2

Before examining the infant of a Mexican American mother, the nurse compliments the child's outfit. The mother becomes visibly distressed. What is the best next action for the nurse to take? 1. Ask the mother's permission to touch the child's hand 2. Interview the mother about the reason for bringing the child to the clinic 3. Reassure the mother that there is no reason for distress 4. Suggest postponing the examination until the mother calms down

1. Ask the mother's permission to touch the child's hand In Latin American culture, an illness called "mal de ojo" ("evil eye") is believed to be caused when a stranger or someone perceived as powerful admires or compliments a child. The "illness," or "curse," is usually manifested by vomiting, fever, and crying. The mal de ojo curse can be broken if the admirer touches the child while speaking to the child or immediately afterward (Option 1). Mexican American mothers may worry when strangers compliment their babies without touching them. To protect against mal de ojo, the child may wear charms or beaded bracelets. If a child is believed to be afflicted with mal de ojo, the parents may consult a traditional healer, or curandero, who may perform rituals meant to cure the child of the curse. (Option 2) Asking the mother about the reason for bringing the child to the clinic will not relieve the mother's distress. (Option 3) This response is nontherapeutic and dismissive, and indicates the nurse's lack of cultural awareness. (Option 4) Postponing the examination does not address the cause of the mother's distress.

Which guiding principle is suitable for dealing with a disaster scenario involving radiation contamination? 1. Assess for copious secretions to determine exposure 2. Assist the victims farthest from the source first 3. Assist the victims with the most severe symptoms first 4. Monitor for diplopia to determine extent of exposure

2. Assist the victims farthest from the source first The key aspects related to radiation exposure are time and distance. The greater the distance, the less dosage received. Acute radiation syndrome has the following phases: prodromal, latent, manifest, and recovery or death. Initially, all victims will appear well; however, the damage is mainly internal, leads to cell destruction, and manifests later on. Victims farthest away from the radiation source are the most salvageable. In this scenario, the principle of disaster nursing is to do the most good for the most people with the available resources. (Option 1) Nerve agents used as biological weapons (eg, sarin) inhibit acetyl-cholinesterase, and their effects are caused by the resulting excess acetylcholine. Common symptoms are miosis, rhinorrhea, copious secretions, shortness of breath, and flaccid paralysis. Treatment is with suction and support ventilation and circulation. However, these symptoms are not related to radiation contamination. (Option 3) Damage from radiation affects the most radiosensitive cells first; these are the hematopoietic, digestive, central nervous system, and cutaneous cells. The presence of severe symptoms indicates extensive internal damage and that the victims are less salvageable in the long term. (Option 4) Neurologic symptoms such as symmetrical descending flaccid paralysis with cranial nerve palsies (ptosis, diplopia, dysphagia, dysphonia) are classic of botulism, which is caused by toxins from the spore-forming anaerobic bacillus Clostridium botulinum. Treatment includes ventilator assistance and the heptavalent botulism antitoxin.

A client is receiving normal saline 75 mL/hr and morphine sulfate via patient-controlled analgesia (PCA) bolus doses. The PCA and normal saline tubing are connected at the "Y" site. The nurse reviews a prescription from the health care provider to discontinue the normal saline. What is the most appropriate nursing action? 1. Change the rate of the normal saline to 10 mL/hr 2. Clarify the prescription with the health care provider 3. Flush the IV with normal saline and then convert it to a saline lock 4. Turn off the normal saline and disconnect it from the "Y" site

2. Clarify the prescription with the health care provider Patient-controlled analgesia (PCA) delivers a set amount of IV analgesic each time the client presses the administration button. With many PCA pumps, a continuous IV solution (eg, normal saline) is required to keep the vein open and flush the PCA medication through the line so that the boluses reach the client. Many facilities have a policy regarding IV fluid for use with PCA; however, a prescription may be required. To ensure uninterrupted delivery of this client's PCA, the nurse should contact the health care provider to clarify the prescription to discontinue the normal saline. (Option 1) A "keep-vein-open" rate (eg, 5-20 mL/hr) may be appropriate; however, a prescription is necessary before the nurse can implement this. (Option 3) This client is still receiving PCA, so it is inappropriate to convert the IV to a saline lock. In addition, this does not address the need to flush the PCA medication through the line. (Option 4) Continuous IV fluids may be required to deliver the PCA boluses; before discontinuing the normal saline, the nurse should receive clarification from the health care provider.

The nurse at the radiological imaging center is admitting a client for an MRI of the right knee. Which information obtained by the nurse should be reported immediately to the prescribing health care provider? 1. The client ate a full breakfast that morning 2. The client has an implantable cardioverter defibrillator (ICD) 3. The client is allergic to povidone-iodine 4. The client took all prescribed cardiac medications before arriving

2. The client has an implantable cardioverter defibrillator (ICD) Radio waves and a magnetic field are used to view soft tissue during MRI. This test is especially useful in diagnosing tumors, disc disease, avascular necrosis, ligament tears, cartilage tears, and osteomyelitis. MRIs can have open or closed chambers. The client should be advised that the procedure is painless but the machine will make loud tapping noises and may cause claustrophobia in some clients inside a closed chamber. MRI is contraindicated in clients with aneurysm clips, metallic implants such as ICDs, pacemakers, electronic devices, hearing aids, and shrapnel. The large magnet of the MRI can damage the ICD or interfere with its function. (Options 1 and 4) MRI is a noninvasive test that does not require anesthesia. The client is not required to have nothing by mouth and can take medications as normally indicated. (Option 3) No povidone-iodine (Betadine) is used during an MRI; gadolinium contrast is used.

A nurse is teaching a parent of an infant about administration of an oral medication. What should be included in the teaching? Select all that apply. 1. Add the medication to the formula bottle before feeding 2. Ask the pharmacy to flavor the medication 3. Hold the infant in a semi-reclining position during administration 4. Use a universal dropper for medication 5. Use the nipple of a bottle to administer the medication

2 3 5 Children can have difficulty accepting oral medications due to their aftertaste. Most medications are provided in a manner that is accepted by children, but the pharmacy has flavorings that can be mixed with a medication to improve its taste. A parent can be instructed to mix medication with jam, ice cream, or pudding to mask an aftertaste. Oral medication should be administered with the infant in a semi-reclining position, which is similar to the feeding position. This position promotes comfort, prevents aspiration, and may be better controlled by the nurse if the child should resist the medication. Placing the prescribed dosage of medication in an empty nipple as the child sucks is a convenient approach to medication administration. (Option 1) Medications are never mixed in a bottle of infant formula as this can affect the taste and the child may then refuse the formula. Also, if the child does not complete the full feed dosage, miscalculations will occur. (Option 4) Droppers are inaccurate as dosage depends on viscosity of the medication and differences in the size of dropper openings. Also, medication may cling to the wall of the dropper. If a dropper is supplied, it should be used only with the specific medication that accompanied it and not to measure other medications. A preferred method of administration is the plastic disposable medication syringe or medicine spoon, which is accurate and can be placed directly in the child's mouth.

A student nurse asks why enteral (tube) feedings, rather than total parenteral nutrition (TPN), are being administered to a client with sepsis and respiratory failure. Which is the best response by the registered nurse? 1. "Enteral feedings have no complications." 2. "Enteral feedings maintain gut integrity and help prevent stress ulcers." 3. "Enteral feedings provide higher calorie content." 4. "Risk of hyperglycemia is lower with enteral feedings than with TPN."

2. "Enteral feedings maintain gut integrity and help prevent stress ulcers." Stress ulcers are a common complication in critically ill clients because the gastrointestinal tract is not a preferential organ. In the presence of hypoxemia, blood is shunted to the more vital organs, increasing the risk of stress ulcers. The early initiation of enteral feedings helps preserve the function of the gut mucosa, limits movement of bacteria (translocation) from the intestines into the bloodstream, and prevents stress ulcers. Enteral feedings are also associated with lower risk of infectious complications compared with TPN. However, the mortality is the same. (Option 1) Complications/problems commonly associated with enteral feedings include aspiration, tube displacement, hyperglycemia, diarrhea, abdominal distension, enteral tube misconnections, and clogged tubes. (Option 3) Caloric and metabolic needs can usually be met adequately using enteral feedings or TPN. Multiple enteral or TPN formulas are available to meet individual client needs. If metabolic demands are not being met using enteral feedings alone, TPN can be added. (Option 4) Illness-related stress hyperglycemia (gluconeogenesis) occurs in clients receiving both enteral feedings and TPN.

The family of a terminally ill, dying client verbalizes concern that the client is becoming dehydrated due to poor fluid intake. When the family asks the nurse about administering IV fluids, the nurse's response is based on an understanding of which statement? 1. Providing artificial hydration at the end of life will make the client feel more comfortable 2. The decision whether to provide artificial hydration should consider client preferences and goals 3. The health care provider will prescribe artificial hydration when the client can no longer swallow 4. Withholding artificial hydration at the end of life speeds up the dying process

2. The decision whether to provide artificial hydration should consider client preferences and goals The decision about providing artificial nutrition to a dying client is complex. Although certain situations involving terminal illness, such as a terminally ill client who wants to attend an important family function, can justify the decision to provide IV fluids, providing artificial hydration in other situations may not be justified and may even be harmful. Ethical principles dictate that client preferences should be respected and that clients/family members have the right to make decisions about artificial nutrition and hydration at the end of life. (Option 1) Artificial hydration does not seem to help dying clients feel more comfortable, and IV fluids could cause distressful symptoms such as respiratory distress, vomiting and diarrhea, and the need for urinary catheterization. (Option 3) The majority of hospice and palliative health care providers do not recommend routine administration of artificial hydration. (Option 4) There is no evidence that withholding artificial hydration at the end of life speeds up the dying process. Research indicates that dying clients who do not receive artificial hydration live just as long as those who do receive IV fluids.

The charge nurse must assign rooms to 4 clients who are scheduled for admission. Which client has the highest priority for a private room assignment? 1. Client who is a known IV drug abuser who has osteomyelitis of the arm and chronic hepatitis C 2. Client with chronic obstructive pulmonary disease who has a latent tuberculosis infection 3. Client with diabetes mellitus and HIV infection who is in diabetic ketoacidosis 4. Client with pneumonia who has a positive methicillin-resistant Staphylococcus aureus nose culture

4. Client with pneumonia who has a positive methicillin-resistant Staphylococcus aureus nose culture A client with a positive nose swab for methicillin-resistant Staphylococcus aureus (MRSA) is colonized and can transmit the bacteria to others. If signs of infection are absent, treatment is not required. Colonized clients are at increased risk for infection with MRSA; if signs (eg, fever, wound drainage, purulent mucus) are present, treatment is required. The Centers for Disease Control and Prevention (CDC) recommends placing a colonized client on contact precautions and in a private room. The CDC also recommends that the highest priority be given to placing a colonized client who may transmit the bacteria through body secretions or excretions (eg, sputum, wound drainage) in a private room. Therefore, the client with pneumonia should be placed in the private room. (Options 1 and 3) The CDC recommends standard precautions for clients with hepatitis C and those who are HIV positive. A private room is not necessary for a client who has osteomyelitis or diabetic ketoacidosis. (Option 2) A client with a latent tuberculosis infection (LTBI) has a positive tuberculin skin test, has no symptoms of infection, and is not contagious. Immunosuppressant drugs, chemotherapy, and debilitating disease can convert a LTBI to active disease. At this time, the client requires only standard precautions.

The nurse working in an intensive care unit receives a prescription from the primary health care provider to discontinue a triple-lumen subclavian central venous catheter. Which interventions will help prevent air embolism on removal? Select all that apply. 1. Applying an air-occlusive dressing 2. Instructing the client to bear down 3. Instructing the client to lie in a supine position 4. Pulling the line harder if there is resistance 5. Pulling the line out when the client is inhaling

1 2 3 To prevent air embolism when discontinuing a central venous catheter, the nurse should perform the following interventions: Instruct the client to lie in a supine position. This will increase the central venous pressure and decrease the possibility of air getting into the vessel (Option 3). Instruct the client to bear down or exhale. The client should never inhale during removal of the line; inhalation will suck more air into the blood vessel via negative suction pressure (Options 2 and 5). Apply an air-occlusive dressing (usually gauze with a Tegaderm dressing) to help prevent a delayed air embolism. If possible, the nurse should attempt to cover the site with the occlusive dressing while pulling out the line (Option 1). Pull the line cautiously and never pull harder if there is resistance. Doing so could cause the catheter to break or become dislodged in the client's vessel (Option 4). Educational objective:

The nurse is caring for a client who is having a thoracentesis. Following the procedure, the nurse monitors for complications. The initial postprocedure monitoring plan should include what? Select all that apply. 1. Level of alertness 2. Lung sounds 3. Oxygen saturation 4. Respiratory pattern 5. Temperature 6. Urine output

1 2 3 4 Thoracentesis is commonly used to treat pleural effusion. The health care provider (HCP) will prepare the skin, inject a local anesthetic, and then insert a needle between the ribs into the pleural space where the fluid is located. A complication of thoracentesis is pneumothorax, which occurs when the needle goes into the lung and causes the lung to slowly deflate, like a balloon with a small hole in it. Bleeding is another, yet less common, complication of the procedure. Signs of pneumothorax include increased respiratory rate, increased respiratory effort, respiratory distress, low oxygen saturation, and absent breath sounds on the side where the procedure was done (where the lung is collapsed) (Options 2, 3, and 4). Tension pneumothorax may also develop, with tracheal shift to the unaffected side, severe respiratory distress, and cardiovascular compromise. Altered level of consciousness may occur due to decreased oxygenation and blood flow to the brain (Option 1). A tension pneumothorax may be prevented by early detection of pneumothorax through appropriate monitoring. (Option 5) Infection would be a later complication (occurring a few days after the procedure), so monitoring temperature is not required during the initial postprocedure period. (Option 6) Urine output should not be affected by thoracentesis or the drugs administered for this procedure.

Which measures will help prevent falls in the elderly clients of a long-term care facility? Select all that apply. 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, especially those including gait, balance, and strength training, not only reduce the risk of falls but also prevent injuries from falls (Option 1). Vision impairment can contribute to fall risks; most adults need additional light by age 50. The nurse should ensure that clients are wearing needed prescription glasses (Option 2). Handrails, particularly in stairwells, hallways, and bathrooms, have been shown to reduce falls (Option 3). 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 (Option 5). (Option 4) Non-slip rubber-soled shoes are recommended to prevent falls.

The nurse caring for a client diagnosed with HIV uses which infection prevention and control measures? Select all that apply. 1. Gloves when contact with body fluids is anticipated 2. Gloves when starting an intravenous line 3. Gown, gloves, face shield, and goggles for every client encounter 4. Hand hygiene before and after providing client care 5. N95 respiratory mask and face shield

1 2 4 Hand hygiene is performed before and after providing client care. HIV is a blood-borne virus, and standard precautions are sufficient protection against viral transmission. The nurse wears gloves when anticipating exposure to blood or body fluids. Isolation gowns are applied if the nurse anticipates splashing of body fluids on clothing. A face shield and goggles are applied if splashing in the eyes is a possibility. The nurse should always don gloves when starting an intravenous line. (Option 3) This would be an acceptable level of protective equipment if the client undergoes a non-sterile procedure with significant splash risk, such as vaginal delivery. (Option 5) Face shields are used when splashing on the face or in the eyes is anticipated. A N95 respirator mask is used when caring for a client with airborne isolation precautions.

A 2-year-old is admitted to the emergency department for anaphylactic reaction to a bee sting. The nurse teaches the parent about emergency use of epinephrine injection. Which statement indicates that the parent understands the instruction? Select all that apply. 1. "I will keep an epinephrine injection in close proximity to my child at all times." 2. "I will give the injection if my child has trouble breathing after a bee sting." 3. "I will give the injection in the upper arm." 4. "The injection can be given through clothing." 5. "If I give the injection, I'll still take my child to the emergency room."

1 2 4 5 A critical part of self-care for a person with a history of anaphylactic reaction is the use of emergency epinephrine injection (EpiPen or EpiPen Jr). The client and/or caregiver should be taught the following principles: The EpiPen should always be available for emergency use and so should be taken along (in purse, pocket, backpack) when the client leaves home (Option 1) The EpiPen should be given when the client first notices any anaphylactic symptoms, such as tightening or swelling of the airway, difficulty breathing, wheezing, stridor, or shock (Option 2) The injection should be given in the mid-outer thigh and can be given through clothing (Options 3 and 4) The client should receive emergency care as soon as possible by calling 911 or going to the emergency department to monitor for further problems (Option 5)

The nurse is preparing to administer medications to the clients. Which client attributes are acceptable for use as client identifiers? Select all that apply. 1. Day, month, and year of birth 2. Last name 3. Medical record number 4. Primary care provider (PCP) 5. Room number

1 3 "The right client" is one of the 6 "rights" of administering medications. Two identifiers are used by comparing client statements or information on the identification band with the client's medication administration record. An identifier should be permanent and unique to the client. Acceptable identifiers include first and last name, medical record number, and birth date (Options 1 and 3). (Option 2) An acceptable name identifier must include both first and last names. More than one client can have the same last name. (Option 4) The name of the PCP is not an acceptable client identifier. It could change, and it is not unique to the client. (Option 5) The room number is not an acceptable client identifier; it could change and may not be unique to the client.

The nurse is providing postmortem care for a client who just died after a long illness and hospitalization. The client had a do-not-resuscitate order in place at the time of death. A family member was at the bedside when the client died. What interventions should the nurse include during postmortem care? Select all that apply. 1. Allow family member to assist with care 2. Call the medical examiner for an autopsy 3. Place a pad under the perineum 4. Remove lines and tubes from the body 5. Remove the client's dentures

1 3 4 Before proceeding with postmortem care, the nurse should consider the need for autopsy and whether the client is an organ donor. Care should be conducted with respect and dignity, providing opportunities for family participation and accommodating religious and cultural rituals when possible (Option 1). To perform postmortem care: Maintain standard or isolation precautions in place at the time of death. Gently close the client's eyes. Remove tubes and dressings per policy, unless an autopsy or organ harvest is pending (Option 4). Straighten and wash the body and change the linens. Handle the body carefully, as tissue damage and bruising occur easily after circulation has ceased. Replace dentures so the face maintains its shape. It is difficult to place dentures once rigor mortis sets in (Option 5). A towel folded under the chin may be needed to keep the jaw closed. Place a pad under the perineum to absorb any stool or urine leaking from relaxed sphincters (Option 3). Raise the head of the bed to prevent blood from pooling and discoloring the face. Remove equipment and soiled linens from the room. Give client belongings to a family member or send with the body. (Option 2) This client's death was expected. It is not necessary to contact the medical examiner for autopsy.

Which equipment warnings indicate a clinical issue with a client and not an issue with the programming of the equipment or a mechanical failure? Select all that apply. 1. The glucometer displays "HI" from a blood specimen of a client with diabetic ketoacidosis 2. The intravenous infusion pump display lights up and sounds an alarm for a few seconds when turned on 3. The patient-controlled analgesia (PCA) pump indicates it is unable to read the barcode on the medication vial 4. The pulse oximeter does not register a heart rate pulsation or reading in a client with peripheral vascular disease 5. The ventilator high pressure alarm sounds for a client intubated for acute respiratory distress syndrome

1 4 5 The following reflect a client's physiologic state and not equipment malfunction: Option 1: "HI" is displayed when a client's glucose is too high (usually 500 mg or above). Option 4: When a client does not have adequate circulation/perfusion at the location of the sensor, the pulse oximeter cannot locate an adequate pulsation and give a reading. Option 5: Ventilators sound an alarm to indicate high pressure when the machine is sensing increased resistance. The nurse should check to see if suctioning is needed (mucus causing resistance), if tubing is bent/kinked, or if tension pneumothorax is present. It is also possible that a client has a deteriorating lung condition causing the high pressure alarm to sound. The alarm is related to the client's condition and is not an indication of ventilator malfunction. (Option 2) The pump performs a self-check when activated. This is an issue with the pump, not the client. (Option 3) A built-in safety mechanism on the Hospira PCA pump triggers a displayed message that the machine cannot read the barcode. This can happen if the vial is turned incorrectly and is not in line with the pump's reader. Some older models will also shut down if the barcode is not read correctly. Validate that the correct vial is being used and is properly positioned. This equipment warning indicates an issue with the nurse or the vial, not the client.

The nurse is assigned to care for 5 clients using assistance from an experienced unlicensed assistive personnel (UAP). Which tasks should the nurse assign to the UAP? Select all that apply. 1. Emptying a urinary drainage bag and recording output 2. Emptying and recharging a Hemovac drain 3. Escorting a disgruntled visitor off the unit 4. Providing perineal care around the Foley catheter with soap and water 5. Reapplying sequential compression devices

1 4 5 In order to delegate appropriately, the nurse must observe the five rights of delegation to ensure that unlicensed assistive personnel (UAP) have the skills and experience required to perform the task. UAP are able to do basic tasks that require little assessment and are safe for them to perform. Obtaining a clean catch urine specimen, emptying a urinary drainage bag (Option 1), and providing perineal care around the Foley catheter with soap and water (Option 4) are all basic tasks that can be safely performed by a UAP. However, specimen collection from a Foley catheter is considered a sterile procedure and should not be assigned to a UAP. Reapplying sequential compression devices can also be delegated to a UAP (Option 5). (Option 2) A Hemovac or Jackson-Pratt wound drain needs to be assessed to ensure it is working properly. Although a UAP can measure the drainage, assessing the functioning of the drain and the drainage, as well as recharging the drain, should be performed by a nurse. (Option 3) With a disgruntled visitor, there may be a need for skilled communication to keep the situation from escalating. The visitor should be escorted off the unit by either a nurse or a security officer.

The nurse observes a student nurse administer a tuberculin skin test using the intradermal route. The nurse intervenes when the student performs which action? 1. Advances tip of needle through epidermis until the bevel is no longer visible under the skin 2. Chooses a 1 mL tuberculin syringe with a 27-gauge 1/4 inch needle; dons clean gloves 3. Injects medication slowly while raising a small wheal (bleb) on the skin 4. Inserts needle at a 10-degree angle almost parallel to skin with the bevel up

1. Advances tip of needle through epidermis until the bevel is no longer visible under the skin Intradermal dermal injections deliver a small amount of medication (0.1 mL) into the dermal layer of the skin, just under the epidermis. This parenteral route is used to perform allergy testing and tuberculosis (TB) screening. The correct procedure for administering a TB intradermal injection is as follows: Choose a 1 mL tuberculin syringe with a 27-gauge 1/4 inch needle then don clean gloves - the syringe is calibrated in hundredths of a millimeter and the intradermal needle is short enough to remain in the dermis with length range of 1/4-5/8 inch (Option 2). Position the left forearm to face upward, and cleanse site that is a hands width above the wrist - the left arm is commonly used for TB testing; the forearm has little hair and subcutaneous tissue and is readily accessible to observe a skin reaction. Place non-dominant hand 1 inch below the insertion site and pull skin downward so that it is taut - taut skin makes it easier to insert the needle and promotes comfort. Insert the needle almost parallel to skin at a 10-degree angle with bevel up - this is important as the medication can enter the subcutaneous tissue if the angle is >15 degrees (Option 4). Advance the tip of the needle through epidermis into dermis; outline of bevel should be visible under the skin - verify that the medication will be injected into dermis (Option 1). Inject medication slowly while raising a small wheal (bleb) on the skin - verify that the medication is being deposited into the dermis (Option 3). Remove needle and do not rub the area - rubbing promotes leakage through the insertion site and medication deposition into the tissue. Circle the area with a pen to assess for redness and induration (according to institution policy) - this delineates the border for measurement of reaction.

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. (Option 2) The situation is no longer diffusible. Quoting authoritative rules will not likely have the desired effect as the client has lost control (and may not be in touch with reality). The nurse's priority is to move out of harm's way. (Option 3) Staff members should call security immediately and/or institute a back-up staff/takedown protocol. The fire alarm will activate a call to a fire department, which is not the type of help needed. However, when security arrives, the "best-trained brain" remains in control and the nurse should direct the actions of the team. (Option 4) When violence (eg, throwing a fire extinguisher) occurs, trying to defuse the situation verbally is no longer the priority.

The nurse is inserting an indwelling (Foley) urinary catheter into a male client. After inserting the catheter about 6 in (15.2 cm), the nurse notes drops of urine in the tubing. What action should the nurse take next? 1. Further insert the catheter 1-2 in (2.5-5.1 cm) 2. Have the client hold his breath 3. Immediately inflate the 5 mL balloon 4. Secure the tubing to the client's leg

1. Further insert the catheter 1-2 in (2.5-5.1 cm) Urine could be in the urethra and evident in the tubing even though the tip with the balloon is not in the bladder. It is necessary to further insert the catheter before inflating the balloon to make sure the tip is in the bladder and not the urethra (causing urethral trauma). In the male client, it is recommended that the catheter be inserted 7-9 in (17-22.5 cm) or until urine flows out, due to the longer urethra. The catheter should then be inserted at least an additional 1 in (2.5 cm) or to catheter bifurcation. (Option 2) The client should be told to take slow, deep breaths to help relax the external sphincter and provide a distraction. (Option 3) The catheter needs to be inserted further before inflating the balloon to prevent urethral trauma. (Option 4) Securing the catheter to the leg occurs after the balloon is inflated and placement is assured.

The nurse collects a sputum specimen from a client with pneumonia. Which directions should the nurse give to the client before collecting the specimen? Select all that apply. 1. "Cough deeply and expectorate into the clean specimen container." 2. "Cough deeply and expectorate into the sterile specimen container." 3. "Inhale deeply several times." 4. "Rinse your mouth with mouthwash." 5. "Rinse your mouth with water." 6. "Sit upright or on the side of the bed."

2 3 5 6 Sputum collection is prescribed to identify respiratory pathogens (eg, in the setting of bacterial pneumonias or tuberculosis). Collection should be done in the morning, as secretions accumulate overnight. A nebulizer treatment may be prescribed to help mobilize secretions. To collect a sputum specimen, the nurse should instruct the client to: Rinse the mouth with water to reduce specimen contamination by oral flora Sit on the side of the bed, if possible, or in a high or semi-Fowler position to allow maximum lung ventilation and expansion Inhale deeply several times to provide enough air to force secretions from the lower airways to the pharynx Cough deeply to raise enough sputum (4-10 mL), and expectorate into the sterile specimen container The nurse should immediately close and label the specimen container as this will prevent contamination or transmission of microorganisms and assure proper client information. The specimen and requisition are transported to the laboratory per policy; some specimens must be sent immediately, and others may be refrigerated. The nurse should then provide oral care for the client and document pertinent information (eg, sputum characteristics, tolerance of procedure). (Option 1) Sputum collection is a sterile procedure. (Option 4) Mouthwash can alter flora in the sample and affect the results.

A behavioral health clinic nurse assesses a 23-year-old client who started taking paroxetine 3 weeks ago. Which statement made by the client is most important for the nurse to investigate? 1. "I don't have much of an appetite since starting this medication." 2. "I have a lot more energy, but I'm feeling just as depressed." 3. "I have been feeling dizzy when I walk around at home." 4. "I have experienced frequent headaches lately."

2. "I have a lot more energy, but I'm feeling just as depressed." Selective serotonin reuptake inhibitors (SSRIs) (eg, fluoxetine, paroxetine, sertraline, citalopram) are used to treat a number of psychiatric conditions (eg, major depressive disorder, generalized anxiety disorder). Clients usually see therapeutic effects in 1-4 weeks. SSRIs may increase the risk of suicide, especially in young adults (age 18-24) during initial therapy or after a dosage increase. A client who reports increased energy without a change in depressive feelings needs to be assessed and monitored for suicidal ideation or actions as the client may now have the energy to execute the suicide plan (Option 2). Common, expected side effects of SSRIs include: Loss of appetite; weight loss or weight gain (Option 1) Gastrointestinal disturbances (nausea, vomiting, diarrhea) Headaches, dizziness, drowsiness, insomnia (Options 3 and 4) Sexual dysfunction Side effects should gradually diminish over 3 months, although some may persist. If symptoms are intolerable or a particular SSRI is ineffective, the client may be switched to a different antidepressant.

The emergency department nurse receives report on 4 clients. Which client will the nurse prioritize for placement in an isolation room? 1. 4-year-old diagnosed with scabies who has red burrows and bumps along the neckline and inner elbows 2. 7-year-old diagnosed with measles who has a fever, conjunctivitis, cough, and maculopapular rash 3. 12-year-old with a positive rapid influenza test who has a fever, cough, and runny nose 4. 14-year-old with 4-inch wound on inner aspect of thigh with a positive culture for methicillin-resistant Staphylococcus aureus

2. 7-year-old diagnosed with measles who has a fever, conjunctivitis, cough, and maculopapular rash Infectious agents that are spread by air currents are among the most contagious of pathogens. Therefore, clients with airborne infections (measles, tuberculosis, varicella, severe acute respiratory syndrome) should be isolated first using airborne precautions. These infections are spread via very small particles that circulate in the air. Clients with airborne infections are placed in an isolation room with negative pressure that provides air exchange or with a high-efficiency particulate air filtration system. (Option 1) Clients with scabies will be placed in contact isolation. The 4-year-old is contagious, but only if direct contact is made. Therefore, isolating the client with airborne precautions is the priority. (Option 3) Clients with influenza are placed on droplet precautions. The 12-year-old can spread pathogens via large droplets released into the air when coughing, sneezing, or talking. The client would be the second priority for isolation. (Option 4) Clients with methicillin-resistant Staphylococcus aureus infection are placed on contact precautions. The 14-year-old is contagious, but only if direct contact is made. The client requires isolation but is not a priority over the client whose pathogens are airborne.

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? 1. Assess the client's orthostatic blood pressure 2. Assist the client to a sitting position 3. Hold and walk with the client 4. Keep the client on bed rest

2. Assist the client to a sitting position 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.

The nurse observes a client who is postoperative total right hip replacement use a cane. Which action by the client indicates an understanding of the correct technique when walking down the stairs? 1. Descends with the cane on the step first, followed by the left leg and then the right leg 2. Descends with the cane on the step first, followed by the right leg and then the left leg 3. Descends with the left leg on the step first, followed by the cane and then the right leg 4. Descends with the right leg on the step first, followed by the left leg and then the cane

2. Descends with the cane on the step first, followed by the right leg and then the left leg To provide maximum support, when climbing up and down any stairs, the client should keep 2 points of support on the floor at all times (eg, both feet or a foot and the cane) and move the cane just before moving the weaker leg, regardless of the direction. When descending stairs, the client should: Lead with the cane Bring the weaker leg down next (in this client, it is the right leg) Finally, step down with the stronger leg (Option 2) When ascending stairs, the client should: Step up with the stronger leg first Move the cane next while bearing weight on the stronger leg Finally, move the weaker leg The nurse may use the mnemonic "up with the good and down with the bad." Cane always moves before the weaker leg.

A client started a 24-hour urine collection test at 6:00 AM. The unlicensed assistive personnel (UAP) reports discarding a urine specimen of 250 mL at 10:00 AM by mistake but adding all specimens to the collection container before and after that time. What action should the nurse take? 1. Add 250 mL to the total output after the 24-hour urine collection is complete tomorrow morning 2. Discard urine and container, and restart the 24-hour urine collection tomorrow morning 3. Discard urine and container, have client void, add urine to new container, and then restart test 4. Relabel the same collection container, and change the start time from 6:00 AM to 10:00 AM

2. Discard urine and container, and restart the 24-hour urine collection tomorrow morning Timed urine collection tests are usually done to assess kidney function and measure substances excreted in the urine (eg, creatinine, protein, uric acid, hormones). These tests require the collection of all urine produced in a specified time period (a crucial step) to ensure accurate test results. The proper container (with or without preservative) for any specific test is obtained from the laboratory. The collection container must be kept cool (eg, on ice, refrigerated) to prevent bacterial decomposition of the urine. Not all of the client's urine was saved during the collection period. Therefore, the nurse or UAP must discard the urine and container and restart the specimen collection procedure. Although a 24-hour urine collection can begin at any time of the day after the client empties the bladder, it is common practice to start the collection in the morning after the client's first morning voiding and to end it at the same hour the next morning after the morning voiding (Option 2). (Option 1) Adding 250 mL to the total output when the test is completed is not an appropriate action as the actual urine output from the 24-hour period is needed for accurate results. (Option 3) To start the collection period, the nurse asks the client to void and discards this specimen (it is not added to the collection container). The 24-hour period starts at the time of the client's first voiding. (Option 4) Relabeling the same container and changing the start time from 6:00 AM to 10:00 AM is not an appropriate action. The container would include part of the urine produced in a 28-hour period, and the test results would be inaccurate.

The nurse plans care for a client who has a positive Romberg test. The nurse will prioritize which intervention? 1. Monitor gag and swallowing reflexes closely 2. Provide for client assistance with ambulation 3. Provide sensory stimulation 4. Speak at a normal volume while facing the client directly

2. Provide for client assistance with ambulation The Romberg test, part of a focused neurologic examination, assesses clients' perceptions of their head in space (vestibular function) and body in space (proprioception). It is used to determine the reason for loss of coordination (ataxia). Clients are asked to stand with the feet together and hands at the sides of the body. They are then asked to close their eyes while ability to maintain balance is assessed. A loss of balance is considered to be a positive Romberg sign and indicates that ataxia is sensory in nature rather than cerebellar. Clients demonstrating a positive Romberg test are likely to have ataxia, or be prone to lose balance, and would require assistance with ambulation. (Option 1) Damage to the glossopharyngeal and vagus nerves (cranial nerves IX and X) would cause problems with swallowing and the gag reflex. (Option 3) Providing for sensory stimulation is important in many disorders of the neurologic system. However, this would not be needed for a client with a positive Romberg test. (Option 4) Speaking at a normal voice while facing a client directly is a measure used for those with hearing loss.

The charge nurse must assign a semi-private room to a client with diabetes mellitus admitted for IV antibiotic therapy to treat leg cellulitis. Which of the 4 room assignments is the best option for this client? 1. Room 1: Client 1 day postoperative laparoscopic cholecystectomy who is awaiting discharge 2. Room 2: Client with dementia and urinary incontinence wearing an external urine collection device 3. Room 3: Client with history of splenectomy 15 years ago, now admitted for pulmonary embolism 4. Room 4: Client with lupus nephritis who is prescribed treatment with azathioprine

2. Room 2: Client with dementia and urinary incontinence wearing an external urine collection device Cellulitis is a common skin bacterial infection that is usually treated with IV antibiotics in clients with diabetes mellitus. Room 2 is the best assignment option for this client with cellulitis. The client with dementia and urinary incontinence who has an external urinary condom catheter is the least susceptible to infection compared to those in rooms 1, 3, and 4. (Option 1) The client who is 1 day postoperative laparoscopic cholecystectomy (surgical procedure with small incisions) is at increased risk for infection. The client with cellulitis should not be placed in room 1. (Option 3) Although this client has pulmonary embolism, the history of prior splenectomy leads to a very high lifelong risk of rapid sepsis. Splenectomy clients need vaccination against encapsulated organisms (eg, pneumococcus, meningococcus, and Haemophilus influenzae type B). Even a low-grade fever should be taken seriously in these clients. The client with cellulitis should not be placed in room 3. (Option 4) Lupus nephritis is a serious renal complication of systemic lupus erythematosus (SLE), an inflammatory autoimmune disease that can lead to end-stage kidney disease. The systemic disease and the immunosuppressant (azathioprine [Imuran]) prescribed to slow its progression increase infection risk. The client with cellulitis should not be placed in room 4.

The nurse is drawing a blood specimen from a client's central line. Identify the steps necessary to prevent transmission of infection while performing this procedure. Select all that apply. 1. Discard the first 6-10 mL of blood drawn from the line 2. Flush the line with sterile normal saline before and after collection 3. Perform hand hygiene 4. Place the specimen in a biohazard bag 5. Scrub the catheter hub with antiseptic prior to use

3 4 5 Blood and bodily fluids are considered hazardous materials and must be placed in containers identifying them as biohazards (eg, biohazard bag) (Option 4). This alerts staff to take the necessary precautions to prevent infection transmission when handling the specimen. Other procedures to prevent transmission of infection include: Meticulous hand hygiene (Option 3) Use of disposable gloves during collection and handling of specimen Cleaning the specimen bag with a disinfecting wipe Proper and immediate transport of specimen to the lab Avoiding placing specimen in clean areas (eg, nursing station) An appropriate antiseptic (eg, 70% alcohol) scrub of the catheter hub prior to use inhibits microorganism entry and prevents transmission of infection to the client (Option 5). (Option 1) When drawing a blood specimen from a central line, the nurse should discard the first blood drawn to prevent an inaccurate lab result, but this will not prevent the transmission of infection. (Option 2) Flushing the line prior to specimen collection will clear any previous infusions and assist in checking patency. It is important to flush the line after collection to remove blood and prevent clotting. Neither action prevents infection transmission.

The nurse is interviewing a non-English-speaking client. Which best practices will the nurse use when working with a professional medical interpreter for clients of limited English proficiency? Select all that apply. 1. Address the interpreter directly 2. Ask the client's adult child to translate 3. Hold a pre-conference with the interpreter 4. Identify any gender or age preferences 5. Speak in short sentences

3 4 5 Title IV of the Civil Rights Act of 1964 initiated national standards for appropriate care of culturally diverse clients. Clients with limited English proficiency have the right to receive medical interpreter services free of charge. When working with an interpreter, the nurse should apply the following best practices to maximize communication and understanding with the client: Address the client directly in the first person Speak in short sentences, pausing to allow the interpreter to speak (Option 5) Ask only one question at a time Avoid complex issues, idioms, jokes, and medical jargon Hold a pre-conference with the medical interpreter to review the goals of the interview (Option 3) Use a qualified professional interpreter whenever possible The nurse should avoid using interpreters from conflicting cultures (eg, Palestinian, Jewish) and be mindful of any cultural, gender, or age preferences (Option 4). (Option 1) The nurse should speak directly to the client, not the interpreter. (Option 2) A family member or friend may not have the vocabulary, knowledge, or skills to provide the best communication for the client. Untrained interpreters may omit or simplify critical pieces of information if they do not understand the terminology.

The nurse is caring for an agitated client with dementia who is pulling at the oxygen and IV tubing. Wrist restraints are applied after less-restrictive safety measures have been ineffective. Which actions are appropriate to protect the client from injury? Select all that apply. 1. Attach wrist restraint straps to the upper side rails 2. Position the client supine to keep restraint straps taut 3. Release restraints at regular intervals and assess behavior 4. Use a square knot to tie restraint straps to the bed 5. Use gauze to pad bony prominences under restraints

3 5 When caring for a client in restraints, the nurse should implement these interventions at regular intervals, according to agency policy (eg, every 2 hours): Provide skin care and range-of-motion exercises. Ensure basic needs are met (eg, fluids, nutrition, elimination). Assess skin integrity and neurovascular status of restrained extremities. Pad bony prominences under restraints if necessary to protect skin (Option 5). Determine need for continued restraint by releasing restraints briefly and assessing the client's reaction. Regularly assessing need for restraints promotes discontinuation of restraints as soon as possible (Option 3). (Option 1) Attach restraint straps to part of the bed frame that moves with bed position changes (eg, raising and lowering head of the bed). Never attach restraints to side rails, which may cause injury when side rails are lowered. (Option 2) Positioning a restrained client supine increases aspiration risk as the client may be unable to reposition self if vomiting occurs. Side-lying or semi-Fowler's position promotes drainage of emesis or oral secretions. (Option 4) Restraint straps should be tied in a quick-release knot, in case of emergency, and never in a square knot, which is difficult to release quickly.

The public health nurse conducts a program at the community senior citizen center about preventing falls at home. Which statement made by a participant indicates that further education is needed? 1. "I bought a new nightlight for the hallway to the bathroom." 2. "I feel so much more secure wearing my electronic fall alert device." 3. "I walk in my stockings at home because it helps to relieve my bunion pain." 4. "My daughter helped me secure the small, thin rug in my kitchen with strong tape."

3. "I walk in my stockings at home because it helps to relieve my bunion pain." According to the Centers for Disease Control and Prevention, 1 out of 3 adults aged >65 experience a fall every year. Walking barefoot or while wearing stockings increases the risk of slipping on slick surfaces. Shoes or slippers with non-skid soles should be worn inside and outside of the home. There are multiple simple strategies that can help reduce falls in the home environment and these include: Exercising regularly for 30 minutes 3 times/week increases strength, balance, coordination, and flexibility; therefore, decreasing fall risk. Maintaining a well-lit, clutter-free environment (eg, adding nightlights and removing or securing area rugs to the floor with double-sided tape) (Options 1 and 4). Using grab bars and non-skid bath mats in the bathroom. Wearing shoes or slippers with non-skid soles, both inside and outside of the home. Periodically reviewing medications and side effects (eg, orthostatic hypotension) with a pharmacist and/or health care provider (HCP). Getting regular vision exams. Wearing an electronic fall alert device. The fear of falling increases fall risk and these devices provide the security of knowing help is available immediately if a fall occurs (Option 2).

A client expresses concern about facial appearance after surgery for excision of a melanoma on the side of the nose. What is the best response by the nurse? 1. "Have you shared your concerns with your health care provider (HCP)?" 2. "If I were you, I would be more worried about whether the melanoma has spread." 3. "Scar tissue formation is part of the natural healing process. We will teach you how to care for your wound to minimize any complications." 4. "There is special make-up you can use to hide any facial scars left from the surgery."

3. "Scar tissue formation is part of the natural healing process. We will teach you how to care for your wound to minimize any complications." Clients facing surgery often have concerns and anxiety over the procedure, postoperative course, outcome, and issues related to altered body image. The best response by the nurse uses 2 therapeutic approaches aimed at reducing the client's concerns and anxiety: The client is provided with factual information about facial surgery and the healing process. The client is given assurance and support that something can be done to minimize the complications of wound healing. This will provide the client with a plan of action and a sense of control over the condition and post-surgical course. It is impossible to predict the lasting effect of the surgery on the client's facial appearance; however, teaching on managing wound care will help lessen the client's anxiety. (Option 1) This is not the best or priority response. Although the HCP will be able to give the client more information and details about the surgery and potential outcomes, the response suggests that the nurse has little or no role in providing information or teaching the client about the upcoming procedure. The response is also a "yes" or "no" question; closed-ended questions tend to minimize nurse-client interactions. (Option 2) This is a non-therapeutic response; it gives advice to the client, suggests that the nurse "knows better," and minimizes the client's concerns. It also introduces a more serious issue about the diagnosis. (Option 4) This is a non-therapeutic response. Although it is true that there are methods to conceal scars and other skin discolorations, the response is dismissive and does not address the client's concerns.

The medical surgical nurse cares for a client who had a mediastinal tumor removed 2 days ago and reports difficulty breathing. The client becomes confused and restless, and respirations are 30/min. What is the nurse's next action? 1. Administer a dose of prescribed prn anti-anxiety medication 2. Call the health care provider who performed the surgery 3. Call the rapid response team 4. Place the client in the left lateral recovery position

3. Call the rapid response team The rapid response team (RRT) consists of a group of health care providers who bring critical care expertise to the bedside of clients demonstrating early signs of deterioration such as dyspnea, confusion, and restlessness. This team differs from the "Code" team that is called when a client stops breathing or goes into cardiac arrest. Any health care worker can call the RRT. (Option 1) The client's restlessness and confusion are likely secondary to low oxygenation. Anxiety will cause hyperventilation, which will only exacerbate the situation. However, administering anti-anxiety medication is not the priority over obtaining help quickly. In addition, the client's oxygenation could deteriorate depending on the prescribed anti-anxiety medication, which could depress respirations. (Option 2) The health care provider who performed the surgery must be notified of the client's deteriorating condition; however, this should be done after calling the RRT. Stabilizing the client is the priority. (Option 4) The recovery position is used as a first aid measure for an unconscious client who is still breathing. The client is placed on the left or right side in a three-fourths prone position with the top leg flexed. This position maintains the airway and ensures that the client does not choke on vomit.

The nurse notes muffled heart tones in a client with a pericardial effusion. How would the nurse assess for a pulsus paradoxus? 1. Check for variation in amplitude of QRS complexes on the electrocardiogram strip 2. Compare apical and radial pulses for any deficit 3. Measure the difference between Korotkoff sounds auscultated during expiration and throughout the respiratory cycle 4. Multiply diastolic blood pressure (DBP) by 2, add systolic blood pressure (SBP), and divide the result by 3; [(DBP x 2) + (SBP)]/3

3. Measure the difference between Korotkoff sounds auscultated during expiration and throughout the respiratory cycle Muffled heart tones in a client with pericardial effusion can indicate the development of cardiac tamponade. This results in the build-up of fluid in the pericardial sac, which leads to compression of the heart. Cardiac output begins to fall as cardiac compression increases, resulting in hypotension. Additional signs and symptoms of tamponade include tachypnea, tachycardia, jugular venous distension, narrowed pulse pressure, and the presence of a pulsus paradoxus. Pulsus paradoxus is defined as an exaggerated fall in systemic BP >10 mm Hg during inspiration. The procedure for measurement of pulsus paradoxus is as follows: Place client in semirecumbent position Have client breathe normally Determine the SBP using a manual BP cuff Inflate the BP cuff to at least 20 mm Hg above the previously measured SBP Deflate the cuff slowly, noting the first Korotkoff sound during expiration along with the pressure Continue to slowly deflate the cuff until you hear sounds throughout inspiration and expiration; also note the pressure Determine the difference between the 2 measurements in steps 5 and 6; this equals the amount of paradox The difference is normally <10 mm Hg, but a difference >10 mm Hg may indicate the presence of cardiac tamponade. (Option 1) Variation in QRS amplitude is termed electrical alternans. It could be present in cardiac tamponade, but it is not how pulsus paradoxus is determined. Electrical alternans is due to the swinging motion of the heart in a fluid-filled pericardial sac. (Option 2) An apical/radial pulse deficit may be present during certain dysrhythmias, but this is not the procedure for measuring pulsus paradoxus. (Option 4) This is the formula for calculating mean arterial pressure.

he nurse admits a client who fell off a 20-ft (6-m) ladder. On arrival in the emergency department, the client is arousable but lethargic. What is the nurse's priority action? 1. Ask about client's chronic medical conditions 2. Assess for level and duration of pain 3. Obtain a Glasgow Coma Scale score 4. Perform a head-to-toe assessment

3. Obtain a Glasgow Coma Scale score After trauma to a client (eg, fall), the nurse performs an emergency or trauma assessment that includes a primary and secondary survey (assessment). The primary assessment determines the status of the airway, breathing, and circulation (ABCs). Next, the nurse evaluates disability (D) of neurological function using the Glasgow Coma Scale (GCS). The GCS measures the client's level of consciousness by assessing the best eye opening response, best verbal response, and best motor response. The lower the GCS score, the higher the risk for the client to develop complications (eg, loss of airway patency, increased intracranial pressure). (Options 1, 2, and 4) Although a health history, head-to-toe assessment, and notation of the client's level of pain are essential for the overall assessment, they are considered part of the secondary survey. This survey's purpose is to get a complete picture of the injuries, but only after the client's priority needs have been addressed.

A home health nurse is teaching the spouse of an elderly client who experienced a stroke ways of reducing risks for falls in the home. Which suggestion by the spouse would be the most effective plan to prevent falls? 1. Have a respite caregiver come once a week to stay with the client so the spouse can go shopping 2. Purchase a walker for the client to use when ambulating around the home 3. Remove all area rugs and install grab bars in the bathroom 4. Take the client for an annual eye exam and new glasses

3. Remove all area rugs and install grab bars in the bathroom All of the choices are appropriate options to reduce falls in the home, but the one with the greatest impact is the removal of all area rugs and installation of grab bars in the bathroom. Area rugs can still cause falls for the client with a walker, with new glasses, and with someone present. In addition, many falls occur in the bathroom while toileting and bathing, making grab bars highly beneficial. (Option 1) Not leaving the client alone is preferable and could decrease the incidence of falls while the spouse is away. However, it is less effective than the removal of area rugs and installation of grab bars in the bathroom. (Option 2) A walker would be beneficial for this client but could get caught on an area rug. (Option 4) Poor eyesight can contribute to falls, but the removal of rugs and installation of grab bars will have a greater impact.

A 3-month-old infant is treated in the emergency department for a spiral femur fracture. The parent reports that the infant sustained the injury after rolling off the bed. What is the priority nursing action? 1. Document a description of the injury 2. Question the mother about where the infant sleeps 3. Report the injury per facility protocol 4. Separate the mother from the infant

3. Report the injury per facility protocol The parent's account of this injury is inconsistent with the developmental milestones of a 3-month-old infant, as the muscles required for rolling over do not develop until age 4-5 months. Additionally, spiral femur fractures indicate that pressure was applied to the leg in opposite directions (torsion), which is an unlikely accidental injury in a nonambulatory child. Fractures in young children, especially nonambulatory infants, are always of concern and suspicious of child abuse. The nurse's priority is to report suspected child maltreatment to the appropriate authorities following facility protocol as required by law in the United States and Canada (Option 3). However, the nurse should also be aware of cultural health practices (eg, cupping, coining) and physiologic conditions (eg, hemophilia, Mongolian spots) mimicking maltreatment. After reporting suspected maltreatment, the nurse should: Facilitate a complete physical evaluation (eg, skeletal survey, growth/development comparisons, radiographic studies, neurologic examination) Document facts and observations objectively, using medical terms when possible (Option 1). Include the history provided by the parent or caregiver and the time period from injury occurrence to evaluation. Perform a review of child-care practices with the caregiver (Option 2). (Option 4) A child and caregiver should only be separated when the child is in immediate physical danger or if authorities must interview a verbal child without the parent present.

A client calls the nurse to report exacerbation of chronic lower back pain after working in the yard all weekend. Knowing that this worsened back pain is probably due to acute inflammation, the nurse recommends which nonpharmacologic intervention? 1. Heating pad 2. Positioning for comfort 3. Rest from pain-aggravating activities 4. Stretching exercises

3. Rest from pain-aggravating activities Acute exacerbation of chronic back pain is usually associated with inflammation triggered by (strenuous and/or repetitive) activities that stress the previously injured area. Interventions should be directed toward reducing inflammation. Nonpharmacologic intervention to treat the inflammation includes rest from pain-aggravating activities which may continue to promote inflammation and delay healing. (Option 1) Applying heat to the injured area can promote the inflammatory process (via vasodilation); therefore, this is not the best intervention at this time. However, after the acute inflammation has resolved (usually within a few days) heat application would be appropriate to reduce pain and muscle spasms. (Option 2) Although the nurse should teach the client to ensure positioning for comfort to reduce pain, this is less likely to impact the inflammatory processes causing the pain. (Option 4) Stretching exercises can also be helpful for back pain but should begin after the acute pain and inflammation have subsided.

Unlicensed assistive personnel report 4 situations to the registered nurse. Which situation warrants the nurse's intervention first? 1. Room 1: Client on a 24-hour urine collection had a specimen discarded by mistake 2. Room 2: Client and family request clergy to administer last rites 3. Room 3: Puncture-resistant sharps disposal container on the wall is full 4. Room 4: Client with diabetes mellitus has an 8 AM fingerstick glucose of 80 mg/dL (4.4 mmol/L)

3. Room 3: Puncture-resistant sharps disposal container on the wall is full Health care workers are required to abide by Occupational Safety and Health Administration standards and regulations to reduce work-related injuries (eg, sharps) and exposure to bloodborne pathogens (eg, HIV, hepatitis B and C). A sharps disposal container should not be overfilled and should be replaced on a regular basis to reduce the risk for a needle stick during disposal. (Option 1) If any urine is discarded by accident during a 24-hour collection test, the procedure must be restarted. A new container will need to be labeled with the appropriate times and date, but immediate intervention is not required. (Option 2) The nurse will arrange for a visit from clergy to administer the last rites (Sacrament of the Sick), a religious ceremony for Roman Catholic clients who are extremely or terminally ill. Although the situation requires prompt intervention, it does not involve a safety hazard. (Option 4) A fingerstick glucose of 80 mg/dL (4.4 mmol/L) is normal (70-110 mg/dL [3.9-6.1 mmol/L]) and requires no intervention unless the client received insulin and refuses or is unable to eat.

The nurse is caring for a 48-year-old executive on the cardiac unit who has just been diagnosed with primary hypertension. Which teaching strategy implemented by the nurse is most likely to be effective for this client? 1. Leave diet pamphlets for the client to review at a later time 2. Refer the client to the nurse case manager to follow up with diet instructions 3. Sit with the client during meal selections and assist with identification of low sodium options 4. Turn the television on in the client's room to the patient education channel to watch

3. Sit with the client during meal selections and assist with identification of low sodium options When teaching clients and caregivers, the nurse must keep in mind several principles of adult learning. These include the learner's: Need to know Readiness to learn Prior experiences Motivation to learn Orientation to learning Self-concept Adults learn best when teaching provides information that the client views as being needed immediately. Readiness to learn is increased if the client perceives a need, has the belief that the change in behavior has value, or perceives the learning activity as new and stimulating. The client's age and occupation may help to determine the vocabulary the nurse uses during teaching. Sitting down with the client to assist with the choice of items on the menu that are low in sodium actively involves the client and provides immediately applicable information. (Option 1) Pamphlets will be helpful to reinforce the teaching that the nurse has already done in the hospital with the client directly. (Option 2) The primary nurse or the nurse case manager can refer the client to be seen by a dietician before leaving the hospital or to follow up with one when discharged. This will be helpful to the client, but the opportunity to teach when the information is immediately applicable is preferred. (Option 4) The hospital's education channel is a good source of information for the client, but it does not actively involve the client in the teaching.

There has been a large-scale community disaster and clients must be roomed together at the hospital. Who are appropriate roommates in light of infection risk principles? Select all that apply. 1. A client diagnosed with varicella and a client with pertussis 2. A client placed in an airborne infection isolation room (AIIR) and a client with heart failure 3. A client receiving chemotherapy and a client with chronic obstructive pulmonary disease (COPD) coughing yellow sputum 4. A client with pelvic inflammatory disease (PID) and a client with coffee ground emesis 5. Two clients diagnosed with tuberculosis

4 5 PID is an acute infection of the upper genital tract. The most common organisms are Chlamydia and Neisseria gonorrhea; PID would not be contagious by being in the same room. There is no infection risk for a client with gastrointestinal bleeding (Option 4). Clients with the same organism can room together (Option 5). (Option 1) Varicella (chicken pox, herpes zoster) requires airborne precautions (and contact precautions also if open lesions are present). Pertussis requires droplet precautions. Both the precautions and the organisms are different, and the clients could cross-infect each other. (Option 2) An AIIR (formerly negative-airflow room) is indicated when the client has an organism transmitted by the airborne route (eg, tuberculosis). No other client should be in the room with a client with this type of infection, especially one with a significant co-morbidity. (Option 3) Chemotherapy causes bone marrow suppression with immunosuppression. Although the client may not need reverse or protective isolation (eg, when absolute neutrophil count is ≤500/mm3), an infectious client should not be placed with this client. Yellow sputum typically indicates bacterial infection. COPD clients can have chronic colored sputum, but infection (bacterial or viral) is the primary cause of exacerbations (the most likely reason the client is in the hospital). This is not a safe option.

The nurse cares for a child with bed bug bites. Which parent statement indicates that further teaching is required? 1. "I need to have the entire house treated by pest control to ensure the bed bugs are gone." 2. "I should concentrate on alleviating scratching as it can cause further complications." 3. "My other family members and pets are at risk of bed bug bites." 4. "This must have happened because I did not wash the bed sheets this week."

4. "This must have happened because I did not wash the bed sheets this week." It is a common misconception that bed bugs are drawn only to dirty environments. They can inhabit any environment and can travel and spread easily in clothing, bags, furniture, and bedding. Although they do not pose significant harm, bed bugs can cause an itchy red rash that can be uncomfortable and affect sleep. Bed bugs should be exterminated, especially in a home with children. (Option 1) It is important to treat the entire house for bed bugs. Washing a single pillowcase or blanket will not stop the infestation. Bed bugs multiply quickly and can hide in any crevice. Once pest control is complete, the home will need to be monitored for signs of lingering bugs. (Option 2) Bed bug bites can cause a rash that clients, especially children, will be inclined to scratch. Precautions should be taken to help alleviate the rash as itching can cause complications such as secondary skin infections. (Option 3) Once a home is infested, the bugs can travel quickly and occupy spaces and crevices. All household members and pets will be afflicted.

A 25-year-old client is about to undergo a unilateral orchiectomy for treatment of testicular cancer. The client says to the nurse, "I'm so worried that my future spouse is going to call off our engagement." What is the best response by the nurse? 1. "Are you concerned about how the surgery will affect your sexuality?" 2. "If you are concerned about infertility, you could always bank your sperm." 3. "The cancer is at an early stage. You are going to be fine." 4. "What have you and your future spouse discussed about your condition?"

4. "What have you and your future spouse discussed about your condition?" A diagnosis of testicular cancer is very often a source of anxiety for a client and can cause concern about sexual performance and fertility. How a client's sexuality is affected by this diagnosis depends on how advanced the cancer is and the course of prescribed treatment. Decisions about sperm banking and/or whether the client wants to procreate in the future are best made prior to surgery, radiation, and/or chemotherapy. The client and significant others need to be given counseling and the opportunity to discuss the potential effects of treatment and the options for preserving sperm. In this scenario, the client's stated concern about the future with the partner may be the way of voicing concern about how the surgery will affect sexuality. In order to determine what counseling or information this client needs, it is most important for the nurse to first assess the client's knowledge of the condition and what the client and the future spouse have already discussed. In addition, by using the therapeutic communication techniques of presenting a general lead and exploration, the nurse can facilitate the conversation and the nurse-client relationship. (Option 1) This is not the best response as it requires a short, single answer from the client and does not provide the opportunity for exploration or elaboration. "Yes" or "no" questions are useful and necessary in some client-nurse interactions. However, generally they are considered to be nontherapeutic as they are not conversation enhancers. (Option 2) Banking sperm is an option for clients with testicular cancer. However, it is more important for the nurse to first explore the client's concerns and knowledge about the condition. (Option 3) This statement by the nurse may be giving false reassurance to the client. In addition, it blocks further discussion or exploration of the client's knowledge about the condition and related concerns.

Which client is most at risk for hospital-acquired methicillin-resistant Staphylococcus aureus (MRSA)? 1. 15-year-old student athlete in the emergency department with a fractured femur 2. 46-year-old with a large abdominal incision and 2 peripheral IV lines 3. 72-year-old who received a permanent pacemaker 24 hours ago 4. 80-year-old with chronic obstructive pulmonary disease (COPD) who is on a ventilator

4. 80-year-old with chronic obstructive pulmonary disease (COPD) who is on a ventilator Clients at highest risk for hospital-acquired MRSA are older adults and those with suppressed immunity, long history of antibiotic use, or invasive tubes or lines (hemodialysis clients). Clients in the intensive care unit (ICU) are especially at risk for MRSA. The 80-year-old client with COPD in the ICU on the ventilator has several of these risk factors. COPD is a chronic illness that can affect the immune system, and clients experience exacerbations that may require frequent antibiotic and corticosteroid use. This client is elderly and also has an invasive tube from the ventilator. (Option 1) A student athlete could be colonized with MRSA from time spent in locker rooms and around athletic equipment. MRSA more often appears as skin infections in this age group. Unless this client has an open fracture, there is no break in skin integrity. (Option 2) This client does have an incision (portal of entry) and invasive lines but is younger and has no evidence of suppressed immunity. (Option 3) This client is older and does have a small surgical incision but is not as high risk as the client with COPD. All clients undergoing pacemaker placement will receive a prophylactic antibiotic to prevent surgical site infection just before surgery.

A client is scheduled for an elective laparoscopic prostatectomy in the morning. The nurse should notify the health care provider (HCP) about which assessment data as soon as possible before surgery? 1. Hemoglobin 15 g/dL (150 g/L), hematocrit 45% (0.45) 2. International Normalized Ratio (INR) 1.3 3. Platelet count 295,000/mm3 (295 × 109/L) 4. Temperature 100.4 F (38 C) with cough

4. Temperature 100.4 F (38 C) with cough Low-grade temperature and cough could indicate the presence of an infection, and the nurse should report these findings to the HCP as soon as possible before surgery. The administration of anesthesia in a client with a fever and cough can exacerbate an unknown viral or bacterial condition, increase the risk for postoperative pneumonia, and interfere with the postoperative healing process. The HCP may prescribe further testing, consult the anesthesia professional, postpone the elective surgery, or proceed with the surgery depending on the individual situation and type of surgery scheduled. (Options 1, 2, and 3) Hemoglobin (13.2-17.3 g/dL [132-173 g/L]), hematocrit (39%-50% [0.39-0.50]), and platelet count (150,000- 400,000/mm3 [150-400 × 109/L]) levels are within normal ranges and do not indicate increased risk for a bleeding problem. Normal INR is 0.75-1.25; 1.3 is only borderline elevation and would not increase the bleeding risk.

The nurse is caring for a client with end-stage liver disease who was admitted for bleeding esophageal varices. The bleeding varices were banded successfully, but the client declined having a transjugular intrahepatic portal-systemic shunt (TIPS) procedure and opted for do not resuscitate (DNR) status. Which topic is most important for the nurse to discuss with the client and family at discharge? 1. Complete abstinence from alcohol 2. Proper use of medications including lactulose 3. The importance of calling the healthcare provider (HCP) immediately if bleeding recurs 4. The purpose and use of the DNR bracelet

4. The purpose and use of the DNR bracelet A client with end-stage liver disease is at high risk for life-threatening events such as bleeding esophageal varices and hepatic encephalopathy. This client continues to be at risk for bleeding varices due to the declined TIPS procedure, which could have prevented further esophageal varices by treating the portal hypertension. This client who is DNR in the hospital should be discharged with a DNR bracelet or an active Physician Orders for Life-Sustaining Treatment (POLST) form in the community setting. This should be done to ensure that the client's wishes for emergency care will be carried out by first responders. (Option 1) Abstinence from alcohol will help delay the progression of end-stage liver disease and its complications. However, this is not always realistic for a client with long-term alcohol addiction. In addition, this client with end-stage liver disease who has chosen to be DNR may also choose to continue drinking if this is deemed important to quality of life. Even though the nurse may not approve of this choice, the client is the one who ultimately makes personal lifestyle and health management decisions. (Option 2) Lactulose and other medications are necessary for managing end-stage liver disease. However, this topic is less important than emergency response and advance care planning issues, particularly in a client with a new DNR order and recent history of bleeding esophageal varices. (Option 3) Although the client and family should know what to do if bleeding recurs, it would be more appropriate to call 911 than the HCP in this emergency situation. In addition, this topic is not as important as the discussion on DNR bracelet use which already covers emergency care for any type of situation.

The charge nurse must assign a room for a client with dementia who was transferred from a long-term care facility and is scheduled for extensive surgical debridement of a stage 4 pressure ulcer. Which room assignment is the most appropriate for this client? 1. Room A: Client with multiple myeloma who is being treated with corticosteroids 2. Room B: Client with diabetes mellitus and osteomyelitis receiving IV antibiotics 3. Room C: Client with a gastrointestinal bleed who has a nasogastric tube set to low suction 4. Room D: Client with an acute migraine headache attack who requires IV analgesia every 2 hours

3 Surgical debridement of a stage 4 pressure ulcer involves using a scalpel to remove necrotic (eschar) or infected tissue from the wound to promote healing. The most appropriate room assignment for this client is Room C, as the client with a gastrointestinal bleed and nasogastric tube is the least susceptible to infection when compared with the clients in rooms A and B. (Option 1) Multiple myeloma is a cancer that involves proliferation of malignant plasma cells (monoclonal antibodies), which are ineffective in providing protection against infection and suppress normal bone marrow cell production (eg, red blood cells, platelets, white blood cells). This client is especially vulnerable to infection due to immunosuppression related to the disease process and to drug therapy with corticosteroids. (Option 2) The postoperative client should not be assigned to a room with a client who has osteomyelitis, an infection of bone. (Option 4) The client with a severe migraine requires frequent administration of analgesia and antiemetic medications, and a quiet dark environment with minimal stimuli to help induce sleep. This is not an appropriate room assignment, as surgery and change of environment can increase agitation, hyperactivity, and disorientation in a client with dementia; these require frequent nursing interventions to maintain safety.

The nurse is conducting a home visit to assess an elderly client with advanced heart failure who lives alone. When the nurse asks about sodium intake, the client becomes angry and says, "I'm so tired of people telling me what to do! I'm going to eat what I want, so leave me alone!" Which of the following is the most appropriate response by the nurse? 1. "I can tell that you want me to go, so I will call in a few days to see how you are doing." 2. "I know you are frustrated with losing control of your life." 3. "It sounds like you are angry. Tell me what's bothering you." 4. "Okay. I'll just check your blood pressure and then go."

3. "It sounds like you are angry. Tell me what's bothering you." The client exhibits anger, which is likely a sign of grief due to loss of control from illness. However, the source of the client's anger is not clear. Therefore, further assessment is now indicated to understand more about the client's feelings and perceptions. Verbalizing feelings may also help the client to move past anger toward acceptance of the loss. The nurse's statement, "It sounds like you are angry" reflects the nurse's perception of the client's emotion and will allow the client to clarify feelings. The open-ended probing statement, "Tell me what's bothering you," facilitates assessment of the client's concerns without making any assumptions about them. This approach will promote accurate assessment of the client's needs and concerns. It will also prevent premature closure, incorrect assumptions, and escalation of the client's anger.

A nurse has received report from the off-going shift that a client is confused and has been identified as a high risk for falls. The nurse shares this information with the unlicensed assistive personnel (UAP). Which finding by the nurse requires intervention? 1. UAP has attached a bed alarm to the client's gown and bed 2. UAP has been making hourly rounds on the client 3. UAP has lowered the bed and raised all 4 side rails 4. UAP has placed a fall risk ID bracelet on the client's wrist

3. UAP has lowered the bed and raised all 4 side rails Placing the client's bed in the lowest position is appropriate, but raising all 4 side rails is considered a form of restraint. Having all 4 side rails up may actually increase clients' risk for falls as they may try to climb up and over the rails. Raising 2-3 side rails is appropriate. The nurse should lower at least one side rail and communicate to the UAP that having all 4 up is inappropriate. (Option 1) Placing a bed alarm would be an appropriate intervention for this client. (Option 2) Making rounds at least hourly is appropriate for this client. The nurse should assess if more frequent rounds are warranted. (Option 4) Placing a fall risk ID band will help communicate to other members of the interdisciplinary team that the client is at risk for falls.

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. (Option 1) It would be better for the nurse to perform the dressing change as the wound is already infected. The client may be able to assist in the home setting. (Option 2) Clean gloves can be used for removal but not for application of a new dressing. (Option 4) Sterile gloves are not needed to remove the existing dressing. A gown and goggles may be required if splashing is possible.

An adult client is admitted with back pain and found to have a metastatic tumor on the spine. The health care provider (HCP) explains that the client has few months to live and is likely to become totally paralyzed below the waist soon. The next day, the client tells the nurse of wanting to be discharged despite the HCP's recommendation that the client stay a few more days. Which is the most appropriate initial response by the nurse? 1. "I understand your desire to leave, but it would be very risky." 2. "I will ask the palliative care nurse to talk with you to help clarify your care goals." 3. "I will let the HCP know that you want to be discharged and do everything I can to make it happen." 4. "Tell me more about your need to leave the hospital."

4. "Tell me more about your need to leave the hospital." Knowing that this client has just received bad news with a limited prognosis, the nurse should anticipate that the client's urgent request for discharge may be due to concerns about needing to complete unfinished business while still functioning. Examples of end-of-life "business" include concerns about family, finances, business responsibilities, and dealing with property and possessions. To get more information, the nurse should assess the client's concern and the motivation behind the request by asking an open-ended question, such as "Tell me more about ______." It is important to gain the client's trust, to actively listen, and to avoid immediately jumping to problem-solving during this assessment (Option 4). With the information gained from the assessment, the nurse will be able to problem-solve with the client while intervening and advocating as appropriate. (Option 1) Although leaving may be risky for the client, the nurse's warning is not an appropriate initial action. (Option 2) The nurse is not taking the time to listen but is passing this responsibility to another member of the team. A palliative care nurse referral may be appropriate in this situation, but the nurse needs more information and must take the time to listen to the client now. (Option 3) This option does not acknowledge the HCP's concern about the client still needing to be hospitalized. The nurse must first understand the client's situation and then take this information to the HCP to negotiate for a solution that acknowledges the concerns of both. Educational objective: A client facing the end of life often has unfinished business that needs to be completed, which may motivate the client to become anxious or insist on discharge. The nurse should assess the client's concern and use this information to design a care plan that will allow the client to make necessary preparations while ensuring medical care to control symptoms.

The nurse helps the health care provider perform a thoracentesis at the bedside. In which of the following positions does the nurse place the client to facilitate needle insertion and promote comfort? 1. Fetal position, lying on unaffected side with knees draw to the abdomen and hands clasped around them 2. Lying on the affected side with head of the bed elevated to 30-45 degrees 3. Prone with head turned to the affected side and arms over the head, supported by a pillow 4. Upright leaning forward over the bedside table, with arms supported on pillows

4. Upright leaning forward over the bedside table, with arms supported on pillows During a thoracentesis, a needle is inserted into the pleural space to remove fluid for diagnostic or therapeutic purposes. Before the procedure, the nurse places the client in an upright sitting position on the side of the bed, leaning forward over the bedside table, with arms supported on pillows. This position ensures that the diaphragm is dependent, facilitates access to the pleural space through the intercostal spaces, and promotes client comfort. (Option 1) The fetal position is appropriate for a client having a lumbar puncture, not a thoracentesis. (Option 2) If unable to sit, the client can be positioned lying on the unaffected, not affected, side. (Option 3) Prone position is not used for this procedure, is uncomfortable, and would make it more difficult for a client with dyspnea to breathe.

Calculate total net fluid intake for an 8-hour shift by adding oral intake, parenteral intake, and amount of dialysate retained.

Calculate total net fluid intake for an 8-hour shift by adding oral intake, parenteral intake, and amount of dialysate retained.

A client with acute ST-elevation myocardial infarction intends to leave the hospital now against medical advice (AMA) regardless of what is recommended. The client is determined to be competent to make personal decisions. Which of the following is the most important for the nurse to do before the client leaves the building? 1. Insist the client sign the AMA form 2. Provide the client with a copy of hospital results 3. Reassure that the client can return later 4. Remove the intravenous catheter

4. Remove the intravenous catheter A competent client can refuse medical treatment and leave against medical advice (AMA). The nurse should inform the health care provider (HCP) immediately. If the client decides to leave the facility, even after the HCP and nurse explain the consequences (including death), or cannot wait until the HCP speaks with the client, the client should be allowed to do so. It is most important that the client's IV catheter be removed to prevent complications (eg, infections) and misuse (eg, access for illicit drug injections). The nurse should document the fluid infused, the site's appearance, and the integrity of the IV catheter. (Option 1) The goal is for the client to always have an informed refusal and to sign the legal form to indicate understanding of that information. However, if the client refuses to sign, the client is still allowed to leave (failure to do so constitutes false imprisonment). The nurse should have witnesses to the events and clearly document in the chart what happened and that the client refused to sign. (Option 2) Discharge instructions, results, and prescriptions can be given despite the client leaving AMA. However, it is not essential to provide the clients with results. Removing the catheter is the priority. (Option 3) Reassuring that a client can return is ethical as the desire is for the client to receive needed care. However, it is not a priority over removal of the catheter.

The nurse receives report on 4 clients. Which client should be seen first? 1. Client with amyotrophic lateral sclerosis experiencing increased dysarthria 2. Client with chronic obstructive pulmonary disease reporting increasing leg edema 3. Client with strep throat and fever of 102 F (38.9 C) on antibiotics for 12 hours 4. Client with urolithiasis reporting wavelike flank pain and nausea

Amyotrophic lateral sclerosis (ALS) is characterized by the progressive loss of motor neurons in the brainstem and spinal cord. Clients have spasticity, muscle weakness, and atrophy. Neurons involved in swallowing and respiratory function are eventually impaired, leading to aspiration, respiratory failure, and death. Care of clients with ALS focuses on maintaining respiratory function, adequate nutrition, and quality of life. There is no cure, and death usually occurs within 5 years of diagnosis. The client with ALS and worsening ability to speak (dysarthria) may also have dysphagia and respiratory distress; this client should be seen first (Option 1). (Option 2) The client with chronic obstructive pulmonary disease and peripheral edema may have cor pulmonale, or right-sided heart failure, from vasoconstriction of the pulmonary vessels. Cor pulmonale is treated with long-term, low-flow oxygen; bronchodilators; and diuretics. This client should be seen second. Right-sided heart failure (peripheral edema) is not as dangerous as left-sided heart failure (pulmonary edema). (Option 3) Fever often occurs with strep throat and may persist for ≥24 hours after initiation of antibiotics. This client should be seen last and should receive an antipyretic. (Option 4) Wavelike flank pain is characteristic of urolithiasis (urinary stones). This client needs pain medication and, possibly, further treatment (eg, lithotripsy) and should be seen third.

A home health nurse visits a client with chronic obstructive pulmonary disease. The nurse teaches the client to use abdominal breathing to perform the "huff" cough technique to facilitate secretion removal. Place the steps in the correct order. All options must be used.

Coughing is an important lung defense mechanism. Clients with chronic obstructive pulmonary disease (COPD) have weakened muscles and narrowed airways that are prone to collapse when under increased pressure. They are therefore unable to generate the high pressure needed to create the explosive rush of air to cough effectively. The low-pressure "huff" cough, which uses a series of mini-coughs, is more effective in mobilizing and expectorating secretions in clients with COPD. When this technique is done correctly, there is less airway collapse, less energy and oxygen consumption, and greater secretion removal. The steps are as follows: Position upright - maximizes lung expansion and gas exchange Inhale through the nose using abdominal breathing and prolong the exhalation through pursed lips for 3 breaths - deflates excess air from lungs Hold breath for 2-3 seconds following an inhalation, keeping the throat open - opens glottic structures and prevents a high-pressure cough Deeply inhale and, while leaning forward, force the breath out gently using the abdominal muscles while making a "ha" sound (huff cough); repeat 2 more times (eg, "ha, ha, ha") - keeps airways open while moving secretions up and out of the lungs. Inhale deeply using abdominal breathing and give one forced huff cough - the last, increased force ("ha") usually results in mucus being expectorated from the larger airways.

The nurse educates a client with obstructive lung disease in the correct use of a short-acting beta agonist metered-dose inhaler without the use of a spacer. Place the steps in the correct order.

Inhalation devices include metered-dose inhalers (MDIs), dry powder inhalers, and nebulizers. The devices deliver a measured dose of medication with each actuation. They are primarily used to treat respiratory disorders but may also be used for some nonrespiratory conditions (eg, diabetes, analgesia). The inhaled route is preferred for beta agonist, anticholinergic, and steroid medications as it causes fewer side effects than the PO route Correct use of the MDI is necessary to receive the full benefit from inhaled medication. The steps are as follows: Shake canister well for about 3-5 seconds. Tilt head back slightly and exhale slowly for 3-5 seconds. Hold canister mouthpiece about 1½ inches in front of open mouth; as an alternative, place the mouthpiece in the mouth with lips sealed around it. Holding it in front of the open mouth prevents impaction of the particles into the tongue and sides of mouth. Compress canister while inhaling slowly for about 3-5 seconds. Hold breath for 10 seconds, if possible, before exhaling. Wait at least 1-2 minutes before taking a second puff of a bronchodilator, if prescribed. The first puff of medication dilates the bronchioles and allows easy passage of the second puff.

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

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

The nurse assesses the breath sounds of a 2-day postoperative total laryngectomy client and determines that suctioning is needed to clear secretions. The client is off the mechanical ventilator and is receiving humidified oxygen via a tracheostomy mask. Place the steps for suctioning the tracheostomy tube in the correct order. All options must be used.

When performing the suctioning procedure, the nurse follows institution policy and observes principles of infection control and client safety. Strict aseptic technique is maintained because suctioning can introduce bacteria into the lower airway and lungs. Place the client in semi-Fowler's position, if not contraindicated, to promote lung expansion and oxygenation. Preoxygenate with 100% oxygen (hyper-oxygenate) to prevent hypoxemia and microatelectasis. Alternately, if the client is breathing room air independently, ask the client to take 3-4 deep breaths. Insert the catheter gently the length of the airway without applying suction to prevent mucosal tissue damage. The distance can be premeasured (0.4-0.8 in [1-2 cm] past the distal end of the tube). Withdraw the catheter slightly (0.4-0.8 in [1-2 cm]) if resistance is felt at the carina (bifurcation of the left and right mainstem) to prevent mucosal tissue damage. Apply intermittent suction while rotating the suction catheter during withdrawal to prevent mucosal tissue damage. Limit suction time to 5-10 seconds with each suction pass to prevent mucosal tissue damage and limit hypoxia.

A client with anemia is receiving a blood transfusion. Fifteen minutes after the transfusion starts, the nurse notes a drop in blood pressure from 110/70 mm Hg to 84/50 mm Hg. The client reports "feeling a little cold." Which actions should the nurse take? Place them in the correct order.

It is important for the nurse to remain with the client for the 1st 15 minutes after starting a blood transfusion to watch for signs of a reaction. These signs include fever, chills, nausea, vomiting, pruritus, hypotension, decreased urine output, back pain, and dyspnea. The client may report a variety of symptoms ranging from none to a feeling of impending doom. If signs of a transfusion reaction occur, the nurse should: Stop the transfusion immediately Using new tubing, infuse normal saline to keep the vein open Continue to monitor hemodynamic status and notify the health care provider of the client's status (Options 1 and 3) Administer any emergency or prescribed medications to treat the reaction; these may include vasopressors, antihistamines, steroids, or intravenous fluids. Collect a urine specimen to be assessed for a hemolytic reaction Provide support and reassurance to the client and family Document the occurrence, notify the blood bank, and send remaining the blood and tubing set back to the blood bank for analysis

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. Your Response/ Incorrect Response Clamp the catheter tubing Place the client in Trendelenburg position on the left side Notify the health care provider (HCP) Administer oxygen as needed Stay with the client and provide reassurance Correct Response Clamp the catheter tubing Place the client in Trendelenburg position on the left side Administer oxygen as needed Notify the health care provider (HCP) Stay with the client and provide reassurance

Leakage of more than 500 mL 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 100 mL/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: Clamp the catheter to prevent more air from embolizing into the venous circulation. Place the client in Trendelenburg position on the left side, causing any existing air to rise and become trapped in the right atrium. Administer oxygen if necessary to relieve dyspnea. Notify the HCP or call an RRT to provide further resuscitation measures. Stay with the client to provide reassurance and monitoring as the air trapped in the right atrium is slowly absorbed into the bloodstream over the course of a few hours.

A 2-year-old who swallowed an overdose of adult cough syrup is being discharged from the emergency department. The parent says to the nurse, "From now on, I'm going to store all medicines in my top dresser drawer." Which is the best response by the nurse? 1. "Can you lock your dresser drawer?" 2. "Make sure all of your medicines have childproof caps." 3. "That sounds like a safe plan." 4. "You need to keep an eye on your child at all times."

1. "Can you lock your dresser drawer?" Children are naturally curious and attracted to medicine, especially if it is sweet and syrupy like many over-the-counter cold products. They usually find medicines when exploring their environment and "getting into everything" when no one is watching. Children may find medicine in a parent's coat pocket or purse, under a counter cabinet, or on a nightstand. Even if a drug is stored in a place that seems out of reach, children can climb on a chair or stool to reach it. Medications are the leading cause of child poisoning. The best preventive measures include placing all medications out of sight, placing them in a drawer or cabinet with a childproof lock, and putting them away after each use (Option 1). (Option 2) Advising a parent/caregiver to ensure that medicine containers have childproof caps is an appropriate instruction; however, it is not the priority response in this situation. (Option 3) Storing medicines in a dresser drawer is not a safe plan unless the drawer can be locked. (Option 4) Although it is impossible for a parent or caregiver to watch a child every minute of the day, toddlers need adult supervision when active and exploring their environment.

An adolescent client is brought to the emergency department after being in a serious motor vehicle crash. The client is undergoing cardiopulmonary resuscitation. The nurse calls the family to inform them to come to the hospital and a family member asks how the client is doing. Which is an example of the ethical principle of beneficence when responding to the client's family? 1. "He is critically ill and we are caring for his needs." 2. "His heart has stopped and we are attempting to revive him." 3. "I don't know how he is doing but you need to come." 4. "I will have the health care provider talk to you once you arrive."

1. "He is critically ill and we are caring for his needs." Beneficence is the ethical principle of doing good. It involves helping to meet the client's (including the family) emotional needs through understanding. This can involve withholding information at times. Stating that the client is critically ill and is being cared for meets the ethical principle of veracity (telling the truth) but also avoids overwhelming the family before they travel to the hospital. The nurse does not want the family to be too distressed to process the situation and arrive safely. (Option 2) This is a true statement but it is being given abruptly to the family without support or gradual adjustment. It might be so distressing that they cannot travel to the hospital safely. (Option 3) This is not a true statement and violates the principle of veracity. It will do nothing to help the family and might even cause them alarm that a nurse there is not informed about what is going on with their child. (Option 4) Although this is an option, it does nothing to deal with the situation and the family's needs adequately. It also "passes the buck" to another provider, and even though this provider can speak to them, the nurse should deal with the family's immediate needs at this point. Once they arrive, the health care provider is usually the one to tell family members about the client's prognosis.

A client has a leg immobilizer applied and leaves the emergency department with crutches. Which instructions by the graduate nurse require the nursing preceptor to intervene? 1. Hold 1 crutch in each hand when standing up from a chair 2. Hold both crutches on the same side when standing up from a chair 3. Touch the back of legs to the seat of the chair when preparing to sit 4. Use an armrest or seat for assistance when lowering body into a chair

1. Hold 1 crutch in each hand when standing up from a chair Standard-type crutches remove the weight from one or both legs and shift it to the upper body. Therefore, if a client is lacking the upper body strength or balance required to use crutches, a walker may be prescribed instead. To rise from a chair, the client holds both crutches by the hand grips with the hand on the same side, slides to the edge of the chair, and grasps the armrest with the other hand or places it on the seat. The client then pushes down on the crutches and the armrest, and uses the unaffected leg for support to rise from the chair. To sit in a chair, the procedure is reversed. The client backs up to the chair until the seat is felt against the legs, and moves both crutches into the hand on the same side and holds them by the hand grips. The client then pushes down on the crutches, reaches back to the armrest or seat with the other hand, uses the unaffected leg for support, and lowers the body into the chair. (Option 2) This instruction by the graduate nurse (GN) is correct; both crutches should be held on the same side. The side on which the crutches are held may vary based on health care provider instructions and the client's injury, physical condition, and degree of upper body strength. The client should not hold crutches on both sides of the chair or in front when getting into or up from a chair. (Option 3) This instruction by the GN is correct; the client should back up to the chair until the legs touch the seat. (Option 4) This instruction by the GN is correct; crutches should never be used as total support, a hand should always be placed on the armrest or seat of the chair for assistance.

A community mental health nurse is a member of a mobile crisis team providing services to victims of a category 4 hurricane. Of these strategies, which would be the priority action for the team to utilize in reaching those who need mental health services? 1. Contacting other social service agencies 2. Knocking on doors 3. Putting up flyers 4. Reporting in to the local command center

4. Reporting in to the local command center Individuals impacted by emergencies such as a natural disaster often experience severe emotional stress and are in need of mental health services. Clients may experience a wide range of emotions and reactions including confusion, fear, hopelessness, grief, survivor guilt, and anxiety. Mental health professionals can provide support, crisis intervention, and promote resilience in coping with the effects of the disaster. Services may be provided in shelters, food distribution centers, churches, "pop-up" disaster relief centers, schools, and/or in homes. However, finding and reaching potential clients and family members in the aftermath of a disaster can be challenging because: Clients may not know where or how to seek help Clients may be afraid or unable to leave their homes Telephone services and other lines of communication may be disrupted Potential clients may leave their homes and go to shelters or alternate housing Transportation may be severely limited It is essential to coordinate outreach efforts to maximize resources and avoid duplication of services and/or inefficiency in providing services. The mobile crisis team's priority action is to check in with the local command center, then to assist in planning outreach strategies with other community agencies, and receive assignments. (Option 1) Contacting other social service agencies may be part of an effort to coordinate services once the team has reported in to the local command center. (Option 2) This is an appropriate outreach strategy after the mobile crisis team has checked in at the local command center and has received the assignments. (Option 3) Putting up flyers may not be a particularly effective way to provide outreach to those affected by a disaster as clients may be afraid to leave their homes or they may be unable to get to where the services are being provided.

A client who is intubated and on mechanical ventilation is receiving continuous enteral tube feedings at 30 mL/hr 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 ≥30 degrees 4. Maintain endotracheal cuff pressure 5. Use caution when administering sedatives

1 3 4 5 Clients who are critically ill are at increased risk for aspiration of oropharyngeal secretions and gastric contents, particularly when they are receiving enteral feedings. Nursing interventions to reduce aspiration risk for clients receiving enteral tube feedings include: Assess client for gastrointestinal intolerance to feedings every 4 hours by monitoring gastric residual and assessing for abdominal distension, abdominal pain, bowel movements, and flatus (Option 1) Assess feeding tube placement at regular intervals Keep head of the bed at ≥30 degrees, with 30-45 degrees being optimal to reduce gastroesophageal reflux and aspiration risk unless otherwise indicated (Option 3) Keep endotracheal cuff inflated at appropriate pressure (about 25 cm H20) for intubated clients, as low cuff pressure increases the risk for aspirating oropharyngeal secretions and/or gastric contents (Option 4) Suction any secretions that may have collected above the endotracheal tube before deflating the cuff if deflation is necessary Use caution when giving sedatives and frequently monitor for over-sedation, which can slow gastric emptying and reduce gag reflex (Option 5) Avoid bolus tube feedings for clients at high risk for aspiration (Option 2) Gastric residual should be checked no less than every 4 hours in intubated clients.

The nurse is providing discharge teaching to several clients with new prescriptions. Which instructions by the nurse are correct in regard to medication administration? Select all that apply. 1. Avoid salt substitutes when taking valsartan for hypertension 2. Take levofloxacin with an aluminum antacid to avoid gastric irritation 3. Take sucralfate after meals to minimize gastric irritation associated with a gastric ulcer 4. When taking ethambutol, notify the health care provider (HCP) of any changes in vision 5. When taking rifampin, notify the HCP if the urine turns red-orange

1 4 Both ACE inhibitors ("prils" - captopril, enalapril, lisinopril, ramipril) and angiotensin receptor blockers ("sartans" - valsartan, losartan, telmisartan) cause hyperkalemia. Salt substitutes contain high potassium and must not be consumed unless approved by the health care provider (HCP) (Option 1). Ethambutol (Myambutol) is used to treat tuberculosis but can cause ocular toxicity, resulting in vision loss and loss of red-green color discrimination. Vision acuity and color discrimination must be monitored regularly (Option 4). (Option 2) Levofloxacin (Levaquin) is a quinolone antibiotic. For this class of antibiotics, 2 hours should pass between drug ingestion and consumption of aluminum/magnesium antacids, iron supplements, multivitamins with zinc, or sucralfate. These substances can bind up to 98% of the drug and make it ineffective. (Option 3) Sucralfate (Carafate, Sulcrate), prescribed to treat gastric ulcers, should be administered before meals to coat the mucosa and prevent irritation of the ulcer during meals. It should also be given at least 2 hours before or after other medications to prevent interactions that reduce drug efficacy. (Option 5) Rifampin (Rifadin), used to treat tuberculosis, normally causes red-orange discoloration of all body fluids. The client should be alerted to expect this change but does not need to notify the HCP.

he same-day surgery nurse performs the preoperative assessment for a client with a history of coronary artery disease scheduled for an elective laparoscopic cholecystectomy. Which statement made by the client is critical to report to the health care provider (HCP) before the surgery? 1. "I didn't take the clopidogrel pill for my heart yesterday or today." 2. "I know I should stop smoking completely, but at least I didn't have a cigarette yesterday or today." 3. "I stopped taking my gingko biloba 2 weeks ago even though it really helps relieve leg cramps when I walk." 4. "I stopped taking naproxen for my arthritis pain 1 week ago and have been taking acetaminophen instead."

1. "I didn't take the clopidogrel pill for my heart yesterday or today." Clopidogrel (Plavix) is an antiplatelet medication that should be discontinued 5-7 days before surgery to decrease the risk for excessive bleeding. The client took this drug 48 hours ago. Therefore, the nurse must notify the HCP. The surgery may be postponed due to the increased risk for intra- and post-operative bleeding (Option 1). (Option 2) All clients should try not to smoke for at least 24 hours before surgery to help prevent oxygenation problems. (Option 3) The client takes gingko biloba to relieve symptoms of intermittent claudication; it was discontinued 2 weeks ago because it can increase the risk for excessive bleeding. (Option 4) Nonsteroidal anti-inflammatory drugs (NSAIDS) such as naproxen (Naprosyn) should be discontinued 7 days before scheduled surgery as they can increase the risk for excessive bleeding. Acetaminophen can be taken to control pain up until surgery.

he charge nurse on a pediatric unit recognizes that it is acceptable for which pair of clients to be assigned to a semi-private room? 1. 4-year-old girl in Buck traction and 5-year-old boy post laparoscopic appendectomy 2. 6-year-old girl with varicella and 7-year-old girl with measles 3. 9-month-old boy with rotavirus infection and 8-month-old boy with salmonella infection 4. 14-year-old girl with sickle cell anemia and 13-year-old girl with periorbital cellulitis

1. 4-year-old girl in Buck traction and 5-year-old boy post laparoscopic appendectomy Although placing pediatric clients of different sexes in a semi-private room is not ideal, the charge nurse must prioritize client room assignments based on client safety. At ages 4 and 5, the male-female pair can room together. The client in Buck traction does not have a transmittable illness. The client post laparoscopic appendectomy is also not infectious. Given the options above, this is the safest room assignment. (Option 2) Children with infections requiring airborne precautions (eg, varicella, tuberculosis, measles) should be placed in a private, airborne infection isolation room (eg, negative airflow room). If required, clients infected with the same organism can be roomed together, but a private room is preferred. (Option 3) Rotavirus is a viral gastroenteritis, and salmonella is a bacterial gastroenteritis. The risk for cross contamination is high, especially with caregivers sharing the facilities. (Option 4) A client with sickle cell anemia is at risk for infection due to spleen dysfunction (repeated infarctions), and a client with periorbital cellulitis has an infection. Although compatible in age and sex, these clients should not share a room.

he nurse dons personal protective equipment (PPE) before providing care for a client in airborne transmission-based precautions. Place the steps for donning PPE in the appropriate sequence. All options must be used.

PPE for the health care worker protects the mucous membranes, airways, skin, and clothing from contact with potentially infectious agents. The category of transmission-based precautions (eg, contact, droplet, airborne) required determines the type of PPE that the health care worker will wear. The exact procedure for donning and removing PPE varies with the level of precautions required. Guidelines are provided by the Centers for Disease Control and Prevention (CDC) and by institution policy and procedure. The sequence for donning PPE includes: Hand hygiene Gown - fully cover torso from neck to knees, arms to end of wrists, and wrap around back; fasten in back of neck and waist Mask or respirator - secure ties or elastic bands at middle of head and neck; fit flexible band to nose bridge; fit snugly to face and below chin; fit-check respirator Goggles or face shield - place over face and eyes and adjust fit; may be combined with mask (visor) Gloves - don and extend to cover wrist of isolation gown

What nursing care related to peripherally inserted IV catheters can reduce the incidence of catheter-related infections? Select all that apply. 1. After insertion, apply sterile tape over the catheter hub 2. Clean ports with 70% alcohol prior to accessing the catheter system 3. Prior to insertion, apply chlorhexidine in a back-and-forth motion using friction 4. Prior to insertion, shave excess hair over selected site 5. Replace or remove the catheter every 48 hours

1 2 3 The nurse should select an IV catheter site on an upper extremity, preferably the hand or forearm. To reduce the incidence of catheter-related infections, the selected site should be cleaned with antiseptic solution using friction (preferably chlorhexidine, using a back-and-forth motion) and then allowed to air dry completely (Option 3). Chlorhexidine is preferred over povidone-iodine as it achieves an antimicrobial effect within 30 seconds whereas povidone-iodine takes ≥2 minutes. After insertion, the catheter hub should be taped down with a narrow strip of sterile tape to prevent accidental removal or excessive back-and-forth motion, which can introduce microorganisms into the vein (Option 1). The Centers for Disease Control and Prevention recommends cleaning access ports with 70% alcohol (Option 2). (Option 4) Excessive hair may be clipped but never shaved as shaving may cause microabrasions and possible portals of entry for microorganisms. (Option 5) Peripheral IV catheters should not be removed or replaced more frequently than every 72-96 hours unless signs of phlebitis or other complications (eg, infiltration, infection) occur.

It is 0700 and the nurse is caring for an 84-year-old client with dementia and a fractured hip. The client has been disoriented to time, place, and person since admission. The client moans frequently and grimaces when moving. He is prescribed morphine IV every 2 hours as needed for pain and was last medicated at 0530. He is scheduled for surgery at 1000 to repair the hip fracture, but the consent has not yet been signed. The client's spouse and child are to arrive at 0900. Which intervention should the nurse carry out first? 1. Administer pain medication 2. Call the health care provider to meet with the family to obtain informed consent 3. Complete the preoperative checklist 4. Perform the morning assessment

4. Perform the morning assessment The morning shift assessment should be completed first to collect baseline assessment data (eg, vital signs, lung sounds, level of consciousness), assess pain, and collect necessary information for the preoperative checklist. (Option 1) Pain medicine is not due until 0730 and can be administered after the initial assessment if necessary. (Option 2) The nurse should call the health care provider after the initial assessment (by 0730) and arrange for a meeting with family members at 0900 to obtain informed consent as the client is not capable of giving it. (Option 3) The preoperative checklist can be completed after consent is obtained.