UWORLD Q Bank #1

An experienced registered nurse (RN) is mentoring a new nurse in the telemetry unit. Which assessment technique by the new nurse requires intervention by the RN? 1. Nurse carefully auscultates for heart murmurs at Erb's point 2. Nurse palpates bilateral carotid arteries simultaneously to assess for symmetry 3. Nurse places client in semi-Fowler's position to assess for jugular venous distension 4. Nurse positions client supine to assess the point of maximal impulse

2. Nurse palpates bilateral carotid arteries simultaneously to assess for symmetry The pulses in the neck should be palpated for information on arterial blood flow. The carotid arteries should be palpated separately to avoid vagal stimulation causing dysrhythmias such as bradycardia or a syncopal episode. Pulse symmetry for other key arteries (eg, temporal, brachial, radial, posterior tibial) is assessed by bilaterally palpating each pair simultaneously.

The clinic nurse is reviewing the laboratory results of a 35yo client who reports fatigue for the last month. Based on the laboratory results, which additional clinical manifestations would the nurse expect? (pt is experiencing hypoparathyroidism) 1. Bradycardia 2. Cold intolerance 3. Constipation 4. Hair loss 5. Warm, moist skin 6. Weight loss

1, 2, 3, 4

The nurse is caring for a client who just had aortic valve replacement surgery. Which assessment information is most important to report to the health care provider (HCP)? 1. Chest tube output of 175mL in past hour 2. International Normalized Ratio (INR) of 1.5 3. Temperature of 100.3 F (37.9C) 4. Total urine output of 85L over past 3 hours

1. Chest tube output of 175mL in past hour Chest drainage >100 mL/hr should be reported to the HCP. Large losses of blood may indicate a compromise of the surgical suture site and may require repair. The client can quickly become hemodynamically unstable and may require a return to surgery or transfusion of blood products

A client in the mental health unit picks up a fire extinguisher and throws it at a nurse standing by the nurses' station. What is the most important intervention by the nurse? 1. Facilitate immediate removal of people from the area 2. Inform the client that the client cannot act that way 3. Pull the fire alarm to get additional immediate help 4. State that the nurse can see the client is upset

1. Facilitate immediate removal of people from the area When a situation is out of control, safety is the primary concern. The nurse and everyone else should leave the area and security should be called immediately.

The nurse is participating in staff training about protecting clients' privacy and confidentiality. Which of the following incidents does the nurse recognize as a violation of client confidentiality? 1. A visitor talking in the waiting room states that the client has alcoholism 2. The licensed practical nurse (LPN) has the client's report sheet in a pocket when going home 3. The nursing assistant tells a client that the hospital roommate went for a gallbladder test 4. The registered nurse tells a visitor to wear a mask because the client is on isolation precautions 5. Two LPNs are discussing a possible cure for ADIS on a crowded elevator

2, 3

The nurse auscultates the lung sounds of a client with SOB. Based on the sounds heard, which action would the nurse anticipate? (Coarse crackles) 1. Administer albuterol via nebulizer 2. Administer furosemide IV push 3. Instruct to use pursed-lip breathing 4. Prepare for chest tube insertion

2. Administer furosemide IV push Coarse crackles are heard primarily during inspiration and are not cleared by coughing. The sound is similar to that of Velcro being pulled apart. Coarse crackles may be confused with fine crackles (eg, atelectasis), which have a high-pitched popping sound. Coarse crackles are present when fluid or mucus collects in the lower respiratory tract (eg, pulmonary edema, pulmonary fibrosis). In HF, the left ventricle fails to eject enough blood, causing increased pressure in the pulmonary vasculature. As a result, fluid leaks into the alveoli (pulmonary edema). Diuretics (eg, furosemide) treat pulmonary edema by increasing fluid excretion by the kidneys)

The nurse is evaluating a return demonstration by the client of a dry dressing change. Which action by the nurse would cause the nurse to intervene? 1. Client applies sterile adhesive dressing over gauze without touching the wound bed 2. Client applies sterile gauze moistened with sterile saline to wound surface 3. Client cleanses site with a sterile saline swab in a spiral pattern from the center out 4. Client removes old dressing with clean gloves and checks site for signs of infection

2. Client applies sterile gauze moistened with sterile saline to wound surface Prior to discharge, the nurse must evaluate the client's ability to perform home wound care. While performing a simple dry dressing change, the client should: -Don clean gloves and perform hand hygiene before and after removing the old dressing -Cleanse the wound bed using sterile saline (or a prescribed cleanser) by moving from "clean" to "dirty", or from the center of the wound outward -Thoroughly dry the wound and surrounding skin using sterile gauze to prevent maceration (breakdown) of underlying tissues -Monitor the site for signs of infection (eg, redness, warmth, purulent drainage) -Apply DRY, sterile gauze over the wound bed -Cover the gauze with an occlusive sterile dressing to keep gauze in place and maintain aspesis. The covering should be applied without touching the wound bed.

A female client who was the victim of acquaintance rape 2 months ago is receiving therapy for posttraumatic stress disorder (PTSD). She says to the nurse, "It's all my fault. I should have known not to accept a drink from someone I just met in a bar". What is the best response by the nurse? 1. "it may take time to overcome those thoughts and feelings" 2. "Those kinds of thoughts are self-destructive. You should stop thinking about it" 3. "You could not have anticipated the rape. You did not deserve or ask for it" 4. "You have to stop blaming yourself so you can move on with your life"

3. "You could not have anticipated the rape. You did not deserve or ask for it"

Which measures will help prevent falls in the elderly clients of a long-term care facility? 1. Exercise programs 2. Good room lighting 3. handrails in stairwell 4. Smooth-soled shoes 5. Staff hourly rounds

1, 2, 3, 5 Falls are a leading predictor of mortality and morbidity in older adults. General exercise programs, esp those including gait, balance, and strength training, not only reduce the risk of falls but also prevent injuries fro falls. Vision impairment can contribute to fall risks; most adults need additional light by age 50. The nurse should endure that clients are wearing needed prescription glasses. handrails, particularly in stairwells, hallways, and bathrooms, have been shown to reduce falls. Studies show that staff rounds at regular intervals (hourly or every other hour) decrease falls and call light use. The practice allows staff to intervene early in needs. Typically staff checks on the "Ps": potty, position, pain, and placement/proximity of personal items (eg, bed height, call light, water, tissues, urinal). A common reason clients get out of bed unassisted is to use the bathroom.

A client is hospitalized for a broken leg. The client has a history of breast cancer and is receiving outpatient chemotherapy; the last infusion was about a week ago. Which staff members can safely care for this client? Select all that apply. 1. Nurse floated from another medical-surgical floor 2. Nurse who is 24 weeks pregnant 3. Nurse with erythematous rash and honey-color crusts on the hand 4. Unlicensed assistive personnel who just received the yearly injectable flu vaccination 5. Unlicensed assistive personnnel with a cold

1, 2, 4 A client who has recently received chemotherapy may be immunocompromised and should be protected from infectious contacts. Infectious contacts include staff members with a cold or impetigo, a common, highly contagious bacterial skin infection. 1. The medsurg nurse has the training to care or a client iwth immunosuppression and a broken leg. If chemotherapy needs to be administered during the hospitalization, a chemotherapy certified nurse will administer the medication 2. The client is not radioactive or infectious and the nurse will not be administering or handling the chemotherapeutic agents. Therefore, it is safe for the pregnant nurse to care for the client. 4. The vaccination does not contain live influenza virus; therefore the UAP is not infectious. The inactivated vaccine is safe and recommended for clients who are immunocompromised.

An intoxicated client not wearing a seatbelt drives into a metal barricade near the entrance to the emergency department. The client's head has hit the windshield, and the client is unconscious. What nurse actions are appropriate? Select all that apply 1. Assess the client for a carotid pulse 2. Determine the client's Glascow Coma Scale score 3. Maintain airway with head-tilt/chin-lift maneuver 4. Place a hard cervical collar on the client 5. Remove the client from the car onto a backboard

1, 2, 4, 5

A client who is intubated and on mechanical ventilation is receiving continuous enteral tube feedings at 30mL/hour via a small-bore nasogastric tube. Which actions should the nurse take to prevent aspiration in this client? Select all that apply 1. Assess abdominal distension every 4 hours 2. Check gastric residual every 12 hours 3. Keep head of the bed at more than or equal to 30 degrees 4. Maintain endotracheal cuff pressure 5. Use caution when administering sedatives

1, 3, 4, 5

A. nurse is participating in an obstetrical emergency simulation in which the health care provider announces shoulder dystocia. Which of the following interventions should the assisting nurse implement? Select all that apply. 1. Assist maternal pushing efforts by applying fundal pressure during each contraction 2. Document the time the fetal head was born 3. Flex the client's legs back against the abdomen and apply downward the symphysis pubis 4. Prepare for a forceps-assisted birth 5. Request additional assistance from other nurses immediately

2, 3, 5 Shoulder dystocia is an unpredictable obstetrical emergency that occurs during vaginal birth when the fetal head delivers but the anterior (top) shoulder becomes wedged behind or under the mother's symphysis pubis. Shoulder dystocia lasting more than 5 minutes is correlated with almost certain fetal asphyxia resulting from prolonged compression of the umbilical cord. Minimizing the time it takes to deliver the fetal body is essential for reducing adverse outcomes (eg, hypoxia, nerve injury, death). When shoulder dystocia occurs, the primary nursing interventions include: -Documenting the exact time of events (eg, birth of fetal head, shoulder dystocia maneuvers) -Verbalizing passing time to guide decision-making by the health care provider (eg, "two minutes have passed") -Performing maneuvers to relieve shoulder impaction (eg, McRoberts maneuver, suprapubic pressure) -Requesting additional help from other staff (eg, nurses, neonatologist) immediately

The nurse removes personal protective equipment (PPE) after completing a wound dressing change or a client in airborne transmission-based precautions. Which PPE should the nurse remove first? 1. Face shield/goggles 2. Gloves 3. Gown 4. Mask/respirator

2. Gloves Gloves --> goggles or face shield --> gown --> mask/ respiratory

The nurse is caring for a client newly admitted with an acute manic episode of bipolar disorder. The nurse identifies which dinner selection as the most appropriate to promote client nutrition? 1. Baked sweet potato, kale, yeast roll, water 2. Cheeseburger, apple, vanilla milkshake 3. Spaghetti with meatballs, fruit salad, milk 4. Vegetable soup, salad, dinner roll, iced tea

2.Cheeseburger, apple, vanilla milkshake When managing the nutritional needs of clients with mania, the nurse should frequently offer energy and protein dense foods that are easily carried and consumed (sandwiches, shakes, hamburgers, pizza slices, burritos, fruit juices, granola bars). These "on-the-go" foods promote nutritional intake in clients who are unable to sit down and complete a traditional meal

The nurse is assessing a 4-yo boy in a pediatric clinic. Which behaviors by the client would concern the nurse for possible Duchenne Muscular Dystrophy? Select all that apply. 1. Frequently trips and falls at home 2. Has painful knees and elbows in the morning 3. Places hands on the thighs to push up to stand 4. Suddenly rigidly extends the arms and legs 5. Walks on tiptoes and has disproportionately large calves

1,3, 5 Duchenne muscular dystrophy is an x-lined recessive (carried by females and affecting males) disorder that causes the progressive replacement of dystrophin, a protein needed for muscle stabilization, with connective tissue. The proximal lower extremities and pelvis are affected first. In response to proximal muscle weakness, the calf muscles hypertrophy (pseudohypertrophy) initially and are later replaced by fat and connective tissue. Children with this raise themselves to a standing position using the classic Gower sign/maneuvar (placing hands on the thighs to push up to stand) and walk on tiptoes. Parents may also report frequent tripping and falling.

The postpartum nurse is caring for a client 8 hours after an uncomplicated cesarean birth. Which of the following interventions should the nurse include in the client's plan of care to reduce the risk of thrombus formation? Select all that apply. 1. Administer analgesics as needed 30 minutes prior to ambulation 2. Assist the client to ambulate starting on the third postoperative day 3. Instruct the client to perform leg exercises hourly while in bed 4. Maintain sequential compression devices on the lower extremities 5. Request a prescription for daily aspirin until the client id discharged

1, 3, 4 The nurse should emphasize interventions that promote blood flow and venous return, esp for clients recovering from cesarean birth. Interventions to prevent posourly -Maintaining pretpartum thrombus formation include: -Promoting early and frequent ambulation by ensuring adequate pain control (eg, administer analgesic 30 min before activity -instruct the client to perform leg exercises (eg, dorsiflexion, plantar flexion), -Maintaining prescribed sequential compression devices during sedentary activities

The nurse is performing a central line tubing change when the client suddenly begins gasping for air and writhing. Order the interventions by priority. All options must be used. Administer oxygen as needed Clamp the catheter tubing Stay with the client and provide reassurance Notify the health care provider (HCP) Place the client in Trendelenburg position on the left side

-Clamp the catheter tubing -Place the client in Trendelenburg position on the left side -Administer oxygen as needed -Notify the HCP -Stay with the client and provide reassurance Leakage of more than 500mL of air into a central venous catheter is potentially fatal. An air embolism in the small pulmonary capillaries obstructs blood circulation. A central venous catheter leaks air rapidly at 100mL/sec. This client requires immediate intervention to prevent further complications (eg, cardiac arrest, death). The nurse should not delay emergency treatment, not even to stop and contact the HCP or the rapid response team (RRT). Priority interventions for active or suspected air embolism are as follows: 1. Clamp the catheter to prevent more air from embolizing into the venous circulation 2. Place the client in Trendelenburg position on the left side, causing any existing air to rise and become trapped in the right atrium 3. Administer oxygen if necessary to relieve dyspnea 4. Notify the HCP or call an RRT to provide further resuscitation measures 5. Stay with the client to provide reassurance and monitoring as the air trapped in the right atrium is slowly absorbed into the bloodstream over the course of a few hours

A client is admitted to the labor and delivery unit with a diagnosis of severe preeclampsia. IV magnesium sulfate is prescribed. Which nursing measures should the nurse include in this client's plan of care? Select all that apply. 1. Assess deep tendon reflexes hourly 2. Ensure availability of calcium gluconate 3. Ensure bright lighting to prevent falls 4. have supplemental oxygen at bedside 5. Limit visitors to minimize stimulation

1, 2, 4, 5 Seizures are a potential complication of worsening preeclampsia, also known as eclampsia. Seizure precautions should be in place for all clients with preeclampsia. Side rails should be padded and the bed kept in the lowest position to prevent trauma during a seizure. Functioning suction equipment and supplemental oxygen should be available at the bedside. During a seizure, the nurse should turn the client to the left side to prevent aspiration and promote uteroplacental blood flow. After the seizure subsides, the nurse should suction any oral secretions and apply oxygen 8-10L/min by facemask. Magnesium sulfate is a central nervous system (CNS) depressant commonly prescribed to prevent seizures in clients with preeclampsia. Deep tendon reflexes should be assessed hourly during administration. Hyperreflexia or clonus may indicate impending seizure activity, whereas hyporeflexia may indicate magnesium toxicity. Calcium gluconate is the reversal agent administered in the event of magensium toxicity and should be immediately available. Environmental stimuli should be minimized to decrease risk for seizures. This may include limiting visitors and the number of caregivers entering/exiting the client's room. Severe preeclampsia is associated with CNS irritability, and excessive stimulation should be avoided. Lights should be lowered to decrease visual stimuli and risk for seizures.

The clinic nurse provides teaching for the parent of a child diagnosed with scabies. Which instructions should the nurse include in the teaching plan? Select all that apply. 1. All persons in close contact with the child need treatment 2. Apply the permethrin cream to all skin surfaces 3. Discard the child's stuffed animals 4. Fumigate all living areas in the home 5. Wash the child's clothing and bedding in hot water

1, 2, 5 Scabies is a highly contagious skin infestation. It spreads easily via direct person-to-person contact (eg, skilled nursing facility, day care, prison). The pregnant female mite burrows into the outer skin layer to lay eggs and feces, leaving a superficial burrow track. Intense itching, especially at night, occurs due to the body's inflammatory response to the mite's eggs and feces Treatment for scabies typically involves 1 or 2 applications of a scabicide cream (5% permethrin). For infants and children, permethrin should be massaged into all skin surfaces from the head to the feet, avoiding contact with the eyes. Even after effective treatment, itching often continues for several weeks. All persons in close contact with the client during the lengthy 30-60day incubation period (time from infestation to sx onset) should also seek tx. To prevent reinfection, clothing and linens should be washed and dried on the hottest settings. Discarding stuffed animals is not required. Nonwashable belongings can be sealed in plastic bags for at least 3 days because scabies mites can survive away from the skin for only 2-3 days. Fumigation of living areas is not necessary.

A 2-year-old is diagnosed with atopic dermatitis (eczema). Which instructions should the nurse teach the parents? Select all that apply. 1. Apply emollient immediately after a bath 2. Dress child in wool pajamas 3. Give tepid baths with mild soap 4. Keep child's nails well-trimmed 5. Thoroughly rub the skin dry after baths

1, 3, 4 The primary goals of management are to alleviate pruritus (itch or unpleasant sensation of skin that provokes the urge to scratch) and keep skin hydrated to reduce scratching. Scratching leads to formation of new lesions and potential secondary infections Parents should be instructed to give tepid baths using gentle soap; hot water and long bubble baths dry skin and should be avoided. Skin should be gently patted dry after bathing, followed by immediate application of an emollient (Eucerin, Cetaphil) to seal in moisture. Nails should be trimmed short and kept filed to reduce scratches, clothing should be soft (cotton) and climate-appropriate to reduce perspiration, which can intensify pruritus. Long-sleeves should be worn at night.

The nurse prepares to administer 9AM medications to a client. Which data should the nurse evaluate prior to administration? Select all that apply. (Meds are: aspirin, metoprolol, quinapril) 1. Blood pressure 2. Blood sugar 3. Heart rate 4. International Normalized Ratio 5. Potassium level

1, 3, 5 Beta blockers and ACE inhibitors are antihypertensive meds and th enurse should assess BP prior to administration Beta blockers lower HR by blocking the action of beta receptors that increase HR and contractility. The nurse should assess BP and HR prior to administration 2. Clients w/ DM require BS checks, but administration of these meds do not. 4. INR are measured/monitored in clients taking warfarin.

The nurse provides discharge instructions to a 67 yo client with chronic bronchitis who was hospitalized for community-acquired pneumonia. Which instructions should be included in the discharge teaching plan? Select all that apply. 1. "Avoid the use of over-the-counter cough suppressant medicines" 2. "Oral antibiotics are not needed at home as you had intravenous IV therapy in the hospital" 3. "Pneumonia vaccination is not needed as you now have lifelong immunity" 4. "Schedule a follow-up with the HCP and chest x-ray" 5. "use a cool mist humidifier in your bedroom at night" 6. "use the incentive spirometer at home"

1, 4, 5, 6 Clients should be taught to understand that sxs of pneumonia (eg, cough, sputum production, SOB, fatigue, and activity intolerance) remain after discharge even though the bacteria are no. longer present and will dissipate over a 2-4 week period, depending on current health status and preexisting conditions. Discharge teaching includes the following: -Avoid the use of over-the-counter cough suppressant medicines. Unless prescribed by the HCP, cough suppressants are avoided as they impair secretion clearance, esp in clients with chronic bronchitis -Schedule a follow-up with the HCP and chest x-ray. Follow up is needed at about 2 weeks after completion of antibiotic therapy. X-ray may be needed at a later time in certain high-risk clients to make sure the pneumonia is resolved with no underlying cancer. -use a cool mist humidifier in your bedroom at night. Humidifiers keep mucus membranes moist, maintain effectiveness of the mucociliary escalator, and facilitate expectoration of mucus. A warm bath also loosens the secretions -Continue using the incentive spirometer at home. Deep breathing and coughing promote lung expansion, ventilation, oxygenation, and airway clearance -Drink 1-2 liters of water a day, if not contraindicated, to help thin secretions and facilitate mobilization. Limit caffeine and alcohol as they can dry mucus membranes d/t diuretic effects -Notify HCP of any increase in sxs (eg, SOB, cough, sputum production, chest pain, fever, confusion) -Avoid all tobacco products and second-hand smoke as these irritate the airways and impair mucociliary clearance and oxygenation -Eat a balanced diet, increase activity slowly over about 2 weeks, and take rest periods when needed to help maintain resistance to infection

The nurse is caring for a client who is taking riluzole for amyotrophic lateral aclerosis (ALS). The client asks, "There's no cure for ALS, so why should I keep taking this expensive drug?" What is the nurse's best response? 1. "It may be able to slow down the progression of ALS" 2. "It reduces the amount of glutamate in your brain" 3. "The case manager may be able to find a program to assist with cost" 4. "You have the right to refuse the medication"

1. "It may be able to slow down the progression of ALS" ALS, aka Lou Gehrig disease, is a debilitating, progressive neurodegenerative disease with no cure. Clients develop fatigue and muscle weakness that progresses to paralysis, dysphagia, difficulty speaking, and respiratory failure. Most clients diagnosed with ALS survive only 3-5 years. Riluzole (Rilutek) is the only medication approved for ALS tx. It's a glutamate antagonist, thought to slow neuron degeneration by decreasing the production and activity of the neurotransmitter glutamate in the brain and spinal cord. In some clients, riluzole may slow disease progression and prolong survival by 3-6 months. The nurse should provide teaching about the purpose of the medication so that the client can make an informed decision about taking it.

The nurse who is caring for a client with acute diverticulitis will immediately report which finding to the health care provider? 1. Abdominal pain has progressed to the left upper quadrant 2. Hemoglobin of 11.2 g/dL 3. Lying on side with knees drawn up to abdomen and trunk flexed 4. White blood cell count of 12,000/mm3

1. Abdominal pain has progressed to the left upper quadrant Diverticula are saclike protrusions or outpouchings of the intestinal mucosa of the large intestine caused by increased intraluminal pressure (chronic constipation). The left (descending, sigmoid) colon is the most common area for diverticula to develop. When these diverticula become inflamed (diverticulitis), the client may experience acute pain (usually in the left lower quadrant) and systemic signs of infection (eg, fever, tachycardia, nausea, leukocytosis). Complications that can occur in some clients are abscess formation (continuous fever despite antibiotics and palpable mass) and intestinal perforation resulting in diffuse peritonitis (progressive pain in other quadrants of the abdomen, rigidity, guarding, rebound tenderness)

What is the drug of choice for a patient experiencing Paroxysmal supraventricular tachycardia? 1. Adenosine IVP 2. Atropine IVP 3. Defibrillation 4. External pacing

1. Adenosine IVP In pSVT the HR can be 150-220/min. With prolonged episodes, the client may experience evidence of reduced CO such as hypotension, palpitations, dyspnea, and angina. Tx includes vagal maneuvers such as Valsalva, coughing, and carotid massage. Adenosine is the drug of choice for PSVT tx. Due to its very short half-life adenosine is administered rapidly via IVP over 102 seconds and followed by a 20mL saline bolus. An increased dose may be given twice if previous administration is ineffective. Beta blockers, calcium channel blockers, and amiodarone can also be considered as alternatives. If vagal maneuvers and drug therapy are unsuccessful, synchronized cardioversion may be used.

The nurse is reviewing new prescriptions for assigned clients. Which prescription would require clarification from the health are provider? 1. Altepase for an ischemic stroke in a client with a blood pressure of 192/112 mmHg 2. Amoxicillin for a respiratory infection in a client who is 20 weeks pregnant 3. Fentanyl for moderate to severe pain in a client post appendectomy with an allergy to codeine 4. Sodium chloride 3% infusion for a client with syndrome of inappropriate antidiuretic hormone

1. Altepase for an ischemic stroke in a client with a blood pressure of 192/112 mmHg Thrombolytic agents (eg, alteplase, tenecteplase, reteplase) are often prescribed to resolve acute thrombotic events (eg, ischemic stroke, myocardial infarction, massive pulmonary embolism). They are recombinant plasminogen activators that active blood fibrinolytic system and dissolve thrombi. Thrombolytic agents are contraindicated in clients with active bleeding, recent trauma, aneurysm, arteriovenous malformation, hx of hemorrhagic stroke, and uncontrolled HTN (blood pressure >180/110mmHg). Therefore, the health care provider should be consulted for clarification. Administering alteplase in the presence of these conditions can cause hemorrhage, including life-threatening intracerebral hemorrhage.

A client, gravida 4 para 3, at 38 weeks gestation arrives in the emergency department with strong contractions that began 1 hour ago. The client is diaphoretic, grunting, and yelling loudly that she wants an epidural because she feels the need to push. What priority action should the nurse take? 1. Apply gloves and assess perineal area 2. Initiate large-bore IV access 3. Notify anesthesia provider of client's request for epidural 4. Obtain fetal heart tones via Doppler

1. Apply gloves and assess perineal area Precipitous birth occurs when labor lasts <3 hours from contraction onset until birth. Signs of imminent birth include involuntary pushing/bearing down wth contractions, grunting, or report of sensations of having a bowel movement. If a client arrives at the hospital in second-stage labor (ie, pushing), the nurse rapidly assesses whether birth is imminent by applying gloves and observing the perineum for bulging or crowning of the presenting fetal part. If the health care provider is not present, the nurse stays with the client, ensures safe client positioning (eg, not standing or on the toilet), and is prepared to act as a birth attendant. The nurse may direct others to perform needed actions (eg, contact provider, assess fetal heart tones, initiate IV access)

A nurse is caring for a client who had a vaginal birth 2 hours ago. The client has saturated a perineal pad in 20 minutes. During assessment, the nurse notices that he client has a boggy fundus that is deviated to the right and slightly above the umbilicus. Which intervention should the nurse perform first? 1. Assist client to use the bedpan to void 2. Begin oxytocin IV infusion at 125 milliunits/min 3. Obtain a complete blood count 4. Start oxygen delivery at 10L/min via nonrebreather facemask

1. Assist client to use the bedpan to void Postpartum vaginal bleeding that saturates a perineal pad in <1 hour is considered excessive. This client saturated a perineal pad in 20 minutes. Based on the nurse's assessment, the boggy funcdus indicates uterine atony. The fundus is also elevated above the umbilicus and deviated to the right, indicating 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 the bladder distension. The. nurse should then perform fundal massage

The nurse is caring for a client who had a permanent ventricular pacemaker inserted. The nurse observes the cardiac monitor and sees a pacing spike followed by a QRS complex for each heartbeat. How should the nurse assess for mechanical capture of this pacemaker? 1. Auscultate the client's apical pulse rate 2. Measure the client's blood pressure 3. Obtain a 12-lead ECG 4. Palpate the client's radial pulse rate

1. Auscultate the client's apical pulse rate Clients with an implanted permanent pacemaker should be assessed for both electrical capture of heart rhythm and mechanical capture of heart rate. In atrial pacing , pacer spikes precede P waves, whereas in ventricular pacing, pacer spikes precede WRS complexes. Pacing spikes should be immediately followed by their appropriate electrical waveform, indicating electrical capture. Checking for mechanical capture is essential to ensure that the electrical activity of the heart corresponds to a pulsatile rhythm. The best method for checking for a pulsatile rhythm is to assess a central pulse (eg, auscultation of apical, palpation of femoral). This rate should be compared to the electrical rate displayed on the cardiac monitor to assess for pulse deficit.

The nurse is providing teaching to the parents of a child with Marfan syndrome. Which topic is the priority for the nurse to address? 1. Avoiding participation in contact sports 2. Informing the dentist of the child's condition 3. Monitoring for development of scoliosis 4. Scheduling annual eye examinations

1. Avoiding participation in contact sports Marfan syndrome is an autosomal dominant disorder affecting the connective tissues of the body. Abnormalities are mainly seen in the cardiovascular, musculoskeletal, and ocular systems. Clients with Marfan syndrome are very tall and thin, with disproportionately long arms, legs, and fingers. Cardiovascular manifestations include abnormalities of the aorta and cardiac valves, including aneurysms, tears (dissection), and leaky heart valves that may require replacement or repair. Therefore, competitive or contact sports are discouraged due to the risk of cardiac injury and sudden death

The nurse receives report on 4 clients. Which client should the nurse see first? 1. Client with a history of chronic hypertension exhibiting epistaxis and blurred vision 2. Client with a unilateral, pulsating headache reporting sensitivity to light 3. Client with episodes of vomiting and abdominal cramps following a outdoor part 4. Client with multiple sclerosis reporting blurred vision and right arm weakness

1. Client with a history of chronic hypertension exhibiting epistaxis and blurred vision Hypertensive encephalopathy (HE) is a medical emergency caused by a sudden elevation in blood pressure (eg, hypertensive crisis) creating cerebral edema and increased intracranial pressure (ICP). Triggers of HE include an acute exacerbation of pre-existing HTN drug use, MAOI-tyramine interaction, head injury, and phenochromocytoma. The client may report severe headache, visual impairment, anxiety, confusion, and observed epistaxis, seizures, or coma HE may precipitate life-threatening complications such as myocardial infarction, hemorrhagic stroke, and acute kidney injury. The client with a history of chronic hypertension and active signs of increased ICP (eg, anxiety, epistaxis) requires immediate assessment and treatment

A client who is 24. hours postoperative bowel resection is receiving IV opioids PRN for severe pain. The nurse reviews the health care provider's prescription to discontinue the continuous IV normal saline. What is the nurse's most appropriate action? 1. Convert to a saline lock 2 Remove the IV catheter 3. Request a prescription for a saline lock 4. Slow the IV fluids to a keep-vein-open rate

1. Convert to a saline lock The nurse should discontinue the IV infusion of normal saline and apply a saline lock to maintain IV access while preventing clotting. The prescription of the HCP to lock the IV catheter is implied, as the client is currently receiving PRN IV opioids. A saline lock is sufficient to maintain the line patency and allows greater mobility than a continuous infusion.

The registered nurse (RN) and licensed practical nurse (LPN) are caring for a client with an established colostomy. Which nursing actions may the RN delegate to the LPN? Select all that apply 1. Assess perfusion of the stoma tissue 2. Assist the client in changing the ostomy pouch 3. Auscultate the client's bowel sounds 4. Develop plan of care to prevent skin breakdown 5. Monitor the color of ostomy drainage

2, 3, 5 Tasks requiring initial assessment, initial or discharge education, care planning, or care of an unstable client require the clinical judgement of the RN and may not be delegated. The RN may delegate care of stable clients with established ostomies to the LPN. Following actions related to ostomy care are generally within the LPN scope of practice: -provide ostomy care and observe for skin breakdown -perform specific assessments (eg, bowel sounds, stoma color) -monitor drainage characteristics (eg, color, amount) -Reinforce education -Irrigate an established ostomy -Document observations and interventions

A nurse on a pediatric unit is admitting a school-aged child with suspected Reye syndrome. Which information obtained during the history taking is most consistent with this condition? 1. No history of varicella vaccine administration 2. Recent exposure to bats 3. Recent influenza infection 4. Recent use of acetaminophen for fever

3. Recent influenza infection Children who develop Reye syndrome often have had a viral infection, esp varicella (chicken pox) or influenza. Clinical manifestations include fever, lethargy, acute encephalopathy, and altered hepatic function. Elevated serum ammonia levels are an expected laboratory finding. Acute encephalopathy manifests with vomiting and a severely altered LOC; it can rapidly progress to seizures and.or coma. The risk of developing Reye syndrome increases if aspirin therapy is used to treat the fever associated with varicella or influenza. As a result of this awareness, there has been a significant increase in the use of acetaminophen or ibuprofen for fever management in children.

The nurse assesses 4 clients in the emergency department. Which client should the nurse prioritize first? 1. 12yo with right lower quadrant abdominal pain that started in the periumbilical region 2. 14 yo with severe scrotal pain; right testis is tender, swollen, and more elevated than the left 3. 16yo with sickle cell disease who has excruciating generalized body pain 4. 34 yo with sudden-onset, right-sided flank pain radiating to the right groin

2. 14 yo with severe scrotal pain; right testis is tender, swollen, and more elevated than the left Testicular torsion is an emergency condition in which blood flow to the testis (scrotum) has stopped. The testicle rotates and twists the spermatic cord, initially causing venous drainage obstruction that leads to swelling and severe pain. Arterial blood supply is subsequently interrupted, resulting in testicular ischemia and necrosis, which require surgical removal of the testes. The condition can be diagnosed with ultrasound. There is a short time frame in which testicular torsion can be treated (to untwist the rotation), generally 4-6 hours, making this condition a priority 1. Right lower quadrant pain referred from the periumbilicalarea is a classic sign of appendicitis. If left untreated, the appendix could perforate and release bacteria into the abdomen, causing peritonitis, a more serious condition. Surgery is usually required within 24 hours. This client should receive prompt attention but is not a priority over the client with testicular torsion. 3. Clients with sickle cell disease have episodes of sickle cell crisis, in which the sickle-shaped cells occlude the blood vessels. This decreased blood flow is responsible for the generalized body pain. This client should be treated emergently with pain medications and IV fluids but is not a priority over the client with testicular torsion. 4. Sudden-onset, right-sided flank pain radiating to the groin is classic for renal stones. Kidney stones are very painful but in most cases cause no permanent damage unless a stone completely blocks kidney flow. This client is not a priority over the client with testicular torsion

The nurse is caring for a 76 yo client newly admitted with pneumonia and C.diff infection. Which of the following would be priority to report to the health care provider? 1. Blood gas results PO2 80mmHg, pCO2 35mmHg, pH 7.38 2. Blood urea nitrogen of 29mg/dL, K of 3.3, Na of 132 3. Coarse crackles in lung bases with moderate sputum production 4. Fever of 100.6 and reports of chills and fatigue

2. Blood urea nitrogen of 29mg/dL, K of 3.3, Na of 132 C. diff overgrowth in the intestine often occurs with normal GI flora is destroyed (eg, antibiotic use). Clients w/ c diff have watery diarrhea, nausea, fever, and abd pain. Hypovolemia can easily develop through the loss of fluids and electrolytes in the stool, esp in infants and the elderly. Clients w/ hypovolemia from GI losses will often have hyponatremia, hypokalemia, and elevated BUN (poor renal perfusion). This client has hyponatremia, hypokalemia, and elevated BUN. Hypovolemia can cause hypotension and renal failure, and electrolyte abnormalities can cause cardiac arrythmias; therefore, these are priority to report. Fluid resuscitation and electrolyte replacement should be initiated promptly to prevent complications

A nurse is admitting a child and observes multiple irregular bruises. which action should the nurse take next? 1. Ask parents to leave the room during the admission process 2. Continue with a detailed interview and physical examination 3. Notify the charge nurse and the social worker 4. Promise not to tell anyone if the child reveals abuse

2. Continue with a detailed interview and physical examination A nurse who suspects child abuse should conduct a detailed interview an physical examination to identify potential indicators of abuse. Iin addition to obvious injuries, abused children may show extremes in behavior, including being overly shy, fearful, or even unusually affectionate. Parents should remain present during the admission process and the nurse should observe parent-child interactions for signs of abusive behavior (eg, refusal to comfort, blaming, belittling). Abusive parents may be hostile or uncooperative with the health care team. The nurse should also assess for inconsistencies between the parents' report and the actual findings.

Yesterday, the client was weaned from the mechanical ventilator and an intravenous infusion of lorazepam. The client has been alert and oriented for 24 hours but is now experiencing confusion. The nurse now evaluates new-onset confusion by assessing the client's sense of place and time, difficulty focusing, short-term memory loss, and increasing lethargy. The nurse suspects which condition in this client? 1. Amnesia 2. Delirium 3. Dementia 4. Psychosis

2. Delirium Delirium or acute cognitive dysfunction is a syndrome commonly seen in hospitalized clients; it is reversible but difficult to diagnose. Clients may manifest delirium states that can be hypoactive (eg, quiet, disorientation, change in LOC, memory loss), hyperactive (eg, restlessness, agitation, hallucinations, paranoia), or mixed. Manifestations of delirium develop acutely and are difficult to differentiate from those associated with pain, anxiety, and medications. Early diagnosis and treatment are advantageous as delirium is associated with increased mortality (esp in critically ill clients on mechanical ventilation).

The nurse is giving a presentation at a community health event. the nurse should provide which instruction on how to prevent botulism? 1. Boil water if unsure of its source 2. Discard canned food with a bulging end 3. Keep milk cold 4. Wash hands

2. Discard canned food with a bulging end Botulism is caused by the GI absorption of the neurotoxin produced by clostridium botulinum. The neurotoxin blocks acetylcholine at the neuromuscular junction, resulting in muscle paralysis. The organism is found int he soil and can grow in any food contaminated wth the spores. Manifestations include descending flaccid paralysis (starting from the face), dysphagia, and constipation (smooth muscle paralysis). the main source is improperly canned or stored food. A metal can's swollen/bulging end can be caused by the gases from c botulinum and should be discarded. The infant form of botulism can occur in children under age 1 year if they eat honey (particularly raw wild honey). The immature gut system in these children makes them more susceptible.

A client at 38 weeks gestation is in latent labor with ruptured membranes and is receiving an oxytocin infusion for labor augmentation. The client is requesting IV pain medication. When administering an IV narcotic during labor, which nursing action is appropriate? 1. Discontinue the oxytocin infusion prior to giving the medication 2. Give the medication slowly during the peak of the next contraction 3. Hold until contractions are occurring at least every 4 minutes for an hour 4. Withdraw 5mL of lactated Ringer from the IV tubing to dilute the medication

2. Give the medication slowly during the peak of the next contraction Administration of IV narcotics during the peak of contractions can help decrease sedation of the fetus and subsequent newborn respiratory depression at birth. Uteroplacental blood flow is significantly reduced during contraction peaks, and administration of IV medication at this time results in less medication crossing the placental barrier. In addition, a higher concentration of medication remains in the maternal vasculature, which increases the effectiveness of pain relief

A client at 32 weeks gestation goes into cardiac arrest. What is the nurse's best action while performing cardiopulmonary resuscitation for this client? 1. Compress chest at second intercostal space, right sternal border 2. Perform chest compressions slightly higher on the sternum 3. Place hands just below the diaphragm to perform chest compressions 4. Position client in the supine position for optimal compressions

2. Perform chest compressions slightly higher on the sternum Common causes of sudden cardiac arrest in pregnant clients include embolism, eclampsia, magnesium overdoses, and uterine rupture. If CPR is required, several modifications must be made to ensure efficacy of the rescue efforts. During pregnancy, the heart is displaced toward the left because the growing uterus pushes upward on the diaphragm, particularly in the third trimester. To accommodate this displacement, the hands should be placed ont he sternum slightly higher than usual for chest compressions during CPR. In addition, a gravid uterus can significantly compress the client's vena cava and aorta,, thereby hindering effective blood flow during CPR. The uerus should be manually displaced to the client's left to reduce this pressure. The nurse can also place a rolled blanket or wedge under the right hip to displace the uterus. If return of spontaneous circulation does not occur after 4 minutes of CPR, emergency cesarean section is usually initiated. Delivery should occur within 5 minutes of initiating CPR

The clinic nurse reinforces education about intimate partner violence for a group of graduate nurses. Which of the following are appropriate for the nurse to include? Select all that apply 1. "Intimate partner violence is most common in low-income families" 2. "Intimate partner violence is rare in same-sex partnerships" 3. "The abusive partner often demonstrates jealousy and possessiveness" 4. "Victims may not leave due to financial concerns or fear of harm by the abuser" 5. "Violence against a female often intensifies during pregnancy"

3, 4, 5 Intimate partner violence (IPV) is physically, emotionally, verbally, or economically abusive behavior inflicted by on partner against another in an intimate relationship, to maintain power and control. Nurses must be aware of the risk factors and signs of IPV to recognize victims of abuse and intervene (eg, separating the victim from the abuser during the health history interview, providing information about community resources). Features of IPV include: - the abusive partner exhibits intense jealousy and possessiveness -the victim of IPV chooses to stay in the relationship for a variety of reasons (eg, fear for life, financial or child custody concerns, religious beliefs) -the abuse begins or intensifies during pregnancy **IPV occurs in all religious, socioeconomic, racial, and educational groups and in both heterosexual and same-sex partnerships

The nurse is caring for a client with suspected pelvic inflammatory disease (PID). When the nurse is obtaining the client's health history, which of the following questions would provide pertinent data about the client's risk factors for PID? Select all that apply. 1. "Are you currently taking oral contraceptives?" 2. "At what age did you experience your first menstrual cycle?" 3. "Do you engage in sexual intercourse with multiple partners?" 4. "Have you ever been diagnosed with a sexually transmitted infection?" 5. "Have you recently had an abortion or pelvic surgery?"

3, 4, 5 PID is a leading cause of ectopic pregnancy and infertility, occurs when bacteria from the genital tract spread upward through the cervix and cause infection of the female reproductive organs (eg, uterus, fallopian tubes, ovaries) and pelvic cavity. Symptoms may include pelvic or lower abd pain, menstrual irregularities or increased menstrual cramps, painful intercourse, fever, and abnormal vaginal discharge. Untreated STIs (eg, gonorrhea, chlamydia) are the most common cause of PID. The nurse should assess for other risk factors, including: -hx of PID -multiple sex partners -previous STI -unprotected sexual intercourse (w/o condom) -Placement of an IUD within the past 3 weeks -recent abortion or pelvic surgery

Which are correct understandings of applying nursing ethical principles? Select all that apply 1. Autonomy is requiring the client to have an advance directive 2. Beneficence is withholding prognosis from a client due to family wishes 3. Fidelity is administering medication as prescribed to the client 4. Justice is telling the client the truth that the biopsy is positive 5. Nonmaleficence is refusing to give report to a nurse who is impaired

3, 5 Ethical principles guide the nurse in making appropriate decisions and act accordingly. They speak to the essence but not to the specifics of the law. Fidelity is exhibiting loyalty and fulfilling commitments made to oneself and others. It includes meeting the expected responsibilities of professional nursing practice and provides the basis of accountability (taking responsibility for one's actions) Nonmaleficence means to do no harm and relates to protecting clients from danger when they are unable to do so themselves due to a mental/physical condition (eg, children, client with Alzheimer disease) and from a nurse who is impaired. Autonomy is the right to make decisions for oneself (eg, informed consent.) Although having an advance directive is an example of autonomy, requiring one violates this principle. The client has a right to refuse even if the nurse believes it is in the client's best interest. When a diagnosis is withheld, even if due to the nurse's or family's good intentions, it violates the principle of autonomy. Beneficence means to do good (eg, implementing interventions to promote the client's well-being) The principle of justice refers to treating all clients fairly (ie, without bias). Veracity is telling the truth as a fundamental part of building a trusting relationship.

The nurse is educating a client recently diagnosed with rheumatoid arthritis about home care and symptom management. Which of the following client statements indicates a need fo further teaching? 1. "Daily range-of-motion exercises are important to keep my joints flexible" 2. "I can use a moist heat pack to help with joint stiffness" 3. "I should elevate my knees with pillows when im sleeping" 4. "I will make sure to rest in between activities throughout the day"

3. "I should elevate my knees with pillows when im sleeping" RA is a chronic, autoimmune disorder characterized by inflammation and damage to synovial joints; progressive fibrosis of joint membranes results in pain, deformity, and stiffness. Over time, remodeling of joint capsules and associated pain reduce the ability to perform activities of daily living (eg, toileting, bathing, dressing) and engage in routine tasks (walking, opening doors) To maximize functional ability and quality of life, the nurse should educate clients with RA about home-care and symptom management strategies: -perform gentle ROM exercises daily to maintain joint flexibility -Apply moist heat packs to stiff joints and ice packs to painful joints -plan frequent rest periods to reduce fatigue and inflammation of affected joints during activities

A client with a diagnosis of atrial fibrillation has just been placed on warfarin therapy. The registered nurse (RN) over hears a student nurse teaching the client about potential food-drug interactions. Which statement made by the student nurse require an intervention by the RN? 1. "Do you take any nutritional supplements?" 2. "You will need to monitor your intake of foods containing vitamin K" 3. "You will not be able to eat green, leafy vegetables while taking this medication" 4. "Your blood will be tested at regular intervals"

3. "You will not be able to eat green, leafy vegetables while taking this medication" Warfarin (Coumadin) works by blocking the availability of vitamin K, which is essential for blood clotting. As a result, the clotting mechanism is disrupted, reducing the risk of a stroke, venous thrombosis, or pulmonary embolism. Suden increases or decreases in the consumption of vitamin K-rich foods could inversely alter the effectiveness of warfarin. An increase in vitamin K could decrease the effectiveness of warfarin, placing the client at increased risk of blood clot formation; a decrease could increase the effectiveness of warfarin, placing the client at increased risk for bleeding.

The nurse is preparing to administer an IM immunization to a 6-month-old infant. Which needle length and injection site would be the most appropriate to minimize a local reaction to the vaccine components? 1. 3/8 inch (9mm) needle in the anterolateral thigh 2. 5/8 inch (16mm) needle in the ventrogluteal muscle 3. 1 inch (25 mm) needle in the anterolateral thigh 4. 1 1/2 inch (38 mm ) needle in the ventrogluteal muscle

3. 1 inch (25 mm) needle in the anterolateral thigh The. needle length and injection site for IM injections are dependent on a client's age and muscle mass. The vastus lateralis muscle in the anterolateral middle portion of the thigh is the preferred IM injection site for newborns (age < 1 month) and infants (age 1-12 months). Selection of the most appropriate needle length is an important factor in ensuring immunization success and minimizing local reactions to vaccine components. If the needle is too short, the IM vaccine is injected into subutaneous fat, resulting in vaccine failure due to poor mobilization of the antigen within adipose tissue.Infants typically require a 1 inch needle for IM injections.

The nurse is caring for a client who, 30 min ago, underwent an. ablation procedure for supraventricular tachycardia in the cardiac catheterization laboratory. The client has a dressing over the femoral insertion site with a small amount of oozing blood. Which action by the nurse causes the charge nurse to intervene? 1. Applies pressure above the femoral insertion site 2. Assesses bilateral pedal pulses frequently 3. Assists client to sit on the side o the bed to use the urinal 4. Reports client chest pain of 2 on a scale of 0-10 to HCP

3. Assists client to sit on the side o the bed to use the urinal Radiofrequency catheter ablation is an invasive procedure that may be used to treat clients with recurrent episodes of SVT. A catheter is inserted through a large artery or vein (eg femoral) and threaded to the heart. Radiofrequency waves are delivered to inactivate tissue in the area of the heart causing the dysrhythmia. After cardiac catheterization, clients must remain supine with the head of bed at more than or equal 30 degrees and the affected extremity straight to prevent bleeding from the catheter insertion site.

The nurse receives telephone messages from the following 4 clients. Which client should the nurse call back first? 1. Client taking cyclosporin who reports swollen and bleeding gums for several days 2. Client taking doxycycline who reports severe sunburn after sun exposure 3. Client taking phenytoin who reports flu-like symptoms and a new painful skin rash 4. Client taking sildenafil who reports dizziness when standing up from a seated positoon

3. Client taking phenytoin who reports flu-like symptoms and a new painful skin rash Phenytoin is an anticonvulsant prescribed for the tx of seizures. Clients should never abruptly stop taking the medication due to the possibility of seizure reoccurrence and status epilepticus. An exception is the development of a rash, which may indicate Stevens-Johnson syndrome (SJS) --> a rare but potentially life-threatening hypersensitivity reaction. It often starts w/ flu-like sxs and a painful, purple or red rash to the skin or mucous membranes that may resemble a third-degree burn. Immediate discontinuation of the triggering agent and notification of the health care provider is necessary to prevent rapid progression and multiple organ failure.

The nurse is caring for an infant diagnosed with Hirschsprung disease who is awaiting surgery. Which assessment finding requires the nurse's immediate action? 1. Abdominal distension with no change in girth for 8 hours 2. Did not pass meconium or stool within 48 hours after birth 3. Episode of foul-smelling diarrhea and fever 4. Excessive crying and greenish vomiting

3. Episode of foul-smelling diarrhea and fever Hirschsprung disease (HD) occurs when a child is born with some sections of the distal large intestine missing nerve cells, rendering the internal anal sphincter unable to relax. As a result, there is no peristalsis and stool is not passed. These newborns exhibit symptoms of distal intestinal obstruction. They have a distended abdomen and will not pass meconium within the expected 24-48 hours. THey also have difficulty feeding and often vomit green bile. Surgical removal of the defective section of bowel is necessary and colostomy may be required. A potentially fatal complication is enterocolitis, an inflammation of the colon, which can lead to sepsis and death. Enterocolitis will present with fever, lethargy; explosive foul-smelling diarrhea; and rapidly worsening abdominal distension.

The emergency nurse is admitting a 12-year-old client who reports palpitations. Which action should the nurse anticipate? 1. Administering epinephrine by rapid IV push 2. Assisting the client to a tripod position 3. Instructing the client to hold their breath and bear down 4. Sedating the client for immediate asynchronous defibrillation

3. Instructing the client to hold their breath and bear down Supraventricular tachycardia (SVT) is the most common tachyarrythmia of childhood and refers to a rapid heart rate of 200-300/min with no variation in rate during activity. It can lead to life-threatening CHF if left untreated. sxs in children may include palpitations, dizziness, or chest pain. Once an ECG confirms SVT, the nurse should anticipate nonpharmacological interventions (ie, vagal maneuvers0 to convert SVT to sinus rhythm if the client is stable. Placing an ice bag to the client's face and instructing the client to hold their breath while bearing down (Valsalva) are vagal maneuvers that can slow electrical conduction through the heart's atrioventricular node. If these maneuvers are ineffective, or if the client becomes unstable, administration of adenosine or synchronized cardioversion is indicated.

The nurse is assessing a 3-year-old client in the emergency department and 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 nurse anticipate? 1. 20-gauge needle insertion at the mid-axillary line for pleural aspiration 2. 4L oxygen at 100% per nasal cannula with bilevel positive airway pressure (BPAP) ventilation standing by 3. Intubation in the operating room with a prepared tracheostomy kit standing by 4. Nebulized racemic epinephrine with pediatric anesthesiologist standing by

3. Intubation in the operating room with a prepared tracheostomy kit standing by Epiglottis should be considered first in a 3-7 year old child with acute respiratory distress, toxic appearance (eg, sitting up, leaning forward, drooling), stridor, and high-grade fever. Tachycardia and tachypnea are also present. This is a pediatric emergency and should be managed with endotracheal intubation; however, intubation of such clients is difficult, and preparation for possible tracheostomy is also standard. The complications of epiglottis are serious and include sudden airway obstruction

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

3. Measure the client's blood pressure Sodium nitroprusside is a highly potent vasodilator (both venous and arteriolar). Venous dilation reduces preload (volume of blood in ventricles at the end of diastole), and arterial dilation reduces afterload (resistance ventricle must overcome to eject blood during asystole). Sodium nitroprusside is commonly used in hypertensive emergencies and for conditions in which blood pressure control is of utmost importance (eg, aortic dissection, acute hypertensive heart failure). Nitroprusside begins to act within 1 minute and can produce a sudden and drastic drop in blood pressure (symptomatic hypotension) if not monitored properly. Therefore the client's blood pressure should be monitored closely (every 5-10 minutes). This client's lightheadedness and cold clammy skin are likely d/t hypotension. Nitroprusside metabolizes to cyanide, and clients w/ renal disease can occasionally develop fatal cyanide toxicity.

The nurse is caring for a 4yo child in the emergency department who has a 104F (40C) temperature, is obtunded, and has a positive Kernig's sign. The parents are refusing antibiotics and any treatment. The parents state that their religious belief is to trust in just prayer and believe the child will receive divine healing. What action does the nurse anticipate? 1. Assisting the parents in signing Against Medical Advice (AMA) papers 2. Discharging the child if parents have power of attorney papers 3. Notifying the hospital administration about the situation 4. Reassuring the parents that their decision will be respected under the principle of autonomy

3. Notifying the hospital administration about the situation A competent adult has the right to make any decision regarding the client's health care even if the provider does not believe it is in the client's best interest. However, parents do not have the right to place their minor child in a life-threatening position. Parents have legal authority to make choices about their child's health care, but not when they do not permit life-saving treatment or when there is a potential conflict of interest, such as child abuse or neglect. The hospital will seek court-appointed custody to treat this child who is seriously ill with dangerously high temperature and signs of severe neurologic deficit. Bacterial meningitis presents with high fever, change in LOC, nuchal rigidity, and meningeal signs (positive Kernig's and Brudzinski's signs). Antibiotic tx is essential.

The clinic nurse prepares to administer a newly prescribed dose of sumatriptan to a client with a migraine headache. Which item in the client's history would cause the nurse to question the prescription? 1. Blood urea nitrogen of 12mg/dL 2. BMI of 34 kg/m2 recorded during today's examination 3. Past medical history of uncontrolled hypertension 4. Takes alprazolam as prescribed for anxiety

3. Past medical history of uncontrolled hypertension Sumatriptan is a selective serotonin agonist prescribed to treat migraine headaches, which are thought to be caused by dilated cranial blood vessels. Triptan drugs, like sumatriptan, work by constricting cranial blood vessels, and clients should be instructed to take a dose at the first sign of a migraine to help prevent and relieve symptoms. Sumatriptan is contraindicated in clients with coronary artery disease and uncontrolled hypertension because its vasoconstrictive properties increase the risk of angina, hypertensive urgency, decreased cardiac perfusion, and acute myocardial infarction. The nurse should question the client about a past medical history of uncontrolled hypertension and report this to the health care provider

The nurse is caring for a client with a history of tonic-clonic seizures. After a seizure lasting 25 seconds, the nurse notes that the client is confused for 20 minutes. The client does not know the current location, does not know the current season, and has a headache. The nurse documents the confusion and headache as which phase of the client's seizure activity? 1. Aural phase 2. Ictal phase 3. Postictal phase 4. Prodromal phase

3. Postictal phase A seizure is an uncontrolled electrical discharge of neurons in the brain that interrupts normal function. Seizure manifestations generally are classified into 4 phases: 1. The prodromal phase: the period with warning signs that precede the seizure (before the aural phase) 2. The aural phase (is the period before the seizure when the client may experience visual or other sensory changes. Not all clients experience or can recognize a prodromal or aural phase before the seizure 3. The ictal phase: period of active seizure activity 4. During the postictal phase, the client may experience confusion while recovering from the seizure. The client may also experience a headache. Postictal confusion can help identify clients by differentiating seizures from syncope. In syncope, there will be only a brief loss of consciousness without prolonged post-event confusion

The. nurse is caring for a client with asthma exacerbation. Blood pressure is 146/86mmHg, pulse 110/min, and respirations are 32/min. The respiratory therapist administers nebulized albuterol as prescribed. One hour after the treatment, the nurse assesses which finding that indicates the drug is producing the therapeutic effect? 1. Constricted pupils 2. Heart rate of 120/min 3. Respirations of 24/min 4. Tremor

3. Respirations of 24/min Albuterol is a short-acting inhaled beta-2 agonist used to control airway obstruction caused by chronic obstructive pulmonary disease, asthma, or bronchitis. It also is used to prevent exercise-induced asthma. The therapeutic effect is relaxation of the smooth muscles of the airways, which results in immediate bronchodilation. Bronchodilation decreases airway resistance, facilitates mucus drainage (expectorates mucus plugs), decreases the work of breathing, and increases oxygenation. As a result of these actions, the respiratory rate will decrease and peak flow will be increases (if tested) However, short-actinb eta-2 agonists are associated with the following side effects (not therapeutic effects): tremor (most frequent), tachycardia and palpitations, restlessness, and hypokalemia. These s/e are d/t the oral depositon of medication (subsequent systemic absorption) and can be reduced with the use of a spacer or chamber device.

The nurse provides teaching about methotrexate to a client with rheumatoid arthritis. It is most important to address which topic regarding this drug? 1. Need for an eye examination 2. Need for sunblock 3. Risk for infection 4. Risk for kidney injury

3. Risk for infection Methotrexate is classified as a folate antimetabolite, 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, infleunza, pneumoccocal) and avoiding crowds and persons with known infections. Live vaccines (eg, herpes zoster) are contraindicated in clients receiving immunosuppressants like this drug. Alcohol should be avoided in clients taking methotrexate as it is hepatotoxic and drinking alcohol increases the risk for hepatotoxicity.

A client is started on lisinopril therapy. Which assessment finding requires immediate action? 1. Blood pressure 129/80mHg 2. Heart rate 100/min 3. Serum creatinine 2.5mg/dL 4. Serum potassium 3.5 mEq/L

3. Serum creatinine 2.5mg/dL The dosage of ACE inhibitors should be adjusted for clients with renal impairment.

The nurse reviews the assigned clients' laboratory results and medication administration records. Which finding is the highest priority for the nurse to follow-up with the health care provider? 1. Gram-negative infection and positive blood cultures in a client prescribed tobramycin 2. Serum B-type natriuretic peptide (BNP) 650pg/mL in a client prescribed furosemide 3. Serum potassium 5.7 mEq/L in a client prescribed spironolactone 4. Serum sodium 132 in a client prescribed IV normal saline solution at 175mL/hour

3. Serum potassium 5.7 mEq/L in a client prescribed spironolactone The client who was prescribed spironolactone (aldactone), a potassium-sparing diuretic that counteracts the potassium loss caused by other diuretics, has high serum potassium. The continuation of this medication puts the client at risk for life-threatening hyperkalemia-induced cardiac dysrhythmias. 1. This client has positive gram-negative blood cultures. Tobramycin, an aminoglycoside antibiotic drug, is used to treat serious gram-negative bacterial infections.there is no indication to follow up w/ HCP. 2. BNP is a hormone released by heart muscle in response to mechanical stress (stretching). BNP levels are usually elevated (normal <100 in clients with heart failure) and a prescription for furosemide is expected 4. The client has hyponatremia and is receiving isotonic normal saline solution; there is no indication to f/u with HCP

The nurse develops a teaching care plan for the client with a prescription to change antidepressant medications from imipramine to phenelzine. Which instruction is appropriate to include in the teaching? 1. Continue avoiding foods high in tyramine until the imipramine withdrawal period is over 2. Skip the nighttime dose of imipramine and start the phenelzine the next morning 3. Taper down the imipramine, then discontinue for 2 weeks before starting phenelzine 4. Taper down the imipramine while gradually increasing the phenelzine

3. Taper down the imipramine, then discontinue for 2 weeks before starting phenelzine When a client switches from a tricyclic antidepressant (TCA) (eg, imipramine, amitriptyline, nortripyline) to a monoamine oxidase inhibitor (MAOI) (eg, phenelzine, isocarboxazid, tranylcypormine), a drug-free period of at least 2 weeks should elapse between the tapered discontinuation of the TCA and the initiation of the MAOI. The timing is based on the half-life value and allows for the first medication to leave the system. Without a washed-out period, the client could experience hypertensive crisis (eg, blurred vision, dizziness, severe headache, shortness of breath). If the TCA is withdrawn abruptly, the client may experience a discontinuation syndrome)

A. nurse is providing anticipatory guidance to a client with early Alzheimer disease and osteoarthritis. Current symptoms include mild forgetfulness and cognition changes. Which is the best example of an educational goal for anticipatory guidance? 1. The client will demonstrate proper organization of medications in a weekly pill box by the end of the teaching session 2. The client will identify and attend a support group meeting for clients with dementia by the end of the. month 3. The client will verbalize 2 home safety changes that can prevent falls during disease progression by the end of the session 4. The client will verbalize 3 example of easy, nutritious meals that can be prepared independently by the end of the clinic visit

3. The client will verbalize 2 home safety changes that can prevent falls during disease progression by the end of the session Anticipatory guidance prepares clients and caregivers for future health needs and is useful throughout life, from pediatric growth and development to anticipated changes related to disease processes. This type of education promotes health and helps to reduce client/caregiver stress and anxiety, which heighten with unexpected cognitive, physical, and emotional changes. Anticipatory guidance educational goals should be client-oriented, realistic, objective, measurable, and focused on preparing for future needs specific to the client. The client with Alzheimer disease and osteoarthritis is at high risk for falls with disease progression. In the early stage, the client can make changes in the home to promote safety in the future.

A nurse is performing a dressing change for a hospitalized client with an infected surgical incision. Which actions should the nurse take? 1. Have the client remove the existing dressing while the nurse prepares sterile supplies. 2. Wear clean gloves for removal and application of a new dressing 3. Wear clean gloves to remove the existing dressing, changing to sterile gloves to apply the new dressing 4. Wear sterile gloves, gown, and goggles to remove the soiled existing dressing

3. Wear clean gloves to remove the existing dressing, changing to sterile gloves to apply the new dressing The existing dressing is already contaminated so clean gloves can be worn to remove and discard it. Surgical wounds should be re-dressed using aseptic technique, which would require sterile gloves and sterile dressing supplies. The nurse should carefully remove the soiled dressing to avoid shedding any microorganisms into the air and expose the wound for minimal time to avoid additional contamination.

The clinic nurse provides teaching for a client scheduled for a barium enema the next day. which statement by the client shows a need for further instruction? 1. "I can expect chalky white stool after the procedure" 2. "I cannot eat or drink 8 hours before the procedure" 3. "I may have abdominal cramping during the procedure" 4. "I will avoid laxatives after the procedure"

4. "I will avoid laxatives after the procedure" A barium enema, or lower gastrointestinal series, uses fluoroscopy to visualize the colon outlined by contrast to detect polyps, ulcers, tumors, and diverticula. This procedure is contraindicated for clients with acute diverticulitis as it may rupture inflamed diverticula and cause subsequent peritonitis. Preprocedure instructions: - Take a cathartic (eg, magnesium citrate, polyethlyene glycol) to empty stool from the colon -Follow a clear liquid diet the day before the procedure to aid in bowel preparation and to prevent dehydration; avoid red and purple liquids -Do not eat or drink anything 8 hours before the test -Expect to be placed in various positions during the procedure. You may experience abdominal cramping and an urge to defecate Post procedure: -Expect the passage of chalky, white stool until all barium contrast has been expelled -Take a laxative (eg, magnesium hydroxide (milk of magnesia) to assist in expelling the barium)). Retained barium can lead to fecal impaction -Drink plenty of fluids to promote hydration and eat a high-fiber diet to prevent constipation

A nurse is assigned to multiple clients. Which client should the nurse reassess as a priority after administering IV morphine for pain relief? 1. 22yo with sickle cell anemia admitted for acute pain crisis 2. 26yo with pneumonia reporting sharp right side chest pain on deep inspiration 3. 55yo who is 1-day postoperative bowel resection reporting pain at the incision site 4. 67yo with obstructive sleep apnea reporting pain at the fractured right tibia

4. 67yo with obstructive sleep apnea reporting pain at the fractured right tibia Obstructive sleep apnea (OSA) is characterized by partial or complete airway obstruction that occurs from relaxation of the pharyngeal muscles, airway closure, and lack of airflow. This leads to repeated episodes of apnea (more than 10 seconds) and hypopnea (less than or 50% of normal ventilation), resulting in hypoxemia and hypercapnia. Administration of general anesthesia or sedating medications (eg, opioids and benzodiazepines) can exacerbate OSA by decreasing pharnygeal muscle tone and increasing airway closure even further. Therefore, being on continuous positive airway pressure (CPAP) is very important in these clients, esp during sleep. The nurse should assess LOC, lung sounds, vitals igns, and pulse oximeter readings,a nd then compare these with the client's baseline measurements. The nurse should also continue to monitor respiratory status as IV morphine peaks in 20 minutes and has a duration of 3-4 hours.

The charge nurse in the coronary care unit must transfer a client to the medical unit to accommodate another acutely ill client from the emergency department. The nurse suggests the transfer of which client to the health care provider? 1. 52 yo with unstable angina and chest pain at rest who has had 3 normal serum troponin I levels 2. 60 yo with new-onset atrial fibrillation of 140/min who is receiving a continual IV infusion of diltiazem 3. 65 yo admitted last night for third-degree heart block who is awaiting permanent pacemaker placement 4. 78 yo with end-stage heart failure and ejection fraction of 15% whose family is requesting palliative care

4. 78 yo with end-stage heart failure and ejection fraction of 15% whose family is requesting palliative care Palliative and end-of-life care for end-stage heart failure focuses on client-centered interventions to provide symptom and pain relief and psychological and spiritual support, rather than curative interventions. The client w/ end-stage HF, a terminal illness, would be most appropriate to transfer as palliative care can be provided in any health care setting.

The charge nurse is preparing for the admission of an elderly client with delirium and agitation associated with urinary tract infection. To promote client safety, which intervention is most important for the charge nurse to implement? 1. A bed near the nursing station 2. Four-point leather restraints 3. Minimizing environmental stimuli 4. One-on-one supervision from a sitter

4. One-on-one supervision from a sitter

The nurse assesses a client with hyperparathyroidism who had a parathyroidectomy 4 hours ago. Which assessment technique should the nurse use to check for complications in this client? 1. Ask client to place backs of the hands against each other to provide hyperflexion of the wrist while the elbows remain flexed 2. Instruct client to lie down and run the heel of one foot down the shin of the other leg 3. Perform Romberg test by asking the client to stand with eyes closed and feet together 4. Place blood pressure (BP) cuff on arm, inflate to pressure > than systolic BP, and hold in place for 3 minutes

4. Place blood pressure (BP) cuff on arm, inflate to pressure > than systolic BP, and hold in place for 3 minutes Normal serum calcium is 8.6 to 10.2mg/dL. Hypocalcemia is a potential complication of parathyroidectomy b/c the parathyroids regulate calcium levels in the blood. When one or more parathyroids are removed, it may take some time for others that have been dormant during hyperparathyroidism (which causes an increase in serum calcium) to begin regulating serum calcium) Trousseau's sign may indicate hypocalcemia before other signs and sxs of hypocalcemia, such as tetany, occur. Trousseau's sign can be elicted by placing the BP cuff on the arm, inflating to a pressure > than systolic BP, and hold in place for 3 minutes. This will occlude the brachial artery and induce a spasm of the muscles of the hand and forearm when hypocalcemia is present Chevostek's sign is another early indicator of hypocalcemia, should be assessed. It may be elicted by tapping the face at the angle of the jaw and observing for contraction on the same side of the face.

A charge nurse is monitoring a newly licensed registered nurse. What action by the new nurse would warrant intervention by the charge nurse? 1. Administers hydromorphone 1mg to a client who rates pain at 7 on a 1 to 10 scale 2. Notifies physician of occasional premature ventricular beats in a client with myocardial infarction 3. Positions a postoperative pneumonectomy client on the affected side 4. Prepares to administer IVPB potassium chloride via gravity infusion for a client with hypokalemia

4. Prepares to administer IVPB potassium chloride via gravity infusion for a client with hypokalemia Treatment of hypokalemia may require an IV infusion of potassium chloride (KCL). The infusion rate should not exceed 10mEq/hr. Therefore, IVPB KCL must be given via an infusion pump so the rate can be regulated. IV KCL should be diluted and never given in a concentrated amount. Furthermore, too rapid infusion can cause cardiac arrest. The charge nurse would need to intervene if the new nurse was attempting to administer IVPB KCL via gravity infusion instead of a pump.

The nurse teaches a parent how to administer an oral liquid medication to a 2-month-old client. The nurse knows that the parent understands the teaching when the parent does which of the following? 1. Allows the client to sip the medication from a cup 2. Expels the medication from a dropper onto the back of the tongue 3. Mixes the medication in the infant's bottle of formula 4. Using a syringe, administers the medication in small amounts into the back of the cheek

4. Using a syringe, administers the medication in small amounts into the back of the cheek Using a syringe to measure the medication is the most accurate technique to ensure that the proper amount of medication is being administered. The correct procedure for administering oral medication to an infant is to place small amounts of the medication at the back of the cheek, allowing time for the infant to swallow each amount. This technique decreases the risk for choking and ensures that all the medication is consumed.

A nurse is giving instructions related to antibiotic eye drops to the parent of a 5-year-old with bacterial conjunctivitis. Which instruction is most important? 1. Discard tissues used to blot excess medication from the eye immediately 2. Have your child lie down before you instill the eye drops 3. Use warm, moist compresses to remove crusting on eyelids 4. Wash hands before and after eye drop instillation

4. Wash hands before and after eye drop instillation Bacterial conjunctivitis (pink eye) is highly contagious. The hands must be washed properly before and after instilling eye drops and after cleaning away eye drainage or crusting; this is the single best method to prevent the spread of infection to the other eye, the parents, other family members, or anyone else.