Study set 1 for RN NCLEX (Kaplan)

The nurse provides care to a client diagnosed with a terminal illness. In which order will the nurse expect the client to demonstrate the stages of grief as described by Elisabeth Kubler-Ross? (Please arrange in order. All options must be used.) 1. Bargaining 2. Acceptance 3. Denial 4. Depression 5. Anger

According to K übler-Ross, the first stage of grief is denial, which is exemplified by shock and disbelief. The second stage is anger. During this stage, the client expresses anger with life choices that caused the disease or actions taken to prevent disease which were ineffective. The third stage is bargaining. That is when the client agrees to change behavior in order to prolong life. The fourth stage is depression. During this stage, the client finally believes that nothing will change the situation. This can lead to tremendous sadness. The final stage is acceptance, as the client accepts that death will occur and takes steps to prepare for the final stage of living. *Think Like A Nurse: Clinical Decision Making* When planning care for a client who is diagnosed with a terminal illness, the nurse must be aware of the stages of grief that often occur. Being aware of these stages, and when to expect them, allows the nurse to provide anticipatory guidance when a terminal diagnosis occurs. While these stages occur in a linear fashion, there is no timetable that can be given when asked about how long each stage should last. *Content Refresher* Loss occurs when a valued person, object, or situation is changed or becomes inaccessible. Grief is an internal emotional reaction to loss. The expected outcome is for individuals to understand the stages of the grieving process and resolve their grief after a suitable time of mourning and be able to resume meaningful life roles and activities.

The charge nurse notes problematic nurse-client interactions when the nurse is assigned a client who is a survivor of sexual abuse. The charge nurse learns that the nurse was sexually abused as a child. The charge nurse takes which action when making assignments? 1. Organize the nurse's assignments to include clients who have been sexually abused to promote a therapeutic environment. 2. Create the nurse's assignments as is normally done and request that the nurse begin outpatient counseling. 3. Assign the nurse to clients who do not have a history of sexual abuse so that the nurse is able to interact therapeutically. 4. Inform the nurse that clients with a psychiatric diagnosis will no longer be assigned due to the history of sexual abuse.

The charge nurse notes problematic nurse-client interactions when the nurse is assigned a client who is a survivor of sexual abuse. The charge nurse learns that the nurse was sexually abused as a child. The charge nurse takes which action when making assignments? 1. Organize the nurse's assignments to include clients who have been sexually abused to promote a therapeutic environment. 2. Create the nurse's assignments as is normally done and request that the nurse begin outpatient counseling. 3. Assign the nurse to clients who do not have a history of sexual abuse so that the nurse is able to interact therapeutically. 4. Inform the nurse that clients with a psychiatric diagnosis will no longer be assigned due to the history of sexual abuse. View Explanation The correct answer is 3 . You answered 3. Explanation Step-by-Step Walkthrough 1) INCORRECT - The charge nurse considers the abilities of each staff member and should not assign the nurse to clients that the nurse is having difficulty caring for in a therapeutic way. 2) INCORRECT - The nurse should receive counseling to deal with unresolved issues. Client care should not be jeopardized while the nurse is in therapy by allowing continued care. 3) CORRECT— Assign the nurse to clients who the nurse is able to deal with in a therapeutic way. 4) INCORRECT - The charge nurse cannot dismiss the nurse from all psychiatric nursing duties based on this information. *Think Like A Nurse: Clinical Decision Making* While nurses are expected to deliver quality, non-judgmental client care, nurses are also humans who deserve reasonable accommodations when a conflict arises. In this case, situation-specific problematic behaviors have been noted. The charge nurse's responsibilities include making fair, reasonable client assignments. When determining a nurse's suitability to provide client care to a specific client, factors that must be considered are both technical and psychosocial in nature. For example, the nurse whose parent recently passed away due to lung cancer may be emotionally overwhelmed by caring for a client who is diagnosed with end-stage lung cancer. Likewise, ethical considerations have an impact on client assignments. For example, a nurse who objects to administering chemotherapy to aid in a nonviable pregnancy termination is not assigned to provide care to a client undergoing this procedure. *Content Refresher* Objectives of therapeutic communication include establishing a trusting, effective, client-centered, goal-directed, professional nurse-client relationship. Use therapeutic communication to assess the client's personal strengths and weaknesses. Assess the client and family communication for strengths, weaknesses, and potential or actual barriers to communication. Determine language, cultural, and literacy barriers to effective communication. Evaluate any environmental factors that could detract from establishment of a trusting nurse-client relationship.

The nurse instructs a client who is prescribed clozapine. Which client statement indicates to the nurse that the teaching session was successful? 1. "I will contact the doctor for a sore throat or fever." 2. "I am taking clozapine because I have an anxiety disorder." 3. "I will monitor my blood glucose level daily." 4. "I can breast feed my baby while taking clozapine."

The nurse instructs a client who is prescribed clozapine. Which client statement indicates to the nurse that the teaching session was successful? 1. "I will contact the doctor for a sore throat or fever." 2. "I am taking clozapine because I have an anxiety disorder." 3. "I will monitor my blood glucose level daily." 4. "I can breast feed my baby while taking clozapine." View Explanation Explanation Step-by-Step Walkthrough 1) CORRECT— Clozapine is a medication that has the potential to suppress bone marrow and cause agranulocytosis. This potentially fatal side effect occurs in 1 to 2% of clients. 2) INCORRECT— Clozapine is an antipsychotic used for the treatment of schizophrenia, not an anxiety disorder. 3) INCORRECT— The health care provider will monitor the CBC, specifically the client's WBC count. Clozapine will be discontinued if the WBCs fall below 2000/mm 3. Daily blood glucose monitoring is not a requirement for clozapine unless the client has a concurrent diagnosis of diabetes mellitus. 4) INCORRECT— Clozapine is excreted in breast milk, so breast feeding is contraindicated. *Think Like A Nurse: Clinical Decision Making* Client education is an expected competency for every nurse. An essential first step is to assess the client's teaching and learning needs, including literacy issues. Health literacy has been shown to be a stronger predictor of health status than age and educational level. For optimal comprehension and compliance, education materials should be written at a sixth-grade or lower reading level, preferably including pictures and illustrations. The nurse should always use the teach-back method. The client should be encouraged to ask questions. Clozapine is an atypical antipsychotic agent. It is not likely to cause extrapyramidal syndrome (EPS). Serious side effects include seizure and agranulocytosis. *Content Refresher:* Medication administration is the process by which prescribed medications are safely dispensed to a client. The nurse needs to teach the client about the medication, the reason for its administration, how and when effectiveness will be determined, and possible adverse effects . In addition, the nurse needs to educate the client about contacting the health care provider if experiencing adverse effects to the medication.

The nurse prepares to administer the influenza vaccine to a client. Which client statement concerns the nurse? 1. "I am allergic to neomycin." 2. "I am allergic to penicillin." 3. "I am allergic to shellfish." 4. "I am allergic to eggs."

The nurse prepares to administer the influenza vaccine to a client. Which client statement concerns the nurse? 1. "I am allergic to neomycin." 2. "I am allergic to penicillin." 3. "I am allergic to shellfish." 4. "I am allergic to eggs." View Explanation Explanation Step-By-Step Walkthrough 1) INCORRECT — This is not a concern for administering the influenza vaccine. An allergy to neomycin is a contraindication for receiving other vaccines, such as the varicella vaccine. 2) INCORRECT — This is not a concern for administering the influenza vaccine. Having an allergy to penicillins raises the concern of a potential cross-allergy to cephalosporins. 3) INCORRECT — This is not a concern for administering the influenza vaccine. This would be a contraindication to diagnostic testing using iodine-based dyes. 4) CORRECT— An allergy to eggs is a contraindication to the flu vaccine. The nurse should not administer the standard vaccination. *Think Like a Nurse: Clinical Decision-Making* Before administering any prescribed medication, the nurse needs to identify drug allergies, possible drug and/or food interactions, and recognize when a medication is contraindicated. The influenza vaccine is incubated in a medium that contains egg proteins. Because of this, the nurse knows that a person with an egg allergy should not receive this vaccination. Other circumstances that contraindicate the use of the influenza vaccine include a history of previous allergic reaction and Guillain-Barré Syndrome (GBS). While it is usually okay for a client to receive the influenza vaccine when experiencing a mild illness, it may be appropriate to ask the client to return for the vaccine once he or she is feeling better to decrease the likelihood of a reaction. *Content Refresher* The influenza vaccine is recommended every flu season. The number of doses is contingent on the client's age and health status; however, it is recommended that everyone needs at least one dose per season. There are many strains of the flu virus and they are constantly changing; therefore, a new flu vaccine is made annually to protect against three or four virus strains. With any medication, including the influenza vaccine, there is a chance of reactions. These reactions are usually mild, but serious reactions are also possible. The influenza vaccine does not provide automatic protection from the flu as it takes approximately 2 weeks for protection to develop. Once developed, the protection lasts for the duration of the current flu season.

The nurse provides care for the client receiving radiation therapy for breast cancer. Which client statements indicate to the nurse that further intervention is needed due to the effects of radiation? (Select all that apply.) 1. "I'm having trouble swallowing these days." 2. "I need to work from home most days." 3. "I have not moved my bowels in three days." 4. "I seem to have a rash under my arm." 5. "I have been pulling my hair out in clumps."

1) CORRECT - Difficulty swallowing indicates pain and/or swelling and requires further intervention. Radiation therapy causes inflammation of nearby epithelial cells, and this can result in further consequences such as malnutrition. 2) CORRECT - This statement may indicate fatigue, a common side effect of radiation therapy. If the fatigue is severe enough to interfere with daily activities, further assessment and possible intervention is warranted. 3) INCORRECT - Constipation is a side effect of radiation to the abdominal area or chemotherapy. Irradiating the chest area is not related to this symptom. 4) CORRECT - Redness or desquamation can occur from radiation and can be severe if not managed properly. At a minimum, the nurse must assess that the client is not using deodorant or applying commercial lotions to the area. 5) INCORRECT - Alopecia is related to systemic chemotherapy or local radiation of the head. If the client is losing hair this needs evaluation, but is not related to effects of the radiation. *Think Like a Nurse: Clinical Decision-Making* Effects of radiation therapy vary according the type and length of treatment. The nurse should teach the client and family about the treatment regimen, supportive care options (e.g., anti-emetics), and what to expect during the course of treatment. The client should be taught which signs and symptoms to report to the provider indicating potential complications (e.g., fever and increasing fatigue). Teaching should be customized to meet the client's needs. *Content Refresher* External beam radiation therapy is a form of cancer treatment that uses highly charged electrons to penetrate malignant tumors with pinpoint accuracy. With external radiation, the nurse needs to anticipate skin changes, possible nausea, and fatigue. The nurse should also monitor for signs of infection.

The nurse instructs a client who is prescribed furosemide. Which client statement indicates that additional teaching is required? 1. "I will take my medicine early in the day." 2. "I will contact the doctor if I feel dizzy." 3. "I will take my medicine with meals." 4. "I will avoid orange juice and bananas."

1) INCORRECT - This medication (a loop diuretic) should be taken early in the day so that sleep will not be disturbed by increased urination. 2) INCORRECT - Furosemide is a loop diuretic that may cause orthostatic hypotension. The client should be instructed to rise slowly. 3) INCORRECT - Taking furosemide with meals minimizes gastrointestinal upset. 4) CORRECT— Furosemide is a loop diuretic that is potassium wasting. The client should be encouraged to increase the intake of potassium-rich foods, such as orange juice and bananas. *Think Like A Nurse: Clinical Decision Making* When teaching about a medication, the nurse needs to keep in mind the purpose for the medication and any actions to prevent the development of side or adverse effects. Furosemide is a loop diuretic that does not save potassium from being excreted from the body through the urine. The client should be instructed to ingest foods that are rich in potassium, which include bananas and orange juice. The client's statement to avoid these food items indicates that teaching has not been effective. *Content Refresher* Hypokalemia is a serum potassium level less than 3.5 mEq/L. Risk factors for hypokalemia include gastrointestinal losses such as vomiting or diarrhea, nasogastric suctioning, potassium excreting diuretics such as furosemide, corticosteroids, and malnutrition. If a client is at risk for hypokalemia, the nurse needs to educate the client about increasing potassium-rich foods, along with taking a prescribed oral potassium supplement. The nurse should monitor the client's potassium levels and collaborate with the health care provider regarding treatments to increase potassium levels.

The nurse visits the home of a client diagnosed with gout. Which client comment causes the nurse concern during the assessment process? 1. "I am losing three pounds per week." 2. "I drink eight glasses of liquid per day." 3. "I am eating more whole grains and fresh fruits." 4. "I do not drink alcoholic beverages anymore."

1) CORRECT - If the client is overweight, a weight loss of 0.5 to 1 lbs (0.23 to 0.5 kg) per week is appropriate. Excessive weight loss may precipitate gouty arthritis. 2) INCORRECT - The client should be drinking eight glasses of liquid per day. 3) INCORRECT - The client should be increasing the intake of whole grains and fresh fruit. 4) INCORRECT - The client with gout should refrain from ingesting alcohol. *Think Like A Nurse: Clinical Decision Making* Before responding to the client's comment, the nurse should recall the pathophysiological process of gout, which is a buildup of uric acid causing swelling and discomfort in the joints and soft tissue. Knowledge of anatomy and physiology provides the nurse with an understanding that if body weight is lost too quickly, the body is unable to rid itself of the uric acid that is created as a byproduct of metabolism. This condition can precipitate an exacerbation of the gout. The nurse should explain this process to the client, reinforce the recommended diet to prevent excessive uric acid in the body, praise the client on the weight loss, but reinforce the need to lose excess pounds slowly. *Content Refresher:* Gout is a disease in which elevated serum uric acid levels result in crystal deposits in joints and surrounding tissue causing inflammation and pain. Associated risk factors for the development of gout include obesity, excessive alcohol consumption, use of thiazide diuretics, use of beta blockers, use of ACE inhibitors, postmenopausal hormonal changes, and use of immunosuppressive agents post transplant. Allopurinol, a uric acid lowering agent, may be prescribed for chronic gout. However, acute gout is not treated with a uric acid lowering agent since a rapid change in uric acid levels may increase the severity of or cause an attack. The nurse should assist the client with immobilization of an affected joint and discuss the need to avoid foods with high purine content (e.g. red meat and shellfish).

After being admitted involuntarily to a mental health facility, a client with a history of assault calls the nurse a "racist bigot." Which action is the most appropriate for the nurse to make? 1. Leave the room after informing the client of returning in 30 minutes. 2. Ask another nurse of the same ethnic background as the client to provide care. 3. Remain sitting quietly until the client is ready to cooperate. 4. Ignore the client's comment and provide care.

1) CORRECT - The history of assault makes this client potentially violent. The nurse's safety is a priority. The nurse should provide the client with time to calm down. 2) INCORRECT - Asking someone else to provide care is inappropriate. It will validate the client's remark and set the stage for staff splitting. 3) INCORRECT - Staying in the room is inappropriate at this time. The client needs time alone to grasp the situation. 4) INCORRECT - Ignoring the comment may intensify the client's anger and make the nurse the target of violence. *Think Like A Nurse: Clinical Decision Making* Because the client has a history of assault, the nurse should leave the room. The client is clearly agitated and could easily become aggressive. Ignoring the comment and staying in the room to provide care could be dangerous for the nurse. *Content Refresher* A crisis is specific event in which a client is unable to cope. This may be due to ineffective coping, which leads to increased stress, decreased resources, and inability to prevent the specific event. During a crisis, there is an initial period of shock, followed by an inability to function, and then a tremendous emotional response. Because of the emotional response, the nurse needs to determine if the client is at risk for physical violence to self or others and initiate appropriate safety measures.

During a well-child checkup, the parent of a two children (2 and 4 years of age) appears tired and frustrated. The parent states, 'I feel like I have been on a whirlwind for over a year. I never thought two children could be so much work. If I have to discipline by kids one more time, I think I will scream! ' Which response by the nurse is most appropriate? 1. 'Tell me about the types of limits you are setting for each child. ' 2. 'Have you thought about preschool for your children? ' 3. 'As they grow, you will miss these busy days with them. ' 4. 'Do you and your spouse agree on the use of time-out?

1) CORRECT - This is an open-ended question that allows the parent to talk more about the limits for each child. This will open further discussion about options. 2) INCORRECT- This is a closed-ended question and does not acknowledge the expressed concerns of the parent. 3) INCORRECT- This discourages further communication and is rather patronizing. It may even convey that the parent should feel guilty about feeling overwhelmed and frustrated. 4) INCORRECT - This is a closed-ended question. It may be useful to explore this topic, but the nurse should first explore the client's expressed concerns. *Think Like A Nurse: Clinical Decision Making* Since the parent is tired and frustrated, the nurse may be able to help the parent with the situation. However, before offering suggestions, the nurse needs to assess what the parent means by 'discipline. ' The best way to assess for this information is to use an open-ended question. Once the discipline and limits are identified, the nurse can proceed with strategies or alternatives for the parent to effectively deal with the toddler and preschool age children's behaviors. *Content Refresher* The nurse should use therapeutic communication skills when responding to the parent's concerns. These include: 1) being silent, 2) showing acceptance, 3) providing recognition, 4) offering self, 5) using broad openings, 6) providing leads and encouragement, 7) timing events, 8) focusing, 9) asking about thoughts and feelings, 10) encouraging comparisons, 11) restating and reframing, 12) reflecting, 13) presenting reality, 14) sharing observations, 15) clarifying meaning, 16) expressing doubt, 17) interpreting feelings, and 18) formulating a plan for care. The nurse avoids non-therapeutic techniques such as reassuring, rejecting, approving/disapproving, agreeing/disagreeing, giving advice, belittling, stereotyping, probing, or using denial.

The nurse reviews prescriptions for a newly admitted client. Which prescriptions does the nurse clarify with the health care provider? ( Select all that apply.) 1. Famotidine 20 mg PO qd. 2. Docusate 100 mg PO twice daily. 3. Captopril 25.0 mg PO every 8 hours. 4. MS ER 30 mg PO twice daily. 5. Tetracycline 250 mg PO four times daily.

1) CORRECT — The abbreviation for daily, "qd," is on the Do Not Use abbreviation list from The Joint Commision. Abbreviations qd (daily) and qod (every other day) are often mistaken for each other. 2) INCORRECT— The docusate prescription is correctly written. 3) CORRECT — The use of a trailing zero is on the Do Not Use abbreviation list from The Joint Commission. If the period is missed, the client receives 10 times the prescribed dosage. 4) CORRECT — The abbreviation for morphine sulfate, "MS," is on the Do Not Use abbreviation list from The Joint Commission because it could also indicate magnesium sulfate. The abbreviation "ER" is not common and should not be used. 5) INCORRECT— The number of times a medication is prescribed daily should be written out. *Think Like A Nurse: Clinical Decision Making* Medication safety is a priority in health care. The Joint Commission has published a list of "Do Not Use" abbreviations. This includes Q.D., QD, q.d., qd (daily),Q.O.D., QOD, q.o.d, and qod (every other day). Lack of leading zero (.X mg) or the use of a trailing zero (X.0 mg) is also prohibited due to the risk of overdosing a client. Typically, this list is posted in the medication room or in high traffic areas for nurses and providers. The official "Do Not Use" list applies to all orders and all medication-related documentation that is handwritten (including free-text computer entry) or on pre-printed forms. *Content Refresher* Documentation serves as the primary source of information by which to monitor adherence to standards of care by nurses and members of the interdisciplinary health care team. Effective documentation is accurate, thorough, legible, and well-organized. Documentation should be timely, contain proper grammar and spelling, and use only authorized abbreviations.

The home care nurse visits an older adult Asian-American woman diagnosed with hypertension and heart failure. Which observation is important for the nurse to follow up? 1. The client is 5 feet tall and weighs 100 lb (45 kg). 2. The client eats whole grains and fresh fruits and vegetables. 3. The client walks 2 miles three times per week. 4. The client abstains from alcohol.

1) CORRECT — The client is at risk for developing osteoporosis because of gender, age, ethnicity, and small body frame. The nurse should encourage the client to increase foods high in calcium and perform weight-bearing exercise regularly. 2) INCORRECT — This is an appropriate diet for hypertension. 3) INCORRECT — This is an appropriate action. Weight-bearing exercises increase bone density, although the nurse should encourage clients with osteoporosis to avoid bowling or other high impact forms of activity. 4) INCORRECT — Abstaining from alcohol is appropriate, as alcohol promotes acidosis, which increases bone reabsorption. *Think Like A Nurse: Clinical Decision Making* The nurse evaluates physical assessment findings and lifestyle choices to identify safety concerns. The nurse should counsel the client on actions to reduce the risk of bone loss, including adequate calcium intake and performing weight-bearing exercises. Provide information about sources of vitamin D, such as fatty fish, egg yolks, fortified cereals, orange juice, and yogurt; vitamin D is needed for calcium absorption. Advise the client to take 10 to 20 mcg of vitamin D in supplement form if serum level is low. If the client takes antacids, encourage the use of those that contain calcium. Educate the client about prescribed medications for osteoporosis, if applicable. Provide safety information to prevent falls/injuries. *Content Refresher* Osteoporosis is a condition in which bone density is lost. Risk factors for osteoporosis include estrogen deficiency, older age, female gender, Caucasian or Asian heritage, family history, inactivity, lack of exposure to sunlight, slight stature, low body weight, poor nutrition, bariatric surgery, smoking, excess alcohol intake, prolonged use of corticosteroids, anticonvulsant medications, hyperthyroidism, hyperparathyroidism, malabsorption syndromes, breast cancer, and lactose intolerance.

The nurse prepares to assess an adolescent during a visit to the clinic for a sports physical examination. Which developmentally appropriate intervention does the nurse include with an adolescent? 1. Allow time for questions without the parent present in the room. 2. Expose the entire body to allow for a quick examination. 3. Allow adolescent females to keep their bra on during the examination. 4. Remain in the examination room while the adolescent undresses.

1) CORRECT-The nurse allows time for questions without the parent present in the room. This intervention gives the adolescent an opportunity to ask sensitive questions that they might not feel comfortable asking in front of a parent. 2) INCORRECT- The nurse performs a head-to-toe assessment, exposing only the area to be examined. Privacy is a significant concern for adolescents. 3) INCORRECT- The nurse asks the adolescent female to remove the bra so the nurse can assess for scoliosis and examine the breasts. 4) INCORRECT- The nurse provides privacy by leaving the examination room while the adolescent undresses and puts on a gown. *Think Like A Nurse: Clinical Decision Making* An adolescent client must have time alone with the nurse and health care provider to discuss health care needs privately and for the nurse to be able to teach about important issues (such as sexuality) without embarrassing the client. Certain sex-related issues are protected topics between the health care team and the client. The nurse can make no assumptions about the adolescent-parent relationship. While some clients will be comfortable discussing private issues with parents present, most will not be comfortable. To optimize the client's health care visit, the nurse must ensure an opportunity for private conversation with the adolescent client. *Content Refresher* Assess the adolescent's psychosocial development. Adolescents should be transitioning to Erikson identity versus the role confusion stage. Determine mental health issues or concerns. Determine the need for immunizations and currency of dental, vision, and hearing screenings. Provide the client education about healthy living (e.g., nutrition, exercise, sleep patterns, and personal habits) and avoiding high-risk behaviors (e.g., use of tobacco, alcohol, or drugs; risky sexual practices). If high-risk behaviors are identified, intervene appropriately. Encourage interaction with peer groups that align with moral and spiritual values. Obtain a room to promote privacy when interviewing, examining, and educating the adolescent.

The nurse provides care for a client admitted with weakness, confusion, and hypoactive bowel sounds. The client's lab results reveal sodium 140 mEq/L (140 mmol/L), ionized serum calcium 4.7 mEq/L (1.2 mmol/L), potassium 1.8 mEq/L (1.8 mmol/L), and blood glucose 110 mg/dL (6.1 mmol/L). Which action does the nurse initiate first? 1. Place the client on a cardiac monitor. 2. Place the client on 2 L/min of oxygen. 3. Administer potassium chloride (KCl) 20 mEq/hour. 4. Offer the client 240 mL of orange juice.

1) CORRECT— A decreased potassium level can result in cardiac dysrhythmia. Place the client on a monitor while preparing to administer the prescribed potassium chloride. A normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.1 mmol/L). 2) INCORRECT - The priority is to place the client on a monitor to assess for dysrhythmia. There is no indication the client is having trouble with breathing or oxygenation or requires the use of supplemental oxygen. 3) INCORRECT - Because a decreased potassium level can result in cardiac dysrhythmia, the nurse will first place the client a cardiac monitor and monitor vital signs. Then the nurse will administer KCL as prescribed. 4) INCORRECT - The nurse's first action is to place the client on a cardiac monitor to assess for the presence of dysrhythmias resulting from the critically low potassium level. Although orange juice is a good source of potassium, this client requires a combination of oral and IV potassium to stabilize the potassium level more rapidly. *Think Like A Nurse: Clinical Decision Making* The nurse needs to know the manifestations and implications that are identified through laboratory test results. The nurse should first analyze each blood test result and then determine which is abnormal. Of the tests listed, the potassium level is critically low, and the nurse should recognize that a low potassium level can cause life-threatening cardiac dysrhythmias. Because of this, the client should be immediately placed on continuous cardiac monitoring before administering the prescribed potassium replacement. *Content Refresher* Hypokalemia is caused by decreased dietary intake, increased loss or a shift into the cells that can occur with alkalotic conditions, and the use of loop and thiazide diuretics. Gastrointestinal losses such as vomiting or diarrhea, nasogastric suctioning, potassium excreting diuretics, corticosteroids (drugs that retain sodium and therefore decrease potassium), malnutrition, or dietary lack of foods high in potassium. When caring for a client with hypokalemia, the nurse should assess for muscle weakness or paresthesias. Assess electrocardiographic changes such as U-wave or rhythm changes. Ask patient about symptoms such as palpitations. Treatment depends on severity of level and symptoms present. Supplemental potassium (oral or intravenous) is administered. Client should be taught about foods high in potassium, and if daily supplemental oral medications are needed, education about the medications should be included.

Following a train accident, the nurse triages a group of victims. When the nurse asks how one of the clients is feeling, the client states matter-of-factly, "Look at all the rescue trucks. It 's like watching a movie. " Which defense mechanism does the nurse identify that the client is using? 1. Dissociation. 2. Regression. 3. Projection. 4. Denial.

1) CORRECT— Dissociation is an unconscious separation of painful feelings from a difficult situation, idea, or object. The client is focusing on what is happening around them, not to them. 2) INCORRECT - Regression is a return to an earlier level of development and the comfort measures associated with that level of functioning. 3) INCORRECT - Projection is attributing one 's own feelings that are unacceptable to someone else, or blaming someone else for one 's own problems. 4) INCORRECT - Denial is an unconscious refusal to admit an unacceptable idea or behavior or the feelings associated with it. *Think Like A Nurse: Clinical Decision Making* The nurse understands exposure to trauma can cause an immediate stress reaction. The client who experiences an unexpected event may not "believe" that the event occurred and react as if the event is happening to someone else. The nurse knows this type of defense mechanism protects the psyche from becoming overwhelmed with the reality of the situation. The client's physical needs should be assessed and orientation to the reality of the situation attempted slowly, so as not to overwhelm the client and cause complete psychological collapse. *Content Refresher* Stress is an emotional or mental strain or concern about a situation or difficult circumstance. When an individual is stressed, coping mechanisms are used. Coping mechanisms are behaviors, thoughts, or feelings that enhance control or bring psychological comfort to a person experiencing stress. There are positive coping mechanisms and negative coping mechanisms. If an individual is unable to manage stress through the use of coping mechanisms, defense mechanisms may be initiated.

The nurse provides care to a client in labor. The baseline fetal heart rate (FHR) is 150-160 beats/min. At the start of a contraction, the FHR decreases to 125 beats/min. The FHR returns to baseline when the contraction ends. Which action does the nurse implement? 1. Continue to monitor the FHR. 2. Turn the client to the left side. 3. Prepare for cesarean delivery. 4. Administer O 2 by face mask at 8 L/min.

1) CORRECT— Early decelerations, which are considered a reassuring FHR pattern, usually represent a normal finding. Early decelerations occur as a result of fetal head compression secondary to uterine contractions. Continued monitoring is indicated. 2) INCORRECT - Positioning the client to the left side, which increases placental perfusion, is an appropriate intervention in response to a nonreassuring FHR pattern. Examples of nonreassuring FHR patterns include absent baseline variability, recurrent late decelerations, and recurrent variable decelerations. Early decelerations are a reassuring FHR and indicate the need for continued monitoring. 3) INCORRECT - Anticipation of cesarean section is an appropriate plan in response to a nonreassuring fetal heart tone pattern, such as absent baseline variability, recurrent late decelerations, and recurrent variable decelerations. However, early decelerations are a reassuring FHR pattern that warrant continued monitoring. 4) INCORRECT - Administration of O 2 by face mask at 8-10 L/min is an appropriate intervention in response to a nonreassuring FHR pattern, such as absent baseline variability, recurrent late decelerations, and recurrent variable decelerations. The client who demonstrates early decelerations, which are a reassuring FHR pattern, should be monitored. *Think Like A Nurse: Clinical Decision Making* The fetal heart rate should remain steady between 120 and 160 beats/min, fluctuating with contractions. If the heart rate does not fluctuate with contractions, decreases below 120 beats/min for a few minutes, or the heart rate repeatedly decelerates after the contraction, the nurse intervenes immediately. Decelerations refer to the decrease in the fetal heart rate in response to contractions. Fetal heart rate is controlled by the autonomic nervous system. Early decelerations mirror the shape of the contraction and are a normal response. Late decelerations are a sign that the fetus is undergoing negative pathophysiological responses to contractions. *Content Refresher* The nurse must be able to interpret the various fetal heart rate (FHR) parameters to determine if the pattern is reassuring (indicating fetal well-being) or non-reassuring (indicating fetal problems) to care for the woman effectively during labor and birth. The nurse should educate the mother/family regarding the FHR monitoring procedure. Provide emotional support, answer questions, and allay anxieties. Assess baseline fetal heart rate and changes in rate and pattern. Monitor the mother's uterine contractions for frequency and duration and fetal response. Note fetal heart rate characteristics and patterns of accelerations and declarations.

The nurse in the newborn nursery receives report on a group of clients. Which client does the nurse assess first? 1. A 2-day-old client, quietly alert, heart rate of 185 beats per minute. 2. A 1-day-old client, crying, and the anterior fontanel is bulging. 3. A 12-hour-old client, respirations 45 and irregular. 4. A 5-hour-old client, hands and feet are blue bilaterally.

1) CORRECT— This newborn has tachycardia. The normal resting rate is 120 to 160 beats per minute, and this finding requires further investigation. 2) INCORRECT - Crying causes increased intracranial pressure; therefore, the anterior fontanel bulging is expected. 3) INCORRECT - The normal respiratory rate is 30 to 50 breaths per minute with apneic episodes. 4) INCORRECT - Acrocyanosis is normal for 2 to 6 hours post-delivery due to poor peripheral circulation. *Think Like A Nurse: Clinical Decision Making* Supraventricular tachycardia (SVT) is the most common arrhythmia diagnosed in pediatric clients. The newborn exhibiting tachycardia, especially at rest, requires further examination and should be seen by the nurse first. The nurse first compares the current readings with the baseline. Any abnormalities in vital signs during the neonatal period, especially with heart rate and respiration, may be indicative of infection. When assessing the newborn client, both the heart rate and respiratory rate should be counted for a full 60 seconds. The nurse should keep in mind that bradycardia in pediatric clients is an ominous sign, usually a result of hypoxia, requiring prompt intervention. *Content Refresher* Immediately after delivery, clamp the umbilical cord and assess the newborn 's Apgar score at the 1 and 5 minute mark (0 to 3 is poor, 4 to 6 is fair, 7 to 10 is normal). Assess for normal newborn vital signs (axillary temperature 97.7 ° to 99.7 °F [36.5 ° to 37.6 °C], heart rate 120 to 160 beats per minute while awake, respiration 30 to 60 breaths per minute, blood pressure 65/41 mm Hg). Assess for the presence of newborn reflexes (e.g., rooting and sucking, palmar grasp, plantar grasp, Moro, Babinski). Ensure prophylactic medications have been administered (e.g., eye prophylaxis and IM vitamin K).

The nurse assesses the breath sounds of a client experiencing shortness of breath. Which type of assessment is the nurse completing? 1. Body systems. 2. Focused. 3. Comprehensive. 4. Psychosocial.

1) INCORRECT - A body systems assessment examines a whole body system, not just a specific area or organ that has an identified problem. 2) CORRECT- In a focused physical assessment, the nurse assesses a specific body area to obtain data about an identified problem. 3) INCORRECT - A comprehensive physical assessment includes an interview and a complete examination of each body system. 4) INCORRECT - A psychosocial assessment addresses psychological and social factors affecting the client. *Think Like a Nurse: Clinical Decision-Making( The nurse is using the first step of the nursing process, which is assessment. There are different types of assessments that the nurse completes, all of which fulfill a specific purpose. A comprehensive assessment is usually the initial assessment and the one that serves as the baseline for the client. All newly gathered assessment data will be compared to the baseline to identify changes. Once the comprehensive assessment is completed, future assessments can be directed to address the body systems that are affected by a disease process or symptom. The assessment performed based on a disease process or symptom is a "focused" assessment. In this scenario, the nurse would focus the client's assessment on the respiratory system due to the manifestation of shortness of breath. *Content Refresher* Assessment is the careful observation and evaluation of a client's health status. It is the first step of the nursing process. A holistic assessment is necessary to obtain data that enables the nurse to make an accurate nursing diagnosis, identify and implement appropriate interventions, and assess their effectiveness. Assessment includes questioning the client regarding the chief complaint; history of the present illness; past medical history; family health history; health practices; health beliefs; and functional, psychosocial, and cultural status. The nurse should also conduct a physical assessment. Physical assessment techniques include inspection, palpation, percussion, and auscultation.

The nurse reviews laboratory reports for a client diagnosed with acute kidney injury who will begin prescribed hemodialysis treatment later today. The client is prescribed 3000 units epoetin alfa subcutaneous three times a week. Which laboratory report requires immediate notification of the health care provider? 1. Hematocrit 31% (0.31). 2. Hemoglobin 12 g/dL (120 g/L). 3. Serum potassium 6.2 mEq/L (6.2 mmol/L). 4. Platelets 154,000 mm 3 (154 x 10 9/L).

1) INCORRECT - A decrease in hematocrit is expected with acute kidney injury. 2) CORRECT— Healthy kidneys produce a hormone called erythropoietin (EPO). This hormones causes the bone marrow to make red blood cells, which then carry oxygen throughout the body. With acute kidney injury, the kidneys do not make enough EPO. As a result, the bone marrow makes fewer red blood cells, causing anemia. A hemoglobin of 12 g/dL (120 g/L) indicates anemia and is associated with a higher risk of thromboembolic events such as a stroke, myocardial infarction, and heart failure. 3) INCORRECT - An increase in serum potassium is expected with acute kidney injury and is being addressed by dialysis. 4) INCORRECT - Platelets are not affected by acute kidney injury. This number of platelets does not indicate an increased risk of bleeding. *Think Like a Nurse: Clinical Decision-Making* Evidence gathered during epoetin alfa injection trials indicated clients should experience a gradual and minimally necessary rise in hemoglobin levels while on this medication to avoid increased clot risk. The nurse considers the difference between hemoglobin and hematocrit. Hematocrit is a measure of the volume of red blood cells (RBCs) in the total blood volume, which includes plasma, RBCs, white blood cells (WBCs), and platelets. Hematocrit is measured as a percentage. Hemoglobin is a measure of the amount of hemoglobin in the blood. An increased hemoglobin level may be due to increased production of RBCs. An elevated RBC count is associated with an increased risk of clot formation. *Content Refresher* Epoetin alfa is prescribed to stimulate red blood cell production, but epoetin alfa is not intended for clients who require immediate correction of severe anemia. Once the target hemoglobin level approaches 12 g/dL (120 g/L), or if the hemoglobin level rises by more than 1 g/dL (10 g/L) in any 2-week period, the dosage should be decreased by 25%. However, the *threshold for a dosage decrease is lower for clients with chronic kidney disease and for clients receiving dialysis*. *For those clients, the dosage should be reduced or therapy interrupted once the hemoglobin level reaches or exceeds 11* g/dL (110 g/L).

The nurse administers carbamazepine to a client for trigeminal neuralgia. Which therapeutic effect does the nurse expect after administering this medication? 1. Relieve accompanying depression. 2. Reduce the possibility of tonic-clonic seizures. 3. Relieve agonizing pain. 4. Provide sedation.

1) INCORRECT - A reduction in depression may occur as a result of the diminished pain, but this is not the primary purpose of giving carbamazepine to the client. 2) INCORRECT - Seizures are not associated with trigeminal neuralgia. 3) CORRECT— The agonizing pain of trigeminal neuralgia may result in severe depression and suicide. Carbamazepine inhibits nerve impulses and reduces the pain of the condition. 4) INCORRECT - Sedation may occur as a result of the diminished pain, but this is not the primary purpose of giving carbamazepine. *Think Like A Nurse: Clinical Decision Making* Trigeminal nerve irritation associated with trigeminal neuralgia creates shocklike facial pain. Unfortunately, nerve pain is difficult to manage. Often, comfort measures and avoiding triggers that irritate the nerve are the only treatment options. Anticonvulsant medications, such as carbamazepine, reduce the nerve 's ability to create the nerve impulse that results in the unpleasant sensation. Carbamazepine commonly reduces pain within a few weeks. *Content Refresher* Trigeminal neuralgia, a chronic, intense, intermittent pain condition, affects the trigeminal nerve (cranial nerve V). The trigeminal nerve supplies the motor and sensory fibers to the face and jaw. Various conditions may precipitate trigeminal neuralgia, such as injury to the nerve, infection, tumor, or multiple sclerosis with damage to the myelin sheath. Symptoms include intermittent sharp pain that radiates from the cheek to jaw line, decreased appetite, weight loss, neck pain, and headache. Anticonvulsants, such as carbamazapine and oxcarbazapine are commonly prescribed to control pain. A muscle relaxant, such as baclofen may be used in combination with an anticonvulsant.

The nurse receives hand-off communication from the nurse who provided care to a group of clients during the previous shift. Which client does the nurse see first? 1. A client with dementia who is at risk for falling. 2. A client with an intravenous (IV) infusion 1 day post-operative. 3. A client with pneumonia reporting shortness of breath. 4. A client with a hip fracture reporting 9/10 on a pain scale.

1) INCORRECT - After seeing the clients with physiological needs, the nurse sees the clients with safety and security needs, such as the client with dementia who is at risk for falling. 2) INCORRECT - After attending to the clients with greater physiological needs, the nurse assesses the client who has IV fluid infusing to evaluate the client's fluid volume status. 3) CORRECT— The nurse sees the client with physiological needs first. Of the clients with physiological needs, the nurse first addresses the client with pneumonia who reports shortness of breath because airway, breathing, and circulation take priority. 4) INCORRECT - After seeing the client with pneumonia who reports shortness of breath, the nurse attends to the client who reports 9/10 pain on a pain scale. *Think Like a Nurse: Clinical Decision-Making* When prioritizing client care, the nurse could use the airway, breathing, and circulation (ABCs) mnemonic as a guide. Based on this scenario, the client experiencing shortness of breath coupled with a diagnosis of pneumonia has a breathing issue necessitating immediate action to prevent a medical emergency. This client requires a complete assessment including measurement of oxygenation prior to notifying the health care provider for further evaluation and treatment. Once this client is stabilized, the client experiencing severe pain can be addressed. *Content Refresher* Pneumonia is simply defined as inflammation of the lungs. This disease process is caused by bacteria, viruses, or aspiration. When caring for a client with pneumonia, monitor for signs of hypoxia. Administer fluids if client exhibits signs of dehydration. Administer antibiotics, bronchodilators, and corticosteroids as prescribed. Administer supplemental oxygen and monitor oxygen saturation when at rest and during activities. Encourage coughing and deep breathing. Assist with breathing treatments. Monitor client's swallow to rule out aspiration. Complications of pneumonia include atelectasis, pleural effusion, bacteremia, sepsis, and respiratory failure.

The charge nurse in the emergency department receives a call from paramedics who are en route with four patients involved in a motor vehicle accident (MVA). Which client does the nurse plan to see first based on paramedic report? 1. An adult with an obvious deformity to the left knee, weak pedal pulses bilaterally, and reports of pain. 2. An adult with a decreased level of consciousness, a heart rate of 126 beats/min, and no obvious injuries. 3. A child with an obvious deformity to the right forearm, a strong radial pulse, and reports of pain. 4. A child, crying uncontrollably, with an abrasion on the forehead and a heart rate of 112 beats/min.

1) INCORRECT - Although this client likely has a dislocation or fracture, pulses are equal, if weak. This is likely the client's baseline assessment. Not the priority client. 2) CORRECT— This client may be experiencing hypovolemic shock related to an unknown hemorrhagic injury and therefore takes priority. 3) INCORRECT - The child likely has a fracture, and the distal circulation is intact. The risk for hemorrhage takes precedence over this client. 4) INCORRECT - Although the child may be at risk for neurological deficit from head injury, crying indicates an appropriate level of consciousness at this time. The elevated heart rate is likely caused by child's crying and requires evaluation. However, this client is not the priority because the risk for hemorrhage takes precedence. *Think Like A Nurse: Clinical Decision Making* When deciding which client to assess first, the nurse utilizes the integrated processes that enhance critical thinking and clinical judgement. The nurse first initiates the concepts of airway-breathing-circulation (ABCs), which are key to survival. The clients with obvious deformities, reporting pain, or crying have an adequate airway. They may have issues with bleeding and circulation; however, at this time, seeing these clients can be delayed. The client with decreased level of consciousness, a rapid heart rate, and no obvious signs of injuries is demonstrating hypovolemic shock possibly caused by internal bleeding injuries. The change in level of consciousness could be from inadequate oxygenation caused by a low circulating blood volume. The rapid heart rate is caused by insufficient amount of blood to support organ function. *Content Refresher* The nurse caring for a client at risk of shock should: Assess baseline vital signs. Monitor blood pressure and heart rate for changes. Assess strength of peripheral pulses, color of skin, warmth, and other indicators of perfusion. Assess urinary output. When hypotensive, keep client flat in bed or use modified Trendelenburg position to enhance blood flow and oxygenation to the brain. Administer IV fluids as prescribed. Assess hemodynamic pressures and titrate medications and fluids as needed. Assess client tolerance of fluid administration. If client has arterial line to monitor blood pressure, assess blood pressure continuously.

A client diagnosed with lung cancer gains 4.4 lb (2 kg) overnight and has a serum sodium of 122 mEq/L (122 mmol/L) and potassium of 4.5 mEq/L (4.5 mmol/L). Which intervention does the nurse expect to be prescribed for this client? 1. Desmopressin. 2. Furosemide 40 mg IV push. 3. Sodium polystyrene sulfonate. 4. IV normal saline to infuse at 125 mL/hr.

1) INCORRECT - Desmopressin is used to treat diabetes insipidus. 2) CORRECT— Lung cancer is a common cause of syndrome of inappropriate antidiuretic hormone (SIADH), which is an abnormal secretion of antidiuretic hormone. This health problem results in increased water absorption and dilutional hyponatremia. Diuretics are used to promote fluid loss. 3) INCORRECT - Sodium polystyrene sulfonate is used to treat hyperkalemia. The client 's potassium level is within normal limits of 3.5 to 5 mEq/L (3.5 to 5 mmol/L). 4) INCORRECT - Fluids are restricted in the treatment of SIADH. *Think Like A Nurse: Clinical Decision Making* The nurse recalls complications that can occur with lung cancer and how those complications may be manifested. Knowledge of pathology and experience will help the nurse to identify that this type of cancer can cause the development of the syndrome of inappropriate antidiuretic hormone (SIADH). With SIADH, the client develops dilutional hyponatremia due to the accumulation of excess body fluid. The weight gain and sodium level support this diagnosis and treatment begins with providing diuretics, as prescribed. This removes excess fluid and helps the body naturally readjust the sodium level. Additional treatment may include a fluid restriction. *Content Refresher* Syndrome of inappropriate antidiuretic hormone (SIADH) is an endocrine disorder in which there is an excess production of antidiuretic hormone resulting in hypervolemia, dilutional hyponatremia, and highly concentrated urine. Causes for SIADH include traumatic brain injury, stroke, meningitis, neoplasms in lungs and colon, pulmonary disorders (emphysema), and adverse effects of anesthetics, barbiturates, or selective serotonin reuptake inhibitors. Treatment focuses on correction of the underlying cause and includes fluid and dietary restrictions with careful monitoring of intake, output, and laboratory values. Drug therapy may include administration of hypertonic saline, diuretics, demeclocycline, and/or lithium carbonate. Vasopressin antagonists are used if heart failure is present. Surgery may be indicated to remove tumor(s).

The nurse assesses a client who gave birth to a neonate 18 hours ago. The client has a temperature of 100.3°F (37.9°C). Which explanation does the nurse give the client regarding the cause of the temperature elevation? 1. "You have an infection of the endometrium." 2. "You are experiencing dehydration and fatigue." 3. "You are experiencing the onset of breast engorgement." 4. "You may have pyelonephritis."

1) INCORRECT - During the first 24 hours, temperature can increase to 100.4°F (38°C) as a result of dehydrating effects of labor. There is no indication that the client is experiencing an infection. 2) CORRECT - During the first 24 hours, temperature can increase to 100.4°F (38°C) as a result of dehydrating effects of labor. 3) INCORRECT - An elevated temperature is not correlated with the onset of breast engorgement. 4) INCORRECT - During the first 24 hours, temperature can increase to 100.4°F (38°C) as a result of dehydrating effects of labor. There is no indication that the client is experiencing an infection. *Think Like A Nurse: Clinical Decision Making* Delivering a baby is an exciting time for the client. After delivery though the body knows that the fetus is no longer in the uterus and begins to change in order to accommodate a non-pregnant state. Excess fluid in the vascular system is eliminated, which can lead to temporary dehydration. Evidence of postpartum dehydration includes a low-grade fever, which can be quickly corrected by the client increasing oral fluid intake. *Content Refresher* Postpartum assessments are a group of observations that are monitored throughout the 6-week postnatal period. These observations reflect the mother's physiological and psychological readjustment to her pre-pregnant state. These assessments include vital signs and a head-to-toe physical assessment. The physical assessment needs to include examining breasts for engorgement and condition of nipples. Assess the height of the uterine fundus for location and its degree of firmness. Note any bladder distention along with the amount, type, and odor of lochia. Assess the perineum for intactness of episiotomy or laceration repair, and for bruising and edema. Examine the client's legs for signs of thrombophlebitis and assess the mother's emotional state.

The nurse obtains health information from a client scheduled for permanent pacemaker insertion. Which information is most important for the nurse to convey to the health care provider (HCP)? 1. Diagnosis of obsessive-compulsive disorder. 2. Uses a hearing aid in the left ear. 3. Works as a computer programmer. 4. Lives in a two-story house.

1) INCORRECT - Having obsessive-compulsive disorder is not the most important information to report to the HCP. This diagnosis may impact teaching about pacemaker management. Anxieties about pacemaker function and safety may be intense. 2) CORRECT— The hearing aid battery may affect the placement of the pacemaker. It should not be placed under the left clavicle in this client. 3) INCORRECT - Equipment that is grounded and well maintained is not a problem. 4) INCORRECT - Clients with pacemakers do not require stair-climbing restrictions unless the heart rhythm shows marked variation in response to this activity. *Think Like A Nurse: Clinical Decision Making* A permanent pacemaker is inserted in a small pocket under the skin, usually on the left-side of the chest. Once the device is implanted, an electrical current is transmitted to the heart to initiate a heart beat. Because the pacemaker transmitter is electrical, the client should be instructed to avoid placing anything that is battery operated on or near the device. The presence of a battery operated hearing aid for the left ear may interfere with the functioning of the pacemaker. Using knowledge of anatomy and physiology and of the medical intervention, the nurse will report the finding so that an adjustment can be made to the transmitter placement. *Content Refresher* Dysrhythmias are caused by ischemia, hypertrophy, electrolyte imbalances, hypoxia, and valvular disorders. Dysrhythmias have the potential to be life-threatening when perfusion is decreased and cardiac output drops. Various anti-arrhythmic medications can also cause dysrhythmias. Risk factors include caffeine, stress, aging, and tobacco, which can potentiate development of some dysrhythmias. Ischemia and infarction related to coronary artery disease may also cause arrhythmias. Clinical manifestations include palpitations, skipped beats, syncope, confusion, dyspnea, chest pain, and fatigue. Administration of medications is a primary treatment for dysrhythmias. Other interventions include pacemaker insertion, internal cardioverter/defibrillator insertion, cardioversion, defibrillation, and ablation.

The nurse provides instructions to a pregnant client who is 28 weeks' gestation. The client is prescribed a 1-hour oral glucose tolerance test (GTT). Which instruction does the nurse include in the teaching? 1. "You will be diagnosed with gestational diabetes if the blood sugar at 1 hour is greater than 140 mg/dL (7.8 mmol/L)." 2. "This test requires you to be connected to a glucose drip." 3. "This test will determine if you have gestational diabetes." 4. "You can continue to eat your normal diet prior to test day."

1) INCORRECT - If the client's blood glucose is greater than 140 mg/dL (7.8 mmol/L) at 1 hour post-glucose intake, the client will be referred for a 3-hour oral GTT for further evaluation. 2) INCORRECT - The client is not connected to a glucose drip. The client will drink a glucose solution. A blood draw will be done 1 hour afterward. 3) INCORRECT - The 1-hour oral glucose test is a screening examination, but generally it will not be the only diagnostic test used. If the client's blood glucose is greater than 140 mg/dL (7.8 mmol/L) at 1 hour post-glucose intake, the client will be referred for a 3-hour oral glucose test for further evaluation. 4) CORRECT - The client should continue to consume a normal diet until the day of the test. *Think Like A Nurse: Clinical Decision Making* Client teaching is essential when providing care to the pregnant client. The nurse must adequate prepare the client regarding what is expected during the different stages of pregnancy along with diagnostic testing that will occur. Clients who are in the second trimester of pregnancy will be prescribed a glucose tolerance test (GTT) to assess for gestational diabetes mellitus. The nurse provides information to the client and then evaluates understanding through the teach-back method. If the nurse determines inadequate understanding of the information presented, the nurse must re-teach the material allowing the client to obtain adequate understanding. *Content Refresher* The 1-hour oral glucose tolerance test (GTT) is a screening tool used to assess for the possibility of gestational diabetes. It is provided to clients between 24 to 28 weeks' gestation. Earlier screening may be recommended for clients at high risk, such as those with a family history or prior history, a large for gestational age fetus, or obesity. The client should be advised to eat and drink normally until 8 hours before the test. First, a fasting blood glucose will be drawn. The client will drink a glucose solution and have another blood glucose level drawn 1 hour later.

The nurse provides care for a client after a renal biopsy. The client reports pain at the biopsy site that radiates to the front of the abdomen. Which complication does the nurse suspect the client is developing? 1. Infection. 2. Bleeding. 3. Renal colic. 4. Hypertension.

1) INCORRECT - It is too early in the postoperative period to see signs of infection. 2) CORRECT - Pain starting at the procedure site and radiating to the flank area and around to the front indicates bleeding. 3) INCORRECT - There is no data to indicate this condition. 4) INCORRECT - Considering the nature of the pain and what it indicates, hypotension is expected. *Think Like a Nurse: Clinical Decision-Making* Prior to kidney biopsy, the nurse follows a pre-procedure checklist to review the client's medical surgical history, coagulation status (e.g., prothrombin time, international normalized ratio, partial thromboplastin time), complete blood count, and metabolic profile. The nurse should also monitor that anticoagulants and antiplatelet drugs (e.g., aspirin or warfarin) were discontinued 2 to 3 days before the procedure in order to decrease the possibility of post-procedure bleeding. Because a renal biopsy involves obtaining kidney tissue by puncture with a large bore needle, the nurse is aware that bleeding is a possible complication. Following renal biopsy, a pressure dressing may be applied on the affected side for 30 to 60 minutes, and the client is placed on bed rest. Vital signs are monitored frequently according to protocol. *Content Refresher:* After a renal biopsy, apply a pressure dressing and have the client lie on the affected side for 30 to 60 minutes. The client should remain on bed rest for 24 hours. Postoperatively, monitor vital signs every 5 to 10 minutes for the first hour. Inspect the biopsy site for bleeding. Instruct the client to avoid heavy lifting for 5 to 7 days and not to take anticoagulant medications until instructed to do so by the health care provider. Absolute contraindications for a renal biopsy include bleeding disorders, only one kidney, and uncontrolled hypertension.

The nurse provides care to a client diagnosed with severe liver disease. Which intervention is appropriate for the nurse to include in this client's plan of care? 1. Low-sodium IV albumin. 2. Sodium polystyrene sulfonate enemas. 3. Sengsteken-Blakemore tube. 4. Low-protein, high-carbohydrate diet.

1) INCORRECT - Low-sodium IV albumin is used to balance osmotic pressure. 2) INCORRECT - Sodium polystyrene sulfonate enemas are used to treat hyperkalemia. 3) INCORRECT - A Sengsteken-Blakemore tube is used to apply pressure against bleeding esophageal varices. 4) CORRECT - A low-protein, high-carbohydrate diet will help reduce the risks of hepatic coma by reducing the level of ammonia that results from the breakdown of proteins. *Think Like A Nurse: Clinical Decision Making* The nurse knows from the study of anatomy and physiology that the liver has many functions, all of which are important. When the liver is damaged through disease, some of these functions can be affected. One important function of the liver involves the metabolism of protein. If the liver is damaged, protein metabolism is adversely effected, increasing the client's risk of developing an accumulation of ammonia in the body. To prevent this from occurring, the client will be prescribed a low-protein diet. The nurse needs to reinforce dietary teaching to prevent complications related to the client's diagnosis. The nurse knows from the study of nutrition that to meet caloric and metabolic needs, the client's diet should be higher in carbohydrates. *Content Refresher* When caring for a client with liver disease, the client should be weighed daily at the same time, on the same scale and wearing the same type of clothing. In addition, monitor intake and output, measure abdominal girth, assess for neck vein distention, monitor and assess skin (specifically for jaundice), monitor level of consciousness, institute bleeding precautions, monitor coagulation studies, place client in high-Fowler's position, provide low sodium/low protein diet, and administer medications as prescribed. The nurse should also monitor serum ammonia levels. A low protein, high carbohydrate diet will reduce ammonia levels.

The nurse makes rounds on the medical unit to assess the care given by the nursing assistive personnel (NAP). Which observation requires an intervention by the nurse? 1. The NAP places the fingers of one hand on the wrist of a client in order to evaluate the respirations. 2. The NAP prepares to take a blood pressure in the left arm of a client recovering from a right mastectomy. 3. The NAP weighs a client on a standing scale while the client is balanced on crutches. 4. The NAP prepares to take an oral temperature on a client recovering from a rhinoplasty.

1) INCORRECT - Placing the fingers on the wrist makes it seem like the pulse is being taken so the client continues to breathe normally. 2) INCORRECT - Taking the blood pressure in the non-operative side is a correct action. Lymphedema of the arm occurs after mastectomy. Taking the blood pressure on the arm on the mastectomy side would decrease the already compromised lymph circulation. 3) INCORRECT - If a client uses crutches, weight should be taken with crutches in place so the client can support weight during the process. Afterward, the crutches should be weighed and their weight then subtracted from the total to conclude the weight of the client. 4) CORRECT - Rhinoplasty compromises the ability of the client to breathe through the nose due to the packing in both nostrils. If the client has to keep the mouth closed for an oral temperature measurement, the client cannot breathe. *Think Like A Nurse: Clinical Decision Making* The nurse should evaluate and monitor the NAP's competency periodically. This will ensure the provision of high-quality and safe client care. Given that the client is unable to breathe through the nose due to the packing in both nostrils, the nurse should inform the NAP during the handoff report how the temperature can be taken (e.g., via the axilla). If the NAP is unfamiliar with caring for clients with rhinoplasty, the nurse should encourage the NAP to ask questions. *Content Refresher* In deciding whether to delegate a nursing task to the NAP, the nurse needs to assess the following factors: the client's present health status, safety of the situation, and the intended client outcome. In addition, the nurse must assess the NAP's knowledge, skill, training, and scope of practice before delegating a task. After delegating a task, the nurse needs to assess the NAP's understanding of the particular instructions. The nurse will follow through with post-task assessment and outcome findings.

The nurse plans care for a client diagnosed with left-sided paralysis and slurred speech. Which direction is most important for the nurse to provide to an unlicensed assistive personnel (UAP)? 1. Report any incontinence. 2. Turn the client every 2 hours. 3. Keep the head of the bed elevated to 30 degrees. 4. Change the linens immediately following a bath.

1) INCORRECT - Reporting incontinence helps prevent skin breakdown. However, cerebral tissue perfusion is the priority for this client. 2) INCORRECT - Turning the client every 2 hours prevents skin breakdown. However, cerebral tissue perfusion is the priority for this client. 3) CORRECT - Elevating the head of the bed facilitates venous drainage from the brain and reduces intracranial pressure. It is best to also maintain the head in a midline neutral position. 4) INCORRECT - Changing the linens after a bath may increase the client's intracranial pressure. Activities should be spaced out so that the client has rest periods between activities. *Think Like A Nurse: Clinical Decision Making* The nurse considers the outcome of each action and utilizes the ABCs to prioritize. The client has left-sided paralysis and slurred speech, which are symptoms of a stroke. It is important to keep the head of the bed elevated for a client with a stroke to reduce intracranial pressure and prevent aspiration, and to ensure unrestricted venous outflow from the cranium and meet circulatory and airway needs. The nurse needs to recognize which direction to the unlicensed assistive personnel (UAP) is related to client safety and reduces risk for harm. Directing the UAP to keep the head of the bed elevated for this client is within the scope of practice of the UAP. *Content Refresher* Increased intracranial pressure occurs when there is an abnormal accumulation of cerebrospinal fluid in the brain, causing cerebral edema. This cerebral edema may be caused by lesions, head/brain injury, cerebral infections, vascular insult, or encephalopathies. The nurse needs to keep the head of bed in a semi-Fowler position to increase venous outflow. Maintain proper position of the client with head and neck in neutral, midline position. Ensure the airway is patent and continuously monitor any changes in level consciousness.

The nurse assesses a client, diagnosed with rheumatoid arthritis, for self-care readiness. Which activity does the nurse ask the client to perform? 1. Ascend and descend stairs. 2. Lace and tie both shoes. 3. Comb hair and brush teeth. 4. Walk without assistance.

1) INCORRECT - Stairs can be eliminated in the client 's environment by installing a ramp. 2) INCORRECT - Inability to tie shoes is a modifiable problem with the use of slip-on or alternative fastener shoes. 3) CORRECT— Performing basic hygiene and grooming must be done daily to maintain overall health. If the client cannot do this, it indicates the need for daily home assistance. 4) INCORRECT - Though ideal, walking unassisted is not necessary for independence. A walker or wheelchair may be used. *Think Like A Nurse: Clinical Decision Making( Assessing self-care readiness often includes determining the client 's ability to perform activities of daily living (ADLs), including the ability to bathe, dress, and self feed, and independence with toileting. The client diagnosed with rheumatoid arthritis may exhibit weakness and contracture as the disease progresses, affecting independence with ADLs. The nurse can assess the client 's needs using standardized tools such as the Katz Index of Independence in Activities of Daily Living. The instrument is most effectively used among older adults in a variety of care settings, when baseline measurements, taken when the client is well, are compared to periodic or subsequent measures. *Content Refresher* Rheumatoid arthritis is a chronic, progressive, autoimmune disease of unknown origin that causes inflammation and degeneration in the joints resulting in painful deformity and immobility, especially in the fingers, wrists, feet, and ankles. The client may exhibit spongy or boggy joints. The client may report weight loss, sensory changes, lymph node enlargement, and fatigue. Observe for joint swelling, warmth, and erythema. Pharmacologic interventions include non-steroidal anti-inflammatory drugs (NSAIDs), analgesics, and immunosuppressive drugs (such as methotrexate and cyclosporine). Collaborate with the physical therapist, occupational therapist, and dietitian.

A client walking down the hall in the outpatient clinic suddenly collapses. The nurse observes the client does not move any extremity. Which is the first action by the nurse? 1. Check the client's carotid pulse. 2. Call for help. 3. Determine if the client is responsive. 4. Begin cardiopulmonary resuscitation.

1) INCORRECT - The carotid pulse is an important assessment, but the very first action is to determine if the client is responsive. 2) INCORRECT - Assess for responsiveness before implementing the call for assistance. 3) CORRECT - The very first action is to determine responsiveness of the client, before intervening with calling for help and assessing for breathing and pulse. 4) INCORRECT - The client must be assessed for unresponsiveness, breathing, and pulse first before CPR is begun. *Think Like a Nurse: Clinical Decision-Making* This is a standard cardiopulmonary resuscitation (CPR) situation. All nurses are trained in basic life support. The nurse will first determine if the client is responsive. If the client does not respond, CPR is initiated. If the client does respond, the nurse still calls for help, but can assess the client by asking questions and determining if something can be implemented immediately. Syncope can occur for a variety of reasons, including unpleasant sights, heat, being emotionally overwhelmed, hypoglycemia, and anything that might cause hypotension or dehydration. *Content Refresher* The initiation of cardiopulmonary resuscitation (CPR) for a client consists of the following: Determine responsiveness. Assess pulse (i.e. palpate carotid pulse for 5 to 10 seconds) and spontaneous breathing. Activate the emergency response system. If pulse is felt, but the client is not breathing, give one breath every 5 to 6 seconds and recheck the pulse every 2 minutes. If no pulse is felt and the client is not breathing, start chest compressions using the compressions-airway-breathing (CAB) approach. Ensure client remains in a supine position on a flat, hard surface. Administer 30 compressions to two breaths. If two rescuers are performing CPR, they should change roles every 2 minutes. Use the automatic external defibrillator (AED) as soon as available if rhythm is shockable (i.e. ventricular fibrillation, pulseless ventricular tachycardia)

During a pregnant client's nonstress test (NST), the nurse observes several late fetal heart rate decelerations. Which nursing action is most appropriate? 1. Reposition the client on the right side. 2. Notify the health care provider for further evaluation. 3. Document these results in the client's record. 4. Stop the oxytocin immediately.

1) INCORRECT - The change in positioning does not resolve the immediate problem of a fetus in possible distress. The health care provider is notified to evaluate the readings of the monitor strip. 2) CORRECT - The appearance of any decelerations of the fetal heart rate during the NST should be immediately evaluated by the health care provider. 3) INCORRECT - Although the monitor strip becomes a part of the client's medical record, the need is for evaluation of the client and fetus. 4) INCORRECT - Oxytocin is not used for the NST. The test is monitoring for fetal well-being. However, the fetal heart rate can give evidence if a fetus is acidotic or neurologically depressed. *Think Like A Nurse: Clinical Decision Making* A nonstress test (NST) is performed to check fetal well-being when it is determined that the fetus might be at risk for an adverse outcome. An NST might be performed when the mother has diabetes mellitus, heart disease, or hypertension. Often, an NST is performed for a post-term fetus to determine whether pregnancy can continue until natural labor occurs or whether labor induction is needed. During this test, the only stress is the baby's own movements. A decreased fetal heart rate in response to fetal movement indicates poor fetal oxygenation. This finding indicates a need to notify the health care provider and likely will result in induction of labor. *Content Refresher* During a late deceleration, the fetal heart rate usually decreases at the peak of the contraction, but it may decrease after the contraction ends. A late deceleration is indicative of fetal hypoxia due to deficient placental perfusion. Causes include pregnancy-induced hypertension, maternal diabetes mellitus, placenta previa, and abruptio placentae. Position the mother in left side-lying position and administer oxygen by mask.

The nurse notes the health care provider prescribed a diet consisting of increased amounts of fresh fruits and vegetables, chicken, and whole grain breads for an adult male client. Which finding does the nurse expect to see on the client's medical record? 1. Blood pressure of 118/70 mm Hg while supine and 124/84 mm Hg while standing. 2. Hematocrit of 40% (0.40) and hemoglobin of 11.2 g/dL (112 g/L). 3. Aspartate aminotransferase 30 U/L (0.5 µkat/L) and alanine aminotransferase 35 U/L (0.58 µkat/L). 4. Creatinine 12.2 mg/dL (1078.5 µmol/L) and blood urea nitrogen 25 mg/dL (8.9 mmol/L).

1) INCORRECT - The client has a blood pressure that is within normal limits. If the client had hypertension, this would require a diet low in salt and fat with limited protein. 2) CORRECT - The normal hematocrit for a male is 42 to 52% (0.42 to 0.52). The normal hemoglobin for a male is 13 to 18 g/dL (130 to 180 g/L). These lab values indicate anemia, for which a diet high in protein, iron, and vitamins is advised. The prescribed diet will provide high amounts of protein, iron, and folic acid. 3) INCORRECT - The normal range for aspartate aminotransferase (AST) is 10 to 30 U/L (0.17-0.51 µkat/L), and the normal range for alanine aminotransferase (ALT) is 10 to 40 U/L (0.17-0.68 µkat/L). Both values are elevated with liver disease, for which a diet of increased carbohydrates, low protein, and low sodium is recommended. This diet would not be appropriate for a client diagnosed with liver disease due to the addition of chicken, which is high in protein. 4) INCORRECT - The normal creatinine is 0.6 to 1.2 mg/dL (53 to 106 µmol/L), and normal blood urea nitrogen (BUN) is 8 to 23 mg/dL (2.9 to 8.2 mmol/L). Both values are elevated with kidney disease, for which a diet with limited protein and restricted potassium, sodium, and phosphorus is recommended. This diet would not be appropriate for a client diagnosed with kidney disease, as it contains too much protein and potassium. *Think Like a Nurse: Clinical Decision-Making* The nurse will review client laboratory results by noting normal ranges and any client deviations. The nurse should anticipate which prescriptions will address any abnormal lab values. In this scenario, the nurse evaluates the diet prescribed and recognizes that it provides protein, iron, and folic acid. The nurse recognizes that this diet may be prescribed for anemia. The client's hemoglobin and hematocrit levels are low, which could indicate iron-deficiency anemia for which the diet is appropriate. *Content Refresher* When providing care for a client with iron deficiency anemia, the nurse should: Administer iron supplements as ordered with vitamin C. Maintain the client's safety if dizzy, weak, and lightheaded. Monitor for constipation when giving iron supplements, and teach the client to eat a diet high in fiber and roughage. Educate the client about foods rich in iron, such as red meats and poultry, beans, dark green leafy vegetables, and fortified cereals.

The nurse instructs a client diagnosed with chronic kidney disease about the appropriate diet. Which food choice by the client demonstrates to the nurse that the teaching was successful? 1. Half cup beets. 2. One orange. 3. 2 T peanut butter. 4. 3 oz chicken breast.

1) INCORRECT - The diet for kidney disease should contain increased calories, high biological protein, low potassium, and low sodium. Beets are a high-potassium vegetable. 2) INCORRECT - Oranges are a high-potassium fruit and should be avoided. 3) INCORRECT - Incomplete protein sources, such as peanut butter, are of low biological value. 4) CORRECT - Eggs, lean meat, fish, and poultry are high biological protein sources that contain sufficient amounts of all the amino acids. Protein intake is determined on the basis of kidney impairment measured by the glomerular filtration rate. *Think Like A Nurse: Clinical Decision Making* Chronic kidney disease is the inability of the kidneys to filter waste and fluids out of the body. The nurse helps the client combat this by exploring ways to decrease the waste put into the body and the waste produced by the body. A renal diet is low in sodium, phosphorus, and protein. Potassium and calcium are often restricted, too. Some protein is necessary in the diet and this should be of high biological value (i.e., a complete protein). The client naturally will struggle with what foods are allowed and why. The nurse helps guide dietary selections and evaluates choices the client makes to determine teaching needs. *Content Refresher* Chronic kidney disease results in uremia, fluid and electrolyte imbalance, anemia, and bone disorders from lack of vitamin D. Almost all body systems are affected by kidney disease. The client will exhibit multiple symptoms, including fluid overload, hypertension, malaise, electrolyte imbalance, uremia, metabolic acidosis, anemia, muscle cramping, confusion, and an inability to focus. Medications, therapeutic diet , and fluid restriction are part of the management of chronic kidney disease until the disease reaches a point where those interventions are not enough for the client to maintain life.

The nurse assess a client who is at 24 weeks' gestation. Which finding causes the nurse to be most concerned? 1. Fetal heart rate of 130 to 140 beats per minute. 2. Fundal height at three fingers below the umbilicus. 3. Fetal movements felt faintly on lower part of abdomen. 4. The woman reports backache and leg cramps when sleeping.

1) INCORRECT - The fetal heart rate at term ranges between a low of 110 to 120 beats/min and a high of 150 to 160 beats/min. The rate is higher in early gestation and slows as term approaches. 2) CORRECT- The fundus is expected to reach the umbilicus around 20 weeks and should be increasing in height above the umbilicus after 20 weeks. A fundal height of three fingers below the umbilicus indicates a fetal problem and would be a priority concern. 3) INCORRECT - Fetal movement, felt by the mother, is first perceived at 16 to 20 weeks' gestation as a faint fluttering in the lower abdomen. 4) INCORRECT - The pressure of the uterus on blood vessels impairs circulation to legs, causing muscle strain and fatigue that results in leg cramps. The enlarging uterus also alters the center of gravity, resulting in lordosis (exaggeration of lumbosacral curve), which causes backache in 45 to 59% of pregnant women. *Think Like A Nurse: Clinical Decision Making* There are various measurements for the nurse to use when assessing a pregnant client. Before beginning an assessment, the nurse should recall the physiological changes that occur in pregnancy, the findings that should be expected, and those that should be further investigated. One physiological change occurs to the uterus. As the fetus grows, the height of the uterus will increase. A general rule of thumb is that the height of the uterus should be at the level of the client's umbilicus at the 20th week of gestation. Since this client's fundal height is below this expectation, fetal growth is not progressing as expected, and requires further investigation. *Content Refresher:* Fetal development is characterized by the physiological growth and development that takes place over approximately 40 weeks.Assess client's knowledge of fetal development. Question the client about previous pregnancies and outcomes. Provide teaching, using printed material and other visual aids to enhance learning. Educate the client about expected body changes. Assess nutritional status, weight, and fundal height. Review lab results obtained during the course of the pregnancy. Educate the client about danger signs and necessity of reporting symptoms. Assist with further studies, which may be prescribed to detect abnormalities in fetal development.

The family member of a client calls to ask the nurse to visit the client. The family member tells the nurse the client is refusing to seek medical attention for severe midsternal chest pain. Which activity will the nurse perform first? 1. Go to the client's home with a stethoscope and blood pressure cuff. 2. Contact the client and report being asked to visit by a family member. 3. Contact 911. 4. Ask the family member if there are color changes and dyspnea.

1) INCORRECT - The nurse needs permission before assisting the client. The nurse should not just arrive and expect to be able to assess the client. 2) CORRECT - The nurse needs to make sure the client wants assistance and will give permission for the nurse to enter the home. 3) INCORRECT - The client must be willing to accept emergency services before a call to 911 for help. 4) INCORRECT - The client needs to be assessed directly and not through information being provided by the family member. *Think Like A Nurse: Clinical Decision Making* Before taking action on the family's request, the nurse needs to recall principles of safe, ethical nursing practice. One of the principles is that of client autonomy. The client should be supported in any health care decisions that are made, regardless of the feelings of others. Even though the family is concerned about the client's symptoms, the client is refusing care and the nurse should recognize the client's right to do so. The nurse should not arrive to the client's home without first contacting the client and asking for permission to visit and complete an assessment. *Content Refresher:* Beneficence is compassion, taking positive actions to help others, and the desire to do good. Beneficence is a core principle of client advocacy. Nurses have the foundational moral imperative of doing right. Before acting with beneficence, the nurse must consider the client's wants and needs for his or her best life. The client's right to autonomy should also be considered. Assess whether the treatment option or the decision to decline treatment is congruent with promoting good for the client. Protect clients from harm by providing safe and ethical nursing practice.

A client who received an intravenous dose of penicillin G develops restlessness, wheezing, and swelling of the lips and tongue. After applying oxygen via nonrebreather face mask, which action will the nurse take next? 1. Initiate an intravenous infusion of warmed 0.9% sodium chloride. 2. Administer epinephrine 1:1000 intravenous push. 3. Give subcutaneous diphenhydramine. 4. Insert an indwelling urinary catheter.

1) INCORRECT - The nurse should initiate an intravenous infusion of warmed 0.9% sodium chloride to help maintain vascular volume. Warming the solution helps prevent hypothermia that can result from the client receiving large amounts of intravenous fluids. However, airway issues are of greater priority. 2) CORRECT - The client is exhibiting symptoms of an anaphylactic reaction. The next action the nurse should take is to administer 0.3 to 0.5 mL of epinephrine 1:1000, by the subcutaneous, intramuscular, or intravenous route, which the nurse can repeat in 20 to 30 minutes if there is an indication. Epinephrine is the medication of choice for anaphylaxis as it can activate three types of adrenergic receptors and thus reverse the reaction to the antigen. This leads to increased blood pressure, decreased epiglottal edema, and decreased bronchoconstriction. 3) INCORRECT - The nurse can give subcutaneous diphenhydramine, an antihistamine, to relieve itching and discomfort. However, airway issues are of greater priority. 4) INCORRECT - The nurse should insert an indwelling urinary catheter to monitor the client's urine output. Anaphylactic shock and decreased cardiac output can lead to decreased renal blood flow. A urine output less than 30 mL/hr places the client at risk for acute kidney injury. However, airway issues are of greater priority. *Think Like A Nurse: Clinical Decision Making* Before implementing actions for this client, the nurse should stop and ask, "What is the reason for this client's symptoms and what can be done to help the client?" Since the symptoms began after receiving penicillin, the nurse should consider a previously unknown allergy to the medication. Actions should focus on supporting the client's airway and breathing. After oxygen is applied, the nurse needs to do something to minimize the symptoms and reduce throat swelling. The medication epinephrine is used to reverse the respiratory effects of an allergic response and should be given to this client immediately. *Content Refresher* Anaphylaxis is a type of distributive shock caused by an allergic response that involves angioedema, urticaria, hypotension, and bronchospasm. It is a medical emergency and must be assessed and treated immediately. Anaphylaxis develops from a prior sensitization to an allergen and then a later re-exposure.If respiratory distress is evident, initiate Basic and Advanced Life Support (ACLS) protocols, provide supplemental oxygen and assist with intubation or airway management. Administer IV fluids rapidly to support perfusion. Administer 0.3 to 0.5 mL of epinephrine 1:1000, by the subcutaneous, intramuscular, or intravenous route. Antihistamines and corticosteroids, as well as inhaled bronchodilators, may also be indicated. Vasopressor medications may be needed for continued hypotension.

The nurse instructs a client about the care of a new colostomy. Which information does the nurse include? (Select all that apply.) 1. Change the ostomy appliance following a meal. 2. Use a moisturizing soap to clean skin around stoma. 3. Place tissue on stoma when changing the appliance. 4. Cut the skin barrier 1/8 inch larger than the stoma. 5. Empty the pouch of stool before removing the appliance. 6. Check stoma for color, size, and shape.

1) INCORRECT - The ostomy appliance needs to be changed first thing in the morning or 2 -4 hours after a meal. The client should avoid changing the appliance following a meal, for this stimulates bowel evacuation. 2) INCORRECT - The client needs to avoid using moisturizing soap to clean the skin around the stoma, for it will interfere with the adhesive of the skin barrier. 3) CORRECT— The client should place tissue on the stoma when changing the appliance, for this will absorb stool and prevent stool from contacting the skin. 4) CORRECT— The client needs to cut the skin barrier no more than 1/8 inch larger than the stoma. This will allow the stoma to expand and prevent stool from contacting peristomal skin. 5) CORRECT— The client needs to empty the pouch of stool before removing the appliance. This will prevent contact of stool to the client's skin. 6) CORRECT— The client needs to check the stoma for color, size, and shape. This will ensure adequate blood flow to the stoma. *Think Like a Nurse: Clinical Decision-Making* The nurse is aware a new colostomy can be overwhelming to a client and teaching needs to be provided in short increments. Each episode of teaching should be focused, provide an opportunity for the client to ask questions, and include the opportunity for the client to provide a return demonstration on the needed care. The client will need to know how to protect the skin around the stoma and the collection device, how to assess the stoma appearance every time the appliance is changed, and how the ostomy appliance should be managed. The nurse would also assess the client for psychosocial concerns such as appearance, odor, sexuality, and the disease process leading to the colostomy. *Content Refresher:* Food passes through the esophagus into the stomach and the small intestine. Through peristaltic action, the loose and acidic liquid slowly moves through the small and large intestine where sodium, potassium, calcium, other nutrients, and water are absorbed. As it becomes more formed and less liquid, it is moved into the rectum and then expelled through the anus. As clients experience alterations to the gastrointestinal tract (obstructions to small or large intestine or inflammatory bowel disease such as crohn's or ulcerative colitis), a colostomy or ileostomy may be required.

The nurse provides care for four clients on a medical surgical unit. The nurse knows that which client is at risk for wound dehiscence and evisceration? 1. A client diagnosed with Parkinson disease who is 5 feet 8 inches (172.7 cm) tall , weighs 150 lb (68 kg), and had a stereotactic pallidotomy two days ago. 2. A client diagnosed with type 2 diabetes mellitus who is 5 feet 5 inches (165.1 cm) tall, weighs 195 lb (88.5 kg), and had an appendectomy one day ago. 3. A client with history of mitral stenosis who is 5 feet 2 inches (157.5 cm) tall, weighs 130 lb (60 kg), and had open-heart surgery for mitral valve reconstruction three days ago. 4. A client with a fractured femur who is 6 feet 1 inch (185.4 cm) tall, weighs 170 lb (77.1 kg), and had open reduction and internal fixation surgery four days ago.

1) INCORRECT - This client is not at high risk for dehiscence, and the wound cannot eviscerate as the incision was made in the skull. 2) CORRECT - The client has three risk factors: being overweight, having type 2 diabetes mellitus (which impairs wound healing), and being post-abdominal surgery. Abdominal surgery is the most frequent type of surgery in which wound dehiscence and evisceration occur. 3) INCORRECT - The client has no major risk factors for wound dehiscence or evisceration. 4) INCORRECT - The client has no major risk factors for wound dehiscence or evisceration. *Think Like A Nurse: Clinical Decision Making* The most frequent location for wound dehiscence and evisceration is the abdomen. Evisceration only occurs with abdominal or thoracic surgical sites, as it entails the protrusion of internal organs from the wound. The client recovering from an appendectomy is at most risk for wound dehiscence and evisceration. Risk factors include the surgical site being in the right lower abdominal quadrant, an existing diagnosis of type 2 diabetes mellitus, and obesity. *Content Refresher* Wound healing is a process to restore tissue integrity by primary or secondary intention. Poor blood flow, inadequate nutritional stores of protein or insufficient calories, diabetes, or infection contribute to prolonged wound healing. Risk factors that delay wound healing include advanced age, arterial or venous insufficiency, obesity, anemia, neuropathy, infection, diabetes mellitus, smoking, and malnutrition.

The nurse in the ambulatory care clinic prepares to perform a venipuncture on a client diagnosed with Crohn disease. The client suddenly becomes upset and asks, "What are you really going to be injecting into my veins? " Which is the best responses by the nurse? 1. "Nothing. I 'm just going to draw some blood. " 2. "What makes you think I 'm going to inject anything into your vein? " 3. "It sounds like you had a bad experience with venipunctures before. " 4. "You sound frightened. What are your specific concerns? "

1) INCORRECT - This response gives true information, but does not allow the client to verbalize feelings. 2) INCORRECT - The response is nontherapeutic, because is sounds defensive. 3) INCORRECT - This response will usually only elicit a yes/no from the client and is nontherapeutic. 4) CORRECT— This response reflects feelings of the client, and allows the client to verbalize feelings and concerns. *Think Like A Nurse: Clinical Decision Making* The nurse should be aware a chronic illness can cause the client to experience anxiety with even the most basic procedures. The nurse should consider the client's health problem before responding and mentally ask, "What can be done to lessen or eliminate the client's concern?" The best way to learn the client's concern is to ask an open-ended question that first reflects the client's behavior and then ask what might be causing the behavior. The client's feelings about the procedure need to be taken into consideration and the nurse needs to respond to the client's statement using a non-threatening approach. *Content Refresher* The nurse needs to use therapeutic communication when caring for this client. Therapeutic communication includes the following communication skills: 1) being silent, 2) showing acceptance, 3) providing recognition, 4) offering self, 5) using broad open statements, 6) asking about thoughts/feelings, 7) restating and reframing, 8) reflecting, 9) presenting reality, 10) sharing observations, and 11) clarifying meaning. The nurse needs to avoid non-therapeutic communication techniques such as reassuring, rejecting, approving/disapproving, agreeing/disagreeing, giving advice, belittling, stereotyping, probing, or using denial.

The nurse provides care for a young adult female client undergoing peritoneal dialysis. The nurse notes that the outflow appears red-tinged. Which action does the nurse take first? 1. Contact the health care provider. 2. Determine if the client is menstruating. 3. Obtain the client's vital signs. 4. Continue with the peritoneal dialysis

1) INCORRECT — The nurse should assess the client first. Blood-tinged effluent is common during the menstrual cycle of premenopausal female clients. 2) CORRECT — Because of the hypertonicity of the dialysate, blood from the uterus can be pulled through the fallopian tubes into the effluent. This is common in premenopausal female clients during menstruation. No intervention is required. 3) INCORRECT — This is an appropriate action if active intraperitoneal bleeding is suspected. However, the nurse should first assess for menstruation, as blood in the effluent of women menstruating requires no intervention. 4) INCORRECT — The nurse should first assess the client. *Think Like A Nurse: Clinical Decision Making* The nurse evaluates the peritoneal dialysis effluent in the context of the particular client. This client is a young adult female and may be experiencing menstruation. The nurse recognizes that an assessment of whether the client is menstruating is needed, as red-tinged effluent would be expected. The menstrual flow can enter the peritoneal cavity and cause the effluent to be blood-tinged. Anticipate the likelihood of the health care provider ordering a complete blood count (CBC). *Content Refresher* Peritoneal dialysis (PD) uses the peritoneal membrane as a semipermeable membrane to filter out toxins and wastes, manage azotemia, and restore electrolyte balance. The nurse needs to observe the client perform the infusion, dwell, and drain phases while noting the color and amount of dialysate after the dwell time. Explain the importance of monitoring serum glucose as the main ingredient in the dialysate is dextrose. Complications associated with PD include peritonitis, sepsis, hypotension, and fluid deficit.

nurse in the outpatient clinic prepares a client for a pap smear. The client's only significant history is hypertension, for which the client takes an anti-hypertensive medication daily. It is most important for the nurse to follow-up on which client statement? 1. "I haven 't had a pelvic exam in 3 years." 2. "Black cohosh helps my hot flashes." 3. "I exercise eight times per week." 4. "I don 't like my partner using a condom."

1) INCORRECT- Depending on the client's risk factors, such as multiple sex partners, the client may need yearly pap smears. The nurse should follow up on this statement, but it is not the priority. 2) CORRECT- Herbal remedies, such as black cohosh, used in management of menopausal symptoms may cause hypotension when used in combination with antihypertensive drugs. The use of this herbal product can affect blood pressure and circulation; therefore, this is the priority statement for the nurse to further assess. 3) INCORRECT- Although typically considered a positive health habit, this amount of exercise could be detrimental. The nurse should ask the client about the amount and intensity of exercise, as well as nutritional support; however, this is not the priority. 4) INCORRECT- The nurse should follow-up to determine if the client is practicing safe sex or if the client needs and wants to protect against STIs and/or pregnancy. While the nurse does need to follow-up regarding this statement, it is not the priority. *Think Like A Nurse: Clinical Decision Making* The nurse must differentiate between a medication 's therapeutic effects, side effects, and adverse effects, in addition to monitoring for medication interactions. Using the Maslow hierarchy to evaluate physiological issues first, the nurse is most concerned when a client reports ingesting supplements and drugs that may interact, such as black cohosh and anti-hypertensive medications. The nurse assesses the client 's needs and educates the client regarding possible hypotension. *Content Refresher* Medication administration is the process by which prescribed medications are knowledgeably and safely dispensed to a client. Assess the client 's medication history, which includes herbs, vitamins, and supplements. In addition, check for medication incompatibilities and interactions. Perform appropriate client assessments and check for contraindications, including allergies, prior to administering medications. The expected outcome is that the client will demonstrate therapeutic effects of the medication without experiencing adverse effects.

Four clients are admitted at the same time to the medical unit. Which client will the nurse assign to a private room? 1. A client diagnosed with bacterial gastroenteritis. 2. A client diagnosed with hepatitis A. 3. A client diagnosed with scabies. 4. A client diagnosed with cirrhosis.

1) INCORRECT— Bacterial gastroenteritis is an acute diarrheal illness, often caused by E. coli, which is transmitted by the fecal-oral route. Standard infection control procedures are sufficient unless the client is diapered or incontinent, in which case contact precautions are required. 2) INCORRECT— Hepatitis A is a form of viral hepatitis transmitted by the fecal-oral route. Standard infection control procedures are sufficient unless the client is diapered and incontinent, in which case contact precautions are required. 3) CORRECT — Scabies is a contagious skin disease caused by mites. It is transmitted by close contact, either directly person-to-person or via contaminated personal items such as clothing or bedding. It requires a private room and contact precautions. 4) INCORRECT— Cirrhosis is not an active infective process and does not require transmission-based precautions. *Think Like A Nurse: Clinical Decision Making* When providing care for a client diagnosed with scabies, the Centers for Disease Control and Prevention (CDC) recommends use of contact precautions in addition to standard precautions. Personal protective equipment (e.g., gowns and disposable gloves) should be worn when caring for the client. Contact precautions should be maintained for 8 hours after treatment. For crusted (Norwegian) scabies, a highly transmissible form, shoe covers should also be worn. Individuals diagnosed with crusted scabies commonly require two treatments a week apart. *Content Refresher* Transmission-based precautions are infection control practices used in health care settings. These precautions are indicated when clients are known, or suspected, to be infected or colonized with infectious agents. Transmission-based precautions are used in addition to standard precautions. The three types of transmission-based precautions include contact, droplet, and airborne. For contact precautions, a gown and gloves should be worn upon room entry. Disposable, single-use, or client-dedicated equipment should be used with a client requiring contact precautions.

A client diagnosed with type 1 diabetes mellitus has a capillary blood glucose of 60 mg/dL (3.3 mmol/L) and reports hunger, sweating, tachycardia, and tremulousness. Which food choices does the nurse select that provide the client with 15 grams of an oral carbohydrate? (Select all that apply.) 1. 8 oz of regular soda. 2. Half cup of plain pasta. 3. Half cup of canned fruit. 4. 2 teaspoons of sugar. 5. 1 cup of whole milk. 6. 125 mL of apple juice.

1) INCORRECT— Eight ounces of regular soda contain 26 grams of carbohydrates. 2) CORRECT— One-half cup of plain pasta contains 15 grams of carbohydrates. 3) CORRECT— One-half cup of canned fruit contains 15 grams of carbohydrates. 4) INCORRECT— Two teaspoons of sugar contain 8.5 grams of carbohydrates. 5) INCORRECT— One cup of whole milk contains 11 grams of carbohydrates. 6) CORRECT— Apple juice in the amount of 125 milliliters contains 15 grams of carbohydrates. *Think Like a Nurse: Clinical Decision-Making* For the client who experiences hypoglycemia, food and drink should be offered only if the client is alert and speaking clearly. If the client demonstrates a decreased level of consciousness, introduction of food or oral fluids may result in aspiration. Sublingual administration of carbohydrates, including glucose gel or granulated sugar, is an available option for these clients. If the client is unconscious, glucose may be prescribed for administration via intravenous, intramuscular, or subcutaneous routes. For the alert client experiencing symptomatic hypoglycemia, the nurse administers only the necessary amount of carbohydrate, as excess carbohydrate administration causes rebound hyperglycemia. The quick carbohydrate dose is followed by a meal, sandwich, or protein-rich snack. *Content Refresher* Hypoglycemia occurs when there is too much insulin in the bloodstream relative to the amount of available glucose. Blood glucose less than 70 mg/dL (3.9 mmol/L) is diagnostic for hypoglycemia. Hypoglycemia can occur when too much insulin or oral hypoglycemic agents are taken, too little food is ingested, or excess physical activity is undertaken. Symptoms of hypoglycemia include shakiness, irritability, cool skin, difficulty concentrating, decreased level of consciousness, slurred speech, nausea, headache, and complaints of hunger. If the client is unconscious, administer 1 mg of glucagon (via intravenous, intramuscular, or subcutaneous injection) or 25 to 50 mL of 50% dextrose (via IV injection). Complications of hypoglycemia include seizures, coma, and possible death.

The nurse counsels an older client about peripheral vascular disease. Which client statement indicates that further teaching is needed? 1. "I should not smoke since it makes my symptoms worse. " 2. "I should exercise, even if it causes pain. " 3. "I should use warm packs if my hands and feet get cold. " 4. "I should stay inside during extreme weather."

1) INCORRECT— Smoking causes vasoconstriction of extremity vessels. Emotional stress and caffeine also cause vasoconstriction. 2) INCORRECT— Exercise increases collateral circulation. The client should walk until pain begins, rest, and then walk a little farther. 3) CORRECT— Decreased sensitivity may result in burns. The client should be instructed to use gloves and socks to warm the hands and feet. Warm moist packs hold heat longer than warm packs and increase the risk for injury. 4) INCORRECT— In peripheral vascular disease, the body cannot adjust to temperature extremes. The client should be instructed to wear socks or insulated shoes at all times and keep the home warm. *Think Like A Nurse: Clinical Decision Making* In clients with peripheral vascular disease (PVD) , an important nursing outcome is prevention of injury to the affected leg. The client should be informed that due to reduced circulation and sensation, the leg is at a higher risk for injury. The nurse should use the teach-back method to verify the client's knowledge related to foot care. The client is taught to inspect feet and legs daily, wear clean cotton or wool socks and well-fitting shoes, avoid sitting with legs crossed, and avoid prolonged standing. *Content Refresher:* When caring for the client with peripheral vascular disease, the nurse should assess strength of distal pulses (dorsalis pedis, posterior tibial, and popliteal), color, and temperature of extremities. Assess for any non-healing wounds. Ask client about symptoms occurring with walking or activities. Educate client about reducing risk for development/progression of disease. Administer prescribed medications and teach client about side effects. Perform wound care as prescribed for non-healing wounds and assess for infection or complications. The client should be instructed to avoid heat therapy for skin that is cut or injured and avoid cold therapy if the client has circulatory problems.

A client is prescribed pentamidine isethionate by the health care provider. Which observation best indicates to the nurse that the medication is effective? 1. Increased T-cell count. 2. Increased deep tendon reflexes. 3. Decreased bleeding and bruising. 4. Decreased crackles and dyspnea.

A client is prescribed pentamidine isethionate by the health care provider. Which observation best indicates to the nurse that the medication is effective? 1. Increased T-cell count. 2. Increased deep tendon reflexes. 3. Decreased bleeding and bruising. 4. Decreased crackles and dyspnea. View Explanation Explanation Step-by-Step Walkthrough 1) INCORRECT— This outcome shows improvement in the client's overall condition, but it is not particularly related to pentamidine. Pentamidine is an anti-protozoal, not anti-retroviral, medication. Pentamidine is used to treat Pneumocystis jiroveci pneumonia, a common opportunistic infection in immunosuppressed clients. 2) INCORRECT— Deep tendon reflexes are not affected by pentamidine. 3) INCORRECT— Pentamidine can cause leukemia and thrombocytopenia as adverse effects, but the desired outcome is improvement in pneumonia. 4) CORRECT — Pentamidine is an anti-protozoal agent used to prevent or treat Pneumocystis jiroveci pneumonia, a common opportunistic infection in immunocompromised clients. The manifestations usually include coughing, fever, dyspnea, fatigue, and weight loss, and crackles are heard in the lungs. *Think Like A Nurse: Clinical Decision Making* Pneumocystis jiroveci pneumonia (PJP), which was previously known as Pneumocystis carinii pneumonia (PCP), is the most common opportunistic infection among individuals diagnosed with HIV. This form of pneumonia may be lethal and does not respond to typical antifungal treatment. Pentamidine is administered as a nebulized or injectable medication. In the absence of other disease complications, therapeutic effects of pentamidine include decreased work of breathing, resolution of fever, diminishing cough, normalization of heart rate, and reduction or absence of pulmonary crackles or rhonchi. Pentamidine is associated with severe side effects. *Content Refresher* Determine the learner's knowledge level regarding Pneumocystis jiroveci pneumonia (PJP) and pentamidine. Allow time for discussion and questions. Minimize distractions and use clear, brief instructions. Determine which factors help or hinder the learning process. Educate the client about medication, including the rationale for administration, the dosage and frequency of administration, and the plan for evaluating the medication's effectiveness. Evaluate the effectiveness of the teaching/learning session using the teach-back method.