NCLEX questions for MidTerm 2

The nurse cares for a client diagnosed with type I diabetes mellitus who came to the emergency department with the acute complication of diabetic ketoacidosis (DKA). After checking the blood glucose, which prescription should the nurse implement first? 1. Insert an indwelling urinary catheter for accurate output calculation 2. Obtain serum potassium level results and report to the primary health care provider 3. Prepare an insulin drip for intravenous (IV) infusion as prescribed 4. Start an IV line and infuse normal saline as prescribed

1 The priority intervention in DKA is to start an IV infusion for bolus rehydration therapy with normal saline. This should occur before insulin infusion as insulin will result in water, potassium, and glucose entering the cells, worsening the dehydration and electrolyte imbalances.

In the intensive care unit, the nurse cares for a client who has been admitted with diabetic ketoacidosis. The client is on a continuous infusion of regular insulin at 5 units/hr via IV pump. Which actions should the nurse expect to implement? Select all that apply. 1. Administer potassium supplement when serum potassium is 3.5-5.0 mEq/L (3.5-5.0 mmoi/L) 2. Discontinue insulin infusion when fingerstick blood glucose is <350 mg/dl 3. Increase the insulin infusion rate when blood glucose level decreases 4. Monitor fingerstick or serum blood glucose every hour 5. Start infusion of dextrose 5% water when blood glucose is <250 mg/dl (13.9 mmoi/L)

1, 4, 5 Insulin shifts the potassium back into the intracellular space. As a result, serum potassium levels will then begin to decrease once insulin is started. This client is on a continuous insulin drip so serum potassium will continue to decrease. When serum potassium is normal, a potassium supplement (usually in the form of an IV piggyback) should be added to the medication regimen to prevent impending hypokalemia (K+ <3.5 mEq/L [3.5 mmoi/L]) (Option 1). Low potassium (hypokalemia) can cause muscle weakness, cramps, fatigue, and life-threatening cardiac arrhythmias. When the client is on an insulin drip, a fingerstick or serum blood glucose level should be checked at least hourly (Option 4). D5W is added to the IV fluid when blood glucose is <250 mg/dl (13.9 mmoi/L) to prevent a hypoglycemic reaction with regular (short-acting) IV insulin (Option 5). Insulin and D5W should be continued until the acidosis resolves. The insulin infusion is titrated down as blood glucose is lowered (Option 3); it is discontinued when the client is switched to subcutaneous injections. This generally occurs when blood glucose is <200 mg/dl (11.1 mmoi/L) and there is no evidence of metabolic acidosis (Option 2).

When monitoring an infant with a left-to-right-sided heart shunt, which findings would the nurse expect during the physical assessment? Select all that apply. 1 . Clubbing of fingertips 2. Cyanosis when crying 3. Diaphoresis during feedings 4. Heart murmur 5. Poor weight gain

3, 4 and 5 Congenital heart defects that cause blood to shunt from the higher pressure left side of the heart to the lower pressure right side (eg, patent ductus arteriosus, atrial septal defect, ventricular septal defect) increase pulmonary blood flow. Left-to-right shunting results in pulmonary congestion, causing increased work of breathing and decreased lung compliance. Compensatory mechanisms (eg, tachycardia, diaphoresis) result from sympathetic stimulation. Clinical manifestations of acyanotic defects may include: • Tachypnea • Tachycardia, even at rest • Diaphoresis during feeding or exertion (Option 3) • Heart murmur or extra heart sounds (Option 4) • Signs of congestive heart failure • Increased metabolic rate with poor weight gain (Option 5) (Option 1) Clubbing of the fingertips is associated with chronic hypoxia caused by decreased pulmonary circulation as occurs with right-to-left heart defects. (Option 2) Right-to-left congenital heart defects (eg, cyanotic defects) impede pulmonary blood flow (eg, tetralogy of Fallot, transposition of the great vessels) and cause cyanosis, which is evident shortly after birth and during periods of physical exertion. Educational objective: Left-to-right cardiac shunts (eg, patent ductus arteriosus, atrial septal defect, ventricular septal defect) result in excess blood flow to the lungs. Manifestations include heart murmur, poor weight gain, diaphoresis with exertion, and signs of heart failure.

A client with type I diabetes mellitus is brought to the emergency department by his wife. The client has fruity breath with rapid, deep respirations at 36 breaths per minute, reports abdominal pain, and appears weak. The nurse should anticipate implementation of which prescription(s)? Select all that apply. 1. Administer dextrose 50 mg intravenous (IV) push 2. Instruct client to breathe into a paper bag to treat hyperventilation 3. Perform a fingerstick and serum blood glucose test 4. Prepare to administer an IV infusion of regular insulin 5. Start an IV line and administer a bolus of normal saline

3, 4, 5 The client is exhibiting the cardinal signs and symptoms of diabetic ketoacidosis (DKA). DKA is an acute life-threatening complication, typically of type I diabetes, characterized by hyperglycemia, ketosis, and acidosis. It is caused by an intense deficit of insulin. Because some of the symptoms of hypoglycemia and DKA overlap, a blood glucose level should be checked to ensure that hyperglycemia is present.Option 1 would make the situation worse, and option 2 is inappropriate as the client is acidotic and needs to blow off the acid.

In the intensive care unit, a client is on mechanical ventilation (MV) after having undergone a fresh tracheostomy with retention sutures placed yesterday. The nurse hears the MV alarm sound and enters the room. The client is coughing, respirations are 40/min, heart rate is 132/min, and the pulse oximeter reading is 80°/o. The nurse also sees the tracheostomy tube lying on the client's chest. What is the nurse's immediate action? 0 1. Apply a rebreathing mask with high concentration oxygen at 12 L/min 0 2. Attempt to reinsert the tube with the obturator in place 0 3. Insert a sterile catheter into the stoma and suction the airway 0 4. Pull the retention sutures apart to lift the trachea and hold the stoma open

Accidental dislodgement of the tube after a fresh (immature, <1 week) tracheostomy is a medical emergency as the tract is not yet healed (matured). Significant tracheal inflammation, edema, bleeding, and closure of the tract (resulting in airway loss) can occur. The goal is to keep the stoma open to maintain the airway and oxygenate the client. If accidental dislodgement occurs, immediate nursing actions should include pulling the retention sutures apart (if present) to lift the trachea and hold the stoma open or inserting a curved hemostat to hold the stoma open if sutures are not present. If desaturation progresses while awaiting the arrival of the emergency team, the nurse can apply a sterile occlusive dressing over the stoma and ventilate the client with a bag-valve mask over the nose and mouth (using gentle pressure). {Option 1) Application of the rebreathing mask will not be effective due to the severity of respiratory distress and because oxygen can escape from the stoma. {Option 2) Before inserting a new tube into an immature tracheostomy, the stoma is first held open with a curved hemostat or by pulling the retention sutures. {Option 3) Advancing a suction catheter into an immature tract can cause increased inflammation, swelling, and bleeding; the oxygen will also be removed when suction is applied. Educational objective: Accidental dislodgement of the tube in a fresh (immature, < 1 week) tracheostomy is a medical emergency. Immediate nursing actions include pulling the retention sutures apart if present, or inserting a curved hemostat to hold the stoma open if sutures are absent. If desaturation progresses, the nurse should apply a sterile occlusive dressing over the stoma and ventilate the client with a bag-valve mask over the nose and mouth.

The nurse is caring for a 72-year-old client with a history of renal calculi and diabetes mellitus who was admitted for acute pyelonephritis. The nurse assesses shaking chills, temperature of 101.2 F (38.4 C), and flank pain. Which of the following is the priority nursing intervention? 1 . Administer intravenous antibiotics 2. Check baseline serum creatinine level 3. Have the client strain all urine 4. Obtain blood and urine cultures

Acute pyelonephritis is an infection of the kidney usually caused by an extension of infection from the lower urinary tract (bladder). Chills and fever, vomiting, flank pain, and costovertebral tenderness are characteristic. Blood and urine cultures should be obtained prior to initiation of antibiotic therapy whenever possible to identify the causative microorganisms and determine the most effective antibiotics (Option 4). Given this client's age and underlying diabetes, sepsis can occur quickly. Therefore, antibiotics should be given immediately after cultures are obtained (Option 1 ). (Option 2} The nurse should check the client's baseline renal function and complete blood count tests to compare subsequent findings. This is not the priority nursing intervention. (Option 3} The client has a history of renal calculi. Straining all urine is not the priority nursing intervention. Educational objective: The priority of care for acute pyelonephritis is to obtain blood and urine cultures before initiating antibiotic therapy whenever possible.

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

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

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

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.

A diabetic woman has a precipitous delivery in the emergency department. Which initial neonate assessment finding is the priority and requires a nursing response? 1 . Apgar score of 7 at 1 minute 2. Apical heart rate of 160/min 3. Circumoral duskiness 4. Jitteriness

Explanation: Answered correctly Time: 3 seconds 65o/o Updated: 07/01/2017 Infants of diabetic mothers are at risk of hypoglycemia and hypocalcemia. The transitional time (the first 6 hours after birth) is especially high risk for hypoglycemia as the fetus produced high levels of insulin in response to the high levels of circulating maternal glucose. The insulin level for a diabetic mother's neonate remains higher than normal in the first few hours of extrauterine life, making the neonate at risk for hypoglycemia. Hypoglycemia in a newborn is considered a blood glucose level <40 mg/dl (2.2 mmoi/L). Symptoms of hypoglycemia include jitteriness, irritability, hypotonia, apnea, lethargy, and temperature instability. (Option 1) An Apgar score of 7-1 0 indicates a stable status. Apgar assessment is normally performed at 1 minute and 5 minutes after birth. If the 5 minute score is <7, additional scores should be assigned every 5 minutes up to 20 minutes. (Option 2) Normal neonatal heart rate is 110-160/min. The rate can increase to 180/min with crying and fall as low as 100/min during sleep. Sustained tachycardia (>160/min) for >1 0 minutes indicates possible sepsis, respiratory distress, or congenital heart abnormality. Bradycardia indicates possible sepsis, increased intracranial pressure, or hypoxia. The neonate's heart rate should be assessed by taking an apical rate for a full minute (noting the rate and rhythm). (Option 3) Circumoral cyanosis is a benign, localized, transient cyanosis around the mouth during the transition period. If it persists, it may be related to a cardiac anomaly. Educational objective: Infants of diabetic mothers are at high risk for hypoglycemia, especially in the transition period. A common symptom of hypoglycemia in a newborn is jitteriness.

The nurse reviews the chart of a client who gave birth 4 hours ago. Which contributing factor indicates that the client has an increased risk of postpartum hemorrhage? 1 . Infant birth weight of 9 lb 2 oz (4139 g) 2. Labor and birth without pain medication 3. Labor that lasted 8 hours 4. Third stage of labor lasting 20 minutes

Explanation: Postpartum hemorrhage (PPH) is usually defined as maternal blood loss of >500 mL after a vaginal birth or >1 000 mL after a cesarean birth. Uterine atony, characterized by a soft, "boggy," and poorly contracted uterus, is the most common cause of early PPH (occurring S24 hours after birth). Delayed PPH (>24 hours after birth) usually results from retained placental fragments associated with a long third stage of labor (ie, time from birth of baby to expulsion of placenta, lasting >30 minutes). Risk factors for PPH include: • History of PPH in prior pregnancy • Uterine distension due to: o Multiple gestation o Polyhydramnios (ie, excessive amniotic fluid) o Macrosomic infant (>8 lb 13 oz [4000 g]) (Option 1) (Option 2) Natural, unmedicated labor and birth reduces the chance of PPH. (Option 3) Labor lasting <24 hours does not increase the risk for PPH. (Option 4) A third stage of labor lasting <30 minutes does not increase the risk for PPH

The nurse who is caring for a 1-month-old with Tetralogy of Fallot will report which finding to the health care provider as a priority? 1 . Hemoglobin level of 24.9 g/dL (249 g/L) 2. Murmur on heart auscultation 3. Oxygen saturation of 82o/o on room air 4. Poor weight gain

Explanation: The normal range for hemoglobin in a 1-month-old is 12.5-20.5 g/dl (125-205 g/L). Hemoglobin of 24.9 g/dl (249 g/L) is diagnostic of polycythemia (elevated hemoglobin levels). Infants with cyanotic cardiac defects can develop polycythemia as a compensatory mechanism due to prolonged tissue hypoxia. Polycythemia will increase blood viscosity, placing an infant at risk for stroke or thromboembolism (Option 1 ). Clubbing is another manifestation of prolonged hypoxia. (Option 2) Cardiac murmur is expected in heart defects. This is not a priority to report. (Option 3) Tetralogy of Fallot (TOF) is a cyanotic cardiac defect. Infants with TOF will normally maintain oxygen saturations of 65°/o-85°/o until the defect is surgically corrected. (Option 4) Poor weight gain is common with congenital heart defects. This finding is not a priority. Feeding intolerance, tachypnea, and dyspnea usually indicate severe hypoxemia. Educational objective: Poor oxygenation can cause elevated levels of hemoglobin (polycythemia), which increase blood viscosity. Thickened serum puts infants at risk for stroke or thromboembolism. An infant with polycythemia must stay hydrated.

The nurse has received report on 4 pediatric clients. Which client should the nurse assess first? 1. Client with coarctation of the aorta and diminished femoral pulses 2. Client with patent ductus arteriosus and a loud machinery-like murmur 3. Client with tetralogy of Fallot and oxygen saturation of 80% on room air 4. Client with ventricular septal defect; tachypnea and diaphoresis during feedings

Explanation: Time: 3 seconds Updated: 04/10/2017 Ventricular septal defect is an acyanotic congenital heart defect causing blood to shunt from the left side of the heart to the right (left-sided heart has higher pressure than right-sided). An increase in pulmonary blood flow causes an increase in workload of the right heart and pulmonary arteries, resulting in pulmonary hypertension. Eventually, blood does not go to the lungs, but instead the pressure on the right side of the heart increases, resulting in shunt reversal. This causes more blood to be shunted to the left ventricle, followed by the left atrium, and then back into the lungs (heart failure). Tachypnea is due to pulmonary volume overload. Diaphoresis is an indication that an infant is expending too much energy during feeding. This client should be assessed first and evaluated for other signs of congestive heart failure (CHF). (Option 1) Coarctation of the aorta (COA) is an obstructive congenital heart defect resulting in decreased cardiac output. Children with COA will have stronger pulses in the upper extremities and diminished pulses in the lower extremities. This is expected until the obstruction is repaired surgically. (Option 2) A patent ductus arteriosus (PDA) occurs when fetal circulation persists after birth. A continuous machinery-like murmur is a normal finding with a PDA. (Option 3) Tetralogy of Fallot {TOF) is a cyanotic congenital heart defect. Right-sided (venous) blood is shunted through the left ventricle via the ventricular septal defect due to the resistance at the pulmonary artery (pulmonary stenosis, one of the components of TOF). This will cause abnormally low oxygen saturation (often in the range of 65%-85°/o), which is expected until the defect is repaired surgically. Educational objective: All left-to-right cardiac shunts (eg, ventricular septal defect, atrial septal defect) will cause an increase in pulmonary blood flow. Shunt reversal can eventually result in heart failure. Children should be kept in an upright position and offered small!, frequent feedings to decrease workload of the heart and lungs.

The home health nurse is visiting an infant who recently had surgery to repair tetralogy of Fallot. The nurse should teach the parents to report which findings indicative of heart failure to the health care provider (HCP)? Select all that apply. 1 . Cool extremities 2. Increase in appetite 3. Puffiness around the eyes 4. Reduction in number of wet diapers 5. Weight loss

Heart failure may develop after surgical repair of tetralogy of Fallot, and infants and children Heart failure may develop after surgical repair of tetralogy of Fallot, and infants and children cancan quickly decompensate hemodynamically when it occurs. Clinical manifestations are grouped into 3 primary categories- impaired myocardial pumping, pulmonary congestion, and systemic venous congestion. {Option 2) The infant would have a decrease in appetite with heart failure symptoms. {Option 5) The infant would more likely have experienced weight gain due to fluid retention. Educational objective: The nurse should teach parents of an infant or child with a repaired congenital heart defect to recognize and report signs and symptoms of heart failure to the HCP. These may include rapid breathing rate; rapid heart rate at rest; dyspnea; activity intolerance (especially during feeding in infants); pale, cool extremities; weight gain; reduction in wet diapers; and puffiness around the eyes.

A nurse is caring for an elderly client who had a colectomy for removal of cancer 2 days ago. The client is becoming increasingly restless. He has been given intravenous morphine every 2 hours for severe pain. Respirations are 28/min and shallow. Which arterial blood gas (ABG) results best indicate that the client is in acute respiratory failure (ARF) and needs immediate intervention? 1 . Pa02 49 mm Hg (6.5 kPa), PaC02 60 mm Hg (8.0 kPa) 2. Pa02 64 mm Hg (8.5 kPa), PaC02 45 mm Hg (6.0 kPa) 3. Pa02 70 mm Hg (9.3 kPa), PaC02 30 mm Hg (4.0 kPa) 4. Pa02 86 mm Hg (11.5 kPa), PaC02 25 mm Hg (3.33 kPa)

Option 1 ARF is defined as inadequate gas exchange that is intrapulmonary (pneumonia, pulmonary embolism) or extrapulmonary (head injury, opioid overdose) in origin. Respiratory failure associated with an alteration in 02 transfer or absorption is type I hypoxemic failure (eg, acute respiratory distress syndrome, pulmonary edema, shock). Respiratory failure associated with carbon dioxide (C02) retention is type II hypercapnic, or ventilatory failure (eg, chronic obstructive pulmonary disease, myasthenia gravis, flail chest). ARF is a potential complication of major surgical procedures, especially those involving the thorax and abdomen, as in this client. ABG values that indicate the presence of ARF are Pa02 S60 mm Hg (8.0 kPa) or PaC02 ~50 mm Hg (6.67 kPa). ARF occurs quickly

The nurse receives news of a local mass shooting. Stable clients need to be discharged to make room for newly admitted clients. Which client would the nurse identify as safe to recommend for discharge? 1. Client on chemotherapy who started antibiotics today for cellulitis of the leg 2. Client with asthma exacerbation who has not required oxygen or a nebulizer in 12 hours 3. Client with diabetes who has nausea, abdominal pain, and vomiting 4. Client with ulcerative colitis and diarrhea who has developed fever and vomiting Submit

Option 2 This client is the most stable, all other clients are not.

An elderly client with type 2 diabetes is admitted to the medical unit due to urosepsis. The client is wearing an insulin pump for continuous subcutaneous insulin infusion therapy. The client's significant other reports that the client self-manages the insulin pump extremely well and keeps blood glucose in the specified target range. What is the admitting nurse's priority action? 1 . Assess the client's level of orientation 2. Assess the insulin pump infusion site 3. Check the prescribed insulin pump settings 4. Consult the diabetic resource nurse or educator

Option 1 Change in mental status and confusion is a common presenting symptom of sepsis in the elderly. The nurse should assess the client's cognitive status and level of orientation and consciousness. Diminished mental acuity, side effects of medication, and impairment related to a medical condition during hospitalization affect the client's ability to manage the insulin pump safely. Mental status is the key to safe insulin pump use, so if the client is not competent to operate the pump, the nurse should notify the health care provider (HCP) and document the findings in the client's electronic medical record. The HCP will determine if continuing the use of the pump during hospitalization is appropriate. {Option 2) Assessing the infusion pump site for signs of infection and intactness of the infusion set is important, but it is not the priority action. {Option 3) The HCP prescribes the basal insulin along with the parameters for bolus and correction doses while the client is hospitalized. The nurse should check and document the make and model, pump settings, type of insulin, and the date that the infusion site and set were changed. However, this is not the priority action. {Option 4) Consulting with the diabetic resource nurse or educator to determine the client's competency and ability to manage a specific type of pump and provide ongoing client education is an appropriate action. However, this is not the priority.

A client in labor with a history of a previous cesarean birth has chosen to attempt a vaginal birth. During labor, which finding would be most concerning to the nurse? 1. Cessation of contractions and maternal tachycardia 2. Fetal tachycardia with moderate variability 3. Increased anxiety and discomfort with contractions 4. Painful, strong contractions every 3-4 minutes

Option 1 Clients attempting vaginal birth after cesarean (VBAC) have a slightly increased risk for uterine rupture due to previous surgical scarring of the uterus. Clients desiring VBAC are usually encouraged to wait for spontaneous onset of labor rather than undergo induction and are monitored closely throughout labor and delivery. The first sign of uterine rupture is usually abnormal fetal heart rate (FHR) patterns. Other manifestations include constant abdominal pain, loss of fetal station, and sudden cessation of uterine contractions (Option 1). Hemorrhage, hypovolemic shock, and maternal tachycardia may occur if severe rupture occurs unrecognized. (Option 2) Most commonly, FHR decelerations followed by fetal bradycardia are indicative of uterine rupture. Fetal tachycardia may be caused by infection, maternal fever, or stimulant drugs. However, moderate variability is a reassuring sign predictive of adequate fetal oxygenation. (Option 3) Contractions normally grow more intense as labor progresses, and increasing anxiety and discomfort are common. However, the nurse should monitor the client for constant, severe abdominal pain, which may indicate uterine rupture. (Option 4) The nurse should be hypervigilant for tachysystole, which increases the risk for uterine rupture. Strong contractions every 3-4 minutes are probably indicative of a normal labor contraction pattern. Educational objective: Clients attempting vaginal birth after cesarean have a slightly increased risk for uterine rupture. Signs of uterine rupture may include abnormal fetal heart rate pattern (ie, decelerations, decreased variability, bradycardia), loss of fetal station, constant abdominal pain, cessation of uterine contractions, and maternal tachycardia.

A client is diagnosed with diabetic ketoacidosis (DKA). The client reports frequent urination, thirst, and weakness. The nurse assesses a temperature of 102.4 F (39.1 C), fruity breath, deep labored respirations with a rate of 30/min, and dry mucous membranes. What is the priority nursing diagnosis (ND) at this time? 1. Deficient fluid volume related to osmotic diuresis 2. Imbalanced nutrition, less than body requirements related to inability to metabolize glucose 3. Ineffective breathing pattern related to the presence of metabolic acidosis 4. Ineffective health maintenance related to the inability to manage DM during illness

Option 1 Deficient fluid volume related to osmotic diuresis secondary to hyperglycemia as evidenced by dry mucous membranes and client report of frequent urination, thirst, and weakness is the priority ND. Hyperglycemia leads to osmotic diuresis, dehydration, electrolyte imbalance, and possible hypovolemic shock and renal failure. Therefore, this condition requires rapid correction through the infusion of isotonic intravenous fluids and poses the greatest risk to the client's survival (Option 1 ).

The nurse has just received report. Which client should the nurse assess first? 1. Client admitted from coronary angiography in the past hour with back pain 2. Client with a deep vein thrombosis (DVT) on heparin drip at 1250 units/hr with an activated partial thromboplastin time (aPTT) of 60 seconds 3. Client with a head injury and a Glasgow Coma Scale of 14 4. Postoperative day 2 coronary artery bypass graft client with incisional pain rated 6 on pain scale

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

A nurse is caring for 4 clients. Which prescription by the health care provider would the nurse question and seek further clarification before administering? 1. 0.45% sodium chloride solution for a client with severe gastroenteritis who had 12 episodes of diarrhea and vomiting in the past 4 hours 2. IV bolus of 1000 ml 0.9% sodium chloride solution for a client in anaphylaxis due to a food allergy 3. IV bolus of 1000 ml 0.9% sodium chloride solution for a client with diabetic ketoacidosis who has a serum glucose level of 650 mg/dl (36.1 mmoi/L) 4. IV mannitol 25°/o solution for a client with a closed head injury who is exhibiting signs of increased intracranial pressure

Option 1 The nurse should question the administration of a hypotonic IV solution (ie, 0.45o/o sodium chloride) to replace gastrointestinal tract fluid losses as this would create a concentration gradient and shift fluid out of the intravascular compartment into the interstitial tissue and cells, worsening the client's fluid volume deficit. Isotonic IV solutions (eg, 0.9% sodium chloride, lactated Ringer's) have the same osmolality as plasma and are administered to expand intravascular fluid volume. These solutions replace fluid losses commonly associated with vomiting and diarrhea, burns, and traumatic injury. (Option 2) Anaphylaxis causes increased capillary permeability, leaking intravascular fluid into free spaces; this places the client at risk for hypotension. Therefore, isotonic solutions should be given to such clients. (Option 3) Extreme hyperglycemia in a client with diabetic ketoacidosis results in osmotic diuresis and dehydration. The immediate initial treatment is IV fluid resuscitation with isotonic 0.9o/o sodium chloride to replace fluid losses, stabilize vital signs, reestablish urine output, and dilute the serum glucose concentration before initiating insulin therapy. (Option 4) A client with head trauma is at risk for increased intracranial pressure due to inflammation and cerebral edema. IV mannitol is an osmotic diuretic that reduces cerebral edema by pulling water from the cerebral cells into the vasculature.

The nurse has received report on the following clients. Which client should the nurse assess first? 1. Client 4 hours postoperative colon resection who has a blood pressure of 90/7 4 mm Hg 2. Client receiving palliative care who has Cheyne-Stokes respiration with 20-second periods of apnea 3. Client with anemia and hemoglobin level of 7 g/dl (70 g/L) who has a pulse of 11 0/min after ambulation 4. Client with diabetic ketoacidosis who has rapid, deep respirations at a rate of 32/min

Option 1: The nurse should first assess the client who had bowel surgery as hypotension can be a manifestation of bleeding, hypovolemia, and early septic shock. The nurse should check vital signs and perform a cardiovascular assessment. (Option 2) Cheyne-Stokes respiration is a repetitive, abnormal, irregular breathing pattern characterized by alternating deep and shallow respirations followed by periods of apnea (10-20 seconds). The pattern is usually associated with certain neurologic conditions (eg, stroke, increased intracranial pressure) and with end of life; it would be expected in this client. (Option 3) Shortness of breath and tachycardia with activity related to decreased hemoglobin level, red cells, and oxygen-carrying capacity would be expected in a client with moderate to severe anemia. (Option 4) Kussmaul breathing is characterized by regular but rapid, deep respirations and is associated with conditions that cause metabolic acidosis (eg, renal failure, diabetic ketoacidosis, shock). Kussmaul breathing would be expected in this client as it is a compensatory action by the lungs to excrete excess acid from the body by hyperventilating, thereby blowing off carbon dioxide (acid gas). Educational objective: Postoperative hypotension can be a manifestation of bleeding, hypovolemia, and sepsis. Changes in vital signs (eg, decreased systolic pressure, tachycardia, tachypnea) and cool, pale skin can indicate decreased cardiac output and altered tissue perfusion

A student nurse initiates oxygen with a nonrebreather mask for a client with acute respiratory distress. While reassessing the client, the RN notices the reservoir bag is fully deflating on inspiration. What immediate action does the RN take to correct the problem? 0 1 . Elevates the head of the bed 0 2. Increases the oxygen flow 0 3. Opens both flutter valves (ports) on the mask 0 4. Tightens the face mask straps

Option 2 A nonrebreather mask is an oxygen delivery device used in a medical emergency. It consists of a face mask with an attached reservoir bag and a one-way valve between the bag and mask that prevents exhaled air from entering the bag and diluting the oxygen concentration. The liter flow must be high enough (up to 15 L/min) to keep the reservoir bag at least 2/3 inflated during inhalation and to prevent the buildup of carbon dioxide in the bag. (Option 1) Elevating the head of the bed allows for maximum chest expansion and promotes oxygenation. It does not inflate the reservoir bag on inhalation or affect the proper operation of the rebreather mask. (Option 3) Ports (exhalation valves) are located on each side of the mask and are covered with rubber discs that act as flutter valves. The valves close on inhalation to prevent entry of room air and open on exhalation to prevent rein halation of exhaled air. The ports should be occluded when initiating the device to fill the reservoir with oxygen. (Option 4) The nonrebreather mask can deliver high concentrations of oxygen if the mask is secured tightly to the face with the head strap to minimize leaks. Tightness of the mask does not affect the filling or deflating of the reservoir bag. Educational objective: A nonrebreather mask is an oxygen delivery device used in a medical emergency. It can deliver up to 95o/o-1 00°/o oxygen concentration if properly maintained during use. Proper care of the device includes monitoring the reservoir bag to assure continual inflation during inhalation; monitoring the 2 exhalation (flutter) valves that cover the ports on each side of the mask; and keeping the mask secured to the face by adjusting the tightness of the head strap to minimize leaks.

Within thirty seconds after birth, an unresponsive and limp newborn is placed on the warmer in the "sniffing" position. The nurse clears the airway, dries, and stimulates the newborn. At 1 minute of life, the newborn has shallow, gasping respirations with a heart rate of 62/min. What action should the nurse take? 1 . Administer epinephrine 2. Begin positive pressure ventilation 3. Continue stimulating the newborn 4. Start chest compressions

Option 2 Airway is the first priority, and the infant is exhibiting signs of collapsed alveoli. The PPV will help to open the airways and promote gas exchange.

The nurse develops a care plan for a critically ill client with acute respiratory distress syndrome (ARDS) who is on a mechanical ventilator. What is the priority nursing diagnosis (ND)? 1 . Imbalanced nutrition 2. Impaired gas exchange 3. Impaired tissue integrity 4. Risk for infection

Option 2 Explanation: ARDS involves damage to the alveolar-capillary membrane, the blood-gas barrier across which oxygen diffuses into the alveoli. When the membrane is damaged, the alveoli collapse and fluid leaks into the alveolar space and impairs gas exchange. Impaired gas exchange related to alveolar-capillary changes and ventilation-perfusion imbalance is the priority ND for a client with ARDS. (Option 1) Imbalanced nutrition (less than body requirements) related to increased metabolic needs and inability to ingest foods due to endotracheal intubation, is an appropriate ND for the client with ARDS. However, it does not pose the greatest threat to survival and is not the priority ND. (Option 3) Impaired tissue (integumentary) related to altered circulation, immobility, and nutritional deficits is an appropriate ND for the client with ARDS. However, it does not pose the greatest threat to survival and is not the priority ND. (Option 4) Risk for infection related to the presence of an endotracheal tube, frequent suctioning, intravenous devices, and indwelling catheters is an appropriate ND for the client with ARDS. However, it does not pose the greatest threat to survival and is not the priority ND. Educational objective: ARDS involves damage to the alveolar-capillary membrane, resulting in fluid leakage into the alveolar space. Impaired gas exchange related to alveolar-capillary changes and ventilation-perfusion imbalance is an appropriate ND for a client with ARDS.

A client at 39 weeks gestation with preeclampsia has a blood pressure of 170/100 mm Hg, 2+ proteinuria, and moderate peripheral edema. Immediately after hospital admission, she develops seizures and uterine contractions. Magnesium sulfate is prescribed. Which finding indicates that the drug has achieved the desired therapeutic effect? 0 1 . Blood pressure <130/80 mm Hg 0 2. Seizure activity stops 0 3. Urine has 1 + protein 0 4. Uterine contractions stop

Option 2 Explanation: Preeclampsia is a systemic disease characterized by hypertension and proteinuria after the 20th gestational week with unknown etiology. Eclampsia is the onset of convulsions or seizures that cannot be attributed to other causes in a woman with preeclampsia. Delivery is the only cure for preeclampsia-eclampsia syndrome. Magnesium sulfate is a central nervous system depressant used to prevent/control seizure activity in preeclampsia/eclampsia clients. During administration, the nurse should assess vital signs, intake and output, and monitor for signs of magnesium toxicity (eg, decreased deep-tendon reflexes, respiratory depression, decreased urine output). A therapeutic magnesium level of 4-7 mEq/L (2.0-3.5 mmoi/L) is necessary to prevent seizures in a preeclamptic client. (Option 1) Hypertension is a sign of preeclampsia. Hydralazine (Apresoline ), methyldopa (Aidomet), or labetalol (Trandate) is used to lower blood pressure (BP) if needed (usually considered when BP is >160/110 mm Hg). (Option 3) Proteinuria is a symptom of preeclampsia. Control of hypertension and delivery will reduce the protein level. Magnesium sulfate is not prescribed to decrease proteinuria. (Option 4) Tocolytic drugs (eg, terbutaline, magnesium sulfate, indomethacin, nifedipine) are used to suppress uterine contractions in preterm labor, allowing pregnancy to be prolonged for 2-7 days so that corticosteroid administration can improve fetal lung maturity. This client is at term, and there is no need to delay delivery. Educational objective: Magnesium sulfate is prescribed for clients with preeclampsia to prevent seizure activity. A therapeutic magnesium level of 4-7 mEq/L (2.0-3.5 mmoi/L) is necessary to prevent seizures in a preeclamptic client.

The nurse and unlicensed assistive personnel (UAP) are performing rounds on their clients. The nurse notes that a 2-hour post vaginal delivery client has saturated the peripad with rubra drainage. What should the nurse do next? 1 . Have the UAP change the client's peripad 2. Immediately assess the client's fundus 3. Obtain a stat hemoglobin and hematocrit 4. Tell the UAP to increase the IV line to 150 mL/hr

Option 2 Explanation: Saturating a peripad in 1-2 hours could indicate hemorrhage, a life-threatening condition. The nurse should assess the client's fundus and, if it is boggy, massage it. The nurse should also assess the client's vital signs and should never leave the client alone. (Option 1} The nurse can delegate changing the peri pad to the UAP; however, it is not the priority at this time. (Option 3} Determining the client's hemoglobin and hematocrit levels will help determine the amount of blood that has been lost, but it is not the priority for this client. (Option 4} The nurse cannot delegate changing IV fluid rates to the UAP as this is beyond the scope of practice. Educational objective: Postpartum hemorrhage is a potentially life-threatening condition that should be addressed immediately. The nurse should first assess the fundus and massage it if boggy.

An adult client with altered mental status and fever has suspected bacterial meningitis with sepsis. Blood pressure is 80/60 mm Hg. Which prescribed intervention should the nurse implement first? 1 . Administer IV antibiotics 2. Infuse bolus of IV normal saline 3. Prepare to assist with lumbar puncture 4. Transport client for head CT scan

Option 2 For bacterial meningitis with sepsis, fluid resuscitation is the priority. Blood cultures should be drawn before starting antibiotics. After a head CT scan is performed to rule out increased intracranial pressure and mass lesions, cerebrospinal fluid cultures should be drawn via lumbar puncture

The nurse is caring for an adolescent client diagnosed with type 1 diabetes. The client exhibits hot, dry skin and a glucose level of 350 mg/dL (19.4 mmoi/L). Arterial blood gases show a pH of 7.27. STAT serum chemistry labs have been drawn. Cardiac monitoring shows a sinus rhythm with peaked T waves, and the client has minimal urine output. What is the nurse's next priority action? 1 . Administer IV regular insulin 2. Administer normal saline infusion 3. Obtain urine for urinalysis c 4. Request prescription for potassium infusion

Option 2 Potassium should never be given until the serum potassium level is known to be normal or low and urinary voiding is observed. Peaked T waves indicate hyperkalemia in this client. Clients with insulin deficiency frequently have increased serum potassium levels due to the extracellular shift despite having total body potassium deficit from urinary losses. Once insulin is given, serum potassium levels drop rapidly, often requiring potassium replacement. Potassium is never given as a rapid IV bolus, as cardiac arrest may result. Educational objective: Clients with diabetic ketoacidosis and hyperosmolar hyperglycemic state require IV normal saline as a priority due to severe dehydration. Once fluids are given as a bolus, insulin is initiated. The serum potassium levels can be elevated in the initial stages despite a low total body potassium. Potassium repletion is started once the serum potassium levels are normalized or trending low (from elevated levels).

The nurse receives the following information in the hand-off report. Which client should the nurse assess first? 1. Client with a paralytic ileus following a colon resection who has abdominal distension, no audible bowel sounds, and nausea 2. Client with alcoholic cirrhosis who has coffee ground nasogastric drainage, blood pressure of 90/60 mm Hg, and pulse of 110/min 3. Client with bacterial peritonitis following surgery for a ruptured appendix who is receiving IV tobramycin and has a temperature of 101 F (38.3 C) 4. Client with dysphagia and a sore throat who has a nasogastric tube to administer contrast media for an abdominal CT scan

Option 2 The nurse should first assess the client with alcoholic cirrhosis, as this condition is associated with gastritis, clotting abnormalities (eg, thrombocytopenia, coagulation disorders), and esophageal varices that increase the risk for hemorrhage (coffee ground emesis from oxidized blood). Hypotension and tachycardia in the presence of blood loss can indicate hypovolemia. The nurse should monitor for signs of hemodynamic instability (eg, hypotension, decreased urine output, peripheral vasoconstriction, pallor) and notify the health care provider of any significant changes from baseline as immediate esophagogastroduodenoscopy is necessary to determine the bleeding site. Treatment to stop the bleeding (eg, heat probe, sclerotherapy) may be indicated. {Option 1) A paralytic ileus is a non-mechanical intestinal obstruction that can occur following abdominal surgery. Expected manifestations include absent or hypoactive bowel sounds due to the lack of bowel motility and peristalsis, and abdominal distension and nausea due to the accumulation of gas and fluids in the bowel. {Option 3) Bacterial peritonitis (peritoneal inflammation) involves the entry of bacteria into the peritoneal cavity and is associated with a ruptured appendix. Elevated temperature would be an expected finding. {Option 4) Sore throat discomfort from irritation of the oropharynx is expected in a client with a nasogastric tube. Educational objective: Clients with alcoholic cirrhosis are at increased risk for hemorrhage due to esophageal varices and coagulation disorders. Hypotension and tachycardia in the presence of blood loss can indicate hypovolemia and require immediate assessment

The nurse is triaging a 7 -year-old with sickle cell crisis. The client is short of breath and vomiting and has severe generalized body and joint pains. Which assessment finding requires the most immediate intervention? 1 . Blood work showing anemia 2. Enlarged spleen on palpation 3. Right arm weakness 4. Swelling of hands and feet

Option 2 This client is exhibiting signs and symptoms of sickle cell crisis, which occurs when the client's sickle-shaped cells block blood flow through the vessels. These clients tend to have a small spleen due to repeated small splenic infarctions (autosplenectomy). Splenic sequestration crisis occurs when a large number of "sickled" cells get trapped in the spleen, causing splenomegaly. This is a lifethreatening emergency as it can lead to severe hypovolemic (hypotensive) shock. The classic assessment finding is a rapidly enlarging spleen. (Option 1) Normal red blood cells live about 120 days. Sickle cells break apart and die within less than 20 days; therefore, the client always has a shortage of red blood cells (anemia). Due to anemia, clients often report feeling fatigued. (Option 3) Right arm weakness could indicate new-onset stroke, a common complication of sickle cell disease that needs to be assessed. However, splenic sequestration is immediately life-threatening and a priority. (Option 4) Swelling of hands and feet (dactylitis) is another symptom of this disease due to the sickled red blood cells blocking blood flow to the hands and feet. This is often detected in babies as the first sign of the disease. Educational objective: Splenic sequestration crisis is a potentially life-threatening emergency of sickle cell disease. A rapidly enlarging spleen and hypotension are the characteristic assessment findings.

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

Option 2. Explanation: Time: 2 seconds Updated: 03/24/2017 Stress ulcers are a common complication in critically ill clients because the gastrointestinal tract is not a preferential organ. In the presence of hypoxemia, blood is shunted to the more vital organs, increasing the risk of stress ulcers. The early initiation of enteral feedings helps preserve the function of the gut mucosa, limits movement of bacteria (translocation) from the intestines into the bloodstream, and prevents stress ulcers. Enteral feedings are also associated with lower risk of infectious complications compared with TPN. However, the mortality is the same. (Option 1) Complications/problems commonly associated with enteral feedings include aspiration, tube displacement, hyperglycemia, diarrhea, abdominal distension, enteral tube misconnections, and clogged tubes. (Option 3) Caloric and metabolic needs can usually be met adequately using enteral feedings or TPN. Multiple enteral or TPN formulas are available to meet individual client needs. If metabolic demands are not being met using enteral feedings alone, TPN can be added. (Option 4) Illness-related stress hyperglycemia (gluconeogenesis) occurs in clients receiving both enteral feedings and TPN. Educational objective: The enteral route is preferred for feeding. Enteral feedings maintain the integrity of the gut, prevent stress ulcers, and help prevent the translocation of bacteria into the bloodstream.

A client is admitted to the intensive care unit with diabetic ketoacidosis. The client is most likely to exhibit which of the following arterial blood gas results? 1. pH 7.26, PaC02 56 mm Hg (7.5 kPa), HC03 23 mEq/L (23 mmoi/L) 2. pH 7.30, PaC02 30 mm Hg (4.0 kPa), HC03 15 mEq/L (15 mmoi/L) 3. pH 7.40, PaC02 40 mm Hg (5.3 kPa), HC03 24 mEq/L (24 mmoi/L) 4. pH 7.58, PaC02 48 mm Hg (6.4 kPa), HC03 44 mEq/L (44 mmoi/L)

Option 2. The arterial blood gas (ABG) result most consistent with the diagnosis of diabetic ketoacidosis (DKA) is metabolic acidosis or partially compensated metabolic acidosis (pH 7.30, PaC02 30 mm Hg [4.0 kPa], HC03 15 mEq/L [15 mmoi/L]).

Which client with an endocrine problem is most appropriate for the charge nurse to delegate to the licensed practical nurse (LPN)? 1. A client experiencing Addisonian crisis with a prescription for hydrocortisone IV 2. A client with Cushing syndrome who needs intermittent urinary catheterization 3. A client with diabetic ketoacidosis on insulin intravenous (IV) infusion 4. A client with thyrotoxicosis and new-onset atrial fibrillation

Option 2: Explanation: Registered nurses (RNs) are able to delegate tasks to LPNs. The nurse delegating a task remains legally responsible for the client's total care during the shift, and may be held liable for delegating inappropriately. Routine procedures such as urinary catheterization fall well within the LPN scope of practice, the other clients are in crisis, requiring acute care. (Options 1, 3) LPNs are trained in many nursing skills; these include but are not limited to nasotracheal suctioning, Foley catheter and nasogastric tube insertion, dressing changes, and subcutaneous, intramuscular, and oral medication administration. However, IV medication administration is typically reserved for the RN. (Option 4) Frequent assessment of unstable clients or clients with changes in condition is an exclusive RN task. Other key components of RN practice that should not be delegated or assigned include planning, implementation of complex care, evaluation, and teaching.

The nurse is caring for a debilitated client with a percutaneous endoscopic gastrostomy (PEG) tube that was inserted 3 days ago for the long-term administration of enteral feedings and medications. While the nurse is preparing to administer the feeding, the tube becomes dislodged. What is the most appropriate intervention? 1. Insert a Foley catheter into the existing tract and inflate the balloon 2. Insert a small-bore nasointestinal tube to administer feedings and medications 3. Notify the health care provider who inserted the PEG tube 4. Reinsert the PEG tube into the existing tract immediately

Option 3 A PEG is a minimally invasive procedure performed under conscious sedation. Using endoscopy, a gastrostomy tube is inserted through the esophagus into the stomach and then pulled through an incision made in the abdominal wall. To keep it secured, the PEG tube has an outer bumper and an inner balloon or bumper. The tube's tract begins to mature in 1-2 weeks and is not fully established until4-6 weeks. It begins to close within hours of tube dislodgement. The nurse should notify the health care provider who placed the PEG tube as early dislodgement (ie, <7 days from placement) requires either surgical or endoscopic replacement (Option 3). (Options 1 and 4) The insertion of a Foley catheter or immediate reinsertion of the PEG tube should not be attempted because the tube's tract is only 3 days old (immature). A reinserted tube could be placed inadvertently into the peritoneal cavity, leading to serious consequences such as peritonitis and sepsis. Therefore, these are not the most appropriate interventions. (Option 2) Small-bore nasointestinal tubes are used for short-term rather than long-term administration of enteral feedings. They are prone to clogging from enteral feedings, undissolved medications, and inadequate tube flushes. They can also kink, coil, and become dislodged by coughing and may require frequent reinsertion. Therefore, they are not the most appropriate intervention. Educational objective: A PEG tube's tract begins to mature in 1-2 weeks and is fully established in 4-6 weeks. Tube dislodgement <7 days from placement requires surgical or endoscopic replacement. Attempting to reinsert a tube through an immature tract can result in improper placement into the peritoneal cavity, leading to peritonitis and sepsis.

An elderly client with sepsis has a blood pressure 96/46 mm Hg, pulse 1 00/min, and respirations 28/min. Pulse oximetry (Sp02) shows 95% on nasal oxygen at 3 L/min. The client remains hypotensive after 2 fluid challenges with normal saline. Two hours later the Sp02 is 86°/o. What is the nurse's first action? 1. Increase oxygen flow rate 2. Notify the health care provider (HCP) of the drop in saturation 3. Reposition the pulse oximeter sensor 4. Request arterial blood gases to confirm the Sp02

Option 3 Educational objective: When pulse oximetry readings are altered, the nurse must determine if changes are associated with decreased perfusion, the effect of vasoactive drugs, excessive movement, or improper sensor placement and fit. The nurse can then take appropriate action.

When assessing a preterm newborn for cold stress, a graduate nurse in the newborn nursery needs further teaching when stating the need to assess for which finding? 1 . Irritability 2. Poor feeding 3. Shivering 4. Weak cry

Option 3 Explanation: Neonates are unable to generate heat by shivering due to their lack of muscle tissue and immature nervous systems; they therefore produce heat by increasing their metabolic rates through nonshivering thermogenesis. Brown adipose tissue (BAT), developed during the third trimester, is metabolized for thermogenesis when available. Once BAT is depleted, nonshivering thermogenesis is less effective and the neonate may experience cold stress, possibly leading to death. Preterm neonates have fewer stores of BAT and are at higher risk for cold stress. Frequent temperature monitoring is the best method to assess if an infant is cold. In cold stress, metabolism increases to generate heat, causing a greater demand for oxygen and glucose and the release of norepinephrine. If adequate oxygenation is not maintained, hypoxia and acidemia occur. Hypoglycemia develops when available glucose is depleted, and repletion of glucose is impaired by gastrointestinal immotility and poor oral intake. Clinical manifestations of cold stress include: • Neurological -altered mental status (irritability or lethargy) (Option 1) • Cardiovascular - bradycardia • Respiratory - tachypnea early, followed by apnea and hypoxia • Gastrointestinal- high gastric residuals, emesis, hypoglycemia (Option 2) • Musculoskeletal- hypotonia, weak suck and cry (Option 4) Educational objective: Premature infants are at high risk for cold stress due to decreased brown adipose tissue and inability to generate heat by shivering. The nurse should carefully assess for signs of cold stress, which include decreased temperature, altered mental status, bradycardia, hypoxia, hypotonia, and a weak cry and/or suck.

A nurse is preparing to administer oxytocin to induce labor in a client. The nurse recognizes that the oxytocin infusion can lead to which of the following? 1 . Decreased postpartum hemorrhage 2. Delayed milk production 3. Fetal distress and cesarean birth 4. High risk of placenta previa

Option 3 Explanation: Oxytocin (a uterine stimulant) is used to induce labor. Contractions can become too strong after oxytocin is used and lead to reduced placental blood flow. Reduced placental blood flow can result in non-reassuring fetal heart rate (FHR) patterns such as late decelerations, fetal bradycardia, tachycardia, or minimal variability. These non-reassuring FHR patterns may necessitate emergency cesarean birth, which would not have been required if the labor had not been induced. (Option 1) After birth, the nurse should observe for postpartum hemorrhage, especially if the client received oxytocin for a long period. The uterine muscles become fatigued and may not contract effectively to compress vessels at the placental site. (Option 2) Oxytocin is a hormone secreted by the pituitary that triggers the milk ejection/let-down reflex (release of milk from the alveoli into the ducts). Prolactin is the pituitary hormone that regulates milk production. Exogenous oxytocin has no known effects on milk production. (Option 4) Greater uterine activity from oxytocin increases the risk of placental abruption and uterine rupture. Placenta previa is abnormal implantation and is unrelated to oxytocin infusion. Educational objective: Oxytocin, a uterine stimulant, is frequently used to induce labor. Oxytocin infusion can result in quick delivery, but it increases the risk for an unnecessary cesarean birth (due to FHR abnormalities), postpartum hemorrhage, and placental abruption.

Which client in a prenatal clinic should the nurse assess first? 1. Client at 11 weeks gestation with backache and pelvic pressure 2. Client at 16 weeks gestation with earache and sinus congestion 3. Client at 27 weeks gestation with headache and facial edema 4. Client at 37 weeks gestation with white vaginal discharge and urinary frequency

Option 3 Gestational hypertension is new-onset high blood pressure (;::140/90 mm Hg) that occurs after 20 weeks gestation without proteinuria. The development of proteinuria with hypertension indicates preeclampsia, which may manifest with symptoms such as headache, visual disturbances, and facial swelling. This client is exhibiting symptoms of preeclampsia and should be assessed first {Option 3). Complications of preeclampsia may include thrombocytopenia, liver dysfunction, and renal insufficiency. Clients with preeclampsia must be monitored closely for sudden worsening, which can lead to serious complications, including eclampsia and/or HELLP syndrome {hemolysis, elevated liver enzymes, and low platelets). (Option 1) Backache and pelvic pressure are common discomforts of pregnancy. The enlarging uterus stretches the supporting ligaments and may cause increased backache. Fluid retention from increasing blood volume causes pelvic congestion, which may be reported as pelvic pressure. (Option 2) Earache and sinus congestion are common discomforts during pregnancy that result from increased blood volume and fluid retention. This client should be assessed to rule out sinus and/or ear infection, but this is not the highest priority. (Option 4) The increase in estrogen and progesterone during pregnancy often results in leukorrhea, a mucoid, white vaginal discharge. Pressure on the bladder from the fetal head during the third trimester may cause diminished bladder capacity and urinary frequency without dysuria. These are common and expected findings. Educational objective: The nurse should assess the client with symptoms of potentially serious complications first before assessing the remaining clients. Signs of hypertensive disorders during pregnancy may include headache and facial edema.

The nurse prepares to administer the prescribed 8 AM medications to 4 clients. The nurse should administer medication to which client first? 1) Client 2 days postoperative abdominal surgery who is to receive enoxaparin for venous thromboembolism prophylaxis 2) Client with hypertension who has a blood pressure of 196/98 mm Hg and is to receive IV hydralazine 3) Client with suspected sepsis who has a temperature of 102.3 F (39.1 C) and is to receive an initial dose of IV ceftazidime 4) 0 4. Client with type 2 diabetes mellitus and blood sugar of 500 mg/dl (27.8 mmoi/L) who is to receive subcutaneous regular insulin and insulin glargine

Option 3 Sepsis is a condition associated with a serious infection in the bloodstream. Evidence-based guidelines recommend the early administration of antibiotic therapy to reduce mortality. Cultures should be obtained quickly and antibiotics administered as soon as possible. Failure to treat early sepsis can lead to septic shock (persistent hypotension) and multiorgan dysfunction syndrome. (Option 1) Subcutaneous venous thromboembolism prophylaxis with enoxaparin following abdominal surgery is usually prescribed once every 24 hours, so administration is not urgent. (Option 2) This client has high blood pressure and needs treatment. However, this is not immediately life-threatening. If nausea, vomiting, and headache were also present, then the client would likely have hypertensive urgency or encephalopathy and need to be treated emergently. (Option 4) This client has high blood glucose and needs to be treated. However, it is not immediately life-threatening unless the client has hyperosmolar hyperglycemic syndrome or diabetic ketoacidosis

The nurse prepares to administer an IV infusion of potassium chloride through a peripheral vein to a client with hypokalemia. The health care provider's prescription states: IV potassium chloride 10 mEq (1 0 mmol)/1 00 mL 5o/o dextrose in water now, infuse over 30 minutes. What is the nurse's priority action? 1. Assess the patency of the peripheral IV site 2. Check the most current serum potassium level 3. Contact the health care provider to verify the prescription 4. Set the electronic IV pump to 100 mL/hr

Option 3 The recommended rates for an intermittent IV infusion of potassium chloride (KCI} are no greater than 10 mEq (1 0 mmol) over 1 hour when infused through a peripheral line and no greater than 40 mEq/hr (40 mmol/hr} when infused through a central line (follow facility guidelines and policy). If the nurse were to administer the medication as prescribed, the rate would exceed the recommended rate of 10 mEq/hr (1 0 mmol/hr) (ie, 10 mEq [1 0 mmol] over 30 minutes= 20 mEq/hr [20 mmol/hr]). A too rapid infusion can lead to pain and irritation of the vein and postinfusion phlebitis. Contacting the health care provider to verify this prescription is the priority action.

There has been a community disaster with multiple victims. Stable clients must be released to make room for the victims. Which clients would the nurse recommend as stable for discharge? Select all that apply. 1. Acute head injury with Glasgow Coma Scale of 12 2. Admitted with cirrhosis of liver with oozing esophageal varices 3. Asthma exacerbation with peak flow at 85% of personal best 4. Deep venous thrombosis on IV heparin with platelets 40,000/mm3 (40 x 1 09/L) 5. Myasthenia gravis with ptosis in the evening

Option 3, 5 The best indication of moving air in a client with asthma is peak flow. The results are categorized as green (~80o/o of personal best and good control), yellow (50%-79% of personal best and caution), and red {<50% of personal best- a medical alert). This client is currently in good control. Other findings to note include effortless breathing, no cough or wheeze, and sleeping well all night {Option 3). Myasthenia gravis is an autoimmune disease in which antibodies attack acetylcholine receptors. This results in weakness in skeletal muscles, especially in the bulbar region that involves eye movement, swallowing/speaking, and breathing. Such clients become more exhausted as the day progresses. The client can be discharged home as ptosis is an expected finding {Option 5). {Option 1) Normal Glasgow Coma Scale is 15; a score of 12 indicates impairment requiring further care. {Option 2) The varices oozing blood are at risk for rupture and/or increasing ammonia (from the digestion of protein in the blood). This client needs treatment. {Option 4) Normal platelet count is 150,000-400,000/mm3 (150-400 x 1 09/L). A potential complication of heparin therapy is thrombocytopenia. The client is at risk for paradoxical thrombosis (eg, stroke, arterial clots) and, rarely, bleeding. Educational objective: Clients with an acute head injury and a Glasgow Coma Scale of 12, thrombocytopenia while on heparin, or oozing varices in cirrhosis are not stable for discharge.

A category 4 hurricane has disrupted a rural local health care system, creating a significant increase in emergency department admissions. Which client would the nurse assess first? 1. 55-year-old with type 2 diabetes mellitus complaining of a headache after being involved in a minor motor vehicle accident ' 2. 45-year-old with type 1 diabetes mellitus with a blood glucose of 690 mg/dl (38.3 mmoi/L) complaining of abdominal pain and fatigue 3. 7-year-old with status asthmaticus and an oxygen saturation of 89% 4. 34-year-old with gestational diabetes, 11 weeks pregnant, who has not been able to "hold anything down" due to nausea and vomiting over the past 2 days

Option 3. Explanation: The child with status asthmaticus is at risk for rapid deterioration of respiratory status and respiratory failure. The clinical finding of decreased oxygen saturation (normal reference is ~95o/o) indicates mild-to-moderate status asthmaticus. This client needs to be treated immediately. {Option 1) This client needs assessment and monitoring of neurological functioning following head trauma. The client is currently stable and has the least priority at this time. Development of altered mental status, spinal pain, nausea, vomiting, or loss of consciousness would shift the status to a higher priority. {Option 2) The clinical findings of fatigue, abdominal pain, and blood glucose level of 690 mg/dL (38.3 mmoi/L) indicate developing diabetic ketoacidosis. This client is at risk of life-threatening hemodynamic instability and needs immediate treatment. However, the client can be seen after the child with status asthmaticus and impending respiratory deterioration. (Severe respiratory instability takes precedence over hemodynamic instability.) {Option 4) This client's history is indicative of dehydration. She needs restoration of normal fluid balance, but she is not at risk of impending severe respiratory or hemodynamic instability, as are clients 3 and 2. Educational objective: Children age <1 0 should automatically be upgraded to 1 level higher than the triaged urgency of their medical! issues. The combination of status asthmaticus and an oxygen saturation ~92% qualifies for the highest priority level of triage at any age.

A client gives birth within an hour of arriving at the labor and delivery unit, and delivers the placenta 5 minutes later. During assessment, the nurse notes that the client's uterus is boggy and midline. Which action should the nurse take first? 1 . Administer IV oxytocin 2. Insert in and out catheter 3. Monitor amount of lochia 4. Perform fundal massage

Option 4 After delivery of the placenta, the uterus begins the process of involution. A boggy uterus indicates uterine atony, a state in which the uterus fails to contract adequately. The uterus should be firmly contracted, midline, and at or slightly below the umbilicus. Excessive blood loss may occur if vessels at the placental detachment site fail to constrict. The initial nursing action for uterine atony with a midline fundus is fundal massage, which stimulates contraction of the uterine smooth muscle (Option 4). If the uterus becomes firm with massage, the nurse should monitor uterine tone, position, and lochia at least every 15 minutes in the initial hour after birth. (Option 1) Uterotonics (eg, oxytocin, misoprostol, methylergonovine) stimulate the uterus to contract and encourage involution. If the uterus fails to become or remain contracted after massage, the next step is uterotonic administration. (Option 2) Bladder distension may interfere with uterine contractility and should be suspected if the fundus is elevated above the umbilicus and/or deviated to the right. The nurse should encourage the client to void soon after birth to prevent bladder distension. (Option 3) Lochia should be monitored frequently in the immediate postpartum period. However, in the presence of uterine atony, fundal massage should be performed even if lochia is minimal. Uncorrected uterine atony will eventually result in excessive blood loss. Educational objective: After placenta delivery, the fundus should be firm, midline, and at or slightly below the umbilicus. The initial nursing action to correct uterine atony with a midline, boggy uterus is fundal massage.

Based on the lung assessment information included in the hand-off report, which client should the nurse assess first? 1. Client 1-day postoperative abdominal surgery who has fine inspiratory crackles at the lung bases 2. Client with chronic bronchitis who has rhonchi in the anterior and posterior chest 3. Client with right-sided pleural effusion who has decreased breath sounds at the right lung base 4. Client with severe acute pancreatitis who has inspiratory crackles at the lung bases [45%]

Option 4 Explanation: Clients with acute pancreatitis can develop respiratory complications including pleural effusions, atelectasis, and acute respiratory distress syndrome (ARDS). These complications are often due to activated pancreatic enzymes and cytokines that are released from the pancreas into the circulation and cause focal or systemic inflammation. ARDS is the most severe form of these complications and can rapidly progress to respiratory failure within a few hours. Therefore, the presence of inspiratory crackles in this client could indicate early ARDS and needs to be assessed further for progression. (Option 1) Fine crackles are a series of distinct, discontinuous, and high-pitched snapping sounds usually heard on inspiration. The sound originates as small atelectatic bronchioles quickly reinflate and can be expected in clients who have undergone abdominal surgery due to shallow breathing related to pain. Although the presence of fine crackles requires treatment (eg, ambulation, deep breathing), this is not the priority assessment. (Option 2) Rhonchi are continuous, low-pitched wheezes usually heard on expiration that sound like moaning or snoring. The sound originates from air moving through large airways (bronchi) filled with mucus secretions and are expected in clients with chronic bronchitis. Although they require treatment (eg, medication, mobilization of secretions), this is not the priority assessment. (Option 3) The lung under the pleural effusion is compressed, and the breath sounds are decreased/absent if auscultated over the area; this is an expected finding. Until the pleural effusion is treated with diuretics or thoracentesis, these findings will remain unchanged. Educational objective: Clients with acute pancreatitis are at high risk for developing acute respiratory distress syndrome.

When triaging 4 pregnant clients in the obstetric clinic, the nurse should alert the health care provider to see which client first? 1. First-trimester client reporting frequent nausea and vomiting 2. Second-trimester client with dysuria and urinary frequency 3. Second-trimester client with obesity reporting decrease in fetal movement 4. Third-trimester client with right upper quadrant pain and nausea

Option 4 Explanation: Right upper quadrant (RUQ) or epigastric pain can be an indicator of HELLP syndrome, a severe form of preeclampsia. HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelet count) is often mistaken for viral gastroenteritis due to its variable and nonspecific presentation. Misdiagnosis may lead to severe complications (eg, placental abruption, liver failure, stroke) and/or maternal/fetal death. Clients may have RUQ pain, nausea, vomiting, and malaise. Headache, visual changes, proteinuria, and hypertension may or may not be present. (Option 1) Nausea and vomiting during the first trimester are normal, expected findings. Vomiting that continues past the first trimester or that is accompanied by fever, pain, or weight loss is considered abnormal and requires intervention. (Option 2) Although urinary frequency is common in pregnancy, dysuria could indicate a urinary tract infection. This client should be evaluated but does not take priority over a client with symptoms of HELLP. (Option 3) Maternal perception of fetal movement can be altered by obesity, maternal position, fetal sleep cycle, fetal position, anterior placenta, and amniotic fluid volume (increased or decreased). This client should be evaluated to determine the cause of decreased fetal movement; however, this is not the priority. Educational objective: HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelet count) is a severe form of preeclampsia. Its clinical presentation can be quite variable and may include nonspecific symptoms such as right upper quadrant/epigastric pain, nausea, vomiting, and malaise.

A client in the critical care unit has a central venous catheter (CVC). The site around the CVC becomes red and inflamed. The client reports chills and nausea and has a temperature of 102 F (38.8 C). The nurse should prepare to implement which prescription first? 1. Administer broad-spectrum intravenous (IV) antibiotic through a new IV site 2. Document the occurrence and notify the hospital's infection control nurse 3. Give ondansetron (Zofran) 4 mg IV push to relieve client's nausea 4. Obtain blood cultures and send tip of the discontinued CVC to the lab for culture

Option 4 Explanation: The client is exhibiting signs and symptoms (eg, fever, chills, nausea) of septicemia (blood infection). Other findings include a subnormal body temperature instead of fever, hypotension, tachycardia, decreased urine output, and confusion. Although eves are warranted to provide important treatment for many clients, they are often a source of infection that can lead to sepsis and septic shock. It is most important to obtain a culture and sensitivity first so that the specific pathogen can be identified prior to starting antibiotics. Identification of the specific pathogen and the antibiotics to which it is sensitive will allow the health care provider (HCP) to determine the best antibiotic for treatment. If the culture is obtained after antibiotic administration, the results will be altered. In addition to obtaining blood cultures x 2, it is standard procedure to cut off the tip of the discontinued eve and send it to the lab to ensure it is the source of the septicemia. Broad-spectrum antibiotics are often prescribed after cultures are obtained to begin treatment and prevent progression to septic shock {Option 1). {Option 2) It is important to document this occurrence in the client's medical record and to follow hospital protocol for reporting infections. However, implementation of client care is a priority. {Option 3) Ondansetron may be administered for nausea symptoms. However, treatment of the cause is the most effective way to reduce symptoms; it is a life-saving measure and therefore the priority.

The nurse is caring for a client with acute pancreatitis. Which subjective and objective assessments would the nurse report immediately? 1. Client is lying with knees drawn up to the abdomen and trunk flexed 2. Client states, "My lips are tingling and numb." 3. Foul-smelling, fatty stool 4. Temperature of 102.2 F (39 C) and increasing abdominal pain

Option 4 Explanation: Time: 2 seconds Updated: 07/17/2017 A high-grade fever or abrupt increase in temperature with worsening abdominal pain could be an indication of a pancreatic abscess, a significant complication of acute pancreatitis. A pancreatic abscess requires immediate intervention (eg, antibiotics, surgical drainage) to reduce the risk of rupture and sepsis; therefore, the health care provider should be notified immediately (Option 4). (Option 1) Clients with acute pancreatitis will position themselves in a side-lying position with knees drawn up to the abdomen and trunk flexed to decrease the pain. (Option 2) An early indicator of hypocalcemia, a possible electrolyte disorder of pancreatitis, is numbness and tingling of the lips and fingers. The nurse should further evaluate the client for possible signs of tetany by assessing for a positive Chvostek's sign or Trousseau's sign. Once further assessment is completed, the findings should be reported. (Option 3) The stool in acute pancreatitis is expected to be fatty and foul-smelling. Educational objective: An abrupt increase in temperature or high-grade fever during an episode of acute pancreatitis must be reported to the health care provider immediately as this may be an indication of a pancreatic abscess. The abscess must be treated promptly to prevent sepsis.

The nurse is assessing a client who had an esophagogastroduodenoscopy (EGO) 2 hours ago. Which finding requires an immediate report to the health care provider? 1. Blood pressure drop from 122/88 mm Hg to 106/72 mm Hg 2. Gag reflex has not returned 3. Sore throat when swallowing 4. Temperature spike to 101.2 F (38.4 C)

Option 4 Explanation: Time: 3 seconds Updated: 04/26/2017 A sudden temperature spike 1-2 hours after an esophagogastroduodenoscopy (EGO) could be a sign of perforation or a developing infection. The nurse should notify the health care provider immediately. (Option 1) This blood pressure drop could be due to several things (sedation, blood loss, sepsis), but without any other symptoms indicating an emergency condition, it is still within the normal range. (Option 2) The gag reflex may take a few hours to return as the EGO involves applying a topical anesthetic to the throat. Absent gag reflex after a prolonged period (6 hours) would require reporting to the health care provider. (Option 3) A sore throat is expected after certain procedures (EGO, intubation) due to local irritation. Warm saline gargles could provide some relief. Educational objective: Fever after an esophagogastroduodenoscopy (EGO) or colonoscopy could be a sign of infection from perforation and should be reported.

When making assignments in the labor and delivery unit, the charge nurse should assign the most experienced newborn admit nurse to attend to the birth of which client? 1. Client with diet-controlled gestational diabetes 2. Client with mild preeclampsia and blood pressure averaging 140/90 mm Hg 3. Client with premature rupture of membranes 6 hours ago at 37 weeks gestation 4. Client with spontaneous rupture of membranes with greenish amniotic fluid

Option 4 Green amniotic fluid indicates that the fetus has passed its first stool (meconium) in utero. Meconium-stained amniotic fluid places the newborn at risk for meconium aspiration syndrome, a type of aspiration pneumonia. A skilled neonatal resuscitation team should be present at the birth of any newborn with meconium-stained fluid for immediate evaluation and stabilization (Option 4). Previously, endotracheal (ET) suctioning was recommended for nonvigorous newborns (eg, depressed respirations, decreased muscle tone, heart rate <100/min) born with meconium-stained fluid; however, recent guidelines indicate that routine ET suctioning is no longer necessary. (Option 1) Neonates born to mothers with gestational diabetes are at risk for hypoglycemia after birth and should be monitored closely during the first 6 hours of life. The risk of newborn hypoglycemia is lower if the mother's diabetes is well-controlled and not insulin-dependent. (Option 2) Clients with severe preeclampsia may need magnesium sulfate therapy for seizure prevention. Maternal magnesium therapy can cause newborn respiratory depression at birth. However, this client's mild preeclampsia does not require magnesium therapy. (Option 3) Premature rupture of membranes (PROM) refers to the rupture of membranes prior to the onset of labor at term gestation (~37wk Od). PROM on its own does not harm the fetus. However, if labor does not begin after PROM, induction of labor may be necessary to decrease the risk for infection (eg, chorioamnionitis). Educational objective: Meconium-stained amniotic fluid places the newborn at risk for meconium aspiration syndrome. A skilled neonatal resuscitation team should be present at birth for immediate newborn evaluation and stabilization.

An elderly client with hypothyroidism is brought to the emergency department for depressed mental status. The client lives alone but has not taken medications for several months or seen a health care provider. Which action should the nurse take first? Vital signs Temperature: 95 F (35 C) Blood pressure: 90/50 mm Hg Heart rate: 50/min Respirations: 37/min 02 saturation: 83% 1. Administer IV levothyroxine 2. Check serum thyroid-stimulating hormone, T3 and T4 3. Place a warming blanket on the client 4. Prepare for endotracheal intubation

Option 4 Myxedema coma is a complication associated with progression of symptoms of hypothyroidism from lethargy and mental sluggishness to a coma state. This client has hypothermia, bradycardia, hypotension, and depressed mental status. Hypothyroidism can also cause hypoventilation due to central depression of respiratory drive, respiratory muscle fatigue, and mechanical obstruction by a large tongue. This client exhibits signs of acute respiratory distress (increased respirations, very low oxygen saturation). Therefore, life-saving measures to facilitate respiratory support, such as mechanical ventilation, must be implemented first. Other treatments include thyroid hormone replacement with levothyroxine (Synthroid) IV push (Option 1), heating warming the client with a warming blanket (Option 3), and frequent diagnostics of the thyroid, including a serum thyroid panel (Option 2). Educational objective: Myxedema coma is a complication associated with progression of hypothyroidism symptoms. The highest-priority intervention is respiratory support for the client exhibiting signs of acute respiratory distress.

The nurse is caring for 4 clients. Based on the assessment data, which client does the nurse anticipate the health care provider transferring to the intensive care unit? 1. 36-year-old with alcohol abuse who is prescribed IV lorazepam every 3 hours for agitation and has a blood pressure of 190/98 mm Hg and serum magnesium level of 1.5 mEq/L (0. 75 mmoi/L) 2. 56-year-old with stable angina who has chest and jaw pain relieved with nitroglycerin, blood pressure of 98/70 mm Hg, and dizziness when getting up 3. 60-year-old with chronic kidney disease who has a blood pressure of 168/88 mm Hg, serum creatinine level of 5.0 mg/dl (442 J,Jmoi/L), and reports nausea and itching 4. 82-year-old with pressure (decubitus) ulcer who has a change in mental status, temperature of 96.4 F (35.8 C), pulse of 11 0/min, and blood pressure of 96/72 mm Hg

Option 4 Sepsis is a potentially life-threatening condition. Physiologic changes related to the aging process, including decreased immune function and inflammatory response (immunosenescence) and altered febrile response to pyrogens, increase the risk for sepsis. Although evidence indicates that early recognition of sepsis is critical to survival, atypical presentation associated with immunosenescence and absence of fever can delay diagnosis and treatment. Hypothermia in the presence of altered mental status, tachycardia, and borderline low blood pressure should alert the nurse to the possibility of early sepsis. Transfer to the intensive care unit for evaluation, continual monitoring, and evidenced-based treatment measures (ie, sepsis bundles) should be anticipated. Pressure ulcer could be the likely source of bacteremia in this client. (Option 1) Hypertension, agitation, and anxiety associated with catecholamine release are expected. The serum magnesium level is normal (1.5-2.5 mEq/L [0.75-1.25 mmoi/L]). (Option 2) Chest and jaw pain relieved with sublingual nitroglycerin and orthostatic hypotension (an adverse effect of nitrate drugs) are expected. (Option 3) Hypertension, elevated serum creatinine level (normal: 0.6-1.3 mg/dl [53-115 !Jmoi/L]), nausea associated with azotemia, and pruritus associated with dry skin are expected for chronic kidney disease clients. Educational objective: Hypothermia can be the presenting feature of sepsis in elderly clients.

A nurse reviews the most current serum laboratory results for assigned clients. Which result is the highest priority to report to the health care provider? 1. Albumin of 3.0 g/dL (30 g/L) in a client with chronic hepatitis 2. B-type natriuretic peptide of 400 pg/mL (400 pmoi/L) in a client with heart failure 3. Magnesium of 1.7 mEq/L (0.85 mmoi/L) in a client with alcohol withdrawal 4. Sodium of 120 mEq/L (120 mmoi/L) in a client with small cell lung cancer

Option 4 Syndrome of inappropriate antidiuretic hormone secretion (SIADH) is often caused by the ectopic production of ADH by a malignant lung tumor (eg, lung cancer). Increased ADH leads to increased water reabsorption and intravascular volume, which results in dilutional hyponatremia. Severe neurologic dysfunction (eg, confusion, seizures) can occur when serum sodium drops below 120 mEq/L (120 mmoi/L) (normal: 135-145 mEq/L [135-145 mmoi/L]). Therefore, hyponatremia is the highest priority to report as it poses the greatest threat to survival. Hyponatremia requires immediate evaluation and treatment (eg, seizure precautions, fluid restriction, intravenous hypertonic saline) by the health care provider. (Option 1) Albumin (normal: 3.5-5.0 g/dl [35-50 g/L]) is a protein formed in the liver. Hepatocytes lose the ability to synthesize albumin when the cells are diseased. Hypoalbuminemia {<3.5 g/dl [<35 g/L]) should be expected in this client. (Option 2) 8-type natriuretic peptide (BNP) (normal: <1 00 pg/ml [1 00 pmoi/L]) is a substance secreted from the cardiac ventricles in response to increases in ventricular pressures and volume. Therefore, BNP is a marker for heart failure and is elevated in clients with both stable and decompensated heart failure. BNP is an expected finding in this client. (Option 3) Clients in alcohol withdrawal usually require magnesium supplements. Hypomagnesemia {<1.5 mEq/L [<0.75 mmoi/L]) results from poor dietary intake, malnutrition, and increased renal excretion, and is common in clients with chronic alcoholism. This finding is within normal limits (normal: 1.5-2.5 mEq/L [0.75-1.25 mmoi/L]).

A nurse is assisting a new mother as she is breastfeeding her infant. The infant has been diagnosed with tetralogy of Fallot. During feeding, the infant becomes cyanotic and is having difficulty breathing. What should be the nurse's first action? 1 . Administer morphine to the infant 2. Administer oxygen via mask 3. Assess infant's vital signs and pulse oximetry 4. Place the infant in the knee-chest position

Option 4 Tetralogy of Fallot is a congenital cardiac defect that typically has 4 characteristics: pulmonary stenosis, right ventricular hypertrophy, overriding aorta, and ventricular septal defect. This infant is experiencing a hypercyanotic episode, or "tet spell," which is an exacerbation of tetralogy of Fallot that can happen when a child cries, becomes upset, or is feeding. The child should first be placed in a knee-to-chest position. Flexion of the legs provides relief of dyspnea as this angle improves oxygenation by reducing the volume of blood that is shunted through the overriding aorta and the ventricular septal defect. (Option 1) Morphine may be considered if the dyspnea is not relieved by the knee-to-chest position. (Option 2) If oxygen saturation remains low, oxygen may need to be administered. (Option 3) Vital signs and pulse oximetry may be checked after the infant has been placed in the knee-chest position. Educational objective: To relieve a hypercyanotic episode, or "tet spell," the nurse should place the infant or child in the knee-chest position.

A client is admitted with severe acute pancreatitis. While obtaining the client's blood pressure, the nurse notices a carpal spasm. What laboratory result would the nurse assess in response to this symptom? 1 . Decreased albumin 2. Elevated troponin 3. Hyperkalemia 4. Hypocalcemia

Pancreatitis is an acute inflammation of the pancreas that results in autodigestion. The most common causes are cholelithiasis and alcoholism. Classic presentation includes severe epigastric pain radiating to the back due to the retroperitoneal location of the pancreas. The pancreatic enzymes (amylase and lipase) are elevated. Serious complications to monitor for include hyperglycemia, hypovolemia (capillary leak~ third spacing), latent hypoxia or acute respiratory distress syndrome (ARDS), peritonitis, and hypocalcemia. Pancreatitis can cause hypocalcemia, but the etiology is unclear. Chvostek's (facial twitching) and Trousseau's (carpal spasm) signs are an indication of hypocalcemia from the decrease in threshold for contraction. Sustained muscle contraction (tetany) and decreased cardiac contractility (cardiac arrhythmia) are concerns related to hypocalcemia. {Option 1) Decreased albumin levels are seen with malnutrition; clients who are alcoholics can have low serum albumin but that alone is not responsible for the client's symptom. {Option 2) Troponin elevation is specific to myocardial infarction and is unrelated to pancreatitis. {Option 3) Potassium abnormalities are not usually present in acute pancreatitis. They are more likely to occur with hemolysis, when the intracellular potassium enters the serum. The ecchymoses in pancreatitis (Grey Turner's sign, Cullen's sign) are due to the bloodstained exudates from autodigestion and are usually only seen in severe cases. Educational objective: Complications of acute severe pancreatitis include hyperglycemia, hypocalcemia, hypovolemia, and ARDS. Trousseau's (carpal spasm) and Chvostek's (facial twitching) signs are an indication of hypocalcemia from the decrease in threshold for contraction

A nurse in the neonatal intensive care unit discovers a cyanotic newborn with excessive frothy mucus in the mouth. What should be the nurse's first action? 1 . Administer 100% oxygen 2. Auscultate the lungs 3. Place infant in knee-chest position 4. Suction the infant's mouth

Option 4 The initial nursing action for a client experiencing cyanosis and excess oral secretions is suctioning the mouth (ie, oropharynx) to clear the airway (Option 4). Excessive frothy mucus and cyanosis in a newborn could be due to esophageal atresia (EA) and tracheoesophageal fistula (TEF). If EAJTEF is suspected, the infant should be kept supine with the head elevated at least 30 degrees to prevent aspiration. A nasogastric tube should be inserted and connected to continuous or intermittent suction until surgical repair. (Option 1) Oxygen cannot be delivered to the lungs if secretions obstruct the airway. Therefore, suctioning is a priority. (Option 2) This infant is aspirating and in immediate distress, which should be addressed without delay. After suctioning the excess saliva and ensuring a clear airway, the nurse may perform further assessments. (Option 3) This infant's cyanosis is a result of aspirating secretions and does not indicate a circulatory problem. The knee-chest position is appropriate to increase pulmonary blood flow in infants with a cyanotic heart defect (eg, tetralogy of Fallot). Educational objective: The initial nursing action for a client experiencing cyanosis and excess oral secretions is oropharyngeal suctioning to ensure airway patency.

The nurse receives a report on the assigned clients for the shift. Which client should the nurse assess first? 1. 1-day postoperative client with lower abdominal pain and no urine output for 6 hours 2. An elderly client with blood pressure 190/88 mm Hg who is asymptomatic 3. Client with hepatitis C virus who has alanine aminotransferase/aspartate aminotransferase (ALT/AST) values 4 times the normal value 4. Client who underwent thyroidectomy yesterday and now has positive Trousseau's sign

Option 4 The prioritization principle is that systemic symptoms are more important than local symptoms. Trousseau's sign (carpal spasm with blood pressure cuff inflation) indicates hypocalcemia. This is a known risk after a thyroidectomy as the parathyroid gland can be inadvertently removed during the surgery due to its very small size. Acute hypocalcemia can cause tetany, laryngeal stridor, seizures, and cardiac dysrhythmias. Assessing this client is a priority over pain or expected findings. (Option 1) This client likely has postoperative urinary retention and needs to be evaluated as soon as possible (second in priority). Although, this condition is painful and could result in kidney injury, it is not immediately life-threatening. (Option 2) This client has isolated systolic hypertension, which is common in elderly clients and they are often asymptomatic. Systolic blood pressure is usually >160 mm Hg but diastolic blood pressure is <90 mm Hg. Treatment might benefit these clients, but this is not a priority. (Option 3) ALT and AST are enzymes released when hepatocytes are destroyed as part of the hepatitis pathology. Hepatitis is diagnosed when these enzymes are ~2-3 times the normal value. The hepatitis C virus usually causes chronic infection. The client's acuity is not directly related to the level of enzymes; this client is not more seriously ill because the enzymes are higher than a client whose labs results are twice the normal value. This is an expected finding and is not a priority. Educational objective: Acute hypocalcemia can be life-threatening due to seizures, tetany (laryngeal stridor), and cardiac arrhythmias. Inadvertent removal of the oarathvroid a land can result in raoid develooment of severe hypoocalcemia.

A client at 38 weeks gestation is in labor and receiving an oxytocin infusion. The continuous fetal heart rate (FHR) monitor displays 2 early decelerations, 3 accelerations, and minimal variability with a baseline FHR of 140/min. 1 . Discontinue oxytocin infusion 2. Place client in the side-lying position 3. Provide oxygen 1 0 L/min via face mask 4. Review medication administration record

Option 4. Explanation: The baseline FHR is normal (110-160/min), and occasional accelerations and early decelerations are reassuring findings. In the presence of these findings, minimal variability may indicate temporary fetal sleep (usually <30 minutes) or central nervous system (CNS) depression. The nurse should first check the medication administration record for recently administered CNS depressants (eg, opioid analgesics). However, minimal or absent variability requires further assessment if accompanied by late decelerations, as it may indicate fetal hypoxemia or acidosis. (Options 1, 2, and 3) Late decelerations indicate utero-placental insufficiency and require nursing interventions to prevent complications. The nurse should place the client in a side-lying position to relieve pressure on the vena cava and place oxygen via face mask to increase placental perfusion. Late decelerations indicate that the fetus is not tolerating the contractions and oxytocin (Pitocin), a medication that stimulates contractions, should be stopped. Educational objective: FHR of 110-160/min, occasional accelerations, and early decelerations are components of a reassuring FHR pattern. Minimal variability usually indicates fetal sleep or the effects of CNS depressants. Late decelerations with minimal variability indicate uteroplacental insufficiency and require further assessment and intervention.

The registered nurse is triaging pediatric clients in the emergency department. Which client is a priority for diagnostic testing and definitive care? 1. 4-year-old with right-sided abdominal mass reporting fatigue 2. 5-year-old with chronic constipation reporting abdominal pain and no bowel movement for 2 days 3. 1 0-year-old with sickle cell anemia reporting generalized pain of "1 0" and brownish urine 4. 13-year-old with type 1 diabetes reporting nausea, vomiting, and abdominal pain

Option 4: Explanation: A client with type 1 diabetes experiencing nausea, vomiting, and abdominal pain is a priority due to the possibility of diabetic ketoacidosis (DKA). Medication (insulin) noncompliance is common in teenagers. The body breaks down fat for fuel and the resulting byproducts, acidic ketones, can cause abdominal pain. Osmotic diuresis (polyuria) results from the elevated glucose levels. The client experiences rapid respirations (Kussmaul's sign) that help compensate for the metabolic acidosis by blowing off carbon dioxide. DKA is a serious condition that can lead to death. If it is ruled out, other pathologies (eg, appendicitis) should be explored. (Option 1) A 4-year-old with an abdominal mass and fatigue likely has Wilms' tumor. Unnecessary abdominal palpation should be avoided to prevent tumor spillage. This client is not the first priority. (Option 2) This child with chronic constipation likely has a stool impaction. The child may need an enema or suppository. (Option 3) This child is experiencing vasoocclusive crisis, which is caused by the occlusion of blood vessels from the sickling of red blood cells when a person with sickle cell disease is exposed to a trigger. Vasoocclusion leads to ischemia and severe pain. Bilirubin released from the destroyed red blood cells results in jaundice and a brownish hue to the urine. These are expected findings. Treatment includes fluids, analgesics, oxygen, folic acid, and blood transfusion (if needed}.

The nurse is making assignments for the next shift. Which client should the nurse assign to the new nurse coming out of orientation? 1. Client diagnosed with chronic anemia receiving iron via IV route [53%] 2. Client newly admitted for uncontrolled diabetes mellitus type 2 with blood glucose >600 mg/dl (33.3 mmoi/L) [3o/o] 3. Client undergoing ultrafiltration for congestive heart failure [3°/o] .4. Client with a prescription for routine hemodialysis who has chronic renal failure [40o/o]

Option 4: Explanation: The nurse is looking for the most stable client to assign to the new nurse. The client who is scheduled for hemodialysis has a chronic disorder and receives this therapy on a regular basis. There is no indication that this client might be unstable. (Option 1) There is a high incidence of IV iron causing hypersensitivity reactions, including anaphylaxis. Therefore, a test dose needs to be given first. This client should be assigned to a more experienced nurse. (Option 2) The client with hyperglycemia is at high risk for diabetic ketoacidosis or hyperglycemic hyperosmolar non ketotic coma. Both are associated with acute and chronic complications and require careful assessment and prompt nursing intervention. This client should also be assigned to a more experienced nurse. (Option 3) Ultrafiltration (removal of excess fluid) is a complex task that requires extra training to perform. It is performed for clients who are not responding to IV diuretics. In addition, clients receiving ultrafiltration are more likely to be hemodynamically unstable due to their advanced heart failure; therefore, it is better for these clients to receive care from an experienced nurse.

A client underwent extracorporeal shock wave lithotripsy with ureteral stent placement for kidney stones. What information should the nurse give to the client at the time of discharge? Select all that apply. 1 . Increase fluid intake to flush out fragments of the stones 2. Report any blood in the urine 3. Report any bruising on the back or abdomen 4. Report any fever or chills 5. Stay in bed for at least 48 hours, getting up only to urinate

Options 1 and 4 Explanation: Extracorporeal shock wave lithotripsy (ESWL) is a noninvasive procedure used to break up kidney stones. It is typically done on an outpatient basis, although the client will require local or general anesthesia. The shock waves break up the stone(s) into a fine sand that can then be excreted in the urine. Ureteral stents are often placed after the procedure to help with the passage of the sand and prevent buildup within the ureter. The stents are removed within 1-2 weeks. The client will be encouraged to drink large amounts of fluids to facilitate washing out of the stone fragments and sand created by the shock waves (Option 1). Infection is a serious complication after the procedure as the breakup of stones can release organisms and cause sepsis (Option 4). Pain can be severe and require analgesics. (Option 2) Hematuria is common, and the urine should go from bright red to pink-tinged over several hours. Hematuria is concerning if the urine remains bright red over a prolonged period (>24 hr). (Option 3) Bruising on the back or abdomen after the procedure is normal. (Option 5) The client may need to rest for the remainder of the day following anesthesia, but ambulation is encouraged to facilitate removal of stone fragments.

Which of the following nursing interventions would the nurse implement when caring for a client newly diagnosed with acute viral hepatitis? Select all that apply. 1 . Administer antiemetic medications as needed 2. Encourage a good breakfast and small, frequent meals 3. Promote rest periods alternating with periods of activity 4. Provide a diet high in protein and low in fat 5. Teach the client to abstain from alcohol

Options 1, 2, 3, and 4 Explanation: Inflammation of the liver is present in acute viral hepatitis. Liver functions (eg, detoxifying the blood, manufacturing bile for lipid digestion) are disrupted, leading to signs and symptoms in various body systems. These include the digestive (eg, nausea, vomiting, anorexia, right upper-quadrant tenderness), urinary (eg, dark-colored urine), musculoskeletal (eg, fatigue, arthralgia, myalgia), and integumentary (eg, pruritus, jaundice) systems. Nursing interventions for the acute phase of hepatitis focus on resting the liver and providing nutrition for healing: 1. Rest o Alternate periods of rest and activity (Option 3) o Avoid alcohol and other drugs that increase liver metabolism (Option 5) o Medications (eg, appetite stimulants, antipruritics, analgesics) should be used cautiously to allow hepatocytes to heal. Antiemetics can be used to prevent nausea (Option 1 ). 2. Nutrition o Encourage small, frequent meals to decrease nausea. Anorexia is lowest in the morning; promote eating a larger breakfast (Option 2). o Provide oral care and avoid extremes in food temperature to increase appetite o Drink adequate amounts of fluid (2500-3000 mUday) and encourage a diet high in carbohydrates and calories (Option 4) Clients with acute hepatitis should eat a diet high in calories and carbohydrates while decreasing fat and protein consumption. The liver produces bile, which aids in lipid digestion. A high-protein diet produces more ammonia and other toxic substances and the inflamed liver may not detoxify these well. Moderation of fat and protein intake allows the liver to rest. Educational objective: Acute viral hepatitis is treated with supportive measures, including rest (alternate activity and rest), avoiding alcohol and hepatotoxic medications, and adequate nutrition (increase calories and carbohydrates; eat small, frequent meals). Clients should reduce their consumption of fats and proteins, which increase liver metabolism.

The nurse is caring for a newly admitted client with worsening cerebral edema from increased intracranial pressure (ICP). The client is intubated and is on mechanical ventilation. Which of the following nursing interventions may help reduce ICP? Select all that apply. .1. Hyperventilate before and after suctioning 2. Maintain a quiet environment .3. Maintain neutral midline head positioning 4. Perform as many nursing interventions as possible together 5. Suction for 30 seconds to remove endotracheal tube secretions at regular intervals

Options 1, 2, and 3 Most nursing activities will increase ICP in critically ill clients. The goal of treatment is to reduce ICP while still managing the client's basic needs. During interventions, ICP should not exceed 25 mm Hg and should return to baseline within a few minutes before continuing with nursing care. Nursing interventions should be performed in small clusters and spaced out during the shift (Option 4). Metabolic demands such as pain, straining, agitation, shivering, fever, hypoxia, and seizures also increase brain blood supply and raise ICP. Important nursing interventions to control these include the following: • Elevate head of the bed to 30 degrees with the head in a neutral position (Option 3) • Administer stool softeners to reduce the risk of Valsalva maneuver • Manage pain well without sedating the client too much • Treat fever aggressively (cool sponges) but avoid having the client shiver or shake • Keep the client in a calm environment with minimal noise and disturbances (eg, alarms, television, hall noise) (Option 2) • Ensure adequate oxygenation to the brain (avoid hypoxia) • Hyperventilate and preoxygenate the client for brief periods such as before suctioning to help reduce ICP. C02 is a potent cerebral vasodilator. Reducing C02 by hyperventilation causes vasoconstriction and reduces ICP (Option 1 ). • Administer medications as prescribed by the health care provider to reduce ICP; these include mannitol and corticosteroids. Mannitol is an osmotic diuretic that can help reduce cerebral edema and ICP through use of a hyperosmolar solution to draw water from the brain and extracellular fluid, allowing for excretion. (Option 5) Suctioning should occur for a maximum of 10 seconds and only as necessary to remove secretions. Prolonged suctioning increases ICP. Educational objective: Metabolic demands such as pain, straining, agitation, shivering, fever, hypoxia, and seizures increase brain blood supply and raise ICP. Nursing interventions should focus on preventing these.

A client at 38 weeks gestation is brought to the emergency department after a motor vehicle crash. She reports severe, continuous abdominal pain. The nurse notes frequent uterine contractions and mild, dark vaginal bleeding. What actions should the nurse take? Select all that apply. 1 . Anticipate emergent cesarean birth 2. Apply continuous external fetal monitoring 3. Assess routine vital signs every 4 hours 4. Draw blood for type and crossmatch 5. Initiate IV access with a 22-gauge catheter

Options 1, 2, and 4 Placental abruption occurs when the placenta separates prematurely from the uterine wall, causing hemorrhage beneath the placenta. Abruptions are classified as partial, complete, or marginal and may be overt (visible vaginal bleeding) or concealed (bleeding behind placenta). Risk factors include abdominal trauma, hypertension, cocaine use, history of previous abruption, and preterm premature rupture of membranes. Symptoms and their severity depend on extent of abruption and include abdominal and/or back pain, uterine contractions, uterine rigidity, and dark red vaginal bleeding. Tachysystole (ie, excessive uterine contractions), with or without fetal distress, is often present, and continuous fetal monitoring is necessary (Option 2). A type and crossmatch should be drawn as treatment may include blood transfusion (Option 4). In severe cases, emergent cesarean birth is indicated (Option 1). Although blood loss is maternal, the loss of functional placental surface area can result in decreased placental perfusion, impaired fetal oxygenation, and fetal death. (Option 3) Maternal vital signs should be assessed frequently for signs of shock (eg, tachycardia, hypotension) as client condition can decline rapidly. In this acute scenario, assessment of vital signs every 4 hours is not sufficient. (Option 5) Abruption may require rapid volume replacement with IV fluid and blood products, requiring large-bore IV access. Peripheral IV access with a 16- or 18-gauge catheter should be initiated. Educational objective: Placental abruption usually presents with abdominal pain and dark red vaginal bleeding. The main concerns are maternal blood loss resulting in hypotension and shock and fetal compromise. Maternal stabilization and expedited birth are indicated.

A 28-year-old client is admitted to the labor and delivery unit for severe preec~ampsia. She is started on IV magnesium sulfate. Which signs indicate that the client has developed magnesium sulfate toxicity? Select all that apply. 1 . 0/4 patellar reflex 2. Blood pressure is 156/84 mm Hg 3. Client voided 600 mL in 8 hours 4. Respirations are 1 0/min 5. Serum magnesium level is 5 mEq/L (2.5 mmoi/L)

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

The emergency department nurse cares for a client admitted with a diagnosis of hyperosmolar hyperglycemic state. The nurse understands which characteristics are commonly associated with this complication? Select all that apply. 1 . Abdominal pain 2. Blood glucose level >600 mg/dL (33.3 mmoi/L) 3. History of type 2 diabetes 4. Kussmaul respirations 5. Neurological manifestations

Options 2, 3, and 5 Hyperosmolar hyperglycemic state is a serious complication usually associated with type 2 diabetes. With this condition, clients are able to produce enough insulin to prevent diabetic ketoacidosis but not enough to prevent extreme hyperglycemia, osmotic diuresis, and extracellular fluid deficit. Because some insulin is produced, blood glucose rises slowly and symptoms may not be recognized until hyperglycemia is extreme, often >600 mg/dl (33.3 mmoi/L). This eventually causes neurological manifestations such as blurry vision, lethargy, obtundation, and progression to coma. Because some insulin is present, symptoms associated with ketones and acidosis, such as Kussmaul respirations (hyperventilation) and abdominal pain, are typically absent (Options 1 and 4).

The emergency department nurse cares for 5 clients. Which of the clients below are at risk for developing metabolic acidosis? Select all that apply. 1. 25-year-old client with claustrophobia who was stuck in an elevator for 2 hours 2. 36-year-old client with food poisoning and severe diarrhea for the past 3 days 3. 40-year-old client with 3-day history of chemotherapy-induced vomiting 4. 75-year-old client with pyelonephritis and hypotension 5. 82-year-old client due for hemodialysis with clotted arteriovenous shunt

Options 2, 4, and 5 Metabolic acidosis is due to an increase in the production or retention of acid or the depletion of bicarbonate via the kidneys or gastrointestinal (GI) tract. In metabolic acidosis there is a decrease in pH (<7.35) and HC03- (<22 mEq [22 mmoi/L]). Common causes of metabolic acidosis include: • Gl bicarbonate losses (eg, diarrhea) (Option 2) • Ketoacidosis (eg, diabetes, alcoholism, starvation) • Lactic acidosis (eg, sepsis, hypoperfusion) (Option 4) • Renal failure (eg, hemodialysis with inaccessible arteriovenous shunt) (Option 5) • Salicylate toxicity (Option 1) A client with claustrophobia who was stuck in an elevator is at risk for an anxiety attack, which leads to hyperventilation and respiratory alkalosis (pH >7.45, PaC02 <35 mm Hg [4.66 kPa]). (Option 3) A client with excessive vomiting is at risk for metabolic alkalosis due to loss of stomach acid.

A nurse is caring for a pregnant client who has hyperemesis gravidarum. Which assessment findings should the nurse anticipate? Select all that apply. 1 . Blood pressure 160/94 mm Hg 2. Large urine protein 3. Positive urine ketones (moderate) 4. Pulse 1 06/min 5. Urine specific gravity 1.010

Options 3, 4 Explanation: Hyperemesis gravidarum is a disorder that causes pregnant clients to have severe nausea and vomiting. This leads to fluid and electrolyte imbalances, nutritional deficiencies, ketonuria, and weight loss. On assessment, the nurse should expect signs and symptoms of dehydration, which include dry mucous membranes, poor skin turgor, decreased urine output, tachycardia, and low blood pressure. Ketonuria indicates that the body is breaking down fat to use for energy due to the client's starvation state. (Options 1 and 5) The client with hyperemesis gravidarum is dehydrated. Blood pressure is expected to be low due to lack of blood volume. The urine specific gravity will be increased (>1.030) as the urine is in a concentrated state. Blood urea nitrogen is also elevated (>20 mg/dl [7 .1 mmoi/L]). (Option 2) Proteinuria is associated with kidney disease or preeclampsia. Hyperemesis does not cause proteinuria. Educational objective: Excessive vomiting (hyperemesis gravidarum) leads to fluid and electrolyte imbalances (hypokalemia, metabolic alkalosis), weight loss, nutritional deficiencies, and ketonuria. The signs and symptoms of dehydration include poor skin turgor, decreased urine output, tachycardia, low blood pressure, and dry mucous membranes.

The nurse is caring for a newborn with patent ductus arteriosus. Which assessment finding should the nurse expect? 1 . Harsh systolic murmur 2. Loud machine-like murmur 3. Soft diastolic murmur 4. Systolic ejection murmur

Patent ductus arteriosus (PDA) is an acyanotic congenital defect more common in premature infants. When fetal circulation changes to pulmonary circulation outside the womb, the ductus arteriosus should close spontaneously. This closure is caused by increased oxygenation after birth. If a PDA is present, blood will shunt from the aorta back to the pulmonary arteries via the opened ductus arteriosus. Many newborns are asymptomatic except for a loud, machine-like systolic and diastolic murmur. The PDA will be treated with surgical ligation or IV indomethacin to stimulate duct closure. (Option 1) A harsh systolic murmur is heard in the setting of ventricular septal defect, an opening between the ventricles of the heart. Ventricular septal defect is an acyanotic defect. (Option 3) A diastolic murmur is heard in mitral stenosis and aortic regurgitation but not in PDA. (Option 4) A systolic ejection murmur is heard in pulmonic stenosis. Right ventricular hypertrophy will develop if this defect is not repaired. In adults, systolic ejection murmur is usually due to aortic stenosis. Educational objective: The ductus arteriosus of a newborn should close spontaneously when fetal circulation changes to pulmonary circulation. If the ductus arteriosus remains open, blood will shunt from the aorta to the pulmonary arteries. The child will be acyanotic but will have a machine-like murmur heard on both systole and diastole.

A nurse is caring for a client who had a vaginal birth 2 hours ago. The client has saturated a perineal pad in 20 minutes. During assessment, the nurse notices that the client has a boggy fundus that is deviated to the right and slightly above the umbilicus. Which intervention should the nurse perform first? 1. Assist client to use the bedpan to void 2. Begin oxytocin IV infusion at 125 milliunits/min 3. Obtain a complete blood count 4. Start oxygen delivery at 1 0 Lim in via nonrebreather facemask

Postpartum vaginal bleeding that saturates a perineal pad in <1 hour is considered excessive. This client saturated a perineal pad in 20 minutes. Based on the nurse's assessment, the boggy fundus indicates uterine atony. The fundus is also elevated above the umbilicus and deviated to the right, indicating a distended bladder. Bladder distension prevents the uterus from contracting sufficiently to control bleeding at the previous placental site. The client should be assisted to void to correct the bladder distension {Option 1). The nurse should then perform fundal massage. {Option 2) Oxytocin is a uterotonic that increases contraction of the myometrium, constricting vessels at the previous placental implantation site. An oxytocin infusion should be initiated if initial attempts to control postpartum bleeding (relief of bladder distention and fundal massage) have failed. The usual postpartum oxytocin IV dosage is 125-200 milliunits/min. {Option 3) A complete blood count is needed to determine hematocrit and hemoglobin levels following excessive postpartum bleeding. However, this is not the immediate priority. {Option 4) Oxygen delivery at 10 Umin via a nonrebreather facemask may be initiated if the client becomes symptomatic following excessive blood loss. However, the first priority is to control the bleeding. Educational objective: Excessive postpartum bleeding is most commonly caused by uterine atony. The nursing priority for uterine atony associated with bladder distension is to assist the client with voiding and then perform fundal massage and other interventions as needed to control excessive bleeding.

A client with pneumonia is transferred from the medical unit to the intensive care unit due to sepsis and worsening respiratory failure. Based on the nurse's progress note, which assessment data are most important for the nurse to report to the health care provider (HCP)? 1. Cough with mucus production 2. Refractory hypoxemia 3. Scattered rhonchi and crackles 4. Temperature 101 F (38.3 C)

Refractory hypoxemia is the hallmark of acute respiratory distress syndrome (ARDS), a progressive form of acute respiratory failure that has a high mortality rate. It can develop following a pulmonary insult (eg, aspiration, pneumonia, toxic inhalation) or nonpulmonary insult (eg, sepsis, multiple blood transfusions, trauma) to the lung. The insult triggers a massive inflammatory response that causes the lung tissue to release inflammatory mediators (leukotrienes, proteases) that cause damage to the alveolar-capillary (A-C) membrane. As a result of the damage, the A-C membrane becomes more permeable, and intravascular fluid then leaks into the alveolar space, resulting in a noncardiogenic pulmonary edema. The lungs become stiff and noncompliant, which makes ventilation and oxygenation less than optimal and results in increased work of breathing, tachypnea and alkalosis, atelectasis, and refractory hypoxemia. Profound hypoxemia despite high concentrations of oxygen is a key sign of ARDS and is the most important assessment finding to report to the HCP. (Options 1 and 3) Cough with mucus production and scattered rhonchi and crackles are expected findings in a client with pneumonia. (Option 4) Temperature is an expected finding in a client with pneumonia who is receiving antibiotic therapy. The white blood cell count can still be elevated after 2 days of antibiotic therapy. Educational objective: Refractory hypoxemia is the inability to improve oxygenation with increases in oxygen concentration. It is the hallmark of ARDS, a progressive form of acute respiratory failure that has a high mortality rate.

An elderly client with staphylococcal pneumonia treated with intravenous antibiotic therapy for 3 days becomes extremely short of breath and restless and is difficult to arouse. Which additional assessment findings indicate to the nurse that the client can be developing sepsis? Select all that apply. 1 . Absent bowel sounds 2. Capillary refill 5 seconds 3. Diminished breath sounds in bases 4. Serum glucose level 180 mg/dL (1 0.0 mmoi/L} 5. Urine output 1 mL/kg/hr

Sepsis is a systemic inflammatory response to an infection and can occur as a complication of pneumonia in clients who do not respond to antibiotic therapy. It is caused by the entry of bacteria from the alveoli into the bloodstream. Manifestations characteristic of sepsis include heart rate >90 beats/min, temperature >100.9 F (38.3 C), systolic blood pressure <90 mm Hg, altered mental status, and hyperglycemia (>140 mg/dl [7.8 mmoi/L]) in the absence of diabetes. The assessment findings most important for the nurse to report to the health care provider include the following: • Absent bowel sounds. Paralytic ileus occurs in the presence of sepsis and hypoxia as blood is shunted away from the gastrointestinal tract to the vital organs. • Capillary refill 5 seconds. Prolonged capillary refill (>3-4 seconds in an adult) indicates inadequate blood flow to peripheral tissues. • Serum glucose >140 mg/dl (7.8 mmoi/L). Gluconeogenesis occurs in response to the physiologic stress of infection. Insulin resistance is associated with anaerobic metabolism. (Option 3) Diminished breath sounds in the bases are expected in an elderly client with pneumonia. (Option 5) Urine output of 1 mUkg/hr is within the normal range (0.5-1.0 mUkg/hr). Educational objective: Sepsis is a complication of pneumonia that can progress to septic shock and/or multisystem organ dysfunction syndrome. To limit progression, the nurse assesses oxygenation (pulse oximeter, arterial blood gases), airway (patency), breathing (respiratory pattern and rate), circulation (vital signs), tissue perfusion (eg, level of consciousness, capillary refill, skin temperature and color, bowel sounds), and urine output.

The nurse receives report on 4 pediatric clients in the emergency department. Which client should be seen first? 1. 3-week-old with fever who is sleeping more than usual and refuses to feed 2. 4-month-old who has painless, new-onset, bilateral testicular swelling 3. 8-month-old who ingested a bottle of bubble soap 30 minutes ago 4. 2-year-old with fever, runny nose, cough, and sore throat for the past 2 days

Sepsis neonatorum is a medical emergency. Newborns may not exhibit obvious signs of infection but instead may have elevated temperature or be hypothermic. Subtle changes such as irritability, increased sleepiness, and poor feeding should be considered red flags. Blood, urine, and cerebrospinal fluid cultures should be obtained immediately and broad-spectrum antibiotics started. (Option 2} This infant has signs of a hydrocele, a fluid-filled testicular mass. Most hydroceles resolve before the first birthday and are not a medical emergency. (Option 3} Children's bubble soap is non-toxic. As a precaution, the poison control center should be contacted, but this is not a priority over a newborn with fever. (Option 4} This child likely has an upper respiratory viral or bacterial (streptococcal) infection. This localized infection is not a priority over generalized/bloodstream infection (neonatal sepsis). Educational objective: Sepsis in a newborn is life-threatening. Newborns with fever, lethargy, and refusal to feed require a full septic workup. Broadspectrum antibiotics should be started immediately after obtaining blood, urine, and cerebrospinal fluid cultures.

A patient is brought to the emergency department in a comatose state after developing hyperosmolar hyperglycemic non-ketotic syndrome (HHNS). The nurse begins her care and assessment of this patient. What is the nurse's first priority in this situation? a)Providing isotonic fluid replacement b) Maintaining the patients cervical spine c) Administering insulin IM d) Monitoring serum chloride levels

a)Providing isotonic fluid replacement

A client at 30 weeks gestation is hospitalized for preeclampsia. Which assessment finding requires priority intervention? 1 . Elevated liver enzymes 2. Lower abdominal pain and vaginal bleeding 3. Swelling of the hands, feet, and face 4. Urine output of 25 ml/hr

option 2 Placental abruption is a possible complication of preeclampsia that can be life-threatening to mother and baby. It occurs when the placenta tears away from the wall of the uterus due to stress, causing significant bleeding to the mother and depriving the baby of oxygen. Bleeding can be concealed inside the uterus. This may require immediate delivery of the baby. {Option 1) Elevated liver enzymes can indicate the start of a more serious condition called HELLP (Hemolysis, Elevated Liver enzymes, Low Platelets), another complication of preeclampsia. This client will need additional laboratory work. If HELLP is diagnosed, the only treatment is delivery. {Option 3) Swelling of the hands, feet, and face are expected findings of preeclampsia and should be assessed frequently. {Option 4) Normal urine output is 30 mL/hr; anything less represents a potential problem. Oliguria and elevated creatinine levels indicate kidney failure and require intervention. This client's urine output of 25 mL/hr does not represent an immediate, lifethreatening condition. Educational objective: Preeclampsia in pregnancy manifests with high blood pressure and protein in the urine. Edema is expected, although it is not part of the criteria. Complications of preeclampsia include eclampsia, placental abruption, and HELLP (Hemolysis, Elevated Liver enzymes, Low Platelets) syndrome.