Complex Care

3 (Rationale:If the nurse notes the presence of bright red drainage on the dressing, it must be reported to the HCP, because this indicates hemorrhage. Options 1, 2, and 4 are inappropriate at this time)

The nurse is caring for a client following enucleation and notes the presence of bright red drainage on the dressing. Which most appropriate action should the nurse take at this time 1.Document the finding. 2.Continue to monitor the drainage. 3.Notify the health care provider (HCP). 4.Mark the drainage on the dressing and monitor for any increase in bleeding.

4 (Rationale:The client should be asked to perform the Valsalva maneuver during tubing changes. This helps avoid air embolism during tubing changes. The nurse asks the client to take a deep breath, hold it, and bear down. If the intravenous line is on the right, the client turns his or her head to the left. This position increases intrathoracic pressure. Breathing normally and exhaling slowly and evenly are inappropriate and could enhance the potential for an air embolism during the tubing change)

The nurse is preparing to change the parenteral nutrition (PN) solution bag and tubing. The client's central venous line is located in the right subclavian vein. The nurse asks the client to take which essential action during the tubing change? 1.Breathe normally. 2.Turn the head to the right. 3.Exhale slowly and evenly. 4.Take a deep breath, hold it, and bear down

4 (Rationale:Hypersensitivity reaction can occur in clients taking salmeterol. Signs include rash; urticaria; and swelling of the face, lips, or eyelids. The nurse should call the HCP immediately if any of these occur. The other options are incorrect)

The nurse has administered a dose of salmeterol to a client. The client develops a generalized rash and urticaria, and the eyelids begin to swell. Which action should the nurse take? 1.Apply a lanolin-based cream to the rash. 2.Encourage the client to drink fluids quickly. 3.Assess the client's vision with a Snellen chart. 4.Call the health care provider (HCP) immediately

2 (Rationale:A gastric lavage must be performed after ingestion of acetylsalicylic acid, and activated charcoal is administered to prevent further absorption of the substance. N-acetylcysteine is the antidote for acetaminophen. Administering ipecac or edetate calcium disodium is not a treatment measure for acetylsalicylic acid poisoning. Edetate calcium disodium may be prescribed for the treatment of lead poisoning. Ipecac causes vomiting, and this substance is used only in specific poisoning conditions; in this situation, vomiting can cause irritation of the esophagus.)

A 5-year-old boy is brought by his mother to the emergency department after ingesting a bottle of acetylsalicylic acid. Which procedure should be initially instituted with this child? 1.Administer ipecac by mouth and monitor emesis. 2.Institute a gastric lavage and administer activated charcoal. 3.Administer a chelating agent such as edetate calcium disodium. 4.Institute a gastric lavage and administer the antidote acetylcysteine

4 (Rationale:A sudden relief of pain from a suspected appendicitis is commonly indicative of a ruptured appendix. This places the individual at risk for peritonitis and shock. The HCP should be notified immediately because of the need to begin intravenous antibiotics to prevent further complications. Although increasing complaints of pain is a concern, the higher priority is sudden relief of pain because of the risk of peritonitis and shock. Temperature should be monitored but is not of highest priority. The child will be placed on NPO (nothing by mouth) status in anticipation of surgery; therefore, option 4 is incorrect.)

A child is admitted to the hospital after being seen in the emergency department with complaints of right lower quadrant abdominal pain, nausea and vomiting, fever, and chills. The health care provider (HCP) suspects appendicitis. Which assessment finding should the nurse immediately report to the HCP? 1.Decreasing oral temperature 2.Increasing complaints of pain 3.Refusal to take fluids by mouth 4.Sudden relief of abdominal pain

2 (Rationale:In the event of shock, the HCP is notified immediately before the nurse changes the child's position or increases intravenous fluids. After craniotomy, a child is never placed in the supine or Trendelenburg's position because it increases intracranial pressure (ICP) and the risk of bleeding. The head of the bed should be elevated. Increasing intravenous fluids can cause an increase in ICP)

A child undergoes surgical removal of a brain tumor. During the postoperative period, the nurse notes that the child is restless, the pulse rate is elevated, and the blood pressure has decreased significantly from the baseline value. The nurse suspects that the child is in shock. Which is the most appropriate nursing action? 1.Place the child in a supine position. 2.Notify the health care provider (HCP). 3.Place the child in Trendelenburg's position. 4.Increase the flow rate of the intravenous fluids

2 (Rationale:If the eye injury is the result of a penetrating object, the object may be noted protruding from the eye. This object must never be removed except by the ophthalmologist because it may be holding ocular structures in place. Application of an eye patch or irrigation of the eye may disrupt the foreign body and cause further tearing of the cornea.)

A client arrives in the emergency department with a penetrating eye injury from wood chips that occurred while cutting wood. The nurse assesses the eye and notes a piece of wood protruding from the eye. What is the initial nursing action? 1.Apply an eye patch. 2.Perform visual acuity tests. 3.Irrigate the eye with sterile saline. 4.Remove the piece of wood using a sterile eye clamp

1 (Rationale:Immediately after laryngectomy, a small amount of bleeding occurs from the tracheostomy that resolves within the first few hours. Otherwise, bleeding that is bright red may be a sign of impending rupture of a vessel. The bleeding in this instance represents a potential threat to life, and the HCP is notified to further evaluate the client and suture or repair the source of the bleeding. The other options do not address the urgency of the problem. Failure to notify the HCP places the client at risk.)

A client begins to experience drainage of small amounts of bright red blood from the tracheostomy tube 24 hours after a supraglottic laryngectomy. Which is the best nursing action? 1.Notify the health care provider (HCP). 2.Increase the frequency of suctioning. 3.Add moisture to the oxygen delivery system. 4.Document the character and amount of drainage

1, 2, 3 (Rationale:An anaphylactic reaction requires immediate action, starting with quickly assessing the client's respiratory status. Although the HCP and the Rapid Response Team must be notified immediately, the nurse must stay with the client. Oxygen is administered and an IV of normal saline is started and infused per HCP prescription. Documentation of the event, actions taken, and client outcomes needs to be done. The head of the bed should be elevated if the client's blood pressure is normal)

A client develops an anaphylactic reaction after receiving morphine. The nurse should plan to institute which actions? Select all that apply 1.Administer oxygen. 2.Quickly assess the client's respiratory status. 3.Document the event, interventions, and client's response. 4.Leave the client briefly to contact a health care provider (HCP). 5.Keep the client supine regardless of the blood pressure readings. 6.Start an intravenous (IV) infusion of D5W and administer a 500-mL bolus

1 (Rationale:Placement of a dressing over a chest wound could convert an open pneumothorax to a closed (tension) pneumothorax. This may result in a sudden decline in respiratory status, mediastinal shift with twisting of the great vessels, and circulatory compromise. If clinical changes occur, the nurse should remove the dressing immediately, allowing air to escape. Therefore, reinforcing the dressing is an incorrect action. The nurse would measure oxygen saturation by oximetry and would call the HCP, but these would not be the first actions in this situation.)

A client experienced an open pneumothorax (sucking wound), which has been covered with an occlusive dressing. The client begins to experience severe dyspnea, and the blood pressure begins to fall. The nurse should first perform which action? 1.Remove the dressing. 2.Reinforce the dressing. 3.Call the health care provider (HCP). 4.Measure oxygen saturation by oximetry

1, 2, 3, 5 (Rationale:If the client begins to hemorrhage from the surgical site after radical neck dissection, the nurse elevates the head of the bed to maintain airway patency and prevent aspiration. The nurse applies pressure over the bleeding site and calls the HCP immediately. The nurse also monitors the client's airway and vital signs)

A client has had radical neck dissection and begins to hemorrhage at the incision site. The nurse should take which actions in this situation? Select all that apply 1.Monitor vital signs. 2.Monitor the client's airway. 3.Apply manual pressure over the site. 4.Lower the head of the bed to a flat position. 5.Call the health care provider (HCP) immediately

1 (Rationale:The nursing interventions for the client with an intra-aortic balloon pump are the same as for any client who has had cardiovascular surgery. The peripheral circulation to the affected limb is monitored for signs of occlusion, such as coolness, mottling, pain, tingling, and decreased or absent distal pulse. Adverse changes are reported immediately. The remaining options are incorrect.)

A client in cardiogenic shock had an intra-aortic balloon pump inserted 24 hours earlier via the left femoral approach. The nurse notes that the client's left foot is cool and mottled and the left pedal pulse is weak. Which action should the nurse take? 1.Call the health care provider immediately. 2.Document these findings, which are expected. 3.Re-evaluate the neurovascular status in 1 hour. 4.Increase the rate of the intravenous nitroglycerin infusion

4 (Rationale:Sinus bradycardia is noted with a heart rate less than 60 beats per minute. This rhythm becomes a concern when the client becomes symptomatic. Hypotension and dizziness are signs of decreased cardiac output. Transcutaneous pacing provides a temporary measure to increase the heart rate and thus perfusion in the symptomatic client. Defibrillation is used for treatment of pulseless ventricular tachycardia and ventricular fibrillation. Digoxin will further decrease the client's heart rate. Continuing to monitor the client delays necessary intervention.)

A client in sinus bradycardia, with a heart rate of 45 beats/minute, complains of dizziness and has a blood pressure of 82/60 mm Hg. Which prescription should the nurse anticipate will be prescribed? 1.Administer digoxin. 2.Defibrillate the client. 3.Continue to monitor the client. 4.Prepare for transcutaneous pacing

4 (Rationale:The energy level used for all defibrillation attempts with a monophasic defibrillator is 360 joules.)

A client in ventricular fibrillation is about to be defibrillated. To convert this rhythm effectively, the monophasic defibrillator machine should be set at which energy level (in joules, J) for the first delivery? 1.50 J 2.120 J 3.200 J 4.360 J

1 (Rationale:Cardiogenic shock occurs with severe damage (more than 40%) to the left ventricle. Classic signs include hypotension; a rapid pulse that becomes weaker; decreased urine output; and cool, clammy skin. Respiratory rate increases as the body develops metabolic acidosis from shock. Cardiac tamponade is accompanied by distant, muffled heart sounds and prominent neck vessels. Pulmonary embolism presents suddenly with severe dyspnea accompanying the chest pain. Dissecting aortic aneurysms usually are accompanied by back pain)

A client is admitted to the emergency department with chest pain that is consistent with myocardial infarction based on elevated troponin levels. Heart sounds are normal and vital signs are noted on the client's chart. The nurse should alert the health care provider because these changes are most consistent with which complication? Refer to chart below. TimePulseRespiratoryBlood pressure 11:00 a.m.92 beats/min24 breaths/min140/88 mm Hg 11:15 a.m.96 beats/min26 breaths/min128/82 mm Hg 11:30 a.m.104 beats/min28 breaths/min104/68 mm Hg 11:45 a.m.118 beats/min32 breaths/min88/58 mm Hg 1.Cardiogenic shock 2.Cardiac tamponade 3.Pulmonary embolism 4.Dissecting thoracic aortic aneurysm

3 (Rationale:Nitroglycerin dilates both arteries and veins, causing peripheral blood pooling, thereby reducing preload, afterload, and myocardial work. This also accounts for the primary side effect of nitroglycerin, which is hypotension. In the absence of continuous direct arterial pressure (intra-arterial) monitoring, the nurse should use an automatic noninvasive blood pressure monitor. The remaining options are not specifically associated with the administration of IV nitroglycerin)

A client is admitted to the hospital with a diagnosis of myocardial infarction (MI) and is going to have an intravenous (IV) nitroglycerin infusion started. Noting that the client does not have an intra-arterial monitoring line in place, what piece of equipment should the nurse obtain for use at the bedside? 1.Defibrillator 2.Pulse oximeter 3.Noninvasive blood pressure monitor 4.Central venous pressure (CVP) insertion tray

1, 3, 5 (Rationale:Angina is chest pain caused by a temporary imbalance between the coronary arteries' ability to supply oxygen and the cardiac muscle's demand for oxygen. Myocardial infarction refers to injury and necrosis of myocardial tissue that occurs when the tissue is abruptly and severely deprived of oxygen. When a client complains of chest pain, it is critical that treatment is immediately initiated and that the nurse assesses for characteristics of angina versus those associated with myocardial infarction. Angina is characterized by substernal chest pain radiating to the left arm. The pain is usually precipitated by exertion or stress, is relieved by nitroglycerin or rest, and lasts less than 15 minutes. Characteristics of myocardial infarction include substernal chest pain that radiates to the left arm; pain in the jaw, abdomen, back, or shoulder can also occur. The substernal chest pain occurs without cause, usually in the morning; is relieved only by opioids, and lasts 30 minutes or longer.)

A client is brought to the emergency department complaining of substernal chest pain. To distinguish between angina and myocardial infarction, the nurse assesses for which characteristics of angina? Select all that apply 1.Chest pain that resolves with rest 2.Chest pain requiring an opioid for relief 3.Chest pain that is relieved by nitroglycerin 4.Chest pain that lasts longer than 30 minutes 5.Chest pain that is usually precipitated by exertion

2, 4, 5, 6 (Rationale:Interventions include giving supplemental oxygen, keeping the arm at the level of the heart, infusing crystalloid fluids through 2 large-bore IV lines, and immobilizing the arm in a position of function with a splint. Applying a tourniquet and placing ice on the area are contraindicated because they enhance the effect of the venom. Keep the person warm and provide calm reassurance. Also, apply continuous cardiac and blood pressure monitoring equipment to quickly detect clinical deterioration. Because venom can cause severe pain at the bite site, opioids are indicated. Provide tetanus prophylaxis and wound care as part of the collaborative plan of care)

A client is brought to the emergency room with a snake bite to the arm. Which treatment interventions should the nurse anticipate? Select all that apply 1.Apply ice to the site. 2.Deliver supplemental oxygen. 3.Apply a tourniquet just above the site. 4.Maintain the extremity at the level of the heart. 5.Infuse crystalloid fluids through 2 large-bore intravenous (IV) lines. 6.Immobilize the affected extremity in a position of function with a splint

3 (Rationale:Peripherally inserted central catheters are intended to be used for clients who need long-term catheter placement. They can be left in place for several months. It is reasonable in cost because the catheter does not need routine replacement, as do traditional peripheral intravenous catheters. The catheter is more comfortable for the client because there is no repeated venipuncture with catheter change. The catheter is also very reliable. It is less likely to infiltrate and can be used for administration of a number of types of medications.)

A client is scheduled for insertion of a peripherally inserted central catheter, and the nurse explains the advantages of this catheter. Which statement by the client indicates a need for follow-up? 1."It is reasonable in cost." 2."This type of catheter is very reliable." 3."It is specifically designed for short-term use." 4."I should not have pain or discomfort with this catheter.

1 (Rationale:Septicemia occurs with the transfusion of blood contaminated with microorganisms. Signs include chills, fever, vomiting, diarrhea, hypotension, and the development of shock. Hyperkalemia causes weakness, paresthesias, abdominal cramps, diarrhea, and dysrhythmias. Circulatory overload causes cough, dyspnea, chest pain, wheezing, tachycardia, and hypertension. A delayed transfusion reaction can occur days to years after a transfusion. Signs include fever, mild jaundice, and a decreased hematocrit level)

A client receiving a transfusion of packed red blood cells (PRBCs) begins to vomit. The client's blood pressure is 90/50 mm Hg from a baseline of 125/78 mm Hg. The client's temperature is 100.8°F (38.2°C) orally from a baseline of 99.2°F (37.3°C) orally. The nurse determines that the client may be experiencing which complication of a blood transfusion? 1.Septicemia 2.Hyperkalemia 3.Circulatory overload 4.Delayed transfusion reaction

4 (Rationale:Optimal weight gain when the client is receiving PN is 1 to 2 lb/week. The client who has a weight gain of 5 lb/week while receiving PN is likely to have fluid retention. This can result in hypervolemia. Signs of hypervolemia include increased blood pressure, crackles on lung auscultation, a bounding pulse, jugular vein distention, headache, peripheral edema, and weight gain more than desired. Thirst and polyuria are associated with hyperglycemia. A decreased blood pressure is likely to be noted in deficient fluid volume)

A client receiving parenteral nutrition (PN) in the home setting has a weight gain of 5 lb in 1 week. The nurse should next assess the client for the presence of which condition? 1.Thirst 2.Polyuria 3.Decreased blood pressure 4.Crackles on auscultation of the lungs

4 (Rationale:When the client who is receiving PN develops a fever, a catheter-related infection should be suspected. The solution and tubing should be changed, and the discontinued materials should be cultured for infectious organisms per HCP prescription. The other options are incorrect. Because culture for infectious organisms is necessary, the discontinued materials are not discarded or returned to the pharmacy or manufacturer)

A client receiving parenteral nutrition (PN) suddenly develops a fever. The nurse notifies the health care provider (HCP), and the HCP initially prescribes that the solution and tubing be changed. What should the nurse do with the discontinued materials? 1.Discard them in the unit trash. 2.Return them to the hospital pharmacy. 3.Save them for return to the manufacturer. 4.Prepare to send them to the laboratory for culture

4 (Rationale:Hypoglycemia is one of the potential complications associated with TPN. Shakiness and diaphoresis are signs of hypoglycemia; therefore, based on these findings, the nurse should first check the blood glucose level. Lung sounds may provide information about refeeding syndrome, which is a complication of TPN causing fluid overload. However, the assessment findings do not indicate that this is occurring. Mental status could be affected by hypoglycemia; however, the nurse has enough information to suspect this complication already and therefore should assess the blood glucose before assessing mental status. Blood pressure is not specifically related to the information in the question and the associated complication of TPN.)

A client who has been receiving total parenteral nutrition (TPN) by way of a central venous access device complains of shakiness and is diaphoretic. Based on these findings, the nurse should perform which assessment next? 1.Lung sounds 2.Mental status 3.Blood pressure 4.Blood glucose level

3 (Rationale:The client with severe flail chest will have significant paradoxical chest movement. This causes the mediastinal structures to swing back and forth with respiration. This movement can affect hemodynamics. Specifically, the client's CVP rises, the filling of the right side of the heart is impaired, and the arterial blood pressure falls. This is referred to as mediastinal flutter. The client with fat embolism experiences chest pain and dyspnea, but this condition occurs as a complication of a bone fracture. Mediastinal shift is a condition in which the structures of the mediastinum shift or move to the opposite side of the chest cavity; this may be caused by a pleural effusion or tension pneumothorax. In hypovolemic shock, the blood pressure falls and the pulse rises; this occurs following hemorrhage.)

A client who has just suffered a large flail chest is experiencing severe pain and dyspnea. The client's central venous pressure (CVP) is rising, and the arterial blood pressure is falling. Which condition should the nurse interpret that the client is experiencing? 1.Fat embolism 2.Mediastinal shift 3.Mediastinal flutter 4.Hypovolemic shock

2 (Rationale:Inamrinone is an inotropic agent used to relieve the manifestations of heart failure. Therapeutic effects include a decrease in weight (fluid), lung crackles, dyspnea, and edema. Blood pressure should remain stable or increase (if the client is hypotensive). Hypotension is an adverse effect of the medication)

A client with heart failure and hypotension has been started on intravenous medication therapy with inamrinone. The nurse determines which finding, if noted in the client, is an adverse effect of the medication? 1.Decreased weight 2.Decreased blood pressure 3.Absence of lung crackles 4.Reduced peripheral edema

2 (Rationale:Classic signs of cardiogenic shock as they relate to myocardial ischemia include low blood pressure and tachycardia. The central venous pressure would rise as the backward effects of the severe left ventricular failure became apparent. Dysrhythmias commonly occur as a result of decreased oxygenation and severe damage to greater than 40% of the myocardium)

A client with myocardial infarction is developing cardiogenic shock. Because of the risk of myocardial ischemia, what condition should the nurse carefully assess the client for? 1.Bradycardia 2.Ventricular dysrhythmias 3.Rising diastolic blood pressure 4.Falling central venous pressure

1 (Rationale:Air embolism occurs when air enters the catheter system, such as when the system is opened for intravenous (IV) tubing changes or when the IV tubing disconnects. Air embolism is a critical situation; if it is suspected, the client should be placed in a left side-lying position. The head should be lower than the feet. This position is used to minimize the effect of the air traveling as a bolus to the lungs by trapping it in the right side of the heart. The positions in the remaining options are inappropriate if an air embolism is suspected)

A client with total parenteral nutrition (TPN) infusing has disconnected the tubing from the central line catheter. The nurse assesses the client and suspects an air embolism. The nurse should immediately place the client in which position? 1.On the left side, with the head lower than the feet 2.On the left side, with the head higher than the feet 3.On the right side, with the head lower than the feet 4.On the right side, with the head higher than the feet

3 (Rationale:If cord prolapse or compression is suspected, the client is immediately repositioned. Cord compression needs to be relieved to allow for adequate fetal oxygenation. The client may be turned to the side or the hips may be elevated to shift the fetal presenting part toward the diaphragm, thereby relieving cord compression. A hands-and-knees position may reduce compression on a cord that is entrapped behind the fetus. Prone, supine, and reverse Trendelenburg's positions will not shift the presenting part toward the diaphragm and could worsen the condition.)

A delivery room nurse is caring for a client in labor. The client tells the nurse that she feels that something is coming through the vagina. The nurse performs an assessment and notes the presence of the umbilical cord protruding from the vagina. The nurse should immediately place the client in which position? 1.Prone 2.Supine 3.On the side 4.Reverse Trendelenburg's

2 (Rationale:Tricyclic antidepressants can be fatal when taken as an overdose, regardless of the amount ingested. Life-threatening symptoms can develop after an overdose. Immediate emergency medical attention and cardiac monitoring are necessary with an overdose of tricyclic antidepressants. Options that delay immediate intervention would not be the priority actions. Vomiting is not induced in an unconscious client.)

A depressed client is found unconscious on the floor in the dayroom of a health care facility. The nurse finds several empty bottles of a prescribed tricyclic antidepressant lying near the client. Which is the priority action of the nurse? 1.Call the Poison Control Center. 2.Call the emergency response team. 3.Determine the exact number of pills taken. 4.Induce vomiting and notify the health care provider

1 (Rationale:Opioids are used for epidural analgesia, which can lead to delayed respiratory depression. For this reason, respirations are monitored for 24 hours after administration of epidural analgesia. Naloxone is an opioid antagonist, which reverses the effects of opioids and is given if the respiratory rate falls below 8 breaths per minute. Betamethasone is a corticosteroid administered to enhance fetal lung maturity. Morphine sulfate and meperidine hydrochloride are opioids and would further compromise the respiratory rate)

A postpartum client who received an epidural analgesic after giving birth by cesarean section is lethargic and has a respiratory rate of 8 breaths per minute. The nurse should obtain which medication from the emergency cart after notifying the health care provider? 1.Naloxone 2.Betamethasone 3.Morphine sulfate 4.Meperidine hydrochloride

4 (Rationale:Fomepizole is used for the treatment of known or suspected ethylene glycol (antifreeze) intoxication. It is administered via the IV route, is not administered undiluted, and is not administered by rapid IV infusion. It is diluted in at least 100 mL of 0.9% normal saline or 5% dextrose in water and administered over a 30-minute period)

The emergency department nurse is preparing to administer fomepizole to a client suspected of ingesting antifreeze solution during a suicidal attempt. The nurse should prepare to administer this medication by which method? 1.Direct intravenous (IV) bolus 2.Diluting the medication and administering it rapidly by the IV route 3.Administering the medication through a nasogastric tube, followed by activated charcoal 4.Diluting the medication in 100 mL of 0.9% normal saline and administering it over 30 minutes

3 (Rationale:The client with a spinal cord injury is at risk for autonomic dysreflexia with an injury above the level of the seventh thoracic vertebra (T7). Autonomic dysreflexia is characterized by severe, throbbing headache; flushing of the face and neck; bradycardia; and sudden severe hypertension. Other signs include nasal stuffiness, blurred vision, nausea, and sweating. Autonomic dysreflexia is a life-threatening syndrome triggered by a noxious stimulus below the level of the injury. The data in the question are not associated with the conditions noted in the remaining options)

The family of a client with a spinal cord injury rushes to the nursing station, saying that the client needs immediate help. On entering the room, the nurse notes that the client is diaphoretic with a flushed face and neck and is complaining of a severe headache. The pulse rate is 40 beats/minute, and the blood pressure is 230/100 mm Hg. The nurse acts quickly, suspecting that the client is experiencing which condition? 1.Spinal shock 2.Pulmonary embolism 3.Autonomic dysreflexia 4.Malignant hyperthermia

1 (Rationale:The client receiving TPN should not gain more than 3 lbs (1.4 kg) per week, with optimal weight gain being 1 to 2 lbs (0.5 to 1 kg) per week. The weight goal for the client on TPN is individual and depends on the client's metabolic needs and baseline weight (whether underweight, overweight, or at optimal weight). The correct option identifies a reasonable weight gain of 2 lbs (1 kg) per week. The remaining options indicate weekly weight gains that are greater than expected.)

The home care nurse is monitoring a client's response to total parenteral nutrition (TPN). The client's weight 1 week earlier was 114 lbs (52 kg). The nurse determines that the client is gaining weight as expected if which morning weight is noted? 1. 116 lbs (52.6 kg) 2. 119 lbs (53.9 kg) 3. 120 lbs (54.4 kg) 4. 122 lbs (55.3 kg)

4 (Rationale:If TPN is discontinued abruptly, rebound hypoglycemia may occur because the pancreas has not yet had time to adjust its secretion of insulin in response to the lower amount of glucose. Therefore, a dextrose in water solution of 10% or 20% is infused temporarily until the replacement bag is available.)

The nurse discovers that an infusion of total parenteral nutrition (TPN) through a central line is empty, and a replacement bag is not yet ready. What should the nurse do next while waiting for the replacement bag? 1.Hang an intravenous infusion of normal saline. 2.Convert the intravenous infusion to a saline lock. 3.Hang an intravenous infusion of 5% dextrose in water. 4.Hang an intravenous infusion of 10% dextrose in water.

3 (Rationale:Circulatory overload is caused by the infusion of blood at a rate too rapid for the client to tolerate. With circulatory overload, crackles are present in addition to dyspnea. An allergic reaction, which is one type of blood transfusion reaction, would produce symptoms such as flushing, dyspnea, itching, and a generalized rash. Hypovolemia is not likely a complication of blood transfusion. With bacteremia, the client would have a fever, which is not part of the clinical picture presented.)

The nurse enters a client's room to assess the client, who began receiving a blood transfusion 45 minutes earlier, and notes that the client is flushed and dyspneic. On assessment, the nurse auscultates the presence of crackles in the lung bases. The nurse determines that this client most likely is experiencing which complication of blood transfusion therapy? 1.Bacteremia 2.Hypovolemia 3.Circulatory overload 4.Transfusion reaction

2 (Rationale:Verapamil is a calcium channel blocker that may be used to treat rapid-rate supraventricular tachydysrhythmias such as atrial flutter or atrial fibrillation. A cardiac monitor is used to determine the client's response to the medication. A pulse oximeter and oxygen are related to respiratory care and may be other useful adjuncts to care, but they are not directly related to the use of this medication. A noninvasive blood pressure monitor also is helpful but is not as essential or critical as the cardiac monitor.)

The nurse has a new prescription to administer verapamil by the intravenous (IV) route. In administering this medication, the most important nursing action should be to use what item to monitor the client's response to the medication? 1.A pulse oximeter 2.A cardiac monitor 3.Supplemental oxygen 4.A noninvasive blood pressure monitor

2 (Rationale:Acetylcysteine can be given orally or by nasogastric tube to treat acetaminophen overdose, or it may be given by inhalation for use as a mucolytic. Before giving the medication as an antidote to acetaminophen, the nurse ensures that the client's stomach is empty through emesis or gastric lavage. The solution is diluted in cola, water, or juice to make it more palatable. It is then administered orally or by nasogastric tube. Acetylcysteine is the antidote to acetaminophen.)

The nurse has a prescription to administer acetylcysteine to a client admitted to the emergency department with acetaminophen overdose. Before giving this medication, what is the nurse's best action? 1.Administer the full-strength solution. 2.Empty the stomach by emesis or lavage. 3.Check that the antidote is readily available. 4.Ensure that the client knows how to use a nebulizer.

1 (Rationale:After adding a medication to a bag of IV solution, the nurse should agitate or rotate the bag gently to mix the medication evenly in the solution. The nurse should then attach a completed medication label. The nurse can then prime the tubing. The IV solution should have been checked for discoloration before the medication was added to the solution. The tubing is attached to the client last.)

The nurse has a prescription to hang a 1000-mL intravenous (IV) bag of 5% dextrose in water with 20 mEq of potassium chloride and needs to add the medication to the IV bag. The nurse should plan to take which action immediately after injecting the potassium chloride into the port of the IV bag? 1.Rotate the bag gently. 2.Attach the tubing to the client. 3.Prime the tubing with the IV solution. 4.Check the solution for yellowish discoloration

2 (Rationale:When hanging an IV antibiotic, the nurse should first check compatibility of the medication and the IV fluids currently prescribed. If the fluids and medication are incompatible, it would then be appropriate to start a second IV site. If they are compatible, the nurse should hang them together so as to avoid having to start another IV site. After this, the nurse should prepare the prepackaged piperacillin/tazobactam per agency policy, then prime the tubing with the IV solution, and then back-prime the medication. Back-priming prevents any medication from being lost during the priming process.)

The nurse has a prescription to hang a 1000-mL intravenous (IV) bag of 5% dextrose in water with 20 mEq of potassium chloride. The nurse also needs to hang an IV infusion of piperacillin/tazobactam. The client has one IV site. The nurse should plan to take which action first? 1.Start a second IV site. 2.Check compatibility of the medication and IV fluids. 3.Mix the prepackaged piperacillin/tazobactam per agency policy. 4.Prime the tubing with the IV solution, and back-prime the medication

2 (Rationale:When cord prolapse occurs, prompt actions are taken to relieve cord compression and increase fetal oxygenation. The client should be positioned with the hips higher than the head to shift the fetal presenting part toward the diaphragm. The nurse should push the call light to summon help, and other staff members should call the health care provider and notify the delivery room. If the cord is protruding from the vagina, no attempt should be made to replace it because to do so could traumatize it and reduce blood flow further. Also as a first action, the examiner should place a gloved hand into the vagina, and hold the presenting part off the umbilical cord. Oxygen, 8 to 10 L/minute, by face mask is administered to the client to increase fetal oxygenation.)

The nurse in a labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. What is the first nursing action with this finding? 1.Gently push the cord into the vagina. 2.Place the client in Trendelenburg's position. 3.Find the closest telephone and page the health care provider stat. 4.Call the delivery room to notify the staff that the client will be transported immediately

3 (Rationale:Acetaminophen overdose is harmful to the liver. Thyroid function is not affected by acetaminophen. A urine medication screen and kidney function tests may be evaluated; however, these laboratory values are not the priority concern.)

The nurse is admitting a young child who arrived from the emergency department after treatment for acetaminophen overdose. After administering the antidote, the nurse should reassess the child, including which priority laboratory value? 1.Thyroid panel 2.Urine drug screen 3.Liver function panel 4.Kidney function tests

3 (Rationale:If bleeding is excessive, the cause may be laceration of the cervix or birth canal. Massaging the fundus if it is firm would not assist in controlling the bleeding. Trendelenburg's position should be avoided because it may interfere with cardiac and respiratory function. Although the nurse would record the findings, the initial nursing action would be to notify the HCP)

The nurse is assessing a client in the fourth stage of labor and notes that the fundus is firm, but that bleeding is excessive. Which should be the initial nursing action? 1.Record the findings. 2.Massage the fundus. 3.Notify the health care provider (HCP). 4.Place the client in Trendelenburg's position

2 (Rationale:Phlebitis at an IV site can be distinguished by client discomfort at the site and by redness, warmth, and swelling proximal to the catheter. If phlebitis occurs, the nurse should remove the IV line and insert a new IV line at a different site, in a vein other than the one that has developed phlebitis. Checking for the presence of blood return should be done before the administration of vancomycin because this medication is a vesicant. Documenting the findings and continuing to monitor the IV site and calling the HCP and requesting that the vancomycin be given orally do not address the immediate problem. Additionally, there could be indications for the prescription of IV as opposed to oral vancomycin for the client. The HCP should be notified of the complications with the IV site, but not asked for a prescription for oral vancomycin)

The nurse is assessing a client's peripheral intravenous (IV) site after completion of a vancomycin infusion and notes that the area is reddened, warm, painful, and slightly edematous proximal to the insertion point of the IV catheter. At this time, which action by the nurse is best? 1.Check for the presence of blood return. 2.Remove the IV site and restart at another site. 3.Document the findings and continue to monitor the IV site. 4.Call the health care provider (HCP) and request that the vancomycin be given orally

1, 4, 5, 6 (Rationale:The nurse should instruct the client to immediately report signs of a transfusion reaction, which can include chest pain, lower back pain, chills, itching, rash, or difficulty breathing. These signs of transfusion reaction would require the nurse to stop the transfusion. Fatigue and sleepiness are unrelated to transfusion reaction)

The nurse is assisting in monitoring a client who is receiving a transfusion of packed red blood cells (PRBCs). Before leaving the room, the nurse tells the client to immediately report which symptoms of a transfusion reaction? Select all that apply. 1.Chills 2.Fatigue 3.Sleepiness 4.Chest pain 5.Lower back pain 6.Difficulty breathing

1 (Rationale:The antidote for acetaminophen is acetylcysteine, which works by preventing the hepatotoxic metabolites of acetaminophen from forming, so early administration is essential. Although the other options may be part of the client's assessment, they do not need to be carried out immediately)

The nurse is assisting in the care of a client who is being seen in the clinic with a suspected acetaminophen overdose. What is the nurse's priority of care? 1.Administer acetylcysteine. 2.Obtain a 12-lead electrocardiogram. 3.Ask the client about other medication use. 4.Ask the client why so many acetaminophen were taken.

2, 3, 5 (Rationale:Although not common, airway obstruction after thyroid surgery is an emergency situation. Therefore, oxygen, suction equipment, calcium gluconate (to treat tetany if it occurs), and a tracheostomy tube insertion set should be readily available in the client's room. These items will be needed to treat this emergency situation. Therefore, options 2, 3, and 5 are correct. There is no reason that a tourniquet needs to be readily available; 50% glucose is used to treat severe hypoglycemia.)

The nurse is caring for a client recovering from a subtotal thyroidectomy. Which supplies should be readily accessible for the care of this client? Select all that apply 1.Tourniquet 2.Suction supplies 3.Calcium gluconate 4.Prefilled syringe of 50% glucose 5.Tracheostomy tube insertion set

4 (Rationale:An overdose from amphetamines can cause agitation, increased temperature, increased pulse, increased respiratory rate, increased blood pressure, cardiac dysrhythmias, myocardial infarction, hallucinations, seizures, and possible death. Therefore, the remaining options are incorrect)

The nurse is caring for a client who has overdosed on amphetamines. The nurse anticipates noting which assessment finding in this client? 1.Bradypnea 2.Bradycardia 3.Hypothermia 4.Hypertension

2 (Rationale:The priority nursing action would be to assess lung sounds. Thermal burns to the lower airways can occur with the inhalation of steam or explosive gases or with the aspiration of scalding liquids. Thermal burns to the upper airways are more common and cause erythema and edema of the airways and mucosal blisters or ulcerations. The mucosal edema can lead to upper airway obstruction, particularly during the first 24 to 48 hours after burn injury.)

The nurse is caring for a client who sustained a thermal burn caused by the inhalation of steam 24 hours ago. The nurse determines that the priority nursing action is to assess which item? 1.Pain level 2.Lung sounds 3.Ability to swallow 4.Laboratory results

4 (Rationale:If a chest tube becomes disconnected, the nurse should as quickly as possible place the end of the tube in a container of sterile water until the drainage system can be replaced. It is not necessary to contact a respiratory therapist at this time. It may be necessary to contact the HCP, but this would not be the initial nursing action. Asking the client to perform a Valsalva maneuver is not appropriate and could be harmful)

The nurse is caring for a client with a chest tube drainage system. While the client is being assisted to sit up in bed in preparation for ambulation, the chest tube accidentally disconnects from the chest drainage system. Which is the initial nursing action? 1.Contact the health care provider (HCP). 2.Call a respiratory therapist to come to the bedside. 3.Encourage the client to perform the Valsalva maneuver. 4.Place the end of the chest tube in a container of sterile water

1 (Rationale:If the drainage system is broken or interrupted or the tube disconnects, the end of the tube should be placed in a bottle of sterile water held below the level of the chest. A new drainage system is then immediately obtained and set up. Placing the client in the prone position and asking the client to hold his or her breath are not helpful. Placing a sterile dressing over the disconnection site will not prevent complications resulting from the tube disconnection. The nurse should also perform an assessment on the client and contact the health care provider.)

The nurse is caring for a client with a chest tube who accidentally disconnects the tube from the drainage system when trying to get out of bed. The nurse immerses the end of the tube in sterile water. What immediate action should the nurse take? 1.Obtain a new drainage system. 2.Ask the client to hold his or her breath. 3.Place the client in a prone position. 4.Place a sterile dressing over the chest tube insertion site.

1 (Rationale:Redness at the catheter insertion site is a possible indication of infection. The nurse would next assess for other signs of infection. Of the options given, the temperature is the next item to assess. The tightness of tubing connections should be assessed each time the PN is checked; loose connections would result in leakage, not skin redness. The expiration date on the bag is a viable option, but this also should be checked at the time the solution is hung and with each shift change. The time of the last dressing change should be checked with each shift change.)

The nurse is changing the central line dressing of a client receiving parenteral nutrition (PN) and notes that the catheter insertion site appears reddened. The nurse should next assess which item? 1.Client's temperature 2.Expiration date on the bag 3.Time of last dressing change 4.Tightness of tubing connections

3 (Rationale:According to the American Heart Association's current guidelines for performing cardiopulmonary resuscitation (CPR), recognition of the critical importance of high-quality CPR and the incompatibility of the lateral tilt with high-quality CPR has prompted the elimination of the recommendation for using the lateral tilt and the strengthening of the recommendation for lateral uterine displacement. Priorities for the pregnant woman in cardiac arrest are provision of high-quality CPR and relief of aortocaval compression. If the fundus height is at or above the level of the umbilicus, manual left uterine displacement can be beneficial in relieving aortocaval compression during chest compressions.)

The nurse is conducting a basic life support (BLS) recertification class and is discussing chest compressions in a pregnant woman. The nurse should tell the class that which action should be taken in an advanced pregnancy client whose fundal height is at or above the umbilicus? 1.Perform the chest compressions directly over the umbilicus. 2.Turn the pregnant client on her side and perform back thrusts. 3.Maintain manual left uterine displacement during compressions. 4.Perform chest thrusts midway between the umbilicus and the pubic bone.

1 (Rationale:Chest locations are found by placing the hands on the lower half of the sternum. To locate this area, find the notch where the rib margin meets the sternum, and place the middle finger on this notch and the index finger next to it. Next, place the heel of the opposite hand on the lower half of the sternum, close to the index finger. Remove the first hand, place it on top of the hand on the sternum, and begin chest compressions. Chest compressions will not be as effective with the hand placements described in the remaining options.)

The nurse is initiating 1-rescuer cardiopulmonary resuscitation on an adult client. The nurse should place the hands in which position to begin chest compressions? 1.On the lower half of the sternum 2.On the upper half of the sternum 3.On the lower third of the sternum 4.On the upper third of the sternum

2 (Rationale:The client is at risk for hypoglycemia; therefore, the solution containing the highest amount of glucose should be hung until the new PN solution becomes available. Because PN solutions contain high glucose concentrations, the 10% dextrose in water solution is the best of the choices presented. The solution selected should be one that minimizes the risk of hypoglycemia. The remaining options will not be as effective in minimizing the risk of hypoglycemia.)

The nurse is making initial rounds at the beginning of the shift and notes that the parenteral nutrition (PN) bag of an assigned client is empty. Which solution should the nurse hang until another PN solution is mixed and delivered to the nursing unit? 1. 5% dextrose in water 2. 10% dextrose in water 3. 5% dextrose in Ringer's lactate 4. 5% dextrose in 0.9% sodium chloride

1 (Rationale:Spontaneous rupture of the gastric balloon, upward migration of the tube, and occlusion of the airway are possible complications associated with a Sengstaken-Blakemore tube. Esophageal rupture also may occur and is characterized by the abrupt onset of severe pain. In the event of any of these life-threatening emergencies, the tube is cut and removed)

The nurse is monitoring a client who required a Sengstaken-Blakemore tube because other measures for treating bleeding esophageal varices were unsuccessful. The client complains of severe pain of abrupt onset. Which nursing action is most appropriate? 1.Cut the tube. 2.Reposition the client. 3.Assess the lumens of the tubes. 4.Administer the prescribed analgesics

4 (Rationale:Lochia is the discharge from the uterus in the postpartum period; it consists of blood from the vessels of the placental site and debris from the decidua. The following can be used as a guide to determine the amount of flow: scant = less than 2.5 cm (<1 inch) on menstrual pad in 1 hour; light = less than 10 cm (<4 inches) on menstrual pad in 1 hour; moderate = less than 15 cm (<6 inches) on menstrual pad in 1 hour; heavy = saturated menstrual pad in 1 hour; and excessive = menstrual pad saturated in 15 minutes. If the client is experiencing excessive bleeding, the nurse should contact the HCP in the event that postpartum hemorrhage is occurring. It may be appropriate to encourage increased fluid intake, but this is not the initial action. It is not appropriate to encourage ambulation at this time. Documentation should occur once the client has been stabilized.)

The nurse is monitoring the amount of lochia drainage in a client who is 2 hours postpartum and notes that the client has saturated a perineal pad in 15 minutes. How should the nurse respond to this finding initially? 1.Document the finding. 2.Encourage the client to ambulate. 3.Encourage the client to increase fluid intake. 4.Contact the health care provider (HCP) and inform the HCP of this finding

3 (Rationale:The nurse should not increase the rate of a fat emulsion to make up the difference if the infusion timing falls behind. Doing so could place the client at risk for fat overload. In addition, increasing the rate suddenly can cause fluid overload. The same principle (not increasing the rate) applies to parenteral nutrition or any intravenous infusion. Therefore, the remaining options are incorrect.)

The nurse is monitoring the status of a client's fat emulsion (lipid) infusion and notes that the infusion is 1 hour behind. Which action should the nurse take? 1.Adjust the infusion rate to catch up over the next hour. 2.Increase the infusion rate to catch up over the next 2 hours. 3.Ensure that the fat emulsion infusion rate is infusing at the prescribed rate. 4.Adjust the infusion rate to run wide open until the solution is back on time

3, 4 (Rationale:When drawing blood from a double-lumen central venous catheter, the proximal port is used because it is usually the port with the largest lumen. For blood cultures, the initial specimen is used for the sample, and the line is not flushed beforehand. Turning off the infusion for 1 minute prevents contaminating the sample with intravenous solution)

The nurse is obtaining blood from a client's double-lumen central venous catheter for blood cultures. Which actions are correct for performing this procedure? Select all that apply. 1.Use the distal port of the catheter for obtaining the blood specimen. 2.Flush with 5 to 10 mL of normal saline before obtaining the specimen. 3.Turn the infusion off for at least 1 minute before obtaining the specimen. 4.Use the initial specimen of blood obtained from the catheter for the blood cultures. 5.Discard the first syringe of blood and use the second syringe for the blood cultures.

4 (Rationale:If the umbilical cord is protruding from the vagina, no attempt should be made to replace it because doing so could traumatize it and further reduce blood flow. The nurse would place a gloved hand into the vagina to the cervix and exert upward pressure against the presenting part to relieve compression of the cord. The nurse also would wrap the cord loosely in a sterile towel saturated with warm, sterile normal saline solution. Oxygen, 8 to 10 L/min by face mask, would be administered to the mother to increase fetal oxygenation, and the woman would be prepared for immediate delivery. However, the immediate action is to relieve pressure on the cord. The woman should already have an external fetal monitor in place.)

The nurse is performing a vaginal assessment of a pregnant woman who is in labor. The nurse notes that the umbilical cord is protruding from the vagina. The nurse would immediately take which action? 1.Administer oxygen to the woman. 2.Transport the woman to the delivery room. 3.Place an external fetal monitor on the woman. 4.Exert upward pressure against the presenting part

4 (Rationale:The neurological system is primarily affected by carbon monoxide poisoning. With high levels of carbon monoxide, the neurological status progressively deteriorates. Although skin color, apical rate, and respiratory rate would be components of the assessment of the client with carbon monoxide poisoning, assessment of the neurological status of the client would elicit data specific to a deterioration in the client's condition.)

The nurse is performing an assessment on a client who was admitted with a diagnosis of carbon monoxide poisoning. Which assessment performed by the nurse would primarily elicit data related to a deterioration of the client's condition? 1.Skin color 2.Apical rate 3.Respiratory rate 4.Level of consciousness

2 (Rationale:The nurse or rescuer puts two adhesive patch electrodes on the client's chest in the usual defibrillator positions. The nurse stops CPR and requests that anyone near the client move away and not touch the client. The defibrillator then analyzes the rhythm, which may take up to 30 seconds. The machine then indicates whether defibrillation is necessary)

The nurse is performing cardiopulmonary resuscitation (CPR) on a client who has had a cardiac arrest. An automatic external defibrillator (AED) is available to treat the client. Which activity will allow the nurse to assess the client's cardiac rhythm? 1.Hold the defibrillator paddles firmly against the chest. 2.Apply adhesive patch electrodes to the chest and move away from the client. 3.Connect standard electrocardiographic electrodes to a transtelephonic monitoring device. 4.Apply standard electrocardiographic monitoring leads to the client, and observe the rhythm

1, 2, 3, 5 (Rationale:The client should be taught that there are only minor activity restrictions with this catheter. The client should protect the site during bathing and should carry MedicAlert identification. The client should have a repair kit in the home for PRN use, because it is a long-term catheter. Redness or swelling at the catheter insertion site needs to be reported because this could indicate a sign of infection.)

The nurse is performing discharge teaching for a client with a peripherally inserted central catheter (PICC). Which instructions should the nurse include? Select all that apply 1.Wear a MedicAlert tag or bracelet. 2.Report redness or swelling at the catheter insertion site. 3.Have a repair kit available in the home for use if needed. 4.Keep activity level to a minimum while this catheter is in place. 5.Cover the PICC dressing with plastic when in the shower or bath

2 (Rationale:The nurse should obtain new IV tubing because contamination has occurred and could cause systemic infection in the client. There is no need to obtain a new IV bag because the bag was not contaminated. Wiping with povidine-iodine or alcohol is insufficient and is contraindicated because the spike will be inserted into the IV bag.)

The nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse goes to insert the spike end of the IV tubing into the IV bag, the tubing drops and the spike end hits the top of the medication cart. The nurse should take which action? 1.Obtain a new IV bag. 2.Obtain new IV tubing. 3.Wipe the spike end of the tubing with povidine-iodine. 4.Scrub the spike end of the tubing with an alcohol swab

2 (Rationale:The nurse should obtain new IV tubing because contamination has occurred and could cause systemic infection to the client. There is no need to obtain a new IV bag because the bag was not contaminated. Wiping with povidone iodine or alcohol is insufficient and is contraindicated because the spike will be inserted into the IV bag)

The nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse goes to insert the spike end of the IV tubing into the IV bag, the tubing drops and the spike end hits the top of the medication cart. The nurse should take which action? 1.Obtain a new IV bag. 2.Obtain new IV tubing. 3.Wipe the spike end of the tubing with povidone iodine. 4.Scrub the spike end of the tubing with an alcohol swab

3 (Rationale:For an intermittent IV infusion that is piggybacked to the primary IV line, the bag for the intermittent infusion is placed higher than the primary solution bag. This allows gravity to assist in infusing the medication. Once the intermittent infusion is complete, the primary IV infusion will resume at the drip rate set for the intermittent infusion. For this reason, it also is important to remember to check the infusion frequently and reset the primary IV drip rate correctly once the intermittent infusion is complete)

The nurse is preparing to infuse (piggyback) a 50-mL dose of a compatible medication through the primary intravenous (IV) line. How should the nurse correctly attach the medication bag? 1.Hanging the medication bag level with the primary IV bag 2.Hanging the medication bag lower than the primary IV bag 3.Hanging the medication bag higher than the primary IV bag 4.Disconnecting the primary IV solution and plugging in the medication

3 (Rationale:IABP therapy most often is used in the treatment of cardiogenic shock and is most effective if instituted early in the course of treatment. Use of IABP therapy is contraindicated in clients with aortic insufficiency and thoracic and abdominal aneurysms. This therapy is not used in the treatment of congestive heart failure or pulmonary edema)

The nurse is reviewing the medical record of a client transferred to the medical unit from the critical care unit. The nurse notes that the client received intra-aortic balloon pump (IABP) therapy while in the critical care unit. The nurse suspects that the client received this therapy for which condition? 1.Heart failure 2.Pulmonary edema 3.Cardiogenic shock 4.Aortic insufficiency

2 (Rationale:Albumin may be used as a plasma expander. Albumin is supplied in a bottle, and vented tubing is required for transfusion. Platelets are used when the client's platelet count is low. Cryoprecipitate is useful in treating bleeding from hemophilia or disseminated intravascular coagulopathy because it is rich in clotting factors. Cryoprecipitate is usually supplied in bags, so vented tubing is not required. Packed red blood cells replace erythrocytes and are not a plasma expander.)

The nurse is told by a health care provider that a client in hypovolemic shock will require plasma expansion. The nurse should prepare which supplies for transfusion? 1.Bag of platelets with filtered tubing 2.Bottle of albumin with vented tubing 3.Cryoprecipitate bag with vented tubing 4.Infusion pump and bag of packed red blood cells

3 (Rationale:When assessing a pulse in an infant (younger than 1 year), the pulse should be checked at the brachial artery. This is because the relatively short, fat neck of an infant makes palpation of the carotid artery difficult. The pulses in the remaining options are also difficult to locate and palpate in an infant.)

The nurse is undergoing annual recertification in basic life support (BLS). The BLS instructor asks the nurse to identify the pulse point to use when determining pulselessness on an infant. Which response by the nurse identifies the most appropriate pulse point? 1.Radial 2.Carotid 3.Brachial 4.Popliteal

3 (Rationale:Ventricular tachycardia is characterized by the absence of P waves, wide QRS complexes (longer than 0.12 seconds), and typically a rate between 140 and 180 impulses/minute. The rhythm is regular.)

The nurse is watching the cardiac monitor and notices that the rhythm suddenly changes. There are no P waves, the QRS complexes are wide, and the ventricular rate is regular but more than 140 beats/minute. The nurse determines that the client is experiencing which dysrhythmia? 1.Sinus tachycardia 2.Ventricular fibrillation 3.Ventricular tachycardia 4.Premature ventricular contractions

1 (Rationale:Atrial fibrillation is characterized by a loss of P waves and fibrillatory waves before each QRS complex. The atria quiver, which can lead to thrombus formation.)

The nurse is watching the cardiac monitor, and a client's rhythm suddenly changes. There are no P waves; instead, there are fibrillatory waves before each QRS complex. How should the nurse correctly interpret the client's heart rhythm? 1.Atrial fibrillation 2.Sinus tachycardia 3.Ventricular fibrillation 4.Ventricular tachycardia

1 (Rationale:If an infusion falls behind schedule, the nurse should not increase the rate in an attempt to catch up, because a hyperosmotic reaction, among other reactions, could result. The solution should not be replaced by another or restarted the next day. An infusion pump should always be used to administer TPN solution)

The nurse notes that a client's total parenteral nutrition (TPN) solution is 4 hours behind. Which action should the nurse take? 1.Assess the infusion pump to be sure it is functioning properly and is set at the correct rate. 2.Increase the infusion rate to a rate that allows the infusion volume to correct itself within a 2-hour period. 3.Replace the TPN solution with 10% dextrose, and restart the solution the following day. 4.Administer the TPN solution using gravity flow because the infusion pump is malfunctioning

2 (Rationale:The client's IV has infiltrated. An infiltrated IV is one that has dislodged from the vein and is lying in subcutaneous tissue. Pallor, coolness, and swelling are the results of IV fluid being deposited in the subcutaneous tissue. When the pressure in the tissues exceeds the pressure in the tubing, the flow of the IV solution will stop. The corrective action is to remove the catheter and start a new IV line at another site. Infection, phlebitis, and thrombosis are likely to be accompanied by warmth at the site, not coolness. Elevating the extremity should be implemented after removing the IV to reduce swelling)

The nurse notes that the client's intravenous (IV) site is cool, pale, and swollen and that the solution is not infusing. What is the nurse's priority action? 1.Elevate the extremity. 2.Remove the IV catheter. 3.Assess for signs of infection. 4.Decrease the rate of infusion

1 (Rationale:Phlebitis at an IV site can be distinguished by client discomfort at the site and by redness, warmth, and swelling proximal to the catheter. If phlebitis occurs, the nurse should discontinue the IV line and insert a new IV line at a different site. Coolness at the site would be noted if the IV catheter was infiltrated. An allergic reaction produces a rash, redness, and itching. A major reaction, such as hypersensitivity, can cause dyspnea, a swollen tongue, and cyanosis.)

The nurse notes that the site of a client's peripheral intravenous (IV) catheter is reddened, warm, painful, and slightly edematous proximal to the insertion point of the IV catheter. After taking appropriate steps to care for the client, the nurse should document in the medical record that the client experienced which condition? 1.Phlebitis of the vein 2.Infiltration of the IV line 3.Hypersensitivity to the IV solution 4.Allergic reaction to the IV catheter material

1 (Rationale:Phlebitis at an IV site can be distinguished by client discomfort at the site, as well as redness, warmth, and swelling proximal to the catheter. The IV line should be discontinued, and a new line should be inserted at a different site. The remaining options are incorrect occurrences.)

The nurse notes that the site of a client's peripheral intravenous (IV) catheter is reddened, warm, painful, and slightly edematous proximal to the insertion point of the IV catheter. After taking appropriate steps to care for the client, the nurse should document in the medical record that which occurred? 1.Phlebitis of the vein 2.Infiltration of the IV line 3.Hypersensitivity to the IV solution 4.Allergic reaction to the IV catheter

3 (Rationale:When giving a medication by IV bolus, if the medication is incompatible with the IV solution, the tubing is flushed before and after the medication with infusions of normal saline. Option 1 is premature and not necessary. Sterile water is not used for an IV flush. Option 4 is inappropriate.)

The nurse plans to administer a medication by intravenous (IV) bolus through the primary IV line. The nurse notes that the medication is incompatible with the primary IV solution. Which is the appropriate nursing action to safely administer the medication? 1.Start a new IV line for the medication. 2.Flush the tubing after the medication with sterile water. 3.Flush the tubing before and after the medication with normal saline. 4.Call the health care provider for a prescription to change the route of the medication

3 (Rationale:Acetylcysteine is the antidote for acetaminophen. Because acetylcysteine has a pervasive flavor of rotten eggs, it must be disguised in a flavored ice drink and is preferably drunk through a straw to minimize contact with the mouth. It is a solution that also is used as a mucolytic agent, administered via nebulization. It is not administered by the IV, IM, or subcutaneous route.)

The nurse prepares to administer acetylcysteine to the client with an overdose of acetaminophen. What is the appropriate action when administering this antidote? 1.Administer the medication subcutaneously in the deltoid muscle. 2.Administer the medication by intramuscular (IM) injection in the gluteal muscle. 3.Mix the medication in a flavored ice drink, and allow the client to drink the medication. 4.Administer the medication mixed in 50 mL of normal saline and piggybacked through the main intravenous (IV) line

2 (Rationale:The client should be taught that only minor activity restrictions apply with this type of catheter. The client should protect the site during bathing and should carry or wear a MedicAlert identification. The client should have a repair kit in the home for use as needed because the catheter is for long-term use)

The nurse provides a list of instructions to a client being discharged to home with a peripherally inserted central catheter (PICC). The nurse determines that the client needs further instruction if the client makes which statement? 1."I need to wear a MedicAlert tag or bracelet." 2."I need to restrict my activity while this catheter is in place." 3."I need to have a repair kit available in the home for use if needed." 4."I need to keep the insertion site protected when in the shower or bath."

1 (Rationale:After defibrillation, the client requires continuous monitoring of electrocardiographic rhythm, hemodynamic status, and neurological status. Respiratory and metabolic acidosis develop during ventricular fibrillation because of lack of respiration and cardiac output. These can cause cerebral and cardiopulmonary complications. Arousable status, adequate BP, and a sinus rhythm indicate successful response to defibrillation.)

The nurse should evaluate that defibrillation of a client was most successful if which observation was made? 1.Arousable, sinus rhythm, blood pressure (BP) 116/72 mm Hg 2.Nonarousable, sinus rhythm, BP 88/60 mm Hg 3.Arousable, marked bradycardia, BP 86/54 mm Hg 4.Nonarousable, supraventricular tachycardia, BP 122/60 mm Hg

1 (Rationale:Whenever a neck injury is suspected, the jaw thrust maneuver should be used during basic life support (BLS) to open the airway. The head tilt-chin lift produces hyperextension of the neck and could cause complications if a neck injury is present. The scene should be checked for safety, and the client should be moved away from a busy traffic road in order to ensure safety.)

The nurse walking in a downtown business area witnesses a worker fall from a ladder. The nurse rushes to the victim, who is unresponsive. A layperson is attempting to perform resuscitative measures. The nurse should intervene if which action by the layperson is noted? 1.Use of the head tilt-chin lift 2.Checking the scene for safety 3.Use of the jaw thrust maneuver 4.Moving the client away from a busy traffic road

4 (Rationale:If flail chest is present, the nurse applies firm but gentle pressure to the flail segments of the ribs to stabilize the chest wall, which will ultimately help the victim's respiratory status. The nurse does not move an injured client for fear of worsening an undetected spinal injury. Removing the victim's shirt is of no value in this situation and could in fact result in chilling the victim, which is counterproductive. Injured clients should be kept warm until help arrives at the scene.)

The nurse witnesses an accident whereby a pedestrian is hit by an automobile. The nurse stops at the scene and assesses the victim. The nurse notes that the victim is responsive and has suffered trauma to the thorax resulting in a flail chest involving at least 3 ribs. What is the nurse's priority action for this victim? 1.Assist the victim to sit up. 2.Remove the victim's shirt. 3.Turn the victim onto the side opposite the flail chest. 4.Apply firm but gentle pressure with the hands to the flail segment

4 (Rationale:The client who has neutropenia may receive a transfusion of granulocytes, or WBCs. These clients often have severe infections and are unresponsive to antibiotic therapy. The nurse notes the results of follow-up WBC counts and differential to evaluate the effectiveness of the therapy. The nurse also continues to monitor the client for signs and symptoms of infection. Erythrocyte count and hemoglobin and hematocrit levels are determined after transfusion of packed red blood cells.)

The nurse, listening to the morning report, learns that an assigned client received a unit of granulocytes the previous evening. The nurse makes a note to assess the results of which daily serum laboratory studies to assess the effectiveness of the transfusion? 1.Hematocrit level 2.Erythrocyte count 3.Hemoglobin level 4.White blood cell count

3 (Rationale:To assess a pulse in an infant (younger than 1 year), the pulse is checked at the brachial or femoral artery. The infant's relatively short, fat neck makes palpation of the carotid artery difficult. The popliteal and radial pulses are also difficult to palpate in an infant)

The nursing instructor teaches a group of students about cardiopulmonary resuscitation. The instructor asks a student to identify the most appropriate location at which to assess the pulse of an infant younger than 1 year of age. Which response would indicate that the student understands the appropriate assessment procedure? 1.Radial artery 2.Carotid artery 3.Brachial artery 4.Popliteal artery

1, 2, 5 (Rationale:The nurse would assess the victim for airway or breathing problems immediately. Then the nurse would examine the amputation site and apply direct pressure using layers of dry gauze or another type of cloth. Sterile gloves and sterile gauze should always be used if available. If sterile materials are not available, clean materials should be used if possible. The gauze that is applied is a pressure dressing and is not removed because of the risk of dislodgment of a clot that may be forming; the pressure dressing will be removed at the hospital. The extremity is elevated above the victim's heart level to decrease the bleeding. The severed finger should be wrapped in dry, sterile gauze (if available) or a clean cloth. It is placed in a watertight, sealed plastic bag. Then the watertight, sealed plastic bag is placed in a bag of ice water. The severed finger is never placed directly on ice; contact between the finger and water is avoided because of the risk of tissue damage. The severed part is transported to the hospital with the victim for possible replanting. Additionally, emergency medical services is called to transport the victim to the hospital.)

The occupational health nurse is called to care for an employee who experienced a traumatic amputation of a finger. Which actions should the nurse take to provide emergency care and prepare the client for transport to the hospital? Select all that apply. 1.Elevate the extremity above heart level. 2.Assess the employee for airway or breathing problems. 3.Remove the layered gauze every 10 minutes to check the bleeding. 4.Wrap the severed finger in moistened gauze, and place it in a bag of ice water. 5.Examine the amputation site and apply direct pressure to the site using layers of gauze

3 (Rationale:If bleeding occurs, the health team intervenes quickly to control it by combining vasoactive medications with endoscopic therapies. Vasoactive medications reduce portal pressure. Vasopressin is a synthetic antidiuretic hormone. Administration of this hormone reduces bleeding. It acts directly on gastrointestinal smooth muscle as a vasoconstrictor. To take advantage of these effects, it should be administered via continuous intravenous infusion. It can also be administered via the subcutaneous route. Therefore, the remaining options are incorrect.)

Vasopressin is prescribed for a client with a diagnosis of bleeding esophageal varices. The nurse should prepare to administer this medication by which route? 1.Orally 2.By inhalation 3.By intravenous infusion 4.Through a Sengstaken-Blakemore tube

2 (Rationale:Wound dehiscence is the separation of wound edges at the suture line. Signs and symptoms include increased drainage and the exposure of underlying tissues. These usually occur 6 to 8 days after surgery. The client should be instructed to remain quiet and avoid coughing or straining. The client should be positioned to prevent further stress on the wound. Sterile dressings soaked with sterile normal saline should be used to cover the wound. The health care provider must be notified after applying this initial dressing to the wound.)

When performing a surgical dressing change of a client's abdominal dressing, the nurse notes an increase in the amount of drainage and separation of the incision line. The underlying tissue is visible to the nurse. What should the nurse do next? 1.Apply a sterile dressing soaked with povidone-iodine. 2.Apply a sterile dressing soaked with normal saline. 3.Irrigate the wound, and apply a dry sterile dressing. 4.Leave the incision exposed to the air to dry the area

1, 2, 3, 4 (Rationale:A subarachnoid bolt is inserted into the subarachnoid space and is used to measure intracranial pressure. Because a subarachnoid bolt is placed in the subarachnoid space, it is not capable of draining cerebrospinal fluid, which is produced in the ventricles. Therefore, the option to drain cerebrospinal fluid is not an intervention. The remaining options are appropriate interventions.)

Which interventions would be included in the care of a client with a head injury and a subarachnoid bolt? Select all that apply 1.Monitor vital signs. 2.Monitor neurological status. 3.Monitor the dressing for signs of infection. 4.Monitor for signs of increased intracranial pressure. 5.Drain cerebrospinal fluid when the intracranial pressure is elevated

3 (Rationale:Normal PCWP ranges from 8 to 15 mm Hg. A PCWP of 20 mm Hg is elevated and corresponds to volume overload of the left ventricle, such as occurs in heart failure. Options 1, 2, and 4 are normal values)

Which readings obtained from a client's pulmonary artery catheter suggest that the client is in left-sided heart failure? 1.Cardiac output of 5 L/min 2.Right atrial pressure of 9 mm Hg 3.Pulmonary capillary wedge pressure (PCWP) of 20 mm Hg 4.Pulmonary artery systolic/diastolic pressures of 24/10 mm Hg

1, 3, 4 (Rationale:If the client experiences air embolus during hemodialysis, the nurse should terminate dialysis immediately, position the client so the air embolus is in the right side of the heart, notify the HCP and Rapid Response Team, and administer oxygen as needed. Slowing the dialysis treatment or giving an intravenous bolus will not correct the air embolism or prevent complications.)

A client being hemodialyzed suddenly becomes short of breath and complains of chest pain. The client is tachycardic, pale, and anxious and the nurse suspects air embolism. What are the priority nursing actions? Select all that apply 1.Administer oxygen to the client. 2.Continue dialysis at a slower rate after checking the lines for air. 3.Notify the health care provider (HCP) and Rapid Response Team. 4.Stop dialysis, and turn the client on the left side with head lower than feet. 5.Bolus the client with 500 mL of normal saline to break up the air embolus.

3 (Rationale:When an umbilical cord is protruding, nursing actions are immediately directed at reducing cord compression and facilitating delivery of the fetus. The cord is wrapped loosely in a sterile towel saturated with warm normal saline to prevent it from drying out and becoming compressed. The client is placed in an extreme Trendelenburg's or modified Sims' position or knee-chest position to reduce compression. A tocolytic is used for inadequate uterine relaxation. IV solutions are administered at a rate greater than a KVO rate.)

A pregnant client being admitted to the labor room tells the nurse that she felt a large gush of fluid before arriving at the hospital. The nurse performs an assessment on the client and notes that the fetal heart rate is 90 beats/minute and that the umbilical cord is protruding from the vagina. What is the appropriate nursing action? 1.Place the woman in a high Fowler's position. 2.Palpate and evaluate contractions while administering a tocolytic. 3.Wrap the cord loosely in a sterile towel saturated with warm, sterile normal saline. 4.Start an intravenous (IV) line with fluids to be administered at a keep-vein-open (KVO) rate only

4 (Rationale:Clients receiving TPN are receiving high concentrations of glucose. To give the pancreas time to adjust to decreasing glucose loads, the infusion rates are tapered down. Before discontinuing the TPN, the body must adjust to the lowered glucose level. If the TPN were suddenly withdrawn, the client could have rebound hypoglycemia. Although the other options are potential complications, they are not risks associated with discontinuing TPN abruptly.)

A client with pancreatitis is being weaned from total parenteral nutrition (TPN). The client asks the nurse why the TPN cannot just be stopped. What is the nurse's best response? 1.Dehydration can result. 2.Hypokalemia may occur. 3.Hypernatremia will occur. 4.Rebound hypoglycemia is a risk

2 (Rationale:Diltiazem hydrochloride is a calcium channel blocker used in the treatment of atrial flutter and fibrillation. It decreases myocardial contractility and workload, thereby decreasing the need for oxygen. A bolus of 0.25 mg/kg is given slowly over 2 minutes, and a continuous infusion of 5 to 10 mg/hour may be administered for up to 24 hours. Therefore, the nurse should prepare to discontinue the infusion after 24 hours. Upon discontinuation of infusion, heart rate reduction may last from 0.5 hours to more than 10 hours (median duration 7 hours). A nonrebreather mask is not necessary. The client's cardiac rhythm is monitored continuously.)

A client with rapid-rate atrial fibrillation has a new prescription for diltiazem hydrochloride by intravenous (IV) bolus followed by a continuous IV infusion of the same medication. What should the nurse plan for with the administration of this medication? 1.Applying a nonrebreather mask 2.Discontinuing the infusion after 24 hours 3.Monitoring the cardiac rhythm every hour 4.Administering the IV bolus over 2 to 3 seconds

2 (Rationale:With effective compressions, carotid pulsations should be present. At its best, CPR produces only 30% of the normal cardiac output, so correct technique is vital. Assessment of the carotid pulse during CPR is the most accurate way to assess the effectiveness of CPR. Correct procedure for CPR in an adult includes a compression-to-ventilation ratio of 30:2. With adults, compressions are performed at a depth of at least 2 inches (5 cm). The 30:2 compression-to-ventilation ratio yields an effective rate of 10 breaths per minute)

An adult client has been unsuccessfully defibrillated for ventricular fibrillation, and cardiopulmonary resuscitation (CPR) is resumed. The nurse confirms that CPR is being administered effectively by noting which action? 1.The ratio of compressions to ventilations is 30:2. 2.The carotid pulse is palpable with each compression. 3.Respirations are given at a rate of 10 breaths per minute. 4.The chest compressions are given at a depth of 1.5 to 2 inches (2.5 to 5 cm)

3 (Rationale:If a client is unconscious and has no pulse, the nurse would shout for help (activate emergency response) and immediately initiate CPR. If the rhythm is shockable, a shock is delivered and then CPR is delivered for 5 cycles. This pattern is repeated 2 more times if the rhythm remains shockable. Treatment with medications is also done during this time to reverse the cause of the ventricular fibrillation. Each of the other options is incorrect.)

Cardiopulmonary resuscitation (CPR) is immediately initiated on a client who is unconscious and has no pulse. A monitor is attached and it is determined that the rhythm is shockable, and defibrillation with 1 shock is delivered. Which action should the nurse plan to take next? 1.Defibrillate 1 more time, and then terminate the resuscitation effort. 2.Administer a bolus of fluid intravenously, and resume defibrillation attempts. 3.Perform CPR for 5 cycles, and then defibrillate again if the rhythm is shockable. 4.Perform CPR for 1 minute, assess, and then defibrillate up to 3 more times

4 (Rationale:Oxygen is administered, 8 to 10 L/minute, via face mask to optimize oxygenation of the circulating blood. Option 1 is incorrect because the intravenous infusion should be increased (per health care provider prescription) to increase the maternal blood volume. Option 2 is incorrect because oxytocin stimulation of the uterus is discontinued if fetal heart rate patterns change for any reason. Option 3 is incorrect because the client is placed in the lateral position with her legs raised to increase maternal blood volume and improve fetal perfusion.)

Fetal distress is occurring with a laboring client. As the nurse prepares the client for a cesarean birth, what is the most important nursing action? 1.Slow the intravenous flow rate. 2.Continue the oxytocin drip if infusing. 3.Place the client in a high Fowler's position. 4.Administer oxygen, 8 to 10 L/minute, via face mask.

3 (Rationale:An urticaria-type reaction is characterized by a rash accompanied by pruritus. This type of transfusion reaction is prevented by pretreating the client with an antihistamine such as diphenhydramine. The remaining medications would not prevent an urticaria-type reaction. Acetaminophen may be prescribed before the administration to assist in preventing an elevated temperature.)

One unit of packed red blood cells has been prescribed for a client with severe anemia. The client has received multiple transfusions in the past, and it is documented that the client has experienced urticaria-type reactions from the transfusions. The nurse anticipates that which medication will be prescribed before administration of the red blood cells to prevent this type of reaction? 1.Ibuprofen 2.Acetaminophen 3.Diphenhydramine 4.Acetylsalicylic acid

2 (Rationale:If the tube is dislodged accidentally, the initial nursing action is to grasp the retention sutures and spread the opening. If agency policy permits, the nurse then attempts to replace the tube immediately. Calling ancillary services or the health care provider will delay treatment in this emergency situation. Covering the tracheostomy site will block the airway)

While changing the tapes on a newly inserted tracheostomy tube, the client coughs and the tube is dislodged. Which is the initial nursing action? 1.Call the health care provider to reinsert the tube. 2.Grasp the retention sutures to spread the opening. 3.Call the respiratory therapy department to reinsert the tracheotomy. 4.Cover the tracheostomy site with a sterile dressing to prevent infection

3 (Rationale:The mother should be instructed to bring the child to the emergency department if the child develops stridor at rest, cyanosis, severe agitation or fatigue, or moderate to severe retractions or is unable to take oral fluids.)

The child with croup is being discharged from the hospital. The nurse provides instructions to the mother and advises the mother to bring the child to the emergency department if which occurs? 1.The child is irritable. 2.The child appears tired. 3.The child develops stridor. 4.The child takes fluids poorly