Nclex 2 Sona

The graduate nurse (GN) is reinforcing education on sitting on and standing up from a chair to a client with crutches. Which instruction by the GN would cause the supervising nurse to intervene? 1. "Hold a crutch in each hand on both sides when standing up from a chair." (68%) 2. "Move to the edge of the chair before standing and use your unaffected leg to rise." (10%) 3. "Touch the back of your unaffected leg to the chair before preparing to sit." (10%) 4. "Use an armrest or seat for assistance when lowering your body into a chair." (10%)

1. "Hold a crutch in each hand on both sides when standing up from a chair." Clients prescribed crutches after a musculoskeletal injury must understand appropriate device use to facilitate independent ambulation, promote wound healing, and prevent reinjury. When educating a client to rise from sitting, the nurse instructs the client to hold the hand grips of both crutches in the hand on the affected side, move to the chair's edge, and hold the armrest with the hand on the unaffected side (Option 1). The client then uses the crutches, armrest, and unaffected leg for support when rising. To sit, the client backs up to the chair and moves both crutches into the hand on the affected side. The client holds the armrest with the other hand and lowers the body. (Option 2) To rise from a chair, the client should move to the edge of the chair and flex the unaffected leg for support. (Option 3) Before sitting, the client should back up to the chair until the unaffected leg touches the chair seat. (Option 4) When standing or sitting, clients should place the hand opposite the injury on the armrest or chair seat for support. Educational objective:When standing or sitting in a chair, clients with crutches should hold both crutches in the hand on the affected side and hold the armrest with the other hand for support. Clients should touch the back of the unaffected leg to the chair before sitting, and should move to the chair edge and rise up with the unaffected leg to stand.

The nurse observes a student nurse administer a tuberculin skin test using the intradermal route. The nurse intervenes when the student performs which action? 1. Advances tip of needle through epidermis until the bevel is no longer visible under the skin (65%) 2. Chooses a 1 mL tuberculin syringe with a 27-gauge 1/4 inch needle; dons clean gloves (19%) 3. Injects medication slowly while raising a small wheal (bleb) on the skin (3%) 4. Inserts needle at a 10-degree angle almost parallel to skin with the bevel up (12%)

1. Advances tip of needle through epidermis until the bevel is no longer visible under the skin Intradermal dermal injections deliver a small amount of medication (0.1 mL) into the dermal layer of the skin, just under the epidermis. This parenteral route is used to perform allergy testing and tuberculosis (TB) screening. The correct procedure for administering a TB intradermal injection is as follows: Choose a 1 mL tuberculin syringe with a 27-gauge 1/4 inch needle then don clean gloves - the syringe is calibrated in hundredths of a millimeter and the intradermal needle is short enough to remain in the dermis with length range of 1/4-5/8 inch (Option 2). Position the left forearm to face upward, and cleanse site that is a hands width above the wrist - the left arm is commonly used for TB testing; the forearm has little hair and subcutaneous tissue and is readily accessible to observe a skin reaction. Place non-dominant hand 1 inch below the insertion site and pull skin downward so that it is taut - taut skin makes it easier to insert the needle and promotes comfort. Insert the needle almost parallel to skin at a 10-degree angle with bevel up - this is important as the medication can enter the subcutaneous tissue if the angle is >15 degrees (Option 4). Advance the tip of the needle through epidermis into dermis; outline of bevel should be visible under the skin - verify that the medication will be injected into dermis (Option 1). Inject medication slowly while raising a small wheal (bleb) on the skin - verify that the medication is being deposited into the dermis (Option 3). Remove needle and do not rub the area - rubbing promotes leakage through the insertion site and medication deposition into the tissue. Circle the area with a pen to assess for redness and induration (according to institution policy) - this delineates the border for measurement of reaction. Educational objective:For TB skin testing: Use a 27-gauge 1/4 inch needle with a 1 mL tuberculin syringe Administer injection on inner forearm at a 10-degree angle with bevel up Make a wheal (bleb) Avoid rubbing site after injection

A client with suspected foot osteomyelitis is scheduled for an MRI. Which findings should the nurse notify the health care provider about before the test? Select all that apply. 1. Aneurysm clip 2. Cardiac pacemaker 3. Colostomy 4. Retained metal foreign body in eye 5. Transdermal testosterone patch

1. Aneurysm clip 2. Cardiac pacemaker 4. Retained metal foreign body in eye Clients must be screened for contraindications before exposure to a magnetic field (MRI) as it can damage implanted devices or metallic implants. Absolute contraindications can preclude testing, and relative contraindications can pose a hazard to the client's devices or implants, affect the quality of the images, or cause discomfort. Absolute contraindications: Cardiac pacemaker (Option 2) Implantable cardioverter defibrillator Cochlear implant Retained metallic foreign body, especially in organs such as the eye (Option 4) Relative contraindications: Prosthetic heart valve Metal plate, pin, brain aneurysm clip, or joint prosthesis (Option 1) - Some of these devices have nonferrous MRI-safe materials and should be verified. Implanted device (eg, insulin pump, medication port) Other factors that can affect the client's eligibility include inability to remain supine for 30-60 minutes and claustrophobia; however, these concerns are often controllable (eg, sedation can be prescribed, open MRI machine can be used). (Option 3) A colostomy is not a contraindication for MRI. (Option 5) Transdermal metal-containing medication patches (clonidine, nicotine, scopolamine, testosterone, or fentanyl) are not a contraindication for MRI. However, the nurse should remove the patch beforehand due to the risk of burns and replace after testing. Educational objective:Usual contraindications for MRI include implanted devices (eg, pacemaker, implantable cardioverter defibrillator, medication ports), certain metal implants (eg, plates, pins, brain aneurysm clips, joint prostheses), and presence of a retained metal foreign body. However, some of these devices are now manufactured with MRI-safe materials that should be verified.

The nurse cares for a confused client who continues to pull at the intravenous (IV) catheter on the left forearm despite frequent instructions not to do so. What is the nurse's next action? 1. Apply a gauze wrap and elastic stockinette around the IV site (54%) 2. Apply a mitt on the right hand (24%) 3. Apply a soft wrist restraint on the right wrist (15%) 4. Apply an arm board to the left arm (4%)

1. Apply a gauze wrap and elastic stockinette around the IV site A physical restraint that restricts body movement should be the last resort to keep a client from interfering with medical treatment. Restraints can cause bodily injury such as pressure ulcers, neurovascular and peripheral circulatory deficits, and psychological trauma. Therefore, less restrictive methods should always be tried first. Concealing the IV site and tubing by wrapping the forearm in gauze and an elastic stockinette can be effective in keeping a confused client from pulling at the IV line. (Options 2, 3, and 4) Applying a hand mitt, soft wrist restraint, or arm board may be necessary if less restrictive techniques, such as concealing the IV site or encouraging family member or sitter involvement, are ineffective in keeping the client from pulling at the IV line. However, applying one of these restraints should not be the nurse's next action. Educational objective:The least restrictive device or method to keep a client from interfering with medical treatment should always be tried first, before applying a physical restraint.

The nurse admits an 80-year-old client with an altered level of consciousness and left-sided weakness following a recent stroke. The client is dehydrated from multiple episodes of diarrhea. Which interventions should the nurse implement to prevent falls? Select all that apply. 1. Apply color-coded, nonslip socks to the client's feet 2. Move the client to a room closer to the nurses' station 3. Place a bedside commode to the right of the client 4. Raise all bed rails before leaving the room 5. Use a bed alarm to alert staff when the client gets up

1. Apply color-coded, nonslip socks to the client's feet 2. Move the client to a room closer to the nurses' station 3. Place a bedside commode to the right of the client 5. Use a bed alarm to alert staff when the client gets up Fall risk precautions Standard Orientation to room & call light Call light within reach Bed in lowest position Uncluttered room Nonslip socks or shoes Well-lit room Belongings within reach High fall risk Bed alarm High fall risk signs Room close to nurses' station Color-coded socks & wristbands The client with right-brain damage following a stroke often experiences left-sided weakness, spatial-perceptual deficits, and impulsiveness, making this client at high risk for falls. Other factors that increase fall risk for older adults include: Unfamiliar surroundings Unsteady gait, decreased strength and coordination Altered mental status Orthostatic hypotension (related to dehydration) Bowel/bladder urgency and/or frequency Application of color-coded, nonslip socks helps prevent a client from slipping and alerts staff to a client's increased risk for falls (Option 1). Placing a commode by the right (stronger) side of the bed decreases the number of steps and time needed to get to a toilet (Option 3). It also decreases the chance of tripping on equipment (eg, IV pump, tubing). Moving the client to a room close to the nurses' station allows frequent observation and a faster response time to calls for assistance (Option 2). A bed alarm alerts staff when the client attempts to get out of bed, which allows for prompt response (Option 5). (Option 4) Raising all bed rails may be constituted as an unlawful use of restraint. Clients with altered mental status may also attempt to climb the side rails and sustain a fall injury. Educational objective:Many falls are associated with bathroom urgency/frequency. Fall risk precautions include placing the client in a room near the nurses' station, placing a bedside commode by the client's stronger side, applying nonslip socks, and using a bed alarm.

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

1. Apply pads to the side rails 2. Have oxygen supplementation available 5. Set up bedside suction equipment 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 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 (40%) 2. Assess the home for sources of excessive noise (11%) 3. Provide information about respite and adult day care (21%) 4. Review behavior-management techniques with caregiver (26%)

1. Ask about the client's recent bowel and bladder habits 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 client who is intubated and on mechanical ventilation is receiving continuous enteral tube feedings at 30 mL/hr via a small-bore nasogastric tube. Which actions should the nurse take to prevent aspiration in this client? Select all that apply. 1. Assess abdominal distension every 4 hours 2. Check gastric residual every 12 hours 3. Keep head of the bed at ≥30 degrees 4. Maintain endotracheal cuff pressure 5. Use caution when administering sedatives

1. Assess abdominal distension every 4 hours 3. Keep head of the bed at ≥30 degrees 4. Maintain endotracheal cuff pressure 5. Use caution when administering sedatives Clients who are critically ill are at increased risk for aspiration of oropharyngeal secretions and gastric contents, particularly when they are receiving enteral feedings. Nursing interventions to reduce aspiration risk for clients receiving enteral tube feedings include: Assess client for gastrointestinal intolerance to feedings every 4 hours by monitoring gastric residual and assessing for abdominal distension, abdominal pain, bowel movements, and flatus (Option 1) Assess feeding tube placement at regular intervals Keep head of the bed at ≥30 degrees, with 30-45 degrees being optimal to reduce gastroesophageal reflux and aspiration risk unless otherwise indicated (Option 3) Keep endotracheal cuff inflated at appropriate pressure (about 25 cm H20) for intubated clients, as low cuff pressure increases the risk for aspirating oropharyngeal secretions and/or gastric contents (Option 4) Suction any secretions that may have collected above the endotracheal tube before deflating the cuff if deflation is necessary Use caution when giving sedatives and frequently monitor for over-sedation, which can slow gastric emptying and reduce gag reflex (Option 5) Avoid bolus tube feedings for clients at high risk for aspiration (Option 2) Gastric residual should be checked no less than every 4 hours in intubated clients. Educational objective:Precautions to prevent aspiration in the client receiving continuous tube feedings include assessing for gastric intolerance (ie, residual, distension) every 4 hours, keeping the head of the bed at ≥30 degrees, using sedation cautiously, and regular assessment of tube placement. If the client is intubated, the nurse should also keep the endotracheal tube cuff inflated and suction appropriately.

A client arrives in the emergency department on a cold winter day. The client is calm, alert, and oriented with a respiratory rate of 20/min and a pulse oximeter reading of 78%. The nurse suspects that the client's pulse oximeter reading is inaccurate. Which factors could be contributing to this reading? Select all that apply. 1. Black fingernail polish 2. Cold extremities 3. Elevated WBC count 4. Hypotension 5. Peripheral arterial disease

1. Black fingernail polish 2. Cold extremities 4. Hypotension 5. Peripheral arterial disease A pulse oximeter is a noninvasive device that estimates arterial blood oxygen saturation by using a sensor attached to the client's finger, toe, earlobe, nose, or forehead. The sensor (reusable clip or disposable adhesive) contains light-emitting and light-sensing components that measure the amount of light absorbed by oxygenated hemoglobin. Because the sensor estimates the value at a peripheral site, the pulse oximeter measurement is reported as blood oxygen saturation (SpO2). Normal SpO2 for a healthy client is 95%-100%. Any factor that affects light transmission or peripheral blood flow can result in a false reading. Common causative factors of falsely low SpO2 include: Dark fingernail polish or artificial acrylic nails (Option 1) Hypotension and low cardiac output (eg, heart failure) (Option 4) Vasoconstriction (eg, hypothermia, vasopressor medications) (Option 2) Peripheral arterial disease (Option 5) (Option 3) Abnormal WBC count has no direct influence on light transmission or peripheral blood flow. Educational objective:Any factor that affects light transmission or peripheral blood flow can cause a falsely low reading for oxygen saturation on pulse oximeter. Common causes include dark nail polish, hypotension, low cardiac output, vasoconstriction (eg, hypothermia, vasopressor medications), and peripheral arterial disease.

A hospitalized client is scheduled for a percutaneous kidney biopsy at 10 AM. At 8 AM, the nurse reviews the client's vital signs and most current serum laboratory results. Which finding is most important to report to the health care provider (HCP)? 1. Blood pressure of 180/100 mm Hg (27%) 2. Creatinine of 2 mg/dL (176.8 µmol/L) (14%) 3. Hemoglobin of 9.8 g/dL (98 g/L) (13%) 4. Platelet count of 120,000/mm3 (120 x 109/L) (43%)

1. Blood pressure of 180/100 mm Hg Percutaneous kidney biopsy is an invasive diagnostic procedure. It involves inserting a needle through the skin to obtain a tissue sample that is then used to determine the cause of certain kidney diseases. The kidney is a highly vascular organ; therefore, uncontrolled hypertension is a contraindication for kidney biopsy as increased renal arterial pressure places the client at risk for post-procedure bleeding. Blood pressure must be lowered and well-controlled (goal <140/90 mm Hg) using antihypertensive medications before performing a kidney biopsy (Option 1). (Option 2) An elevated serum creatinine level (normal: 0.6-1.3 mg/dL [53-115 µmol/L) can be expected in a client with probable renal disease. This is not the most important finding to report to the HCP. (Option 3) A decreased hemoglobin level (normal adult male: 13.2-17.3 g/dL [132-173 g/L]; normal adult female: 11.7-15.5 g/dL [117-155 g/L]) can be expected in a client with probable renal disease due to decreased erythropoietin production. The nurse should continue to monitor the client's hemoglobin post-procedure as it can decrease further (within 6 hours) if bleeding occurs. (Option 4) Only neurosurgery and ocular surgery require a platelet count >100,000/mm3 (100 x 109/L). Most other surgeries can be performed when the platelet count is >50,000/mm3 (50 x 109/L). Although the platelet count is low (normal 150,000-400,000/mm3 [150-400 x109/L]), it is not the most important finding to report to the HCP. Educational objective:The kidney is a highly vascular organ and the risk of bleeding is a major complication after a percutaneous biopsy. The client should have normal coagulation studies, an adequate platelet count, and well-controlled blood pressure prior to the procedure to reduce bleeding risk. Additional Information Reduction of Risk Potential NCSBN Client Need

The community health nurse is preparing to teach a group of African American women about prevention of diseases common to their ethnic group. Based on the incidence of disease within this group, which disorders should the nurse plan to discuss? Select all that apply. 1. Cervical cancer 2. Hypertension 3. Ischemic stroke 4. Osteoporosis 5. Skin melanoma

1. Cervical cancer 2. Hypertension 3. Ischemic stroke The incidence of cervical cancer is higher among Hispanics, American Indians, and African Americans. The mortality rate for cervical cancer among African American women is twice as high as that for white American women (Option 1). African Americans have the highest incidence of hypertension in the world, and this condition is more prevalent among the women than men in this ethnic group. The mortality rate for hypertension among African American women is higher than that for white American women (Option 2). African Americans have a higher incidence of ischemic stroke than whites or Hispanics. Risk factors for stroke are related to an increased rate of hypertension, diabetes mellitus, and sickle cell anemia (Option 3). (Option 4) White and Asian women have a higher incidence of osteoporosis than African Americans, but the disease affects all ethnic groups. (Option 5) Melanoma of the skin is more common in people who are of white ancestry, light-skinned, and over age 60 with frequent sun exposure. The incidence of melanoma is 10 times higher in white Americans than African Americans. Educational objective:African Americans have the highest incidence of hypertension in the world as well as increased incidence of stroke and cervical cancer. Whites have a high incidence of osteoporosis and skin cancer (melanoma).

The nurse is administering a pink pill to a hospitalized medical-surgical client. The alert, oriented client says, "This is a pill I haven't seen before." What follow-up action should the nurse take next? 1. Check the health care provider's prescription in the medical record (69%) 2. Explain that the health care provider has prescribed the medication (1%) 3. Look up the medication in the pharmacology reference (9%) 4. Teach the client about the purpose of the medication (18%)

1. Check the health care provider's prescription in the medical record Safe medication administration is conducted according to 6 rights: Right client using 2 identifiers Right medication Right dose Right route Right time Right documentation When a mentally competent client questions a drug administration, the safest option is to first check the prescription to verify the 6 rights of medication administration (Option 1). If an error is ruled out (eg, different brand, new order) the nurse should follow up with appropriate teaching. (Option 2) The nurse must first verify all aspects of proper medication administration. If they are correct, the nurse should provide appropriate teaching on why the health care provider prescribed the medication. Explaining that the nurse is just following orders is rarely the correct answer. (Option 3) A pharmacology reference can verify information about the medication but will not confirm that the client is the correct recipient. Acceptable identifiers include first and last name, medical record number, and birth date. (Option 4) The nurse can teach the client about the purpose of the medication after the 6 rights have been verified. Educational objective:When a competent client questions a new medication, the nurse should first verify the 6 rights of safe medication administration: right client, medication, dose, route, time, and documentation. If safe administration has been confirmed, the nurse should then provide appropriate teaching to the client.

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 (90%) 2. Discuss how important it is for the client to pay attention during the teaching (2%) 3. Maintain eye contact during the teaching by following the client's movements (2%) 4. Provide written instructions and a private place for the client to learn independently (5%)

1. Continue teaching the client and verify understanding by return demonstration 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.

Which interventions does the nurse perform to promote normal rest and sleep patterns for a critically ill client? Select all that apply. 1. Dimming the lights at night 2. Increasing the level of continuous IV sedation during nighttime hours 3. Leaving the television on for diversion at night 4. Opening the window blinds/shades in the morning 5. Scheduling interventions and activities during the day when possible 6. Turning off equipment alarms in the client's room at night

1. Dimming the lights at night 4. Opening the window blinds/shades in the morning 5. Scheduling interventions and activities during the day when possible It is important to maintain the client's normal circadian rhythms in the intensive care unit (ICU). Interventions that help to maintain the normal sleep-wake cycle include dimming the lights at night, providing quiet and uninterrupted periods of sleep when possible, scheduling interventions and activities during the day, frequently reorienting the client as necessary, and opening the shades in the morning. Excessive stimuli and lack of sleep can predispose the client to delirium. (Option 2) Continuous IV sedation, if indicated, should be given at the lowest dose adequate for pain management. (Option 3) Unless the client is awake and chooses to have the television turned on, this extra stimulus is disruptive to sleep. (Option 6) Turning the alarms off in the client's room would pose a risk to safety, as the nurse may not be alerted to a change in condition or equipment failure. If possible, alarm parameters should be adjusted according to the client's routine to prevent unnecessary awakening. Educational objective:To prevent disorientation and delirium in the ICU, it is important to develop a plan of care that includes maintaining the client's normal circadian rhythm.

The nurse is caring for a client who develops Clostridium difficile colitis after multiple days of antibiotic therapy. Which infection control measures are appropriate to implement? Select all that apply. 1. Disinfect surfaces with diluted bleach solution 2. Hand hygiene with alcohol-based hand rub 3. Wear a face mask 4. Wear a protective gown 5. Wear nonsterile gloves

1. Disinfect surfaces with diluted bleach solution 4. Wear a protective gown 5. Wear nonsterile gloves C difficile poses a unique hazard in health care settings. This infection of the colon may develop/spread through contact with the organism or after prolonged antibiotic therapy alters normal bowel flora, allowing for C difficile overgrowth. Clients with C difficile infection should be placed on strict contact precautions in private rooms. These precautions require staff to wear protective gowns and gloves when entering the client's room (Options 4 and 5). Hand hygiene using soap and water is the only effective method for removing C difficile spores (Option 2). In addition, alcohol is not an effective agent for killing C difficile spores; therefore, a diluted bleach solution must be used to disinfect contaminated equipment and surfaces (Option 1). (Option 3) Contact precautions require the caregiver to wear a gown and gloves. A face mask must be worn as personal protective equipment if an organism is spread via droplets. However, it is not required to prevent the spread of a contact-transmissible infection. The nurse should not wear a mask solely to avoid the unpleasant odor associated with C difficile diarrhea as this may be offensive and embarrassing to the client. Educational objective:C difficile infection requires strict contact precautions, including wearing a gown and gloves at all times. Alcohol cannot kill C difficile spores, so caregivers must use soap and water in place of alcohol-based hand sanitizers. Contaminated surfaces and equipment should be disinfected using a diluted bleach solution.

The nurse is drawing blood from a client's peripheral vein for laboratory specimens. Which of the following are correct nursing actions? Select all that apply. 1. Do not leave a tourniquet on more than 1 minute while looking for a vein 2. Draw the specimen while the skin is still wet with the alcohol prep 3. If pulsating red blood is noted, withdraw the needle and apply pressure for 5 minutes 4. Use a highly visible vein on the ventral side of the client's wrist 5. Vigorously shake the specimen tube to mix obtained blood with anticoagulant solution

1. Do not leave a tourniquet on more than 1 minute while looking for a vein 3. If pulsating red blood is noted, withdraw the needle and apply pressure for 5 A tourniquet is applied 3-5 inches above the desired puncture site for no longer than 1 minute when looking for a vein. If longer time is needed, release the tourniquet for at least 3 minutes before reapplying. Prolonged obstruction of blood flow by the tourniquet can change some test results. Pulsating bright red blood indicates that an artery was accessed. If this happens, the needle should be removed immediately and pressure should be applied for at least 5 minutes, followed by a pressure dressing to prevent a hematoma. (Option 2) Skin preparation involves cleaning using an antiseptic solution and friction and allowing the skin to air dry. Remaining solution may hemolyze and/or dilute the blood sample. Traditionally, alcohol (alone or with povidone iodine) is applied in a circular motion, from insertion site outward (clean to dirty). Current research suggests that the most effective method is applying chlorhexidine (2%) in a back and forth motion, followed by adequate drying time. (Option 4) The veins on the ventral aspect of the wrist are located near nerves, resulting in painful venipuncture and a higher risk of nerve injury. There is also an increased risk of arterial access on the ventral aspect of the wrist, and so this site should be avoided. (Option 5) The filled tube should be gently inverted 5-10 times to mix anticoagulant solution with the blood. Vigorously shaking the tube can cause hemolysis and false results. Educational objective:When performing phlebotomy for a laboratory specimen, allow the cleansed area to air dry, do not use the veins on the ventral side of wrist, position the tourniquet for no more than 1 minute at a time, and invert the tube gently 5-10 times to mix the solution with blood. Insertion in an artery will cause pulsation; if this happens, immediately remove the needle and apply pressure for 5 minutes. minutes

Which interventions should the nurse perform when assisting the health care provider with removal of a client's chest tube? Select all that apply. 1. Ensure the client is given an analgesic 30-60 minutes before tube removal 2. Instruct the client to breathe in, hold it, and bear down while the tube is being removed 3. Place the client in the Trendelenburg position 4. Prepare a sterile airtight petroleum jelly gauze dressing 5. Provide the health care provider with sterile suture removal equipment

1. Ensure the client is given an analgesic 30-60 minutes before tube removal 2. Instruct the client to breathe in, hold it, and bear down while the tube is being removed 4. Prepare a sterile airtight petroleum jelly gauze dressing 5. Provide the health care provider with sterile suture removal equipment A chest tube is removed when drainage is minimal (<200 mL/24 hr) or absent, an air leak (if present) is resolved, and the lung has reexpanded. The general steps for chest tube removal include: Premedicate the client with analgesic (eg, IV opioid, nonsteroidal anti-inflammatory drug [ketorolac]) 30-60 minutes before the procedure to promote comfort as evidence indicates that most clients report significant pain during removal (Option 1). Provide the health care provider (HCP) with sterile suture removal equipment (Option 5). Instruct the client to breathe in, hold it, and bear down (Valsalva maneuver) while the tube is removed to decrease the risk for a pneumothorax. Most HCPs use this technique to increase intrathoracic pressure and prevent air from entering the pleural space (Option 2). Apply a sterile airtight occlusive dressing to the chest tube site immediately; this will prevent air from entering the pleural space (Option 4). Perform a chest x-ray within 2-24 hours after chest tube removal as a post-procedure pneumothorax or fluid accumulation usually develops within this time frame. (Option 3) The client should be placed in semi-Fowler's position or on the unaffected side to promote comfort and facilitate access for tube removal. Educational objective:Before chest tube removal, the client is given an analgesic and then asked to perform Valsalva during the procedure. The nurse should also bring sterile suture removal equipment and a sterile airtight occlusive dressing. Post-procedure chest x-ray is necessary within 2-24 hours.

The nurse is caring for a client with a feeding tube that has become obstructed. Which intervention should the nurse implement first to unclog the tube? 1. Flush and aspirate the tube with warm water (60%) 2. Instill a digestive enzyme solution into the tube (3%) 3. Instill cola or cranberry juice into the tube (11%) 4. Use a small-barrel syringe to flush the tube (24%)

1. Flush and aspirate the tube with warm water Enteral feeding tubes are more likely to become obstructed if the tube is not flushed frequently enough, medications are not adequately crushed or diluted before administration, a thick feeding formula is used, or a small-bore feeding tube is required. Interventions to unclog a feeding tube are more successful if they are initiated immediately. The nurse should first attempt to dislodge the clogged contents by using a large-barrel syringe to flush and aspirate warm water in a back-and-forth motion through the tube (Option 1). (Option 2) If a feeding tube cannot be unclogged with warm water, the nurse may then attempt to use a digestive enzyme solution. These commercial declogging kits contain prefilled syringes of enzymatic solution that must be added to the tube and dwell in it for a period of time (usually 30 minutes to 1 hour) before flushing and aspiration are attempted. (Option 3) Instilling a carbonated beverage (eg, dark cola) or cranberry juice into a clogged feeding tube is not appropriate. The acidity of either liquid can worsen an obstruction, and the dark color may mask gastrointestinal bleeding. (Option 4) Flushing a feeding tube with a small-barrel syringe can create too much pressure and rupture the tube. Educational objective:When a feeding tube becomes clogged, the nurse should first attempt to unclog the tube by using a large-barrel syringe to flush and aspirate warm water in a back-and-forth motion through the tube. A digestive enzyme solution may help if warm water flushing is not effective.

A client has been admitted with a catheter-associated, vancomycin-resistant enterococcal bacteremia. Which interventions should the nurse implement? Select all that apply. 1. Keep dedicated equipment for client 2. Perform hand hygiene before exiting the room 3. Place a "No Visitors" sign on the client's door 4. Wear a face mask when in the room 5. Wear an isolation gown when providing direct care

1. Keep dedicated equipment for client 2. Perform hand hygiene before exiting the room 5. Wear an isolation gown when providing direct care In addition to standard precautions, the client infected with multidrug-resistant organisms (eg, vancomycin-resistant enterococci [VRE] or methicillin-resistant Staphylococcus aureus [MRSA]), Clostridium difficile, and scabies will require contact precautions that include the following: Place client in a private room (preferred) or semi-private room with another client with the same infection Dedicate equipment for client (must be kept in the client's room and disinfected when removed from room) (Option 1) Wear gloves when entering the room Perform excellent hand hygiene before exiting the room (use soap and water or alcohol-based hand rubs for MRSA and VRE, but only soap and water for C difficile and scabies) (Option 2) Wear gown with client contact and remove it before leaving the room (Option 5) Place door notice for visitors Ensure client leaves the room only for essential clinical reasons (ie, tests, procedures) (Option 3) The client with MRSA or VRE is allowed to have visitors. However, these individuals will need instructions from the nursing staff about hand hygiene and the use of gloves and gowns and their disposal prior to leaving the client's room. A sign should be placed on the client's door to inform visitors about these precautions. (Option 4) A face mask is required for droplet precautions. An N95 particulate respirator mask is required for certain airborne precautions (eg, tuberculosis). Educational objective:The client with multidrug-resistant organism (MRSA or VRE) infections, C difficile diarrhea, or scabies will require institution of contact precautions such as good hand hygiene on entry and exit of the client's room, gloves on entry, and a gown for direct client care. The client's room should have dedicated equipment, and the door should have a sign informing visitors about these precautions.

The nurse is teaching a postoperative client to use a volume-oriented incentive spirometer device. Place the teaching steps in the proper order. All options must be used.

1. Exhale normally and place the mouthpiece in the mouth 5. Seal lips tightly on mouthpiece 4. Inhale deeply, until piston is elevated to predetermined level 3. Hold breath for at least 2-3 seconds 2. Exhale slowly around the mouthpiece Incentive spirometry is recommended in postoperative clients to prevent atelectasis associated with incisional pain, especially in upper abdominal incisions (close to the diaphragm). Adequate pain medication should be administered before using the incentive spirometry. Guidelines recommend 5-10 breaths per session every hour while awake. Volume-oriented or flow-oriented sustained maximal inspiration (SMI) devices can be used. The client instructions for using a volume-oriented SMI device include: Assume a sitting or high Fowler position, which optimizes lung expansion, and exhale normally While holding the device at an even level, seal the lips tightly on the mouthpiece to prevent leakage of air around it Inhale deeply through the mouth until the piston is elevated to the predetermined level of tidal volume. The piston is visible on the device and helps provide motivation. Hold the breath for at least 2-3 seconds (up to 6 seconds) as this maintains maximal inhalation Exhale slowly to prevent hyperventilation Breathe normally for several breaths before repeating the process Cough at the end of the session to help with secretion expectoration Educational objective:Incentive spirometry is recommended to prevent atelectasis in postoperative clients. Clients with incisional pain should receive adequate pain medication prior to the inhalations. The client is instructed to use the device while sitting upright, seal the lips tightly around the mouthpiece, inhale deeply, sustain the maximal inspiration for at least 2-3 seconds, exhale slowly before repeating the procedure, and cough at the end of the session.

An elderly client is brought to the emergency department with lethargy, chills, and sharp chest pain with deep breathing. Pulse oximeter shows 93% on room air and respirations are 24/min. What is the nurse's initial action? 1. Administer intravenous (IV) morphine (7%) 2. Auscultate the client's lung sounds (55%) 3. Initiate an IV infusion of normal saline (5%) 4. Initiate nasal oxygen at 3 L/min (32%)

2. Auscultate the client's lung sounds Assessment is the first step in the nursing process that is used to gather information. Lung auscultation is the nurse's initial action with this client. Before intervening, the nurse should assess respiratory status and vital signs to obtain the baseline data that will be compared to subsequent changes. (Option 1) Morphine is administered to provide comfort and pain relief. This is an appropriate intervention to facilitate breathing and oxygenation, but it is not the best initial action. Assessment of respiratory status and vital signs should be performed before intervening. (Option 3) Initiation of an IV infusion of saline is done to provide hydration and IV access. This is an appropriate intervention, but it is not the best initial action. (Option 4) Although the saturation is decreased (93%) and the respiratory rate is increased (24/min), both are adequate to support oxygenation at this time. Nasal oxygen at 3 L/min should be initiated to improve oxygenation. Even though this is an appropriate intervention, it is not the best initial action. Educational objective:The nurse should first assess the client's condition before intervening. This is important as the ability to plan effective nursing care, set priorities, identify appropriate interventions, and make sound clinical decisions is based on the information obtained from the assessment.

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

2. Client receives 1 mg morphine instead of prescribed 0.5 mg morphine 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 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 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 (13%) 2. Complications, including death, could result (73%) 3. The client will be billed for the equipment regardless (0%) 4. The surgeon will be informed of the refusal (12%)

2. Complications, including death, could result 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.

The nurse learns that an Orthodox Jewish client has not started taking recently prescribed diltiazem extended-release capsules. The client states "I cannot take the medication in this form." What is the nurse's first action? 1. Ask the health care provider to prescribe a different calcium channel blocker (13%) 2. Consult with the pharmacist to see if an alternate form of the drug is available (76%) 3. Open the capsule and sprinkle the medication in a cup of applesauce (6%) 4. Warn the client about the dangers of uncontrolled hypertension (3%)

2. Consult with the pharmacist to see if an alternate form of the drug is available Members of the Orthodox Jewish faith observe strict dietary laws that dictate whether certain foods and medications are considered kosher (fit to be consumed). Most capsules are coated in gelatin, a substance made from the collagen of animals, which is generally considered nonkosher. The nurse should first ask the pharmacist if an equivalent, gelatin-free form of the medication (eg, tablets) is available. If no alternate form is available, the client may want to consult with a rabbi as laws may be relaxed for those who are ill. Educational objective:Due to Orthodox Jewish dietary laws, it is not acceptable for clients who follow a kosher diet to consume capsules made from gelatin. The nurse should ask the pharmacist if an alternate form of the medication is available. If not, the client may want to consult a rabbi as laws may be relaxed for those who are ill.

The nurse is assigned to care for a hospitalized confused client with an indwelling urinary catheter. On entering the client's room, the nurse notes the client pulling at the catheter and grimacing in pain. Blood is trickling from the client's meatus and the urine in the drainage bag is pink. Which action should the nurse take first? 1. Collect a urine specimen and send to the lab (3%) 2. Deflate the balloon on the urinary catheter (74%) 3. Remove the catheter by gently pulling from the urethra (2%) 4. Use a sterile 4x4 pad to absorb the blood around the meatus (18%)

2. Deflate the balloon on the urinary catheter Because signs of traumatic injury are present, the nurse should follow steps to remove the catheter before further complications such as obstruction occur. Steps for removing an indwelling catheter include the following: Perform hand hygiene Ensure privacy and explain the procedure to the client Apply clean gloves Place a waterproof pad underneath the client Remove any adhesive tape or device anchoring the catheter Follow specific manufacturer instructions for balloon deflation Loosen the syringe plunger and connect the empty syringe hub into the inflation port Deflate the balloon by allowing water to flow back into the syringe naturally, removing all 10 mL, or applicable amount (note the size of the balloon labeled on the balloon port). If water does not flow back naturally, use only gentle aspiration. Remove the catheter gently and slowly; inspect to make sure it is intact and fragments were not left in the client. If any resistance is met, stop the removal procedure and consult with the urologist for removal Empty and measure urine before discarding the catheter and drainage bag in the biohazard bin or according to hospital policy Remove gloves and perform hand hygiene (Option 1) A urine specimen can be collected after the balloon is deflated or after the catheter is removed if needed. (Option 4) The meatus should be cleaned after balloon deflation. Educational objective:When the urinary catheter balloon occludes the urethra, it should be deflated immediately to prevent further injury or complication. After balloon deflation, gently and slowly remove the catheter. If there is resistance, notify the urologist.

A client started a 24-hour urine collection test at 6:00 AM. The unlicensed assistive personnel (UAP) reports discarding a urine specimen of 250 mL at 10:00 AM by mistake but adding all specimens to the collection container before and after that time. What action should the nurse take? 1. Add 250 mL to the total output after the 24-hour urine collection is complete tomorrow morning (7%) 2. Discard urine and container, and restart the 24-hour urine collection tomorrow morning (61%) 3. Discard urine and container, have client void, add urine to new container, and then restart test (22%) 4. Relabel the same collection container, and change the start time from 6:00 AM to 10:00 AM (8%)

2. Discard urine and container, and restart the 24-hour urine collection tomorrow morning Timed urine collection tests are usually done to assess kidney function and measure substances excreted in the urine (eg, creatinine, protein, uric acid, hormones). These tests require the collection of all urine produced in a specified time period (a crucial step) to ensure accurate test results. The proper container (with or without preservative) for any specific test is obtained from the laboratory. The collection container must be kept cool (eg, on ice, refrigerated) to prevent bacterial decomposition of the urine. Not all of the client's urine was saved during the collection period. Therefore, the nurse or UAP must discard the urine and container and restart the specimen collection procedure. Although a 24-hour urine collection can begin at any time of the day after the client empties the bladder, it is common practice to start the collection in the morning after the client's first morning voiding and to end it at the same hour the next morning after the morning voiding (Option 2). (Option 1) Adding 250 mL to the total output when the test is completed is not an appropriate action as the actual urine output from the 24-hour period is needed for accurate results. (Option 3) To start the collection period, the nurse asks the client to void and discards this specimen (it is not added to the collection container). The 24-hour period starts at the time of the client's first voiding. (Option 4) Relabeling the same container and changing the start time from 6:00 AM to 10:00 AM is not an appropriate action. The container would include part of the urine produced in a 28-hour period, and the test results would be inaccurate. Educational objective:It is common practice to start a 24-hour urine collection test at the time of the client's first voiding in the morning. If any urine is discarded by accident during the test period, the procedure must be restarted. All produced urine should be placed in the same container and kept cool (on ice).

The nurse observes a student nurse administer ear drops to an elderly client to help loosen cerumen. The nurse intervenes when the student performs which action? 1. Instills ear drops at room temperature (1%) 2. Instills ear drops with dropper by occluding the ear canal (69%) 3. Places a cotton ball loosely in outermost auditory canal after the instillation (14%) 4. Pulls pinna up and back and instills drops (14%)

2. Instills ear drops with dropper by occluding the ear canal (69%) Otic medications are used to treat infection, soften cerumen for later removal, and facilitate removal of an insect trapped in the ear canal. They are contraindicated in a client with a perforated eardrum. The general procedure for instilling ear drops includes the following steps: Perform hand hygiene and don clean gloves. The ear canal is not sterile, but aseptic technique is used Position the client side-lying with the affected ear up (if not contraindicated). This facilitates administration and prevents drops from leaking out of the ear Warm ear drops to room temperature (ie, use hand or warm water) to help avoid vertigo, dizziness, or nausea as the internal ear is sensitive to temperature extremes (Option 1) Pull the pinna up and back to straighten the ear canal in clients >4 years old and adults. Pull the pinna down and back in clients <3 years old (Option 4) Support hand on the client's head and instill the prescribed number of drops by holding the dropper 1 cm (1/2 in) above the ear canal. This avoids damaging the ear canal with the dropper (Option 2) Apply gentle pressure to the tragus (fleshy part of external ear canal) if it does not cause pain, which facilitates the flow of medication into the ear canal Instruct the client to remain side-lying for at least 2-3 minutes to facilitate medication distribution and prevent leakage Place a cotton ball loosely in the client's outermost ear canal for 15 minutes, only if needed, to absorb excess medication. Perform this with caution and avoid in infants or very young clients as it is a choking hazard (Option 3) Educational objective:To administer otic medications in an adult client, follow these steps: (1) Perform hand hygiene, (2) position the client side-lying with the affected ear up, (3) pull pinna up and back, (4) administer prescribed number of ear drops, (5) instruct the client to remain side-lying for 2-3 minutes, and (6) place cotton ball loosely in the outer ear canal for 15 minutes (if needed).

A graduate nurse (GN) is caring for a client with right lower leg cellulitis that is seeping clear fluid. Which action by the GN requires intervention by the supervising nurse? 1. Applying a warm compress to the affected extremity (57%) 2. Maintaining the affected leg flat on the bed (30%) 3. Marking and dating the reddened areas (5%) 4. Wearing a gown and gloves while bathing the client (6%)

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

The nurse prepares to insert an indwelling urinary catheter for a female client. The nurse assesses for allergies, explains the procedure to the client, gathers equipment, and then performs perineal care. Place in order the steps the nurse should take when inserting the urinary catheter. All options must be used.

2. Perform hand hygiene and open a sterile urinary catheterization kit 1. Apply sterile gloves and place sterile drape under the client's buttocks 6. Use the nondominant hand to gently spread the labial folds 3. Use the dominant hand to cleanse the labial folds with antiseptic swabs 4. Use the dominant hand to cleanse the urethral meatus with antiseptic swabs Steps for indwelling urinary catheter insertion for the female client include: Position the client supine with knees flexed and hips slightly externally rotated. Perform hand hygiene and open a sterile catheterization kit (Option 2). Apply sterile gloves and place a sterile drape underneath the client's buttocks (Option 1). Remove the protective covering from the catheter, lubricate the catheter tip, and pour antiseptic solution over cotton balls or swab sticks while maintaining sterility of gloves and sterile field. Use the nondominant hand to gently spread the labia. The nondominant hand is now contaminated (Option 6). Use the dominant (sterile) hand to cleanse the labia and urinary meatus with antiseptic-soaked cotton balls or swab sticks. Cleanse in an anteroposterior direction (from the clitoris toward the anus). Use a new swab for each swipe to avoid transferring bacteria between areas. Cleanse the labia majora first, then the labia minora, and lastly the urinary meatus (Options 3 and 4). Use the dominant hand to insert the catheter until urine return is visualized in the tubing (usually 2-3 inch [5-7.6 cm]), and then advance it an additional 1-2 inch (2.5-5 cm) (Option 5). Hold the catheter in place with the nondominant hand, and then use the dominant hand to inflate the balloon. Educational objective:To insert an indwelling urinary catheter in a female client: perform hand hygiene; apply sterile gloves and place a sterile drape under the client; arrange supplies on a sterile field; gently spread the labia with the nondominant hand; cleanse the labia majora, then the labia minora, and lastly the urinary meatus; insert the catheter until urine return is visualized; advance an additional 1-2 inch (2.5-5 cm); and inflate the balloon. Additional Information Reduction of Risk Potential NCSBN Client Need

The nurse is caring for a client who has deep venous thrombosis and is prescribed a continuous IV infusion of heparin 25,000 units in 500 mL of D5W at 1300 units/hr. After 6 hours of the heparin infusion, the client's PTT is 44 seconds. The nurse must adjust the infusion rate according to the heparin drip protocol (shown in the exhibit). According to the protocol, at what rate in milliliters per hour (mL/hr) should the nurse set the IV infusion pump?

28 The original heparin dose is 1300 units/hr. This client's PTT is 44 seconds, which is below the therapeutic range of 55-70 seconds (as shown in the exhibit), indicating that the client requires a higher dose of heparin for adequate anticoagulation. According to the heparin drip protocol (protocols vary per institution), the rate should be increased by 100 units/hr, or to an infusion rate of 1400 units/hr, which converts to 28 mL/hr. Using dimensional analysis, use the following steps to calculate the rate in milliliters per hour at which the IV infusion pump should be set to deliver 1400 units/hr (original dose of 1300 units/hr increased by 100 units/hr per protocol): Educational objective:To calculate the IV infusion rate of heparin, the nurse should first adjust the dosage as prescribed (eg, 1300 + 100 units/hr). After identifying the prescribed dose (eg, 1400 units/hr) and available medication (eg, 25,000 units/500 mL), the nurse converts to the rate in milliliters per hour (28 mL/hr).

The public health nurse conducts a program at the community senior citizen center about preventing falls at home. Which statement made by a participant indicates that further education is needed? 1. "I bought a new nightlight for the hallway to the bathroom." (0%) 2. "I feel so much more secure wearing my electronic fall alert device." (1%) 3. "I walk in my stockings at home because it helps to relieve my bunion pain." (65%) 4. "My daughter helped me secure the small, thin rug in my kitchen with strong tape." (32%)

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

The orthopedic health care provider instructs a client with a fractured right femur, who has been non-weight bearing for the past 5 weeks, to progress to full weight bearing on the right leg. Which advanced crutch gait that most closely resembles normal walking should the office nurse teach the client? 1. 2-point gait (28%) 2. 3-point gait (34%) 3. 4-point gait (36%) 4. 5-point gait (1%)

3. 4-point gait The client who is rehabilitating from an injury of the lower extremity usually progresses from no touch down, non-weight bearing status, using the 3-point gait (Option 2) to touch down with partial weight bearing status, using the 2 point-gait (Option 1), to full weight bearing status, using the 4-point gait. The nurse teaches the client how to use the most advanced gait, the 4-point crutch gait. It requires weight bearing on both legs and is the most stable as there are 3 points of support on the ground at all times (eg, 2 crutches and 1 foot; 2 feet and 1 crutch). It is the easiest to use as it resembles normal walking: advance right crutch, then left foot, and advance left crutch, then right foot. (Option 3) (Option 4) There are 5 crutch gaits: 2-point, 3-point, 4-point, swing-to, and swing-through. There is no 5-point crutch gait. Educational objective:The 4-point crutch gait is appropriate for a client with leg weakness, who can bear partial or full weight with both legs. It is the easiest gait to use as it resembles normal walking and provides the most stability with 3 points of support on the ground at all times

A nurse is caring for a group of clients on a medical surgical unit. Which client is most at risk for contracting a nosocomial infection? 1. 51-year-old client who received a permanent pacemaker 48 hours ago (3%) 2. 60-year-old client who had a myocardial infarction 24 hours ago (1%) 3. 74-year-old client with stroke and an indwelling urinary catheter for 3 days (90%) 4. 75-year-old client with dementia and dehydration who is on IV fluids (5%)

3. 74-year-old client with stroke and an indwelling urinary catheter for 3 days A nosocomial infection occurs in a hospital (hospital-acquired) or other health care setting and is not the reason for the client's admission. Many nosocomial infections are caused by multidrug resistant organisms. These infections occur 48 hours or more after admission or up to 90 days after discharge. Clients at greater risk include young children, the elderly, and those with compromised immune systems. Other risk factors include long hospital stays, being in the intensive care unit, the use of indwelling catheters, failure of health care workers to wash their hands, and the overuse of antibiotics. The most common nosocomial infection is urinary tract infection, followed by surgical site infections, pneumonia, and bloodstream infections. The 74-year-old client is most at risk due to age and the presence of the urinary catheter. The nurse will need to be on high alert for this complication and should follow infection control procedures diligently. (Option 1) This client does have a surgical incision, which poses a risk for infection. However, this client is younger and does not have any underlying chronic condition to compromise the immune system. (Option 2) This client does not fall in the category of elderly and has no surgical incision or indwelling catheters other than a possible IV site. (Option 4) This client is at risk due to age and presence of an IV catheter. However, the risk is not as high as the client with the urinary catheter. Educational objective:The nurse should be aware of the risk for nosocomial infections in young children, elderly, and immunocompromised clients, especially those with long hospital stays, indwelling catheters, and surgical incisions.

A client with terminal cancer is prescribed fentanyl patches for pain management while receiving hospice care at home. Which instructions related to this medication should the nurse provide? Select all that apply. 1. Apply a heating pad over the patch to aid drug absorption 2. Cut the patch in half before application if less medication is needed 3. Fold the used patch in half so that the edges adhere and immediately discard 4. Place the patch 1 in (2.5 cm) from the source of pain for maximal effectiveness 5. Remove the old patch when applying a new patch every 72 hours

3. Fold the used patch in half so that the edges adhere and immediately discard 5. Remove the old patch when applying a new patch every 72 hours Fentanyl, a potent opioid analgesic, is administered IV to treat acute pain and as a transdermal patch (Duragesic) dosed in mcg/hr to treat chronic pain. When given via transdermal patch, fentanyl is absorbed systemically through the skin to provide continuous analgesia. Patches are replaced every 72 hours, and the used patch must be removed before applying a new one (Option 5). Used patches must be folded and discarded immediately, as some medication remains in a used patch. Opioid medications must be stored and disposed of securely (eg, flushed down the toilet, discarded in a sharps container) as accidental exposure is potentially fatal for children, pets, and caregivers (Option 3). (Option 1) Heat (eg, heating pad) should not be placed over a patch as this accelerates absorption. (Option 2) Cutting a transdermal patch damages the drug-delivery system, results in administration of an imprecise dose, and risks exposure to the person cutting the patch. (Option 4) Transdermal patches should be applied to an area of flat, intact skin (eg, upper back, chest) to prevent accidental removal. The site should be clean, with little hair. Unlike transdermal patches, topical analgesic patches (eg, lidocaine, capsicum) deliver drug locally and are placed near the site of pain. Educational objective:Fentanyl patches are changed every 72 hours, and used patches must be folded and discarded securely before a new one is applied. Patches should be applied to flat, intact skin to prevent accidental removal. Patches should not be cut, and heat should not be placed over them

The nurse recognizes that which factors place a client at increased risk for falls? Select all that apply. 1. Age of 50 2. Diagnosis of ovarian cancer 3. Lying pulse 80/min, standing pulse 110/min 4. Osteoarthritis of knees 5. Takes carbidopa/levodopa 6. Uses a cane to ambulate

3. Lying pulse 80/min, standing pulse 110/min 4. Osteoarthritis of knees 5. Takes carbidopa/levodopa 6. Uses a cane to ambulate Positive orthostatic vital signs (eg, rise in pulse of ≥20/min) indicate increased risk of syncope and falls (Option 3). Osteoarthritis of the knees limits joint mobility, increasing the risk for falls. Presence of IV therapy, wet floors, rooms congested with furniture, and improper toilet seat or bed height are factors that increase this risk (Option 4). Carbidopa/levodopa (Sinemet) is an antiparkinson medication. Parkinson disease increases the risk of falls due to gait abnormality (eg, shuffling gait). Carbidopa/levodopa (Sinemet) may also cause dizziness, involuntary movements, and orthostatic hypotension, further increasing the risk for falls (Option 5). The use of an ambulatory aid such as a cane, walker, or crutches indicates a balance/gait problem and places the client at higher risk of falling (Option 6). (Option 1) Fall risk does not increase until age >65-75. (Option 2) Ovarian cancer does not inherently affect cognition and neurologic or muscular function and is therefore not a risk for falling. Advanced disease with weakness, perhaps from the treatment, could constitute a risk for a fall. Educational objective:Fall risks include using assistive ambulatory devices, orthostasis, taking sedatives or antiparkinson medications, or being age >65-70.

The nurse plans to start an IV line on a female client hospitalized with pneumonia. The nurse reviews the electronic medical record for relevant information and learns that the client is right-handed and has a history of a left-sided mastectomy with lymph node removal. Which site is best for the nurse to select for the client's IV line? 1. Basilic vein of the left forearm (4%) 2. Cephalic vein in the right antecubital space (28%) 3. Median vein of the right forearm (63%) 4. Radial vein of the left wrist (4%)

3. Median vein of the right forearm The client's medical history should be reviewed prior to starting an IV line so that the nurse can identify any contraindications to specific anatomical sites. Lymph node removal during a mastectomy may affect lymphatic fluid drainage on the affected side and cause lymphedema or other complications such as infection, venous thromboembolism, or trauma to the affected arm. The nurse must avoid any needlesticks, IV insertions, or blood pressure measurements in the affected arm (Options 1 and 4). The nondominant side is preferred when no medical contraindications exist. However, in this case, the right forearm is best because the client had a left-sided mastectomy (Option 3). Other considerations when selecting IV sites include avoidance of areas that have obstructed blood flow, dialysis sites, areas distal to old puncture sites, bruised areas, painful areas, or areas with skin conditions or signs of infection. (Option 2) The antecubital space should be avoided when possible (except for emergency insertion) as it inhibits mobility and may be positional. Educational objective:The nurse should review the client's medical record and assess for contraindications to IV sites, including impaired lymphatic drainage (prior mastectomy), arteriovenous fistula or graft (used for hemodialysis), and areas distal to old puncture sites.

A nurse is caring for a 2-year-old child diagnosed with nephrotic syndrome who is in diapers and has red, edematous genitals. Which collection technique is appropriate for the nurse to obtain daily urine specimens for proteinuria testing with a urine dipstick? 1. Apply adhesive urine collection bag around the genital area and wait for the child to void (40%) 2. Intermittently catheterize the child every morning to avoid contaminating the specimen (21%) 3. Place cotton balls in a dry diaper; when wet, squeeze urine onto dipstick (32%) 4. Place urine dipstick in the child's diaper overnight and check result in the morning (5%)

3. Place cotton balls in a dry diaper; when wet, squeeze urine onto dipstick Nephrotic syndrome is characterized by massive proteinuria and hypoalbuminemia, which results in severe edema most evident in the abdomen, face, and perineum. Daily dipstick urinalysis determines the presence and pattern of urine protein loss to monitor for exacerbations. To collect a nonsterile urine specimen from a child who is not toilet trained, the nurse can place several cotton balls in a dry diaper and later squeeze urine onto a dipstick. The diaper is checked frequently and the sample collected and tested within 30 minutes of urination for the most accurate result. (Options 1 and 4) Children with nephrotic syndrome often have significant edema of the scrotum or labia. Placing a urine dipstick in the child's diaper or applying a standard adhesive urine collection bag around the genital area would cause further irritation and increased risk for skin breakdown. (Option 2) Children with nephrotic syndrome have a high risk for infection from immunosuppressive effects of corticosteroid therapy. Intermittent or continuous catheterizations are invasive procedures that may cause urinary tract infections. Urine cultures are the only specimen requiring sterile collection techniques (eg, clean catch, catheterization). Educational objective:Children with nephrotic syndrome often require daily urinalysis to monitor for proteinuria. Urine collection bags or dipsticks in the diaper risk breakdown of edematous skin. To collect a nonsterile urine specimen from a child in diapers, the nurse can place cotton balls in a dry diaper and later squeeze urine onto a dipstick.

A nurse is reviewing the most recent laboratory results of a client on the telemetry floor. The client is currently asymptomatic, and the telemetry monitor indicates sinus rhythm. Which of the following critical values is most likely due to laboratory error? 1. Blood urea nitrogen (BUN) of 60 mg/dL (21.4 mmol/L) (6%) 2. Creatinine of 4.0 mg/dL (354 µmol/L) (2%) 3. Potassium of 7.0 mEq/L (7.0 mmol/L) (87%) 4. Sodium of 155 mEq/L (155 mmol/L) (2%)

3. Potassium of 7.0 mEq/L (7.0 mmol/L) With the exception of clients in end-stage renal disease, a serum potassium value >6.5 mEq/L (6.5 mmol/L) in any client who is walking and talking should raise the suspicion of an erroneously elevated serum potassium (pseudohyperkalemia) from poor hematology technique, hemolysis, or clotting. A serum potassium level of 7.0 mEq/L (7.0 mmol/L) would normally constitute a life-threatening electrolyte imbalance that would cause severe weakness or paralysis, unstable arrhythmias, and eventual cardiac arrest. An assessment would focus on evaluating cardiac symptoms and muscle strength and be reported to the health care provider (HCP). In this case, it is likely that a repeat blood draw would be prescribed. Pseudohyperkalemia can be avoided on the repeat blood draw by using heparin-impregnated hematology vials to prevent clotting, minimal use of a tourniquet and fist clenching, and use of a larger gauge needle for the sample. (Option 1) This blood urea nitrogen (BUN) value is elevated (normal 6-20 mg/dL [2.1-7.1 mmol/L]) and could be related to kidney damage or dehydration. Therefore, it is not the most likely erroneous result. (Option 2) Similar to the BUN level, this creatinine value is significantly elevated (normal 0.6-1.3 mg/dL [53-115 µmol/L]). Further nursing assessment is indicated, with documentation and involvement of the HCP in evaluating the impact of this kidney damage on the client's health. (Option 4) This sodium value is high (normal 135-145 mEq/L [135-145 mmol/L]) and requires further exploration. The nursing assessment should be documented and reported to the HCP. Educational objective:High serum potassium levels could be due to hemolysis or clotting during the blood draw. If a clinical assessment does not correlate with the laboratory values, repeat testing is needed.

The nurse is caring for an agitated client with dementia who is pulling at the oxygen and IV tubing. Wrist restraints are applied after less-restrictive safety measures have been ineffective. Which actions are appropriate to protect the client from injury? Select all that apply. 1. Attach wrist restraint straps to the upper side rails 2. Position the client supine to keep restraint straps taut 3. Release restraints at regular intervals and assess behavior 4. Use a square knot to tie restraint straps to the bed 5. Use gauze to pad bony prominences under restraints

3. Release restraints at regular intervals and assess behavior 5. Use gauze to pad bony prominences under restraints When caring for a client in restraints, the nurse should implement these interventions at regular intervals, according to agency policy (eg, every 2 hours): Provide skin care and range-of-motion exercises; ensure basic needs are met (eg, fluids, nutrition, elimination). Assess skin integrity and neurovascular status of restrained extremities; pad bony prominences under restraints, if necessary, to protect skin (Option 5). Determine the need for continued restraint by releasing restraints briefly and assessing the client's reaction; regularly assessing the need for restraints promotes discontinuation as soon as possible (Option 3). (Option 1) Restraint straps should be attached to areas that move with the bed frame (ie, elevates with the frame and head of the bed). Areas that do not move with (eg, base) or move independently of (eg, side rails) the frame should never be used, as injury may occur when they are raised or lowered (eg, pulling, entrapment). (Option 2) Supine positioning increases aspiration risk as the client may be unable to self-reposition if vomiting occurs. Side-lying or semi-Fowler position promotes drainage of emesis or oral secretions. (Option 4) Restraint straps should be tied in a quick-release knot, in case of emergency, and never in a square knot, which is difficult to release quickly. Educational objective:Nurses caring for restrained clients must ensure that basic needs are met, assess skin integrity and neurovascular status of restrained extremities, and determine the need for continued use. Supine position is avoided to decrease aspiration risk. Quick-release knots are used to attach restraints to parts of the bed frame that move with bed position changes.

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 (0%) 2. Purchase a walker for the client to use when ambulating around the home (4%) 3. Remove all area rugs and install grab bars in the bathroom (91%) 4. Take the client for an annual eye exam and new glasses (2%)

3. Remove all area rugs and install grab bars in the bathroom 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 registered nurse observes a graduate nurse who is inserting a small-bore nasojejunal feeding tube. Which action by the graduate nurse requires intervention by the registered nurse? 1. Asking the client to take small sips of water during insertion (16%) 2. Marking the tube at the exit point from the naris (9%) 3. Removing the stylet before the x-ray is performed (61%) 4. Stopping insertion of the tube while the client is coughing (12%)

3. Removing the stylet before the x-ray is performed Small-bore nasoenteric (eg, nasoduodenal, nasojejunal) tubes are often placed using a stylet (guide wire), a metal wire running through the tube that facilitates advancement through the gastrointestinal tract. Once the tube is inserted, the nurse should obtain an x-ray to verify that the tube terminates in the intestine as prescribed, not in the airway or stomach. After placement verification, the nurse should remove the stylet to allow tube feeding (Option 3). To avoid perforating the gut, the nurse should never reinsert the stylet when a feeding tube is in place. If the tube is not properly positioned and the stylet has been removed, the nurse must remove the tube and start over. (Options 1 and 4) The client should sip water during insertion to close the airway and open the esophagus. With each swallow the nurse should advance the tube a little. The nurse should stop advancing when the client is inhaling or coughing to avoid inserting the tube into the airway and then continue advancing when the client is able to swallow again. (Option 2) Marking the exit point from the naris on the tube allows visualization of changes in external tube length that may indicate tube dislodgement. Educational objective:After placing a new, small-bore nasoenteric (eg, nasoduodenal, nasojejunal) feeding tube, the nurse should obtain an x-ray to verify tube placement and should leave the stylet (guide wire) in place until tube placement is verified. The nurse should never reinsert a stylet into a nasoenteric tube. Additional Information Reduction of Risk Potential NCSBN Client Need (61%)

A 3-month-old infant is treated in the emergency department for a spiral femur fracture. The parent reports that the infant sustained the injury after rolling off the bed. What is the priority nursing action? 1. Document a description of the injury (15%) 2. Question the mother about where the infant sleeps (26%) 3. Report the injury per facility protocol (52%) 4. Separate the mother from the infant (4%)

3. Report the injury per facility protocol The parent's account of this injury is inconsistent with the developmental milestones of a 3-month-old infant, as the muscles required for rolling over do not develop until age 4-5 months. Additionally, spiral femur fractures indicate that pressure was applied to the leg in opposite directions (torsion), which is an unlikely accidental injury in a nonambulatory child. Fractures in young children, especially nonambulatory infants, are always of concern and suspicious of child abuse. The nurse's priority is to report suspected child maltreatment to the appropriate authorities following facility protocol as required by law in the United States and Canada (Option 3). However, the nurse should also be aware of cultural health practices (eg, cupping, coining) and physiologic conditions (eg, hemophilia, Mongolian spots) mimicking maltreatment. After reporting suspected maltreatment, the nurse should: Facilitate a complete physical evaluation (eg, skeletal survey, growth/development comparisons, radiographic studies, neurologic examination) Document facts and observations objectively, using medical terms when possible (Option 1). Include the history provided by the parent or caregiver and the time period from injury occurrence to evaluation. Perform a review of child-care practices with the caregiver (Option 2). (Option 4) A child and caregiver should only be separated when the child is in immediate physical danger or if authorities must interview a verbal child without the parent present. Educational objective:Injuries in a nonambulatory child, especially fractures, warrant suspicion. The nurse has a duty to report suspected child maltreatment to the appropriate authorities as required by law. Additional Information Psychosocial Integrity NCSBN Client Need

A nurse is performing a dressing change for a hospitalized client with an infected surgical incision. Which actions should the nurse take? 1. Have the client remove the existing dressing while the nurse prepares sterile supplies (0%) 2. Wear clean gloves for removal and application of a new dressing (6%) 3. Wear clean gloves to remove the existing dressing, changing to sterile gloves to apply the new dressing (89%) 4. Wear sterile gloves, gown, and goggles to remove the soiled existing dressing (3%)

3. Wear clean gloves to remove the existing dressing, changing to sterile gloves to apply the new dressing The existing dressing is already contaminated so clean gloves can be worn to remove and discard it. Surgical wounds should be re-dressed using aseptic technique, which would require sterile gloves and sterile dressing supplies. The nurse should carefully remove the soiled dressing to avoid shedding any microorganisms into the air and expose the wound for minimal time to avoid additional contamination. (Option 1) It would be better for the nurse to perform the dressing change as the wound is already infected. The client may be able to assist in the home setting. (Option 2) Clean gloves can be used for removal but not for application of a new dressing. (Option 4) Sterile gloves are not needed to remove the existing dressing. A gown and goggles may be required if splashing is possible. Educational objective:When changing the dressing of a surgical incision, the nurse may wear clean gloves to remove the existing dressing but should wear sterile gloves to apply a new one.

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 (9%) 2. Document the response and notify the health care provider and perioperative team (13%) 3. Follow up with the client regarding the nature of the spiritual needs or religious practices (68%) 4. Notify the hospital chaplain and tell the client that the chaplain will come by to assist (9%)

3.Follow up with the client regarding the nature of the spiritual needs or religious practices (68%) 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.

The student nurse is preparing to perform a heel stick on a neonate to collect blood for diagnostic testing. Which statement by the student nurse indicates a need for further education? 1. "I can perform the stick on either the medial or lateral side of the outer aspect of the heel." (35%) 2. "Sucrose and a pacifier can help alleviate the infant's pain and stress during the puncture." (15%) 3. "The heel area should be warmed for 3-5 minutes prior to puncture." (17%) 4. "Venipuncture should be reserved only for failed heel sticks because it is more painful." (32%)

4. "Venipuncture should be reserved only for failed heel sticks because it is more painful. The neonatal heel stick (heel lancing) is used to collect a blood sample to assess capillary glucose and perform newborn screening for inherited disorders (eg, congenital hypothyroidism, phenylketonuria). Proper technique is essential for minimizing discomfort and preventing complications and includes: Select a location on the medial or lateral side of the outer aspect of the heel (Option 1). Avoid the center of the heel to prevent accidental insult to the calcaneus. Puncture should not occur over edematous or infected skin. Warm the heel for several minutes with a warm towel compress or approved single-use instant heat pack to promote vasodilation (Option 3). Cleanse the intended puncture site with alcohol. Sucrose and nonnutritive sucking on a pacifier may reduce procedural pain (Option 2). Use an automatic lancet, which controls the depth of puncture. Lancing the heel too deeply can result in penetration of the calcaneus bone, leading to osteochondritis or osteomyelitis. An acceptable alternate method of blood collection in the neonate is venipuncture (ie, drawing blood from a vein). Venipuncture is considered less painful and often requires fewer punctures to obtain a sample, especially if a larger volume is needed (Option 4). Educational objective:To perform a neonatal heel stick, select a location on the medial or lateral side of the outer aspect of the heel to avoid insult to the calcaneus bone. Provide comfort measures (eg, nonnutritive sucking), warm the selected puncture site to promote vasodilation, cleanse with alcohol, and puncture using an automatic lancet.

It is 0700 and the nurse is caring for an 84-year-old client with dementia and a fractured hip. The client has been disoriented to time, place, and person since admission. The client moans frequently and grimaces when moving. He is prescribed morphine IV every 2 hours as needed for pain and was last medicated at 0530. He is scheduled for surgery at 1000 to repair the hip fracture, but the consent has not yet been signed. The client's spouse and child are to arrive at 0900. Which intervention should the nurse carry out first? 1. Administer pain medication (20%) 2. Call the health care provider to meet with the family to obtain informed consent (23%) 3. Complete the preoperative checklist (4%) 4. Perform the morning assessment (51%)

4. Perform the morning assessment (51%) The morning shift assessment should be completed first to collect baseline assessment data (eg, vital signs, lung sounds, level of consciousness), assess pain, and collect necessary information for the preoperative checklist. (Option 1) Pain medicine is not due until 0730 and can be administered after the initial assessment if necessary. (Option 2) The nurse should call the health care provider after the initial assessment (by 0730) and arrange for a meeting with family members at 0900 to obtain informed consent as the client is not capable of giving it. (Option 3) The preoperative checklist can be completed after consent is obtained. Educational objective:Before surgery, the nurse makes sure informed consent is obtained, performs a complete physical assessment to collect baseline data and determine the client's physiologic and psychologic status, and completes the preoperative checklist

A student nurse prepares to change a large wet-to-damp sterile wound dressing and uses a disposable moisture-proof sterile drape to set up the sterile field. The precepting nurse intervenes when the student performs which action? 1. Holds the package 6" (15 cm) above the sterile field and drops the sterile gauze onto the field (3%) 2. Opens the sterile gauze package with ungloved hands (13%) 3. Places the sterile gauze dressings within 2" (5 cm) from the edge of the sterile drape (7%) 4. Pours sterile normal saline solution (NSS) into a sterile basin from a bottle opened 30 hours ago (75%)

4. Pours sterile normal saline solution (NSS) into a sterile basin from a bottle opened 30 hours ago The sterility of an opened bottle of sterile saline cannot be guaranteed. Some institutions' policies permit recapped bottles of solution to be reused within 24 hours of opening, and some require disposal of the remaining solution. Therefore, the nurse should intervene when the student uses sterile saline from a bottle that was opened >24 hours ago. The general steps for preparing the sterile field for a wet-to-damp dressing change include: Perform hand hygiene. Open a sterile gauze package that has a partially sealed edge with ungloved hands by grasping both sides of the edge, one with each hand, and pull them apart while being careful not to contaminate the gauze (Option 2). Hold the inverted opened gauze package 6" (15 cm) above the waterproof sterile field so it does not touch the field, and then drop the gauze dressing onto the sterile field (Option 1). Place the sterile dressings on the sterile field 2" (5 cm) from the edge; the 1" (2.5 cm) margin at each edge is considered unsterile because it is in contact with unsterile surfaces (Option 3). Use sterile NSS from a recapped bottle that was opened <24 hours ago (if policy permits). Educational objective:The general steps for preparing the sterile field for a wet-to-damp dressing change include: Perform hand hygiene. Open a sterile gauze package with ungloved hands. Hold the inverted opened gauze package 6" (15 cm) above the sterile field. Place the sterile gauze dressing more than 1" (2.5 cm) from the edge of the sterile field. Use sterile NSS from a recapped bottle that was opened <24 hours ago (if policy permits).

The nurse is preparing to care for a client with acute myelogenous leukemia who is going through induction chemotherapy. The client's laboratory results are shown in the exhibit. Which intervention would be a priority for this client? Click on the exhibit button for additional information. 1. Administer erythropoietin injection (8%) 2. Minimize venipunctures and avoid intramuscular injections (16%) 3. Place sequential compression devices (SCDs) to the legs (0%) 4. Provide a private room and neutropenic precautions (74%)

4. Provide a private room and neutropenic precautions The client's laboratory results show severe neutropenia, with a reduced white blood cell count (normal 4,000-11,000/mm3 [4.0-11.0×109/L]) and reduced absolute neutrophil count (normal 2200-7700/mm3 [2.2-7.7 ×109/L]). Protection against infection is the most important goal for this client. The following neutropenic precautions are indicated: A private room Strict handwashing Avoiding exposure to people who are sick Avoiding all fresh fruits, vegetables, and flowers Ensuring that all equipment used with the client has been disinfected (Option 1) The client's laboratory results show moderate anemia. Blood transfusion and/or erythropoietin injections are important but not a priority. Infections in immunocompromised clients are life threatening. (Option 2) The client's platelet count of 78,000/mm3 (78 ×109/L) is decreased but not dangerously low; therefore, it is not the highest priority intervention. Avoiding intramuscular injections and minimizing venipunctures is most important when the platelet count is below 50,000/mm3 (50 ×109/L), as these can cause prolonged bleeding. (Option 3) This client would need SCDs for prevention of deep vein thrombosis to the legs as anticoagulants may not be used due to the risk of bleeding from low borderline platelet count. However, this is not a priority over infection prevention. Educational objective:Neutropenic precautions should be used to prevent infection in clients who have low white blood cell and absolute neutrophil counts and are receiving chemotherapy. Infections in these clients are life threatening.

The health care provider writes a prescription for hydromorphone 10 mg intravenous push every 2 hours prn for the post-operative client. The usual recommended dose is 0.2-1 mg every 2-3 hours prn. What action should the nurse initially take? 1. Administer the medication and monitor client frequently (1%) 2. Ask a nursing colleague if this drug amount is used (0%) 3. Check hydromorphone dose that the client had previously (14%) 4. Question the prescription with the prescriber (82%)

4. Question the prescription with the prescriber The nurse needs to have appropriate knowledge about a medication prior to administering it. Hydromorphone (Dilaudid) is a potent narcotic that has 5-10 times the strength of morphine. This client was prescribed a hydromorphone dose that is too high given that the typical maximum dose is 2 mg. As the drug prescription is outside a safe range, it must be questioned and cannot be administered automatically. (Option 1) A prescription that greatly exceeds the safety range should not be given without questioning/clarification. However, anytime the outer limit of drug dosing of a potent narcotic is administered, the client should be monitored frequently for adverse effects. This includes the sedation scale and arousability as sedation precedes respiratory depression for narcotics. (Option 2) When there is a medication dosing question, authoritative resources (eg, the pharmacist, current drug literature) should be consulted rather than relying on a nursing colleague who could be mistaken. (Option 3) Even if the client is opiate-tolerant, the dosage is significantly outside the safety range and the prescription should be questioned or clarified. Educational objective:When a medication prescription is outside the safety range, the nurse must question/clarify the prescription with the prescriber and not administer the drug automatically.

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 (5%) 2. Discontinue the tube feeding (10%) 3. Send a stool sample to the lab for culture and sensitivity (20%) 4. Slow the rate of administration of the feeding (63%)

4. Slow the rate of administration of the feeding 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.

A client is scheduled for an elective laparoscopic prostatectomy in the morning. The nurse should notify the health care provider (HCP) about which assessment data as soon as possible before surgery? 1. Hemoglobin 15 g/dL (150 g/L), hematocrit 45% (0.45) (1%) 2. International Normalized Ratio (INR) 1.3 (20%) 3. Platelet count 295,000/mm3 (295 × 109/L) (7%) 4. Temperature 100.4 F (38 C) with cough (71%)

4. Temperature 100.4 F (38 C) with cough (71%) Low-grade temperature and cough could indicate the presence of an infection, and the nurse should report these findings to the HCP as soon as possible before surgery. The administration of anesthesia in a client with a fever and cough can exacerbate an unknown viral or bacterial condition, increase the risk for postoperative pneumonia, and interfere with the postoperative healing process. The HCP may prescribe further testing, consult the anesthesia professional, postpone the elective surgery, or proceed with the surgery depending on the individual situation and type of surgery scheduled. (Options 1, 2, and 3) Hemoglobin (13.2-17.3 g/dL [132-173 g/L]), hematocrit (39%-50% [0.39-0.50]), and platelet count (150,000- 400,000/mm3 [150-400 × 109/L]) levels are within normal ranges and do not indicate increased risk for a bleeding problem. Normal INR is 0.75-1.25; 1.3 is only borderline elevation and would not increase the bleeding risk. Educational objective:The HCP should be notified as soon as possible if a client scheduled for surgery develops manifestations that could indicate a possible infection. Anesthesia and the physiologic stress of surgery in the presence of fever and cough can cause potential intraoperative and postoperative complications.

An elderly client with end-stage renal disease who has refused dialysis is admitted to a long-term care facility for rehabilitation following hospitalization. The next day, the client becomes agitated and says to the nurse, "I've got to get back home to my things. I have so much to do." Which is the most likely interpretation of this client's behavior? 1. The client has been admitted to the facility without the client's consent (4%) 2. The client is becoming delirious and should be assessed for infection (37%) 3. The client is concerned that someone might steal possessions (2%) 4. The client wants to take care of business before imminent death (55%)

4. The client wants to take care of business before imminent death

An unconscious client is brought to the emergency department by the paramedics after being hit by a car. An emergency craniotomy is required. The client has no identification. What action should be taken next? 1. Contact the national database to see if the client has a healthcare proxy (1%) 2. Contact the police to help identify the client and locate family members (2%) 3. Obtain a court order for the client's surgical procedure (3%) 4. Transport the client to the operating room under implied consent (93%)

4. Transport the client to the operating room under implied consent (93%) Implied consent in emergency situations includes the following criteria: There is an emergency Treatment is required to protect the client's health It is impractical to obtain consent It is believed that the client would want treatment if able to consent In this case, it would be assumed that the client would want life-saving surgery; the health care provider should proceed.

A client newly returned to the unit after knee surgery asks the nurse for assistance to a chair. What action should the nurse implement first? 1. Ask another nurse to help (3%) 2. Delegate the task to unlicensed assistive personnel (1%) 3. Premedicate the client for pain (7%) 4. Verify the client's activity prescription (88%)

4. Verify the client's activity prescription A client newly admitted from a surgical procedure may have activity restrictions or bed rest prescribed for a certain period. Before assisting the client to the chair, the nurse needs to verify the activity level prescribed by the health care provider. Getting the client out of bed too early could cause injury to the surgical site or result in a fall. (Option 1) A client who had knee surgery will likely be unable to bear any weight on the affected limb. Depending on the client's size, it may be prudent for the nurse to get additional help. This could be requested after the activity prescription has been verified. (Option 2) Assistance with ambulation is often delegated to unlicensed assistive personnel (UAP); however, the nurse should verify the prescription first. It would also be prudent to have the UAP assist the nurse as this is the client's first time up after surgery. (Option 3) The nurse should assess the client's pain level before providing pain medication. Educational objective:The nurse should verify activity prescriptions before getting clients out of bed after surgery or a procedure. The nurse should be present when these clients begin ambulating and may need assistance from another nurse or unlicensed assistive personnel.

The nurse inserts a small-bore nasogastric (NG) tube and prepares to initiate enteral feedings for a hospitalized client with laryngeal cancer. Which action should the nurse take first? 1. Crush and administer medications (0%) 2. Dilute enteral formula as prescribed (0%) 3. Flush the tube with 30 mL of water (6%) 4. Verify tube placement with an x-ray (92%)

4. Verify tube placement with an x-ray (92%) Enteral feedings are given to provide nutrition to clients who are unable to take in nutrients by mouth. Placement verification is imperative prior to initiating enteral feedings to prevent complications such as aspiration. Lung aspiration can lead to pneumonia, acute respiratory distress syndrome, and abscess formation. Methods to verify the tube placement include the following: Imaging - visualization of tube placement by x-ray is the standard protocol to ensure proper placement prior to initiating enteral tube feedings Gastric content pH testing - although testing the pH of aspirated contents is an evidence-based method, it is typically used to assess for displacement after initial x-ray verification. It can also be used to test the position of the tube prior to each feed as the frequent x-rays expose the client to radiation. Gastric pH is usually acidic (<5) because of acid secretion. pH ≥6 indicates bronchial secretions and incorrect placement. Air auscultation - verification by auscultating air is not an evidence-based method for placement verification After placement is verified, the nurse may flush the tube with water (Option 3), administer prescribed medications (Option 1), flush the tube again, and then prepare and deliver the enteral feeding (Option 2). Educational objective:Visualization of NG tube placement by x-ray is the standard protocol to ensure proper placement prior to initiating enteral tube feedings. Verification by auscultating air is not an evidence-based method of placement verification.

A 2-year-old is admitted to the emergency department for anaphylactic reaction to a bee sting. The nurse teaches the parent about emergency use of epinephrine injection. Which statement indicates that the parent understands the instruction? Select all that apply. 1. "I will keep an epinephrine injection in close proximity to my child at all times." 2. "I will give the injection if my child has trouble breathing after a bee sting." 3. "I will give the injection in the upper arm." 4. "The injection can be given through clothing." 5. "If I give the injection, I'll still take my child to the emergency room."

1. "I will keep an epinephrine injection in close proximity to my child at all times." 2. "I will give the injection if my child has trouble breathing after a bee sting." 4. "The injection can be given through clothing." 5. "If I give the injection, I'll still take my child to the emergency room." A critical part of self-care for a person with a history of anaphylactic reaction is the use of emergency epinephrine injection (EpiPen or EpiPen Jr). The client and/or caregiver should be taught the following principles: The EpiPen should always be available for emergency use and so should be taken along (in purse, pocket, backpack) when the client leaves home (Option 1) The EpiPen should be given when the client first notices any anaphylactic symptoms, such as tightening or swelling of the airway, difficulty breathing, wheezing, stridor, or shock (Option 2) The injection should be given in the mid-outer thigh and can be given through clothing (Options 3 and 4) The client should receive emergency care as soon as possible by calling 911 or going to the emergency department to monitor for further problems (Option 5) Educational objective:Emergency self-injection of epinephrine (EpiPen) can be done through clothing into the mid-outer thigh when the client first notices any anaphylactic symptoms.

The health care provider prescribes intravenous fluid resuscitation for a client in hypovolemic shock. The nurse should anticipate the rapid infusion of which intravenous solution initially? 1. 0.9% Sodium chloride (65%) 2. 5% Albumin (4%) 3. Dextrose 5% and lactated Ringer's (25%) 4. Dextrose 5% and water (3%)

1. 0.9% Sodium chloride Normal saline is the fluid of choice for rapid correction of hypotension in most situations, including hypovolemic and septic shock. It can be administered in large quantities rather rapidly and is inexpensive. (Option 2) When 5% albumin, a colloid solution, is infused into the intravascular space, it mobilizes fluid from the extravascular tissues into the extracellular vascular space. Although it is equally effective in expanding intravascular fluid volume, it is expensive and not the initial fluid of choice. It can be used in clients with low intravascular protein (albumin) content and hypotension but increased fluid in extravascular tissues (eg, cirrhosis with ascites). (Option 3) When dextrose 5% and lactated Ringer's, a hypertonic solution, is infused into the intravascular space, it mobilizes fluid from the extravascular tissue into the extracellular vascular space. Although it may be used to expand fluid volume, it is not the initial intravenous fluid of choice. (Option 4) When the dextrose in dextrose 5% and water is metabolized, a hypotonic solution is left. In large volumes, it can cause shift of the fluid into the extravascular compartment, which may cause further hypotension in clients with low blood pressure. Hypotonic solutions (0.45% saline or dextrose 5% and water) are typically used to treat hypernatremia. Educational objective:Isotonic solutions are used for immediate fluid resuscitation in clients with hypovolemic shock. Additional Information Physiological Adaptation NCSBN Client Need

The nurse is caring for a client who weighs 450 lb (204.1 kg) 2 days after bariatric surgery. The client is pleasant, cooperative, and able to fully bear weight. What would be the most appropriate method for transferring this client safely? 1. 1-person safety standby with walker (41%) 2. 2-person full-body sling lift (9%) 3. 2-person standing-assist lift (34%) 4. 4-person full-body sling lift (14%)

1. 1-person safety standby with walker When determining the most appropriate method to transfer a client safely, the nurse should assess: Whether the client can bear weight Whether the client is cooperative This client is able to bear full weight despite having a heavy body and can cooperate during the transfer. Therefore, such clients should be encouraged to do as much as they can for themselves, anticipating discharge in the near future. It is appropriate to transfer this client with 1 person standing by for safety. If the client was unable to bear full weight, more assistance would be needed. The number of caregivers providing assistance during the transfer of a heavier client should be increased to promote safety for the client and staff. When working with bariatric clients, equipment that has the capacity to bear the client's full weight and accommodate their size should be used while maintaining the client's dignity throughout the process. (Options 2 and 3) These would not be necessary as this client can fully bear weight and cooperate with caregiver instructions during the transfer. (Option 4) A 4-person sling lift transfer is appropriate for the bariatric client who cannot bear weight or cooperate with the transfer. Educational objective:A client who is able to fully bear weight and cooperate can transfer independently with standby assistance for safety. If there is any concern for caregiver or client safety during the transfer of a bariatric client, the type of equipment should be reconsidered and the number of caregivers should be increased.

A client is able to partially bear weight and follow the nurse's instructions. Which would be the most appropriate method for the nurse to use to safely transfer this client? 1. 1-person stand and pivot with gait belt and walker (55%) 2. 1-person standby assist with walker (16%) 3. 2-person motorized stand-assist lift (7%) 4. 2-person stand and pivot with gait belt and walker (20%)

1. 1-person stand and pivot with gait belt and walker Recommended bed-to-chair transfer method Weight bearing Transfer method Full Independent; no assistance required 1-person standby assistance or observation for clients who are uncooperative or at high risk for falls Partial 1-person assist stand & pivot transfer with gait belt or motorized assist device if cooperative 2-person assist with full-body sling if client is uncooperative None Motorized assist device if client is cooperative & has upper body strength 2-person assist with full-body sling if client is uncooperative &/or has no upper body strength Client should use as much of his or her own strength as possible. Use assistive devices when lifting >35 lb (15.9 kg) of client's body weight To determine the most appropriate method to safely transfer a client for the first time, the nurse should assess: Whether the client can bear weight Whether the client is cooperative If the client is cooperative and able to partially bear weight, a safe transfer requires a 1-person stand and pivot technique with a gait belt or powered stand-assist lift (Option 1). If the client can fully bear weight and is cooperative, the client will not require an assisted transfer. However, a caregiver should stand by during the first transfer for safety or for assistance (Option 2). (Option 3) This method would be appropriate for a client who has no weight-bearing ability but can follow instructions and has enough upper body strength to use a motorized stand-assist lift. (Option 4) If the nurse determines that the client cannot be safely transferred with assistance from 1 caregiver, a 2-person stand and pivot transfer may be performed. However, the nurse should first encourage the client to use as much own strength as possible. Educational objective:If the client is cooperative and able to partially bear weight, a safe transfer requires a 1-person stand and pivot technique with a gait belt or powered stand-assist lift.

The nurse is performing open endotracheal suctioning for a client with a tracheostomy tube. Which of the following actions by the nurse are appropriate? Select all that apply. 1. Administers 100% oxygen prior to suctioning the client 2. Applies suction while withdrawing the catheter from the airway 3. Instills sterile normal saline into the tracheostomy prior to suctioning 4. Limits suctioning to 20 seconds during each suction pass 5. Uses sterile gloves and technique throughout the procedure

1. Administers 100% oxygen prior to suctioning the client 2. Applies suction while withdrawing the catheter from the airway 5. Uses sterile gloves and technique throughout the procedure Open endotracheal (ET) suctioning is a skill performed to remove pulmonary secretions and maintain airway patency in clients who are unable to clear secretions independently. ET suctioning is important to promote gas exchange and prevent alveolar collapse, but inappropriate technique increases the client's risk for complications (eg, pneumonia, hypoxemia) or tracheal injury (eg, trauma, bleeding). To reduce the risk of complications and injury during ET suctioning, the nurse should: Preoxygenate with 100% oxygen and allow for reoxygenation periods between suction passes (Option 1) Suction only while withdrawing the catheter from the airway (Option 2) Use strict sterile technique throughout suctioning (Option 5) Limit suctioning to ≤10 seconds on each suction pass (Option 3) Instilling sterile normal saline solution or sterile water (ie, lavaging) in the client's airway, a practice no longer supported by evidence, greatly increases the risk for infection by potentially transporting bacteria from the upper airway into the lower airways. (Option 4) Suctioning longer than 10 seconds increases risk for collapse of airway structures (eg, alveoli, bronchioles) and hypoxemia (ie, oxygen saturation <90%). Educational objective:Open endotracheal (ET) suctioning is a skill used to clear secretions and maintain airway patency. When performing ET suctioning, the nurse preoxygenates with 100% oxygen, applies suction only while withdrawing the catheter, uses sterile technique, and limits each suction pass to ≤10 seconds

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?

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 pediatric nurse is preparing to administer an acetaminophen suppository to an 11-month-old with pyrexia. Which actions are appropriate? Select all that apply. 1. Advance past the external sphincter only 2. Guide suppository along the rectal wall 3. Hold buttocks together firmly after insertion 4. Position client supine with knees and feet raised 5. Use gloved fifth finger for insertion

2. Guide suppository along the rectal wall 3. Hold buttocks together firmly after insertion 4. Position client supine with knees and feet raised 5. Use gloved fifth finger for insertion

The occupational health nurse administers an intradermal tuberculin skin test (TST) to a health care worker (HCW). The site must be assessed for a reaction afterward. The nurse instructs the HCW to return in how many hours? 1. 12 hours (0%) 2. 24 hours (7%) 3. 36 hours (14%) 4. 72 hours (76%)

4. 72 hours (76%)

The nurse is teaching a client to self-administer enoxaparin subcutaneously for the outpatient treatment of deep-vein thrombosis (DVT). The client points to the site of planned injection. Which site indicates that the client understands the instructions?

Enoxaparin is a low-molecular-weight heparin used in the prevention and treatment of DVT. It is administered as a deep subcutaneous injection and is usually given in the abdomen. Clients or family members may be taught how to administer the injections. The injection should be made on the right or left side of the abdomen, at least 2 in from the umbilicus. An inch of skin should be pinched up and the injection made into the fold of skin with the needle inserted at a 90-degree angle. Educational objective:The nurse can teach a client or caregiver to inject subcutaneous enoxaparin. The appropriate site of injection is on the right or left side of the abdomen at least 2 in from the umbilicus.

An infant is experiencing respiratory depression immediately after a vaginal delivery using epidural analgesia with morphine. The health care provider prescribes 0.1 mg/kg naloxone IM to be given STAT once. The client weighs 3600 grams and naloxone 0.4 mg/mL is available. How many milliliters will the nurse administer? Record your answer using one decimal place.

0.9 To calculate the milliliters per dose of naloxone, the nurse should first identify the prescribed dose (eg, 0.1 mg/kg/dose) and available dose (eg, 0.4 mg/mL), then convert to milliliters per dose (eg, 0.9 mL/dose).

The nurse is inserting an indwelling (Foley) urinary catheter into a male client. After inserting the catheter about 6 in (15.2 cm), the nurse notes drops of urine in the tubing. What action should the nurse take next? 1. Further insert the catheter 1-2 in (2.5-5.1 cm) (82%) 2. Have the client hold his breath (1%) 3. Immediately inflate the 5 mL balloon (14%) 4. Secure the tubing to the client's leg (1%)

1. Further insert the catheter 1-2 in (2.5-5.1 cm) Urine could be in the urethra and evident in the tubing even though the tip with the balloon is not in the bladder. It is necessary to further insert the catheter before inflating the balloon to make sure the tip is in the bladder and not the urethra (causing urethral trauma). In the male client, it is recommended that the catheter be inserted 7-9 in (17-22.5 cm) or until urine flows out, due to the longer urethra. The catheter should then be inserted at least an additional 1 in (2.5 cm) or to catheter bifurcation. (Option 2) The client should be told to take slow, deep breaths to help relax the external sphincter and provide a distraction. (Option 3) The catheter needs to be inserted further before inflating the balloon to prevent urethral trauma. (Option 4) Securing the catheter to the leg occurs after the balloon is inflated and placement is assured. Educational objective:Insert the Foley urinary catheter further if drops appear in the tubing to ensure that the tip with the balloon is in the bladder. Inflating the balloon before advancing the catheter could result in urethral trauma.

A nurse in a pediatric clinic is preparing to administer ear drops to a 5-year-old. Which is an appropriate action by the nurse? 1. Have the child sit upright with the chin tilted down (14%) 2. Pull the pinna upward and back (75%) 3. Remove the medication from the refrigerator just before use (4%) 4. Touch the dropper to the entrance of the ear canal (5%)

2. Pull the pinna upward and back When administering an otic medication to an adult or child age 3 and older, the pinna is pulled upward and back to straighten the external ear canal (Option 2). For an infant, the pinna is pulled downward and straight back. (Option 1) The child should be placed in the prone or supine position with the head turned to the appropriate side. (Option 3) Otic medication should be warmed to room temperature if removed from a refrigerator prior to administration. Holding the bottle in the palm of the hand is an effective method of warming. Instilling cold drops into the ear can cause a vestibular reaction, resulting in dizziness and vomiting. (Option 4) The medication dropper should be held near the entrance to the ear canal without touching it. This technique allows the drops to fall against the wall of the canal, reducing discomfort while avoiding contamination of the dropper. After instilling the drops, the child should remain with the affected ear up for several minutes to allow full coverage of the medication. Educational objective:When administering otic medication to children age 3 and older, the pinna is pulled upward and back to straighten the ear canal. The child is placed in a prone or supine position with the head turned to the appropriate side, and the medication is allowed to drop against the wall of the canal.

The nurse is conducting a home visit to assess an elderly client with advanced heart failure who lives alone. When the nurse asks about sodium intake, the client becomes angry and says, "I'm so tired of people telling me what to do! I'm going to eat what I want, so leave me alone!" Which of the following is the most appropriate response by the nurse? 1. "I can tell that you want me to go, so I will call in a few days to see how you are doing." (0%) 2. "I know you are frustrated with losing control of your life." (4%) 3. "It sounds like you are angry. Tell me what's bothering you." (94%) 4. "Okay. I'll just check your blood pressure and then go." (0%)

3. "It sounds like you are angry. Tell me what's bothering you. Educational objective:The client with serious illness who exhibits anger may be experiencing anxiety, grief, or fear. The nurse should remain at a safe distance while attempting to diffuse the situation; assess the client's concerns using a calm, non-threatening approach; reflect the client's statements; and try to understand the client's feelings, perceptions, and beliefs to address the priority problem.

The unlicensed assistive personnel (UAP) reports finding a reddened area on a client's sacrum during a bath. What is the nurse's priority action? 1. Direct the UAP to apply a protective foam dressing (1%) 2. Document results of the Braden Scale in the electronic record (1%) 3. Notify the health care provider (HCP) (1%) 4. Perform an assessment on the client's skin (96%)

4. Perform an assessment on the client's skin A reddened area on the sacrum puts the client at risk for skin breakdown. The nurse should first perform an assessment on the client's skin to see if there are any other reddened areas or skin breakdown present. This should be compared to previous assessments or serve as a baseline assessment of skin integrity. The Braden Scale, a tool for predicting pressure sore risk, would be appropriate to use as part of the assessment. (Option 1) After the nurse has performed a skin assessment, it may be appropriate to direct the UAP to apply a protective foam dressing to the area. (Option 2) Documentation should occur after the client has been assessed thoroughly and received care. (Option 3) After assessing the client, the nurse can decide whether to notify the HCP. Educational objective:When the nurse receives report of a change in client condition from the UAP, the nurse should reassess the client before completing other interventions.

A client postoperative from a transurethral prostatectomy has a triple-lumen, indwelling urinary catheter and is receiving continuous bladder irrigation of sterile normal saline solution at 175 mL/hr. The nurse empties the urine drainage bag for a total of 2300 mL at the end of the 8-hour shift. How many milliliters (mL) should the nurse document as the net urine output for the shift? Record your answer using a whole number.

A transurethral prostatectomy (TURP) is a surgical prostate-removal procedure commonly performed for male clients with prostate cancer. Following a TURP, clients typically receive continuous bladder irrigation (CBI) with a sterile, isotonic solution (eg, normal saline) via indwelling urinary catheter. CBI prevents bladder obstruction by large blood clots in the bladder or urethra. Monitoring urine output in clients receiving CBI can be challenging because there is continuous output from the irrigation. To calculate net urine output, the nurse should subtract the irrigation input from the total catheter output. Use the following steps to calculate the net urinary output: Educational objective:Continuous bladder irrigation is a therapy commonly used to prevent bladder obstruction by blood clots after a prostatectomy. To calculate the net urine output in a client with continuous bladder irrigation, the nurse should subtract the total amount of irrigating solution infused from the total amount of catheter output.

A nurse is caring for a client who has a chest tube drainage system in place. Where would the nurse observe to assess for tidaling?

The water seal chamber of the chest tube drainage system is filled with sterile water and acts as a one-way valve preventing air from entering the client's chest cavity. The water level in the water seal chamber rises and falls with inspiration and expiration, a process known as tidaling. This movement occurs in section B of the water seal chamber and indicates that the system is functioning properly and maintaining appropriate negative pressure. (Section A) This is the suction control chamber, which is usually set at -20 cm H2O to maintain negative pressure in the system. Bubbling will occur when suction is applied. (Section C) The air leak gauge (part of the water seal chamber) allows for assessment of air leaks. Continuous bubbling indicates an air leak in the system. (Section D) This is the drainage collection chamber in which fluid from the client's pleural cavity will collect; the nurse will assess the color and amount and record the output. Educational objective:Tidaling is the fluctuation that occurs in the water seal chamber in relation to the client's respiratory movements. The level of sterile water will rise with inspiration and fall with expiration, indicating proper function of the chest tube drainage system.

Which client is at the greatest risk for development of hospital-acquired pressure injuries? 1. 25-year-old client with quadriplegia, urosepsis, temperature of 101 F (38.3 C), and white blood cell count of 18,000/mm3 (18.0 x 109/L) (46%) 2. 50-year-old client with AIDS who is receiving norepinephrine infusion and has a weight loss of 20 lb (9.1 kg) in a month, prealbumin level <10 mg/dL (100 mg/L), and mean arterial pressure of 50 mm Hg (26%) 3. 80-year-old client 2 days post hip replacement with dementia, 2 Jackson-Pratt drains, and hemoglobin level of 14 g/dL (140 g/L) (23%) 4. 87-year-old client 2 days post open cholecystectomy (3%)

2. 50-year-old client with AIDS who is receiving norepinephrine infusion and has a weight loss of 20 lb (9.1 kg) in a month, prealbumin level <10 mg/dL (100 mg/L), and mean arterial pressure of 50 mm Hg (26%) Pressure injuries are areas of localized skin injury and underlying tissue caused by external pressure with or without friction and/or shearing. These result from ischemia and hypoxia of tissue following periods of prolonged pressure. Clients at greatest risk include older adults with limited movement and long bone (femur) or hip fractures, those with quadriplegia, and the critically ill. Clients with deficits in mobility and activity, incontinence, inadequate nutrition, chronic illness, renal failure, anemia, problems with oxygenation, edema, or infection are also at increased risk. This client (Option 2) has 5 risk factors: chronic illness and immune deficiency disease; significant weight loss; prealbumin <16 mg/dL (<160 mg/L), indicating inadequate nutrition and protein deficiency; hypotension (decreases perfusion pressure); and receiving norepinephrine (Levophed), a vasoconstrictor. These risks affect circulation, capillary perfusion pressure, and the ability to provide adequate nutrition to the cells. (Option 1) This client has 4 risk factors: a deficit in independent mobility and activity, spinal cord injury with quadriplegia, decreased sensation, and fever and infection. (Option 3) This client has 3 risk factors: advanced age, surgery, and dementia. Hemoglobin is within the normal range. (Option 4) This client has 2 risk factors: advanced age and surgery. Surgery can be associated with deep-tissue injuries. Positioning and immobility during the surgical procedures (>2½ hours) and receiving anesthetic and vasoactive drugs (to treat hypotension) present a special risk for the development of deep-tissue injury in postoperative clients. Educational objective:Although pressure injuries can develop in any client with limited mobility and activity, those at most risk include older adults; those with quadriplegia; the critically ill; and those with fracture of a long bone or hip, incontinence, nutritional deficits, chronic illness, renal failure, anemia, oxygenation and circulation problems, infection, or fever.

A nurse is instructing the caregiver of an 8-month-old client regarding administration of oral amoxicillin. The client is prescribed 25 mg/kg/day of amoxicillin in 2 divided doses for 5 days. The client weighs 16.5 lb and the amoxicillin solution is prepared as 125 mg/5 mL. How many mL of amoxicillin should the nurse instruct the caregiver to administer for each dose? Record the answer using two decimal places.

3.75 Educational objective:To calculate the milliliters per dose of oral amoxicillin, the nurse should first identify the prescribed dose (eg, 25 mg/kg/day divided in two doses) and available medication (eg, 125 mg/5 mL solution) and then convert to milliliters per dose (eg, 3.75 mL/dose).

The nurse prepares to insert a large-bore nasogastric tube for gastric decompression. After obtaining equipment, the nurse identifies the client, performs hand hygiene, applies clean gloves, assesses nares, and selects a naris. Place the remaining steps in the correct order. All options must be used.

5. Measure, mark, and lubricate tube 4. Instruct client to extend neck back slightly 3. Gently insert tube just past nasopharynx 2. Ask client to flex head forward and swallow 1. Advance tube to the marked point 6. Verify tube placement and anchor Steps for inserting a nasogastric tube for gastric decompression include the following: Perform hand hygiene and apply clean gloves (no need for sterile gloves) Place client in high Fowler's position Assess nares and oral cavity and select naris Measure and mark the tube Curve 4-6" tube around index finger and release Lubricate end of tube with water-soluble jelly Instruct client to extend neck back slightly Gently insert tube just past nasopharynx, aiming tip downward Rotate tube slightly if resistance is met, allowing rest periods for client Continue insertion until just above oropharynx Ask client to flex head forward and swallow small sips of water (or dry if NPO) Advance tube to marked point Verify tube placement and anchor - use agency policy and procedure to verify placement by anchoring tube in place and obtaining an abdominal x-ray. Aspirating gastric contents and testing the pH may also give an indication of placement (pH should be 5.5 or below). Auscultation of inserted air is acceptable for confirming tube placement initially, but is not definitive as it is not an evidence-based method. Nothing may be administered through the tube until x-ray confirmation is obtained, or this may cause aspiration. Educational objective:Key steps when inserting a large-bore nasogastric tube include using clean gloves; inspecting nares; measuring, marking, and lubricating tube; instructing client to extend the neck back slightly; inserting tube past the nasopharynx and continuing advancement until just above oropharynx; asking the client to flex the head forward and swallow; advancing tube to marked point; and verifying tube placement using abdominal x-ray and anchoring.

The nurse cares for a client with aortic stenosis who was admitted due to syncope on exertion and dyspnea. Identify the area where the nurse would best auscultate the client's heart murmur.

Aortic stenosis (AS) is a type of valvular heart disease characterized by narrowing of the aortic valve opening, which limits the left ventricle's ability to eject blood into the aorta. AS may occur from hardening (ie, calcification) of the valves, congenital heart disorders, or inflammation. If left untreated, AS may result in heart failure and pulmonary hypertension as compensatory mechanisms fail. When assessing a client with AS, the nurse should auscultate in the aortic area (ie, second intercostal space at the right sternal border) for a loud, systolic ejection murmur heard following the first heart sound. The aortic area, rather than directly over the heart valve, is the preferred location for auscultation as the heart sounds travel in the direction the blood flows. Additional clinical manifestations of aortic stenosis include chest pain, shortness of breath, and/or syncope that are worsened by exertion. Educational objective:Aortic stenosis is a type of valvular heart disease causing narrowing of the valve between the left ventricle and aorta, impairing ejection of blood from the heart. Nurses attempting to auscultate heart murmurs associated with aortic stenosis should listen at the right sternal border, second intercostal space (ie, aortic area). Additional Information Reduction of Risk Potential NCSBN Client Need