Nclex

The nurse is reinforcing education about ascending stairs using a modified 3-point gait to a client prescribed crutches after a left ankle sprain. Place the instructions for ascending the stairs in the correct order. All options must be used. Your Response/ Incorrect Response 2. Assume the tripod position, then bear body weight on the crutches 4. Transfer body weight to the unaffected leg and raise the body onto the stair 1. Advance the affected leg and crutches up the stair 3. Place the unaffected leg onto the stair

Answer: 2. Assume the tripod position, then bear body weight on the crutches 3. Place the unaffected leg onto the stair 4. Transfer body weight to the unaffected leg and raise the body onto the stair 1. Advance the affected leg and crutches up the stair Clients prescribed crutches after a musculoskeletal injury must be educated on appropriate device use to facilitate independent ambulation, promote wound healing, and prevent reinjury. A common method used to climb stairs is the modified three-point gait ("leading with the good leg"), which is used to prevent weight-bearing on the injured leg. Nurses should instruct clients with crutches to use the following steps to ascend the stairs with the modified three-point gait: Assume the tripod position (ie, crutch stance) and place body weight on the crutches while preparing to move the unaffected leg. Place the unaffected leg (ie, good leg) onto the step. Transfer body weight from the crutches to the unaffected leg and then use the unaffected leg (ie, good leg) to raise the body up onto the step. Advance the affected leg and the crutches together up the step. Realign the crutches with the unaffected leg on the step before repeating the process. Educational objective: Using a modified three-point gait to ascend the stairs, the client should place body weight on the crutches and step up with the unaffected leg. Body weight should then be transferred from the crutches to the unaffected leg. The client should raise the body to align with the unaffected leg, followed by the affected leg and crutches together. Additional Information Basic Care and Comfort NCSBN Client Need

A home health nurse visits a client with Alzheimer disease. The caregiver appears frustrated and reports that the client has been persistently restless and agitated. Which nursing action is the priority at this time? 1. Ask about the client's recent bowel and bladder habits 2. Assess the home for sources of excessive noise 3. Provide information about respite and adult day care 4. Review behavior-management techniques with caregiver

Answer: 1 Alzheimer disease (AD) is a form of dementia that causes a progressive decline of cognitive and physical abilities. Behavioral changes (eg, agitation, aggression, resistance to care) often result from the client's inability to identify a stressor. Stressors may include pain or problems with elimination (eg, constipation) or eating (eg, inability to feed oneself). The nurse's priority must be identifying and solving problems related to the client's basic physiological needs according to the Maslow hierarchy of needs (Option 1). (Option 2) Environmental stressors (eg, excessive noise, overstimulation) may cause behavioral changes such as agitation or restlessness in clients with AD and should be addressed after intervening to meet the client's basic needs. (Option 3) Caregiver support is essential to client care, especially in the home health environment. After addressing the client's needs, the nurse should provide information about community support groups, respite care, and adult day care to help reduce caregiver fatigue. (Option 4) The nurse should use behavioral-management techniques (eg, reassurance, distraction, redirection) to assist with deescalation. However, the nurse must assess for and address sources of agitation first. Educational objective: When caring for a client with Alzheimer disease who has increasing or persistent behavioral changes, the nurse should first assess for possible physical stressors such as pain or problems with elimination or eating.

A student nurse assesses and obtains a urine specimen from a client with methicillin-resistant Staphylococcus aureus (MRSA) who is on contact precautions. The registered nurse intervenes when the student performs which action? 1. Cleans the disposable stethoscope with chlorhexidine solution before reuse with a different client 2. Removes the urine specimen cup from the room in a sealed biohazard bag 3. Scrubs the Foley catheter collection port with alcohol for 15 seconds before withdrawing a urine specimen 4. Uses an alcohol-based hand antiseptic solution after removing gloves

Answer: 1 Clients with a health care-associated infection, such as methicillin-resistant Staphylococcus aureus, are placed on contact precautions to prevent transmission of microorganisms. Contact precautions include standard precaution measures in addition to use of a gown and gloves and single-client-use equipment (eg, stethoscopes, blood pressure cuffs, thermometers). Disposable or single-client-use equipment must not be shared between clients or transferred to other care areas. Dedicated equipment should be kept in the room for client care, and then disinfected or discarded when no longer needed (Option 1). (Option 2) The urine specimen should be placed in a leak-proof specimen cup and then sealed in a biohazard bag before transport to the laboratory. (Option 3) To prevent specimen contamination and the introduction of bacteria into the client's urinary tract, the nurse should scrub the Foley collection port with alcohol or chlorhexidine for 15 seconds before withdrawing a specimen. (Option 4) Hand hygiene with an alcohol-based hand rub is recommended, unless there is visible soiling of the hands with body fluids, or after contact with Clostridium difficile. In both situations, hand hygiene must be performed with soap and water to thoroughly remove contaminants left behind by alcohol-based rubs. Educational objective: Nurses should implement contact precautions (eg, gown/gloves, single-client-use equipment) for clients with methicillin-resistant Staphylococcus aureus to prevent transmission of microorganisms. Single-client-use or disposable equipment should not be shared between clients. Hand hygiene with alcohol-based hand rubs is appropriate unless visible soiling or exposure to Clostridium difficile occurs.

The nurse is teaching a client of American Indian heritage how to self-administer insulin. As the nurse describes the necessary steps in the injection process, the client continuously avoids eye contact and occasionally turns away from the nurse. Which action is most appropriate for the nurse to take in this situation? 1. Continue teaching the client and verify understanding by return demonstration 2. Discuss how important it is for the client to pay attention during the teaching 3. Maintain eye contact during the teaching by following the client's movements 4. Provide written instructions and a private place for the client to learn independently

Answer: 1 Communication with individuals of various cultures may be difficult for the nurse at times due to cultural language differences (ie, verbal and nonverbal communication styles including the use of silence). The mainstream American and European cultures value direct eye contact, believing that it is a sign of attention and trustworthiness. People of American Indian and Asian cultures view direct eye contact as rude and disrespectful and will likely move the eyes away, not allowing the nurse to maintain eye contact. If the client avoids eye contact during a teaching episode, the most appropriate action is to continue with the instruction and verify understanding by return demonstration. (Option 2) Lecturing the client about the importance of listening to the instructions for insulin self-injection would most likely be interpreted as degrading and disrespectful. (Option 3) In the American Indian culture, it is disrespectful to maintain eye contact during a conversation. (Option 4) A client learning the process of self-administration of insulin requires guidance and evaluation from the registered nurse before, during, and after the teaching session. The client should not be sent to a quiet place to learn the procedure independently. Educational objective: Individuals of American Indian and Asian cultures view direct eye contact as rude and disrespectful and will likely move the eyes away during conversations in an attempt to prevent it. The nurse demonstrates culturally competent care by respecting and accepting this cultural communication pattern.

A client is undergoing chest tube placement in the emergency department after being involved in a motor vehicle collision. The client's spouse arrives and demands to be with the client. Which action should the nurse take? 1. Allow the spouse in the room, out of the way of care providers, and explain the events occurring with the client 2. Assist the spouse in observing outside the room through a window and have a chaplain explain the care being provided 3. Explain the client's condition, but inform the spouse that entering the room is not allowed until the client is stabilized 4. Inform the spouse that being in the room during procedures is unsafe for the client, and escort the spouse to the waiting area

Answer: 1 Family member presence at bedside during invasive procedures or resuscitation efforts is an important component of psychosocial care for the client and family. When a client's support person is allowed to be present at bedside to witness care during acute events, the support person is often able to better understand the client's condition and may have decreased anxiety and better coping with unexpected or poor outcomes (eg, cardiac arrest, death). Therefore, the nurse should, when possible, support and facilitate family presence in the room and provide information about the events that are occurring (Option 1). (Option 2) Requiring family members to watch through the window, rather than at the bedside, may increase their stress and impair coping. Although chaplains may assist with an individual's emotional or spiritual needs, chaplains are not trained to provide information related to medical or surgical interventions. (Option 3) Denying the support person's presence in the room may be appropriate in certain situations (eg, uncontrollable emotional outbursts, interference with care, risks to support person health/safety). However, the nurse should provide the option of being present in the room when possible. (Option 4) Although some health care professionals express concern that support person presence may negatively impact client outcomes, there is no evidence for this claim. Educational objective: The presence of family members during invasive procedures supports the psychosocial needs of the client and family. The nurse should reinforce family presence at bedside and provide information to the client's support person about the care being provided.

Before examining the infant of a Mexican American mother, the nurse compliments the child's outfit. The mother becomes visibly distressed. What is the best next action for the nurse to take? 1. Ask the mother's permission to touch the child's hand 2. Interview the mother about the reason for bringing the child to the clinic 3. Reassure the mother that there is no reason for distress 4. Suggest postponing the examination until the mother calms down

Answer: 1 In Latin American culture, an illness called "mal de ojo" ("evil eye") is believed to be caused when a stranger or someone perceived as powerful admires or compliments a child. The "illness," or "curse," is usually manifested by vomiting, fever, and crying. The mal de ojo curse can be broken if the admirer touches the child while speaking to the child or immediately afterward (Option 1). Mexican American mothers may worry when strangers compliment their babies without touching them. To protect against mal de ojo, the child may wear charms or beaded bracelets. If a child is believed to be afflicted with mal de ojo, the parents may consult a traditional healer, or curandero, who may perform rituals meant to cure the child of the curse. (Option 2) Asking the mother about the reason for bringing the child to the clinic will not relieve the mother's distress. (Option 3) This response is nontherapeutic and dismissive, and indicates the nurse's lack of cultural awareness. (Option 4) Postponing the examination does not address the cause of the mother's distress. Educational objective: Many Latin Americans believe in "mal de ojo," or "evil eye," a cultural belief in an illness thought to be manifested in children by vomiting, fever, and crying. It is believed to be caused when a stranger admires a child without touching the child at the same time or immediately afterward.

A client in the mental health unit picks up a fire extinguisher and throws it at a nurse standing by the nurses' station. What is the most important intervention by the nurse? 1. Facilitate immediate removal of people from the area 2. Inform the client that the client cannot act that way 3. Pull the fire alarm to get additional immediate help 4. State that the nurse can see the client is upset

Answer: 1 When a situation is out of control, safety is the primary concern. The nurse and everyone else should leave the area, and security should be called immediately. (Option 2) The situation is no longer diffusible. Quoting authoritative rules will not likely have the desired effect as the client has lost control (and may not be in touch with reality). The nurse's priority is to move out of harm's way. (Option 3) Staff members should call security immediately and/or institute a back-up staff/takedown protocol. The fire alarm will activate a call to a fire department, which is not the type of help needed. However, when security arrives, the "best-trained brain" remains in control and the nurse should direct the actions of the team. (Option 4) When violence (eg, throwing a fire extinguisher) occurs, trying to defuse the situation verbally is no longer the priority. Educational objective: Safety is the priority when violence occurs. People should leave the area and call security immediately.

The nurse is contributing to the plan of care for a client who has active varicella with open, moist lesions. Which of the following actions are appropriate to include in the plan of care? Select all that apply. 1. Don gown, gloves, and N95 respirator when entering the client's room 2. Ensure that pregnant staff members are not assigned to care for this client 3. Place single-use, disposable thermometer and stethoscope in the room 4. Place the client in a private room with negative air pressure 5. Request discontinuation of isolation precautions once all lesions are dry and crusted

Answer: 1,2,3,4,5 NCLEX® CHANGE AS OF 2017 - Please note that select-all-that-apply (SATA) questions on NCLEX can now include any number of correct responses. Only ONE option or up to ALL options may be correct. UWorld questions now reflect this change. Visit NCSBN® NCLEX FAQs for more information. Airborne precautions Indications Tuberculosis Varicella zoster* (chickenpox) Herpes zoster** (shingles) Rubeola (measles) Components N95 respirator or powered air-purifying respirator Negative-pressure isolation room with high-efficiency particulate air filter As needed if contact with body fluid is anticipated: clean gloves, disposable gown, goggles/face shield *Only when uncrusted lesions are present; contact precautions also required. **Only in disseminated disease or immunocompromised clients; contact precautions also required. Varicella (chickenpox) is a highly contagious infection characterized by a generalized rash of itchy, vesicular lesions. Both chickenpox and shingles are caused by the varicella-zoster virus (VZV), which is transmitted through airborne particles or contact with open vesicles. For chickenpox and disseminated (widespread) shingles, the nurse should use precautions for both airborne isolation (ie, N95 respirator mask), negative air pressure room) and contact isolation (eg, gown, gloves, disposable equipment) (Options 1 and 3). Once the vesicles have crusted, the client is no longer contagious, and isolation precautions may be discontinued (Option 5). Rooms with negative air pressure are equipped with specialized air equipment that continuously filters air out of the room and creates a negative pressure gradient that prevents infectious airborne particles from escaping through the doorway (Option 4). Pregnant health care workers should not be exposed to clients with TORCH infections (Toxoplasmosis, Other [VZV/parvovirus B19], Rubella, Cytomegalovirus, Herpes simplex virus), as these infections can cause fetal abnormalities (Option 2). Educational objective: Varicella-zoster virus (ie, chickenpox, shingles) is transmitted through airborne particles or contact with open vesicles. For chickenpox and disseminated shingles, the nurse should use precautions for both airborne isolation (ie, N95 particulate respirator mask, room with negative air pressure) and contact isolation (eg, gown, gloves, disposable equipment) until vesicles have crusted.

The nurse is reinforcing instructions to a client on collection of a sputum specimen for culture and sensitivity. Which of the following client statements indicate that teaching has been effective? Select all that apply. 1. "I should rinse my mouth with water before collecting the sputum." 2. "I will be careful not to touch the inside of the specimen cup or lid." 3. "I will inhale deeply a few times and then cough forcefully." 4. "It is best to collect the sputum mid-day when my secretions are loose." 5. "It is helpful if I am sitting upright when I collect the sputum."

Answer: 1,2,3,5 Sputum culture and sensitivity testing is used to identify infectious organisms in the respiratory tract and determine which antimicrobials are most effective at treating the identified organism. Nurses assisting a client to collect sputum should instruct the client to: Rinse the mouth with water before collecting the sputum sample to reduce bacteria in the mouth and prevent specimen contamination by oral flora (Option 1) Avoid touching the inside of the sterile container or lid to avoid accidental specimen contamination by normal flora of the skin (Option 2) Inhale deeply several times and then cough forcefully, which promotes expectoration of lower lung secretions and increases sample volume (Option 3) Assume a sitting or upright position before specimen collection, if possible, to promote cough strength during collection (Option 5) (Option 4) Sputum specimens should be collected early in the morning after awakening, which improves the quality of the sample because secretions accumulate overnight due to cough inhibition. A nebulizer treatment may be prescribed to help mobilize thick secretions. Educational objective: Collection of a sputum specimen by expectoration is a sterile procedure that requires the client to breathe deeply and cough effectively. The nurse should instruct the client to rinse the mouth with water, sit upright, inhale deeply several times, and cough prior to expectorating. The client should avoid touching the inside of the sterile container or lid. Sputum should be collected in the morning to improve sample quality. Additional Information Reduction of Risk Potential NCSBN Client Need

The nurse cares for a client admitted to the hospital following a motor vehicle accident caused by the client's newly diagnosed seizure disorder. The health care provider prescribes seizure precautions for the client. The nurse prepares to initiate which interventions? Select all that apply. 1. Apply pads to the side rails 2. Have oxygen supplementation available 3. Prepare to insert a urinary catheter 4. Remove all linen from the bed 5. Set up bedside suction equipment

Answer: 1,2,5 Clients with seizures are at increased risk for injury during seizure activity. Seizure precautions are nursing interventions that can help protect a client during a seizure. These precautions typically include: Raising the upper side rails on the bed to prevent the client from falling to the floor during a seizure. The side rails are also padded to prevent client injury due to hitting the hard plastic rails during a seizure (Option 1). During a seizure, a client may be unable to control secretions, increasing the risk for an impaired airway. Suction equipment and oxygen equipment are set up at the bedside (Options 2 and 5). Some facilities also encourage the use of a continuous pulse oximeter. (Option 3) Clients may experience urinary incontinence during a seizure, but unless the health care provider prescribes a urinary catheter, it is not typically used as part of seizure precautions. Inserting a urinary catheter puts the client at risk for a urinary tract infection. (Option 4) It is not necessary to remove all linen from the client's bed. If a client has a seizure, any blankets or pillows that are in the way or pose a threat can be removed, but the client may have linen on the bed while on seizure precautions. Educational objective: Seizure precautions are safety measures that typically include raising the upper side rails, placing padding on the side rails, and preparing bedside suction and oxygen equipment.

A blood transfusion is prescribed for a client experiencing complications of sickle cell anemia with a hemoglobin level of 6 g/dL (60 g/L). Which of the following actions by the registered nurse are appropriate? Select all that apply. 1. Asks another licensed nurse to verify client identifiers and blood before administration 2. Delegates all vital sign measurements to the unlicensed assistive personnel 3. Prepares O-negative blood for an AB-positive client 4. Transfuses the blood over a 6-hour period of time 5. Uses filtered tubing with normal saline to administer blood

Answer: 1,3,5 Blood transfusions are commonly administered to clients experiencing anemia or acute blood loss. To ensure client safety during blood administration, the nurse should: Verify two client identifiers (eg, name, medical record number, date of birth), the prescription, and the blood products with another licensed health care provider (Option 1). Ensure that blood type and Rh type are compatible (Option 3). An Rh-positive client can safely receive Rh-positive or Rh-negative blood. Administer the blood via filtered tubing with normal saline to prevent clumping in the tube and hemolysis of red blood cells (Option 5). Monitor vital signs during transfusion per facility-specific protocol (eg, before transfusion, 15 minutes after transfusion begins, periodically). Transfuse blood products within 4 hours due to the risk for bacterial growth. (Option 2) The nurse remains with the client for the first 15 minutes (ie, approximately 50 mL) of the transfusion and obtains vital signs directly to monitor for adverse reactions (eg, fever, chest pain). Delegating vital signs to unlicensed assistive personnel after the initial 15-30 minutes may be appropriate for stable clients. (Option 4) Infusing blood over 6 hours increases the risk of bacterial contamination and hemolysis of the blood product. Educational objective: The nurse facilitates safe blood administration by verifying the prescription, blood type, and at least two client identifiers with another licensed health care provider; administering blood with normal saline; obtaining vital signs directly for the first 15 minutes (ie, approximately 50 mL of the transfusion); and transfusing blood within 4 hours.

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

Answer: 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. Additional Information Safety and Infection Control NCSBN Client Need

The health care provider prescribes a continuous IV infusion of regular insulin at 5 units/hr. The infusion bag contains 50 units of regular insulin in 100 mL of normal saline solution. At what rate in milliliters per hour (mL/hr) does the nurse set the IV pump? Record your answer using a whole number.

Answer: 10 ml/hr Using dimensional analysis, use the following steps to calculate the infusion rate of regular insulin: Identify the prescribed, available, and required medication information Prescribed: 5 units regular insulinhr Available: 50 units regular insulin100 mL normal saline Required: mLhr Convert prescription to infusion rate needed for administration Prescription×available medication=mLhr Educational objective: To calculate the infusion rate of IV regular insulin, the nurse should first identify the prescribed dose (eg, 5 units/hr) and available dose (eg, 50 units/100 mL) and then convert to milliliters per hour (eg, 10 mL/hr). Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

The male client had a hemicolectomy. The client is refusing to wear the prescribed sequential compression devices (SCDs). What is most important for the nurse to communicate to the client? 1. An appropriate form must be signed, verifying refusal 2. Complications, including death, could result 3. The client will be billed for the equipment regardless 4. The surgeon will be informed of the refusal

Answer: 2 Just as there is informed consent, there is informed refusal. The client should be made aware of all the possible complications (including the possible worst-case scenario, which is usually death) when making a decision, and this should be documented. The nurse should try to work with the client to get at least partial compliance when it is in the client's best interest (eg, wear the SCDs for a limited time). (Option 1) This would occur, but it is more important to make the client aware of the potential implications of this refusal so that the client can make an informed refusal. (Option 3) Safe, quality care is the priority, not financial concerns. The nurse should avoid discussing financial implications when a client is making care decisions. (Option 4) Depending on the hospital policy, a refusal to wear the SCDs could result in an additional form being completed and the refusal documented in the medical record. Documentation should include the information given to the client and the client's understanding of that information. Even if the client refuses to sign the form, the nurse should obtain other witnesses and document the refusal in detail in the medical record. Educational objective: The most important aspect of a client's refusal for treatment is to make sure that the client is informed of the potential results of the refusal.

Which client incident would be classified as an adverse event that requires an incident/event/irregular occurrence/variance report? Select all that apply. 1. Client admitted with white blood cell count of 28,000 mm3 (28.0 × 109/L) and dies from sepsis 2. Client receives 1 mg morphine instead of prescribed 0.5 mg morphine 3. Client refuses pneumonia vaccination and contracts pneumonia 4. Nurse did not report client's new hemoglobin result of 6 g/dL (60 g/L) to oncoming nurse 5. Provider was not notified of client's positive blood culture results

Answer: 2,4,5 An adverse event is an injury to a client caused by medical management rather than a client's underlying condition. It may or may not be preventable. The Institute of Medicine (2000) recognizes 4 types of errors. They are: Diagnostic (delay in diagnosis, failure to employ indicated tests, failure to act on results of monitoring) Treatment (error in performance of procedure, treatment, dose; avoidable delay) Preventive (failure to provide prophylactic treatment, inadequate follow-up/monitoring of treatment) Other (failure of communication, equipment failure, system failure) Option 2 is a treatment error. Option 4 is a communication error as well as inadequate follow-up. Option 5 is a communication error and a failure to respond to an abnormal test. Timely reporting of critical results of tests and diagnostic procedures is part of the Joint Commission Hospital National Patient Safety Goals. (Option 1) The client was admitted with signs of a severe infection and the death is likely a result of that process rather than a medical error. (Option 3) Under the ethical principle of autonomy, the client has the right to refuse anything even if it is not to the client's ultimate best interest. The pneumonia could be due to lack of vaccination, but there is no direct relationship. Educational objective: Adverse events are injuries caused by medical management rather than a client's underlying condition. Types of errors include diagnostic, treatment, preventive, and failure of communication, equipment, or other systems.

The nurse admits an 81-year-old client with gastroenteritis. Admission vital signs are temperature 101 F (38.3 C), blood pressure 90/42 mm Hg, pulse 118/min, and respirations 32/min. Pulse oximetry shows 88%. The nurse suspects which of the following factors may be affecting accuracy of the pulse oximetry reading? 1. Dehydration 2. Elevated temperature 3. Hypotension 4. Tachypnea

Answer: 3 A pulse oximeter is a noninvasive device that estimates the arterial blood saturation (SaO2) by using a sensor attached to the adult client's finger, toe, earlobe, nose, or forehead. The sensor (reusable clip or disposable adhesive) contains both light-emitting and light-sensing components and measures the amount of light absorbed by hemoglobin in the arterial blood. Because the sensor estimates the value at a peripheral site, the oximeter reports the value as SpO2. The sensor relies on adequate tissue perfusion, so low blood flow or decreased perfusion can decrease SpO2 readings. Conditions associated with low blood flow or decreased perfusion states include cardiac dysrhythmias, heart failure, peripheral vascular disease, edema, hypotension, hypovolemic shock, and vasoconstriction (eg, hypothermia, smoking, drugs). Other factors affecting accuracy of the reading include improper positioning or fit of the sensor, excessive movement, smoke inhalation, and carbon monoxide poisoning. (Option 1) Although dehydration can be associated with conditions that could cause decreased pulse oximetry readings, it is not an independent factor. (Option 2) Elevated temperature is not a factor that could cause an inaccurately low pulse oximeter reading. (Option 4) Although tachypnea can be associated with conditions that could cause decreased pulse oximetry readings, it is not an independent factor. Educational objective: Because the pulse oximeter sensor relies on adequate tissue perfusion, any condition associated with low blood flow or low perfusion states can decrease the reading. Pulse oximetry is also inaccurate in clients with carbon monoxide poisoning.

A home health nurse is teaching the spouse of an elderly client who experienced a stroke ways of reducing risks for falls in the home. Which suggestion by the spouse would be the most effective plan to prevent falls? 1. Have a respite caregiver come once a week to stay with the client so the spouse can go shopping 2. Purchase a walker for the client to use when ambulating around the home 3. Remove all area rugs and install grab bars in the bathroom 4. Take the client for an annual eye exam and new glasses

Answer: 3 All of the choices are appropriate options to reduce falls in the home, but the one with the greatest impact is the removal of all area rugs and installation of grab bars in the bathroom. Area rugs can still cause falls for the client with a walker, with new glasses, and with someone present. In addition, many falls occur in the bathroom while toileting and bathing, making grab bars highly beneficial. (Option 1) Not leaving the client alone is preferable and could decrease the incidence of falls while the spouse is away. However, it is less effective than the removal of area rugs and installation of grab bars in the bathroom. (Option 2) A walker would be beneficial for this client but could get caught on an area rug. (Option 4) Poor eyesight can contribute to falls, but the removal of rugs and installation of grab bars will have a greater impact. Educational objective: The nurse should educate the client and family about removing area rugs and installing grab bars in the bathroom to reduce the risk of falls in the home.

The client screams at the nurse, "You are all incompetent here! I have been waiting for 2 hours!" How should the nurse respond initially? 1. "I know you are upset, but I will have to call security if you continue to scream." 2. "I see that you are frustrated, but the delay cannot be avoided." 3. "It is upsetting to wait so long. How can I best help you?" 4. "The wait is long today, but you will receive quality, unhurried care when it is your turn."

Answer: 3 Nontherapeutic communication techniques Asking personal questions Attempting to gather client information for personal curiosity "Why don't you & your spouse have children yet?" Giving personal opinions Stating a personal judgment or choice that takes away client decision-making "If I were you, I would stop taking my child there." Changing the subject Attempting to focus on a different topic, which shows lack of empathy & stalls communication "Let's talk about what you want for lunch instead." Automatic responses Making generalized, stereotyped statements or clichés that lack empathy "You can't win them all." False reassurance Offering hope when the outcome is unsure "Everything is going to be all right." Asking for explanations Attempting to gather information inappropriately, causing the client to feel tested or accused "Why" questions Approval or disapproval Imposing one's values or beliefs on the client's statements "You shouldn't consider plastic surgery; it's wrong." Defensive responses Avoiding or challenging criticism, which implies that the client doesn't have a right to the stated opinion "I know what I am doing. I wouldn't intentionally hurt you." Arguing Challenging or disagreeing, which implies that the client's thoughts are not real or valid "You can't be tired; you slept all night." Therapeutic communication is used to establish trust, encourage communication, and display respect for the client. Validating the client's feelings and offering self convey concern and understanding by the nurse and help establish a therapeutic dialogue (Option 3). Together, these techniques can be helpful for diffusing negative emotions. (Option 1) Security may be called if the client appears to be losing control or is a risk to self or others. However, initially calling security or using an authoritative approach may further escalate the situation and does not address the client's concern. The nurse should initially try to diffuse the situation and the client's anger. (Options 2 and 4) In both options the client's feelings are validated, but defensive statements follow. When the nurse defends, clients are made to feel as if their opinions and feelings do not matter. These options also do not indicate that the nurse is willing to seek a solution. Educational objective: When a client is angry and upset, therapeutic communication skills such as giving recognition, validating feelings, and offering self may help deescalate the situation. The nurse should not initially ignore the client, use threats or cite rules, or make defensive statements.

The nurse is teaching a client with insomnia about techniques to improve sleep habits. Which statement by the client requires further teaching? 1. "I will avoid naps later in the day." 2. "I will keep the bedroom temperature cool." 3. "I will read in bed before trying to go to sleep." 4. "I will try to go to bed and wake up at the same time each day."

Answer: 3 Sleep hygiene refers to a group of practices that promote regular, restful sleep. The nurse should encourage clients who have trouble sleeping (insomnia) to maintain good sleep habits. A primary objective is reducing stimuli in the bedroom. Clients should be taught to avoid non-sleep-related activities (eg, reading, television, working) other than sex in bed. Relaxed reading before bed is helpful for stimulating sleep but should occur in a different setting, not in bed (Option 3). The nurse should encourage the following healthy sleep habits: Avoid caffeine, nicotine, and alcohol within 4-6 hours of sleep Exercise daily but avoid exercise or strenuous activity within 4-6 hours of sleep Avoid going to bed hungry or eating a heavy meal just before bed Practice relaxation techniques (eg, deep breathing) if stress is causing insomnia (Option 1) It is best to avoid naps during the day, especially later in the day. Any naps taken should be short (20-30 min). (Option 2) The client should keep the bedroom slightly cool, quiet, and dark for comfort. (Option 4) As much as possible, the client should develop a consistent sleep-wake pattern (ie, same bedtime and wake time each day) to obtain 7-8 hours of sleep nightly. Educational objective: The nurse should teach clients with insomnia good sleep hygiene such as using the bed for sleep only (no reading or television), avoiding stimulants (eg, caffeine) before bedtime, keeping the bedroom cool and dark, and developing a consistent sleep-wake pattern (ie, same bedtime and wake time each day).

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

Answer: 3 The recommended rates for an intermittent IV infusion of potassium chloride (KCl) are no greater than 10 mEq (10 mmol) over 1 hour when infused through a peripheral line and no greater than 40 mEq/hr (40 mmol/hr) when infused through a central line (follow facility guidelines and policy). If the nurse were to administer the medication as prescribed, the rate would exceed the recommended rate of 10 mEq/hr (10 mmol/hr) (ie, 10 mEq [10 mmol] over 30 minutes = 20 mEq/hr [20 mmol/hr]). A too rapid infusion can lead to pain and irritation of the vein and postinfusion phlebitis. Contacting the health care provider to verify this prescription is the priority action. (Option 1) The nurse would assess the IV site for swelling, tenderness, and redness just before initiating the KCl infusion and every 30 minutes during administration. However, this is not the priority action. (Option 2) The nurse would check the most current serum potassium level just before administering the KCl and may obtain another level following the infusion, if prescribed. This is not the priority action. (Option 4) An electronic IV pump should always be used to administer KCl. To administer the infusion at the recommended rate of 10 mEq/hr (10 mmol/hr), the nurse would set the pump at 100 mL/hr, but this is not the priority action. Educational objective: The maximum rate for infusion of IV potassium chloride through a peripheral vein is 10 mEq/hr, and the maximum rate through a central vein is 40 mEq/hr. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

A graduate nurse is caring for a client with a triple-lumen peripherally inserted central catheter in the right arm. Which actions by the graduate nurse indicate that more education is needed? Select all that apply. 1. Flushing the line before and after each medication administration 2. Pausing the parenteral nutrition prior to drawing blood from a different port 3. Reinforcing a torn peripherally inserted central catheter line dressing with tape 4. Scrubbing the port with alcohol for 5 seconds before use 5. Taking the client's blood pressure in the left arm

Answer: 3,4 A peripherally inserted central catheter (PICC) is a venous access device that is inserted via the cephalic or basilic vein and terminates in the superior vena cava. It is indicated for administration of noxious medications (eg, parenteral nutrition, chemotherapy), for long-term IV therapy, or in clients with poor venous access. Proper care and aseptic technique are important to maintain lumen patency and eliminate the risk of life-threatening central line-associated bloodstream infection (CLABSI). The nurse should inspect the insertion site for signs of infection (redness, drainage) and dressing integrity. Routine care includes sterile dressing changes every 48 hours with a gauze dressing or 7 days with a transparent semipermeable dressing (biopatch) as well as immediately if dressing is loose/torn, soiled, or damp. The line should be flushed before and after medication administration and per facility protocol (Option 1). Blood pressure and venipuncture should not be performed on the affected arm as compression of the vein can alter its integrity (Option 5). All infusing medications (except vasopressors) must be paused before drawing blood from the PICC to prevent false interpretation of the client's serum levels (Option 2). (Option 3) Dressings that no longer occlude the insertion site must be changed immediately. Loose corners may be temporarily reinforced with tape. (Option 4) The nurse should "scrub the hub" with alcohol or chlorhexidine/alcohol for 10-15 seconds. This should be done before flushing, drawing blood, or administering medication. Educational objective: Peripherally inserted central catheter lines provide central venous access for clients who require long-term medication administration or infusion of noxious substances. Maintaining the line integrity with aseptic technique and routine care (sterile dressing changes, flushing the line, blood pressures/venipunctures on unaffected arm) is important for continued use and prevention of central line-associated bloodstream infections.

The nurse is caring for a client with Clostridium difficile colitis. Which of the following infection control measures by the nurse are appropriate? Select all that apply. 1. Applies sterile gloves before performing client care 2. Ensures surgical masks are worn by staff in the client's room 3. Requests that the client be assigned to a single-client room 4. Uses alcohol-based sanitizers for hand hygiene 5. Wears a single-use, disposable gown during client care

Answer: 3,5 Contact precautions Organisms MDR organisms (eg, MRSA, VRE) Enteric organisms (eg, Clostridium difficile) Scabies Infection-control measures Hand hygiene (soap & water for C difficile) Nonsterile gloves Gown Private room preferred MDR = multidrug-resistant; MRSA = methicillin-resistant Staphylococcus aureus; VRE = vancomycin-resistant Enterococcus. Clostridium difficile is a highly infectious bacteria causing severe colitis in infected clients. When caring for a client with C difficile, it is critical that the nurse implement contact isolation precautions to prevent transmission of microorganisms between clients, including: Placing the client in a single-client room, if possible, or in a cohort with other clients infected with C difficile (Option 3) Wearing a single-use, disposable gown and clean gloves during all client care and discarding the equipment before leaving the room (Option 5) Performing hand hygiene before and immediately after client care with soap and water Using dedicated medical equipment (eg, stethoscope, blood pressure cuff) that is not shared between clients and always remains in the client's room (Option 1) Clean, rather than sterile, gloves are required during care of a client with C difficile to prevent transmission of infection to other individuals. (Option 2) Surgical masks are required when caring for a client prescribed droplet isolation precautions but are needed only in clients with contact isolation precautions if performing activities with the possibility of body fluid splashing (eg, suctioning, wound care). (Option 4) When caring for clients with C difficile, it is critical to perform hand hygiene with soap and water, rather than alcohol-based sanitizers. Alcohol-based sanitizers are unable to effectively kill spore-forming bacteria (eg, C difficile, anthrax). Educational objective: Clostridium difficile is a highly infectious bacteria requiring contact isolation precautions, including a single-client room assignment if available, disposable gowns and clean gloves, and hand hygiene with soap and water. Surgical masks are not necessary unless performing client care with the possibility of body fluid splashing.

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

Answer: 4 Clients with airborne infections such as TB, measles, or chickenpox (varicella) are confined to a negative-pressure room except when traveling to various departments for essential diagnostic procedures or surgery. While being transported through the health care facility, the client on airborne transmission-based precautions wears a surgical mask to protect health care workers (HCWs) and other clients from respiratory secretions. (Options 1 and 2) The client on airborne transmission-based precautions must wear a surgical mask to contain exhaled respiratory secretions. The other personal protective equipment is not necessary. (Option 3) The Centers for Disease Control and Prevention recommends that HCWs who transport clients wear N95 respirator masks as protection against exposure to airborne droplets. N95 respirator masks protect HCWs by removing particles from inhaled air. The client is already infectious and does not require protection from inhaled air. Educational objective: While away from the negative-pressure isolation room, all clients on airborne transmission-based precautions must wear a surgical mask to contain exhaled respiratory secretions.

The nurse performs nasogastric (NG) tube insertion using a large-bore NG tube on a hospitalized client with a gastrointestinal bleed. During insertion, after the tube passes the nasopharynx, the client begins to cough and gag. Which action should the nurse take first? 1. Ask the client to take several small sips of water 2. Continue to slowly advance the tube until placement is reached 3. Gently remove the tube and reinsert in the other naris if possible 4. Pull back on the tube slightly and then pause to give the client time to breathe

Answer: 4 During NG tube insertion, the tube sometimes slips into the larynx or coils in the throat, which can result in coughing and gagging. The nurse should withdraw the tube slightly and then stop or pause while the client takes a few breaths. After the client stops coughing, the nurse can proceed with advancement (Option 2), asking the client to take small sips of water to facilitate advancement to the stomach (Option 1). The client should not be asked to swallow during coughing or aspiration may occur. If resistance or obstruction occurs during tube advancement, the nurse should rotate the tube while trying to advance it. If resistance continues, the tube should be withdrawn and inserted into the other naris if possible (Option 3). Educational objective: Coughing and gagging commonly occur during NG tube insertion if the tube coils in the throat or slips into the larynx. When this happens, the nurse should pull back on the tube slightly and then pause to give the client time to recover and breathe before advancing the tube.

A client with type 1 diabetes has a prescription for 20 units of NPH insulin daily at 7:30 AM and regular insulin before meals, based on a sliding scale. At 7:00 AM, the client's blood glucose level is 220 mg/dL (12.2 mmol/L), and the client's breakfast tray has arrived. What action should the nurse take? Click on the exhibit button for additional information. 1. Administer 20 units of NPH insulin now and then 6 units of regular insulin after the morning meal 2. Administer 26 units of insulin: 20 units of NPH insulin and 6 units of regular insulin in 2 separate injections 3. Administer 26 units of insulin: 20 units of NPH mixed with 6 units of regular insulin in the same syringe, drawing up the NPH into the syringe first 4. Administer 26 units of insulin: 20 units of NPH mixed with 6 units of regular insulin in the same syringe, drawing up the regular insulin first

Answer: 4 Intermediate-acting insulins (NPH) can be safely mixed with short-acting (regular) and rapid-acting (lispro, aspart) insulins in one syringe (Option 4). Six units of regular insulin are needed to address the client's blood glucose reading (220 mg/dL [12.21 mmol/L]) along with the scheduled 20 units of NPH insulin. Prepare the mixed dose: Inject the NPH insulin vial with 20 units of air without inverting the vial or passing the needle into the solution. Inject 6 units of air into the regular insulin vial and withdraw the dose, leaving no air bubble. Draw NPH, totaling 26 units in one syringe. Any overdraw of NPH into the syringe will necessitate wasting the total quantity. Most long-acting insulins (eg, glargine, detemir) are not suitable for mixing and typically are packaged in prefilled injection pens. (Option 1) The 2 insulins may be safely given together before the meal because regular insulin has a rapid onset of action, whereas NPH has a slower onset but longer duration. (Option 2) The insulins can be given as 2 separate injections; however, this increases client discomfort and infection risk. (Option 3) Regular insulin should be drawn first to avoid contaminating the regular insulin vial with NPH insulin (mnemonic - RN: Regular comes before NPH). Educational objective: NPH insulin and regular insulin may be safely mixed and administered as a single injection. Regular insulin should be drawn into the syringe before intermediate-acting insulin to decrease the risk of cross-contaminating multidose vials (mnemonic - RN: Regular comes before NPH).

A legally blind client is being prepared to ambulate 1 day after an appendectomy. What is the most appropriate action by the nurse? 1. Arrange for the client's service dog to come to the health care facility as soon as possible 2. Describe the environment in detail so the client can ambulate safely with a cane 3. Instruct the unlicensed assistive personnel to walk beside the client and lead by the hand 4. Walk slightly ahead of the client with the client's hand resting on the nurse's elbow

Answer: 4 On the first postoperative day, the nurse assists the client with ambulation to evaluate alertness, pain level, signs of orthostatic hypotension, problems with gait or mobility, and ability to ambulate safely. The nurse also considers pre-existing limitations to ambulation such as the use of assistive aids (eg, sighted guides, canes, guide dogs). Clients who used any ambulatory assistive aids before surgery require postoperative evaluation prior to ambulatory independence. When walking with a client who is legally blind, the nurse uses the sighted-guide technique by walking slightly ahead of the client with the client holding the nurse's elbow. The nurse should describe the environment while ambulating the client. (Option 1) The service dog may be brought to the hospital to assist in ambulation once the nurse has determined the client can ambulate safely. (Option 2) After evaluation by the nurse, the client may be allowed to use a cane to ambulate around the nursing unit. (Option 3) Instructing the unlicensed assistive personnel to ambulate the client is an inappropriate assignment for a client who is 1 day postoperative and legally blind. Nursing assessment is required to determine if the client is able to ambulate safely. Educational objective: When ambulating a client who is legally blind, the nurse uses the sighted-guide technique by walking slightly ahead with the client holding the nurse's elbow.

The nurse is assisting with procedural moderate sedation (conscious sedation) at a client's bedside. The unlicensed assistive personnel (UAP) comes to the door and indicates that the client in the next room needs the nurse right now. How should the nurse respond? 1. Ask the UAP to go back and ask the client what the current needs are 2. Ask the UAP to stay and take over while the nurse goes to check on the client in the next room 3. Tell the UAP to inform the client in the next room that the nurse will be there shortly 4. Tell the UAP to tell the charge nurse about the needs of the client in the next room

Answer: 4 With procedural moderate sedation at the bedside, the nurse takes on the role of an anesthetist. The nurse's role is to monitor the client's condition while the health care provider focuses on performing the procedure. The nurse should never leave the client during the procedure. The best response is to have an available nurse (the charge nurse) go assess and deal with the needs of the client next door. (Option 1) This action would place the UAP in the role of assessing and prioritizing, which is beyond the scope of the UAP's practice. In addition, the nurse must stay in the room and cannot meet the other client's need as a result. (Option 2) Taking on the role of assessing/monitoring (related to anesthesia) and/or administering additional intravenous drugs during the procedure is beyond the scope of the UAP's practice. (Option 3) The UAP has already communicated that the client's need is urgent. The client should not be kept waiting without further assessment to evaluate the situation. Educational objective: The nurse takes on the role of anesthetist when assisting with bedside procedural moderate sedation and cannot leave the client during the procedure. Additional Information Reduction of Risk Potential NCSBN Client Need

A client is receiving a blood transfusion. Fifteen minutes after the transfusion starts, the nurse notes a drop in blood pressure from 110/70 to 84/50 mm Hg. The client reports "feeling a little cold." Based on this assessment, in what order should the nurse complete the following actions? All options must be used. Unordered Options 1. Administer prescribed vasopressor 2. Collect urine specimen 3. Document the occurrence 4. Stop the blood transfusion 5. Using new tubing, infuse normal saline into the vein

Answer: 4,5,1,2,3 It is important for the nurse to remain with the client for 15 minutes after starting a blood transfusion to monitor for signs of a reaction. These signs include fever, chills, nausea, vomiting, pruritus, hypotension, decreased urine output, back pain, and dyspnea. The client may report a variety of symptoms ranging from none to a feeling of impending doom. If signs of a transfusion reaction occur, the nurse should: Stop the transfusion immediately (Option 4). Using new tubing, infuse normal saline to keep the vein open (Option 5). Continue to monitor hemodynamic status and notify the health care provider and blood bank. Administer any emergency or prescribed medications to treat the reaction; these may include vasopressors, antihistamines, steroids, or IV fluids (Option 1). Collect a urine specimen to be assessed for a hemolytic reaction (Option 2). Document the occurrence and send the remaining blood and tubing set back to the blood bank for analysis (Option 3). Educational objective: If signs or symptoms of a blood transfusion reaction occur, the nurse should stop the infusion immediately and use new tubing to keep the vein open with normal saline. The nurse should continue to monitor the client's hemodynamic status, and administer prescribed drugs. The nurse should also collect a urine specimen to be assessed for a hemolytic reaction.

A school nurse observes a 3-year-old begin to choke and turn blue while eating lunch. What should be the nurse's initial action? 1. Abdominal thrusts 2. Back blows and chest thrusts 3. Blind sweep of the child's mouth 4. Call 911 for an ambulance

Answer:1 Foreign body aspiration is an emergency that requires immediate intervention when witnessed or highly suspected. The primary rescue intervention for adults and children over age 1 is abdominal thrusts, known as the Heimlich maneuver. This maneuver entails applying upward thrusts with a fist to the upper abdomen just beneath the rib cage. The upward action causes the diaphragm to forcefully expel air out of the airway, carrying the foreign body out with it. If the child is conscious and able to cough or make sounds, the nurse should ask the child to forcefully cough before intervening. These signs indicate a partial obstruction still allowing airflow, which may be cleared with strong coughing. However, any signs of respiratory distress (eg, stridor, inability to speak, weak cough, and cyanosis) require immediate intervention. (Option 2) Back blows and chest thrusts are appropriate interventions for a choking infant under age 1. Older children require abdominal thrusts to clear an obstructed airway. (Option 3) Blind sweeping a child's mouth can force a loosely obstructing object to fully block the airway or cause the object to fall farther into the airway, requiring surgical removal. (Option 4) This child is experiencing a blocked airway, which is a medical emergency that requires intervention at the skill level of a nurse. The nurse can ask a bystander to contact 911 while attempting to clear the airway. This differs from a situation such as anaphylaxis, in which the nurse would require epinephrine and would call 911 for immediate assistance. Educational objective: The Heimlich maneuver (ie, upward abdominal thrusts under the rib cage) is the primary rescue intervention for children over age 1 with a foreign body airway obstruction causing respiratory distress. Back blows and chest thrusts are appropriate interventions for a choking infant under age 1. Blind sweeping of a child's mouth should not be attempted.

The charge nurse is notified that a client is being admitted with a diagnosis of active shingles with a disseminated rash. Which room assignment is most appropriate for this client? 1. A private room with contact and droplet precautions 2. A private room with negative airflow and contact and airborne precautions 3. A private room with positive airflow and airborne precautions 4. A semi-private 2-bed room with standard precautions

Answer:2 Shingles (herpes zoster) is a reactivation of the varicella-zoster (chicken pox) virus. It is more likely to occur when a client's immune system is compromised by disease (eg, HIV infection) or treatments (eg, chemotherapy). Shingles lesions that are open may transmit the infection by both air and contact. The client with disseminated shingles that are not crusted over will require contact precautions, airborne precautions, and a negative airflow room to prevent transmission of the infection to others in the hospital. Negative airflow pulls air from the hospital environment into the room, and the air from the hospital room then goes directly to the outside rather recirculating to the rest of the hospital. Localized shingles require only standard precautions for clients with intact immune systems and contained/covered lesions. (Option 1) Negative airflow and airborne precautions are also required in addition to contact precautions. Droplet precautions are not necessary. (Option 3) Positive airflow would pull fresh air from outside into the hospital room, and then the air from the room would circulate throughout the rest of the hospital. It is not appropriate for this type of infection. Instead, positive airflow would be used for protective isolation in a client who is immunocompromised. (Option 4) A semi-private room is not appropriate for this client with a communicable illness. Standard precautions are used for localized shingles in clients with intact immune systems and contained/covered lesions. Educational objective: The client with open lesions from a herpes virus infection, such as shingles or chicken pox, will require both contact and airborne precautions and a private room with negative airflow.

A client on hospice home care is taking sips of water but refusing food. Family members appear distressed and insist that the personal care worker "force feed" the client. What is the priority nursing action? 1. Explain to the family that this is a normal physiological response to dying 2. Explore the family's thoughts and concerns about the client's refusal of food 3. Recommend a feeding tube 4. Tell the family that "force feeding" the client could cause the client to choke on the food

Answer:2 When a terminally ill person refuses food, family members often become upset and frustrated in their roles of nurturers and caregivers; they may feel personally rejected. Refusal of food is associated with "giving up" and is a reminder that their loved one is dying. It is not uncommon for family members to believe that a client would get stronger by eating instead of refusing food. The registered nurse needs to explore family members' concerns and fears and listen as they express their feelings. The nurse can help them identify other ways to express how they care. The nurse should also provide education about the effects of food and water during all stages of the illness. (Option 1) Families and caregivers need to understand the effects of food and water in all stages of a terminal illness; however, it is more important to first explore the family's feelings and concerns. (Option 3) Although it is not unusual for a client to be admitted to hospice with a feeding tube already in place, tubes are generally not placed after a client begins receiving hospice services. (Option 4) This is a true statement, but it is not the priority nursing action. Educational objective: It is very common for family members to become distressed when a terminally ill loved one refuses food. The nurse needs to explore their fears and concerns and help them identify other ways to express how they care.

The nurse is reviewing a client's preoperative questionnaire, which indicates a religious preference with spiritual needs concerning surgery scheduled later today. Which action is most appropriate at this time? 1. Ask the client when a spiritual leader or clergy member is coming to visit 2. Document the response and notify the health care provider and perioperative team 3. Follow up with the client regarding the nature of the spiritual needs or religious practices 4. Notify the hospital chaplain and tell the client that the chaplain will come by to assist

Answer:3 Spirituality and religious beliefs are often integral parts of a client's life and can be therapeutic in the management of illness. Some studies have found that clients who engage in regular spiritual or religious practices have shorter recovery times, better coping mechanisms, and improved health outcomes. Spiritual, cultural, or religious needs should be accommodated within the plan of care. During the nursing process, the nurse should first assess the client's needs to best address them. By following up with the client regarding the questionnaire and asking about the specific nature of spiritual needs or religious practices, the nurse can effectively assist the client and create an appropriate plan of care (Option 3). (Option 1) Asking a client if a spiritual leader or clergy member is coming to visit may alarm the client or raise suspicion about the surgery. It also assumes that the client's religious or spiritual practices involve a spiritual leader or clergy person. (Option 2) The nurse should attempt to gather more information before notifying the perioperative team. Simply documenting the questionnaire response does not address the client's spiritual needs. (Option 4) The chaplain should not be called until the nurse has assessed the client's specific needs. The client may not wish to see a chaplain. Educational objective: Spiritual, cultural, and religious needs are an important part of the nursing assessment and plan of care. Clients have the right to verbalize and practice their beliefs; the nurse should facilitate spiritual practices within the plan of care.

A client calls the nurse to report exacerbation of chronic lower back pain after working in the yard all weekend. Knowing that this worsened back pain is probably due to acute inflammation, the nurse recommends which nonpharmacologic intervention? 1. Heating pad 2. Positioning for comfort 3. Rest from pain-aggravating activities 4. Stretching exercises

Answer:3 Acute exacerbation of chronic back pain is usually associated with inflammation triggered by (strenuous and/or repetitive) activities that stress the previously injured area. Interventions should be directed toward reducing inflammation. Nonpharmacologic intervention to treat the inflammation includes rest from pain-aggravating activities which may continue to promote inflammation and delay healing. (Option 1) Applying heat to the injured area can promote the inflammatory process (via vasodilation); therefore, this is not the best intervention at this time. However, after the acute inflammation has resolved (usually within a few days) heat application would be appropriate to reduce pain and muscle spasms. (Option 2) Although the nurse should teach the client to ensure positioning for comfort to reduce pain, this is less likely to impact the inflammatory processes causing the pain. (Option 4) Stretching exercises can also be helpful for back pain but should begin after the acute pain and inflammation have subsided. Educational objective: Rest from activities that aggravate pain and inflammation is a nonpharmacologic comfort intervention to decrease the inflammation due to acute pain.

The charge nurse must assign rooms to 4 clients who are scheduled for admission. Which client has the highest priority for a private room assignment? 1. Client who is a known IV drug abuser who has osteomyelitis of the arm and chronic hepatitis C 2. Client with chronic obstructive pulmonary disease who has a latent tuberculosis infection 3. Client with diabetes mellitus and HIV infection who is in diabetic ketoacidosis 4. Client with pneumonia who has a positive methicillin-resistant Staphylococcus aureus nose culture

Answer:4 A client with a positive nose swab for methicillin-resistant Staphylococcus aureus (MRSA) is colonized and can transmit the bacteria to others. If signs of infection are absent, treatment is not required. Colonized clients are at increased risk for infection with MRSA; if signs (eg, fever, wound drainage, purulent mucus) are present, treatment is required. The Centers for Disease Control and Prevention (CDC) recommends placing a colonized client on contact precautions and in a private room. The CDC also recommends that the highest priority be given to placing a colonized client who may transmit the bacteria through body secretions or excretions (eg, sputum, wound drainage) in a private room. Therefore, the client with pneumonia should be placed in the private room. (Options 1 and 3) The CDC recommends standard precautions for clients with hepatitis C and those who are HIV positive. A private room is not necessary for a client who has osteomyelitis or diabetic ketoacidosis. (Option 2) A client with a latent tuberculosis infection (LTBI) has a positive tuberculin skin test, has no symptoms of infection, and is not contagious. Immunosuppressant drugs, chemotherapy, and debilitating disease can convert a LTBI to active disease. At this time, the client requires only standard precautions. Educational objective: The Centers for Disease Control and Prevention recommends contact precautions and private room placement for a client who is colonized with methicillin-resistant Staphylococcus aureus, especially if the client can transmit the bacteria through body secretions or excretions.

An adult client has developed diarrhea 24 hours after the initiation of total enteral nutrition via nasogastric tube. The client is receiving a hypertonic formula. What is the best nursing action? 1. Dilute the formula with water 2. Discontinue the tube feeding 3. Send a stool sample to the lab for culture and sensitivity 4. Slow the rate of administration of the feeding

Answer:4 Most clients tolerate hypertonic and isotonic enteral formulas without complications. However, because of their higher osmolality, hypertonic formulas sometimes cause nausea, vomiting, or diarrhea, especially during the initiation of total enteral nutrition. The gastrointestinal tract will pull fluid from the surrounding intra- and extravascular compartments to dilute the formula, making it similar to body fluid osmolality. This process is similar to dumping syndrome and may cause temporary diarrhea with cramps, nausea, and vomiting. Slowing down the rate of administration of total enteral nutrition will usually alleviate these problems. The feeding can gradually progress to the established goal rate. (Option 1) Diluting enteral formulas is not necessary. This practice may increase the risk of intolerance secondary to microbial contamination. A diluted formula supports microbial growth better than a full-strength formula. Diluting total enteral nutrition may also be detrimental because the client may receive inadequate nutrition; it will take a larger volume of fluid to provide the same number of calories and protein. (Option 2) It is not necessary to discontinue the feeding; the client needs nutrition support. (Option 3) Sending a stool sample for culture and sensitivity would be appropriate if bacterial contamination or a bacterial infection is suspected as the cause of the diarrhea. It is not the best nursing action in this situation. Educational objective: Complications of total enteral nutrition at the start of treatment are nausea, vomiting, and diarrhea. These signs and symptoms can usually be alleviated by slowing down the rate of administration and then gradually increasing the rate to the established goal.