July 19th

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

4. IF I GET CONSTIPATED, I WILL USE A SUPPOSITORY 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). (Option 1) Fluid intake should be encouraged in this client. (Option 2) The client is at risk for postoperative deep vein thrombosis and pulmonary embolism. Ambulation is an important part of preventing these serious surgical complications. Ambulation will also help reduce constipation. (Option 3) The client who goes home with an indwelling catheter should learn how to clean around the catheter at the urinary meatus with warm water and soap to prevent infection. Educational objective: Clients who have had an open radical prostatectomy for prostate cancer should avoid anything that could cause strain on the rectal area. Straining, suppositories, and enemas are contraindicated in these clients, and interventions should be implemented to prevent constipation.

The nurse is assessing a client with advanced amyotrophic lateral sclerosis. Which of the following assessment findings does the nurse expect? Select all that apply. 1. Diarrhea 2. DIfficulty breahting 3. Difficulty swallowing 4. Muscle weakness 5. Resting tremor

2, 3, & 4 Amyotrophic lateral sclerosis (ALS, Lou Gehrig disease) is a debilitating neurodegenerative disease with no cure. ALS causes progressive degeneration of motor neurons in the brain and spinal cord. Physical symptoms include fatigue, progressive muscle weakness, twitching and muscle spasms, difficulty swallowing, difficulty speaking, and respiratory failure (Options 2, 3, and 4). Most clients survive only 3-5 years after the diagnosis as there is no cure. Treatment focuses on symptom management. Interventions include: Respiratory support with noninvasive positive pressure (eg, bilevel positive airway pressure [BiPAP]) or invasive mechanical ventilation (eg, via tracheostomy) Feeding tube for enteral nutrition Medications to decrease symptoms (eg, spasms, uncontrolled secretions, dyspnea) Mobility assistive devices (eg, walker, wheelchair) Communication assistive devices (eg, alphabet boards, specialized computers) (Option 1) Constipation due to decreased mobility is more common in ALS. Diarrhea is not seen. (Option 5) Resting tremor is characteristic of parkinsonism. Educational objective: Amyotrophic lateral sclerosis causes motor neuron degeneration that leads to progressive muscle weakness, twitching and muscle spasms, difficulty swallowing, difficulty speaking, and respiratory failure. There is no cure. Treatment focuses on symptom management.

A client with an asthma exacerbation has been using her albuterol rescue inhaler 10-12 times a day because she cannot take a full breath. What possible side effects of albuterol does the nurse anticipate the client will report? Select all that apply. 1. Constipation 2. Difficulty sleeping 3. Hives with pruritus 4. Palpitations 5. Tremors

2, 4, & 5 Albuterol is a short-term beta-adrenergic agonist used as a rescue inhaler to treat reversible airway obstruction associated with asthma. Dosing in an acute asthma exacerbation should not exceed 2-4 puffs every 20 minutes x 3. If albuterol is not effective, an inhaled corticosteroid is indicated to treat the inflammatory component of the disease. Albuterol is a sympathomimetic drug. Expected side effects mimic manifestations related to stimulation of the sympathetic nervous system, and commonly include insomnia, nausea and vomiting, palpitations (from tachycardia), and mild tremor. (Option 1) Constipation is not a common side effect of inhaled beta-agonist drugs. (Option 3) Hives can occur as a sign of an allergic reaction and are not a common anticipated side effect of an inhaled beta-agonist drug. Educational objective: Albuterol is a short-term beta-agonist rescue drug used to control symptoms of airway obstruction and promote bronchodilation. It is a sympathomimetic drug; common expected side effects include insomnia, nausea and vomiting, palpitations (tachycardia), and mild tremor.

During the shift report, the night charge nurse tells the day charge nurse that the night unlicensed assistive personnel (UAP) is totally incompetent. What is the best response for the day charge nurse to give? 1. Encourage the night nurse to provide the UAP with additional training 2. Indicate that it is the night nurse's job to deal with staff problems 3. Remind the night nurse that the UAP is doing the best job the UAP can do 4. Suggest that the night nurse discuss concerns with the nurse manager

4. SUGGEST THAT THE NIGHT NURSE DISCUSS CONCERNS WITH THE NURSE MANAGER Incompetency is a concern for client safety and quality care. The nurse manager is responsible for hiring/firing and setting up additional training times or experiences for staff. The situation should be discussed with the person who has 24/7 responsibility for the unit so that an appropriate response can be given to the night nurse's perceptions (Option 4). (Option 1) The night nurse can provide task-specific instructions/training, but incompetence implies a global dysfunction beyond minor, on-the-job, intermittent instructions. In addition, other factors could be involved that may be influencing the UAP's behavior, such as personal issues or impairment from substance abuse. It is best to discuss this situation with a higher authority to determine the best approach. (Option 2) This response is something the night nurse knows. The need is to decide the next action. The scope of this problem is probably beyond the night nurse's responsibility and authority. (Option 3) This response may be true. However, the bottom line is finding out if the UAP's performance is of adequate quality and safe for clients. The amount of effort that the caregiver is expending is not the bottom line. Educational objective: When a caregiver's performance is below the standard of care needed to provide safe and quality care to clients, the appropriate authority should be notified so that the situation can be handled.

A client with ascites due to cirrhosis has increasing shortness of breath and abdominal pain. The health care provider requests that the nurse prepare the client for a paracentesis. Which nursing actions would the nurse implement prior to the procedure? Select all that apply. 1. Educate pt about the procedure and obtain informed consent 2. Initiate NPO status 6 hours prior to the procedure 3. Obtain baseline vitals, abdominal circumference, and weight 4. Place pt in high fowler position or as upright as possible 5. Request that the pt empty the bladder

3, 4, & 5 Paracentesis is performed to remove excess fluid from the abdominal cavity or to collect a specimen of ascitic fluid for diagnostic testing. Paracentesis is not a permanent solution for treating ascites and is performed only if the client is experiencing impaired breathing or pain due to ascites. Prior to a paracentesis, nursing actions include: Verify that the client received necessary information to give consent and witness informed consent Instruct the client to void to prevent puncturing the bladder (Option 5) Assess the client's abdominal girth, weight, and vital signs (Option 3) Place the client in the high Fowler position or as upright as possible (Option 4) (Option 1) Paracentesis is an invasive procedure requiring delivery of informed consent by the health care provider (HCP). The HCP explains the benefits and risks of the procedure. The nurse's role is to witness informed consent and verify that it has occurred. (Option 2) NPO status is not required for paracentesis, which is often performed at the bedside or in an HCP's office using only a local anesthetic. Educational objective: Paracentesis is an invasive procedure for removing fluid from the abdominal cavity to improve symptoms or collect a specimen for testing. After informed consent has been obtained, the client should be encouraged to void to prevent bladder trauma, be positioned upright, and have a set of baseline vitals, weight, and abdominal circumference measurements collected before the procedure begins.

The nurse is caring for a mechanically ventilated client with a tracheostomy tube in the intensive care unit. What client care tasks can be safely delegated to experienced unlicensed assistive personnel? Select all that apply. 1. Clean area around trach stoma with NS 2. Inform the family that the HOB must be elevated at least 30 degrees 3. Obtain and document RR and O2 sat 4. Perform oral care, using a tonsil tip suction device to suction the oropharynx 5. Perform passive and active ROM

3, 4, & 5 The client on a ventilator in the intensive care setting requires vigilant nursing care. The nurse would need to consider the stability of the client and the experience level of unlicensed assistive personnel (UAP) before delegating tasks. With training and ongoing skill evaluation, UAP can be helpful in caring for the client on a ventilator. While considering the 5 rights of delegation (right task, right person, right circumstances, right communication/direction, and right supervision/evaluation), the nurse may choose to delegate the following client care tasks: Measurement of vital signs (Option 3) Fingerstick blood glucose testing Personal hygiene and skin care Oral care (Option 4) Passive or active range-of-motion exercises (Option 5) Measurement of urine output (Option 1) The tracheostomy is the surgically created airway for this client; care of this site requires nursing expertise (eg, infection control, safety precautions) and should only be done by a nurse. (Option 2) The client on a ventilator should have the head of the bed raised ≥30 degrees as this elevation reduces aspiration risk and allows for better chest expansion. The nurse is responsible for teaching; UAP may remind the family about the need to keep the head of the bed elevated. Educational objective: When caring for the client on a ventilator, the nurse may consider delegating the following tasks to unlicensed assistive personnel: vital sign measurement, oral care, personal hygiene, blood glucose testing, passive or active range-of-motion exercises, and measurement of urine output.

An 82-year-old client with acute diverticulitis develops severe sepsis. The nurse is most likely to assess which manifestations of the systemic inflammatory response syndrome associated with sepsis? Select all that apply. 1. CVP of 18 2. MAP of 80 3. RR of 28 4. Sinus tachycardia of 118 5. Temp of 101.2 6. WBC of 13,000

3, 4, 5, & 6 Systemic inflammatory response syndrome (SIRS) occurs when the body undergoes a major insult (eg, trauma, infection, burns, hemorrhage, multiple transfusions). Stimulation of the immune response leads to activation of white blood cells (WBCs), release of inflammatory mediators, increased capillary permeability, and inflammation of organs. The sepsis continuum progresses in severity from sepsis, to severe sepsis, to septic shock, to multiple organ dysfunction (MODS). Sepsis is an exaggerated systemic inflammatory response associated with a documented or suspected infection. Severe sepsis is sepsis complicated by organ dysfunction. Septic shock is severe sepsis with hypotension despite fluid resuscitation. MODS occurs in relation to decreased perfusion and is the end point of the sepsis continuum. It is important for the nurse to recognize manifestations of SIRS to promote early recognition, prevention, and treatment of infection and to limit its progression to MODS. Diagnostic criteria for SIRS include 2 or more of the following manifestations: Hyperthermia (temperature >100.4 F [38 C]) or hypothermia (temperature <96.8 F [36 C]) Heart rate >90/min Respiratory rate >20/min or alkalosis (PaCO2 <32 mm Hg [4.3 kPa]) Leukocytosis (WBC count >12,000/mm3 [12.0 x 109/L] or 10% immature neutrophils [bands]) The heart rate, respiratory rate, and temperature are elevated, and the WBC count is increased; these findings indicate the presence of SIRS. (Option 1) CVP (normal 2-8 mm Hg) indicates circulating volume. It is decreased, not increased, in septic shock due to massive vasodilation and maldistribution of blood flow. An abnormal finding is not associated with SIRS and would not be expected in this client. (Option 2) Sepsis with hypotension and decreased perfusion despite fluid resuscitation is a characteristic finding in septic shock. An MAP of 80 mm Hg is within the normal range (70-105 mm Hg). It is not associated with SIRS and is not an expected finding in this client. Educational objective: Temperature (hyper- or hypothermia), respirations >20/min, heart rate >90/min, and WBC count >12,000/mm3 (12.0 x 109/L) are assessed to document SIRS. The presence of 2 or more of these findings indicates the syndrome.

When performing developmental screenings in the well-child clinic, the registered nurse understands that which child is at highest risk of developing autism spectrum disorder? 1. 2 year old who has a vocabulary of 10 words 2. 3 year old who received MMR immunization at age 1 year 3. 4 year old whose 10 year old sibling has the disorder 4. 5 year old whose parents were age 42 at the time of birth

3. 4 YEAR OLD WHOSE 10 YEAR OLD SIBLING HAS THE DISORDER Although the cause of autism spectrum disorder (ASD) is unknown, numerous studies indicate that it has a strong genetic component. The underlying genetic source is unknown in the majority of cases; however, researchers hypothesize that genetic factors predispose to an autism phenotype and that genetic expression is influenced by environmental factors. (Option 1) A 2-year-old with a vocabulary of a few words only is a concern; however, there are a number of factors and/or conditions that could cause language or overall developmental delay. (Option 2) There is no scientific evidence that the measles, mumps, and rubella vaccine or thimerosal-containing vaccines (eg, influenza) are linked to ASD. (Option 4) Retrospective studies have linked parents of older age to autism; however, this association is inconclusive. Educational objective: There is strong scientific evidence of a genetic component to autism spectrum disorder (ASD). As a result, parents who have a child with ASD are at higher risk of having another child with this disorder. There is no evidence that supports a link between vaccines and ASD, and studies on associations between advanced parental age and the disorder are inconclusive.

The nurse provides discharge teaching for the parent of a child newly prescribed methylphenidate for attention-deficit hyperactivity disorder (ADHD). The nurse advises the parent that the child might experience which side effects? 1. Decreased BP and growth delays 2. Heart palpitations and weight gain 3. Loss of appetite and restlessness 4. Trouble sleeping and a dry cough

3. LOSS OF APPETITE AND RESTLESSNESS Stimulant medications are commonly used to treat ADHD in children and adults. Methylphenidate (Ritalin) and amphetamines (eg, dextroamphetamine, lisdexamfetamine) are the most commonly used stimulants. The major problems with stimulant medications include: Decreased appetite and weight loss - can lead to growth delays Cardiovascular effects - hypertension and tachycardia (particularly in adults) Appearance of new or exacerbation of vocal/motor tics Excess brain stimulation - restlessness, insomnia Abuse potential - misuse, diversion, addiction (Option 1) Growth delays are a common side effect. The medications may cause hypertension, not hypotension. (Option 2) Heart palpitations are a common side effect; weight loss, not weight gain, can be a problem. (Option 4) Trouble sleeping is a common side effect, but the medications do not cause a dry cough. Educational objective: Methylphenidate (Ritalin) is a central nervous system stimulant with the following potential side effects: anorexia and weight loss/growth delays, restlessness and insomnia, hypertension and tachycardia, vocal or motor tics, and abuse potential.

The clinic nurse prepares to administer a newly prescribed dose of sumatriptan to a client with a migraine headache. Which item in the client's history would cause the nurse to question the prescription? 1. BUN of 12 2. BMI of 34 3. Past medical histry of uncontrolled hypertension 4. Takes alprazolam as prescribed for anxiety

3. PAT MEDICAL HISTORY OF UNCONTROLLED HYPERTENSION Sumatriptan is a selective serotonin agonist prescribed to treat migraine headaches, which are thought to be caused by dilated cranial blood vessels. Triptan drugs, like sumatriptan, work by constricting cranial blood vessels, and clients should be instructed to take a dose at the first sign of a migraine to help prevent and relieve symptoms. Sumatriptan is contraindicated in clients with coronary artery disease and uncontrolled hypertension because its vasoconstrictive properties increase the risk of angina, hypertensive urgency, decreased cardiac perfusion, and acute myocardial infarction. The nurse should question the client about a past medical history of uncontrolled hypertension and report this to the health care provider (Option 3). (Option 1) A blood urea nitrogen level of 12 mg/dL (4.28 mmol/L) is a normal value (normal range 6-20 mg/dL [2.1-7.1 mmol/L]). (Option 2) Sumatriptan is not contraindicated for underweight or overweight clients. (Option 4) Sumatriptan is not contraindicated with alprazolam therapy. However, because of its serotonergic effects, clients already taking selective serotonin reuptake inhibitors (eg, sertraline, paroxetine) or selective norepinephrine reuptake inhibitors (eg, venlafaxine, duloxetine) should be monitored for signs of serotonin syndrome. Educational objective: Sumatriptan relieves migraines by constricting dilated cranial blood vessels. Sumatriptan is contraindicated in clients with coronary artery disease and uncontrolled hypertension because the vasoconstrictive effects can cause hypertensive urgency, angina, decreased cardiac perfusion, and acute myocardial infarction.

The nurse is performing a central line tubing change when the client suddenly begins gasping for air and writhing. Order the interventions by priority. All options must be used.

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

Which of the following are violations of the Health Insurance Portability and Accountability Act (HIPAA) regarding confidentiality of privileged health information (PHI)? Select all that apply. 1. A pregnancy result is given to a husband without the wife's permission 2. The pt overhearsm through a privacy curtain, the RN call report on someone 3. The RN calls the pt by firsgt and last name 4. The rn tells the transporting tech that the pt has breast cancer 5. UAP tells the discharged pt, "you take care now!"

1 & 4 Under HIPAA, a client's information regarding medical treatment is private and cannot be released without the client's permission. There must be a reasonable effort to limit the use of, disclosure of, and requests for PHI to the minimum necessary to accomplish the intended purpose. The client's PHI is to be shared with the spouse only with the client's permission. Lawsuits have resulted when findings a client wanted private were given to the spouse (eg, the husband was not the father of the baby). PHI is shared with an employee on a "need-to-know" basis. A transporting employee does not need to know the client's diagnosis. The employee would need to know if there was a need for personal protective equipment related to infectious precautions. A transporting ambulance paramedic who is managing care would need to know the diagnosis. (Option 2) This is an inadvertent communication and is not considered a HIPAA violation. Similarly, publicly calling for help ("Code blue in room 12") is not a violation. (Option 3) A client's name is not PHI. A person's identity is obvious in public. Although some institutions choose not to use a name or use a code name for someone famous, calling a person's name is not a violation. (Option 5) Any employee can provide socially acceptable well wishes to a client. It does not involve PHI. Educational objective: HIPAA requirements related to PHI include not giving results to a spouse without permission or telling a client diagnosis to an employee who does not need to know. It is not a violation to call clients by their names, have information overheard inadvertently, or indicate well wishes.

The clinic nurse prepares to teach the parent of a child who has been diagnosed with scabies. Which instructions should the nurse include in the teaching plan? Select all that apply. 1. All persons in contact with the child need treatment 2. Apply permethrin to all body areas below the head 3. Discard the child's stuffed animals 4. Fumigate all the living areas 5. Wash the pt's bedding in hot water

1, 2, & 5 Scabies is a skin infestation caused by the Sarcoptes scabiei mite. It spreads easily via direct person-to-person contact (eg, nursing homes, day cares, prisons). The pregnant female mite burrows into the outer skin layer (dead layer) to lay eggs and feces, leaving a superficial burrow track. Intense itching, especially at night, occurs due to the body's inflammatory response to the mite's eggs and feces. The lengthy 30-60 day incubation period (timeframe between infestation and appearance of symptoms) makes it necessary to treat all persons who have had contact with the infested child during that time. Those age >2 months can receive one-time treatment with scabicide cream (1% permethrin is used most often), which is applied to all body areas below the head. It is important to inform the parents and child that itching will continue for several weeks after proper treatment is given (Options 1 and 2). Scabies mites do not survive away from human skin for more than 2-3 days. Therefore, disinfecting the client's clothes, linens and stuffed animals involves placing these in a plastic bag (for a minimum of 3 days) or machine washing them in hot water and drying them on the hottest dryer cycle. Fumigation of living areas is also not needed for the same reason (Options 3, 4, and 5). Educational objective: Scabies is spread easily via direct skin-to-skin contact. Due to the lengthy incubation period of scabies, all who have been in contact with the infested child must be treated. This involves a one-time application of a scabicide (typically 1% topical permethrin). The child's bedding and clothing should be placed in plastic bags (for a minimum of 3 days) or washed in hot water and dried on the hottest dryer cycle.

The nurse is caring for a client in the acute phase of meningococcal meningitis. Which nursing actions should be included in the client's plan of care? Select all that apply. 1. Assign pt to a private room 2. Don mask before entering room 3. Elevate head of bed 10-30 degrees 4. Keep padded tongue blade at bedside 5. Maintain dimmed room lighting

1, 2, 3, & 5 Bacterial meningitis is an inflammation of the membranes that cover the brain and spinal cord and is caused by bacterial infection. Symptoms include headache, neck stiffness, nausea, vomiting, photophobia, fever, and altered mental status. The client with meningitis is at risk for seizure due to increased neuroirritability from fever and alterations in intracranial pressure. Bacterial meningitis is frequently caused by Neisseria meningitidis (meningococcus) in adults. Meningococcal meningitis is highly infectious and requires strict droplet isolation precautions (eg, surgical mask, private room, client masked during transport) (Options 1 and 2). For clients with meningitis, a restful, reduced stimulus environment (eg, quiet, dimly lighted, cool temperature) promotes healing and reduces neuroirritability and seizure risk (Option 5). The client should be on bed rest with the head of the bed elevated 10-30 degrees to promote venous return from the brain and reduce sudden changes in intracranial pressure (Option 3). (Option 4) Seizure precautions (eg, padded bed rails, oxygen and suction equipment at bedside) should be maintained for a client with meningitis. The client may require suction after a seizure has occurred, but nothing should be inserted into the client's mouth during a seizure, including a padded tongue blade, due to the risk of damaging the teeth or oral mucosa. Educational objective: Care for the client with meningococcal meningitis includes droplet isolation precautions, seizure precautions, reduced stimulus environment (eg, quiet, dimly lit), and bed rest with the head of the bed elevated between 10-30 degrees.

The nurse reinforces teaching about self-management strategies for a client with urge incontinence. Which of the following statements indicate that teaching has been effective? Select all that apply. 1. I am going to join a walking program to lose excess weight 2. I may hav dry mouth as a side effect from the oxybutynin 3. I really need caffeine to get myself going in the morning 4. I should perform kegel exercises several times daily 5. I will void every 2 hours until I am having fewer accidents

1, 2, 4, & 5 Urge incontinence (UI), also known as overactive bladder, occurs when the bladder contracts randomly, causing a strong, sudden urge to urinate that is followed by urine leakage. UI may occur without cause or may result from spinal cord injury and impairment of the bladder (eg, interstitial cystitis) or neurological system (eg, Parkinson disease, stroke). Interventions for clients with UI include: Loss of excess weight to reduce pressure on the pelvic floor (Option 1). Anticholinergic medications (eg, oxybutynin, tolterodine) to decrease bladder spasms. Dry mouth (xerostomia) is a frequent adverse effect (Option 2). Avoidance of bladder irritants (eg, artificial sweeteners, caffeine, citrus juices, alcohol, carbonated drinks, nicotine) (Option 3). Pelvic floor exercises (eg, Kegel) to strengthen the muscles and help prevent urinary leakage (Option 4). Bladder training (eg, voiding every 2 hours while awake) and gradually lengthening intervals between voiding (Option 5). Educational objective: Management of urge incontinence includes loss of excess weight, anticholinergic medications (eg, oxybutynin), avoidance of bladder irritants, pelvic floor exercises, and bladder training. Dry mouth is a common adverse effect of anticholinergic medications.

Which of these instructions is appropriate teaching for a 60-year-old woman? Select all that apply. 1. Consume adequate sources of calcium and vitamin d 2. Increase intake of food sources of iron and take supplements 3. Observe for unilateral leg swelling when taking hormone replacement therapy 4. Remain upright for 30 minutes when taking a bihosphate 5. Vaginal spotting after menopause is a common, insignificant sign of aging

1, 3, & 4 The average age of menopause in the United States is 50-52. Major health risks of menopause include osteoporosis and heart disease. Bisphosphonates, such as alendronate (Fosamax), risedronate (Actonel), or ibandronate (Boniva), decrease bone resorption so that loss of bone density is minimized. They must be consumed in the morning, on an empty stomach, with at least 30 minutes before other drugs. The medication is taken with a full glass of water and the client must remain upright for at least 30 minutes to aid absorption and prevent esophageal irritation (Option 4). Adequate sources (both food and supplements) of calcium and vitamin D are required to build bone mass (Option 1). HRT can improve bone mass and prevent osteoporosis but is associated with increased risk of thrombotic complications (deep vein thrombosis, stroke, myocardial infarction) and some cancers (breast, uterine). Therefore, it is used only in clients who have disabling hot flashes. Unilateral leg swelling is a classic symptom of venous thromboembolism (Option 3). (Option 2) Anemia in older adults is usually not related to lack of iron intake, especially once menstruation has stopped. Excessive iron intake can lead to iron overload, and the risk of excess iron tends to be higher with aging. (Option 5) Postmenopausal bleeding or abnormal premenopausal bleeding is the most common symptom of endometrial cancer and requires follow-up. Educational objective: A postmenopausal woman (usually after age 51) is at risk for osteoporosis and heart disease. Clients should remain upright after taking a bisphosphonate and consume calcium and vitamin D for bone health. Clotting disorder is a risk with HRT. Intermittent vaginal spotting after menopause can be a sign of endometrial cancer.

Which nursing interventions are appropriate for managing the care of a client receiving mechanical ventilation and continuous IV sedation? Select all that apply. 1. Maintain HOB at 30-45 degrees 2. Mute ventilator alarms at night to allow the pt to rest 3. Pause sedation daily to assess weaning readiness 4. Perform oral care with chlorhexidine solution 5. Place a manual resuscitation bag at the bedside

1, 3, 4, & 5 Clients requiring mechanical ventilation are at risk for a variety of ventilator-associated complications (eg, aspiration, pneumonia). When caring for a client receiving mechanical ventilation, the nurse should: Monitor respiratory status (eg, lung sounds, breathing pattern), airway patency, and ventilator functionality (eg, settings, alarm parameters). Maintain the head of the bed at 30-45 degrees to reduce aspiration risk (Option 1). Use the minimum amount of sedation necessary for client comfort (eg, compliant with ventilator, opens eyes to voice). Continuous IV sedation should be paused daily for evaluation of spontaneous respiratory effort and appropriateness for weaning off the ventilator (Option 3). Perform oral care with chlorhexidine oral solution every 2 hours, or per facility policy (Option 4). Perform tracheal suctioning as needed. Monitor correct endotracheal tube placement by noting insertion depth. Place emergency equipment at bedside (eg, manual resuscitation bag) (Option 5). (Option 2) Although the client should have a quiet environment at night, ventilator alarms should never be muted, as they may indicate life-threatening complications (eg, accidental extubation, tubing disconnection). Educational objective: When caring for a client requiring mechanical ventilation, the nurse should monitor respiratory status and airway patency (eg, breath sounds, insertion depth of endotracheal tube), maintain an appropriate level of sedation, assess for weaning readiness, prevent ventilator-associated infection (eg, oral care with chlorhexidine, head of the bed at 30-45 degrees), and implement safety measures (eg, emergency equipment at bedside, ventilator alarms on).

The nurse has provided education for a client with newly diagnosed ankylosing spondylitis. Which client statements indicate a need for further teaching? Select all that apply. 1. I should continue strenuous exercise during flare ups 2. I should do stretching activities such as swimming or raquet sports 3. I should quit smoking and perform breathing exercises 4. I will sleep on a soft mattress to help decrease my morning stiffness 5. I will take the prescribed ibuprofen on an empty stomach

1, 4, & 5 Ankylosing spondylitis (AS) is an inflammatory disease affecting the spine that has no known cause or cure. AS is characterized by stiffness and fusion of the axial joints (eg, spine, sacroiliac), leading to restricted spinal mobility. Low back pain and morning stiffness that improve with activity are the classic findings. Involvement of the thoracic spine (costovertebral) and costosternal junctions can limit chest wall expansion, leading to hypoventilation. The client with AS should do the following: Promote extension of the spine with proper posture, daily stretching, and swimming or racquet sports (Option 2) Stop smoking and practice breathing exercises to increase chest expansion and reduce lung complications (Option 3) Manage pain with moist heat and nonsteroidal anti-inflammatory drugs (NSAIDs) Take immunosuppressant and anti-inflammatory medications as prescribed to reduce inflammation and increase mobility (Option 1) It is best to rest during flare-ups. The client should wait to exercise until the pain and inflammation are under control. (Option 4) Clients with AS are encouraged to sleep on their backs on a firm mattress to prevent spinal flexion and the resulting deformity. (Option 5) Ibuprofen and other NSAIDs should be taken with a meal or snack to avoid gastric upset. Educational objective: Ankylosing spondylitis is an inflammatory spinal disease characterized by back pain and morning stiffness that improves with exercise/activity. Chest wall restriction is a serious complication. Treatment is targeted at reducing pain (moist heat, nonsteroidal anti-inflammatory drugs) and maintaining skeletal mobility (proper posture, stretching, breathing exercises) to promote activities of daily living.

A client with suspected moderate to large pericardial effusion is admitted for monitoring. The nurse performs a head-to-toe assessment. Which of these findings indicate likely cardiac tamponade and require immediate intervention? Select all that apply. 1. BP of 90/70 2. Bounding peripheral pulses 3. Decreased breath sounds on left side 4. Distant heart tones 5. Jugular venous distention

1, 4, & 5 Pericardial effusion is a buildup of fluid in the pericardium. Tamponade, a serious complication of pericardial effusion, develops as the effusion increases in volume and results in compression of the heart. The heart struggles to contract effectively against the fluid, and cardiac output can decrease drastically. This life-threatening complication requires an emergency pericardiocentesis (a needle inserted into the pericardial sac to remove fluid). Signs and symptoms of cardiac tamponade include: Hypotension with narrowed pulse pressure (Option 1) Muffled or distant heart tones (Option 4) Jugular venous distension (Option 5) Pulsus paradoxus Dyspnea, tachypnea Tachycardia (Option 2) Bounding pulses may be present during fluid overload or hypertension. They may also be present with anxiety or fever. The client with possible tamponade will have evidence of decreased cardiac output and is more likely to have weak, thready pulses. (Option 3) Decreased breath sounds on the left side are not specific to the development of cardiac tamponade. Decreased breath sounds could indicate conditions such as atelectasis, pleural effusion, or pneumothorax. Educational objective: The client with a moderate to large pericardial effusion is at risk for the development of cardiac tamponade. Signs and symptoms of tamponade include muffled or distant heart tones, narrowed pulse pressure, jugular venous distension, pulsus paradoxus, dyspnea, tachypnea, and tachycardia. The nurse should report these findings to the health care provider immediately and prepare for a pericardiocentesis.

A mother reports to the pediatric nurse that her 3-year-old child coughs at night and at times until he vomits. The symptoms have not improved over the past 2 months despite multiple over-the-counter cough medications. What should the nurse explore related to a possible etiology? 1. Ask about exposures to trigger such as pet dander 2. Assess for the presence of a butterfly rash 3. History of intolerance to wheat food products 4. Palpate for an abdominal mass from pyloric stenosis

1. ASK ABOUT EXPOSURES TO TRIGGER SUCH AS PET DANDER Asthma is a chronic inflammatory disease of the lungs in genetically susceptible children. Frequent cough, especially at night, is the warning signal that the child's airway is very sensitive to stimuli; it may be the only sign in "silent" asthma. Common triggers include indoor contaminants (eg, tobacco smoke, pet dander, cockroach feces), outdoor contaminants (eg, air pollution), and allergic disease (eg, hay fever, food allergies). (Option 2) A red or pink butterfly rash across the cheeks and bridge of the nose is classic for systemic lupus erythematosus (SLE), an autoimmune disease that affects connective tissue. The child has no symptoms of SLE. Manifestations are acute (eg, nephritis, arthritis, vasculitis) or involve a gradual onset of nonspecific symptoms. (Option 3) Celiac, or gluten-sensitive, enteropathy is a chronic malabsorption syndrome. There is intolerance for gluten, a protein found in wheat, barley, rye, and oats. This condition affects absorption of nutrients; it does not cause nausea. (Option 4) Pyloric stenosis is a hypertrophy of the pylorus that results in stenosis of the passage between the stomach and the duodenum. Symptoms become evident 2-8 weeks after birth. It starts with occasional vomiting that eventually becomes forceful/projectile vomiting as the obstruction becomes complete. Dehydration and electrolyte imbalance result. The thickened pyloric muscle can sometimes be palpated and can be confirmed with ultrasound. This child is too old for this complication. Educational objective: Pediatric asthma can present as night coughing until the child vomits.

The hospice nurse is caring for an actively dying client who is unresponsive and has developed a loud rattling sound with breathing ("death rattle") that distresses family members. Which prescription would be most appropriate to treat this symptom? 1. Atropine 2. Lorazepam 3. Morphine 4. Ondansetron

1. ATROPINE The "death rattle" is a loud rattling sound with breathing that occurs in a client who is actively dying. When the client cannot manage airway secretions, the movement of these secretions during breathing causes a noisy rattling sound. This can distress family and friends at the bedside of the dying client. The "death rattle" can be treated using anticholinergic medications to dry the client's secretions. Medications include atropine drops administered sublingually or a transdermal scopolamine patch. (Option 2) Lorazepam is a benzodiazepine that is used to treat anxiety and restlessness in terminally ill clients. It can be effective for alleviating dyspnea exacerbated by anxiety, but it is ineffective for controlling secretions (the cause of the "death rattle"). (Option 3) Morphine is an opioid analgesic that is effective for pain treatment as well as terminal dyspnea. The client is not exhibiting these symptoms, so morphine would be inappropriate. (Option 4) Ondansetron will help the nausea and vomiting but is not very effective for treating the "death rattle." Educational objective: The "death rattle" is a noisy rattling sound with breathing commonly seen in a dying client who is unresponsive and no longer able to manage airway secretions. Anticholinergic medications such as transdermal scopolamine or atropine sublingual drops effectively treat this symptom by drying up the excess secretions.

The nurse assesses a client with a history of cystic fibrosis who is being admitted with a pulmonary exacerbation. Which assessment finding would require immediate action? 1. Current O2 reading is 90% on room air 2. Expectorating blood tinged sputum 3. Loss of appetite and recent 5 lb weight loss 4. No bowel movement in the past 48 hours

1. CURRENT O2 READING IS 90% ON ROOM AIR In cystic fibrosis (CF), a defective protein responsible for transporting sodium and chloride causes the secretions from the exocrine glands to be thicker and stickier than normal. The sticky respiratory secretions lead to the inability to clear the airway and a chronic cough. The client eventually develops chronic lung disease (bronchiectasis) and is at risk for recurrent lung infections. These clients are also at risk for rupture of the damaged alveoli, which results in sudden-onset pneumothorax. Findings of pneumothorax include sudden worsening of dyspnea, tachypnea, tachycardia, and a drop in oxygen saturation. Because many of these findings can be seen with lung infection, a sudden drop in oxygen saturation could be the only early clue. The client with CF will often have a decreased pulse oximetry (reflects oxygen saturation in the blood) reading due to the chronicity of the disease process and damage to the lungs; however, a reading of 90% requires urgent intervention. (Option 2) Clients with CF often cough up blood-streaked sputum (hemoptysis) as a result of damage to blood vessels in the airway walls secondary to infections. However, this usually resolves with treatment of the infection. Frank hemoptysis needs urgent assessment. (Option 3) Maintaining weight is a challenge in those with CF due to the malabsorption of carbohydrates, fats, and proteins caused by the impaired enzyme secretions in the gastrointestinal tract. In addition, weight and appetite loss may indicate an undiagnosed underlying lung infection. This will need to be addressed, but oxygenation is the priority. (Option 4) Fecal retention and impaction are common in CF due to decreased water and salt secretion into the intestines. This will need to be addressed, but oxygenation is the priority. Educational objective: When addressing the multiple needs of a client with cystic fibrosis, airway and oxygen saturation are the priorities. Pneumothorax can be a complication of cystic fibrosis.

The home health nurse reviews the serum laboratory test results for a client with seizures. The phenytoin level is 27 mcg/mL. The client makes which statement that may indicate the presence of dose-related drug toxicity and prompt the nurse to notify the health care provider? 1. I am feeling unsteady when I walk 2. I am getting up to urinate aout 4 times during the night 3. I have a metallic taste in my mouth when I eat 4. My gums are getting so puffy and red

1. I AM FEELING UNSTEADY WHEN I WALK Phenytoin (Dilantin) is an anticonvulsant drug used to treat generalized tonic-clonic seizures. The therapeutic serum phenytoin reference range is between 10-20 mcg/mL. Levels are measured when therapy is initiated, periodically throughout treatment to guide dosing until a steady state is attained (3-12 months), and if seizure activity increases. Early signs of toxicity include horizontal nystagmus and gait unsteadiness. These may be followed by slurred speech, lethargy, confusion, and even coma. Bradyarrhythmias and hypotension are usually seen with intravenous phenytoin. (Option 2) Nocturia is an expected side effect of diuretics but not phenytoin. Nocturia is also seen with diabetes mellitus and benign prostatic hyperplasia. (Option 3) Metallic taste in the mouth is often seen with metronidazole but not with phenytoin. (Option 4) Gingival hyperplasia is a common expected side effect of phenytoin and does not indicate drug toxicity. It occurs more often in clients <23 years of age who are prescribed >500 mg/day. Good oral hygiene can limit symptoms. Educational objective: Phenytoin, an anticonvulsant drug, is used to treat generalized tonic-clonic seizures. Common symptoms of phenytoin drug-induced toxicity involve the central nervous system and include ataxia, nystagmus, slurred speech, and decreased alertness.

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

1. I AM HAVING PROBLEMS EXTENDING MY FINGERS SINCE THIS MORNING 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). (Option 2) The nurse should educate the client about ways to prevent medication-related nausea, or the HCP may consider switching pain medications. This would be addressed last. (Option 3) The client must be instructed to never stick anything inside the cast; this can lead to altered skin integrity and infection. This would be addressed third. (Option 4) A warm spot on the cast with a foul odor can indicate infection under the cast, especially if the client has been sticking objects inside to scratch the skin. This would be addressed second. Educational objective: Volkmann contracture (wrist contracture, inability to extend the fingers) occurs as a result of ischemia from compartment syndrome after a distal humerus fracture. It is a medical emergency that requires immediate intervention.

The nurse on the medical unit finishes receiving the change of shift hand-off report at 7:30 AM. Which assigned client should the nurse see first? 1. Pt with a GI bleed, who is receiving a unit of PRBC 2. Pt with a ulcerative colitis flare up has temp of 101 and abdominal cramping 3. Pt with a fib on telemetry, prescribed warfarin, with an INR of 3.2 4. Pt with chronic kidney disease scheduled for bedside hemodialysis at 8:00 am with a serum creatinine of 8.4

1. PT WITH A GI BLEED, WHO IS RECEIVING A UNIT OF PRBC The nurse should check on the assigned clients in the following order: Client with the gastrointestinal bleed receiving packed red blood cells (PRBCs) - the nurse should: Check the infusion device; flow rate; and IV site, tubing, and filter Collect baseline physical assessment data against which to compare subsequent assessments Assess for complications associated with the administration of PRBCs, which include fluid overload and an acute transfusion reaction; these can occur at any time during the transfusion (Option 1) Client with chronic kidney disease scheduled for dialysis in 30 minutes - the nurse should perform a baseline assessment before dialysis is initiated. The nurse should then prepare the client by making sure the client eats breakfast, administering prescribed morning medications that are not dialyzed out, and holding those that are dialyzed out. Elevated creatinine level (eg, normal 0.6-1.3 mg/dL [53-115 µmol/L]) is an expected finding. (Option 4) Client with ulcerative colitis (UC) with elevated temperature and abdominal pain - UC is an inflammatory bowel disease; fever and lower-quadrant abdominal cramping are expected findings. After assessing the client, the nurse will administer an analgesic and an antipyretic as prescribed. (Option 2) Client with history of atrial fibrillation, prescribed warfarin (Coumadin) - the client is on telemetry; in most facilities, if dysrhythmias occur, the monitor technician/nurse will notify the primary care nurse immediately. The goal INR is 2.0 to 3.0 for atrial fibrillation. An INR of 3.2 is expected when adjusting the warfarin dose. (Option 3) Educational objective: To prioritize client care, the nurse first identifies the type of problem, its associated complications, and the desired outcomes. The nurse then decides which client has the most urgent problems and needs and assesses that client first.

A client in the postoperative period after an open reduction and internal fixation of a left wrist fracture reports constant, severe arm pain that is unrelieved by prescribed morphine administered 30 minutes ago. The client's nail beds appear dusky. What are the nurse's appropriate actions? Select all that apply. 1. Apply a heating pad and encourage ROM exercises 2. Assess the temperature and movement of the fingers 3. Elevate the arm on pillows above the level of the heart 4. Notify the HCP 5. Reassure the pt, document findings, and reassess in 1 hour

2 & 4 Compartment syndrome, a serious postoperative complication, is caused by decreased blood flow to the tissue distal to the injury. It results from either decreased compartment size (restrictive dressings, splints, or casts) or increased pressure within the compartment (bleeding, inflammation, and edema). Earliest symptoms may include pain or numbness that is unrelieved by medication. Subsequent findings include diminished/absent pulses, pallor, coolness, swelling, decreased movement, and cyanosis. Failure to treat this condition can lead to loss of limb function, paralysis, and tissue necrosis. The nurse should assess neurovascular status and report to the health care provider immediately (Options 2 and 4). Removal of tight bandages/casts and fasciotomy (surgery) are required to relieve the pressure. (Option 1) Heat should not be applied to a client experiencing altered sensation, as it may burn the client. Active range of motion will not resolve compartment syndrome and delays needed care. (Option 3) Elevating the arm on pillows and providing additional analgesia may help reduce symptoms but may also reduce perfusion of the extremity. Instead, the extremity should be positioned at the level of the heart. (Option 5) Documenting findings is important. However, reassurance and reassessment 1 hour later without immediate intervention delays needed care. Educational objective: Compartment syndrome is caused by decreased blood flow to the tissue distal to the injury and can cause ischemic necrosis. Acute compartment syndrome following surgery or casting is potentially limb-threatening and requires emergency evaluation by a health care provider.

A client with type 1 diabetes has a prescription for 30 units of insulin glargine at bedtime. Fingerstick blood glucose measurements are prescribed before meals and at bedtime with regular insulin based on a sliding scale. At 9:00 PM, the client's blood glucose measurement is 180 mg/dL (10.0 mmol/L). What action should the nurse take? Click on the exhibit button for additional information. 1. Administer 30 units of glargine; give the pt a snack, then administer 2 units of regular insulin 2. Administer 30 units of glargine and 2 units of regular insulin in 2 different injections 3. Mix 30 units of glargine with 2 units og regular insulin in the same syringe, drawing up the glargine first 4. Mix 30 units of glargine with 2 units of regular insulin in the same syringe, drawing up the regular insulin first

2. ADMINISTER 30 UNITS OF GLARGINE AND 2 UNITS OF REGULAR INSULIN IN 2 DIFFERENT INJECTIONS A combination of long-acting insulin (eg, glargine, detemir) with rapid- (eg, lispro, aspart) or short-acting (eg, regular) insulin is often prescribed for clients with diabetes. The different onsets, peaks, and durations mimic the body's natural insulin levels and enhance glycemic control. Long-acting (basal) insulins have no peak and may last 24 hours or longer. Short-acting insulins peak 2-5 hours after administration and last approximately 5-8 hours. Regular or rapid-acting insulins may be given on a sliding scale at prescribed intervals (eg, before meals and at bedtime) and are dosed based on the client's blood glucose measurement. Insulin glargine and regular insulin may be safely given concurrently due to the differences in onset, peak, and duration (Option 2). (Option 1) Because long-acting insulins have no peak, they should not potentiate hypoglycemia. Regular insulin may cause hypoglycemia. However, concurrent administration of regular insulin with insulin glargine will not increase the probability of hypoglycemia as each medication has a different onset, peak, and duration; therefore, a snack is not required. (Options 3 and 4) Insulin glargine should not be mixed in a single syringe with any other insulin as the mixture may alter the pharmacodynamics of the drug. Educational objective: Sliding-scale regular insulin can be concurrently administered with scheduled insulin glargine without potentiating hypoglycemia as long as both medications are properly dosed and administered as separate injections. Insulin glargine should not be mixed in a syringe with any other insulin.

Within thirty seconds after birth, an unresponsive and limp newborn is placed on the warmer in the "sniffing" position. The nurse clears the airway, dries, and stimulates the newborn. At 1 minute of life, the newborn has shallow, gasping respirations with a heart rate of 62/min. What action should the nurse take? 1. Administer epinephrine 2. Begin positive pressure ventilation 3. Continue stimulating the newborn 4. Start chest compressions

2. BEGIN POSITIVE PRESSURE VENTILATION Newborns are evaluated immediately after birth for adaptation to extrauterine life. Newborns requiring resuscitative measures should be cared for using structured, evidence-based interventions, such as the neonatal resuscitation program (NRP) algorithm. Each step of the NRP algorithm requires rapid assessment and decision-making at 30-second intervals. NRP dictates that positive pressure ventilation (PPV) be started when a newborn's heart rate is <100/min. Effective PPV will often result in a rising heart rate and return of spontaneous respirations. (Option 1) Epinephrine is administered after chest compressions, if the heart rate remains < 60/min. (Option 3) The newborn has already been stimulated for 30 seconds, and placed in the optimal "sniffing" position. The next step is initiation of PPV if the heart rate remains <100/min. (Option 4) Chest compressions are started after at least 30 seconds of quality PPV, if the newborn's heart rate remains <60/min. The landmark for compressions is the middle third of the sternum just below an imaginary line drawn between the nipples. Either the two-finger, or two-thumb technique may be used for newborn chest compressions. Educational objective: Neonatal resuscitation interventions after birth are initiated at 30-second intervals, with continual assessment of the newborn's adaptation to extrauterine life. Positive pressure ventilation (PPV) is started if heart rate is <100/min; compressions are started if the newborn's heart rate remains <60/min after at least 30 seconds of quality PPV.

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

2. GIVE THE MEDICATION SLOWLY DURING THE PEAK OF THE NEXT CONTRACTION Administration of IV narcotics (eg, nalbuphine, butorphanol, meperidine) during the peak of contractions can help decrease sedation of the fetus and subsequent newborn respiratory depression at birth (Option 2). Uteroplacental blood flow is significantly reduced during contraction peaks, and administration of IV medication at this time results in less medication crossing the placental barrier. In addition, a higher concentration of medication remains in the maternal vasculature, which increases the effectiveness of pain relief. (Option 1) There is no reason to discontinue oxytocin prior to IV administration of pain medication. However, IV push medications should not be given through IV lines already infusing medication. (Option 3) Narcotics do not typically inhibit contraction patterns or labor progress when labor is well established (ie, contractions every 2-5 minutes). However, it is inappropriate to withhold pain medication simply because the frequency of contractions is inadequate. For some clients, IV narcotics are used to provide pain relief and promote rest when latent labor is prolonged. (Option 4) Narcotics given by IV push may be diluted according to manufacturer directions so that they can be more easily pushed over the recommended administration interval. Diluent should never be obtained from the IV bag or tubing due to the risk of inadvertently adding medication to IV fluids. Educational objective: IV narcotics administered to laboring women can cause fetal sedation and subsequent respiratory depression at birth. Administering IV narcotics at the peak of contractions reduces the amount of narcotic that crosses the placental barrier and affects the fetus

A graduate nurse (GN) is caring for a client with right lower leg cellulitis that is seeping clear fluid. Which action by the GN requires intervention by the supervising nurse? 1. Applying a warm compress to the affected extremity 2. Maintaining the affected leg flat on the bed 3. Marking and darting the reddened areas 4. Wearing a gown and gloves while bathing the pt

2. MAINTAINING THE AFFECTED LEG FLAT ON THE BED Cellulitis is inflammation of the subcutaneous tissues that is typically caused by bacterial infection (eg, Staphylococcus aureus, group A Streptococcus) resulting from an insect bite, cut, abrasion, or open wound. Cellulitis is characterized by redness, edema, pain, and fever. Nurses caring for clients with cellulitis should ensure that the affected extremity is elevated when the client is sitting or lying down to promote lymphatic drainage. Flat or dependent positioning may worsen edema, which delays recovery and contributes to pain (Option 2). In addition, clients with weeping or draining wounds must be protected from prolonged exposure to moist or soiled linens as this exposure promotes tissue injury and infection. (Option 1) Applying warm compresses promotes circulation to the area of infection, alleviates discomfort, and helps reduce edema. (Option 3) Daily marking and dating of reddened areas assist with monitoring improvement or worsening of the infection. Redness that progresses past the marked areas indicates ineffective antibiotic therapy and should be reported to the health care provider. (Option 4) Although standard precautions are typically sufficient for cellulitis, a gown and gloves are worn when contact with body fluids (eg, urine, stool) or potentially infectious drainage is expected, such as during bathing. Educational objective: Nurses caring for clients with cellulitis should ensure that the affected extremity is elevated to reduce edema. Additional nursing interventions include applying warm compresses, monitoring the size of the cellulitis, and using personal protective equipment to prevent infection transmission.

The nurse performs the admission history for a 70-year-old client with newly diagnosed chronic obstructive pulmonary disease (COPD). Which statements made by the client does the nurse recognize as the most significant contributing factors to the development of COPD? Select all that apply. 1. I have been drinking alcohol almost daily since age 20 2. I have been overweight for as long as I can remember 3. I have smoked about a pack of cigarettes a day since I was 16 years old but quit last year 4. I know I eat too much fast food 5. I was a car mechanic for about 40 years and had my own garage

3 & 5 Chronic obstructive pulmonary disease (COPD) generally refers to 2 conditions, emphysema and chronic bronchitis. A combination of the 2 is common. It affects about 12 million people and is the 3rd leading cause of death in the United States. It occurs most commonly in the seventh decade of life. COPD is categorized by slowly progressive, persistent airflow obstruction that is closely associated with chronic airway inflammation. The major risk factor is tobacco smoke (eg, cigarette, pipe, cigar). Although the client quit smoking cigarettes last year, he smoked a pack a day for 53 years. Working as a car mechanic for 40 years is a major risk factor because of prolonged exposure to carbon monoxide fumes. Exposure to irritating chemicals, fumes, or vapors in the presence of cigarette smoking increases the risk of developing COPD. (Option 1) Alcohol use is not associated with the development of COPD. (Options 2 and 4) Although poor nutrition can contribute negatively to overall health status, it is not one of the most significant risk factors for development of COPD. Educational objective: Chronic airway inflammation is closely associated with the development of COPD. Specific etiologic factors include tobacco smoke, prolonged occupational exposure to chemicals and dust, air pollution, and genetics (eg, alpha1-antitrypsin deficiency).

The nurse is performing an initial assessment on a client diagnosed with Addison's disease. Which assessment findings should the nurse anticipate? Select all that apply. 1. Acanthosis nigricans 2. Hirsutism 3. Hyperpigmented skin 4. Truncal obesity 5. Weight loss

3 & 5 Addison's disease, or chronic adrenal insufficiency, occurs when the adrenal glands do not produce adequate amounts of steroid hormones (mineralocorticoids, glucocorticoids, androgens). Symptoms include weight loss, muscle weakness, low blood pressure, hypoglycemia, and hyperpigmented skin (skin folds, buccal area, palmar crease). Hyperpigmented skin is a characteristic universal finding; this results from increased adrenocorticotropic hormone which is due to a decrease in cortisol negative feedback. Treatment consists of replacement therapy with oral mineralocorticoids and corticosteroids (Options 3 and 5). (Option 1) Acanthosis nigricans is a skin condition that occurs with obesity and diabetes and appears as velvet-like patches of darkened, thick skin. These areas typically occur around the back of the neck and in the groin and armpits. (Option 2) Hirsutism is a condition in women that consists of male-pattern hair growth on the face, lower abdomen, chest, and back. Common causes are polycystic ovary syndrome and Cushing's syndrome. Loss of libido and decreased axillary and pubic hair are common in Addison's disease due to lower levels of androgens. (Option 4) Clients with Cushing's syndrome, an overproduction of steroid hormones, have truncal obesity or large deposits of abdominal fat. Educational objective: Addison's disease (chronic adrenal insufficiency) leads to hyperpigmented skin, low blood pressure, weight loss, and muscle weakness.

A child with a high level of school absenteeism has been determined to have school phobia. The school nurse should counsel the child's parent/caregiver to take which action? 1. Allow the child to stay home when the child seems particularly anxious 2. Encourage the parent to sit in the classroom with the child 3. Insist on school attendance immediately, starting with a few hours a day 4. Return the child to school when the cause of the school phobia is dentified

3. INSIST ON SCHOOL ATTENDANCE IMMEDIATELY, STARTING WITH A FEW HOURS A DAY School phobia (also known as school refusal or school avoidance) is a childhood anxiety disorder in which the child experiences an irrational and persistent fear of going to school. Having the child return to school immediately is the best approach for resolving school phobia and is associated with a faster recovery. If necessary, gradual exposure to the school environment can be implemented; the child can attend school for a few hours and then gradually increase the time to a full day. A gradual approach may decrease the child's sensitization to the classroom. If the child is allowed to remain out of school, the problem will only worsen, with potential deterioration of academic performance and social relationships. (Option 1) Allowing the child to stay home will only reinforce the acting-out behaviors associated with refusal to attend school. The parent/caregiver needs to support the child and talk about the cause of the anxiety, but the child needs to go to school. (Option 2) Having the parent/caregiver stay in the classroom with the child is not a permanent solution to relieving the child's anxiety and is not recommended. (Option 4) Determining the cause of the school phobia is important in helping to alleviate the child's symptoms and in coping with the return to school. However, returning the child to the classroom immediately is the most important action. Educational objective: A child with school phobia needs to return to the classroom immediately. Insisting on school attendance, along with other supportive interventions, will help the child make a faster adjustment.

A nurse is caring for a 2-year-old with a new diagnosis of strabismus. Which intervention should the nurse anticipate? 1. Eye drops in the abnormal eye 2. Measurement of IOP 3. Patching the stronger eye 4. Correction with laser surgery

3. PATCHING THE STRONGER EYE Strabismus (crossed eyes) is a disorder involving misalignment of the eyes caused by a congenital defect or acquired weakness of an eye muscle. One eye may appear deviated inward (esotropia) or outward (exotropia). When the visual axes are not in alignment, the brain perceives 2 images (diplopia) and suppresses the weaker image to compensate. If left untreated by age 4-6, permanent reduction or loss of visual acuity in the affected eye (amblyopia) can occur. Initial treatments vary depending on the underlying cause. One common treatment is to strengthen the muscles of the weaker eye by wearing a patch over the stronger eye or using special corrective lenses. If nonsurgical methods are unsuccessful, surgical intervention to shorten or reposition an eye muscle for more effective movement may be required. (Option 1) The use of eye drops in the abnormal eye is not an effective treatment for strabismus. Some uncommon treatments of strabismus may include drops in the normal/stronger eye to blur the vision and increase use of the weaker eye. Eye drops are more commonly used to treat glaucoma. (Option 2) Monitoring of IOP would be necessary in a client with glaucoma. Strabismus is not associated with abnormal IOP. (Option 4) Surgical repair of strabismus involves changes to the muscles controlling the eye and does not utilize a laser. Laser surgery is an appropriate treatment for refractive errors, such as myopia, hyperopia, or astigmatism. Educational objective: Strabismus is a disorder involving misalignment of the eyes (eg, one eye deviated inward or outward) caused by a congenital or acquired defect of an eye muscle. Treatment of strabismus may include wearing a patch over the stronger eye to develop strength in the weaker eye.

The nurse is teaching a client with advanced chronic obstructive pulmonary disease who was prescribed oral theophylline. Which client statement indicates that additional teaching is required? 1. I need to avoid caffeinated products 2. I need to get my blood drug elvels checked periodically 3. I need to report anorexia and sleeplessness 4. I take cimetidine rather than omeprazole for heartburn

4. I TAKE CIMETIDINE RATHER THAN OMEPRAZOLE FOR HEARTBURN Theophylline is a bronchodilator with a low therapeutic index and a narrow therapeutic range (10-20 mcg/mL). The serum level should be monitored frequently to avoid severe adverse effects. Toxicity is likely to occur at levels >20 mcg/mL. Individual titration is based on peak serum theophylline levels, so it is necessary to draw a blood level 30 minutes after dosing. Theophylline can cause seizures and life-threatening arrhythmias. Toxicity is usually due to intentional overdose or concurrent intake of medications that increase serum theophylline levels. Cimetidine and ciprofloxacin can dramatically increase serum theophylline levels (>80%). Therefore, they should not be used in these clients. (Option 1) Caffeinated products (eg, coffee, cola, chocolate) should be avoided as they would intensify the adverse effects (eg, tachycardia, insomnia, restlessness) of theophylline. (Option 2) The best way to prevent toxicity is to monitor drug levels periodically and adjust the dose. (Option 3) The signs of toxicity that should be reported are anorexia, nausea, vomiting, restlessness, and insomnia. Educational objective: Theophylline can cause seizures and life-threatening arrhythmias due to its narrow therapeutic range (10-20 mcg/mL). The dose is adjusted based on peak drug levels, obtained 30 minutes after the dose is given. Clients should avoid caffeinated products and medications that increase serum theophylline levels (eg, cimetidine, ciprofloxacin).

When making assignments in the labor and delivery unit, the charge nurse should assign the most experienced newborn admit nurse to attend to the birth of which client? 1. Pt with diet controlled gestational diabetes 2. Pt with mild preeclampsia and BP averaging 140/90 3. Pt with premature rupture of membranes 6 hours ago at 37 weeks gestation 4. Pt with spontaneous rupture of membranes with greenish amniotic fuid

4. PT WITH SPONTANEOUS RUPTURE OF MEMBRANES WITH GREENISH AMNIOTIC FLUID Green amniotic fluid indicates that the fetus has passed its first stool (meconium) in utero. Meconium-stained amniotic fluid places the newborn at risk for meconium aspiration syndrome, a type of aspiration pneumonia. A skilled neonatal resuscitation team should be present at the birth of any newborn with meconium-stained fluid for immediate evaluation and stabilization (Option 4). Previously, endotracheal (ET) suctioning was recommended for nonvigorous newborns (eg, depressed respirations, decreased muscle tone, heart rate <100/min) born with meconium-stained fluid; however, recent guidelines indicate that routine ET suctioning is no longer necessary. (Option 1) Neonates born to mothers with gestational diabetes are at risk for hypoglycemia after birth and should be monitored closely during the first 6 hours of life. The risk of newborn hypoglycemia is lower if the mother's diabetes is well-controlled and not insulin-dependent. (Option 2) Clients with severe preeclampsia may need magnesium sulfate therapy for seizure prevention. Maternal magnesium therapy can cause newborn respiratory depression at birth. However, this client's mild preeclampsia does not require magnesium therapy. (Option 3) Premature rupture of membranes (PROM) refers to the rupture of membranes prior to the onset of labor at term gestation (≥37wk 0d). PROM on its own does not harm the fetus. However, if labor does not begin after PROM, induction of labor may be necessary to decrease the risk for infection (eg, chorioamnionitis). Educational objective: Meconium-stained amniotic fluid places the newborn at risk for meconium aspiration syndrome. A skilled neonatal resuscitation team should be present at birth for immediate newborn evaluation and stabilization.