July 4th
The nurse is caring for a client after a motor vehicle accident. The client's injuries include 2 fractured ribs and a concussion. The nurse notes which of the following as expected neurological changes for the client with a concussion? Select all that apply. 1. Asymmetrical pupillary constriction 2. Brief loss of conciousness 3. Headache 4. Loss of vision 5. Retrograde amnesia
2, 3, & 5 A concussion is considered a minor traumatic brain injury and results from blunt force or an acceleration/deceleration head injury. Typical signs of concussion include: A brief disruption in level of consciousness Amnesia regarding the event (retrograde amnesia) Headache These clients should be observed closely by family members and not participate in strenuous or athletic activities for 1-2 days. Rest and a light diet are encouraged during this time. (Options 1 and 4) The following manifestations indicate more serious brain injury and are not expected with simple concussion: Worsening headaches and vomiting (indicate high intracranial pressure) Sleepiness and/or confusion (indicate high intracranial pressure) Visual changes Weakness or numbness of part of the body Educational objective: Expected neurological changes with a concussion include brief loss of consciousness, retrograde amnesia, and headache. These clients should be observed closely by family members and not participate in strenuous or athletic activities for 1-2 days.
The nurse is reviewing new prescriptions from the health care provider. Which prescription would require further clarification? 1. Atorovastin for hyperlipidemia in a pt with angina pectoris 2. Bupropion for smoking cessation in a pt with emphysema 3. Cyclobenzaprine for muscle spams in a pt with hepatitis 4. Metronidazole for trichomoniasis in a pt wit Crohn disease
3. CYCLOBENZAPRINE FOR MUSCLE SPASMS IN A PT WITH HEPATITS 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). (Option 1) Atorvastatin (Lipitor) is a statin prescribed for hyperlipidemia. It is used for primary and secondary prevention of cardiovascular disease and would not warrant further clarification when used in a client with angina pectoris. (Option 2) Bupropion (Wellbutrin, Zyban) and varenicline (Chantix, Champix) are commonly prescribed for smoking cessation. Both bupropion and varenicline can cause serious neuropsychiatric effects (eg, depression, suicide); however, there is no contraindication for clients with emphysema. (Option 4) Metronidazole (Flagyl) is an antibiotic that can be used to treat a Trichomonas infection. There is no contraindication for its use in clients with Crohn disease. Educational objective: Like many medications, skeletal muscle relaxants (eg, cyclobenzaprine) are metabolized hepatically. In the presence of hepatic impairment (eg, hepatitis), drug metabolism is reduced and results in the accumulation of medication in the body, which leads to toxicity and serious adverse effects.
The health care provider is preparing to place a fetal scalp electrode to monitor the fetus of a laboring client. Which of the following assessment findings should the nurse communicate to the health care provider immediately? 1. Cervix 3 cm dilated 2. Fetal presenting part is engaged 3. Fetus is in the breech position 4. Hepatitis B surface antigen test is positive
4. HEPATITIS B SURFACE ANTIGEN TEST IS POSITIVE A fetal scalp electrode (FSE) is a common, internally applied, electronic monitoring device used to evaluate the fetal heart rate more closely. Indications for FSE placement may include high-risk maternal conditions (eg, obesity, diabetes, hypertension) and/or fetal complications (eg, late decelerations, minimal variability). The nurse should notify the health care provider (HCP) about intact amniotic membranes because artificial rupture of membranes will be required; FSE placement involves inserting a small, sharp electrode directly into the fetal scalp or presenting part. FSE placement should be avoided, if possible, in the presence of bloodborne infections (eg, hepatitis B, HIV) because the risk of fetal infection is increased by the small puncture created by the FSE (Option 4). (Option 1) Cervical dilation of at least 2-3 cm is required for FSE placement. Sufficient dilation allows the HCP to verify that the FSE is not on the fontanelles, face, genitals, or cervix. (Option 2) It is helpful if the fetal presenting part is engaged to allow proper placement, but it is not required. (Option 3) A breech fetus is not a contraindication to FSE placement; however, the HCP should take care to avoid the fetus' genital region. Educational objective: Placement of a fetal scalp electrode (FSE) may be necessary when strict, continuous fetal heart rate monitoring is required. The nurse should be aware of the client's cervical dilation (≥2-3 cm dilated), membrane status, and history of bloodborne infections (eg, hepatitis B, HIV) prior to FSE placement.
The clinic nurse evaluates a client who was prescribed lithium therapy a month ago for bipolar disorder. Which client statement would cause the most concern? 1. I've felt the need for an afternoon nap most days this week 2. I've gained 3 lbs since I began taking this medication 3. I've had the stomach flu for the past couple of days 4. My mouth seems drier than usual lately.
3. I'VE HAD THE STOMACH FLU FOR THE PAST COUPLE OF DAYS Lithium is often used in the treatment of bipolar disorder. It has expected, mild side effects as well as potentially serious ones related to drug toxicity. Drowsiness, weight gain, dry mouth, and gastrointestinal upset are expected, mild side effects. Lithium toxicity occurs with dehydration, hyponatremia, decreased renal function, and drug-drug interactions (eg, nonsteroidal anti-inflammatory drugs, thiazide diuretics). Lithium and sodium are closely related in the body. Acute viral gastroenteritis (stomach flu) presents with abrupt onset of diarrhea, nausea, vomiting, and abdominal pain. Clients with vomiting and diarrhea are at risk of developing dehydration and/or low serum sodium, increasing the risk for lithium toxicity (Option 3). (Option 1) Drowsiness is an expected side effect. The nurse should advise the client to avoid hazardous activities and driving until the effects of lithium are known or this side effect subsides. (Option 2) Weight gain is an expected side effect. The nurse should provide client education about healthy food choices and proper exercise and/or provide for a dietary consult. (Option 4) Dry mouth is an expected side effect. The nurse should provide client teaching about measures to counteract this side effect (eg, ice chips, sugarless gum or candy, drinking plenty of water). However, excessive urination and polydipsia indicate nephrogenic diabetes insipidus from lithium toxicity. Educational objective: Dehydration and sodium loss from vomiting and diarrhea can lead to toxic lithium levels in clients receiving lithium therapy.
The nurse assesses 4 clients in the emergency department. Which client should the nurse prioritize first? 1. 12 year old with RLQ abdominal pain that started in the periumbilical region 2. 14 year old with severe scrotal pain; right testicle is tender, swollen, and more elevated than the left 3. 16 year old with sickle cell disease who has excrutiatinggeneralized body pain 4. 34 year old with sudden onset, right sided flank pain radiating to the right groin
2. 14 YEAR OLD SEVERE SCROTAL PAIN; RIGHT TESTIS IS TENDER, SWOLLEN, AND MORE ELEVATED THAN THE LEFT 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. (Option 1) Right lower quadrant pain referred from the periumbilical area is a classic sign of appendicitis. If left untreated, the appendix could perforate and release bacteria into the abdomen, causing peritonitis, a more serious condition. Surgery is usually required within 24 hours. This client should receive prompt attention but is not a priority over the client with testicular torsion. (Option 3) Clients with sickle cell disease have episodes of sickle cell crisis, in which the sickle-shaped cells occlude the blood vessels. This decreased blood flow is responsible for the generalized body pain. This client should be treated emergently with pain medications and IV fluids but is not a priority over the client with testicular torsion. (Option 4) Sudden-onset, right-sided flank pain radiating to the groin is classic for renal stones. Kidney stones are very painful but in most cases cause no permanent damage unless a stone completely blocks kidney flow. This client is not a priority over the client with testicular torsion. 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.
What is the best activity for a school-aged child hospitalized for vaso-occlusive sickle cell crisis? 1. Finger painting 2. Playing a game of chinese checkers in the activity room 3. Playing video games 4. Watching a movie
4. Watching a movie A child in vaso-occlusive sickle cell crisis will be experiencing a high level of pain due to the occlusion of small blood vessels from increased red blood cell sickling. Supportive and symptomatic treatment includes round-the-clock pain management with opioids, intravenous fluids for hydration, and bed rest to decrease energy expenditure and oxygen demand. Age-specific nonpharmacologic strategies should also be implemented to manage pain and help limit the amount of needed narcotic analgesia. For a school-aged child, such activities include distraction (watching TV, listening to music, reading), relaxation, guided imagery, warm soaks, positioning, and gentle massage. (Option 1) Finger painting is messy and best done in the activity room; it is not appropriate for a child confined to bed. (Option 2) A child must be on bed rest when in vaso-occlusive sickle cell crisis. Playing a game in the activity room does not maintain bed rest and would be too stimulating for the child. (Option 3) Playing video games may be too exciting and stimulating for the child; an environment low in stimuli will promote rest. Educational objective: Supportive and symptomatic treatment for vaso-occlusive sickle cell crisis includes pain management and bed rest. Nonpharmacologic measures to alleviate pain include distraction (watching TV, listening to music, reading), relaxation, guided imagery, warm soaks, positioning, and gentle massage.
A nurse prepares a client for knee arthroscopy requiring general anesthesia. Which actions should the nurse complete? Select all that apply. 1. Encourage the pt to void prior to surgery 2. Ensure that the pt has been on NPO status 3. Place signed informed consent in the pt's chart 4. Replace the current 20 gauge with an 18 gauge 5. Witness that the corrct surgery site is marked by the surgeon
1, 2, 3, & 5 Nursing responsibilities prior to surgery include assessment, client teaching, and communication with the health care provider. Client allergies and history are confirmed while baseline vital signs are collected. Other nursing preoperative responsibilities include: Confirming that informed consent has taken place and signed documents are placed in the client's chart (Option 3). Encouraging the client to void to reduce the risk of retention in the immediate recovery period (Option 1). Ensuring that the client has been on NPO status to avoid aspiration during surgery and documenting when it started (Option 2). Witnessing and documenting preoperatively that the correct surgical site is marked by the surgeon with a permanent marker. Verify this with the client, ensuring that surgery will take place on the correct side/site (Option 5). (Option 4) If an IV line has not been started, an 18-gauge catheter is preferred. However, if a functioning IV line is already present, a 20-gauge is acceptable. Blood products, if needed during surgery, can be transfused through a 20-gauge catheter if necessary. Educational objective: When preparing a client for surgery, the nurse needs to ensure that informed consent has taken place and signed documents are in the chart. The nurse also witnesses that the correct operative site is marked and verified by the client and ensures that the client is NPO and voids prior to surgery.
Emergency medical service personnel are transporting a near-drowning victim who is currently hypothermic. Based on anticipated vital signs, the nurse needs to prepare for which interventions? Select all that apply. 1. Covering pt with warm blankets 2. Logrolling pt from side to side frequently 3. Mechanical ventilation 4. Warmed blood admin 5. Warmed IV fluids
1, 3, & 5 The initial management of a near-drowning victim focuses on airway management due to potential aspiration (leading to acute respiratory distress syndrome), pulmonary edema, or bronchospasm (leading to airway obstruction). Hypoxia is managed and prevented by ensuring a patent airway via intubation and mechanical ventilation as necessary (Option 3). Careful handling of the hypothermic client is important because as the core temperature decreases, the cold myocardium becomes extremely irritable. Frequent turning could cause spontaneous ventricular fibrillation and should not be performed during the acute stage of hypothermia. Continuous cardiac monitoring should be initiated (Option 2). There are passive, active external, and active internal rewarming methods. Passive rewarming methods include removing the client's wet clothing, providing dry clothing, and applying warm blankets. Active external rewarming involves using heating devices or a warm water immersion. Active internal rewarming is used for moderate to severe hypothermia and involves administering warmed IV fluids and warm humidified oxygen (Options 1 and 5). (Option 4) Unless blood loss has occurred from trauma during the near-drowning incident, administration of blood products is not indicated. Educational objective: Emergency department care of near-drowning victims includes advanced airway management, aggressive oxygenation, establishing IV access and administering IV fluids (warmed if hypothermic), and monitoring for cardiac arrhythmias and fluid imbalances.
A parent calls the after-hours triage nurse about a 3-year-old who is sick with the flu. Which report by the parent would necessitate intervention by the nurse? 1. Acetaminophen being given every 4 hours for fever 2. Bismuth subsalicylate beinng used for nausea 3. Ibuprofen being given every 6 hours for body aches 4. Popsicles and gelatin desserts being used for hydration
2. BISMUTH SUBSALICYLATE BEING USED FOR NAUSEA The nurse should tell the parent to discontinue the use of bismuth subsalicylate (Pepto-Bismol) as it contains a salicylate (same class as aspirin) and could possibly cause Reye syndrome. Reye syndrome can develop in children with a recent viral illness such as varicella or influenza. It can cause acute encephalopathy and hepatic dysfunction. Children with viral infections should not be given aspirin or products containing salicylates. (Options 1 and 3) Acetaminophen and ibuprofen are being used appropriately. (Option 4) Sufficient fluids are important to maintain hydration in the child with influenza. Water and fluids should be offered frequently; popsicles and gelatin desserts (eg, Jell-O) provide a palatable means of getting children to ingest fluids. Educational objective: The nurse should tell the parent not to administer any product containing aspirin or salicylates to a child with a viral infection (eg, influenza, varicella) to prevent Reye syndrome.
An 8-month-old infant is scheduled for a femorally inserted balloon angioplasty of a congenital pulmonic stenosis in the cardiac catheterization laboratory. Which finding should the nurse report to the health care provider that could possibly delay the procedure? 1. Auscultation of a load heart murmur 2. Infant has been NPO for four hours 3. Infant has severe diaper rash 4. Slight cyanosis of the nail beds
3. INFANT HAS SEVERE DIAPER RASH Pulmonic stenosis causes increased pressure in the right side of the heart as the ventricle tries to push blood through the narrowed pulmonary area to the lungs. In severe pulmonic stenosis, higher pressure in the right side of the heart causes unoxygenated blood to travel to the left side through the foramen ovale (or other congenital defect) and into the systemic circulation, leading to chronic hypoxia and cyanosis and requiring repair (interventional catheterization or surgery). The presence of severe diaper rash should be reported to the health care provider (HCP). This could delay the procedure if the rash is in the groin area where access is planned for a femorally inserted arterial cannula. Yeast or bacteria may be present on the rash and could be introduced into the bloodstream with the arterial stick (Option 3). (Option 1) A loud heart murmur can be an expected finding in a child with pulmonic stenosis. (Option 2) Children are NPO for 4-6 hours or longer before the procedure. Younger children and infants may have a shorter period of NPO status and should be fed right up to the time recommended by the HCP. (Option 4) Cyanosis indicates severe pulmonic stenosis with right-to-left shunt and the need for interventional catheterization or surgery without delay. Educational objective: The nurse should report the presence of severe diaper rash in an infant who has an interventional catheterization procedure planned. The rash may delay the procedure due to possible contamination at the insertion site.
The nurse administers the prescribed dose of hydromorphone 2 mg to a client who is 2 days postoperative from a colostomy. Which assessment finding is most important for the nurse to follow-up? 1. Pt has 1 emesis of gree fluid 2. Pt has no bowel movement for 2 days 3. Pt falls asleep while talking to the nurse 4. Pt reports expereincing pruritis
3. PT FALLS ASLEEP WHILE TALKING TO THE NURSE Respiratory depression is the most serious side effect of narcotic medication. Sedation precedes respiratory depression. Falling asleep during a conversation scores "3" on the Pasero Opioid-Induced Sedation Scale (POSS); no additional narcotics should be given to the client. Other classes of drugs (eg, non-steroidal anti-inflammatory medications) can be given if the client is still in pain. The client will also be at increased risk for respiratory depression if the pain is completely relieved and/or it is night time. No additional narcotics should be given until the client is at level 2 sedation on POSS (eg, slightly drowsy, easily aroused). (Option 1) Nausea or vomiting is a typical side-effect of narcotic administration, especially when it is given in a larger dose or to the opioid-naïve client. It usually lessens with time and repeat administration. Nausea or vomiting would not be a concern unless it is excessive or severe. The nurse should ensure that the client receives adequate hydration (eg, intravenous fluids, clear liquids, antiemetics). (Option 2) Constipation is a known side effect of opioid administration and does not lessen with long-term administration. Proactive measures are needed as long as the client is on narcotics. However, large intestine peristalsis does not usually start until 2-3 days after surgery. (Option 4) Pruritus (itching) is a known side effect of narcotic administration. It is usually treated with diphenhydramine (Benadryl) or some other antihistamine. Educational objective: Sedation precedes respiratory depression in narcotic administration. A client (especially if on high doses) should be assessed for sedation level. Level 3 sedation on POSS requires that no additional narcotics be administered to the client.
A client is seen following a motor vehicle collision. An IV infusion of 1 L 0.9% normal saline solution was administered before arrival at the hospital. The IV line is now infusing at 200 mL/hr. Which assessment finding alerts the nurse to the development of hypovolemic shock? 1. JVD 2. MAP 65 3. UOP <0.5 4. Warm, flushed skin
3. UOP <0.5 Hypovolemic shock most commonly occurs from blood loss but can occur in any condition that reduces intravascular volume. Hypovolemia is classified as either an absolute (eg, hemorrhage, surgery, gastrointestinal bleeding, vomiting, diarrhea) or a relative (eg, pancreatitis, sepsis) fluid loss. Reduced intravascular volume results in decreased venous return, decreased stroke volume and cardiac output, inadequate tissue perfusion, and impaired cellular metabolism. Clinical manifestations of hypovolemic shock are associated with inadequate tissue perfusion and include: Change in mental status Tachycardia with thready pulse Cool, clammy skin Oliguria Tachypnea Decreased urine output (<0.5 mL/kg/hr) despite fluid replacement indicates inadequate tissue perfusion to the kidneys and is a manifestation of hypovolemic shock in a client with normal renal function (Option 3). (Option 1) Jugular venous distension is associated with increased central venous pressure and intravascular volume. Hypovolemic shock is associated with decreased intravascular volume and central venous pressure (<2 mm Hg). (Option 2) A mean arterial blood pressure of 70-105 mm Hg is considered normal, and >60 mm Hg is needed for adequate tissue perfusion to vital organs (brain, coronary artery). (Option 4) Warm, flushed skin can be an early sign of septic or neurogenic shock but is not associated with hypovolemic shock. Educational objective: Clinical manifestations of hypovolemic shock are associated with inadequate tissue perfusion and include change in mental status; tachypnea; tachycardia with thready pulse; cool, clammy skin; and oliguria.
The labor and delivery (L&D) nurse is floated to a medical-surgical floor for a shift. Which client is most appropriate for the charge nurse to assign to the L&D nurse? 1. Pt with an occluded AV fistula receiving IV heparin infusion 2. Pt with cirrhosis and ascites requiring bedside paracentesis 3. Pt with diabetes who is one day post op belowe the knee amputation 4. Pt with pyelonephritis who is febrile and receiving IV antibiotics
4. PT WITH PYELONEPHRITIS WHO IS FEBRILE AND RECEIVING IV ANTIBIOTICS Nurses must sometimes "float" to a nursing unit outside of their normal area of practice based on staffing needs. A nurse who floats to an unfamiliar practice area should be assigned clients who do not require specialized knowledge and can be safely managed with similar skills as with their usual client population. It is the responsibility of the floated nurse to inform the supervisor of any lack of experience with the client population and to request orientation to the unit. Labor and delivery (L&D) nurses possess focused knowledge and training to care for the obstetric population but are able to generalize many skills to other client populations. L&D nurses frequently care for pregnant women with urinary tract infections and would be familiar with the management of a client with pyelonephritis. The administration of IV antibiotics is a general nursing skill with which all nurses should be familiar (Option 4). (Option 1) The L&D nurse is likely unfamiliar with IV heparin administration, which requires close monitoring and specific knowledge of infusion titration. (Option 2) The L&D nurse likely lacks the specific knowledge required to assist with bedside paracentesis and monitor for potential post-procedure complications. (Option 3) A client who undergoes an amputation has unique educational and care needs, with which the L&D nurse is likely unfamiliar. Educational objective: A float nurse should be assigned clients who require care similar to the nurse's usual client population. Clients requiring care from a nurse with specialized knowledge should not be assigned to a float nurse.
The nurse cares for a group of clients on a medical surgical floor. The client with which condition is at highest risk for developing syndrome of inappropriate antidiuretic hormone (SIADH)? 1. Carpal tunnel sundrome 2. Diabetes mellitus 3. Sciatica 4. Small cell lung cancer
4. SMALL CELL LUNG CANCER SIADH is an endocrine condition in which too much ADH is produced, causing water retention, increased total body water, and dilutional hyponatremia (low serum sodium). Some cancer cells, particularly those of small cell lung cancer, have the ability to produce and secrete ADH, leading to SIADH. Other causes include central nervous system disorders (eg, stroke, trauma, neurosurgery) and some commonly used medications (eg, desmopressin, carbamazepine). (Options 1 and 3) Carpal tunnel syndrome is a result of aggravated tendons in the wrists causing narrow, pinched nerves. Sciatica is numbness, tingling, or pain caused by an irritation of the sciatic nerve. Both are examples of peripheral nerve disorders. SIADH is more common among clients with central nerve disorders (eg, stroke, neurosurgery). (Option 2) Diabetes mellitus is an endocrine disorder characterized by hyperglycemia and is not commonly associated with SIADH. Educational objective: ADH is sometimes produced and secreted by cancer cells, especially lung cancer cells causing SIADH, a condition in which too much ADH causes water retention, increased total water, and dilutional hyponatremia.
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 HCP
4. USE ALTERNATIVE BIRTH CONTROL UNTIL CLEARED BY THE HCP 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). (Options 1, 2, and 3) The length of time and number of ejaculations necessary to evacuate remaining sperm will vary. The only way to ascertain that the ejaculate no longer contains sperm is to test a client's semen samples. Educational objective: To prevent an unwanted pregnancy following a vasectomy, alternative methods of birth control should be used until semen samples are found to be free of sperm.
