July 9

The nurse is performing a physical assessment on a 2-year-old with cold symptoms and a fever at home of 101.7 F (38.7 C). The parent is concerned about the child's ability to cooperate during the examination. Place the components of assessment in the order the nurse would perform them. All options must be used.

-Auscultate the child's heart and lungs -Interact with the parent in a friendly manner -Measure the child's height and weight -Play with the child using a finger puppet -Take the child's vital signs

The nurse is administering IV hydromorphone to a client every 3-4 hours as needed for postoperative pain. Which interventions should the nurse implement? Select all that apply. 1. Administer IV hydromorphone over 5-10 seconds 2. Administer PRN stool softener with daily medication 3. Hold hydromorphone if pt is not practicing deep breathing exercises 4. Perform reassessment an hour after administration 5. Tell the pt to call for assistance before getting out of bed

2 & 5 Opioid analgesics (eg, hydromorphone, morphine) are effective for controlling moderate to severe pain. Major side effects include sedation, respiratory depression, hypotension, and constipation. The client is at risk for falls from sedation or hypotension and should not get out of bed unassisted (Option 5). Slowed bowel motility persists throughout opioid use, and measures to prevent constipation (eg, administration of daily stool softeners) should be implemented (Option 2). (Option 1) IV hydromorphone should be administered slowly over 2-3 minutes. Rapid IV administration of opioid analgesics can cause severe hypotension and respiratory or cardiac arrest. (Option 3) Postoperative clients may experience pain with breathing exercises (eg, turning, coughing, deep breathing, incentive spirometry). Uncontrolled postoperative pain may cause clients to avoid deep breathing and lead to atelectasis and pneumonia. The nurse should administer opioids to achieve adequate pain control as needed to encourage participation in postoperative exercises and prevent complications. (Option 4) The nurse should reassess pain and sedation level during the opioid's peak effect, which is 15-30 minutes after administration of IV hydromorphone. Educational objective: Opioid analgesics are effective for managing postoperative pain, which encourages participation in deep breathing exercises. Side effects of opioid analgesics include sedation, respiratory depression, hypotension, and constipation. The nurse should administer IV hydromorphone slowly over 2-3 minutes, monitor sedation level, instruct the client not to get out of bed unassisted, and administer PRN stool softeners.

The nurse is caring for a 7-year-old child diagnosed with nephrotic syndrome who will be discharged soon. Which statement by the parent indicates the need for reinforcement of teaching? 1. Cutting down on added salt will be good for the whole family 2. I'll organize lots of playdates to keep my child's spirits up 3. I'll restrict my child's fluids if I notice swelling or weight gaijn 4. I'll test for protein in my child's urine every day

2. I'LL ORGANIZE A LOT OF PLAYDATES TO KEEP MY CHILD'S SPIRITS UP Nephrotic syndrome, an autoimmune disease, affects children age 2-7 and is characterized by increased permeability of the glomerulus to proteins (eg, albumin, immunoglobulins, natural anticoagulants). Loss of albumin in urine leads to hypoalbuminemia; this causes decreased plasma oncotic pressure, which allows fluid to leak out of the vascular spaces. Reduced plasma volume (hypovolemia) activates kidneys to retain salt and water (renin-angiontensin-aldosterone system). Clients will have generalized edema, weight gain, loss of appetite (from ascites), and decreased urine output. Loss of immunoglobulins makes children susceptible to infection. Treatment typically includes: Corticosteroids and other immunosuppressants (eg, cyclosporine) Loss of appetite management by making foods fun and attractive Infection prevention (eg, limiting social interaction until the child is better) (Option 2) (Option 1) A regular diet without added salt is prescribed to prevent edema while in remission. More stringent sodium restrictions are necessary when symptoms are present. (Option 3) Fluid restriction is needed in severe cases of edema. (Option 4) There is a high risk for recurrence after recovery, and relapses may occur several times per year. The parent/caregiver should test daily for proteinuria, weigh the child weekly, and keep a diary of results. Early detection and treatment improve the course of the illness. Educational objective: Nephrotic syndrome is characterized by massive proteinuria, edema, and hypoalbuminemia. Home management includes a low-sodium diet with attractive foods; infection prevention; fluid restriction for severe edema; and monitoring of weight gain and proteinuria to detect relapse.

A nurse on a pediatric unit is admitting a school-aged child with suspected Reye syndrome. Which information obtained during the history taking is most consistent with this condition? 1. No history of varicella vaccine adminstration 2. Recent exposure to bats 3. Recent influenza infection 4. Recent use of acetaminophen use

3. RECENT INFLUENZA INFECTION Children who develop Reye syndrome often have had a recent viral infection, especially varicella (chicken pox) or influenza. Clinical manifestations include fever, lethargy, acute encephalopathy, and altered hepatic function. Elevated serum ammonia levels are an expected laboratory finding. Acute encephalopathy manifests with vomiting and a severely altered level of consciousness; it can rapidly progress to seizures and/or coma. The risk of developing Reye syndrome increases if aspirin therapy is used to treat the fever associated with varicella or influenza. As a result of this awareness, there has been a significant increase in the use of acetaminophen or ibuprofen for fever management in children. (Option 1) Although a child who has not received the varicella vaccine may have an increased risk of developing chicken pox, this evidence alone is not enough to substantiate suspected Reye syndrome. (Option 2) Recent exposure to bats would place the child at risk for rabies, a severe infection affecting the nervous system. This finding would not be indicative of Reye syndrome. (Option 4) The use of aspirin to treat fever, especially in clients with Kawasaki disease, can be associated with Reye syndrome. Acetaminophen is an appropriate antipyretic choice to reduce the risk of Reye syndrome. Educational objective: Reye syndrome is characterized by fever, acute encephalopathy, and altered hepatic function. It often develops following a viral infection, especially varicella or influenza. The risk of developing Reye syndrome increases if aspirin therapy is used to treat fever.

The nurse is planning teaching for a client newly diagnosed with Sjögren's syndrome. Which measures will the nurse include in the teaching plan? Select all that apply. 1. Chewing sugar free gum or using artificial saliva 2. Scheduling regular dental examinations 3. SHowering with lukewarm water and avoiding harsh soaps 4. Using OTC decongestants to alleviate nasal symptoms 5. Using OTC lubricants to ease vaginal dryness

1, 2, 3, & 5 Sjögren's syndrome is a chronic autoimmune disorder in which moisture-producing exocrine glands of the body are attacked by white blood cells. The most commonly affected glands are the salivary and lacrimal glands, leading to dry eyes (xerophthalmia) and dry mouth (xerostomia). Dryness in these areas can lead to corneal ulcerations, dental caries, and oral thrush. Other areas that can be affected and their symptoms include: Skin - dry skin and rashes Throat and bronchi - chronic dry cough Vagina - vaginal dryness and painful intercourse Treatment is focused on alleviating symptoms as there is currently no cure for Sjögren's syndrome. Over-the-counter or prescribed drops are used to relieve itching, burning, dryness, and gritty sensation in the eyes. Wearing goggles may offer further protection from drying caused by the wind. Dry mouth is treated with sugarless gum and candy or artificial saliva. Regular dental appointments to prevent dental caries are recommended. Lubricants (eg, K-Y Jelly) help to ease vaginal dryness. Use of lukewarm water and mild soap when showering can prevent dry skin. Avoiding low-humidity environments (eg, centrally heated houses, airplanes) and using humidifiers to maintain adequate humidity (mainly at night) are also recommended. (Option 4) Clients with Sjögren's syndrome are advised to avoid decongestants as they cause further dryness to the mouth and nasal mucosa. These clients should also avoid oral irritants (eg, coffee, alcohol, nicotine) and acidic drinks (eg, carbonated beverages, juices) and instead sip water frequently. Educational objective: Clients with Sjögren's syndrome need measures to combat the effects of damaged moisture-producing glands. These include eye drops, sugar-free candy or artificial saliva, vaginal lubricants, frequent dental examinations, lukewarm showers with mild soap, and avoiding decongestants.

The nurse has just received report. Which client should the nurse assess first? 1. Pt admitted from coronary angiography in the past hour with back pain 2. Pt with a DVT on heparin drip with an aPTT of 60 seconds 3. Pt with a head injury and a glasgow coma scale of 14 4. Postoperative day 2 coronary artery bypass graft pt with incisional pain rated 6 om pain scale

1. PT ADMITTED FROM A CORONARY ANGIOGRAPBY IN THE PAST HOUR WITH BACK PAIN Post-procedure care of a client who has undergone heart catheterization should focus on evaluating hemodynamics - blood pressure, heart rate, strength of the distal pulses, color, and temperature of extremities. The client should be also assessed several times per hour for active bleeding, hematoma, or pseudoaneurysm formation at the incision. The first hour after cardiac catheterization requires assessment every 15 minutes. Any report of back or flank pain should be assessed for possible retroperitoneal bleeding as back pain, tachycardia, and hypotension may be the only indication of internal bleeding. More than a liter of blood can pool behind the peritoneum in the pelvis undetected, and it may take up to 12 hours before a significant drop in hematocrit can be measured. Internal bleeding after cardiac catheterization is particularly dangerous due to frequent use of anticoagulant prescriptions in these clients. (Option 2) A heparin infusion is used for a client with DVT. An aPTT of 60 indicates a therapeutic value. The therapeutic range for a client on anticoagulation is usually 46-70 seconds (1½ -2 times the normal value). (Option 3) This client should be evaluated hourly for any change in neurological status. However, because the highest possible score on the Glasgow Coma Scale is 15 for a fully alert person, a client with a score of 14 is not in need of urgent reassessment. (Option 4) The report of incisional pain on postoperative day 2 would take second priority for further assessment, but evaluating a client with possible internal bleeding takes priority. Educational objective: Clients with any indication of compromised airway, breathing, or circulation always take priority. Signs of retroperitoneal bleeding are subtle and the onset of back pain or hypotension after angiography always requires further assessment for internal bleeding.

The nurse completes the preoperative assessment for a client scheduled for a total knee replacement today. Which information should the nurse report to the health care provider (HCP) as soon as possible before the surgery? 1. Has allergy to strawberries 2. Is experiencing burning on urination starting yesterday 3. Rates knee oain as 9 out of 10 4. Stopped taking colexib 7 days ago

2. IS EXPERIENCING BURNING ON URINATION STARTING YESTERDAY A recent/current infection is a contraindication to total joint replacement surgery as a wound infection is more likely to occur in a client with a preexisting infection. The nurse should report the new onset of burning on urination to the HCP. Burning could indicate the presence of a urinary tract infection. (Option 1) Allergy to strawberries is not a contraindication to the scheduled surgery. However, a latex allergy should be documented. (Option 3) Severe knee pain is expected in a client undergoing a total knee replacement. (Option 4) Clients are directed to stop taking nonsteroidal anti-inflammatory drugs, including selective COX-2 inhibitors (eg, celecoxib [Celebrex]), 7 days before surgery to decrease the risk of intra- and postoperative bleeding. Educational objective: A recent/current infection is a contraindication to elective total joint replacement surgery. Any clinical manifestation that could indicate the presence of an infection should be reported to the HCP as soon as possible before the surgery.

A nurse on the medical surgical unit has just received report. Which client should be seen first? 1. Pt 1 day post femoral popliteal bypass grafting who has an IV antibiotic due now 2. Pt diagnosed with DVT yesterday who reports some chest discomfort and cough 3. Pt with HTN and BP of 180/92 who reports a headache 4. Pt on fall precautions who just called the nure's station for assistance in using the bathroom immediately

2. PT DIAGNOSED WITH A DVT YESTERDAY WHO REPORTS SOME CHEST DISCOMFORT AND COUGH The client with DVT who is experiencing chest discomfort and cough should be seen first. This client is exhibiting possible signs of pulmonary embolism (PE), which can be a life-threatening complication. Signs and symptoms of PE include dyspnea, hypoxemia, tachypnea, cough, chest pain, hemoptysis, tachycardia, syncope, and hemodynamic instability. The nurse should elevate the head of the bed, administer oxygen, and assess the client. The health care provider should be notified of these findings. (Option 1) The administration of an IV antibiotic is important but should be done after the nurse has assessed the client with DVT. (Option 3) This client is hypertensive and most likely has a headache due to the high blood pressure. The nurse should assess this client after the client with DVT and administer any antihypertensives needed. (Option 4) This client can be delegated to unlicensed assistive personnel who can go to the room immediately. Educational objective: The nurse should prioritize the assessment of any client with DVT who is experiencing respiratory signs and symptoms and/or chest pain due to potential development of PE.

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

3. 65 YEAR OLD WITH TACHYCARDIA OF 110 AFTER LIVER BIOPSY The liver is a highly vascular organ and bleeding is a major complication. Tachycardia is an early sign of internal hemorrhage. The 65-year-old client should be assessed first. (Option 1) Tachycardia can be caused by underlying infection and can resolve with treatment of the infection. Valve infections can require several weeks of antibiotics. This client is not the priority. (Option 2) Pancreatitis is a very painful condition and sinus tachycardia is expected. These clients are also at risk of developing complications such as third spacing of volume and require large quantities of IV fluids. This client is the second priority. (Option 4) Atrial fibrillation is commonly treated with calcium channel blockers such as diltiazem. The dosage needs to be adjusted to achieve a goal heart rate of <100/min. Atrial fibrillation is usually not immediately life-threatening. Educational objective: Liver biopsy can cause internal bleeding. Clients with internal bleeding require priority assessment.

The emergency department nurse is triaging clients. Which neurologic presentation is most concerning for a serious etiology and should be given priority for definitive treatment? 1. History of bells palsy with unilateral facial droop and drooling 2. History of MS and reporting recent blurred vision 3. Reports unilateral facial pain when cunsuing hot foods 4. Temple region hit by ball, loss of conciousness, but Glasgow coma scale is now 14

4. TEMPLE REGIONS HIT BY BALL, LOSS OF CONCIOUSNESS, BUT GLASGOW COMA SCALE IS NOW 14 Epidural hematoma is an accumulation of blood between the skull bone and dura mater. The majority of epidural hematomas are associated with fracture of the temporal bone and subsequent rupture or tear of the middle meningeal artery. The bleed is arterial in origin, and so hematoma develops quickly. The clinical presentation of epidural hematoma is characteristic. The client may lose consciousness at the time of impact. The client then regains consciousness quickly and feels well for some time after the injury. This transient period of well-being is called a lucid interval. It is followed by a quick decline in mental function that can progress into coma and death. (Option 1) Bell's palsy (peripheral facial paralysis) is an inflammation of the facial nerve (CN VII) in the absence of other disease etiologies, such as stroke. There is flaccidity of the affected side with drooling. This differs from the concerning drooling with epiglottis in which the client's throat is too sore and/or swollen to swallow saliva. Treatment includes steroids, measures to relieve symptoms, and protection of the eye (which may not close tightly), but the condition is not emergent. (Option 2) Multiple sclerosis is a chronic, relapsing, and remitting degenerative disorder involving the brain, optic nerve, and spinal cord. Optic neuritis is a common presentation but is not life-threatening. (Option 3) Trigeminal neuralgia (tic douloureux) presents with paroxysms of unilateral excruciating facial pain along the distribution of the trigeminal nerve (CN V) that are often triggered by touch, talking, or hot/cold air or intake. Carbamazepine (Tegretol) is the drug of choice; the condition is not life-threatening. Educational objective: The classic presentation of intracranial epidural bleed is loss of consciousness to a period of lucidity and then gradual loss of consciousness. The bleed is arterial in origin, and so hematoma develops quickly. Emergent diagnosis and treatment are needed to prevent brain stem herniation.

A 28-year-old client is admitted to the labor and delivery unit for severe preeclampsia. She is started on IV magnesium sulfate. Which signs indicate that the client has developed magnesium sulfate toxicity? Select all that apply. 1. 0/4 patellar reflex 2. BP is 156/84 3. Pt voided 600 ml in 8 hours 4. Respirations are 10 min 5. Serum magnesium level is 5

1 & 4 Normal blood level of magnesium is 1.5-2.5 mEq/L (0.75-1.25 mmol/L). However, a therapeutic magnesium level of 4-7 mEq/L (2.0-3.5 mmol/L) is necessary to prevent seizures in a preeclamptic client (Option 5). Magnesium toxicity causes central nervous system depression because toxic magnesium levels (>7 mEq/L) [3.5 mmol/L]) block neuromuscular transmission. Absent or decreased deep-tendon reflexes (DTRs) are the earliest sign of magnesium toxicity. DTRs are scored on a scale of 0-4+ and should be assessed during magnesium infusion; normal findings are 2+ (Option 1). If toxicity is not recognized early (eg, decreasing DTRs), clients can progress to respiratory depression, followed by cardiac arrest (Option 4). Assessments (including vital signs) should be performed every 5-15 minutes during the loading dose, followed by 30- to 60-minute intervals until the client stabilizes, then every 2 hours. Treatment for magnesium toxicity is immediate discontinuation of the infusion. Administration of calcium gluconate (antidote) is recommended only in the event of cardiorespiratory compromise. (Option 2) Hypertension is a sign of preeclampsia, not of magnesium toxicity. Hydralazine (Apresoline), methyldopa (Aldomet), or labetalol (Trandate) is used to lower blood pressure (BP) if needed (typically when BP is >160/110 mm Hg). (Option 3) Urine output <30 mL/hr is a sign of magnesium toxicity. Educational objective: The therapeutic level of magnesium for preeclampsia-eclampsia treatment is 4-7 mEq/L (2.0-3.5 mmol/L). Signs of magnesium toxicity are decreased or absent deep-tendon reflexes, respiratory depression, decreased urine output (<30 mL/hr), and cardiac arrest. Calcium gluconate (antidote) should be readily available in the event of cardiorespiratory compromise.

Which client condition is concerning and requires further nursing assessment and intervention? Select all that apply. 1. Before liver biopsy, pulse is 80/min and BP is 120/80; 1 hour afterward pulse is 112 and BP is 90/60 2. Before lumbar puncture, pulse is 100/min and BP is 140/86; 1 hour afterward, pulse is 80/min and BP is 126/82 3. Pt with coronary artery disease on metoprolol, pulse is 62 4. Elderly pt with black stools, pulse is 112 5. Neonate crying inconsolably at feeding time, pulse is 160

1 & 4 The liver is very vascular, which places it at risk for internal bleeding after a tissue sample is removed for biopsy. Liver dysfunction typically results in coagulopathy as many coagulation factors are synthesized in the liver, thereby increasing the risk for bleeding. Early signs of blood loss/shock are tachypnea, tachycardia, and agitation. A later sign is hypotension. Black stools (melena) indicates slow upper gastrointestinal bleeding; tachycardia may indicate significant blood loss. Therefore, this client needs immediate assessment. (Option 2) This change in vital signs from preprocedure to postprocedure most likely reflects decreased anxiety. This client's vital signs are within normal range. Lumbar puncture does not produce bleeding serious enough to make a client hypotensive. If this client was bleeding, it would compress the spinal cord, causing paralysis in the lower extremities. (Option 3) This client has a pulse of 62/min (normal 60-100/min), which indicates a therapeutic effect of metoprolol. The nurse should monitor for bradycardia, which is a common and expected finding following administration of a beta-adrenergic blocker. Bradycardia would require nursing intervention only if the client became symptomatic (eg, hypotension, dizziness, nausea). (Option 5) A neonate's resting pulse is 110-160/min. Crying or vigorous kicking can cause a temporary rise. Vital signs are concerning if they rise when a client is at rest. Educational objective: Vital sign changes that are early signs of concern for hypovolemic shock are tachypnea, tachycardia, and agitation; hypotension is a late finding.

The nurse is preparing to defibrillate a client who suddenly went into ventricular fibrillation. Which steps are essential prior to delivering a shock? Select all that apply. 1. Apply defibrillator pads 2. Call out and look around to ensure that everyone is "all clear" 3. Continue chest compressions until ready to deliver shock 4. Ensure adequate IV sedation has been given 5. Ensure that the synchronization button is turned on

1, 2, & 3 Defibrillation is indicated in clients with ventricular fibrillation (Vfib) and pulseless ventricular tachycardia. Cardiopulmonary resuscitation (CPR) should be initiated and compressions continued until the shock is ready to be delivered (Option 3). Certain pulseless rhythms (asystole and pulseless electrical activity) do not need defibrillation. Steps to perform defibrillation are as follows: Turn on the defibrillator Place defibrillator pads on the client's chest (Option 1) Charge defibrillator. Chest compressions should continue until defibrillator has charged and is ready to deliver the shock. Before delivering the shock, ensure that the area is "all clear." Confirm that no personnel are touching the client, bed, or any equipment attached to the client (Option 2). Deliver the shock Immediately resume chest compressions (Option 4) IV sedation is not necessary for defibrillation as the client is already unconscious. It is often given prior to elective synchronized cardioversion to ease anxiety and decrease pain. (Option 5) Synchronized cardioversion delivers a shock on the R wave of the QRS complex and would not be appropriate for a client in Vfib (no identifiable QRS complexes). Rhythms that are ideal for synchronized cardioversion are supraventricular tachycardia, ventricular tachycardia with a pulse, and atrial fibrillation with rapid ventricular response. If the defibrillator is not synchronized with the R wave in a client with a pulse, the shock may be delivered on the T wave and can cause a lethal arrhythmia (eg, Vfib). Educational objective: The steps for defibrillation are as follows: Turn on the defibrillator, place pads on the client's chest, charge defibrillator, ensure the area is "all clear," deliver the shock, then resume compressions immediately.

The health care provider prescribes amoxicillin/clavulanate (liquid) twice a day for a child with acute sinusitis. What instructions are most important for the parents? Select all that apply. 1. Administer it with food is nausea or diarrhea develops 2. Complete the medication course even if the child is better 3. Expect a rash, which is normal, as a side effect 4. Shake the medicine well before use 5. Use a household spoon to measure the dose

1, 2, & 4 Amoxicillin/clavulanate belongs to aminopenicillin group and is often used to treat respiratory infections. Instructions for parents about amoxicillin include: The medication may be taken with or without food as food does not affect absorption The most common side effects of this medication are nausea, vomiting, and diarrhea. If nausea or diarrhea develops, the medicine may be administered with food to decrease the gastrointestinal side effects (Option 1). Shake the liquid well prior to administration. Administer at evenly spaced intervals throughout the day to maintain therapeutic blood levels (Option 4). Ensure that the child receives the full course of therapy; do not discontinue the medication if the child is feeling better or symptoms have resolved (Option 2). (Option 3) Rash, itching, dyspnea, or facial/laryngeal edema may indicate an allergic reaction, and the medication should be discontinued. (Option 5) Pediatric liquid medications are often dispensed with a measuring device designed to administer the exact dose prescribed. The following calibrated devices may be included: dropper, oral syringe, plastic measuring cup, or measuring spoon. Educational objective: Amoxicillin/clavulanate in liquid form should be shaken well prior to administration; the correct dose is administered using a calibrated measuring device. It is taken with or without food, at evenly spaced intervals, and until all the medication is consumed. If nausea or diarrhea develops, the medication may be administered with food.

The nurse is caring for a client who is in active labor at 39 weeks gestation and receiving a continuous intravenous (IV) infusion of oxytocin. The nurse notes frequent and persistent late decelerations on the fetal monitor. What actions should the nurse take? Select all that apply. 1. Administer oxygen via a nonrebreather face mask 2. Change the maternal position to the lateral side 3. Discontinue oxytocin infusion 4. Notify HCP 5. Perform a nitrazine test

1, 2, 3, & 4 This client is experiencing late decelerations. Nurses may use the mnemonic "VEAL CHOP" to help recall the different causes of change in fetal heart rate tracings. Late decelerations indicate uteroplacental insufficiency and are a sign of fetal intolerance to labor. Interventions are directed at correcting the cause of late decelerations, and delivery may be necessary. Nursing actions to improve fetal perfusion and oxygenation include: Discontinue uterotonic drugs (eg, oxytocin [Pitocin]) to reduce uterine activity—FIRST action Change the maternal position to the left side to relieve compression of the inferior vena cava Administer oxygen at 8-10 L/min via nonrebreather face mask Give prescribed intravenous (IV) bolus of lactated Ringer's or normal saline Notify the HCP (Option 5) The fern and nitrazine paper tests are used to assess for the presence of leaking amniotic fluid. The fern paper test is positive when a ferning pattern of dried amniotic fluid is visualized under a microscope. Nitrazine paper tests the pH of vaginal secretions (acidic with pH of 4.5-5.5). This test is positive when the pH strip turns blue, which indicates the presence of amniotic fluid (basic with pH of 7.0-7.5). These tests would be expected to be positive as this client is in active labor. Educational objective: Late decelerations indicate uteroplacental insufficiency and are a sign of fetal intolerance to labor. These are treated by discontinuing or decreasing oxytocin infusion (FIRST action), changing the maternal position to the lateral side, administering 8-10 L/min oxygen via a nonrebreather face mask, and giving an IV fluid bolus.

The nurse in an outpatient clinic receives a blood test report of moderately elevated thyroid-stimulating hormone (TSH) and markedly decreased T3 and T4 levels. Which signs and/or symptoms should be expected in the client's evaluation? Select all that apply 1. Cold intolerance 2. COnstipation 3. Forgetfullness 4. Hair loss 5. Warm, moist skin 6. Weight l.oss

1, 2, 3, & 4 Hypothyroidism is a thyroid disorder characterized by thyroid hormone deficit (low T3 and T4). TSH is elevated due to compensatory increase from pituitary. Hypothyroidism affects almost every body system and is predominately associated with a slow metabolic rate. Some common manifestations include the following: Decreased gut motility leading to constipation Cool and pale skin due to decreased blood flow; hyperkeratosis results in dry and rough skin Brittle nails and hair; hair loss due to poor blood supply Bradycardia from low metabolic state Joint pains and muscle aches are common Clients can develop dementia and depression due to mental slowing Cold intolerance characteristic Modest weight gain (Options 5 and 6) Weight loss; heat intolerance; shakiness; diarrhea; and warm, moist skin are symptoms associated with hyperthyroidism or an increased metabolic rate. Educational objective: Signs and symptoms of hypothyroidism (a thyroid hormone deficit) are associated with a low metabolic rate. Weight gain, constipation, dry skin, hair loss, cold intolerance, bradycardia, mental slowing (dementia and depression), and anemia are some of the most common manifestations.

The nurse is caring for a client at risk for aspiration pneumonia due to a stroke. What nursing actions help prevent this potential complication during hospitalization? Select all that apply. 1. Add a thickening agent to the fluids 2. Avoid sedating medications before meals 3. Place head of bed at 30 degrees or more 4. Restrict visitors who show signs of illness 5. Teach neck flexion during swallowing

1, 2, 3, & 5 Aspiration pneumonia develops when aspirated material (eg, food, emesis, gastric reflux) causes an inflammatory response and provides a medium for bacterial growth. At-risk conditions include cognitive changes (eg, dementia, head injury, stroke, sedation), difficulty swallowing, compromised gag reflex, and tube feeding. Aspiration-prevention measures include: Prevent vomiting of gastric contents by administering prescribed antiemetics (eg, ondansetron). Ensure that the client is fully awake before eating. Administration of sedating medications (eg, opioids, benzodiazepines) should be timed to prevent sedation during meals (Option 2). Elevate the head of the bed to at least 30 degrees (90 degrees during and for 30 minutes after meals) (Option 3). Encourage clients to facilitate swallowing by flexing the neck (chin to chest) (Option 5). Thicken liquids (eg, with nectar or honey) for clients with dysphagia; thin liquids are more difficult to control when swallowing (Option 1). Monitor for coughing, gagging, and pocketing food. (Option 4) Performing strict handwashing and limiting sick visitors are important infection-control measures; however, they do not prevent noninfectious aspiration pneumonia. Educational objective: Measures to prevent aspiration pneumonia include administering medications to prevent vomiting, avoiding mealtime sedation, maintaining head-of-bed elevation at 30 degrees or more (90 degrees during and 30 minutes after meals), and encouraging neck flexion while swallowing. Clients with dysphagia should receive thickened liquids and be monitored for coughing, gagging, and pocketing food.

The nurse is reviewing the medication administration record of a client with atrial fibrillation. Which of the following should the nurse monitor before giving these medications? Select all that apply. Click the exhibit button for more information. 1. Digoxin level 2. Glucose 3. INR 4. Platelet count 5. Serum potassium

1, 2, 4, & 5 The complete blood count (hemoglobin, hematocrit, platelet count) should be assessed periodically with the administration of enoxaparin, an anticoagulant that can cause bleeding and thrombocytopenia (Option 4). Digoxin levels are monitored for suspicion of digoxin toxicity (ie, serum levels >2 ng/mL) (Option 1). Potassium levels should also be monitored in clients receiving digoxin, as hypokalemia can potentiate digoxin toxicity (Option 5). Prednisone is a glucocorticoid that can cause hyperglycemia. Glucose levels should be monitored periodically in clients receiving this medication (Option 2). (Option 3) Low-molecular-weight heparins (eg, enoxaparin, dalteparin) produce a stable response at recommended dosages and negate the need for monitoring of activated partial thromboplastin time (aPTT) or international normalized ratio (INR) levels. aPTT is monitored when administering unfractionated heparin. INR is monitored in clients receiving warfarin (Coumadin). Educational objective: The nurse should routinely monitor laboratory values prior to administering medications. A complete blood count should be assessed periodically in clients receiving enoxaparin to monitor for bleeding and thrombocytopenia. Digoxin and potassium levels should be assessed with the administration of digoxin. Glucose levels should be monitored in the client receiving glucocorticoids.

The nurse is performing telephone triage with a client at 38 weeks gestation who thinks she may be in labor. Which questions would help the nurse determine whether the client is in labor? Select all that apply. 1. Do you feel like the contractions are getting stronger 2. Does anything you do make the pan better 3. Have you lost your mucous plug 4. How frequent are the contractions 5. Where do you feel the contraction pain most

1, 2, 4, & 5 True labor is defined as contractions that cause progressive cervical change over time. Probable signs of labor are identified by assessing the timing and intensity of contractions, the success of comfort measures in relieving the pain, and the location of the pain (Options 2 and 5). Consistent, intense contractions that get stronger and closer together (more frequent over time) and are associated with lower back discomfort that radiates to the abdomen are indicative of true labor (Options 1 and 4). If a woman is experiencing Braxton Hicks contractions (ie, "false labor"), the nurse should provide encouragement and education about signs of labor and suggest comfort measures. Comfort measures relieve maternal anxiety, increase coping, and encourage normal progression of labor. The nurse may suggest walking, taking a warm bath, resting in a lateral position, having a snack, staying hydrated, and voiding often. (Option 3) During pregnancy, a collection of secretions forms a "mucous plug" in the cervical canal, acting as a protective barrier. Although the client may notice expulsion of the mucous plug in the days preceding labor, it is not necessarily a sign of labor. Educational objective: True labor is defined as contractions that cause progressive cervical change over time. Consistent, intense contractions that get stronger and closer together and are associated with lower back discomfort that radiates to the abdomen are indicative of probable labor.

The parents of a 2-year-old client ask how they can help their child cope with hospitalization. Which of the following suggestions should the nurse give the parents? Select all that apply. 1. Follow as many home routines as possible 2. Organize a visit from a playgroup friend 3. Sleep in the child's hospital room at night 4. Take the child on regular visits to the playroom 5. Tell the child they did not cause the illness

1, 3, & 4 Hospitalization for toddlers (ie, 12-36 months) is particularly difficult due to separation anxiety and a limited ability to cope with stress. Toddlers thrive on home rituals and routines, which bring stability and reassurance. Hospitalization can severely disrupt these routines, triggering frustration and temper tantrums. Caregivers should maintain as many home routines as possible (eg, sleeping, eating) to help the child cope with unfamiliar hospital surroundings and procedures (Option 1). Parents should also stay with the child as much as possible, including overnight (ie, rooming-in), to provide consistency and alleviate separation anxiety (Option 3). Play, an important part of a child's emotional and social well-being, is an effective coping mechanism for children of all ages to deal with the stress of being away from home. The playroom is a safe place for children to act out their fears and anxieties related to illness and hospitalization (Option 4). (Option 2) A visit from friends is not likely to provide much comfort to a toddler and may actually cause additional stress. Adolescents, who are driven by peer interaction, would be more likely to benefit from this strategy. (Option 5) Preschool-aged children (3-5 years) have egocentric and magical thinking, which may cause them to think that their illness is due to something they have done or thought. Toddlers do not think this way. Educational objective: Coping mechanisms used by hospitalized toddlers include following homes rituals and routines, having parents stay with the child (including overnight), and using the playroom for relief of anxiety and fear.

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

1, 3, & 4 Receptive aphasia refers to impairment or loss of language comprehension (ie, speech, reading) that is caused by a neurological condition (eg, stroke, traumatic brain injury). The terms "aphasia" and "dysphasia" can be used interchangeably as both refer to impaired communication; however, "aphasia" is more commonly used. When assisting a client with receptive aphasia to complete activities of daily living, the nurse should avoid completing tasks for the client and should instead encourage independence using appropriate communication techniques. Appropriate interventions to aid communication include: Ask short, simple, "yes" or "no" questions (Option 1). Use gestures or pictures (eg, communication board) to demonstrate activities (Option 4). Remain patient and calm, allowing the client time to understand each instruction (Option 3). (Option 2) Clients with aphasia often become frustrated due to inability to communicate effectively. Frustration does not result from the nurse's care, so reassigning the client to a different care provider is not an effective solution. (Option 5) Eye contact is important in all communication, but raising the voice will not help. Speaking loudly will not improve comprehension and may increase anxiety and confusion. Educational objective: Receptive aphasia refers to impairment or loss of language comprehension. Appropriate interventions to aid communication include asking short, simple, "yes" or "no" questions; using hand gestures or pictures to demonstrate activities; and patiently allowing the client time to understand each instruction.

Which of the following drug administrations should be reported as a practice error? Select all that apply. 1. Cephalexin administered; pt has history of anaphylaxis from penicillin 2. Hydromorphone 2 mg sdministered; pt reports pruritis 3. Immunizations for 3 month old administered in ventrogluteal site 4. Oral niacin administered; pt has facial flushing 5. Warfarin administered; pt at 12 weeks gestation

1, 3, & 5 Warfarin (Coumadin) is generally contraindicated in pregnancy. Warfarin is a teratogen and exposure during early pregnancy can result in fetal malformations (warfarin embryopathy). It crosses the placenta, resulting in fetal anticoagulation; dangerous fetal bleeding, including intracranial hemorrhage, can occur. As a result, a client on warfarin is taught to use effective contraception (Option 5). For children age <7 months, the site for immunizations is the anterolateral thigh (vastus lateralis). The gluteus medius muscle (muscle injected with a ventrogluteal injection) is developed through crawling and walking. The muscles are not developed enough at this age to be used as an acceptable site (Option 3). History of penicillin hypersensitivity should be determined prior to administration. Clients who are truly allergic to penicillins (eg, anaphylaxis) have an increased risk of allergy to other beta-lactam antibiotics. The incidence of cross-reactivity is 1%-4% (Option 1). (Option 2) Pruritus (itching) is a known side effect of narcotic administration, particularly if the client is opioid naïve. It does not represent true allergy and is often treated with an antihistamine. Nausea is also quite common when opioid therapy is initiated, but clients quickly develop tolerance. (Option 4) Niacin (nicotinic acid or B3) is used in large doses for lipid-lowering properties. In large doses, it may produce cutaneous vessel vasodilation. The resulting warm sensation within the first 2 hours after oral ingestion is uncomfortable but harmless. It may last for several hours. Effects usually subside as therapy continues. Educational objective: Do not administer warfarin if the client is pregnant. Intramuscular injections are given in the vastus lateralis to children age <7 months. Penicillins and cephalosporins can have a cross-sensitivity response. Narcotic-induced pruritus is not a true allergy.

A client is seen in the ambulatory care center for treatment of a second episode of acute gout. Which lifestyle modifications would help prevent future exacerbations? Select all that apply. 1. Acheive and maintain healthy weight 2. Avoid foods containing protein 3. Drink plenty of fluids 4. Increase meat intake 5. Limit alcohol consumption

1, 3, & 5 Gout is an inflammatory condition caused by ineffective metabolism of purines, which causes uric acid accumulation in the blood. Uric acid crystals typically form in the joints. Kidney stones can also develop, increasing the risk of kidney damage. Clients with medical risk factors (eg, obesity, hypertension, dyslipidemia, insulin resistance) and other lifestyle factors (eg, poor diet, alcohol consumption, sedentary lifestyle) have increased risk for future gout attacks. Improvements in uric acid control are often seen when weight loss is accompanied by dietary modifications (Option 1). Suggested modifications include: Increasing fluid intake (2 L/day) to help eliminate excess uric acid (Option 3) Implementing a low-purine diet, particularly avoiding organ meats (eg, liver, kidney, brain) and certain seafood (eg, sardines, shellfish) Limiting alcohol intake, especially beer (Option 5) Following a healthy, low-fat diet, as excess dietary fats impair urinary excretion of urates (Option 2) It is unpalatable and impractical to avoid all foods containing protein. The risk of developing gout increases with high dietary purine intake but not necessarily with protein intake. Low-fat dairy products are good sources of protein that are associated with a reduced risk of gout. (Option 4) Increasing intake of meat, especially organ meats, will not prevent future gout attacks but may precipitate them. Educational objective: Weight loss and dietary modifications may reduce the frequency of acute episodes of gout. These strategies include increasing fluids, limiting daily alcohol consumption, and avoiding organ meats and seafood to reduce purine load.

Which actions by a registered nurse are reportable to the state board of nursing? Select all that apply. 1. Administering hydromorphone without a prescription 2. Being habitually tardy to work 3. Documenting an intervention that was not performed 4. Stealing narcotics 5. Walking off duty in the middle of a shift

1, 3, 4, & 5 The National Council of State Boards of Nursing advises any individual who has knowledge of a potential violation of a nursing law or rule to file a complaint with the appropriate state board of nursing. A nurse should be knowledgeable concerning the presiding board's stance on mandatory reporting and which actions are considered reportable. In general, reportable actions may include any behavior by a licensed nurse that is unsafe, unethical, incompetent, impaired (eg, by substances or a mental or physical condition), or in violation of nursing law. Practicing outside of the scope of the license is reportable even if the practice meets quality standards (Option 1). Documenting an intervention that was not performed is considered falsification of records regarding client care and is a reportable action (Option 3). Stealing narcotics is a criminal offense (a violation punishable by the state that can result in prison or a fine) and is reportable in all states. Many states offer an alternate rehabilitation program to nurses who diverted or abused drugs (Option 4). Abandonment (eg, leaving without proper replacement of personnel and transfer of responsibility for client care) is reportable in all states (Option 5). (Option 2) Work habits are handled under the facility's management policies and are often part of the criteria for discipline and/or termination. If the facility has 24-hour care, the off-going nurse cannot leave without someone assuming responsibility for the clients or waiting for the tardy nurse. Educational objective: Nurse offenses reportable to the state board of nursing include criminal acts (such as theft), practicing outside of the scope, falsification of records, and client abandonment. Any individual may file a complaint regarding an action that is potentially unethical, incompetent, impaired, or in violation of nursing law.

The nurse is returning the results of a urine pregnancy test to a client currently taking several medications. Which of the following prescriptions are contraindicated in pregnancy? Select all that apply. 1. Doxycycline 2. Fluticasone 3. Insulin aspart 4. Isotretinoin 5. Lisinopril 6. Thyroxine

1, 4, & 5 Doxycycline (Doryx) should not be used during pregnancy as it can impair bone mineralization in the fetus. Isotretinoin (Accutane) is a category X medication in pregnancy and causes severe birth defects. Retinoids may not be prescribed to a premenopausal client without a formal agreement to participate in the iPledge prescription tracking program. A commitment to always use at least 2 forms of birth control to prevent pregnancy is required. Angiotensin-converting enzyme (ACE) inhibitors such as lisinopril (Prinivil) should also not be used in pregnancy as they can affect kidney development in the fetus. (Option 2) Inhaled corticosteroids are classified under the United States Food and Drug Administration Pregnancy Category C - the drug has not been conclusively proven to be safe during pregnancy, but the prescription should be continued if there is a clear medical need (eg, severe asthma). (Option 3) Insulin is safe for use during pregnancy. (Option 6) The use of thyroxine (Synthroid) in pregnancy should be monitored carefully to provide an appropriate dose for the physiological changes of maternity, but it is not teratogenic. Educational objective: Commonly used medications that are absolutely contraindicated in pregnancy include doxycycline, isotretinoin, and ACE inhibitors.

The nurse is teaching the mother of a newborn about gastroesophageal reflux. What does the nurse suggest to help prevent reflux? Select all that apply. 1. Burp during and after feedings 2. Engage baby in active play after the feeding 3. Feed baby in side-lying position 4. Hold baby upright 20-30 minutes after each feeding 5. Offer small but more frequwnt feeds 6. Place baby on tummy after feeding

1, 4, & 5 Gastroesophageal reflux (GER) is attributed to an immature lower esophageal sphincter. It is common in infants age ≤3 months and results in spitting up after feeds. If an infant is gaining weight and meeting developmental milestones, treatment is aimed at controlling the symptoms. Because infants with GER are at risk for aspiration and apnea, caregivers should be instructed in cardiopulmonary resuscitation. Burping the baby frequently helps expel trapped air before milk builds up over it. If there is milk over an air pocket, the milk will come up with the burp (Option 1). Holding the baby upright for 20-30 minutes after feedings allows gravity to assist in keeping the food in the stomach while the stomach settles (Option 4). Feeding the baby smaller but more frequent feeds prevents the stomach from becoming too full and expelling extra milk and allows for more complete emptying before the next feed. It also ensures that the child is getting the required ounces daily (Option 5). (Options 2, 3, and 6) These infants should not be rocked or agitated by active play for at least 30 minutes after feeding and should be kept calm and upright. Placing them on the stomach creates abdominal pressure, which can aggravate the reflux. Infants should not be placed in a car seat after feedings as this can increase intra-abdominal pressure and cause reflux. Educational objective: Infants with gastroesophageal reflux should be offered small, frequent feeds; burped frequently during the feeding; and kept in an upright position during and after feedings.

Which pediatric presentation in the emergency department should the nurse follow up for possible abuse and mandatory reporting? 1. a 2 month old who rolled off the changing tbale and is now lethargic 2. A 3 month old with a flat bluish discoloration on the buttock that the mote=her says has been present since birth 3. A 3 year old with forehead bruises that the mother says come from running into a table 4. A 4 year old pulled boiling water off the stove and has splattered burns on the arms

1. A 2 MONTH OLD WHO ROLLED OFF THE CHANGING TABLE AND IS NOW LETHARGIC Infants do not start rolling until age 4 months and normally roll front to back at 5 months. This explanation for the injury does not fit the growth capacity of the child. Because lethargy is present, head injury must be ruled out. (Option 2) Congenital dermal melanocytosis (Mongolian spots) are an expected finding. These are seen on the lower back and/or buttock more often in African American, Asian, Hispanic, and Native American infants. Although they can be mistaken for bruising and the size and location should be documented, they are not a concerning finding and usually disappear by school age. (Option 3) A toddler's forehead is the height of many tables. Due to toddlers' lack of coordination, this explanation is plausible in the absence of other concerning findings (eg, child is afraid of caregiver, multiple bruises of various ages over other parts of the body, malnourished). (Option 4) Due to the child's short height, this is a credible explanation. A child can pull water down from a higher-level stove top. Burns that are suspicious for abuse include scalds without splash marks; scalds with a clear line of demarcation/immersion ("dunking"); scalds involving the perineum, genitalia, and buttocks; burns on the back (versus the front) of the child; mirror-image burn injury of the extremities; and cigarette burns. Educational objective: Infants begin to roll at age 4-5 months. History that does not match growth and development is a concern for abuse. Burns with splash, bruises from areas typically hit when falling, and Mongolian spots are expected findings.

The nurse is admitting a client at 41 weeks gestation for induction of labor due to oligohydramnios. Considering the client's indication for induction, what should the nurse anticipate? 1. Additional neonatal personnel present for birth 2. Intermittent fetal monitoring during labor 3. Need for forceps assisted birth 4. Need for uterotonic drugs for postpartum hemorrhage

1. ADDITIONAL NEONATAL PERSONNEL PRESENT DURING BIRTH Amniotic fluid is produced by the fetal kidney and serves 2 major purposes - to prevent cord compression and promote lung development. Oligohydramnios is a condition characterized by low amniotic fluid volume. This can occur due to fetal kidney anomalies (eg, renal agenesis or urine flow obstruction) or fluid leaking through the vagina (eg, undiagnosed ruptured membranes). Fluid volume also declines gradually after 41 weeks. Small uterine size for gestational age or a fetal outline that is easily palpated through the maternal abdomen should raise suspicion for oligohydramnios. Ultrasound confirms the diagnosis. Major complications of oligohydramnios are: Pulmonary hypoplasia - due to the lack of normal alveolar distension by aspirated amniotic fluid. Therefore, additional neonatal personnel should attend the birth in anticipation of possible resuscitation (Option 1). Umbilical cord compression - continuous (not intermittent) fetal monitoring should be applied to monitor for variable decelerations (Option 2). (Option 3) Operative vaginal birth (ie, use of forceps or vacuum) may be indicated due to prolonged second-stage labor or fetal distress. Oligohydramnios does not increase the likelihood of operative vaginal birth. (Option 4) Polyhydramnios (excessive amniotic fluid volume) is a risk factor for postpartum hemorrhage due to overdistension of the uterus. Oligohydramnios is not associated with postpartum hemorrhage. Educational objective: Oligohydramnios increases the risk for umbilical cord compression and pulmonary hypoplasia. Additional neonatal personnel should be present for possible resuscitation and/or evaluation of the newborn. The nurse should anticipate continuous fetal monitoring during labor to monitor for signs of cord compression.

The nurse is reviewing new prescriptions for assigned clients. Which prescription would require further clarification from the health care provider? 1. Altepase for an ischemic stroke in a pt with a BP of 192/112 2. Amoxicillin for a respiratory infection in a pt who is 20 weeks pregnant 3. Fentanyl for moderate to severe pain in a pt post appendectomy with an allergy to codeine 4. Sodium chloride 3% for a pt with SIADH

1. ALTEPASE FOR AN ISCHEMIC STROKE IN A PT WITH A BP OF 192/112 Thrombolytic agents (eg, alteplase, tenecteplase, reteplase) are often prescribed to resolve acute thrombotic events (eg, ischemic stroke, myocardial infarction, massive pulmonary embolism). They are recombinant plasminogen activators that activate the blood fibrinolytic system and dissolve thrombi. Thrombolytic agents are contraindicated in clients with active bleeding, recent trauma, aneurysm, arteriovenous malformation, history of hemorrhagic stroke, and uncontrolled hypertension (blood pressure >180/110 mm Hg). Therefore, the health care provider should be consulted for clarification. Administering alteplase in the presence of these conditions can cause hemorrhage, including life-threatening intracerebral hemorrhage (Option 1). (Option 2) Most penicillin derivates (eg, ampicillin, amoxicillin) and cephalosporins (eg, cephalexin, ceftriaxone) are generally considered safe for use by women who are pregnant or lactating. (Option 3) Fentanyl is appropriate in postoperative clients with moderate to severe pain, even those with a history of allergies to codeine. Both drugs have opiate agonist effects but are chemically different. Codeine is a derivative of natural opiates (eg, morphine), whereas fentanyl is completely synthetic. (Option 4) Syndrome of inappropriate antidiuretic hormone (SIADH) secretion results in water retention and dilutional hyponatremia. Clients with SIADH often require hypertonic saline for sodium repletion to increase serum sodium levels with a minimal infused volume of water. Educational objective: Thrombolytic agents (eg, alteplase, tenecteplase, reteplase) place clients at risk for bleeding. Therefore, they are contraindicated in clients with active bleeding, recent trauma, aneurysm, arteriovenous malformation, history of hemorrhagic stroke, and uncontrolled hypertension.

A male client has terminal metastatic disease. He arrives at the emergency department with respirations of 6/min and an advance directive indicating to withhold resuscitative efforts. What should the nurse's response be? 1. Apply oxygen at 2L BNC 2. Ask the pt if he wants to change his mind 3. Ask the spuse what she wants done 4. Determine who has medical power of attorney

1. APPLY OXYGEN AT 2L BNC Advance directives are prepared by a client prior to the need to indicate the client's wishes. A living will gives instructions about future medical care and treatment if the client is unable to communicate. A medical power of attorney is the individual designated to make health care decisions should a client become unable to make an informed decision. It allows more flexibility to deal with unique situations. Because the client has indicated specific desires, these should be honored. This is especially true as the client has a terminal condition (versus, for example, an acute choking episode that could be easily reversed). Oxygen can provide comfort and is not resuscitative when given by nasal cannula. (Option 2) Advance directives are determined ahead of time to guide decision making at the time of the event. The client can indicate a desire to make a change, and the original decision should be honored. This client could be experiencing hypoxia and thus not thinking as clearly as when the advance directives were made. Asking about changes could imply that he should make a change, which is not true. The original decision should be honored; however, the client can indicate a desire to make a change. (Option 3) The client's advance directives take legal precedence over the spouse's wishes. The spouse is consulted when there are no advance directives or durable power of attorney for health care. (Option 4) Advance directives include living wills with written directives on how to handle situations. A medical power of attorney is used in situations not covered by the written directives. This client has indicated his wishes. A durable power of attorney for health care is used only when clients have not expressed wishes or cannot speak for themselves. Educational objective: Advance directives include a living will (specific situations put in writing) or a medical power of attorney (an individual appointed when the clients are unable to speak for themselves). The client's wishes should be honored.

The spouse of an immunocompromised client is diagnosed with influenza virus infection. The spouse asks the office nurse how long contact with the client should be avoided to prevent the infection from spreading. What is the nurse's most appropriate response? 1. Avoid close contact for about a week 2. It's impossible to avoid contact with the pt. Just wash your hands often 3. You are sick already, and so you are not contagious anymore 4. You don't have to worry as long as the pt has received the influenza vaccination

1. AVOID CLOSE CONTACT FOR ABOUT A WEEK The influenza virus has an incubation period of 1-4 days, with peak transmission starting at about 1 day before symptoms appear and lasting up to 5-7 days after the illness stage begins (Option 1). (Option 2) Influenza is transmitted by inhaling droplets that an infected individual exhales into the air when sneezing, coughing, or speaking. If contact with others is unavoidable, wearing a mask can offer some protection against virus transmission. (Option 3) Individuals with the influenza virus can transmit the virus during the incubation period and illness stage of the infection. It is not appropriate to assume that the spouse can no longer transmit the infection. (Option 4) Although vaccination provides immunity against influenza in about 2 weeks after inoculation, it does not offer complete protection against all virus strains. Therefore, close contact with others should be avoided during the illness stage, especially those with an impaired immune system. Educational objective: Influenza is a highly contagious respiratory infection transmitted by airborne droplets and direct contact. It has an incubation period of 1-4 days, with peak transmission starting at about 1 day before symptoms appear and lasting up to 5-7 days after the illness stage begins. Vaccination does not offer complete protection against all virus strains.

The parent of an 11-month-old child calls the pediatric outpatient clinic and tells the nurse that the child was exposed to measles 2 days ago during a family trip to a theme park. What is the best response by the nurse? 1. Bring the baby to the clinic for the MMR vaccine 2. Check the baby's temperature twice a day 3. Do not allow the child to have contact with other children 4. Does your child have a fever or rash?

1. BRING THE BABY TO THE CLINIC FOR THE MMR VACCINE The Centers for Disease Control and Prevention (CDC) recommends that the first dose of MMR vaccine be given to children between age 12-15 months to ensure optimal vaccine response. However, the vaccine is safe for children age <12 months; it could provide some protection or modify the clinical course of the disease if administered within 72 hours of the child's initial measles exposure. Immunoglobulin, if administered within 6 days of exposure, is also utilized as post-exposure prophylaxis. A child who receives the MMR vaccine prior to the first birthday will need to be revaccinated at age 12-15 months and again between age 4-6 years. (Option 2) Because a fever is one of the first emerging signs of a measles infection, it would be appropriate to advise the parent to check the child's temperature. However, this is not the most important action. (Option 3) This is not the most important instruction to give to the parent. After receiving the MMR vaccine, the child can be around other children. If the child does not receive the MMR vaccine, exposure to other children would not be advised. (Option 4) Although fever and rash are 2 of the clinical signs of measles, the measles incubation period is 7-21 days. The clinical indicators of measles would not be seen only 2 days after exposure. Educational objective: As advised by the CDC, a child age <12 months can and should receive the MMR vaccine when there is an outbreak of measles and the child risks contracting the illness due to an exposure. The child will need to be revaccinated between age 12-15 months and between age 4-6 years.

The nurse is caring for a client in the immediate postoperative period following an exploratory laparotomy after sustaining a gunshot wound to the abdomen. Which assessment finding is most important for the nurse to report to the health care provider? 1. Cold and clammy skin 2. Oxygen saturation of 92% 3. Sinus tachycardia of 108/min 4. UOP of 0.6

1. COLD AND CLAMMY SKIN Hypovolemic (hemorrhagic) shock may occur after abdominal trauma or surgery as mesenteric edema resolves and previously compressed sites of bleeding reopen. The shock continuum is staged in severity from initial (I) to irreversible (IV). During the initial stage, there is inadequate oxygen to supply the demand at the cellular level and anaerobic metabolism develops. At this point, there may be no recognizable signs or symptoms. As shock progresses to the compensatory stage, sympathetic compensatory mechanisms are activated to maintain homeostasis (eg, oxygenation, cardiac output). Cold, clammy skin indicates failing compensatory mechanisms (ie, progressive stage), and immediate intervention is necessary to prevent irreversible shock and death (Option 1). (Option 2) Slightly low oxygen saturation may occur when there is inadequate oxygen supply and increased metabolic demand. It is not the most important finding to report. (Option 3) Sinus tachycardia is part of the compensatory response to maintain cardiac output and oxygen demand. It is not the most important finding to report. (Option 4) As shock continues, the kidneys decrease filtration and increase reabsorption to maintain blood pressure, eventually resulting in decreased urinary output. Normal urine output is 0.5-1 mL/kg/hr or >30 mL/hr. Educational objective: Cold, clammy skin in a client with shock indicates that compensatory mechanisms are failing and that hypoperfusion is occurring. This should be reported promptly to the health care provider as immediate intervention is necessary to prevent irreversible shock.

The nurse is preparing to assess a client visiting the women's health clinic. The client's obstetric history is documented as G5T1P2A1L2. Which interpretation of this notation is correct? 1. The pt had 1 birth at 37 wk od gestation or beyond 2. The pt had 3 births between 20 wk and 36 wk and 6 d gestation 3. The pt has 3 currently living children 4. The pt is currently not pregnant

1. THE PT HAD 1 BIRTH AT 37 WK OD GESTATINO OR BEYOND The GTPAL system is a shorthand system of documenting a client's obstetric history. This client (G5T1P2A1L2) has been pregnant 5 times (G5); had 1 term birth (T1), 2 preterm births (P2), and 1 abortion (A1); and has 2 currently living children (L2). The client's term birth is indicated by the T1 portion of the GTPAL notation (Option 1). (Option 2) The client had 2 preterm births, indicated by the P2 portion of the GTPAL notation. (Option 3) The client has 2 currently living children, as indicated by the L2 portion of the GTPAL notation. If a child born full- or preterm is not living (due to stillbirth from 20 wk 0 d and beyond or infant/child death after birth), that birth and subsequent death is counted toward T or P (term or preterm) but is not notated under L (currently living children); T and P record total number of births without regard to current living status. This client has 2 currently living children (L2), which is 1 less than the client's total notation for term + preterm (T1 + P2 = 3). Therefore, the client has experienced the death of 1 child who had been born at 20 wk 0 d gestation or beyond. (Option 4) If a client is currently pregnant, the number of pregnancies (gravida) will be greater than the number of births (term, preterm, and abortions combined). This client is a G5, and T1 + P2 + A1 = 4. Therefore, the client is currently pregnant. Educational objective: The GTPAL system notational components are G - gravida (number of pregnancies, regardless of outcome and including current pregnancies), T - term (37 wk 0 d gestation and beyond), P - preterm (20 wk 0 d through 36 wk 6 d gestation), A - abortions (before 20 wk 0 d gestation; spontaneous or induced), and L - currently living children.

The nurse administers a prescribed oral dose of radioactive iodine (RAI) to a female client with hyperthyroidism. The nurse should instruct that the client utilize which of the following home precautions during the first 3-7 days after ingestion? Select all that apply. 1. Continue breastfeeding if applicable; RAI is not secreted through breast milk 2. Do not use bare hands to handle food that is to be served to others 3. Isolate personal clothing, toweks, and linens; wash them separately from the rest of the laundry in the home 4. Stop using any prescribed antithyroid drugs or beta-adrenergic blockers 5. Use a separate toilet and flush 2-3 times after each use

2, 3, & 5 RAI is the primary form of treatment for individuals with hyperthyroidism. It destroys or damages the thyroid gland (or a part of it). RAI has a delayed response and may take up to 3 months to have a maximum effect. For this reason, other medications should be maintained to lower thyroid hormone synthesis and treat symptoms of hyperthyroidism until RAI begins to have maximum effect (Option 4). Depending on dosage, clients who receive RAI should be taught to use the following precautions for up to 1 week: Avoid close proximity to pregnant women or children Do not breastfeed as RAI may be excreted through breast milk and could harm the infant (Option 1) Do not share utensils with others or use bare hands to handle food that is to be served to others Isolate personal laundry (eg, bed linens, towels, daily clothes) and wash it separately Use a separate toilet from the rest of the family and flush 2-3 times after each use Wash hands frequently and thoroughly, especially after restroom use Drink plenty of fluids Sleep in a separate bed from others and do not sit near others in an enclosed area for a prolonged period of time (eg, train or flight travel) Educational objective: RAI destroys or damages the thyroid (or part of it) but has a delayed response and may take up to 3 months to have a maximum effect. It is important for the nurse to teach the client about precautions to prevent exposing others to this radioactive substance.

The nurse plans to teach the parents of a child diagnosed with pediculosis capitis. Which instructions should the nurse include in the teaching plan? Select all that apply. 1. It is not necessary to treat your other children 2. Soak your child's comb and hair accessories in boiling water for 10 minues 3. The family pet will need treatment with a pediculicide 4. Use a nit comb daily for 2 weeks after pediculicide treatment 5. Vacuum your furniture, carpets, and mattresses every few days

2, 4, & 5 Pediculosis capitis (head lice) is a contagious parasitic infestation that is often seen in school-age children. The female louse lays eggs (nits) on the hair shaft close to the scalp that hatch in 7-10 days. The adult louse cannot survive away from the host's head for >48 hours. However, the nits can live away from the host (eg, on hairbrushes, carpets, hats) for up to 10 days. The infestation can spread between children when they share lice-infested items. Treatment involves applying a pediculicide (usually permethrin 1% cream) to the head and removing nits with a nit comb or by hand. After diagnosis, it is advised to use the nit comb at least every 2-3 days for 2 weeks. Carpets, rugs, and upholstered furniture must be vacuumed frequently to remove any lice or nits that might be present. The client's bedding should be washed in hot water and dried on the hottest dryer setting. Non-washable items can be sealed in a plastic bag for 2 weeks to kill lice. All hairbrushes, combs, and ornaments should be soaked in boiling water for 10 minutes or lice-killing products for 1 hour (Options 2, 4, and 5). (Option 1) The affected child's siblings may need treatment with a pediculicide. Children who share a bedroom and items such as combs, brushes, hair ornaments, hats, and towels are at risk for acquiring head lice. (Option 3) Household pets do not transmit human lice; treating them is not necessary. Educational objective: Pediculosis capitis (head lice) is a parasitic infestation that is seen often in school-age children. Measures to control the spread and reinfestation include using nit combs, soaking hair brushes and accessories in boiling water, and vacuuming rugs/carpets frequently.

The educator on a rehabilitation unit is teaching a graduate nurse (GN) about caring for clients who have had a stroke. Which of the following statements by the GN indicate correct understanding of the teaching? Select all that apply. 1. Approach pt's with visual impairment from the affected side when entering the room 2. Instruct pts with unilateral weakness to dress by donning clothes on the affected side first 3. Provide written instruction for activities of daily living to pts with receptive aphasia. 4. Teach pts with left sided neglect to turn their heads to scan the environment 5. Teach families of pts with right sided stroke to exect impulsive behaviors

2, 4, & 5 Clients with unilateral weakness from stroke may have limited mobility and control on the affected side. Clients being taught to dress independently should first clothe the affected side, which decreases the need for movement of impaired extremities and allows unrestricted use of unaffected limbs for assistance (Option 2). Unilateral neglect is an alteration in sensory perception that causes clients to ignore input from the affected side, leading to performing actions only on one side (eg, eating food on only the right side of the plate). Teaching clients to turn the head to fully scan the environment reduces the tendency to neglect one side (Option 4). Clients with right-sided cerebrovascular accidents tend to be impulsive and unaware of deficits. Teaching the client's family to expect disinhibition and emotional outbursts helps family members cope with the behavioral changes and reduces frustration during interactions (Option 5). (Option 1) The nurse should approach clients with unilateral blindness from the unaffected side to avoid startling the client. (Option 3) Receptive aphasia (ie, Wernicke aphasia) is impairment of verbal and written language comprehension. Visual aids and hand gestures may be more effective means of communication. Educational objective: Neurological impairments from a stroke may include unilateral weakness and neglect, impulsiveness, and aphasia. The nurse should teach the client methods to improve visual perception (eg, turning head to affected side, scanning the environment) and overcome unilateral weakness (eg, dressing affected side first).

A client with chronic obstructive pulmonary disease (COPD) is admitted for pneumonia. The client is restless. The nurse identifies a diagnosis of impaired gas exchange. Which intervention is most effective in promoting adequate gas exchange? 1. Administer morphine 2. Administer oxygen using venturi mask 3. Maintain IV NS infusion at prescribed rate of 125 4. Position head of bed in semi fowlers position

2. ADMINISTER OXYGEN USING VENTURI MASK Central chemoreceptors located in the respiratory center of the brain (medulla) respond to changes in blood carbon dioxide and hydrogen ions by either increasing or decreasing ventilation to normalize the pH. When the receptors sense a low pH (acidosis), ventilation increases to rid the body of excess carbon dioxide; when the receptors sense a high pH (alkalosis), ventilation decreases to retain carbon dioxide. Peripheral chemoreceptors located in the carotid and aortic bodies respond to low levels of oxygen and stimulate the respiratory center to increase ventilation. Many clients with COPD breathe because their oxygen levels are low rather than because carbon dioxide levels are high. This is commonly referred to as the hypoxemic drive. If they receive too high a level of inspired oxygen, this drive can be blunted. It is therefore important for these clients to receive a "guaranteed" amount of oxygen as an increase in inspired oxygen can decrease the drive to breathe. To promote adequate gas exchange, the nurse should use a high-flow Venturi mask to deliver a specified, guaranteed amount of oxygen. Because this device has a mechanism that controls the mixture of room air, the inspired oxygen concentration remains constant despite changes in respiratory rate, depth, or tidal volume. It is the most appropriate intervention to promote adequate gas exchange. (Option 1) Morphine is effective in relieving restlessness and anxiety, but it can cause respiratory depression in clients with COPD. When hypoxemia, hypercarbia, and acidosis are corrected, restlessness and anxiety should resolve. It is not the best intervention to promote adequate gas exchange in this client. (Option 3) Intravenous and oral fluids are effective in thinning respiratory secretions for easier mobilization. This is not the best intervention to promote adequate oxygenation in this client. (Option 4) Positioning the client in high, rather than semi-Fowler's, position would be more effective in relieving difficulty breathing. Educational objective: Many clients with COPD breathe because their oxygen level is low (hypoxemic drive) not because blood carbon dioxide is high. If these clients receive too high a concentration of oxygen, it can blunt the drive to breathe. The Venturi mask provides all the oxygen required in the exact amount because the device controls the mixture of room air. The fraction of inspired oxygen is therefore "guaranteed" and does not vary with changes in the client's respiratory rate, depth, or tidal volume.

The clinic nurse receives phone calls about the following 4 clients. Which call should the nurse return first? 1. A 6 month old who received the diptheria, tetanus, acellular pertussis vaccine 18 hours ago and developed fever of 102 and injection site redness 2. An 11 month old with inconsolable crying and drawing up of the legs toward the abdomen 3. A 4 year old diagnosed with right lung pneumonia 2 days ago who has chest pain when breathing deeply 4. A 15 year old whose eyes are red and itchy and have yellow discharge

2. AN 11 MONTH OLD WITH INCONSOLABLE CRYING AND DRAWING UP OF THE LEGS TOWARDS THE ABDOMEN Inconsolable crying and drawing up of the legs toward the abdomen in a child age 6-36 months could indicate intussusception or some other abdominal pathology (eg, appendicitis). Additional findings in intussusception include stools that have mucus and blood, often called "currant jelly" stools, and vomiting. Intussusception occurs when one section of bowel telescopes over another, which can block the passage of intestinal contents, interrupt blood supply, and cause intestinal tears (perforation). It is an emergency, and the client should be brought to the emergency department for further evaluation. (Option 1) Mild to moderate fever and local reactions are common after diphtheria, tetanus, acellular pertussis (DTaP) injections. Severe allergic reaction (eg, anaphylaxis) and encephalopathy (eg, decreased level of consciousness, prolonged seizures) are the most serious reactions that require priority attention. (Option 3) Pneumonia is often accompanied by chest and side pain that worsens with deep breathing due to rubbing of the nearby inflamed pleura (pleuritis). This would not be the priority phone call. (Option 4) These symptoms are consistent with bacterial conjunctivitis, or inflammation of the clear membrane (conjunctiva) that covers the eye. This client is second in priority. Educational objective: Intussusception occurs when one section of bowel telescopes over another. Inconsolable crying, drawing up of the legs toward the abdomen, and "currant jelly" stools (mixed with blood and mucus) are the classic findings. It is an emergency and can lead to bowel obstruction, decreased blood supply, and perforation.

A 62-year-old client is scheduled for open abdominal aneurysm repair. What key assessment should be made by the nurse preoperatively? 1. Assess and compare BP in each arm 2. Assess character and quality of peripheral pulse 3. Assess for presence or absence of hair on lower extremities 4. Assess for presence of bowel sounds

2. ASSESS CHARACTER AND QUALITY OF PERIPHERAL PULSES Open aneurysm repair involves a large abdominal incision and requires cross-clamping the aorta proximally and distally to the aneurysm. Establishing baseline data is essential for comparison with postoperative assessments. The nurse should pay special attention to the character and quality of peripheral pulses and renal and neurologic status. Dorsalis pedis and posterior tibial pulse sites should be marked for easy location postoperatively. A decreased or absent pulse with cool, pale, mottled, or painful extremity postoperatively can indicate embolization or graft occlusion. Graft occlusion may require reoperation. (Option 1) Comparison of blood pressures in each arm may be helpful in an assessment of an upper aortic dissection or congenital aortic coarctation, but not in assessing an abdominal aortic aneurysm. (Option 3) Absence of hair growth on the lower extremities is more specific for peripheral artery disease. (Option 4) Although auscultation of bowel sounds is part of a basic assessment, it is not considered a key assessment preoperatively. It will become more of a priority postoperatively in assessment of ileus. Educational objective: Preoperative assessment of the character and quality of peripheral pulses provides a baseline for rapid postoperative assessment and identification of emergent complications (embolization, graft occlusion).

A hospitalized client with a history of obstructive sleep apnea sleeps while wearing a full face mask with continuous positive airway pressure (CPAP). Oxygen saturation drops to 85% during the night. What is the nurse's first action? 1. Assess LOC and lung sounds 2. CHeck the tightness of the straps and mask 3. Notify the HCP immediately 4. Remove the mask and administer supplemental oxygen

2. CHECK THE TIGHTNESS OF THE STRAPS AND MASK Obstructive sleep apnea (OSA) is a chronic condition that involves the relaxation of pharyngeal muscles during sleep. The resulting upper airway obstruction with multiple events of apnea and shallow breathing (hypopnea) leads to hypoxemia and hypercapnia. CPAP is an effective treatment for OSA; it involves using a nasal or full face mask that delivers positive pressure to the upper airway to keep it open during sleep. In this case, the nurse's first action should be to check the tightness of the straps that hold the mask in place. The full face mask must fit snugly over the client's nose and mouth without air leakage to maintain the positive airway pressure and prevent obstruction of upper airway airflow. Readjustment of the head straps may be necessary (Option 2). (Option 1) Underlying OSA is the most likely reason for this client's drop in oxygen saturation during sleep. If CPAP is not effective, then the characteristic OSA signs (eg, hypoxia, hypercapnia) will occur. In addition, decreased level of consciousness and lung sounds are expected when there is no airflow to the lungs. Although the nurse should assess these parameters, this should not be the first action. (Option 3) If the attempt to readjust the straps and mask seal does not reverse the client's hypoxemia quickly, the nurse should notify the health care provider and respiratory therapist (per institution policy). However, this should not be the nurse's first action. (Option 4) Supplemental oxygen may be indicated if readjustment of the straps and mask seal does not reverse the client's hypoxemia quickly. This should not be the nurse's first action. Educational objective: CPAP is prescribed for clients with obstructive sleep apnea in the home and clinical settings. The mask is secured with adjustable head straps to maintain a snug fit over the face to prevent air leakage and loss of positive pressure.

A nurse has received new medication prescriptions for a client admitted with hypertension and an exacerbation of chronic obstructive pulmonary disease. Which prescription should the nurse question? 1. Amlodipine 2. Codeine 3. Ipratropium 4. Methylprednisolone

2. CODEINE Codeine is a narcotic analgesic used for acute pain or as a cough suppressant. Depressing the cough reflex can cause an accumulation of secretions in the presence of chronic obstructive pulmonary disease (COPD), leading to respiratory difficulty. In general, sedatives (eg, narcotics, benzodiazepines) can also depress the respiratory center and effort; therefore, they should not be given to clients with respiratory diseases (eg, asthma, COPD). (Option 1) Calcium channel blockers (eg, amlodipine, nifedipine) are used to treat hypertension and do not worsen bronchoconstriction, unlike beta blockers (eg, metoprolol, atenolol). (Option 3) Ipratropium (Atrovent) is a short-acting inhaled anticholinergic often used in combination with a short-acting beta-agonist (eg, albuterol) to promote bronchodilation and reduce bronchospasm. (Option 4) Methylprednisolone (Solu-Medrol) is a systemic glucocorticoid that improves respiratory symptoms and overall lung function in clients experiencing an exacerbation of COPD. Educational objective: Codeine is a narcotic medication with antitussive properties that can cause an accumulation of secretions in clients with chronic obstructive pulmonary disease and lead to respiratory distress. Caution is advised when sedatives are prescribed for clients with respiratory diseases.

A student nurse asks why enteral (tube) feedings, rather than total parenteral nutrition (TPN), are being administered to a client with sepsis and respiratory failure. Which is the best response by the registered nurse? 1. Enteral feedings have no complications 2. Enteral feedings maintain gut integrity nd help prevent stress ulcers 3. Enteral feedings provide higher calorie content 4. Risk of hyperglycemia is lower with enteral feedings than with TPN

2. ENTERAL FEEDINGS MAINTAIN GUT INTEGRITY AND HELP PREVENT STRESS ULCERS Stress ulcers are a common complication in critically ill clients because the gastrointestinal tract is not a preferential organ. In the presence of hypoxemia, blood is shunted to the more vital organs, increasing the risk of stress ulcers. The early initiation of enteral feedings helps preserve the function of the gut mucosa, limits movement of bacteria (translocation) from the intestines into the bloodstream, and prevents stress ulcers. Enteral feedings are also associated with lower risk of infectious complications compared with TPN. However, the mortality is the same. (Option 1) Complications/problems commonly associated with enteral feedings include aspiration, tube displacement, hyperglycemia, diarrhea, abdominal distension, enteral tube misconnections, and clogged tubes. (Option 3) Caloric and metabolic needs can usually be met adequately using enteral feedings or TPN. Multiple enteral or TPN formulas are available to meet individual client needs. If metabolic demands are not being met using enteral feedings alone, TPN can be added. (Option 4) Illness-related stress hyperglycemia (gluconeogenesis) occurs in clients receiving both enteral feedings and TPN. Educational objective: The enteral route is preferred for feeding. Enteral feedings maintain the integrity of the gut, prevent stress ulcers, and help prevent the translocation of bacteria into the bloodstream.

The nurse preparing an educational seminar on sexually transmitted infections for female college students should advise that which 2 infections are leading causes of pelvic inflammatory disease and infertility? 1. Genital herpes and HIV 2. Gonorrhea and chlamydia 3. HPV and syphillis 4. Yeast and trichomoniasis

2. GONORRHEA AND CHLAMYDIA Gonorrhea and chlamydia can lead to pelvic inflammatory disease (PID) and infertility. They are referred to as "silent infections" because many affected women show no symptoms. Infections of the fallopian tubes and uterus can lead to permanent damage and infertility. The Centers for Disease Control and Prevention recommend annual chlamydia and gonorrhea screening for all sexually active females age <25 and older females with risk factors. Both chlamydia and gonorrhea are treatable. The use of latex condoms is recommended to reduce the risk of contracting chlamydia and gonorrhea. (Options 1 and 3) Herpes can lead to multiple, very painful genital vesicles/ulcers. HIV infection does not cause genital abnormalities. Human papillomavirus causes genital and anal warts. Syphilis usually causes a painless genital ulcer. The uterus and fallopian tubes (organs affected by PID) are typically not involved in any of these infections. (Option 4) Trichomoniasis and candidiasis (yeast infection) can lead to vaginitis (vaginal inflammation and discharge). They do not usually involve the uterus or fallopian tubes to cause infertility. Educational objective: Gonorrhea and chlamydia are the most common causes of pelvic inflammatory disease, which can lead to infertility. Therefore, annual gonorrhea and chlamydia screening is recommended for all sexually active females age <25 and older females with risk factors.

Which nursing instruction is the highest priority when teaching a 38-year-old female client newly diagnosed with stress incontinence? 1. Coaching related to kegel exercises 2. Importance of voiding every 2 hours 3. Minimizing caffeine and alcohol 4. Use of incontinence pads and pessary

2. IMPORTANCE OF VOIDING EVERY 2 HOURS The nursing care plan for a client experiencing stress incontinence includes pelvic floor exercises, bladder training, incontinence products, and lifestyle modifications. The highest priority for a client newly diagnosed with stress incontinence is preventing skin breakdown and urinary tract infections through bladder training. Teaching the client to empty the bladder every 2 hours when awake and every 4 hours at night reduces these risks (Option 2). Pelvic floor exercises (eg, Kegel exercises), which strengthen the sphincter and structural supports of the bladder, are an essential part of the teaching plan but are not the priority for this client (Option 1). It will take approximately 6 weeks for pelvic floor muscle strength to improve. Natural bladder irritants (eg, smoking, caffeine, alcohol) increase incontinence and should be eliminated but are not the priority in this client (Option 3). Pessaries relieve minor pelvic organ prolapse and may be used in some clients when initial conservative measures fail. This client should receive initial instruction on the importance of emptying the bladder often (Option 4). Educational objective: Nursing interventions related to stress incontinence include bladder training (eg, voiding every 2 hours), pelvic floor exercises (eg, Kegel exercises), lifestyle modifications (weight loss, reduction of dietary bladder irritants, smoking cessation), and incontinence products.

A client is receiving scheduled doses of carbidopa-levodopa. The nurse evaluates the medication as having the intended effect if which finding is noted? 1. Improvement in short term memory 2. Improvement in spontaneous activity 3. Reduction in number of visual hallucinations 4. Reduction of dizziness with standing

2. IMPROVEMENT IN SPONTANEOUS ACTIVITY Parkinson disease is caused by low levels of dopamine in the brain. Levodopa is converted to dopamine in the brain, but much of this drug is metabolized before reaching the brain. Carbidopa helps prevent the breakdown of levodopa before it can reach the brain and take effect. This combination medication is particularly effective in treating bradykinesia (generalized slowing of movement). Tremor and rigidity may also improve to some extent. Carbidopa-levodopa (Sinemet) once started should never be stopped suddenly as this can lead to akinetic crisis (complete loss of movement). However, prolonged use can also result in dyskinesias (spontaneous involuntary movements) and on/off periods when the medication will start or stop working unpredictably. (Option 1) Carbidopa-levodopa does not improve memory. Medications for the treatment of Alzheimer disease, such as donepezil and rivastigmine, are used to improve cognition and memory. (Options 3 and 4) Orthostatic hypotension and neuropsychiatric disturbances (eg, confusion, hallucinations, delusions, agitation, psychosis) are serious and important adverse effects of carbidopa-levodopa. Health care providers usually start the medications at low doses and gradually increase them to prevent these effects. Educational objective: The combination medication carbidopa-levodopa is most helpful for treating bradykinesia in Parkinson disease and can also improve tremor and rigidity to some extent. It is started in low doses to prevent orthostatic hypotension and neuropsychiatric adverse effects. Carbidopa-levodopa once started should never be stopped suddenly as doing so can lead to akinetic crisis (complete loss of movement).

The nurse is developing teaching materials for a client diagnosed with ulcerative colitis. The client will receive sulfasalazine. Which of the following instructions are included in the discharge teaching plan? Select all that apply. 1. Avoid small, frequent meals 2. Can have a cup of coffee with each meal 3. Eat a low residue, high protein, high calorie diet 4. Increase fluid intake to at least 2000 ml/day 5. Medications shoudl be continues even after resolution of symptoms 6. Take daily vitamin and mineral supplements

3, 4, 5, & 6 A low-residue, high-protein, high-calorie diet, along with daily vitamin and mineral supplements, is encouraged to meet the nutritional and metabolic needs of the client with ulcerative colitis. The low-residue diet limits trauma to the inflamed colon and may lessen symptoms. Easily digested foods such as enriched breads, rice, pastas, cooked vegetables, canned fruits, and tender meats are included in the diet. Raw fruits and vegetables, whole grains, highly seasoned foods, fried foods, and alcohol are avoided. The well-balanced diet includes at least 2000-3000 mL/day of fluid to maintain fluid and electrolyte balance and hydration. (Option 1) Small, frequent meals are encouraged to lessen the amount of fecal material present in the gastrointestinal tract and to decrease stimulation. (Option 2) Caffeine, alcohol, and tobacco are gastric irritants that stimulate the intestine and should be avoided. (Option 5) The prescribed sulfasalazine should be continued even when symptoms subside to prevent relapse. Because sulfasalazine hinders the absorption of folate, folic acid supplements are encouraged. Educational objective: A low-residue, high-protein, high-calorie diet with supplemental vitamins and minerals is recommended for a client diagnosed with ulcerative colitis. The well-balanced diet includes small, frequent meals and at least 2000-3000 mL/day of fluid to maintain fluid and electrolyte balance and hydration.

The nurse receives change of shift report on 4 clients. Which client should the nurse assess first? 1. 6 month old with respiratory syncytial virus and pulse ox of 90% 2. 1 year old with otitis media and a temp of 102.5 rectally 3. 2 year old with suspected epiglottitis 4. 3 year old who has a barking cough

3. 2 YEAR OLD WITH SUSPECTED EPIGLOTTITIS Epiglottitis, a sudden-onset medical emergency due to Haemophilus influenzae, causes severe inflammatory obstruction above and around the glottis. The affected child will typically progress from having no symptoms to having a completely occluded airway within hours. Sitting in a tripod position (upright and leaning forward with the chin and tongue sticking out) is a classic presentation. The child will likely drool and be very restless and anxious secondary to airway obstruction and hypoxia. Throat inspection should not be done until emergency intubation is readily available (if necessary). (Option 1) Oxygen saturation ≥90% is the treatment goal for bronchiolitis caused by respiratory syncytial virus. (Option 2) This temperature is an expected finding in the setting of otitis media and does not carry the urgency of airway impairment. (Option 4) A barking-type cough is seen in viral croup syndromes. The resonant hoarse cough is secondary to narrowed airways. Croup is typically mild but can become life-threatening if the airway swells excessively. This child would need to be assessed next. Educational objective: Epiglottitis is a medical emergency as the child can rapidly progress from being asymptomatic to having a completely occluded airway. Emergency intubation equipment should be readily available.

A client with medically managed coronary artery disease is being seen for a follow-up examination. During medication reconciliation, the nurse identifies which medication as requiring further assessment? 1. 10 mg isosorbide dinitrate twice daily 2. 20 mg atorovastin once daily 3. 500 mg naproxen twice daily 4. 2000 mg fish oil once daily

3. 500 NAPROXEN TWICE DAILY Nonsteroidal anti-inflammatory drugs (NSAIDs) (eg, naproxen, ibuprofen) are commonly prescribed or purchased over-the-counter for their analgesic, antipyretic, and anti-inflammatory properties. However, the use of NSAIDs increases the risk of thrombotic events (eg, heart attack, stroke) in clients with cardiovascular disease (eg, coronary artery disease [CAD]), especially with long-term use. The nurse should assess for the reason the client is taking naproxen and alert the health care provider (Option 3). (Option 1) Isosorbide dinitrate (Isordil) is a long-acting nitrate medication prescribed to prevent angina in clients with CAD. Nitrate medications prevent angina by causing vasodilation of the peripheral vessels (decreasing cardiac workload) and the coronary arteries (improving coronary artery perfusion). (Option 2) Atorvastatin (Lipitor) is a statin drug prescribed to lower cholesterol, which can reduce the risk of atherosclerosis and coronary artery disease. (Option 4) Fish oil is an herbal remedy often taken by clients with heart disease or those at risk. It contains omega-3 fatty acids, which can decrease triglycerides. Educational objective: Clients with cardiovascular disease (eg, coronary artery disease) should be cautioned against taking nonsteroidal anti-inflammatory drugs (eg, naproxen) due to the increased risk of thrombotic events (eg, heart attack, stroke).

Which group of food selections would be the best choice for a client advancing to a full liquid diet 3 days after bariatric surgery? 1. Apple juice, mashed potatoes, chocolate pudding 2. Chicken broth, low fat omelet, strwaberry icecream 3. Creamy wheat cereal, blended cream of chicken soup, protein shake 4. Low fat vanilla yogurt, smooth peanut butter, vegetable juice

3. CREAMY WHEAT CEREAL, BLENDED CREAM OF CHICKEN, PROTEIN SHAKE Bariatric surgery (eg, gastric banding, sleeve gastrectomy) reduces stomach capacity. A client's bariatric postoperative diet is restricted to foods that are low in simple carbohydrates and high in nutrients (eg, protein, fiber). After gastric surgery, consumption of simple carbohydrates can lead to dumping syndrome (ie, cramping, diarrhea). The client will tolerate only small meals of clear liquids at first, advance to full liquids 24-48 hours after surgery, and then progress gradually to solid foods as the gastrointestinal tract heals. Small, frequent meals are recommended to avoid overstretching of the pouch and to prevent nausea, vomiting, and regurgitation. The best food choices for a bariatric full liquid diet are cream soups, refined cooked cereals, sugar-free drinks, and low-sugar protein shakes and dairy foods (Option 3). (Option 1) Fruit juices and puddings are high in sugar and not acceptable for a bariatric full liquid diet. Mashed potatoes are considered appropriate for a soft diet. (Option 2) Ice cream is high in sugar and not acceptable for a bariatric full liquid diet. Eggs are appropriate for a soft diet. (Option 4) Yogurt is high in sugar and not appropriate for a bariatric full liquid diet. Peanut butter and vegetable juice are appropriate for a soft diet. Educational objective: Clients recovering from bariatric surgery are given small, frequent meals to prevent nausea, vomiting, and regurgitation related to overstretching of the stomach. The bariatric postoperative diet is restricted to foods that are high in nutrients (eg, protein, fiber) and low in simple carbohydrates to prevent dumping syndrome.

A client has been on long-term therapy with esomeprazole. What is essential for the nurse to ask the client? 1. Are you drinking plenty of water with the medication 2. Are you taking the medication after meals 3. Have you had a bone density test recently 4. Have you had your blood pressure taken regularly

3. HAVE YOU HAD A BONE DENSITY TEST RECENTLY Long-term therapy with a proton pump inhibitor (PPI) (eg, omeprazole, pantoprazole, esomeprazole) may decrease the absorption of calcium and promote osteoporosis. A bone density test can assess if the client already has osteoporosis. Hospitalized clients also have an increased risk of diarrhea caused by Clostridium difficile. PPIs cause suppression of acid that otherwise would have prevented pathogens from more easily colonizing the upper gastrointestinal tract. This leads to increased risk of pneumonias. (Option 1) Drinking extra water and being upright for 30 minutes after taking bisphosphonates (eg, risedronate, alendronate) is necessary to prevent esophagitis. However, this is not necessary with PPI use. (Option 2) The medication should be taken prior to meals. (Option 4) PPIs do not affect blood pressure. Educational objective: Long-term use of PPIs (eg, omeprazole, pantoprazole, esomeprazole) is associated with osteoporosis, C difficile infection, and pneumonias. Clients should be encouraged to increase calcium and vitamin D intake to help prevent osteoporosis.

The nurse provides teaching about methotrexate to a 28-year-old client with rheumatoid arthritis. Which client statement indicates the need for further instruction regarding this drug? 1. I know my resistance to germ will be lower, so I shouldn't get a flu shot this year 2. I should take precautions to prevent pregnancy while I take this medicine 3. I will have an eye exam every 6 months to check for damages caused by my medication 4. It will be a difficult change for me, but I will not have wine with dinner anymore

3. I WILL HAVE AN EYE EXAM EVERY 6 MONTHS TO CHECK FOR DAMAGE CAUSED BY MY MEDICATION Methotrexate (Rheumatrex) is classified as a folate antimetabolite, antineoplastic, immunosuppressant drug to treat various malignancies and as a nonbiologic disease-modifying antirheumatic drug (DMARD) to treat rheumatoid arthritis and psoriasis. The client's statement about getting an eye examination every 6 months indicates that further teaching is necessary as these examinations are not indicated for clients prescribed methotrexate (Option 3). However, frequent eye examinations are required for clients prescribed the nonbiologic antimalarial DMARD hydroxychloroquine (Plaquenil) as it can cause retinal damage. (Option 1) Methotrexate is an immunosuppressant and can cause bone marrow suppression. Clients are at risk for infection. They should avoid crowded places and individuals with known infection and should receive appropriate killed (inactivated) vaccines (eg, influenza, pneumococcal). Live vaccines (eg, herpes zoster) are contraindicated. (Option 2) Clients should not become pregnant while taking methotrexate or for at least 3 months after it is discontinued as the drug is teratogenic and can cause congenital abnormalities and fetal death. (Option 4) Clients taking methotrexate should avoid alcohol as the prescription drug is hepatotoxic and drinking alcohol increases the risk for hepatotoxicity. Educational objective: Methotrexate is a disease-modifying antirheumatic drug used to treat rheumatoid arthritis and psoriasis. The major adverse effects associated with methotrexate include bone marrow suppression, hepatotoxicity, congenital abnormalities, and fetal death.

A couple is excited about finding out the sex of their baby during ultrasound at 14 weeks gestation. What is the nurse's best response? 1. Basic structures of major organs are not yet formed 2. External genitalia are not usually visualized until 21-24 weeks 3. If the baby is in the right position, the genitalia may be visualized 4. Sex cannot be determined until fetal movement is felt

3. IF THE BABY IS IN THE RIGHT POSITION, THE GENITALIA MAY BE VISUALIZED By the end of 12 weeks gestation, fetal sex can often be determined by the appearance of the external genitalia on ultrasound, depending on the quality of the image. (Option 1) By the end of 8 weeks gestation, all major organ systems are in place, and many are functioning in a simple way. By 7 weeks gestation, fetal heart tones can be detected. (Options 2 and 4) Clients typically begin feeling fetal movements in the second trimester at around 16-20 weeks gestation. Parous (have been pregnant before) clients can notice this earlier than the nulliparous (first pregnancy). Fetal sex can be determined as early as the end of 12 weeks gestation. Educational objective: Fetal heart tones can be detected by 7 weeks gestation. Fetal sex may be determined on ultrasound as early as the end of 12 weeks gestation. Fetal movements are typically felt at around 16-20 weeks gestation.

The nurse is caring for a client in the immediate postoperative period following a carotid endarterectomy. The client is drowsy with slurred speech. Which assessment finding would cause the nurse to notify the healthcare provider immediately? 1. Diminished gag reflex after endotracheal tube removal 2. Increased agitation level and pulling at linens 3. Left arm driftduring bilateral extension 4. Responds to verbal commands with eyes closed

3. LEFT ARM DRIFT DURING BILATERAL ARM EXTENSION A carotid endarterectomy is a surgical procedure performed to remove plaque from the carotid artery to improve cerebral perfusion. The nurse must closely assess for signs of new or worsening alterations in neurologic status, as surgical manipulation of arteries and blood flow increases the risk of stroke. Monitoring the client's neurologic status postoperatively can be challenging, as the effects of anesthesia degrade the neurologic examination. Nurses should use the FAST acronym to assess for stroke: Facial drooping: Numbness or droopiness on one side of the face Arm weakness: Weakness or drifting of one arm when raised to shoulder level (Option 3) Speech difficulties: Slurring of words, incomprehensible speech, inability to understand others Time: Notation of the time of symptom onset, which is critical for guiding treatment (Option 1) Diminished gag reflex is common after anesthesia and endotracheal tube removal. The gag reflex should return as the client awakens. (Option 2) Individuals recovering from anesthesia may have alterations in mood or affect (eg, agitation, anxiety, tearfulness) that will resolve as anesthesia wears off. (Option 4) Drowsiness and somnolence during purposeful interactions (ie, following commands) are expected after anesthesia. Educational objective: Following a carotid endarterectomy, the client should be monitored for alterations in mental status that are unexpected in the context of typical postanesthesia symptoms (eg, diminished gag reflex, altered affect, drowsiness). The FAST assessment (Facial drooping, Arm weakness or drift, Speech difficulties, Time) assists with identifying alterations that may indicate stroke.

Which of the following statements made by the mother of a child recently diagnosed with celiac disease indicates a need for further teaching? 1. I will need to read the labels of all processed foods 2. It is okay if my child eats rice, corn, and potatoes 3. My child can have small amounts of food containing wheat as long as she remains symptom free 4. My child will need to be on a gluten free diet for the rest of her life

3. MY CHILD CAN HAVE SMALL AMOUNTS OF FOOD CONTAINING WHEAT AS LONG AS SHE REMAINS SYMPTOM FREE The following are important principles to teach clients with celiac disease: All gluten-containing products should be eliminated from the diet. These include wheat, barley, rye, and oats. Rice, corn, and potatoes are gluten free and are allowed on the diet. Deficient vitamins (mainly fat-soluble vitamins), iron, and folic acid should be replaced. Processed foods (eg, chocolate candy, hot dogs) may contain "hidden" sources of gluten such as modified food starch, malt, and soy sauce. Food labels should indicate that the product is gluten free. Clients will need to be on a gluten-free diet for the rest of their lives. Eliminating gluten from the diet reduces the risk of nutritional deficiencies and intestinal cancer (lymphoma). Eating even small amounts of gluten will damage the intestinal villi although the client may have no clinical symptoms. All sources of gluten must be eliminated from the diet (Option 3). Educational objective: All sources of gluten must be eliminated from the diet of a client with celiac disease; consuming small amounts, even in the absence of clinical symptoms, will increase the risk of damage to the intestinal villi. Clients can have foods containing rice, corn, and potatoes. They should read food labels and follow the diet for the rest of their lives.

A client is admitted to the hospital for severe headaches. The client has a history of increased intracranial pressure (ICP), which has required lumbar punctures to relieve the pressure by draining cerebrospinal fluid. The client suddenly vomits and states, "That's weird, I didn't even feel nauseated." Which action by the nurse is the most appropriate? 1. Document the amount of emesis 2. Lower the head of the bed 3. Notify the HCP 4. Offer anti-nausea medication

3. NOTIFY THE HCP Unexpected and projectile vomiting without nausea can be a sign of increased ICP, especially in the client with a history of increased ICP. The unexpected vomiting is related to pressure changes in the cranium. The vomiting can be associated with headache and gets worse with lowered head position. The most appropriate action is to obtain a full set of vital signs and contact the HCP immediately. (Option 1) Documentation is important, but it is not the priority action. (Option 2) The head of the bed should be raised, not lowered, for clients with suspected increased ICP. Raising the head of the bed to 30 degrees helps to drain the cerebrospinal fluid via the valve system without lowering the cerebral blood pressure. (Option 4) The vomiting is caused not by nausea but by pressure changes in the cranium. Anti-nausea medications are often not effective. Decreasing intracranial pressure will help the vomiting. Educational objective: Notify the HCP of signs/symptoms of increased ICP, including unexpected vomiting. The vomiting is often projectile, associated with headache, and gets worse with lowering the head position.

The nurse is caring for a client with severe chronic obstructive pulmonary disease (COPD). The nurse anticipates which laboratory results for this client? 1. Anemia 2. Neutopenia 3. Polycythemia 4. Thrombocytopenia

3. POLYCYTHEMIA The client with severe COPD will have a chronically low oxygen level, hypoxemia. To compensate, the body produces more red blood cells (RBCs) to carry needed oxygen to the cells. A high RBC count is called polycythemia. (Option 1) Anemia is not expected and will worsen symptoms of COPD. (Option 2) Neutropenia (low white blood cell count) is not expected in COPD. Chemotherapy and many medications (clozapine [antipsychotic], methimazole [antithyroid]) can cause neutropenia which increases the risk of infection. (Option 4) Thrombocytopenia (low platelet count) is not anticipated in COPD. Alcohol use, HIV infection, and many medications (heparin) can cause thrombocytopenia. Educational objective: Polycythemia, an increase in RBCs, is an anticipated compensatory response to chronically low blood oxygen levels in clients with severe COPD.

The nurse is working in the emergency department. Which client should the nurse see first? 1. 12 year old with severe enck muscle spasms who is taking haloperidol for tourretes syndrome 2. 80 year old with irritability and agitation who has taken alprazolam for 2 weeks 3. Pt taking clozapine who has sudden onset of fever, diaphoresis, and change in mental status 4. Pt taking olazapine who has dry mouth, blurry vision, and constipation

3. PT TAKING CLOZAPINE WHO HAS SUDDEN ONSET OF HIGH FEVERM DIAPHORESISM AND CHANGE IN MENTAL STATUS The client taking clozapine is exhibiting classic signs of neuroleptic malignant syndrome (NMS), an uncommon but life-threatening adverse reaction to anti-psychotic medications. NMS is characterized by high fever, muscular rigidity, altered mental status, and autonomic dysfunction. Treatment includes supportive care (eg, rehydration, cooling body temperature) and immediate discontinuation of the medication. Due to the life-threatening nature of NMS, this client needs to be seen first to assess for generalized muscle rigidity. (Option 1) Severe neck spasms in an individual taking haloperidol (and other psychotropic medications) indicate a dystonic reaction. This client is in no immediate danger but needs treatment with IV benztropine (Cogentin) as soon as possible. The client should be seen second. (Option 2) Benzodiazepines can cause paradoxical worsening of agitation in elderly clients. This client needs a change in medication but does not need to be seen immediately. (Option 4) Dry mouth, blurry vision, and constipation are common anti-cholinergic side effects of olanzapine (and other psychotropic medications). These symptoms usually resolve after the client has taken the medication for a few weeks; treatment is symptomatic (eg, increased fluids, sugar-free chewing gum, high-fiber foods, avoidance of driving). This client can be seen last. Educational objective: Neuroleptic malignant syndrome (NMS) usually presents with mental status changes, fever, muscle rigidity, and autonomic instability after starting antipsychotic medications. Treatment involves discontinuation of the medication and supportive care (eg, rehydration, cooling body temperature). NMS is a life-threatening condition.

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

3. PT WITH A FEMORAL EXTERNAL FIXATOR WHO HAS A TEMPERATURE OF 100.9 AND REDNESS AND PAIN AROUND THE PIN SITES External fixation stabilizes bone by inserting metal pins through skin into the bone and attaching them to a metal rod outside the skin. The nurse should assess this client first as any signs and symptoms of an infection (eg, low-grade fever, drainage, pain, redness, swelling) warrant immediate evaluation and treatment. Localized pin tract infection can progress to osteomyelitis, a serious bone infection that requires long-term treatment with antibiotics. (Option 1) The dose of levothyroxine, a thyroid replacement drug that raises the metabolic rate, may need to be adjusted as the client is now exhibiting manifestations of hyperthyroidism (eg, nervousness, sweating, insomnia). (Option 2) Hemoptysis can sometimes be seen with pneumonia, lung abscess, tuberculosis, and lung cancer, as well as in bronchiectasis. Unless there is a significant amount of blood, this is not a concerning finding. (Option 4) Epigastric abdominal pain and steatorrhea (voluminous, foul-smelling, fatty stools) due to fat malabsorption are expected findings in chronic pancreatitis. Appropriate pain medication and pancreatic enzyme supplements (prior to each meal) are administered for prevention. Educational objective: An external fixator stabilizes bone by inserting metal pins through skin into the bone and attaching them to a metal rod outside the skin. Signs and symptoms of infection (eg, fever, drainage, pain, redness, swelling) warrant immediate evaluation and treatment with antibiotics as these can progress to osteomyelitis, a serious bone infection.

After the nurse receives the change-of-shift report, which client should the nurse assess first? 1. Pt with asthma who has shortness of breath and highpitched expiratory wheezing 2. Pt with diabetes and a stasis leg ulcer dressing saturated with serosanguineous drainage 3. Pt with heart failure who is short of breath and coughing up pink frothy sputum 4. Pt with left plleural effusion and absent breath sounds in the left base

3. PT WITH HEART FAILURE WHO IS SHORT OF BREATH AND COUGHING UP PINK FROTHY SPUTUM The ABC (airway, breathing, circulation) and Maslow's hierarchy of needs frameworks are commonly used to prioritize client needs. This client with heart failure who is short of breath and coughing up pink frothy sputum has developed acute pulmonary edema (fluid filling the alveoli), a potentially life-threatening condition. This client's status has deteriorated from baseline, is potentially the most hemodynamically unstable, and should be assessed first. (Option 1) This client with shortness of breath and high-pitched expiratory wheezing is experiencing expected clinical manifestations of asthma and is the second most unstable client at this time. (Option 2) Diabetic stasis leg ulcers can be associated with large amounts of serous or serosanguineous drainage and is an expected manifestation. This client is not the most unstable at this time. (Option 4) Absent breath sounds in the lung base in this client with pleural effusion is an expected finding as the collection of fluid in the pleural space prevents the lung from expanding. This client is not the most unstable at this time. Educational objective: Information communicated in the change of shift report should provide the nurse with information needed to identify the type of problem the client has, its associated complications, and the risks to survival. The ABC (airway, breathing, circulation) and Maslow's hierarchy of needs frameworks are commonly used to prioritize client needs.

A client has a serum potassium level of 2.8 mEq/L, and the health care provider (HCP) prescribes intravenous (IV) potassium chloride (KCL). The nurse administers 10 mEq KCL/100 mL 5% dextrose in water at 100 mL/hr through the client's peripheral IV line using an infusion pump. Shortly after initiation of the infusion, the client reports feeling burning and discomfort at the IV site. What is the nurse's priority action? 1. Botify the HCP to request a PICC 2. Notify the HCP to request an oral preparation of KCL 3. Slow the rate of KCL infusion 4. Stop the KCL infusion immediately

3. SLOW THE RATE OF THE KCL INFUSION KCL, an electrolyte replacement to correct hypokalemia, is a high-alert drug that is never administered by the IV push, intramuscular, or subcutaneous routes. The recommended peripheral infusion rate is 5-10 mEq/hr. However, the nurse should always follow institution IV guidelines and policy and procedure for administering KCL. The nurse's priority action is to slow the infusion rate if the client feels a burning discomfort at the IV site shortly after initiation of the infusion. KCL irritates the vein, and irritation and discomfort at the site is expected. Slowing the infusion rate is effective in alleviating discomfort. (Option 1) KCL in concentrations 20-40 mEq/100 mL at a maximum rate of 40 mEq/hr should be administered through a central venous access device (CVAD) (eg, PICC, centrally inserted catheter) to prevent postinfusion phlebitis. A concentration of 10 mEq KCL/100 mL can be administered through a peripheral vein at the recommended infusion rate. (Option 2) The IV infusion is preferred over the oral preparation to decrease the risk for dysrhythmias when hypokalemia must be corrected quickly. Some clients may need both oral and IV forms if the serum potassium levels are markedly low. However, this action is not a priority. (Option 4) Rapid correction of this client's hypokalemia (2.8 mEq/L) is necessary due to risk for hypokalemia-associated dysrhythmias. Stopping the infusion when not necessary further increases risk. The nurse assesses the site at least every hour for adverse reactions (eg, redness, pain, swelling, phlebitis, thrombosis, extravasation or infiltration), and stops the infusion if any occur. Educational objective: Potassium chloride (KCL) administered by the IV route is prescribed for rapid correction of hypokalemia (<3.5 mEq/L). It is irritating to the vein but can be administered slowly through a peripheral vein at recommended infusion rates (5-10 mEq/hr). KCL concentrations 20-40 mEq/100 mL at a maximum rate of 40 mEq/hr should be administered through a CVAD to prevent postinfusion phlebitis or infiltration.

The nurse determines that further teaching is needed if a client with constipation makes which statement? Select all that apply. 1. I will go to the restroom when I have the urge to have abowel movement 2. I will increase my exercise to at least 3 times a week 3. I will increase my intake of fruits and vegetables 4. I will increase tea or coffee consumption to stimulate the bowel 5. I will use a laxative every other day if needed

4 & 5 Constipation is a symptom of many different disease processes (eg, Parkinson's disease, diabetic neuropathy, depression), procedures (eg, abdominal surgery, bowel manipulation), and medications (eg, anticholinergics, diuretics, opioids, antacids, antihypertensives). Immobility, low-fiber diets, decreased fluid intake, and irregular bowel habits increase the likelihood of constipation. Teach the client and/or caregiver the following to prevent constipation: Consume 20-30 g of fiber a day (unless contraindicated); fiber softens stool and increases bulk, stimulating defecation. High-fiber foods include fruits, vegetables, whole grains, nuts, seeds, and legumes (Option 3). Drink 2-3 L of fluids a day (unless contraindicated); avoid caffeinated beverages (eg, coffee, tea, cola) that promote diuresis. Exercise at least 3 times a week; movement stimulates peristalsis and defecation (Option 2) Maintain a healthy bowel regimen - avoid delaying defecation when the urge is felt, defecate at the same time each day, and track bowel movements to identify if there is a change in bowel patterns (Option 1) Avoid laxatives and enemas unless prescribed by a health care provider; overuse can cause dependency (Option 4) Consuming 8 glasses of water and fruit juices is recommended. Clients should avoid caffeinated beverages (eg, tea, cola, coffee) as they promote diuresis, which may lead to dehydration and worsening of constipation. (Option 5) Overuse of laxatives or enemas can lead to dependency and fluid and electrolyte imbalances. Educational objective: Healthy eating habits (consuming 20-30 g of fiber a day, drinking 2-3 L of fluids a day), exercise, and creating a bowel regimen (avoiding delay of defecation, defecating at the same time each day) are important practices that prevent constipation. Clients should avoid the regular use of laxatives and enemas as dependency may result.

At 8 AM, medications are prescribed for assigned clients. Which medication should the nurse administer first? 1. Acetylsalicylic acid for a pt with a history of coronary artery disease and ischemic stroke 2. Metformin for a pt with serum glucose of 285 who is scheduled for a CT scan with contrast 3. Morphine sulfate for a pt with terminal lung cancer who has chronic bone pain 4. Pyridostigmine for a pt with myasthenia gravis exacerbation who reports difficulty swallowing

4. PYRIDOSTIGMINE FOR A PT WITH MYASTHENIA GRAVIS EXACERBATION WHO REPORTS DIFFICULTY SWALLOWING Myasthenia gravis (MG) is a chronic, neurologic autoimmune disorder that involves damage to acetylcholine receptors at the neuromuscular junctions, which results in skeletal muscle weakness. The ocular (ptosis) and facial muscles, along with those responsible for chewing and swallowing, are affected initially; however, weakness can progress to the respiratory muscles (eg, intercostal, diaphragm). Pyridostigmine (Mestinon) is a first-line drug that inhibits acetylcholine breakdown and is prescribed to temporarily increase muscle strength in clients with MG. It is the priority medication as difficulty swallowing indicates weakness of the muscles involved in swallowing and increases aspiration risk. (Option 1) Acetylsalicylic acid (Aspirin) is prescribed daily to prevent ischemic attacks and myocardial infarction in clients with coronary artery disease and ischemic stroke; it is not the priority medication. (Option 2) Metformin (Glucophage) is an anti-hyperglycemic drug that can cause lactic acidosis in clients with kidney disease. Contrast used for CT scan can cause kidney injury. It is recommended that the drug be held before and resumed 48 hours after the CT scan (if renal function [creatinine] is normal). (Option 3) Analgesia with opioids is appropriate to treat chronic pain associated with terminal cancer. However, decreasing the aspiration risk is more urgent than providing pain relief. Educational objective: Pyridostigmine (Mestinon) inhibits acetylcholine breakdown and is prescribed to temporarily increase muscle strength in clients with myasthenia gravis. The ocular and facial muscles, along with those responsible for chewing and swallowing, are affected initially; this can increase the client's aspiration risk.

A neonate on ventilator support is diagnosed with trisomy 18 (Edwards syndrome). What would be an appropriate action by the nurse? 1. Discuss a plan to decrease ventilator support as the lungs become stronger with the parents 2. Provide parents with information on the medical treatment plan for the neonate 3. Provide the test results to the parents and give them information to read about trisomy 18 4. Request a meeting with the palliative care team and the parents to discuss end of life choices

4. REQUEST A MEETING WITH THE PALLIATIVE CARE TEAM AND THE PARENTS TO DISCUSS END OF LIFE CHOICES Life expectancy of a neonate with trisomy 18 is typically a few weeks. A discussion of end-of-life choices would be appropriate in this situation as the neonate is already experiencing respiratory difficulty. A palliative care team will be an asset in this discussion. (Option 1) Trisomy 18 is a genetic disorder with a short life expectancy. Discussing the improvement of the neonate's lungs will give the parents false hope regarding recovery and would be inappropriate at this time. (Option 2) There is no cure or treatment for a neonate with trisomy 18 at this time. (Option 3) Providing test results to the parents is out of the scope of nursing practice as it is the health care provider (HCP) who discusses this with them. The nurse may provide information for the parents to read, but this would be appropriate after the HCP has discussed the disorder. Educational objective: Trisomy 18 (Edwards syndrome) is a chromosome anomaly characterized by severe cardiac defects and multiple musculoskeletal deformities. Life expectancy for trisomy 18 is a few weeks after birth, neonates rarely survive to their first birthday. End-of-life issues should be discussed early after the diagnosis is confirmed. Trisomy 13 (Patau syndrome) also results in early death.

A 14-year-old is scheduled for surgery to treat scoliosis. The child will be hospitalized for about a week and then discharged home to recuperate for 3-4 weeks before returning to school. What is the best activity the nurse can recommend to promote age-specific growth and development during this time? 1. Attending selected after school events and social activities 2. Keeping up with schoolwork 3. Reading teen magazines 4. Visits from friends

4. VISITS FROM FRIENDS During adolescence, being with a peer group is part of the process of achieving individual identity, the most important developmental task at this age. An adolescent's friends have more influence than parents, teachers, or any other adults. Social relationships and activities help to provide a sense of belonging, acceptance, and approval. Having face-to-face visits and spending time with friends will help counteract feelings of isolation and loneliness during the client's recuperative period. In addition, the client is at risk for body image disturbance related to the scoliosis and surgery. The client may be particularly sensitive about body image and needs understanding and acceptance from peers. (Option 1) The client can attend school functions or social activities with friends when off all pain medication and when the spine has healed sufficiently. (Option 2) It is important for the client to keep up with schoolwork, but it is not a priority for recovery. (Option 3) Reading teen magazines can be a diversionary activity and may help distract the client from any pain, but it is not a priority. Educational objective: Friends play a significant role in the adolescent's quest for identity and provide a source of support, belonging, and understanding. Interacting with friends during recuperation after surgery is important to help counteract feelings of loneliness and isolation.

A parent calls the nursing triage line during the evening. The parent says that a 7-year-old was found playing in an area with poison ivy and asks what to do. Which is the most important instruction to give the parent? 1. Apply cool, wet compresses for itching 2. Apply topical cortisone ointment to the area 3. Discourage the child from scratching the area 4. Wash the skin where the contact occurred

4. WASH THE SKIN WHERE THE CONTACT OCCURRED Poison ivy can cause a contact dermatitis rash in those who are sensitive to the oily resin found on the leaves, stems, and roots of the plant. About 50% of people who come in contact with the plant develop a rash. It is often linear in appearance where the plant brushed against the skin. The rash develops 12-48 hours after exposure and can last for several weeks. The severity of the rash depends on the amount of resin on the skin. It is most important to first thoroughly wash the area to remove the resin and prevent its spread to other areas of the body. (Options 1, 2, and 3) Applying cool, wet compresses; applying topical cortisone; and discouraging the child from scratching the area are all appropriate after the rash has developed. Washing the area has the highest priority and is most important immediately after exposure. Educational objective: Immediately after exposure to poison ivy, the client should be instructed to thoroughly wash the area to remove the oily resin, which is responsible for causing the rash that follows in 12-48 hours.