NCLEX® Readiness

Standardized Communication The nurse prepares to contact the healthcare provider about a change in the client's condition. Place each statement in the I.S.B.A.R. communication format in the correct order.

1. "Hello, this is Nurse Jones on the medical-surgical unit at Chamberlain Hospital." 2. "The client started complaining of nausea yesterday evening and vomited several times during the night." 3. "The client is a 53-year-old female admitted 2 days ago with pneumonia and started on levofloxacin at 1700 yesterday. She complains of poor appetite." 4. "The client reported feeling very nauseated after the dose of levofloxacin 1 hour ago." 5. "Could you prescribe ondansetron to be administered before the antibiotic?" I.S.B.A.R. is an interprofessional communication technique used in healthcare that stands for situation, background, assessment, and recommendation. ​ The nurse must first identify themselves and their role. "Hello, this is Nurse Jones on the medical-surgical unit at Chamberlain Hospital."​ The situation or reason for contacting the provider, is, "The client started complaining of nausea yesterday evening and vomited several times during the night."​ The background information is, "The client is a 53-year-old female admitted 2 days ago with pneumonia and started on levofloxacin at 1700 yesterday. She complains of poor appetite."​ The assessment data is, "The client reported feeling very nauseated after the dose of levofloxacin one hour ago."​ The recommendation to the provider is, "Could you prescribe ondansetron to be administered before the antibiotic?"

Mixing Regular and Intermediate-Acting Insulin for Administration A nurse is preparing to instruct a client who is newly diagnosed with diabetes mellitus type 1 on mixing regular and NPH insulin into one syringe for subcutaneous injection. Place the steps for this procedure into the correct order.

1. Gently rotate the NPH insulin vial. 2. Clean the top of each vial with alcohol. 3. Inject air into the vial of NPH insulin. 4. Inject air into the vial of regular insulin. 5. Withdraw regular insulin. 6. Withdraw NPH insulin. 7. Safely recap the needle using a single-hand approach. NPH (intermediate-acting) insulin is cloudy, and the particles must be gently rotated to mix before withdrawing from the multi-dose vial. ​ The top of each vial should be cleaned with alcohol prior to injecting air. ​ Inject air into the NPH vial first, then into the regular insulin vial. Air must always be injected into a vial before removing any solution.​ Regular insulin is clear, and the vial must not be contaminated with NPH insulin. Withdraw the regular insulin first, then using the same needle, withdraw the NPH insulin. ​ Safely recap the needle using a single-hand approach. ​ The steps for combining regular and NPH insulin into a single syringe for injection can be remembered with the mnemonic, "Clear then cloudy."

Acetaminophen Overdose The nurse reviews the electronic health record (EHR) of a 16-year-old client admitted to the pediatric unit for treatment following an overdose of acetaminophen. In what order should the nurse perform these prescriptions, from first to last?

1. Insert peripheral venous access device 2. Normal saline 100 mL bolus 3. N-acetylcysteine infusion 150 mg/kg over one hour 4. N-acetylcysteine infusion 12.5 mg/kg over four hours 5. N-acetylcysteine infusion 6.25 mg/kg over sixteen hours 6. Clear liquid diet as tolerated First, the nurse should insert the peripheral venous access device. The normal saline bolus should be administered before N-acetylcysteine because that medication will be delivered continuously over a longer period. A clear liquid diet is the lowest priority after treatment of the client's condition has been initiated. The nurse should also obtain acetaminophen level now and every eight hours.

Reviewing Provider Prescriptions The nurse receives a client as a new admission. The client is experiencing a sickle cell crisis. After reviewing the provider's prescriptions, select the row from the provider's prescription that indicates the need to contact the healthcare provider for clarification.​ Provider Prescriptions 6/5 @ 1245 1. Morphine 1 mg by mouth every 4 hours as needed for pain greater than 5/10​ 2. Hydroxyurea 35 mg/kg to be administered by mouth on June 12 if client is still in the hospital​ 3. Oxygen via nasal canula to keep O2 Sat greater than 92%​ 4. Infuse D5W intravenously at 125 mL/hour ​ 5. Diet: Regular - as tolerated. Increased fluid intake ​ 6. Occupational and physical therapy consultations ​ 7. Notify on-call hematologist of client's admission ​

1. Morphine 1 mg by mouth every 4 hours as needed for pain greater than 5/10​ Pain is the most prominent feature when a client is admitted with a sickle cell crisis. Nurses must ensure that these clients receive adequate pain relief and nurses need to advocate for the client with the provider. The nurse should contact the provider to clarify the dose and frequency of the morphine as a client with a sickle cell crisis will need greater pain control. The recommendation is that these clients receive a continuous intravenous analgesic along with an analgesic scheduled on an as-needed basis for breakthrough pain. This client is only prescribed a small dose of an as-needed medication given orally which will not manage the client's pain when in a sickle cell crisis. The nurse should remain professional in communication with the provider and collaborate to ensure adequate pain control measures are in place. The other prescriptions are expected for a client in a sickle cell crisis.

Interpreting Acid-Base Imbalance​ Arterial blood gas results are pH 7.48, PaCO2 42, and HCO3- 35. The nurse correctly reports the result as _______, ________ , and _______.

Alkalosis​ Metabolic​ Uncompensated​ Since the pH is elevated, the result is alkalosis. The PaCO2 is normal, so this is not a respiratory problem. The HCO3- is elevated, indicating a metabolic concern. No compensation has occurred because the pH is elevated and the PaCO2 is normal. ​ ROME is an acronym to remember how to interpret acid-base imbalance, which stands for "Respiratory Opposite; Metabolic Equal."​

Interpreting Acid-Base Imbalance​ Arterial blood gas results are pH 7.36, PaCO2 68, and HCO3- 36. The nurse correctly reports the result as _______ , ________ , and ________.

Acidosis​ Respiratory​ Compensated​ ​Since the pH is normal (but less than 7.4) and both the CO2 and HCO3- are elevated, compensation has occurred. Since the CO2 was more abnormal than HCO3-, the type of acidosis is respiratory in origin and has been balanced by the increased HCO3-. ROME is an acronym to remember how to interpret acid-base imbalance, which stands for "Respiratory Opposite; Metabolic Equal."​

Electrolyte Imbalances​ The nurse is caring for a client with a phosphate level of 6.2 mg/dL (reference range: 3 - 4.5 mg/dL). For each finding, click to specify if the assessment finding is anticipated or not anticipated.

Anticipated Hypotension​ Diminished peripheral pulses​ Positive Chvostek's sign​ Prolonged cardiac QT interval​ Not Anticipated Absent deep tendon reflexes​ Hypoactive bowel sounds​ Serum calcium level 10 mg/dL​ Phosphate and calcium have an inverse relationship; therefore, hyperphosphatemia leads to hypocalcemia (serum level less than 9 mg/dL). ​ Assessment findings include bradycardia, hypotension, diminished peripheral pulses, Trousseau's and Chvostek's signs, hyperactive deep tendon reflexes, hyperactive bowel sounds, and prolonged cardiac QT interval.​ Absent deep tendon reflexes and hypoactive bowel sounds are signs of hypercalcemia. ​ Other symptoms of hypocalcemia can be remembered with the acronym CATS: Convulsions​ Arrhythmias​ Tetany​ Spasms

Anticipating Prescriptions The nurse is caring for a client who presents to the emergency department (ED) with chest pain that radiates to the left arm and shortness of breath that started while mowing the lawn. The client reports taking three nitroglycerin sublingual tablets at home while waiting for the ambulance to arrive. Vital signs are T 98.2 °F (36.7 °C), P 118, BP 165/92, RR 28, and pulse oximetry reading 88% on room air. For each potential prescription, click to specify if the prescription is anticipated or not anticipated in the care of this client. Initiate supplemental oxygen 2 L per nasal cannula. Apply 1.5 inches nitroglycerin paste on the left side of the chest. Cover with occlusive dressing. Administer meperidine 50 mg intravenously now. Administer aspirin 325 mg by mouth now. Administer clomipramine 250 mg intramuscularly now.

Anticipated Initiate supplemental oxygen 2 L per nasal cannula. Administer aspirin 325 mg by mouth now. Not Anticipated Apply 1.5 inches nitroglycerin paste on the left side of the chest. Cover with occlusive dressing. Administer meperidine 50 mg intravenously now. Administer clomipramine 250 mg intramuscularly now. The client's pulse oximetry reading is 88% on room air, requiring supplemental oxygen. Remember, that supplemental oxygen may not be indicated if the oxygen saturation is normal. ​ Aspirin works on platelets by stopping their clotting action. Since clots can block the blood supply to the heart, aspirin can help blood flow more easily. ​ Intravenous nitroglycerin infusion is needed during an acute myocardial infarction. Nitroglycerin paste is used to treat angina. ​Morphine is the drug of choice to treat pain caused by myocardial infarction. It decreases blood pressure and pulse and increases venous return to the heart, thereby reducing myocardial oxygen demand. ​ Clomipramine is a tricyclic antidepressant used to treat symptoms of obsessive-compulsive disorder. It is administered orally and is not used to treat myocardial infarction. ​ The acronym to remember initial treatment of acute coronary syndrome (myocardial infarction) is MONA (Morphine, Oxygen, Nitroglycerin, and Aspirin). ​

Fetal Heart Rate Monitoring​ The nurse is caring for a client in Stage 1 of labor and analyzing the fetal heart rate pattern. Match the fetal heart rate deceleration to the corresponding cause and initial action. Fetal Heart Deceleration ​ Early deceleration ​Variable deceleration ​Late declaration ​ Cause ​ Fetal head compression ​Umbilical cord compression ​ Placental insufficiency Initial Action ​ Continue to monitor ​ ​Position change ​ Discontinue oxytocin infusion ​

Early deceleration - Fetal head compression - Continue to monitor ​ ​Variable deceleration - ​Umbilical cord compression ​- ​Position change ​ ​Late declaration ​- Placental insufficiency - Discontinue oxytocin infusion ​ The acronym VEAL CHOP helps the student remember this information. Early decelerations are normal and expected. As the fetal head descends through the birth canal, the head is compressed. The nurse should continue to monitor labor progress. Variable decelerations are caused by umbilical cord compression. This can occur due to fetal position; therefore, changing maternal position will change fetal position and may alleviate the cord compression. ​ Late decelerations are caused by placental insufficiency due to diminished blood and oxygen flow through the placenta. This is the most concerning of the fetal heart decelerations and requires immediate action. The initial action is to discontinue oxytocin infusion, if prescribed. Then, the nurse should place the mother on her left side, initiate an intravenous fluid bolus, and consider supplemental oxygen.

Planning Client Care​ The nurse is caring for a client with dyspnea and a productive cough who is using accessory muscles to breathe. Vital signs are T 103.4 °F (39.7 °C), P 118, BP 165/92, RR 28, and pulse oximetry reading 89%. Click to specify if each nursing action is essential, non-essential, or contraindicated. Place the client in a supine, side-lying position. Administer supplemental oxygen 15 L via a non-rebreather mask. Obtain sputum culture then initiate levofloxacin intravenously. Assess family members for exposure to respiratory infection.

Essential Obtain sputum culture then initiate levofloxacin intravenously. Non-essential Assess family members for exposure to respiratory infection. Contraindicated Place the client in a supine, side-lying position. Administer supplemental oxygen 15 L via a non-rebreather mask. The client has symptoms of a respiratory infection. Cultures should be obtained first, then antibiotics is started. ​ Once the client is stable and infection is identified, further testing may be necessary. ​This action is non-essential currently. Place the client in high-Fowler's to improve oxygenation and ventilation. ​Use the least amount of oxygen possible to elevate the client's oxygen saturation. Try a nasal cannula first as the client's oxygen saturation is only slightly lowered.

Administering Heparin Name: Heather Fialiata Age: 61 Provider: J. Hanakai​ Code Status: Full Admit Wt: 205 lbs (93.2 kg) Allergies: NKDA Provider Prescriptions 11/15 Admit to intensive care unit Initiate two peripheral IV lines Administer heparin bolus IV 40 units/kg Initiate heparin IV infusion 18 units/kg/hr for 6 hours then follow heparin titration protocol Recheck anti-Xa level 6 hours after initiating heparin infusion The nurse has an IV pump that can be programmed to run rates in whole numbers. The available heparin from the pharmacy is: Heparin Sodium for injection IV or Subcut use 10,000 units per 1 mL Heparin in 0.9% NaCl 25,000 units in 500 mL After reviewing the electronic health record (EHR), for each potential nursing action, click to specify whether the action is appropriate or not appropriate when preparing and administering the prescribed heparin.​

High-risk medications can fit into the high alert category in which the medications have a high likelihood of causing harm to the client even when they are used as prescribed. Heparin is a high-risk medication that requires careful preparation and administration techniques. The nurse needs to verify the safety of the medication by verifying the client's identity, weight, allergies, and health history. Two nurses need to verify both heparin doses. A direct IV push is outside the scope of practice for the LPN/LVN, so the nurse needs an RN to complete the verification steps. The tubing should be labeled as heparin and should not be mixed with other agents. The bolus is given via IV push and is not a part of what is programmed into the IV pump. The IV pump needs to be set to run at 34 mL/hr. The client weighs 93.2 kg, so the client is getting 1677.6 units of heparin per hour (93.2 x 18). The available solution is heparin 25,000 units/500 mL so the pump should be set for 34 mL/hr. [(1677.6 x 500) / 25,000)]. The nurse needs to check the anti-Xa in 6 hours so the volume to be infused is not the entire bag of heparin, but rather the amount that will be infused over 6 hours (34 x 6 = 204 mL). Heparin has a short half-life so, in many cases, if the client is showing signs of toxicity, discontinuing the infusion is sufficient. However, having the antidote, protamine sulfate, available on the unit is important so that it is ready if needed.​

Managing Heparin Administration The nurse cares for a client with pulmonary emboli receiving intravenous (IV) heparin therapy per the facility's heparin protocol. The client weighs 100 kg. The infusion was initiated at a starting rate of 18 units/kg/hr and has been running for 6 hours. The hanging heparin bag is 25,000 units in 250 mL D5W. The nurse receives the client's current anti-Xa value and finds it is 0.8 units/milliliter. Before answering this question, review the heparin titration protocol.​ For each potential nursing action, click to specify whether the intervention is indicated or not indicated for the care of the client at this time.​

Indicated Instruct the lab to draw an anti-Xa level in 6 hours Reprogram the pump to run at 17 mL/hour Assess the client for petechiae and bruising Assess the integrity of the IV site Not Indicated Bolus the client with 4000 units of heparin Turn off the IV pump Administer protamine sulfate as an antidote Ask the client if unilateral leg pain is present The nurse must recognize that the high anti-Xa level means that the client is getting too much heparin and the infusion rate needs to be slowed down according to the protocol. The protocol for 0.8 units/mL indicates that there is no bolus, the IV infusion is not stopped, and the running infusion needs to be decreased by 1 unit/kg/hour. The current rate is running at 18 units/kg/hour (18 mL/hr), so it needs to be changed to 17 units/kg/hr (17 mL/hr). The protocol dictates that after the rate change the nurse should schedule another anti-Xa lab to be drawn in 6 hours. Additionally, the nurse must understand that heparin is an anticoagulant; therefore, when heparin is having an increased effect, the nurse should be alert to signs/symptoms of bleeding in the client. The nurse should check the client for petechiae and new bruises as well as check if there is bleeding around the IV site. Determining the presence of unilateral leg pain is not as high a priority as the client is at risk of bleeding more than new clot formation currently. Assessment of the anti-Xa labs provides a more accurate assessment of the heparin activity within the body and requires fewer dosage adjustments to achieve and maintain a therapeutic range as compared with the previous aPTT test that was used in heparin titration. The typical goal is to maintain anti-Xa levels between 0.3-0.7 units/mL, but this is based on client need and indication for use.

Assessment Findings The nurse admits a client into the emergency department with shortness of breath, chest tightness, and wheezing. The client is barely able to complete a sentence, but the nurse learns that the client has a history of asthma. The client tried a rescue inhaler but "it did not work." The client was coughing a lot but then struggled to cough. The nurse initiates the prescribed albuterol nebulizer. For each potential assessment finding, click to specify whether the finding indicates a potential improvement, signals a worsening condition, or is unrelated to the condition of the client after completion of the nebulizer treatment.​

Potential Improvement Lower pitch to expiratory wheeze Client able to complete sentences Increased coughing with nebulizer treatment Worsening Condition No audible breath sounds Client is restless Unrelated Mist stops coming from the nebulizer after 10 minutes Client reports increased thirst An albuterol nebulizer treatment is needed by some clients with asthma when they have an asthmatic attack that does not respond to the use of a rescue inhaler. A lower pitch to the wheeze means the airways are starting to open more, which means more air is moving through the airways. The client is not completely open since a wheeze is still present, but it does show an improvement. The client being able to cough some again and being able to complete sentences shows there is improvement after the treatment. Lack of audible breath sounds and restlessness are indications of a worsening condition as they indicate no air movement and hypoxia. Mist will stop coming from the nebulizer end when all the solution has been used up, which is about 5-15 minutes after starting the treatment. Gently tapping the sides of the nebulizer container will help ensure that all medication has been aerosolized before turning off the machine. The completion of the treatment does not indicate a change in the condition itself. Thirst after an asthma attack is not an indicator of improvement nor a sign of worsening of the attack. Open-mouth breathing can be the reason for the increased thirst.

Evaluating Client Response to Treatment​ 03/22/YY @ 1445​ The client is oriented and drowsy but easily arousable ​and reporting extreme thirst. Serum blood glucose: ​927 mg/dL (74-106 mg/dL) 03/22/YY @ 1445​ P 125​ BP 89/52​ RR 32 03/22/YY @ 1630​ P 104​ BP 122/68​ RR 32 03/22/YY @ 1445​ pH 7.18​ PaCO2 38​ HCO3- 19 03/22/YY @ 1630​ pH 7.36​ PaCO2 25​ HCO3- 20

The nurse is caring for a client with diabetic ketoacidosis who is being treated with intravenous regular insulin after a 1500 mL bolus of 0.9% sodium chloride. Urinary output was 1225 mL over 4 hours and is now 100 mL over the past 2 hours. The client is confused and combative. Serum glucose is 675 mg/dL (reference range: 74-106 mg/dL). For each assessment finding, click to specify if the client's condition is improving, has declined, or is unchanged. Improved Compensated metabolic acidosis Blood pressure Urinary Output Serum glucose Declined Level of consciousness No change Respiratory rate The client was in uncompensated metabolic acidosis but is now in compensated metabolic acidosis due to respiratory efforts (Kussmaul respirations) to raise the pH. As the pH has returned to normal, this represents an improvement. ​The client was hypotensive, and the blood pressure has improved following intravenous bolus of fluid replacement. ​Urinary output was 306 mL/hour and is now 50 mL/hour. This is an improvement in the client's condition. ​The client's serum glucose was 927 mg/dL but has dropped to 675 mg/dL after intravenous regular insulin was started. This represents a positive response to treatment. ​The client's level of consciousness has declined. They were oriented, drowsy but easily arousable upon admission and are now confused and combative. ​The respiratory rate is unchanged at 32/minute. ​

Hyperglycemic Hyperosmolar Syndrome The nurse cares for a client admitted into the emergency room with a diagnosis of hyperglycemic hyperosmolar syndrome. Provider Prescriptions 11/15 1. Admit to intensive care unit 2. Initiate two peripheral IV lines 3. Regular insulin 0.2 units/kg IV bolus 4. Regular insulin drip at 0.1 units/kg/ hr - titrate following hyperglycemia protocol 5. IV fluids: 0.9% sodium chloride bolus at 500 mL/hr 6. Ampicillin 500 mg IV every 4 hours 7. Complete blood count 8. Comprehensive metabolic panel and serum osmolality 9. Arterial blood gases 10. NPO Vital Signs 11/15 Temp 101.5 °F ​ (38.6 °C) HR 117 RR 22 BP (MAP) 68/44 mmHg (52) Glucose 1112 mg/dL After reviewing the electronic health record (EHR), drag each word choice to fill in the blank in each sentence.​

The nurse knows that ________is the priority concern for the client. The nurse should administer ________ first. The nurse will question the healthcare provider about the ________ prescription. infection acidosis dehydration hyperthermia 0.9% NaCl insulin drip ampicillin insulin IV push ampicillin 500 mg IV regular insulin 0.2 units/kg IV bolus 0.9% NaCl IV fluid at 500 mL/hr regular insulin drip 0.1 units/kg/hr A client with hyperglycemic hyperosmolar syndrome (HHS) is profoundly dehydrated. The nurse must rapidly initiate the IV fluid bolus as rehydration is the key to stopping the cycle with HHS. The first prescription should be the fluid bolus, next the nurse will give the insulin bolus, and then they can initiate the insulin infusion following the hyperglycemia protocol. The nurse should question the prescription for ampicillin to gain clarification about its use. It is the nurse's responsibility to verify the right drug and, if the nurse does not see an indication for use, then clarification is needed from the prescriber. The client's temperature is elevated but this is from dehydration and hyperglycemia rather than an infectious process. A client with HHS does not develop acidosis as there is still some functional insulin left. Infections can precipitate HHS in clients, but the nurse needs more clarification on why the antibiotic is prescribed.​

Transmission-Based Precautions The nurse is caring for a child with rotavirus who is vomiting and has diarrhea. Which protective precautions should the nurse employ to prevent contraction and spread of the infection? a. Contact precautions b. Gown and gloves c. Gloves and surgical mask d. Droplet precautions

a. Contact precautions Rotavirus is a gastrointestinal virus requiring contact precautions. The environment must be cleaned and disinfected frequently, and soiled linens and diapers must be frequently removed from the room. Remember that contact precautions involve the use of gowns and gloves for routine care, but may also include the use of a face shield if there is a risk of splashing liquid. ​ There is a vaccine to prevent rotavirus which is administered orally at 2, 4, and 6 months of age. Though a gown and gloves are used, the correct answer is the umbrella option, which is "contact precautions".

Heart Failure A nurse is educating a client about which clinical manifestations of left-sided heart failure they should report to the healthcare provider. Which symptoms identified by the client would indicate understanding of the teaching? Select all that apply. a. Dyspnea b. Hepatomegaly​ c. Ascites​ d. Crackles in lung fields​ e. Coughing​ f. Distended neck veins​ g. Peripheral edema​ h. Weight gain​ i. Hemoptysis

a. Dyspnea d. Crackles in lung fields​ e. Coughing​ i. Hemoptysis When the left ventricle fails, the heart cannot effectively pump blood out of the heart and into systemic circulation. This increases pressure in the pulmonary system which forces fluid from the pulmonary capillaries into the pulmonary tissue and alveoli.​ The acronym DOCHAP helps with remembering the signs of left-sided heart failure. (Dyspnea, Orthopnea, Cough, Hemoptysis, Adventitious breath sounds, and Pulmonary congestion). When the right ventricle fails, the right side of the heart cannot eject blood or handle the volume that returns to it from venous circulation. This causes systemic manifestations, such as hepatomegaly, ascites, distended neck veins, and lower extremity edema. ​ The acronym AWHEAD helps with remembering the signs of right-sided heart failure (Anorexia, Weight gain, Hepatomegaly, Edema, Ascites, and Distended neck veins). ​

A nurse is caring for a client who presents to the Emergency Department with an elevated temperature, photophobia, nuchal rigidity, and a severe headache. Which is the priority action by the nurse?​ a. Implement droplet precautions pending test results. ​ b. Evaluate immunization records. ​ c. Transfer the client to the Intensive Care Unit.​ d. Create a plan for discharge. ​

a. Implement droplet precautions pending test results. ​ To answer this question, the candidate must recognize that the client is exhibiting manifestations of meningitis. Meningitis is communicable, and the client should be placed in droplet precautions pending test results to avoid transmission. ​ The nurse should evaluate immunization records, create a plan for discharge, and will likely transfer the client to the ICU, but these are not the priority. Preventing the spread of a communicable disease is the priority. ​ Meningitis symptoms include fever, neck pain, sleepiness, vomiting, joint pain, rash, headache, seizures, and light sensitivity.

Dietary Restrictions in Phenylketonuria The nurse is providing dietary education to a pregnant client with phenylketonuria (PKU). Which foods, if appearing on the client's lunch tray, would indicate a need for further teaching? Select all that apply. a. Nuts b. Eggs c. Dairy d. Meat e. Bananas f. Legumes

a. Nuts b. Eggs c. Dairy d. Meat f. Legumes Phenylketonuria (PKU) is a genetic disorder that results in central nervous system damage from toxic levels of phenylalanine, an essential amino acid. Foods containing phenylalanine should be restricted to keep blood phenylalanine levels low, especially during pregnancy. ​ Phenylketonuria diet restrictions can be remembered using the acrostic, "Meet Dirty Dan's New Enemies," which stands for meat, dairy products, dry beans, nuts, and eggs.

A nurse is caring for a client diagnosed with heart failure who is receiving a bolus of 0.9% sodium chloride intravenously. Which symptom is indicative of fluid volume overload?​ a. Hypotension​ b. Weak bilateral radial pulses​ c. Increased urine specific gravity​ d. Bilateral lung crackles

d. Bilateral lung crackles Fluid volume overload is characterized by hypertension, bounding peripheral pulses, decreased urine specific gravity, and bilateral lung crackles. This question represents foundational thinking, as the candidate is only required to remember symptoms that may indicate fluid volume overload.

Caring for a Client With Diabetes Mellitus Type 1​ The nurse is caring for a client diagnosed with diabetes mellitus type 1. The client reports feeling irritable and anxious with diaphoresis and tremors. After serving the client a glass of milk, the nurse should next? a. check serum glucose b. initiate seizure precautions c. administer insulin

a. check serum glucose The client is experiencing signs of hypoglycemia. A simple carbohydrate (15 grams) should be served immediately to raise the blood sugar. Check the blood glucose level 15 minutes later. If the blood sugar remains less 70 mg/dL, repeat the simple carbohydrate snack. Once the blood sugar is above 70 mg/dL, the client should eat a complex carbohydrate and protein snack.​ The acronym TIRED will help the nurse remember the signs of hypoglycemia: Tachycardia and tremors​ Irritable and anxious​ Restless​ Excessive hunger​ Diaphoresis​ Other signs are headache, confusion, and slurred speech. ​ You could also remember the mnemonic "Hot and dry = Sugar high; Cold and Clammy = Eat some candy." The client is not experiencing impending signs of a seizure, so initiating seizure precautions is not the next action. If the nurse administers insulin, the serum glucose level will get lower.

Caring for a Client With Paranoia A nurse is caring for a client who is exhibiting paranoid behavior. The nurse should first ________ then next ________. a. maintain physical boundaries b. provide calming therapeutic touch c. ignore the behavior a. engage with the client frequently b. explain that delusions are not real c. contact the healthcare provider

a. maintain physical boundaries a. engage with the client frequently Paranoid personality disorder is characterized by suspiciousness and mistrust of others. The client may be argumentative, hostile, controlling, and have thoughts of grandiosity. ​ Interventions for paranoia include maintaining physical boundaries, avoiding overcrowding the client, providing a daily schedule of activities, engaging with the client briefly but frequently, and abstaining from arguing about delusions. ​ The nurse should not touch the client, ignore the client's behavior, or explain that delusions are not real. Contacting the healthcare provider is not the first or next action. Review the image for warning signs that a mental health crisis is developing. Remember that the first priority is safety of the client and others followed by appropriate nursing interventions.

A nurse is caring for a child following a tonsillectomy. Which action is the priority?​ ​a. Encourage gentle nose blowing to remove secretions b. Administer analgesics on a schedule​ c. Offer orange or grape juice to maintain hydration d. Maintain supine position to encourage adequate ventilation​

b. Administer analgesics on a schedule​ Pediatric clients are often administered analgesics on a schedule instead of as needed. Children often lack an understanding of pain control and the need to request pain medication.​ Nose blowing, sneezing, coughing, and throat clearing risk disruption of the surgical site and increase the risk for hemorrhage following a tonsillectomy. Only clear liquids that are not acidic should be provided. All clients undergoing ear, nose, or throat surgery should remain elevated (not supine) to help with drainage of secretions.

Procedure Complications The nurse is caring for a client who is scheduled for a hysterosalpingogram. Review the client's EHR. Which client data should alert the nurse to a potential complication? ​ Body mass index 40.3​ Tonsillectomy at age 18​ Allergic to shrimp​ Chronic asthma T 98.9 °F (37.2 °C)​ BP 130/89​ P 102​ RR 22 Glucose 103 mg/dL​ Hemoglobin 13.1 g/dL​ Total cholesterol 275 mg/dL​ Low density lipoproteins (LDL) 150 mg/dL​ Reference ranges:​ Glucose 70-110 mg/dL​ Hemoglobin 12-16 g/dL​ Total Cholesterol <200mg/dL​ Low density lipoproteins (LDL) <130 a. Laboratory values ​ b. Allergies c. BMI d. Vital signs​

b. Allergies A hysterosalpingogram uses radiography and contrast dye to evaluate the shape of the uterus and fallopian tube patency. It is often prescribed to identify causes of repetitive miscarriage or infertility. Clients with an allergy to shellfish (shrimp) should not receive contrast dye. Hysterosalpingography: radiological examination of the uterine cavity and uterus.

Administering Chemotherapeutic Agents The nurse cares for a client receiving chemotherapy for leukemia. What actions should the nurse take when preparing and administering a vesicant agent? Select all that apply.​ a. Place used supplies and protective equipment in the regular trash. b. Check for blood return prior to administration. c. Infuse an antiemetic medication through the same line as the chemotherapy. d. Use a central line instead of a peripheral line. e. Have a second qualified nurse verify the medication with the primary nurse. f. Place absorbent pads underneath the lines when initiating the infusion. g. Wear personal protective equipment when handling the lines. h. Monitor for erythema, pus, red streaks, or bruising at the line site.

b. Check for blood return prior to administration. d. Use a central line instead of a peripheral line. e. Have a second qualified nurse verify the medication with the primary nurse. f. Place absorbent pads underneath the lines when initiating the infusion. g. Wear personal protective equipment when handling the lines. h. Monitor for erythema, pus, red streaks, or bruising at the line site. A central line or port should be used for intravenous chemotherapy as peripheral lines are easily damaged from the consistency of the chemotherapy. The nurse should verify patency by checking for blood return in the line prior to the administration of chemotherapeutic agents. If infiltration of an IV occurs during the delivery of a non-vesicant, it can irritate the surrounding tissue. Extravasation from the delivery of a vesicant agent can erode and cause permanent damage to tissues. The nurse should watch for signs of irritation and extravasation on the client's skin such as redness, streaking, bruising, and pus. A second qualified nurse should verify the medication just prior to administration. When administering the chemotherapy, a closed, needleless system is used, and there should be a dedicated line so no other medications are infused in that line. Nurses should protect themselves with double gloves, goggles, and a gown when handling chemotherapeutic agents. The nurse should keep a spill kit near the bedside. The nurse should discard items used during the infusion into a dedicated container for chemotherapy waste, and not in the regular trash.

Cardiovascular Dysrhythmias​ The nurse is caring for a client with telemetry monitoring and observes an electrocardiogram (ECG) rhythm that shows:​ one P wave for every QRS interval​ PR interval 0.16 seconds​ QRS complex 0.06 seconds​ heart rate 64 beats per minute​ Which action should the nurse take? a. Draw serum potassium level. b. Document the findings. ​ c. Notify the provider.​ d. Call the code team.​

b. Document the findings. ​ The electrocardiogram is displaying a normal sinus rhythm. The heart rate is within normal limits (60-100). The PR interval is normal (0.12-.20 seconds). The QRS complex is normal (0.04-0.10 seconds). There are no abnormalities noted in this rhythm; therefore, the nurse should continue to monitor the client and document the findings.​ Drawing laboratory values, notifying the provider, and initiating a code are not indicated at this time.

Nursing Actions Vital Signs 4/4 Temp 97.2 °F ​(36.2 °C) HR 98 RR 18 BP 144/88 mmHg Pulse Oximetry 95% O2 RA Laboratory Results 4/4 Hemoglobin 7.8 g/dL (11.6-15 g/dL) Blood urea nitrogen 44 mg/dL (8-20 mg/dL) Creatinine 4.1 mg/dL (0.6-1.2 mg/dL) Glucose 142 mg/dL (70-100 mg/dL) Potassium 5.3 mEq/L (3.5-5.0 mEq/L) The nurse receives a hand-off report for a client scheduled for dialysis in two hours. After reviewing the electronic health record (EHR), which actions should the nurse take? Select all that apply. a. Administer the first of 2 units of prescribed packed red blood cells. b. Hold the prescribed dose of sodium polystyrene sulfonate by mouth daily. c. Hold the prescribed IV antibiotic ordered every 6 hours, due now. d. Deliver the prescribed dose of NPH insulin 5 units subcutaneously. e. Hold the prescribed dose of lisinopril 20 mg by mouth daily.

b. Hold the prescribed dose of sodium polystyrene sulfonate by mouth daily. c. Hold the prescribed IV antibiotic ordered every 6 hours, due now. d. Deliver the prescribed dose of NPH insulin 5 units subcutaneously. e. Hold the prescribed dose of lisinopril 20 mg by mouth daily. The nurse should hold the blood pressure medication, antibiotics, and sodium polystyrene sulfonate, since dialysis is scheduled in 2 hours and the medications will be removed during the process. Potassium will be reduced during dialysis, so getting the client dialyzed is a priority over polystyrene administration. It is safe for the nurse to deliver the insulin as the client can eat before and during dialysis. The blood is best given during dialysis so that the client does not experience fluid overload.

The nurse is caring for a client who had a vaginal delivery 8 hours ago. Vaginal bleeding is heavy, and the uterus feels soft and boggy. Which is the initial action by the nurse?​ a. Document the findings and continue to monitor.​ b. Massage the fundus until firm. ​ c. Reposition the client into modified Trendelenburg.​ d. Place dry pads under the client to monitor bleeding.

b. Massage the fundus until firm. ​ To answer this question, the candidate must remember that a boggy uterus (atony) is the primary cause of postpartum hemorrhage. The initial action is to massage the uterus until it is firm and to express any clots that may have accumulated inside the uterus. ​ In the modified Trendelenburg position, the client remains flat with the legs above the level of the heart. This position helps to prevent and treat hypovolemia and facilitates venous return. However, it does not resolve the primary problem; therefore, it is not the initial action by the nurse. ​ Placing dry pads under the client to monitor bleeding should happen after the uterus is firm, so this is not the initial action.​ Documenting the findings is appropriate, and the nurse should continue to monitor. However, massaging the uterus must occur first to resolve the immediate problem. ​

Contraindications for Ipratropium Bromide​ Click to highlight the client's history that must be reported as a contraindication to treatment with ipratropium bromide. The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is currently prescribed ipratropium bromide, glyburide, budesonide, and Montelukast. In addition to COPD, the client has a history of melanoma, benign prostatic hyperplasia, diabetes mellitus type 2, and closed-angle glaucoma. They have a 25 pack-year history of cigarette smoking but successfully completed a smoking cessation program last year. ​

benign prostatic hyperplasia & closed-angle glaucoma

Pre-Procedure Teaching The nurse is planning care for a client who will undergo an esophagogastroduodenoscopy (EGD) in the morning. Which pre-procedure instructions should the nurse provide to the client? a. Every client is required to arrive at 0800 for the procedure. ​ b. Never take routine medications before a procedure. c. Avoid eating or drinking for 8 hours before the procedure. d. Drink only clear liquids the morning of the procedure. e. Take all routine medications the morning before the procedure. ​

c. Avoid eating or drinking for 8 hours before the procedure. An EGD is a visual examination of the esophagus, stomach, and duodenum using a flexible, lighted endoscope. It is used for diagnostic and therapeutic purposes and takes less than 30 minutes to perform.​ Pre-procedure teaching includes: ​ ● Avoid anticoagulants, aspirin, and non-steroidal anti-inflammatory medications for 48-72 hours before the procedure due to risk of bleeding.​ ● Other regularly prescribed medications can be taken the morning of the procedure with small sips of water, unless otherwise instructed by the healthcare provider.​ ● Remain NPO for 6-8 hours before the procedure.​ ● Explain the procedure.

Administering Intravenous Push Medications The nurse prepares to administer an intravenous push (IVP) medication to a client via a saline locked (capped) peripheral IV site. Which actions should the nurse take to safely administer the IVP? Select all that apply. ​ a. Start a second IV line to administer the medication. b. Confirm the medication is compatible with the fluids infusing. c. Compare the medication name to the provider's prescription. d. Assess the IV site for redness and pain. e. Hang a gravity bag of normal saline for infusion. f. Determine the rate of administration in mL/hour. g. Confirm two client identifiers.

c. Compare the medication name to the provider's prescription. d. Assess the IV site for redness and pain. g. Confirm two client identifiers. Before administering any IV medication, the nurse should verify the medication prepared is the medication that was prescribed, assess the site for redness, pain, or swelling, and confirm two client identifiers. Because this is an intravenous push in a capped line, medication compatibility with fluid does not need to be checked as there is no fluid infusing when the client has a capped line. A gravity infusion bag is not required, and the rate of administration is mL per minute. The capped line (saline locked) means it is available for use and not running any medication or fluid. The nurse should flush the line prior to administering the medication but does not need to start a new IV line.

Analyzing Client Data​ The nurse is caring for a client following a motor vehicle accident who is exhibiting hypertension, bradycardia, and bradypnea. The client is most likely experiencing ________ caused by ________. a. asthma exacerbation b. hypovolemic shock c. increased intercranial pressure a. subdural hematoma b. ruptured spleen c. allergen trigger

c. increased intercranial pressure a. subdural hematoma The client is exhibiting signs of increased intracranial pressure possibly caused by a subdural hematoma. Hypertension, bradycardia, and bradypnea are late signs of increased ICP, known as Cushing's Triad. ​ Pain, anxiety, and hypovolemic shock would result in hypertension, tachycardia, and tachypnea. ​ To differentiate between increased ICP and hypovolemic shock, remember that the vital signs are opposite. ICP: ​​↑BP, ​↓Pulse, ↓RR ​ Hypovolemic Shock: ​↓BP, ↑Pulse, ↑RR

A client presents to the Emergency Department (ED) reporting an obstetrical history of G5-T4-P0-A0-L4. The nurse observes crowning of the fetal presenting part. Which is the priority action by the nurse?​ a. Provide emotional support to the client.​ b. Move the client to the labor unit.​ c. Monitor time frequency and duration of contractions. d. Preheat the infant warmer and gather delivery supplies.​

d. Preheat the infant warmer and gather delivery supplies.​ Though providing emotional support and monitoring contractions are important actions, the priority action is the preparation for immediate delivery by preheating the infant warmer and gathering delivery supplies. The fetal presenting part is crowning, and the mother is laboring her fifth child. Delivery is imminent; therefore, there is no time to move this client to the labor unit.

Danger Signs of Pregnancy​ The nurse is caring for a client who is 30 weeks pregnant. Which assessment findings must be immediately reported to the healthcare provider? Select all that apply. a. Constipation with hemorrhoids​ b. Chronic low back ache​ c. Dyspepsia and frequent belching​ d. Swelling of the face and hands​ e. Spots in the visual field​

d. Swelling of the face and hands​ e. Spots in the visual field​ Changes to the body caused by pregnancy result in normal discomforts of pregnancy. However, the nurse must differentiate between normal discomforts and danger signs. The alphabet cue, ABCS, helps with remembering danger signs of pregnancy. ​ Abdominal pain​ Blurred vision, bleeding​ Chills and fever, cerebral disturbances​ Swelling of the upper body, sudden escape of fluid ​ These signs could indicate either preeclampsia, infection, preterm labor, or placenta previa or abruption.​ Constipation from slowed GI peristalsis leading to hemorrhoids is a normal discomfort of pregnancy. Chronic low back ache due to increasing lordosis and a shifted center of gravity is a normal discomfort of pregnancy. Dyspepsia (indigestion) with frequent belching from slowed GI motility is a normal discomfort of pregnancy. ​ If you guessed preeclampsia, then you are correct! Preeclampsia is the development of hypertension and proteinuria after Week 20 in a previously normotensive client. Other symptoms include severe headaches, edema of the hands and face, epigastric pain, vision changes, and hyperreflexia. Preeclampsia can progress to eclampsia, which is characterized by seizure activity, if not managed.

Priority Medications The nurse reviews discharge medications with a client. While explaining the new medications, the client asks if they can have one glass of wine at a wedding in the coming week. After reviewing the client's information, highlight the priority medication in the electronic health record (EHR) that indicates the client needs to avoid alcohol consumption.​ Discharge medications include fluticasone for environmental allergies. For infection, take metronidazole 1 tablet twice a day for 7 days. Also, take amoxicillin 1 capsule three times a day for 14 days. ​

metronidazole Metronidazole is an antibiotic used to treat certain types of bacterial and parasitic infections. Drinking alcohol with metronidazole is known to cause abdominal cramping, headache, vomiting, and seizures. Alcohol will not stop amoxicillin or fluticasone from working if taken in moderation.