NCLEX

The nurse is caring for a client with bacterial meningitis, identified as Neisseria meningitidis who has a stage 4 pressure injury. What personal protective equipment is most appropriate for the nurse to wear when performing a dressing change? Select all that apply. 1. Disposable Gown 2. Face shield 3. Gloves 4. N95 respirator 5. Surgical mask

1,2,3,5 Explanation Common applications of droplet precautions Neisseria meningitidis Haemophilus influenzae type B Diptheria Mumps Rubella Pertussis Group A Streptococcus [strep throat] Viral influenza Personal protective equipment Surgical mask Private room As needed for procedures with risk of splash or body fluid contact; gloves, gown, goggles/face shield Bacterial meningitis and many respiratory illnesses [eg. influenza] are transmitted through large droplets of secretions spread into the air by coughing, sneezing, or talking. These droplets can land on surfaces up to 6 feet [1.8 meters] away from the client. Droplet precautions for routine care [eg. medication administration] require the use of a surgical mask, as the highest risk of transmission is through inhalation of droplets. [Option 5] Wearing a face shield, gown, and glo

A client has just returned to the room after having a mammogram. The client is teary and in a shaky voice says to the nurse, "The radiology technician told me that it looks really bad - the tumor in my breast is very large." Which is the best response by the nurse? 1. "I can see that you are very upset. Let's talk about what happened." [93%] 2. "I'll report the technician to the head of the radiology department." [0%] 3. "The technician never should have said that to you." [1%] 4. "Your health care provider will discuss treatment options with you." [4%]

Correct answer 1 Explanation Acknowledging that the client is upset conveys concern and understanding on the part of the nurse and helps establish a therapeutic dialogue. The client can vent feelings and discuss fears because the nurse provides the opportunity to talk about what happened (focusing and listening). This action also establishes interpersonal sensitivity and helps the nurse relate therapeutically to the client. Clients who feel threatened or injured by their medical condition(s) need to feel safe and supported. The nurse is in a unique position to provide the nurturing and caring that clients need as they cope with medical diagnoses and difficult situations. (Option 2) This is not an appropriate response; the proper chain of command would have the nurse report the event to a supervisor. (Option 3) This statement may be true, but it does not facilitate a dialogue about the client's feelings and fears, (Option 4) This response does not address the client's feelings or what happened during the mammogram. Educational objective; Therapeutic communication techniques such as acknowledgement of feelings, focusing, and listening can help establish a dialogue and relationship with a client that is protective, supportive, nurturing, and caring.

A new nurse attends a risk management class on the indications and legal implications of using chemical restraints to maintain client safety. Which prescription should the nurse question before administering? 1. Haloperidol for a client with a fall history who keeps getting out of bed without assistance [70%] 2. Lorazepam for a client who is in alcohol withdrawal and is extremely agitated [5%] 3. Olanzapine for a client with schizophrenia who is exhibiting violent behavior [4%] 4. Propofol for a client who is intubated and receiving mechanical ventilation [19%]

Correct answer 1 Explanation Chemical restraints are medications (eg, benzodiazepines, psychotropics) used to restrict freedom of mavement or to control socially disruptive behavior in clients who have no medical indications for them. Although this client is at risk of injury from falling, the use of a psychotropic drug is not considered the standard treatment for a client with a history of falls who keeps getting out of bed without assistance. The least restrictive method to ensure client safety (eg, bed alarm, sitter, assistive devices) should be tried first before administering a chemical restraint. Therefore, the nurse should question the prescription for haloperidol (Haldol) in this client (Option 1). (Option 2) Benzodiazepines (eg, lorazepam [Ativan], diazepam, chlordiazepoxide) are considered standard treatment to control agitation in the client in alcohol withdrawal. (Option 3) Antipsychotics (eg, olanzapine [Zyprexa], ziprasidone [Geodon], haloperidol) are considered standard treatment to control violent behavior in the client with schizophrenia. (Option 4) Propofol (Diprivan) is considered standard treatment to sedate the client receiving mechanical ventilation to provide ventilator control, prevent accidental extubation, and promote comfort. Educational objective: Medications that are standard treatments for specific, conditions (eg, alcohol withdrawal, schizophrenia, mechanical ventilation) are not considered chemical restraints. The nurse should question a chemical restraint prescription that may not be medically necessary for a client's safety.

The nurse is caring for a client newly prescribed crutches. Which finding indicates the need for further teaching? 1. The axillary pads are torn and show signs of wear [65%] 2. The client has a 30-degree bend at the elbow when walking [8%] 3. The crutches and injured foot are moved simultaneously in a 3-point gait [16%] 4. There is a 3 finger-width space noted between the axilla and axillary pad [9%]

Correct answer 1 Explanation The proper fit and use of crutches are important in preventing injury. They include: • Proper measurement and fit - There should be a 3-4 finger-width space (1-2 in [2.5-5 cm]) between the axilla and axillary pad (Option 4). Clients are taught to support body weight on the hands and arms, not the axillae. Handgrip location should allow 20-30 degrees of flexion at the elbow (Option 2). • Proper gait - The 3-point gait is used for restrictions of partial or no weight-bearing on the affected extremity. The injured extremity and crutches are moved simultaneously (Option 3). The client who is rehabilitating from an injury of the lower extremity usually progresses from non-weight-bearing status (3-point gait) to partial weight-bearing status (2-point gait) to full weight-bearing status (4-point gait). (Option 1) Wear and tear of the axillary pads raises concern for the incorrect use or fit of crutches. Excessive and prolonged pressure on the axillae can cause localized damage to the radial nerve at the axillae. This leads to a reversible condition known as crutch paralysis, or palsy, and is caused by crutches that are too long or by leaning on the top of the crutches when ambulating. Educational objective: Proper crutch fit includes a 3-4 finger-width space between the axillary pad and axilla and a handgrip location that allows 20-30 degrees of elbow flexion. Clients should support their body weight on the hands and arms, not the axillae. Wear and tear on the crutch pads may indicate improper use or fit. Clients progress from 3-point gait (no to partial weight-bearing) to 2-point gait and then 4-point gait as rehabilitation

The nurse prepares to administer a cleansing enema to a client with constipation. Which interventions are appropriate? Select all that apply. 1. Assist the client into left lateral position with right knee flexed 2. Encourage the client to retain the enema for as long as possible 3. Insert tubing into the rectum with the tip directed toward the umbilicus 4. Keep the enema solution refrigerated until ready to administer 5. Slow administration rate if the client reports abdominal cramping

Correct answer 1,2,3,5 Explanation Cleansing enemas (eg, normal saline, soapsuds, tap water) relieve constipation by stimulating intestinal peristalsis. When administering an enema, appropriate interventions include: Place the client in a left lateral position with the right knee flexed (ie, Sims position) to promote flow of the enema into the colon (Option 1). Hang the enema bag no more than 12 in (30 cm) above the rectum to avoid overly rapid administration. Lubricate the enema tubing tip and gently insert 3-4 in (7.6-10 cm) into the rectum. Direct the tubing tip toward the umbilicus (ie, anteriorly) during insertion to prevent intestinal perforation (Option 3). Encourage the client to retain the enema for as long as possible (eg, 5-10 minutes) (Option 2). Open the roller clamp on the tubing to allow the solution to flow in by gravity. If the client reports abdominal cramping, use the roller clamp to slow the rate of administration (Option 5). (Option 4) Enemas are administered at room temperature or warmed, as cold enema solutions cause intestinal spasms and painful cramping. Enemas may be warmed by placing the container of solution in a basin of hot water. Educational objective: When administering an enema, the nurse should place the client in the left lateral position with the right knee flexed, insert the tubing into the rectum with the tip directed toward the umbilicus, and slow the rate of administration if the client reports abdominal cramping. Enemas should be administered at room temperature or warmed.

A client is receiving IV potassium. The V pump displays an occlusion alarm. The tubing is free of occlusions, and the IV flushes easily without symptoms of infiltration. Which action should the nurse take next? 1. Discard potassium and document administration of a partial dose (2%] 2. Exchange the IV pump witha different one [86%] 3. Insert a new IV catheter in a different location [6%] 4. Remove the pump and administer medication by gravity drip (4%)

Correct answer 2 Explanation IV infusion pumps display an occlusion alarm when IV solution cannot be infused due to pressure in the line. Common causes of occlusion include clamped or kinked V tubing, clotting in the IV catheter, and kinking in the IV catheter with extremity movement (eg, elbow, wrist). The nurse should assess the tubing and IV site and flush the IV catheter to check patency. In the absence of identifiable oclusion, an alarming V pump should be exchanged for a diferent one (Option 2). Malfunctioning equipment may harm the client and should be removed from the care area. The malfunctioning equipment is labeled as out of service and is sent for maintenance. (Option 1) An IV pump alarm does not indicate that a medication is no longer needed. The nurse should replace a malfunctioning pump and restart the medication. (Option 3) An IV catheter that has no symptoms of occlusion (ie, resistance to flushing) or infiltration (eg, swelling, coolness, pain) does not need to be replaced. (Option 4) V pump infusion is more accurate than gravity drip. IV pumps are required when administering high-risk IV medications (eg. heparin, insulin, potassium). IV potassium should never be administered by gravity as it may cause lethal arrhythmias if administered too quickly. Educational objective: If an IV infusion pump displays an alarm without an identifiable problem, the nurse should replace the pump. Malfunctioning equipment may harm the client and should be removed from the care area. The equipment is labeled as out of service and sent for maintenance.

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 instils drops [14%]

Correct answer 2 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: 1. Perform hand hygiene and don clean gloves. The ear canal is not sterile, but aseptic technique is used 2. 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 3. 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) 4. 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) 5. 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) _ 6. 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 7. Instruct the client to remain side-lying for at least 2-3 minutes to facilitate medication distribution and prevent leakage 8. 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 client with Ebola was just admitted to the unit. Which actions by the nurse would represent appropriate care of this client? Select all that apply. 1. Ensuring the client wears an N95 respirator at all times. 2. Keeping the door of the client's room closed at all times 3. Maintaining a log of everyone in and out of the client's room 4. Removing both pairs of gloves before removing gown and mask 5. Restricting visitors from entering the client's room

Correct answer 2,3,5 Explanation Ebola (viral hemorrhagic fever) is an extremely contagious disease with a high mortality rate. Clients require standard, contact, droplet, and airborne precautions (eg, impermeable gown/coveralls, N95 respirator, full face shield, doubled gloves with extended cuffs, single-use boot covers, single-use apron). The client is placed in a single-client airborne isolation room with the door closed (Option 2). Visitors are prohibited unless absolutely necessary for the client's well-being (eg, parent visiting an infected child) (Option 5). For disease surveillance, a log is maintained of everyone entering or exiting the room, and all logged individuals are monitored for symptoms (Option 3). Procedures and use of sharps/needles are limited whenever possible. There are currently no medications or vaccines approved by the Food and Drug Administration to treat Ebola. Prevention is crucial. (Option 1) In a private airborne isolation room, the client does not require a respirator mask. However, all other individuals entering the room must don appropriate personal protective equipment (PPE). (Option 4) The PPE removal process after caring for a client with Ebola requires strict monitoring by a trained observer. The outer gloves are first cleaned with disinfectant and removed, The inner gloves are wiped between removal of every subsequent piece of PPE (eg, respirator, gown) and removed last. Educational objective: Ebola is an extremely contagious viral disease with a high mortality rate. Infected clients require extensive infection precautions, including an airborne isolation room, strict personal protective equipment use, restriction of visitors, and a log of individuals who enter and exit the room.

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 DeW 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? Click on the exhibit button for additional information. Record your answer using a whole number.

Correct answer 28 mL/hr Explanation 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 mililiters 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); 1. Identify the prescribed, available, and required medication information Prescribed: 1400 units heparin/hr Available: 25,000 units heparin/500mL Required: mL/hr 2. Convert prescription to infusion rate needed for administration Prescription × available medication = mL/hr OR (units/hr) (mL/units heparin) = mL heparin/hr OR (1400 units heparin/hr)(500 mL/25,000 units heparin) = 28mL/hr 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). Alternate method The formula method is an alternate way to calculate medication dosages. However, this method may increase the occurrence of miscalculation and medication errors. If you choose to use this method, do not round any calculations until the final step. Using the formula method, use the following step to calculate the infusion rate of heparin in milliliters per hour: Prescribed dose/available x available volume = infusion rate in mL/hr OR 1400 units heparin/25,000 units heparin x 500mL = 28mL heparin/hr Exhibit Heparin drip protocol PTT (seconds) Hold infusion

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%]

Correct answer 3 Explanation 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.

While turning a client, the nurse observes that the client's radiation implant has dislodged and is now lying on the linens. Which action by the nurse is appropriate? 1. Get the client out of bed and away from the radiation source [6%] 2. Manually reinsert the implant and notify the health care provider [1%] 3. Use long-handled forceps to secure the implant in a lead container (86%] 4. Wrap the implant in the linens and place it in a biohazard bag (5%]

Correct answer 3 Explanation An internal radiation implant (ie, brachytherapy) emits radiation in or near a tumor to treat certain malignancies. When caring for clients undergoing brachytherapy, the nurse should monitor closely for evidence of implant dislodgment. The dislodged implant emits radiation that can be dangerous to health care workers at the bedside. Long-handled forceps and a lead-lined container should be kept in the room of the client who has a radioactive implant in case of dislodgment. If dislodgment occurs, the nurse should first use long-handled forceps to place the implant in a lead-lined container to contain radiation exposure (Option 3). The nurse should also notify the health care provider (radiation oncologist). (Option 1) Containing the source quickly is a priority as the implant continues to emit radiation that could be dangerous to the staff coming to evaluate the client and clean the room. (Option 2) The nurse should not handle dislodged radiation implants without the use of forceps. Furthermore, device reinsertion should be performed only by the health care provider. (Option 4) Wrapping the implant in linens and placing it within a biohazard bag does not reduce radiation exposure. Educational objective: If an internal radiation implant has dislodged, the nurse should use long-handled forceps to place it in a lead-lined container to contain radiation exposure.

The nurse is caring for a client with active pulmonary tuberculosis. Which elements of infectious disease precautions are mandatory for the nurse when providing routine care? Select all that apply. 1. Gown 2. Goggles or face shield 3. Hand washing 4. N95 particulate respirator 5. Surgical mask

Correct answer 3,4 Explanation Airborne precautions Indications Tuberculosis Varicella* (chickenpox) Herpes zoster** (shingles) Rubeola (measles) Components N95 respirator or powered air-purifying respirator Negative-pressure isolation room with high-efficiency particulate air filter As needed if contact with body fluid is anticipated: clean gloves, disposable gown, goggles/face shield *Only when uncrusted lesions are present; contact precautions also required. **Only in disseminated disease or immunocompromised clients; contact precautions also required. Isolation is mandatory for clients with conditions that involve airborne transmission, and rooms must use both negative air pressurization and high-efficiency particulate air (HEPA) filters to avoid contamination. A class N95 or higher particulate respirator must be worn during client care. All clients with symptoms consistent with a suspected airborne illness should be given a surgical mask to wear as soon as they are assessed during triage. Good hand hygiene is always the first and last element of infection control in any client care setting. (Options 1 and 2) Wearing a gown and face shield would be necessary only if the nurse suspected splash of body fluids from procedural client care, not from routine care such as assessment or medication administration. Contact precautions may also be necessary if the tuberculosis is extrapulmonary with draining lesions (eg, cutaneous tuberculosis). (Option 5) For client care involving airborne precautions, a class N95 or higher respirator must be used in lieu of a surgical mask to avoid potential exposure to aerosolized particles. Surgical masks are rated for barrier protection for droplet splashing and filtration of large respiratory particles only. Clients should be given surgical masks during their transportation. Educational objective: Tuberculosis requires airborne precautions. Clients suspected of having tuberculosis should be given a surgical mask to wear on entering any health care setting. Clients are placed in negative-pressure isolation rooms. Nurses must use a class N95 or higher particulate respirator.

The nurse is preparing to administer a continuous enteral feeding for a client with a nasogastric tube. Place the steps in the correct order. All options must be used. 1. Administer the prescribed feeding solution 2. Elevate the head of the bed 30-45 degrees 3. Flush the tube with 30 mL of water 4. Identify the client using 2 identifiers

Correct answer 4,2,5,3,1 Explanation The steps for administering a continuous enteral feeding include: Identify the client using 2 identifiers (eg, first and last name, medical record number, date of birth) (Option 4) and explain the procedure to the client. Perform hand hygiene and apply clean gloves. Elevate the head of the bed 230 degrees and keep it elevated for at least 30 minutes after feeding to minimize the risk of aspiration (Option 2). Validate tube placement by checking the gastric pH as well as assessing the external tube length and comparing it with the measurement at the time of insertion. The tube should be marked at the nostril with a permanent marker during the initial x-ray validation (Option 5). Check gastric residual volume. Flush the tube with 30 mL of water after checking residual volume, every 4-6 hours during feeding, and before and after medication administration (Option 3). Administer the prescribed enteral feeding solution by connecting the tubing and setting the rate on the infusion pump (Option 1). Educational objective: The general steps for administering a continuous enteral feeding include identifying the client, elevating the head of bed at least 30 degrees, validating tube placement, flushing the tube with 30 mL of water, and administering the prescribed enteral feeding 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

Correct answer 1,3 Explanation 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.

The student nurse verbalizes the procedure for obtaining a wound culture to the nurse preceptor. Which of the following statements by the student indicate a correct understanding? Select all that apply. 1. "I will apply the prescribed bacitracin ointment after collecting the wound culture." 2. "I will cleanse the wound by gently flushing it with normal saline." 3. "I will obtain a sample of the drainage accumulated since the last dressing change." 4. "I will perform hand hygiene and apply new gloves before obtaining the wound culture." 5. " will swab the wound from the outermost margin toward the center."

Correct answer [1,2,4] Explanation Wound cultures identify microorganisms to aid in prescribing appropriate antibiotics and are obtained as follows: 1. Perform hand hygiene, and apply clean gloves. Remove the old dressing. Remove and discard gloves. 2. Perform hand hygiene, and apply sterile gloves. Assess the wound bed. Cleanse the wound bed and surrounding skin with normal saline (eg, flushing, swabbing with gauze) to remove drainage and debris (Option 2). Remove and discard gloves. 3. Perform hand hygiene, and apply clean gloves. Gently swab the wound bed with a sterile swab, from the wound center toward the outer margin (Options 4 and 5). Avoid contact with skin at the wound edge as it can contaminate the specimen with skin flora. 4. Place the swab in a sterile specimen container; avoid touching the swab to the outside of the container. 5. Apply prescribed topical medication (g, bacitracin) after obtaining cultures to prevent interference with microorganism identification (Option 1). Apply new dressing. 6. Remove and discard gloves, and perform hand hygiene. Label the specimen, and document the procedure. (Option 3) Pooled purulent exudate likely contains skin flora different from the pathogen(s) responsible for the infection. Microorganisms responsible for infection are most likely found in viable tissue. Educational objective: Wound cultures are used to identify microorganisms and select appropriate antibiotics. The nurse should assess and clean the wound, swab from the wound center toward the outer margin, and avoid contamination (eg, hand hygiene, not touching intact skin with swab) to prevent misidentification of microorganisms.

A nurse is caring for a 3-month-old client with a new tracheostomy. Which findings would indicate a need for suctioning? Select all that apply. 1. Audible gurgling 2. Heart rate 105/min 3. Increased irritability 4. Oxygen saturation 88% 5. Respiratory rate 30/min

Correct answer [1,3,4] Explanation Artificial airways (eg, tracheostomies, endotracheal tubes) impair the cough mechanism and ciliary function, causing an increase in thick secretions that may occlude the airway. Focused respiratory assessments are critical to determine the need for suctioning and to maintain a patent airway. To decrease the risks associated with the procedure (eg, atelectasis, hypoxemia, trauma, infection), suctioning should be performed only when necessary. Assessment findings that indicate a need for suctioning include: Decreased oxygen saturation (Option 4) Altered mental status (eg, irritability, lethargy) (Option 3) Increased heart rate (normal infant range: 90-160) Increased respiratory rate (normal infant range: 30-60) Increased work of breathing (eg, flared nostrils, use of accessory muscles) Adventitious breath sounds (eg, crackles, wheezes, rhonchi) (Option 1) Pallor, mottled, or cyanotic skin coloring (Options 2 and 5) Respiratory rate of 30/min and heart rate of 105/min are within normal limits for an infant and would not indicate distress or a need for suctioning. Educational objective: Assessment findings that indicate the need to suction a client's tracheostomy or endotracheal tube include decreased oxygen saturation, altered mental status (eg, irritability), increased heart rate or respirations, increased work of breathing, and adventitious breath sounds.

A 2-year-old who swallowed an overdose of adult cough syrup is being discharged from the emergency department. The parent says to the nurse, "From now on, I'm going to store all medicines in my top dresser drawer." Which is the best response by the nurse? 1. "Can you lock your dresser drawer?" 2. "Make sure all of your medicines have childproof caps." 3. "That sounds like a safe plan." 4. "You need to keep an eye on your child at all times."

Correct answer [1] Explanation Children are naturally curious and attracted to medicine, especially if it is sweet and syrupy like many over-the-counter cold products. They usually find medicines when exploring their environment and "getting into everything" when no one is watching. Children may find medicine in a parent's coat pocket or purse, under a counter cabinet, or on a nightstand. Even if a drug is stored in a place that seems out of reach, children can climb on a chair or stool to reach it. Medications are the leading cause of child poisoning. The best preventive measures include placing all medications out of sight, placing them in a drawer or cabinet with a childproof lock, and putting them away after each use (Option 1). (Option 2) Advising a parent/caregiver to ensure that medicine containers have childproof caps is an appropriate instruction; however, it is not the priority response in this situation. (Option 3) Storing medicines in a dresser drawer is not a safe plan unless the drawer can be locked. (Option 4) Although it is impossible for a parent or caregiver to watch a child every minute of the day, toddlers need adult supervision when active and exploring their environment. Educational objective: The most important strategy to prevent accidental drug overdoses in children is teaching parents and caregivers to keep medicines out of sight, in a locked drawer or cabinet. Parents/caregivers should also be advised to put drugs away after each use.

Before examining the infant of a Mexican American mother, the nurse compliments the child's outfit. The mother becomes visibly distressed. What is the best next action for the nurse to take? 1. Ask the mother's permission to touch the child's hand [44%] 2. Interview the mother about the reason for bringing the child to the clinic [38%] 3. Reassure the mother that there is no reason for distress [11%] 4. Suggest postponing the examination until the mother calms down [4%]

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

The spouse of a client calls the nurse at the clinic and reports that the client is not feeling well and is concerned that something is seriously wrong. How should the nurse respond initially? 1. Ask the spouse to further describe the client's symptoms 2. Indicate that privacy rules prevent discussion of concerns with the spouse 3. Offer a same-day appointment to the client 4. Tell the spouse to have the client call the nurse

Correct answer [1] Explanation The first step in the nursing process is assessment. In this situation, additional information is needed before the nurse can determine the next course of action (Option 1). (Option 2) The United States' Health Insurance Portability and Accountability Act (HIPAA) and Canada's Personal Information Protection and Electronic Documents Act (PIPEDA) prevent release of private, privileged health care information to people who do not need to know it for a client's care. In this case, the nurse is not releasing any information and is obtaining further information to assess the client's condition. In addition, there is no privacy violation in obtaining information that the spouse would know. (Option 3) Additional information is required before knowing whether the client needs to be seen in the clinic. The client may need instruction to instead call 911 and go to the emergency department. (Option 4) The nurse can ask the client to call, but the client may be unable (eg, seizure, unconscious) or unwilling to do so. In addition, the client may not be aware of signs (eg, acute-onset confusion) that are concerning to the spouse. The situation is unclear (eg, the client may have trouble speaking lie, stroke symptom]) but may be clarified after the nurse receives additional information from the spouse. Educational objective: The nurse should further assess the situation and gather more information when a spouse calls reporting troublesome symptoms in a client. It is not a violation to obtain information about a client from a knowledgeable source.

A client who is 24 hours postoperative bowel resection is receiving IV opioids PRN for severe pain. The nurse reviews the health care provider's prescription to discontinue the continuous IV normal saline. What is the nurse's most appropriate action? 1. Convert to a saline lock 2. Remove the IV catheter 3. Request a prescription for a saline lock 4. Slow the IV fluids to a keep-vein-open rate

Correct answer [1] Explanation The nurse should discontinue the IV infusion of normal saline and apply a saline lock to maintain IV access while preventing clotting. The prescription of the health care provider (HCP) to lock the IV catheter is implied, as the client is currently receiving PRN IV opioids (Option 1). A saline lock is sufficient to maintain the line patency and allows greater mobility than a continuous infusion. (Option 2) The client is only 24 hours postoperative abdominal surgery, so IV access is necessary to administer medications (eg, antibiotics, analgesics, antiemetics). (Options 3 and 4) The HCP's prescription specifies discontinuing IV fluids but not removing the IV catheter or slowing the infusion to a keep- vein-open (KVO) rate. Also, the nurse would need to clarify a KVO prescription with the HCP for a precise rate. Educational objective: IV access is necessary for administering intermittent IV opioids to control postoperative pain. A saline lock keeps the line patent and allows greater mobility than a continuous infusion.

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

Correct answer [2,3,4,1] Explanation Clients prescribed crutches after a musculoskeletal injury must be educated on appropriate device use to facilitate independent ambulation, promote wound healing, and prevent reinjury. A common method used to climb stairs is the modified three-point gait ("leading with the good leg"), which is used to prevent weight-bearing on the injured leg. Nurses should instruct clients with crutches to use the following steps to ascend the stairs with the modified three-point gait: 1. Assume the tripod position (ie, crutch stance) and place body weight on the crutches while preparing to move the unaffected leg. 2. Place the unaffected leg (ie, good leg) onto the step. 3. Transfer body weight from the crutches to the unaffected leg and then use the unaffected leg (ie, good leg) to raise the body up onto the step. 4. Advance the affected leg and the crutches together up the step. 5. Realign the crutches with the unaffected leg on the step before repeating the process. Educational objective: Using a modified three-point gait to ascend the stairs, the client should place body weight on the crutches and step up with the unaffected leg. Body weight should then be transferred from the crutches to the unaffected leg. The client should raise the body to align with the unaffected leg, followed by the affected leg and crutches together.

The nurse initiates prescribed intravenous (IV) therapy on an 86-year-old hospitalized client. Which life span concept(s) should be considered when initiating IV therapy and caring for an older adult receiving IV therapy? Select all that apply. 1. Avoid infusion devices in confused clients as alarms can be disruptive 2. Cardiac and renal changes may put the client at risk for hypervolemia 3. Older adults may have more fragile veins, increasing the risk of infiltration 4. Skin protectants and nonporous tape are helpful in reducing skin tears on fragile skin 5. Use a 30-45-degree angle on insertion because older adults have deeper veins that roll

Correct answer [2,3,4] Explanation The nurse must consider several life span changes that occur with aging when initiating IV therapy and caring for IV infusions in the older adult. Important considerations include the following: The age-related cardiovascular and renal function changes that can occur in the elderly, such as a mild increase in the size and thickness of the heart, prolonged filling time, and declined glomerular filtration rate, may put the client at risk for rapid development of hypervolemia. Use of an infusion pump is recommended, even in clients with dementia, as they are at increased risk for fluid imbalance (Option 1). Older adults with fragile veins are at increased risk for IV infiltration; therefore, the site should be monitored carefully by the nurse every 1-2 hours. Fragile skin may tear easily; use nonporous tape, skin protectant solutions, and minimal tourniquet pressure. Because hearing and visual impairments may pose a problem for client education, the nurse should speak clearly and face the client when speaking. Use the smallest gauge catheter (24-26 gauge) indicated for the client's therapy as veins are more fragile. Consider vein sites to promote client independence (non-dominant arm, avoiding back of the hand). Use a 5-15-degree angle on insertion as veins of the elderly are usually more superficial (Option 5). Educational objective: Important age-related considerations for the older adult receiving IV herapy include consideration of renal and cardiac function to prevent hypervolemia, use of an infusion pump for control, close monitoring of the site for infiltration and infection, measures to prevent skin tears, and use of small-bore (24-26 gauge) IV catheters and correct technique (5-15-degree angle) for insertion of an IV into fragile veins.

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

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

The nurse has unlicensed assistive personnel (UAP) caring for a client with an acute attack of Meniere disease. Which action by the UP will require follow-up by the nurse? 1. Assist the client in ambulating to the bathroom 2. Dim the room lights 3. Place the bed in low position with all side rails up 4. Turn off the television

Correct answer [3] Explanation Meniere disease (endolymphatic hydrops) results from excess fluid accumulation in the inner ear. Clients have episodic attacks of vertigo, tinnitus, hearing loss, and aural fullness. The vertigo can be severe and is associated with nausea and vomiting. Clients report feeling being pulled to the ground (drop attacks). Fall precautions that should be instituted include assisting the client when arising and ambulating (Option 1), placing the bed in low position, and raising side rails. However, raising all side rails is considered a restraint and would be inappropriate. The nurse would need to intervene and instruct the UAP that 2 or 3 side rails lifted up would be sufficient (Option 3). (Options 2 and 4) Vertigo may be minimized by staying in a quiet, dark room and avoiding sudden head movements. The client should reduce stimulation by not watching television and not looking at flickering lights. Educational objective; Safety is a priority for the client experiencing an acute attack of Meniere disease. Fall precautions include placing the bed in low position, raising 2 or 3 side rails, and assisting the client with arising and ambulating. Vertigo can be minimized by staying in a quiet, dark room without a television or flickering lights,

There has been an explosion at a local chemical plant. A private car arrives at the emergency department with 4 victims whose clothes are saturated with a strong-smelling liquid. The victims are wheezing. The nurse should implement which intervention first? 1. Assessing the clients' respiratory systems 2. Decontaminating the clients 3. Donning personal protective equipment 4. Providing oxygen by nasal cannula

Correct answer [3] Explanation Nursing priorities when implementing a chemical contamination emergency response plan include the following: 1. Restricting other clients, staff, and bystanders from the victims' vicinity to protect non-affected individuals and the health care facility from the contaminant 2. Donning personal protective equipment to protect the nurse when providing care (Option 3) 3. Decontaminating the clients outside the facility before initiating treatment. If the chemical is not removed, it will continue to cause respiratory distress; contaminated clothing is left outside the facility to reduce the risk of contaminating staff and other clients (Option 2). 4. Assessing and providing treatment of symptoms. Initial treatment is for the symptoms (eg, wheezing), regardless of the specific cause (Options 1 and 4). Educational objective: The nurse should always protect other clients, staff, and the health care facility first in a chemical contamination. Personal protective equipment should be put on before decontamination. Victims should be decontaminated outside the facility before care is administered.

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 2. Wear clean gloves for removal and application of a new dressing 3. Wear clean gloves to remove the existing dressing, changing to sterile gloves to apply the new dressing 4. Wear sterile gloves, gown, and goggles to remove the soiled existing dressing

Correct answer [3] Explanation 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 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." 2. "Sucrose and a pacifier can help alleviate the infant's pain and stress during the puncture." 3. "The heel area should be warmed for 3-5 minutes prior to puncture." 4. "Venipuncture should be reserved only for failed heel sticks because it is more painful."

Correct answer [4] Explanation 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.

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 2. Ask a nursing colleague if this drug amount is used 3. Check hydromorphone dose that the client had previously 4. Question the prescription with the prescriber

Correct answer [4] Explanation 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.

The nurse is to administer an albuterol nebulizer treatment to a client with acute bronchospasm. The prescribed dosage is 5 mg every 4 hours. The available solution is albuterol (0.083%) inhaled, 2.5 mg/3 mL. How many mililiters (mL) should the nurse administer with each dose? Record your answer as a whole number.

Correct answer [6 mL] Explanation Using dimensional analysis, use the following steps to calculate the volume in milliliters of albuterol per dose: 1. Identify the prescribed, available, and required medication information Prescribed : 5 mg albuterol/dose Available : 2.5 mg albuterol/3 mL solution Required : mL/dose 2. Convert prescription to the volume needed for administration Prescription x available medication = mL/dose OR [mg albuterol/dose] [mL albuterol solution/mg albuterol] = mL albuterol solution/dose OR [5 mg albuterol/dose] [3 mL albuterol solution/2.5 mg albuterol] = 6 mL albuterol solution/dose Educational objective: To calculate the milliliters per dose of nebulized albuterol, the nurse should first identify the prescribed dose (eg, 5 mg) and available dose (eg 2.5 mg/3 mL) and then convert to milliliters per dose (eg, 6 mL/dose). Alternate method The formula method is an alternate way to calculate medication dosages. However, this method may increase the occurrence of miscalculation and medication errors. If you choose to use this method, do not round any calculations until the final step. Using the formula method, use following step calculate the volume in mililiters of albuterol per dose: 1. Prescribed dose/available dose x available volume = mL/dose OR 5 mg albuterol/2.5 mg albuterol x 3 mL albuterol solution = 6 mL albuterol solution/dose

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

Correct answer[1,2,5] Explanation 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.

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? Please use the button shown below to view the image and make your selection(s)

Explanation 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.