Other Other

A client arrives in the emergency department on a cold winter day. The client is calm, alert, and oriented with a respiratory rate of 20/min and a pulse oximeter reading of 78%. The nurse suspects that the client's pulse oximeter reading is inaccurate. Which factors could be contributing to this reading?

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

The nurse receives morning report on 4 clients who were admitted 24 hours earlier for injuries incurred in motor vehicle collisions. Which client should the nurse assess first?

A lung contusion (bruised lung) caused by blunt force can occur when an individual's chest hits a car steering wheel. This injury is potentially life-threatening because bleeding into the lung and alveolar collapse can lead to acute respiratory distress syndrome. Clients should be monitored for 24-48 hours as symptoms (eg, dyspnea, tachypnea, tachycardia) are usually absent initially but develop as the bruise worsens. Inspiratory chest pain can lead to hypoventilation, and an oxygen saturation of 90% (normal: 95%-100%) indicates hypoxemia. Therefore, the nurse should assess this client with lung contusion first and then notify the health care provider as immediate interventions to decrease the work of breathing and improve gas exchange (eg, supplemental oxygen, medications, ventilatory support) may be necessary. (Option 1) Ecchymosis and bruising due to trauma would be expected. (Option 2) Skin irritation under rough cast edges is common; oval strips of adhesive or moleskin tape applied to the cast edge (petals) can provide padding. Neurovascular assessment and elevation are necessary as swelling can indicate venous compression. This is not a life-threatening priority. (Option 4) In a client with a pneumothorax, intermittent bubbling in the water-seal chamber consistent with respirations (due to air escaping from the pleural space) is expected until the lung has fully expanded. Educational objective:A lung contusion (bruised lung) caused by a blunt force to the chest is potentially life-threatening. Clients should be monitored for 24-48 hours after the injury for manifestations of hypoventilation and hypoxemia as these are usually absent initially but develop as the bruise worsens

The emergency nurse admits a semiconscious client with periorbital bruising and severe tongue edema after a laceration sustained in an unwitnessed tonic-clonic seizure. The health care provider prescribes a nasopharyngeal airway to maintain airway patency. Which initial action by the nurse is appropriate?

A nasopharyngeal airway (NPA) is a tube-like device used to maintain upper airway patency. NPAs are frequently used in alert or semiconscious clients, as they are less likely to cause gagging, and in clients with oral trauma or maxillofacial surgery. NPAs should never be inserted in clients who may have head trauma (eg, facial or basilar skull fractures), such as might occur during an unwitnessed seizure. NPAs inserted in clients with skull fractures may be malpositioned into underlying tissues/structures (eg, brain). Therefore, the nurse should immediately clarify prescriptions for NPAs in clients with head trauma (Option 1). An NPA may be inserted after imaging (eg, CT scan) rules out fracture. (Option 2) Once skull fracture is ruled out and an NPA is inserted, the nurse verifies appropriate airway placement by auscultating the lungs. (Option 3) Inappropriate NPA size increases the risk for airway obstruction, sinus blockage, and infection. To select an appropriate size, the nurse measures from the tip of the client's nose to the earlobe and selects a diameter smaller than the naris. (Option 4) Bleeding disorders and use of anticoagulant or antiplatelet medication (eg, aspirin) are relative contraindications to NPA insertion, as these increase the risk of bleeding. However, skull fracture must be excluded prior to placement. Educational objective:A nasopharyngeal airway (NPA) is a tube-like device used to maintain upper airway patency. NPAs should not be inserted in clients with suspected head trauma until skull fracture can be excluded as there is a risk for unintentional malpositioning into underlying tissue/structures (eg, brain)

The nurse completes the preoperative assessment for a client scheduled for a total knee replacement today. Which information should the nurse report to the health care provider (HCP) as soon as possible before the surgery?

A recent/current infection is a contraindication to total joint replacement surgery as a wound infection is more likely to occur in a client with a preexisting infection. The nurse should report the new onset of burning on urination to the HCP. Burning could indicate the presence of a urinary tract infection. (Option 1) Allergy to strawberries is not a contraindication to the scheduled surgery. However, a latex allergy should be documented. (Option 3) Severe knee pain is expected in a client undergoing a total knee replacement. (Option 4) Clients are directed to stop taking nonsteroidal anti-inflammatory drugs, including selective COX-2 inhibitors (eg, celecoxib [Celebrex]), 7 days before surgery to decrease the risk of intra- and postoperative bleeding. Educational objective:A recent/current infection is a contraindication to elective total joint replacement surgery. Any clinical manifestation that could indicate the presence of an infection should be reported to the HCP as soon as possible before the surgery

Four clients come to the emergency department (ED). Which client should the triage registered nurse (RN) assign as highest priority for definitive diagnosis and treatment?

Although this elderly client may be unconscious due to intoxication, vomit and decreased level of consciousness place this client at risk for airway obstruction. Treatment of this client is a priority, and measures must be taken to protect the airway (eg, rescue position, head of bed elevation, intubation). (Option 1) Bacterial infection is the most common cause of COPD exacerbation. Although clients with COPD usually have cough and sputum, it becomes a concern when the sputum changes in color, consistency, or volume. This client needs antibiotics. The goal pulse oximetry reading for COPD is typically 90%-93% as many clients with COPD rely on their hypoxemic drive to breathe. Therefore, this client is stable and can wait until the unconscious elderly client is treated. (Option 2) This child has fifth disease ("slapped-cheek," erythema infectiosum), which is caused by parvovirus B19. Symptoms, in addition to a bright-red facial rash, include fever and general flulike symptoms. It is harmless unless the client has a hemolytic/immunodeficient condition. Pregnant women should avoid contact with infected individuals as the virus can be transmitted to the fetus and cause anemia. Prioritization is determined by acuity, and therefore children do not automatically receive higher priority. However, due to the potential exposure of this child to a pregnant client in the ED, the triage RN should prioritize this client ahead of the one with vaginal infection. (Option 3) This client is exhibiting a classic sign of the common Candida vaginitis (yeast) infection. Classic signs and symptoms include itching and irritation in the vulva or vagina, white cheesy vaginal discharge, and low vaginal pH. Although uncomfortable, this client is stable and can safely wait up to 2 hours for treatment. Educational objective:A client with emesis and decreased level of consciousness is a priority due to airway obstruction risk. Sputum changes in a client with COPD signal infection that can cause exacerbation. Although "slapped-cheek" disease in children is usually a harmless viral infection, pregnant women should avoid exposure

The nurse reviews and reinforces an asthma action plan with a client who has moderate persistent asthma. Which statement by the client indicates an understanding of how to follow a plan appropriately when peak expiratory flow (PEF) readings are in the green, yellow, or red zones?

An asthma action plan is an individualized management plan developed collaboratively between the client and the HCP to facilitate self-management of asthma. It includes information on daily and long-term treatment, prescribed medicines and when to take them according to a zone system, how to manage worsening symptoms or attacks, and when to call the HCP or go to the emergency department. The action plan uses traffic signal colors to categorize into zones degrees of asthma symptom severity and airway obstruction (peak flow meter readings): Green zone indicates asthma is under control and PEF is 80%-100% of personal best. When in this zone, there is no worsening of cough, wheezing, or trouble breathing (Option 1). Yellow zone means caution; even on a return to the green zone after use of rescue medication, further medication or a change in treatment is needed (Option 2). Red zone indicates a medical alert and signals the need for immediate medical treatment if the level does not return to yellow immediately after taking rescue medications (Option 4). Educational objective:A peak flow meter uses traffic signal colors to categorize degrees of asthma symptoms. Green zone indicates asthma is under control. Yellow zone indicates caution, symptoms are getting worse, PEF is 50%-80% of personal best, and there is a need for further medication. Red zone indicates the need for emergency treatment if the level does not immediately return to yellow after taking rescue medications

A nurse is providing anticipatory guidance to a client with early Alzheimer disease and osteoarthritis. Current symptoms include mild forgetfulness and cognition changes. Which is the best example of an educational goal for anticipatory guidance?

Anticipatory guidance prepares clients and caregivers for future health needs and is useful throughout life, from pediatric growth and development to anticipated changes related to disease processes. This type of education promotes health and helps to reduce client/caregiver stress and anxiety, which heighten with unexpected cognitive, physical, and emotional changes. Anticipatory guidance educational goals should be client-oriented, realistic, objective, measurable, and focused on preparing for future needs specific to the client. The client with Alzheimer disease and osteoarthritis is at high risk for falls with disease progression. In the early stage, the client can make changes in the home to promote safety in the future (Option 3). (Option 1) Memory aids (eg, pill organizers, alarms) should be used now, while the client has only mild cognition changes. As the disease progresses, a caregiver should take over medication management. (Option 2) Support groups are an appropriate intervention for current psychosocial needs (eg, depression). (Option 4) Clients with osteoarthritis are at risk for nutritional deficits due to functional decline (eg, inability to open jars), and clients with Alzheimer disease can forget to eat. The nurse should address this current need by teaching simple meal planning. Educational objective:Anticipatory guidance addresses expected changes related to growth and development or disease progression. Educational goals should be client-oriented, realistic, objective, measurable, and focused on preparing for future needs specific to the client

The nurse performs medication reconciliation for a 94-year-old client who has type 2 diabetes, hypothyroidism, and heart failure caused by a previous myocardial infarction. Due to risks outweighing benefits, the nurse plans to talk with the health care provider about discontinuing which medication?

Beers Criteria lists medications that may be inappropriate for the geriatric population due to risks outweighing benefits. The nurse collaborates with the health care provider to minimize polypharmacy and reduce adverse effects (eg, falls, confusion). Sulfonylureas (eg, glyburide) stimulate insulin release via the pancreas and carry a risk for severe and prolonged hypoglycemia in the geriatric population due to potential delayed elimination. Avoidance of these drugs is recommended by the Beers Criteria. Instead, other medications that are at lower risk for hypoglycemia should be used (eg, metformin) (Option 3). (Option 1) Aspirin is used to prevent platelet aggregation in clients with a history of stroke or myocardial infarction. Aspirin and other nonsteroidal anti-inflammatory medications (eg, ibuprofen) have an increased risk of gastrointestinal bleeding. Therefore, aspirin is used cautiously in the older adult population, and doses should not exceed 325 mg/day. (Option 2) Furosemide is a loop diuretic used to treat fluid overload in heart failure, making it an important part of symptom management. This drug may cause dehydration if the client is not ingesting food and fluids well; otherwise, it should be continued. (Option 4) Levothyroxine is required to maintain thyroid hormone levels in clients with hypothyroidism. Major side effects typically occur only with improper dosing (eg, elevated levels). Educational objective:The Beers Criteria can be used to identify potentially inappropriate drugs that contribute to adverse events (eg, falls, confusion) and drug toxicity in older adults. Sulfonylureas (eg, glyburide) should be avoided due to potential delayed elimination causing risk for prolonged hypoglycemia

The nurse responds to the call light of a client with chronic obstructive pulmonary disease (COPD) who says, "I can't breathe." The client seems to be having difficulty breathing and is nervous and tremulous. Vital signs are stable, oxygen saturation is 92% on 2 L, and there are clear breath sounds bilaterally. Which intervention would be most appropriate at this time?

Anxiety is an emotional reaction to a perceived threat. For the client with COPD, the fear of having difficulty breathing can actually trigger difficulty breathing, which worsens as the client's anxiety increases. This client is stable, with no obvious cause of shortness of breath. The nurse should intervene by calmly coaching the client through breathing exercises, which will promote relaxation and help alleviate the anxiety that is causing the client to feel short of breath. (Option 1) The client's lung sounds are clear bilaterally and so albuterol, a bronchodilator used for wheezing, will not be helpful. Its action as an adrenergic agonist may cause tachycardia and tremulousness and actually worsen the client's anxiety. (Option 2) Trigger avoidance and problem solving are appropriate strategies for long-term control of anxiety and shortness of breath. However, these are not appropriate at this time as the client has acute symptoms that need to be controlled. (Option 4) This client has normal oxygen saturation. Constant monitoring is not likely to alleviate the symptoms unless the client is reassured by this knowledge. However, the client's anxiety may actually be worsened by worrying about the saturation results and the alarms that are likely to be triggered by monitoring. Educational objective:Anxiety is common in clients with COPD and can contribute to difficulty breathing. In the client with acute shortness of breath and normal assessment findings, appropriate interventions are controlled breathing and relaxation

The nurse is providing discharge instructions on the proper use of prescribed short-acting beta agonist and inhaled corticosteroid metered-dose inhalers to a client with newly diagnosed asthma. Which instructions should the nurse include?

Asthma is a disorder of the lungs characterized by reversible airway hyper-reactivity and chronic inflammation of the airways. Albuterol (Proventil) is a short-acting beta agonist (SABA) administered as a quick-relief, rescue drug to relieve symptoms (eg, wheezing, breathlessness, chest tightness) associated with intermittent or persistent asthma. Beclomethasone (Beconase) is an inhaled corticosteroid (ICS) normally used as a long-term, first-line drug to control chronic airway inflammation. When using an ICS metered-dose inhaler (MDI), small particles of the medication are deposited and can impact the tongue and mouth. Rinsing the mouth and throat well after using the MDI and not swallowing the water are recommended to help prevent a Candida infection (thrush) (white spots on tongue, buccal mucosa, and throat), a common side effect of ICSs. The use of a spacer with the inhaler can also decrease the risk of developing thrush (Option 2). When both MDIs are to be taken at the same time, clients are instructed to take the SABA first to open the airways and then the ICS to provide better delivery of the medication. It is important for the nurse to clarify indications and sequencing as the SABA is a rescue drug taken on an as-needed basis and is not always taken with the ICS (Options 4 and 5). (Option 1) Inhaled corticosteroids (eg, fluticasone, beclomethasone) are not rescue drugs. They are prescribed to be taken on a regular schedule (eg, morning, bedtime) on a long-term basis to prevent exacerbations and should not be omitted even if the SABA is effective. (Option 3) Taking the albuterol (Proventil) inhaler apart, washing the mouthpiece (not canister) under warm running water, and letting it air dry at least 1-2 times a week is recommended. Medication particles can deposit in the mouthpiece and prevent a full dose of medication from being dispensed. Taking the ICS inhaler apart and cleaning it every day is recommended. Educational objective:Proper use of the short-acting beta agonist (SABA) inhaler includes taking it apart and rinsing the mouthpiece with warm water 1-2 times a week. Proper use of the inhaled corticosteroid (ICS) inhaler includes taking it apart and rinsing the mouthpiece with warm water daily and rinsing the mouth and throat after each use to prevent a Candida infection (thrush). When these medications are administered together, the sequence is SABA first to open the airways and ICS second

The school nurse creates a cafeteria menu for a newly enrolled child with celiac disease. Which lunches would be appropriate for this child?

Celiac disease (celiac sprue) is an autoimmune disorder in which the body is unable to process gluten, a protein found in most grains. Gluten consumption will damage the villi of the small intestine; this results in malabsorption of fats (steatorrhea, foul-smelling stools) and other nutrients, which can lead to malnutrition and failure to thrive. The child will need to adhere to a gluten-free diet for life. Rice, corn, and potatoes are gluten free and are allowed in the diet (Options 2, 3, and 5). A child with celiac disease cannot eat barley, rye, oats, or wheat (mnemonic - BROW). (Option 1) A child with celiac disease cannot consume barley or French bread as both contain gluten. (Option 4) Peanut butter and jelly on rice cakes are permitted but not the oatmeal cookie. Educational objective:Celiac disease is an autoimmune disorder in which an individual cannot tolerate gluten, a protein found in barley, rye, oats, and wheat (BROW). Rice, corn, and potatoes are allowed in the diet and can be used as grain substitutes. Affected individuals must adhere to a gluten-free diet for life.

The nurse should plan to teach which client about the need for prophylactic antibiotics prior to dental procedures?

Certain individuals should receive prophylactic antibiotics prior to dental procedures to prevent infective endocarditis (IE). These include the following: Prosthetic heart valve or prosthetic material used to repair heart valve Previous history of IE Some forms of congenital heart diseaseUnrepaired cyanotic congenital defectRepaired congenital defect with prosthetic material or device for 6 months after procedureRepaired congenital defect with residual defects at the site or adjacent to the site of a prosthetic patch or device Cardiac transplantation recipients who develop heart valve disease (Option 1) The client with acute MI and heart failure is not at risk for IE. (Option 2) The client with mitral valve repair without the use of prosthetic material is at low risk for IE. (Option 4) The client with mitral valve prolapse with or without regurgitation, or aortic valve disease does not require prophylaxis for IE. Educational objective:Clients with any form of prosthetic material in their heart valves or who have unrepaired cyanotic congenital heart defect or prior history of IE should take prophylactic antibiotics prior to dental procedures to prevent development of IE

A client with chronic obstructive pulmonary disease reports recent weight loss and poor appetite. The client states that bloating, exhaustion, and shortness of breath make eating "not worth the effort." Which statements by the nurse are appropriate to help improve the client's nutritional status?

Consuming adequate nutrition is difficult for clients with advanced chronic obstructive pulmonary disease (COPD), as chewing and swallowing increase work of breathing and a full stomach increases pressure on the diaphragm. As a result, clients often lose weight because their energy expenditure is greater than their nutritional intake. To optimize nutritional intake, clients should: Drink fluids between meals, rather than before or during, to prevent stomach distension and decrease pressure on the diaphragm while eating (Option 1). Eat small, frequent meals, snacks, and supplements that are high in calories and protein. Smaller meals require less energy to chew and swallow, resulting in less fatigue and dyspnea (Option 2). Perform oral hygiene before meals. Chronic mouth breathing leads to dry mouth; excessive sputum and medication side effects can alter the taste of food, decreasing the appetite (Option 5). (Option 3) For clients with advanced COPD, exercise is discouraged for 1 hour before and 1 hour after eating as it increases oxygen demand and fatigue. (Option 4) Gas-forming foods (eg, broccoli, beans, cabbage) and carbonated beverages should be avoided as they cause intestinal bloating and increased pressure on the diaphragm. Educational objective:Consuming adequate nutrition is difficult for clients with advanced chronic obstructive pulmonary disease as eating increases dyspnea and fatigue. To optimize nutrition, clients should avoid drinking fluids while eating; eat small, frequent, high-calorie, high-protein meals and snacks; avoid exercising for 1 hour before and 1 hour after eating; and perform oral hygiene before meals

The nurse cares for a child newly diagnosed with cystic fibrosis. What should be included in the client's multidisciplinary plan of care to be discussed with the parents?

Cystic fibrosis (CF) is a genetic disorder involving the cells lining the respiratory, gastrointestinal (GI), and reproductive tracts. A defective protein responsible for transporting sodium and chloride causes secretions in these areas to be thicker and stickier than normal. These abnormal secretions plug smaller airway passages and ducts in the GI tract, which can impair digestive enzymes and result in ineffective absorption of essential nutrients. These sticky respiratory secretions lead to a chronic cough and inability to clear the airway, eventually causing chronic lung disease (bronchiectasis). As a result of these changes, the client's life span is shortened; most affected individuals live only into their 30s. Chest physiotherapy helps remove sticky secretions that cause ineffective airway clearance (Option 2). Aerobic exercise is beneficial to promote removal of airway secretions, improve muscle strength, and increase lung capacity (Option 1). Financial needs must be discussed, as clients with CF have a large financial burden due to health care costs, medications, and special equipment (Option 3). (Option 4) A diet high in fat and calories is recommended due to defective digestive enzymes and impaired nutrient absorption. (Option 5) Fluids are not restricted; liberal intake is recommended to assist in thinning respiratory secretions. Educational objective:Clients with cystic fibrosis should have a diet high in fat and calories to combat nutrient malabsorption. Liberal fluid intake is encouraged to loosen thick secretions. Chest physiotherapy and aerobic exercise are performed to remove airway secretions. Financial needs are addressed as clients have a large financial burden.

A client with heart failure is prescribed an IV infusion of dobutamine. The concentration of dobutamine is 250 mg in 500 mL D5W. At what rate in milliliters per hour (mL/hr) should the nurse program the IV pump?

Dobutamine hydrochloride is a positive inotropic drug that increases cardiac muscle contractility. Using dimensional analysis, perform the following steps to calculate the administration rate of dobutamine (DOB) in milliliters per hour: Identify the prescribed dose, available medication, and required medication information Prescribed: 10 mcg DOBkg|min Available: 250 mg DOB500 mL Required: mL DOBhrPrescribed: 10 mcg DOBkgmin Available: 250 mg DOB500 mL Required: mL DOBhr To calculate the infusion rate of dobutamine, the nurse should first identify the prescribed dose (eg, 10 mcg/kg/min) and available medication (eg, 250 mg/500 mL) and then convert to milliliters per hour (eg, 84 mL/hr).

The nurse is triaging victims at the site of a mass casualty incident. Which victim should be seen first?

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 four categories. When prioritizing clients for treatment, emergent needs should be managed first followed by urgent and nonurgent needs. If no clients are identified as having emergent needs, clients with urgent needs (eg, open fractures with palpable pulses) should be treated first (Option 2). (Options 1 and 3) Clients who are expectant due to the severity of their injuries (eg, severe neurological trauma, full-thickness burns >60% total body surface area) are the lowest priority for treatment. However, the nurse should provide palliative care, if possible, while addressing the needs of others. (Option 4) Clients with nonurgent needs (eg, minor lacerations) should receive treatment after emergent and urgent clients. Educational objective:During mass casualty events, the goal is the greatest good for the greatest number of people. Clients are triaged rapidly using a color-coded system that ranks them from highest medical priority to lowest: red (emergent), yellow (urgent), green (nonurgent), and black (expectant)

The nurse is reinforcing discharge instructions with a client following a partial gastrectomy. Which of the following instructions should the nurse include to prevent dumping syndrome?

Following a partial gastrectomy, many clients experience dumping syndrome, which occurs when gastric contents empty too rapidly into the duodenum, causing a fluid shift into the small intestine. This results in hypotension, abdominal pain, nausea/vomiting, dizziness, generalized sweating, and tachycardia. The symptoms usually diminish over time. Recommendations to delay gastric emptying include: Consume meals high in fat, protein, and fiber, which take more time to digest and remain in the stomach longer than carbohydrates (Option 1). These foods also help meet the body's energy needs. Avoid consuming fluids with meals because this causes stomach contents to pass faster into the jejunum, which worsens symptoms. Fluid intake should occur up to 30 minutes before or after meals. Slowly consume small, frequent meals to reduce the amount of food in the stomach (Option 3). Avoid meals high in simple carbohydrates (eg, sugar, syrup) because these may trigger symptoms when the carbohydrates break down into simple sugars. Avoid sitting up after a meal because gravity increases gastric emptying. Instead, lying down after meals is encouraged (Option 5). (Option 2) Avoid meals high in simple carbohydrates because these may trigger dumping syndrome. (Option 4) Avoid consuming fluids with meals to reduce the risk of dumping syndrome. Educational objective:Dumping syndrome is a complication of gastrectomy. To delay gastric emptying and reduce the risk of dumping syndrome, clients should consume meals low in carbohydrates and high in fiber, proteins, and fats; avoid fluids during meals; eat small, frequent meals; and lie down after eating

The nurse is caring for a client diagnosed with Guillain-Barré syndrome (GBS) after a recent gastrointestinal (GI) illness. Monitoring for which of the following is a nursing care priority for this client?

GBS is an acute, immune-mediated polyneuropathy that is most often accompanied by ascending muscle weakness and absent deep-tendon reflexes. Many clients have a history of antecedent respiratory tract or GI infection. Lower-extremity weakness progresses over hours to days to involve the thorax, arms, and cranial nerves. However, neuromuscular respiratory failure is the most life-threatening complication. Early signs indicating impending respiratory failure include: Inability to cough Shallow respirations Dyspnea and hypoxia Inability to lift the head or eye brows Assessing the client's pulmonary function by serial spirometry is also recommended. Measurement of forced vital capacity (FVC) is the gold standard for assessing ventilation; a decline in FVC indicates impending respiratory arrest requiring endotracheal intubation. (Option 1) Severe autonomic dysfunction can present as diaphoresis and facial flushing. (Option 2) The client with GBS is also at risk for paralytic ileus, which is related to either immobility or nerve damage. As a result, the nurse should monitor for the presence hypoactive/absent bowel sounds. (Option 4) Clients with GBS are at risk of developing deep venous thrombosis due to lack of ambulation and should receive pharmacologic prophylaxis (heparin) and support stockings. Although symptoms in options 1, 2, and 4 represent a progressive illness and are important to communicate to the health care provider promptly, they are not the highest priority compared to impending respiratory failure. Educational objective:Respiratory distress is a potential complication of progressing paralysis in clients with Guillain-Barré syndrome. The nurse should prioritize and monitor for the presence of this complication. Measurement of serial spirometry (FVC) is the gold standard for assessing ventilation

The nurse is reinforcing teaching to a client with a hiatal hernia. Which statement by the client indicates that further teaching is needed?

Hiatal hernia is a group of medical conditions characterized by abnormal movement of the stomach and/or esophagogastric junction into the chest due to a weakness in the diaphragm. Although hiatal hernias may be asymptomatic, many people experience heartburn, chest pain, dysphagia, and shortness of breath when the abdominal organs move into the chest. Symptoms of hiatal hernias are often exacerbated by increased abdominal pressure, which promotes upward movement of abdominal organs. Clients with hiatal hernias who are obese are often encouraged to lose excess weight by performing light activities (eg, short walks) because obesity increases abdominal pressure. However, nurses should teach clients to avoid activities that promote straining (eg, weight lifting), which increases abdominal pressure (Option 4). (Options 1 and 2) Sitting up for several hours after meals and sleeping with the head of the bed elevated at least 6 inches (15 cm) reduces upward movement of the hernia and decreases the risk of gastric reflux. (Option 3) If symptoms of hiatal hernias are uncontrolled with home management (eg, weight loss, diet modification, positioning after meals), surgical revision of the diaphragm may be required to prevent organ movement. Educational objective:Hiatal hernia is characterized by abnormal movement of the stomach and/or esophagogastric junction into the chest due to diaphragmatic weakness. Nurses educating clients with hiatal hernias about symptom management should instruct them to avoid activities that increase abdominal pressure (eg, weight lifting), sleep with the head of the bed elevated, and remain upright for several hours after meals

A client with heart failure is started on furosemide. The laboratory results are shown in the exhibit. The nurse is most concerned about which condition?

Hypomagnesemia (normal: 1.5-2.5 mEq/L [0.75-1.25 mmol/L]) causes a prolonged QT interval that increases the client's susceptibility to ventricular tachycardia. Torsades de pointes is a type of polymorphic ventricular tachycardia coupled with a prolonged QT interval; it is a lethal cardiac arrhythmia that leads to decreased cardiac output and can develop quickly into ventricular fibrillation. The American Heart Association recommends treatment with IV magnesium sulfate. (Option 1) Characteristics of atrial fibrillation (AF) include an irregularly irregular rhythm and replacement of P waves by fibrillatory waves. Although electrolyte disturbances increase the likelihood of developing AF, clients can have this chronic condition managed with anticoagulation therapy. AF is usually associated with an underlying heart disease and is rarely immediately life-threatening. (Option 2) Atrial flutter is characterized by sawtooth-shaped flutter waves. There is no clinical evidence suggesting that hypomagnesemia leads to atrial flutter, which is associated with underlying heart disease (eg, mitral valve disorders, cardiomyopathy, cor pulmonale). (Option 3) Mobitz II (type II second-degree atrioventricular block) is usually not associated with electrolyte disturbances but is more often associated with conduction system disease or drug toxicity (eg, beta blockers, calcium channel blockers). Educational objective:In a client with hypomagnesemia, it is important to assess the QT interval. The client is most at risk for torsades de pointes, a serious complication that can develop quickly into ventricular fibrillation (lethal arrhythmia)

A client had a thoracotomy 2 days ago to remove a lung mass and has a right chest tube attached to negative suction. Immediately after turning the client to the left side to assess the lungs, the nurse observes a rush of approximately 125 mL of dark bloody drainage into the drainage tubing and collection chamber. What is the appropriate nursing action?

Immediately following a thoracotomy, chest tube drainage (50-500 mL for the first 24 hours) is expected to be sanguineous (bright red) for several hours and then change to serosanguineous (pink) followed by serous (yellow) over a period of a few days. A rush of dark bloody drainage from the chest tube when the client was turned following a period of minimal drainage is most likely related to retained blood due to a partial blockage in the tube. Bright red drainage indicates active bleeding and would be of immediate concern. (Option 2) The chest tube should not be clamped because it is placed to drain the fluid leaking after surgery. (Option 3) The nurse would notify the health care provider immediately of bright red drainage or continued increased drainage (>100 mL/hr) and of changes in the client's vital signs and cardiovascular status that could indicate bleeding (eg, hypotension, tachycardia, tachypnea, decreased capillary refill, cool and pale skin). This is not the appropriate action. (Option 4) It would be appropriate to request repeat serum hematocrit and hemoglobin levels if active bleeding is suspected, but the postoperative levels are stable at this time. This is not the appropriate action. Educational objective:A client will usually have a chest tube in place for several days following a thoracotomy to drain blood from the pleural space. A rush of dark bloody drainage from the tube when the client coughs, turns, or is repositioned following a period of minimal drainage is most likely related to retained blood due to a partial blockage in the tube. Bright red chest drainage indicates active bleeding and would be of immediate concern

A client with heart failure has gained 5 lb (2.26 kg) over the last 3 days. The nurse reviews the client's blood laboratory results. Based on this information, what medication administration does the nurse anticipate?

In heart failure, cardiac output is reduced because the heart is unable to pump blood adequately. This reduction in cardiac output reduces perfusion to the vital organs, including the kidneys. Decreased renal blood flow triggers the kidneys to activate the renin-angiotensin system as a compensatory mechanism, which increases blood volume by increasing water resorption in the kidneys. This compensatory mechanism results in fluid volume excess and dilutional hyponatremia (more free water than sodium). Dilutional hyponatremia can be treated with fluid restriction, loop diuretics, and ACE inhibitors (eg, lisinopril, captopril). Furosemide works to resolve hyponatremia by promoting free water excretion, allowing for hemoconcentration and increased sodium levels (Option 3). (Option 1) 0.45% sodium chloride is a hypotonic solution. Giving hypotonic saline would provide more free water than sodium, thereby worsening fluid overload and hyponatremia. (Option 2) The client's calcium is within normal limits and does not need replacement. (Option 4) Sodium polystyrene sulfonate (Kayexalate, Kionex) is a medication used to treat hyperkalemia that works by exchanging sodium for potassium across the mucous membranes of the bowel and then excreting potassium via stool. Sodium polystyrene sulfonate is not indicated if potassium is within normal limits. Educational objective:Heart failure is characterized by reduced cardiac output, which can reduce renal blood flow. Reduced renal blood flow activates the renin-angiotensin system, resulting in fluid volume excess and dilutional hyponatremia. Loop diuretics (eg, furosemide) promote free water excretion, allowing for hemoconcentration and increased sodium levels

The nurse assesses a child with intussusception. Which assessment findings require priority intervention?

Intussusception occurs when part of the intestine telescopes into another adjacent part and causes a blockage. This leads to swelling and decreased blood supply to the intestine. Tissue death as well as perforation to the bowel may result. If perforation occurs, the client could develop peritonitis in which the peritoneum in the abdomen becomes inflamed due to infection. This can quickly lead to sepsis and multiple organ failure. Peritonitis is characterized by fever, abdominal rigidity, guarding, and rebound tenderness. This condition can be fatal if it is not treated quickly. (Option 2) Absence of tears in a painful procedure during which the client is crying is a sign of dehydration. This is very common in clients with intussusception and should be treated. IV fluids should be started, and the client's hydration status (vital signs, mucus membranes, capillary refill) should be assessed frequently. (Option 3) A classic sign of intussusception is blood-streaked mucous stool, sometimes referred to as "currant jelly-like" stool. This is expected with intussusception. Treatment is an enema of either air or barium to unfold the intestine. (Option 4) A "sausage-shaped" right-sided mass is commonly felt on palpation in clients with intussusception. This is an expected finding for this condition. Educational objective:Intestinal perforation and peritonitis are common complications of intestinal obstruction (eg, intussusception). Peritonitis is characterized by fever, abdominal rigidity, guarding, and rebound tenderness and is a surgical emergency

A newly reassigned nurse enters a hospital room at the beginning of the shift and finds the client unconscious and unresponsive. Resuscitation is initiated and then continued by the rapid response team. The nurse realizes that there is a do not resuscitate (DNR) prescription posted in the client's chart. Which action is correct?

Many health care professionals react to an emergency situation automatically. However, some states and provinces will further penalize health care workers with loss of their professional license if they fail to render cardiopulmonary resuscitation in an emergency situation. Health care professionals will not be penalized for an honest mistake. However, resuscitation must end immediately after they are notified of the error (Option 1). (Option 2) Continuing treatment until the code status is verified with the health care provider (HCP) constitutes malpractice. Before a do not resuscitate prescription can be posted in a client's medical record/chart, the HCP must provide documentation that the client's code status has been established through consultation with the client or family. (Options 3 and 4) Gross negligence of a client's advance directive can result in legal action. Educational objective:Failure to stop an erroneous code on a client with an advance directive in a timely fashion may result in legal action

A client with ascites due to cirrhosis has increasing shortness of breath and abdominal pain. The health care provider requests that the nurse prepare the client for a paracentesis. Which nursing actions would the nurse implement prior to the procedure?

Paracentesis is performed to remove excess fluid from the abdominal cavity or to collect a specimen of ascitic fluid for diagnostic testing. Paracentesis is not a permanent solution for treating ascites and is performed only if the client is experiencing impaired breathing or pain due to ascites. Prior to a paracentesis, nursing actions include: Verify that the client received necessary information to give consent and witness informed consent Instruct the client to void to prevent puncturing the bladder (Option 5) Assess the client's abdominal girth, weight, and vital signs (Option 3) Place the client in the high Fowler position or as upright as possible (Option 4) (Option 1) Paracentesis is an invasive procedure requiring delivery of informed consent by the health care provider (HCP). The HCP explains the benefits and risks of the procedure. The nurse's role is to witness informed consent and verify that it has occurred. (Option 2) NPO status is not required for paracentesis, which is often performed at the bedside or in an HCP's office using only a local anesthetic. Educational objective: Paracentesis is an invasive procedure for removing fluid from the abdominal cavity to improve symptoms or collect a specimen for testing. After informed consent has been obtained, the client should be encouraged to void to prevent bladder trauma, be positioned upright, and have a set of baseline vitals, weight, and abdominal circumference measurements collected before the procedure begins.

The nurse is changing the dressing, injection caps, and IV tubing of a client who is receiving total parenteral nutrition through a right peripherally inserted central venous catheter. The nurse should implement what actions to prevent complications during this procedure?

Peripherally inserted central venous catheters (PICC) are commonly used for long-term antibiotic administration, chemotherapy treatments, and nutritional support with total parenteral nutrition (TPN). Complications related to the PICC are occlusion of the catheter, phlebitis, air embolism, and infection due to bacterial contamination. Prior to a central line dressing change, the nurse performs hand hygiene (Option 3). The central line dressing change is performed using sterile technique with the nurse wearing a mask to prevent contamination of the site with microorganisms or respiratory secretions (Option 5). During injection cap and tubing changes, the client is instructed to hold the breath (or perform the Valsalva maneuver) to prevent air from entering the line, traveling to the heart, and forming an air embolism (Option 1). (Option 2) When performing the dressing change, the client should be instructed to turn the head away from the PICC site to prevent potential contamination of the insertion site by microorganisms from the client's respiratory tract. (Option 4) During dressing, injection caps, and tubing changes, the client is placed in the supine position. If an air embolism is suspected, the client should be placed in the Trendelenburg position (head down) on the left side, causing any existing air to rise and become trapped in the right atrium. Educational objective:The central line dressing change is performed using a sterile technique that includes wearing sterile gloves and mask to prevent contamination of the site with microorganisms or respiratory secretions. During injection cap, tubing, and dressing changes, the client is instructed to turn the head away from the peripherally inserted central venous catheter site to prevent site contamination by the client's respiratory secretions. During cap/tubing changes, the client is instructed to hold the breath (or perform the Valsalva maneuver) to prevent air from entering the line, traveling to the heart, and forming an air embolism

A client in the emergency department has an acute myocardial infarction. The health care provider (HCP) has prescribed thrombolytic therapy. Which assessment data should the nurse report immediately to the HCP?

Prior intracranial hemorrhage Structural cerebrovascular lesion (eg, arteriovenous malformation, aneurysm) Ischemic stroke within 3 months (except within 3 hr) Suspected aortic dissection Active bleeding or bleeding diathesis Significant head trauma within 3 months Thrombolytic therapy aims to stop the infarction process, dissolve the thrombus in the coronary artery, and reperfuse the myocardium. This treatment is used when facilities do not have an interventional cardiac catheterization laboratory or when such a facility is too far away to transfer the client safely. Client selection is important because all thrombolytics lyse the pathologic clot but may also lyse other clots (eg, at a postoperative site). Minor or major bleeding can be a complication. Inclusion criteria for thrombolytic therapy in clients with acute myocardial infarction include chest pain lasting ≤12 hours, 12-lead ECG findings indicating acute ST-elevation myocardial infarction, and no absolute contraindications (eg, history of cerebral arteriovenous malformation) (Option 1). (Option 2) Active menstruation is not a contraindication for thrombolytic therapy. Research shows that the risk of increased menstrual bleeding due to thrombolytic administration is low and not life-threatening. Physiologic menstrual bleeding is also not a contraindication for anticoagulation therapy. (Option 3) Chest pain is one of the inclusion criteria for thrombolytic therapy. (Option 4) Uncontrolled blood pressure of >180 mm Hg systolic or >110 mm Hg diastolic is a relative contraindication for thrombolytic therapy. This client's blood pressure (170/92 mm Hg) is elevated but not uncontrolled, which does not rule out this therapy. Educational objective:The candidate for thrombolytic therapy should be screened for absolute and relative contraindications. The nurse should immediately notify the health care provider if the client has history of arteriovenous malformation, which is an absolute contraindication to the use of thrombolytics

An 8-month-old infant is scheduled for a femorally inserted balloon angioplasty of a congenital pulmonic stenosis in the cardiac catheterization laboratory. Which finding should the nurse report to the health care provider that could possibly delay the procedure?

Pulmonic stenosis causes increased pressure in the right side of the heart as the ventricle tries to push blood through the narrowed pulmonary area to the lungs. In severe pulmonic stenosis, higher pressure in the right side of the heart causes unoxygenated blood to travel to the left side through the foramen ovale (or other congenital defect) and into the systemic circulation, leading to chronic hypoxia and cyanosis and requiring repair (interventional catheterization or surgery). The presence of severe diaper rash should be reported to the health care provider (HCP). This could delay the procedure if the rash is in the groin area where access is planned for a femorally inserted arterial cannula. Yeast or bacteria may be present on the rash and could be introduced into the bloodstream with the arterial stick (Option 3). (Option 1) A loud heart murmur can be an expected finding in a child with pulmonic stenosis. (Option 2) Children are NPO for 4-6 hours or longer before the procedure. Younger children and infants may have a shorter period of NPO status and should be fed right up to the time recommended by the HCP. (Option 4) Cyanosis indicates severe pulmonic stenosis with right-to-left shunt and the need for interventional catheterization or surgery without delay. Educational objective:The nurse should report the presence of severe diaper rash in an infant who has an interventional catheterization procedure planned. The rash may delay the procedure due to possible contamination at the insertion site

The nurse assesses a client 5 minutes after initiating a blood transfusion. The client has shortness of breath, itching, and chills. The nurse immediately turns off the transfusion and disconnects the tubing at the catheter hub. What action should the nurse take next?

Signs of a transfusion reaction include chills, fever, low back pain, flushing, and itching. Nursing interventions include: Stop transfusion immediately and disconnect tubing at the catheter hub. Maintain IV access with normal saline, using new tubing to prevent hypotension and vascular collapse (Option 2). Notify health care provider (HCP) and blood bank. Monitor vital signs. Recheck labels, numbers, and the client's blood type. Treat client's symptoms according to the HCP's prescription. Collect blood and urine specimens to evaluate for hemolysis. Return blood and tubing set to the blood bank for additional testing. Complete necessary facility paperwork to document the reaction. (Option 1) Monitoring vital signs would be the step after ensuring IV access, administering normal saline, and notifying the HCP. (Option 3) The nurse should ensure continued IV access before notifying the HCP. The HCP will likely prescribe IV medications (eg, vasopressors, antihistamines, corticosteroids) to treat the transfusion reaction, so a patent IV is critical. (Option 4) Mislabeling blood and administering the wrong blood type are the most common causes of a transfusion reaction. However, maintaining IV access takes priority over investigating a potential clinical error. Educational objective:During a blood transfusion reaction, the nurse should immediately stop the transfusion and initiate normal saline to maintain IV access and prevent hypotension and vascular collapse

The nurse admits a client with newly diagnosed unstable angina. Which information obtained during the admission health history is most important for the nurse to report to the health care provider (HCP) immediately?

Sildenafil (Viagra) is a phosphodiesterase inhibitor used to treat erectile dysfunction. The use of sildenafil is most important for the nurse to report to the HCP. This must be communicated immediately as concurrent use of nitrate drugs (commonly prescribed to treat unstable angina) is contraindicated as it can cause life-threatening hypotension. Before any nitrate drugs can be administered, further action is necessary to determine when sildenafil was taken last (ie, half-life is about 4 hours). (Option 1) Clients do not always report the amount of alcohol they consume accurately. The nurse should monitor all clients for alcohol withdrawal syndrome as it is quite common in hospitalized clients. (Option 2) Getting up 4 times during the night to void can be associated with medication, an enlarged prostate gland, or drinking fluids at bedtime. Further action may be needed to determine the cause of the nocturia, but this is not the most significant information to report to the HCP. (Option 3) Smoking 1 pack of cigarettes daily needs to be addressed as tobacco causes vasoconstriction and decreased oxygen supply to the body tissues. Further action is needed regarding smoking cessation education. However, the client's tobacco history is not the most important information to report to the HCP. Educational objective:Nitrate drugs are prescribed to treat angina. The concurrent use sildenafil (Viagra) and nitrates is contraindicated as it can cause life-threatening hypotension

A client admitted to the cardiac care unit with markedly elevated blood pressure and heart failure is receiving a continuous infusion of nitroprusside. Thirty minutes later, the client appears pale with cold, clammy skin and reports being lightheaded. Which is the priority nursing action?

Sodium nitroprusside is a highly potent vasodilator (both venous and arteriolar). Venous dilation reduces preload (volume of blood in ventricles at the end of diastole), and arterial dilation reduces afterload (resistance ventricle must overcome to eject blood during systole). Sodium nitroprusside is commonly used in hypertensive emergencies and for conditions in which blood pressure control is of utmost importance (eg, aortic dissection, acute hypertensive heart failure). Nitroprusside begins to act within 1 minute and can produce a sudden and drastic drop in blood pressure (symptomatic hypotension) if not monitored properly. Therefore, the client's blood pressure should be monitored closely (every 5-10 minutes). This client's lightheadedness and cold clammy skin are likely due to hypotension. Nitroprusside metabolizes to cyanide, and clients with renal disease can occasionally develop fatal cyanide toxicity. (Option 1) Auscultation of lung sounds is a common assessment for the client in heart failure. However, in this client the signs and symptoms indicate hypotension and make checking the blood pressure a higher priority. (Option 2) Checking capillary refill can give the nurse information about perfusion status. Capillary refill may be prolonged and should be checked in this client, but after blood pressure is measured. (Option 4) The ECG of this client should be reviewed. The client is at risk for rhythm abnormalities, but because hypotension is the main adverse effect of nitroprusside, the blood pressure should take precedence. Educational objective:Sodium nitroprusside is given as an infusion for the short-term treatment of acute decompensated heart failure, especially in clients with markedly elevated blood pressure. It is a potent vasodilator and reduces preload and afterload. The main adverse effect is symptomatic hypotension, necessitating close monitoring of blood pressure

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

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

The nurse is performing a cardiac assessment. Where does the nurse expect to feel the client's point of maximal impulse (PMI)?

The PMI is also called the apical pulse. It reflects the pulsation of the apex of the heart and should be felt medial to the midclavicular line at the 4th or 5th intercostal space. When the PMI is below the 5th intercostal space or left of the midclavicular line, the heart may be enlarged. Educational objective:During cardiac assessment, the nurse should palpate the PMI medial to the midclavicular line at the 4th or 5th intercostal space. Palpation of the PMI below the 5th intercostal space or to the left of the midclavicular line may indicate cardiac enlargement.

The nurse assessing a client's pain would expect the client to make which statement when describing the abdominal pain associated with appendicitis?

The appendix is a blind pouch located at the junction of the ileum of the small intestine and the beginning of the large intestine (cecum). When infected or obstructed (foreign body, fecal material, tumor, lymph tissue), the appendix becomes inflamed, causing acute appendicitis. Signs and symptoms of acute appendicitis include the following: Pain: Continuous; begins in the periumbilical region and then moves to the right lower quadrant centering at McBurney's point (one-third of the distance from the right anterior superior iliac spine to the umbilicus) (Option 3) Gastrointestinal symptoms: Anorexia, nausea, and vomiting Rebound tenderness and guarding Clients with acute appendicitis attempt to decrease pain by preventing increased intraabdominal pressure (eg, avoiding coughing, sneezing, deep inhalation) and lying still with the right leg flexed. (Option 1) Burning pain in the upper abdomen can be due to gastric or duodenal ulcers. If the ulcers are located posteriorly, the client may experience back pain. (Option 2) Pain in the left lower quadrant is associated with diverticulitis (often in the sigmoid colon). Other signs and symptoms include a palpable, tender abdominal mass and systemic symptoms of infection (fever, increased C-reactive protein, and leukocytosis with a left shift). (Option 4) Pain and tenderness in the epigastric or right upper quadrant of the abdomen that is referred to the right scapula is associated with acute cholecystitis. Clients may also experience indigestion, nausea, vomiting, restlessness, and diaphoresis. Educational objective: Pain associated with acute appendicitis typically begins in the periumbilical region and migrates to the area overlying the appendix (McBurney's point). The client will attempt to decrease pain by lying still with the right leg flexed and preventing increased intraabdominal pressure (eg, avoiding coughing, sneezing, deep inhalation)

A client is being admitted for a potential cerebellar pathology. Which tasks should the nurse ask the client to perform to assess if cerebellar function is within the defined limits?

The cerebellum is involved in 2 major functions: coordination of voluntary movements and maintenance of balance and posture. Maintenance of balance is assessed with gait testing and includes watching the client's normal gait first and then the gait on heel-to-toe (tandem), on toes, and on heels (Option 5). Coordination testing involves the following: Finger tapping - ability to touch each finger of one hand to the hand's thumb (Option 4). Rapid alternating movements - rapid supination and pronation Finger-to-nose testing - clients touch the clinician's finger and then their own nose as the clinician's finger varies in location Heel-to-shin testing - client runs each heel down each shin while in a supine position (Option 1) This is a test of sensory function, specifically fine touch (graphesthesia). Other tests for this include identifying an object in the hand (stereognosis) and two-point discrimination. (Option 2) Shrugging the shoulders against resistance (as well as turning the head against resistance) is a test for cranial nerve (CN) XI (spinal accessory). (Option 3) In a client who has an intact gag reflex, the ability to swallow water helps to assess CN IX (glossopharyngeal) and CN X (vagus). The nurse can also observe for a symmetrical rise of the soft palate and uvula by asking the client to say "ah." Educational objective:The cerebellum is involved in coordination of voluntary movements and maintenance of balance and posture. Balance is assessed with heel-to-toe gait testing. Coordination is assessed with finger tapping, rapid alternating movements, finger-to-nose testing, and heel-to-shin testing

A nurse on the medical surgical unit has just received report. Which client should be seen first?

The client with DVT who is experiencing chest discomfort and cough should be seen first. This client is exhibiting possible signs of pulmonary embolism (PE), which can be a life-threatening complication. Signs and symptoms of PE include dyspnea, hypoxemia, tachypnea, cough, chest pain, hemoptysis, tachycardia, syncope, and hemodynamic instability. The nurse should elevate the head of the bed, administer oxygen, and assess the client. The health care provider should be notified of these findings. (Option 1) The administration of an IV antibiotic is important but should be done after the nurse has assessed the client with DVT. (Option 3) This client is hypertensive and most likely has a headache due to the high blood pressure. The nurse should assess this client after the client with DVT and administer any antihypertensives needed. (Option 4) This client can be delegated to unlicensed assistive personnel who can go to the room immediately. Educational objective:The nurse should prioritize the assessment of any client with DVT who is experiencing respiratory signs and symptoms and/or chest pain due to potential development of PE

The nurse is reviewing the medication administration record of a client with atrial fibrillation. Which of the following should the nurse monitor before giving these medications?

The complete blood count (hemoglobin, hematocrit, platelet count) should be assessed periodically with the administration of enoxaparin, an anticoagulant that can cause bleeding and thrombocytopenia (Option 4). Digoxin levels are monitored for suspicion of digoxin toxicity (ie, serum levels >2 ng/mL) (Option 1). Potassium levels should also be monitored in clients receiving digoxin, as hypokalemia can potentiate digoxin toxicity (Option 5). Prednisone is a glucocorticoid that can cause hyperglycemia. Glucose levels should be monitored periodically in clients receiving this medication (Option 2). (Option 3) Low-molecular-weight heparins (eg, enoxaparin, dalteparin) produce a stable response at recommended dosages and negate the need for monitoring of activated partial thromboplastin time (aPTT) or international normalized ratio (INR) levels. aPTT is monitored when administering unfractionated heparin. INR is monitored in clients receiving warfarin (Coumadin). Educational objective:The nurse should routinely monitor laboratory values prior to administering medications. A complete blood count should be assessed periodically in clients receiving enoxaparin to monitor for bleeding and thrombocytopenia. Digoxin and potassium levels should be assessed with the administration of digoxin. Glucose levels should be monitored in the client receiving glucocorticoids

The nurse is caring for a client with a history of headaches. The client has talked to the nurse, smiled at guests, and maintained stable vital signs. The nurse notes the following changes in the client's status. Which assessment finding is critical to report to the health care provider (HCP)?

The level of consciousness is the most important, sensitive, and reliable indicator of the client's neurological status. Changes in the level of consciousness can represent increased intracranial pressure and reduced cerebral blood flow. Changes in vital signs usually do not appear until intracranial pressure has been elevated for some time, or they may be sudden in cases of head trauma. (Option 1) The blood pressure is slightly elevated but does not warrant immediate action or signify an emergency situation. (Option 3) A poor appetite is not an emergency finding or situation. (Option 4) The respiratory rate is slightly low, but if it is not irregular it is not an emergency as a single observation. This finding would warrant further assessment and continued monitoring, but it is not as significant as the change in level of consciousness. Educational objective:A change in level of consciousness for the neurological client should be reported to the HCP. The level of consciousness is the most sensitive and reliable indicator of the client's neurological status

A nurse is changing a sterile dressing for a client with an infected wound. While doing so, the unlicensed assistive personnel (UAP) reports that another client is requesting medication for postoperative pain. What is the nurse's most appropriate action?

The nurse can prioritize care according to the degree of urgency, the extent of threat to the client's survival, and the potential for complications. At this time, the other client's pain issue is of medium urgency and does not pose an immediate threat to survival. The most appropriate nursing action is to inform the postoperative client that you will be there shortly, and complete changing the sterile dressing (Option 3). Interrupting the sterile dressing change for a client with an infected wound puts the client at risk for injury, as microorganisms can invade the uncovered wound. However, if the dressing change were lengthy, the nurse could delegate the task of medicating the postoperative client to another nurse (Option 4). (Option 1) Although taking vital signs when a client reports pain is appropriate, evidence indicates that vital signs are unreliable physiologic indicators for pain. (Option 2) The UAP is instructed to ask the client if they are having pain and then report back to the nurse. However, the registered nurse is responsible for pain assessment and should not delegate this task to the UAP. Educational objective:A nurse can prioritize client needs and problems according to the degree of threat to the client's survival and the potential for complications. The nurse uses clinical judgment to decide which client situation requires immediate attention and which one can wait

The nurse on the step-down cardiothoracic unit receives the change-of-shift hand-off report. Which client should the nurse assess first?

The nurse should assess the pulses (eg, femoral, posterior tibial, dorsalis pedis) and skin color and temperature of the lower extremities in the client with the abdominal aortic aneurysm (AAA) repair first. Pulses can be absent for 4-12 hours after surgery due to vasospasm. However, a pedal pulse decreased from the client's baseline or an absent pulse with a painful, cool, or mottled extremity 2 days postoperative can indicate the presence of an arterial or graft occlusion. This client's condition poses the greatest threat to survival. (Option 2) An elevated white blood cell count (>11,000/mm3 [11.0 x 109/L]) could be caused by an underlying infection or the stress of the surgery. This needs to be assessed as soon as possible, but it does not take priority over the possible limb loss with graft occlusion. (Option 3) A decreased ejection fraction (normal 55%-70%) results in decreased cardiac output and inability to meet oxygen demand, leading to shortness of breath and activity intolerance. The nurse should assess lung sounds. However, this is an expected finding, so the nurse does not need to assess this client first. (Option 4) Subcutaneous emphysema is air in the tissue surrounding the chest tube insertion site and can occur in a client with a pneumothorax. The nurse should assess lung sounds and palpate to determine the degree of emphysema. However, this is an expected finding, so the nurse does not need to assess this client first. Educational objective:A pedal pulse decreased from baseline or an absent pedal pulse and a cool or mottled extremity in a client who is postoperative abdominal aortic aneurysm repair can indicate the presence of an arterial or graft occlusion and poses the greatest threat to survival.

The nurse has received report on the following clients. Which client should the nurse assess first?

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

A nurse is assessing a 1-month-old infant with an atrial septal defect (ASD). Which assessment finding does the nurse expect?

The nurse would expect to hear a murmur with an atrial septal defect. This defect is an abnormal opening between the right and left atria, allowing blood from the higher pressure left atrium to flow into the lower pressure right atrium. The back-and-forth flow of blood between the 2 chambers causes a vibration that is heard as a murmur on auscultation. ASD has a characteristic systolic murmur with a fixed split second heart sound. Some clients may also have a diastolic murmur. (Option 1) Muffled heart tones are not typical in ASD. Muffled heart tones that are heard postsurgical intervention are concerning for cardiac tamponade. (Option 3) Atrial and ventricular septal defects are acyanotic congenital heart defects because the blood from the high pressure left side (oxygenated blood) goes to the low pressure right side. (Option 4) Weak lower and strong upper extremity pulses are present in coarctation of the aorta. Educational objective:In a child with atrial septal defect, the nurse would expect to hear a heart murmur on auscultation of heart sounds

The nurse is teaching a client with advanced chronic obstructive pulmonary disease who was prescribed oral theophylline. Which client statement indicates that additional teaching is required?

Theophylline is a bronchodilator with a low therapeutic index and a narrow therapeutic range (10-20 mcg/mL). The serum level should be monitored frequently to avoid severe adverse effects. Toxicity is likely to occur at levels >20 mcg/mL. Individual titration is based on peak serum theophylline levels, so it is necessary to draw a blood level 30 minutes after dosing. Theophylline can cause seizures and life-threatening arrhythmias. Toxicity is usually due to intentional overdose or concurrent intake of medications that increase serum theophylline levels. Cimetidine and ciprofloxacin can dramatically increase serum theophylline levels (>80%). Therefore, they should not be used in these clients. (Option 1) Caffeinated products (eg, coffee, cola, chocolate) should be avoided as they would intensify the adverse effects (eg, tachycardia, insomnia, restlessness) of theophylline. (Option 2) The best way to prevent toxicity is to monitor drug levels periodically and adjust the dose. (Option 3) The signs of toxicity that should be reported are anorexia, nausea, vomiting, restlessness, and insomnia. Educational objective: Theophylline can cause seizures and life-threatening arrhythmias due to its narrow therapeutic range (10-20 mcg/mL). The dose is adjusted based on peak drug levels, obtained 30 minutes after the dose is given. Clients should avoid caffeinated products and medications that increase serum theophylline levels (eg, cimetidine, ciprofloxacin)

The emergency department nurse is obligated to make a report for which situations?

There are several circumstances in which the nurse is legally required to report to appropriate civil authorities: Suspected elder abuse must be reported to the appropriate authorities for investigation. The nurse has a legal obligation to report signs of abuse regardless of clients' ability or willingness to advocate for themselves (Option 2). The nurse should report deaths that meet medical examiner reporting guidelines (eg, suspected to be the result of a crime, trauma, or suicide) to the authorities for investigation. The local medical examiner has the legal authority and obligation to perform an autopsy independent of the family's wishes (Option 3). For the sake of client safety, nurses should immediately report impaired or intoxicated health care workers, regardless of their position (Option 5). Under the Health Insurance Portability and Accountability Act, a client's reason for an emergency department visit cannot be communicated to employers without the client's permission (Option 1). Health authorities must be notified of a reportable sexually transmitted disease regardless of client wishes. Depending on the condition, authorities may report findings to sexual contacts, but it is a violation of client privacy for the nurse to share this information with the client's family or spouse (Option 4). Educational objective:The nurse is required to report an impaired coworker, a suspicious death, and elder abuse to appropriate authorities. The nurse is legally prohibited from sharing health information with employers or family members without the client's permission.

A client with hypertension and type 2 diabetes has recently started taking chlorthalidone. Which report by the client is most concerning to the nurse?

Thiazide diuretics (eg, hydrochlorothiazide, chlorthalidone) are prescribed to treat hypertension and edema. The major side effects of thiazide diuretics include: Hypokalemia - manifests as muscle cramps (Option 3) Hyponatremia - manifests as altered mental status and seizures Hyperuricemia - may precipitate or worsen gout attacks Hyperglycemia - may require adjustment of diabetic medications Hypokalemia is the most serious side effect of thiazide diuretics as it can lead to life-threatening cardiac dysrhythmias. (Option 1) Orthostatic hypotension may be a side effect of any diuretic. The nurse should teach the client to sit for a few minutes before standing and rise slowly. The nurse should also check that the client's blood pressure is not too low. (Option 2) Mild to moderate hyperglycemia is common with thiazides and needs to be addressed. However, it is not life-threatening and therefore not a priority. (Option 4) Most thiazide diuretics are sulfa derivatives and can therefore cause photosensitivity. The nurse should encourage the client to use sunscreen and wear protective clothing. Educational objective:The nurse should suspect hypokalemia in the presence of muscle cramps in a client taking diuretics. Hypokalemia can lead to dangerous ventricular dysrhythmias

An 81-year-old client is admitted to a rehabilitation facility 3 days after total hip replacement. The next morning, the unlicensed assistive personnel (UAP) takes the client's vital signs, but when the UAP goes back to assist the client with a shower, the client curses at and tries to hit the UAP. Which of the following is the most appropriate response by the registered nurse?

This client is exhibiting behaviors that are concerning for delirium. Therefore, the nursing priority is to perform a targeted assessment to determine whether the client has delirium and its cause. Delirium is characterized by behavior changes and confusion that have an acute onset, and it is usually reversible. Common causes in older adults include infection, medications, and hypoxia. This client's vital signs (mildly elevated temperature, respiratory rate, and hypoxia) and recent surgery suggest pulmonary infection as the cause of the delirium. Although a temperature of 98.7 F (37 C) is normal for younger adults, it may indicate fever in an 81-year-old as mean body temperature decreases with age. Other signs of pulmonary infection include crackles in the lungs, productive cough, and pleuritic chest pain. (Option 2) The nurse is making an assumption and there is not enough information to support dissatisfaction as the cause of this client's behavior. Further assessment is needed. (Option 3) This client is exhibiting signs of delirium, which is a medical emergency. Leaving the client alone without further assessment and appropriate, timely intervention would constitute negligence. (Option 4) The nurse is assuming that the client has dementia based on age. However, only 1 of every 8 older adults has dementia. Educational objective: Delirium is a common manifestation of a serious physiologic instability in older adults and is characterized by acute changes in cognition and behavior. When a client is suspected of having delirium, the nursing priority is assessment for the cause of the delirium to guide interventions

An elderly client tells the nurse "I have experienced leg pain for several weeks when I walk to the mailbox each afternoon, but it goes away once I stop walking." What is the priority assessment the nurse should perform?

This client is exhibiting symptoms of intermittent claudication or ischemic muscle pain that can be due to peripheral artery disease (PAD). PAD impairs circulation to the client's extremities. The nurse should first check for the adequacy of blood flow to the lower extremities by palpating for the presence of posterior tibial and dorsalis pedis pulses and their quality. Poor circulation to the extremities can place the client at increased risk for development of arterial ulcers and infection. The quality of circulation to the extremities will guide the treatment plan for this client; management will include risk factor modification for cardiovascular disease, drug therapy, and possibly surgical revascularization. (Option 1) Dry, scaly skin can be present in the client with PAD. It is a chronic condition of PAD and is not the priority assessment. (Option 2) When circulation to the extremities is impaired, the skin on the lower legs becomes thin, shiny, and taut; hair loss also occurs on the lower legs. This develops over time and would indicate that PAD has been present for a period of time and is not the priority assessment. (Option 4) The nurse should obtain a dietary history to assess for risk factors associated with cardiovascular disease. However, this is a lower level priority in this situation. Educational objective:The nurse caring for a client with intermittent claudication from PAD should assess the adequacy of circulation to the extremities by palpating and assessing the quality of posterior tibial and dorsalis pedis pulses. The quality of circulation will guide the treatment plan including risk factor modification, drug therapy, and possible surgical revascularization.

A client with severe vomiting and diarrhea has a blood pressure of 90/70 mm Hg and pulse of 120/min. IV fluids of 2-liter normal saline were administered. Which parameters indicate that adequate rehydration has occurred?

This client's initial vital signs show tachycardia and hypotension, which are classic signs of hypovolemia. Normal capillary refill is less than 3 seconds and is an indication of normal hydration and perfusion (Option 1). Obligatory urine output is 30 mL/hr, and this client has 90 mL/hr. Urine output is one of the best indicators of adequate rehydration (Option 4). The urine specific gravity is within a normal range (1.003 to 1.030), which can indicate normal hydration (Option 5). (Option 2) Narrowing pulse pressure (the difference between systolic and diastolic) is a sign of hypovolemic shock and would not indicate adequate rehydration. The client arrived with a narrow pulse pressure already. (Option 3) This is indicative of orthostatic vital signs. When a client stands, the body normally vasoconstricts to maintain the blood pressure from the effects of gravity. If a client is dehydrated, the body has already maximally vasoconstricted, and there is no compensatory mechanism left to adjust to the position change. Educational objective:Signs of adequate hydration are normal urine specific gravity (1.003 to 1.030), adequate volume of urine output (>30 mL/hr), and capillary refill of less than 3 seconds. Pulse pressure narrows in shock, and positive orthostatic vital signs (decreasing systolic blood pressure and rising heart rate) with position change indicate dehydration.

The charge nurse in the telemetry unit has delegated the task of giving a bed bath to a male Arab client who practices traditional Islamic customs. Which communication to the female nursing assistant demonstrates appropriate cultural sensitivity to this client?

To provide culturally competent care, it is important for the nurse to realize that in many Arab cultures, a man is not allowed to be alone with a woman other than his wife. It may also be inappropriate for a female health care worker to physically care for him; however, in some instances, direct physical care from the opposite sex is allowed if a third party is present. (Option 2) Eye contact varies greatly among cultural groups. Some cultures (eg, Arab, Asian, Native American) view eye contact as a sign of disrespect or aggressiveness. This could be a concern with this client, but it is not as high a priority as respecting the client's cultural beliefs of not being alone in the same room with a member of the opposite sex. (Option 3) Some cultures (eg, Native American, Asian) are comfortable with silence and see it as a sign of respect, privacy, or respect for elders. (Option 4) In some Asian and Hispanic cultures, the head is thought to be the basis of one's strength or soul, and touching a person's head is considered disrespectful. Educational objective:The nurse should be aware that in many Arab cultures a man is not allowed to be alone with a woman other than his wife. In addition, cultural customs may not allow physical care by a member of the opposite sex. The nurse needs to plan accordingly to provide culturally sensitive care

The nurse is admitting a 4-year-old diagnosed with Wilms tumor. The child is scheduled for a right nephrectomy in the morning. Which action is a priority in the preoperative care plan?

Wilms tumor (nephroblastoma) is a kidney tumor that usually occurs in children age <5. Most often it involves only one kidney, and the prognosis is good if the tumor has not metastasized. Wilms tumor is usually diagnosed after caregivers observe an unusual contour in the child's abdomen. Once the diagnosis is suspected or confirmed, the abdomen should not be palpated, as this can disrupt the encapsulated tumor. It is important to post the sign "DO NOT PALPATE ABDOMEN" at the bedside. It is also essential that the child be handled carefully during bathing. (Option 1) Assessment of a child's development level and emotional maturity will help determine the appropriate approach to use during the many painful procedures that the child will undergo in rapid succession. However, this assessment is not a priority. (Option 2) If the tumor has metastasized, adventitious sounds may be present. Auscultating for them is not a priority. (Option 4) Some clients may have hypertension due to excess production of renin, and this will require monitoring. However, it is not as important as ensuring that the abdomen is not palpated. Educational objective:Wilms tumor is discovered when caregivers note an unusual bulging/swelling on one side of a child's abdomen. The abdomen should not be palpated until after the diagnosis is suspected or confirmed as this can disrupt the tumor and cause dissemination of tumor cells