3 | UWorld NCLEX-PN

Which client in the emergency department should the nurse see first? 1. 2-year-old with fever and sore throat who is restless and drooling 2. 7-year-old with appendicitis who has right lower quadrant pain and vomiting 3. 9-year-old with immune thrombocytopenia who has generalized petechia 4. 17-year-old with cystic fibrosis who is coughing up thick, blood-tinged sputum

CORRECT ANSWER: 1 Diagram of epiglottis: https://imgur.com/vQYUhlH Acute epiglottitis is a supraglottic inflammatory process that occurs most commonly in children with Haemophilus influenza type b (Hib) infection. Inflammation of the epiglottis can cause airway obstruction and is a medical emergency. Common signs of impending airway obstruction include restlessness, stridor, and drooling due to dysphagia (Option 1 is correct). The nurse should prepare to assist with emergent endotracheal intubation. (Option 2 is wrong) If left untreated, the inflamed appendix may rupture, causing peritonitis, major abscess, or partial bowel obstruction. The client with acute appendicitis may require antibiotic administration and emergent surgical appendectomy. Although appendicitis is an emergent condition, a client with impending airway obstruction from epiglottitis must be seen immediately. (Option 3 is wrong) Immune thrombocytopenia (ITP) is an acquired disorder in which antibodies cause decreased platelet survival and production. Petechiae, pinpoint lesions on the skin from capillary hemorrhages, are a common sign of ITP. Acute ITP usually resolves spontaneously without complications, and management is primarily supportive (eg, platelet monitoring, corticosteroids, IV immunoglobulin). (Option 4 is wrong) Cystic fibrosis affects the secretory glands, resulting in thick sputum that may become blood-tinged from frequent coughing. A client with cystic fibrosis who has blood-tinged sputum should be evaluated, but care may be safely delayed until after caring for the client with impending airway obstruction.

The nurse is reinforcing education for a client recently diagnosed with an anaphylactic allergic reaction to latex. Which statement by the client indicates that the client correctly understands the condition? 1. "I do not need to worry about my allergy when I am outside of a health care environment." 2. "I should keep my epinephrine auto-injector pen with me at all times." 3. "I will be fine as long as I check labels to ensure that products do not contain latex." 4. "I will start eating healthier foods such as bananas and avocados."

CORRECT ANSWER: 2 Anaphylactic shock, the most severe form of an allergic reaction, is a medical emergency. Hives, itching, or a rash may or may not appear before rapid swelling of the face, mouth, and throat (ie, angioedema) makes breathing difficult or impossible within minutes. Clients with an anaphylactic allergic reaction should keep an epinephrine auto-injector pen with them at all times (Option 2 is correct). An intramuscular epinephrine injection into the thigh rapidly counteracts the life-threatening swelling, hypotension, and vasodilation that characterize anaphylaxis. Diphenhydramine is also given to treat the rash or itching (eg, hives, wheals, urticaria). (Option 1 is wrong) Latex products are extremely common. The nurse should reinforce education to clients that rubber products (eg, condoms, balloons, rubber bands) and other medical supplies (eg, gloves, urinary catheters) may contain latex. (Option 3 is wrong) Numerous products contain trace amounts of latex. This information may be omitted on labels and is therefore not reliable. (Option 4 is wrong) Bananas, avocados, strawberries, chestnuts, and kiwifruit have been classified as having high-risk potential for cross-reaction allergy development. Clients should be advised to eat these foods cautiously due to potential cross-allergenicity. In addition, anaphylaxis cannot be remediated by diet or exercise. The client must avoid latex and use emergency medications if exposed.

The nurse is caring for a 27-year-old female client. Here is her history and physical: https://imgur.com/Rq450KM From the history and physical, select the findings that are most concerning at this time.

CORRECT ANSWER: - Unevenly distributed bruising noted on client's arms and face - Bilateral petechiae noted on the neck List of concerning signs from intimate partner violence: https://imgur.com/vlsFwUc Intimate partner violence is physically, emotionally, verbally, sexually, or economically abusive behavior inflicted by one partner against the other in an intimate relationship to maintain power and control. During pregnancy, added emotional and financial stress may trigger or escalate abuse. The abuse can endanger the health and safety of both mother and fetus. Physical signs concerning for abuse include burns; bruises in certain shapes (eg, belt, cigarettes) or in different stages of healing; and bilateral petechiae on the neck, face, eyes, and ears secondary to strangulation. In addition, clients may demonstrate behavioral symptoms of abuse (eg, depression, withdrawn demeanor, gaze fixed on the ground [no eye contact], minimal speech) and/or subtle signs of fear when around their abuser, including having low self-esteem.

A client with schizophrenia spends time in the dayroom, sitting in a corner watching television, but does not initiate conversation or social interaction with other clients or staff. What is the most appropriate activity for the client? 1. Helping plan a unit picnic 2. Playing bingo with other clients 3. Playing board games with a staff member 4. Singing together in a group

CORRECT ANSWER: 3 Schizophrenia is a psychiatric disorder in which clients have disturbed thought processes and impaired communication, affecting their ability to establish personal relationships and manage day-to-day interactions. For clients exhibiting negative symptoms (eg, social isolation, flat affect, apathy), the nurse can facilitate interpersonal functioning with one-on-one interaction in which the client can practice basic social skills in a nonthreatening way (eg, one-on-one board games). Once the client feels more comfortable, the nurse can encourage participation in activities requiring group interaction (Option 3 is correct). (Options 1, 2, and 4 are wrong) The client with schizophrenia who exhibits negative symptoms is not ready to plan or participate in group activities. However, group activities may become appropriate as the client begins to tolerate social interaction.

The nurse prepares to administer a client's scheduled prandial regular insulin plus a correctional dose based on a sliding-scale as the client's breakfast tray arrives. The client's fasting blood glucose level is 210 mg/dL (11.7 mol/L). How many total units of regular insulin should the nurse administer? The exhibit below is for your information. Record your answer using a whole number. Patient exhibit: https://imgur.com/VfcRujV

CORRECT ANSWER: 10 units Picture of work/explanation for correct answer: https://imgur.com/AwXxnbx

The nurse is reinforcing education about disease transmission. Which measure helps reduce contraction of West Nile virus? 1. Avoid raw, unpeeled fruits or vegetables 2. Limit contact with pets 3. Use insect repellent 4. Wash all bedding in hot water

CORRECT ANSWER: 3 West Nile virus is a mosquito-borne disease that may be asymptomatic or cause symptoms that range from mild (eg, fever, nausea, body aches) to severe (eg, encephalitis. The disease is most common during the summer months, especially during humid weather. Prevention focuses on avoiding mosquitoes and includes: • Using mosquito repellent (Option 3 is correct) • Wearing light-colored long sleeves and long pants outdoors; mosquitoes are attracted to dark-colored cloth • Avoiding outdoor activities at dawn and dusk when mosquitoes are most active (Option 1 is wrong) Food and water precautions are indicated for infectious diseases contracted through contaminated water or food, such as hepatitis A or typhoid (enteric) fever. (Option 2 is wrong) Limiting contact with infected pets is classic advice for avoiding ringworm, a superficial fungal skin infection. West Nile virus is not known to infect pets or be transmitted by them. (Option 4 is wrong) Washing bedding in hot water is a classic instruction to help reduce allergies/asthma (eg, from dust mites) or scabies (a contagious skin infection caused by mites).

The nurse reviews the laboratory results for an adult male client admitted with septic shock. Which value requires the most immediate action? 1. BUN level of 44.4 mg/dL 2. Creatinine level of 1.1 mg/dL 3. Hematocrit of 48% 4. Potassium level of 5.9 mEq/L

CORRECT ANSWER: 4 Serum potassium (normal: 3.5-5 mEq/L) may increase in clients with progressive shock as a result of metabolic acidosis, which can cause a shift of potassium from the intracellular to the extracellular compartments. Because the most significant manifestation of hyperkalemia is a disturbance in cardiac conduction and the development of cardiac dysrhythmias, correction of the imbalance requires immediate action (Option 4 is correct). (Option 1 is wrong) Although a BUN level of 44.4 mg/dL (normal: 6-20 mg/dL) is elevated, it does not require immediate action. It can increase in clients in a shock state as the result of decreased perfusion to the kidneys (prerenal azotemia) or extrarenal factors such as dehydration, fever, or gastrointestinal bleed. (Options 2 and 3 are wrong) Normal creatinine level is 0.6-1.3 mg/dL and normal hematocrit level for an adult male is 39%-50%. Normal laboratory values require no intervention.

The nurse is caring for a 19-year-old female client in the women's health clinic. Nurse's Notes: https://imgur.com/nP4cHIu Vital Signs: https://imgur.com/aHMJTsU Laboratory Results (1): https://imgur.com/2m5vSDd Laboratory Results (2): https://imgur.com/fqUeJDE For each potential intervention, specify if the intervention is expected or not for the care of the client. 1. Strain all urine 2. Administer antibiotics 3. Perform renal ultrasound 4. Encourage daily intake of 2-3L of water 5. Remind the client to void after sexual intercourse 6. Promote timed voiding and urge suppression techniques

CORRECT ANSWER: Expected: 2, 4, 5 Not Expected: 1, 3, 6 Diagram of clinical features of urinary tract infections: https://imgur.com/F2l1O6F Cystitis is inflammation of the bladder commonly caused by a urinary tract infection (UTI). Clinical manifestations include urinary frequency, painful urination, urgency, and lower abdominal pain. Expected interventions for clients with suspected cystitis include the following: • Obtaining a urine sample for urinalysis and culture to confirm the presence of infection • Promptly administering antibiotics (eg, trimethoprim-sulfamethoxazole) to treat the source of infection and minimize potential complications of an ascending infection (eg, pyelonephritis, urosepsis) • Encouraging daily intake of 2-3 L of water to dilute urine and promote flushing of bacteria • Monitoring the client for signs of worsening infection (eg, flank pain, nausea, vomiting) • Reminding the client to void after sexual intercourse to flush bacteria from the urethra and reduce the risk of recurrent UTIs • Administering analgesic medication to reduce pain Straining the urine using a kitchen strainer or a tea strainer to catch the stone may be performed for clients who are excreting renal calculi (ie, kidney stones), but it is not expected for clients with cystitis. A renal ultrasound may be performed for clients with recurrent UTIs who are not responding to antibiotic therapy or to evaluate for complications of worsening infection (eg, renal abscess). However, it is not expected for clients with simple cystitis. Urge suppression and timed voiding (eg, voiding every 45 min) are behavioral techniques used to manage an overactive bladder (eg, urge incontinence). This is not expected for clients with simple cystitis because urinary stasis increases the risk for recurrent infection.

A nurse is reinforcing teaching on oral medication administration to the parents of a 3-month-old. Which statement by the parents indicates the need for further teaching? 1. "I should add the medication to a bottle of formula before feeding." 2. "I should direct liquid medication to the back and inside of the cheek." 3. "I should hold my baby in a semi-reclining position during administration." 4. "I should use an oral syringe to measure the medication."

CORRECT ANSWER: 1 Administering liquid oral medications to infants requires specialized techniques to prevent aspiration and ensure correct dosing. Medications should never be mixed in a bottle of infant formula: if the child does not complete the feed, the full dose will not be administered (Option 1 is correct). The medication may also affect the taste of the formula, and the infant may refuse subsequent feeds. (Options 2 and 4 are wrong) Pediatric liquid medications should be administered by an oral syringe, which has small, accurate measurement increments and helps to prevent overmedicating. The liquid medication should be directed toward the back of the infant's cheek and dispensed slowly in small amounts, allowing the infant to swallow between squirts. If the medication is given into the back of the throat in large amounts or too quickly, the infant may aspirate. (Option 3 is wrong) Oral medication should be administered with the infant in a semi-reclining position, similar to the feeding position. This position promotes comfort and prevents aspiration.

The nurse is caring for a client with chronic pancreatitis. Which meal should the nurse recommend when assisting the client to select food items from a menu? 1. Baked tilapia with lemon wedge, sweet potatoes, and green peas 2. Cream of potato soup and roast beef sandwich on a croissant 3. Sautéed salmon, macaroni and cheese, string beans, and a biscuit 4. Shrimp enchiladas with tomato salsa, rice, cornbread, and refried beans

CORRECT ANSWER: 1 Chronic pancreatitis is an inflammatory disease that causes the tissue of the pancreas to become fibrotic, impairing pancreatic endocrine and exocrine functions. Chronic pancreatitis is most commonly caused by alcohol abuse, but may also result from biliary tract disease (eg, cholelithiasis), autoimmune processes, or cystic fibrosis. Lifestyle modification is a key component of treatment and includes cessation of alcohol and smoking as well as dietary modifications. Clients with pancreatitis often cannot secrete lipase in sufficient quantities to digest consumed fats. Therefore, clients should follow a low-fat diet, with the degree of fat restriction based on the severity of disease. Due to lack of endogenous lipase, oral supplementation of pancreatic enzymes is often required before meals. To avoid exacerbating gastric discomfort, the client should avoid spicy and gas-forming foods Low-fat food choices include lean meats (eg, fish, chicken), nonfat dairy products, vegetables/fruits prepared without added fat, and low-fat carbohydrates (eg, green peas) (Option 1 is correct). (Options 2, 3, and 4 are wrong) Most dairy-containing foods (eg, macaroni and cheese, creamed soup), baked goods (eg, biscuits, cornbread, croissants), and some meats (eg, roast beef) are high in fat. Refried beans also contribute to gas formation and promote bloating. Salsas and spicy foods should be avoided.

A practical nurse is assisting a registered nurse in developing a care plan for a client who has undergone surgery for the creation of a permanent ileostomy. Which action by the client best indicates adjustment to the new ostomy? 1. Client is able to look at and touch the stoma 2. Client reads the materials provided on ostomy care 3. Client requests information about ostomy support groups 4. Client verbalizes methods to control gas and odor

CORRECT ANSWER: 1 Clients with new ostomies may experience grief or loss related to the alteration in body image and loss of bowel control. Clients must begin to accept the change in body image before becoming independent in self-care. Clients who are not coping with these changes may refuse to look at or participate in care of the stoma. The client's ability to look at and touch the stoma indicates acceptance of the change (Option 1 is correct). Interventions to facilitate coping include: • Supportive counseling and assistance in psychosocial adjustment • Teaching and facilitation of ostomy self-care • Provision of information about community resources (Option 2 is wrong) Reading educational materials is a passive activity and is not a strong indicator that the client is ready for self-care. (Option 3 is wrong) Community organizations can offer support and education. However, a client request for support group information does not indicate psychosocial adjustment to the new ostomy. (Option 4 is wrong) The client's ability to verbalize self-care methods indicates an understanding of teaching but does not demonstrate psychosocial adjustment to the new stoma.

The nurse is caring for a 27-year-old female client. Here is her history and physical: https://imgur.com/Rq450KM Look in the pictures you sent me for the nurse's notes on her. Complete the following sentence by choosing from the list of options. The nurse recognizes that the client is in the __________ phase of the cycle of violence 1. Honeymoon 2. Tension building 3. Acute battering Note: this question you need the nurse's notes for the patient to answer it, but you did not send me that.

CORRECT ANSWER: 1 Diagram of the cycle of violence: https://imgur.com/piRx8sw The nurse recognizes that the client is in the honeymoon phase of the cycle of violence (COV). The COV demonstrates a recurring pattern of behaviors that the abuser uses to exert control over the partner. It is broken down into three phases: • Tension-building phase (first phase): The client senses that the abuser's frustration tolerance is declining (eg, lashes out but apologetic afterward). The survivor becomes nurturing and overly compliant due to a fear of escalation. Feelings of self-blame, rationalization, and denial are also common (eg, "Alcohol is causing added stress."). As minor abusive incidents continue, the abuser fears the partner will leave the relationship and begins to use threats as a form of intimidation. As time progresses, the incidents intensify causing the survivor to feel helpless and emotionally withdrawn from the relationship. • Acute battering (incident) phase (second phase): This is the most violent phase of the COV. Tension reaches a peak, precipitated by the abuser's deteriorating emotional state. The abuser initially justifies the behavior (eg, "He/she deserved it."). However, after the incident, the abuser may recognize the loss of behavioral control. • Honeymoon phase (third phase): This typically follows the abusive incident phase. The abuser can be charming, remorseful, and often promises that the abuse will never occur again. The survivor may feel helpless and eager to believe that the abuse will end. The survivor stays in the relationship with hope that the partner will remain this way, even if this cycle repeats itself multiple times.

The unlicensed assistive personnel (UAP) reports being splashed in the eye while emptying urine from the catheter bag of a client with AIDS. The UAP is afraid of becoming infected with HIV and requests immediate testing. What is the nurse's priority action? 1. Direct the UAP to immediately flush the eye with water at the unit's eyewash station 2. Reassure the UAP that the risk for HIV is low because urine does not transmit the virus 3. Refer the UAP to the occupational health department for postexposure prophylaxis 4. Send the UAP to the facility's emergency department for medical evaluation

CORRECT ANSWER: 1 Following accidental eye exposure to body fluids (eg, blood, urine) or chemicals, health care workers should immediately flush the affected eye with water or saline for at least 10 minutes to reduce exposure to potentially infected material and prevent/reduce injury (eg, burn) (Option 1 is correc6). The risk of HIV transmission through urine is low unless there is visible blood in the fluid; however, flushing the eye is the priority action with any accidental exposure. (Option 2 is wrong) The nurse should address the fears of the unlicensed assistive personnel (UAP), but the most urgent action is for the UAP to flush the eye. (Option 3 is wrong) All exposure incidents should be reported to appropriate personnel, including the occupational health department, which is responsible for managing immediate postexposure (eg, testing, prophylaxis) and follow-up care (eg, testing, counseling). However, flushing the eye is the priority. (Option 4 is wrong) Depending on the facility, the UAP may have additional eye irrigation in the emergency department, confidential medical evaluation for HIV by a qualified health care provider, and occupational HIV postexposure prophylaxis if medically indicated. However, these actions are not the priority.

The nurse receives handoff of care report on four clients. Which client should the nurse see first? 1. Client who had an emergency appendectomy 48 hours ago and is reporting hearing ocean waves and seeing fish swimming through the walls 2. Client who had an exploratory laparoscopy 2 hours ago and has absent bowel sounds and is reporting nausea 3. Client with diabetes mellitus who has a foot ulcer and is reporting feeling "pins and needles" in the lower legs 4. Client with Parkinson disease who has tremors while resting and has developed black-colored urine after taking carbidopa/levodopa

CORRECT ANSWER: 1 Hallucinations represent a serious safety risk to the client and others; they may compel clients to engage in behaviors or activities that trigger self-injury or violence toward others (eg, command hallucinations). Hallucinations experienced by clients who do not have a psychiatric illness may indicate withdrawal from alcohol or narcotics, which can be life threatening without prompt intervention. Nurses should promptly assess clients with new or worsening hallucinations (Option 1 is correct). (Option 2 is wrong) Clients undergoing abdominal surgery (eg, exploratory laparoscopy) often have nausea and absent bowel sounds postoperatively for the first few hours due to side effects of anesthetics and decreased peristalsis after bowel manipulation. (Option 3 is wrong) Clients with diabetes mellitus may develop diabetic neuropathy as a complication of neurovascular damage from inadequate long-term blood glucose management. Feeling "pins and needles" is an uncomfortable but harmless symptom of diabetic neuropathy. (Option 4 is wrong) Resting tremors are an expected finding associated with Parkinson disease. Carbidopa/levodopa, a common medication used to manage symptoms of Parkinson disease, can cause a harmless darkening of urine color (eg, brown, black).

Several children at a local pediatric clinic are found to have hemoglobin levels of 10-11 g/dL. Which dietary modification would most likely help increase hemoglobin levels in these clients? 1. Ensuring adequate intake of meat, fish, and poultry 2. Increasing consumption of fruits and vegetables 3. Prioritizing intake of milk and other dairy products 4. Providing orange juice fortified with vitamin D at meals

CORRECT ANSWER: 1 Iron deficiency is the leading cause of anemia worldwide. Most cases of iron deficiency anemia (IDA) result from inadequate intake of foods high in iron. In IDA, red blood cells are small (microcytic) with reduced hemoglobin content, appearing paler (hypochromic) under a microscope. The richest dietary sources of iron include meat, fish, and poultry, which provide a form of iron that is easily absorbed by the body (Option 1 is correct). Plant-based foods (eg, dried fruits, nuts, legumes, green leafy vegetables, whole grains) are not as iron rich and contain a less bioavailable form of iron than animal-based foods. However, foods high in vitamin C (eg, tomatoes, potatoes, strawberries) may boost iron absorption when consumed with iron-rich foods. (Option 2 is wrong) Fruits and vegetables are not the best sources of dietary iron. (Option 3 is wrong) Milk and milk products are poor sources of dietary iron, and excessive calcium intake interferes with iron absorption. Overconsumption of milk, along with little or no consumption of other foods, is a leading cause of iron deficiency in young children. (Option 4 is wrong) Although sources of vitamin C (eg, orange juice) may enhance iron absorption, increased intake of iron-rich foods is priority in treatment of IDA. Vitamin D has no direct effect on anemia.

The nurse caring for a client who had a femoral angioplasty finds the client's leg pale, cool, and pulseless. The nurse calls the health care provider at 2 AM, and the HCP begins to yell at the nurse, stating, "I'm sick and tired of you calling me in the middle of the night!" What is the best response by the nurse? 1. "I'm concerned that this client may lose a leg unless something is done immediately." 2. "I'm sorry to bother you. Is there someone else you'd like me to call?" 3. "It's my job to report critical findings, just like it's your job to come see my client right now." 4. "Yelling is unprofessional. I'll need to file a report with my supervisor once the client is stable."

CORRECT ANSWER: 1 The stress of bullying and workplace violence impairs clinical judgment and creates an unsafe environment for clients. In response to unprofessional conduct, the nurse should shift the focus of the conversation back to the client's needs, especially in situations that may result in client injury Option 1 is correct). (Option 2 is wrong) Offering to call a different provider fails to address the urgency of the situation. The priority is for the nurse to advocate for the client's needs, as the client is experiencing a serious limb-threatening postsurgical complication. (Option 3 is wrong) Confrontational statements are more likely to provoke a fight rather than result in appropriate intervention for the client. (Option 4 is wrong) Incidents of bullying and workplace violence should be reported to a nursing supervisor, but the priority is to ensure that the client's needs are addressed.

The nurse participates in a health screening event for skin cancer. Which clinical finding would be most concerning? 1. Client with a blue and black, irregularly shaped papule on the hand 2. Client with a pearly, pink papule with ulceration on the ear 3. Client with a pink patch with silvery scales on the neck 4. Client with a red, scaly patch with rough edges on the forehead

CORRECT ANSWER: 1 The three most common types of skin cancer include squamous cell carcinoma, basal cell carcinoma, and melanoma. Melanomas are the most dangerous because they grow rapidly and are highly metastatic, resulting in a high mortality rate. When screening for skin cancer, the nurse should use the ABCDE method to identify lesions with melanoma-like characteristics. The ABCDE method includes assessing lesions for: • A - Asymmetry (eg, one half unlike the other) • B - Border irregularity (eg, notched or irregular edges) • C - Color changes and variation (eg, new blue or black pigmentation) (Option 1 is correct) • D - Diameter of 6 mm or larger (approximately the size of a pencil eraser) • E - Evolving (eg, changes in shape, size, and color) (Option 2 is wrong) Basal cell carcinomas are slow growing and have a pearly appearance; they usually do not metastasize. This client is a second priority. (Option 3 is wrong) Psoriasis is a common disorder characterized by silvery, scaly patches that can cause itching. (Option 4 is wrong) Actinic keratoses are precancerous lesions that are erythematous and have a hard texture and irregular borders.

The nurse identifies which of the following risk factors as contributing to the development of peripheral artery disease? Select all that apply. 1. Cigarette smoking 2. Diabetes mellitus 3. Hyperlipidemia 4. Oral contraceptive use 5. Prolonged standing

CORRECT ANSWER: 1, 2, 3 Diagram of peripheral artery disease: https://imgur.com/oKs86F0 In peripheral artery disease (PAD), the arteries of the extremities become atherosclerotic (progressive thickening and hardening due to chronic vascular damage). PAD reduces tissue perfusion and can cause ischemic pain of the lower extremities with movement or exercise (intermittent claudication). Pain with PAD can also occur at rest and manifests in the lower extremities as burning, aching, or numbness. Factors that cause chronic vascular changes and increase risk for PAD include: • Smoking: Chronic vasoconstriction from nicotine inhalation (Option 1 is correct) • Hypertension: Vessel damage from chronically elevated vascular resistance • Diabetes mellitus: Inflammatory vascular changes from hyperglycemia (Option 2 is correct) • Hyperlipidemia: Increased plaque formation (ie, atherosclerosis) (Option 3 is correct) (Option 4 is wrong) Elevated estrogen levels (eg, oral contraceptive use, pregnancy, hormone replacement therapy) make blood hypercoagulable. However, elevated estrogen levels are more likely to form thrombi in veins than in arteries due to lower venous pressure and slower blood flow (eg, venous stasis). (Option 5 is wrong) Unlike chronic venous insufficiency, in which vessels ineffectively return blood from the feet to the central circulation, standing is not a risk factor for PAD, because standing facilitates blood flow by gravity to the lower extremities.

The nurse is planning care for a client with a fractured femur who was placed in balanced suspension skeletal traction 2 hours ago. Which of the following interventions should the nurse include? Select all that apply. 1. Encourage intake of at least 2 L of fluid per day to prevent constipation 2. Ensure that the weights hang freely and do not touch the ground 3. Monitor skin integrity and signs of infection at the pin insertion sites 4. Perform frequent neurovascular checks on the affected extremity 5. Remove the weights briefly every 4 hours to prevent muscle spasms

CORRECT ANSWER: 1, 2, 3, 4 Skeletal traction involves surgically inserting screws, wires, and/or pins directly into a fractured bone and applying a pulling force (traction) via a pulley system and a rope. The pulley system allows free-hanging weights to suspend from the foot of the client's bed and pull on the skeletal pins to maintain alignment of the proximal and distal portions of the fractured bone. Appropriate nursing interventions for clients in skeletal traction include: • Encouraging increased fluid intake (≥2 L/day) to reduce the risk for constipation caused by immobility (Option 1) • Ensuring that the weights hang freely and are not resting on the ground or on medical equipment (Option 2 is correct) • Monitoring skin integrity and pin insertion sites for signs of infection (eg, erythema, drainage, swelling, malodor) (Option 3 is correct) • Performing frequent neurovascular checks, especially in the first 24 hours of traction therapy (Option 4 is correct) • Inspecting the rope for fraying and ensuring its correct position in the pulley track • Ensuring proper alignment of the client and the pulley system to facilitate union of the fractured bone (Option 5 is wrong) Skeletal traction not only provides proper alignment during bone healing, but also helps reduce muscle spasms that result from malalignment of the fracture. The weights should not be removed, even briefly, unless prescribed by the health care provider.

The nurse is caring for a 68-year-old client. Here is their history and physical: https://imgur.com/M5GosAT The client is preparing for discharge and has been prescribed home oxygen. Which of the following client statements indicate a correct understanding of the discharge teaching? Select all that apply. 1. "I will notify my power company that I have an oxygen concentrator in case the power goes out." 2. "I will refrain from using wool blankets." 3. "I will replace the nasal cannula every 2 to 4 weeks or after I have been sick with a cold." 4. "I will turn the oxygen flow rate down when I am near an open flame." 5. " will wash the nasal cannula at least once every week with soap and water."

CORRECT ANSWER: 1, 2, 3, 5 Clients requiring long-term oxygen therapy may be prescribed a portable oxygen delivery system for use at home to allow increased independence and comfort in daily life. The nurse should reinforce teaching for home oxygen therapy, including: • Notifying the power company that home oxygen is in use to prioritize return of power for electrical oxygen concentrators (Option 1 is correct) • Avoiding wool or synthetic fabrics that may cause static electricity and ignite the oxygen-exposed fabric. Although oxygen is not combustible itself, oxygen supports combustion and can worsen fires. Therefore, it is critical to educate clients on safety precautions for home oxygen use (Option 2 is correct). • Replacing the nasal cannula every 2 to 4 weeks or following upper respiratory illness to avoid reintroducing infectious microorganisms (Option 3 is correct) • Washing the nasal cannula at least once every week with soap and water to prevent infection Option 5 is correct) (Option 4 is wrong) The client should avoid open flames while using oxygen to reduce fire risk. In addition, clients should maintain an oxygen flow rate prescribed by the health care provider. Also, clients should not allow smoking inside the house or near the oxygen delivery system.

The nurse determines that a client with incontinence and limited mobility is at increased risk for skin breakdown and pressure injury. While caring for this client, which of the following nursing interventions are appropriate? Select all that apply. 1. Applying moisture barrier cream to the skin after performing perineal care 2. Providing foods that are high in protein and that contain adequate calories 3. Repositioning the client every 2 hours and using devices to maintain position 4. Restricting fluid intake to <= 2 L/day to reduce the number of incontinent episodes V 5. Using foam padding on chairs to elevate the client's elbows and heels

CORRECT ANSWER: 1, 2, 3, 5 List of National pressure Injury Advisory Panel pressure injury prevention guidelines: https://imgur.com/n59ApA4 Pressure injuries are caused by long periods of external pressure that compresses dermal capillaries and the underlying soft tissue. Friction against the skin and shearing forces can also contribute to pressure injury. The nurse should assess every client's risk for pressure injury (using the Braden scale) on admission and at least once daily during hospitalization. To prevent pressure injury, the nurse should: • Use emollients and barrier creams to hydrate, protect, and strengthen the skin (Option 1 is correct). • Provide foods high in protein with adequate caloric intake to strengthen the skin as much as possible (Option 2 is correct). • Reposition clients every 2-4 hours using devices (eg, pillows, foam wedges) to maintain position; avoid pulling/dragging the client in bed because shearing can occur (Option 3 is correct). • Use foam padding on chairs, commode seats, and other surfaces to help reduce pressure on bony prominences (Option 5 is correct). • Provide prompt incontinence care and use additional barrier cream to keep skin clean and dry; this will further help reduce irritation and associated breakdown of the skin. (Option 4 is wrong) Adequate fluid intake is vital to ensure adequate hydration and circulation. Fluid restriction can make the skin drier and cause hemoconcentration, leading to poor circulation and an increased risk for pressure injury.

The nurse is caring for a 68-year-old client. Here is their history and physical: https://imgur.com/M5GosAT For each potential prescription, specify whether the prescription is anticipated or not anticipated for the care of the client. 1. Administer antibiotics 2. Administer corticosteroids 3. Apply oxygen via nasal cannula 4. Provide a cough suppressant as needed 5. Assist with administering an IV fluid bolus 6. Administer a bronchodilator nebulizer treatment

CORRECT ANSWER: 1, 2, 3, 6 are anticipated. 4 and 5 are not anticipated. Anticipated interventions for a client with an acute exacerbation of chronic obstructive pulmonary disease (COPD) include: • Initiating antibiotics to treat the suspected underlying respiratory infection (eg, copious, greenish-yellow sputum) that most likely triggered the acute exacerbation • Administering corticosteroids to reduce airway inflammation and improve ventilation • Providing supplemental oxygen via nasal cannula to improve hypoxia • Administering a bronchodilator nebulizer to open the airways. A beta agonist (eg, albuterol) is often administered with an anticholinergic (eg, ipratropium) for a synergistic effect. • Coughing (huff coughing) should be encouraged in clients with COPD to clear secretions and open the airways. Therefore, a cough suppressant is not anticipated. • An IV fluid bolus is not anticipated for a client with a COPD exacerbation. Rapid administration of IV fluid could lead to pulmonary edema and worsening symptoms. Maintenance fluids, especially if the client has reduced oral intake or excessive insensible losses (sweating), can be administered.

The nurse is admitting a client with a seizure disorder and delegates preparation of the client's room to the student nurse. Which of the following actions by the student nurse indicate a correct understanding of seizure precautions? Select all that apply. 1. Ensures that suction equipment is present and operable 2. Ensures that supplemental oxygen and a bag valve mask are present 3. Places an oral airway at the head of the bed 4. Places padding on the side rails of the bed 5. Tapes a padded tongue blade at the head of the bed

CORRECT ANSWER: 1, 2, 4 Diagram of seizure precautions: https://imgur.com/61h1HL6 Clients experiencing seizures are at risk for injury and airway compromise. Seizure precautions should be instituted for all clients at risk for seizure, especially those with a medical history of seizure activity. To promote client safety, the nurse should ensure that the appropriate equipment is placed in the client's room and is readily available. Appropriate equipment includes: • Suction equipment for managing oral secretions and vomitus to help prevent aspiration (Option 1 is correct) • Supplemental oxygen, bag valve mask, and endotracheal intubation supplies because of the risk of airway occlusion, aspiration, apnea, and impaired respiratory effort (Option 2 is correct) • Padding for the side rails of the bed to prevent injury during clonic seizure activity (Option 4 is correct) (Options 3 and 5 are wrong) The nurse should never place anything in the mouth of a client experiencing a seizure. During tonic and/or clonic seizures, clients typically clench the jaw involuntarily. When this occurs, objects in the mouth (eg, oral airway, padded tongue blade) may break or dislodge, choking the client and/or damaging the teeth. Suctioning or endotracheal intubation, if needed, should be performed after the seizure ends.

The nurse is caring for a 68-year-old client. Here is their history and physical: https://imgur.com/M5GosAT While ambulating in the hallway with a portable oxygen tank, the client begins having difficulty breathing. For each potential intervention, specify if the intervention is indicated or not indicated for the care of the client. 1. Perform percussive therapy 2. Encourage pursed-lip breathing 3. Apply a nonrebreather mask and increase the oxygen flow rate 4. Call the respiratory therapist to administer a breathing treatment

CORRECT ANSWER: 1, 2, 4 are indicated. 3 is not indicated Interventions that are indicated for shortness of breath in a client with an acute exacerbation of chronic obstructive pulmonary disease (COPD) include: • Performing percussive therapy to dislodge and move mucus from the lower to upper airways for clearance • Encouraging the client to perform pursed-lip breathing to open the airways, move trapped air out of the lungs, and reduce dyspnea • Calling the respiratory therapist to administer a breathing treatment (ie, inhaled bronchodilator) to open the airways Supplemental oxygen is a mainstay of therapy for clients with COPD. However, overcorrecting hypoxemia can suppress the drive to breathe because clients with COPD typically rely on hypoxemia rather than hypercapnia to stimulate the respiratory drive due to chronic carbon dioxide gas retention. A nonrebreather mask delivers a very high fraction of inspired oxygen (FiOz) and is not indicated for a client with COPD due to the risk for over-oxygenation. Oxygen should be titrated to the minimum amount necessary to maintain a capillary oxygen saturation of 88%-92%. A Venturi mask is the best choice for clients with COPD because the adapter allows precise control of the FiO2 that the client will receive.

The nurse is caring for a client with multiple renal calculi. Which of the following interventions should the nurse anticipate? Select all that apply. 1. Administer analgesics at regularly scheduled intervals 2. Encourage fluid intake of up to 3 L/day 3. Instruct client to stay on bed rest 4. Provide massage to the client's flank 5. Strain all urine for the presence of stones

CORRECT ANSWER: 1, 2, 5 The formation of renal calculi (ie, kidney stones) can be due to various factors (eg, family history, dietary imbalances, immobilization, dehydration). Manifestations include sudden, severe abdominal or flank pain and nausea/vomiting. Client management focuses on analgesics administered at regularly scheduled intervals, rehydration of up to 3 L/day unless contraindicated by other comorbidities, and ambulation to facilitate the passage of calculi (Options 1 and 2 are correct). To retrieve stones that the client may pass, the nurse should strain all urine obtained (Option 5 is correct). The collected stones are analyzed to determine their composition (eg, calcium oxalate, calcium phosphate, struvite, uric acid, cystine), which can then direct preventive measures, such as dietary and lifestyle changes, after discharge. (Option 3 is wrong) Immobilization is a contributing cause of renal calculi formation and should be avoided. Ambulation and frequent mobilization are encouraged as tolerated to help facilitate the passage of calculi. (Option 4 is wrong) Massage therapy to the flank should not be performed to prevent further instigation of renal colic. Other interventions, such as monitored heat therapy, would be acceptable.

A 2-year-old receives follow-up care at the clinic for atopic dermatitis (eczema). Which of the following instructions should the nurse reinforce with the parents regarding appropriate hygiene for this client? Select all that apply. 1. Apply emollient immediately after a bath 2. Dress child in wool pajamas 3. Give tepid baths with mild soap 4. Keep child's nails well trimmed 5. Thoroughly rub the skin dry after baths

CORRECT ANSWER: 1, 3, 4 Atopic dermatitis (AD), also known as eczema, is a chronic skin disorder characterized by pruritus, erythema, and dry skin. The exact cause of AD is unknown, although it may be associated with an impaired skin barrier and resulting immune response to invading allergens. The primary goals of management are to alleviate pruritus and keep skin hydrated to reduce scratching. Scratching leads to formation of new lesions and potential secondary infections. • Skin should be gently patted dry after bathing, followed by immediate application of an emollient to seal in moisture (Option 1 is correct). • Parents should be instructed to give tepid baths using gentle soap; hot water and long bubble baths dry the skin and should be avoided (Option 3 is correct). • Nails should be trimmed short and kept filed to reduce scratches (Option 4 is correct). • Clothing should be soft (eg, cotton) and climate-appropriate to reduce perspiration, which can intensify pruritus. Long sleeves should be worn at night. • The client should avoid trigger factors, such as heat and low humidity. (Option 2 is wrong) Wool pajamas and other rough fabrics can cause itching and sweating. Soft cotton fabrics are a better choice. (Option 5 is wrong) Rubbing or vigorous drying can damage the skin and lead to exacerbations or infection. Skin should be patted dry gently.

The nurse is caring for a client who had a stroke two weeks ago and has moderate receptive aphasia. Which of the following actions should the nurse implement to help the client follow simple commands regarding activities of daily living (ADL)? Select all that apply. 1. Ask simple questions that require "yes" or "no" answers 2. If the client becomes frustrated, seek a different care provider to complete ADL 3. Remain calm and allow the client time to understand each instruction 4. Show the client pictures of ADL (eg, shower, toilet, toothbrush) or use gestures 5. Speak slowly but loudly while looking directly at the client

CORRECT ANSWER: 1, 3, 4 Receptive aphasia refers to impairment or loss of language comprehension (ie, speech, reading) that is caused by a neurological condition (eg, stroke, traumatic brain injury). The terms "aphasia" and "dysphasia" can be used interchangeably as both refer to impaired communication; however, "aphasia" is more commonly used. When communicating with a client who has receptive aphasia, appropriate interventions include: • Ask short, simple, "yes" or "no" questions (Option 1 is correct). • Remain patient and calm, allowing the client time to understand each instruction (Option 3 is correct). • Use hand gestures or pictures (eg, communication board) to demonstrate activities (Option 4 is correct). (Option 2 is wrong) Clients with aphasia often become frustrated due to inability to communicate effectively. Frustration does not result from the nurse's care, so assigning the client to a different care provider is not an effective solution. (Option 5 is wrong) Eye contact is important in all communication but raising the voice will not help. Speaking loudly will not improve comprehension and may increase anxiety and confusion.

A client at 41 weeks gestation is admitted to the labor and delivery unit for labor induction. The nurse assists the health care provider with an amniotomy. Which of the following actions by the nurse are appropriate? Select all that apply. 1. Check the client's temperature at least every 2 hours 2. Keep the client supine with the bed flat for 2 hours after the procedure 3. Monitor the fetal heart rate before and after the procedure 4. Note the color, odor, and consistency of the amniotic fluid 5. Perform perineal care and change absorbent pads as needed

CORRECT ANSWER: 1, 3, 4, 5 Diagram of amniotomy: https://imgur.com/ArWABFf Amniotomy refers to artificial rupture of membranes (AROM), which may be performed by the health care provider to augment or induce labor. After AROM, there is an increased risk for infection from organisms ascending into the uterus and risk for umbilical cord prolapse if the fetal head is not firmly applied to the cervix. When assisting with AROM, the nurse should: • Monitor for infection by checking the client's temperature at least every 2 hours after the procedure (Option 1). • Monitor the fetal heart rate before and after the procedure, as compression of a prolapsed cord can cause fetal bradycardia and distress (Option 3 is correct). • Document the quality and amount of amniotic fluid, which should be colorless and without a foul odor. Yellow-green fluid can indicate fetal passage of meconium in utero; a strong, foul odor may indicate infection (Option 4 is correct). • Provide frequent perineal care to increase comfort and prevent transmission of organisms into the uterus from contaminated amniotic fluid (Option 5 is correct). (Option 2 is wrong) After AROM, the client should be assisted to an upright position to encourage the fetal head to remain firmly applied to the cervix. Supine positioning decreases uteroplacental blood flow and fetal oxygenation.

The practical nurse is assisting with the care of a client on the labor and delivery unit. Here are the materials about the client: Nurses' Notes: https://imgur.com/jD8ZtEv History and Physical: https://imgur.com/5AiKUDw Vital Signs: https://imgur.com/9HvPXyj Select the 4 findings that require immediate follow-up: 1. Blood pressure 2. Cervical examination 3. Deep tendon reflexes 4. Epigastric pain 5. Headache 6. Urine output

CORRECT ANSWER: 1, 3, 4, 5 Diagram of preeclampsia: https://imgur.com/1qOJSLO Preeclampsia is a hypertensive disorder of pregnancy that can lead to eclampsia (ie, seizures). Although the exact pathogenesis of preeclampsia is unclear, it is thought that systemic vasospasm leads to the characteristic manifestations of hypertension and end-organ damage (eg, renal). The definitive treatment is delivery of the fetus and placenta. The client has already been diagnosed with preeclampsia, but the condition can rapidly worsen. The nurse should immediately follow up if severe features of preeclampsia develop, including: • Systolic blood pressure (BP) ≥160 mm Hg and diastolic BP ≥110 mm Hg, which require pharmacological intervention to decrease BP (Option 1 is correct) • Neurological symptoms (eg, hyperreflexia, headaches), which indicate central nervous system irritability and may indicate an impending eclamptic seizure (Options 3 and 5 are correct) • Epigastric, or right upper quadrant, pain, which is associated with liver damage and swelling that require further diagnostic studies (Option 4 is correct) • Visual disturbances (eg, dark spots, blurry vision) (Option 2 is wrong) The client's cervix dilated from closed to 2 cm and effaced from 0% to 25%, findings indicating that the cervical ripening agent was effective. Cervical dilation and effacement are expected outcomes of the labor-induction process and do not require immediate follow-up. (Option 6 is wrong) The nurse should monitor urine output for clients with preeclampsia because low urine output (ie, <30 mL/hr) may indicate renal insufficiency. However, a urine output of 50 mL in the past hour is adequate and does not require immediate follow-up by the nurse.

The practical nurse is collaborating with the registered nurse to conduct a developmental assessment of a 4-year-old child. Which of the following tasks does the nurse anticipate that the child will perform successfully? Select all that apply. 1. Drawing a circle 2. Jumping rope with both feet 3. Sitting quietly for 30 minutes 4. Using a spoon and fork 5. Walking up and down stairs

CORRECT ANSWER: 1, 4, 5 List of developmental milestones of preschoolers: https://imgur.com/GBQtU6W Preschool-age children begin to master more gross motor activities while rapidly increasing their fine motor abilities. The preschooler age 4 should have the fine motor skills to manipulate small tools (eg, scissors, pencil) and therefore be able to draw simple shapes (eg, circle, square) and perform more self-care activities (eg, eating with a spoon and fork) (Options 1 and 4 are correct). The gross motor skills and balance of a child age 4 improve, allowing for more independent, complex movements (eg, walking up and down stairs) (Option 5 are correct). (Option 2 is correct) A preschool-age child typically gains the ability to jump rope around age 5. A child age 4 would not yet be expected to jump rope successfully. (Option 3 is correct) It is normal for preschool-age children to be unable to sit quietly for longer than 15 minutes at a time.

The nurse cares for a 74-year-old client with Clostridioides (formerly Clostridium) difficile colitis and a history of stroke with left-sided weakness. Which of the following nursing actions are appropriate to promote client safety? Select all that apply. 1. Apply color-coded, nonslip socks to the client's feet 2. Encourage the client to use a cane on the left side for support 3. Lower the bed and raise all bed rails before exiting the room 4. Place a bedside commode on the client's right side 5. Remind the client to call for assistance before toileting

CORRECT ANSWER: 1, 4, 5 List of fall risk precautions: https://imgur.com/k3AJriX The nurse should ensure that fall risk precautions (eg, nonslip socks, lowering the bed) are implemented for clients with multiple fall risk factors (eg, advanced age, neuromuscular weakness). Color-coded, nonslip socks help prevent a client from slipping and alert staff to a client's increased risk for falls (Option 1 is correct). Most falls are unobserved and occur in the client's room or bathroom. Evidence shows a correlation between falls and hurrying to the bathroom due to bowel/bladder urgency and/or frequency (eg, incontinence, Clostridioides [formerly Clostridium] difficile infection). For clients with unilateral weakness, assisting with toileting and placing a bedside commode on the client's unaffected, or "strong," side help prevent falls (Options 4 and 5 are correct). (Option 2 is wrong) A cane can provide support to a client with impaired mobility. However, the client with unilateral weakness should use the cane on the unaffected, or "strong," side. (Option 3 is wrong) Lowering the bed is appropriate, but raising all bed rails is considered a restraint. Also, evidence shows that clients with impaired cognition (eg, dementia, delirium) can become entrapped in bed rails when trying to climb over them to exit the bed and are more likely to fall with all rails raised. Message @Matt's Notes

A female client who is sexually active has had three urinary tract infections (UTIs) in 12 months. Which of the following instructions should the nurse reinforce about preventing UTI recurrence? Select all that apply. 1. Increase daily intake of fluids 2. Use a spermicidal contraceptive jelly 3. Use an over-the-counter douche after intercourse 4. Use fragrance-free perineal deodorant products 5.Void immediately after intercourse 6. Wear underwear made of cotton

CORRECT ANSWER: 1, 5, 6 Female clients should implement the following interventions to help prevent recurrent urinary tract infections (UTIs): • Take all antibiotics as prescribed; bacteria may still be present even if symptoms have improved. • Increase fluid intake; this dilutes the urine (minimizing bladder irritation), promotes frequent urination, and prevents urinary stasis (Option 1 is correct). • Wipe from front to back to prevent introducing bacteria from the vagina and anus into the urethra. • Void after sexual intercourse to flush out bacteria that may have entered the urethra Option 5 is correct). • Avoid synthetic fabrics (eg, nylon, spandex), which seal in moisture and create an environment conducive to bacterial proliferation; cotton underwear is recommended instead (Option 6 is correct). • Take showers instead of baths, because bath products (eg, bubble bath, oils) and bacteria in bath water can irritate the urethra and increase the risk of infection. (Option 2 is wrong) Avoid spermicidal contraceptive jelly because it can suppress the production of protective vaginal flora, allowing proliferation of pathogenic bacteria, which may cause UTIs. In addition, diaphragms increase pressure on the urethra and bladder neck, which may inhibit complete bladder emptying; they should not be used until symptoms subside and the antibiotic course is completed. (Options 3 and 4 are wrong) Avoid douching and feminine perineal products (eg, deodorants, powders, sprays), because they can alter the vaginal pH and normal flora, increasing the risk for infection.

The nurse cares for a client with end-stage liver disease who is not a candidate for a liver transplant. The client is considering participation in a research study investigating an experimental therapy. In discussing possible enrollment in the study with the client, which of the following statements by the nurse are appropriate? Select all that apply. 1. "Ask the research team about the risks, consequences, and benefits before signing consent." 2. "Before signing consent, make sure you understand the study's duration and your obligations." 3. "In your own words, can you tell me what you have been told about the study and what you will be required to do?" 4. "Remember that if you participate, you are not obligated to stay in the study. You may withdraw at any time." 5. "To maintain the integrity of the study, certain information may be withheld, such as potential for harm or discomfort."

CORRECT ANSWER: 1,2,3,4 Informed consent must be obtained from clients participating in a clinical trial. Prior to participation in a study, the researcher or a member of the research team must: • Inform the participant of the study's risks, consequences, and benefits (Option 1 is correct). • Explain the study's purpose, duration, and procedures and participant's obligations (eg, time commitment, evaluations) (Option 2 is correct). • Ask participants to explain the study in their own words, allowing the nurse to identify any need for clarification (Option 3 is correct). • Assure the participant that personal information will remain confidential. • Ensure that consent is obtained voluntarily and that the participant is fully capable of understanding the terms of the study prior to signing the consent form • Disclose the participant's ability to withdraw from the study at any time (Option 4 is correct). (Option 5 is wrong) Before the participant signs the consent form, the research team must disclose any potential for harm or discomfort associated with the study.

The nurse is caring for a 68-year-old client. Here is their history and physical: https://imgur.com/M5GosAT The client is diagnosed with an acute exacerbation of chronic obstructive pulmonary disease. Which of the following assessment findings support this diagnosis? Select all that apply. 1. Altered mental status 2. Increased cough frequency 3. Increased sputum production 4. Wheezing 5. Worsening dyspnea

CORRECT ANSWER: 1,2,3,4,5 An exacerbation of chronic obstructive pulmonary disease (COPD) occurs when symptoms acutely worsen beyond the client's baseline, often triggered by infection. Manifestations of acute COPD exacerbation include: • Altered mental status (eg, confusion, decreased level of consciousness) due to impaired gas exchange and carbon dioxide gas retention (hypoxemia and hypercapnia) (Option 1 is correct) • Increased cough frequency as the client tries to clear excess sputum (Option 2 is correct) • Increased sputum production or a change in sputum characteristics (eg, color, consistency), which may indicate infection (Option 3 is correct) • Wheezing, which occurs as air moves through narrowed airways (Option 4 is correct) • Worsening dyspnea due to increased sputum and air trapping in the alveoli (Option 5 is correct) • Decreased exercise tolerance and fatigue

The nurse responds to a neighbor's calls for help and finds the neighbor's infant choking but still responsive. Which intervention is most appropriate at this time? 1. Call 911 and begin cardiopulmonary resuscitation 2. Perform 5 back slaps followed by 5 downward chest thrusts 3. Perform a finger sweep of the mouth to assess for foreign objects 4. Place the infant on the lap and perform abdominal thrusts

CORRECT ANSWER: 2 Diagram of Heimlich maneuver with infants under 1: https://imgur.com/xr1nkxR To relieve choking in a responsive infant, the rescuer should: • Hold the infant face down on the forearm with the infant's head slightly lower than the body. The rescuer's forearm is supported on the thigh to avoid compressing the infant's soft throat tissue and fontanelles. • Forcefully perform 5 back slaps between the infant's shoulder blades with the heel of the hand. Using both forearms, turn the infant face up on the forearm with the head slightly lower than the body. Forcefully provide 5 chest thrusts in a downward motion over the lower half of the breastbone using 2-3 fingers (Option 2 is correct). • Repeat the cycle until the object is expelled or the infant becomes unresponsive. (Option 1 is wrong) Cardiopulmonary resuscitation is not initiated until the infant becomes unresponsive. The priority intervention for a responsive infant is to attempt to dislodge the object obstructing the airway. (Option 3 is wrong) Finger sweeps are avoided unless the object is visualized and the rescuer is able to retrieve it easily with the fingers. Performing a blind finger sweep can push a foreign object further into the airway. (Option 4 is wrong) Abdominal thrusts are used in children age ≥1 and adults and are not recommended in infants (ie, age <1). Educational objective:

An earthquake has caused a mass-casualty incident in the community. Stable clients must be released to make room for incoming clients affected by the incident. Which client should the nurse recognize as most appropriate for discharge? 1. Client with an acute head injury and a Glasgow Coma Scale score of 12 2. Client with an asthma exacerbation who has a peak flow at 85% of personal best 3. Client with deep venous thrombosis on IV heparin and platelet count of 40.000/mm3 4. Client with liver cirrhosis and oozing esophageal varices who is receiving lactulose

CORRECT ANSWER: 2 In a disaster situation, the nurse should discharge stable clients to make space available for a high volume of incoming injured clients. A client with asthma who has a peak flow of ≥80% of personal best has good control of symptoms and airway compliance and is considered stable for discharge. Peak flow is the best measurement of airway compliance for asthma; a peak flow of <80% indicates uncontrolled symptoms requiring further acute treatment and monitoring (Option 2 is wrong). (Option 1 is wrong) The Glasgow Coma Scale is used to assess level of consciousness in clients, with a score of 15 being normal. A client who sustained an acute head injury and has a Glasgow Coma Scale score of 12 has moderate neurologic impairment requiring further observation and care. (Option 3 is wrong) A client who is receiving IV anticoagulation and has thrombocytopenia (ie, platelets <150,000/mm3) may have heparin-induced thrombocytopenia and is at risk for paradoxical arterial thrombosis (eg, stroke) and, rarely, bleeding. This client requires further evaluation and care. (Option 4 is wrong) A client with oozing esophageal varices may experience gastrointestinal hemorrhage if the varices rupture and is at risk for increasing ammonia (from the digestion of protein in the blood). This client needs continued care (eg, lactulose administration) and intervention.

During the discharge process, the nurse observes a new parent placing a newborn into a car seat in the vehicle. Which action by the parent requires the nurse to intervene? 1. Anchors the car seat in the center of the vehicle's back seat 2. Dresses the newborn in a sleep sack before securing the harness 3. Keeps the car seat at a 45-degree angle 4. Uses a car seat that faces the rear of the vehicle

CORRECT ANSWER: 2 Diagram/list of motor vehicle restraints: https://imgur.com/HCoe6aA Vehicle safety for newborns and small children is important for reducing preventable injuries and deaths. Newborns and children age <2 years must be placed in a rear-facing car seat in the vehicle's back seat. The car seat's harness is secured snugly at or below the shoulders, at the hips, and between the legs; the connectors clip together at the center of the chest. The harness fits securely when the newborn is dressed in lightweight clothing. Tucking blankets between the newborn and the harness or dressing the newborn in bulky coats or a sleep sack reduces the car seat's effectiveness (Option 2 is correct). (Option 1 is wrong) The car seat should be placed in the back seat and in the center (away from the doors), if possible. This protects the child from airbag deployment as well as collisions to the vehicle's sides. (Option 3 is wrong) When the car seat tilts back at a 45-degree angle, there is less danger of the newborn's head and neck falling forward and obstructing the newborn's airway. (Option 4 is wrong) A rear-facing car seat protects the newborn's head and neck from whiplash in a collision.

The nurse witnessed a signed informed consent for an inguinal hernia repair surgery. During the procedure, the surgeon discovers a secondary ventral hernia that also requires repair. Which action should the nurse perform? 1. Add the secondary hernia to the consent form that the client signed before the procedure 2. Call the client's medical power of attorney so that the surgeon can obtain consent for the additional procedure 3. Document that an additional hernia was found and that it will require surgery at a later time 4. Witness an additional consent after the client is awake and both procedures are complete

CORRECT ANSWER: 2 Informed consent is required before any nonemergent procedure. The 3 principles of informed consent include: • The surgeon clearly explains the diagnosis, planned procedure with risks and benefits, expected outcome, alternate treatments, and prognosis without surgery. • The client indicates understanding of the information. • The client is competent and gives voluntary consent. The nurse is responsible for witnessing the client's signature and ensuring that the client is competent and understands information provided by the surgeon. Clients who are unconscious or under the influence of mind-altering drugs (eg, opioids) cannot provide consent. If the sedated client requires procedures not listed on the consent form, the client's next of kin, legal guardian, or power of attorney should be contacted so that the surgeon can explain the situation and obtain consent (Option 2 is correct). (Option 1 is wrong) Modifying a consent form after it has been signed is an illegal falsification of documentation. (Option 3 is wrong) Unless family members deny consent or cannot be reached, it is in the client's best interest to have the hernia repaired during this surgery rather than go through the physical and financial strain of a second surgery. (Option 4 is wrong) Procedures can be performed without prior consent only when lifesaving measures are necessary. Obtaining consent after a procedure is illegal and considered assault and battery.

The nursing unit has implemented a quality-improvement program to improve client pain management. Which is the best indicator of improved pain management? 1. Better client pain control as reported by a survey of the unit's nurses 2. Improved clients' self-reported pain scores on chart audits 3. Increase in number of PRN analgesics administered to clients 4. Increase in positive feedback on a client satisfaction survey

CORRECT ANSWER: 2 Measurements for quality improvement should be client-centered and objective (quantifiable), rather than subjective. An evidence-based data collection method (eg, numeric pain scale) should be used, if applicable (Option 2 is correct). When evidence-based criteria are measured, survey results can be used as objective, retrospective measurements of a positive change. (Option 1 is wrong) Subjective, second-hand perceptions of client pain control reported by nurses may not reflect the actual adequacy of client pain relief. Objective, client-reported measurement tools should be used instead. (Option 3 is wrong) Increased analgesic administration could be attributed to many factors, including fluctuations in the number of clients on the unit or diversion of medication by staff (eg, theft. In addition, clients may obtain pain relief by nonpharmacologic means, and these measures are not reflected by measuring the number of analgesics administered. (Option 4 is wrong) Positive commentary on client satisfaction surveys is a subjective criterion. Overall client satisfaction is related to all aspects of care, including those unrelated to pain relief.

The nurse reinforces teaching to a client with hand osteoarthritis whose health care provider has recommended topical capsaicin for pain relief. Which instruction about capsaicin should the nurse reinforce to the client? 1. Apply a heating pad or warm compress for 20 minutes after applying cream 2. Apply cream to hands and wait at least 30 minutes before washing them 3. Stop using the cream if a burning or stinging sensation occurs • 4. Use only if oral pain medications have been ineffective

CORRECT ANSWER: 2 Topical capsaicin cream is an over-the-counter analgesic that effectively relieves minor pain (eg, osteoarthritis, neuralgia). The nurse should instruct the client to wait at least 30 minutes after massaging the cream into the hands before washing to ensure adequate absorption (Option 2 is correct). The client should avoid contact with mucous membranes (eg, nose, mouth, eyes) or skin that is not intact, because capsaicin is a component of hot peppers which can cause a burning sensation. When applying cream to other areas of the body (eg, knee), the client should wear gloves or wash hands immediately after application. (Option 1 is wrong) The application of heat with capsaicin is contraindicated because heat causes vasodilation, which increases medication absorption and can lead to a chemical burn. (Option 3 is wrong) Local irritation (burning, stinging, erythema) is common and usually subsides within the first week of regular use. If the client experiences persistent pain, redness, or blistering, the cream should be discontinued and the health care provider notified. (Option 4 is wrong) Topical capsaicin is often used concurrently with acetaminophen or NSAIDs (eg, naproxen, celecoxib) to effectively treat osteoarthritis pain. Capsaicin should be used regularly (ie, 3 to 4 times daily) for long periods (eg, weeks to months) to achieve the desired effect.

The nurse prepares to administer an intermittent bolus enteral feeding to a client via a nasogastric tube. Which of the following actions by the nurse are appropriate? Select all that apply. 1. Aspirate and discard 50 mL of gastric residual 2. Auscultate bowel sounds prior to feeding 3. Check the tube placement marking at the naris insertion site 4. Elevate the head of the bed to 45 degrees 5. Ensure that the formula is at room temperature

CORRECT ANSWER: 2, 3, 4, 5 Before administering intermittent enteral feedings, the nurse should: • Assess bowel function (eg, auscultate bowel sounds, measure gastric residual) to evaluate feeding tolerance (Option 2 is correct). • Check the tube placement marking at the naris insertion site. Displacement of the marking indicates that the tube may have been partially pulled out (Option 3 is correct). • Elevate the head of the bed to 30-45 degrees (and keep it elevated 30-60 minutes afterward) to minimize aspiration risk (Option 4 is correct). • Confirm tube placement (eg, radiology report, gastric aspirate pH) to ensure that the tip of the tube is correctly placed in the stomach or small intestine. • Flush tube with 30 mL of water (and again after feedings) to prevent clogging. • Ensure enteral feeding formula is at room temperature to prevent abdominal cramping/discomfort (Option 5 is correct). (Option 1 is wrong) Aspirated gastric residual volume (GRV) should be returned to the stomach because repeatedly discarding it may cause hypokalemia and metabolic alkalosis. Facility policy may advise holding enteral feeding for high GRVs (eg, >500 mL) to minimize aspiration risk. However, a RV of 50 mL is not excessive and should be returned. Some facilities no longer routinely check RVs because recent evidence shows that this practice impairs calorie delivery and may be ineffective for predicting aspiration risk.

A nurse is caring for a client who had a transurethral resection of the prostate and is receiving continuous bladder irrigation by gravity. Which of the following tasks can the nurse delegate to unlicensed assistive personnel? Select all that apply. 1. Calculating the difference between irrigant intake and total drainage output 2. Cleaning around the catheter insertion site daily 3. Immediately notifying the nurse if the client reports pain 4. Increasing the irrigation rate when the urine becomes more red than pink 5. Measuring the total volume of output in the drainage collection bag

CORRECT ANSWER: 2, 3, 5 Continuous bladder irrigation is prescribed following surgical transurethral resection of the prostate and prevents obstruction of urine outflow by removing clotted blood from the bladder. A 3-way catheter is used to continuously infuse solution into the bladder by gravity. The catheter drains urine, irrigant solution, and blood into a collection bag. The licensed practical nurse (LPN) should consider the five rights of delegation when delegating to unlicensed assistive personnel (UP): • Catheter care is a routine, noncomplex task that may safely be delegated to UAP (Option 2 is correct). • Any client reports of pain or bladder spasms to UAP should immediately be conveyed to the PN because these symptoms may indicate obstruction (Option 3 is correct). • Measuring output is routine data measurement. UP should report the volume to the LPN, who will determine the adequacy of drainage (Option 5 is correct). (Option 1 is wrong) Clots or kinks may obstruct drainage and cause a smaller volume of outflow than inflow. The nurse should calculate this difference to determine the need to reestablish patency using manual irrigation. (Option 4 is wrong) The irrigation rate should be titrated to maintain light pink outflow drainage with few clots. UP lack the knowledge and skills necessary to titrate inflow rate or monitor drainage quality.

The nurse is assisting with a presentation on protecting clients' privacy and confidentiality. Which of the following incidents does the nurse recognize as a violation of client confidentiality? Select all that apply. 1. A family member informs the registered nurse that the client has not been taking the prescribed metformin at home 2. An oncology nurse reviews the electronic health record of a friend in the emergency department who was the victim of a recent mass shooting event 3. The licensed practical nurse (LPN) leaves the client's report sheet in the cafeteria after lunch 4. The LPN tells the unlicensed assistive personnel (UAP), who is pregnant, not to enter the room of a client with toxoplasmosis 5. The UAP tells a client that the hospital roommate will return to the room after receiving hemodialysis

CORRECT ANSWER: 2, 3, 5 The nurse is ethically and legally obligated to protect clients' privacy and maintain confidentiality of their protected health information (PHI). Any client's PHI should only be shared with health care team members directly involved in that client's care. A client's electronic health record should never be accessed by staff members who are not involved in that client's care (Option 2 is correct). Report sheets used by staff often include clients' PHI and must remain with staff at all times and be securely shredded at the end of each shift (Option 3 is correct). Without the client's permission, PHI (eg, diagnoses, treatments) cannot be shared with a hospital roommate (Option 5 is correct). (Option 1 is wrong) Health information from the client or client's family members can be provided to health care staff as long as it is not done in public areas. In fact, family members often provide valuable insight into the client's lifestyle and medication regimen at home. (Option 4 is wrong) Nurses are obligated to help protect staff and visitors by ensuring implementation of appropriate infection prevention precautions. Pregnant health care workers should not be exposed to clients with teratogenic infections (mnemonic - TORCH: Toxoplasmosis, Other [varicella-zoster virus/parvovirus B19], Rubella, Cytomegalovirus, Herpes simplex virus).

The nurse is caring for a client who is 2 days postoperative craniotomy with bone flap removal. The nurse notes clear wound drainage saturating the dressing over the incision. Which action by the nurse is most appropriate at this time? 1. Cleanse the incision site with saline and apply a new, sterile dressing 2. Mark the edges of the drainage on the dressing and continue to monitor 3. Notify the health care provider of the color and amount of drainage 4. Turn the client onto the nonoperative side using the log-rolling technique

CORRECT ANSWER: 3 A craniotomy involves incision into the cranium and is indicated for elevated intracranial pressure or removal of tumors, blood, or abscesses. Postoperative clients are at risk for developing a cerebrospinal fluid (CS) leak from an intraoperative dural injury, which increases the risk for meningitis. Excessive drainage from a craniotomy incision (eg, saturated dressing, >50 mL per shift into the drain) or from the nose or ear suggests a possible CSF leak requiring immediate notification of the health care provider (HCP) (Option 3 is correct). Interventions focus on decreasing strain on the dural tear to encourage closure and include bedrest, lumbar drain placement, and surgical intervention. (Option 1 is wrong) The incision should not be re-dressed until the HCP can evaluate the wound and drainage. (Option 2 is wrong) The nurse should mark the drainage edges at least once per shift for comparison. However, a saturated dressing may indicate a CSF leak. (Option 4 is wrong) Repositioning may be indicated but is not the most appropriate action at this time. Specific client positioning postoperative craniotomy is prescribed by the HCP. The head of the bed is usually elevated approximately 30 degrees to facilitate venous drainage and prevent increased intracranial pressure. If flat positioning is prescribed, the nurse should log-roll the client to alternate between the back and the nonoperative side.

The nurse cares for a client with an established ascending colostomy. Which client statement indicates a need for further teaching? 1. " always try to drink 3 L of water each day." 2. "I avoid eating beans, broccoli, and cauliflower." 3. "I change the appliance and bag every other day." 4. "I empty the bag when it's about one-third full."

CORRECT ANSWER: 3 Colostomies may be performed on any part of the colon. Stool becomes more solid as it passes through the colon, so drainage characteristics vary with the location of the ostomy. Ascending colostomies produce semiliquid stool. Stool is contained in an ostomy appliance bag secured to the skin. The appliance opening is cut to fit closely around the stoma. If the appliance does not fit well, liquid stool may leak onto the peristomal area, resulting in skin irritation due to the digestive enzymes in stool. Peristomal skin irritation may also occur if the ostomy appliance is changed too frequently. The appliance should be changed every 5-10 days (Option 3 is correct). (Option 1 is wrong) The semiliquid consistency of stool from an ascending colostomy results in increased fluid loss, placing the client at risk for fluid and electrolyte imbalance. The client is encouraged to drink plenty of fluids to prevent dehydration. (Option 2 is wrong) A client with a colostomy has few dietary restrictions except to decrease intake of odorous and gas-forming foods (eg, beans, cauliflower, onions, broccoli). (Option 4 is wrong) The ostomy bag is emptied when one-third full because leaking and skin irritation may occur if the appliance becomes too heavy and pulls away from skin.

The nurse is caring for a 68-year-old client. Here is their history and physical: https://imgur.com/M5GosAT Which clinical finding is most concerning for respiratory distress? 1. Decreased breath stounds 2. Distended neck veins 3. Nasal flaring 4. Productive cough

CORRECT ANSWER: 3 Diagram of Chronic Obstructive Pulmonary Disease (COPD): https://imgur.com/68Ah8Qj Chronic obstructive pulmonary disease (COPD) is a progressive, irreversible lower respiratory tract condition characterized by chronic inflammation, airway remodeling, and reduced expiratory airflow. COPD is associated with air trapping due to alveolar enlargement and hyperinflation and/or airway obstruction due to inflammation and increased sputum production. Infection can precipitate an acute exacerbation. Findings that suggest acute respiratory distress or impending respiratory failure include nasal flaring, retractions (eg, supraclavicular area), grunting (in children), and change in body posture (leaning forward). These occur as a compensatory mechanism to reduce work of breathing. In clients with COPD, signs of respiratory distress may indicate an acute exacerbation (Option 3 is orrect). (Option 1 is wrong) Decreased breath sounds are expected in clients with COPD due to decreased air flow through the bronchioles and alveoli. This finding occurs as COPD progresses and is not as reliable as nasal flaring to identify acute respiratory distress. (Option 2 is wrong) In clients with COPD, lung hyperinflation increases intrathoracic pressure, resulting in neck vein distension during expiration. This finding occurs as COPD progresses and is not as reliable as nasal flaring to identify acute respiratory distress. (Option 4 is wrong) A productive cough with greenish-yellow sputum is concerning for infection; it could be due to pneumonia or simple bronchitis (can be viral). Although this may contribute to respiratory distress, this finding alone does not indicate respiratory distress.

The nurse receives report on four clients at change of shift. Which client should the nurse see first? 1. Client who smokes who has intermittent leg pain that is worse with walking and eases with rest 2. Client with diabetes who has burning and numbness in both lower legs and feet 3. Client with leg swelling and calf pain who was on a 15-hour flight 2 days ago 4. Client with pain, edema, and redness in the leg following a dog bite 1 hour ago

CORRECT ANSWER: 3 Diagram of Deep Vein Thrombosis: https://imgur.com/fwiYE2h Life-threatening physiological problems (eg, airway, breathing, circulation) are the highest priority followed by less threatening problems (eg, pain, potential for infection). Unilateral edema and calf pain could be signs of a deep venous thrombosis (DVT), a high-priority circulation problem in which a lower-extremity clot may dislodge, travel, and cause life-threatening complications (eg, pulmonary embolism) (Option 3 is correct). Prolonged immobilization (eg, airplane travel, bed rest) increases the risk for DVT. (Option 1 is wrong) A client with leg pain during activity that is relieved by rest may have intermittent claudication, a classic sign of peripheral artery disease. This condition is not an immediate threat to survival. (Option 2 is wrong) The diabetic client with poor glucose control is at risk for developing neuropathy (burning, tingling, or loss of sensation) of a limb due to changes in the nerves. This is a chronic, progressive condition and is not an immediate threat to survival. (Option 4 is wrong) The client with a dog bite will need antibiotics and possibly a rabies vaccination, but there is no immediate threat to survival.

The nurse receives report on four clients. Which client should the nurse see first? 1. Client who is confused and trying to pull out the indwelling urinary catheter 2. Client who is scheduled for hydrotherapy and has removed the dressing over an infected foot ulcer 3. Client whose dressing is saturated with bright red blood 2 hours after foot amputation surgery 4. Client with an arteriovenous graft who is experiencing new-onset pain and redness at the site

CORRECT ANSWER: 3 Following amputation, clients are at risk for hemorrhage. A small amount of bleeding at the amputation site is expected postoperatively, but a saturated dressing indicates excessive blood loss. The nurse should immediately apply a pressure dressing and notify the health care provider (Option 3 is correct). Care for other clients may be safely delayed until the client who is actively bleeding is stabilized. (Option 1 is wrong) A client who is confused and attempting to remove a line or drain is at risk for injury. Until mental status improves or invasive lines and tubes are discontinued, this Client may require reorientation and one-to-one observation. (Option 2 is wrong) An infected foot ulcer should remain covered to protect healing tissue and contain drainage. Dressings are changed at regular intervals and removed intermittently for wound assessment or therapies (eg, debridement, hydrotherapy [whirlpool bath]). A dressing that falls off or is removed prior to hydrotherapy can be temporarily replaced with a sterile towel or gauze bandages, with a new dressing applied after therapy. (Option 4 is wrong) A client whose arteriovenous graft has signs of infection (eg, erythema, fever) is at risk for thrombosis, graft failure, or systemic infection. This client requires evaluation by the health care provider and possible surgical repair.

A client is seen following a motor vehicle collision. An IV infusion of 1 L of normal saline solution was administered before arrival at the hospital. The IV line is now infusing at 200 mL/hr. Which finding alerts the nurse to the development of hypovolemic shock? 1. Jugular venous distension 2. Mean arterial pressure of 65 mm Hg 3. Urine output of 28 mL/hr 4. Warm, flushed skin

CORRECT ANSWER: 3 Hypovolemic shock most commonly occurs from blood loss but can occur in any condition that reduces intravascular volume. Hypovolemia is classified as either an absolute (eg, bleeding, vomiting, diarrhea) or a relative (eg, third spacing) fluid loss. Reduced intravascular volume results in decreased venous return, stroke volume, and cardiac output; inadequate tissue perfusion; and impaired cellular metabolism. Clinical manifestations of hypovolemic shock are associated with inadequate tissue perfusion and include: • Change in mental status • Tachycardia with thready pulse • Cool, clammy skin • Oliguria • Tachypnea Decreased urine output (<30 L/hr) despite fluid replacement indicates inadequate tissue perfusion to the kidneys and is a manifestation of hypovolemic shock in a client with normal renal function Option 3 is correct). (Option 1 is wrong) Jugular venous distension occurs with increased central venous pressure and intravascular volume. (Option 2 is wrong) A mean arterial pressure of 70-105 mm Hg is considered normal, and >60 mm Hg is required for adequate tissue perfusion to vital organs (brain, coronary artery). (Option 4 is wrong) Warm, flushed skin can be an early sign of septic or neurogenic shock but is not associated with hypovolemic shock.

A nurse is assisting in the admission of a child with leukemia to the pediatric unit. Which client could share a room with this child? 1. A client recovering from a ruptured appendix 2. A client with cystic fibrosis 3. A client with minimal change nephrotic syndrome 4. A client with rheumatic fever

CORRECT ANSWER: 3 Leukemia, the most common form of childhood cancer, is characterized by unrestricted proliferation of abnormal white blood cells (lymphoblasts), resulting in depression of normal bone marrow activity (ie, myelosuppression). Neutropenia and immaturity of white blood cells places the client at risk for infection. If a client with leukemia must share a semiprivate room, the other client in the room should not have an infectious illness. It would be appropriate for a client with leukemia to share a room with a client with minimal change nephrotic syndrome, a noninfectious condition of the glomeruli that poses no risk to the client with leukemia (Option 3 is correct). (Option 1 is wrong) Appendicitis may be a result of an infectious process, and a ruptured appendix can lead to peritonitis and sepsis. A client recovering from a ruptured appendix poses a risk for infection to the client who has leukemia. (Option 2 is wrong) Clients with cystic fibrosis (CF) have pulmonary complications due to thickening of the mucus that traps bacteria. The tracheobronchial tree becomes colonized with bacteria, and recurrent respiratory infections are a lifelong problem. A client with CF poses a risk for infection to the client who has leukemia. (Option 4 is wrong) Rheumatic fever occurs following pharyngitis caused by group A beta-hemolytic Streptococcus. A client with rheumatic fever poses a risk for infection to the child with leukemia.

A nurse is called in from home to help care for an influx of clients being admitted after a bus accident. While assisting a coworker to prepare for incoming clients, the nurse becomes concerned that the coworker may be under the influence of an impairing substance. Which action by the nurse is best? 1. Ask another coworker to observe the individual to confirm the suspicion 2. Confront the coworker about the concern and offer emotional support 3. Speak with the nursing supervisor in private about the concern 4. Telephone the appropriate regulatory agency and make a report

CORRECT ANSWER: 3 Nurses have an ethical and professional obligation to protect and promote client safety. One common, but often underrecognized, threat to client safety is receiving care from impaired medical professionals. Impairment may occur due to physical injuries, mental illness, and/or the use of impairing substances (eg, alcohol, narcotics, recreational drugs). Regardless of the cause, a nurse who suspects that a coworker may be impaired at work should immediately report the concern to a supervisor to prevent potential harm to clients (Option 3 is correct). (Option 1 is wrong) The nurse should report concerns regarding potentially impaired coworkers directly to a nursing supervisor. Involving additional staff is unwarranted and delays managerial action. (Option 2 is wrong) A potentially impaired coworker should be confronted by a nursing supervisor unless the nurse's behavior poses an imminent risk of harm to the client. (Option 4 is wrong) Reporting to the appropriate regulatory agency must be done if use of an impairing substance is confirmed. However, the nursing supervisor should be notified first so that immediate action can be taken to protect clients from harm.

The nurse receives laboratory reports on four clients. Which report is most concerning and should be reported to the health care provider? 1. Client admitted with pneumonia who has a PaCO2 of 32 mm Hg 2. Client receiving warfarin for atrial fibrillation who has an IN of 2.5 3. Client who had a total knee replacement 2 hours ago and whose hemoglobin is 7 g/dL 4. Client with chronic obstructive pulmonary disease who has a Pa02 of 85 mm Hg

CORRECT ANSWER: 3 Blood loss is a common complication of a total knee replacement, and a hemoglobin level of 7 g/dL is very low (normal adult male: 14-18; normal adult female: 12-16). This client should be assessed for active bleeding and for signs associated with severe anemia (eg, tachycardia, shortness of breath). The health care provider should be notified as soon as possible (Option 3 is correct). (Option 1 is wrong) Although a normal PaCO2 is 35-45 mm Hg, clients with pneumonia, as well as those with asthma, panic attacks, and pulmonary embolism, have tachypnea. Rapid breathing causes more carbon dioxide gas (CO2) to be exhaled, thereby reducing the amount of CO2 in the blood (ie, PaCO2). (Option 2 is wrong) Warfarin is prescribed to prevent blood clotting in clients with atrial fibrillation. To prevent clotting, the dosage of warfarin is adjusted to maintain an INR of 2-3. This client's INR is therapeutic. (Option 4 is wrong) A PaO2 greater than 80 mm Hg is a normal finding. In clients with chronic obstructive pulmonary disease (COPD), CO, becomes trapped in the lungs due to blocked airways. The body adjusts to elevated CO2 levels (which trigger increased respiratory rate in clients without COPD) and then uses the amount of oxygen in the blood (eg, PaO2) to regulate breathing.

The health care provider has just informed a client who has diabetes and chronic kidney disease of the need to start dialysis. The client tearfully says to the nurse, "I don't know what I'm going to do; everything was so overwhelming before, and now there is this." How should the nurse respond? 1. "You can cry and get it all out; I will stay with you." 2. "You have dealt with diabetes, you can conquer dialysis." 3. "You sound very discouraged and frightened." 4. "You still have a lot to live for; think about your family."

CORRECT ANSWER: 3 List of therapeutic communication techniques: https://imgur.com/PBYijoZ Clients may feel overwhelmed when managing chronic illnesses. The nurse should assist them in processing difficult news or events through discussion of thoughts and feelings, which also fosters rapport. Reflecting, or referring the statement back to the client, is a therapeutic communication technique that promotes open dialogue and encourages the client to recognize feelings (Option 3 is correct). Acknowledging feelings is an important step in successfully navigating difficult circumstances. (Option 1 is wrong) Encouraging the client to cry if needed conveys concern but does not encourage further discussion of feelings. (Option 2 is wrong) Giving false reassurance is an example of a nontherapeutic communication technique that may seem supportive; however, it inappropriately offers hope for an outcome that the nurse cannot guarantee. False reassurance also invalidates and hinders discussion of the client's feelings. (Option 4 is wrong) Making cliché statements or automatic responses (eg, "you have a lot to live for") or shifting the focus to others' feelings (eg, "think about your family") invalidates the client's feelings and impedes open communication.

A nurse is caring for a client who was admitted following a suicide attempt. Which client statement is most concerning? 1. "I don't think that I will ever be okay again." 2. "I feel so angry because I failed at my attempt." 3. "I have been sleeping all the time lately." 4. "Very soon everything will be much better."

CORRECT ANSWER: 4 A client who has attempted suicide is at risk for repeated attempts and death by suicide. After beginning treatment (eg, antidepressant therapy), clients are at even higher risk because they begin to have more energy, allowing them to follow through with suicide plans. The nurse should assess the client's verbal and nonverbal cues and recognize that a sudden positive outlook is the most concerning sign that the client may have determined a plan for suicide and is at peace with it (Option 4 is correct). The nurse should directly ask the client about a suicide plan. (Options 1 and 2 are wrong) Hopelessness (belief that a situation is intolerable, inescapable, or unending) and anger are expected reactions to an unsuccessful suicide attempt. The nurse should encourage clients to share feelings to build rapport, support the client, and decrease feelings of isolation during an acute suicidal episode. (Option 3 are wrong) It is common for clients with depression and recent suicidal ideation to have either insomnia or excessive sleepiness. If sleep disturbances continue after the therapeutic effect of prescribed antidepressants should have occurred, the medication regimen may require adjustment.

A nurse is assisting in the postoperative care of a client who had a heart transplant. What intervention is most important to implement? 1. Apply sequential compression devices 2. Assist client in changing positions slowly 3. Encourage coughing and deep breathing 4. Use careful handwashing and aseptic technique

CORRECT ANSWER: 4 Clients receiving transplanted organs are prescribed lifelong immunosuppressive medications (eg, cyclosporine, tacrolimus) to prevent organ rejection, placing them at high risk for life-threatening infection. Postoperative infection control measures incorporate strict handwashing, aseptic technique for procedures, and possible reverse isolation (Option 4 is correct). (Option 1 is wrong) Sequential compression devices are used to prevent postoperative deep venous thrombosis (DVT). Although DVT prophylaxis is important for all clients postoperatively, it does not take priority over infection prevention for clients who are immunosuppressed. (Option 2 is wrong) The newly transplanted heart is denervated from the client's autonomic nervous system and is unable to appropriately respond to increased physical demands (eg, increased heart rate with activity). The client should be taught how to avoid orthostatic hypotension (eg, change positions slowly); however, this does not take priority over infection prevention. (Option 3 is wrong) Coughing, deep breathing, and incentive spirometry are interventions important for prevention of atelectasis and pneumonia. However, strict implementation of hand hygiene and aseptic technique is the most effective way to reduce the risk of all acquired infections in clients who are immunocompromised.

The emergency department nurse has only one isolation room available. Which client should be assigned to the isolation room? 1. Child with chickenpox for the past 14 days whose lesions are crusted and dried 2. Child with impetigo who has been on antibiotics for 3 days 3. Child with leg rash secondary to poison ivy exposure 4. Child with suspected pertussis who has paroxysms of coughing

CORRECT ANSWER: 4 List of common applications of droplet precautions & personal protective equipment (PPE): https://imgur.com/JfNlnih Paroxysms of rapid coughing that lead to vomiting are a key feature of pertussis (whooping cough) infection. Pertussis is a highly contagious disease that can be deadly if contracted in infancy before vaccination is started. This client should be placed on droplet precautions immediately to prevent the spread of the disease (Option 4 is correct). (Option 1 is wrong) Varicella (chickenpox) is no longer contagious once the lesions have crusted and dried, which can take as long as 3 weeks. Until lesions are crusted, a hospitalized client with varicella should be on airborne and contact isolation precautions. (Option 2 is wrong) Impetigo is a bacterial infection of the skin that causes crusty lesions with highly contagious drainage to the face, often spreading to other areas of the body. Impetigo is no longer contagious after 24 hours of antibiotics. (Option 3 is wrong) A client with a poison ivy rash is not contagious and does not require isolation. The rash develops only from contact with the urushiol oil from the plant itself. The pustules do not contain this oil; therefore, the rash cannot be spread via person-to-person contact.

The nurse is caring for a group of 1-day-old clients in the newborn nursery. Which finding requires immediate attention? 1. Abdominal breathing with 15-second pauses in a sleeping newborn 2. Apical pulse of 165/min in a newborn who is crying 3. Heart murmur in a newborn who is feeding appropriately 4. Respirations of 68/min with grunting in a newborn after cesarean birth

CORRECT ANSWER: 4 Newborns normally have respirations of 30-60/min. Sustained tachypnea, nasal flaring, retractions, and grunting are signs of newborn respiratory distress. Respiratory distress may be related to retained amniotic fluid in the lungs (more common following cesarean birth), meconium aspiration, or infection (Option 4 is correct). The newborn should be continuously monitored and may require respiratory support (eg, supplemental oxygen, noninvasive positive pressure ventilation) until the underlying cause is corrected and respiratory status stabilizes. (Option 1 is wrong) Characteristics of normal newborn respiratory patterns may include shallow, irregular, or abdominal respirations. Periodic pauses in respirations lasting <20 seconds often occur during the rapid eye movement (REM) cycle and decrease with age. (Option 2 is wrong) The apical heart rate should be counted for a full minute and is normally 100-160/min. Stimulated states (eg, crying, activity) may cause increased heart rate (ie, ≥180/min), respirations, and blood pressure. The nurse should recheck vital signs when the newborn is calm. (Option 3 is wrong) A physiologic heart murmur is expected in the first 48 hours of life during the transition from fetal to neonatal circulation. Newborns with congenital heart disease have a pathologic heart murmur associated with other abnormal findings (eg, vital signs, cyanosis, poor feeding).

A client has developed diarrhea 24 hours after the initiation of continuous enteral tube feeding with a hypertonic formula. Which intervention is appropriate? 1. Collect a stool sample for culture and sensitivity 2. Dilute the formula with water 3. Discontinue the tube feeding 4. Slow the tube feeding rate of administration

CORRECT ANSWER: 4 Specific enteral tube feeding formulas are prescribed to meet a client's individual nutritional needs (eg, high-protein, low-carbohydrate). Hypertonic (hyperosmolar) formulas have a high concentration of carbohydrates and/or lipids, which can cause gastrointestinal upset (eg, diarrhea, abdominal cramps, nausea/vomiting), especially during the initiation of tube feeding. As in gastric dumping syndrome, fluid rapidly shifts into the intestines from surrounding compartments in an attempt to dilute the highly concentrated intestinal contents. Slowing down the tube feeding rate usually alleviates gastrointestinal upset by decreasing the volume of formula in the intestines (Option 4 is correct). When tube feeding is initiated, the rate is gradually increased to a prescribed goal rate to minimize the risk of gastrointestinal upset. The nurse should collaborate with the health care provider and/or dietitian to adjust the goal rate and formula as needed. (Option 1 is wrong) Sending a stool sample for culture and sensitivity would be appropriate if gastrointestinal infection is suspected as the cause of diarrhea. However, collecting a stool sample does not directly address the diarrhea. (Option 2 is wrong) Diluting tube feeding formula with water increases the risk of microbial contamination, which can lead to infection. A diluted formula supports microbial growth better than a full-strength formula. (Option 3 is wrong) The tube feeding should not be discontinued completely because this prevents the client from receiving necessary nutritional support. The tube feeding rate or formula should be adjusted if gastrointestinal upset occurs.

The nurse is caring for a 27-year-old female client. Here is her history and physical: https://imgur.com/Rq450KM Look in the pictures you sent me for the nurse's notes on her The client is planning to live separately from her spouse. Which statement by the client indicates a need for further teaching? • 1. " have arranged for my baby and I to live with a friend." 2. "Individual counseling will help me cope with the loss of my spouse." 3. "I would like to notify local law enforcement of the abuse." 4. "We can live together again in the future when the alcohol use stops."

CORRECT ANSWER: 4 The most dangerous time for a survivor of intimate partner violence (IPV) is when the relationship ends. Violent behaviors may escalate as the abuser attempts to regain power. Therefore, if a client decides to separate from the abuser, the nurse should reinforce safety teaching and determine the client's readiness for change. Although substance use can precipitate a violent event, the actual cause of IPV is the abuser's need to exert control. The client's belief that alcohol use is responsible for the violence (as in the honeymoon phase of the cycle of violence) indicates that the client may not be fully prepared to leave the relationship (Option 4 is correct). The nurse should reinforce teaching about the cycle of violence and ways the abuser may entice the client back into the relationship (eg, promising to change behavior). (Option 1 is wrong) A key element of a safety plan is a secure place to live. The client is indicating appropriate preparedness to leave the violent relationship by arranging to live with a friend. (Option 2 is wrong) Professional counseling can help survivors cope with the loss of the relationship and address incurred trauma. Counseling can also assist with associated mental health consequences of IPV (eg, posttraumatic stress disorder, low self-esteem, depression). (Option 3 is wrong) Notifying law enforcement can provide additional protection for survivors. The nurse should provide support and resources to the client throughout the legal process.

The home health nurse is visiting a client who has been prescribed home oxygen. The nurse observes wall-to-wall stacks of old newspapers and magazines in every room, with narrow pathways that barely permit passage. What is the priority nursing action? 1. Call the mobile community mental health crisis unit 2. Contact a service to remove the newspapers and magazines 3. Reconcile the client's home medications 4. Reinforce teaching about the safe use of oxygen equipment

CORRECT ANSWER: 4 This client exhibits signs of hoarding disorder, an anxiety disorder characterized by persistent difficulty in discarding possessions, even those with no value (eg, bottles, newspapers). Clients with hoarding disorder may allow items to clutter and obstruct living areas, creating severe environmental and fire hazards. These clients are usually unconcerned by their behavior and rarely seek mental health services, although the behavior may distress family or friends. The nurse's primary goal is to ensure safety of the client using home oxygen. The nurse must reinforce the importance of keeping oxygen sources away from flame or sparks, not smoking while oxygen is in use, and safely storing empty oxygen bottles for avoiding serious accidents in an environment that is at high risk for hazardous events (eg, fire, entrapment) (Option 4 is correct). (Option 1 is wrong) Referral to mental health services is an appropriate intervention, but it is not the highest priority. (Option 2 is wrong) The nurse cannot independently attempt to remove items. If the nurse attempts to do so without consent, the client may experience severe anxiety, agitation, or hostility. (Option 3 is wrong) Reconciling the client's home medications is appropriate, but it is not the priority nursing action.

The nurse is reviewing the charts of four clients in the outpatient pediatric clinic. Which client should the nurse see first? 1. 6-month-old who received the diphtheria-tetanus-acellular pertussis vaccine 18 hours ago and developed a fever of 102 F (38.9 C) and injection site redness 2. 11-month-old with inconsolable crying and drawing up of the legs toward the abdomen 3. 4-year-old who was diagnosed with right lung pneumonia 2 days ago and who has chest pain when breathing deeply 4. 15-year-old whose eyes are red and itchy and have a yellow discharge

CORRECT ANSWER: 2 Diagram of Intussusception: https://imgur.com/OS8PAks Inconsolable crying and drawing up of the legs toward the abdomen in a child age 6-36 months could indicate intussusception or another abdominal pathology (eg, appendicitis. Additional findings in intussusception include stools that contain mucus and blood, often called "currant jelly" stools, and vomiting. Intussusception occurs when one section of bowel telescopes over another, which can block the passage of intestinal contents, interrupt the blood supply, and cause intestinal tears (perforation). It is an emergency, and the client should be seen immediately for further evaluation (Option 2 is correct). Care for more stable clients may be safely delayed until after caring for the client with potential intussusception. (Option 1 is wrong) Mild to moderate fever and local reactions are common after vaccinations. Severe allergic reactions (eg, anaphylaxis) and encephalopathy (eg, decreased level of consciousness, prolonged seizures) are the most serious reactions and require priority attention. (Option 3 is wrong) Pneumonia is often accompanied by chest and side pain that worsens with deep breathing due to rubbing of the nearby inflamed pleura (pleuritis). This client's symptoms are expected findings. (Option 4 is wrong) Red, itchy eyes with yellow discharge indicates bacterial conjunctivitis, or inflammation of the clear membrane (conjunctiva) that covers the eye. This client will need ophthalmic antibiotics and education on preventing the spread of infection to others.

The nurse is caring for a client with metastatic cancer. At 9 PM, the night-time health care provider (HCP) rounds on the client and is alarmed to find the client bradypneic, hypotensive, and somnolent. The HCP requests that the nurse give the client naloxone. Which of the following is the best action by the nurse? Patient exhibit: https://imgur.com/gwtEDak 1. Approach the client's family to discuss whether to give naloxone in light of the client's wishes 2. Call the palliative HCP who prescribed the morphine sulfate to discuss the change in prescription 3. Describe the client's assessment data and plan of care, and do not give naloxone 4. Place the prescribed morphine on standby and obtain the naloxone prescription

CORRECT ANSWER: 3 Clients at the end of life should be relieved of pain and discomfort according to the ethical principles of beneficence (doing good) and nonmaleficence (doing no harm). As a client advocate, the nurse should actively ensure that unwanted or unwarranted treatment and client suffering are minimal. The client has requested a natural death without resuscitative efforts. Other health care providers (HCPs) may be unaware of the client's status or recent changes to the plan of care. Therefore, the nurse should inform the night-time HCP of the changes and should not give the naloxone even if cardiac and pulmonary functions are suppressed (Option 3 is correct). (Option 1 is wrong) The client and family already decided to withdraw treatment and pursue palliation; approaching the family about whether to intervene is inappropriate and may cause undue grief and guilt. (Option 2 is wrong) Before escalating the situation by calling the palliative HCP, the nurse should explain the client's status and wishes. If the night-time HCP insists that naloxone be given, the nurse should notify the charge nurse or supervisor. (Option 4 is wrong) Naloxone rapidly reverses the effects of opioid medications (eg, morphine). The resulting pain and discomfort for this client oppose nursing standards of care, violate the client's wishes, and are harmful to the client.

The licensed practical nurse collects data on several older adult clients. Which finding is a priority to report to the supervising registered nurse? 1. Client taking metoprolol who has a pulse of 54/min and blood pressure of 154/82 mm Hg О 2. Client with a PEG tube who has 345 mL of gastric residual volume aspirated before enteral feeding 3. Client with chronic obstructive pulmonary disease who has an SpO2, of 92% 4. Client with pneumonia who is receiving IV fluids and has a new S3 heart sound

CORRECT ANSWER: 4 Diagram of cardiac cycle & heart sounds: https://imgur.com/66IvBDo An S3 sound occurs when blood from the atrium is pumped into a noncompliant ventricle. S3 is heard after S2 (ventricular gallop). It may present as a normal finding in young adults. However, a new S3 in older adults is a significant finding because it may indicate the development of volume overload or heart failure. These conditions require prompt intervention because they may rapidly progress to life-threatening events (eg, respiratory compromise, cardiogenic shock). In this client, excessive IV fluids may be causing volume overload (Option 4 is correct). (Option 1 is wrong) Metoprolol is a beta-adrenergic blocker often used to treat heart failure and hypertension. Common side effects of beta blockers are bradycardia and hypotension. The health care provider should be notified if the client develops a heart rate of <50/min, hypotension, or cardiac symptoms (eg, dizziness, lightheadedness, nausea, chest pain) before or after administration. (Option 2 is wrong) Repeated high gastric residual volumes (eg, >250 mL) in clients receiving enteral feedings may indicate delayed stomach emptying and require adjustment to prevent nausea, vomiting, and abdominal distension. (Option 3 is wrong) Chronic obstructive pulmonary disease is a lung disorder that often causes dyspnea, hypoxia, and hypercarbia due to irreversible remodeling of the lower airways. The oxygen saturation goal for such clients is often 88%-92%.

A pediatric client weighing 66 lb is prescribed ibuprofen 5 mg/kg by mouth every 6 hr PRN for fever. It is available as an oral solution of 20 mg/mL. How many milliliters (mL) of ibuprofen should be given to the client per dose? Record your answer using one decimal place.

CORRECT ANSWER: 7.5 mL Reason/work for correct answer: https://imgur.com/L5vmJ7g

A client in the postoperative period after an open reduction and internal fixation of a left wrist fracture reports constant, severe arm pain that is unrelieved by prescribed morphine administered 30 minutes ago. The client's nail beds appear dusky. What is the appropriate nursing action? 1. Apply a heating pad and encourage range-of-motion exercises © 2. Check the temperature and movement of the fingers 3. Elevate the arm on pillows above the level of the heart 4. Reassure the client, document findings, and evaluate in 1 hour

CORRECT ANSWER: 2 List of clinical manifestations of compartment syndrome (7 Ps): https://imgur.com/Qtu0Rcp Compartment syndrome, a serious postoperative complication, is caused by decreased blood flow to the tissue distal to the injury. It results from either decreased compartment size (restrictive dressings, splints, or casts) or increased pressure within the compartment (bleeding, inflammation, edema). The earliest symptoms may include pain and numbness that are unrelieved by medication. Subsequent findings include diminished/absent pulses, pallor, coolness, swelling, decreased movement, and cyanosis. Failure to treat this condition can lead to loss of limb function, paralysis, and tissue necrosis. The nurse should collect data on the client's neurovascular status and report to the health care provider immediately (Option 2 is correct). Removal of tight bandages/casts and fasciotomy (surgery) are required to relieve the pressure. (Option 1 is wrong) Heat should not be applied to clients experiencing altered sensation because it may burn them. Active range-of-motion exercises will not resolve compartment syndrome and delays needed care. (Option 3 is wrong) Elevating the arm on pillows and providing additional analgesia may help reduce symptoms but may also reduce perfusion of the extremity. Instead, the extremity should be positioned at the level of the heart. (Option 4 is wrong) Documenting findings is important. However, reassurance and evaluation 1 hour later without immediate intervention delays needed care.

The nurse is caring for a hospitalized client with an acute exacerbation of heart failure. The client receives digoxin 0.5 mg PO once daily, furosemide 40 mg PO twice daily, and potassium chloride (KCI) 20 Eq PO twice daily. The client reports trouble swallowing the large KCI pill. The client's potassium level is 3.7 mEq/L. What action should the nurse take? 1. Consult with the pharmacist to see if other oral forms of KCI are available 2. Crush the pill and mix it with applesauce or pudding 3. Hold the KCI until the health care provider makes rounds 4. Instruct the client to tuck the chin to the chest when swallowing the pill

CORRECT ANSWER: 1 Potassium chloride (KCI) is commonly prescribed to correct or prevent hypokalemia. Oral KCI is available in extended-release tablets, capsules, dissolvable packets, effervescent tablets, and as an oral liquid. If a client has difficulty swallowing large pills, the nurse should consult the pharmacist to see if other forms of KCI are available and to determine if the medication is safe to crush (Option 1 is correct). If a more appropriate form (eg, liquid) is available, the nurse should discuss that change in route with the health care provider and obtain an updated prescription. (Option 2 is wrong) Some pills or capsules are sustained-release formulations, and crushing them may alter the release of the drug and cause an overdose of the medication. The nurse should consult the pharmacist before altering the form of the drug. (Option 3 is wrong) Use of a loop diuretic, such as furosemide, is a common cause of potassium depletion. Holding the KCI dose may cause the client's potassium level to fall below normal (<3.5 mEq/L), which can potentiate digoxin toxicity (eg, cardiac dysrhythmias, gastrointestinal upset). (Option 4 is wrong) Tucking the chin to the chest during swallowing is a technique used to prevent aspiration. This most likely will not help the client swallow the large pill.

The nurse is providing postoperative care for a client who had an aortic valve replacement two days ago and has a chest tube. Which finding is most important to report to the supervising registered nurse? 1. Chest tube output of 175 mL in the past hour 2. International normalized ratio of 1.5 3. Temperature of 100.3 F (37.9 C) 4. Urine output of 90 mL over the past 3 hours

CORRECT ANSWER: 1 Diagram of chest drainage system: https://imgur.com/T4fX6Mu Chest tubes are used to drain air or fluid from the mediastinal or pleural space. Chest tube drainage >100 mL/hr may indicate hemorrhage from a disrupted suture site (Option 1 is correct). The client can quickly become hemodynamically unstable from large amounts of blood loss and may require blood transfusion or emergency surgery. (Option 2 is wrong) Clients who receive a mechanical valve replacement should receive anticoagulation (eg, warfarin) after surgery to prevent thrombus formation on the valve, which could embolize and cause stroke. The goal INR for a client with a mechanical valve is 2.5-3.5 and should be achieved within 5 to 7 days after starting warfarin. (Option 3 is wrong) Fevers are common and expected during the first few days following major surgery. The nurse should monitor the client for other signs of infection (eg, incisional redness, heat, swelling) because a low-grade fever (eg, 100.3 F [37.9 C]) is not a reliable indicator of postoperative infection. (Option 4 is wrong) The nurse should closely monitor the client's urine output (minimum ≥30 mL/hr). Low urine output can indicate a decrease in cardiac output due to complications of valve replacement (eg, bleeding, valve dysfunction, dysrhythmias).

The nurse in an outpatient clinic cares for a client with primary adrenal insufficiency (Addison disease) who has been taking hydrocortisone 20 mg/day for the last 8 years. Which client data is most important to report to the health care provider? 1. Development of moon face 2. Fever of 100 F (37.8 C) for 2 days 3. Heart rate increase from 75 to 84/min 4. Weight gain of 6 lb (2.7 kg) in 3 months

CORRECT ANSWER: 2 Corticosteroid therapy is the primary classification of medications used to treat Addison disease, an adrenocortical insufficiency. Signs and symptoms of infection should be reported to the health care provider immediately. Use of corticosteroids can cause immunosuppression. Infection can develop quickly and spread rapidly. Its anti-inflammatory effects may also mask signs of infection such as inflammation, redness, tenderness, heat, fever, and edema. In addition, physiological stress such as infection can trigger Addisonian crisis, a life-threatening complication of Addison disease (Option 2 is correct). (Options 1, 3, and 4 are wrong) Tachycardia, moon face, and weight gain are also adverse effects of long-term corticosteroid therapy; however, they are not as life-threatening as infection.

When reinforcing teaching for a client with polycythemia vera, which of the following instructions should the nurse include? Select all that apply. 1. Elevate the legs and feet when sitting 2. Increase dietary intake of foods rich in iron 3. Increase fluid intake during exercise and hot weather 4. Increase bath water temperature to reduce itching 5. Report swelling or tenderness in the legs

CORRECT ANSWER: 1, 3, 5 Polycythemia vera (P) is a chronic disorder of the bone marrow in which too many BCs, WBCs, and platelets are produced. Clients with PV are at risk of developing blood clots (ie, thrombosis) due to increased blood viscosity. Clients should be instructed to: • Elevate the legs when sitting and wear support stockings to promote venous return (Option 1 is correct). • Increase fluid intake when fluid loss is anticipated (eg, perspiration) to prevent an additional increase in blood viscosity (Option 3 is correct). • Report signs of thrombosis (eg, swelling and tenderness of the legs) (Option 5 is correct). (Option 2 is wrong) The client should not increase intake of iron-containing foods and supplements, because this can cause further increases in hemoglobin production. Clients with PV need periodic phlebotomy to remove excess blood. (Option 4 is correct) Itching is a common and frustrating symptom of PV. Reducing bath water temperature, using starch baths, and patting the skin dry (rather than rubbing vigorously) are beneficial in reducing itching.

The pediatric nurse plans a home visit for a 2-year-old who will soon be discharged with home health care. Which condition presents the most concern as a safety hazard in the child's home environment? 1. Family lives in a rural area 2. House is heated by a wood-burning stove 3. House was built in 1983 4. Parents are unemployed with limited financial resources

CORRECT ANSWER: 2 The safety of the home environment should be assessed prior to discharge of pediatric clients, especially those with illnesses requiring continuing health care services in the home. The nurse can prioritize safety risks according to Maslow's hierarchy of needs. An open wood-burning stove is a fire hazard that may cause physiologic damage from smoke inhalation or burns (Option 2 is correct). The nurse should investigate the family's access to other utilities and determine whether the stove is the home's only source of heat. (Option 1 is wrong) Rural environments are not an inherent risk to the safety of the child. However, follow-up may be required to ensure the client has access to resources (eg, grocery store, hospital. (Option 3 is wrong) Houses built before 1978 have a high probability of containing lead-based paint. Active renovations can significantly increase the amount of lead released into the home environment, causing lead poisoning (eg, neurologic and motor impairment). Living in a house built in 1983 is not associated with an increased risk of lead exposure. (Option 4 is wrong) Unemployment and limited financial resources can cause increased stress and require further evaluation but would not take priority over a physical safety hazard.

The palliative care nurse is caring for a terminally ill pediatric client who does not respond to verbal stimuli. The client's parent asks, "How can you tell if my child is in pain?" Which of the following findings would the nurse describe as signs of pain? Select all that apply. 1. Blank facial expression 2. Clenched jaw 3. Groaning 4. Knees bent up to chest 5. Lying still

CORRECT ANSWER: 2, 3, 4 Diagram of FLACC Scale: https://imgur.com/60iwJ1w The FLACC scale (face, legs, activity, cry, and consolability) can be used to recognize pain in a pediatric client who is nonverbal or obtunded (nonresponsive). According to the FLACC scale, findings that indicate pain include: • Facial grimacing or frowning, clenched jaw, open mouth, or closed eyes (Option 2 is correct) • Restless or tense leg movements, kicking, or knees bent up toward chest (Option 4 is correct) • Restless activity, including squirming, arching, jerking, or fixed (stiff) position • Crying, moaning and groaning, whimpering, or screaming (Option 3 is correct) • Inconsolability and difficulty in comforting (eg, hugging, verbal reassurance) the client (Option 1 is wrong) A pediatric client who is comfortable will usually have a blank or neutral facial expression. Grimacing, frowning, and clenching of the jaw indicate pain, based on the FLACC scale. (Option 5 is wrong) A pediatric client who is comfortable will be relaxed and lie still. Restless movements, including squirming and jerking, indicate pain based on the FLACC scale.

The nurse is caring for a client whose unborn child has been diagnosed with anencephaly. Which of the following actions are appropriate to support the client in preparation for birth? Select all that apply. 1. Avoid bringing up the newborn's prognosis to prevent upsetting the client 2. Discuss the newborn's expected appearance with the client 3. Explain to the client that grieving cannot truly begin until one cries 4. Explore the client's preferences for social and spiritual support during labor 5. Remind the client of the ability to conceive again in the future

CORRECT ANSWER: 2, 4 Anencephaly (ie, the absence of a major portion of the brain and skull of a fetus) is incompatible with life. When caring for clients expecting the birth of a child with a poor prognosis, the nurse plays an important role in assisting to coordinate care and facilitating grief and psychological adjustment. Exploring the client's preferences for social (eg, family, friends) and spiritual (eg, chaplain, clergy) support helps the nurse accommodate the client's emotional and psychological needs and create a comforting setting (Option 4 is correct). To ease anxiety related to contact with the newborn, the nurse should offer to explain the newborn's expected appearance (ie, unique physical features) and potential bonding opportunities after birth (Option 2 is correct). (Option 1 is wrong) Avoiding discussion of the client's unique situation invalidates the client's experience and does not facilitate the grieving process. (Option 3 is wrong) The nurse should encourage parents to express grief in their own way and at their own pace, which may not include crying. (Option 5 is wrong) Reminding the client of the ability to have other children in the future invalidates the condition/prognosis of the current child.

The licensed practical nurse (LPN) and registered nurse (RN) are caring for a client with systemic lupus erythematosus. Which of the following tasks delegated by the RN should the LPN question? Select all that apply. 1. Administering oral immunosuppressant medications 2. Initiating a transfusion of packed RBCs 3. Monitoring client vital signs and pain level 4. Obtaining a sterile urine specimen for culture 5. Planning topics for client discharge teaching

CORRECT ANSWER: 2, 5 The licensed practical nurse (LP) should recognize that the registered nurse (RN) cannot delegate initial assessment or teaching or tasks requiring clinical judgment. The RN is responsible for creating the plan of care and preparing discharge instructions. Although the LP can assist in monitoring the client undergoing a blood transfusion, the RN must initiate transfusions and evaluate the client receiving blood products. The LP cannot accept delegation of tasks involving discharge teaching or initiating blood product transfusion (Options 2 and 5 are correct). (Options 1, 3, and 4 are wrong) The scope of practice for the LP includes administering most medications (except those given as a primary IV infusion or IV push), gathering clinical data about the client (eg, auscultating lung or bowel sounds, monitoring vital signs), and performing sterile procedures (eg, urinary catheterization, specimen collection).

The nurse is caring for a 27-year-old female client. Here is her history and physical: https://imgur.com/Rq450KM Look in the pictures you sent me for the nurse's notes on her Which intervention should the nurse perform first? 1. Clean the facial laceration and assist with suture placement 2. Contact social services to provide resources for survivors of domestic violence 3. Relocate the client to a room without the spouse 4. Take pictures of the client's injuries and document them on a body map Note: this question you need the nurse's notes for the patient to answer it, but you did not send me that.

CORRECT ANSWER: 3 The priority intervention for survivors of intimate partner violence is to remove any source of immediate danger. Clients should be questioned alone so the suspected abuser is unable to guide their answers or intimidate them from providing truthful responses. However, the suspected abuser should never be directly confronted because this can further endanger both the client and staff. Due to the spouse's escalating, agitated behavior (eg, clenched fists, pacing), the client should be relocated to a room without the spouse to prevent potential harm (Option 3 is correct). (Option 1 is wrong) Cleaning the laceration and preparing for sutures are appropriate interventions that should be performed after ensuring client safety. (Option 2 is wrong) Notifying social services of suspected abuse should occur with the client's permission after any immediate threats are removed and after physiological needs are met. This should not be done in the presence of any potential abusers. (Option 4 is wrong) The nurse should follow facility guidelines for reporting, documenting, gathering evidence, and/or photographing injuries (after obtaining client consent). Thorough documentation of details of the injury (eg, size, color, shape, area on a body map will be needed to facilitate any legal proceedings. Documentation does not take priority over client safety.

The nurse reinforces teaching about home care for the family members of a client admitted after a suicide attempt. Which of the following instructions are appropriate for the nurse to include? Select all that apply. 1. "Avoid discussion about suicide because it may increase the risk for additional attempts." 2. "If the client mentions self-harm, change the topic of conversation to a positive subject." 3. "Maintain a list of community resources and a suicide hotline for quick reference." 4. "Remove excess and unused medications, firearms, and knives from the home." 5. "Sudden positive outlook or calmness may indicate an impending suicide attempt."

CORRECT ANSWER: 3,4,5 Clients who have attempted suicide are at risk for further attempts. When providing education about care of a client with suicidal ideations, the nurse should encourage follow-up with the health care provider (HCP), enrollment in community-based counseling, and adherence to the prescription regimen (eg, antidepressant medications). The nurse should educate family members about measures to promote the client's safety, including: • Maintaining a list of phone numbers for community resources and suicide hotlines to which the client or family members can quickly refer in moments of acute suicidality (Option 3 is correct) • Creating a safe home environment by removing potentially dangerous items (eg, excess medications, firearms, knives) (Option 4 is correct) • Recognizing that a sudden positive outlook or calmness may be a sign that the client has developed a plan for suicide and feels hopeful about having resolution (Option 5 is correct) (Options 1 and 2 are wrong) The client's risk for acting on suicidal thoughts may be reduced, not increased, when provided the opportunity to express thoughts and related feelings. All communication about self-harm should be addressed directly with therapeutic communication.

A client with terminal cancer is prescribed fentanyl patches for pain management while receiving hospice care at home. Which of the following instructions related to this medication should the nurse reinforce when demonstrating application of the patch? Select all that apply. 1. Apply a heating pad over the patch to aid drug absorption 2. Cut the patch in half before application if less medication is needed 3. Fold the used patch in half so that edges adhere and immediately discard 4. Place patch over source of pain for maximum effectiveness 5. Remove old patch when applying a new patch every 72 hours

CORRECT ANSWER: 3, 5 Fentanyl, a potent opioid analgesic, is administered IV to treat acute pain and as a transdermal patch dosed in mcg/hr to treat chronic pain. When given via transdermal patch, fentanyl is absorbed systemically through the skin to provide continuous analgesia. Used patches must be folded and discarded immediately, because some medication remains in a used patch. Opioid medications must be stored and disposed of securely (eg, flushed down the toilet, discarded in a sharps container) because accidental exposure is potentially fatal for children, pets, and caregivers (Option 3 is correct). Patches are replaced every 72 hours, and used patches must be removed before applying a new one (Option 5 is correct). (Option 1 is wrong) Heat (eg, heating pad) should not be placed over a patch because this accelerates absorption. (Option 2 is wrong) Cutting a transdermal patch damages the drug-delivery system, results in administration of an imprecise dose, and risks exposure to the person cutting the patch. (Option 4 is wrong) Transdermal patches should be applied to an area of flat, intact skin (eg, upper back, chest) to prevent accidental removal. The site should be clean, with little hair. Unlike transdermal patches, topical analgesic patches (eg, lidocaine, capsicum) deliver drug locally and are placed near the site of pain.

The charge nurse is making assignments for the shift. Which assignment should the practical nurse question? 1. Client who had surgery yesterday and needs a sterile dressing change and frequent oral analgesics 2. Client with an established tracheostomy and a prescription to titrate supplemental oxygen as needed 3. Client with an existing colostomy that requires irrigation and placement of a new pouch 4. Client with newly diagnosed diabetes requiring discharge teaching regarding insulin administration

CORRECT ANSWER: 4 Diagram of scope of practice: https://imgur.com/H9K1Ul6 Assignments accepted by practical nurses (Ps) should be within the scope of practice outlined by their respective state boards of nursing. In general, the PN should provide safe, focused nursing care to clients with predictable needs. The PN may reinforce teaching that the registered nurse (RN) has initiated. The newly diagnosed diabetic client requires in-depth teaching regarding medication and blood glucose monitoring that has not been previously provided by the RN (Option 4 is correct). (Options 1, 2, and 3 are wrong) The PN should be able to provide safe and effective care using fundamental nursing skills to stable clients with routine and predictable needs. Care of established colostomies or tracheostomies and sterile dressing changes require nursing discretion and skill (eg, sterile gloving, titration of continuous oxygen), but these clients are physiologically stable.

The client has metastatic cancer, and a living will on file indicates that the client does not want cardiopulmonary or pharmacologic resuscitation. The client is brought to the emergency department with respirations of 4/min and a heart rate of 20/min. What action does the nurse anticipate? 1. Administer manual breaths to the client with a bag-valve-mask apparatus 2. Ask the client if any changes have been made to the living will 3. Identify and call the client's durable power of attorney for health care 4. Provide the client with comfort measures and call the next of kin

CORRECT ANSWER: 4 The 2 most common forms of advance directives are living wills and durable powers of attorney for health care. When available, these take effect when the client cannot self-advocate or make decisions (eg, serious injury, terminal illness, dementia, end of life. A living will is a legal document representing the client's specific wishes regarding medical care (eg, life-saving measures); it is written in advance of the client's inability to make decisions. If a client has a living will, it should be honored (Option 4 is correct). (Option 1 is wrong) Manual ventilation is part of cardiopulmonary resuscitation. This would go against the client's desires; however, a nasal cannula can be applied for comfort. (Option 2 is wrong) If the client indicates a change of mind, it should be honored. However, a client with respirations of only 4/min and a heart rate of 20/min does not have adequate perfusion and oxygenation to the brain and is no longer able to make decisions. The client's wishes were indicated when the client was able to think clearly, and these wishes should be honored at this time. (Option 3 is wrong) A durable power of attorney makes medical decisions on behalf of the client, taking into consideration the situation and the client's known wishes. However, a durable power of attorney is not required if the client has a living will.

A client with primary hypothyroidism who has been taking levothyroxine for 1 year has gained 10 Ib (4.5 kg) in 6 months, despite having a poor appetite. The client states, "| feel sleepy all the time." Laboratory results today show high levels of thyroid-stimulating hormone (TSH). Which information should the nurse reinforce to the client? 1. "A new prescription will be issued for a decreased dose of levothyroxine." 2. "Discontinue levothyroxine immediately; we will reassess TSH levels in 3 months." 3. "Start taking levothyroxine with dietary fiber or calcium to increase its effectiveness." 4. "You will need to get a new prescription for an increased dose of levothyroxine."

CORRECT ANSWER: 4 Thyroid-stimulating hormone (TSH) is released from the pituitary gland to stimulate the thyroid to secrete hormones (T3, T4). When sufficient thyroid hormone is circulating, negative feedback causes a normally functioning pituitary to slow or stop the release of TSH. However, in primary hypothyroidism, the thyroid is unable to synthesize enough T3 or T4. In response to low circulating thyroid hormones, the pituitary continues to release TSH, resulting in high TSH levels. Levothyroxine, a thyroid hormone replacement, is the most common treatment for hypothyroidism, a condition in which a thyroid hormone deficit slows the metabolic rate (eg, weight gain despite poor appetite, lethargy, fatigue). Levothyroxine dosing is adjusted to regulate circulating thyroid hormone levels; this creates a euthyroid (normal) state and TSH levels are decreased (Option 4 is correct). (Options 1 and 2 are wrong) Decreasing the dose or discontinuing levothyroxine would lead to increased TSH and worsening hypothyroidism as the amount of circulating thyroid hormone decreases. (Option 3 is wrong) For best results, levothyroxine should be taken on a consistent morning schedule, before food ingestion. Foods containing certain ingredients (eg, walnuts, soy products, dietary fiber, calcium) can affect drug absorption.

Several 12-month-old infants are brought to the clinic for routine immunizations. Which situation would be most important for the nurse to clarify with the provider before administering the vaccination? 1. Haemophilus influenza type b vaccine for a client allergic to penicillin 2. Hepatitis A vaccine for a client with a "cold" and temperature of 99 F (37.2 C) 3. Pneumococcal vaccine for a client with local swelling after last immunization 4. Varicella-zoster vaccine for a client recently diagnosed with leukemia

CORRECT ANSWER: 4 Vaccines should be administered at specific ages and intervals as passive placental immunity decreases and the child's immune system develops enough to produce antibodies in response to the vaccine. The nurse should always assess for allergies to vaccine components (eg, neomycin, gelatin, yeast) and screen for an allergy to latex (eg, lips swelling from contact with bananas, kiwis, or latex balloons). Most vaccines do not contain any latex; however, the nurse should use latex free equipment if an allergy is noted. Severely immunocompromised children (eg, corticosteroid therapy, chemotherapy, AIDS) generally should not receive live vaccines (eg, varicella-zoster vaccine, measles-mumps-rubella, rotavirus due to the body's limited ability to prevent virus multiplication, which could result in a possible severe vaccine-induced illness (Option 4 is correct). Passive immunization, by transfusing immunoglobulins made from another person who has been vaccinated against an antigen, may be the only option for children with severe immunosuppression. Common misperceptions of contraindications to immunization: • Penicillin allergy. Allergies to nonvaccine components are not contraindications to immunization. No vaccines available in the United States contain penicillin (Option 1 is wrong). • Mild illness (with or without an elevated temperature) (Option 2 is wrong) • Mild site reactions (eg, swelling, erythema, soreness) (Option 3 is wrong) • Recent infection exposure • Current course of antibiotics

The nurse is preparing to change a central venous catheter dressing using a chlorhexidine gluconate (CHG)-impregnated patch and transparent adhesive dressing. Place the procedural steps in the correct order. All options must be used. 1. Apply CHG patch over catheter insertion cite and cover with a sterile transparent dressing 2. Cleanse the site with CHG for at least 30 seconds using friction; allow to air-dry completely 3. Discard the clean gloves perform hand hygiene, and apply sterile gloves 4. Perform hand hygiene, don face mask, place a mask on the client, and apply clean gloves 5. Remove old dressing and CHG-impregnated patch; inspect insertion site

CORRECT ANSWER: 4, 5, 3, 2, 1 Central line dressing changes are sterile procedures and must be performed correctly to prevent infection. Steps should be performed in the following order: • Perform meticulous hand hygiene. • Don a surgical mask and apply a mask to the client (or ask the client to turn the head away from the dressing). Apply clean gloves (Option 4). • Remove the old dressing, including the chlorhexidine gluconate (CHG) - impregnated patch, making sure not to touch the insertion site (Option 5). • Inspect the site for drainage, erythema, heat, or inflammation. • Discard the clean gloves, perform hand hygiene, and apply sterile gloves (Option 3). • Cleanse the site with antimicrobial solution (eg, CHG), in a back-and-forth motion using friction, for at least 30 seconds; allow to air-dry completely (Option 2). • Apply the CHG-impregnated patch over the catheter insertion site and cover with the sterile transparent dressing (or use a CHG gel transparent dressing), making certain the edges of the dressing adhere well (Option 1). • Sign, date, and initial the dressing. • Document the procedure.