication of this procedure?

3 Botulinum toxin type A (Botox) blocks neuromuscular transmission by inhibiting acetylcholine release from nerve endings. The drug is used for treating wrinkles, blepharospasm, and cervical dystonia. Complications are uncommon when Botox is used for cosmetic purposes but can be life-threatening if they occur. The toxin can also relax the muscles used for swallowing and breathing, resulting in dysphagia (aspiration risk) and respiratory paralysis. (Options 1 and 2) Botulism can be associated with constipation and urinary retention due to relaxation of smooth muscle. Unlike in Clostridium tetani infection (tetanus), the painful rigidity and spasms of the neck, back, and abdominal muscles are absent in botulism. (Option 4) Ataxia and hand tremor usually indicate drug toxicity (eg, phenytoin, lithium). Educational objective: Botulinum toxin type A (Botox) inhibits the release of acetylcholine from nerve endings and causes relaxation of skeletal/smooth muscles. On occasion, surrounding muscle weakness can lead to dysphagia and respiratory paralysis.

The nurse is reinforcing meal planning teaching to a group of clients with celiac disease. Which meal is appropriate for the nurse to include? 1. baked salmon with rice, steamed vegetables, and dinner roll 2. breaded pork chops, corn on the cob, and steamed snow peas 3. grilled chicken, green beans, and mashed potatoes 4. spaghetti with italian tomato sauce and meatballs

3 Celiac disease is an autoimmune disorder in which chronic inflammation caused by gluten damages the small intestine. The following are important dietary principles to teach clients with celiac disease: All gluten-containing products should be eliminated from the diet. These include wheat, barley, rye, and oats. Rice, corn, and potatoes are gluten-free and are allowed on the diet (Option 3). Processed foods (eg, chocolate candy, hot dogs) may contain "hidden" sources of gluten such as modified food starch, malt, and soy sauce. Food labels should indicate that the product is gluten-free. Clients will need to be on a gluten-free diet for the rest of their lives. Eliminating gluten from the diet reduces the risk for nutritional deficiencies and intestinal cancer (lymphoma). Eating even small amounts of gluten will damage the intestinal villi, even though the client may have no clinical symptoms. Therefore, all sources of gluten must be eliminated from the diet. (Option 1) Baked salmon, rice, and steamed vegetables are permitted on a gluten-free diet. The dinner roll contains gluten and should be avoided. Baked goods and breads (including white and wheat) contain gluten unless the package is labeled "gluten-free" or the products are made from non gluten sources (eg, rice flour). (Option 2) Although meat, fish, and poultry are permitted, marinated and breaded protein sources should be avoided. Corn and snow peas are appropriate selections for a gluten-free diet. (Option 4) Pasta contains gluten and should be avoided. Gluten-free pastas are available and are safe to consume. Educational objective: All sources of gluten must be eliminated from the diet of a client with celiac disease. Consuming small amounts, even in the absence of clinical symptoms, will increase the risk for damage to the intestinal villi. Clients can have foods containing rice, corn, and potatoes. They should read food labels and follow the diet for the rest of their lives.

The nurse is reviewing new prescriptions from the health care provider. Which prescription would require further clarification?

3 Cyclobenzaprine (Flexeril) is a common, centrally acting skeletal muscle relaxant prescribed for muscle spasticity, muscle rigidity, and acute or chronic muscle pain/injury. Centrally acting muscle relaxants interfere with reflexes within the central nervous system (CNS) to decrease muscle spasm and rigidity. Like many medications, muscle relaxants are metabolized by the liver. The presence of liver disease (eg, hepatitis) decreases hepatic metabolism and can cause a buildup of medication, leading to medication toxicity and increased CNS depression (eg, weakness, confusion, drowsiness, lethargy). The prescription for a muscle relaxant would need to be clarified in a client with liver disease (Option 3). (Option 1) Atorvastatin (Lipitor) is a statin prescribed for hyperlipidemia. It is used for primary and secondary prevention of cardiovascular disease and would not warrant further clarification when used in a client with angina pectoris. (Option 2) Bupropion (Wellbutrin, Zyban) and varenicline (Chantix, Champix) are commonly prescribed for smoking cessation. Both bupropion and varenicline can cause serious neuropsychiatric effects (eg, depression, suicide); however, there is no contraindication for clients with emphysema. (Option 4) Metronidazole (Flagyl) is an antibiotic that can be used to treat a Trichomonas infection. There is no contraindication for its use in clients with Crohn disease. Educational objective: Like many medications, skeletal muscle relaxants (eg, cyclobenzaprine) are metabolized hepatically. In the presence of hepatic impairment (eg, hepatitis), drug metabolism is reduced and results in the accumulation of medication in the body, which leads to toxicity and serious adverse effects.

The emergency department nurse is caring for a client who requires gastric lavage for a drug overdose. Which action would be appropriate?

3 Gastric lavage (GL) is performed through an orogastric tube to remove ingested toxins and irrigate the stomach. GL is rarely performed as it is associated with a high risk of complications (eg, aspiration, esophageal or gastric perforation, dysrhythmias). GL is only indicated if the overdose is potentially lethal and if GL can be initiated within one hour of the overdose. Activated charcoal administration is the standard treatment for overdose, but it is ineffective for some drugs (eg, lithium, iron, alcohol). Intubation and suction supplies should always be available at the bedside during GL in case the client develops aspiration or respiratory distress (Option 3). (Option 1) GL is usually performed through a large-bore (36 to 42 French) orogastric tube so that a large volume of water or saline can be instilled in and out of the tube. (Option 2) During GL, clients should be placed on their side or with the head of bed elevated to minimize aspiration risk. (Option 4) GL should be initiated within one hour of overdose ingestion to be effective. The client's stomach should be decompressed first, but lavage should be initiated as soon as possible afterwards. Educational objective: Gastric lavage is used to remove ingested toxins and irrigate the stomach after a drug overdose. It should be initiated within one hour of overdose. The nurse should position the client to prevent aspiration and have emergency respiratory equipment at the bedside.

The nurse reinforces education with a client starting isotretinoin for acne. Which statement indicates the client needs further instruction?

3 Isotretinoin is an oral acne medication derived from vitamin A. Due to teratogenic risk and severity of side effects (eg, Stevens-Johnson syndrome, suicide risk), isotretinoin is used to treat only severe and/or cystic acne not responding to other treatments. Exposure to any amount of this medication during pregnancy can cause birth defects. Clients are required to enter a Web-based risk management plan (iPLEDGE) and use 2 forms of contraception (Option 4). Taking vitamin A supplements along with isotretinoin can cause vitamin A toxicity, which can cause increased intracranial pressure, gastrointestinal upset, liver damage, and changes in skin and nails. Therefore, clients should be instructed to avoid vitamin A supplements while taking this medication (Option 3). (Option 1) Blood donation is also prohibited during the duration of treatment and up to a month after treatment ends due to the possibility of inadvertent transfusion to a pregnant woman. (Option 2) Isotretinoin should not be taken with tetracycline because the latter also increases the risk for intracranial hypertension. Educational objective: Isotretinoin is a vitamin A derivative prescribed to treat severe and/or cystic acne. Side effects include birth defects, skin changes (eg, dry skin, skin fragility, cutaneous atrophy), and risk for increased intracranial pressure. Clients need to be instructed to avoid tetracycline, excess sun and tanning, and vitamin A supplements. Women of child-bearing age should use 2 forms of contraception to prevent pregnancy.

A nurse is providing care to a group of postpartum clients. Which client comment should prompt further investigation?

3 Perinatal mood disorders may occur at any time during pregnancy but are often precipitated in the postpartum period by the sudden drop in estrogen and progesterone levels after birth. Clients with postpartum depression may feel intense and persistent irritability, anxiety, anger, guilt, and sadness. Such feelings may affect the ability to care for the newborn or themselves. A client showing irritability and disinterest in caring for the newborn should be further assessed for postpartum depression and offered a referral for follow-up care. (Option 1) Maternal fatigue or decreased energy is common after birth and while caring for a newborn. The nurse can reassure the client that sleeping when the newborn sleeps is a good strategy as normal newborn sleep and feeding habits may require the client's attention frequently day and night. (Options 2 and 4) Postpartum blues ("baby blues") is a common, milder form of depression characterized by emotional lability, sadness, anxiety, and difficulty sleeping. However, the client's ability to function properly is not affected, and symptoms subside within 2 weeks without treatment. If symptoms persist after 2 weeks, further assessment may be necessary. Educational objective: Perinatal mood disorders may occur at any time during pregnancy but are more common in the immediate postpartum period. Clients with postpartum depression may feel intense and persistent anxiety, anger, guilt, and sadness. A client showing irritability and disinterest in caring for the newborn should be assessed for postpartum depression and offered a referral for follow-up care.

A nurse is reinforcing teaching about breastfeeding. Which statement by the client indicates correct understanding of the teaching?

3 Proper breastfeeding technique ensures adequate intake for the infant while promoting bonding and comfort for the mother. Breastfeeding should be on demand, whenever the infant displays behaviors of hunger (eg, crying, rooting reflex). Most newborns will feed at least 8-12 times a day. The infant should be fed approximately 15-20 minutes per breast, with both breasts offered at each feeding (Option 1). As growth occurs, the infant will become more proficient and total feeding time will decrease. Key principles of proper breastfeeding and latch technique include the following: The client should hold the infant "tummy to tummy," with the mouth positioned in front of the nipple. The infant's head should be facing forward, keeping the body in alignment (Option 2). Common breastfeeding positions include clutch hold, cradle, cross-cradle, and side-lying. The infant needs to grasp both the nipple and part of the areola to ensure proper latching (Option 4). If the infant grasps the nipple only, breastfeeding will be painful for the mother due to pinching. If the infant latches incorrectly or needs to be removed from the breast, the client should insert a finger to break the suction prior to moving the infant away (Option 3). If the infant is pulled off the breast incorrectly, nipple trauma may occur, leading to sore nipples and painful breastfeeding. Educational objective: Breastfeeding should be on demand and last approximately 15-20 minutes per breast for newborns. The infant should be held "tummy to tummy" at nipple level. The nipple and part of the areola should be grasped in the infant's mouth. Before removing the infant from the breast, the suction should be broken using a finger inserted beside the gums.

The nurse administers the prescribed dose of hydromorphone 2 mg to a client who is 2 days postoperative from a colostomy. Which assessment finding is most important for the nurse to follow-up?

3 Respiratory depression is the most serious side effect of narcotic medication. Sedation precedes respiratory depression. Falling asleep during a conversation scores "3" on the Pasero Opioid-Induced Sedation Scale (POSS); no additional narcotics should be given to the client. Other classes of drugs (eg, non-steroidal anti-inflammatory medications) can be given if the client is still in pain. The client will also be at increased risk for respiratory depression if the pain is completely relieved and/or it is night time. No additional narcotics should be given until the client is at level 2 sedation on POSS (eg, slightly drowsy, easily aroused). (Option 1) Nausea or vomiting is a typical side-effect of narcotic administration, especially when it is given in a larger dose or to the opioid-naïve client. It usually lessens with time and repeat administration. Nausea or vomiting would not be a concern unless it is excessive or severe. The nurse should ensure that the client receives adequate hydration (eg, intravenous fluids, clear liquids, antiemetics). (Option 2) Constipation is a known side effect of opioid administration and does not lessen with long-term administration. Proactive measures are needed as long as the client is on narcotics. However, large intestine peristalsis does not usually start until 2-3 days after surgery. (Option 4) Pruritus (itching) is a known side effect of narcotic administration. It is usually treated with diphenhydramine (Benadryl) or some other antihistamine. Educational objective: Sedation precedes respiratory depression in narcotic administration. A client (especially if on high doses) should be assessed for sedation level. Level 3 sedation on POSS requires that no additional narcotics be administered to the client.

The student nurse observes the respiratory therapist (RT) preparing to draw an arterial blood gas from the radial artery. The RT performs the Allen's test and the student asks why this test performed before the blood sample is drawn. Which statement made by the RT is most accurate?

3 The radial artery site at the wrist is preferred for collecting an arterial blood gas sample because it is near the surface, is easy to palpate and stabilize, and has good collateral supply from the ulnar artery. The patency of the ulnar artery can be confirmed with a positive modified Allen's test. The modified Allen's test includes the following steps: Instruct the client to make a tight fist (if possible) Occlude the radial and ulnar arteries using firm pressure Instruct the client to open the fist; the palm will be white if both arteries are sufficiently occluded Release the pressure on the ulnar artery; the palm should turn pink within 15 seconds as circulation is restored to the hand, indicating patency of the ulnar artery (positive Allen's test) If the Allen's test is positive, the arterial blood gas can be drawn; if negative and the palm does not return to a pink color, an alternate site (eg, brachial artery, femoral artery) must be used. (Option 1) Capillary refill is tested by applying pressure to the fingernail bed to cause blanching. If refill is adequate, the nail bed should become pink in less than 3 seconds after pressure is released. (Option 2) The radial artery is palpated with the fingertips to determine the presence of the radial pulse. (Option 4) A neurologic deficit is assessed by monitoring color, sensation, and movement of the hand. Educational objective: The radial artery site at the wrist is preferred for collecting an arterial blood gas sample because it is near the surface, easy to palpate and stabilize, and has good collateral supply from the ulnar artery. The patency of the ulnar artery must be confirmed by performing a modified Allen's test to assure adequate circulation to the hand before proceeding with the arterial blood gas collection.

A client with chronic kidney disease is admitted with pneumonia and pleurisy. The client's laboratory results are shown in the exhibit. Which prescription will the nurse question? Click on the exhibit button for additional information. EXHIBIT: Laboratory results Hemoglobin 9.0 g/dL (90 g/L) Platelets 267,000/mm3 (267 × 109/L) White blood cells 14,500/mm3 (14.5 × 109/L) Creatinine 2.8 mg/dL (214 µmol/L) 1. acetaminophen 500 mg PO every 6 hours 2. epoetin alfa 15,000 units subcutaneous injection, once monthly 3. ketorolac 15 mg IV every 6 hours, as needed for pain 4. levofloxacin 500 mg IV, once daily

3 This client has chronic kidney disease with an elevated serum creatinine level. Ketorolac (Toradol) is a highly potent nonsteroidal anti-inflammatory drug (NSAID) often used for pain and available in intravenous form. However, NSAIDs (eg, indomethacin, ibuprofen, naproxen, ketorolac) are nephrotoxic and should be avoided in clients with kidney disease. Also, the client should not be given 2 types of NSAIDs simultaneously (eg, naproxen plus ibuprofen) as they can be toxic to the stomach and kidneys. (Option 1) Prescribing acetaminophen as needed is appropriate to treat fever. (Option 2) Clients with chronic kidney disease often have anemia due to erythropoietin deficiency. Recombinant erythropoietin injections are often prescribed to treat anemia. (Option 4) Levofloxacin is an appropriate antibiotic to use for treating pneumonia. Educational objective: Nonsteroidal anti-inflammatory drugs (NSAIDs) (eg, indomethacin, ibuprofen, naproxen, ketorolac) are nephrotoxic and should be avoided in clients with kidney disease. In addition, clients taking a NSAID medication should not take a different NSAID medication at the same time.

The health care provider has told a client to take over-the-counter supplemental calcium carbonate 1000 mg/day for treatment of osteoporosis. Which instruction should the clinic nurse reinforce with the client?

4 Calcium and vitamin D are essential for bone strength. Calcium carbonate (Caltrate) has the most available elemental calcium of over-the-counter products and is inexpensive; it is therefore the preferred calcium supplement for most clients with osteoporosis. Calcium absorption is impaired when taken in excess of 500 mg per dose. Therefore, most clients should take supplements in divided doses (<500 mg per dose). These should be taken within an hour of meals as food increases calcium absorption. Constipation is a frequent side effect of calcium supplements, so clients should be advised to take appropriate precautions. Calcium carbonate and calcium acetate (PhosLo) are used to reduce serum phosphorous levels in clients with chronic kidney disease. In such cases, calcium should remain in the intestine and bind the phosphorous present in food; the calcium phosphorus product would then be excreted in stool. Therefore, these clients should take calcium supplements before meals. (Option 1) Calcium levels may need to be checked periodically, but it is not necessary to do so monthly. (Option 2) Vitamin D also increases calcium absorption and is important for treatment of osteoporosis. There is no need to stop it. (Option 3) Calcium does not need to be taken at any particular time of day. Educational objective: The nurse should encourage the client with osteoporosis to take supplemental calcium with food to increase its absorption. Vitamin D will also enhance absorption. Multiple daily doses are recommended as calcium absorption is impaired when taken in excess of 500 mg per dose. Constipation is a frequent side effect of calcium supplementation.

The nurse is caring for a client recently diagnosed with an active deep vein thrombosis (DVT). Which action by the client would require an immediate intervention by the nurse? 1. the client has a temperature of 100 F (37 C) 2. the client is ambulating up and down the hallways 3. the client is breathing at a rate of 16/min 4. the client is massaging the leg at the site of inflammation

4 Clients with active DVT are at risk for developing a pulmonary embolism (PE). In the case of active DVT, the clot may become dislodged by massage or use of sequential compression devices on the affected extremity. The nurse would intervene immediately if a client was observed massaging the site, as this may actually trigger an embolism. (Option 1) Mild fever would be expected with a diagnosis of DVT. (Option 2) The client should not be kept immobilized out of a fear of dislodging the clot. Further immobility creates venous stasis and risks clot formation. Early ambulation is not shown to increase the risk for PE as previously believed. Ambulation is strongly encouraged after a full medical evaluation finds no risk of impending embolization. Bedrest with limb elevation may be prescribed initially for clients with severe pain and edema. (Option 3) This is a normal respiratory rate in an adult. A respiratory rate of more than 20/min and symptoms of dyspnea could indicate a PE. Educational objective: DVT is best prevented by avoiding extended bed rest and encouraging ambulation even after the diagnosis. Massaging the site of inflammation is highly discouraged.

The nurse is speaking to a client who takes desmopressin nasal spray for diabetes insipidus. Which statement by the client is most important for the nurse to report to the health care provider?

4 Desmopressin is a medication often used to treat central diabetes insipidus, a disease characterized by reduced antidiuretic hormone (ADH) levels that may result in dehydration and hypernatremia. Desmopressin mimics the effects of naturally occurring ADH, which increases renal water resorption and concentrates urine. However, this effect also increases the risk for water intoxication from decreased urine output. Clients receiving desmopressin must have their fluid and electrolyte status closely monitored for symptoms of water intoxication/hyponatremia (eg, headache, mental status changes, weakness). The nurse should immediately notify the health care provider (HCP) of client reports of water intoxication symptoms, as severe hyponatremia may progress to seizure, neurologic damage, or death (Option 4). (Option 1) Clients on desmopressin are often on fluid restriction as part of therapy. Frequent reinforcement may be necessary. (Option 2) Rhinitis and upper respiratory infection (eg, a cold) can decrease the effectiveness of desmopressin nasal spray therapy and may require dosage adjustments by the HCP. However, dosage adjustments can be addressed after symptoms of water intoxication. (Option 3) Side effects of desmopressin nasal spray include nasal irritation, congestion, and pain. If the client cannot tolerate side effects of nasal spray, oral dosing may be prescribed by the HCP. Educational objective: Clients taking desmopressin for diabetes insipidus are at risk for water intoxication and hyponatremia. Client reports of headache, mental status change, and/or muscle weakness may indicate hyponatremia from water intoxication and should be reported to the health care provider immediately.

The nurse providing culturally sensitive care to a group of new mothers should reinforce information concerning breastfeeding to which client?

4 Not all cultures believe in the child-bearing practices and rituals associated with bonding and breastfeeding that are standard in the American health care setting. For example: The American health care setting encourages the initiation of breastfeeding within the first hours after birth to stimulate the production of oxytocin, which promotes contraction of the uterus and assists in prevention of uterine hemorrhage. Mothers of southern Asian, sub-Saharan African, Pacific Island, Native American, and Hispanic ancestry may believe colostrum is harmful and therefore do not initiate breastfeeding until their breast milk comes in. However, some of these mothers may be willing to feed their newborn colostrum if they are taught about the antibody and laxative properties that it provides. (Option 1) Mothers of African descent may choose to breastfeed until the child is age 2. (Option 2) Mothers of Arabian ancestry value privacy and modesty; therefore, they may choose to bottle-feed while in the hospital and begin breastfeeding once discharged home. (Option 3) Many European-Caucasian mothers wish to breastfeed immediately after birth. Educational objective: Mothers of southern Asian, sub-Saharan African, Pacific Island, Native American, and Hispanic ancestry may believe that colostrum is harmful to the newborn. Mothers of Arabian ancestry value privacy and modesty; therefore, they may choose to bottle-feed while in the hospital and begin breastfeeding once they are home.

Which client has the greatest risk for respiratory depression when receiving opioids for pain management?

4 Respiratory depression is a potentially life-threatening adverse effect of opioids (eg, morphine, fentanyl, hydrocodone). After opioid administration, the nurse must carefully monitor the client's respiratory status, especially during the medication's peak effect time. The client's risk for opioid-related respiratory depression increases when combined with additional risk factors, including: Advanced age Recent surgery (highest risk during first 24 hours after surgery) Concurrent administration of other sedating medications (eg, benzodiazepines, antihistamines) Underlying pulmonary disease (eg, chronic obstructive pulmonary disease [COPD]) History of snoring and/or obstructive sleep apnea History of smoking Obesity Opioid-naive status (ie, client has not recently been taking opioids on a regular basis) The 70-year-old client has 3 significant risk factors for opioid-related respiratory depression, including advanced age, COPD, and recent surgery. Clients with COPD who have hypercarbia and hypoxemia have even greater risk for respiratory depression when receiving opioids (Option 4). (Option 1) This client has 1 risk factor, history of pulmonary disease. (Option 2) This client has 1 risk factor, recent surgery. In addition, clients with heroin addiction may develop opioid tolerance (decreased responsiveness to the analgesic and side effects of opioids). These clients have less risk for opioid-related respiratory depression but also often require higher doses to achieve pain management. (Option 3) This client has 1 risk factor, sleep apnea. Educational objective: Factors that increase risk for opioid-related respiratory depression include advanced age, recent surgery, concurrent use of other sedating medications, underlying pulmonary disease, snoring/sleep apnea, history of smoking, obesity, and opiate-naive status.

Which client has the greatest risk for respiratory depression when receiving opioids for pain management? 1. 20 year old client with chronic bronchitis receiving inhaled albuterol therapy every 4 hours 2. 30 year old client with heroin addiction with rotator cuff repair surgery this morning 3. 50 year old client with sleep apnea and left foot cellulitis who is scheduled for a bone scan later today 4. 70 year old client with chronic obstructive pulmonary disease with knee replacement this morning

The nurse is reinforcing instructions about the use of regular and neutral protamine Hagedorn (NPH) insulin. Which statement by the client indicates that further instruction is needed?

4 The Institute for Safe Medication Practices has labeled insulin a high-alert medication. These types of medication can be safe and effective when administered or taken according to recommendations. However, errors in administration may cause death or serious illness. NPH is an intermediate-acting insulin with a duration of 12-18 hours; it is generally prescribed 2 times daily (morning and evening). Regular insulin and other rapid-acting insulins (lispro, aspart, glulisine) are typically used with a sliding scale for tighter control of blood glucose throughout the day. These are generally taken before meals and at bedtime. (Options 1, 2, and 3) These are correct statements and indicate the teaching objective was completed successfully. Educational objective: NPH is an intermediate-acting insulin with a duration of 12-18 hours and typically prescribed twice a day.

A client in the postpartum unit has a temperature of 100.9 F (38.3 C) and tachycardia on the second day following a cesarean delivery. Examination shows uterine tenderness, fundus +2 above the umbilicus, moderate lochia rubra with a foul smell, and chills. Which prescription should the nurse implement first?

4 This client's findings indicate a possible uterine infection (postpartum endometritis). Clients develop fever, chills, tachycardia, uterine tenderness, and foul-smelling lochia. Postpartum endometritis is usually caused by polymicrobial infection and is treated with broad-spectrum antibiotics. If the health care provider prescribes blood cultures (Option 4), they must be obtained prior to initiating antibiotic therapy as the medication may alter laboratory results (Option 2). After the results of the blood culture are obtained, the antibiotic prescribed may be changed for appropriate treatment. (Option 1) Acetaminophen administration for fever is not the priority action for this client. The nurse can treat the client's fever after blood cultures are drawn and IV antibiotic therapy is initiated. (Option 3) Placement of a saline IV lock for administration of antibiotics may be completed after obtaining a blood culture. Drawing a blood culture from an IV site is not recommended. Careful preparation of the skin prior to needle puncture will decrease the chance of specimen contamination. Educational objective: Postpartum uterine infection may occur following vaginal or cesarean delivery. A blood culture is obtained prior to starting broad-spectrum antibiotics.

The nurse is reinforcing proper insulin self-administration technique to a client of American Indian heritage. As the nurse describes the necessary steps in the injection process, the client avoids eye contact and occasionally turns away from the nurse. Which action is most appropriate for the nurse to take in this situation?

1 Communication with individuals of various cultures may be difficult for the nurse at times due to cultural language differences (ie, verbal and nonverbal communication styles, including the use of silence). The mainstream American and European cultures value direct eye contact, believing that it is a sign of attention and trustworthiness. People of American Indian and Asian cultures view direct eye contact as rude and disrespectful and will likely move the eyes away, not allowing the nurse to maintain eye contact. If these clients avoid eye contact during a teaching episode, the most appropriate action is to continue with the instruction and verify understanding by return demonstration. (Option 2) Lecturing the client about the importance of listening to the instructions for insulin self-injection would most likely be interpreted as degrading and disrespectful. (Option 3) In the American Indian culture, maintaining eye contact during a conversation is viewed as disrespectful. Attempting to force eye contact would likely make the client uncomfortable or upset. (Option 4) A client learning the process of insulin self-administration requires guidance and evaluation from the nurse before, during, and after the teaching session. The client should not be sent to a quiet place to learn the procedure independently. Educational objective: Individuals of American Indian and Asian cultures view direct eye contact as rude and disrespectful and will likely move their eyes away during conversations in an attempt to prevent it. The nurse demonstrates culturally competent care by respecting and accepting this cultural communication pattern.

The nurse is caring for a client newly prescribed crutches. Which finding indicates the need for further teaching?

1 The proper fit and use of crutches are important in preventing injury. They include: Proper measurement and fit - There should be a 3-4 finger-width space (1-2 in [2.5-5 cm]) between the axilla and axillary pad (Option 4). Clients are taught to support body weight on the hands and arms, not the axillae. Handgrip location should allow 20-30 degrees of flexion at the elbow (Option 2). Proper gait - The 3-point gait is used for restrictions of partial or no weight-bearing on the affected extremity. The injured extremity and crutches are moved simultaneously (Option 3). The client who is rehabilitating from an injury of the lower extremity usually progresses from non-weight-bearing status (3-point gait) to partial weight-bearing status (2-point gait) to full weight-bearing status (4-point gait). (Option 1) Wear and tear of the axillary pads raises concern for the incorrect use or fit of crutches. Excessive and prolonged pressure on the axillae can cause localized damage to the radial nerve at the axillae. This leads to a reversible condition known as crutch paralysis, or palsy, and is caused by crutches that are too long or by leaning on the top of the crutches when ambulating. Educational objective: Proper crutch fit includes a 3-4 finger-width space between the axillary pad and axilla and a handgrip location that allows 20-30 degrees of elbow flexion. Clients should support their body weight on the hands and arms, not the axillae. Wear and tear on the crutch pads may indicate improper use or fit. Clients progress from 3-point gait (no to partial weight-bearing) to 2-point gait and then 4-point gait as rehabilitation continues.

A client with coarse crackles at the base of both lungs suddenly becomes agitated, anxious, cyanotic, and dyspneic. Which of the following positions is appropriate?

1 This client is experiencing acute pulmonary edema. Sitting upright (high Fowler's position) at the edge of the bed with the legs dangling is the appropriate position. This position will reduce the venous return to the heart and congestion to the lung, promote lung expansion, and immediately alleviate the client's symptoms and respiratory effort. (Options 2, 3, and 4) Left Sims', supine, and modified Trendelenburg positions will increase the venous return, augment pulmonary congestion, and worsen the client's condition. Modified Trendelenburg is an optimal position for a client in hypovolemic shock. Educational objective: The proper positioning for acute pulmonary edema is high Fowler's with the legs dangling.

The nurse reinforces teaching for the parents of a child with impetigo. Which of the following statements by a parent indicates correct understanding of teaching? Select all that apply.

1,3,5 Impetigo is a highly contagious bacterial skin infection, most commonly occurring in children during hot, humid weather. Impetigo is characterized by itchy, burning, red pustules that rupture to form honey-colored crusts. When treated with antibiotic ointment and/or oral antibiotics, lesions are no longer contagious after 24-48 hours and typically heal within a week. Without antibiotics, impetigo typically resolves within 2-3 weeks but remains highly contagious until lesions heal. To care for and decrease transmission of impetigo, interventions include: Performing handwashing before and after touching the infected area (Option 1) Isolating the infected person's clothing and linens and washing them in hot water (Option 3) Keeping the infected person's fingernails short and clean to prevent bacteria from collecting under them and to deter scratching (Option 4) Avoiding close contact with others for 24-48 hours after initiation of antibiotic therapy (Option 5) Keeping the infected area covered with gauze when in contact with others (eg, while at school) (Option 2) Impetigo lesions should be soaked with warm water, saline, or Burow's solution (a skin-soothing astringent) and gently cleansed with mild antibacterial soap before applying antibiotic ointment. This helps remove infected crusts and reduce irritation. Alcohol is irritative and should be avoided. Educational objective: Impetigo is a highly contagious bacterial skin infection. Caregivers can decrease transmission by keeping the client's nails short and clean, isolating the client's linens and washing them with hot water, and preventing close contact with others while the client is contagious. Lesions are soaked and cleansed with mild antibacterial soap to remove crusts before applying antibiotic ointment.

The nurse is conducting intake interviews at the clinic. Which client situations would require the nurse to intervene? Select all that apply.

1,4,5 Iron is absorbed better on an empty stomach; ascorbic acid (vitamin C), such as found in citrus fruits and juices, increases the absorption of iron. However, milk products decrease iron absorption and should be avoided (Option 1). Metronidazole (Flagyl) is used to treat trichomoniasis and amebiasis. Consuming alcohol while taking the medication may elicit a disulfiram (Antabuse)-like reaction. Alcohol should be avoided for at least 48 hours after treatment is completed (Option 4). Many antihistamines also have anticholinergic effects. Anticholinergics have an antimuscarinic effect that can increase intraocular pressure and are therefore contraindicated in closed-angle glaucoma. Other contraindications include urinary retention (benign prostatic hyperplasia) and bowel obstruction related to the anticholinergic drug's effect on the smooth muscle in the urinary and gastrointestinal tract (Option 5). (Option 2) Enteral nutrition decreases levothyroxine absorption; as a result, it should be taken early in the morning on an empty stomach (at least 30 minutes before food intake). (Option 3) Phenazopyridine (Pyridium) is used as a local anesthetic in the treatment of urinary tract infection. The azo dye turns the urine an orange-red color. The client needs to be reassured that this is an expected result and could stain clothing. Educational objective: Clients taking metronidazole (Flagyl) should avoid alcohol. Those with glaucoma or urinary retention should avoid anticholinergic drugs. Oral iron is better absorbed on an empty stomach and with vitamin C. Phenazopyridine (Pyridium) will turn urine an orange-red color.

An overweight toddler is diagnosed with iron deficiency anemia. Which is the most likely explanation for the anemia?

2 Iron deficiency anemia is the most common chronic nutritional disorder in children. There are many risk factors for iron deficiency, including insufficient dietary intake, premature birth, delayed introduction of solid food, and consumption of cow's milk before age 1 year. One common cause in toddlers is excessive milk intake, over 24 oz/day. In addition to becoming overweight, toddlers who consume too much milk develop iron deficiency due to the likely exclusion of iron-rich foods in favor of milk, a poor source of available iron. Treatment of iron deficiency anemia includes oral iron supplementation and increased consumption of iron-rich foods (eg, leafy green vegetables, red meats, poultry, dried fruit, fortified cereal). It is also important to limit milk intake (16-24 oz/day) in toddlers to ensure a balanced diet. (Option 1) Red meat and other meat products are considered good sources of dietary iron. However, clients may be at risk for obesity if meat consumption exceeds protein and caloric needs. (Option 3) Gastrointestinal blood loss, which can occur if infants under age 1 year are fed cow's milk, is a potential cause of iron deficiency anemia. However, excessive milk intake is a more common cause, particularly in clients over age 1 year. (Option 4) Impaired or decreased iron transfer is a potential cause of iron deficiency anemia, particularly in preterm infants or infants born in multiples. However, iron stores received from the mother are typically depleted by age 5-6 months (2-3 months for preterm infants); after this point, iron must be acquired through dietary sources. Because this client is a toddler (age 1-3 years), impaired iron transfer is not a likely cause of the current anemia. Educational objective: Iron deficiency anemia is the most common nutritional disorder in children. Risk factors include premature birth, cow's milk before age 1 year, and excessive milk intake in toddlers. Prevention and treatment are achieved through proper nutrition (eg, meat, leafy green vegetables, fortified cereal) and supplementation.

The nurse is reinforcing teaching on behavioral strategies to treat fecal incontinence due to functional constipation to the parent of a 6-year-old. Which statement by the parent indicates a need for further teaching?

2 Fecal incontinence (ie, encopresis, soiling) refers to the repeated passage of stool in inappropriate places by children age ≥4 years. In more than 80% of cases, it is due to functional constipation (retentive type); in about 20% of cases, it may be caused by psychosocial triggers (nonretentive type). Management of fecal incontinence/constipation includes 3 primary components: Disimpaction followed by prolonged laxative therapy, dietary changes (increased fiber and fluid intake), and behavior modification. Behavioral strategies are used to promote and restore regular toileting habits and to gain the child's cooperation and participation in the treatment program. Behavioral interventions include the following: Regularly schedule toilet sitting times 5-10 minutes after meals for 10-15 minutes (Option 4). Provide a quiet activity for the child during toilet sitting, which will help pass the time and make the experience more "enjoyable" (Option 1). Initiate a reward system to boost the child's participation in the treatment program; the reward would be given for effort, not for success of evacuation in the toilet (children with retentive encopresis have dysfunctional anal sphincters and little control over bowel movements; it would not be effective to give a reward for something over which the child has no control) (Option 2). Keep a diary or log of toilet sitting times, stooling, medications, and episodes of soiling to evaluate the success of the treatment (Option 3). Educational objective: A reward system is a behavioral strategy used in the treatment of functional incontinence (due to constipation). The reward is given to encourage the child's involvement in the treatment to restore normal bowel function. Rewards are given for the child's effort and participation, not for having bowel movements while sitting on the toilet.

The nurse is reinforcing teaching for parents of a child diagnosed with fifth disease. Which statement by a parent indicates a need for further teaching?

2 Fifth disease ("slapped face," or erythema infectiosum) is a viral illness caused by the human parvovirus and affects mainly school-age children. The virus spreads via respiratory secretions, and the period of communicability occurs before onset of symptoms. The child will have a distinctive red rash on the cheeks that gives the appearance of having been slapped. The rash spreads to the extremities and a maculopapular rash develops, which then progresses from the proximal to distal surfaces. The child may have general malaise and joint pain that are typically well controlled with nonsteroidal anti-inflammatory drugs such as ibuprofen. Affected children typically recover quickly, within 7-10 days. Once these children develop symptoms (eg, rash, joint pains), they are no longer infectious. Isolation is not usually required unless the child is hospitalized with aplastic crisis or immunocompromising condition. (Options 1, 3, and 4) These statements indicate that parent teaching regarding fifth disease was effective. Educational objective: Children with fifth disease are communicable only prior to onset of symptoms (eg, rash, joint pains). The causative agent, human parvovirus, spreads via respiratory secretions. Fifth disease is self-limiting and short-lived; treatment is given to alleviate symptoms. Isolation is not usually required for a non-hospitalized child.

A nurse is assessing a 1-month-old infant with an atrial septal defect (ASD). Which assessment finding does the nurse expect?

2 The nurse would expect to hear a murmur with an atrial septal defect. This defect is an abnormal opening between the right and left atria, allowing blood from the higher pressure left atrium to flow into the lower pressure right atrium. The back-and-forth flow of blood between the 2 chambers causes a vibration that is heard as a murmur on auscultation. ASD has a characteristic systolic murmur with a fixed split second heart sound. Some clients may also have a diastolic murmur. (Option 1) Muffled heart tones are not typical in ASD. Muffled heart tones that are heard postsurgical intervention are concerning for cardiac tamponade. (Option 3) Atrial and ventricular septal defects are acyanotic congenital heart defects because the blood from the high pressure left side (oxygenated blood) goes to the low pressure right side. (Option 4) Weak lower and strong upper extremity pulses are present in coarctation of the aorta. Educational objective: In a child with atrial septal defect, the nurse would expect to hear a heart murmur on auscultation of heart sounds.

A young Spanish-speaking client is experiencing a spontaneous abortion (miscarriage). Which illustrates the best use of an interpreter to explain the situation to the client? Select all that apply.

2,3,5 Clients from many cultures will be more responsive if the interpreter is the same gender, especially when the condition is highly personal or sensitive (Option 2). The nurse should maintain good eye contact when communicating with the client. The interpreter should translate the client's words literally. Communication is with the client, not the interpreter. The nurse should use basic English rather than medical terms, speak slowly, and pause after 1-2 sentences to allow for translation (Option 3). Providing simple instructions about upcoming actions in the order they will occur will be easier for the client to understand. For example, the nurse can indicate that there will be surgery and then a follow-up visit as opposed to, "You'll follow up with the health care provider after your procedure" (Option 5). (Option 1) The nurse should obtain feedback to be certain that the client understands. This feedback should extend beyond nodding as some people nod to indicate that they are listening or nod in agreement to "save face" even though they do not understand. It is better to use a tactic such as having the client repeat back information (which is then translated into English). (Option 4) Using a fee-based agency or language line is preferred if an appropriate bilingual employee is not available. The client may not want the friend/relative to know about this personal situation, or the person may not be able to adequately translate medical concepts and/or understand client rights. Educational objective: When an interpreter is needed, the nurse should attempt to use a trained, proficient, same-sex individual rather than a family member or personal friend. The nurse should speak slowly and directly to the client, not the interpreter; provide information in the sequence it will occur; and obtain feedback of comprehension beyond merely nodding.

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

2,4,5, Incisions may take 4-6 weeks to heal. The nurse should teach clients how to care for their incisions by providing the following instructions: Wash incisions daily with soap and water in the shower. Gently pat dry (Option 4). Itching, tingling, and numbness around the incisions may be present for several weeks due to damage to the local nerves (Option 1). Avoid tub baths due to the risk of infection (Option 3). Do not apply powders or lotions on incisions as these trap bacteria at the incision site (Option 3). Report any redness, swelling, drainage increase, or if the incision has opened (Option 2). Wear a supportive elastic hose on the legs and elevate them when sitting to decrease swelling (Option 5). Educational objective: The nurse should instruct the client with chest and leg incisions from coronary artery bypass grafting to wash them daily with soap and water in the shower. In addition, the client must be instructed not to apply any powders or lotions to the incisions; to report any redness, swelling, or drainage increase; and to wear an elastic compression hose on the legs.

The practical nurse monitoring a 3-year-old finds dyspnea, high fever, irritability, and open-mouthed drooling with leaning forward. The parents report that the symptoms started rather abruptly. The client has not received age-appropriate vaccinations. Which set of actions should the practical nurse anticipate?

3 Epiglottitis should be considered first in a 3- to 7-year-old with acute respiratory distress, toxic appearance (eg, sitting up, leaning forward, drooling), stridor, and high-grade fever. Tachycardia and tachypnea are also present. The complications of epiglottitis are serious and include sudden airway obstruction. Epiglottitis is a pediatric emergency and should be managed with endotracheal intubation. However, intubating such clients is difficult, and as a result, preparation for possible tracheostomy is also standard. (Option 1) This is a recommended therapy for spontaneous tension pneumothorax, which is demonstrated by tracheal deviation, absent lung sounds, and severe abrupt hypotension and dyspnea. (Option 2) Neither oxygenation nor bilevel positive airway pressure is acceptable in acute epiglottitis as the trachea can close completely due to edema. (Option 4) This is the appropriate therapy for croup, not epiglottitis. Croup presents with a characteristic hacking cough, which is absent in epiglottitis. Educational objective: When assessing a client with symptoms suggestive of epiglottitis (eg, acutely ill, drooling, leaning forward, dyspnea), the nurse should prepare for an emergency airway.

A client who is diagnosed with breast cancer asks the nurse, "Am I going to die?" Which statement by the nurse promotes a therapeutic relationship?

3 Many individuals diagnosed with cancer experience anxiety and fear related to death and desire to talk with someone about these feelings. To promote a therapeutic relationship, the nurse should initiate conversations by acknowledging clients' fears, use open-ended statements to invite them to talk about death, and actively listen as they verbalize their feelings. (Option 1) The nurse offers false reassurance by making this statement. Providing false reassurance is not part of a therapeutic relationship or an effective communication strategy. (Option 2) This statement does not acknowledge the client's concerns and blocks communication. The nurse should first assess the client's cultural and spiritual practices. If the client requests spiritual support, then the nurse may make a referral to the chaplain's office. (Option 4) By changing the subject, the nurse is attempting to redirect the conversation away from the client's desire to talk about death; this does not promote a therapeutic relationship. Educational objective: Fear of dying is a common concern for many clients with a terminal disease. The nurse should acknowledge these feelings and use open-ended statements and active listening to invite clients to talk about death.

The nurse is caring for an infant with suspected meningitis and preparing to assist with a lumbar puncture. What is the appropriate nursing intervention?

3 The optimal position for access during a lumbar puncture is to have the client's head and knees tucked in and the back rounded out. This provides the most room for the health care provider (HCP) to perform the procedure and allows for a good hold to keep the client still. A lumbar puncture is a sensitive procedure, and it is important to keep the child from moving during needle insertion. (Option 1) Unless the client has improper air exchange, oxygen administration is not needed. The nasal cannula will most likely bother the child and lead to unnecessary movement during needle placement. (Option 2) The HCP performing the lumbar puncture will feel the spine for correct needle placement and then sterilize and prepare the chosen area for needle insertion. (Option 4) Unless the client is unstable, there is no need to record vital signs every 15 minutes. The client should be awake and alert, and the procedure should be fairly short in duration. Educational objective: Performing a lumbar puncture on a child is a very sensitive procedure that requires accuracy. The correct position and ability to hold the child still are important to achieve the best result and minimize the risk for complications.

The practical nurse reviews the laboratory results for 4 clients. Which laboratory value is most important for the practical nurse to report to the registered nurse for evaluation?

4 Adalimumab (Humira), a tumor necrosis factor (TNF) inhibitor, is a biologic disease-modifying antirheumatic drug (DMARD) classified as a monoclonal antibody. Its major adverse effects are similar to those of other TNF inhibitor drugs (eg, etanercept [Enbrel], infliximab [Remicade]) and include immunosuppression and infection (eg, current, reactivated). An elevated white blood cell count in this client can indicate underlying infection and should be reported immediately. (Option 1) This client with Clostridium difficile infection will have an elevated white blood cell (WBC) count. The client is receiving appropriate therapy (eg, metronidazole, oral vancomycin). The nurse will need to monitor the WBC count and report it if it keeps increasing. (Option 2) The liver produces most blood clotting factors. Clients with liver cirrhosis will lose this ability and are at risk for bleeding. This client's prothrombin time is mildly elevated (normal 11-16 seconds), which is expected with cirrhosis. (Option 3) Corticosteroids increase blood glucose. This is expected, and the client may need treatment if the glucose levels are markedly increased for a prolonged period. Most clients with asthma exacerbation are expected to take a 5- to 7-day course of steroids. Educational objective: Adalimumab (Humira), etanercept (Enbrel), and infliximab (Remicade) are common tumor necrosis factor inhibitors and biologic disease-modifying antirheumatic drugs. Major adverse effects associated with their use include immunosuppression and infection.

The nurse prepares equipment for insertion of a large-bore nasogastric (NG) tube for a hospitalized client. Which actions should the nurse take to measure and mark the tube? Select all that apply.

3,4 Because distance from the nares to the stomach varies with each client, it is important to measure and mark the NG tube prior to insertion to ensure its correct placement in the stomach. The Traditional Method is most commonly used for large-bore NG tube placement. Traditional Method: Using the end of the tube that will eventually rest in the stomach, measure from the tip of the nose, extend the tube to the earlobe and then down to the xiphoid process (Options 1, 2, and 3). Mark the distance with a small piece of tape that can be easily removed (Options 4 and 5). Educational objective: Ensure proper measurement prior to inserting a large-bore NG tube by measuring from the tip of the nose, extending the tube to the earlobe, and then down to the xiphoid process. Mark the distance with a small piece of tape that can be easily removed.

The nurse cares for a client diagnosed with Addison disease. Which clinical finding would the nurse anticipate?

4 Addison disease (chronic adrenal insufficiency) occurs when the adrenal glands produce inadequate amounts of steroid hormones (eg, mineralocorticoids, glucocorticoids, androgens). It is characterized by: Hypoglycemia, weight loss, and muscle weakness: A deficit of glucocorticoids (eg, cortisol) decreases the amount of liver glycogen and prevents gluconeogenesis (Option 4). Hyperpigmented skin, especially on the knees, elbows, buccal area, and palmar creases: Low cortisol triggers the production of excess ACTH from the pituitary gland. Hypotension: A deficit of aldosterone prevents the retention of water and sodium. Hyperkalemia: Potassium is retained when sodium is lost in urine. Treatment for Addison disease consists of replacement therapy with oral mineralocorticoids and corticosteroids. (Option 1) Acanthosis nigricans, a skin condition related to insulin resistance from obesity and diabetes, appears as velvet-like patches of darkened, thick skin, typically on the back of the neck and in the groin and armpits. (Options 2 and 3) Cushing syndrome (overproduction of steroid hormones) produces "opposite" symptoms from Addison disease. Clients have truncal obesity, "buffalo hump" (fat deposits in the shoulders), hyperglycemia from excess glucocorticoids, and hypertension from excess aldosterone. Increased sex hormones cause hirsutism (male-pattern hair growth in females). Immune suppression from increased glucocorticoids increases the risk of infection and delays healing. Educational objective: Addison disease occurs when the adrenal glands produce inadequate amounts of steroid hormones (eg, mineralocorticoids, glucocorticoids). It is characterized by hyperpigmented skin, hypoglycemia, weight loss, muscle weakness, hypotension, and hyperkalemia.

What is the best activity for a school-aged child hospitalized for vaso-occlusive sickle cell crisis?

4 A child in vaso-occlusive sickle cell crisis will be experiencing a high level of pain due to the occlusion of small blood vessels from increased red blood cell sickling. Supportive and symptomatic treatment includes round-the-clock pain management with opioids, intravenous fluids for hydration, and bed rest to decrease energy expenditure and oxygen demand. Age-specific nonpharmacologic strategies should also be implemented to manage pain and help limit the amount of needed narcotic analgesia. For a school-aged child, such activities include distraction (watching TV, listening to music, reading), relaxation, guided imagery, warm soaks, positioning, and gentle massage. (Option 1) Finger painting is messy and best done in the activity room; it is not appropriate for a child confined to bed. (Option 2) A child must be on bed rest when in vaso-occlusive sickle cell crisis. Playing a game in the activity room does not maintain bed rest and would be too stimulating for the child. (Option 3) Playing video games may be too exciting and stimulating for the child; an environment low in stimuli will promote rest. Educational objective: Supportive and symptomatic treatment for vaso-occlusive sickle cell crisis includes pain management and bed rest. Nonpharmacologic measures to alleviate pain include distraction (watching TV, listening to music, reading), relaxation, guided imagery, warm soaks, positioning, and gentle massage.

A client with advanced multiple sclerosis (MS) has been a resident in a nursing home for the past 2 years. One day, the client tells the nurse, "I want to get out of here and try living in my own home." What is the best response by the nurse?

4 After 2 years of residence, this client has expressed a desire to leave the nursing home and return home. This client with advanced MS will need maximal assistance with basic activities of daily living (bathing, grooming, toileting, transfers, locomotion), meal preparation, laundry, shopping, and other housekeeping chores. Discharging this client to care at home will require much planning and present numerous challenges related to safety, finances, support and informal caregiver system, durable medical equipment, and layout of the home. Therefore, before any discussion or planning can take place, the nurse needs to determine why the client wants to go home at this point in time. The nurse should also ask the client if something happened in the nursing home. However, asking "why" or "yes/no" questions is non-therapeutic and will not facilitate a meaningful nurse-client interaction. By using the therapeutic communication technique of exploring, the nurse can encourage the client to discuss thoughts, feelings, and reasons for wanting to leave the current residence. (Option 1) This is important information to obtain when planning the discharge of a client who needs care at home; however, it is not the priority assessment. (Option 2) This would be an appropriate nursing action after the nurse has discussed and assessed the reasons why the client wants to return home. (Option 3) This is an appropriate response as it presents the reality of the client's situation, but it is not the priority response. Educational objective: Exploring is a therapeutic communication technique that will facilitate further assessment of a particular subject or experience. It is a technique that is especially helpful when a client makes a statement or presents a topic that alerts the nurse that there could be additional information beyond the surface of the initial communication.

After receiving shift report, the nurse is assessing a client started on trimethoprim-sulfamethoxazole 2 days ago for treatment of a urinary tract infection. The client reports itching, and the nurse notices a diffuse maculopapular rash on the client's face. What should the nurse do first?

4 Clients may not know the signs and symptoms of allergies or not remember a past history of allergies, which causes underreporting of allergies. Therefore, reassessing client allergies is the first and oftentimes the quickest action (Option 4). To ensure that the client report is accurate, the nurse should ask about specific signs and symptoms that would indicate an allergy (eg, hives, rash, diarrhea) as the client may not be aware of these indicators. A diffuse maculopapular rash is a typical manifestation of an allergic medication reaction that develops within the first 3 days of starting a new medication. The registered nurse (RN) should be notified and should ask the client about any signs and symptoms of anaphylaxis. The health care provider (HCP) should be notified to assess, diagnose, and treat the rash. If a medication allergy is diagnosed, the client's record should be updated and the pharmacist should be notified. (Option 1) Diphenhydramine is an antihistamine used to treat mild allergic reactions. This would be appropriate to administer after an allergic reaction is confirmed by the HCP. Corticosteroids (eg, prednisone) have an anti-inflammatory action and may also be used to prevent or treat a mild allergic reaction. (Option 2) A drug rash is a mild allergic reaction. Injectable epinephrine (Epi-pen) would only be used when the client is having a severe anaphylactic reaction, with swelling of the airway and/or cardiovascular collapse. (Option 3) A drug rash is usually a systemic type of reaction with diffuse rash evident on the face, trunk, and limbs. Therefore, assessment of the client's trunk and limbs would be the second nursing action after reassessing allergy history. Educational objective: A client with signs of a potential allergic reaction should be assessed quickly, including allergy history and physical assessment (face, trunk, and limbs) with attention to signs of anaphylaxis. The health care provider should then be notified to assess the client, and the client's allergies should be updated in the medical record.

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

4 During NG tube insertion, the tube sometimes slips into the larynx or coils in the throat, which can result in coughing and gagging. The nurse should withdraw the tube slightly and then stop or pause while the client takes a few breaths. After the client stops coughing, the nurse can proceed with advancement (Option 2), asking the client to take small sips of water to facilitate advancement to the stomach (Option 1). The client should not be asked to swallow during coughing or aspiration may occur. If resistance or obstruction occurs during tube advancement, the nurse should rotate the tube while trying to advance it. If resistance continues, the tube should be withdrawn and inserted into the other naris if possible (Option 3). Educational objective: Coughing and gagging commonly occur during NG tube insertion if the tube coils in the throat or slips into the larynx. When this happens, the nurse should pull back on the tube slightly and then pause to give the client time to recover and breathe before advancing the tube.

A client's family presses the call button and reports that they are unable to wake the client. Place the nurse's next actions in the correct order. All options must be used.

Correct Response Attempt to shake the client awake Call for help Check for breathing and a pulse for 10 seconds Begin chest compressions Notify the health care provider

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

2,3,5 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. Educational objective: Cardiac and respiratory drive is increased to maintain cardiac output and oxygenation in the setting of anemia.

The nurse is caring for a client who underwent a transsphenoidal hypophysectomy to remove a pituitary adenoma. Which intervention(s) should the nurse implement? Select all that apply. 1. encourage coughing frequently to prevent pneumonia. 2. inspect the mouth and perform mouth care every 4 hours 3. maintain the head of the bed in a flat position 4. perform frequent neurologic checks 5. remind the client to not use a toothbrush for 10 days

2,4,5 A hypophysectomy is a surgical procedure that involves removal of part of the pituitary gland. A transsphenoidal approach involves insertion of an endoscope between the inner aspect of the upper lip and gingiva, through the sella turcica, bottom of the nose, and sphenoid sinuses to the pituitary gland. There is no external incision. The dural opening is closed with a patch of fat graft taken from the abdomen or outer thigh. As a result, the client should be prepared for an additional incision. Postoperative care focuses primarily on preventing disruption of the patch closure of the dura and cerebrospinal fluid (CSF) leak. This care includes the following: Frequent mouth care with a soft sponge to prevent infection; this includes no use of a toothbrush for at least 10 days to prevent suture line disruption. The nurse should teach the client to avoid coughing, sneezing, or straining. These actions can cause CSF leakage. Any clear nasal drainage should be tested for the presence of CSF, indicated by a glucose level >30 mg/dL in the fluid (Option 1). The nurse should perform frequent neurological checks and report signs of increased intracranial pressure or bleeding to the health care provider. The head of bed should be maintained at a 30-degree angle to decrease intracranial pressure (Option 3). Educational objective: A hypophysectomy using a transsphenoidal approach is a surgical procedure to remove part of the pituitary; it involves the insertion of an endoscope through the inner aspect of the upper lip all the way to the pituitary. Nursing care includes frequent mouth care with a soft sponge to avoid infection and disruption to the suture line, frequent neurological checks, and maintaining the head of the bed at a 30-degree angle.

A client is scheduled for coronary artery bypass surgery in the morning. In the middle of the night, the nurse finds the client wide awake. The client demonstrates symptoms of extreme anxiety and tells the nurse about wanting to refuse the surgery. Which statement by the nurse would be most appropriate? 1. "please try not to worry, you have a excellent surgeon" 2. "tell me how you feel about your surgery" 3. "why are you considering refusing the surgery?" 4. "you have the right to make your own decisions and can refuse the surgery"

"Tell me about how you feel about your surgery," is the most appropriate statement to encourage the client to express the source of anxiety. Using an open-ended question enables the client to take control of the conversation and direct it to concerns about the surgery. The nurse can then address the specific concerns identified and provide individualized explanations and support. (Option 1) This statement is nontherapeutic as giving false reassurance minimizes the client's concerns and diminishes trust between the nurse and client. (Option 3) This statement is non therapeutic and intimidating. Asking "why" and "how" is an ineffective method of gathering information. (Option 4) A client may share a decision with the nurse in an effort to discuss feelings. This statement is nontherapeutic because giving approval of the client's decision does not encourage the client to express concerns about the surgery. Educational objective: Therapeutic conversation techniques (eg, active listening, using open-ended questions) encourage the client to express feelings and ideas and establish an open, trusting relationship with the nurse. Nontherapeutic communication techniques (eg, expressing approval or disapproval, giving advice, asking why) discourage expression of feelings and ideas and close down the conversation between the nurse and client.

The nurse reinforces discharge instructions to a client who was hospitalized for deep venous thrombosis that has now resolved. Which instructions should the nurse include to prevent reoccurrence? Select all that apply. 1. do not travel by car or airplane for at least 3-4 weeks 2. drink plenty of fluids daily and limit caffeine and alcohol intake 3. elevate legs on a footstool when sitting and dorsiflex the feet often 4. resume the walking or swimming exercise program as soon as possible after getting home 5. sit in a crossed legged yoga position for 5-10 minutes as this benefits circulation

2,3,4 Discharge teaching for a client who had deep venous thrombosis (DVT) emphasizes minimization of risk factors and interventions to promote blood flow and venous return and prevent reoccurrence. Teaching points include the following: Drink plenty of fluids and limit caffeine and alcohol intake to avoid dehydration, which predisposes to blood hypercoagulability and venous thromboembolism (Option 2). Elevate legs when sitting, and dorsiflex the feet often to reduce venous hypertension and edema and to promote venous return (Option 3). Begin or resume a walking/swimming exercise program as soon as possible to promote venous return through contraction of the calf and thigh muscles (Option 4). Change position frequently to promote venous return and circulation and prevent venous stasis. Stop smoking to prevent endothelial damage and vasoconstriction as this promotes clotting. Avoid wearing restrictive clothing (eg, Spanx, tight jeans) that interferes with circulation and promotes clotting. The nurse would suggest consultation with a nutritionist or enrollment in a weight-loss program to overweight/obese clients as excess weight contributes to venous insufficiency and hypertension by compressing large pelvic vessels. (Option 1) Traveling does not need to be avoided. During extended travel periods (>4 hours), clients are instructed to use preventive measures (eg, wear knee-high compression stockings, exercise calf and foot muscles every 30 minutes, take frequent breaks and walk briefly every hour, recline in their seats, remove objects around the feet and legs to allow maximal movement, drink ample fluids to avoid dehydration). (Option 5) Clients should avoid sitting in any cross-legged position and should never cross the legs at the knees or ankles as this compresses the veins and limits venous return. Educational objective: Discharge teaching for a client who had deep venous thrombosis emphasizes minimization of risk factors (eg, venous stasis, hypercoagulability of blood, endothelial damage) and interventions to promote blood flow and venous return and prevent reoccurrence (eg, adequate fluid intake, frequent position changes, elevation of the legs, regular exercise, smoking cessation).

The nurse is caring for a client with diabetes who is being discharged with a prescription for glyburide. Which statement by the client indicates a need for further instruction?

4 The major adverse effects of sulfonylurea medications (eg, glyburide, glipizide, glimepiride) are hypoglycemia and weight gain. Weight gain should be addressed. Clients taking glyburide should be taught to use sunscreen and protective clothing as serious sunburns can occur. (Option 1) Clients taking sulfonylureas should avoid alcohol as it lowers blood glucose and can lead to severe hypoglycemia. (Option 2) Hypoglycemia (serum glucose <70 mg/dL [3.9 mmol/L]) is a major side effect of sulfonylurea medications. A fasting blood glucose <60 mg/dL (3.3 mmol/L) indicates moderate to severe hypoglycemia and the medication needs to be reassessed. (Option 3) Even foods labeled "diabetic", "sugar free," or "sugarless" may contain carbohydrates such as honey, brown sugar, and corn syrup, all of which can elevate blood sugar. Educational objective: The major adverse effects of sulfonylurea medications are hypoglycemia and weight gain. Alcohol must be avoided while taking these medications due to the risk of severe hypoglycemia. Glyburide can also make clients sunburn easily.

A nurse is caring for a postpartum client who has breast engorgement following breastfeeding. Which instructions should the nurse reinforce regarding relief of breast engorgement?

1 Breast engorgement is often painful, and the following treatments are recommended in a client who is breastfeeding: Continue breastfeeding - Frequent feedings with complete emptying of each breast is the best treatment for breast engorgement. Newborns should nurse for at least 10-15 minutes on each breast to ensure complete emptying (Option 1). Do not pump breasts between feedings - Pumping between feedings will increase breast milk production and worsen breast engorgement. Apply a warm/cold compress - Warm compresses can be used to soften the breast and nipple before breastfeeding, and cold compresses can be used to minimize swelling afterward. Take warm showers - Allowing warm water to trickle over breasts in the shower a few times a day minimizes discomfort and reduces pressure by allowing a small amount of milk to be released. Use anti-inflammatory analgesics - An anti-inflammatory drug, such as ibuprofen, is recommended for pain associated with breast engorgement. (Option 2) Although application of ice minimizes swelling, warm compresses are recommended before attempting to breastfeed. (Option 3) Breastfeeding should be continued during treatment of breast engorgement. (Option 4) Manually expressing or pumping breast milk is indicated only if the newborn misses a feeding. Breastfeeding is a supply and demand process; manually expressing breast milk and pumping will increase milk production. Educational objective: For breast engorgement in a client who is breastfeeding, treatments that the nurse should recommend include frequent breastfeeding with complete emptying of the breasts, avoidance of pumping and expressing breast milk between feedings, and managing pain with warm/cold compresses and anti-inflammatory analgesics.

A nurse is caring for a client with type 2 diabetes mellitus who was recently started on pioglitazone. Which client data obtained by the nurse is most important to report to the registered nurse?

1 Thiazolidinediones (also called glitazones; rosiglitazone [Avandia] and pioglitazone [Actos]) are used to treat type 2 diabetes mellitus. These agents improve insulin sensitivity but do not release excess insulin, leading to a low risk for hypoglycemia (similar to metformin). These drugs can worsen heart failure by causing fluid retention and increase the risk of bladder cancer. Heart failure or volume overload is a contraindication to thiazolidinedione use. These medications also increase the risk of cardiovascular events such as myocardial infarction. (Option 2) The target blood pressure for a client with diabetes is <140/90 mm Hg. (Option 3) The goal HbA1c for a client with diabetes is <7%. (Option 4) Diabetic retinopathy, a condition treated with retinal photocoagulation, is unrelated to thiazolidinedione use. If the client has a history of bladder cancer, then it should be reported. Educational objective: Thiazolidinediones (rosiglitazone [Avandia] and pioglitazone [Actos]) increase the risk of cardiovascular events (eg, mycoardial infarction, heart failure) and bladder cancer. Thiazolidinedione use increases insulin sensitivity but carries a low risk for hypoglycemia (similar to metformin).

A client tells the nurse of wanting to lose 20 lb (9 kg) in time for the client's daughter's wedding, which is 16 weeks away. How many calories (kcal) will the client have to eliminate from the diet each day to meet this goal? 1. 450 kcal/day 2. 625 kcal/day 3. 860 kcal/day 4. 1,000 kcal/day

2 A reduction or energy expenditure of 3,500 calories (kcal) will result in a weight loss of 1 lb (0.45 kg). To lose 20 lb (9 kg), the client needs to reduce intake by a total of 70,000 kcal (3500 kcal x 20 lb [9 kg] = 70,000 kcal). Over a period of 16 weeks, this would require a daily reduction of: 625 kcal (70,000 kcal / [16 weeks x 7 days] = 625 kcal/day) Adding an exercise regimen to the client's daily routine would facilitate additional weight loss and/or reduce the need for severe caloric restriction. (Option 1) Reducing intake by 450 kcal/day over 16 weeks would result in a weight loss of 14.5 lb (6.5 kg). (Option 3) Reducing intake by 860 kcal/day over 16 weeks would result in a weight loss of 27.5 lb (12.4 kg). (Option 4) Reducing intake by 1000 kcal/day over 16 weeks would result in a weight loss of 32 lb (14.5 kg). Educational objective: A reduction or energy expenditure of 3500 calories (kcal) will result in a weight loss of 1 lb.

A client with gout who was started on allopurinol a week ago calls the health care provider's (HCP's) office with several concerns. The nurse should recognize which report by the client as being significant and requiring immediate follow-up?

3 Allopurinol is a medication frequently used in the prevention of gout. Gout is a buildup of uric acid deposited in the joints that causes pain and inflammation. The medication helps to prevent uric acid deposits in the joints and the formation of uric acid kidney stones. Any rash in a client taking allopurinol, even if mild, should be reported immediately to the HCP. The nurse should direct the client to stop taking the medication immediately, schedule an appointment, and notify the HCP. A rash caused by allopurinol may be followed by more severe hypersensitivity reactions that can be fatal, including Stevens-Johnson syndrome and toxic epidermal necrolysis. (Option 1) Allopurinol can take several months to become effective. Its primary use is to prevent gout attacks; it is not effective in treating acute attacks. The client will need to continue to take anti-inflammatory drugs (eg, nonsteroidal anti-inflammatory drugs or colchicine) for acute attacks. (Option 2) Clients are directed to take allopurinol with a full glass of water and to increase daily fluid intake to prevent kidney stones. This will cause an increase in urination and is an expected outcome. (Option 4) Nausea can be prevented by instructing the client to take the medication with food or following a meal. Educational objective: The nurse should direct the client taking allopurinol for gout to immediately discontinue the medication and report to the HCP if any rash develops. Allopurinol-induced rashes can develop into severe and sometimes fatal hypersensitivity reactions, such as Stevens-Johnson syndrome. Similar instructions should be given to clients taking anticonvulsants (eg, carbamazepine, phenytoin, lamotrigine) and sulfa antibiotics.

A 24-year-old female client has been prescribed isotretinoin for severe nodulocystic acne that has been resistant to other therapies. Which instruction is most important for the nurse to reinforce with this client?

4 Isotretinoin (Accutane) decreases sebum secretion and is prescribed for severe, disfiguring nodular acne that has been unresponsive to other therapies, including antibiotics. It is a pregnancy category X drug and is known to cause serious birth defects if taken during pregnancy. Females prescribed isotretinoin must have 2 negative pregnancy tests before taking the medication. Also, 2 forms of contraception must have been in place for at least 1 month prior to starting isotretinoin, and these must be continued both during treatment and for 1 month after the medication is discontinued. Before refills can be obtained, enrollment in a risk management program is required to verify that pregnancy tests are negative and 2 forms of contraception are being used. Blood donation is also discouraged while on therapy and for 1 month afterward to ensure that pregnant women do not receive any donated blood. (Option 1) Dryness of the eyes, mouth, and skin are common side effects. Lubricating eye drops may be needed to wear contacts. Some clients are unable to wear contacts while taking this medication. Good oral hygiene and skin care are needed. (Option 2) Capsules should be swallowed whole with at least 8 oz of water or other fluid. Capsules should not be broken, crushed, or chewed as contents of opened capsules could irritate esophagus. (Option 3) This medication causes photosensitivity. The nurse should teach the client to use sunscreen routinely. Educational objective: Isotretinoin is a pregnancy category X drug and will cause birth defects if taken during pregnancy. The client must use 2 forms of birth control for 1 month prior to taking the medication as well as during treatment and 1 month afterward. The client must also be enrolled in a risk management program prior to receiving refills.

The clinic nurse is reinforcing teaching to a client about levothyroxine, which the health care provider has prescribed for newly diagnosed hypothyroidism. Which statement made by the client indicates that further teaching is needed?

4 Several medications impair the absorption of levothyroxine (Synthroid). Common offenders are antacids, calcium, and iron preparations. Some of these could be present in several over-the-counter multivitamin and mineral tablets. Therefore, clients with hypothyroidism should be instructed to take levothyroxine on an empty stomach, preferably in the morning, separately from other medications. The most common reason for inadequately treated hypothyroidism is deficient knowledge related to the medication regimen (eg, not taking daily, taking with other medications). (Option 1) Levothyroxine dosing is adjusted based on blood tests for thyroid-stimulating hormone or other thyroid hormone levels. The dose is not the same for each client. (Option 2) Thyroid supplementation with levothyroxine usually requires lifelong therapy. (Option 3) Levothyroxine has a long half-life, so dosing is once daily. Educational objective: Levothyroxine should be taken on an empty stomach, preferably in the morning, separately from other medications.

The nurse is reading the revised medication prescriptions for a client recently admitted with type 1 diabetes mellitus. Which prescription should the nurse question and report to the health care provider?

4 Subcutaneous injection is the only indicated route for NPH insulin administration; it should never be administered via IV push. Regular insulin and certain rapid-acting insulins are the only forms of insulin that can be administered via IV push; this is typically performed only in an acute care facility under close observation by a registered nurse. (Option 1) Administration of 10 units regular insulin IV push for blood glucose >250 mg/dL (13.9 mmol/L) is appropriate and does not need to be reported to the health care provider. (Option 2) Administration of 14 units glargine insulin subcutaneous injection every night at 8:00 PM is appropriate, and a new prescription is not required. (Option 3) Administration of 18 units aspart insulin subcutaneous injection 15 minutes before breakfast is appropriate, and a new prescription is not required. Educational objective: Subcutaneous injection is the only indicated route for NPH insulin administration; it should never be administered via IV push.

The parent of a 5-year-old child calls the clinic to report the recurrence of a nosebleed for which the child was seen a week ago. Which of the following instructions should the nurse reinforce? Select all that apply.

1,2,3 Epistaxis (nosebleed) is a common and rarely serious nasal condition that can be caused by dry mucous membranes, local injury (eg, nose-picking), insertion of a foreign body, or rhinitis. Epistaxis usually involves the anterior nasal septum and often resolves spontaneously or with simple home management. Home management of epistaxis includes: Prioritizing application of direct, continuous pressure to the soft, compressible area below the nasal bone for 10 minutes to promote clot formation (Option 2) Holding a cold cloth or ice pack to the bridge of the nose to induce vasoconstriction and slow bleeding (Option 1) Attempting to keep the client with epistaxis quiet and calm as emotional outbursts and noncooperation create a challenge to implementing interventions and stopping bleeding (Option 3) (Option 4) Positioning a child with epistaxis in a horizontal position or with the head tilted backward promotes drainage of blood into the throat, which increases the risk of swallowing or aspirating blood. Clients with epistaxis should sit upright and tilt the head forward. (Option 5) Epistaxis is typically managed at home. However, the caregiver should seek emergency care if the client's breathing is impaired, or the bleeding is excessive or uncontrollable with home measures or resulted from a traumatic injury. Educational objective: Epistaxis (nosebleed) is a nasal condition typically occurring from local injury (eg, nose-picking) or irritation. Initial epistaxis management includes calming the client; tilting the head forward; applying direct, continuous nasal pressure for 10 minutes; and applying cold packs to the nasal bridge.

The community health nurse is preparing to reinforce teaching to a group of African American women about prevention of diseases common to their ethnic group. Based on the incidence of disease within this group, which disorders should the nurse plan to discuss? Select all that apply.

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

The student nurse is applying a condom catheter for an ambulatory client who is uncircumcised and incontinent of urine. The precepting nurse should intervene when the student performs which action?

3 Paraphimosis occurs when the uncircumcised male foreskin cannot be returned (reduced) to its original position, after being pulled back (retracted) behind the glans penis, resulting in pain, progressive swelling of the foreskin, and impaired lymph and blood flow. Paraphimosis can occur when a health care worker accidentally leaves the foreskin in the retracted position for an extended period of time (eg, under a condom catheter sheath). It is critical for the precepting nurse to intervene when the student nurse retracts the foreskin before applying the condom catheter to avoid permanent damage to the glans resulting from impaired circulation (Option 3). (Option 1) The drainage tubing is attached to a leg collection bag in a mobile client to enable ambulation, prevent tube kinking, and facilitate gravity drainage. (Option 2) A 1-2 in (2.5-5 cm) space should be left between the tip of the penis and the end of the condom to prevent penile irritation and pooling of urine in the condom. (Option 4) If the condom catheter is not self-adhesive, elastic adhesive is used in a spiral fashion to secure the device to the penis. Adhesive tape may cause irritation and/or injury, and should not be used. Educational objective: Health care providers should ensure a client's foreskin is fully reduced before applying a condom catheter, as prolonged retraction can cause paraphimosis, progressive swelling of the foreskin, vascular compromise, and permanent damage to the glans.

A client recovering at home following a left total knee replacement 7 days ago is using a cane to go up and down the stairs under the supervision of the home health nurse. Which client action indicates a need for reinforcement of teaching?

3 To provide full support when climbing stairs, clients should hold the cane on the stronger side and move the cane before moving the weaker leg, regardless of the direction of the stairs (Option 2). They should also keep 2 points of support on the floor at all times (eg, both feet, cane and foot) and face forward when going up or down the stairs, especially if there is no handrail (Option 1). The nurse should instruct the client on the following: When ascending stairs: Step up with the stronger leg first (in this client, the right leg) Move the cane next while bearing weight on the stronger leg Finally, move the weaker leg (in this client, the left leg) When descending stairs: Lead with the cane Bring the weaker leg down next Finally, step down with the stronger leg The nurse may use the mnemonic "up with the good and down with the bad." The cane always moves before the weaker leg. (Option 4) Clients are usually hospitalized for 3-4 days following a total knee replacement and can bear full weight by the time of discharge. Early ambulation and weight-bearing helps to hasten recovery and prevent complications (eg, thromboembolism). Educational objective: Clients who have had total knee replacement surgery can typically bear full weight by the time of discharge. To reduce the risk of falls, the client should hold the cane on the stronger side and face forward when going up and down the stairs. To ascend the stairs, the client should first step up with the stronger leg, next bear weight on that leg and move the cane, and finally step up with the weaker leg.

The nurse assessing a client with an upper gastrointestinal bleed would expect the client's stool to have which appearance? 1. black tarry 2. bright red bloody 3. light gray "clay colored" 4. small, dry, rocky-hard masses

1 The nurse would expect a client experiencing an upper gastrointestinal (GI) bleed to have black tarry stools (melena). As blood passes through the GI tract, digestion of the blood ensues, producing the black tarry appearance. (Option 2) Bright red bloody stool (hematochezia) would indicate a lower GI hemorrhage. (Option 3) Decreased bile flow into the intestine due to biliary obstruction would produce a light gray "clay-colored" stool. (Option 4) Small, dry, rocky-hard masses are an indication of constipation. Inactivity, slow peristalsis, low intake of fiber in the diet, decreased fluid intake, and some medications (eg, anticholinergics) may contribute to constipation. Educational objective: Clients with upper gastrointestinal (GI) bleed tend to have black tarry stools (melena). Lower GI bleeding will have bright red bloody stool. Blood present on surface of stool indicates hemorrhoids.

The practical nurse is monitoring a client 12 hours after the prolonged vaginal delivery of a term infant. Which finding should be reported to the registered nurse?

2 A foul odor of lochia suggests endometrial infection. This client has an increased risk of infection due to her prolonged labor, which involved multiple cervical examinations. The odor of lochia is usually described as "fleshy" or "musty." A foul smell warrants further evaluation. Other signs of endometrial infection are maternal fever, tachycardia, and uterine pain/tenderness. (Option 1) Palpation of the postpartum uterine fundus is commonly uncomfortable. If the client has increasing pain, further evaluation is needed. (Option 3) Major signs and symptoms of endometrial infection include temperature >100.4 F (38.0 C), chills, malaise, excessive uterine tenderness, and purulent, foul-smelling lochia. During the first 24 hours postpartum, temperature is normally elevated, but a reading of >100.4 F (38 C) requires further evaluation. (Option 4) The white blood cell count is normally elevated during the first 24 hours postpartum (up to 30,000/mm3 [30.0 x 109/L]). Leukocyte levels that are not decreasing require further evaluation. Educational objective: Signs of endometrial infection include elevated temperature, chills, malaise, excessive pain, and foul-smelling lochia. During the first 24 hours postpartum, temperature and white blood cell count are normally elevated. Fever and leukocyte counts that do not decrease require further evaluation.

A client with type I diabetes mellitus is prescribed an insulin pump. The nurse reinforces the diabetic educator's teaching regarding transitioning from multiple daily injections to continuous subcutaneous insulin infusion (CSII) therapy. Which statement indicates that the client understands the advantages of using this therapy?

2 An insulin pump is a small, battery-operated device about the size of a pager. The infusion set holds a syringe (reservoir) filled with rapid-acting insulin (175-315 units) and delivers the drug from the pump to the client through a needle or catheter that is usually secured to the abdomen with an adhesive patch. The pump delivers insulin in 2 ways: As a steady, measured, and continuous dose (basal rate) 24 hours a day As an intermittent dose (bolus) administered manually at mealtime to cover carbohydrate intake and as a supplemental dose to correct pre- or postprandial hyperglycemia. CSII therapy delivers the insulin more accurately than injections, so the client experiences fewer swings in blood glucose levels and hypoglycemic episodes, as compared with the administration of insulin using a needle and syringe, or pen. (Option 1) Although the pump can calculate and deliver a more precise dose to regulate blood glucose levels more effectively, a bolus dose must be administered manually at mealtime to cover carbohydrate intake. (Option 3) Pumps used most commonly (open-loop) cannot respond to changes in the client's glucose levels. The American Diabetes Association recommends that clients using CSII check their blood glucose levels 4-8 times a day: fasting, pre-meal, 2-hours postprandial, bedtime, at 3:00 AM weekly, when experiencing symptoms of hypoglycemia, after treating low blood sugar, and before exercise. Some insulin pumps (closed-loop system) are equipped with continuous blood glucose monitoring (CBGM) systems, which can detect blood glucose levels without a fingerstick. However, CBGM does not completely eliminate the need to test blood sugar because some machines must be calibrated every day to validate accuracy. (Option 4) Use of the insulin pump facilitates tighter glucose control, leading to more normal metabolism. However, if the client continues to take in more calories than needed for a given amount of activity or exercise, glucose that is not used by the cells accumulates as fat and results in weight gain. Educational objective: A client prescribed CSII is taught how to self-manage the insulin pump. Key points include the importance of checking blood glucose levels at least 4 times a day, how to administer a bolus dose at mealtime to cover carbohydrate intake, how to administer a supplemental bolus dose to correct pre- and postprandial hyperglycemia, and the importance of balancing diet and exercise to avoid excess weight gain.

When unlicensed assistive personnel (UAP) assist a client with a chest tube back to bed from the bedside commode, the plastic chest drainage unit accidentally falls over and cracks. The UAP immediately report this incident to the nurse. What is the nurse's immediate action? 1. clamp the tube close to the clients chest until a new chest drainage unit is set up 2. notify the health care provider 3. place the distal end of the chest tube into a bottle of sterile saline 4. position the client on the left side

3 If the chest tube is disconnected or if the chest drainage unit breaks, cracks, or malfunctions, submerge the distal end of the chest tube 1-2 in (2-4 cm) below the surface of a 250 mL bottle of sterile water or saline. This creates an immediate water seal and prevents air from entering the pleural space as the new chest drainage system is established (Option 3). To prepare for this contingency, emergency equipment, including 2 chest tube clamps, a 250-mL bottle of sterile water or saline solution, and antiseptic wipes, should be kept at the bedside. To prevent accidental disconnection of the chest tube from the tubing, secure all connections with tape or bands according to hospital policy and procedure. (Option 1) Unless prescribed by the health care provider (HCP), chest tube clamping time should not exceed 1 minute as it raises intrapleural pressure, which can lead to a tension pneumothorax. Chest tubes are not routinely clamped. Clamping briefly is acceptable when checking for an air leak in the system or when changing the disposable collection unit. (Option 2) It is not necessary to notify the HCP when replacing a chest drainage system unless the client develops respiratory distress. (Option 4) Positioning the client on the left side is appropriate if a central line is inadvertently pulled out as this will allow any air that may have been sucked in to rise to the right atrium. It is not an appropriate intervention for a chest tube disconnection or a crack or malfunction in a chest drainage unit. Educational objective: If a chest tube disconnects from the chest drainage system or if a chest drainage unit cracks or malfunctions, submerge the distal end of the chest tube 1-2 in (2-4 cm) below the surface of a 250 mL bottle of sterile water or saline solution.

The practical nurse is collecting data on a client receiving methotrexate to treat rheumatoid arthritis. Which finding associated with this drug is most important for the nurse to report to the registered nurse?

3 Methotrexate (Rheumatrex) is a nonbiologic disease-modifying antirheumatic drug prescribed to treat rheumatoid arthritis. Adverse effects associated with this medication include bone marrow suppression, hepatotoxicity, and gastrointestinal irritation (eg, nausea, vomiting, diarrhea). Bone marrow suppression can lead to anemia, leukopenia, and thrombocytopenia. Anemia manifests as fatigue, dyspnea on exertion, and pallor. Leukopenia increases the risk for infection. Thrombocytopenia presents as petechiae, purpura, or bleeding. Petechiae are small, purplish hemorrhagic skin spots that occur when the platelet count is <150,000/mm3 (150x109/L) (Option 3). Bone marrow suppression is managed with dose reduction or discontinuation of the medication. (Option 1) Mild temporary alopecia, although uncommon, is an expected adverse effect of methotrexate. It does not require intermediate intervention and is not the most important finding to report. (Option 2) Nausea and vomiting are the most common side effects (25%-60%) associated with methotrexate. Although the registered nurse should be notified to request a prescription for an antiemetic, nausea is not the most important finding to report. (Option 4) Stomatitis (inflammation of the mouth, oral ulcers) is a common side effect associated with methotrexate. It can be prevented with folic acid supplementation. Although the condition is uncomfortable, it would not require immediate intervention and is not the most important finding to report. Educational objective: Methotrexate (Rheumatrex) is a nonbiologic disease-modifying antirheumatic drug prescribed to treat rheumatoid arthritis. Major adverse effects include bone marrow suppression and hepatotoxicity. Most common side effects can be prevented by folic acid supplementation.

The nurse is caring for a client with immune thrombocytopenic purpura. Which client statements indicate a need for further teaching? Select all that apply.

3,5, Immune thrombocytopenic purpura (ITP) is an autoimmune condition in which antibodies bind to and cause destruction of platelets. Clients with ITP have a platelet count <150,000/mm3 (150 x 109/L) and are at increased risk of bleeding. Key teaching to reduce the client's risk of bleeding includes: Use soft-bristle toothbrushes, gentle flossing, and nonalcoholic mouthwashes. These prevent periodontal disease and gingival bleeding (Option 1). Avoid activities that may cause trauma (eg, high-intensity sports). Appropriate exercise includes low-impact activity (eg, walking) while wearing nonskid footwear to help prevent falls (Option 2). Take prescribed stool softeners and laxatives as needed. These medications prevent hard stools and straining, which can cause anorectal fissuring, bleeding, and hemorrhoids (Option 4). (Option 3) Clients with ITP should use electric razors instead of safety or straight razors. Electric razors have a more complete guard, reducing the risk of accidentally nicking the skin. (Option 5) Clients with ITP should avoid nonsteroidal anti-inflammatory drugs (eg, aspirin, ibuprofen, ketorolac), which further impair platelet function. Acetaminophen and opiates are better options for pain management. Educational objective: Clients with immune thrombocytopenic purpura (ITP) have low platelet counts and an increased risk of bleeding. Appropriate care for clients with ITP includes safe exercise; using stool softeners, electric razors, and soft-bristle toothbrushes; and avoiding nonsteroidal anti-inflammatory drugs.

A client has just been prescribed allopurinol for chronic gout. Which instruction is most important for the nurse to reinforce to the client?

4 Allopurinol is prescribed to prevent gout attacks (pain and inflammation in joints caused by uric acid deposits). It inhibits uric acid production and improves solubility. Allopurinol should be taken with a full glass of water, and it is very important for the nurse to educate the client about fluid intake with this medication. The client should also increase daily fluid intake as this will help prevent the formation of renal stones and promote diuresis (increase drug and uric acid excretion). (Option 1) Biosynthesis of uric acid occurs in the liver, and antigout medications are excreted via the kidneys; therefore, liver and renal function should be checked periodically. In addition, blood counts should be monitored as some antigout medications can cause blood dyscrasias. This is important but does not have priority over the daily need for increased fluids. (Option 2) This is a common instruction given about the storage of many medications. It helps to ensure potency of the medication and prevent deterioration. (Option 3) Taking allopurinol with food or after a meal can help to prevent gastric upset. Educational objective: It is important for the nurse to educate the client taking allopurinol about drinking a full glass of water with each dose and increasing overall fluid intake. Increased fluids help to prevent renal stones and promote diuresis and uric acid excretion.

The school nurse is assisting a student with type 1 diabetes mellitus to calculate the insulin dosage needed based on the student's lunch menu selections. Using the prescribed carbohydrate-to-insulin ratio, how much insulin should the student receive? Record your answer using a whole number. Click on the exhibit button for additional information. EXHIBIT: Nutritional information Menu selection Carbohydrate content 2 soft tacos 45 g Unsweetened applesauce 15 g 2% milk carton (8 oz [240 mL]) 15 g Medication prescription Insulin lispro: 1 unit subcutaneously per 15 g carbohydrate consumed, before each meal

5U Carbohydrate-based insulin dosing uses carbohydrate counting to calculate the insulin dosage required at meal times. Carbohydrate-based insulin dosing is a form of basal-bolus insulin therapy, which typically involves fixed, basal doses of a short- or intermediate-acting insulin (eg, regular insulin, insulin NPH) and variable, bolus doses of rapid-acting insulin (eg, insulin lispro) at specific intervals (eg, before meals). The client's individually prescribed carbohydrate-to-insulin ratio is used to calculate the insulin bolus dose. The following steps are performed to calculate the carbohydrate-based dosage of insulin lispro: Calculate the total number of carbohydrates in the meal Total carbohydrates: 45 g+15 g+15 g=75 g carbohydrates Convert prescription to dosage needed for administration

The nurse is assessing a client with rheumatoid arthritis who is being considered for adalimumab therapy. Which statement made by the client needs further investigation?

1 Infliximab, adalimumab, and etanercept are tumor necrosis factor (TNF) inhibitors that suppress the inflammatory response in autoimmune diseases such as rheumatoid arthritis, Crohn disease, and psoriasis. Due to the immunosuppressive action of TNF inhibitors, clients taking these drugs are at increased risk for infection. A client with current, recent, or chronic infection should not take a TNF inhibitor (Option 1). (Option 2) The immunosuppressive action of TNF inhibitors can activate latent tuberculosis (TB). Therefore, a tuberculin skin test (TST) should be administered prior to beginning TNF inhibitor therapy, and clients who test positively for latent TB must also undergo treatment for TB before starting therapy. Clients should have a TST every year while receiving the drug. (Option 3) Clients taking immunosuppressive TNF inhibitors (eg, adalimumab) should receive an annual inactivated (injectable) influenza vaccine to reduce the risk of contracting the flu virus. Clients taking TNF inhibitors or other immunosuppressants are at risk for infection and therefore should not receive live attenuated vaccines. (Option 4) Many clients with rheumatoid arthritis use nonsteroidal anti-inflammatory medications (eg, celecoxib, naproxen) in conjunction with antirheumatic and/or targeted therapies (eg, methotrexate, adalimumab, etanercept) to effectively treat pain and minimize inflammation. Educational objective: Clients with infection should not take tumor necrosis factor (TNF) inhibitors (eg, infliximab, adalimumab, etanercept) as these suppress the immune response. Before starting drug therapy, clients should be tested for tuberculosis and receive the inactivated (injectable) influenza vaccine. Clients taking TNF inhibitors should avoid live vaccines.

A nurse is caring for a client with an exacerbation of chronic obstructive pulmonary disease (COPD) and a history of type 2 diabetes mellitus requiring insulin. The client has been prescribed prednisone. The nurse anticipates which need?

3 Corticosteroids (eg, methylprednisolone, prednisone, dexamethasone) are given to combat inflammation in the lungs in clients with COPD exacerbation. All glucocorticoids can cause an increase in blood sugar. This may lead to the need for a higher dose of insulin based on the client's blood sugar level. (Option 1) Most glucocorticoids have some mineralocorticoid activity, causing fluid retention and worsening hypertension. (Option 2) Prednisone is started at a higher dose and then gradually decreased for COPD exacerbation and most other conditions. A slow taper will prevent adrenal crisis. (Option 4) Intake and output are not affected by corticosteroids. Educational objective: Corticosteroids commonly cause hyperglycemia and worsen hypertension. When taken in combination with NSAIDs, they can increase the risk of peptic ulcer disease. Corticosteroids in general are started at high doses and slowly tapered to reduce the risk of sudden adrenal crisis.

The nurse is reinforcing discharge instructions for a client with degenerative joint disease and a new prescription for naproxen. What instructions regarding this drug does the nurse include? Select all that apply.

4,5 Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) commonly prescribed to decrease joint pain and inflammation. All NSAIDs (eg, indomethacin, ibuprofen) are associated with the following: Gastrointestinal (GI) toxicity: Symptoms of GI bleeding, such as black, tarry stools, should be reported. Gastrointestinal upset (eg, dyspepsia, pain) can be reduced if the medicine is taken with food. Kidney injury: Long-term use of NSAIDs is associated with kidney injury. Hypertension and heart failure: NSAIDs can cause fluid retention, which can exacerbate conditions such as heart failure, cirrhosis/ascites, and hypertension. Bleeding risk: Clients should notify the health care provider if NSAIDs are taken concurrently with aspirin, other NSAIDs, or anticoagulant/antiplatelet drugs as these can increase the risk of GI bleeding. (Option 1) Clients should not drive when taking sedating antihistamines or benzodiazepines. (Option 2) Orthostatic hypotension is common with blood pressure medications (eg, ACE inhibitors, alpha blockers) but not with NSAIDS. (Option 3) Suicidal thoughts are commonly associated with selective serotonin reuptake inhibitors (antidepressants) and varenicline (Chantix), a smoking cessation medication. Educational objective: All nonsteroidal anti-inflammatory drugs (eg, indomethacin, ibuprofen, naproxen) are associated with gastrointestinal toxicity, kidney injury, exacerbation of fluid overload/hypertension, and bleeding risk. They should be used at the lowest dose and for the shortest time possible.

A nurse is reinforcing appropriate interventions with the parent of an infant who had a febrile seizure. Which instruction is appropriate to review?

1 Febrile seizures are an alarming experience for parents. They most commonly occur in children age 6 months to 6 years, with the peak incidence at age 18 months. The etiology is unknown. Simple febrile seizure management typically involves reassurance regarding the benign nature of most febrile seizures, and education about the risk of recurrence (around 30%) and seizure safety precautions (eg, side-lying positioning, removal from harmful environments). Parents should use antipyretics such as acetaminophen or ibuprofen to control fevers and make the child more comfortable. However, there is no evidence that antipyretics reduce the risk of future febrile seizures. After the administration of antipyretics, additional cooling methods that may be beneficial for reducing fever include applying cool, damp compresses to the forehead; increasing air circulation in the room; and wearing loose or minimal clothing to increase skin exposure to air. However, care should be taken to prevent shivering, which can further raise the metabolic rate above that caused by fever. (Options 2 and 4) Bathing an infant in tepid water and placing ice bags under the arms and around the neck are not recommended techniques as these induce shivering, increase metabolic activity, have no antiseizure effects, and cause discomfort for the child. These cooling techniques are more effective for a child experiencing hyperthermia (eg, with heat stroke). (Option 3) Parents should be instructed to call 911 and seek medical assistance for a seizure lasting more than 5 minutes. Neurologic damage can occur with frequent and prolonged seizures. Educational objective: Febrile seizures, although alarming, are generally benign. Parents should be instructed on appropriate cooling methods (eg, antipyretics, cool compresses), seizure safety precautions, and the avoidance of shivering.

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

1,2,4 When performing phlebotomy, clean the site, "fix" or hold the vein taut, and then insert the needle bevel up at a 15-degree angle (no steeper than 30 degree). Some recommend bevel down for children. This will help prevent going through the vein completely. The Infusion Nurses Society (INS) identifies the standard of care as no more than 2 attempts by any 1 individual. If the nurse is unable to successfully draw blood after 2 attempts, a phlebotomist or a different nurse should be asked to complete the blood draw. The affected side of a client who has had a mastectomy (especially with lymph node removal) should not be used. It places the client at risk for infection and lymphedema. (Option 3) An arm without IV infusion is preferred. If it is necessary to use the arm with the IV infusion, the specimen should be collected from a vein several centimeters below (distal to) the point of IV infusion, with the tourniquet placed in between. (Option 5) The finger specimen should be obtained from the third or fourth finger on the side of the fingertip, midway between the edge and midpoint. The puncture should be made perpendicular to the fingerprint ridges. Puncture parallel to the ridges tends to make the blood run down the ridges and will hamper collection. A heel stick collection on an infant should be done on the plantar surface. Educational objective: When obtaining blood from a client, insert the needle at 15-degree angle, limit attempts to 2, and avoid the side of a mastectomy. A capillary specimen should be obtained at the side of the finger pad. Never draw a specimen above an IV infusion.

The nurse is reviewing lifestyle and nutritional strategies to help reduce symptoms in a client with newly diagnosed gastroesophageal reflux disease. Which strategies should the nurse include? Select all that apply. 1. choose foods that are low in fat 2. do not consume any foods containing dairy 3. eat three large meals a day to minimize snacking 4. limit or eliminate the use of alcohol and tobacco 5. try to avoid caffeine, chocolate, and peppermint

1,4,5 Gastroesophageal reflux disease (GERD) occurs when chronic reflux of stomach contents causes inflammation of the esophageal mucosa. The lower esophageal sphincter (LES) normally prevents stomach contents from entering the esophagus. Any factor that decreases the tone of the LES (eg, caffeine, alcohol), delays gastric emptying (eg, fatty foods), or increases gastric pressure (eg, large meals) can precipitate GERD. Lifestyle and dietary measures that may prevent GERD and associated symptoms include: Weight loss, as excessive abdominal fat may increase gastric pressure Small, frequent meals with sips of water or fluids to help facilitate the passage of stomach contents into the small intestine and prevent reflux from becoming overly full during meals (Option 3) Avoiding GERD triggers such as caffeine, alcohol, nicotine, high-fat foods, chocolate, spicy foods, peppermint, and carbonated beverages (Options 1, 4, and 5) Chewing gum to promote salivation, which may help neutralize and clear acid from the esophagus Sleeping with the head of the bed elevated Refraining from eating at bedtime and/or lying down immediately after eating (Option 2) Clients with GERD generally do not need to minimize or eliminate dairy products from the diet; however, they should choose low-fat or nonfat products. Educational objective: Lifestyle and dietary measures that help prevent or minimize symptoms of gastroesophageal reflux disease include avoiding dietary triggers such as alcohol, caffeine, chocolate, peppermint, and high-fat foods. Clients should consume small, frequent meals and discontinue the use of tobacco products.

A child received the varicella immunization. The day after the injection, the parent calls the nurse to say that the child has discomfort, slight redness, and 2 vesicles at the injection site. Which instruction should the nurse reinforce?

2 The varicella immunization is administered to prevent infection of varicella zoster, commonly known as chickenpox. Side effects of the immunization include discomfort, redness, and a few vesicles at the injection site. Covering the vesicles with clothing or a small bandage will reduce the risk of transmission from any exudate. Once the vesicles have dried, or crusted, a dressing is no longer necessary. (Option 1) Acetaminophen is the appropriate medication to reduce the discomfort of the injection. Aspirin should be avoided in children due to the risk of Reye syndrome. (Option 3) Unless the rash becomes widespread, isolation of the child is unnecessary. It is unlikely that the infection will be transmitted by the 2 vesicles, but covering them with clothing or a small bandage will decrease the risk of transmission. (Option 4) Discomfort, redness, and a few vesicles at the injection site are common side effects of the varicella immunization and do not require the attention of a healthcare provider. Educational objective: Discomfort, redness, and vesicles at the injection site are common side effects of the varicella immunization. Covering the vesicles with clothing or a small bandage will reduce the risk of transmission from any exudate.

A client with right-sided weakness becomes dizzy, loses balance, and begins to fall while the nurse is assisting with ambulation. Which nursing actions would best prevent injury to the client and nurse while guiding the client to a horizontal position on the floor?

3 To prevent injury to the nurse and the client if the client is falling, the nurse uses good body mechanics to try to break the fall and guide the client to the floor if necessary. These actions include: Step slightly behind the client and place the arms under the axillae or around the client's waist Place feet wide apart with knees bent - creates a broad base of support, provides stability, and reduces the risk for back injury to the nurse Place one foot behind the other and extend the front leg - allows the nurse to bring the client backward by using the leg muscles to rock backward while supporting the client's weight Let the client slide down the extended leg to the floor - lowers the client gently to the floor while keeping the client's head protected from injury (Options 1 and 4) These actions do not provide close proximity to the client, a broad base of support, or a lower center of gravity to increase the nurse's stability and help prevent back injury. (Option 2) These actions are appropriate for helping a client rise from the bed or chair but not for assisting a falling client to the floor. Educational objective: These nursing actions can help prevent injury if a client is falling while the nurse is assisting with ambulation: step slightly behind the client with feet wide apart and knees bent, place arms under the axillae or around the client's waist, place one leg behind the other and extend the front leg, and let the client slide down the extended leg to the floor.

The nurse is caring for a client who was recently prescribed methadone for chronic, severe back pain. The client indicates taking extra tablets in the last 6 hours when the pain recurred. Which findings during discharge require the client to be monitored longer in the hospital setting? Select all that apply.

1,3,5 Methadone is a potent narcotic with a unique, long half-life (up to 50+ hours) due to its lipophilic properties (combines with lipids). However, its analgesic effect lasts only 6-8 hours. Thereafter, a large amount of the drug is still being released from the fat cells due to the long half-life, which creates a risk of overdose in clients who inadvertently self-medicate for additional pain relief. Early signs of toxicity are nausea/vomiting and lethargy. Falling asleep with stimulation is classified as obtunded and requires additional observation/monitoring. Sedation precedes respiratory depression, a life-threatening complication of severe toxicity (Options 1 and 3). A normal, healthy, nonsmoking adult should have a pulse oximetry reading of 97%-100%; 95%-100% is considered acceptable. The low pulse oximetry reading indicates inadequate depth or rate of respiration (Option 5). (Option 2) Itching sensation (pruritus) is an expected finding with narcotic use, especially in the opiate naïve, and can be managed with an antihistamine. (Option 4) Occasional premature ventricular contractions are a common finding in most adults. With methadone use, there is a risk of electrocardiogram changes and dysrhythmias, including ventricular tachycardia; therefore, the client should have cardiac monitoring. Educational objective: Methadone is a potent narcotic with a long half-life. Early signs of toxicity are nausea/vomiting and lethargy. Clients should have pulse oximetry and electrocardiogram monitoring. Ventricular tachycardia is a potential life-threatening complication.

A client 4 days post colostomy is preparing to be discharged home. Which findings are concerning and should be further investigated? Select all that apply. 1. client states "I will need home heath to empty the pouch" 2. client states "There is a little gas in the colostomy bag" 3. no bowel sounds are present and the client reports nausea 4. skin surrounding the stoma is red and excoriated 5. stoma is red, edematous, and smaller than the previous day

1,3,4 After a colostomy, the stoma should be beefy red and edematous but will begin to shrink over the course of a few days as inflammation subsides (Option 5). There should be no mucocutaneous separation (eg, separation of the stoma from the abdominal wall), unusual bleeding (eg, moderate to large amounts of blood in the ostomy pouch), or signs of inadequate circulation, including stoma ischemia (eg, pale, dusky) and necrosis (eg, dark red, purple, black). Appliances should be resized during the first several weeks to ensure proper fit, preventing skin breakdown (eg, excoriation) due to stool coming into contact with the skin (Option 4). Within 24 hours of surgery, the client should demonstrate signs of returning gastrointestinal motility, including resolution of nausea, active bowel sounds, and flatus (Option 2). Nausea and absent bowel sounds may indicate postoperative ileus and should be reported to the health care provider (Option 3). Clients should change the pouch according to the manufacturer's instructions (every 5-10 days) and if the skin surrounding the stoma becomes irritated (eg, burning). The nurse should also assess the client with a new ostomy for body image disturbance and ineffective coping (eg, client unwilling to care for the ostomy) (Option 1). Educational objective: Careful assessment of clients with new ostomies should include the stoma site (eg, perfusion, approximation to the skin), gastrointestinal function (eg, bowel sounds, flatus, stool), and self-care and body image. Appliances must be properly fitted to prevent skin breakdown (eg, excoriation).

The nurse reinforces medication instructions to a client with primary adrenal insufficiency (Addison disease) who is prescribed hydrocortisone 10 mg orally 3 times a day. Which instructions should be included? Select all that apply.

2,3,4 Clients taking long-term corticosteroid replacement should be taught the following: Do not discontinue glucocorticoid therapy abruptly. Abrupt discontinuation could lead to addisonian crisis, a life-threatening complication (Option 1). Report any signs and symptoms of infection to the health care provider (HCP) immediately. Corticosteroid use can cause immunosuppression, and infection can develop quickly and spread rapidly. The anti-inflammatory effects of corticosteroids may also mask signs of infection, such as inflammation, redness, tenderness, heat, fever, and edema (Option 3). Stay attuned to signs and symptoms of stress, which may require an increased dose of corticosteroid. A stress response (surgery, trauma) can cause a sudden decrease in cortisol levels, triggering addisonian crisis (Option 6). A side effect of corticosteroid therapy is hyperglycemia. Report signs of hyperglycemia, including increased urine, hunger, and thirst. Clients with diabetes mellitus must be vigilant in checking blood glucose levels (Option 4). Corticosteroids are catabolic to bone (osteoporosis) and muscle (muscle weakness). A diet high in calcium (at least 1500 mg/day) and protein (1.5 g/kg/day) but low in fat and simple carbohydrates is recommended. Cataracts are a side effect of corticosteroids, particularly glucocorticoid therapy. Make an appointment with an optometrist yearly to assess for cataracts (Option 2). Corticosteroid medications can cause gastric irritation and should not be taken on an empty stomach (Option 5). Recognize signs and symptoms of Cushing syndrome and report them to the HCP. Develop a regular HCP-approved exercise program. Educational objective: Corticosteroids are the primary drugs used to treat Addison disease. It is imperative that the nurse teach the client about this medication, including to never stop it abruptly, notify the health care provider of signs and symptoms of infection, and monitor blood glucose closely if diabetes is a comorbid condition.

A nurse is caring for a 3-month-old infant who has bacterial meningitis. Which clinical findings support this diagnosis? Select all that apply. 1. depressed anterior fontanelle 2. frequent seizures 3. high pitched cry 4. poor feeding 5. presence of the babinski sign 6. vomiting

2,3,4,6 Bacterial meningitis is an inflammation of the meninges in the brain and spinal cord that is caused by specific types of bacteria, including group B streptococcal, meningococcal, or pneumococcal pathogens. Clinical manifestations of bacterial meningitis in infants age <2 include: Fever or possible hypothermia Irritability, frequent seizures High-pitched cry Poor feeding and vomiting Nuchal rigidity Bulging fontanelle possible but not always present One of the most common acute complications of bacterial meningitis in children is hydrocephalus. Long-term complications include hearing loss, learning disabilities, and brain damage. Due to the severity of potential complications, prompt identification and immediate treatment are vital for any client with suspected bacterial meningitis. (Option 1) Infants with bacterial meningitis may have bulging fontanelles due to an increase in intracranial pressure. Depressed fontanelles indicate severe dehydration. (Option 5) The Babinski reflex can be present up to 1-2 years and is a normal expected finding; it does not indicate meningitis. Educational objective: Bacterial meningitis is inflammation of the meninges in the brain and spinal cord caused by bacterial infection. Key characteristics of bacterial meningitis in infants under age 2 include frequent seizures, a high-pitched cry, poor feeding, nuchal rigidity, and possible bulging fontanelles.

The nurse is caring for a client with cirrhosis. Assessment findings include ascites, peripheral edema, shortness of breath, fatigue, and generalized discomfort. Which interventions would be appropriate for the nurse to implement to promote the client's comfort? Select all that apply. 1. encourage adequate sodium intake 2. place client in semi-fowler position 3. place client in trendelenburg position 4. provide alternating air pressure mattress 5. use music to provide a distraction

2,4,5, In a client with cirrhosis and ascites, discomfort is often due to pressure of the fluid on the surrounding organs. Shortness of breath occurs due to the upward pressure exerted by the abdominal ascites on the diaphragm, which restricts lung expansion. Positioning the client in semi-Fowler or Fowler position can promote comfort, as this position can reduce the pressure on the diaphragm (Option 2). In semi-Fowler position, the head of the bed is elevated 30-45 degrees; in Fowler position, elevation is 45-60 degrees. Side-lying with the head elevated can also be a position of comfort for the client with ascites as it allows the heavy, enlarged abdomen to rest on the bed, reducing pressure on internal organs and allowing for relaxation. Meticulous skin care is a priority due to the increased susceptibility of skin breakdown from edema, ascites, and pruritus. It is important to use a specialty mattress and implement a turning schedule of every 2 hours (Option 4). A distraction can take the client's mind off the current symptoms and may also help promote comfort in many different situations. Some of these distractions include listening to music, watching television, playing video games, or taking part in hobbies (Option 5). (Option 1) This client has ascites and peripheral edema; higher levels of fluid or sodium intake can worsen these conditions. (Option 3) In Trendelenburg position, the bed is tilted with the head lower than the legs. This position is contraindicated in the client with ascites, as it may exacerbate shortness of breath by causing the abdominal ascites to push upward on the diaphragm, restricting lung expansion. Educational objective: The client with discomfort and shortness of breath due to ascites should be positioned in the semi-Fowler or Fowler position to promote comfort and lung expansion. Music and other methods of distraction may also promote comfort. Meticulous skin interventions (eg, specialty mattress, turning schedule) are important to prevent tissue breakdown.

A nurse is caring for a client who had a vaginal birth 2 hours ago. The nurse notes that the client's perineal pad is saturated with blood 20 minutes after placing a new pad. The client's fundus is boggy, palpable above the level of the umbilicus, and deviated to the right. Which intervention should the nurse perform first?

3 Postpartum vaginal bleeding that saturates a perineal pad in <1 hour is considered excessive. Furthermore, a boggy fundus indicates uterine atony. A fundus elevated above the umbilicus and deviated to the right suggests a distended bladder. Bladder distension prevents the uterus from contracting sufficiently to control bleeding at the previous placental site. The client should be assisted to void to correct bladder distension (Option 3). The nurse should then perform fundal massage and reevaluate bleeding. (Option 1) Oxytocin (Pitocin) stimulates uterine contraction, which compresses blood vessels at the previous placental implantation site. Oxytocin may be given IM if initial attempts to control postpartum bleeding (eg, relief of bladder distension, fundal massage) fail and the client has no working IV line. (Option 2) Oxygen delivery at 10 L/min via a nonrebreather facemask may be initiated if the client becomes symptomatic following excessive blood loss. However, the first priority is to control the bleeding. (Option 4) Blood tests to determine hemoglobin and hematocrit levels may be needed following excessive postpartum bleeding. However, this intervention does not correct the immediate problem of uterine atony related to bladder distension. Educational objective: Excessive postpartum bleeding is commonly caused by uterine atony. If the nurse suspects uterine atony is caused by bladder distension (ie, boggy fundus, fundus above the umbilicus and deviated to the right) the client should first be assisted to void; fundal massage and oxytocin should follow as needed to control the bleeding.

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