Exit Exam Study Guide Part 1

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

Correct Answe 3: Measure the difference between Korotkoff sounds auscultated during expiration and throughout the respiratory cycle Rationale: Muffled heart tones in a client with pericardial effusion can indicate the development of cardiac tamponade. This results in the build-up of fluid in the pericardial sac, which leads to compression of the heart. Cardiac output begins to fall as cardiac compression increases, resulting in hypotension. Additional signs and symptoms of tamponade include tachypnea, tachycardia, jugular venous distension, narrowed pulse pressure, and the presence of a pulsus paradoxus. Pulsus paradoxus is defined as an exaggerated fall in systemic BP >10 mm Hg during inspiration. *** The procedure for measurement of pulsus paradoxus is as follows: 1. Place client in semirecumbent position 2. Have client breathe normally 3. Determine the SBP using a manual BP cuff 4. Inflate the BP cuff to at least 20 mm Hg above the previously measured SBP 5. Deflate the cuff slowly, noting the first Korotkoff sound during expiration along with the pressure 6. Continue to slowly deflate the cuff until you hear sounds throughout inspiration and expiration; also note the pressure 7. Determine the difference between the 2 measurements in steps 5 and 6; this equals the amount of paradox 8. The difference is normally <10 mm Hg, but a difference >10 mm Hg may indicate the presence of cardiac tamponade.

which intervention is essential prior to starting a client on atorvastatin therapy? 1. assessing for muscle strength 2. assessing the client's dietary intake 3. determine if the client is on digoxin therapy 4. monitoring liver function tests

Correct Answer 2 Assessing the clients dietary intake Rationale: the client's central venous pressure (cvp) is elevated (normal value 2-8 mm Hg), indicating increased systemic circulation volume and increase right ventricular preload.Pulmonary artery wedge pressure (pawp) is also elevated (Normal value 6-12 mmHg), indicating increased left side failure. the treatment goal is to decrease fluid volume and preload. Furosemide is a loop diuretic that will decrease both left-and right side preload.

The nurse is caring for a 72-year-old client 1 day postoperative colectomy. The nurse assesses an increased work of breathing, diminished breath sounds at the bases with fine inspiratory crackles, respirations 12/min and shallow, and pulse oximetry 96% on 2 L oxygen. There is no jugular venous distension or peripheral edema. Pain is regulated with client-controlled morphine. Which prescription does the nurse anticipate? 1. Bolus dose of IV morphine 2. Incentive spirometer 3. IV furosemide 4. Non-rebreather mask

Correct Answer 2 Incentive spirometer Rationale: During the initial postoperative period, a client needs respiratory interventions to keep the lungs expanded and prevent atelectasis and postoperative pneumonia. Atelectasis is maximal during the second postoperative night. Clients can be asymptomatic or have increased work of breathing, hypoxia, and basal crackles. Postoperative pain, opioid respiratory depression, limited mobility, and reluctance to take a deep breath due to anticipated pain contribute to postoperative atelectasis. The elderly and postoperative abdominal and thoracic surgery clients are at increased risk for atelectasis. The incentive spirometer encourages the client to breathe deeply with maximum inspiration. This action improves ventilation and oxygenation by expanding the lungs, encourages coughing, and prevents or improves atelectasis. It is the most appropriate prescription for this client.

A client is being discharged home after an open radical prostatectomy. Which statement indicates a need for further teaching? 1. "I will try to drink lots of water." 2. "I will try to walk in my driveway twice a day." 3. "I will wash around my catheter twice a day." 4. "If I get constipated, I will use a suppository."

Correct Answer 4: "If I get constipated, I will use a suppository." Rationale: Following open radical prostatectomy, any rectal interventions such as suppositories or enemas must be avoided to prevent stress on the suture lines and problems with healing in the surgical area. The client should not strain when having a bowel movement for these reasons. Therefore, interventions to prevent constipation are an important part of postoperative care and discharge teaching. Prevention of constipation is particularly important while the client remains on opioid analgesics, which can cause constipation (Option 4).

A client is prescribed long-term pharmacologic therapy with hydroxychloroquine to treat systemic lupus erythematosus. Which intervention related to the drug's adverse effects should the nurse include in the teaching plan? 1. Have an ophthalmologic examination every 6 months 2. Take the medication on an empty stomach 3. Take vitamin D and calcium supplements 4. Wear a MedicAlert bracelet

Correct Answer: 1 Have an ophthalmologic examination every 6 months Rationale: Hydroxychloroquine (Plaquenil) is an antimalarial drug, but it is more commonly prescribed to reduce fatigue and treat the skin and arthritic (eg, joint inflammation, pain) manifestations of systemic lupus erythematosus (SLE). Hydroxychloroquine can also help to reduce lupus exacerbations in clients with inactive to mild disease, but several months can pass before its therapeutic effects become apparent. Although rare, serious adverse drug reactions such as retinal toxicity and visual disturbances can occur with hydroxychloroquine. Therefore, clients are instructed to undergo regular ophthalmologic examination every 6-12 months (Option 1). Educational objective: Hydroxychloroquine (Plaquenil) is used to treat the skin and arthritic manifestations ofSLE. Taking the medication with food can help alleviate gastrointestinal upset. Serious adverse drug reactions include retinopathy and visual disturbances; therefore, regular ophthalmologic examination every 6-12 months is required.

The nurse cares for an elderly client with type II diabetes who was diagnosed with diabetic retinopathy. Which statement by the client requires the most immediate action by the nurse? 1. "Half of my vision looks like it's being blocked by a curtain." 2. "I have to use reading glasses to see small print." 3. "My vision seems cloudy and I notice a lot of glare." 4. "The colors don't seem as bright as they used to."

Correct Answer: 1 "Half of my vision looks like it's being blocked by a curtain." Rationale: Chronic hyperglycemia can cause microvascular damage in the retina, leading to diabetic retinopathy, the most common cause of new blindness in adults. Option 1 indicates a retinal detachment requiring emergency management. A partial retinal detachment may be painless and cause symptoms such as a curtain blocking part of the visual field, floaters or lines, and sudden flashes of light. An unrepaired complete retinal detachment can cause blindness.

A 55-year-old client on a medical-surgical unit has just received a diagnosis of pancreaticcancer. The client says to the nurse, "Is this disease going to kill me?" What is the best response by the nurse? 1. "Hearing this diagnosis must have been difficult for you. What are your thoughts?" 2. "We will do everything possible to prevent that from happening." 3. "Well, we're all going to die sometime." 4. "You should concentrate on getting better rather than thinking about death."

Correct Answer: 1 "Hearing this diagnosis must have been difficult for you. What are your thoughts?" Rationale: The stress of receiving a life-threatening diagnosis often causes clients to feel very vulnerable. There is a tendency to keep feelings and concerns closed off; clients may not be able to express how distressed they feel or find the right words to express feelings and concerns. In asking, "Is this disease going to kill me?," the client is most likely not looking for a direct "yes" or "no" answer. This would immediately close off the conversation and create a missed opportunity for a meaningful engagement and communication with the nurse. It is more likely that this question is being asked to provide an opening for further discussion about the meaning of this devastating diagnosis as well as the client's thoughts and feelings. The nurse can facilitate a sense of trust, connection, and collaboration by the following: ***Providing empathy - acknowledging the distressing nature of the diagnosis ***Providing situations (eg, broad opening for discussion) in which the client can share thoughts and feelings in a safe environment ***Active listening - being very attentive to what the client is saying and trying to understand what the client is thinking and feeling ***Focusing - going beyond words and explanations to attain new awareness of a client's concerns ***Communicating effectively will assist the client in coping with difficult situations, reducing stress, and developing approaches for making necessary life changes

The nurse is assessing a client in the outpatient clinic who has a cast on for a distal humerus fracture. Which statements made by the client would be the priority to assess further? 1. "I am having problems extending my fingers since this morning." 2. "I can't take any of the pain medicine because it makes me feel sick." 3. "I have to scratch under the cast with a nail file because of the itching." 4. "I noticed a warm spot on my cast, and a bad smell is coming from it."

Correct Answer: 1 "I am having problems extending my fingers since this morning." Rationale: Volkmann contracture occurs as a result of compartment syndrome associated with distal humerus fractures. Swelling of antecubital tissue causes pressure within the muscle compartment, restricting arterial blood flow (brachial artery). The resulting ischemia leads to tissue damage, wrist contractures, and an inability to extend the fingers. A Volkmann contracture is a medical emergency that can cause permanent damage to the extremity if left untreated. Any restrictive dressing should be removed immediately, and the health care provider (HCP) must be notified for possible surgical intervention (eg, fasciotomy).

The nurse is teaching self-care management to a client experiencing an outbreak of genital herpes. Which statement by the client indicates a need for further teaching? 1. "I will be sure we use condoms during intercourse as long as I have lesions." 2. "I will not touch the lesions to prevent spreading the virus to other parts of my body." 3. "I will use a hair dryer on a cool setting to dry the lesions after taking a shower." 4. "I will use warm running water and mild soap without perfumes to wash the area."

Correct Answer: 1 "I will be sure we use condoms during intercourse as long as I have lesions." Rationale: Herpes simplex virus type 2 (HSV-2) is usually associated with genital herpes. Lesionsare painful and appear as multiple small, vesicularlesions. Management strategies focus on disease spread, including autoinoculation (eg, fingers) and pain relief, and include: ***Avoid sexual activity when lesions are present as the virus spreads through contact with the lesion; barrier contraception is not sufficient during an outbreak (Option1). (1) After the outbreak has resolved, condoms should be used in future sexual encounters as transmission is possible even in the absence of active lesions. ***Keep the area with lesions clean and dry. ***Avoid use of perfumed soaps and bubble baths. ***Maintain proper hand hygiene and avoid touching the lesions to prevent spreading. ***Use sitz baths and oatmeal baths to provide comfort and relief of itching and burning.

A client who was discharged 3 days ago following prostatectomy calls the clinic and tells the nurse of passing some small blood clots and experiencing a decreased urinary stream. What is the nurse's best response? 1. "I'll consult the health care provider (HCP) and then give you further instructions." 2. "Those symptoms are normal the first week following surgery." 3. "Try to bear down as if having a bowel movement." 4. "You should increase your daily fluid intake."

Correct Answer: 1 "I'll consult the health care provider (HCP) and then give you further instructions." Rationale: Signs of complications after a prostatectomy, such as bleeding, passage of blood clots, a decrease in the urinary stream, urinary retention, or symptoms of a urinary tract infection, should be reported to the HCP for further evaluation. Educational objective: Following a prostatectomy, bleeding is a potential complication that requires a thorough assessment. Any bleeding, passage of clots, decrease in urinary stream, urinary retention, or symptoms of urinary tract infection should be reported to the HCP.

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

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

The nurse assesses 4 clients. Which assessment finding requires the nurse's priority action? 1. 26-year-old with splenectomy reports a headache and chills 2. 40-year-old with immune thrombocytopenic purpura has petechiae on the arms 3. 60-year-old with marked anemia reports shortness of breath when ambulating 4. 68-year-old with polycythemia vera has a hematocrit of 66% (0.66)

Correct Answer: 1 26-year-old with splenectomy reports a headache and chills Rationale: The spleen is part of the immune system and functions as a filter to purify the blood and remove specific microorganisms that cause infections (eg, pneumococcal pneumonia, meningococcal meningitis). Overwhelming postsplenectomy bacterial infection or rapid-onset sepsis are major lifelong complications in a client without a functioning spleen. A minor infection can quickly become life-threatening, and so any indicator of infection such as a low-grade fever, chills, or headache needs immediate intervention (eg, cultures, imaging, antibiotic therapy). Therefore, the client with the splenectomy who is reporting headache and chills requires immediate action. Educational objective: Overwhelming postsplenectomy bacterial infection is a major lifelong complication in clients without a functioning spleen. A minor infection can quickly become life-threatening and septic; therefore, any indicator of infection requires immediate attention and treatment intervention.

The post-anesthesia care unit nurse receives report on a client after abdominal surgery. What sounds would the nurse expect to hear when auscultating the bowel? 1. Absent bowel sounds 2. Borborygmi sounds 3. High-pitched and gurgling sounds 4. Swishing or buzzing sounds

Correct Answer: 1 Absent bowel sounds Rationale: Auscultation of abdominal sounds during physical assessment includes bowel and cardiovascular components. Bowel sounds are normally intermittent (every 5-15 seconds), high-pitched, gurgling sounds that can be auscultated with the diaphragm of the stethoscope in all 4quadrants. Cardiovascular bruits (swishing, humming, buzzing) are rarely benign and usually indicate arterial narrowing or dilation. Procedures that require bowel manipulation cause a temporary halting of peristalsis (paralytic ileus) for the first 24-48 hours, resulting in absent bowel sounds (Option 1). For bowel sounds to be considered absent, the nurse must auscultate for 2-5 minutes in each quadrant. Peristalsis will usually return in the small intestine in 24 hours, but the large intestine may be delayed 3-5 days. Other procedures requiring general anesthesia, late stages of mechanical obstruction, and peritonitis may cause absent bowel sounds.

The nurse cares for a client with type 1 diabetes mellitus who is obtunded and responding to only painful stimuli. A STAT blood sample reveals a blood glucose level of 38 mg/dL (2.11 mmol/L). Which initial action by the nurse is best? 1. Administer 50% dextrose in water IV push 2. Assist the client to drink 4 oz (120 mL) of orange juice 3. Measure the client's heart rate and blood pressure 4. Observe for sweating, shakiness, and pallor

Correct Answer: 1 Administer 50% dextrose in water IV push Rationale: Hypoglycemia, a potentially life-threatening complication of diabetes mellitus, is identified by blood glucose <70 mg/dL (<3.9 mmol/L) and often occurs as a result of illness or inappropriate use of antidiabetic medications. When blood glucose levels (BGLs) are low, the body activates the autonomic nervous system, causing shakiness, palpitations, and sweating. Without intervention, hypoglycemia may cause altered mental status (eg, difficulty speaking, confusion), which may progress to seizures, coma, and death. Nurses caring for clients with hypoglycemia and altered mental status or dysphagia should immediately administer IV glucose replacement (eg, 50% dextrose in water) to quickly restore BGLs and prevent potentially lethal neurological changes (Option 1). Afterward, the nurse should retest the BGL every 15 minutes, repeating treatment if it remains low.

A client with dilated cardiomyopathy has the rhythm shown in the exhibit. Which action should the nurse take first? 1. Assess the client for a pulse 2. Assess the oxygen saturation 3. Initiate cardiopulmonary resuscitation (CPR) 4. Prepare to defibrillate the client

Correct Answer: 1 Assess the client pulse Rationale: Clients in ventricular tachycardia (VT) can be pulseless or have a pulse. Treatment is based on this important initial assessment. VT with a pulse should be further assessed for clinical stability or instability. Signs of instability include hypotension, altered mental status, signs of shock, chest pain, and acute heart failure. Educational objective: The client in VT must be assessed for the presence or absence of a pulse before further assessment or treatment is initiated. The unstable (hypotensive) client in VT with a pulse is treated with synchronized cardioversion.

An elderly client with type 2 diabetes is admitted to the medical unit due to urosepsis. The client is wearing an insulin pump for continuous subcutaneous insulin infusion therapy. The client's significant other reports that the client self-manages the insulin pump extremely well and keeps blood glucose in the specified target range. What is the admitting nurse's priority action? 1. Assess the client's level of orientation 2. Assess the insulin pump infusion site 3. Check the prescribed insulin pump settings 4. Consult the diabetic resource nurse or educator

Correct Answer: 1 Assess the client's level of orientation Rationale: Change in mental status and confusion is a common presenting symptom of sepsis in the elderly. The nurse should assess the client's cognitive status and level of orientation and consciousness. Diminished mental acuity, side effects of medication, and impairment related to a medical condition during hospitalization affect the client's ability to manage the insulin pump safely. Mental status is the key to safe insulin pump use, so if the client is not competent to operate the pump, the nurse should notify the health care provider (HCP) and document the findings in the client's electronic medical record. The HCP will determine if continuing the use of the pump during hospitalization is appropriate.

The emergency department nurse performs an admission assessment for a client with priapism of about 3 hours duration who also has sickle cell anemia. What assessment finding is of most concern and warrants immediate notification of the health care provider? 1. Bluish discoloration of the erect penis 2. Drank a 6-pack of beer 8 hours ago 3. Extreme penile pain rated as 9 on 0-10 scale 4. Has not voided for at least 6 hours

Correct Answer: 1 Bluish discoloration of the erect penis Rationale: Priapism is a sustained, painful erection often associated with sickle cell anemia, as the sickling (crescent shaping) of red blood cells can lead to penile vascular occlusion, erectile tissue hypoxia, and tissue necrosis. Bluish discoloration is of most concern as it can be a sign of ischemia to the penis.

A client with active pulmonary tuberculosis is prescribed 4-drug therapy with ethambutol. The community health nurse instructs the client to notify the health care provider immediately if which adverse effect associated with ethambutol occurs? 1. Blurred vision 2. Dark-colored urine 3. Difficulty hearing 4. yellow skin

Correct Answer: 1 Blurred vision Rationale: Ethambutol (Myambutol) is used in combination with other antitubercular drugs (eg, isoniazid, rifampin, pyrazinamide) to treat active tuberculosis. The client must have baseline andperiodic eye examinations during therapy as optic neuritis is a potentially reversible adverse effect. The client is instructed to report signs of decreased visual acuity and loss of color (red- green) discrimination.

A nursing unit implements a quality improvement process of written reminders to ameliorate incentive spirometer (IS) use in postoperative clients. What is the best indicator that the client goal for this process has been met? 1. Chart audits indicate that client incidence of nosocomial pneumonia decreased by 20% 2. Documentation shows that 100% of nurses attended an inservice seminar on the topic 3. Nurses report an increased number of written reminders given to appropriate clients 4. Surgeons who admit to the unit report increased satisfaction with current client IS use

Correct Answer: 1 Chart audits indicate that client incidence of nosocomial pneumonia decreased by 20% Rationale: The best indicators of a successful intervention (desired effect achieved) are objective criteria. This is an objective measurable result that can be correlated with the intervention.

Which client does the nurse assess first after receiving morning report? 1. Client 1 day postoperative with intravenous (IV) patient-controlled analgesia (PCA) who reports burning at the IV site Client with a bowel obstruction prescribed continuous nasogastric suction who was admitted yesterday Client with atrial fibrillation and an irregular heart rate of 94/min Client with dementia and Clostridium difficile (C difficile) who was incontinent of liquid stool

Correct Answer: 1 Client 1 day postoperative with intravenous (IV) patient-controlled analgesia (PCA) who reports burning at the IV site Rationale: The nurse assesses the client who reports burning at the PCA IV site first. The analgesia runs through a special PCA administration set that is attached to the PCA pump. It is attached to a running IV line, which is on its own infusion pump, to flush the PCA drug through the IV line each time a dose is administered. If the IV line infiltrates the subcutaneous tissue or the catheter becomes occluded, the PCA drug can back up into the primary tubing each time a dose is administered, resulting in inadequate pain control. In addition, burning can indicate phlebitis, which causes vessel wall injury and can lead to thrombophlebitis (Option 1).

The nurse reviews the laboratory results of several clients. Which finding should the nurse report to the health care provider immediately? 1. Client who is receiving tube feedings and has a phenytoin level of 8 mcg/mL (32 mcmol/L) 2. Client with a heart rate of 62/min who has a digoxin level of 1.3 ng/mL (1.7 nmol/L) 3. Client with a new prosthetic aortic valve who has an INR of 3.0 4. Client with a poor appetite and a lithium level of 0.8 mEq/L (0.8 mmol/L)

Correct Answer: 1 Client who is receiving tube feedings and has a phenytoin level of 8 mcg/mL (32 mcmol/L) Rationale Narrow therapeutic index medications have a higher chance of producing adverse effects due to a very small difference between therapeutic and toxic levels. These medications require close monitoring of serum drug levels for adequate, but not toxic, dosing. Clients should also be monitored for signs of toxicity, which are specific to each medication.

A client with a blood pressure (BP) of 250/145 mm Hg is admitted for hypertensive crisis. The health care provider prescribes a continuous IV infusion of nitroprusside sodium. Which of these is the priority goal in initial management of hypertensive crisis? 1. Decrease mean arterial pressure (MAP) by no more than 25% 2. Keep blood pressure at or below 120/80 mm Hg 3. Maintain heart rate (HR) of 60-100/min 4. Maintain urine output of at least 30 mL/hr

Correct Answer: 1 Decrease mean arterial pressure (MAP) by no more than 25% Rationale: Hypertensive crisis is a life-threatening emergency due to the possibility of severe organ damage. If not treated promptly, complications such as intracranial hemorrhage, heart failure, myocardial infarction (MI), renal failure, aortic dissection, or retinopathy may occur. Emergency treatment includes IV vasodilators such as nitroprusside sodium. It is important to lower the blood pressure slowly, as too rapid a drop may cause decreased perfusion to the brain, heart, and kidneys. This may result in stroke, renal failure, or MI. The initial goal is usually to decrease the MAP by no more than 25% or to maintain MAP at 110-115 mmHg. The pressure can then be lowered further over a period of 24 hours. MAP is calculated by adding the systolic blood pressure (SBP) and double the diastolic blood pressure (DBP), and then dividing the resulting value by 3. MAP = (2 x DBP + SBP) / 3

The registered nurse (RN) on an orthopedic unit is orienting a new graduate nurse (GN) assigned to a client with a fractured hip and in Buck's traction. The RN intervenes when the GN performs which action? 1. Elevates the head of the bed 45 degrees 2. Holds the weight while the client is repositioned up in bed 3. Loosens the Velcro straps when the client reports that the boot is too tight 4. Provides the client with a fracture pan for elimination needs

Correct Answer: 1 Elevates the head of the bed 45 degrees Rationale: Buck's skin traction maintains proper alignment of an injured body part by using weights to apply a continuous pulling force. Appropriate actions for a client in Buck's skin traction include: ***The client should be supine or in semi-Fowler's position (maximum of 20-30 degrees). Elevating the head of the bed more than 30 degrees would promote sliding (Option 1). ***Regularly assess the neurovascular status and skin integrity of the limb intraction. Loosen Velcro straps if the boot is too tight as they can impair neurovascular status and skin integrity; tighten the straps if the boot is too loose as this can decrease effectiveness of the traction. When a change is made in the application of the boot or traction pulley system, the nurse should reassess neurovascular status in 30minutes (Option 3). ***Provide a fracture pan, which is smaller than a bedpan, for elimination needs to minimize client movement and provide comfort (Option 4). ***Weights should be free-hanging at all times and should never be placed onto the bed or touch the floor. A staff member should support the weight while the client is repositioned up in bed to prevent excessive pull on the extremity (Option 2). Skeletal traction is applied directly to the bone with a metal wire or pin and is used to immobilize, position, or align a fracture when continuous traction is needed and skin traction is not possible. Removing the weights can cause injury to the client and should never be removed unless there is a life-threatening situation.

A 37-weeks-pregnant woman comes to the emergency department with a fractured ankle. Which assessment finding is mostconcerning and requires the nurse to follow up? 1. Fetal heart rate remains 206/min 2. Fetus kicked 4 times in the past hour 3. Mother reports feeling 2 contractions every hour 4. Mother's hemoglobin is 11 g/dL (110 g/L)

Correct Answer: 1 Fetal heart rate remains 206/min rationale: Fetal tachycardia is a baseline of >160 beats/min for >10 minutes. Tachycardia needs evaluation and continued surveillance. The most sensitive indicators of fetus health are fetal movement and fetal heart rate.

A client at 20 weeks gestation states that she started consuming an increased amount of cornstarch about 3 weeks ago. Based on this assessment, the nurse should anticipate that the health care provider will order which laboratory test(s)? 1. Hemoglobin and hematocrit levels 2. Human chorionic gonadotropin level 3. Serum folate level 4. White blood cell count

Correct Answer: 1 Hemoglobin and hematocrit levels Rationale Pica is the abnormal, compulsive craving for and consumption of substances normally not considered nutritionally valuable or edible. Common substances include ice, cornstarch, chalk, clay, dirt, and paper. Although the condition is not exclusive to pregnancy, many women only have pica when they are pregnant. Pica is often accompanied by iron deficiency anemia due to insufficient nutritional intake or impaired iron absorption. However, the exact relationship between pica and anemia is not fully understood. The health care provider would likely order hemoglobin and hematocrit levels to screen for the presence of anemia.

The nurse cares for an 11-lb (5-kg) infant admitted with dehydration and prepares to calculate intake and output over an 8-hour shift. Using the data in the exhibit, calculate the total output in milliliters for the 8-hour shift. Record your answer as a whole number.

Correct Answer: 178mL Rationale: To measure the urinary output of an infant in diapers, subtract the weight of the diaper when dry from its weight when wet. One (1) gram of weight is equal to one (1) milliliter offluid. Adequate urinary output for an infant is 2 mL/kg/hr. Calculation: Urine output in diapers: Diaper 1: 50 − 30 = 20 g Diaper 2: 52 − 30 = 22 g Diaper 3: 46 − 30 = 16 g Total mg of urine:58 g = 58 mL Total output: (Emesis) + (Urine) = 120 mL + 58 mL = 178 mL Educational objective: Urinary output for a child in diapers is calculated by subtracting the dry weight of the diaper from its weight when wet. One (1) gram of weight is equal to one (1) milliliter of fluid

During the first prenatal assessment, the client reports the last normal mentrual period starting on March 1 and ending on March 5, but also slight spotting on March 23. The client had unprotected intercourse on March 15. Using Naegele's Rule, what is the estimated date of birth? 1. December 8 2. December 12 3. December 22 4. December 30

Correct Answer: 2 December 8 Rationale: • EDB = (LMP minus 3 months) + 7 days Various methods to determine the estimated date of birth (EDB) include use of Naegele's rule, ultrasound, uterine height measurement (McDonald's measurement), and auscultation of fetal heart rate with a Doppler device. The most accurate dating of pregnancy involves use of ultrasound around the 16th-18th week of pregnancy. However, Naegele's rule can be used to quickly determine an EDB early in the pregnancy. This calculation uses the date of the first day of the last normal menstrual period (LMP) for determination of EDB. This client's LMP is March 1, minus 3 months = December 1. Add 7 days to obtain EDB = December 8. Clients who conceive in January, February, and most of March will deliver in the currentyear. Those who conceive after March will deliver in the following year; as a result, a third step is adding 1 to the current year to determine the estimated date of birth. For example, LMP of May 10, 2014, would have an EDB of February 17, 2015. It is important to note that Naegele's rule is based on a client having a menstrual cycle of 28 days. It therefore may not be as accurate if the client has a shorter or longer menstrual cycle. Educational objective: Naegele's rule provides a quick determination of the estimated date of birth (EDB). EDB = (LMP minus 3 months) + 7 days. If the LMP occurs in January, February, or March, the EDB will be in the current year. If the LMP occurs after March, the EDB will be in the next year.

The health care provider (HCP) orders a small bowel follow-through (SBFT) for a client. Which instructions should the nurse include when teaching the client about this test? 1. "After the test, you may notice your stools are tarry black for a few days." 2. "During the test, a series of x-rays will be taken to assess the function of the small bowel." 3. "The HCP will use an endoscope to visualize your small bowel." 4. "Your examination is scheduled for 8:00 AM. Please drink all of the polyethylene glycol by midnight."

Correct Answer: 2 "During the test, a series of x-rays will be taken to assess the function of the small bowel." Rstionale: An SBFT examines the anatomy and function of the small intestine using x-ray images taken in succession. Barium is ingested, and x-ray images are taken every 15-60 minutes to visualize the barium as it passes through the small intestine (Option 2). Using this technique, decreased motility (eg, ileus), increased motility (eg, malabsorption syndromes), fistulas, or obstructions are identified. Clients should be instructed as follows: ***Fast 8 hours prior to the examination. ***The test usually takes 60-120 minutes, but if obstruction or decreased motility is present, it can take longer. ***Drink plenty of fluids after the examination to facilitate barium removal. Chalky stools may be present 24-72 hours after the examination. If brown stools do not return after 72 hours or abdominal pain or fullness is present, contact the HCP.

The nurse provides instruction to a community group about lung cancer prevention, health promotion, and smoking cessation. Which statement made by a member of the group indicates the need for further instruction? 1. "Even though I am getting nicotine in my patches, I am not being exposed to all of the other toxic stuff in cigarettes." 2. "I can't get lung cancer because I don't smoke." 3. "My husband needs to take smoking cessation classes." 4. "We installed a radon detector in our home."

Correct Answer: 2 "I can't get lung cancer because I don't smoke." Rationale: Smoking is responsible for 80%-90% of all lung cancers. Although the risk is greater among smokers, former smokers and nonsmokers can develop lung cancer as well. Risk factors include secondhand smoke, air pollution, genetic predisposition, and exposure to radon, asbestos, and chemicals in the workplace.

The nurse is assessing a client at 36 weeks gestation during a routine prenatal visit. Which statement by the client should the nurse investigate first? "I am not sleeping as well due to cramps in my calves at night." "I have noticed less kicking movements as the baby grows bigger." "Over the last few weeks, I have not been able to wear any of my shoes." "Sometimes I feel short of breath after walking up a flight of stairs."

Correct Answer: 2 "I have noticed less kicking movements as the baby grows bigger." Rationale: Fetal movement is a sign of fetal health and indicates an intact fetal central nervoussystem. Fetal movement may occur numerous times per hour during the last trimester of pregnancy, although the client may not perceive every movement. Multiple factors (eg, maternal substance abuse, medications, fasting, fetal sleep) can affect fetal movement. However, fetal movements should not decrease as the fetus increases in size. Decreased fetal movement is a potential warning sign of fetal compromise (ie, impaired oxygenation), which may precede fetal death (Option 2). The nurse prioritizes assessment of client reports of decreased fetal movement to evaluate fetal well-being (eg, nonstress test).

The nurse is teaching the parents of a 4-month-old who has developed positional plagiocephaly (flat head syndrome). Which statement by the parents indicates a need for further teaching? 1. "I should alternate head positions when the infant is supine." 2. "I should place the infant in the prone position during naps." 3. "I will minimize the amount of time the infant is in a car seat." 4. "I will place interesting toys opposite the affected side."

Correct Answer: 2 "I should place the infant in the prone position during naps." Rationale: Positional plagiocephaly (flat head syndrome) occurs when an infant's soft, pliable skull is placed in the same position for an extended time. Positional plagiocephaly has become common due to the Safe to Sleep (formerly Back to Sleep) campaign, which advocates for infants to sleep in the supine position to prevent sudden infant death syndrome (SIDS). The risk of SIDS outweighs the benefit of a shapely head; the infant should not be placed in the prone position to sleep, even for a daytime nap (Option 2). Plagiocephaly can usually be prevented or corrected by: 1. Frequently alternating the supine infant's head position from side to side (Option 1) 2. Minimizing the amount of time an infant's head rests against a firm surface (eg, car seat) (Option 3) 3. Placing pictures and toys opposite the favored (affected) side to encourage turning the head (Option 4) 4. Placing the infant in the prone position for 30-60 min/day ("tummy time")

While delegating to the unlicensed assistive personnel (UAP), the registered nurse (RN) should utilize the 5 rights of delegation. The "right direction and communication" related to the task is one of those rights. Which statement best meets that standard? 1. "I need for you to take vital signs on all clients in rooms 1-10 this morning." 2. "Mr. Wu's blood pressure has been low. Please take his vital signs first and let me know if his systolic blood pressure is <100." 3. "Mrs. Jones fell out of bed during the night. Be sure you keep a close eye on her this shift." 4. "Would you please make sure Mr. Garcia in bed 8 ambulates several times?"

Correct Answer: 2 "Mr. Wu's blood pressure has been low. Please take his vital signs first and let me know if his systolic blood pressure is <100." *** Five Rights of Delegation Rationale: In the Joint Statement on Delegation (2007), the American Nurses Association and the National Council of State Boards of Nursing outline the 5 Rights of Delegation as seen in the table above. The RN needs to direct the UAP's actions and communicate clearly about the assigned tasks including any specific information necessary for completion (eg, methods for collection, time frame, when to report back to the RN). Option 2 gives the UAP directions with prioritization and specific instructions for reporting back findings.

The registered nurse (RN) is supervising a graduate nurse (GN) providing postoperative teaching for a male client after an inguinal hernia repair. Which statement by the GN would cause the RN to intervene? 1. "Elevate your scrotum and apply an ice bag to reduce swelling." 2. "Practice coughing to clear secretions and prevent pneumonia." 3. "Stand up to use the urinal if you have difficulty voiding." 4. "Turn in bed and perform deep breathing every 2 hours."

Correct Answer: 2 "Practice coughing to clear secretions and prevent pneumonia." Rationale: An inguinal hernia is the protrusion of abdominal contents through the inguinal canal, which appears as a bulge in the lateral groin. Herniation occurs spontaneously or results from increased intraabdominal pressure (eg, heavy lifting). Inguinal hernias occur most commonly in male clients and are usually repaired with minimally invasive surgery. If intestinal strangulation develops, the client requires emergency treatment to prevent bowel ischemia orperforation. Strangulation symptoms include abdominal distension, severe pain, nausea, and vomiting. To prevent hernia reoccurrence after surgical repair, the client is taught to avoid activities that increase intraabdominal pressure (eg, coughing, heavy lifting) for 6-8 weeks (Option 2). If sneezing or coughing are unavoidable, the client should splint incisions and keep the mouth open while sneezing.

The nurse administers 15 units of aspart insulin subcutaneously to a hospitalized client with type 1 diabetes mellitus at 7:00 AM for a fasting blood glucose of 180 mg/dL (10 mmol/L). Which nursing action is a priority? 1. Ensure that the client continues to fast for at least 30 more minutes 2. Give the client breakfast within 15 minutes 3. Recheck the blood glucose in 1 hour 4. Teach the client about the signs and symptoms of hyperglycemia

Correct Answer: 2 Give the client breakfast within 15 minutes Rationale: Aspart (NovoLOG) is a rapid-acting insulin with an onset of 10-15 minutes. Onset is the time it takes for the insulin to enter the circulation and begin to lower blood glucose. The peak effect takes 30 minutes-3 hours and the duration of action is 3-5 hours. It is important for the nurse to ensure that the client eats within 15 minutes of administration of aspart/lispro/glulisine to prevent an insulin-related hypoglycemic reaction (Option 2). Educational objective: It is important for the nurse to ensure that the client eats within 15 minutes of administration of rapid-acting insulins such as aspart (NovoLOG), lispro (HumaLOG), and glulisine (Apidra) to prevent an insulin-related hypoglycemic reaction.

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

Correct Answer: 2 214-year-old with severe scrotal pain; right testis is tender, swollen, and more elevated than the left Rationale: Testicular torsion is an emergency condition in which blood flow to the testis (scrotum) has stopped. The testicle rotates and twists the spermatic cord, initially causing venous drainage obstruction that leads to swelling and severe pain. Arterial blood supply is subsequently interrupted, resulting in testicular ischemia and necrosis, which require surgical removal of the testis. The condition can be diagnosed with ultrasound. There is a short time frame in which testicular torsion can be treated (to untwist the rotation), generally 4-6 hours, making this condition a priority. Educational objective: Testicular torsion can result in testicular ischemia and necrosis from inadequate blood supply. There is a short time frame (4-6 hours) in which testicular torsion can be treated to prevent death of the testicle, and the client will most likely require emergency surgery.

The nurse is caring for an adolescent client diagnosed with type 1 diabetes. The client exhibits hot, dry skin and a glucose level of 350 mg/dL (19.4 mmol/L). Arterial blood gases show a pH of 7.27. STAT serum chemistry labs have been drawn. Cardiac monitoring shows a sinus rhythm with peaked T waves, and the client has minimal urine output. What is the nurse's next priority action? 1. Administer IV regular insulin 2. Administer normal saline infusion 3. Obtain urine for urinalysis 4. Request prescription for potassium infusion

Correct Answer: 2 Administer normal saline infusion Rationale: This client has diabetic ketoacidosis (DKA). All clients with DKA experience dehydration due to osmotic diuresis. Prompt and adequate fluid therapy restores tissue perfusion and suppresses the elevated levels of stress hormones. The initial hydrating solution is 0.9% saline infusion.

The nurse is preparing medications for the following 4 clients. Which prescription should the nurse clarify with the health care provider before administration? 1. Acetaminophen for a client with a temperature of 102.2 F (39 C) with productive cough 2. Azathioprine for a client with Crohn disease with leukopenia who is reporting malaise 3. Baclofen for a client with multiple sclerosis who reports dizziness when changing positions 4. Colchicine for a client with an acute gout attack who reports intense, burning left toe pain

Correct Answer: 2 Azathioprine for a client with Crohn disease with leukopenia who is reporting malaise Rationale: Azathioprine is an immunosuppressant drug that can cause bone marrow depression and increase the risk for infection. It is prescribed to treat autoimmune conditions such as inflammatory bowel diseases (eg, Crohn disease) and to prevent organ transplantrejection. Fatigue and nausea can be expected as minor adverse effects or may be associated with the disease. However, leukopenia (white blood cell count <4,000/mm3 [4 × 109/L]) can be a severe adverse effect of the drug and should be reported to the health care provider before administering the medication due to high risk for infection (Option 2).

The nurse teaches a client with osteopenia, who is lactose intolerant, how to increase dietary calcium and vitamin D intake. Which lunch food is the best choice? 1. Broiled chicken breast 2. Canned sardines 3. Egg white omelet 4. Peanut butter

Correct Answer: 2 Canned sardines Rationale: Osteopenia is more than normal bone loss for the client's age and sex. Adequate dietary intake of calcium and vitamin D is necessary to promote bone growth, prevent resorption (bone loss), and prevent progression to osteoporosis. Milk and milk products are the best sources of calcium. However, other food sources are available for individuals who are lactose intolerant. They include some fish (eg, sardines, salmon, trout), tofu, some green vegetables (eg, spinach, kale, broccoli), and almonds. Good food sources of vitamin D include egg yolks and oily fish (eg, salmon, sardines, tuna). Canned sardines are the best choice as sardines are an excellent source of calcium and vitamin D (Option 2).

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

Correct Answer: 2 Clarify the prescription with the health care provider Rationale: Patient-controlled analgesia (PCA) delivers a set amount of IV analgesic each time the client presses the administration button. With many PCA pumps, a continuous IV solution (eg, normal saline) is required to keep the vein open and flush the PCA medication through the line so that the boluses reach the client. Many facilities have a policy regarding IV fluid for use with PCA; however, a prescription may be required. To ensure uninterrupted delivery of this client's PCA, the nurse should contact the health care provider to clarify the prescription to discontinue the normal saline.

A child received the varicella immunization. The day after the injection, the parent calls the nurse to say that the child has discomfort, slight redness, and 2 vesicles at the injection site. What instruction would be appropriate for the nurse to provide to this parent? 1. Administer aspirin to decrease discomfort 2. Cover the vesicles with a small bandage until they are dry 3. Isolate the child from other children for 21 days to avoid exposure 4. Make an appointment with the health care provider (HCP) as soon as possible

Correct Answer: 2 Cover the vesicles with a small bandage until they are dry Rationale: The varicella immunization is administered to prevent infection of varicella zoster, commonly known as chickenpox. Side effects of the immunization include discomfort, redness, and a few vesicles at the injection site. Covering the vesicles with clothing or a small bandage will reduce the risk of transmission from any exudate. Once the vesicles have dried, or crusted, a dressing is no longer necessary.

A female client with liver cirrhosis and chronic anemia is hospitalized for a deep venous thrombosis. The client is receiving a heparin infusion and suddenly develops epistaxis. Which laboratory value would indicate that the heparin infusion needs to be turned off? 1. Hematocrit of 30% (0.30) 2. Partial thromboplastin time of 110 seconds 3. Platelet count of 80,000/mm3 (80 x 109/L) 4. Prothrombin time of 11 seconds

Correct Answer: 2 Partial thrombosplastin time of 110 seconds Rationale: Heparin is an anticoagulant that helps prevent further clot formation. It is titrated based on a partial thromboplastin time (PTT). The therapeutic PTT target is 1.5-2.0 times the normal reference range of 25-35 seconds. A PTT value >100 seconds would be considered critical and could result in life-threatening side effects. Common sentinel events that result from heparin drips include epistaxis, hematuria, and gastrointestinal bleeds. Educational objective: Heparin infusions require close monitoring by the nurse. The partial thromboplastin time is the laboratory value required to accurately monitor the therapeutic effects of heparin

The registered nurse is developing a nursing care plan for a client who has just undergone surgery for treatment of ulcerative colitis with the creation of a permanent ileostomy. What is the priority outcome for this client? 1. The client will contact the United Ostomy Association of America 2. The client will look at and touch the stoma 3. The client will read the materials provided on ostomy care 4. The client will verbalize methods to control gas and odor

Correct Answer: 2 The client will look at and touch the stoma Rationale: A client who has undergone ostomy surgery must become independent in self-care. This requires adaptation to a significant alteration in body image and dealing with a number of psychosocial issues that are associated with a change in appearance and the loss of bowel control. It is not uncommon for a client to cope with this loss by refusing to look at or participate in the care of the stoma. Nursing interventions for this client will include: ***Supportive counseling and assistance in psychosocial adjustment ***Teaching and facilitating self-care ***Providing information about the reason for the surgery, prognosis, potential complications, and community resources. The priority outcome of nursing care is that the client will look at and touch the stoma; this is an indication that the client has accepted or begun to accept the change in body image and functioning and can begin participating in self-care.

The nurse prepares to administer clozapine to a client with schizophrenia. Which client statement would require priority investigation before administering the medication? 1. "I have gained a few pounds since I started this medication." 2. "I have had a sore throat for 3 days and feel feverish today." 3. "I have noticed increased salivation and drooling." 4. "I often feel sleepy when I take this medication."

Correct Answer: 2 "I have had a sore throat for 3 days and feel feverish today." Rationale: Clozapine (Clozaril) is an atypical antipsychotic medication used to manage schizophrenia in clients who have not improved with other antipsychotic medications. Clozapine is highly effective at controlling schizophrenia; however, it has many severe, life-threatening adverse effects, including agranulocytosis, cardiac disease (myocarditis), and seizures. Agranulocytosis (decreased neutrophils) increases the risk for infection. Clients require serial monitoring of white blood cell counts and frequent assessment for signs of infection (eg, sore throat, fever, flulike symptoms), which should be reported immediately to the health care provider (Option 2).

The nurse administers 8 units of regular insulin subcutaneously at 11:30 AM to a client with type 1 diabetes mellitus and serves the client lunch 30 minutes later. The client eats a few bites, becomes nauseated, and is unable to finish the meal. When is the client at highest risk for experiencing an insulin-related hypoglycemic reaction? 1. 12:30 PM 2. 2:00 PM 3. 5:00 PM 4. 6:00 PM

Correct Answer: 2 2:00 PM Rationale: The client is at highest risk for experiencing an insulin-related hypoglycemic reaction when the drug peaks. The peak indicates the time during which insulin works at its maximum strength to lower the blood glucose. Regular insulin is short-acting and peaks 2-5 hours after administration. The onset of regular insulin is 30 minutes-1 hour with duration of 5-8 hours.

The nurse admits a postoperative client following weight loss surgery. Which prescription should the nurse question? 1. Begin a sugar-free, clear liquid diet 2. Insert nasogastric tube for uncontrolled nausea 3. Place client in low Fowler position during mealtimes 4. Start morphine via patient-controlled analgesia

Correct Answer: 2 Insert nasogastric tube for uncontrolled nausea Rationale: Bariatric surgery for weight loss involves a surgical modification of the client's stomach and/or small intestine to restrict the client's intake. Postoperative nursing care focuses on managing pain and nausea and monitoring for complications (eg, infection, fluid and electrolyte imbalance, dumping syndrome, anastomotic leak). Nasogastric tubes are contraindicated after gastric surgery due to potential disruption of the surgical site, which can cause hemorrhage and anastomotic leak (Option 2). Postoperative nausea would be controlled using IV antiemetics.

The nurse is caring for an 83-year-old bedridden client experiencing fecal incontinence. Which nursing interm-61tervention is the highest priority for this client? 1. Consult with the wound care nurse specialist 2. Insert a rectal tube to contain the feces 3. Provide perianal skin care with barrier cream 4. Use incontinence briefs to protect the skin

Correct Answer: 3 Rationale: Disruptions of motor function (anal sphincter and rectal floor muscle dysfunction) and/or sensory function (lack of urge to defecate or inability to sense stool) can result in fecal incontinence. The presence of stool can lead to skin breakdown, urinary tract infections, spread of infection (eg, Clostridium difficile), and contamination of wounds. Therefore, maintenance of perineal and perianal skin integrity is the highest priority. Stool should be removed promptly from the skin by gently cleansing the perineum and perianal area with mild soap. Dry the soiled area and apply a thick moisture barrier product to the skin (Option 3). Clean, dry linens and clothing should be provided.

The nurse is admitting a client with a possible diagnosis of Guillain-Barré syndrome. When collecting data to develop a plan of care for the client, the nurse should give priority to which of the following items? 1. Orthostatic blood pressure changes 2. Presence or absence of knee reflexes 3. Pupil size and reaction to light 4. Rate and depth of respirations

Correct Answer: 4 Rate and depth of respirations Rationale: Guillain-Barré syndrome (GBS) is an acute, immune-mediated polyneuropathy that is most often accompanied by ascending muscle paralysis and absence of reflexes. Lower-extremity weakness progresses over hours to days to involve the thorax, arms, and cranial nerves(CNs). Neuromuscular respiratory failure is the most life-threatening complication. The rate and depth of the respirations should be monitored (Option 4). Measurement of serial bedside forced vital capacity (spirometry) is the gold standard for assessing early ventilation failure.

An experienced nurse precepts a graduate nurse caring for a hospitalized client who has a prescription for a transfusion of packed red blood cells (RBCs) to be hung over 3 hours. Which statement by the graduate nurse indicates the correct rationale for asking the client to void prior to starting the transfusion? 1. "A drop in blood pressure is expected during the transfusion and getting up to void may cause a fall." 2. "Bedrest is required; therefore, voiding will prevent intermittent catheterization during the procedure." 3. "If a transfusion reaction occurs, it will be important to collect a fresh urine specimen to check for hemolyzed RBCs." 4. "The urine is collected and analyzed prior to starting the transfusion to assess the client's baseline results."

Correct Answer: 3 "If a transfusion reaction occurs, it will be important to collect a fresh urine specimen to check for hemolyzed RBCs." Rationale: The nurse should ask the client to void or empty the urinary catheter and discard urine prior to starting a blood transfusion. In the event of an acute hemolytic transfusion reaction, afresh urine specimen should be collected and sent to the laboratory to analyze for hemolyzed RBCs. An acute hemolytic transfusion reaction is a life-threatening reaction in which the host's antibodies rapidly destroy the transfused RBCs and is generally related to incompatibility. Early signs of a hemolytic reaction include red urine, fever, and hypotension; late signs include disseminated intravascular coagulation and hypovolemic shock. The transfusion should be stopped immediately if any sign of transfusion reaction occurs. Starting the transfusion with an empty bladder will help ensure that any urine specimen collected after a reaction is reflective of the body's physiological processes after the blood transfusion has started (Option 4).

Which statement by a client with a diagnosis of dependent personality disorder would the nurse recognize as progress toward a positive therapeutic outcome? 1. "I really appreciate all the time you have spent trying to help me." 2. "I think I really messed up at work today." 3. "My mother could not drive me here today, so I took the bus." 4. "When my parents go away on vacation, I'm planning to stay with my cousin."

Correct Answer: 3 "My mother could not drive me here today, so I took the bus." Rational: Individuals with dependent personality disorder have a persistent and extreme need to be taken care of that manifests as submissive and clinging behaviors and fear of separation. Additional characteristics of dependent personality disorder may include: ***Difficulty in making day-to-day decisions ***An excessive need for advice, reassurance, and nurturance from others ***Lack of self-confidence - afraid to do things on one's own ***Afraid of confrontation or expressing disagreement with others ***Feelings of helplessness and anxiety when alone; fear of being unable to take care of oneself A client making a decision about and carrying out a daily activity on his/her own would be indicative of progress toward a therapeutic outcome. Educational objective: Clients with dependent personality disorder have an extreme need to be taken care of by another person, cannot make decisions on their own, and have intense fear of separation and being left alone. The ability to make

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

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

The parent of a 1-year-old says to the nurse, "I would like to start toilet training my child as soon as possible." What information does the nurse provide to the parent that correctly describes a child's readiness for toilet training? 1. "A good time to start toilet training is when your child can dress and undress autonomously." 2. "When your child can sit on the toilet until urination occurs, you can start toilet training." 3. "Your child may be ready to start toilet training when able to communicate and follow directions." 4. "Your child will be ready to start toilet training at about age 15 months."

Correct Answer: 3 "Your child may be ready to start toilet training when able to communicate and follow directions." Rationale: Toilet training is a major developmental achievement for the toddler. The degree of readiness progresses relative to development of neuromuscular maturity with voluntary control of the anal and urethral sphincters occurring at age 18-24 months. Bowel training is less complex than bladder training; bladder training requires more self-awareness and self-discipline from the child and is usually achieved at age 21⁄2-31⁄2 years. In addition to physiological factors, developmental milestones rather than the child's chronological age signal a child's readiness for toilet training. These include the ability to: ***Ambulate to and sit on the toilet ***Remain dry for several hours or through a nap ***Pull clothes up and down ***Understand a two-step command ***Express the need to use the toilet (urge to defecate or urinate) ***Imitate the toilet habits of adults or older siblings ***Express an interest in toilet training

The nurse evaluates the effectiveness of desmopressin use for diabetes insipidus in a client with a pituitary tumor. Which client assessment finding indicates that the medication is having the desired effect? 1. Appetite has improved 2. Blood glucose is 110 mg/dL (6.1 mmol/L) 3. Urine output has decreased 4. Urine specific gravity is lower

Correct Answer: 3 3. Urine output has decreased Rationale: Diabetes insipidus (DI) results in low levels of antidiuretic hormone (ADH), which is produced by the hypothalamus and stored in the pituitary gland. The function of ADH is to concentrate urine by signaling the kidneys to retain water in the setting of thirst. When ADH levels are insufficient, the kidneys excrete large quantities of very dilute urine (polyuria). This causes hypernatremia (elevated serum sodium due to deficit of free water) and increased serum osmolality, which lead to excessive thirst (polydipsia). Desmopressin acetate (DDAVP) is a synthetic form of ADH, which can be administered intravenously, orally, or via nasal spray. Effectiveness of therapy with desmopressin would be manifested by decreased urinary output and increased urine specific gravity as the urine becomes less dilute (Option 3). Educational objective: Use of desmopressin acetate (DDAVP) in clients with diabetes insipidus will lower urinary output and cause the urine specific gravity to increase.

The nurse assistant reports vital signs on 4 clients. Which client should be a priority for the nurse to assess? 1. 28-year-old with infective endocarditis and heart rate of 105/min 2. 45-year-old with acute pancreatitis and sinus tachycardia of 120/min 3. 65-year-old with tachycardia of 110/min after liver biopsy 4. 74-year-old on diltiazem drip with atrial fibrillation and heart rate of 115/min

Correct Answer: 3 65-year-old with tachycardia of 110/min after liver biopsy Rationale: The liver is a highly vascular organ and bleeding is a major complication. Tachycardia is an early sign of internal hemorrhage. The 65-year-old client should be assessed first. Educational objective: Liver biopsy can cause internal bleeding. Clients with internal bleeding require priority assessment.

A 15-year-old parent brings a 4-month-old infant for a well-baby checkup. The parent tells the nurse that the baby cries all the time; the parent has tried everything to keep the infant quiet but nothing works. What is the priority nursing action? 1. Advise the parent to give a pacifier whenever the infant cries 2. Ask the parent to describe what is done to "keep the baby quiet" 3. Assess the infant's pattern and frequency of crying 4. Explore the parent's support system

Correct Answer: 3 Assess the infant's pattern and frequency of crying Rationale: During the first 3-4 months of life, it is not unusual for an infant to cry 1-3 hours a day in response to being hungry, thirsty, tired, in pain, bored, or lonely. A very young, first-time parent may not have an appreciable understanding of normal infant behavior and may perceive normal crying as excessive. It is most important for the nurse to assess the infant's pattern and quality of crying to better understand whether it is normal behavior or a sign of something more serious that requires further evaluation and treatment. The nurse needs to determine: ***What "all the time" means ***When the "all the time" crying started ***What makes the crying worse and what makes it better ***The quality of the crying (tone, pitch, loudness) ***Length and quality of periods of silence

Several children are brought to the emergency room after a boating accident in which they were thrown into the water. The children are now 6 hours post admission to the clinical observation unit. Which client should the nurse evaluate first? 1. Client who did not require CPR but now has a new oxygen requirement of 2 L via nasal cannula to maintain a saturation of 95% 2. Client who did not require CPR but was coughing on arrival to the hospital and is now crying inconsolably and asking for the mother 3. Client who received CPR for 2 minutes on the scene and whose respiratory rate has now dropped from 61/min to 18/min 4. Client who was briefly submerged in water and received rescue breaths on the scene and is now irritable and refusing food and drink

Correct Answer: 3 Client who received CPR for 2 minutes on the scene and whose respiratory rate has now dropped from 61/min to 18/min Rationale: Clients with morbidity related to immersion in water are described as having submersion injury. Even if an individual was submerged for a very brief time, it is possible that water may have been aspirated, which can lead to respiratory compromise. Observation for at least 6 hours is recommended as the majority of significant respiratory problems will manifest in this time period. A marked decrease in respiratory rate or increased work of breathing may indicate respiratory fatigue, and immediate intervention is needed (Option 3). Impending respiratory failure is the immediate priority.

A nurse receives information in a change of shift report. Which client is the priority? 1. Client prescribed levothyroxine to treat hypothyroidism who reports nervousness, sweating, and insomnia 2. Client receiving intravenous antibiotics for bacterial pneumonia who reports cough with blood-tinged sputum 3. Client with a femoral external fixator who has a temperature of 100.9 F (38.3 C) and redness and pain around the pin sites 4. Client with chronic pancreatitis who reports upper abdominal pain and voluminous, foul- smelling, fatty stools

Correct Answer: 3 Client with a femoral external fixator who has a temperature of 100.9 F (38.3 C) and redness and pain around the pin sites Rationale: External fixation stabilizes bone by inserting metal pins through skin into the bone and attaching them to a metal rod outside the skin. The nurse should assess this client first as any signs and symptoms of an infection (eg, low-grade fever, drainage, pain, redness, swelling) warrant immediate evaluation and treatment. Localized pin tract infection can progress to osteomyelitis, a serious bone infection that requires long-term treatment with antibiotics.

The emergency department nurse receives report on 4 clients. Which client should the nurse assess first? 1. Client with acute cholecystitis who reports right shoulder pain 2. Client with gastroparesis who reports persistent nausea and vomiting 3. Client with intractable lower back pain who reports new urinary incontinence 4. Client with Ménière disease who reports increasing tinnitus

Correct Answer: 3 Client with intractable lower back pain who reports new urinary incontinence Rationale: Cauda equina syndrome is a disorder that results from injury to the lumbosacral nerve roots (L4-L5) causing motor and sensory deficits. The main symptoms are severe lower back pain, inability to walk, saddle anesthesia (ie, motor weakness/loss of sensation to inner thighs and buttocks), and bowel and bladder incontinence (late sign). Cauda equina syndrome is a medical emergency. Treatment requires urgent reduction of pressure on the spinal nerves to prevent permanent damage. This client displays characteristic late signs of cauda equine syndrome (ie, incontinence); therefore, the nurse should assess this client first. Educational objective: Signs and symptoms of cauda equina syndrome (eg, acute spinal/back pain, inability to walk, saddle anesthesia, bowel/bladder incontinence) require emergency attention to prevent permanent damage.

The nurse prepares to administer an IV infusion of potassium chloride through a peripheral vein to a client with hypokalemia. The health care provider's prescription states: IV potassium chloride 10 mEq (10 mmol)/100 mL 5% dextrose in water now, infuse over 30 minutes. What is the nurse's priority action? 1. Assess the patency of the peripheral IV site 2. Check the most current serum potassium level 3. Contact the health care provider to verify the prescription 4. Set the electronic IV pump to 100 mL/hr

Correct Answer: 3 Contact the health care provider to verify the prescription Rationale: The recommended rates for an intermittent IV infusion of potassium chloride (KCl) are no greater than 10 mEq (10 mmol) over 1 hour when infused through a peripheral line and no greater than 40 mEq/hr (40 mmol/hr) when infused through a central line (follow facility guidelines and policy). If the nurse were to administer the medication as prescribed, the rate would exceed the recommended rate of 10 mEq/hr (10 mmol/hr) (ie, 10 mEq [10 mmol] over 30 minutes = 20 mEq/hr [20 mmol/hr]). A too rapid infusion can lead to pain and irritation of the vein and postinfusion phlebitis. Contacting the health care provider to verify this prescription is the priority action.

The nurse is reviewing new prescriptions from the health care provider. Which prescription would require further clarification? 1. Atorvastatin for hyperlipidemia in a client with angina pectoris 2. Bupropion for smoking cessation in a client with emphysema 3. Cyclobenzaprine for muscle spasms in a client with hepatitis 4. Metronidazole for trichomoniasis in a client with Crohn disease

Correct Answer: 3 Cyclobenzaprine for muscle spasms in a client with hepatitis Rationale: Cyclobenzaprine (Flexeril) is a common, centrally acting skeletal muscle relaxant prescribed for muscle spasticity, muscle rigidity, and acute or chronic muscle pain/injury. Centrally acting muscle relaxants interfere with reflexes within the central nervous system (CNS) to decrease muscle spasm and rigidity. Like many medications, muscle relaxants are metabolized by the liver. The presence of liver disease (eg, hepatitis) decreases hepatic metabolism and can cause a buildup of medication, leading to medication toxicity and increased CNS depression (eg, weakness, confusion, drowsiness, lethargy). The prescription for a muscle relaxant would need to be clarified in a client with liver disease (Option 3).

The nurse is caring for a 50-year-old client in the clinic. The client's annual physical examination revealed a hemoglobin value of 10 g/dL (100 g/L) compared to 13 g/dL (130 g/L) a year ago. What should be the nurse's initial action? 1. Encourage intake of over-the-counter iron pills 2. Encourage intake of red meat and egg yolks 3. Facilitate a screening colonoscopy 4. Facilitate another blood test in 6 months

Correct Answer: 3 Facilitate a screening colonoscopy Rationale: Early signs of colorectal cancer are usually nonspecific and include fatigue, weight loss, anemia, and occult gastrointestinal bleeding. Clients should have regular screening colonoscopy for colon cancer starting at age 50 if their risk is average or earlier if their risk is high. Colorectal screening can also include fecal occult blood test or fecal immunochemical test annually. New-onset anemia should be taken seriously at this client's age, and colon cancer must be ruled out. The etiology of anemia must be determined prior to recommending treatment.

The nurse administers lactulose to a client diagnosed with cirrhosis and hepatic encephalopathy. Which nursing action is inappropriate when administering this medication? 1. Assess mental status and orientation 2. Give on an empty stomach for rapid effect 3. Hold if 3 soft stools occur in a day 4. Mix with fruit juice to improve flavor

Correct Answer: 3 Hold if 3 soft stools occur in a day Rationale: The desired therapeutic effect of lactulose is the production of 2-3 soft bowel movements each day; therefore, the dose is titrated until the therapeutic effect is achieved. This therapeutic dose should not be held but instead should be maintained until the desired outcomes are reached (improved mental status, decreased ammonia levels) (Option 3). The client's electrolyte levels should be closely monitored during therapy as lactulose is a laxative that can cause dehydration, hypernatremia, and hypokalemia. Educational objective: Increased ammonia levels in the blood can lead to hepatic encephalopathy, a complication of liver disease. Lactulose, a laxative, removes ammonia and is given orally with juice, milk, or water or rectally via enema to produce 2-3 soft bowel movements a day. Therapeutic effects are evident via laboratory results and improving mental status.

The nurse working on the inpatient psychiatric unit is preparing to administer 9:00 AM medications to a client. The medication administration record is shown in the exhibit. On assessment, the client is tremulous, exhibits muscle rigidity, and has a temperature of 101.1 F (38.4 C). Which action should the nurse take? 1. Give all medications, including acetaminophen, and reassess in 30 minutes 2. Hold the haloperidol, give acetaminophen, and reassess in 30 minutes 3. Hold the haloperidol and notify the health care provider (HCP) immediately 4. Hold the hydrochlorothiazide and notify the HCP immediately

Correct Answer: 3 Hold the Haloperidol and notify the health xare provider (HCP) Immediately Rationale: This client is exhibiting signs and symptoms of neuroleptic malignant syndrome (NMS), a rare but potentially life-threatening reaction. NMS is most often seen with the "typical" antipsychotics (eg, haloperidol, fluphenazine). However, even the newer "atypical" antipsychotic drugs (eg, clozapine, risperidone, olanzapine) can cause the syndrome. NMS is characterized by fever, muscular rigidity, altered mental status, and autonomic dysfunction (eg, sweating, hypertension, tachycardia). Treatment is supportive and is directed at reducing fever and muscle rigidity and preventing complications. Treatment in an intensive care unit (ICU) may be required. The most important intervention is to immediately discontinue the antipsychotic medication and notify the HCP for further assessment.

The nurse is caring for a client diagnosed with Guillain-Barré syndrome (GBS) after a recent gastrointestinal (GI) illness. Monitoring for which of the following is a nursing care priority for this client? 1. Diaphoresis with facial flushing 2. Hypoactive or absent bowel sounds 3. Inability to cough or lift the head 4. Warm, tender, and swollen leg

Correct Answer: 3 Inability to cough or lift the head Rationale GBS is an acute, immune-mediated polyneuropathy that is most often accompaniedby ascending muscle weakness and absent deep-tendon reflexes. Many clients have a history of antecedent respiratory tract or GI infection. Lower-extremity weakness progresses over hours to days to involve the thorax, arms, and cranial nerves. However, neuromuscular respiratory failure is the most life-threatening complication. Early signs indicating impending respiratory failure include: Inability to cough Shallow respirations Dyspnea and hypoxia Inability to lift the head or eye brows Assessing the client's pulmonary function by serial spirometry is alsorecommended. Measurement of forced vital capacity (FVC) is the gold standard for assessing ventilation; a decline in FVC indicates impending respiratory arrest requiring endotracheal intubation.

A graduate nurse (GN) is caring for a client with acute appendicitis who is awaiting surgery. Which action by the GN would require the precepting nurse to intervene? 1. Administers morphine IV PRN for pain 2. Initiates continuous normal saline IV 3. Provides a heating pad for abdominal discomfort 4. Teaches client about prescribed strict NPO status

Correct Answer: 3 Initiates continuous normal saline IV Rationale: Appendicitis is inflammation of the appendix often resulting from obstruction by fecal matter. Appendiceal obstruction traps fluid and mucus typically secreted into the colon, causing increased intraluminal pressure and inflammation. As appendiceal intraluminal pressure and inflammation increase, blood circulation to the appendix is impaired, resulting in swelling and ischemia. These factors increase the risk for appendiceal perforation,a medical emergency, which may lead to peritonitis and sepsis. Appendicitis is often treated surgically via removal of the appendix (ie, appendectomy). Nurses caring for clients with appendicitis should avoid interventions that increase intestinal blood circulation, gut motility, or appendiceal intraluminal pressure. The application of heat to he abdomen (eg, heating pad, warm blanket) increases intestinal circulation and the risk for appendiceal perforation (Option 3).

A child on the playground is experiencing an anaphylactic reaction. The school nurse arrives with an EpiPen. The weather is cold and the child is wearing several layers of clothing. How should the nurse proceed with the EpiPen? 1. Inject into the upper arm where the sleeve can be pulled up 2. Inject into the most accessible vein 3. Inject through the clothing into thigh and hold in place for 10 seconds 4. Take the child inside, remove excess clothing, and inject into the thigh

Correct Answer: 3 Inject through the clothing into thigh and hold in place for 10 seconds Rationale: The EpiPen is designed to be administered through clothing with a swing and firm push against the mid-outer thigh until the injector clicks. The position should be held for 10 seconds to allow the entire contents to be injected (Option 3). The site should be massaged for an additional 10 seconds. Timing is essential in the delivery of epinephrine during an anaphylactic reaction. The nurse should administer the medication immediately on the playground without removing the child's clothing. Any delays can cause client deterioration and make maintenance of a patent airway difficult (Option 4).

The nurse is developing a nutritional plan for a 6-month-old who has recently been started on solid foods. Which of the following recommendations has the highest priority in the plan? 1. Canned baby food is more expensive than food prepared at home 2. Finger foods can be introduced before the child has teeth 3. New foods should be introduced at least 5-7 days apart 4. Rice cereal can be mixed with cow's milk to increase nutritional intake

Correct Answer: 3 New foods should be introduced at least 5-7 days apart Rationale: The introduction of solid foods generally occurs at 4-6 months. The process usually starts with a form of iron-fortified infant cereal, such as rice or oatmeal. Cereal can be mixed with breast milk, formula, or water. When introducing new foods, it is important to allow 5-7 days between foods to observe for any allergies to a particular food. Allergic responses often worsen with subsequent exposure, so it is a priority to identify food triggers as soon as possible (Option 3).

An 84-year-old client with oxygen-dependent chronic obstructive pulmonary disease is admitted with an exacerbation and steady weight loss. The client has been in the hospital 4 times over the last several months and is "tired of being poked and prodded." Which topic would be most important for the nurse to discuss with this client's health care team? 1. Need for discharge to a skilled nursing facility 2. Nutritional consult with instructions on a high-calorie diet 3. Option of palliative care 4. Physical therapy prescription to promote activity

Correct Answer: 3 Option of Palliative Care Rationale: This client with advanced chronic obstructive pulmonary disease is approaching the end of life. The client has expressed the desire to avoid further tests, treatments, and hospitalizations. The goals of care should be consistent with the client's wishes and emphasize comfort and quality of life. Palliative care is appropriate for clients who wish to focus on quality of life and symptom management rather than life-prolonging treatments (Option 3). Palliative care may eventually include hospice care, after it is determined that the client has a life expectancy of less than 6 months. The nurse should advocate for the client and collaborate with members of the health care team to explore care options based on the client's wishes.

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

Correct Answer: 3 Risk for infection Rationale: Methotrexate (Rheumatrex) is classified as a folate antimetabolite, antineoplastic, immunosuppressant drug used to treat various malignancies and as a nonbiologic disease- modifying antirheumatic drug (DMARD) used to treat rheumatoid arthritis and psoriasis. Methotrexate can cause bone marrow suppression resulting in anemia, leukopenia, and thrombocytopenia. Leukopenia and its immunosuppressant effects can increase susceptibility to infection. Clients should be educated about obtaining routine killed (inactivated) vaccines (eg, influenza, pneumococcal) and avoiding crowds and persons with known infections. Live vaccines (eg, herpes zoster) are contraindicated in clients receiving immunosuppressants, such as methotrexate. Alcohol should be avoided in clients taking methotrexate as it is hepatotoxic and drinking alcohol increases the client's risk for hepatotoxicity.

A graduate student, who has been studying for final exams and using energy drinks to stay awake, comes to the clinic reporting a fluttering feeling in the chest. The student is connected to the cardiac monitor that displays the rhythm in the exhibit. The nurse recognizes this as which rhythm? 1. Atrial flutter 2. Sinus rhythm with premature atrial contractions (PACs) 3. Sinus rhythm with premature ventricular contractions (PVCs) 4. Ventricular tachycardia

Correct Answer: 3 Sinus rhythm with premature ventricular contractions (PVCs) Rationale: A PVC is a contraction coming from an ectopic focus in the ventricles. It is a premature (early) conduction of a QRS complex. PVCs are wide and distorted in shape compared to a QRS conducted through the normal conduction pathway. PVCs can be associated with stimulants (eg, caffeine), medications (eg, digoxin), heart diseases, electrolyte imbalances, hypoxia, and emotional stress. PVCs are usually not harmful in the client with a healthy heart. In the client with myocardial ischemia/infarction, PVCs indicate ventricular irritability and increase the risk for the rhythm to deteriorate into a life-threatening dysrhythmia (eg, ventricular tachycardia, ventricular fibrillation). The nurse should assess the client's physiological response, including apical-radial pulse. Treatment is based on the underlying cause of the PVCs (eg, oxygen for hypoxia, reduction of caffeine intake, electrolyte replacement).

The nurse cares for a group of clients in a medical surgical unit. The client with which diagnosis and condition requires the most immediate assistance by the nurse? 1. Post cholecystectomy, reporting incision pain of a 5 on a scale of 1-10 2. Post open reduction of the right femur, reporting nausea 3. Type 1 diabetes mellitus with a blood glucose of 55 mg/dL (3.1 mmol/L) 4. Type 2 diabetes mellitus with a blood glucose of 250 mg/dL (13.9 mmol/L)

Correct Answer: 3 Type 1 diabetes mellitus with a blood glucose of 55 mg/dL (3.1 mmol/L) Rationale: Hypoglycemia (blood glucose <70 mg/dL [3.9 mmol/L]) is the most life-threatening condition listed. It occurs when the proportion of insulin exceeds the glucose in theblood. Counterregulatory hormones (eg, epinephrine) are then released and the autonomic nervous system is activated, causing multiple hypoglycemia-associated symptoms, including increased heart rate, shakiness, sweating, hunger, anxiety, and pallor. The lack of glucose in the brain is also responsible for other symptoms, including disorientation, impaired vision and speech, seizures, and coma. However, most clients respond rapidly to the correction of hypoglycemia.

A client with unstable angina and chronic kidney disease is receiving a continuous infusion of unfractionated heparin. Which value for activated partial thromboplastin time (aPTT) would indicate to the nurse that the heparin therapy is at an optimal therapeutic level? 1. 30 seconds 2. 35 seconds 3. 60 seconds 4. 5 seconds

Correct Answer: 3 60 seconds Rationale: Unfractionated heparin is used as an anticoagulant in unstable angina. It prevents the conversion of fibrinogen to fibrin and prothrombin to thrombin, both components of clot formation. The aPTT is a laboratory test that characterizes blood coagulation. It is used to monitor treatment effects of clients receiving heparin. The normal aPTT is 25-35seconds. Heparin infusions are titrated to obtain a therapeutic value of aPTT, typically 1.5-2 times the normal value. Therapeutic value for aPTT is 46-70 seconds. The nurse would evaluate the aPTT for a therapeutic value and make adjustments in the rate of infusion of the heparin as needed.

The parent of a 6-year-old calls the nurse and reports that the child was playing outside in the snow and the child's feet now appear red and swollen. What is the best response by the nurse? 1. "Bring the child to the health care provider's (HCP) office immediately." 2. "Give your child something warm to drink." 3. "Massage the child's feet gently until they warm up." 4. "Place the child's feet in warm water immediately."

Correct Answer: 4 "Place the child's feet in warm water immediately." Rationale: The clinical indications of a cold injury include redness and swelling of the skin (chilblains or pernio) and blanched skin with hardness of the affected area (frostbite). For any cold injury, it is important to re-warm the area as soon as possible to restore blood flow and reduce the risk of permanent tissue damage. The recommendation for re-warming is immersion of the affected area in warm water (104 F [40 C]) for about 30 minutes or until the area turns pink in cases of frostbite. The face and ears can be re-warmed with the application of warm facecloths (Option 4).

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

Correct Answer: 4 "This must have happened because I did not wash the bed sheets this week." Rationale: It is a common misconception that bed bugs are drawn only to dirty environments. They can inhabit any environment and can travel and spread easily in clothing, bags, furniture, and bedding. Although they do not pose significant harm, bed bugs can cause an itchy red rash that can be uncomfortable and affect sleep. Bed bugs should be exterminated, especially in a home with children.

The nurse prepares a client for discharge following a vasectomy. The client asks, "When can I have sexual intercourse with my wife without using a condom?" What is the best response by the nurse? 1. "Discontinue alternative birth control after at least 5 ejaculations." 2. "There is no need to use alternative birth control following today's procedure." 3. "Use alternative birth control for 6 months following today's procedure." 4. "Use alternative birth control until cleared by the health care provider."

Correct Answer: 4 "Use alternative birth control until cleared by the health care provider." Rationale: A vasectomy is a surgical procedure performed for permanent male sterilization. During the procedure, the vasa deferentia (ie, ducts that carry sperm from the testicles to the urethra) are cut and sealed, preventing sperm from entering the ejaculate. The vasa deferentia are severed in the scrotum at the site before the seminal vesicles and prostate. As a result, the procedure should not affect the ability to ejaculate, amount and consistency of ejaculatory fluid, or other physiological mechanisms (eg, hormone production, erection, orgasm). Following a vasectomy, sperm continue to be produced but are absorbed by the body. Following the procedure, it can take several months for the remaining sperm to be ejaculated or absorbed. Alternative birth control should be used until the health care provider confirms that semen samples taken at a follow-up appointment are free of sperm; otherwise, pregnancy can occur (Option 4).

An African American client comes to the clinic for a follow-up visit 2 months after starting enalapril for hypertension. Which client statement should be reported to the health care provider immediately? 1. "Is there anything I can take for my dry, hacking cough?" 2. "My blood pressure this morning was 158/84 mm Hg." 3. "Sometimes I feel somewhat dizzy when I stand up." 4. "Will you look at my tongue? It feels thicker than normal."

Correct Answer: 4 "Will you look at my tongue? It feels thicker than normal." Rationale: Angioedema is swelling that usually affects areas of the face (lips, tongue), larynx, extremities, gastrointestinal tract, and genitalia. The swelling often starts in the face and can quickly become life-threatening as it progresses to the airways. Angioedema is an adverse effectof ACE inhibitors (eg, enalapril, lisinopril, captopril) and occurs more commonly in African American clients. Unlike other typical drug allergies, this side effect can occur any time after starting the medication. The nurse should immediately report angioedema to the health care provider and carefully monitor the client (Option 4).

The partner of a client with borderline personality disorder calls the clinic and reports coming home from work to find the client with self-inflicted superficial cuts to the arm. The partner tells the nurse, "My partner does something like this every time I have to go away on business. My partner is not serious about doing something really harmful, just trying to stop me from going away." What is the best response by the nurse? 1. "Are you still going to take your business trip?" 2. "It sounds like you are having a difficult time coping with your partner's behavior." 3. "Your partner is most likely doing it for attention, so it's best to just ignore it." 4. "Your partner needs to be seen in the clinic today."

Correct Answer: 4 "Your partner needs to be seen in the clinic today." Rationale: Clients diagnosed with borderline personality disorder (BPD) often make suicidal threats, gestures, and attempts. They may use these behaviors to bring about a response when there is a real or perceived risk of abandonment from a significant other. All suicidal behavior should be taken seriously; the client's current self-injurious action needs to be evaluated to assess whether it involved suicidal intent. Clients with BPD have been known to demonstrate years of benign suicide threats and gestures before completing asuicide. Predicting a client's risk for completing a suicide is difficult due to the impulsive nature of the behavior.

A 24-year-old female client has been prescribed isotretinoin for severe nodulocystic acne that has been resistant to other therapies. Which instruction is most important for the nurse to reinforce with this client? 1. "Apply lubricating eye drops when wearing contacts." 2. "Swallow capsules whole." 3. "Use sunscreen routinely." 4. "Use 2 forms of contraception."

Correct Answer: 4 4. "Use 2 forms of contraception." Rationale: Isotretinoin (Accutane) decreases sebum secretion and is prescribed for severe, disfiguring nodular acne that has been unresponsive to other therapies, including antibiotics. It isa pregnancy category X drug and is known to cause serious birth defects if taken during pregnancy. Females prescribed isotretinoin must have 2 negative pregnancy tests before taking the medication. Also, 2 forms of contraception must have been in place for at least 1 month prior to starting isotretinoin, and these must be continued both during treatment and for 1 month after the medication is discontinued. Before refills can be obtained, enrollment in a risk management program is required to verify that pregnancy tests are negative and 2 forms of contraception are being used. Blood donation is also discouraged while on therapy and for 1 month afterward to ensure that pregnant women do not receive any donated blood. Educational objective: Isotretinoin is a pregnancy category X drug and will cause birth defects if taken during pregnancy. The client must use 2 forms of birth control for 1 month prior to taking the medication as well as during treatment and 1 month afterward. The client must also be enrolled in a risk management program prior to receiving refills.

The charge nurse on a medical-surgical step-down unit is responsible for makingassignments. Which client is most appropriate to assign to a new graduate nurse who is still in orientation? 1. 65-year-old client 1 day postoperative left femoral-popliteal bypass graft surgery with a diminished pedal pulse 2. 66-year-old client admitted for hypertensive crisis 2 days ago; blood pressure currently 180/102 mm Hg; reports headache and blurred vision 3. 75-year-old client with an ischemic stroke transferred from the intensive care unit 1 hour ago; unresponsive with right-sided paralysis 4. 78-year-old client with diabetes and cellulitis of the left foot; requires frequent dressing changes due to excessive drainage

Correct Answer: 4 78-year-old client with diabetes and cellulitis of the left foot; requires frequent dressing changes due to excessive drainage Rationale: The new nurse has the basic skills to provide insulin coverage if necessary, perform wound care (eg, assessment, sterile dressing changes, documentation), and provide diabetic teaching for this client.

A nurse performs the initial assessments for 4 assigned clients. The nurse identifies which client as being at greatest risk for the development of delirium? 1. 32-year-old client with gastroenteritis 2. 55-year-old client with coronary artery disease, 4 days post coronary bypass surgery 3. 60-year-old client with type II diabetes, 2 months post bilateral above-knee amputations 4. 80-year-old client with chronic obstructive pulmonary disease, chronic respiratory failure, and urosepsis

Correct Answer: 4 80-year-old client with chronic obstructive pulmonary disease, chronic respiratory failure, and urosepsis Rationale: Major predisposing factors for the development of delirium in hospitalized clients include: 1. Advanced age 2. Underlying neurodegenerative disease (stroke, dementia) 3. Polypharmacy 4. Coexisting medical conditions (eg, infection) 5. Acid-base/arterial blood gas imbalances (eg, acidosis, hypercarbia, hypoxemia) 6. Metabolic and electrolyte disturbances 7. Impaired mobility - early ambulation prevents delirium 8. Surgery (postoperative setting) 9. Untreated pain and inadequate analgesia Client 4 has 4 predisposing risk factors: advanced age, acidosis and hypoxemia associated with chronic respiratory failure, and sepsis. This client is at greatest risk for developing delirium. Educational objective: Risk factors for hospital-induced delirium include advanced age, underlying neurodegenerative disease, infections, medical illness, surgery, impaired mobility, and inadequate pain control.

The nurse receives report on 4 clients. Which client should the nurse assess first? 1. Client 1 day postoperative receiving patient-controlled analgesia with morphine who reports itching and nausea 2. Client receiving maintenance IV normal saline solution with labeled tubing indicating that tubing was changed 48 hours ago 3. Client with a pulmonary embolus receiving continuous IV heparin infusion and warfarin who has an International Normalized Ratio of 1.9 4. Client with a resistant bacterial infection receiving IV vancomycin who reports discomfort at the peripheral IV site

Correct Answer: 4 Client with a resistant bacterial infection receiving IV vancomycin who reports discomfort at the peripheral IV site Rationale: Phlebitis is an inflammation of a vein. Common manifestations include pain, swelling, warmth at the site, and redness extending along the vein. Causes include irritating drugs (eg, vancomycin), catheter movement within the vein (eg, inadequate stabilization), or bacteria (eg, poor aseptic technique). If signs of phlebitis are present, immediate removal of the catheter is necessary as phlebitis can lead to thrombophlebitis and emboli or a bloodstream infection. Educational objective: Manifestations of phlebitis associated with a peripheral IV catheter include pain, swelling, warmth at the site, and redness extending along the vein. If phlebitis is present, immediate removal of the catheter is necessary as the condition can lead to a serious bloodstream infection or thrombophlebitis.

After making initial rounds on all the assigned clients by 8:00 AM, which client should the nurse care for first? 1. Client 1-day postoperative who was medicated with tramadol 50 mg orally 1.5 hours ago 2. Client 1-day postoperative with pink colored urine after transurethral resection of the prostate (TURP) 3. Client scheduled for discharge today who needs instruction on how to change a sterile dressing 4. Client with adenocarcinoma scheduled for a lobectomy at 9:00 AM who was restless and awake all night

Correct Answer: 4 Client with adenocarcinoma scheduled for a lobectomy at 9:00 AM who was restless and awake all night Rationale: The nurse should care for the client with adenocarcinoma scheduled for a lobectomy at 9:00 AM first. Not being able to sleep the night before surgery is a common manifestation of anxiety and fear; these emotions can negatively affect recovery. For this reason, it is important to identify and listen to the client's concerns (eg, diagnosis of cancer, fear of death, pain, anesthesia), teach the client about what to expect following surgery (eg, pain control, tubes, intensive care environment), and provide emotional support to help alleviate the fear and anxiety. The nurse can provide for the physical preparation of the client and complete the preoperative checklist as well.

A nurse in the emergency department cares for 4 clients with orthopedic injuries. Which client should the nurse assess first? 1. Client who sustained a closed, incomplete ulnar fracture while playing sports 2. Client with bilateral metacarpal fractures after falling out of bed 3. Client with multiple myeloma who has a vertebral fracture and aching back pain 4. Client with pain and obvious shoulder deformity reporting a "pins-and-needles" sensation

Correct Answer: 4 Client with pain and obvious shoulder deformity reporting a "pins-and-needles" sensation Rationale: Joint dislocations may become orthopedic emergencies because articular bone may compress surrounding vasculature, causing limb-threatening distal ischemia (Option 4). When a joint is dislocated, the articular tissues, blood vessels, and nerves are often traumatized by stretching. Signs of joint dislocation include pain, deformity, decreased range of motion, and extremity paresthesia. The nurse should frequently assess neurovascular status and provide analgesics until the dislocation can be reduced and immobilized.

A major disaster involving hundreds of victims has occurred, and an emergency nurse is sent to assist with field triage. Which client should the nurse prioritize for transport to the hospital? 1. Client at 8 weeks gestation with spotting and pulse of 90/min 2. Client with a compound femoral fracture and an oozing laceration 3. Client with fixed and dilated pupils and no spontaneous respirations 4. Client with paradoxical chest movement throughout respirations

Correct Answer: 4 Client with paradoxical chest movement throughout respirations Rationale: Disaster triage is based on the principle of providing the greatest good for the greatest number of people. Clients are triaged rapidly using a color-coded system to categorize them from highest medical priority (emergent) to lowest (expectant). The client with flail chest (ie, paradoxical chest movement during respiration) from multiple fractured ribs is at risk for respiratory failure from impaired ventilation. In addition, mobile fractured ribs may puncture the pleura or vessels, causing hemothorax and/or pneumothorax at any time. Therefore, this client would be classified as emergent due to airway compromise, which requires immediate treatment (Option 4).

The charge nurse in the cardiac intensive care unit responds to a client room where a resuscitation effort is in progress. The client's immediate family member refuses to leave the room. How should the charge nurse handle this situation? 1. Call security to escort the family member to the waiting room 2. Have the family member stand or sit in an area that is not in the staff's way 3. Inform the family member that relatives are not allowed in rooms during emergency situations 4. Let the family member stay and assign a staff person to explain what is happening

Correct Answer: 4 Let the family member stay and assign a staff person to explain what is happening Rationale: If family members are not causing a disruption in care of the client, they should be allowed to stay in the room with a staff member assigned to explain the interventions being implemented. The nurse should always try to be an advocate for the client and family. Witnessing the efforts of the resuscitation team can be reassuring even when the outcome is negative. The charge nurse should be prepared to escort family members from the room if they become disruptive.

A nurse in the intensive care unit is caring for a client in the immediate postoperative period following abdominal surgery. The nurse receives several prescriptions. Which prescription should the nurse initiate first? 1. Acetaminophen 1000 mg IVPB every 8 hours 2. Cefazolin 2 g IVPB once, now 3. Norepinephrine 0.02-2.0 mcg/kg/min titrated IV 4. Normal saline 2 L via rapid IV bolus

Correct Answer: 4 Normal saline 2 L via rapid IV bolus Rationale: Hypotension, tachycardia, and low central venous pressure (normal: 2-8 mm Hg) may indicate hypovolemic shock. Central venous pressure is a measurement of right ventricular preload (volume within the ventricle at the end of diastole) and reflects the client's fluid volume status. This client is recovering from major abdominal surgery and has a low-grade fever, placing the client at risk for fluid volume losses (eg, blood loss during surgery, insensible losses[sweating]). This client should be treated with isotonic fluids (eg, normal saline, lactated Ringer solution) to restore adequate fluid volume status. IV boluses of isotonic fluids (ie, fluid resuscitation) increase intravascular volume, which increases blood pressure and end-organ perfusion (Option 4).

A nurse is assisting a new mother as she is breastfeeding her infant. The infant has been diagnosed with tetralogy of Fallot. During feeding, the infant becomes cyanotic and is having difficulty breathing. What should be the nurse's first action? 1. Administer morphine to the infant 2. Administer oxygen via mask 3. Assess infant's vital signs and pulse oximetry 4. Place the infant in the knee-chest position

Correct Answer: 4 Place the infant in the knee-chest position Rationale: Tetralogy of Fallot is a congenital cardiac defect that typically has 4 characteristics: pulmonary stenosis, right ventricular hypertrophy, overriding aorta, and ventricular septal defect. This infant is experiencing a hypercyanotic episode, or "tet spell," which is an exacerbation of tetralogy of Fallot that can happen when a child cries, becomes upset, or is feeding. The child should first be placed in a knee-to-chest position. Flexion of the legs provides relief of dyspnea as this angle improves oxygenation by reducing the volume of blood that is shunted through the overriding aorta and the ventricular septal defect.

The unlicensed assistive personnel on the cardiac floor reports to the registered nurse that during the first vital sign measurement on the shift, a client's blood pressure measured 198/102 mm Hg on the automated blood pressure machine. What action should the nurse take first? 1. Have the unlicensed assistive personnel recheck the client's blood pressure 2. Immediately notify the health care provider 3. Obtain the client's PRN labetalol from the medication dispensing machine 4. Recheck the client's blood pressure with a manual cuff

Correct Answer: 4 Recheck the client's blood pressure with a manual cuff Rationale: This client's abnormally high blood pressure increases the risk for complications such as stroke. The nurse should assess this client and recheck the blood pressure with a manual cuff to verify the accuracy of the previous measurement taken by the unlicensed assistive personnel (UAP). The nurse will need to assess the client further before making additional nursing judgments and taking action. Educational objective: When the unlicensed assistive personnel (UAP) reports an abnormal vital sign to the nurse, the nurse should assess the client further. It is inappropriate delegation to have the UAP recheck the client.

The nurse is assessing a client with hypertension and essential tremor 2 hours after receiving a first dose of propranolol. Which assessment is most concerning to the nurse? 1. Client reports a headache 2. Current blood pressure is 160/88 mm Hg 3. Heart rate has dropped from 70/min to 60/min 4. Slight wheezes auscultated during inspiration

Correct Answer: 4 Slight wheezes auscultated during inspiration Rationale: Propranolol is a nonselective beta-blocker that inhibits beta1 (heart) and beta2 (bronchial) receptors. It is used for many indications (eg, essential tremor) in addition to blood pressure control. Blood pressure decreases secondary to a decrease in heartrate. Bronchoconstriction may occur due to the effect on the beta2 receptors. The presence of wheezing in a client taking propranolol may indicate that bronchoconstriction or bronchospasm is occurring. The nurse should assess for any history of asthma or respiratory problems with this client and notify the health care provider (HCP).

The nurse caring for a client with tuberculosis (TB) transports the client to the radiology department for a chest x-ray. The nurse ensures that the client uses which personal protective equipment when out of the negative-pressure room? 1. Isolation gown, surgical mask, goggles, and gloves 2. Isolation gown and surgical mask 3. N95 respirator mask 4. Surgical mask

Correct Answer: 4 Surgical Mask Rationale: Clients with airborne infections such as TB, measles, or chickenpox (varicella) are confined to a negative-pressure room except when traveling to various departments for essential diagnostic procedures or surgery. While being transported through the health care facility, the client on airborne transmission-based precautions wears a surgical mask to protect health care workers (HCWs) and other clients from respiratory secretions.

A graduate nurse (GN) is inserting an oropharyngeal airway in a client emerging from general anesthesia. The nurse preceptor intervenes when the GN performs which action? 1. Inserts oropharyngeal airway (OPA) into mouth with curved end pointing upward 2. Measures OPA against the cheek and jaw angle before insertion 3. Rotates OPA tip downward once it reaches the soft palate 4. Tapes OPA to ensure it is secure and to prevent dislodgement

Correct Answer: 4 Tapes OPA to ensure it is secure and to prevent dislodgement Rationale: An oropharyngeal airway (OPA) is a temporary, artificial airway device used to prevent tongue displacement and tracheal obstruction in clients who are sedated or unconscious. As consciousness and the ability to protect the airway return, the client will often cough or gag, indicating a need to remove the OPA; clients may also independently remove or expel the OPA. Nurses caring for a client with an OPA must ensure that the device is easily removable from the client's mouth, as an obstructed (eg, taped) OPA may cause choking and aspiration (Option 4).

The home care nurse is making an initial visit to a client just discharged after admission for severe exacerbation of chronic obstructive pulmonary disease (COPD). The nurse observes wall-to-wall stacks of old newspapers and magazines in every room, with pathways that just allow passage from one room to another. 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 discharge medications 4. Teach the safe use of oxygen

Correct Answer: 4 Teach the safe use of oxygen Rationale: This client exhibits signs of hoarding disorder, an anxiety disorder defined by the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (American Psychiatric Association) as persistent difficulty with discarding or parting with possessions, even those of littlevalue. Clients with hoarding disorder will typically accumulate items such as clothing, food, boxes, bags, newspapers, and magazines. These items commonly fill up and clutter their living areas and can create environmental and fire hazards. The client will most likely experience severe anxiety if the items are removed. Clients with hoarding disorder may never seek mental health services or come to the attention of a mental health professional. Their own behavior usually does not concern them, although it may cause great distress in family members or friends. The treatment for the client with severe COPD will include home oxygen therapy. The priority nursing action is to ensure the safety of the client when using oxygen in an environment that is already at high risk for a hazardous event.

The emergency department nurse is triaging clients. Which neurologic presentation is most concerning for a serious etiology and should be given priority for definitive treatment? 1. History of Bell's palsy with unilateral facial droop and drooling 2. History of multiple sclerosis and reporting recent blurred vision 4. Reports unilateral facial pain when consuming hot foods 5. Temple region hit by ball, loss of consciousness, but Glasgow Coma Scale score is now 14

Correct Answer: 4 Temple region hit by ball, loss of consciousness, but Glasgow Coma Scale score is now 14 Rationale: Epidural hematoma is an accumulation of blood between the skull bone and dura mater. The majority of epidural hematomas are associated with fracture of the temporal bone and subsequent rupture or tear of the middle meningeal artery. The bleed is arterial in origin, and so hematoma develops quickly. The clinical presentation of epidural hematoma is characteristic. The client may lose consciousness at the time of impact. The client then regains consciousness quickly and feels well for some time after the injury. This transient period of well-being is called a lucid interval. It is followed by a quick decline in mental function that can progress into coma and death.

The clinic nurse is asked by the mother of a 15-month-old, "I am worried about my child's thumb sucking and its effects on tooth alignment. What should I do?" What is the nurse's best response? 1. "As long as your child's thumb sucking stops by age 2-3 years when all of the primary teeth have erupted, there is little concern." 2. "Because your child already has teeth, it is important to implement a plan to stop the thumb sucking as soon as possible." 3. "Newer research shows that thumb sucking has little effect on a child's teeth." 4. "The risk for misaligned teeth occurs when thumb sucking persists after eruption of permanent teeth."

Correct Answer: 4 "The risk for misaligned teeth occurs when thumb sucking persists after eruption of permanent teeth." Rationale: Rooting and sucking are a part of an infant's natural reflexes. Nonnutritive sucking assists in helping the infant to feel secure. Some parents become very concerned about their infants sucking fingers, thumbs, or a pacifier and try to stop the behavior. As a rule, if thumb sucking stops before the permanent teeth begin to erupt, misalignment of the teeth and malocclusion can be avoided. Parents should be taught that teasing and punishing a child for using a pacifier or sucking the thumb is not an effective method for getting the child to stop. This can increase the child's anxiety and cause the child to increase the behavior.

A major earthquake has occurred. Local gas lines and water pipes are breaking with resulting fires and flooding in collapsed buildings. Multiple victims arrive at the triage area. Which client should the nurse care for first? 1. Client with charred, leathery skin over entire back, chest, and legs 2. Client with cool skin, shivering from sitting in water until rescued 3. Client with diabetes who was unable to take prescribed insulin today 4. Client with high-pitched, crowing inspiratory respirations

Correct Answer: 4 Client with high-pitched, crowing inspiratory respirations Rationale: disaster triage is based on the principle of providing the greatest good for the greatest number of people. Clients are triaged rapidly using a color-coded system to categorize them from highest medical priority (emergent) to lowest (expectant). The client with stridor (eg, high- pitched, crowing inspiratory respirations), which typically occurs from constricted or blocked upper airways, is at risk for impending respiratory failure due to a compromised airway. This client should be classified as emergent, requiring immediate treatment and possibly prophylactic intubation (Option 4).

When triaging 4 pregnant clients in the obstetric clinic, the nurse should alert the health care provider to see which client first? 1. First-trimester client reporting frequent nausea and vomiting 2. Second-trimester client with dysuria and urinary frequency 3. Second-trimester client with obesity reporting decrease in fetal movement 4. Third-trimester client with right upper quadrant pain and nausea

Correct Answer: 4 Third-trimester client with right upper quadrant pain and nausea Rationale: Right upper quadrant (RUQ) or epigastric pain can be an indicator of HELLP syndrome, a severe form of preeclampsia. HELLP syndrome (Hemolysis, Elevated Liver enzymes,and Low Platelet count) is often mistaken for viral gastroenteritis due to its variable and nonspecific presentation. Misdiagnosis may lead to severe complications (eg, placental abruption, liver failure, stroke) and/or maternal/fetal death. Clients may have RUQ pain, nausea, vomiting, and malaise. Headache, visual changes, proteinuria, and hypertension may or may not be present.

The nurse is calculating IV fluid resuscitation for a client weighing 85 kg with visible partial- thickness burns covering 40% of the body. Using the Parkland formula, how many liters of IV fluid resuscitation are needed during the first 8 hours? Record your answer using one decimal place. BOOK PAGE 77

Correct Answer: 6.8L Rationale: Burn injuries are caused by direct tissue damage from exposure to caustic (eg, thermal, chemical, electrical) sources. This initial tissue injury, combined with the systemic inflammatory response, causes increased capillary permeability, fluid and electrolyte shifts, and decreased intravascular volume. This intravascular loss often leads to hypovolemic shock in clients with extensive burns and requires emergency fluid resuscitation for client survival. The Parkland formula is an IV fluid resuscitation protocol used to calculate the fluid replacement needed in the first 24 hours after a burn injury. Half of the calculated fluid volume is administered during the first 8 hours after injury, when the greatest amount of intravascular volume loss occurs. The following steps should be used to calculate the volume needed for infusion during the first 8 hours.

A client, who has been hospitalized for 3 days with major depressive disorder, has stayed in the room and not gotten out of bed except for toileting. The nurse enters the room to remind the client that breakfast will be served in the dining room in 20 minutes. The client says, "I'm not hungry and I don't feel like doing anything." What is the best response by the nurse? 1. "I will help you get ready; then we can walk to the dining room together." 2. "I'll have breakfast brought to your room." 3. "It's okay. You can join us when you are ready." 4. "You'll feel better when you get up."

Correct Answer:1 "I will help you get ready; then we can walk to the dining room together." Rationale: Reduced appetite and low energy level are common clinical findings in major depressive disorder. The lethargy accompanying the depressed mood makes it difficult for a client with this diagnosis to even get up and out of bed. Personal hygiene and grooming are neglected, and there is no desire to interact with others. The client needs direction and structure in performing activities of daily living (ADLs); waiting for the client to feel more energetic and initiate activity and interaction on one's own is not helpful. Assisting the client with ADLs helps convey a sense of caring, provides an opportunity for interaction with the nurse, and helps raise the client's self esteem.

The nurse provides discharge instruction to a client at 14 weeks gestation who has received a prophylactic cervical cerclage. which client statement indicates an understanding of teaching? 1. "i need to be on bed rest for the duration of my pregnancy." 2. "I will notify my health care provider if I start having low back aches." 3. "Pelvic pressure is to be expected after cerclage placement." 4. "the cerclage will be removed once my baby is at 28 weeks."

Correct answer 2 "I will notify my health care provider if I start having low back aches." Rationale: A cervical cerclage is places to prevent preterm delivery, usually in clients with histories of second trimester loss or premature birth. A heavy suture is place transvaginally or transadbdominally to keep the internal cervical os closed. Placement occurs at 12-14 weeks gestation for clients with a history of cvervical insufficiency (ie, painless, premature cervicaldilation and miscarriage or preterm delivery) or up to 23 weeks gestation if signs of cervical insufficiency (eg, short cervix) are notes. Educational objective: Loop diuretics (eg, furosemide, bumetanide, torsemide) are effective in decreasing both right ventricular preload and left ventricular preload.

The office nurse for an orthopedic health care provider receives 4 telephone messages. Which client does the nurse call back first? 1. Client who had a left total knee replacement 7 days ago and reports cramping pain in the left calf 2. Client with a fractured wrist who reports severe itching under a cast that was applied 3 days ago 3. Client with an ankle sprain who is using crutches and reports tingling in the forearm and fingers 4. Client with an intact anterior cruciate ligament injury who reports tightness in the knee unrelieved with ice

Correct answer: 1 Client who had a left total knee replacement 7 days ago and reports cramping pain in the left calf Rationale: The nurse should call the client with the knee replacement first. Cramping calf pain can indicate the presence of a deep vein thrombosis (DVT), which can occur following joint replacement surgery despite prophylactic anticoagulation. This symptom needs immediate intervention with diagnostic testing (eg, venous Doppler study) as a venous embolus can lead to a pulmonary embolus, which is potentially life-threatening.

The nurse has just admitted a client with a history of aortic abdominal aneurysm who is experiencing back pain. The nurse needs to assess for a bruit. Where would the nurse place the stethoscope to auscultate for a bruit?

Rationale: An aneurysm is an outpouching or dilation of a vessel wall. An abdominal aneurysm occurs on the aorta. A bruit, a swishing or buzzing sound that indicates turbulent blood flow in the aneurysm, is best heard with the bell of the stethoscope. It may be auscultated over the aortic aneurysm in the periumbilical or epigastric area slightly left of the midline. Educational objective: The nurse should listen for a bruit with the bell of the stethoscope over the periumbilical or epigastric area.