some questions from u-world

A client with advanced multiple sclerosis (MS) has been a resident in a nursing home for the past 2 years. One day, the client tells the nurse, "I want to go get out of here and try living in my own home." What is the BEST response by the nurse? 1. "do you have family or friends to take care of you?" 2. "I'll make a referral to the local home care agency in your area." 3. "It will be very difficult to manage your care at home." 4. "Tell me how you think your life would be different if you moved from here."

***Answer:4 After 2 years of residence, this client has expressed a desire to leave the nursing home and return home. This client with advanced MS will need maximal assistance with basic activities of daily living (bathing, grooming, toileting, transfers, locomotion), meal preparation, laundry, shopping, and other housekeeping chores. Discharging this client to care at home will require much planning and present numerous challenges related to safety, finances, support and informal caregiver system, durable medical equipment, and layout of the home. Therefore, before any discussion or planning can take place, the nurse needs to determine why the client wants to go home at this point in time. The nurse should also ask the client if something happened in the nursing home. However, asking "why" or "yes/no" questions is non-therapeutic and will not facilitate meaningful nurse-client interaction. By using the therapeutic communication technique of exploring, the nurse can encourage the client to discuss thoughts, feelings, and reasons for wanting to leave the current residence. (Option 1) This is important information to obtain when planning the discharge of a client who needs care at home; however, it is not the priority assessment. (Option 2) This would be an appropriate nursing action after the nurse has discussed and assessed the reasons why the client wants to return home. (Option 3) This is an appropriate response as it presents the reality of the client's situation, but it is not the priority response. Educational objective:Exploring is a therapeutic communication technique that will facilitate further assessment of a particular subject or experience. It is a technique that is especially helpful when a client makes a statement or presents a topic that alerts the nurse that there could be additional information beyond the surface of the initial communication. Additional Information Psychosocial Integrity NCSBN Client Need

A client with chronic kidney disease has blood laboratory results as shown in the exhibit. What is the best afternoon snack to provide to this client? 1. Apple slices with caramel dip 2. Chips and avocado dip 3. Nonfat yogurt with orange slices 4. Vanilla pudding with strawberries

Answer: 1 Clients with chronic kidney disease (CKD) have decreased glomerular filtration, resulting in retention of fluid, potassium, and phosphorus. Fluid retention is initially treated with sodium restriction and diuretic therapy. Dietary adjustments should also be made to reduce serum potassium and phosphorus. Laboratory values are key to determining allowable foods. Dairy products (eg, milk, yogurt) and certain fruits (eg, bananas, oranges, coconuts, watermelons, and avocados) contain high potassium levels. Dairy products also contain high phosphorus levels. Examples of allowable foods for CKD clients include apples, pears, grapes, pineapple, blackberries, blueberries, and plums. (Option 2) Avocados are high in potassium; the chips may be high in sodium. (Options 3 and 4) Pudding and yogurt contain dairy products and are high in phosphorous and potassium. Oranges are high in potassium. Educational objective: The diet for a client with chronic kidney disease may need to be restricted in fluids, sodium, potassium, and phosphorus. Dairy products (eg, milk, yogurt) and certain fruits (eg, bananas, oranges, coconuts, watermelons, and avocados) contain high potassium levels. Dairy products are also high in phosphorus.

The nurse is assessing a 4-day-old, term neonate who is breastfed exclusively. Which assessment finding should the nurse report to the health care provider for further assessment regarding possible formula supplementation? 1. 10% weight loss since birth 2. Cracked, peeling skin 3. Feeds every 2-3 hours 4. Runny, seedy, yellow stools

Answer: 1 During the first 3-4 days of life, a weight loss of approximately 5%-6% of birth weight is expected due to fluid excretion (eg, urine, stool, respirations). Weight loss usually ceases around 5 days of life in healthy newborns, who return to their birth weight by 7-14 days of life. A weight loss of >7% of birth weight warrants further evaluation. The nurse should assess the newborn, review intake and output, observe breastfeeding technique (eg, positioning, effective latching), and notify the health care provider. To prevent further weight loss, breastfeeding support and formula supplementation (eg, via spoon or syringe) may be indicated until exclusive breastfeeding is adequate (Option 1). (Option 2) Peeling of the term newborn's skin is a sign of physical maturity and is expected around the third day of life. Cracked, peeling skin may be present at birth in post-term (ie, >42 weeks gestation) newborns. (Option 3) Feeding every 2-3 hours is normal for breastfed newborns; breastmilk is easily digested and more frequent feeding is noted than in formula-fed newborns. (Option 4) After passing meconium, newborns produce transitional stools that are thin and yellowish-brown or yellowish-green. Stools of breastfed newborns progress to a seedy, yellow paste. Bottle-fed newborns have firmer, light brown stools. Educational objective: During the first 3-4 days of life, a weight loss of approximately 5%-6% of birth weight is expected due to fluid excretion through urine, stool, and respirations. Weight loss >7% may indicate the need for breastfeeding support and formula supplementation and require evaluation.

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

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

The nurse prepares to administer IV vancomycin to an 80-year-old client with a methicillin-resistant Staphylococcus aureus infection. The nurse should notify the health care provider about which serum laboratory results before administering the drug? Select all that apply. 1. Blood urea nitrogen is 60 mg/dL (21.4 mmol/L) 2. Creatinine is 2.1 mg/dL () 3. Glucose is 140 mg/dL () 4. Hemoglobin 1.5 g/dL (150) 5. Magnesium is 1.5 mEq/L (0.75 mmol/L) 6. White Blood Cell count is 14,000/mm^3(14.0x10^9/L)

Answer: 1 & 2 Vancomycin is a glycopeptide antibiotic that is excreted by the kidneys. It is used to treat serious infections with gram-positive microorganisms (Staphylococcus aureus [methicillin-resistant Staphylococcus aureus]) and diarrhea associated with Clostridium difficile. Serum vancomycin trough level is monitored before the 4th dose (15-20 mg/L [10.4-13.8 µmol/L] is optimal). Blood urea nitrogen (BUN) and creatinine levels are monitored regularly (usually 2-3 times/week) in clients receiving the drug due to increased risk of nephrotoxicity, especially in those with impaired renal function, receiving aminoglycosides, and who are >60 years old. The health care provider (HCP) can lower the dose, decrease the drug administration frequency, or discontinue vancomycin. It is important to know the baseline values of BUN and creatinine to monitor trending and identify if there is an increase. Before administering this drug, the nurse should notify the HCP that the client's BUN (60 mg/dL [21.4 mmol/L]) and creatinine (2.1 mg/dL [185.6 µmol/L]) are both increased. The normal range for BUN is 6-20 mg/dL (2.1-7.1 mmol/L) and creatinine is 0.6-1.3 mg/dL (53-115 µmol/L). (Option 3) An elevated glucose level (>110 mg/dL [6.1 mmol/L]) is expected in a client with an infection due to physiological stress and gluconeogenesis; this does not need to be reported to the HCP. (Option 4) A hemoglobin level of 15 g/dL (150 g/L) is normal (13.2-17.3 g/dL [132-173 g/L] in adult men; 11.7-15.5 g/dL [117-155 g/L] in adult women) and does not need to be reported to the HCP. (Option 5) A magnesium level of 1.5 mEq/L (0.75 mmol/L) is normal (1.5-2.5 mEq/L [0.75-1.25 mmol/L]) and does not need to be reported to the HCP. (Option 6) A white blood cell count of 14,000/mm3 (14.0 × 109/L) is elevated and expected in a client with a serious infection; this does not need to be reported to the HCP. Educational objective:As nephrotoxicity can occur, monitoring of vancomycin trough level to maintain optimal drug level and renal function is indicated in clients receiving vancomycin, especially in those with impaired renal function and who are >60 years old.

A cardiac catherization was performed on a client 2 hours ago. The catheter was inserted into the left femoral artery. What signs of potential complications should the nurse report IMMEDIATELY to the health care provider (HCP)? Select all that apply 1. Bleeding at the catherization site 2. Client lying down and quietly watching television 3. Client taking only sips of fluids 4. Left foot remarkably cooler than right foot 5. Urine output of 100ml since the procedure

Answer: 1 & 4 Bleeding at the puncture site indicates that a clot has not formed at the insertion site. This is an arterial bleed as catheterization was done via the femoral artery. Arterial bleeds can lead to hypovolemic shock and death if not treated immediately. Reduced warmth in the lower extremity of the insertion site is a sign of decreased perfusion (lack of oxygenated blood flow) to the extremity and can result in tissue necrosis of the affected area. (Option 2) The client may lie flat for several hours and is encouraged to engage in quiet activities for 24 hours after the procedure to prevent dislodging the clot at the insertion site. (Option 3) Although clients are encouraged to drink fluids to flush dyes out of their system and prevent dehydration, decreased fluid intake would not warrant notifying the HCP. (Option 5) Urine output in this client is above 30 mL/hr and considered to be within the normal range. Educational objective: If not treated immediately, arterial bleeds can lead to hypovolemic shock and death. Reduced warmth in the lower extremity of the catheter insertion site is a sign of decreased perfusion (lack of oxygenated blood flow).

The nurse reviews the serum laboratory results and medication administration records for assigned clients. Which prescriptions should the nurse question and validate with the health care provider before administering? Select all that apply. 1. Bumetanide in the client with heart failure who has hypokalemia 2. Calcium acetate in the client with chronic kidney disease who has hyperphosphatemia 3. Carvediolol in the client with heart failure who has an elevated B-type natriuretic peptide level 4. Isoniazod in the client with tuberculosis who has elevated liver enzymes 5. Metronidazole in the client with Clostrdium difficile infection who has leukocytes

Answer: 1 & 4 Bumetanide is a potent loop diuretic (eg, furosemide, torsemide) used to treat edema associated with heart failure and liver and renal disease. The diuretic inhibits reabsorption of sodium and water from the tubules and promotes renal excretion of water and potassium. The nurse should question the bumetanide prescription as the client with heart failure has hypokalemia (potassium <3.5 mEq/L [3.5 mmol/L]) and is already at increased risk for life-threatening cardiac dysrhythmias associated with this electrolyte imbalance (Option 1). Isoniazid is a first-line antitubercular drug used to treat latent or active tuberculosis. The nurse should question this prescription as increased liver function tests (eg, alanine aminotransferase, aspartate aminotransferase) can indicate development of drug-induced hepatitis (Option 4). (Option 2) Calcium acetate (PhosLo) is a phosphate binder used to treat hyperphosphatemia (normal phosphorous: 2.4-4.4 mg/dL [0.78-1.42 mmol/L]) in clients with chronic kidney disease. Calcium acetate lowers the serum phosphorous level by binding to dietary phosphate and excreting it in feces. (Option 3) Carvedilol (Coreg) is a beta blocker used to improve cardiac output and slow the progression of heart failure. B-type natriuretic peptide (BNP) (normal: <100 pg/mL [100 pmol/L]) is secreted from the ventricles in response to the increased ventricular stretch. Elevated BNP is expected in a client with heart failure; the nurse need not question this prescription. (Option 5) Metronidazole (Flagyl) is the first-line anti-infective drug used to treat infectious diarrhea caused by Clostridium difficile. Leukocytosis is expected with this bacterial infection. Educational objective: Loop diuretics (eg, bumetanide, furosemide, torsemide) can cause hypokalemia (potassium <3.5 mEq/L [3.5 mmol/L]). Elevated liver enzymes in clients receiving the antitubercular drug isoniazid can indicate development of drug-induced hepatitis.

The nurse is planning care for a client experiencing an acute attack of Meniere disease. Which action is a high priority to include in the plan of care? 1. Initiate fall precations 2. Keep the emesis basin at bedside 3. Provide a quiet environment 4. Start intravenous fluids

Answer: 1 (initiate fall precaution) Meniere disease (endolymphatic hydrops) results from excess fluid accumulation inside the inner ear. Clients have episodic attacks of vertigo, tinnitus, hearing loss, and aural fullness. The vertigo can be severe and associated with nausea and vomiting. Clients report feelings of being pulled to the ground (drop attacks). During an attack, the client is treated with vestibular suppressants, including sedatives (eg, benzodiazepines such as diazepam), antihistamines (eg, diphenhydramine, meclizine), anticholinergics (eg, scopolamine), and antiemetics. The nurse's priority is to plan for client safety with fall precautions given the severe vertigo and use of sedating medications. Fall precautions include adjusting the bed to a low position with side rails up and instructing the client to call for help before getting up. Vertigo may be minimized by staying in a quiet, dark room and avoiding sudden head movements. The client should reduce stimulation by not watching television or looking at flickering lights. The client's diet should be salt restricted to prevent fluid buildup in the ear. (Option 2) An emesis basin should be provided at the bedside, but fall precautions are the priority. (Option 3) A quiet environment can help minimize vertigo. However, it is a lower priority than the fall precautions. (Option 4) Most clients with Meniere disease require parenteral fluids given the nausea and vomiting. However, these are not the highest priority. Educational objective: Clients with Meniere disease (endolymphatic hydrops) can have severe vertigo, tinnitus, hearing loss, and aural fullness. It is a priority for the nurse to institute safety measures, such as fall precautions, for these clients. They will require a salt-restricted diet.

A client allergic to bee stings was stung about 20 minutes ago at a picnic. Based on the assessment data, the nurse anticipates which immediate actions? (select all that apply) 1. Inhaled albuterol 2. Intramuscular epinephrine 3. Intravenous methylprednisolone 4. Intravenous metoprolol 5. Intravenous nitroglycerine

Answer: 1 2 3 Anaphylactic shock has an acute onset, and manifestations usually develop quickly (20-30 minutes). It is caused by a systemic IgE-mediated hypersensitivity allergic reaction to drugs, foods, and venom. Anaphylactic shock results in hypotension and respiratory manifestations, including laryngeal edema (from inflammation) and bronchoconstriction (primarily from release of histamine); these can lead to cardiac and respiratory arrest. The management of anaphylactic shock includes: 1.) Call for help (activate emergency management systems) - first action 2.) Maintain airway and breathing - administer high-flow O2 via non-rebreather mask 3.) Epinephrine, intramuscular - the drug of choice and should be given next. Epinephrine stimulates both alpha- and beta-adrenergic receptors, dilates bronchial smooth muscle (beta 2), and provides vasoconstriction (alpha 1). The IM route is better than the subcutaneous route. The dose should be repeated every 5-15 minutes if there is no response. 4.) Elevate the legs 5.) Volume resuscitation with IV fluids 6.) Bronchodilator such as albuterol is administered to dilate the small airways and reverse bronchoconstriction 7.) Antihistamine (diphenhydramine) is administered to modify the hypersensitivity reaction and relieve pruritus 8.) Corticosteroids (methylprednisolone [Solu-Medrol]) are administered to decrease airway inflammation and swelling associated with the allergic reaction (Option 4) Metoprolol (beta blocker) should not be given as the blood pressure is already low. (Option 5) Nitroglycerine would also cause hypotension and should not be given. Morphine is avoided as it can worsen pruritus and hypotension. Educational objective: Diphenhydramine (Benadryl), IM epinephrine, inhaled beta agonists, and methylprednisolone (Solu-Medrol) are administered to treat the manifestations associated with anaphylactic shock. They modify the histamine response and treat pruritus, reverse bronchoconstriction, and decrease airway inflammation, respectively. IM epinephrine can be repeated for poor response.

The parents of a 2-year old client as hot they can help their child cope with hospitalization. Which of the following suggestions should the nurse give the parents? (select all that apply) 1. Follow as many home routines as possible 2. Organize a visit from a playgroup friend 3. Sleep in the child's hospital room at night 4. Take the child on regular visits to the playroom 5. Tell the child they did not cause the illness

Answer: 1,3,4 Hospitalization for toddlers (ie, 12-36 months) is particularly difficult due to separation anxiety and a limited ability to cope with stress. Toddlers thrive on home rituals and routines, which bring stability and reassurance. Hospitalization can severely disrupt these routines, triggering frustration and temper tantrums. Caregivers should maintain as many home routines as possible (eg, sleeping, eating) to help the child cope with unfamiliar hospital surroundings and procedures (Option 1). Parents should also stay with the child as much as possible, including overnight (ie, rooming-in), to provide consistency and alleviate separation anxiety (Option 3). Play, an important part of a child's emotional and social well-being, is an effective coping mechanism for children of all ages to deal with the stress of being away from home. The playroom is a safe place for children to act out their fears and anxieties related to illness and hospitalization (Option 4). (Option 2) A visit from friends is not likely to provide much comfort to a toddler and may actually cause additional stress. Adolescents, who are driven by peer interaction, would be more likely to benefit from this strategy. (Option 5) Preschool-aged children (3-5 years) have egocentric and magical thinking, which may cause them to think that their illness is due to something they have done or thought. Toddlers do not think this way. Educational objective: Coping mechanisms used by hospitalized toddlers include following homes rituals and routines, having parents stay with the child (including overnight), and using the playroom for relief of anxiety and fear.

A 2-year-old at an outpatient clinic stops breathing and does not have a pulse. CPR is initiated. When the automated defibrillator (AED) arrives, the nurse notes that it has only adult AED pads. What is the appropriate action at his time? 1. Continue CPR without using the automated external defibrillator (AED) until paramedics arrive 2. Place one AED pad on the chest and the other on the back 3. Place one AED on the upper right chest and the other on the lower left side 4. Place one AED pad on the upper right chest and dispose of the other

Answer: 2 An automated external defibrillator (AED) should be used as soon as it is available. Pediatric AED pads or a pediatric dose attenuator should be used for children age birth to 8 years if available. Standard adult pads can be used as long as they do not overlap or touch. If adult AED pads are used, one should be placed on the chest and the other on the back ("sandwiching the heart"). (Option 1) If an AED is available, it should be placed on the client as soon as possible. Research shows that survival rates increase when CPR and defibrillation occur within 3-5 minutes of arrest. (Option 3) Standard placement of adult AED pads on a 2-year-old would cause the pads to touch or overlap. Touching or overlapping of pads allows the shock to move directly from one pad to the other without traveling through the heart. (Option 4) Both AED pads are necessary for the defibrillator to work effectively. Educational objective: An automated external defibrillator (AED) should be used as soon as it is available. Adult AED pads can be used on a pediatric client if pediatric pads are unavailable. One pad is placed on the chest and the other is placed on the back ("sandwiching the heart").

The nurse is assessing a client 15 minutes after initiating nitroglycerin infusion for suspected acute coronary syndrome. Which clinical finding is the priority? 1. The client reports a headache 2. The client reports feeling dizzy and lightheaded 3. The client reports feeling flushed 4. The client reports feeling nervous

Answer: 2 Nitroglycerin is a nitrate that causes vasodilation and relaxation of vascular smooth muscle. In clients with acute coronary syndrome, it is administered by IV infusion to decrease preload and prevent spasm of the coronary arteries, thereby increasing perfusion and oxygen supply to the cardiac muscle. Due to systemic vasodilation, this client is at risk for significant hypotension. The nurse should follow up immediately if the client reports dizziness or lightheadedness, which may indicate profound hypotension (Option 2). If the client is found to be hypotensive, the nurse may need to decrease or discontinue the infusion. (Option 1) Headache is a common side effect of nitroglycerin therapy and is often a sign that the medication is working properly. It is not a priority, although acetaminophen may be given for pain relief. (Options 3 and 4) Systemic vasodilation and decreased cardiac preload may cause the client to feel flushed and nervous during infusion. However, reports of dizziness and lightheadedness should take priority. Educational objective: Nitroglycerin is a vasodilator that may be administered by IV infusion in the management of acute coronary syndrome. Clients receiving nitroglycerin are at risk for profound hypotension resulting from systemic vasodilation. The nurse should immediately assess a client with signs of hypotension (eg, dizziness, lightheadedness) because the nitroglycerin infusion may need to be decreased or stopped.

A child received the varicella immunization. The day after the injection, the parent calls the nurse to say that the child has discomfort, slight redness, and 2 vesicles at the injection site. What instruction would be appropriate for the nurse to provide to this parent? 1. Administer aspirin to decrease discomfort 2. Cover the vesicles with a small bandage until they are dry 3. Isolate the child from other children for 21 days to avoid exposure 4. Make an appointment with health care provider (HCP) as soon as possible

Answer: 2 The varicella immunization is administered to prevent infection of varicella zoster, commonly known as chickenpox. Side effects of the immunization include discomfort, redness, and a few vesicles at the injection site. Covering the vesicles with clothing or a small bandage will reduce the risk of transmission from any exudate. Once the vesicles have dried, or crusted, a dressing is no longer necessary. (Option 1) Acetaminophen is the appropriate medication to reduce the discomfort of the injection. Aspirin should be avoided in children due to the risk of Reye syndrome. (Option 3) Unless the rash becomes widespread, isolation of the child is unnecessary. It is unlikely that the infection will be transmitted by the 2 vesicles, but covering them with clothing or a small bandage will decrease the risk of transmission. (Option 4) Discomfort, redness, and a few vesicles at the injection site are common side effects of the varicella immunization and do not require the attention of an HCP. Educational objective: Discomfort, redness, and vesicles at the injection site are common side effects of the varicella immunization. Covering the vesicles with clothing or a small bandage will reduce the risk of transmission from any exudate.

A client, gravida 4 para 3, at 38 weeks gestation arrives in the emergency department with strong contractions that began 1 hour ago. The client is diaphoretic, grunting, and yelling loudly that she wants an epidural because she feels the need to push. What priority action should the nurse take? 1. Apply gloves and assess perineal area 2. Initiate large-bore Iv access 3. Notify anesthesia provider of client's request for epidural 4. Obtain fetal heart tones

Answer: 2 Precipitous birth occurs when labor lasts <3 hours from contraction onset until birth. Signs of imminent birth include involuntary pushing/bearing down with contractions, grunting, or report of sensations of having a bowel movement. If a client arrives at the hospital in second-stage labor (ie, pushing), the nurse rapidly assesses whether birth is imminent by applying gloves and observing the perineum for bulging or crowning of the presenting fetal part (Option 1). If the health care provider is not present, the nurse stays with the client, ensures safe client positioning (eg, not standing or on the toilet), and is prepared to act as a birth attendant. The nurse may direct others to perform needed actions (eg, contact provider, assess fetal heart tones, initiate IV access). (Option 2) Large-bore IV access (ie, 18G or larger) is helpful for administrating oxytocin in the immediate postpartum period. However, the nurse first confirms that birth is not imminent before performing other actions. (Option 3) Notifying the anesthesia provider would be appropriate after confirming that birth is not imminent and performing other nursing actions to ensure client and fetal well-being (eg, assessing fetal heart tones, initiating IV access). (Option 4) The nurse should assess fetal heart tones and perform other interventions after determining that birth is not imminent. Educational objective:Precipitous birth is defined as <3 hours of labor from contraction onset until birth. When a client arrives at the hospital in second-stage labor, the nurse rapidly assesses whether birth is imminent before performing other interventions. Additional Information Management of Care NCSBN Client Need

When no changes are made to the diet or prescribed insulin, which client with type 1 diabetes mellites does the nurse anticipate having the highest risk of developing hypoglycemia?

Answer: 2 -40 year old experienced cyclist Hypoglycemia (blood glucose <70 mg/dL [3.9 mmol/L]) is an acute and sometimes life-threatening complication of diabetes mellitus. It occurs when the proportion of insulin exceeds the glucose in the blood. Counterregulatory hormones (eg, epinephrine) are then released and the autonomic nervous system is activated, causing symptoms of hypoglycemia such as sweating, tremor, and hunger. Aerobic exercise typically lowers blood glucose levels. As muscles use up glucose, the liver is unable to produce enough glucose to keep up with the demand. Even an experienced exerciser should check blood glucose levels before, during, and after exercise, and also carry a carbohydrate drink or snack in case of a hypoglycemic episode (Option 2). Clients with an acute illness (eg, influenza, cellulitis) are more likely to experience hyperglycemia. Increased glucose levels occur due to the physiological stress response caused by infection (Options 1 and 3). Hyperglycemia is also a side effect of prednisone (Option 4). Educational objective:Aerobic exercise typically lowers blood glucose levels as glucose production in the liver fails to keep up with elevated glucose uptake by the muscles at work. Additional Information Reduction of Risk Potential NCSBN Client Need

While preparing to insert a peripheral IV line, the nurse notices scarring near the client's left axilla. The client confirms a history of left breast cancer and modified radical mastectomy. Which actions should the nurse take? Select all that apply. 1. Advance the entire stylet into the vein upon venipuncture 2. Insert the IV line into the most distal site of the right arm 3. Place an appropriate precaution sign above the bed 4. Review the medical record for history of mastectomy 5. Teach the client to keep the left arm in a dependent position

Answer: 2, 3, 4 A modified radical mastectomy includes removal of axillary lymph nodes that are involved in lymphatic drainage of the arm. Any trauma (eg. IV extravasation) to the arm on the operative side can result in lymphedema, characterized by painful and lengthy swelling, as normal lymphatic circulation is impaired by scarring. Therefore, starting an IV line in this arm is contraindicated. The nurse should insert the IV line into the most distal site of the unaffected side (Option 2). For client safety, it is also important to ensure documentation of the mastectomy history, place a restricted extremity armband on the affected arm, and place a sign above the client's bed notifying hospital staff of necessary mastectomy precautions (eg, no blood pressure measurements, venipuncture, or IV lines) (Options 3 and 4). In general, venipuncture is contraindicated in upper extremities affected by: - Weakness - Paralysis - Infection - Arteriovenous fistula or graft (used for hemodialysis) - Impaired lymphatic drainage (prior mastectomy) (Option 1) The stylet should be advanced until blood return is seen (approximately ¼ inch). If advanced fully, the stylet may penetrate the posterior wall of the vein and cause a hematoma. (Option 5) Keeping the affected arm in a dependent position for a long time can increase lymphedema. The client should be reminded that raising the limb helps drainage. Educational objective: IV line insertion is contraindicated on the operative side of clients with a prior mastectomy. Additional contraindications for IV line insertion include weakness, paralysis, or infection of the arm; or presence of an arteriovenous fistula.

A registered nurse is making pre-procedure phone calls to clients scheduled for cardiac pharmacologic nuclear stress testing the following day. Which instructions should the nurse give the clients? Select all that apply 1. Decaffeinated coffee or tea can be consumed 2. Do not consume caffeine for 24 hours before the test 3. Do not smoke on the day of the test 4. Do not take beta-blockers on the day of the test 5. Take diabetic medications as usual before the test

Answer: 2, 3, 4 A pharmacologic nuclear stress test utilizes vasodilators (eg, adenosine, dipyridamole) to simulate exercise when clients are unable to tolerate continuous physical activity or when their target heart rate is not achieved through exercise alone. These drugs produce vasodilation of the coronary arteries in clients with suspected coronary heart disease. A radioactive dye is injected so that a special camera can produce images of the heart. Based on these images, the health care provider (HCP) can visualize if there is adequate coronary perfusion. Pre-procedure client instructions include the following: - Do not eat, drink, or smoke on the day of the test (NPO for at least 4 hours). Small sips of water may be taken with medications (Option 3). - Avoid caffeine products 24 hours before the test (Option 2). - Avoid decaffeinated products 24 hours before the test as these contain trace amounts of caffeine (Option 1). - Do not take theophylline 24-48 hours prior to the test (if tolerated). - If insulin/pills are prescribed for diabetes, consult the HCP about appropriate dosage on the day of the test. Hypoglycemia can result if the medicine is taken without food (Option 5). - Some medications can interfere with the test results by masking angina. Do not take the following cardiac medications unless the HCP directs otherwise, or unless needed to treat chest discomfort on the day of the test: - Nitrates (nitroglycerine or isosorbide) - Dipyridamole - Beta blockers (Option 4) Educational objective: Clients scheduled for cardiac nuclear pharmacologic stress testing should not eat, drink, or smoke on the day of the test; avoid both caffeinated and decaffeinated products for 24 hours before the test; and avoid taking theophylline or antianginal medications unless otherwise instructed by the health care provider.

An obese client with diabetes who had a bowel resection 5 days ago says, "I felt like I split open when I was coughing." On assessment, the nurse notes that the incision edges are separated and a loop of bowel is protruding through the wound. Which nursing actions would be appropriate? Select all that apply. 1. Administer one oral tablet of oxycodone prescribed PRN for pain. 2. Assess a full set of vital signs 3. Cover the viscera with sterile dressings saturated in normal saline (NS) solution 4. Notify the health care provider (HCP) immediately 5. Place the client in low Fowler's position with knees slightly flexed

Answer: 2, 3, 4, 5 Total separation of wound layers with protrusion of the internal viscera through the incision is known as evisceration. Evisceration is a medical emergency that can lead to localized ischemia, peritonitis, and shock. Emergency surgical repair is necessary. Clients at risk for poor wound healing (eg, obesity, diabetes mellitus) are at increased risk for evisceration. When an abdominal wound evisceration occurs, the nurse should take the following actions: - Remain calm and stay with the client. Have someone notify the HCP immediately and bring sterile supplies. Instruct the client not to cough or strain. - Place the client in low Fowler's position (no more than 20 degrees) with knees slightly flexed to relieve pressure on the abdominal incision and have the client maintain absolute bed rest to prevent tissue injury. - Assess vital signs (and repeat every 15 minutes) to detect possible signs and symptoms of shock (eg, hypotension, tachycardia, tachypnea). - Cover the viscera with sterile dressings saturated in NS solution to prevent bacterial invasion and keep the exposed viscera from drying out. - Document interventions taken and the appearance of the wound and eviscerated organ (eg, color, drainage). If the blood supply is interrupted, the protruding organs can become ischemic (dusky) and necrotic (black). (Option 1) This client should immediately be made NPO in preparation for possible emergency surgery. Only IV analgesics should be administered if the client is in pain. Educational objective: Emergency nursing management of wound evisceration includes the following: Stay with the client and have someone bring sterile supplies Notify the HCP and make the client NPO in preparation for emergency surgery Place the client in low Fowler's position with knees slightly flexed Cover viscera with sterile dressings saturated in NS solution Assess vital signs and monitor for signs of shock

A home health nurse is visiting a client who underwent right-sided mastectomy with lymph node removal. The client is concerned about swelling in her arm on the affected side. Which instructions should the nurse discuss with the client? Select all that apply. 1. Avoid massaging the arena 2. Avoid receiving vaccinations in the affected arm 3. Elevate the arm above the heart 4. Perform isometric exercises 5. Use an intermittent pneumatic compression sleeve

Answer: 2,3,4,5 Lymphedema is the accumulation of lymph fluid in the soft tissue. It can occur as a result of lymph node removal or radiation treatment. When the axillary nodes cannot return lymph fluid to central circulation, the fluid can accumulate in the arm, hand, or breast. The client's arm may feel heavy or painful, and motor function may be impaired. The presence of lymphedema increases the client's risk for infection or injury of the affected limb. Interventions to manage lymphedema include: - Decongestive therapy (massage technique to mobilize fluid) - Compression sleeves or intermittent pneumatic compression sleeve (Option 5) - Compression sleeves are graduated with increased distal pressure and less proximal pressure. -Clothing should also be less constrictive at the proximal arm and over the chest. - Elevation of arm above the heart (Option 3) - Isometric exercises (Option 4) Avoidance of venipunctures (eg, IV catheter insertion, blood draw), blood pressure measurements, and injections (eg, vaccinations) on the affected limb (Option 2) Injury prevention (limb less sensitive to temperature changes)Infection prevention (limb more prone to infection through skin breaks) (Option 1) Clients often learn massage techniques (ie, decongestive therapy) from physical therapists to increase lymphatic drainage and promote circulation of the extremity. Educational objective: Management for lymphedema includes decongestive massage therapy, compression bandages or sleeves, elevation of the arm above heart level, isometric exercises, and avoidance of venipuncture or blood pressure measurements on the affected limb.

The nurse is providing care for a client with Alzheimer disease who often becomes angry and agitated 20 minutes or more after eating. The client accuses the nurse of not providing food, saying, "I'm hungry. You didn't feed me." The nurse should take which action 1. Give the client gentle reminders that the client has already eaten 2. Say the client can have a snack in a couple of hours 3. Serve the client half of the meal initially and offer the other half later 4. Take a picture of the client having a meal and show it when the client becomes upset

Answer: 3 Alzheimer disease & eating problems Earlier stages - Forgetting that a meal was consumed due to short-term memory loss - Anorexia & weight loss secondary to depression &/or recognition of the disease Middle stages - Forgetting to eat at all - Not recognizing the sensations of hunger & thirst - Forgetting how to utensils - Consuming nonfood items - Refusing to eat - Restlessness: Inability to sit long enough to consume a meal Later stages - Inability to feed oneself - Dysphagia Most clients with Alzheimer disease experience eating and nutritional problems throughout the course of their disease. During the earlier stages, it is common for clients to forget that they have eaten recently. The best approach is for caregivers to give clients something to eat when they say they are hungry. Smaller meals throughout the day, along with low-calorie snacks, are effective strategies for clients who forget that they have eaten. (Option 1) Reality orientation has been recommended in the past as a way to deal with confusion (eg, dementia, Alzheimer disease), but research has shown that it may cause anxiety and distress. Validation therapy is a newer and more therapeutic approach that validates and accepts the client's reality. (Option 2) Offering to provide a snack later does not address the client's stated need to eat now. Delay in giving food will only further increase the client's anger and frustration. (Option 4) Showing a picture of the client having a meal is confrontational and will have no meaning to the client. Educational objective: Clients with Alzheimer disease experience eating and nutritional problems throughout the course of the disease. During the earlier stages, it is common for them to forget that they have eaten recently. The best approach is for caregivers to give clients something to eat when they say they are hungry.

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? 1. Auscultate the client's lings 2. Check the client's capillary refill 3. Measure the client's blood pressure 4. Review the client's electrocardiogram (ECG)

Answer: 3 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 is assessing 4 clients in the emergency department. Which client should the nurse prioritize for care? 1. Client with live cirrhosis and ascites who has increasing abdominal distention and needs therapeutic paracentesis 2. Client with new-onset ascites from a suspected ovarian mass who needs paracentesis for diagnostic studies 3. Client with ulcerative colitis who has a fever, bloody diarrhea, and abdominal distension and needs an abdominal x-ray 4. Nursing home client with dementia who has stool impaction and abdominal distention and needs a stool disimpaction

Answer: 3 The client with ulcerative colitis who has abdominal distension, bloody diarrhea, and fever likely has toxic megacolon. This is a common, life-threatening complication of inflammatory bowel disease and is seen more frequently in ulcerative colitis than in Crohn disease. Toxic megacolon can also be associated with Clostridium difficile infection and other forms of infectious colitis. Severe colonic inflammation causes release of inflammatory mediators and bacterial products which contribute to colonic smooth muscle paralysis. Rapid colonic distension ensues, thinning the intestinal wall and making it prone to perforation. Imaging confirms the diagnosis. (Option 1) This client with liver cirrhosis and ascites needs periodic paracentesis for relief of distension in addition to diuretics (eg, spironolactone, furosemide) for advanced-stage disease. However, this client is not the priority. (Option 2) This client needs paracentesis for fluid cytology (eg, diagnostic paracentesis) to evaluate for malignancy. This client is not the priority. (Option 4) Clients with dementia have decreased mobility, drink less fluid (eg, impaired thirst, do not ask for water), and often take medications with anticholinergic properties. Such factors make these clients prone to severe constipation, and they often need manual disimpaction. This client is not the priority. Educational objective: Toxic megacolon is a common, life-threatening complication of inflammatory bowel disease. Clients present with abdominal pain/distension, bloody diarrhea, fever, and signs of shock (eg, hypotension, tachycardia).

A nurse is screening clients at a community health event. Which of the following client statements should the nurse recognize as a warning sign of cancer? (select all that apply) 1. For the past few years, I get productive cough in the winter that goes away in spring 2. I occasionally have heartburn an hour after I eat fried foods and sausage 3. Last month when I was doing my breast self-examination, I noticed a marble-sized lump 4. My mole is itchy, and the borders have become uneven with a blackish to bluish color. 5. Recently I have noticed that my bowel movements appear black

Answer: 3,4,5 Cancer is a growth of abnormal cells in an organ system that may impair the organ's function and spread throughout the body. Many cancers are invasive and life threatening if allowed to reach late stages of development. However, cancer is often difficult to identify early as the client may be asymptomatic or have only vague symptoms. Nurses should screen clients for and immediately report warning signs of cancer, which can be remembered with the mnemonic CAUTION: - Change in bowel or bladder habits (Option 5) - A sore that does not heal - Unusual bleeding or discharge from a body orifice - Thickening or a lump in the breast or elsewhere (Option 3) - Indigestion or difficulty in swallowing that does not go away - Obvious change in a wart or mole (Option 4) - Nagging cough or hoarseness (Option 1) A productive cough that is annual and seasonal, particularly occurring in the winter, may indicate chronic bronchitis. The nagging cough found in clients with lung cancer is persistent, rather than seasonal. (Option 2) A client report of occasional indigestion after specific triggers (eg, high-fat or spicy food, caffeine) may indicate gastroesophageal reflux disease. However, indigestion that is persistent or chronic indigestion may indicate cancer. Educational objective: Warning signs of cancer for nurses to monitor include change in bowel or bladder habits, a sore that does not heal, unusual bleeding or discharge, thickening or a lump in the breast or elsewhere, indigestion or difficulty swallowing, any obvious change in a wart or mole, and nagging cough or hoarseness (mnemonic: CAUTION).

A nurse is instructing the caregiver of an 8-month-old client regarding administration of oral amoxicillan. The client is prescribed 25mg/kg/day of amox

Answer: 3.75 Using dimensional analysis, the following steps are performed to calculate the volume of amoxicillin per dose: 1.) Identify the prescribed, available, and required medication information Prescribed: 25 mg amoxicillin kg/day Available: 125 mg amoxicillin/5 mL solution Required: mL/dose 2.) Convert prescription to volume needed for administration using dimensional analysis Prescription×available medication=mL/dose OR (mg amoxcillin ÷ kg/day)(kg/lbs)(lbs/ )(day/dose)(mL mg amoxicillin)=mL amoxicillindosemg amoxcillinkg/daykglbslbs daydosemL mg amoxicillin=mL amoxicillindose OR ⎛⎝25 mg amoxicillinkg/day⎞⎠⎛⎝kg2.2 lbs⎞⎠(16.5 lbs )⎝day2 doses⎞⎠⎛⎝5 mL 125 mg amoxicillin⎞⎠=3.75 mL amoxicillindose 25 mg amoxicillinkg/daykg2.2 lbs16.5 lbs day2 doses5 mL 125 mg amoxicillin=3.75 mL amoxicillindose Educational objective: To calculate the milliliters per dose of oral amoxicillin, the nurse should first identify the prescribed dose (eg, 25 mg/kg/day divided in two doses) and available medication (eg, 125 mg/5 mL solution) and then convert to milliliters per dose (eg, 3.75 mL/dose).

A 25-year-old client is about to undergo a unilateral orchiectomy for treatment of testicular cancer. The client says to the nurse, "I'm so worried that my future spouse is going to call off our engagement." What is the BEST response by the nurse? 1. "Are you concerned about how the surgery will affect you sexuality?" 2. "If you are concerned about infertility, you could always bank you sperm." 3. " The cancer is at an early stage. You are going to be fine." 4. " What have ou and your future spouse discussed about your condition?"

Answer: 4 A diagnosis of testicular cancer is very often a source of anxiety for a client and can cause concern about sexual performance and fertility. How a client's sexuality is affected by this diagnosis depends on how advanced the cancer is and the course of prescribed treatment. Decisions about sperm banking and/or whether the client wants to procreate in the future are best made prior to surgery, radiation, and/or chemotherapy. The client and significant others need to be given counseling and the opportunity to discuss the potential effects of treatment and the options for preserving sperm. In this scenario, the client's stated concern about the future with the partner may be the way of voicing concern about how the surgery will affect sexuality. In order to determine what counseling or information this client needs, it is most important for the nurse to first assess the client's knowledge of the condition and what the client and the future spouse have already discussed. In addition, by using the therapeutic communication techniques of presenting a general lead and exploration, the nurse can facilitate the conversation and the nurse-client relationship. (Option 1) This is not the best response as it requires a short, single answer from the client and does not provide the opportunity for exploration or elaboration. "Yes" or "no" questions are useful and necessary in some client-nurse interactions. However, generally they are considered to be nontherapeutic as they are not conversation enhancers. (Option 2) Banking sperm is an option for clients with testicular cancer. However, it is more important for the nurse to first explore the client's concerns and knowledge about the condition. (Option 3) This statement by the nurse may be giving false reassurance to the client. In addition, it blocks further discussion or exploration of the client's knowledge about the condition and related concerns. Educational objective: A diagnosis of cancer is a cause of anxiety for any client due to concerns about prognosis. A client with a diagnosis of testicular cancer will have additional concerns about sexual performance and fertility. Using therapeutic communication techniques, such as a broad opening and a general lead and exploration, will facilitate the nurse-client relationship and a meaningful discussion about the condition and concerns.

the nurse is caring for a 72-year-old client with hypothyroidism admitted to the emergency department for altered mental status. the client lives alone but has taken medication or seen a health care provider for several months. Which action is the priority? 1. Administer IV levothyroxine 2. check serum TSH, triiodothyronine, and thyroxine 3. Place a warming blanket on the client 4. Prepare for endotracheal intubation

Answer: 4 Clinical features of myxedema coma - Hypothermia - Hypoventilation - Bradycardia - Hyper-/ hypotension with narrow pulse pressure - Decreased mental status, psychosis, seizure, & coma - Nonpitting edema of hands, face, & tongue - Pericardial effusion - Hyponatremia & hypoglycemia - Possible concurrent adrenal insufficiency or hypothalamic/pituitary dysfunction Myxedema coma refers to a state of severe hypothyroidism causing decreased level of consciousness (eg, lethargy, stupor) that may progress to a comatose state. Myxedema coma is characterized by hypothermia, bradycardia, hypotension, and hypoventilation. Hypoventilation may occur as a result of respiratory muscle fatigue and mechanical obstruction by an edematous tongue. Clients with signs of respiratory failure (eg, slow or shallow breathing, low oxygen saturation) require emergency endotracheal intubation and mechanical ventilation. The nurse should provide respiratory support (eg, ventilation with a bag-valve-mask) and prepare to assist with intubation (Option 4). (Option 1) Clients with myxedema coma require thyroid hormone replacement with IV levothyroxine to correct the hypothyroid state but only after respiratory status is secured. Improvement in clinical status may not occur for up to a week after initiation of hormone replacement. (Option 2) A serum thyroid panel (eg, TSH, triiodothyronine, thyroxine) is required to confirm hypothyroidism, and these measurements should be monitored during treatment; however, the nurse should ensure that the client is stable before reviewing laboratory values. (Option 3) A warming blanket should be placed on the client to treat hypothermia; however, respiratory support is the priority. Educational objective: Myxedema coma is a state of severe hypothyroidism and decreased level of consciousness that may progress to coma and respiratory failure. The nurse should provide respiratory support (eg, ventilation with a bag-valve-mask) and prepare to assist with intubation.

Which client is at "greatest risk" for respiratory depression when receiving opioids for pain control? 1. 20-year-old client with bronchitis receiving inhaled bronchodilator therapy every 4 hours 2. 30-year-old client with heroin addiction with rotator cuff repair surgery this morning 3. 50-year-old client with sleep apnea and left foot cellulitis and scheduled for a bone scan 4. 70-year-old client with chronic obstructive pulmonary disease (COPD) with knee replacement this morning

Answer: 4 The following are at greatest risk for respiratory depression related to opioid use for analgesia: the elderly; those with underlying pulmonary disease, history of snoring (with or without apnea), obesity, or smoking (more than 20-pack-year history); the opiate naïve, especially if treated for acute pain; and post surgery (first 24 hours). The 70-year old client has 3 significant risk factors: advanced age, COPD, and surgery within 24 hours. COPD clients who have hypercarbia and hypoxemia are at even greater risk for respiratory depression when receiving opioids. (Option 1) This client has 1 risk factor, pulmonary disease. (Option 2) This client has 1 risk factor, surgery within 24 hours. His addiction to heroin gives him a higher tolerance for opioids. (Option 3) This client has 1 risk factor, sleep apnea. Educational objective: Factors that increase risk for respiratory depression related to opioid use for pain control include advanced age, underlying pulmonary disease, snoring, obesity, smoking, opiate naïve, and surgery.

A client with a mandibular fracture who has the upper and lower teeth wired together begins to choke on excessive oral secretions. What is the nurse's immediate action? 1. Cut the wires 2. Elevate the head of the bed 3. Notify the health care provider 4. Suction the mouth and oropharynx

Answer: 4 The priority for a client with a mandibular fracture whose teeth have been wired together is maintaining a patent airway. If the client begins to choke on oral secretions, the nurse should immediately attempt to clear the airway by suctioning via the oral or nasopharyngeal route. If this intervention is ineffective, cutting the wires may be necessary. (Option 1) Cutting the wires can cause collapse of the fractured jaw and exacerbate the airway problem. This action is not the first priority unless the situation is an emergency (eg, acute respiratory distress, cardiopulmonary arrest requiring intubation). A wire cutter must be taped to the head of the client's bed at all times, including during travel. (Option 2) Elevating the head of the bed is a preventive measure. Because the client is choking, the priority is suctioning secretions to clear the airway. The nurse should also turn the client to the side if the client has excessive oral secretions or begins to vomit to decrease the risk of aspiration. (Option 3) The nurse should intervene to maintain the airway before calling the health care provider. A prescription for nasogastric suction to decompress the stomach may be indicated to reduce the risk of vomiting. Educational objective: Maintaining a patent airway is the priority for clients with mandibular fractures who are unable to open their mouths. If choking occurs, the immediate intervention is to suction the mouth and oropharynx. If this is ineffective, cutting the wires may be necessary.

The nurse educates a 30-year-old female client who is being evaluated for hyperthyroidism with a radioactive iodine uptake (RAIU) test. Which instruction(s) should the nurse include in the teaching plan? 1. "A pregnancy test must be obtained prior to RAIU rest administration" 2. "All jewelry or metal around the neck area should be removed before the RAIU test" 3. "Antithyroid medications should held for 5-7 days before the RAIU test" 4. "Conscious sedation will be used to help with relaxation during the RAIU test" 5. " It is important to refrain from eating or drinking for at least 12 hours before the RAIU test."

Answers: 1, 2, 3 A RAIU test involves administering a low dose of radioactive iodine, in contrast to radioactive iodine treatment for some types of thyroid cancer, which uses a high dose to destroy all thyroid tissue. The thyroid gland is the only tissue that uses iodine, which is a key component of thyroid hormones. A scan is performed at 2, 6, and 24 hours to assess the areas actively absorbing iodine, which can narrow the diagnosis to hyperfunctioning thyroid disorders (eg, Graves' disease). Important nursing considerations: - Notify the primary health care provider (PHCP) if computerized tomography scan or other recent x-ray using iodine contrast has been performed; the iodine may alter the test results. - Antithyroid or thyroid hormone medication should be held for 5-7 days before undergoing a RAIU test as these can also alter results. - All premenopausal women must take a pregnancy test before the procedure, as radioactive iodine could adversely affect the development of the fetal thyroid gland. Important aspects of client education: - Maintain nothing by mouth (NPO) status for 2-4 hours prior to the procedure (Option 5). Eating may resume 1-2 hours after swallowing the iodine; a normal diet can be restarted when the test ends. Remove dentures and jewelry/metal around the neck to allow clear visualization during the scan. - Drink plenty of fluids after the procedure to clear RAI from the system. Notify the PHCP if you are allergic to any medications (eg, iodine). However, a RAIU test is generally safe (even in the presence of an iodine allergy) due to the diminutive amount of iodine used. - You will be awake during the procedure but there should be no discomfort (Option 4). - Do not breastfeed immediately after this procedure, and ask your PHCP when breastfeeding may resume. Educational objective: RAIU measures the metabolic activity in the thyroid gland in order to differentiate between the many types of thyroid disorders. For an accurate measurement, medications affecting the thyroid should be held 7 days prior to the test date and clients are NPO for 4 hours prior to iodine administration. Premenopausal women must take a pregnancy test. Dentures, metal, and jewelry should be removed.

A newly admitted client describes symptoms of dizziness and feeling faint on standing. The client has a history of type 2 diabetes, coronary artery disease, and bipolar disorder. Which medications may be contributing to the client's symptoms? Select all that apply. 1. Atorvastatin 2. Metformin 3. Metoprolol 4. Olanzapine 5. Omeprazole

Drugs commonly associated with orthostatic hypotension include: 1. Most antihypertensive medications, particularly sympathetic blockers such as beta blockers (e.g metroprolol) and alpha blockers (e.g terazosin) (option 3) 2. Antipsychotic medications (e.g clanzipine, resperidone) and antidepressants (e.g selective serotonin reuptake inhibitors) (options 4) 3. Volume-depleting medications such as diuretics (e.g furosemide, hydrochlorothiazide) 4. Vasodilator medications (e.g nitroglycerine, hydralazine) 5. Narcotics (e.g morphine) Clients at risk for developing orthostatic hypotension should be instructed to: 1. Take medications at bedtime, if approved by the health care provider 2.Rise slowly from supine to standing position, in stages (especially in the morning) 3. Avoid activities that reduce venous return and worsen orthostatic hypotension (e.g straining, coughing, walking in hot weather) 4. Maintain adequate hydration (Option 1) Muscle cramps & liver injury, not orthostatic hypotension, are the major adverse effects of statin medications (e.g astorvastatin) (Option 2) Major side effects of metformin are lactic acidosis and gastrointestinal disturbances (metallic taste in the mouth, nausea, and diarrhea). Unlike insulin, metformin does not usually cause hypoglycemia. Orthostatic hypotension is not a common side effect. (Option 5) Proton pump inhibitors (eg, omeprazole) are associated with increased risk of pneumonia, Clostridium difficile diarrhea, and calcium malabsorption (osteoporosis), but not orthostatic hypotension. Educational objective: Medications commonly associated with orthostatic hypotension include most antihypertensives, most antipsychotics and antidepressants, and volume-depleting agents. Clients are instructed to rise slowly when standing to prevent a drop in blood pressure.

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

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