NCLEX_RN Test 1

The nurse is caring for a client with cellulitis of the leg. At 11:00 AM, the client reported itching and received a PRN dose of diphenhydramine. At 9:00 PM, the client reports trouble sleeping and requests another dose of diphenhydramine to help with sleep. Which action is most appropriate? Click on the exhibit button for additional information. 1. Administer a dose of diphenhydramine as it is within the specified time interval 2. Administer a dose of lorazepam to encourage relaxation 3. Inform the client that no medications can be administered for sleep at this time 4. Request a prescription for a sleep aid from the health care provider

A PRN (ie, as needed) medication prescription must state the name, dose, route, and purpose of the medication (eg, pain, nausea, sleep) and the time interval between doses. The nurse should administer a PRN medication for its prescribed purpose only. If the client requires medication for a different purpose, the nurse should contact the health care provider (HCP) to either clarify the current prescription or request a new prescription. If a client requests a sleep aid and does not have a prescription for sleep medication, the nurse should contact the HCP to request a prescription (Option 4). (Option 1) If diphenhydramine (Benadryl) is prescribed every 8 hours PRN and the previous dose was at 11:00 AM, it would be appropriate to administer a dose at 9:00 PM; however, diphenhydramine that is prescribed for itching may be administered only for itching. (Option 2) Lorazepam that is prescribed for anxiety may be administered only for anxiety. (Option 3) Informing a client that there is no prescribed medication that can be administered for sleep does not resolve a client's request for help with sleep. The nurse should implement actions to address the client's difficulty sleeping. Educational objective:A PRN prescription states the name, dose, route, and purpose of the medication (eg, for pain, nausea, sleep) and the time interval between doses. A nurse must administer a PRN medication for its prescribed purpose only.

The nurse is preparing to teach a 15-year-old primigravid client at 16 weeks gestation during an initial prenatal visit. Which information would be a priority for the nurse to include? 1. Discuss the need for increasing dietary iron intake 2. Provide education on the benefits of breastfeeding 3. Stress the importance of consistent prenatal care 4. Teach the signs and symptoms of preeclampsia

Adolescents have an increased risk for complications during pregnancy (eg, low birth weight, preterm birth, preeclampsia, anemia). They may have a self-focused outlook on life and may not consider the consequences of their actions, which may negatively affect their health and that of the fetus. The primary goal of the first prenatal visit is to establish rapport and emphasize the importance of consistent prenatal care so that complications can be prevented or detected early (Option 3). The nurse also monitors for risky behaviors (eg, substance abuse, unprotected sex), nutritional deficiencies, factors affecting emotional well-being (eg, body image concerns related to pregnancy weight gain), and social risk factors (eg, poverty, poor support system, sexual assault/abuse). (Option 1) Education about dietary iron intake (eg, meat; green, leafy vegetables; iron-fortified cereals) and iron supplementation should begin at this visit; however, it is not more important than ensuring that the client receives consistent prenatal care to prevent or monitor for pregnancy complications. (Option 2) Teaching about breastfeeding is essential and should begin early in pregnancy but is not a priority at the initial visit. (Option 4) Pregnant adolescents are often primigravidas, which increases the risk of preeclampsia. Signs and symptoms of this condition (eg, hypertension, persistent headaches, vision changes) should be discussed after 20 weeks gestation. Educational objective:Adolescents have an increased risk for complications during pregnancy (eg, low birth weight, preterm birth, preeclampsia, anemia). The primary goal of initial teaching is to establish rapport and emphasize the importance of consistent prenatal care so that complications can be prevented or detected early. Health Promotion and Maintenance

The nurse receives report on 4 clients. Which client should the nurse see first? 1. Client with a right-sided ischemic stroke who is confused and is repeatedly getting out of bed without assistance (58%) 2. Client with an asthma exacerbation who was administered albuterol 15 minutes ago and has a heart rate of 110/min (15%) 3. Client with diabetes who has a blood glucose of 290 mg/dL (16.1 mmol/L) and has a scheduled dose of insulin aspart due (9%) 4. Client with obstructive sleep apnea who is 12 hours postoperative and maintaining an oxygen saturation of 92% on room air (16%)

Clients who have had a stroke can experience cognitive dysfunction (eg, confusion), neglect on one side, deficits in spatial perception, and paralysis (hemiplegia), all of which increase the risk for injury (eg, falls). The nurse should see this client first to ensure that safety precautions (eg, bed alarm, nonslip socks) are in place to prevent injury (Option 1). The least restrictive measures (eg, orienting the client, room assignment near the nursing station) should be implemented prior to initiating restraints. (Option 2) Albuterol is a beta-adrenergic agonist that stimulates the sympathetic nervous system to cause bronchodilation and relieve asthma symptoms. Expected side effects include tachycardia, palpitations, and tremors. (Option 3) The nurse should administer the prescribed dose of insulin for a client with a blood glucose of 290 mg/dL (16.1 mmol/L). However, a client with a high risk of injury is the priority. (Option 4) Anesthetics and sedating analgesics may exacerbate symptoms of obstructive sleep apnea. Although oxygen saturation is below 95%, the client is stable on room air. Educational objective:Clients who have suffered a stroke can experience cognitive dysfunction (eg, confusion) and hemiplegia, resulting in a high risk for injury (eg, falls). The nurse should ensure that safety precautions (eg, bed alarm, nonslip socks) are in place.

The charge nurse on a medical-surgical unit is helping a student nurse formulate a care plan for a client with constipation. Which intervention in the care plan would cause the charge nurse to intervene? 1. Allow the client to ambulate in the hall as tolerated 2. Encourage the client to increase intake of nuts and seeds 3. Leave the client alone in the room when using the restroom 4. Request coffee to be included with breakfast trays

Constipation is a symptom of many different disease processes (eg, Parkinson disease, diabetic neuropathy, depression), procedures (eg, abdominal surgery, bowel manipulation), and medications (eg, anticholinergics, diuretics, opioids). Clients should be encouraged to drink 2-3 L of fluids each day, maintain a healthy bowel regimen—including avoiding delay of defecation when the urge is felt—defecate at the same time each day, and track bowel movements to identify if there is a change in bowel patterns. Immobility, a low-fiber diet, decreased fluid intake, and irregular bowel habits increase the likelihood of constipation. The client should avoid caffeinated beverages (eg, coffee, colas) because they promote diuresis, which may lead to dehydration and worsening of constipation (Option 4). (Option 1) The client should be encouraged to ambulate as often as tolerated because movement stimulates peristalsis and defecation. (Option 2) Provide the client with high-fiber foods, such as fruits, vegetables, whole grains, nuts, seeds, and legumes because fiber softens stool and increases bulk. (Option 3) Privacy can influence a client's ability to defecate. The nurse should provide privacy by leaving the client alone while using the restroom and provide a call button if assistance is needed. Educational objective:Ensuring ambulation, increasing fiber consumption, providing privacy, and creating a bowel regimen (eg, avoiding delay of defecation, defecating at the same time each day) are important practices that prevent constipation. Clients should avoid caffeinated beverages, which cause diuresis.

The nurse is caring for a client who has been pronounced brain dead. The client is a registered organ donor. The client's family is voicing concerns about the possibility of disfigurement because they want to have an open casket funeral. How should the nurse respond? 1. "If the family is not in complete agreement about organ donation, we won't be able to proceed." (9%) 2. "Once the body is dressed, there is no evidence of organ removal. An open casket will be fine." (69%) 3. "Some organ procurement leaves evidence on the body. You may want to consider a closed casket." (9%) 4. "Your family member consented to be an organ donor. You should really honor this wish." (12%)

Friends and family of deceased clients often have questions about, and may even be suspicious of, the organ donation process, especially during their time of loss and grieving. Organ procurement does not leave obvious evidence on the client's body when the body is dressed. Special precautions and techniques are used by the surgical team and funeral home personnel (eg, morticians) to maintain the integrity and outward appearance of the body (Option 2). Funeral arrangements are not delayed by organ donation and the family will not incur any costs related to procurement. An organ transplant coordinator should be consulted by the nurse to address the family's specific questions related to donation. (Option 1) Consent is not needed from the family if the client is already registered to be an organ donor. (Option 3) Organ procurement does not leave obvious evidence once a body is clothed and prepared for viewing. A closed casket is not necessary. (Option 4) Family members should be advised of the donor's wishes and have their questions answered as to how procurement will proceed. However, the nurse should never try to invoke guilt when communicating with clients or families. Educational objective:A deceased client who is registered as an organ donor does not need familial consent for organ procurement to proceed. Organ donation does not delay or interfere with funeral arrangements or leave obvious evidence on the body; deceased clients can still be displayed according to their wishes, including open casket funeral services. Psychosocial Integrity NCSBN Client Need

The nurse receives handoff of care report on four clients. Which client should the nurse assess first? 1. Client who had an emergency appendectomy 48 hours ago and is reporting hearing waves and seeing fish swimming through the walls 2. Client who had an exploratory laparoscopy 2 hours ago and has absent bowel sounds and is reporting nausea 3. Client with diabetes mellitus who has a foot ulcer and is reporting feeling pins and needles in the lower legs 4. Client with Parkinson disease who has tremors while resting and developed black-colored urine after taking carbidopa/levodopa

Hallucinations represent a serious safety risk to the client and others because these may compel clients to engage in behaviors or activities that trigger self-injury or violence toward others (eg, command hallucinations). Hallucinations experienced by clients without a psychiatric illness may indicate withdrawal from alcohol or narcotics, which can be life-threatening without prompt intervention. Nurses should promptly assess clients with new or worsening hallucinations (Option 1). (Option 2) Clients undergoing abdominal surgery (eg, exploratory laparoscopy) often have nausea and absent bowel sounds for the first few hours postoperatively due to side effects of anesthetics and decreased peristalsis after bowel manipulation. (Option 3) Clients with diabetes mellitus may develop diabetic neuropathy as a complication of neurovascular damage from inadequate long-term blood glucose management. Feeling "pins and needles" is an uncomfortable but harmless symptom of diabetic neuropathy. (Option 4) Resting tremors are an expected finding with Parkinson disease. Carbidopa/levodopa, a common medication used to manage symptoms of Parkinson disease, can cause a harmless darkening of urine color (eg, brown, black). Educational objective:Clients with new or worsening hallucinations require prompt assessment. Hallucinations increase the risk for injury to self and others and may be a symptom of life-threatening illnesses (eg, alcohol withdrawal).

Based on the nursing assessment progress notes, what is the correct staging of the client's pressure injury? Click on the exhibit button for additional information. 1. Stage 1 (10%) 2.Stage 2 (75%) 3.Stage 3 (12%) 4 .Stage 4 (1%) Educational objective:Stage 2 pressure injuries have partial-thickness skin loss (abrasion, blister, or shallow crater). The skin blisters or forms an open sore, and the area around the sore may be red and irritated

Pressure injuries are staged from 1 to 4 to classify the degree of tissue damage and determine the most appropriate and effective wound treatments. Stage 1: Intact skin with nonblanchable redness Stage 2: Partial-thickness skin loss (abrasion, blister, or shallow crater) involving the dermis or epidermis; the wound bed is red or pink and may be shiny or dry Stage 3: Full-thickness skin loss; subcutaneous fat is visible but not tendon, muscle, or bone; tunneling may be present Stage 4: Full-thickness skin loss with visible tendon, muscle, or bone; slough or eschar (scabbing, dead tissue) may be present; undermining and tunneling may be present Pressure injuries are described as "unstageable" if the base is covered by necrotic tissue or eschar

The nurse is planning care for a client with a fractured femur who was placed in balanced suspension skeletal traction 2 hours ago. Which of the following interventions should the nurse include? Select all that apply. 1. Encourage intake of at least 2 L of fluid per day to prevent constipation 2. Ensure that the weights hang freely and do not touch the ground 3. Monitor skin integrity and signs of infection at the pin insertion sites 4. Perform frequent neurovascular checks on the affected extremity 5. Remove the weights briefly every 4 hours to prevent muscle spasms

Skeletal traction involves surgically inserting screws, wires, and/or pins directly into a fractured bone and applying a pulling force (traction) via a pulley system and a rope. The pulley system allows free-hanging weights to suspend from the foot of the client's bed and pull on the skeletal pins to maintain alignment of the proximal and distal portions of the fractured bone. Appropriate nursing interventions for clients in skeletal traction include: Encouraging increased fluid intake (≥2 L/day) to reduce the risk for constipation caused by immobility (Option 1) Ensuring that the weights hang freely and are not resting on the ground or on medical equipment (Option 2) Monitoring skin integrity and pin insertion sites for signs of infection (eg, erythema, drainage, swelling, malodor) (Option 3) Performing frequent neurovascular checks, especially in the first 24 hours of traction therapy (Option 4) Inspecting the rope for fraying and ensuring its correct position in the pulley track Ensuring proper alignment of the client and the pulley system to facilitate union of the fractured bone (Option 5) Skeletal traction not only provides proper alignment during bone healing, but also helps reduce muscle spasms that result from malalignment of the fracture. The weights should not be removed, even briefly, unless prescribed by the health care provider. Educational objective:When caring for clients in skeletal traction, the nurse should encourage increased fluid intake, ensure that pulley weights hang freely, inspect pin sites for signs of infection, and perform frequent neurovascular checks on the affected extremity.

The nurse is preparing to administer acetaminophen to a 4-year-old client weighing 43 lb. Based on the prescription, what is the volume of medication in milliliters (mL) that the child should receive with each dose? Click on the exhibit button for more information.Record your answer using a whole number. Medication prescriptionAcetaminophen: 15 mg/kg/dose PO q6h PRN for temperature >101 F (38.3 C)Available ConcentrationAcetaminophen: 160 mg/5 mL oral suspension

To calculate the appropriate volume of acetaminophen oral suspension to administer per dose, the nurse should first identify the prescribed dose (eg, 15 mg/kg) and available concentration (eg, 160 mg/5 mL) and then convert to milliliters per dose (eg, 9 mL/dose). The formula method is an alternate way to calculate medication dosages. However, this method may increase the occurrence of miscalculation and medication errors. If you choose to use this method, do not round any calculations until the final step. Using the formula method, use the following steps to calculate the volume of acetaminophen per dose: Convert pounds to kilograms kg2.2 lb43 lb2=19.5454¯ kg Calculate the prescribed dose in milligrams 15 mg acetaminophenkgdose19.5454¯ kg2=293.1818¯ mg acetaminophendose Convert the prescription to administration volume Prescribed doseavailable medication×available volume=mL/dose OR 293.1818¯ mg acetaminophen160 mg acetaminophen×5 mL=9.1619¯ mL acetaminophendose Round to a whole number 9.1619¯ mLdose=9 mLdose

The nurse reinforces teaching to a client recently diagnosed with urge incontinence. Which of the following client statements about self-management strategies indicate that teaching has been effective? Select all that apply. 1. "I drink diet cola with meals because it contains fewer calories than regular soda." 2. "I have an appointment with a nutritionist to help me manage my diet so that I can lose my excess weight." 3. "I joined a smoking cessation support group at the community center." 4. "I plan to do my daily Kegel exercises when I am riding the train to and from work." 5. "I will make sure to urinate every 2 hours to reduce urgency and have fewer accidents."

Urge incontinence (UI), also known as overactive bladder, occurs when the bladder contracts randomly, causing a strong, sudden urge to urinate followed by urine leakage. UI may occur without cause or may result from neurological system dysfunction (eg, Parkinson disease, stroke) or spinal cord injury. Interventions for clients with UI include: Losing excess weight to reduce pressure on the pelvic floor (Option 2) Avoiding dietary bladder irritants (eg, caffeine, nicotine, artificial sweeteners, citrus juices, alcohol, carbonated drinks) (Option 3) Performing pelvic floor exercises (eg, Kegel) to strengthen the pelvic muscles and help prevent urinary leakage (Option 4) Taking anticholinergic medications (eg, tolterodine, oxybutynin), which reduce bladder spasms Using bladder training, such as voiding every 2 hours while awake and gradually lengthening the intervals between voiding (Option 5) (Option 1) Clients with UI should avoid bladder irritants such as drinks that contain caffeine and artificial sweeteners because these ingredients can exacerbate UI symptoms. Educational objective:Urge incontinence (UI) involves random bladder contractions that cause a strong, sudden urge to urinate followed by urine leakage. Interventions for UI include losing excess weight, avoiding dietary bladder irritants, performing pelvic floor exercises, taking anticholinergic medications, and using bladder training techniques.

While the nurse is transporting a client to a new unit, the client's chest tube drainage system falls off the bed and the tube becomes dislodged from the chest wall. What is the nurse's priority action? 1. Activate the hospital emergency response system 2. Apply supplemental oxygen and quickly transport to the new unit. 3. Check the client's respiratory pattern and effort and oxygen saturation 4. Firmly cover the insertion site with the palm of a clean, gloved hand

Explain 4. CORRECT Chest tube are inserted into the pleural cavity to facilitate drainage of air (pneumothorax), blood (hemothorax) or other fluid. Chest tubes are sutured in place, but dislodgment can occur. If this happens, a sterile occlusive dressing (eb petrolatum gauze) must immediately be place over the insertion site until the HCP can assess the client and insert a new chest tube. If such dressing are not immediately available, the nurse should cover the insertion site with something clean and occlusive. 1. The nurse should cover the site and assess the client prior to activating the EM responds system. 2. It may be necessary to provide supplemental oxygen if a chest tube is accidentally dislodge. This intervention would be done after the site is occluded. 3. After the chest tube insertion site is covered, the client should be reassessed. The nurse should not delay covering the chest tube site as pneumothorax or tension pneumothorax may occur quickly

The nurse caring for a male client prepares to insert an indwelling urinary catheter. The nurse assesses for allergies, explains the procedure to the client, and asks unlicensed assistive personnel to perform perineal care while equipment is gathered. Place in order the steps the nurse should take when inserting the urinary catheter. All options must be used.

Steps for indwelling urinary catheter insertion for the male client include: Perform hand hygiene and open sterile catheterization kit (Option 3). Apply sterile gloves and place sterile fenestrated drape with opening centered over penis (Option 2). Maintaining sterility of gloves, arrange remaining kit supplies on sterile field. Remove protective covering from catheter, lubricate catheter tip, and pour antiseptic solution over cotton balls or swab sticks. Firmly grasp penis with nondominant hand, retracting foreskin if present. Nondominant hand is now considered contaminated and remains in this position for duration of procedure (Option 6). Use dominant (sterile) hand to cleanse in a circular motion from the meatus to the glans with antiseptic solution using cotton balls or swab sticks. Use new cotton ball/swab stick with each swipe (Option 4). Use dominant hand to pick up catheter and insert it until urine return is visualized in catheter tubing (Option 5). Advance to bifurcation of catheter tubing. Hold in place and inflate balloon (Option 1). Urine return in catheter tubing may be from urethra and does not indicate that balloon tip is fully inside bladder. Because male urethra varies in length, balloon should not be inflated until catheter is fully advanced. Educational objective:To insert an indwelling urinary catheter in a male client, perform hand hygiene, apply sterile gloves and place sterile fenestrated drape, arrange supplies on sterile field, grasp penis with nondominant hand, cleanse from meatus to glans using dominant hand, insert catheter until urine return is visualized, advance catheter to tubing bifurcation, and inflate balloon.

A client with chronic kidney disease is admitted with urosepsis. Based on the admitting diagnosis and laboratory results, which of the following prescriptions should the nurse question? Select all that apply. Click the exhibit button for additional information. 1. Administer IV ceftriaxone 2. Continue home dose of valsartan 3. Initiate continuous cardiac telemetry 4. Obtain blood and urine cultures 5. Obtain CT scan of the abdomen with contrast

Urosepsis is a bloodstream infection that originates from the urinary tract. Standard immune responses are insufficient, thereby triggering an exaggerated immune response. Tissue perfusion decreases and causes potentially life-threatening organ impairment. Clients with preexisting disease of one or more organ systems (eg, chronic kidney disease [CKD]) are at increased risk for septic shock in which overwhelming sepsis causes cardiovascular collapse and impaired ability to meet the body's metabolic and cellular demands. CKD impairs the excretion of excess potassium and can potentiate hyperkalemia, leading to life-threatening cardiac arrhythmias (eg, ventricular fibrillation). Angiotensin II receptor antagonists (eg, valsartan) can be used to manage hypertension associated with CKD; however, these medications should be avoided because of the risk for worsening hyperkalemia (Option 2). Clients with CKD and elevated creatinine are unable to adequately excrete the iodinated contrast administered for CT scans, resulting in toxic effects from the contrast (Option 5). (Options 1 and 4) Blood and urine cultures should be obtained prior to antibiotic initiation to identify the specific pathogen affecting the client. While waiting for the results of the cultures, a nonnephrotoxic, broad-spectrum antibiotic (eg, ceftriaxone) may be administered. (Option 3) Continuous cardiac telemetry and vital sign monitoring should be initiated because hyperkalemia and sepsis can lead to cardiovascular complications (eg, dysrhythmias, hypotension). Educational objective:When caring for clients with chronic kidney disease and urosepsis, the nurse should question the administration of iodinated contrast due to decreased excretion and angiotensin II receptor antagonists because of the risk for worsening hyperkalemia.

A nurse is caring for a client who had a transurethral resection of the prostate and is receiving continuous bladder irrigation by gravity. Which of the following tasks can the nurse delegate to unlicensed assistive personnel? Select all that apply. 1. Calculating the difference between irrigant intake and total drainage output 2. Cleaning around the catheter insertion site daily 3. Immediately notifying the nurse if the client reports pain 4.Increasing the irrigation rate when the urine becomes more red than pink 5.Measuring the total volume of output in the drainage collection bag

2,3,5 CORRECT Continuous bladder irrigation is prescribed following surgical transurethral resection of the prostate and prevents obstruction of urine outflow by removing clotted blood from the bladder. A 3-way catheter is used to continuously infuse the solution into the bladder by gravity. The catheter drains urine, irrigant solution, and blood into a collection bag. The registered nurse (RN) should consider the five rights of delegation when delegating to unlicensed assistive personnel (UAP): Catheter care is a routine, noncomplex task that may be safely delegated to UAP (Option 2). Any client reports of pain or bladder spasms to UAP should be immediately conveyed to the RN because these symptoms may indicate obstruction (Option 3). Measuring output is routine data measurement. UAP should report the volume to the RN, who will determine the adequacy of drainage (Option 5). (Option 1) Clots or kinks may obstruct drainage and cause a smaller volume of outflow than inflow. The nurse should calculate this difference to determine the need to reestablish patency using manual irrigation. (Option 4) The irrigation rate should be titrated to maintain light-pink outflow drainage with few clots. It is not within the UAP's scope of practice to titrate the inflow rate or to monitor drainage quality. Educational objective:To maintain patency of a continuous bladder irrigation system, the registered nurse (RN) must monitor the quality of drainage, titrate the inflow rate, and manually irrigate as needed. The RN may delegate routine tasks (eg, catheter care, measuring output) to unlicensed assistive personnel. Five rights of delegation Right task - Within delegatee's scope of practice - Routine, frequently recurring task; minimal potential risk - Established sequence of steps; requires little to no modification for individual clients - Predictable outcome Right circumstances - Relatively stable client; noncomplex task - Adequate staffing, resources & supervision available Right person - Delegator should assess competency prior to delegating - Delegatee must have the appropriate knowledge, skills & abilities Right direction/communication - Delegator needs to provide clear instructions; must include specific client concerns & observations to be reported back or recorded Delegatee should verbalize understanding & have the opportunity to ask questions Right supervision/evaluation - Monitor, evaluate & intervene as needed - Delegator retains ultimate accountability for task

The nurse cares for a client with an established ascending colostomy. Which statement made by the client indicates that further teaching is required? 1. "I always try to drink 3 liters of water each day." (11%) 2. "I avoid eating beans, onions, broccoli, and cauliflower." (9%) 3. "I change the appliance and bag every other day." (69%) 4. "I empty the bag when it is about one-third full."

3. CORRECT Colostomies may be performed on any part of the colon (ascending, transverse, descending, sigmoid). Stool becomes more solid as it passes through the colon, so stool drainage characteristics vary with location of the ostomy. Ascending colostomies produce semiliquid stool. Stool is contained in an ostomy appliance bag secured to the skin. The appliance opening is cut to fit closely around the stoma. If the appliance does not fit well, liquid stool may leak onto the peristomal skin, and skin irritation occurs due to the digestive enzymes in stool. Peristomal skin irritation may also occur if the ostomy appliance is removed and changed too frequently. The appliance should be changed every 5-10 days (Option 3). (Option 1) The semiliquid consistency of stool from an ascending colostomy results in increased fluid loss. The client is encouraged to drink plenty of fluids to prevent dehydration. (Option 2) The client with a colostomy has few dietary restrictions, but the client may be encouraged to decrease intake of odorous and gas-forming foods (eg, beans, onions, broccoli). (Option 4) The ostomy bag is emptied when it becomes one-third full. Leaking and skin irritation may occur if the appliance becomes too heavy and pulls away from the skin. Educational objective:Peristomal skin irritation is prevented by ensuring that ostomy appliances fit closely around the stoma and that the appliance is changed every 5-10 days. The ostomy bag is emptied when one-third full. The client with a colostomy is encouraged to drink plenty of fluids and decrease intake of gas-forming foods.

The charge nurse is responsible for making room assignments for multiple clients. Which pair of client assignments to a shared room is appropriate? 1. Client with blood loss anemia and client with intractable diarrhea. 2. Client with gastroenteritis and client with chemotherapy included nausea and vomiting. 3. Client who had a bowel resection 1 day ago and client with asthma exacerbation 4. Client who had a total hi arthroplasty 2 days ago and client with influenza..

3. CORRECT When making room assignments, it is important to remember that a client with an active or suspected infection should not be paired with a client who has a exacerbation dose not have an infection and is not at risk for spreading infection to a client who had recent bowel resection surgery. 1. A client with un-contained or excessive excretions, drainage, or secretions (profuse diarrhea, draining wounds) is more likely to spread infection, if present, and therefore should be assigned to a private room. 2. The client who has chemotherapy-induced nausea and vomiting is likely immunocompromised secondary to the chemotherapy and is therefore vulnerable to infection from a client with gastroenteritis. 4. A client who has a fresh surgical wound has an increased risk of infection and should not be paired with a client with an active influenza infection, which is transmitted through the droplet route.

The charge nurse is educating a new nurse on IV start technique for a 6-year-old with autism spectrum disorder. Which statement by the new nurse indicates that further teaching is required? 1. "I will explain the procedure with the use of pictures." (30%) 2. "I will have the child's caregiver at the bedside to provide comfort." (3%) 3. "I will hold the child's hand as a soothing measure." (60%) 4. "I will limit the number of hospital staff in the room to ease anxiety." (5%)

Autism spectrum disorders (ASDs) are neurodevelopmental disorders characterized by impaired social interaction and behavior. Each child with ASD has unique communication needs, which the nurse should incorporate into an individualized plan of care. When performing a procedure on a child with ASD, the nurse should engage the following communication techniques to ease the child's anxiety and increase cooperation: Provide brief, concrete, and developmentally appropriate communication or demonstrations, explaining each step during the procedure. Children with ASD may respond to pictures, as they tend to be visually oriented (Option 1). Encourage caregivers to remain near the child to provide comfort and reassurance (Option 2). Reduce stimulation by limiting the number of staff members in the room (Option 4). Introduce staff or equipment slowly, preferably with caregivers nearby. (Option 3) Children with ASD may experience stress in response to touching and eye contact. Limit physical contact until conferring with the child's caregiver to assess which actions are soothing and which may trigger behavioral outbursts. Educational objective:Children with autism spectrum disorder (ASD) respond well to brief, concrete, and developmentally appropriate communication. The nurse can ease anxiety during procedures by involving caregivers and reducing stimulation. Physical touch and eye contact may activate a stress response in children with ASD.

The nurse responds to the bed alarm of a client with a urinary tract infection and finds the client lying on the floor and soiled with urine. Which of the following entries by the nurse are appropriate to include when documenting the event? Select all that apply. 1. Blood pressure 102/60 mm Hg, heart rate 97/min, and SpO2 98% on room air 2. Client found at 2310 soiled with urine, lying on the floor near foot of bed 3. Client has continuously refused to use the call bell as instructed 4. Client states, "My bottom hurts a lot and I feel a little bit dizzy." 5. Jones, MD, notified at 2322. Will observe for indications of injury.

An adverse event is an unusual occurrence, accident, or injury unrelated to the client's underlying condition. Adverse events must be acknowledged and documented in the chart. It is essential for the nurse to note the actions taken in response to the event (eg, client teaching, safety precautions) and interventions implemented to rectify or reduce harm to minimize nursing liability. When documenting client care, nurses should use accurate, detailed, and objective statements (eg, what the nurse sees or hears) that are free from biased language and personal judgments. Examples of appropriate documentation include: Data gathered by direct measurement (eg, vital signs, wound measurements) (Option 1) Observations (eg, client actions [eg, crying] or observable assessments [eg, soiled with urine]) (Option 2) Client statements, documented as direct quotes (Option 4) Detailed descriptions of nursing actions and interventions (eg, which health care provider was notified) (Option 5) (Option 3) Documenting "client has continuously refused" is negatively biased and may be interpreted as anger or frustration from the nurse. The nurse should document that the call bell was within the client's reach and that teaching has been frequently reinforced to use the call bell for assistance. It would also be appropriate to document any client statements about refusing to use the call bell. Educational objective:The nurse should always use accurate, detailed, and factual documentation that is free from biased language and personal judgments. Appropriate documentation includes data from direct measurements, objective observations, client statements, and descriptions of nursing actions.

The registered nurse supervises a licensed practical nurse (LPN) and unlicensed assistive personnel (UAP) caring for clients receiving brachytherapy. Which action would require the nurse to intervene? 1. LPN who reinforces the purpose of prescribed bed rest for a client with a radium implant for cervical cancer 2. LPN who, when caring for a client with a radium implant, turns away from the client while wearing a lead apron 3. UAP who changes the bed linens of a client with a radium implant and leaves the removed linens in the room 4. UAP who empties the urinal of a client with implanted radioactive seeds for prostate cancer into the toilet

Brachytherapy is an internal radiation treatment that is ingested, injected into a cavity or bloodstream, or implanted (eg, seeds, capsules, wires). Brachytherapy emits radiation in or near a tumor to treat certain malignancies. When caring for clients undergoing brachytherapy, nurses should maintain specific precautions to ensure safety, including: - Limit the time of exposure (eg, 30 min/day). Cluster care and wear a designated (ie, not shared with anyone else) dosimeter badge. -Maximize distance from the source; 6 feet (1.8 m) is recommended. -Use shielding (eg, lead apron, portable lead shields) appropriately. Lead aprons typically shield the front of the body; turning the back to the client is a risk for exposure (Option 2). Pregnant women and children should not be exposed to clients undergoing brachytherapy. (Option 1) Clients receiving cervical brachytherapy should remain on bed rest to prevent dislodgment of the implant. (Option 3) Dressings, bed linens, and trash must remain in the client's room until the implant is removed. (Option 4) The body fluids of clients with implanted radioactive seeds in the prostate are generally not radioactive. Some seeds may be passed through the urine; however, they emit very little radiation.

During the discharge process, the nurse observes a new parent placing a newborn into a car seat in the vehicle. Which action by the parent requires the nurse to intervene? 1. Anchors the car seat in the center of the vehicle's back seat 2. Dresses the newborn in a sleep sack before securing the harness 3. Keeps the car seat at a 45-degree angle 4. Uses a car seat that faces the rear of the vehicle

Vehicle safety for newborns and small children is important for reducing preventable injuries and deaths. Newborns and children age <2 years must be placed in a rear-facing car seat in the vehicle's back seat. The car seat's harness is secured snugly at or below the shoulders, at the hips, and between the legs; the connectors clip together at the center of the chest. The harness fits securely when the newborn is dressed in lightweight clothing. Tucking blankets between the newborn and the harness or dressing the newborn in bulky coats or a sleep sack reduces the car seat's effectiveness (Option 2). (Option 1) The car seat should be placed in the back seat and in the center (away from the doors), if possible. This protects the child from airbag deployment as well as collisions to the vehicle's sides. (Option 3) When the car seat tilts back at a 45-degree angle, there is less danger of the newborn's head and neck falling forward and obstructing the newborn's airway. (Option 4) A rear-facing car seat protects the newborn's head and neck from whiplash in a collision. Educational objective:When traveling by automobile, newborns and children age <2 must be placed in a rear-facing car seat in the back seat. The car seat's harness should be secured snugly at or below the shoulders, at the hips, and between the legs; parents should avoid using blankets, bulky coats, or sleep sacks between the newborn and the harness.

The nurse is preparing to administer insulin lispro at 1700 to a client with type 1 diabetes mellitus whose blood glucose level was 245 mg/dL at 1645. During what time frame is the client at highest risk for hypoglycemia? 1. 1730-2000 2. 1900-2200 3. 2000-0700 4. 2100-0500

1. CORRECT: Rapid-acting insulins (eg, aspart, lispro) peak quickly, often within 30 minutes to 3 hours of administration. Therefore, the client who receives insulin lispro at 1700 is at highest risk for hypoglycemia from 1730-2000 2. Insulin glargine is a long-acting insulin that does not have a peak effect. The peak effect of regular insulin, which is short acting, is 2-5 hours. Clients who receive regular insulin at 1700 would be most at risk for hypoglycemia from 1900-2200. 3. Insulin detemir, a long-acting insulin, takes peak effect in 3-14 hours. Clients who receive insulin detemir at 1700 would be most at risk for hypoglycemia from 2000-0700. 4. Insulin NPH, an intermediate-acting insulin, takes peak effect in 4-12 hours. Clients who receive insulin NPH at 1700 are most at risk for hypoglycemia from 2100-0500.

The nurse is caring for a client with tracheal cancer. At 9:00 PM, an on-call health care provider (HCP) rounds on the client and is alarmed to find the client bradypneic, hypotensive, and somnolent. The HCP requests that the nurse give the client naloxone. Which of the following is the best action by the nurse? Progress Notes: - 1300 Palliative care HCP progress notes: Efforts to shrink tumor unsuccessful. Family conference held with client regarding poor prognosis and quality of life. Client desires to receive comfort measures only. Code status changed to do not resuscitate - 1905 Nurse shift assessment: Client groaning, drooling, dyspnea, respiratory rate 29, wheezes and stridor on auscultation, pain 9/10 Medications: - Lorazepam: 2-4 mg IVP, q2h PRN for agitation and nausea - Morphine sulfate: 1 mg/mL IVPB, titrate dose every 5 minutes as needed for pain and dyspnea (continuous) - Scopolamine: 1.5 mg transdermal q72h (2100) 1. Approach the client's family to discuss whether to give naloxone in light of the client's wishes 2. Call the palliative HCP who prescribed the morphine sulfate to discuss the change in prescription 3. Describe the client's assessment data and plan of care, and do not give naloxone 4. Place the morphine infusion on standby and obtain the naloxone prescription

1. The client and family already decided to withdraw treatment and pursue palliation; approaching the family about whether to intervene is inappropriate and may cause undue grief and guilt. 2. Before escalating the situation by calling the palliative HCP, the nurse should explain the client's status and wishes. If the on-call HCP insists that naloxone be given, the nurse should notify the charge nurse or supervisor. 3. CORRECT: Clients at the end of life should be relieved of pain and discomfort according to the ethical principles of beneficence (doing good) and nonmaleficence (doing no harm). As a client advocate, the nurse should be actively involved in ensuring that unwanted or unwarranted treatment and client suffering are minimal. The client has requested a natural death without resuscitative efforts. Other HCPs (eg, on-call HCPs) may be unaware of the client's status or recent changes to the plan of care; therefore, the nurse should inform the on-call HCP of the changes and should not give the naloxone 4. Naloxone rapidly reverses the effects of opioid medications (eg, morphine). The resulting pain and discomfort for this client oppose nursing standards of care, violate the client's wishes, and are harmful to the client.

A 2-month-old infant is admitted with respiratory syncytial virus and bronchiolitis. Which interventions would the nurse anticipate? Select all that apply. 1. Administer antipyretics 2. Initiate IV fluids 3. Keep the head of the bed flat 4. Maintain isolation precautions 5. Suction as needed

1, 2, 4, 5. CORRECT: Interventions for severe RSV infection are supportive, including providing supplemental oxygen and suctioning to support oxygen exchange and clear the airway, elevating the head of the bed to improve diaphragmatic expansion and promote secretion clearance, administering antipyretics to reduce fever and provide comfort, and initiating IV fluids to correct dehydration due to fever, tachypnea, or poor oral intake. RSV is transmitted via direct contact with respiratory secretions. Contact isolation is required, and droplet precautions are added if within 3 ft (0.91 m) of the client, depending on facility policy.

The nurse is caring for a client with a central venous catheter (CVC) who reports feeling nauseated and chilled. The nurse notes that the CVC insertion site is red and inflamed and that the client has a temperature of 102 F (38.8 C). Which new prescription from the health care provider should the nurse implement first? 1. Administer ondansetron 4 mg IV push PRN for nausea or vomiting 2. Document the occurrence and notify the hospital's epidemiology team 3. Initiate the first dose of IV piperacillin/tazobactam via a new peripheral IV 4. Obtain blood cultures and discontinue the central venous catheter

1, 2. Administering medications for comfort, completion of documentation, and facility-based report protocols should be done as soon as possible. However, to prevent progression to sepsis, treatment of a suspected CRBSI should not be delayed. 3. Initiation of antibiotics is essential in treating infection and preventing its progression. However, the nurse should first draw blood cultures and remove the CVC, if possible. 4. CORRECT: When caring for a client with signs of a central line-related bloodstream infection, the nurse should obtain blood cultures and remove the device, if possible, before beginning antibiotic therapy. Other nursing interventions (eg, symptom management, documentation) should be done after initiating treatment of the infection.

After addressing a group of young adults about sexual health and hygiene, the nurse recognizes that teaching regarding genital warts and the human papillomavirus (HPV) has been effective when hearing which client statements? Select all that apply. 1. "Genital warts that have been treated are at risk of recurrence." 2. "I should begin Pap testing as soon as I am sexually active." 3. "I should receive the HPV vaccine series even if I am already sexually active." 4. "Infection with HPV increases my risk of cervical cancer." 5. "Using condoms during sex will eliminate the risk of spreading the virus."

1, 3, 4. CORRECT: Genital warts can be treated (eg, topical podophyllin, cryotherapy, laser surgery) but may recur at any time. High-risk HPV strains (types 16 and 18) increase risk of cervical, oral, and genital cancers. The HPV vaccine helps prevent HPV infection and is most effective if taken before becoming sexually active. However, current guidelines suggest that even teens and young adults (age ≤26) who have already become sexually active may benefit from HPV vaccination 2. The majority of clinical organizations recommend that cervical cancer screening (Pap testing) be initiated at age 21, regardless of sexual history. In women age <21, HPV infection rarely progresses to malignancy. Overdiagnosis and treatment of potentially benign HPV infections can lead to negative reproductive outcomes in the future (eg, pregnancy loss, preterm birth). 5. Barrier methods (eg, condoms) can reduce the risk of HPV transmission. However, abstinence is the only definitive way to eliminate the risk of contracting STIs.

The nurse is reviewing new arterial blood gas results for a client with an exacerbation of chronic obstructive pulmonary disease. The client's serum pH is 7.45. Which result noted by the nurse is a priority to report to the health care provider? 1. HCO3− of 35 mEq/L (35 mmol/L) 2. Hemoglobin of 19 g/dL (190 g/L) 3. PaCO2 of 67 mm Hg (8.91 kPa) 4. PaO2 of 52 mm Hg (6.92 kPa)

1, 3. Clients with COPD chronically retain CO2, resulting in respiratory acidosis. This client's results are consistent with compensated respiratory acidosis in which renal resorption of HCO3− increases to normalize serum pH. 2. Clients with COPD often experience chronic hypoxia and may demonstrate a compensatory increase in hemoglobin (ie, polycythemia) to promote maximal oxygen transport. 4. CORRECT: PaO2 <60 mm Hg (7.98 kPa) in a client with COPD indicates significant hypoxemia, which requires the nurse to contact the health care provider for additional interventions (eg, oxygen, positive-pressure ventilation) (Option 4).

The nurse conducts a developmental assessment of a 4-year-old child. Which of the following tasks does the nurse anticipate that the child will perform successfully? Select all that apply. 1. Draw a circle 2. Jump rope with both feet 3. Sit quietly for 30 minutes 4. Use a spoon and fork 5.Walk up and down stairs

1, 4, 5 CORRECT Preschool-age children begin to master more gross motor activities while rapidly increasing their fine motor abilities. The preschooler age 4 should have the fine motor skills to manipulate small tools (eg, scissors, pencil) and therefore be able to draw simple shapes (eg, circle, square) and perform more self-care activities (eg, eating with a spoon and fork) (Options 1 and 4). The gross motor skills and balance of a child age 4 improve, allowing for more independent, complex movements (eg, walking up and down stairs) (Option 5). (Option 2) A preschool-age child typically gains the ability to jump rope around age 5. A child age 4 would not yet be expected to jump rope successfully. (Option 3) It is normal for preschool-age children to be unable to sit quietly for longer than 15 minutes at a time. Educational objective:Normal preschool developmental milestones include the ability to manipulate small tools (eg, scissors, pencil) to perform activities such as drawing a circle and using eating utensils. Preschool-age children should have mastered gross motor activities such as stair climbing. It is normal for them to be unable to sit still longer than 15 minutes at a time.

The nurse administers an intermittent bolus enteral feeding to a client via nasogastric tube. Which of the following actions by the nurse are appropriate? Select all that apply. 1. Aspirate and discard 50 mL of gastric residual prior to feeding 2. Assess the tube placement marking at the naris insertion site 3. Auscultate the client's bowel sounds prior to feeding 4. Keep the client's head of the bed elevated at 45 degrees 5. Slow the feeding rate if the client develops abdominal cramping

2,3,4,5 CORRECT Before administering intermittent enteral feedings, the nurse should: Check the tube placement marking at the naris insertion site. Displacement of the marking indicates that the tube may have been partially withdrawn (Option 2). Assess bowel function (eg, auscultate bowel sounds, measure gastric residual) to evaluate feeding tolerance (Option 3). Elevate the head of the bed to 30-45 degrees (and keep it elevated 30-60 min afterward) to minimize aspiration risk (Option 4). Confirm tube placement (eg, radiology report, gastric aspirate pH) to ensure that the tip is correctly placed in the stomach or small intestine. Flush tube with 30 mL of water (and again after feedings) to prevent clogging. During administration of intermittent enteral feedings, the feeding rate should be slowed if abdominal cramping develops. This may occur if feeding is administered too quickly or the formula is cold (Option 5). (Option 1) Aspirated gastric residual volume (GRV) should be returned to the stomach because repeatedly discarding aspirate may cause hypokalemia and metabolic alkalosis. Facility policy may advise holding enteral feeding for high GRVs (eg, >500 mL) to minimize aspiration risk. However, a GRV of 50 mL is not excessive and should be returned. Some facilities no longer routinely check GRVs because recent evidence shows that this practice impairs calorie delivery and may be ineffective for predicting aspiration risk. Educational objective:Before administering intermittent enteral feedings, the nurse should confirm tube placement, assess bowel function, elevate the head of the bed to 30-45 degrees, and return gastric aspirate to the stomach. The feeding should be administered slowly, and the tube flushed with water before and after.

A nurse in the cardiac intensive care unit assesses a client with diabetes mellitus who underwent a percutaneous coronary intervention with stent placement via the left femoral artery 3 hours ago. Which assessment finding requires priority notification of the health care provider? 1. 1+ palpable pedal pulses bilaterally 2. 2-cm area of ecchymosis in the left groin 3. Angina rated as 4 on a pain scale of 0-10 4. Blood glucose of 220 mg/dL (12.2 mmol/L)

3. CORRECT Percutaneous coronary intervention (PCI) with stent placement is performed to improve coronary artery patency and increase cardiac perfusion. A balloon and stent are inserted via a catheter through a large artery (eg, femoral artery) and threaded toward the blocked coronary artery. The balloon expands the stent against the arterial wall, compressing plaque and improving patency. The stent remains in the client after the balloon and catheter are removed. Potential complications of PCI include thrombosis, stent occlusion, bleeding/hematoma, and limb ischemia. The nurse should immediately notify the health care provider of postprocedure angina, which indicates possible thrombosis or stent occlusion; necessary prescriptions (eg, nitroglycerin, second PCI) should be obtained and promptly initiated (Option 3). (Option 1) Neurovascular assessments of the affected extremity should be compared with the unaffected extremity and the client's baseline; this client's 1+ pulses are not a concern because they are bilateral, not unilateral. Most clients with diabetes mellitus and coronary artery disease may also have baseline peripheral artery disease. (Option 2) A small amount of bleeding/ecchymosis is expected at the access site due to anticoagulation therapy, which is initiated prior to PCI. The nurse should assess for signs of hematoma formation and retroperitoneal hemorrhage. (Option 4) Increased blood glucose must be treated but is not a priority over stent occlusion.

The staff nurse caring for a client with a history of substance use disorder approaches the charge nurse and says, "My client is constantly requesting pain medicine. I had to administer normal saline instead of morphine because it is too early for another dose of morphine." Which action by the charge nurse is the priority at this time? 1. Document the incident in the nurse's employee file and review it with the unit manager (8%) 2. Follow institutional protocol for filing an incident or variance report (30%) 3. Instruct the nurse to notify the health care provider about the lack of pain relief (52%) 4. Report the incident to the hospital's ethics committee for evaluation (8%)

3. CORRECT Administration of a placebo (a substance with no therapeutic effect) outside of a consented research trial is unethical and deceitful. When faced with an ethical dilemma, the nurse should address the client's needs prior to reporting or documenting the unethical behavior. Clients with a history of substance use disorder and increased opioid tolerance often require a higher-dose analgesic or stronger opioid (eg, hydromorphone) to achieve pain relief. The priority action by the charge nurse is to instruct the staff nurse to contact the health care provider to discuss the client's frequent requests for morphine to alleviate uncontrolled pain (Option 3). (Options 1 and 2) Any documentation or reporting (eg, variance or incident report) should be completed after addressing the issue with the nurse, to ensure the client receives the appropriate medications for pain relief. (Option 4) A hospital ethics committee examines the overall plan of care for clients with complex, often life- or limb-threatening conditions. A scenario such as this client's should be resolved by unit management and not be escalated to the ethics committee unless it becomes a pervasive issue or a pattern of behavior among nursing staff. Educational objective:Administration of a placebo outside of a consented research trial is unethical and deceitful. When faced with an ethical dilemma, the nurse should address the client's needs prior to reporting or documenting the unethical behavior.

A nurse is preparing to administer a unit of packed red blood cells to a client with hemoglobin of 7 g/dL (70 g/L). The unit secretary retrieved the blood 25 minutes ago. When entering the client's room, the nurse notes that the client's IV is not patent and is unsuccessful at inserting the new IV. What should the nurse do next? 1. Have another nurse attempt to restart the IV 2. Notify the health care provider of the delay 3. Place the blood in the unit refrigerator 4. Return the blood to the blood bank

4. CORRECT 1. It is reasonable for the nurse or another nurse to attempt to restart the IV. However, this takes time, so the blood should be returned to the blood bank first. 2. If the client has symptoms related to the low hemoglobin level (<11.7 g/dL in female and <13.2 g/dL in male clients), such as low blood pressure, the HCP should be notified. This would occur after the blood is sent back to the blood bank and attempts to restart the IV have occurred. 3. Blood products should not be placed in the unit refrigerator as the temperature cannot be precisely regulated. 4. CORRECT: Blood products should not be left at room temperature for >30 minutes before a transfusion is started. Leaving blood out at room temperature for a prolonged period increases the likelihood of bacterial growth. If the start of the transfusion is delayed, the blood should be returned to the blood bank, where it can be refrigerated at a precise temperature

A client comes to the emergency department with crushing substernal chest pain. Which interventions should the nurse complete? Select all that apply. 1. Administer morphine 2. Check blood pressure and heart rate 3. Draw blood specimen 4. Obtain a 12-lead ECG 5. Position client in the supine position

1, 2, 3, 4. CORRECT: The nurse should rapidly assess (eg, vital signs, heart and lung sounds, pain) and intervene (eg, 2 large-bore IV lines, morphine, oxygen, nitroglycerin, aspirin) for the client with acute chest pain. Upright positioning improves ventilation and reduces pressure on the heart. The nurse should obtain a 12-lead ECG, chest x-ray, and blood work (eg, cardiac markers), and place the client on continuous cardiac monitoring. 5. Unless contraindicated the client should be placed in an upright, seated position (not supine); upright positioning improves ventilation and reduces pressure on the heart.

A client with emphysema arrives at the clinic for a routine follow-up visit. Which manifestations are characteristic of emphysema? Select all that apply. 1. Activity intolerance 2. Barrel chest 3. Hyperresonance on percussion 4. Stridor 5. Tracheal deviation

1, 2, 3. CORRECT: Emphysema is characterized by alveolar wall destruction. Lung tissues lose elasticity (recoil) due to permanently enlarged, "floppy" alveoli. This causes hyperinflation of the lungs (air trapping), manifested by hyperresonance on percussion and prolonged expiration. Hyperinflation of the lungs causes the client to develop a barrel-shaped chest. Hyperinflated lungs also prevent the client from meeting oxygen demands during increased activity, leading to activity intolerance and anxiety Pursed lip breathing ("puffing"), accessory muscle use, and the tripod position (leaning forward with hands on the knees) are seen during exertion and as the disease progresses. 4. Stridor (harsh, high-pitched breathing) is due to obstruction or constriction of the large (upper) airway (eg, aspiration of a foreign object, anaphylaxis, epiglottitis). Stridor indicates life-threatening airway compromise and requires prompt intervention. It is not a manifestation of emphysema. 5. Tracheal deviation occurs with a tension pneumothorax, not emphysema. When an injury causes air to become trapped in the pleural space, intrapleural pressure increases and pushes on the heart and great vessels. This causes a mediastinal shift that manifests externally as tracheal deviation.

The nurse is caring for an adult client who is in soft wrist restraints. Which nursing actions should be included in the plan of care? Select all that apply. 1. Offer fluids, nutrition, and toileting every 2 hours and as needed 2. Perform neurovascular assessment every hour 3. Reassess client's continued need for restraints every 12 hours 4. Release restraints to perform range of motion exercises every 2 hours 5. Remove restraints for a trial discontinuation every 4 hours

1, 2, 4. CORRECT: Facilities may determine the frequency of client monitoring; however, general guidelines include: performing hourly neurovascular checks (eg, pulses, color, skin temperature, sensation, movement), briefly releasing restraints for skin integrity assessment and range of motion exercises every 2 hours, and offering fluids, nutrition, and toileting every 2 hours and as needed 3. Restraints should be a last resort and discontinued as soon as possible. The nurse should regularly reassess (eg, every hour) the client's continued need for restraints. 5. Once restraints are discontinued, a new prescription is required to reapply them. Trial discontinuations are not permitted.

The nurse is reinforcing education about lifestyle choices to help reduce symptoms for a client with gastroesophageal reflux disease. Which of the following statements by the client indicate a correct understanding? Select all that apply. 1. "I have switched from coffee to decaffeinated herbal tea in the mornings." 2. "I plan to join a smoking-cessation program." 3. "I prefer to eat three large meals a day and avoid snacking." 4. "I prop myself up on a couple of pillows when I go to sleep." 5. "I will switch to low-fat dairy products and avoid high-fat foods."

1, 2,4, 5. CORRECT: Gastroesophageal reflux disease (GERD) occurs when chronic reflux of stomach contents causes inflammation of the esophageal mucosa. The lower esophageal sphincter normally prevents stomach contents from entering the esophagus. Factors that decrease the tone of the lower esophageal sphincter (eg, caffeine, alcohol), delay gastric emptying (eg, fatty foods), or increase gastric pressure (eg, large meals) can precipitate GERD. Lifestyle and dietary measures that may help prevent GERD and associated symptoms include: Weight loss because excessive abdominal fat may increase gastric pressureAvoiding GERD triggers such as caffeine, alcohol, nicotine, high-fat foods, chocolate, spicy foods, peppermint, and carbonated beverages may help prevent GERD and associated symptoms 2. CORRECT: Discontinuing the use of tobacco products may help prevent GERD and associated symptoms Refraining from eating at bedtime and/or lying down immediately after eating 3. Clients with GERD should eat small, frequent meals with sips of water or fluids to help facilitate the passage of stomach contents into the small intestine and help prevent reflux from an overly full stomach during and after meals. 4. CORRECT: Sleeping with the head of the bed elevated may help prevent GERD and associated symptoms

A client is receiving packed red blood cells intravenously through a double-lumen peripherally inserted central catheter (PICC) line. During the transfusion, the nurse receives a new prescription to begin amphotericin B IVPB. What is the nurse's best action? 1. Administer amphotericin B through the unused lumen of the PICC line 2. Insert a peripheral IV line to begin infusion of amphotericin B 3. Interrupt the blood transfusion to infuse amphotericin B, then resume after infusion 4. Wait 1 hour after transfusion finishes before administering amphotericin B

1, 2. Although starting a peripheral IV line or using the unused lumen of the peripherally inserted central catheter line would prevent mixing the drug with the blood products, it would not help distinguish the onset of potentially fatal sequela from either component 3. Transfusions should not be interrupted after initiation except in cases of transfusion-related reactions or fluid overload. In addition, interrupting and restarting transfusions increases the risk for infection. Blood products should be transfused within 4 hours of removal from refrigeration. 4. CORRECT: At least one hour should be allowed between completion of a blood transfusion and administration of amphotericin B. The adverse effects of a transfusion-related reaction and an adverse reaction from amphotericin B are similar, and the observation time allows the nurse to distinguish the triggering event if symptoms develop.

Which client situation would be classified as an adverse event, requiring the nurse to complete an incident report? Select all that apply. 1. Cerebrospinal fluid sample is sent to the laboratory labeled as a urine sample 2. Client who has a hemoglobin of 6 g/dL (60 g/L) refuses recommended blood products 3. Nurse does not report potassium result of 6.5 mEq/L (6.5 mmol/L) to health care provider 4. Postpartum client who is post epidural anesthesia falls while ambulating to the bathroom 5. Provider prescribes 5,000 units of heparin, nurse gives 1 mL (10,000 units/mL) of heparin

1, 3, 4, 5. CORRECT: Adverse events are unforeseen or unintended outcomes that result in harm, or have the potential to cause harm, and require the completion of incident reports. Examples of client incidents include falls, mislabeled laboratory specimens, medication administration errors, and communication errors. 2. Under the ethical principle of autonomy, the client has the right to refuse any recommended medical treatment, even if doing so could result in potential harm to the client.

The nurse is performing a medication reconciliation during a clinic visit with a client recently prescribed lithium. Which of the client's home medications is the priority to clarify with the health care provider? 1. Acetaminophen 2. Hydrochlorothiazide 3. Metformin 4. Sulfadiazine

1, 4. CORRCT Acetaminophen and sulfa antibiotics (eg, sulfadiazine) do not interact with lithium and are safe for the client to take. 2. CORRECT: Lithium is a mood stabilizer used to treat bipolar affective disorders. Medications such as thiazide diuretics, nonsteroidal anti-inflammatory drugs, and antidepressants can cause elevated lithium levels, which increases the risk of toxicity. 3. Lithium levels are not affected by antidiabetic medications such as metformin; however, lithium has been known to increase serum glucose levels. This may necessitate a dose adjustment of the antidiabetic medications. The client's blood glucose should be monitored, but this effect is not the most concerning at this time.

A nurse is reading a client's tuberculin skin test 48 hours after placement and notes an 11-mm area of induration. The client is a recent immigrant from Nigeria and reports no symptoms. Which actions would be appropriate by the nurse? Select all that apply. 1. Ask the client about a history of bacille Calmette-Guérin vaccine 2. Document the negative response in the client's medical record 3. Have the client return in a week to receive a second injection 4. Obtain a prescription for a chest x-ray from the health care provider 5. Place the client in droplet precautions and wear a surgical mask during care

1, 4. CORRECT: Prior administration of the bacille Calmette-Guérin vaccine can produce a false positive tuberculin skin test (purified protein derivative [PPD] reaction). Positive PPD reactions in clients who are asymptomatic need further evaluation with chest x-ray. Tuberculin purified protein derivative (PPD) skin tests (ie, Mantoux test) screen individuals for tuberculosis (TB) exposure. The skin is assessed at the administration site 48-72 hours after placement. Positive results include an induration of ≥5 mm in high-risk populations, ≥10 mm in clients with potential risk or mild immunosuppression, and ≥15 mm in healthy individuals. If a client's tuberculin skin test (TST) is positive, the nurse should: Ask clients who emigrated from high-prevalence countries if they have received the bacille Calmette-Guérin (BCG) vaccine. It is commonly administered to children in high-prevalence countries but causes false-positive PPD tests (Option 1). Interferon-gamma release assay testing is preferred in BCG-vaccinated clients because it does not produce false-positive results. Obtain a prescription for a chest x-ray to differentiate latent TB from active disease in asymptomatic clients (Option 5) (Options 2 and 3) PPD test is positive because there is an induration >10 mm and the client emigrated from a high-prevalence country <5 years ago. There is no indication to repeat the TST. (Option 4) Clients with active TB are placed under airborne isolation precautions (eg, N95 respirator mask, negative-pressure room) , not droplet precautions (eg, surgical mask). In addition, this client has no symptoms of active disease, so precautions are not warranted. Educational objective:Tuberculin purified protein derivative (PPD) skin tests screen individuals for tuberculosis exposure. Prior administration of the bacille Calmette-Guérin vaccine can produce a false-positive tuberculin skin test. Positive PPD reactions in clients who are asymptomatic require evaluation with chest x-ray to rule out active disease. Reduction of Risk Potential NCSBN Client Need Copyright © UWorld. All rights reserved.

The nurse auscultates the lung sounds of a client with shortness of breath. Then, the nurse notifies the HCP about the adventitious sounds heard. Which medication prescription should the nurse anticipate for coarse crackles? 1. Albuterol 2. Bumetanide 3. Guaifenesin 4. Methylprednisolone

1, 4. Clients with asthma or chronic obstructive pulmonary disease (eg, emphysema) develop wheezing due to bronchospasm. Bronchodilators (eg, albuterol, ipratropium) and systemic corticosteroids (eg, methylprednisolone) may be prescribed to these clients. 2.CORRECT: Coarse crackles (loud, low-pitched bubbling) are heard primarily during inspiration and are not cleared by coughing. The sound is similar to that of Velcro being pulled apart. Coarse crackles may be confused with fine crackles (eg, atelectasis), which have a high-pitched, popping sound. Coarse crackles are present when fluid or mucus collects in the lower respiratory tract (eg, pulmonary edema, pulmonary fibrosis). During heart failure, the left ventricle fails to eject enough blood, causing increased pressure in the pulmonary vasculature. As a result, fluid leaks into the alveoli (pulmonary edema). Loop diuretics (eg, bumetanide, furosemide) treat pulmonary edema by reducing intravascular fluid volume through significant increase of fluid excretion by the kidneys 3. Clients with acute upper respiratory infections or chronic bronchitis (ie, inflammation of the upper airways) may be prescribed guaifenesin to loosen and improve the expectoration of mucus. Clients with chronic bronchitis typically develop rhonchi (ie, sonorous wheezes), which are continuous, low-pitched adventitious breath sounds that resemble moaning or snoring.

A nurse is caring for a client with unstable angina. After 5 minutes on a nitroglycerin IV infusion, the client reports relief of chest pain but a new dull, throbbing headache. What is the appropriate nursing action? 1. Decrease the infusion rate and reassess the client's report of pain 2. Document the finding and administer prescribed acetaminophen 3. Notify the health care provider and request a CT scan of the head 4. Stop the infusion immediately and notify the health care provider

1, 4. If the headache becomes severe or persistent despite acetaminophen, the HCP may temporarily decrease the dose. The nurse should not arbitrarily stop the infusion or decrease the rate. 2. CORRECT: Nitroglycerin is a potent vasodilator used to treat acute coronary syndrome. Headache is an expected side effect that decreases with continued therapy and can be treated with aspirin or acetaminophen. A headache is not concerning unless it is severe or persistent and/or accompanied by severe hypotension or signs of increased ICP 3. Nitroglycerin therapy can precipitate increased intracranial pressure (ICP). Additional signs of increased ICP (eg, decreased level of consciousness, vomiting, Cushing triad) should be reported to the HCP. A CT scan of the head is not indicated at this time.

The nurse is caring for an 82-year-old client with a history of falls. Which of the following interventions are appropriate to promote client safety? Select all that apply. 1. Activate the bed alarm before leaving the room 2. Assign the client to a room near the nurses' station 3. Keep the lights dim to create a calm environment 4. Place a bedside commode next to the client's bed 5. Request a prescription for a vest or belt restraint

1,2,4 CORRECT Implementation of fall risk precautions promotes client safety. Standard fall risk precautions (eg, bed in lowest position, call alight within reach) are appropriate for all clients. However, a client with multiple fall risk factors (eg, advanced age, previous history of falls) requires additional precautions, including: Activating the bed alarm before leaving the room to alert others if the client attempts to get out of bed (Option 1) Assigning the client to a room near the nurses' station to allow frequent observation and faster response time to calls for assistance (Option 2) Placing the bedside commode, assistive devices (eg, canes, walkers), and personal belongings (eg, eyeglasses, hearing aids, cell phones) as close to the client as possible (without obstructing walkways) to decrease the number of steps needed to ambulate (Option 4) Applying a high fall risk sign on the client's door to alert other staff members (Option 3) Keeping the lights dim increases the risk of falls, particularly when the client is in an unfamiliar environment. A well-lit room promotes orientation and helps the client avoid obstacles during ambulation. (Option 5) Restraints increase agitation and are associated with serious complications (eg, impaired perfusion and skin integrity). Restraints are indicated only if less-restrictive measures fail to keep the client safe. The nurse should first consider alternatives such as family involvement or supervision by a trained staff sitter. Educational objective:The nurse promotes client safety by implementing fall risk precautions. A client with multiple fall risk factors requires additional precautions (eg, bed alarm, room close to the nurses' station, bedside commode close to the bed).

The nurses on a medical-surgical unit maintain a public social media page. Which of the following social media posts written by a nurse breaches client confidentiality? Select all that apply. 1. "I private-messaged everyone a cute story about our sweet client with dementia." 2. "It breaks my heart that our paraplegic client was so neglected by her husband." 3. "So proud of how well our nurses worked together yesterday, despite how busy we were!" 4. "The client in room 5 is positive for influenza, so please remember your flu vaccines!" 5. "Wash your hands well if you had room 4 this week! Cultures are positive for Clostridioides (formerly Clostridium) difficile."

1,2,4,5 CORRECT Nurses are ethically and legally obligated to prevent breaches of confidentiality when using social media. Nurses should protect client confidentiality and safeguard any protected health information (PHI) learned during care. PHI may include the client's name, diagnosis, history, examination results, or treatment and may be discussed only in a private setting with staff members who are directly involved in the client's care. Sharing information in private messages or using social media privacy settings does not protect client confidentiality. Once PHI has been shared through social media, it can be copied or shared again by others and can always be retrieved, even after deletion (Option 1). Sharing PHI while referring to a client by a diagnosis, nickname, or room number does not protect the client's confidentiality. Even if a client or group of clients is referred to in a general way without using names, nonspecific information can still reveal clients' identities to a third party (Options 2, 4, and 5). (Option 3) When used responsibly, social media can be a valuable tool for networking with colleagues, sharing professional information, and supporting peers. However, careless use of social media that reveals client PHI, even unintentionally, can prompt disciplinary action from employers and regulatory boards. Educational objective:The nurse is responsible for protecting client confidentiality and preventing inappropriate sharing of protected health information (PHI). Sharing a client's PHI on social media breaches confidentiality, even if the client's name is not identified or sharing it in a private message

The nurse is reinforcing discharge teaching for a client who is experiencing age-related hearing loss. Which of the following actions should the nurse implement? Select all that apply. 1. Encourage the client to repeat back teaching 2. Ensure adequate lighting in the client's room 3. Provide teaching to the family instead of the client 4. Sit directly in front of the client while speaking 5. Use printed materials with pictures and illustrations

1,2,4,5 CORRECT Clients who have presbycusis (ie, age-associated hearing loss) require accommodations to promote engagement in care and ensure understanding of teaching. Nursing interventions should focus on facilitating effective and inclusive communication with clients to maintain their safety, including: Encouraging the client to repeat back instructions (ie, closed-loop communication) (Option 1). If the client is unable to repeat them back, provide further clarification with an alternative approach. Sitting directly in front of the client in a well-lit room so all visual cues, such as facial expressions and hand gestures, can be seen (Options 2 and 4). Using printed materials with visuals, such as pictures and illustrations, or acting out demonstrations to supplement verbal instructions (Option 5). (Option 3) The client should always remain the focus of teaching. With the client's consent, including the family in teaching can be helpful; however, the client should not be excluded. Educational objective:Clients with hearing loss require accommodations to ensure effective communication and understanding. Nursing interventions include encouraging clients to repeat back teaching, sitting directly in front of the client when speaking in a well-lit room, and using printed materials with visual aids

A client with a history of a seizure disorder has a seizure while sitting in a chair. Which nursing interventions are appropriate for a client experiencing a seizure? Select all that apply. 1. Administer oxygen as needed if client becomes cyanotic 2. Insert a flexible nasopharyngeal airway for airway protection 3. Move the client from the chair to the floor to prevent a fall 4. Record the duration of seizure activity for documentation 5. Restrain the client's arms and legs to prevent injury

1,3,4 CORRECT During seizure activity, the priority is client safety. Nursing interventions include: Administer oxygen as needed in response to signs of hypoxia (eg, cyanosis, pallor) (Option 1). Assist seated or standing clients to lie down while protecting the head, and position the client on the side to maintain a patent airway and prevent aspiration (Option 3). Loosen restrictive clothing and clear the area near the client (eg, furniture corners, sharp or hard objects) to prevent injury. Record and document the time and duration of the seizure (Option 4). (Option 2) Although clients may require oxygen if they are symptomatic (decreased oxygen saturation level), artificial airways or other objects are never inserted into the mouth or nose during a seizure due to the risk for trauma. A nasopharyngeal airway would not prevent the tongue from obstructing the airway during a seizure. When seizure activity has stopped, suctioning and/or insertion of an oral airway may be necessary if the client's airway is obstructed. (Option 5) The client should never be restrained during a seizure. Strong muscle contractions occur during seizures; therefore, if the client is restrained, injury could occur. Educational objective:During seizure activity, the priority nursing interventions are to provide oxygen as needed, assist the client to safely lie down (if seated or standing), position the client on the side to maintain a patent airway, loosen restrictive clothing, and remove objects from the immediate area. The nurse also documents the time and duration of seizure activity.

The nurse in the emergency department is assessing telemetry strips for assigned clients. Which client tracing is a priority for the nurse to assess? 1. Atrial fibrillation 2. First-degree heart block 3. ST-segment elevation 4. Premature ventricular contraction

1. Atrial fibrillation is characterized by an irregularly irregular rhythm with P waves replaced by fibrillatory waves, resulting in ineffective atrial contraction. Clients are at increased risk for clot formation (long-term), which can cause a stroke or pulmonary embolism; however, signs of cardiac injury take priority. 2. First-degree heart block is characterized by a prolonged PR interval. Clients are usually asymptomatic and do not require immediate assessment. 3. CORRECT: An ST-segment elevation myocardial infarction (STEMI) occurs when at least one of the coronary arteries is completely occluded. The ST segment is the portion of the ECG between the QRS complex and the T wave. Prompt treatment (eg, percutaneous coronary intervention, thrombolytics) is needed to restore myocardial oxygen supply and limit myocardial damage. 4. Premature ventricular contractions are early contractions of the ventricles that originate from an ectopic focus and result in a wide, distorted QRS complex. They are usually not harmful and can occur as a response to stimulants (eg, caffeine, nicotine, alcohol) or electrolyte imbalances.

A nurse receives change-of-shift report on 4 clients. Which client should the nurse assess first? 1. Client who experienced a transient ischemic attack 2 days ago and is due to receive scheduled aspirin 2. Client who had a subdural hemorrhage 36 hours ago and is requesting a breakfast tray 3. Client with a bowel resection receiving total parenteral nutrition who had 4,800 mL of urine output during the last shift 4. Client with a stroke receiving tissue plasminogen activator whose Glasgow Coma Scale changed from 9 to 13

1. A client experiencing a transient ischemic attack has stroke-like symptoms that later resolve. Such clients are often placed on prophylactic antithrombotic treatment (eg, aspirin, clopidogrel) to prevent future strokes. This client requires scheduled medication but is not an immediate priority. 2. A client with a subdural hemorrhage should be frequently assessed for neurological changes and early symptoms of increased intracranial pressure (eg, headache, nausea). A verbal request for breakfast indicates that the client is stable and therefore does not require immediate attention. 3. CORRECT: TOTAL PARENTERAL NUTRITION (TPN) may be prescribed for clients with dysfunction of the gastrointestinal tract (eg, short bowel). GLUCOSE (dextrose) is a primary component of TPN solutions; therefore, the nurse should monitor blood glucose and assess for symptoms of HYPERGLYCEMIA (eg, polydipsia, POLYURIA, headaches, blurred vision). A urine output of 4,800 mL during a shift may indicate hyperglycemia. Symptomatic clients should be assessed and treated immediately as hyperglycemia can lead to SEIZURES, COMA, or DEATH. 4. Tissue plasminogen activator is administered to clients with ischemic strokes to dissolve clots in the brain. A Glasgow Coma Scale change from 9 to 13 demonstrates improving neurological status.

The nurse in an ambulatory surgery center triages telephone messages from clients. Which client should the nurse call back first? 1. Client who had a colonoscopy with polypectomy who reports abdominal cramping and a small amount of rectal bleeding 2. Client who had a lumbar laminectomy with spinal fusion 3 days ago who reports straining to have a bowel movement 3. Client who underwent laparoscopic inguinal hernia repair yesterday who reports difficulty urinating 4. Client who underwent placement of an arteriovenous graft who reports a temperature of 100.9 F

1. A small amount of rectal bleeding and abdominal cramping is expected following a colonoscopy as the bowel contracts to expel the air inserted during the procedure. Following a colonoscopy, clients should notify the HCP of severe abdominal pain, distension, and excessive bleeding, which may indicate bowel perforation. 2. Following surgery, constipation can occur due to decreased ambulation and narcotic pain medications. The client may require a stool softener to reduce straining. 3. Anesthesia and opioid analgesics may cause postoperative urinary retention for up to 3 days following surgeries, especially abdominal or pelvic surgeries. This client should be instructed on measures to aid voiding (eg, standing) and may need to come to the clinic for bladder ultrasound or straight catheterization. 4. CORRECT: Arteriovenous (AV) graft placement involves surgical connection of an artery and a vein using a synthetic material to graft a hemodialysis access site. Postoperative infection of an AV graft may cause thrombosis, graft failure, or systemic infection. Fever in a postoperative client may indicate infection of the graft site, which warrants immediate notification of the HCP; this client may require antibiotics and surgical removal of the graft

The nurse is caring for a pediatric client with osteomyelitis. Prior to the nurse administering IV antibiotics, the client's parent states, "We don't believe in antibiotics. Healing comes from within, and medications are toxic to that process." What is the nurse's priority response? 1. "Please tell me how medications are toxic to the healing process." 2. "Please tell me your understanding of your child's condition." 3. "What type of healing practices would you prefer for your child?" 4."Without this medication, your child can get worse and could die."

1. Asking about beliefs regarding medications in general may help in developing a teaching plan. However, it is more important to educate the parent about this child's specific and immediate need for antibiotics. 2. CORRECT: IV antibiotics are necessary for treating osteomyelitis (infection of the bone), and without them, the client is at risk for potentially life-threatening complications (eg, sepsis). Parental refusal of necessary medication for a minor creates an ethical dilemma. The nurse's first response should be assessment of a parental knowledge deficit regarding the client's condition. The nurse should ask open-ended questions, allowing the parent to demonstrate knowledge. With education and proper understanding of the condition, the parent may consent to the necessary treatment 3. Preferred healing practices are an important aspect of spiritual assessment; however, the priorities are to obtain parental consent for and initiate necessary treatment. Spiritual and cultural elements may be appropriate to include after physical needs (eg, IV antibiotics) are met. 4. Although true, this statement is inflammatory and would likely cause the situation to deteriorate, possibly leading to total refusal of care by the parent. It is most effective and important to respectfully assess parental knowledge and educate parents to obtain consent.

The nurse is caring for a client who had an anterior wall myocardial infarction 2 days ago. The telemetry technician notifies the nurse at 8:30 AM that the client is in ventricular trigeminy. What is the nurse's priority intervention? Click the exhibit button for additional information. Laboratory results Sodium140 mEq/L (140 mmol/L) Potassium3.0 mEq/L (3.0 mmol/L) Magnesium1.8 mg/dL (0.9 mmol/L) Creatinine1.1 mg/dL (97 µmol/L) Medication administration record Aspirin 81 mg PO daily Amiodarone 200 mg PO daily Allergies: NoneMedications Potassium replacement protocol If serum potassium is:≤3.2 mEq/L (3.2 mmol/L) Administer potassium chloride 40 mEq PO every 2 hours x 2 doses 3.3-3.8 mEq/L (3.3-3.8 mmol/L) Administer potassium chloride 40 mEq PO x 1 dose ≥3.9 mEq/L (3.9 mmol/L)No treatment Repeat serum potassium levels 2 hours after completion of potassium replacement. If creatinine >1.5 mg/dL (133 �mol/L), do not initiate protocol. Call health care provider for specific orders.

1. CORRECT In ventricular trigeminy, premature ventricular contractions (PVCs) occur every third heartbeat. Myocardial injury (eg, myocardial infarction) predisposes the client to ectopy (eg, PVCs), which increases the client's risk for lethal dysrhythmias (eg, ventricular tachycardia). PVCs are caused and/or exacerbated by hypoxia, electrolyte imbalances, emotional stress, stimulants, fever, and exercise. This client's morning laboratory results show hypokalemia (potassium <3.5 mEq/L [3.5 mmol/L]); therefore, the priority is treatment of the underlying cause of the ectopy by administering the prescribed potassium replacement (Option 1). Health care providers (HCPs) often prescribe electrolyte replacement algorithms to clients at risk for electrolyte imbalances (eg, myocardial injury, receiving diuretics) unless a contraindication exists (eg, serum creatinine >1.5 mg/dL [133 µmol/L], anuric, weight <99.2 lb [45 kg]). (Option 2) Amiodarone is an antiarrhythmic medication with a long duration of action (ie, 13-107 days). An acute drop in the drug level is not likely the cause of the ectopy. The nurse should administer amiodarone as prescribed after initiating the potassium replacement. (Option 3) Correcting the electrolyte imbalance should resolve the client's ectopy, preventing the need for defibrillation. (Option 4) The HCP should be notified; however, the nurse should first assess the client and initiate potassium replacement. Educational objective:Myocardial injury can predispose a client to premature ventricular contractions (PVCs), placing the client at risk for lethal dysrhythmias (eg, ventricular tachycardia). PVCs are caused and/or exacerbated by hypoxia, electrolyte imbalances, emotional stress, stimulants, fever, and exercise. Treatment of the underlying cause is the priority.

The nurse witnesses the collapse of a child while outdoors. The child is not breathing and has a pulse of 50/min. The nurse calls emergency services and initiates rescue breathing. After 2 minutes of rescue breaths, the child is still not breathing and is pale with a pulse of 30/min. What is the nurse's next action? 1. Initiate chest compressions (52%) 2. Perform abdominal thrusts (13%) 3. Provide rescue breaths for an additional 2 minutes (14%) 4. Use a finger to check the child's mouth for blockage (20%)

1. CORRECT Infants and children (age 1 year to puberty) often develop respiratory distress and bradycardia prior to cardiac arrest. After witnessing the collapse of a child who is not breathing but has a pulse, the nurse should contact emergency services and begin rescue breathing. Rescue breathing is performed at a rate of 1 breath every 2-3 seconds. If the pulse remains ≤60/min and there are signs of poor perfusion (eg, skin pallor), the nurse should initiate chest compressions and reassess the pulse every 2 minutes (Option 1). (Option 2) Abdominal thrusts (Heimlich maneuver) are done to expel a foreign object from a client who is choking but responsive. In the event that the child becomes unresponsive, the nurse should lower the client to the ground and begin chest compressions. (Option 3) If the heart rate increases to >60/min with signs of adequate perfusion (eg, skin pink, capillary refill <3 seconds) but the child is still apneic, rescue breaths should continue. (Option 4) A finger sweep of the client's mouth can force a loosely obstructing object to fully block the airway or cause the object to fall farther into the airway. Blockages should be removed only if they are visible and easily accessible. Educational objective:If a collapsed child is apneic with a pulse ≤60/min, the nurse should begin rescue breathing. If the pulse remains ≤60/min after initiation of rescue breaths and the child has signs of poor perfusion (eg, pallor), the nurse should initiate compressions.

A client with sickle cell crisis reports severe generalized pain. Which intervention is a priority for correcting vasoocclusion? 1. Administering high-flow IV fluids (72%) 2. Applying oxygen via nasal cannula (17%) 3. Maintaining strict bed rest (3%) 4. Transfusing packed red blood cells (6%)

1. CORRECT Sickle cell crisis occurs when inadequate oxygenation or hydration exacerbates sickling and causes red blood cells (RBCs) to clump together in the capillaries (vasoocclusion). Vasoocclusion causes severe ischemic pain, hypoxia, and possible organ dysfunction if left untreated. Adequate oxygenation and hydration may reverse the acute sickling response. In the sickled state, RBCs cannot carry enough oxygen from the lungs to the tissues, even with supplemental oxygen. The priority intervention is the administration of IV fluids to reduce blood viscosity and restore perfusion to the areas previously affected by vasoocclusion (Option 1). Only after IV rehydration reverses vasoocclusion can nonsickled RBCs effectively carry supplemental oxygen to the tissues (Option 2). (Option 3) Bed rest improves oxygen use and reduces energy consumption during sickle cell crisis but does not directly resolve vasoocclusion. (Option 4) Blood transfusions provide the client with nonsickled RBCs, increasing the oxygen-carrying capacity of the blood. However, this therapy is generally reserved for clients with sickle cell disease who do not respond to rehydration with IV fluids. Educational objective:Sickle cell crisis results from vasoocclusion of sickled red blood cells in the microcirculation, resulting in severe ischemic pain.

A nurse is teaching an inservice regarding prevention of venous thromboembolism. Which nursing interventions should be included in the teaching? Select all that apply. 1. Administer scheduled anticoagulants 2. Apply sequential compression devices 3. Elevate the legs with pillows behind the knees 4. Have clients ambulate regularly as tolerated 5. Instruct clients to point and flex the feet in bed

1. CORRECT: Administration of anticoagulants (eg, enoxaparin), usually prescribed in clients with a moderate or high risk of VTE (eg, postsurgical) unless contraindicated (eg, active bleeding) 2. CORRECT: Application of compression devices or antiembolism stockings to limit venous stasis 3. Elevating the legs while in bed promotes venous return by gravity. However, the nurse should ensure that any pillows used to elevate the legs do not place pressure directly behind the knees, as pressure on the posterior knees compresses leg veins. Clients should also avoid crossing the legs to prevent pressure on the back of the knees. 4. CORRECT: Frequent ambulation, 4-6 times daily as tolerated, to improve circulation and promote venous return 5. CORRECT: Foot and leg exercises (eg, extend and flex the feet and knees) to promote venous return by activating calf muscles

A new nurse is providing hospice care for a terminally ill client who reports dyspnea. Which intervention would cause the charge nurse to intervene? 1. Administering oxygen via a nonrebreather mask 2. Administering prescribed morphine PRN 3. Providing a portable fan to improve air flow in the room 4. Providing relaxation strategies such as music and guided imagery

1. CORRECT: Nonrebreather masks are used to deliver high concentrations of oxygen in emergency situations. They require a tight face seal, which is uncomfortable and may cause claustrophobia and increased anxiety. High-flow oxygen can paradoxically decrease respiratory drive and cause carbon dioxide retention, further worsening the perception of dyspnea. 2, 3, 4. Terminally ill clients often experience dyspnea (air hunger). Initial interventions to reduce the perception of dyspnea include administering prescribed opioids to decrease respiratory effort, providing low-flow oxygen by nasal cannula, implementing comfort measures, and relieving anxiety.

The nurse is caring for an African American client with disseminated intravascular coagulation. Which locations are best to assess for the presence of petechiae? 1. Buccal mucosae and conjunctivae of the eyes 2. Nail beds of the fingers and toes 3. Palms of the hands and soles of the feet 4. Skin over the sacrum and behind the heels

1. CORRECT: Skin assessment of dark-skinned clients can be challenging as dark pigmentation makes it difficult to detect color changes. To best assess for petechiae in a dark-skinned client, the nurse should observe the buccal mucosae or conjunctivae. 2. The nail bed of the finger is the best location to assess dark-skinned clients for cyanosis, a blue discoloration that may occur with hypoxemia (ie, decreased blood oxygen). Petechiae generally do not occur in the nail bed. 3. The palms of the hands and soles of the feet are ideal locations for assessing other skin color changes that may occur in dark-skinned clients, such as jaundice (ie, yellowing of the skin due to increased bilirubin in the blood). However, these are not ideal locations to assess for petechiae in a dark-skinned client. 4. Over the sacrum and behind the heels are common locations for pressure injury formation; skin here typically appears dark, especially in dark-skinned clients.

The health care provider has explained the risks and benefits of a planned surgical procedure and asks the nurse to witness the client's signature on the consent form. Which situation would affect the legitimacy of the signature? 1. Client asks whether a blood transfusion will be required during surgery 2. Client expresses a fear of postoperative pain 3. Client received a dose of hydrocodone for pain 12 hours ago 4. Client wishes to wait to sign the consent until the spouse is present

1. CORRECT: To provide informed consent, a client must be a mentally competent adult; understand the explained procedure, risks, benefits, and alternatives; and sign voluntarily without coercion. Before witnessing a client's signature, the nurse should ensure that the client meets these criteria. A client question regarding the need for a blood transfusion during surgery indicates an incomplete understanding of risk and would invalidate the signature 2. Fears about the recovery process do not indicate confusion about the procedure itself. Fear about postoperative pain is an opportunity for the nurse to provide teaching and emotional support. 3. Narcotics and other medications (eg, some antiemetics) can cause sedation and impairment. The client can provide informed consent only after the effects of sedating medications have worn off. The duration of action for hydrocodone is 4-6 hours; a client who received a dose 12 hours ago would no longer be impaired from the medication. 4. Many clients wish to have family members present during the preoperative period to offer emotional support. The need for family presence does not invalidate an informed consent signature unless clients are mentally incompetent and require a legal next of kin to make medical decisions on their behalf.

The nurse reinforces teaching to a client recently diagnosed with urge incontinence. Which of the following client statements about self-management strategies indicate that teaching has been effective? Select all that apply. 1. "I drink diet cola with meals because it contains fewer calories than regular soda." 2. "I have an appointment with a nutritionist to help me manage my diet so that I can lose my excess weight." 3. "I joined a smoking cessation support group at the community center." 4. "I plan to do my daily Kegel exercises when I am riding the train to and from work." 5. "I will make sure to urinate every 2 hours to reduce urgency and have fewer accidents."

1. Clients with UI should avoid bladder irritants such as drinks that contain caffeine and artificial sweeteners because these ingredients can exacerbate UI symptoms 2. CORRECT: Losing excess weight to reduce pressure on the pelvic floor 3. CORRECT: Avoiding dietary bladder irritants (eg, caffeine, nicotine, artificial sweeteners, citrus juices, alcohol, carbonated drinks) 4. CORRECT: Performing pelvic floor exercises (eg, Kegel) to strengthen the pelvic muscles and help prevent urinary leakage 5. CORRECT: Using bladder training, such as voiding every 2 hours while awake and gradually lengthening the intervals between voiding

The nurse on the antepartum unit is performing shift assessments of several pregnant clients. Which client assessment is the priority to report to the health care provider? 1. Client with gestational diabetes mellitus reporting dysuria 2. Client with hyperemesis gravidarum with a blood pressure of 90/48 mm Hg 3. Client with oligohydramnios and a reactive fetal nonstress test 4. Client with preeclampsia with 3+ reflexes and 2 beats of clonus

1. Clients with gestational diabetes mellitus are more susceptible to infection (eg, urinary tract infection, vaginal yeast infection). Although the client's report of dysuria may indicate a urinary tract infection, the assessment findings do not indicate immediate risk. 2. Hyperemesis gravidarum usually affects clients in the first trimester and is characterized by severe nausea and vomiting that can lead to dehydration, hypotension, electrolyte imbalances, and nutritional deficits. This client should be assessed for further symptoms of hypotension (eg, dizziness, blurry vision) before notifying the HCP 3. Oligohydramnios indicates low amniotic fluid, which may lead to umbilical cord compression and fetal compromise. However, a reactive nonstress test is a reassuring finding. 4. CORRECT: Clients with preeclampsia are at risk for developing preeclampsia-associated seizure activity (eg, ECLAMPSIA) as a result of increased central nervous system irritability. The presence of NEUROLOGIC MANIFESTATIONS (eg, HYPERREFLECIA, clonus) may indicate worsening preeclampsia and can precede SEIZURE ACTIVITY . This client is at the most immediate risk of harm and is the priority to report to the HCP. To assess for CLONUS, the nurse firmly dorsiflexes the foot with 1 hand while supporting the leg and ankle with the other hand. The abnormal finding of positive clonus is identified when RHYTHMIC, JERKING "BEATS" OF THE FOOT are present as the foot is released and allowed to fall back into plantar flexion.

The nurse is reinforcing education with a client with Marfan syndrome who is recovering from an aortic root repair and mechanical aortic valve replacement via sternotomy and is prescribed warfarin. Which of the following statements by the client indicate appropriate understanding of teaching? Select all that apply. 1. "Because I have a mechanical valve, I will not need antibiotics for dental procedures." 2. "I will have to have my spouse lift and carry heavy objects for me for several months." 3. "I will need to take the prescribed warfarin for the rest of my life." 4. "If I gain 3 lb (1.36 kg) or more in a week, I will need to tell my health care provider." 5. "My usual razor blades will need to be replaced with an electric shaver."

1. Clients with mechanical heart valves are at high risk for infective endocarditis because bacteria can adhere to and proliferate on components of the valve. The client should receive prophylactic antibiotics before invasive respiratory and dental procedures, including routine dental cleanings 2, 3, 4, 5. CORRECT: The client should avoid lifting heavy objects to prevent disruption of the sternotomy sutures/wires. Anticoagulant therapy (eg, warfarin) will be needed for life after a mechanical valve replacement to prevent thromboembolic events (eg, stroke) and valve thrombosis. Signs and symptoms of heart failure (eg, weight gain ≥3 lb in a week) should be reported immediately because they may indicate valve failure. Bleeding precautions (eg, using an electric shaver) should be initiated because anticoagulant therapy increases the risk of uncontrolled bleeding.

A nurse in the cardiac intensive care unit receives report on 4 clients. Which client should the nurse assess first? 1. Client 2 months post heart transplant with sustained sinus tachycardia of 110/min at rest 2. Client 3 hours post coronary artery stent placement via femoral approach and reporting severe back pain 3. Client receiving IV antibiotics for infective endocarditis with a temperature of 101.5 F (38.6 C) 4. Client who had coronary bypass graft surgery 3 days ago and has swelling in the leg used for the donor graft

1. During a heart transplant, the donor heart is cut off from the autonomic nervous system (denervated), which alters the heart rate during rest and exercise after the transplant. The transplanted heart is expected to be tachycardic (eg, 90-110/min). 2. CORRECT: Percutaneous coronary intervention via the femoral approach places the client at increased risk for retroperitoneal hemorrhage, which is exacerbated by anticoagulants. Back pain, hypotension, flank ecchymosis (Grey-Turner sign), hematoma formation, and diminished distal pulses can be early signs of bleeding into the retroperitoneal space and require immediate intervention. 3. Infective endocarditis is often associated with cardiac valve disease and requires long-term antibiotic therapy (4-6 weeks). Characteristic manifestations include fever, myalgia, chills, joint pain, anorexia, and petechiae. 4. Some clients notice swelling in the leg used for donor venous graft (interruption of blood flow). Elevating the leg and wearing compression stockings can help decrease symptoms.

The clinic nurse is assessing a client who is being treated for depression and suicidal ideation. Which client statement best indicates that the client is not currently at risk for suicide? 1. I lost m imipramine prescription. Could i have a refill? 2. I plan to attend my grandchild's graduation next month 3. I seem to have a lot more energy since started therapy 4. I will sign a no suicide contract at today

1. During nonemergency cardioversion of a hemodynamically stable client, a sedative (eg, midazolam) is often administered for client comfort. 2. CORRECT: Synchronized cardioversion uses a specifically timed, low-energy electrical impulse to momentarily disrupt the electrical cardiac cycle and "reset" the heart to a slower, regular rhythm. Tachyarrhythmias (eg, atrial fibrillation or flutter) with a pulse may be managed with cardioversion. Cardioversion requires the defibrillator's synchronize function to be activated so that the shock is delivered during the R wave. Failing to enable the synchronize feature may result in delivery of a potentially lethal, asynchronous shock. 3. Removing chest hair and ensuring that the chest is clean and dry improves defibrillator pad adherence. 4. If the cardioversion is elective and not an emergency, the client should sign a consent form. The nurse can assist with preparing the form and witnessing the client's signature.

The primary nurse is preparing a client with atrial fibrillation for scheduled cardioversion. What action by the primary nurse requires the charge nurse to intervene? 1. Assembles equipment and obtains a prescription for preprocedural IV sedation 2. Ensures that defibrillator is programmed as prescribed and synchronize function is off 3. Uses clippers to remove the client's chest hair prior to placing defibrillation pads 4. Verifies that the client has provided informed consent and that documentation is signed

1. During nonemergency cardioversion of a hemodynamically stable client, a sedative (eg, midazolam) is often administered for client comfort. 2. CORRECT: Synchronized cardioversion uses a specifically timed, low-energy electrical impulse to momentarily disrupt the electrical cardiac cycle and "reset" the heart to a slower, regular rhythm. Tachyarrhythmias (eg, atrial fibrillation or flutter) with a pulse may be managed with cardioversion. Cardioversion requires the defibrillator's synchronize function to be activated so that the shock is delivered during the R wave. Failing to enable the synchronize feature may result in delivery of a potentially lethal, asynchronous shock. 3. Removing chest hair and ensuring that the chest is clean and dry improves defibrillator pad adherence. 4. If the cardioversion is elective and not an emergency, the client should sign a consent form. The nurse can assist with preparing the form and witnessing the client's signature.

A nurse hears various alarms sounding from different client rooms. Which alarm will the nurse address first? 1. Distal occlusion alarm on an infusion pump infusing heparin 2. Low-pressure limit alarm on a ventilator 3. Monitor alarm for a low respiratory rate of 11 breaths/min 4. Occlusion alarm on a continuous enteral feeding pump

1. Heparin is used to treat thromboembolic conditions (eg, pulmonary embolism); however, a brief interruption is not life-threatening. A distal occlusion alarm indicates that there is an obstruction to the flow of medication that occurs distal to the infusion pump (eg, between the infusion pump and the client). Causes include infiltration, clotting, displaced IV catheter, kinked tubing, and/or client positioning. 2. CORRECT: A low-pressure limit alarm on the ventilator is triggered when the amount of positive pressure necessary to deliver a breath to the client is decreased. A decrease in resistance to airflow occurs due to complications that arise in the client (eg, loss of airway), artificial airway (eg, cuff leak), and/or ventilator system (eg, tubing disconnect). All of these conditions impair airway and ventilation; therefore, addressing this alarm is the highest priority 3. The client with a low respiratory rate alarm should be assessed second. A low respiratory rate alarm may be caused by client factors (eg, sedation, shallow breathing) or equipment error (eg, malposition of ECG leads). 4. An occlusion alarm on the enteral feeding pump requires intervention, however; this is not a priority action. Possible causes include kinked tubing, food or medication blockage, or client positioning.

The nurse prepares to administer potassium chloride to a client through a peripherally inserted IV line. What are the appropriate nursing interventions related to administration of this medication? Select all that apply. 1. Administer as IV bolus 2. Assess IV site frequently 3. Assess renal function laboratory results and urine output 4. Place client on cardiac monitor 5. Verify that IV pump infusion is not >10 mEq/hr (10 mmol/hr)

1. KCl is never administered by IV push or as a fluid bolus. KCl is always diluted and given via infusion pump. 2. CORRECT: Potassium is a vesicant; therefore, the IV insertion site should be monitored frequently for extravasation to prevent tissue necrosis 3. CORRECT: Renal function should be assessed as clients with impaired renal function are unable to excrete potassium and other electrolytes effectively, potentially leading to toxicity. To assess renal function, the nurse should monitor renal function laboratory results (eg, blood urea nitrogen, creatinine) and urine output 4. CORRECT: Clients receiving KCl IV should have periodic cardiac monitoring during therapy, as changes in potassium levels can cause cardiac rhythm disturbances and rapid infusion can cause cardiac arrest 5. CORRECT: The maximum infusion rate of KCl through a peripheral line is 10 mEq/hr (10 mmol/hr) and the maximum concentration is 40 mEq/L (40 mmol/L). Higher rates and concentrations require a CVC

The health care provider (HCP) prepares to place a fetal scalp electrode (FSE) to monitor the fetus of a laboring client. Which information is most important for the nurse to communicate to the HCP before FSE placement? 1. Amniotic fluid is meconium stained 2. Client is HIV positive 3. External fetal monitor shows late decelerations 4. Fetal presenting part is at +1 station

1. Meconium-stained amniotic fluid may indicate fetal distress but is not a contraindication to FSE placement. 2. CORRECT: Placement of a fetal scalp electrode may be necessary when strict, continuous fetal heart rate monitoring is required. The nurse should be aware of the client's cervical dilation (≥2-3 cm), membrane status, and history of bloodborne infections (eg, hepatitis B, HIV) prior to electrode placement. 3. Late decelerations suggest impaired fetal oxygenation and are an indication for FSE placement. 4. It is helpful if the fetal presenting part is engaged (ie, 0, +1, or +2 station) to facilitate proper placement, but it is not required.

The nurse is reviewing client phone messages. Which client should the nurse call back first? 1. Client asking whether to take the morning dose of phenytoin before surgery the next day 2. Client taking dabigatran who reports heavier bleeding with her menstrual cycle 3. Client taking metronidazole who reports abdominal cramping and diarrhea 4. Client who has taken the last dose of insulin glargine and needs a refill

1. Missing a dose of phenytoin (Dilantin), an antiseizure medication, could precipitate seizure activity. The client should be instructed to take the medication as prescribed with a small sip of water; however, this client does not take priority over one with active bleeding. 2. CORRECT: Dabigatran (Pradaxa) is a thrombin inhibitor anticoagulant often prescribed to prevent thrombotic events in clients with atrial fibrillation, pulmonary embolism, and deep vein thrombosis. Clients taking dabigatran are at increased risk for bleeding and hemorrhage. Clients with signs of abnormal bleeding (eg, bruising; blood in the urine, sputum, vomitus, or stool; epistaxis; heavy menstrual bleeding [menorrhagia]) should be prioritized as prompt intervention and treatment may be required 3. Gastrointestinal upset is a common side effect of many antibiotics, including metronidazole (Flagyl). Abdominal discomfort may be relieved by taking the medication with food or a glass of milk. 4. This client requires a refill of insulin to prevent hyperglycemic episodes but is not a priority over a client with active bleeding. Glargine is long-acting insulin that works for 24 hours.

The nurse assists with medication reconciliation for a client visiting the clinic for a follow-up appointment. Which medication reported by the client requires further investigation? Click the exhibit button for additional information. Medical health history: hypertension, coronary artery disease, chronic stable angina Surgical health history: Coronary artery bypass with stent 1. 0.3 mg of nitroglycerin sublingual PRN 2. 10 mg of ezetimibe PO once daily 3. 20 mg of lisinopril PO once daily 4. 200 mg of celecoxib PO once daily

1. Sublingual nitroglycerin may be prescribed to alleviate an exacerbation of acute angina in a client with a history of chronic stable angina. Nitrates promote coronary vasodilation, thereby improving blood flow and relieving ischemic chest pain. 2. Ezetimibe inhibits cholesterol absorption from the small intestine, which reduces the risk of atherosclerosis and helps to treat coronary artery disease 3. ACE inhibitors (eg, lisinopril, enalapril, captopril) are prescribed to treat hypertension. These medications interfere with the conversion of angiotensin I to angiotensin II, which lowers blood pressure by reducing vasoconstriction and promoting sodium excretion. ACE inhibitors 4. CORRECT: NSAIDs (eg, naproxen, ibuprofen, celecoxib) are used for their analgesic, antipyretic, and anti-inflammatory properties. However, they increase the risk of thrombotic events (eg, myocardial infarction [MI], stroke), especially in clients with cardiovascular disease (eg, coronary artery disease). The nurse should investigate why a client with a history of cardiovascular disease is taking an NSAID and alert the HCP of its use

A nurse is performing cardiopulmonary resuscitation (CPR) on an adult at a swimming pool. A bystander brings the automated external defibrillator (AED). The nurse notes that the victim is wet, lying in a small pool of water, and wearing a transdermal medication patch on the upper right chest. What is the most appropriate action at this time? 1. Do not use the AED and continue CPR until paramedics arrive 2. Move the client away from the pool of water before applying AED pads 3. Remove the transdermal patch and wipe the chest dry before using the AED 4. Wipe the chest dry and apply the AED pads over the transdermal patch

1. The AED is used as soon as it is available; its use should not be delayed. 2. The entire body does not need to be completely dry; the chest should be quickly wiped, as this is where the electrical current travels. The AED can still be used if the client is damp or lying in a small puddle of water. 3. CORRECT: An automated external defibrillator (AED) is used as soon as possible for improved outcomes. The chest should be clean and dry, and any medication patches should be removed before applying the AED pads 4. AED pads should not be placed over medication patches as this interferes with conduction and can burn the skin.

The nurse is performing a home visit for a child with cystic fibrosis who had a percutaneous endoscopic gastrostomy (PEG) tube placed 6 weeks ago. During inspection of the PEG tube, the nurse should correctly recognize which finding as expected? 1. External gastrostomy tube bumper is secured tightly to, and pressing against, the skin 2. Gastrostomy tube movement of 0.2 in (0.5 cm) is noted when the client coughs 3. Increased amounts of red, bumpy tissue are near the stoma compared to previous assessment 4. Resistance is felt when rotating the tube during cleaning

1. The external gastrostomy tube bumper should always rest loosely above the skin. Bumpers that tightly press against the abdomen promote tissue breakdown from pressure and friction. 2. CORRECT: An expected finding that indicates appropriate device function is slight in-and-out movement of the PEG tube (ie, ≤0.25 in [≤ 0.6 cm]), especially when coughing. PEG tubes are secured loosely against the skin, which allows the tube to move, thereby preventing device-related pressure injuries. 3. Granulation tissue (ie, red or pink skin with a bumpy texture) is an expected finding near the stoma and indicates wound healing. However, large or increasing amounts indicate abnormal healing or injury to the stoma. 4. Resistance when rotating a PEG tube often indicates adherence of the device to underlying tissues, which requires surgical revision of the device by the health care provider.

The nurse is preparing to administer a continuous dopamine infusion at 5 mcg/kg/min. The client weighs 187 lb and the available medication contains 400 mg of dopamine in 250 mL of D5W. At what rate in milliliters per hour (mL/hr) should the nurse program the infusion pump? Record the answer using a whole number.

16 Prescribed = 5mcg dopamine / kg & min Available = 400 mg dopamine / 250 mL Required = mL / hr (5 mcg dopamine / kg & min) --> (60 min / hr) --> (kg / 2.2 lbs) --> (187 lbs / ___ ) --> (mg dopamine / 1000 mcg dopamine) --> (250 mL / 400 mg dopamine) = 15.93 mL dopamine /hr

The nurse in the public health clinic is caring for a client with pubic lice. Which of the following statements should the nurse include in the education? Select all that apply. 1. "Pubic lice are only passed through sexual contact." 2. "Remove nits from pubic hair with a fine-toothed nit comb." 3. "Sexual partners should also receive treatment." 4. "Wash clothes and linens with hot water." 5."Wash pubic hair with lice treatment shampoo."

2,3,4,5 CORRECT Pediculosis pubis (ie, "crabs") is an infestation of pubic lice. Pubic lice are most often passed via sexual contact and feed on human blood for nourishment. Clients with pubic lice have intense itching in the affected area. The nits (ie, lice eggs) are attached to hair shafts and appear as yellow-white ovals. Pubic lice may also infest eyelashes, facial hair, and body hair (eg, chest, axilla). Clients with pubic lice should be given the following instructions: Use lice treatment shampoo (1% permethrin) or rinse on pubic and body hair to kill lice (Option 5) After treatment, remove nits with a fine-toothed nit comb, fingernails, or tweezers (Option 2) Wash and dry clothes, towels, and bedding with hot water and highest-heat dryer setting (Option 4) Sexual partners should also receive pubic lice treatment (Option 3) (Option 1) Pubic lice may be passed through close contact and sharing of linens. All household members are at risk for developing a pubic lice infestation and should be screened. Educational objective:Clients with pubic lice are instructed to use lice treatment shampoo (1% permethrin) or rinse on pubic and body hair, remove nits with a fine-toothed comb, and launder clothes and linens with hot water and highest-heat dryer setting. Sexual partners should also receive treatment, and all household members should be screened for lice. Nursing interventions: seizure Before - Remove potential sources of injury, place padding - Keep oxygen at bedside - Assess therapeutic level of antiepileptic drugs - Identify seizure triggers, areas for further client education During - Protect client's head from injury if possible - Place client in rescue position (left lateral) - Insert nothing into the mouth - Do not restrain limbs or torso After - Document timing, symptoms - Remain with client - Perform neurological assessment - Assess for physical injury

When caring for a client with ulcerative colitis, which nursing activities are appropriate for the registered nurse to delegate to the licensed practical nurse? Select all that apply. 1. Administer a blood transfusion 2. Administer a prescribed suppository 3. Discuss dietary modifications with the dietitian 4. Monitor for a change in bowel sounds 5. Remind the client to track daily weights

2,4,5 CORRECT 1. A blood transfusion may be necessary, depending on the severity of symptoms. LPNs cannot initiate a blood transfusion, but they can monitor the client for adverse effects. 2. CORRECT: . It is within the LPN's scope of practice to administer medications via most routes, including topically via the rectum (eg, suppositories) 3. A low-residue, high-protein, high-calorie diet, along with daily vitamin and mineral supplements, is encouraged to meet the nutritional and metabolic needs of the client with UC. However, collaboration is part of the planning process and cannot be delegated. 4. CORRECT: Clients with UC typically have hyperactive bowel sounds. LPNs can monitor assessment findings after the initial assessment by an RN 5. CORRECT: Frequent diarrhea may cause weight loss and electrolyte imbalances; therefore, the client should be taught to measure daily weights. The registered nurse (RN) cannot delegate tasks requiring clinical judgment (eg, initial teaching, assessment, planning, evaluation). However, a licensed practical nurse (LPN) can reinforce teaching already provided by the RN

A client is at 28 weeks gestation with suspected preeclampsia. Which of the following signs/symptoms indicate that the client has developed this syndrome? Select all that apply. 1. Anemia 2. Epigastric pain 3. Frequent urination 4. Headache and blurry vision 5. Proteinuria

2,4,5 CORRECT Preeclampsia is a multisystem disorder that can occur during pregnancy, usually after 20 weeks gestation; it is defined as new-onset hypertension (≥140/90 mm Hg) and proteinuria or signs of end-organ damage (Option 5). Preeclampsia is caused by placental dysfunction that leads to decreased uteroplacental perfusion, resulting in inadequate volumes of oxygenated blood to the fetus. The fetal response to inadequate oxygenation is slowed growth (ie, fetal growth restriction) and preferential shunting of blood from the periphery (eg, kidneys) to the brain, leading to decreased fetal urine output and oligohydramnios. Additional manifestations of preeclampsia include: Epigastric or right upper quadrant pain due to hepatic damage and swelling (Option 2) Headache/visual changes due to severe hypertension, cerebral edema, and/or central nervous system irritability (Option 4) (Option 1) Pregnancy causes an intravascular volume expansion larger than the rise in the number of red blood cells, resulting in hemodilution. Inadequate iron stores or intake can also play a role. Anemia is not a specific indicator or criterion for preeclampsia. (Option 3) Frequent urination is common in pregnancy due to increased pressure on the bladder, or it could be related to a urinary tract infection but is not associated with preeclampsia. Educational objective:Preeclampsia is a multisystem disorder that can occur during pregnancy and is defined as new-onset hypertension and proteinuria or signs of end-organ damage. Cerebral symptoms (eg, headache, visual changes) from severe hypertension and/or epigastric pain secondary to decreased liver perfusion and hepatic damage can occur.

The nurse is applying knee-length compression stockings onto a client with chronic venous insufficiency. Which of the following actions are appropriate? Select all that apply. 1. Instructs client that stockings will be worn only at night 2. Measures circumference of both calves at the widest point 3 .Rolls down any excess length at the top of the stocking 4. Selects a size larger to avoid friction against a leg laceration 5.Smooths out any wrinkles or creases in the stocking

2,5 CORRECT Thromboembolic deterrent stockings (TED hose) are elastic stockings that provide graduated compression to the leg to promote venous return and reduce risk of venous thromboembolism. Correct sizing and application of TED hose are essential to effectively promote venous return. Stockings that are too large will not provide adequate compression, and stockings that are too tight or applied incorrectly may impair perfusion. When applying TED hose, the nurse should: Select a size of knee-length stockings by measuring length from the heel to the popliteal area and circumference at the widest point of the calf (Option 2). Ensure stockings are free of folds, rolls, or wrinkles that can have a tourniquet-like effect, exacerbating venous stasis and impairing perfusion (Option 5). (Option 1) Stockings should be worn continually and may be removed 1-3 times a day for vascular and skin integrity assessment. It is especially important to wear TED hose when the legs are in a dependent position while sitting or standing, usually during the day. (Option 3) Rolling down any excess length will have a tourniquet-like effect that can impair perfusion. (Option 4) Friction against nonintact skin (eg, stasis ulcers, lacerations) is alleviated by applying an occlusive dressing. Applying a size larger than recommended based on measurements will not provide adequate compression. Educational objective:Thromboembolic deterrent stockings (TED hose) promote venous return and reduce the risk of venous thromboembolism. TED hose are worn continually and should be properly sized, free of folds, rolls, or wrinkles.

While the nurse and unlicensed assistive personnel are turning an intubated and heavily sedated client during a bath, the client coughs and expels the endotracheal tube. What is the priority nursing action? 1. Assess respiratory rate and breath sounds to ensure ventilation is occurring (23%) 2. Deliver rescue breathing with a bag-valve-mask attached to 100% oxygen (62%) 3. Immediately alert the health care provider and prepare for reintubation (9%) 4. Initiate a code blue to prepare for potential cardiac arrest due to hypoxemia (3%)

2. CORRECT Accidental extubation is a medical emergency. A sedated client is unable to protect the airway and requires immediate reintubation. If a client is accidentally extubated, the nurse should remain with the client, protect the airway using the head-tilt chin-lift or the jaw-thrust maneuver if spinal injury is suspected, and deliver breaths using a bag-valve-mask with 100% oxygen until reintubation is achieved (Option 2). (Option 1) Assessing the respiratory rate and breath sounds is important but is not the priority action. Rescue breathing should not be delayed because sedation significantly depresses respiration. Assessment is important for a new problem but not for an existing one, especially if delayed care can lead to life-threatening complications. (Option 3) Another nurse can alert the health care provider. Oxygenation is the priority action. (Option 4) While there is a risk for cardiac arrest, the nurse should support the client's airway and breathing to prevent arrest. A code blue should be initiated if cardiac arrest occurs. Educational objective:If accidental extubation occurs, the nurse should immediately provide ventilation with a bag-valve-mask and call for assistance to prepare for reintubation. Frequent assessment of the intubated client ensures proper tube placement and patency can prevent accidental extubations.

The pediatric nurse plans a home visit for a 2-year-old who will soon be discharged with home health care. Which condition presents the most concern as a safety hazard in the child's home environment? 1. Family lives in a rural area 2. House is heated by a wood-burning stove 3. House was built in 1983 4. Parents are unemployed with limited financial resources

2. CORRECT The safety of the home environment should be assessed prior to discharge of pediatric clients, especially those with illnesses requiring continuing health care services in the home. The nurse can prioritize safety risks according to Maslow's hierarchy of needs. An open wood-burning stove is a fire hazard that may cause physiologic damage from smoke inhalation or burns (Option 2). The nurse should investigate the family's access to other utilities and determine whether the stove is the home's only source of heat. (Option 1) Rural environments are not an inherent risk to the safety of the child. However, follow-up may be required to ensure the client has access to resources (eg, grocery store, hospital). (Option 3) Houses built before 1978 have a high probability of containing lead-based paint. Active renovations can significantly increase the amount of lead released into the home environment, causing lead poisoning (eg, neurologic and motor impairment). Living in a house built in 1983 is not associated with an increased risk of lead exposure. (Option 4) Unemployment and limited financial resources can cause increased stress and require further evaluation but would not take priority over a physical safety hazard. Educational objective:A wood-burning stove is a fire, burn, and smoke-inhalation hazard with the potential to cause physiologic damage. The nurse should assess all clients' access to utilities and resources. Education on lead-based paint should be provided to those living in houses built before 1978.

The nurse in the cardiac intensive care unit receives report on 4 clients. Which client should the nurse assess first? 1. Client who is receiving IV antibiotics for infective endocarditis with a temperature of 101.5 F (38.6 C) (3%) 2. Client who underwent coronary artery stent placement via femoral approach 3 hours ago and is reporting severe back pain (81%) 3. Client who underwent coronary bypass graft surgery 3 days ago and has swelling in the leg used for the donor graft (4%) 4. Client who underwent heart transplantation 2 months ago with sustained sinus tachycardia of 110/min at rest (9%)

2. CORRECT A client who undergoes percutaneous coronary intervention (PCI) and intracoronary stent placement using the femoral approach is at increased risk for retroperitoneal hemorrhage. Administration of antithrombotic drugs before, during, and after PCI can exacerbate potentially life-threatening bleeding from the femoral artery. Hypotension, back pain, flank ecchymosis (eg, Grey Turner sign), hematoma formation, and diminished distal pulses can be early signs of bleeding into the retroperitoneal space and require immediate intervention (eg, notify health care provider, serial complete blood count, CT scan of the abdomen) (Option 2). (Option 1) Infective endocarditis is often associated with cardiac valve disease and requires long-term antibiotic therapy (4-6 weeks). Characteristic manifestations include fever, myalgia, chills, joint pain, anorexia, and petechiae. (Option 3) Some clients notice swelling in the leg used for donor venous graft (interruption of blood flow). Elevating the leg and wearing compression stockings can help decrease symptoms. (Option 4) During heart transplantation, the donor heart is cut off from the autonomic nervous system (denervated), altering the heart rate during rest and exercise after the procedure. The heart rate of the transplanted heart is expected to be at the high end of normal or tachycardic (eg, 90-110/min). Educational objective:Percutaneous coronary intervention via the femoral approach places the client at increased risk for retroperitoneal hemorrhage, which can be exacerbated by antithrombotic drugs. Back pain, hypotension, flank ecchymosis (eg, Grey Turner sign), hematoma formation, and diminished distal pulses can be early signs of bleeding into the retroperitoneal space and require immediate intervention.

The nurse helps a client with end-stage renal disease and a serum potassium level of 5.2 mEq/L (5.2 mmol/L) to plan menu choices. Which items would be best to include in the meal plan? 1. Black beans and rice, sliced tomatoes, half a cantaloupe 2. Grilled chicken sandwich on white bread, applesauce 3. Hamburger patty on whole wheat bun, carrot sticks, chocolate pudding 4. Poached salmon, green peas, baked potato, strawberries

2. CORRECT: The kidneys' ability to excrete potassium is compromised in clients with end-stage renal disease. These clients should avoid foods high in potassium (eg, green leafy and cruciferous vegetables; legumes; melons; bananas; strawberries; milk and milk products; most beef, fish, and shellfish; and whole grains) to maintain normal serum potassium levels

The nurse is preparing to don sterile gloves before suctioning a client's tracheostomy. Place the steps of donning sterile gloves in the correct order. All options must be used. 1. Open the inner glove package by folding back the edges 2. Perform hand hygiene, and remove the outer glove package.. 3. Place dominant hand fingers under cuff on outside of nondominant glove. 4. Pull on dominant hand glove. 5. Pull on nondominant hand glove. 6. Use nondominant hand to grasp cuff on inside of dominant hand glove.

2. Perform hand hygiene, and remove the outer glove package.. 1. Open the inner glove package by folding back the edges 6. Use nondominant hand to grasp cuff on inside of dominant hand glove. 3. Place dominant hand fingers under cuff on outside of nondominant glove. 4. Pull on dominant hand glove. 5. Pull on nondominant hand glove. Sterile procedures (eg, urinary catheter insertion, tracheostomy suctioning) require the nurse to wear sterile gloves. Insertion of catheters into the body can introduce infectious microorganisms; correctly donning sterile gloves decreases infection risk. The nondominant hand is used to apply the glove of the dominant hand first. Using the dominant hand to apply the second glove improves dexterity and decreases the risk of contamination of the gloved dominant hand. The correct procedure for donning sterile gloves is as follows: Perform hand hygiene and remove the outer glove package (Option 2). Place the inner glove package on a clean, dry surface. Open the inner package by carefully folding back the edges (Option 1). Use the nondominant hand to grasp the cuff of the dominant glove. Touch only the inside surface of the glove (Option 6). Use the fingers of the nondominant hand to pull on the dominant hand glove (Option 3). Place the fingers of the gloved dominant hand under the cuff of the nondominant glove. Keep the gloved thumb pulled away to prevent contact with the skin of the nondominant hand (Option 5). Pull on the nondominant hand glove (Option 4).

The charge nurse is making client assignments for the oncoming shift. Which client assignment is most appropriate for a nurse who is 10 weeks pregnant? 1. Client currently receiving brachytherapy for endometrial cancer 2. Client with a disseminated herpes zoster rash on the face and scalp 3. Client with a methicillin-resistant Staphylococcus aureus wound infection 4. Client with pneumonia who recently traveled to a region with the Zika virus

3. CORRECT Health care workers (HCWs) who are pregnant do not carry a high risk for contracting methicillin-resistant Staphylococcus aureus (MRSA) as long as appropriate infection precautions (ie, contact precautions) are in place (Option 3). Even if the HCW who is pregnant were to contract MRSA, there are few known harmful effects to the fetus. Because TORCH infections (Toxoplasmosis, Other [eg, syphilis], Rubella, Cytomegalovirus, Herpes simplex virus) can cause fetal abnormalities, HCWs who are pregnant should not be assigned clients with these infections. (Option 1) Clients receiving brachytherapy have radioactive implants placed in a body cavity. To safely care for these clients, HCWs limit/cluster client time and keep a distance of at least 6 ft (1.8 m) unless wearing lead shielding for direct care. If possible, HCWs who are pregnant should not care for these clients because fetal radiation exposure is teratogenic. (Option 2) Varicella-zoster virus (eg, herpes zoster [shingles]) is a TORCH infection, and HCWs who are pregnant should avoid caring for these clients. (Option 4) Zika virus may be transmitted through mosquito bites, infected body fluids, and sexual contact. Using standard precautions should provide protection; however, because Zika is known to cause birth defects, HCWs who are pregnant should not care for a client who has been exposed to the virus, if at all possible. Educational objective:Health care workers (HCWs) who are pregnant can safely care for clients with methicillin-resistant Staphylococcus aureus by using contact precautions. Clients receiving radioactive therapy or with infections known to be teratogenic should not be assigned to HCWs who are pregnant.

A pregnant client at 38 weeks gestation is admitted to the labor and delivery unit reporting contractions, severe abdominal pain, and dark vaginal bleeding. What is the nurse's priority action? 1. Initiate a large-bore (18-gauge) peripheral IV line (16%) 2. Notify the operating room staff of emergency cesarean birth (13%) 3. Palpate the abdomen and apply a fetal heart rate monitor (58%) 4. Perform a vaginal examination to assess cervical dilation (10%)

3. CORRECT Placental abruption (abruptio placentae) occurs when the placenta prematurely detaches from the uterine wall. This life-threatening complication can interrupt fetal oxygen supply and cause maternal hemorrhage. Associated symptoms may include frequent contractions, abdominal pain, dark red vaginal bleeding, uterine tenderness, and elevated uterine resting tone. Priorities include assessment of maternal vital signs, palpation of the abdomen/uterus, and continuous fetal heart rate monitoring (Option 3). If monitoring indicates fetal distress and/or maternal hemodynamic compromise, the health care team will prepare for emergency cesarean birth. (Option 1) Clients with placental abruption require large-bore (eg, 18-gauge) IV access to allow for fluid resuscitation and possible administration of blood products. However, assessing maternal/fetal status is the first step before initiating these interventions. (Option 2) Although emergency cesarean birth may become necessary, vaginal birth may be possible with a mild or partial abruption. Assessing maternal/fetal status and relaying that information to the health care provider is the priority. (Option 4) Vaginal examination is not performed in the presence of active bleeding until the possibility of placenta previa is ruled out; placenta previa typically presents with painless vaginal bleeding. Information about bleeding should be relayed to the health care provider, who can then determine if a vaginal examination would be appropriate. Educational objective:The priorities of care for suspected placental abruption include close monitoring of the client (hemodynamic status) and fetus (continuous fetal heart rate monitoring). Additional interventions may include initiation of a large-bore IV line, administration of fluids and blood products, and possible emergency cesarean birth.

An older adult client takes multiple prescription medications plus several over-the-counter medications. Which intervention by the clinic nurse is most important in reducing the risk for drug interactions? 1. Assist client with making a list of all medications, doses, and times to be taken 2. Encourage client to obtain all prescription medications from the same pharmacy 3.Have client bring all medications taken regularly or occasionally to each appointment 4. Instruct client to use a pill organizer to separate pills by day and time (11%)

3. CORRECT Polypharmacy and the physiologic changes associated with aging place older adults at an increased risk of adverse drug events. Decreased renal and hepatic function causes increased drug half-life and impaired drug clearance, potentially resulting in toxicity and adverse events. Clients may see different health care providers and receive multiple prescriptions for different health problems (polypharmacy). Clients should be encouraged to bring all medications (ie, prescription, over-the-counter [OTC], herbal supplements) they take regularly and occasionally to each appointment so that potential drug interactions can be evaluated (Option 3). (Option 1) Keeping a list of all medications and their dosages is a good idea to help organize the client's medications. However, the client may not remember all the medications and may not regularly update the list. (Option 2) Getting all medications from the same pharmacy is preferable. The pharmacist can monitor for possible interactions from prescription drugs, but many clients do not report the use of OTC medications or herbal supplements to the pharmacist. (Option 4) A pill organizer helps the client remember to take medications at the appropriate times. By ensuring drugs are taken at prescribed intervals, some interactions can be avoided. However, this may not take into account herbal supplements and OTC drugs taken as needed. Educational objective:To reduce the risk for drug interactions, the nurse should encourage clients to bring all medications (ie, prescription, over-the-counter, herbal supplements) to each appointment.

The nurse cares for a client with a terminal disease who created a do not attempt resuscitation (DNAR) directive. The client stops breathing and loses their pulse. The client's adults child states, "Please, do whatever you can to save them!". Which intervention is appropriate? 1. Call for help to obtain emergency medications while initiating CPR 2. Call the health care provider to confirm the DNAR directive (7%) 3. Explain the client's resuscitation directive to the client's child (84%) 4.Request the presence of a health care proxy at the bedside (5%)

3. CORRECT Advance directives outline the client's choices for medical care (eg, CPR, mechanical ventilation) ahead of time. This allows the family and care team to follow the client's wishes at the end of life, when the client may be unable to make choices known. Clients can create a do not attempt resuscitation (DNAR) directive instructing that CPR and other life-saving measures be withheld. With an advance directive in place, the client's wishes should be followed, even if they conflict with the wishes of loved ones (Option 3). (Option 1) Initiating CPR on a client with a DNAR directive does not respect the wishes of the client to forgo life-saving measures and allow natural death. Nurses must advocate for clients' wishes, even if family members disagree. (Option 2) The client has a terminal illness and in their advance directive expressed wishes that were verified prior to initiating the DNAR directive; therefore, there is no need to clarify with the health care provider. (Option 4) A medical power of attorney (health care proxy) is a person the client has designated to make decisions on their behalf if they cannot make decisions on their own. The presence of an existing advanced directive does not require a health care proxy because the client's wishes have been established and should be honored. Educational objective:Advance directives outline the client's choices for medical care at the end of life, including resuscitation directives. Client's wishes for medical care are honored over the wishes of family members.

Four pediatric clients are brought to the emergency department at the same time. Which client should be seen first? 1. Child who is unable to eat or drink without vomiting (13%) 2. Child with a recently placed tympanostomy tube that has fallen out (5%) 3. Child with bruising behind the ears after a football injury (68%) 4. Child with increased pain at skeletal pin insertion sites on the leg (11%)

3. CORRECT Bruising behind the ear (eg, Battle sign) following head trauma may indicate a basilar skull fracture (Option 3). Because of their close proximity to the brainstem, basilar skull fractures pose a risk of serious intracranial injury, which is the most common cause of traumatic death in children. Other signs include blood behind the tympanic membrane, periorbital hematomas (ie, raccoon eyes), and cerebrospinal fluid leakage from the nose or ears. This client requires cervical spine immobilization, close neurologic monitoring, and support of airway, breathing, and circulation. (Option 1) Vomiting with oral intake may indicate infection (viral or bacterial). Most serious abdominal processes (eg, obstruction, intussusception, appendicitis) also have abdominal pain. This client may require IV fluids and antiemetics but is not a priority. (Option 2) Tympanostomy tubes placed for recurrent otitis media may fall out of the ear canal. This child should be evaluated for the presence of infection and the need for possible tube reinsertion, but this is a common occurrence and can wait to be addressed. (Option 4) Increasing pain at skeletal pin sites after surgical fracture repair may indicate infection or displacement of the pins. Pin displacement may compromise blood flow to the leg. The nurse should assess the neurovascular status of the limb, but this does not take priority over a basilar skull fracture. Educational objective:A client with signs of basilar skull fracture (eg, periorbital hematomas, bruising behind the ear, leakage of cerebrospinal fluid) requires immediate cervical spine immobilization, neurologic assessment, and airway, breathing, and circulation support.

There has been a major disaster involving a manufacturing plant explosion. The emergency department nurse is sent to triage victims. Which client should the nurse send to the hospital first? 1. Client who has partial-thickness burns on both hands (6%) 2. Client who is screaming and has a left lower arm laceration (4%) 3. Client with a broken, protruding right tibia and gray, pulseless foot (64%) 4 .Client with a gaping head wound and Glasgow Coma Scale score of 3 (24%)

3. CORRECT During a mass casualty event, the goal of the nurse is to triage rapidly and provide the greatest good for the greatest number of people. Clients are commonly triaged using a color-coded system and placed into 4 categories. When prioritizing clients for treatment, emergent needs should be managed first, followed by urgent and then nonurgent. The client with an open fracture and impaired distal perfusion (eg, absent distal pulses, capillary refill >3 sec) has an emergent need for care as limb loss may occur without rapid intervention (Option 3). (Option 1) Nonurgent treatment is appropriate for the client with partial-thickness burns to a small portion of the body (eg, hands). (Option 2) Depending on the size and depth of the laceration, this client would most likely be categorized as nonurgent or urgent. (Option 4) A large, open head wound and a Glasgow Coma Scale score of 3 is indicative of severe neurological trauma. This client has a poor prognosis regardless of treatment (expectant) and would be the lowest priority. Educational objective:During a mass casualty event, the goal is the greatest good for the greatest number of people. Clients are triaged rapidly using a color-coded system that establishes them with highest medical priority to lowest: red (emergent), yellow (urgent), green (nonurgent), and black (expectant).

A client is receiving packed RBCs intravenously through a double-lumen peripherally inserted central catheter (PICC) line. During the transfusion, the nurse receives a new prescription to begin intravenous piggyback (IVPB) amphotericin B. What is the nurse's best action? 1. Administer amphotericin B through an open lumen of the PICC line (18%) 2. Insert a peripheral IV line to begin infusion of amphotericin B (21%) 3. Interrupt the blood transfusion to infuse amphotericin B, then resume after infusion (0%) 4. Wait 1 hour after blood transfusion finishes before administering amphotericin B (58%)

4. CORRECT Amphotericin B is an antifungal medication used to treat systemic fungal infections. It is commonly associated with severe adverse effects, including hypotension, fever, chills, and nephrotoxicity. Due to the similarity between the adverse effects of amphotericin B and the symptoms of a blood transfusion reaction (eg, chills, fever, hypotension, kidney injury), the nurse's best action is to complete the blood transfusion and allow one hour of observation before initiating amphotericin B (Option 4). This enables the nurse to distinguish between transfusion-related reactions and adverse effects from amphotericin B. (Options 1 and 2) Although starting a peripheral IV line or using an open lumen of the peripherally inserted central catheter line would prevent mixing amphotericin B with the blood products, it would not allow the nurse to distinguish the onset of a potentially fatal reaction from either component. (Option 3) The nurse should not interrupt a blood transfusion after initiation except in cases of transfusion-related reactions or fluid overload. In addition, pausing and restarting blood transfusions increases the risk for contamination of blood products. The nurse should complete transfusion of blood products within 4 hours of removal from refrigeration. Educational objective:At least one hour should be allowed between completion of a blood transfusion and administration of amphotericin B. The adverse effects of a transfusion-related reaction and an adverse reaction from amphotericin B are similar, and the observation time enables the nurse to distinguish the triggering event if symptoms develop.

The nurse is reviewing the medical history of a client who has sustained a right tibia/fibula fracture from a fall. The nurse identifies which finding as most likely to hinder healing? 1. BMI of 29.5 kg/m2 (8%) 2.Family history of osteoporosis (16%) 3.History of a daily glass of wine (1%) 4.Peripheral arterial disease (74%)

4. CORRECT Bone healing depends on multiple factors, including nutrition, adequate circulation, and age. A client with peripheral arterial disease has decreased perfusion to the extremities due to atherosclerotic changes in the arteries. Without adequate perfusion, the bone is not supplied with the oxygen and nutrients required for healing (Option 4). (Option 1) A BMI of 25-29.9 kg/m2 indicates that the client is overweight. A sedentary lifestyle often leads to elevated BMI and also correlates with decreased bone density, which places the client at risk for fractures. However, neither sedentary lifestyle nor elevated BMI directly affects bone healing. (Option 2) Osteoporosis (low bone density) increases the risk of fractures and delays bone healing. Although a family history does increase the risk of osteoporosis, the family history itself would not directly hinder bone healing as this client has not been diagnosed with osteoporosis. (Option 3) Heavy alcohol use is associated with inadequate nutrition and can decrease osteoblastic activity (ie, bone formation). However, a single serving of alcohol (ie, 12 oz of beer, 5 oz of wine, 1.5 oz of liquor) per day is considered moderate usage and is not a risk factor for delayed healing. Educational objective:Bone healing after fracture depends on multiple factors, including age, nutritional status, and perfusion. A client with peripheral arterial disease is at risk for impaired bone healing.

A client with type 1 diabetes mellitus has prescriptions for NPH insulin and regular insulin. At 7:30 AM, the client's blood glucose level is 322 mg/dL (17.9 mmol/L), and the breakfast tray has arrived. What action should the nurse take? Click the exhibit button for additional information. 1. Administer 25 units of NPH insulin now and then 12 units of regular insulin after the morning meal (1%) 2. Administer 37 units of insulin: 25 units of NPH insulin and 12 units of regular insulin in 2 separate injections (9%) 3. Administer 37 units of insulin: 25 units of NPH mixed with 12 units of regular insulin in the same syringe, drawing up the NPH into the syringe first (11%) 4. Administer 37 units of insulin: 25 units of NPH mixed with 12 units of regular insulin in the same syringe, drawing up the regular insulin first (77%) Exhibit Medication administration record Medication administration record Allergies: Penicillin MedicationsTime NPH insulin: 25 units subcutaneously, twice daily 0730, 2100Regular insulin: Per sliding scale, subcutaneouslyBefore meals and at bedtimeSliding-Scale Blood Glucose LevelsRegular Insulin Dose<150 mg/dL (<8.3 mmol/L)0 units150-199 mg/dL (8.3-11.0 mmol/L)4 units200-249 mg/dL (11.1-13.8 mmol/L)8 units250-299 mg/dL (13.9-16.6 mmol/L)10 units300-350 mg/dL (16.7-19.4 mmol/L)12 units>350 mg/dL (>19.4 mmol/L)16 units; notify the health care provider

4. CORRECT Intermediate-acting insulins (NPH) can be safely mixed with short-acting (regular) and rapid-acting (eg, lispro, aspart) insulins in one syringe (Option 4). Due to the client's blood glucose reading (322 mg/dL [17.9 mmol/L]), 12 units of regular insulin are needed along with the scheduled 25 units of NPH insulin. Prepare the mixed dose: Inject 25 units of air into the NPH insulin vial without inverting the vial or passing the needle into the solution. Inject 12 units of air into the regular insulin vial and withdraw the dose, leaving no air bubbles. Draw 25 units of NPH insulin, totaling 37 units in one syringe. Any overdraw of NPH into the syringe will necessitate wasting the entire quantity. Most long-acting insulins (eg, glargine, detemir) are not suitable for mixing and typically are packaged in prefilled injection pens. (Option 1) The two insulins can be safely given together before the meal because regular insulin has a rapid onset of action, whereas NPH has a slower onset but longer duration. (Option 2) The insulins can be given as two separate injections; however, this increases client discomfort and infection risk. (Option 3) Regular insulin should be drawn up first to avoid contaminating the regular insulin vial with NPH insulin (mnemonic - RN: Regular before NPH). Educational objective:NPH insulin and regular insulin may be safely mixed and administered as a single injection. Regular insulin should be drawn into the syringe before intermediate-acting insulin to avoid cross-contaminating multidose vials (mnemonic - RN: Regular before NPH).

When the nurse provides education about starting risperidone, which statement by the client's parent indicates a need for further teaching? 1. "I will call the clinic if the client has a fever or muscle stiffness." (4%) 2. "I will not worry if the client sleeps more often when taking this medicine." (21%) 3. "I will remind the client to move slowly and not stand up too quickly." (3%) 4. "It is normal for the client to become shaky and restless when agitated." (69%)

4. CORRECT Second-generation (atypical) antipsychotic medications (eg, risperidone, quetiapine, olanzapine) are used to treat schizophrenia, bipolar disorder, and other mental health disorders. The nurse should educate clients and caregivers on the potential adverse effects of atypical antipsychotic medications. Symptoms are evaluated on an individual basis; most minor symptoms can be managed with a decrease in dosage or change in medication. One of the main adverse effects the nurse should recognize with second-generation antipsychotic medications is extrapyramidal symptoms (EPSs). EPSs include manifestations of akathisia (ie, restlessness, fidgeting), parkinsonism (eg, tremors, shuffling gait), and tardive dyskinesia (eg, lip smacking, facial grimacing). These symptoms are important to monitor because they may be easily mistaken for agitation or negative schizophrenic symptoms (eg, pacing, rocking) (Option 4). The health care provider may prescribe anticholinergics (eg, benztropine, diphenhydramine) or benzodiazepines to treat EPSs. (Option 1) The client should report fever and muscle rigidity, which may indicate a potentially fatal adverse effect of antipsychotic medications, neuroleptic malignant syndrome, which requires emergency intervention. (Option 2) The nurse should teach that the sedating effects of second-generation antipsychotic medications (eg, drowsiness, hypersomnia [ie, excessive daytime sleepiness]) are common. (Option 3) The caregiver should identify that the client needs to change positions slowly to prevent orthostatic hypotension, another potential adverse effect of antipsychotic medications. Educational objective:Second-generation (atypical) antipsychotic medications are used to treat schizophrenia, bipolar disorder, and other mental health disorders. Major adverse effects of second-generation antipsychotic medications include extrapyramidal symptoms (eg, akathisia, parkinsonism, tardive dyskinesia), neuroleptic malignant syndrome, sedation, and orthostatic hypotension.

After listening to the parents' reports and seeing the following pediatric clients, the nurse knows that which client demonstrates signs of abuse that may necessitate mandatory reporting? 1. 1-year-old with dyspnea, drooling, and a swollen tongue after eating part of a houseplant (2%) 2. 2-year-old who is crying and has a large forehead hematoma after falling out of a chair (5%) 3. 3-year-old with second-degree burns on the face after pulling a cup of hot tea off the table (3%) 4. 5-year-old whose x-ray reveals 1 new and 2 healed humerus fractures after falling from a tree (87%)

4. CORRECT The nurse should be aware of signs of physical, sexual, and emotional abuse and comply with state or provincial mandatory reporting. Signs of abuse may include: Shaken baby syndrome (ie, irritability or lethargy, poor feeding, emesis, seizures) Burns in the shape of household items (eg, iron, spatula), from cigarettes, or from immersion in scalding liquid Repeated injuries in varied stages of healing (eg, bruises, burns, fractures) (Option 4) Injuries to genitalia Lapsed time between the injury and the time when care is sought Inconsistency between the injury and the caregiver's explanation of the injury (eg, client's developmental age, mechanism of injury) (Options 1, 2, and 3) Toddlers and young children are prone to many accidental injuries (eg, aspiration or poisoning from foreign objects in the mouth, climbs onto and falls from furniture, pulling of objects from the table). The injuries and caregivers' explanations are reasonable for these clients. Prior to discharge, the nurse should instruct caregivers on child safety measures within the home to prevent future injury. Educational objective:The nurse should be aware of signs of physical, sexual, and emotional abuse, including repeated injuries in varied stages of healing, shaken baby syndrome, and injuries to genitalia. Suspicion of abuse necessitates mandatory reporting according to state or provincial laws.

A nurse is caring for a client at 37 weeks gestation who is undergoing a contraction stress test. Which fetal strip should the nurse associate with a negative contraction stress test?

A contraction stress test (CST) evaluates fetal well-being under stress by identifying uteroplacental insufficiency. Uterine blood flow is decreased during uterine contractions, which stresses the fetus during labor. Contractions are stimulated using either oxytocin administration or nipple stimulation. A fetal tracing is evaluated until 3 uterine contractions, each lasting 40-60 seconds, are captured within 10 minutes. A negative test has no late or variable decelerations and is associated with good fetal outcomes (Option 2). A positive test includes late decelerations with ≥50% contractions. A suspicious or equivocal test includes variable or prolonged decelerations or late decelerations with <50% contractions. A CST may be combined with a nonstress test to further evaluate fetal well-being. A negative CST with a reactive nonstress test provides strong reassurance of fetal well-being. (Options 1 and 4) These fetal tracings show late decelerations, indicating uteroplacental insufficiency. They indicate a positive test and an at-risk fetus. (Option 3) This fetal tracing has variable decelerations, indicating umbilical cord compression. This is a suspicious or equivocal test and follow-up testing is indicated. Educational objective:A contraction stress test evaluates fetal well-being during uterine contractions. Contractions are stimulated by oxytocin administration or nipple stimulation. A negative test has no late or variable decelerations and is associated with good fetal outcomes. Late or variable decelerations indicate a need for further evaluation.

The nurse precepting a graduate nurse (GN) reviews age-related changes that increase older adult clients' risk for respiratory infections. Which of the following statements by the GN indicate a correct understanding? Select all that apply. 1. "The ability to cough forcefully decreases." 2. "The chest wall may become less flexible." 3. "The immune system response is diminished." 4. "The mucous membranes become drier." 5. "The number and motility of cilia decrease."

ALL CORRECT: With aging, mucus becomes thicker and more difficult to clear because the mucous membranes produce and secrete less mucus. Costal cartilage becomes calcified, reducing lung compliance and expansion. The respiratory muscles become weaker and the cough is less forceful. The number of respiratory cilia is decreased, and they become less effective in their brushing motion. All these changes reduce the body's ability to clear mucus and pathogens. The immune system of older adults is also diminished as the function and quality of lymphocytes (ie, T cells, B cells) are altered and respiratory defenses (eg, mucus clearance) are impaired. The older adult's dry mucous membranes are also more vulnerable to respiratory pathogens and infection.

The nurse is planning care for a client with bipolar disorder and acute mania who is being admitted involuntarily after attempting to run across a five-lane highway. Which intervention is the priority to include in the care plan? 1. Assist the client with dressing by giving instructions one at a time (4%) 2. Collaborate with unit staff to set consistent limits on manipulative behaviors (30%) 3.Offer high-calorie snacks the client can eat while on the move and during tasks (63%) 4.Secure the client's credit cards to prevent compulsive spending and bankruptcy (2%)

Bipolar disorder is characterized by alternating episodes of depression and mania. Manic clients demonstrate hyperactivity and distractibility and may refuse to sit still long enough to drink or eat, placing them at risk for inadequate nutritional intake. When caring for a client with mania, the nurse should prioritize physiological needs over psychological or self-fulfillment needs. The nurse can address imbalanced nutrition in a manic client by providing high-calorie snacks and finger foods that the client can carry and eat without having to sit down (Option 3). (Option 1) Clients with mania are highly distractible and may require encouragement to engage in self-care and health activities (eg, medication compliance). However, these do not take priority over physiological needs. (Option 2) Manic clients often lack impulse control and may demonstrate manipulative and/or high-risk behaviors (eg, sexual promiscuity, uninhibited social interaction) that impair their safety and that of others. It is critical that the nurse collaborate with staff to set consistent limits on these behaviors. (Option 4) Personal items may be used to facilitate personal harm (eg, credit cards for excess spending). The nurse must secure items that could lead to harmful behavior. Educational objective:Manic clients demonstrate hyperactivity and distractibility and may refuse to sit still long enough to drink or eat, placing them at risk for inadequate nutritional intake. The nurse should provide high-calorie finger foods and snacks, monitor and limit risk-prone or manipulative behaviors, and assist with self-care activities. Psychosocial Integrity NCSBN Client Need

The nurse is teaching about constipation prevention to a client. Which of the following client statements indicate appropriate understanding of the teaching? Select all that apply. 1. "Drinking more caffeinated drinks such as tea and soda helps to stimulate the bowel." 2. "Having a routine for bowel movements is important, but I should not wait if I feel the urge." 3. "I can use an over-the-counter laxative every other day if needed." 4. "I should try to eat more fruits and vegetables every day." 5. "Increasing my daily exercise level may help keep my bowel movements regular."

Constipation is a symptom of many disease processes (eg, Parkinson disease, diabetic neuropathy, depression), procedures (eg, abdominal surgery, bowel manipulation), and medications (eg, anticholinergics, diuretics, opioids). Immobility, a low-fiber diet, decreased fluid intake, and irregular bowel habits increase the likelihood of constipation. Educate clients to prevent constipation by: Encouraging a healthy bowel regimen by avoiding delaying defecation. If the urge is felt, defecate at the same time daily, and when possible, track bowel movements to identify changes in patterns (Option 2) Increasing consumption of fruits and vegetables to reach a daily fiber intake of at least 20 g (unless contraindicated) because fiber softens and increases the bulk of stool, which promotes defecation (Option 4) Increasing daily exercise levels because activity stimulates peristalsis and promotes defecation (Option 5) Drinking 2-3 L of noncaffeinated fluids daily (unless contraindicated), which prevents drying and hardening of stool in the colon (Option 1) Clients should avoid caffeinated beverages, which promote diuresis and dehydration and may lead to constipation. (Option 3) Clients should avoid using laxatives and enemas unless prescribed by a health care provider because overuse can cause physical and psychological dependence. Educational objective:Constipation is a symptom of many disease processes, procedures, and medications. To prevent constipation, educate the client to increase daily fiber intake, drink 2-3 L of fluids daily, increase daily activity levels, and initiate a bowel regimen (avoiding delay of defecation, defecating at the same time each day).

The student nurse assists in caring for a client who is scheduled for electroconvulsive therapy for the treatment of depression. Which statement by the student indicates a need for further teaching? 1. "A bite block will be placed in the client's mouth to prevent injuries to the tongue and teeth." 2. "Because this client has a mental illness, the agent with medical power of attorney should sign the informed consent document." 3. "The client should have had nothing to eat or drink for at least 6-8 hours prior to the procedure." 4. "The client will receive a muscle relaxant and short-acting anesthetic before the current is delivered."

Electroconvulsive therapy (ECT) is a procedure in which the client receives an electrical current via electrodes placed on the temples to induce a brief seizure. It can be used to treat clients with mood disorders (eg, major depression, bipolar disorder) or schizophrenia. Informed consent is required for ECT. Clients who have mental illness can give or withhold consent unless they have been deemed incompetent through legal proceedings (Option 2). The client is also deemed incompetent if inebriated, psychotic, delirious, or under the influence of mind-altering medication. Guidelines for determining competency to give consent apply to all clients, with or without mental illness. (Option 1) Although the client receives a neuromuscular blockade, the muscles around the jaw contract when the current is applied. A bite block is used during ECT to prevent dental and tongue injuries. (Option 3) Clients should be NPO for at least 6-8 hours prior to ECT to prevent aspiration during the procedure. (Option 4) Clients undergoing ECT receive a short-acting IV anesthetic and muscle relaxant to ensure client comfort and prevent musculoskeletal injury. Educational objective:Electroconvulsive therapy is a procedure that induces a brief seizure to treat clients with mood disorders or schizophrenia. Informed consent must be obtained from the client prior to the procedure unless the client has been deemed legally incompetent or meets other standards for incompetency (eg, inebriation). Prior to ECT, clients should be NPO for 6-8 hours and receive both a short-acting anesthesia and a muscle relaxant as well as a bite block.

The nurse accidentally administers orally dissolving mirtazapine through a client's percutaneous endoscopic gastrostomy tube instead of the prescribed sublingual route. After assessing the client for adverse reactions, what is the nurse's priority action? 1. Disclose the medication error to the client 2. Document the error on an incident report 3. Inform the nurse manager about the error 4. Notify the prescribing health care provider

Medication errors (eg, wrong medication, wrong route) are events that may lead to client harm. Route administration errors alter medication absorption, resulting in subtherapeutic effects or life-threatening adverse reactions. Orally dissolving mirtazapine is an antidepressant specifically formulated for mucous membrane absorption, allowing quick entry into the bloodstream. Crushing and administering this medication through a percutaneous endoscopic gastrostomy tube is a wrong-route medication error. If medication errors occur, the priority is client safety. The nurse should first assess for adverse effects and stabilize the client's condition, if needed. The nurse should then immediately notify the health care provider (HCP) of the error and assessment findings (Option 4). The HCP may prescribe new interventions to prevent or reduce harm to the client. (Options 1, 2, and 3) The nurse should inform the client and nurse manager about the error and complete an incident report after stabilizing the client's condition, notifying the HCP, and implementing new prescriptions. Educational objective:Client safety is the priority when a medication error (eg, wrong medication, wrong route) occurs. After an error, the nurse should first assess and stabilize the client, then immediately inform the health care provider. After implementing new prescriptions, the nurse should notify both the client and nurse manager about the error and complete an incident report. Safety and Infection Control

The nurse on an inpatient mental health unit is caring for a client with paranoid delusions who is refusing to eat. The client states that all the food and drinks have been poisoned. Which intervention by the nurse is appropriate? 1. Contact the client's family and ask them to bring prepared food from home 2. Inform the client that tube feedings will be initiated if the client refuses to eat 3. Offer to taste the client's food and drinks while the client observes 4. Provide the client food in unopened single-serving packages

Paranoia is the belief that others desire or are attempting to persecute or harm (eg, spy on, cheat, follow, poison) the individual. Clients with paranoid delusions often are suspicious of other people, including health care professionals, and may refuse treatment or aid out of fear of being harmed. Management of paranoia focuses on building trust with and grounding the client in reality. When the client believes food has been poisoned, the nurse can build trust and promote adequate nutrition by offering unopened, individually packaged food (Option 4). (Options 1 and 3) Requesting that the client's family bring outside "safe" food or proving the food is safe (eg, tasting the food) does not acknowledge reality and reinforces the delusion that the food could be poisoned. (Option 2) Threatening invasive feedings if the client does not eat is not therapeutic or ethical and may support the delusion of poisoning. Educational objective:Nurses caring for clients who have paranoid delusions must work to build a trusting relationship and ground the client while ensuring basic needs are met (eg, nutritional intake). When clients believe food is poisoned, the nurse should offer unopened, individually packaged food to promote adequate intake without reinforcing delusions.

The nurse on the cardiac unit reviews a current rhythm strip from a client who experienced an inferior wall myocardial infarction. What action should the nurse take first? Click on the exhibit button for additional information. 1. Document the rhythm as an expected finding (30%) 2. Obtain the transcutaneous pacemaker (20%) 3. Prepare to administer adenosine IV (13%) 4. Review medications the client is receiving (35%)

The client is experiencing a second-degree type 2 atrioventricular (AV) block (Mobitz II), which is characterized by more P waves than QRS complexes. The PR intervals are consistent or constant, reflecting regular conduction of electrical impulses through the AV node, but dropped QRS beats randomly occur as ventricular conduction is blocked. A second-degree type 2 AV block can rapidly deteriorate to complete heart block (third-degree AV block), which is life-threatening. The nurse should quickly obtain a transcutaneous pacemaker, assess the client for symptoms (eg, bradycardia, hypotension, syncope), and be prepared to pace the client if symptoms occur (Option 2). If the client is asymptomatic, the pacemaker is kept nearby in case the rhythm deteriorates, and the health care provider is alerted. (Option 1) A common complication following myocardial infarction is the development of new arrhythmias. Although a second-degree type 2 AV block is not completely unexpected in this client, it indicates a concerning situation that requires assessment and monitoring. (Option 3) Adenosine is used to treat supraventricular tachycardia. Adenosine creates a transient heart block, which then allows the heart to resume normal sinus rhythm. It is never given for bradyarrhythmias. (Option 4) Medications should be reviewed as drug toxicity (eg, beta blockers, digoxin) can cause this type of block. However, this can be done after other interventions. Educational objective:Second-degree type 2 atrioventricular heart blocks are characterized by consistent PR intervals and dropped QRS complexes. Clients should have temporary pacing immediately available as rapid deterioration to complete heart block can occur.

The nurse cares for a client with depression who states, "If I tell you something, will you keep it a secret?" What statement by the nurse is correct? 1. "I cannot make that promise; I may need to share it with your therapist." 2. "Tell me, and we can discuss the pros and cons of keeping it a secret." 3. "What is the importance of the secret that you wish to share?" 4."Yes, as long as you do not tell me that you are planning to hurt yourself."

The therapeutic nurse-client relationship focuses on client needs and has clear, well-defined professional boundaries. Keeping a client's secrets is a sign of countertransference (eg, overinvolvement with the client) and a violation of the professional boundary. When asked to keep a secret, the nurse must be honest and state that it may be necessary to tell others on the health care team (Option 1). The client can then decide whether or not to disclose the information. (Option 2) Implying that the nurse might or might not ultimately keep the secret may cause the client to lose trust in the nurse. (Option 3) Asking indirect questions about a secret might seem like an effort to trick the client into telling it; the nurse should be honest and direct with the client. (Option 4) In addition to divulging self-harm, the client might disclose other issues (eg, past or potential homicidal behavior, relationship issues) that require the nurse to notify the mental health care team. Educational objective:When asked to keep a secret, the nurse must be honest and state that it may be necessary to tell others on the health care team. Keeping a client's secrets is a sign of countertransference (eg, overinvolvement with the client) and a violation of the professional boundary. Management of Care NCSBN Client Need

A client arrives in the emergency department with right-sided paralysis and slurred speech. The nurse understands that the client cannot receive thrombolytic therapy due to which reason? 1. Client had gallbladder surgery 2 months ago (12%) 2. Client has a blood pressure of 175/100 mm Hg 3. Client has experienced loss of the gag reflex 4. Client's symptoms started 12 hours earlier

Thrombolytic therapy (ie, t-PA) is used to dissolve blood clots and restore perfusion in clients with ischemic stroke. The nurse should assess for contraindications to t-PA due to the risk for hemorrhage. Clients have a 3- to 4.5-hour window from onset of symptoms to receive t-PA to achieve full effectiveness of thrombolytic therapy (Option 4). (Option 1) Recent major surgery (ie, within the past 14 days) is a contraindication because t-PA dissolves all clots in the body and may therefore disrupt the surgical site. Gallbladder surgery 2 months prior is outside the window of contraindication. (Option 2) To receive t-PA, clients must have a systolic blood pressure (BP) ≤185 mm Hg and diastolic BP ≤110 mm Hg. In addition, BP should be maintained at ≤180/105 mm Hg throughout the administration of thrombolytic therapy and 24 hours thereafter. (Option 3) Loss of the gag reflex and other major functions would most likely make the client a candidate for thrombolytics due to proof of deficits from stroke. Other contraindications include hemorrhagic stroke and stroke or head trauma within the past 3 months. Educational objective:Thrombolytic therapy (ie, t-PA) is used to treat and dissolve blood clots in clients with ischemic stroke. This therapy should be administered within 3-4.5 hours of symptom onset. Contraindications include severe hypertension (ie, blood pressure >185/110 mm Hg), coagulation disorders, and major surgery within the past 14 days.