U World NCLEX (Mixed with MK Principles)

What do all aminoglycosides end with? (what suffix)

-mycin

What are 4 risk factors for lithium toxicity (4 Ds)?

1. Dehydration 2. Decrease renal function (in elderly) 3. Diet low in Na+ 4. Drug to drug interactions (NSAIDS and Thiazide diuretics)

What 6 indications will a nurse include to educate a patient on Epinephrine auto-injector?

1: Administer injection at 90-degrees angle at first sign of anaphelactic reaction 2: Inject Epi pen on thigh through clothing 3: Hold for 10 seconds 4: Expect tachycardia, palpitations, and dizziness after 5: Seek medical attention 6: Store Pen at room temp NOT TOO HOT OR COLD

What 3 interventions can be implemented to relief Occiput posterior?

1: Apply counterpressure to the client's sacrum during contractions. Firm, continuous pressure is applied with closed fist, heel of the hand, or other firm object. 2: Change positions frequently (30-60 min) 3: Maintain a LEFT lateral position

How many alarms are set up when using a vent for a pt and which ones are they?

2- high pressure and low pressure

How long can a Clonidine patch be patched for?

7 days

What occurs in a Ventricular trigeminy?

A PVC every third heartbeat

What does aPTT measure?

A lab test that determines blood coagulation time

When a pt is infectious and is started on antibiotic regimen, when will the individual NOT be CONTAGIOUS?

After they have completed 24 hours of antibiotics and are afebrile.

What is a Coronary Arteriogram?

An invasive diagnostic study of the coronary arteries, heart chambers, and function of the heart.

What does management of IBS consist of?

Focuses on reducing diarrhea or constipation, abdominal pain, and stress.

Where are Beta 1 receptors located?

Heart, Kidney

Does wine vinaigrette contain alcohol?

NO

What is torsades de pointes?

Polymorphic V tach in which the QRS complex twists around the baseline. May occur spontaneously or when the patient has HYPOkalemia or HYPOmagnesemia or following meds that prolong the QT

What is the definition of denial?

Refusal to accept the reality of a problem

What are 3 common signs of impending airway obstruction in a pt with acute epiglottitis?

1. Restlessness 2. Stridor 3. Drooling due to dysphagia

If on the NCLEX there is a questions that has 24hr creatinine clearance vs a serum creatinine, which one would be more precise?

24 hr creatinine clreance

What is chlorthalidone?

Thiazide diuretic

Off label usage of Alpha 1 blockers

Treat urinary retention, kidney stones in women

What medication requires you to check aPTT?

Unfractioned Heprin

What are the age groups that the Heimlich maneuver (upward thrust) be performed on?

Children over 1 age

What is the number one problem in all abuse situations?

Denial of abuser

When you get a denial question, what should you pay attention to?

Whether it is loss or abuse

If ineffective breastfeeding occurs, the nurse should perform what 4 interventions:

1. Assess baby's sucking reflex and physical condition 2. Assess the mother's brestfeeding technique (positioning, behavior/anxiety during breastfeeding) 3. Teach how to express milk by hand and use an electric pump to enhance milk production 4. Refer to a lactation consultant if ineffective breastfeeding occurs longer than 24 hrs

Describe emphysema

Characterized by alveolar wall destruction. Lung tissues lose elasticity (recoil) due to permanently enlarged, "floppy" alveoli. This causes hyperinflation of the lungs (air trapping), manifested by hyperresonance on percussion and prolonged expiration.

What is Compartment syndrome (CS) and how does it happen?

Compression of vascular structures by either external compression (restrictive dressings/casts) or increased pressure within a compartment (bleeding, inflammation, and edema)

How should a nurse assess for petechiae in african americans?

Conjunctivae of the eyes and the buccal mucosae

When PTSD is present in a pt, what is the first intervention the nurse should perform?

Encourage the pt to talk about it, and also use active listening as a therapeutic approach

Can Methadone cause heart abnormalities?

Have ECGs before starting medication, 1 month after starting, and annually while on it because methadone can cause QT-interval prolongation and lethal arrhythmias (eg, torsade de pointes) (Option 5).

What are 2 signs of increased intraocular pressure?

Increased intraocular pressure can cause damage to the blood vessels and retina and cause potential permanent vision loss. Coughing, vomiting, straining to lift objects (>5 lb), and bending at the waist temporarily increase intraocular pressure and must be avoided after eye surgery. Antiemetic medication is administered as needed following ophthalmic surgery to prevent vomiting.

What is the first-line anti-infective used to treat diarrhea caused by C.diff?

Metronidazole (Flagyl) is the first-line anti-infective drug used to treat infectious diarrhea caused by Clostridium difficile. Leukocytosis is expected with this bacterial infection.

Once a pt who suffered a hypertensive crisis is STABLE, what are the IV meds substituted by?

Oral anti-hypertensive meds

Can preeclampsia occur during post-partum and how serious can it get?

Persistent headache and blurred vision could indicate postpartum preeclampsia. The majority of clients with preeclampsia develop symptoms before birth; however, a small percentage do not develop the complication until several days after birth. This potentially serious condition can rapidly worsen, leading to seizures and death if left untreated. Additional signs and symptoms may include high blood pressure, proteinuria, and edema (Option 2).

How do you treat codependency?

Set limits and enforce them (Saying "NO")

If pt is on a PCA pump, what will tell you the pt will need to get off of it?

Since PCA pumps depress respirations (DOWN), getting too much so resp will go too LOW, which means pt will be under-ventilating (respiratory acidosis) - Respiratory acidosis will tell you to get the pt off of the PCA pump

What are Sulfonylurea (Glyburide) medications used for?

Sulfonylureas are a group of medicines used in the management of Type 2 diabetes. Sulfonylureas lower blood glucose levels by stimulating insulin release from the Beta cells of the pancreas. Their action is dependent upon the presence of functioning Beta cells, therefore, sulfonylureas do not work in people with type 1 diabetes.

What are 5 more severe symptoms of HYPOglycemia?

1. Altered LOC 2. Impaired vision 3. Impaired speech 4. Seizure 5. Coma

What are TED hose and what do they do?

Thomboembolic deterrent stockings- promote venous return and reduce risk of venous thromboembolism

Alpha 1 blockers are used for what?

To treat hypertension (promotes vasodialtion) & prostatic hyperplasia (BPH)

What interaction does Phenytoin (Dilantin) have with tube feedings?

Tube feedings decrease Dilantin absorption, which reduces serum drug concentrations (10-20 mcg/mL) and may precipitate seizures. Feeding should be paused 1-2 hrs before and after phenytoin administration to ensure adequate absorption.

What is a blood vessel called when it carries blood TO the heart?

Vein for example: Pulmonary vein circulating blood toward the heart

With abuse, you?

CONFRONT

What is more life threatening, Hypo or Hyper glycemia?

Hypoglycemia

What is pruritus?

Pruritus or itch is defined as an unpleasant sensation of the skin that provokes the urge to scratch. It is a characteristic feature of many skin diseases and an unusual sign of some systemic diseases.

Risk associated with stent placement using the femoral approach

Retroperitoneal hemorrhage (showing up as back pain)

What should be done with blood if transfusion is delayed due to unexpected event?

Returned to blood bank to be refrigerated at a precise temp

TIP: In SATA questions, if you know for a fact a few of the options are the answer, STOP THERE, DO NOT choose more options!

DO NOT choose an extra one you may be iffy about, when in doubt just go with the options you are SURE of

What is the most common cause of iron deficiency anemia in toddlers?

Excessive milk intake, over 24 oz/day

When a child with Kawasaki disease is DC'ed home, what symptom should the parents immediately report the the HCP?

Fever

If a child with a VP shunt has a temp of 99 F (37 C), what should a parent do?

Fever may indicate shunt infection, but a temp of 99 F (37 C) remains within acceptable parameter. Contacting the HCP is not indicated.

Where are Alpha 1 receptors located?

Blood vessels, eye, bladder, prostate (P.E.B.B)

What kind of lotion can be used to alleviate pruritis?

Calamine

What should the nurse do after stabalizing pt on the ventilator?

Call resp therapist

What 5 most important interventions a post-op ICD implantation patient should receive?

1: Refrain from lifting the affected arm above the shoulder until approved by the health care provider to prevent dislodgment of the lead wire on the endocardium 2: Firing the ICD may be painful (like a blow to the chest) 3: Driving is possible after being cleared by the MD 4: Traveling is not restricted, ICD can set off magnet detector (hand-held wand should not be held over ICD) 5: Patient should carry ICD ID card and list of meds needed for travel

What are 2 possible side-effect of using the HFCWO?

1. Nausea 2. Vomiting

What 2 "mean old -mycins" are used exclusively to steriize the bowel?

1. Neomycin 2. Kanamycin

What is the Central Venous Pressure (CVP) value?

2-8 mm Hg

What is the aPTT lab value?

25-35 seconds

What is Occiput posterior position?

A malposition that occurs when the fetal occiput rotates and faces the mother's posterior or sacrum.

When you get a scenario, ask yourself "is it lung?"; if so, then?...

It is a RESPIRATORY problem (Rocket science lmao)

What symptoms can a pt manifest if both CVP and PAWP are elevated?

Crackles

What is the function of Beta 2 receptors when stimulated?

Lungs: -Bronchodilation GI smooth muscle: -Relaxes GI tone and motility Liver: -Activation of glycogenesis (creation of glucose), Increases blood sugar Uterus: -Relaxes Uterus

What is codependency?

When the significant other gets positive self esteem from doing things or making decisions for an abuser.

Are trophs drawn from all "mean old -mycins" why or why not?

Yes because they have a narrow therapeutic windows

Can a nasal cannula be used in comfort measures?

Yes, provides low-flow oxygen, which provides psychological comfort and ease feelings of apprehension

What are some symptoms that will be seen in pts with Alkalosis (pH is UP)?

- Irritability - Hyperreflexia (+3, +4) - Tachypnea - Tachycardia - Borborygmi (another word for increased bowel sounds) - Seizure

What 2 meds can exacerbate potassium levels in a pt with CKD?

1. ACE inhibitors 2. ARBs

What are 2 reasons for Factor Xa inhibitor meds being prescribed more frequently than other oral anticoagulants (eg, Warfarin)?

1. They have a lower risk of bleeding 2. It is unnecessary to perform routine monitoring of clotting times (eg, PT/INR, PTT)

What is dicyclomine hydrochloride?

Anticholinergic used to relax smooth muscle and dry secretions. **Contraindication is if pt has urine retention and glaucoma**

What kind of med is Phenytoin?

Anticonvulsant to prevent seizures

What is Amphotericin B?

Antifungal med used to treat systemic fungal infections

What hypospadias?

Hypospadias is a condition where the meatus isn't at the tip of the penis. Instead, the hole may be any place along the underside of the penis.

What med is given after pt is treated with activated charcoal and why?

IV sodium bicarb, to make the blood and urine more alkaline, therefore promoting urinary excretion of salicylate

Description of metabolic acidosis:

LOW pH & LOW HCO

What is the common area where diverticula develop?

Left (decending, sigmoid) colon

What is the difference between manipulation and codependency

Negative vs. Neutral: -If what the significant other is asked to do is neutral (no harm), then it is simply dependency/codependency -If what the significant other is being asked to do something harmful for the significant other, then it is manipulation

Is Kawasaki Disease contagious?

No

What is a Sinusoidal Fetal Heart Rate?

Repetitive, wave-like fluctuations with absent variability and no response to contractions

If parents of a 3 month old take the baby to the ED and the findings suggest a spiral femur fracture, what should be the PRIORITY action by the nurse and why?

Report the injury per protocol. Fractures of nonambulatory infants are always of concern and suspicious of child abuse.

What is irritable bowel syndrome (IBS)?

Spastic colon, chronic bowel condition caused by altered intestinal motility. Peristaltic action is affected, causing diarrhea, constipation, or a combination of both. -common in women r/t stress and anxiety -not an infection or inflammatory process

What is they pH goes opposite from bicarb?

Then it it is Respiratory

What is methylergonovine (Methergine) used for?

Inducing uterine contractions and stops postpartum/postabortion bleeding (increases BP)

What 4 assessments should the nurse do if a pt's oximeter tracing is questionable? (waveform is erratic)

- When an electronic assessment reading is questionable, the nurse should always assess the pt first for possible etiology. 1. Pt's LOC 2. Skin temp 3. Oxygenation/perfusion status 4. Check for motion artifact

What are 5 early signs of bleeding into the retroperitoneal space?

1. Hypotension 2. Back pain 3. Flank ecchymosis (grey turner sign) 4. Hematoma formation 5. Diminshed distal pulses

At age 12, how many hrs of sleep do kids need?

9 hrs

What indicates a negative Nitrazine pH test?

A Yellow, olive-yellow, or olive green

What indicates a positive Nitrazine pH test?

A blue-green, blue-gray, or deep blue color

What acid base balance status needs an ambu-bag at bedside? Acidodic or Alkilosis pt?

Acidodic- potential to respiratory arrest

If pt is under ventilating, what should you pick?

Acidosis

Which would be the appropriate client criteria for activating a rapid response team at the hospital? Select all that apply.

Any provider worried about the client's condition OR An acute change in any of the following: - Heart rate <40 or >130/min - Systolic blood pressure <90 mm Hg - Respiratory rate <8 or >28/min - Oxygen saturation <90 despite oxygen - Urine output <50 mL/4 hr - Level of consciousness

What should be the expected outcome when assessing a baby for the Moro reflex?

Baby should extend and raise the arms and fingers fanned out and then curls into fetal position

What is appropriate intervention for choking pts under the age of 1 year old?

Back blow and chest thrusts are appropriate interventions

What is battery?

Battery is the intentional touching of a person that is legally defined as unacceptable or occurs without the person's consent

Blood glucose (BG) that indicates a Hypoglycemic state?

Below 70mg/dL (3.9 mmol/L)

If Dr ordered nurse to wean off pt in a ventilator in the AM, 6AM ABGs came in and the pt is in a RESPIRATORY ACIDOSIS state, what would the nurse have to do?

DO NOT proceed with order and notify Dr- pt is under-ventilated already so weaning him/her off will only make it worse

Is urinary retention an UP or DOWN symptom?

DOWN

What is it called when the diverticula become inflamed?

Diverticulitis

If packed red blood cells are administered to a pt but later receives a new prescription of amphetericin B IVPB, how should the nurse administer the prescriptions?

Due to similarity between the adverse effects of amphotericin B and the symptoms of blood transfusion reaction, the nurse should allow one hour of observation before initiating amphetericin B

How often should women at ages 21-29 be screened with Pap smear?

Every 3 years

What is Leopold maneuver?

Feeling the pt's abdomen to determine the position and presentation of the baby

What site is used for a Coronary Arteriogram?

Femoral or radial artery (usually femoral)

What meds should be given to decrease fluid volume and preload in a pt with elevated CVP and PAWP?

Furosemide (lasix)

What Bishop score is considered adequate to follow through with induction of labor in nulliparous women?

Greater than or equal to 6-8

If pt has requested comfort care, and Dr prescribes med such as Nalaxone, what should nurse do?

HCP may be unaware of the pt's status or recent changes to the plan of care; therefore, the nurse should inform the on-call HCP of the changes and should not give the Nalaxone (explain new plan of care)

Description of Resp Alkalosis:

HIGH pH & LOW PaCO2

How can epiglottitis be prevented?

Haemophilus influenza type B (HiB), which is covered under the standard vaccinations given during the 2- and 4-month visits.

What can long term usage of corticosteroids cause?

Immunosupression, and the anti-inflammatory effects may also mask signs of infection (eg, inflammation, redness, tenderness, heat, fever, edema).

Which factor places a first trimester pt at increased risk for preterm labor?

Infection (eg, periodontal disease, UTI) is strongly associated with preterm labor, particularly when untreated. Infection causes release of inflammatory mediators such as prostaglandins, which are uterotonic (ie, promote contractions) and contribute to cervical softening.

What is Orlistat (Xenical)?

Inhibits pancreatic lipase that prevent the breakdown and absorption of fats from the intestine

pulmonary contusion

Injury or bruising of lung tissue that results in hemorrhage

What in our body produces vitamin K?

Intestinal bacteria

Name a med that is a bronchodilator & is non-selective beta-adrenergic agonist?

Isoproterenol (Isuprel)

What is sloughing?

Layer of dead tissue that sheds off living tissue

What can be administered before and while having CPT and why should it be administered?

Nebulized bronchodilators before or during to open up the airway and mobilize secretions

What 3 risk factors should the nurse educate a pt on about the rsik for prostate cancer?

Nonmodifiable risk factors (eg, those the client cannot control) include African American ethnicity, having a first-degree relative with prostate cancer, and increasing age.

What is an alternative to a TST (Mantoux) (TB test) if a pt is allergic to the protein?

QuantiFERON-TB (QFT) blood test

Who would be dependent, the significant other or the abuser?

The abuser is dependent

What kind of drug is any med that has the prefix nitro-?

Vasodialator

The nurse is caring for a client who weighs 450 lb (204.1 kg) 2 days after bariatric surgery. The client is pleasant, cooperative, and able to fully bear weight. What would be the most appropriate method for transferring this client safely?

When determining the most appropriate method to transfer a client safely, the nurse should assess: - Whether the client can bear weight - Whether the client is cooperative

Can standard adult AED be used on children?

Yes, Standard adult pads can be used as long as they do not overlap or touch. If adult AED pads are used, one should be placed on the chest and the other on the back ("sandwiching the heart").

Is it normal for a post op pt who has obstructive skeep apnea to have a sat of 92% at room air? If so, why?

Yes, anesthetics and sedating analgesics may exacerbate symptoms but a 92% at room air for this pt is considered stable

Should the HCP be informed about a positive HIV mother before having a FSE?

Yes, because the risk of fetal infection is increased by the small puncture

Can Multivitamins still be taken when on Orlistat?

Yes, but >2 hrs after taking Orlistat, NOT WITH ORLISTAT

How often are "mean old -mycins" administered?

q8

What is the difference between 1st and 2nd generation Antihistamines?

-1st generation: Can cross the blood brain barrier -2nd generation: Cannot cross the blood brain barrier, also have less sedation than 1st

Which 8 drug classes are classified as potentially harmful drugs to the elderly that contribute to drug-induced toxicity, cognitive dysfunction, and falls?

1. Antipsychotics- Amitriptyline 2. Anticholinergics 3. Antihistamines- Chlorpheniramine 4. Antihypertensive 5. Benzodiazapines- Lorazepam 6. Diuretics 7. Opioids 8. Sliding insulin scales

What 2 rhythms are CONTRAINDICATED for defibrillation and why?

1. Asystole- no conduction is present therefore shock cannot be implemented 2. Pulseless Electrical Activity (PEA)- Same reason as asystole

What are 6 nursing interventions a nurse should take in consideration when caring for a pt on a mechanical ventilator?

1. Monitor resp status and airway patency (Breath sounds) 2. Maintain an appropriate lvl of sedation 3. Assess weaning readiness (sedation holidays) 4. Prevent ventilator-associated infection with chlorohexidine 5. HOB at 30-45 degrees 6. Implement safety measures (have vent alarms on and have emergency equip at bedside)

What are 2 ways to correct vasoocclution in a sickle cell crisis?

1. Oxygenation- Supplemental oxygen 2. Hydration- IV fluids

3 examples in which advance directive should make decisions regarding a patient?

1. Pt has aphasia 2. Pt has a GCS of 7 or below 7 3. Pt becomes confused

What 2 BP results confirm preeclampsia?

1. Systolic BP greater than or equal to 140 mm Hg or diastolic BP greater than or equal to 90 mm Hg on 2 occasions at least 4 hrs apart 2. Systolic BP greater than or equal to 160 mm Hg or diastolic BP greater than or equal to 110 mm Hg confirmed on repeat check

What 4 steps should be done if high pressure alarm goes off (in order)?

1. Unkink tubing 2. Empty water out of tubing 3. Turn, cough, deep breath 4. Suction

When performing a well-child assessment on a 2-month-old baby the nurse should... Organize the assessments in correct order: (hint: Begin with less startling assessment) 1. Observe skin color and respiratory pattern 2. Auscultate heart and lungs 3. Palpate fontanelles 4. Assess pupillary response 5. Elicit Moro Reflex

4, 2, 5, 1, 3

When do babies form the muscles to be able to turn over to their sides or all the way over?

4-5 months

What is urge incontinence?

Also known as overactive bladder, occurs when the bladder contracts randomly, causing a strong, sudden urge to urinate followed by urine leakage.

Explain ectopic pregnancy

An ectopic pregnancy occurs when a fertilized egg implants and begins to grow outside the uterine cavity, frequently in the fallopian tubes. Clients with ectopic pregnancies may report a positive pregnancy test, vaginal spotting/bleeding, and/or abdominal pain.

What does the phrase "(M)ac kussmal" refer to?

Compensatory respiratory mechanism for (M)etabolic acidosis

What is the second question you ask yourself?

Is the pt over-ventilating, or under-ventilating? -It is critical for respiratory pts

What is beneficence?

Promoting the well being of individuals and the public (do good) Ex- doing dental screenings

When delegating UAP something, the word "reminding" is the same thing as?

Reminding (this is something that UAP are certainly able to do, remind but not teach) ** SHOULD NOT be confused with reinforce, which only LPN/LVNs can do!**

What can kill of bacteria in the gut, leading to vitamin K deficiency?

Some antibiotics that are taken PO

What is a papsmear?

Test allows early detection of cervical dysplasia (cancer)

The registered nurse is developing a nursing care plan for a client who has just undergone surgery for treatment of ulcerative colitis with the creation of a permanent ileostomy. What is the priority outcome for this client?

The priority outcome of nursing care is that the client will look at and touch the stoma; this is an indication that the client has accepted or begun to accept the change in body image and functioning and can begin participating in self-care.

What should be worn when a pt is on droplet precautions?

Gloves and mask

What 2 concepts should always be incorporated when using Orlistat?

1. Diet modifications 2. Exercise regimen

What 3 important measure should be taken in an advanced cardiovascular life-support incident (ACLS)?

1. IV epinephrine 2. Intubation 3. Treatment of reversible causes (eg, hypovolemia, hyperkalemia)

In babies with cleft palate, how long should their bottle feeding last?

20-30 minutes and no more than that because it may be tiring for them

Description of Resp Acidosis:

LOW pH & HIGH PaCO2

How does one build trust among a paranoid pt that believes will be food poisoned?

Offering unopened, individually packaged food

What is Wernicke's (Korsakoff's) syndrome? (Wernicke's is different from Korsakoff's but the NCLEX will use them interchangeable)

Psychosis induced by vitamin B1 (Thiamine) deficiency.

Can an LPN be assigned a pt admitted after a suicide attempt and started on oral Lorazepam?

YES- A suicidal client requires one-on-one supervision and maintenance of a safe environment. The nurse should ensure the client's safety and prevent self-harm while assisting with routine care (eg, oral medications) and activities of daily living. This assignment is appropriate for an LPN.

What is aversion therapy?

A type of behavior therapy designed to make a patient give up an undesirable habit by causing them to associate it with an unpleasant effect. (Ex: Make pt feel sick, and hate drinking)

How does Antabuse (disulfiram) work?

It will interact with alcohol and make pt super sick to their stomach (horribly ill)

What is a "mean old -mycin"?

"Big guns" antibiotics that are used to treat life threatening infections

What are aminoglycosides?

"Big guns" antibiotics- used to treat SERIOUS/RESISTANT, life threatening, diseases/infections, Gram-negative.

What should be monitored, knowing that "mean old -mycins" cause nephrotoxicity?

- Creatinine (NOT BUN)

What 3 thromboembolism preventive meds in selected procedures are given?

1. Aspirin 2. Heparin 3. Enoxaprin

What should be the CORRECT ORDER to don PPE?

1. Gown 2. Mask 3. Goggles 4. Gloves "Go-Mask-Go-Gloves"

What are 3 signs or characteristics of DDH in pts older than the age group <2-3 months?

1. Limited hip abduction occurs as contractures develop, particularly once the infant is age >3 months. 2 In children with one-sided DDH, the affected leg may be shorter than the opposite leg. However, this is also apparent after age 3 months. 3. These signs include a notable limp, walking on the toes, and a positive Trendelenburg sign (pelvis tilts down on unaffected side when standing on the affected leg). In the case of bilateral DDH, the child may also develop a waddling gait and severe lordosis.

When are they given?

24 hrs before and after the surgery

What time frame must tPA be administered?

3-4.5 hr window from onset of symptoms

What is percutaneous coronary intervention?

A PCI is where they take a catheter to the blocked portion of the vessel, blow up a balloon to compress fatty tissue and allow more blood flow and uses a femoral approach

Varicella-zoster virus (VZV) is characterized by lesions that begin as maculopapular rash, then progress to weeping vesicular lesions, how Long does it take for these lesions to crust over?

Approx. 1 weeks

Broca aphasia vs. Wernicke

Broca (expressive) aphasia is a nonfluent aphasia resulting from damage to the frontal lobe. Clients with Broca aphasia can comprehend speech but demonstrate speech difficulties. The speech pattern often consists of short, limited phrases that make sense but display great effort and frequent omission of smaller words (eg, "and," "is," "the"). Clients with Broca aphasia are aware of their deficits and can become frustrated easily. In comparison, clients with Wernicke (receptive) aphasia are unaware of their speech impairment.

What is cachexia?

Cachexia is a condition that causes extreme weight loss and muscle wasting.

What is Codependent Behavior?

Codependent persons will focus all their attention on others at the expense of their own sense of self.

The charge nurse observes a new staff nurse collecting a urine sample for urinalysis and culture as pictured. What is the charge nurse's best action? Click on the exhibit button for additional information. 1. Advise the staff nurse to discard the collected urine specimen and record the output (45%) 2. Advise the staff nurse to put the lid on the cup and immediately transfer it to a biohazard bag (23%) 3. Instruct the staff nurse to discard the first small amount of urine before collecting the sample (22%) 4. Remind the staff nurse that the specimen should be kept cool until it is sent to the laboratory (8%)

Correct answer: 1 Urine specimens must be collected aseptically from the port located on the catheter tubing of an indwelling urinary catheter. Obtaining urine from a collection bag is improper technique, and it would not be considered a viable specimen (Option 2). In this case, the collected urine should be measured and discarded (Option 1). Colonization and multiplication of bacteria within the stagnant urine in the collection bag may occur and cause incorrect results. In addition, some urinary drainage bags are impregnated with an antimicrobial agent to help prevent catheter-associated urinary tract infections; these agents can also negatively affect the results of a urinalysis or culture. To collect a urine specimen: 1. Clean the collection port with an alcohol swab 2. Aspirate urine with a sterile syringe 3. Use aseptic technique to transfer the specimen to a sterile specimen cup (Option 3) The urine sample should be collected aseptically from the port on the catheter; therefore, the current specimen should be discarded as it was collected incorrectly.

What is fifth disease (erythema infectiosum)?

Erythema infectiosum "slapped face" is a viral illness caused by the human parvovirus and affects mainly school-aged children. The virus spreads via respiratory secretions, and the period of communicability occurs before onset of symptoms.

In a disaster triage, what are the characteristics of an Expectant (Black) case and what 4 examples display those characteristics?

Extensive injuries w/ poor prognosis regardless of treatment. 1. Pulselessness 2. Apnea 3. Severe neurological trauma 4. Full-thickness burns >60% total body surface area

Can consuming some types of antibiotics while being on warfarin decrease or increase risk of bleeding?

INCREASE risk of bleeding

What would be a secondary toxic effect the "mean old -mycins" can cause?

Nephrotoxicity

What does adynamic mean?

No movement

Are all -mycin drugs antibiotics?

Not all drugs that end in -Mycin are aminoglycosides

What is isotretinoin?

Oral acne med derived from vitamin A

What kind of gloves should be used in a vaginal examination?

Sterile gloves

What can follow a pericardial effusion if aggravated?

Tamponade- as effusion increases in volume and results in compression of the heart

What is the most important intervention for a child with Wilm's tumor?

The abd should not be palpated, as this can disrupt the encapsulated tumor. (a sign should be posted that reads "DO NOT PALPATE ABDOMEN" at bedside)

What is usually the first sign of uterine rupture?

The first sign of uterine rupture is usually abnormal fetal heart rate (FHR) patterns.

When do tet spells occur?

They occur during stressful or painful procedures, on sudden waking, and with hunger, crying, and feeding

When a pt comes to emergency triaging, how should children <10 yrs of age be triaged?

They should automatically be upgraded to 1 lvl higher than the triaged urgency of their medical issue

What are selective serotonin re-uptake inhibitors?

Used to treat a number of psychiatric conditions (EG, major depressive disorder, generalized anxiety disorder)

When are they contraindicated?

When pt suffered blood loss or has thrombocytopenia

Is it Wernicke's syndrome preventable, and how?

Yes- giving B1 (Thiamine) vitamin

Can a UAP be assigned to walk a legally blind pt?

NO- not trained to do so

What does elevated CVP and PAWP indicate?

Left-sided heart failure

What are 2 symptoms of Dementia?

1: Can be alert, but disoriented to time 2: Becoming more and more forgetful, but attention level is usually normal

What are 2 symptoms of delirium?

1: Fluctuating mental status 2: Inattention with disorganized thinking and or alt level of consciousness

When does Gestational diabetes screening occur?

24-28 weeks of gestation

When should a TB test be rechecked?

48-72 hrs later

Why should pts with latent TB avoid steroids?

A pt with Latent Tuberculosis infection who begins treatment with a corticosteroid (Perdnisone) is at increased risk for conversion to ACTIVE TB disease. Therefore, the nurse should notify the HCP.

What is paroxysmal?

A spasm (violent one)

If pt is over ventilating, what should you pick?

Alkalosis

What are universal precautions?

Assumes blood and body fluid of ANY patient could be infectious

What kind of therapy is Disulfiram (Antabuse)?

Aversion therapy

If a pt taking Orlistat mentions they have "started taking multivitamin with their dinner-time dose", what teaching should be provided by the nurse?

Because Orlistat blocks the absorption of fats, it also interferes with fat-solubale vitamin (A,D,E,K) uptake

What is the function of Alpha 2 receptors when stimulated?

Blood vessels: -Decreases BP (reduces norepinephrine) GI smooth muscle: -Increases GI tone & motility

What is the function of Alpha 1 receptors when stimulated?

Blood vessels: -Vasoconstrict, BP increases, increases contractability of heart Eyes: -Dilate Bladder: -Relax, sphincter contracts Prostate: -Contracts

What is a pericardial effusion?

Build up of fluid between the pericardium and heart. Produces a restrictive pressure on the heart

What kind of activity must a pt with Marfan syndrome avoid?

Cardiovascular manifestations of Marfan syndrome include abnormalities of the aorta and cardiac valves, including aneurysms, tears (dissection), and leaky heart valves that may require replacement or repair. Therefore, competitive or contact sports are discouraged due to the risk of cardiac injury and sudden death.

What area should pediatric AED cover?

Chest and back. Pediatric AED pads or a pediatric dose attenuator should be used for children age birth to 8 years if available.

What kind of therapy is used with pts with Cystic Fibrosis (CF) to promote airway clearance and why?

Chest physiotherapy, percussing of chest to loosen and drain thick resp secretions

Chest tube placement

Chest tube insertion should be performed with the client's arm raised above the head on the affected side. If possible, the head of the bed should be raised 30-60 degrees to reduce risk of injury to the diaphragm.

What is Sjorgen's syndrome?

Chronic autoimmune disorder in which moisture-producing exocrine glands of he body are attacked by white blood cells. The most commonly affected glands are the salivary and lacrimal glands, leading to dry eyes (xerophthalmia) and dry mouth (xerostomia).

What should the nurse prioritize when not being able to figure out an endotracheal ventilator and pt is under-ventilated?

Disconnect the ventilator and manually ventilate the pt with resuscitation bag device at 10-15 L/min oxygen until the ventilator alarm state an be resolved

What is Meniere's disease?

Fluctuating sensorineural hearing loss in adults. Dizzy spells , fullness in ear, tinnitus.

Rule of B's:

If the pH and the Bicarb are Both in the same direction, then it is metabolic (Both are going Up or down)

What is histrionic personality disorder?

In a person with histrionic personality disorder, self-esteem depends on the approval of others. People with this disorder have an overwhelming desire to be noticed, and often behave dramatically or inappropriately to get attention. -Theatrical -Center of attention -Extreme emotionality -Approval seeking -Low frustration tolerance -Unable to delay gratification

What is Stevens-Johnson syndrome, how does it begin, and when can this happen?

It is a life-threatening hypersensitive reaction, often starts with flu-like symptoms and a painful, purple or red rash to the skin or mucous membranes that may resemble a 3rd-degree burn. Medication or infections can trigger this adverse reaction.

What should the nurse's response be to a pt who wishes to share a secrete with the nurse but does not want anyone else to know?

Keeping pt's secrete is a sign of countertransference (overinvolvement with the pt) and a violation of the professional boundary. The nurse must be honest and state that it may be necessary to tell others on the health care team. The pt can then decide whether or not to disclose the information.

What does a higher Bishop score indicate?

Likelihood of successful vaginal labor induction

Would we use the 3 -thro-'s for minor infections or sever infections?

MINOR ONLY

Can 2nd generation antihistamines be taken with alcohol?

May be taken with moderate amount of alcohol, but NOT RECOMMENDED

Name of Alpha 1 Blockers

Meds ending in -azosin & -nitrate

What are SELECTIVE Beta 2 Meds

Meds ending with -buterol, promotes bronchodilation

When you don't know what a diagnosis is, it will always be what?

Metabolic acidosis

If pt has hyperemisis and got dehydrated what base balance is the pt in?

Metabolic acidosis because hyperemisis (UP) caused dehydration (DOWN), therefore it makes the status go DOWN = acidosis

What happens when pt skips Metaformin dose due to not eating a meal?

Metformin increases the sensitivity of insulin receptors in cells and reduces glucose production by the liver. These actions increase the efficacy of insulin present in the body and prevent large rises in blood glucose after meals. Because metformin does not stimulate insulin secretion by the pancreas, the risk of hypoglycemia is minimal. Although skipping meals would cause a drop in blood glucose, metformin would not cause further hypoglycemia.

What are petechiae and when does it happen?

Petechiae are reddish or purple pinpoints on the skin that occur due to bleeding from capillaries. Petechiae usually occur due to blood vessel injury or bleeding dsorders (Thrombocytopenia, disseminated intravascular coagulation (DIC))

Where should the top of the fundus be felt at 16 wks of gestation?

Roughly halfway between the symphysis pubis and the umbilicus

What can ASD turn into if the symptoms continue beyond a month?

Post-traumatic stress disorder

After opening a sterile saline bottle, what is the time frame in which it can still be used?

Reuse within 24 hrs of opening

What is status asthmaticus and how does it happen?

Status asthmaticus is respiratory failure that comes with the worst form of acute severe asthma, or an asthma attack. If an attack comes on quickly and it doesn't respond to regular treatment, it can lead to status asthmatiscus

What is capsaicin used for?

Topical analgesic to relieve minor peripheral pain.

In a pt with VZV that is immunocompromised, list are 4 treatments and 3 teaching for the pt/legal guardian of pt (if child)?

Treatment: 1. Cool oatmeal baths 2. Topical antihistamines 3. Acetaminophen (for fever) 4. Require aggressive treatment: Antivirals (Acyclovir) Teachings: 1. Antivirals should be taken until all lesions have crusted 2. VZV is spread via airborne and contact transmission 3. Immunocompromised pt's should not receive live vaccines

Too much suctioning can cause more of what?

Trigger more mucus production

Do ventilation and respiratory rate correlate with each other at all, explain?

Ventilation does NOT correlate to respiratory rate (Ex: If pt is breathing at rate of 50 RR/min and their SaO2 is at 78 on 8 L/min of oxygen, pt is still under ventilating even though the pt is breathing very rapidly (rate has nothing to do with ventilation, not about the rate it is about SaO2)

What means can HIV be transferred to another person? (4 things)

1. Blood 2. Semen 3. Breast milk 4. Vaginal secretions

What 5 criteria is the cervix scored on?

1. Consistency 2. Position 3. Dilation 4. Effacement 5. Station

What are 3 Factor Xa inhibitor meds?

1. Rivaroxaban (Xarelto) 2. Edoxaban 3. Apixaban

What are 5 nursing interventions for a pt with ASD?

1. Assess for ideas and plans to commit self-harm 2. Assess for ineffective coping (eg, use of drugs and alcohol) 3. Assess impact of ASD on the pt's job performance, relationship, sleep pattern, and ability to perform ADL's 4. Explain that feelings and/or symptoms occurring after traumatic events are normal, this can help the pt with anxiety 5. Explore coping strategies used in previous stressful events

What 5 interventions should the nurse anticipate for a Preterm labor before 34 wks gestation?

1. Administer IM antenatal glucocorticoids (betamethasone) 2. Administer antibiotics to prevent GBS infections in the newborn if preterm birth occurs 3. Administer tocolytic meds to suppress uterine activity to allow betamethasone to work 4. Monitor prenatal lab results, including cultures 5. Continuous fetal monitoring, since fetus is at risk and also when mag sulfate is being infused

What are 2 adverse effects of Sulfonylurea medications?

1. Hypoglycemia 2. Weight gain

What are 4 important actions a nurse must do when a pt seizes while sitting on a chair?

1. Assist pt to lie down while protecting the head, and position them on the side to maintain patent airway and prevent aspiration 2. Loosen restrictive clothing and clear area near the pt 3. Administer O2 as needed if signs of hypoxia occur 4. Record and document the time and duration of seizure

What 3 heart rhythms should only be CARDIOVERTED and why?

1. Ventricular tachycardia (w/ pulse) 2. Atrial fibrillation w/ rapid ventricular response 3. Supraventricular tachycardia- Cardioversion delivers a low-energy shock to the R wave of the QRS complex to restart the rhythm (**Initial treatment of SVT is vagal stimulation, tell pt to bear down as if having a bowel movement, using the valsalva maneuver**)

What are 4 major roles of a case management nurse?

1. Decrease fragmentation of care (eg, obtaining health info from pt's nursing home facility) 2. Helps coordinate care and communication between HCPs 3. Makes referrals 4. Arranges for home health or placement after discharge

What are 7 items pts should avoid that contain hidden alcohol?

1. Mouthwash- even if they swish and swallow 2. Aftershave- even through it is topical (will make them nauseated) 3. Perfumes and colognes 4. Insect repellents (mosquito sprays) 5. Any over the counter med that ends in -elixir 6 Alcohol based hand sanitizers 7. Uncooked icings (vanilla extract)

When does birth weight double?

By age 6 months and tripling by age 12 months

What birth method should a prenatal pt with placenta accreta be prepared?

C-section

What are 4 common side effects of SSRIs?

1. Loss of appetite; weight loss or weight gain 2. GI disturbances (nausea, vomiting, diarrhea) 3. Headaches, dizziness, drowsiness, insomnia 4. Sexual dysfunction

What 2 kinds of pain meds that are able to be given to a pt with open fractured?

1. Ketorolac (NSAID) 2. Opioids

When is methylergonovine contraindicated?

When pt has high blood pressure (eg, Preeclampsia, preexisting hypertension)

What is the #1 none-DOWNER/UPPER drug that is abused?

Laxatives

A nurse has received new medication prescriptions for a client admitted with hypertension and an exacerbation of chronic obstructive pulmonary disease. Which prescription should the nurse question? 1. Amlodipine (12%) 2. Codeine (63%) 3. Ipratropium (13%) 4. Methylprednisolone (11%)

Codeine is a narcotic analgesic used for acute pain or as a cough suppressant. Depressing the cough reflex can cause an accumulation of secretions in the presence of chronic obstructive pulmonary disease (COPD), leading to respiratory difficulty. In general, sedatives (eg, narcotics, benzodiazepines) can also depress the respiratory center and effort; therefore, they should not be given to clients with respiratory diseases (eg, asthma, COPD).

The nurse is caring for a client who was just resuscitated following an out-of-hospital cardiac arrest. The client does not follow commands and remains comatose. What intervention does the nurse anticipate being added to the client's plan of care? 1. Assisting the health care provider in discussing a do-not-resuscitate order with the family (14%) 2. Obtaining equipment and cold fluids for induction of therapeutic hypothermia (21%) 3. Placing a small-bore nasogastric feeding tube for enteral nutrition (42%) 4. Planning for passive range-of-motion exercises to prevent contractures (21%)

Neurologic injury is the most common cause of mortality in clients who have had cardiac arrest, particularly ventricular fibrillation or pulseless ventricular tachycardia. Inducing therapeutic hypothermia in these clients within 6 hours of arrest and maintaining it for 24 hours has been shown to decrease mortality rates and improve neurologic outcomes. It is indicated in all clients who are comatose or do not follow commands after resuscitation. The client is cooled to 89.6-93.2 F (32-34 C) for 24 hours before rewarming. Cooling is accomplished by cooling blankets; ice placed in the groin, axillae, and sides of the neck; and cold IV fluids. The nurse must closely assess the cardiac monitor (bradycardia is common), core body temperature, blood pressure (mean arterial pressure to be kept >80 mm Hg), and skin for thermal injury. The nurse must also apply neuroprotective strategies such as keeping the head of the bed elevated to 30 degrees. After 24 hours, the client is slowly rewarmed.

What is a Boston brace?

The Boston brace, Wilmington brace, thoracolumbosacral orthosis (TLSO) brace, and Milwaukee brace are used to diminish the progression of deformed spinal curves in scoliosis. Braces do not cure the existing spinal deformities but do prevent further worsening. These braces are also sometimes used for clients who undergo spinal fusion. The braces are molded plastic shells worn around the trunk of the body under the client's outer clothing. Due to the risk for skin breakdown, clients should wear a cotton t-shirt under the brace to decrease skin irritation and absorb sweat. Compliance is a major problem in most adolescents as they are preoccupied with body image and appearance. Psychosocial issues (eg, body image, sense of control, socialization) are very important to discuss. Many clients may find it helpful to meet other individuals their age who also wear the braces. (Option 1) The use of lotion or powder can cause skin irritation due to heat buildup beneath the brace. (Option 2) It is important to build and maintain strength in the spinal muscles to promote stabilization throughout treatment. Most prescribed bracing courses allow brace removal for such exercises. (Option 3) The exact course of bracing treatment varies based on the type of brace and severity of spinal curvature. Most braces are worn for 18-23 hours per day and removed for bathing and exercise. Clients should never shower while wearing a hard brace as padding will absorb moisture and promote skin breakdown.

What is dependency?

When the abuser gets a significant other to make decisions for them or do thing for them. (Ex: can you do this or do that...)

What are 5 interventions for pts with Urge incontinence?

1. Losing excess weight to reduce pressure on pelvic floor 2. Avoid dietary bladder irritants (caffeine, nicotine, artificial sweeteners, citrus juices, alcohol, carbonated drinks) 3. Perform pelvic floor exercises 4. Taking anticholinergic medications 5. Bladder training, such as voiding every 2 hrs while awake and gradually lengthening the intervals between voiding

What should be done if extravasation occurs in an IV line with norepinephrine? (3 main interventions)

1. Stop and DC the IV infusion immediately 2. Elevate the affected arm 3. Notify HCP

How often should pts be suctioned?

Only as needed, after they unsuccessfully turned, coughed, and deep breathing then you proceed to suction

A client is having a severe asthma attack lasting over 4 hours after exposure to animal dander. On arrival, the pulse is 128/min, respirations are 36/min, pulse oximetry is 86% on room air, and the client is using accessory muscles to breathe. Lung sounds are diminished and high-pitched wheezes are present on expiration. Based on this assessment, the nurse anticipates the administration of which of the following medications? Select all that apply.

Pharmacologic treatment modalities recommended by the Global initiative for Asthma (2014) to correct hypoxemia, improve ventilation, and promote bronchodilation include the following: - Oxygen to maintain saturation >90% - High-dose inhaled short-acting beta agonist (SABA) (albuterol) and anticholinergic agent (ipratropium) nebulizer treatments every 20 minutes - Systemic corticosteroids (Solu-Medrol)

It is easier to treat dependency or manipulation?

manipulation- people think they are idiots for being manipulated

What is placenta accreta?

Abnormal placenta implantation, it implants directly into the myometrium rather than the endometrium

How much of a gap should be between the crutch pads and axilla?

1-2 inches (2.5-5 cm)

How long does it take for SSRIs to have a therapeutic effect?

1-4 weeks

When making room assignments with pts, what 3 types of combinations should be avoided?

1. Active or suspected infection w/ fresh surgical wound (within 24 hrs) 2. Active or suspected infection w/ immunocompromised 3. Excessive body excretions, draining, or secretions are likely to spread infection, if present, so should be assigned to private room

What are 2 general symptoms that diverticulitis causes?

1. Acute pain, usually in the left lower quadrant 2. Systemic signs of infection

When dealing with a pt with ASD, what 5 interventions can the nurse implement?

1. Assess for ideas and plans to commit self-harm 2. Assess for ineffective coping (use of drugs or alcohol) 3. Assess impact of ASD on pt's job, fam relationships, sleep pattern, and ability to perform ADL's 4. Explain experiencing difficult symptoms is normal 5. Explore coping strategies used in previous stressful situations and TALK ABOUT IT

If a pt is allergic to latex, what other 2 items should the pt stay away from?

1. Bananas 2. Kiwis

Regarding venous thromboembolism preventions, what are 2 positions the pt must avoid?

1. Crossing legs 2. Pillows used to elevate legs placed behind the knees- pressure on the posterior knees compresses leg veins

What are 5 supplements that can increase risk of bleeding?

1. Gingko biloba 2. Garlic 3. Ginseng 4. Ginger 5. Feverfew

What 2 interventions can the nurse implement to a HYPOglycemic pt who is conscious?

1. Give pt orange juice 2. Sugar tabs

When wearing full PPE (gown, gloves, mask, and eye protection), what should be the CORRECT ORDER when removing PPE?

1. Gloves 2. Goggles 3. Gown 4. Mask **Alphabetical order**

What are 5 main contrainidcations for tPA?

1. Hemorrhagic stroke 2. Uncontrolled hypertension 3.If surgery was preformed within the last 14 days 4. The pt has thrombocytopenia (<100,000/mm3) 5. Head trauma within the past 3 months

What are 4 examples of reactive symptoms?

1. Hyperactive sensory 2. Sleep disturbance 3. Difficulty concentrating 4. Easily startled

What are chlorthalidone major side-effects (4 H's)?

1. Hypokalemia- Muscle cramps 2. Hyponatremia- Altered mental status 3. Hyperuricemia- Worsen gout attacks 4. Hyperglycemia- May require adjustment of diabetic meds

What kind of adverse side effects is Amphotericin B commonly associated with? (4 main ones)

1. Hypotension 2. Fever 3. Chills 4. Nephrotoxicity

What 4 traits does Codependent person display when in a relationship with an addict?

1. Individual keeps another person's addiction a secrete 2. Suffers physical or psychological abuse from the addict 3. Not allowing the addict to suffer the consequences of their actions 4. Makes excuses for the addict's habits

What are the 7 Live Vaccines?

1. Mumps, Measles, Rubella (MMR) 2. Shingles 3. Herpes 4. Varicella 5 Yellow fever 6. Rotavirus 7. Influenza (intranasal)

What are the 3 major goals to provide supportive care for symptom relief and prevention of complication in pts with acute pancreatitis?

1. NPO status - The client is maintained on NPO status as any ingestion of food will stimulate the excretion of pancreatic enzymes. A nasogastric tube is used to suction out gastric secretions; this will reduce nausea and lessen stimulation of the pancreas as these juices will move to the duodenum. 2. Pain management - Intravenous opioids (eg, hydromorphone, fentanyl) are frequently utilized for pain management. Morphine can also be used; worsening pancreatitis due to increase in sphincter of Oddi pressure has not been proven in studies. 3. IV fluids - Aggressive fluid replacement to prevent hypovolemic shock is critical. Inflammation of the pancreas releases chemical mediators that increase capillary permeability and cause third spacing (fluid going into empty spaces).

What are 4 characteristics of a pt that is at highest risk for hospital-acquired MRSA?

1. Older adults 2. Suppressed immunity 3. Long history of antibiotic use 4. Invasive tubes or lines (eg, hemodialysis pt's)

What are 5 clinical manifestations of pulmonary edema?

1. Orthopnea and/or paroxysmal nocturnal dyspnea 2. Anxiety and restlessness 3. Tachypnea often >30/min (and kussmal breathing) 4. Frothy (bubbling), blood-tinged sputum 5. Crackles

What are 3 supportive treatments for ITP?

1. Platelets monitoring 2. Corticosteroids 3. IV immunoglobulin

What are the 4 steps to do when med error occurs (in order from most important to least)?

1. Prioritize pt safety by assessing for adverse effects 2. Notify HCP 3. Notify nurse manager 4. Complete an IRIS

What are 5 accommodations for pts with hearing impairment?

1. Sitting directly in front of them 2. Well lit room so all visual cues are visible (facial expressions and hand gestures) 3. Encourage repeating back of instructions 5. Consider printed material with visuals

What is 1 contraindication for skeletal traction unless prescribed by the Dr?

1. Weights should not be removed, even briefly

What is considered a therapeutic value of aPTT?

1.5-2 times the value of aPTT: 46-70 seconds

At what age are solid foods generally introduced?

4-6 months

What is the Pulmonary Artery Wedge Pressure (PAWP) value?

6-12 mm Hg

How long is medication treatment for a pt with Multidrug-resistant tuberculosis (MDR-TB)?

6-9 months

What level is considered Lithium toxicity?

> 1.5 mEq/L

What is Disulfiram (Antabuse)?

A drug prescribed by doctors, which causes the drinker to become violently ill when consumes alcohol

Ventricular tachycardia

A rapid heart rhythm in which the electrical impulse begins in the ventricle (instead of the atrium), which may result in inadequate blood flow and eventually deteriorate into cardiac arrest. (treatment for VT w/pulse is synchronized cardioversion and amiodrone; for pulseless is defibrillation)

What is a hypertensive crisis?

A severe increase in blood pressure that can lead to a stroke. Extremely high blood pressure — a systolic > or = 180 or a diastolic > or = 120 mm Hg or higher damages blood vessels. They become inflamed and may leak fluid or blood. As a result, the heart may not be able to pump blood effectively. Can damage organs if BP is not lowered adequately.

Apgar scale

A standard measurement system that looks for a variety of indications of good health in newborns

What is a nitrazine pH test?

A strip inserted into the vagina can differentiate between amniotic fluid, which is alkaline, and vaginal fluid, which is acidic

What is an advanced directive?

A written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor.

What should a nurse teach a caregiver about extended-release pain meds prescribed to a pt with chronic cancer? (hint: to relive pain for as long as possible?

Administer extended-release as scheduled, even if the pt does not report pain (around the clock)

Every abused drug is either...

An UPPER or a DOWNER

Patent ductus arteriosus (PDA)

An abnormal opening between the pulmonary artery and the aorta caused by failure of the fetal ductus arteriosus to close after birth

The nurse is providing discharge instructions to a client receiving oxybutynin for overactive bladder. Which client statement indicates that further teaching is required? 1. "I am looking forward to our summer vacation at the beach." (57%) 2. "I plan to eat more fruits and vegetables to prevent constipation." (10%) 3. "I should not drive until I know how this drug affects me." (17%) 4. "I will drink at least 6-8 glasses of water daily." (14%)

Answer: 1 Oxybutynin (Ditropan) is an anticholinergic medication that is frequently used to treat overactive bladder. Common side effects include: - New-onset constipation - Dry mouth - Flushing - Heat intolerance - Blurred vision - Drowsiness Decreased sweat production may lead to hyperthermia. The nurse should instruct the client to be cautious in hot weather and during physical activity (Option 1).

The nurse is preparing to assess a client visiting the women's health clinic. The client's obstetric history is documented as G5T1P2A1L2. Which interpretation of this notation is correct? 1. The client had 1 birth at 37 wk 0 d gestation or beyond (66%) 2. The client had 3 births between 20 wk 0 d and 36 wk 6 d gestation (16%) 3. The client has 3 currently living children (8%) 4. The client is currently not pregnant (8%)

Answer: 1 The GTPAL system is a shorthand system of documenting a client's obstetric history. This client (G5T1P2A1L2) has been pregnant 5 times (G5); had 1 term birth (T1), 2 preterm births (P2), and 1 abortion (A1); and has 2 currently living children (L2). The client's term birth is indicated by the T1 portion of the GTPAL notation (Option 1).

The nurse on the step-down cardiothoracic unit receives the change-of-shift hand-off report. Which client should the nurse assess first? 1. 2 days postabdominal aortic aneurysm repair with a pedal pulse decreased from baseline (49%) 2. 2 days postcoronary bypass graft surgery with a white blood cell count of 18,000/mm3 (18.0 × 109/L) (16%) 3. Cardiomyopathy with an ejection fraction of 25% and dyspnea on exertion (19%) 4. Pneumothorax with a chest tube to negative suction and subcutaneous emphysema (14%)

Answer: 1 The nurse should assess the pulses (eg, femoral, posterior tibial, dorsalis pedis) and skin color and temperature of the lower extremities in the client with the abdominal aortic aneurysm (AAA) repair first. Pulses can be absent for 4-12 hours after surgery due to vasospasm. However, a pedal pulse decreased from the client's baseline or an absent pulse with a painful, cool, or mottled extremity 2 days postoperative can indicate the presence of an arterial or graft occlusion. This client's condition poses the greatest threat to survival.

The nurse is monitoring a client who is in active labor with a cervical dilation of 6 cm. Which uterine assessment finding requires an intervention by the nurse? 1. Contraction duration of 95 seconds (60%) 2. Contraction frequency of every 3 minutes (15%) 3. Contraction intensity of 45 mm Hg (8%) 4. Uterine resting tone of 10 mm Hg (15%)

Answer: 1 Uterine contractions decrease circulation through the spiral arterioles and the intervillous space, which can stress the fetus. Uterine contraction duration should not exceed 90 seconds. During the first stage of labor, duration should be 45-80 seconds. A duration exceeding 90 seconds can result in reduction of blood flow to the placenta due to uterine hypertonicity.

Which pediatric respiratory presentation in the emergency department is a priority for nursing care? 1. Client with an acute asthma exacerbation but no wheezing (48%) 2. Client with bronchiolitis with low-grade fever and wheezing (15%) 3. Client with runny nose with seal-like barking cough (22%) 4. Cystic fibrosis client with fever and yellow sputum (13%)

Answer: 1 When an acute asthma exacerbation occurs, the child has rapid, labored respirations using accessory muscles. The child often appears tired due to the ongoing effort. In the case of severe obstruction (from airway narrowing as a result of bronchial constriction, airway swelling, and copious mucus), wheezing/breath sounds are not heard due to lack of airflow. This "silent chest" is an ominous sign and an emergency priority. In this situation, the onset of wheezing will be an improvement as it shows that air is now moving in the lungs.

The emergency department nurse assesses an intubated client with multiple trauma injuries who recently arrived via emergency medical services. Which intervention should the nurse perform first? 1. Administer PRN pain medication (12%) 2. Assist with central line placement (36%) 3. Cover with warm blankets (21%) 4. Obtain prescribed x-rays (29%)

Answer: 2 (LOOK AT PICTURE)

When assessing a preterm newborn for cold stress, a graduate nurse in the newborn nursery needs further teaching when stating the need to assess for which finding? 1. Irritability (16%) 2. Poor feeding (21%) 3. Shivering (40%) 4. Weak cry (21%)

Answer: 3 Neonates are unable to generate heat by shivering due to their lack of muscle tissue and immature nervous systems; they therefore produce heat by increasing their metabolic rates through nonshivering thermogenesis. Brown adipose tissue (BAT), developed during the third trimester, is metabolized for thermogenesis when available. Once BAT is depleted, nonshivering thermogenesis is less effective and the neonate may experience cold stress, possibly leading to death. Preterm neonates have fewer stores of BAT and are at higher risk for cold stress. Frequent temperature monitoring is the best method to assess if an infant is cold. In cold stress, metabolism increases to generate heat, causing a greater demand for oxygen and glucose and the release of norepinephrine. If adequate oxygenation is not maintained, hypoxia and acidemia occur. Hypoglycemia develops when available glucose is depleted, and repletion of glucose is impaired by gastrointestinal immotility and poor oral intake.

A nurse is documenting notes in the client's electronic record after making rounds on assigned clients. Which entry is an appropriate documentation? 1. Client appears to be sleeping. Eyes closed. (4%) 2. Client reports, "I'm in pain." Medication provided. (9%) 3. Inspiratory wheezes heard in bilateral lower lung fields (82%) 4. Voided x 1 (3%)

Answer: 3 The electronic record is a legal document and should contain factual, descriptive, objective information that the nurse sees, feels, hears, and smells. It should be the result of direct observation and measurement. "Inspiratory wheezes heard in bilateral lung fields" best fits these criteria. The nurse should avoid vague terms such as "appears," "seems," and "normal." These words suggest that the nurse is stating an opinion and do not accurately communicate facts or provide information on behaviors exhibited by the client. The nurse should provide exact measurements, establish accuracy, and not provide opinions or assumptions.

The health care provider (HCP) has prescribed amitriptyline 25 mg orally every morning for an elderly client with recent herpes zoster infection (shingles) and severe postherpetic neuralgia. What is the priority nursing action? 1. Encourage increased fluid intake (19%) 2. Provide frequent rest periods (10%) 3. Teach the client to get up slowly from the bed or a sitting position (55%) 4. Tell the client to wear sunglasses when outdoors (14%)

Answer: 3 Tricyclic antidepressants (eg, amitriptyline, nortriptyline, desipramine, imipramine) are commonly used for neuropathic pain. Side effects are especially common in elderly clients.Due to the increased risk of falling, the priority nursing action is to teach the client to get up slowly from the bed or a sitting position.

A nurse on the telemetry unit receives a client admitted from the emergency department with acute alcohol intoxication, confusion, and a diabetic toe ulcer. Which intervention would be the priority? 1. Assess for signs of alcohol withdrawal (55%) 2. Assess the need for alcohol rehabilitation referral (1%) 3. Let the client sleep off the alcohol intoxication (1%) 4. Monitor blood glucose levels during the night (42%)

Answer: 4 Alcohol is a toxin that causes central nervous system depression. Acute alcohol intoxication can cause confusion, coordination impairment, drowsiness, slurred speech, mood swings, and uninhibited actions. Alcohol can also cause hypoglycemia, especially in clients with diabetes mellitus. Although the client is intoxicated, it is difficult to determine if the confusion is caused by alcohol or hypoglycemia or both. The priority is to monitor blood glucose during the night to watch for hypoglycemia, which would require immediate intervention.

Abdominal paracentesis positioning

Abdominal paracentesis is used to remove ascitic fluid from the peritoneal cavity in end-stage liver disease (cirrhosis). The client should be positioned in high Fowler's or sat upright to facilitate the flow of fluid to the bottom of the peritoneal cavity, where the needle will be inserted. The client should void prior to the procedure to decrease the risk of bladder puncture.

What would abuser say when significant other finally decides to say "NO"?

Abuser will try hitting their self-esteem

What should be the primary treatment for an overdose of acetylsalicylic acid (ASA) (eg, aspirin), activated charcoal or gastric lavage and why?

Activated charcoal should be the FIRST treatment in pts with signs of ASA toxicity who manifest symptoms such as disorientation, vomiting, hyperpnea, diaphoresis, restlessness. The charcoal binds to available salicylates, thus limiting further absorption in the small intestine and enhancing elimination. On the other hand, there is no convincing evidence that gastric lavage decreases morbidity.

When does fundal height begin to correlate to the wks of gestation?

After 20 wks

When is cervical cancer screening typically initiated in females?

Age 21 or older than 21, regardless of age at onset of sexual activity.

What does it mean for pH to go "UP"?

Alkalosis

Which acid base disorder needs suction at bedside, Acidosis or Alkalosis?

Alkalosis- More likely to have a seizure and aspirate

When introducing new food to babies, how much time should be allowed between each new food?

Allow several days (4-7) days between each new food to observe for any reaction to a specific food

Otitis Externa (Swimmer's Ear)

An infection of the outer ear, with severe painful movement of the pinna and tragus, redness and swelling of pinna and canal, scanty purulent discharge.

A male client has terminal metastatic disease. He arrives at the emergency department with respirations of 6/min and an advance directive indicating to withhold resuscitative efforts. What should the nurse's response be? 1. Apply oxygen at 2 L by nasal cannula (61%) 2. Ask the client if he wants to change his mind (8%) 3. Ask the spouse what she wants done (1%) 4. Determine who has medical power of attorney (28%)

Answer: 1 Advance directives are prepared by a client prior to the need to indicate the client's wishes. A living will gives instructions about future medical care and treatment if the client is unable to communicate. A medical power of attorney is the individual designated to make health care decisions should a client become unable to make an informed decision. It allows more flexibility to deal with unique situations. Because the client has indicated specific desires, these should be honored. This is especially true as the client has a terminal condition (versus, for example, an acute choking episode that could be easily reversed). Oxygen can provide comfort and is not resuscitative when given by nasal cannula. (Option 2) Advance directives are determined ahead of time to guide decision making at the time of the event. The client can indicate a desire to make a change, and the original decision should be honored. This client could be experiencing hypoxia and thus not thinking as clearly as when the advance directives were made. Asking about changes could imply that he should make a change, which is not true. The original decision should be honored; however, the client can indicate a desire to make a change.

The nurse is teaching a seminar about atypical presentation of myocardial infarction. The nurse teaches about which factor that increases a client's risk of experiencing atypical symptoms? 1. Female gender (67%) 2. History of smoking (13%) 3. Hyperlipidemia (6%) 4. Hypertension (12%)

Answer: 1 Atypical presentation of a myocardial infarction (MI) refers to a client who is having characteristic symptoms (eg, sweating, nausea, dyspnea) with no chest pain. Although any client may have atypical symptoms during an MI, certain factors increase the risk of atypical presentation. Clients with advanced age or female gender have a greater risk for atypical presentation during an MI (Option 1). **Clients with diabetes or neuropathy may have impaired pain perception due to nerve dysfunction, which makes them more likely to have an atypical presentation, or a silent MI (ie, asymptomatic).**

An adolescent client is brought to the emergency department after being in a serious motor vehicle crash. The client is undergoing cardiopulmonary resuscitation. The nurse calls the family to inform them to come to the hospital and a family member asks how the client is doing. Which is an example of the ethical principle of beneficence when responding to the client's family? 1. "He is critically ill and we are caring for his needs." (46%) 2. "His heart has stopped and we are attempting to revive him." (13%) 3. "I don't know how he is doing but you need to come." (1%) 4. "I will have the health care provider talk to you once you arrive." (38%)

Answer: 1 Beneficence is the ethical principle of doing good. It involves helping to meet the client's (including the family) emotional needs through understanding. This can involve withholding information at times. Stating that the client is critically ill and is being cared for meets the ethical principle of veracity (telling the truth) but also avoids overwhelming the family before they travel to the hospital. The nurse does not want the family to be too distressed to process the situation and arrive safely.

A client is 1-day postoperative abdominoplasty and is discharged to go home with a Jackson-Pratt (JP) closed-wound system drain in place. The nurse teaches the client how to care for the drain and empty the collection bulb. Which statement indicates that the client needs further instruction? 1. "I'll empty the JP bulb when it is totally full so that I don't have to unplug it so many times." (79%) 2. "I'll pull the plug on the JP bulb and pour the drainage into the measurable specimen cup." (4%) 3. "I'll squeeze the JP bulb from side-to-side as I hold it in my hand." (8%) 4. "While the JP bulb is totally compressed, I'll clean the spout with alcohol and replace the plug." (7%)

Answer: 1 It is common for clients to be discharged with a JP closed-wound surgical drain in place after abdominal and breast reconstruction surgery. The purpose of the drain is to prevent fluid buildup in a closed space, which can put tension on the suture line and compromise the integrity of the incision, increase the risk for infection, and decrease wound healing. The general procedure for emptying the drainage device includes the following steps in order: - Perform hand hygiene as asepsis must be maintained to prevent the transmission of microorganisms even though there is less chance of bacteria entering the wound using a closed-wound drainage device (eg, JP, Hemovac) than an open-drain device (eg, Penrose) - Pull the plug on the bulb to open the device and pour the drainage into a small, calibrated container (eg, plastic water cup, urine specimen container) as this facilitates recording accurate drainage output (Option 2) - Empty the device every 4-12 hours unless it is 1/2 to 2/3 full before then because as the small capacity bulb (100 mL) fills, the amount of negative pressure in the bulb decreases (Option 1) - Compress the empty bulb by squeezing it from side-to-side with 1 or 2 hands until it is totally collapsed. Although the reservoir can be collapsed by pressing the bottom towards the top, compressing the sides of the reservoir (bulb) is recommended as it is more effective in establishing negative pressure (Option 3) - Clean the spout on the bulb with alcohol and replace the plug when it is totally collapsed to restore negative pressure (Option 4)

After a traumatic head injury, a 36-year-old client on a mechanical ventilator is declared brain dead. The client's spouse states, "Maybe this happened for a reason. Do you think organ donation is possible?" Which response by the nurse is appropriate? 1. "A specialized team reviews each case for eligibility. I will contact them to review your spouse's history." (51%) 2. "It depends on whether your spouse gave consent to be an organ donor before the injury." (39%) 3. "Organ donation often provides comfort to family members who are grieving the loss of a loved one." (7%) 4. "You seem to be thinking the worst. Your spouse was young and healthy, and we are doing everything we can." (1%)

Answer: 1 Organ and tissue donation involves surgical transfer of organs to living clients. Whenever a client's death is considered imminent, or in cases of irreversible neurologic injury (eg, brain death), nurses are responsible for initiating contact with the regional organ procurement organization (OPO) or facility organ donation coordinator. Nurses should utilize careful therapeutic communication to provide support for the client's family following brain death. However, nurses should never directly approach family members about organ donation, as it involves many legal and ethical concerns and complex eligibility factors that should be addressed by the OPO. The OPO arranges for specialized health care professionals to contact the family directly to determine the client's eligibility, provide information, and obtain consent. The OPO also extensively screens the client for disease, as immunosuppressive therapy makes organ recipients vulnerable to infection and cancer. **(Option 2) Some regions have organ donor registries that allow individuals to express their wishes, but in most cases the client's family consents for donation.**

Why does defibrillation not work none-electrical active organized rhythm?

Defibrillation will not ignite the electrical conduction, it will spark a reorganized rhythm and without any kind of conduction it will not work

If you as a nurse walk into a pt's room and find him/her pulseless and monitor marks asystole (absence of ventricular electrical activity), should the pt be defibrilated, if yes, why or why not?

Defirbrillation is contraindicated when there is no electrical activity present (asystole) or when the heart muscle is not contracting despite an organized rhythm (Pulseless Electrical Activity or PEA) Proceed with Advanced cardiopulmonary life support (ACLS)

Yesterday, the client was weaned from the mechanical ventilator and an intravenous infusion of lorazepam. The client has been alert and oriented for 24 hours but is now experiencing confusion. The nurse now evaluates new-onset confusion by assessing the client's sense of place and time, difficulty focusing, short-term memory loss, and increasing lethargy. The nurse suspects which condition in this client?

Delirium or acute cognitive dysfunction is a syndrome commonly seen in hospitalized clients; it is reversible but difficult to diagnose. Clients may manifest delirium states that can be hypoactive (eg, quiet, disorientation, change in level of consciousness, memory loss), hyperactive (eg, restlessness, agitation, hallucinations, paranoia), or mixed. Manifestations of delirium develop acutely and are difficult to differentiate from those associated with pain, anxiety, and medications. Early diagnosis and treatment are advantageous as delirium is associated with increased mortality (especially in critically ill clients on mechanical ventilation). Delirium is difficult to assess; it is recommended that nurses use a standardized tool (eg, Confusion Assessment Method for the ICU) or checklist (eg, Intensive Care Delirium Screening) for this purpose.

A 49 year old alcoholic asks her 55 year old significant other to buy her alcohol to the store, what is it considered?

Dependency

A newborn diagnosed with trisomy 18 (Edwards syndrome) is on ventilator support. The client's parents have repeatedly asked when their child will be able to breathe without the ventilator. Which action by the nurse is appropriate? 1. Facilitate a meeting between the health care providers, palliative care team, and parents to discuss care plan (81%) 2. Notify the parents of the newborn's genetic test results and provide information to read about trisomy 18 (8%) 3. Provide the parents with information about various options for curative medical treatment for their child (5%) 4. Share with the parents that many newborns with trisomy 18 live long enough to go home with their families (4%)

Answer: 1 Trisomy 18 (Edwards syndrome) is a life-threatening chromosomal abnormality that affects multiple organ systems. Many fetuses affected by this condition die in utero. Of the newborns that survive birth, half will die in the first week of life and most do not make it to the first birthday. Before withdrawal of ventilator support, it is appropriate for the nurse to request a collaborative meeting between the health care providers (HCPs) and the palliative care team to help the parents understand their child's condition as well as make decisions about interventions and the potential need for end-of-life care (Option 1). **The nurse should not notify parents of genetic test results; this is the responsibility of the HCP. Information regarding the newborn's condition may be provided after the HCP notifies the parents of test results.**

What is Diabetic ketoacidosis (DKA) and what is priority in these types of pts?

Diabetic ketoacidosis (DKA) is a life-threatening complication of diabetes mellitus that occurs from a lack of insulin production. Insulin deficits prevent glucose from entering cells to provide energy and lead to intracellular starvation despite hyperglycemia (ie, >250 mg/dL [>13.9 mmol/L]), ketosis, and metabolic acidosis. DKA clients are at risk for hypovolemic shock due to glucose-induced osmotic diuresis. The priority in managing DKA is fluid resuscitation with isotonic crystalloids (usually 0.9% sodium chloride solution [ie, normal saline]) to restore intravascular volume and perfusion to vital organs, especially the kidneys, which help excrete excess glucose (Option 2). Fluid resuscitation also prevents hypovolemic shock and normalizes electrolyte and glucose levels via hemodilution.

The nurse is admitting a client with a seizure disorder and delegates preparation of the client's room to the student nurse. Which of the following actions by the student nurse indicate a correct understanding of seizure precautions? Select all that apply. 1. Ensures that suction equipment is present and operable 2. Ensures that supplemental oxygen and a bag valve mask are present 3. Places an oral airway at the head of the bed 4. Places padding on the side rails of the bed 5. Tapes a padded tongue blade at the head of the bed

Answer: 1, 2, 4 ***(Options 3 and 5) The nurse should never place anything in the mouth of a client experiencing a seizure. During tonic and/or clonic seizures, clients typically clench the jaw involuntarily. When this occurs, objects in the mouth (eg, oral airway, padded tongue blade) may break or dislodge, choking the client and/or damaging the teeth. Suctioning or endotracheal intubation, if needed, should be performed after the seizure ends.***

What position should babies and older children assume if a Tet spell occurs and why, explain?

During a Tet spell, place infant in a knees-to-chest position to improve pulmonary blood flow by increasing systemic vascular resistance. Older children may assume a squatting position. Intermittent oxygenation can also be used to treat spells if necessary.

What must be be done to a pt with acute epiglottitis that has an obstructed airway?

Emergent endotracheal intubation

The nurse provides instruction to a community group about lung cancer prevention, health promotion, and smoking cessation. Which statement made by a member of the group indicates the need for further instruction? 1. "Even though I am getting nicotine in my patches, I am not being exposed to all of the other toxic stuff in cigarettes." (7%) 2. "I can't get lung cancer because I don't smoke." (90%) 3. "My husband needs to take smoking cessation classes." (0%) 4. "We installed a radon detector in our home." (2%)

Answer: 2 Smoking is responsible for 80%-90% of all lung cancers. Although the risk is greater among smokers, former smokers and nonsmokers can develop lung cancer as well. Risk factors include secondhand smoke, air pollution, genetic predisposition, and exposure to radon, asbestos, and chemicals in the workplace.

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

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

How is the FHR determined?

FHR is determined within 10 minute span, must be at least for 2 minutes straight

Which client finding is most important for the nurse to follow up? 1. Client with distinct liver edge even with right costal margin (13%) 2. Client with pyelonephritis who has costovertebral angle tenderness (12%) 3. Client with rash that has purplish blotches that do not blanch (31%) 4. Client with spinal injury whose toes point downward with the Babinski test (42%)

Answer: 3 Purpura refers to reddish-purple blotches on the skin that do not blanch with pressure due to bleeding underneath the skin. Further assessment must be done to evaluate for a potentially serious etiology, such as blood dyscrasia.

How often should gastric secretions be assessed in a client who is intubated and on mechanical ventilation receiving continuous enteral tube feedings at 30 mL/hr via a small-bore nasogastric tube?

Gastric residual should be checked no less than every 4 hours in intubated clients.

Description of Metabolic Alkalosis:

HIGH pH & HIGH HCO3

Hypoglycemic symptoms

Headache Anxiety Hunger Dizziness Impaired vision Tachycardia Shaking Irritability Weakness/fatigue Sweating Sleepiness Confusion Lack of coordination Seizures Unconsciousness

How should Malignant Hyperthermia (MH) be treated?

IV dantrolene to reverse the process by slowing metabolism. Succinylcholine should be discontinued. Other interventions include applying cooling blankets to reduce temp, and treating high potassium levels.

Which subjective or objective assessment finding would the nurse expect to find in a client with severe aortic stenosis? 1. Bounding peripheral pulses (12%) 2. Diastolic murmur (27%) 3. Loud second heart sound (13%) 4. Syncope on exertion (46%)

Answer: D Aortic stenosis is a narrowing of the aortic valve, which obstructs blood flow from the left ventricle to the aorta. As stenosis progresses, the heart cannot overcome the worsening obstruction, and ejects a smaller fraction of blood volume from the left ventricle during systole. This decreased ejection fraction results in a narrowed pulse pressure (ie, the difference between systolic and diastolic blood pressures) and weak, thready peripheral pulses. With exertion, the volume of blood that is pumped to the brain and other parts of the body is insufficient to meet metabolic demands, resulting in exertional dyspnea, anginal chest pain, and syncope. (Option 2) On auscultation, aortic stenosis produces a loud, ejection systolic murmur over the aortic area as blood is ejected from the left ventricle through the stenosed aortic valve during systole.

A nurse auscultates a loud cardiac murmur on a newborn with suspected trisomy 21 (Down syndrome). A genetic screen and an echocardiogram are scheduled that day. The neonate's vital signs are shown in the exhibit. What would be an appropriate action for the nurse to complete next? Click on the exhibit button for additional information. 1. Call the health care provider (HCP) immediately (6%) 2. Document the assessment finding (76%) 3. Place the neonate in a knee-chest position (10%) 4. Provide oxygen to the neonate (6%) Vital signs- Temperature: 98.6 F (37 C) Heart rate: 146/min Respirations: 42/min O2 saturation: 98%

Atrioventricular (AV) canal defect is a cardiac anomaly often associated with trisomy 21 (Down syndrome). As an echocardiogram is already scheduled for that day, documenting the assessment finding would be the appropriate action for the nurse to complete at this time.

A nurse cares for a client on life support who has been declared brain dead. Which intervention is appropriate at this time, despite the family wanting for life support to be discontinued?

Before life support is discontinued, Local organ procurement services (OPS) are notified for every client death, per hospital protocol. If the client is deemed appropriate as a donor, then OPS collaborate with hospital staff in approaching the client's family about organ donation.

What happens to the blood when the body begins to break down ketones?

Causes metabolic acidosis (LOW ph & LOW HCO3)

What 3 measures are taught before a colonoscopy?

Colonoscopy evaluates colonic mucosa. Therefore, clients should follow instructions to keep the colon clean with no stool left for better visualization during the procedure. These instructions include: 1. Clear liquid diet the day before 2. Nothing by mouth 8-12 hours prior to the examination 3. The health care provider prescribes a bowel-cleansing agent such as a cathartic, enema, or polyethylene glycol (GoLYTELY) the day before the test. The type of prep depends on the health care provider's preference and client health status.

Why should ostomy appliance bag fit closely around the stoma?

If appliance does not fit well, liquid stool may leak onto the peristomal skin, and causing irritation due to digestive enzymes.

A client at 20 weeks gestation reports "running to the bathroom all the time," pain with urination, and foul-smelling urine. Which question is most important for the nurse to ask when assessing the client?

If cystitis goes unreported or untreated, the infection may ascend to the kidneys and cause pyelonephritis. During pregnancy, pyelonephritis requires IV antibiotics and hospitalization because of the increased risk of preterm labor. Therefore, priority assessment is to rule out indicators of pyelonephritis (eg, flank pain, fever) in clients who report UTI symptoms to ensure appropriate diagnosis and treatment. **NOT asking about E.coli UTI wiping from "back to front" **

When can a pt resume drinking if they decide to while taking Disulfiram, without getting sick?

If off for two weeks, will be able to drink without sickness again

The home health nurse visits a client who is rehabilitating after a tibial fracture. Which interventions are appropriate to include in the client's teaching plan to promote safety in the home when using crutches? Select all that apply. 1. Keep a clear path to the bathroom 2. Look down at the feet when walking 3. Remove scatter rugs from floors 4. Use a small backpack/shoulder bag to hold personal items 5. Wear rubber-soled shoes, preferably without laces

Correct answer: 1,3,4,5 Interventions to promote safety when using crutches in the home include the following: - Keep the environment free of clutter and remove scatter rugs to reduce fall risk (Options 1 and 3) - Look forward, not down at the feet, when walking to maintain an upright position, which will help prevent muscle and joint strain, maintain balance, and reduce fall risk (Option 2) - Use a small backpack, fanny pack, or shoulder bag to hold small personal items (eg, eyeglasses, cell phone), which will keep hands free when walking (Option 4) - Wear rubber- or non-skid-soled slippers or shoes without laces to reduce fall risk (Option 5) - Rest crutches upside down on the axilla crutch pads when not in use to prevent them from falling and becoming a trip hazard - Keep crutch rubber tips dry. Replace them if worn to prevent slipping.

A diabetic client is prescribed metoclopramide. Which of the following side effects must the nurse teach the client to report immediately to the health care provider? Select all that apply. 1. Excess blinking of eyes 2. Dry mouth 3. Dull headache 4. Lip smacking 5. Puffing of cheeks

Correct answer: 1,4,5 Metoclopramide (Reglan) is prescribed for the treatment of delayed gastric emptying, gastroesophageal reflux (GERD), and as an antiemetic. Similar to antipsychotic drugs, metoclopramide use is associated with extrapyramidal adverse effects, including tardive dyskinesia (TD). This is especially common in older adults with long-term use. The client should call the health care provider immediately if TD symptoms develop, including uncontrollable movements such as: - Protruding and twisting of the tongue - Lip smacking - Puffing of cheeks - Chewing movements - Frowning or blinking of eyes - Twisting fingers - Twisted or rotated neck (torticollis)

In which position would the nurse place a client recovering from a right modified radical mastectomy who is admitted from the post-anesthesia unit?

Immediately after mastectomy surgery, the client is placed in a semi-Fowler's position with the affected side's arm and hand elevated on several pillows to promote drainage and prevent venous and lymphatic pooling. Flexing and bending of the affected side's fingers is begun immediately with gradual increase in arm movement over the next few postoperative days. Postoperative arm and shoulder exercises are initiated slowly with the goal of full range of motion of the affected side within 4-6 weeks of the mastectomy.

What are Factor Xa inhibitors used for?

Anticoagulants to prevent and treat venous thromboembolisms (eg, pt with Afib)

Give an example of medical battery:

Any HCP who performs a medical or surgical procedure without reciving the required informed consent from a competent client (or parent/legal guardian in the case of child) is committing battery and could be legally charged

What is assault and what is an example?

Assault is a deliberate threat with the power to carry out the threat. Ex: Nurse threatens to put a pt in restraints if the pt does not stay in bed

What does a Bishop score tell you in a prenatal patient?

Assessment and rating of cervical favorability and readiness for induction of labor

When on Antabuse, what should be the most important pt teaching?

Avoid ALL alcohol content, especially hidden alcohol

Where are Alpha 2 receptors located?

Blood vessels, GI smooth muscle (BG)

What is implied consent?

Implied consent in emergency situations includes the following criteria: - There is an emergency - Treatment is required to protect the client's health - It is impractical to obtain consent - It is believed that the client would want treatment if able to consent In this case, it would be assumed that the client would want life-saving surgery; the health care provider should proceed.

What is an early sign of increased ICP?

Change in LOC

What is another way an ostomy gets peristomal skin irritation?

Changing the appliance too often

The graduate nurse (GN) is reinforcing education on sitting on and standing up from a chair to a client with crutches. Which instruction by the GN would cause the supervising nurse to intervene?

Clients prescribed crutches after a musculoskeletal injury must understand appropriate device use to facilitate independent ambulation, promote wound healing, and prevent reinjury. When educating a client to rise from sitting, the nurse instructs the client to hold the hand grips of both crutches in the hand on the affected side, move to the chair's edge, and hold the armrest with the hand on the unaffected side (Option 1). The client then uses the crutches, armrest, and unaffected leg for support when rising.

A teenage client with sickle cell disease is admitted with a diagnosis of crisis. The client's current prescription is morphine 2 mg intravenous push every 4 hours prn. The client appears comfortable while watching television and tells the nurse "I have severe intolerable pain," and rates it a "10." What action should the nurse take?

Clients with sickle cell crisis often have excruciating pain related to the occlusion from the sickling and resulting ischemia. These individuals usually need large doses of narcotics as prior treatment has led to drug tolerance; they may also metabolize the drugs differently. Using only external cues to judge a client's pain is invalid as these clients have often learned how to distract themselves from focusing on the pain. Use of continuous PCA is recommended for relief rather than prn administration.

When is pt considered in a Diabetic Ketoacidosis state and how does it occur?

Complication of Type 1 diabetes characterized by a BG of >250 mg/dL resulting in ketosis, or breakdown of fat. Thus causing an acidodic state.

A client, gravida 4 para 3, at 38 weeks gestation arrives in the emergency department with strong contractions that began 1 hour ago. The client is diaphoretic, grunting, and yelling loudly that she wants an epidural because she feels the need to push. What priority action should the nurse take? 1. Apply gloves and assess perineal area (55%) 2. Initiate large-bore IV access (6%) 3. Notify anesthesia provider of client's request for epidural (2%) 4. Obtain fetal heart tones via Doppler (35%)

Correct answer: 1 Precipitous birth occurs when labor lasts <3 hours from contraction onset until birth. Signs of imminent birth include involuntary pushing/bearing down with contractions, grunting, or report of sensations of having a bowel movement. If a client arrives at the hospital in second-stage labor (ie, pushing), the nurse rapidly assesses whether birth is imminent by applying gloves and observing the perineum for bulging or crowning of the presenting fetal part (Option 1). If the health care provider is not present, the nurse stays with the client, ensures safe client positioning (eg, not standing or on the toilet), and is prepared to act as a birth attendant. The nurse may direct others to perform needed actions (eg, contact provider, assess fetal heart tones, initiate IV access). (Option 2) Large-bore IV access (ie, 18G or larger) is helpful for administrating oxytocin in the immediate postpartum period. However, the nurse first confirms that birth is not imminent before performing other actions.

The nurse is preparing to administer a scheduled dose of metoclopramide IV to a client with diabetic gastroparesis. Which clinical finding causes the nurse to question the prescription? 1. Diarrhea (25%) 2. Frequent burping (8%) 3. Headache (10%) 4. Sucking lip motions (56%)

Correct answer: 4 Metoclopramide is a commonly used antiemetic medication that treats nausea, vomiting, and gastroparesis by increasing gastrointestinal motility and promoting stomach emptying. With extended use and/or high doses, metoclopramide may lead to the development of tardive dyskinesia (TD), a movement disorder that is characterized by uncontrollable motions (eg, sucking/smacking lip motions) and is often irreversible (Option 4). The movement alterations of TD may impact a client's essential activities of daily living (eg, eating, dressing) and overall quality of life. The nurse should question the administration of a medication associated with TD in clients experiencing movement alterations. (Option 1) Metoclopramide increases gastrointestinal motility, which may result in diarrhea in some clients. This symptom is reversible and usually easily managed.

The nurse is caring for a client with a balloon tamponade tube in place due to bleeding esophageal varices. The client suddenly develops respiratory distress, and the nurse finds that the tube has been partially pulled out. Which intervention should be the nurse's priority? 1. Contact the health care provider (7%) 2. Cut the tube with scissors (46%) 3. Increase gastric suction level (1%) 4. Place the client in high Fowler position (44%)

Correct answer: 2 A balloon tamponade tube (eg, Sengstaken-Blakemore, Minnesota) is used to temporarily control bleeding from esophageal varices. It contains 2 balloons and 3 lumens. The gastric lumen drains stomach contents, the esophageal balloon compresses bleeding varices above the esophageal sphincter, and the gastric balloon compresses from below. A weight is attached to the external end of the tube to provide tension and hold the gastric balloon securely in place below the esophageal sphincter. Airway obstruction can occur if the balloon tamponade tube becomes displaced and a balloon migrates into the oropharynx. Scissors are kept at the bedside as a precaution; in the event of airway obstruction, the nurse can emergently cut the tube for rapid balloon deflation and tube removal (Option 2).

When triaging 4 pregnant clients in the obstetric clinic, the nurse should alert the health care provider to see which client first? 1. First-trimester client reporting frequent nausea and vomiting (0%) 2. Second-trimester client with dysuria and urinary frequency (6%) 3. Second-trimester client with obesity reporting decrease in fetal movement (47%) 4. Third-trimester client with right upper quadrant pain and nausea (45%)

Correct answer: 4 Right upper quadrant (RUQ) or epigastric pain can be an indicator of HELLP syndrome, a severe form of preeclampsia. HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelet count) is often mistaken for viral gastroenteritis due to its variable and nonspecific presentation. Misdiagnosis may lead to severe complications (eg, placental abruption, liver failure, stroke) and/or maternal/fetal death. Clients may have RUQ pain, nausea, vomiting, and malaise. Headache, visual changes, proteinuria, and hypertension may or may not be present.

A child with attention-deficit hyperactivity disorder (ADHD) has been taking methylphenidate for a year. What are the priority nursing assessments when the client comes to the clinic for a well-child visit? 1. Attention span and activity level (28%) 2. Dental health and mouth dryness (7%) 3. Height/weight and blood pressure (52%) 4. Progress with schoolwork and in making friends (11%)

Correct answer: 3 Methylphenidate (Ritalin, Concerta) is a central nervous system stimulant used to treat ADHD and narcolepsy. It affects neurotransmitters (dopamine and norepinephrine) in the brain that contribute to hyperactivity and lack of impulse control. A common side effect of methylphenidate is loss of appetite with resulting weight loss. Parents and caregivers should be instructed to weigh the child with ADHD at least weekly due to the risk of temporary interruption of growth and development. It is very important to compare weight/height measures from one well-child checkup to the next. If weight loss becomes a serious problem, methylphenidate can be given after meals; however, before meals is preferable. Another side effect of methylphenidate is increased blood pressure and tachycardia. These should be monitored before and after starting treatment with stimulants.

A client who was suddenly overwhelmed with an intense fear that something terrible was going to happen is brought to the emergency department by the spouse after they were out at dinner. The client is now shaking, hyperventilating, and having heart palpitations. What is the priority nursing action? 1. Encourage the client to perform deep breathing exercises (47%) 2. Explore possible reasons for the episode (4%) 3. Place the client in a private room and tell the client to relax (1%) 4. Remain in the room with the client (47%)

Correct answer: 4 This client is experiencing the symptoms of a panic attack and should not be left alone. The priority nursing action is to stay with the client to ensure the client's safety and offer support.

What is the primary treatment for Addison's disease?

Corticosteroid therapy (ig, hydrocotisone, dexamethasone, predninsone) is the primary treatment for Addison disease.

When confronting an "old dog" nurse that has been on the floor for years, because she finds everything you do as wrong, how would you confront the nurse?

DO NOT say: Why do you attack me? you DO say: I seem to be having a problem, what could I do to make it better? - Use I instead of YOU to confront

What is 1 type of med that is contraindicated with Sjorgen's syndrome?

Decongestants as they cause further dryness to the mouth and nasal mucosa. -Also avoid oral irritants (eg, coffee, alcohol, nicotine) and acidic drinks (eg, carbonated drinks and juices) and instead sip water frequently.

What treatment goal should a pt with elevated CVP and PAWP have?

Decrease fluid volume and pre-load

What causes a low pressure alarm to go off?

Decreased resistance

What is the herb Evening primrose used for?

Eczema or skin irritations

What is wound dehiscence?

Edges of a surgical wound fail to approximate and separate

If a child is showing symptoms of varicella after he/she received a shot and has 2 open vesicles around the injection site only, what should be done?

Cover them with a bandage

Which interventions should the nurse include when caring for a client who has had endovascular repair of an abdominal aortic aneurysm? Select all that apply.

Endovascular abdominal aortic aneurysm repair is a minimally invasive procedure that involves the placement of a sutureless aortic graft inside the aortic aneurysm via the femoral artery. It does not require an abdominal incision. The nurse will need to monitor the puncture sites in the groin area for bleeding or hematoma formation (Option 2). Peripheral pulses should be palpated and monitored frequently in the early post-op period and routinely afterward (Option 5). Renal artery occlusion can occur due to graft migration or thrombosis so careful monitoring of urine output and kidney function should be part of nursing care (Option 4). (Option 1) No abdominal incision is required in endovascular repair. (Option 3) Chest tubes are not required in endovascular repair.

How long does it take for lithium carbonate to reach therapeutic levels?

Few weeks (1-4 weeks)

How should fontanelles feel in babies before they fuse?

Flat but slightly pulsating noted in the anterior fontanelle are normal as if temporary bulging when the infant cries, coughs, or is lying down

What position is BEST for a pt with a Hip fracture?

For a client with a hip fracture, the affected extremity is kept abducted using splints or pillows between the legs; elevation is contraindicated due to the risk of affecting alignment.

What is hemophilia and how is it treated?

Hemophilia is a hereditary bleeding disorder caused by a deficiency in coagulation proteins. Treatment consists of replacing the missing clotting factor and teaching the client about injury prevention, including: -Avoid medications such as ibuprofen and aspirin that have platelet inhibition properties. - Avoid intramuscular injections; subcutaneous injections are preferred. - Avoid contact sports and safety hazards; noncontact activities (eg, swimming, jogging, tennis) and use of protective equipment (eg, helmets, padding) are encouraged. - Dental hygiene is necessary to prevent gum bleeding, and soft toothbrushes should be used. - MedicAlert bracelets should be worn at all times.

What is the most common cause of cervical cancer in women?

Human papillomavirus (HPV)

What should be done to correct Torsade de pointes?

If pt has HYPOmagnesemia, then first-line treatment is IV magnesium -Treatments may also include defibrillation and discontinuation of any QT-prolonging meds. The nurse should also review the client's medical record for any condition or medication that may prolong the QT interval and precipitate another episode of torsades de pointes, including: - Antiarrhythmics (eg, sotalol, amiodarone, ibutilide, dofetilide) (Option 1) - Macrolide antibiotics (eg, erythromycin, azithromycin) - Electrolyte abnormalities: Hypokalemia and hypomagnesemia (NOT HYPERmagnesemia)

What is priority of care in a pt suffering with pulmonary edema?

Improve oxygenation, a diuretic removes excess fluid in the lungs

What is an adverse side effect of SSRIs?

Increase the risk of suicide- if pt has increased energy levels without a change in depressive feelings, they need to be monitored for suicidal ideation or actions as the pt may now have the energy to execute the suicidal plan

What should be done to prevent the spread of varicella if a child with varicella burst out in a rash with open lesions?

Isolate them for about 21 days or so until the lesions scab up, this is to prevent spreading of it from the open vesicles

What does Central Venous Pressure (CVP) measure?

It indicates mean right atrial pressure and is frequently used as an estimate of right ventricular preload

Where should the top of the fundus be felt at by 12 wks of gestation?

Just above the symphysis pubis

What is a great concern with a post op abd aneurysm repair?

Kidney injury (since the operation site is near the kidneys) - Routinely monitor the pt's BUN and creatinine levels as well as urine output. Urine should be at least 30 ml/hr.

When abnormal ABGs (pH normal, PaCO2 is high, PaO2 is low) are found in a pt with COPD, what finding is PRIORITY to report to the HCP?

LOW Pao2: indicates significant hypoxemia and requires prompt intervention

A 40 year old gets her 17 year old daughter to go buy them alcohol, what would this be considered: Manipulation or Dependency?

Manipulation

What is Marfan syndrome?

Marfan syndrome is an autosomal dominant disorder affecting the connective tissues of the body. Abnormalities are mainly seen in the cardiovascular, musculoskeletal, and ocular systems. Clients with Marfan syndrome are very tall and thin, with disproportionately long arms, legs, and fingers.

Can air pass from nares and oropharynx into the lungs in an intubated pt?

No

Is Iron deficiency more common in the elderly?

No, excessive iron intake can lead to iron overload, and the risk of excess iron tends to be higher with aging.

Does Misoprostol affect BP?

No, only muscle contractions

If a pt on an ET tube has a low tidal wave, would increasing o2 delivery on the vent to 100% be effective, why or why not?

No, the vent is unable to deliver the programmed volume to the pt, the lungs must be manually ventilated with a valve mask to open up the lungs fully

How should blood be stored, explain?

Not be left at room temp. for more than 30 minutes before a transfusion is started. Leaving blood out at room temp can increase the likelihood of bacterial growth.

What should be done if an newborn has a absent Moro reflex?

Notify HCP STAT

What child is at a high-risk of developing autism spectrum disorder?

Numerous studies indicate that it has a strong genetic component. The underlying genetic source is unknown in the majority of cases; however, researchers hypothesize that genetic factors predispose to an autism phenotype and that genetic expression is influenced by environmental factors. (A sibling of a child who has the disorder)

What is noxious stimuli?

Pain is termed nociceptive (nocer - to injure or to hurt in Latin), and nociceptive means sensitive to noxious stimuli. Noxious stimuli are stimuli that elicit tissue damage and activate nociceptors. Nociceptors are sensory receptors that detect signals from damaged tissue or the threat of damage and indirectly also respond to chemicals released from the damaged tissue. Nociceptors are free (bare) nerve endings found in the skin, muscle, joints, bone and viscera.

If a pt gets into a cardiac tamponade state, what must be done to resolve it?

Pericardiocentesis (needle inserted into the pericardial sac to remove fluid)

What is a common sign of ITP?

Petechiae

What electrolyte does CKD impair teh excretion of?

Potassium

As the pH goes so goes my patient except for?

Potassium- If pH goes UP, K+ goes DOWN, and vice versa

What is PRIORITY complication in pregnant women?

Preeclampsia

What is nonmaleficence?

Provides everyone that protect all patients from harm Ex- providing protective eyewear to the patient

Explain what a negative symptoms of schezophrenia is as opposed to positive ones

Pts with schizophrenia often become anxious when around other individuals and will seek to be alone to relieve anxiety. Impaired social and interpersonal functioning (eg, social withdrawal, poor social interaction skills) are common negative symptoms of schizophrenia. These are more difficult to treat than the positive symptoms (eg, hallucinations, delusions) and contribute to a poor quality of life. (Ex: If pt experiencing negative symptoms, such as walking away from nurse, nurse must let the pt simply walk away in silence)

How do you deal with psychosis: If pt says he needs to leave asap because he is going to the white house what should you do?

Redirect the pt- Tell pt to take a shower then go watch CNN to see what the news of the day is in Washington D.C

What can happen if Phenytoin is stopped abruptly?

Seizures can reoccur and status epilepticus (seizure last more than 30 min) (can be mortal)

Anaphalactic shock

Severe allergic reaction system release of histamines massive vasodilation decreases BP

What kind of pain does Extended-release oxycodone (Oxycotin) manage?

Severe chronic pain

How does HPV spread?

Sexual contact, including skin-to-skin contact even when using condom during sexual intercourse.

Does patent ductus arteriosis go away eventually?

Small PDAs often close on their own within the first few months of life. In premature newborn babies, medicine can often help the ductus close. After the first few weeks of life, medicine won't work as well to close the ductus and surgery may be required.

What to do to confront denial in lost and grief?

Support it

Proper swaddle for hip dysplasia in newborns

Swaddle the infant with hips flexed and abducted

How should nitroglycerin be taken and when should a pt call EMS (911)?

Take 1 pill /5min up to 3 doses, if pain is unimproved or worsening 5 minutes after the first dose.

How is fifth disease treated and what is the recovery time?

The child may have general malaise and joint pain that are treated with NSAIDs such as ibuprofen. Affected children typically recover quickly, within 7-10 days.

Nurse gets 2 calls, one from a a person stating that her significant other has been experiencing depression and is now making suicidal threats. The other call is from a a person stating that there are voices in their head telling them to hurt their neighbor, which should the nurse prioritize and why?

The person experiencing command hallucinations because they are alone and can be homicidal or suicidal instantly

When can hypercyanotic episodes occur?

They occur when unoxygenated blood enters the systemic circulation, resulting in cyanosis (peripheral extremities turn blue) and hypoxemia (Destatting).

What is the purpose of defibrillation?

To convert lethal ventricular dysrhythmias (ie, V-fib and Pulseless V-tach) into an organized rhythm by passing electrical shock through the heart.

How is Sjorgen's syndrome treated?

Treatment is focused on alleviating symptoms as there is currently no cure for it.

When is best to give pts their Statin meds?

Trials found greater reduction in total and LDL cholesterol when statins (especially those that are short-acting; eg, simvastatin) are taken in the evening or at bedtime as opposed to during the day.

Another word for respiratory acidosis (DOWN)?

Under-ventilating

What is a contraindication in comfort measures?

Using a nonrebreather mask. It delivers high concentration of O2 in emergency situations. They require a tight face seal, which is uncomfortable and may cause claustrophobia and increased anxiety.

What is another name for Ebola?

Viral hemorrhagic fever

The word "at this time" in the NCLEX world means?

What is the next step to do

What symptom(s) can Occiput posterior fetal position cause the mother?

Increased back pain "back labor"

Ex: when someone says "I'm not an alcoholic" but yet they drink a 6 pack at 10AM, what should be said to thatr individual?

"You say you're not an alcoholic, but you drink a 6 pack at 10 AM"

What are some 2nd generation meds?

-Cetirizine -Fexofenadine -Loratadine

What is the only scenarios that you will answer METABOLIC ALKALOSIS in?

-Prolonged gastric suctioning (losing gastric acid)

What is the difference between Wernicke's vs. Korsakoff's?

-Wernicke's: encephalapathy -Korsakoff: psychosis (lost of touch with reality)- induced by B1 deficiency

What are the Bishop score values of each category?

0-3

What are 2 primary symptoms of Wernicke's syndrome?

1. Amnesia 2. Confabulation (making up stories to fill in memory loss-believe as true)

What 2 disconnection types will cause the alarm to go off?

1. Disconnection of the main tubing- if so, reconnect it 2. Disconnection of the O2 sensor tubing (sense FiO2 at the trach area)- plug the sensor back in

What are 4 signs of systemic infection?

1. Fever 2. Tachycardia 3. Nausea 4. Leukocytosis

What should a nurse always assess during each antenatal visit?

1. Maternal BP 2. Weight 3. Emotional status 4. fetal HR 5. Fundal height

In what 2 cases will the "mean old -mycins" be administered orally and why?

1. When pt has Hepatic encephalopathy- because nromal gut flora (Ecoili) produces much ammonia, leading to hepatic encephalopathy. Sterilizes bowel. Also not absorbable, so will not even go to liver. 2. Pre-op bowel surgery to sterilize gut before the surgery

What is a stork bite birthmark and is it dangerous?

A mark is a salmon-colored patch (nevus simplex or angel kiss); this is a developmental vascular abnormality that will disappear within 1 year. It is at the nape of the neck but can also be seen on the eyelid, upper lip, or between the eyes. The mother needs reassurance and teaching.

What is Halo/ring test and how is it done?

A method for determining whether bloody discharge from the ears or nose contained cerebrospinal fluid (CSF). By adding a few drops of the blood-tinged fluid to gauze and assessing for the characteristic pattern of coagulated blood surrounded by CSF

How is ATRIAL ARRHYTHMIAS/SUPRAVENTRICULAR TACHYCARDIA treated?

ABCD's: • Adenosine/ADENOCARD >>> push in less than 8 seconds >>> FAST IV PUSH o IV PUSH: When you don't know, you go slow BUT THIS IS ONE YOU HAVE TO KNOW!!! Use BIG vein. o Can go into asystole for 30 seconds since it's such a fast push BUT they should come back!!! • Beta-blockers >>> "-lol" o Negative ino/chrono/drono = they are like valium for your heart o Treat AAA and AA o Therefore SE à Hypotension & headache just like CCB • Calcium Channel Blockers >>> like VALIUM for your heart; same as Beta Blockers • Digitalis >>> digoxin, lanoxin KNOW NAMES!**

What does elevated PAWP indicate?

Increased left ventricular preload

If a pt has a basilar skull fracture, what does that put them at risk for?

Infection

What does skin tenting mean?

Poor skin turgor or "tenting" is associated with skin moisture and elasticity. It is usually associated with dehydration, not fluid overload.

How is placenta accreta detected?

Prenatal ultrasound

When are the HPV vaccines given?

Ages 11-12, but vaccines can be given as early as 9 and up to 26

How does pulley system work?

Allows free-hanging weights to suspend from the foot of the pt's bed, and pull on the skeletal pins to maintain alignment of proximal and distal portions of the fractured bone

How is VENTRICULAR TACH and PVCs treated?

Amiodarone or lidocaine

What is brachytherapy?

An internal radiation treatment that is ingested, injected into a cavity or bloodstream, or implanted (eg, seeds, capsules, wires). Emits radiation in or near a tumor to treat certain malignancies.

The nurse working in a gastrointestinal clinic is reviewing the list of walk-in clients. Which client should the nurse see first? 1. Client reporting constipation since having a barium enema 3 days ago (48%) 2. Client reporting moderate flatulence after a resolved bowel obstruction (2%) 3. Client with irritable bowel syndrome reporting 3 or 4 loose stools a day for the past 3 days (8%) 4. Client with ulcerative colitis reporting 2 or 3 loose, bloody stools a day (40%)

Answer: 1 Barium, a contrast medium, aids in the visualization of tumors, obstructions, polyps, and other abnormalities. Barium can be administered rectally (ie, enema) to fill the lower gastrointestinal tract and facilitate clear x-ray images of the large intestine. After the procedure, clients should increase fluid intake and consume foods high in fiber to facilitate removal of the barium. Retention of barium can cause fecal impaction or bowel obstruction, resulting in severe complications such as bowel perforation and peritonitis. Reports of constipation should be assessed further as intervention (eg, laxatives, suppositories) may be needed to help evacuate the barium and prevent complications. **(Option 4) Bloody diarrhea is an expected finding in clients with ulcerative colitis; fewer than 4 stools a day indicates mild disease. Although this client should be assessed, the client with a potential bowel obstruction related to barium is higher priority.**

A nurse is discussing the concept of parallel play with parents of toddlers. Which statement should the nurse include to describe this type of play? 1. "Children play near other children but without significant interaction." (88%) 2. "Children playing together are strongly influenced by each other's choice of toy." (7%) 3. "The child primarily plays alone or with familiar people, such as parents." (2%) 4. "When playing in a group, one child will take on a follower role." (1%)

Answer: 1 Play is an important developmental task of childhood and reflects the child's physical, social, and emotional health. Parallel play is independent play near other children with minimal group interaction and is typical of toddlers (age 12-36 months) (Option 1). Toddlers engaging in parallel play may share toys and verbalize thoughts, but they primarily focus on doing their own activities rather than directly interacting with others in organized play.

The hospice nurse is caring for an actively dying client who is unresponsive and has developed a loud rattling sound with breathing ("death rattle") that distresses family members. Which prescription would be most appropriate to treat this symptom? 1. Atropine sublingual drops (33%) 2. Lorazepam sublingual tablet (13%) 3. Morphine sublingual liquid (48%) 4. Ondansetron sublingual tablet (4%)

Answer: 1 The "death rattle" is a loud rattling sound with breathing that occurs in a client who is actively dying. When the client cannot manage airway secretions, the movement of these secretions during breathing causes a noisy rattling sound. This can distress family and friends at the bedside of the dying client. The "death rattle" can be treated using anticholinergic medications to dry the client's secretions. Medications include atropine drops administered sublingually or a transdermal scopolamine patch.

If nurse administers placebo instead of pain med because pt is constantly demanding more pain meds, what should charge nurse instruct nurse to do first?

Pts with opioid tolerance often require a higher dose analgesic or stronger opioid to achieve pain relief. First, the nurse must contact HCP to discuss the pt's frequent requests for morphine to alleviate uncontrolled pain.

The camp nurse conducts a class for incoming summer counselors on prevention of tick bites and Lyme disease. Which instructions should the nurse include? Select all that apply. 1. Apply a tick repellent spray before outdoor activities 2. Avoid hiking through areas of tall grass and thick underbrush 3. Cover ticks found on skin with petroleum jelly 4. Report bull's-eye rash or flulike symptoms to a health care provider 5. Wear a long-sleeved shirt tucked into pants and closed-toe shoes while hiking

Answer: 1, 2, 4, 5 Lyme disease develops after a bite from a deer tick infected with Borrelia burgdorferi. Clients initially develop flulike symptoms (eg, headache, fever, myalgia, fatigue). Many clients develop erythema migrans, a bull's-eye rash; however, it is not always present. Any of these symptoms should be reported immediately to a health care provider (Option 4). The client will likely be prescribed antibiotics (eg, doxycycline, amoxicillin) to treat Lyme disease and prevent it from causing complications (eg, carditis, chronic arthritis, meningitis, facial paralysis). To prevent tick bites during outdoor activities, clients should: - Apply an insect repellent spray that contains tick-repelling ingredients (eg, DEET, picaridin) (Option 1) - Avoid tall grass and thick underbrush, and hike only in the center of the trails (Option 2) - Wear long-sleeved shirts tucked into pants, long pants tucked into socks or boots, and closed-toed shoes (Option 5)

Do allergy shots induce an immediate and potentially fatal anaphylacic reaction?

Rarely, the pt must remain at the facility for 30 minutes after a shot so the nurse can monitor for severe systemic reactions (respiratory failure, tongue and throat swelling).

What is a standard protocol for a pt receiving a blood transfusion? (6 main steps)

Remain with pt for 15 minutes after starting the transfusion to monitor for signs of reaction. Symptoms include fever, chills, nausea, vomiting, pruritus, hypotension, decreased urine output, back pain, and dyspnea. If these occur, the nurse should: 1. Stop the infusion 2. Using new tubing, infuse NS to keep the vein open 3. Continue to monitor hemodynamic status and notify the health care provider and blood bank 4. Administer any emergency prescribed meds to treat the reaction; these may include vasopressors, antihistamines, steroids, or IV fluids 5. Collect urine specimen to be assessed for hemolytic reaction 6. Document the occurrence, send blood back to blood bank

The nurse is caring for a debilitated client with a percutaneous endoscopic gastrostomy (PEG) tube that was inserted 3 days ago for the long-term administration of enteral feedings and medications. While the nurse is preparing to administer the feeding, the tube becomes dislodged. What is the most appropriate intervention? 1. Insert a Foley catheter into the existing tract and inflate the balloon (22%) 2. Insert a small-bore nasointestinal tube to administer feedings and medications (3%) 3. Notify the health care provider who inserted the PEG tube (55%) 4. Reinsert the PEG tube into the existing tract immediately (17%)

Answer: 3 A PEG is a minimally invasive procedure performed under conscious sedation. Using endoscopy, a gastrostomy tube is inserted through the esophagus into the stomach and then pulled through an incision made in the abdominal wall. To keep it secured, the PEG tube has an outer bumper and an inner balloon or bumper. The tube's tract begins to mature in 1-2 weeks and is not fully established until 4-6 weeks. It begins to close within hours of tube dislodgement. The nurse should notify the health care provider who placed the PEG tube as early dislodgement (ie, <7 days from placement) requires either surgical or endoscopic replacement (Option 3). (Options 1 and 4) The insertion of a Foley catheter or immediate reinsertion of the PEG tube should not be attempted because the tube's tract is only 3 days old (immature). A reinserted tube could be placed inadvertently into the peritoneal cavity, leading to serious consequences such as peritonitis and sepsis. Therefore, these are not the most appropriate interventions. (Option 2) Small-bore nasointestinal tubes are used for short-term rather than long-term administration of enteral feedings. They are prone to clogging from enteral feedings, undissolved medications, and inadequate tube flushes. They can also kink, coil, and become dislodged by coughing and may require frequent reinsertion. Therefore, they are not the most appropriate intervention.

The nurse prepares to assess a newly admitted client diagnosed with chronic alcohol abuse whose laboratory report shows a magnesium level of 1.0 mEq/L (0.5 mmol/L). Which assessment finding does the nurse anticipate? 1. Constipation and polyuria (2%) 2. Increased thirst and dry mucous membranes (2%) 3. Leg weakness and soft, flabby muscles (28%) 4. Tremors and brisk deep-tendon reflexes (66%)

Answer: 4 Hypomagnesemia, a low blood magnesium level (normal 1.5-2.5 mEq/L [0.75-1.25 mmol/L]), is associated with alcohol abuse due to poor absorption, inadequate nutritional intake, and increased losses via the gastrointestinal and renal systems. It is associated with 2 major issues: 1. Ventricular arrhythmias (torsades de pointes): This is the most serious concern (priority). 2. Neuromuscular excitability: Manifestations of low magnesium, similar to those found in hypocalcemia and demonstrated by neuromuscular excitability, include tremors, hyperactive reflexes, positive Trousseau and Chvostek signs, and seizures.

What is a blood vessel called when it carries blood AWAY from the heart?

Artery for example: Pulmonary artery going away from the heart to the lungs

Can a pt with a permanent pacemaker perform ROM?

Avoid lifting the arm above the shoulder on the side of the pacemaker until approved by the HCP as this can cause dislodgement of the pacemaker lead wires

A client without prenatal care gives birth to a newborn at term gestation. The client denies opioid or other illicit drug use during pregnancy. When monitoring the newborn, which of the following signs would indicate neonatal abstinence syndrome to the nurse? Select all that apply. 1. Irritability and restlessness 2. Meconium ileus and floppy muscle tone 3. Microcephaly and cleft palate 4. Nasal congestion and frequent sneezing 5. Poor feeding and loose stools

Correct answer: 1,4,5 Neonatal abstinence syndrome (NAS) or opioid withdrawal results from maternal, habitual use of illicit drugs during pregnancy and begins within days or weeks after birth. Opioid abuse (eg, hydrocodone, methadone, heroin) is the most common cause, although other medications (eg, benzodiazepines) can contribute to the condition.

A client has been given instructions about collecting a urine specimen to test creatinine clearance. The client indicates correct understanding of the specimen collection procedure by making which statement? 1. "A catheter is placed temporarily then removed after I void." (0%) 2. "I must provide a midstream sample in a sterile container." (37%) 3. "I will need to collect all my urine in a container for 24 hours." (50%) 4. "The first AM specimen is best as it is more concentrated." (11%)

Creatinine clearance is a measure of glomerular function and is a sensitive indicator of renal disease progression. A 24-hour urine collection is needed for the test. When the test begins, the first urine specimen is discarded and the time is noted. All other voided urine for the next 24 hours is collected in a container and kept cool. At the end of the 24 hours, the client should void one last time and add the specimen to the container. Blood is drawn to measure serum creatinine level in addition to urine creatinine.

What is uterine atony?

Failure of uterus to contract adequately after deliver

If you find tubing disconnected on floor or on the pt's chest what should be done before reconnecting it?

Floor: change out for new one Chest: clean with alcohol and reconnect

When encountering multicultural pt's, what is the most appropriate question a nurse can ask to assess their knowledge about a new medical condition they were recently diagnosed with?

Have the pt express what they think caused their condition or problem to gain knowledge of their beliefs and understandings about the conditions

What is the function of Beta 1 receptors when stimulated?

Heart: -Increase heart contraction, increase heart rate Kidney: -Increase renin (retains Na+ & water) secretion, Increases angiotensin, Increases BP

What should a nurse do first if she sees irregular bruises on a child (NOT A BABY) ?

If the nurse suspects child abuse, conduct a detailed interview and physical exam to identify potential indicators of abuse (Note: since a child can communicate and is ambulatory, they are prone to get bruising by falling, etc. which makes it different from a baby, especially a newborn)

Where should the pulse oximeter be placed in order to get the most accurate reading in a pt with shock?

In pts with decreased peripheral tissue perfusion who are receiving vasopressors, pulse oximetery readings are usually more accurate when the sensor is placed on the forehead rather than on the finger. -Vasopressors are used in pts with shock to increase stroke volume, cardiac output, and MAP.

Air embolus emergency

In the event of an air embolus, the head of the bed should be lowered (Trendelenburg) and the client positioned on the left side; this will cause the air to rise to the right atrium. The health care provider should be notified immediately and the nurse should remain with the client.

What would be an abnormal finding when assessing lochia drainage?

In the immediate postpartum period, lochia should be assessed frequently to monitor for postpartum hemorrhage. Soaking a perineal pad in ≤1 hour would indicate excessive bleeding that requires urgent intervention.

What triggers a high pressure alarm in a ventilator?

Increased resistance to airflow- machine is having to push too hard to get air into the pt's lungs

What does it indicate when CVP is elevated?

Increased systemic circulation volume and increased right ventricular preload

Is dementia reversible?

Irreversible confusional state

What is clonidine used for and how does it work?

It is an Alpha-agonist (alpha 2 receptor) hypotensive agent. Treats HTN by decreasing your heart rate and relaxing the blood vessels so that blood can flow more easily through the body.

In a disaster triage, what are the characteristics of an Emergent (RED) case and what 4 examples display those characteristics?

Life-threatening injuries w/ high probability for survival if immediate treatment is received. 1. Shock 2. Compromised airway 3. Unstable wounds 4. Chest trauma Tip to remember this: It must (S.U.C.C) the most to be that hurt... (LOL to remember EMERGENT)

What is an ileal conduit?

Loops of stapled off ileum made into a pouch, anastomosed to the ureters and then brought to the abdominal wall skin to allow drainage in urine in patients who undergo removal of bladder

Mediastinal chest tube

Mediastinal chest tubes are used to drain air or fluid from the mediastinal space and/or pericardial cavity (ie, after cardiac surgery). Obstruction (eg, clot) of the chest tube will result in excess fluid buildup in the pericardium, leading to inhibited cardiac contractility and eventual diagnosis of cardiac tamponade. Cardiac tamponade is a life-threatening form of obstructive shock marked by decreased cardiac output and eventually obstructive cardiac arrest if untreated.

Can norepinephrine be discontinued (or stopped abruptly) in a pt with hypovolemic shock?

NO - Norepinephrine causes vasoconstriction and improves heart contractility/output, but the effects end quickly. It should be tapered slowly and cautiously to avoid the progression or relapse of shock.

What is a normal finding in an adult when assessing Babinski reflex?

Normal finding would be absent Babinski reflex (ie, toes point downward with stimulus to the sole). The presence of Babinski reflex (ie, toes fan outward and upward with stimuli) is expected in infants up to age 1, but in an adult may indicate a brain or spinal cord lesion.

If burning or stinging sensation occurs while using Capsaicin (Zostrix) what should be done?

Normal finding, pts should be taught this side effect subsides within the first week of regular use

How does a pt with peritonitis prefer to lie to lessen pain?

Lying still and take shallow breaths to avoid stretching the inflamed peritoneum

What about infantile diarrhea and why?

Metabolic acidosis- diarrhea causes dehydration, therefore causing acidosis

What will acute renal failure cause and why?

Metabolic acidosis- everything that isn't lung, or prolonged suction has to be metabolic acidosis

What teaching should a nurse provide to the parents when the child with KD is DC'ed, regarding fever outbreak?

Monitor for fever checking temp orally or rectally q6 hrs for the first 48 hrs following the last fever, temp should also be checked daily until the follow-up appointment

What is montelukast (singular) for?

Montelukast (Singulair) is a leukotriene receptor blocker with both bronchodilator and anti-inflammatory effects; it is used to prevent asthma attacks but is not recommended as an emergency rescue drug in asthma.

Should NSAIDs be taken by pts with medical history of hypertension or CAD? why?

NO, they increase the risk of thrombotic events especially in pts with cardiovascular disease

What is one route to avoid when administering "mean old -mycins" and why?

Oral- affects the absorption of the drugs, has no systemic effect

What is the most concerning toxic effect in the "mean old -mycins"?

Ototoxic

When do side effects of SSRIs diminish?

Over 3 months

Another word for respiratory alkalosis (UP)?

Over-ventilating

What are PVCs associated with? (cause)

PVCs can be associated with stimulants (eg, caffeine), medications (eg, digoxin), heart diseases, electrolyte imbalances, hypoxia, and emotional stress.

Why should a smartphone (cellphone) NEVER be placed directly over a permanent pacemaker?

Pacemakers can mistakenly detect electromagnetic interference from smartphones as a cardiac signal, causing them to briefly stop working. This leads to a pause in the cardiac rhythm of the pacing-dependent patient and may result in syncope.

Is consent required to treat an STI in a minor?

Parental consent for treatment of an STD is not required in this situation. All 50 states and the District of Columbia allow minors (age 12-14 or older) to consent to testing and treatment.

A client at 20 weeks gestation states that she started consuming an increased amount of cornstarch about 3 weeks ago. Based on this assessment, the nurse should anticipate that the health care provider will order which laboratory test(s)?

Pica is the abnormal, compulsive craving for and consumption of substances normally not considered nutritionally valuable or edible. Common substances include ice, cornstarch, chalk, clay, dirt, and paper. Although the condition is not exclusive to pregnancy, many women only have pica when they are pregnant. Pica is often accompanied by iron deficiency anemia due to insufficient nutritional intake or impaired iron absorption. However, the exact relationship between pica and anemia is not fully understood. The health care provider would likely order hemoglobin and hematocrit levels to screen for the presence of anemia.

The nurse is planning care for a client being admitted with newly diagnosed quadriplegia (tetraplegia). Which intervention will the nurse prioritize?

Quadriplegia (tetraplegia) occurs when the lower limbs are completely paralyzed and there is complete or partial paralysis of the upper limbs. This is usually due to injury of the cervical spinal cord. Depending on the area of injury and extent of cord edema, the airway can be adversely affected. The priority assessment for this client is the status of the airway and oxygenation. The nurse should frequently assess breath sounds, accessory muscle use, vital capacity, tidal volume, and arterial blood gas values (if prescribed).

What is Wilm's tumor?

Renal tumor of embryonal origin that is most commonly seen in children 2-5yrs. Most times it involves only one kidney, and the prognosis is good if the tumor has not metastasized.

What is skeletal traction and how does it work?

Screws, wires, and/or pins directly into a fractured bone and applying a pulling force (traction) via a pulley system and rope.

In a disaster triage, what are the characteristics of an Urgent (YELLOW) case and what 2 examples display those characteristics?

Serious injuries requiring treatment within 30 min and 2 hrs. 1. Open fracture w/ palpable distal pulse 2. Large wound

How to treat manipulation?

Set limit and enforce them: say NO

What does Sinusoidal Fetal Heart Rate suggest?

Sever fetal anemia potentially due to fetomaternal hemorrhage (abd trauma) or (fetal infection e.g parvovirus)

Simple characteristics of the 5 pressure ulcer stages:

Stage 1- Redness, non-blanchable, no open skin Stage 2- Open ulcer, red/pink wound, looks like a popped blister Stage 3- Visible subcutaneous fat, no bone, tendon, or muscle exposure Stage 4- Exposed bone, tendon, or muscle Unstageable- Necrotic, echar (black scab)

What can nuchal rigidity indicate in a pt that cannot tuck their chin to chest?

The neck should be supple and able to be flexed toward the chest. Nuchal rigidity requires follow-up due to possible meningeal irritation related to infection (eg, meningitis).

What is induration in a TB test and what does it have to do with skin appearing red?

The redness in a TB test does not indicate a positive test, induration does. Induration means that an individual has been exposed to TB, has developed antibodies, and is infected with TB bacteria

What is Cushing's triad and what is it an indication of?

They are late signs of increased ICP. Irregular respirations, systolic hypertension with a widening pulse pressure, slow full bounding pulse. **If seen in a pt, have a CT scan done to rule out intracranial bleed**

What do Thiazide diuretics promote retention of?

Thiazide diuretics increase the elimination of N+, K+, Mg, Cl- and they promote calcium reabsorption.

The client is brought to the emergency department after falling off a roof and landing on his back. A T1 spinal fracture is diagnosed. The client's blood pressure is 74/40 mm Hg, pulse is 50/min, and skin is pink and dry. What nursing action is a priority?

This presentation is classic for neurogenic shock, a distributive shock. Vascular dilation with decreased venous return to the heart is present due to loss of innervation from the spine. Classic signs/symptoms are hypotension, bradycardia, and pink and dry skin from the vasodilation. Neurogenic shock usually occurs in cervical or high thoracic injuries (T6 or higher). Systolic blood pressure should remain at 80 mm Hg or above to adequately perfuse the kidneys. Administration of fluids is a priority to ensure adequate kidney and other organ perfusion.

What should the nurse attempt to do first when Low tidal volume alarm goes off?

Troubleshoot the most common causes that can be setting it off

What kind of ulcers are more common in PAD vs. Chronic venous insufficiency?

Ulcers and gangrene occur usually at the most distal part of the body, where circulation is poorest.This increased venous pressure inhibits arterial blood flow to the area, resulting in inadequate supply of oxygen and nutrients to area cells and the development of stasis ulcers, which are typically found around the medial side of the ankle.

What is the difference between confrontation and aggression?

- With confrontation you confront the problem - Aggression is usually directed to the person

What kind of PPE is used with universal precautions (hint: 4 pieces of equipment)?

-Gloves -Gown -Mask -goggles or face shield

What are 6 initial interventions in the emergency management of chest pain?

1. Assess ABCs (vital signs, heart and lung sounds) 2. Obtain 12 lead ECG 3. Apply oxygen if required 4. Insert 2 large-bore IV lines and prescribe medications (nitroglycerin, aspirin, morphine) 5. Initiate continuous cardiac monitoring 6. Prepare pt for additional therapy

What are 3 signs of uterine rupture that stand out from any other prenatal complication?

1. Constant abdominal pain 2. Loss of fetal station 3. Cessation of uterine contractions

What are the 5 stages of grief?

1. Denial- Healthy and normal 2. Anger 3. Bargaining 4. Depression 5. Acceptance -DABDA (In order)

What 3 "mean old -mycins" are not considered part of them despite having the same name?

1. Erythromycin 2. Zithromycin 3. Clarithromycin So you "thro" them off this list!...

What are 3 possible consequences the pt can experience if he/she does not adhere to medication or does not finish the treatment?

1. Risk reactivating the MDR-TB 2. Increase the bacteria's drug resistance 3. Disease can be spread more easily

What are 6 P's (signs) of CS?

1. Unrelieved pain by re-positioning or analgesics 2. Pallor 3. Pulselessness 4. Paresthesias (pins and needles, tingling) 5. Poikilothermia (coolness) 6. Paralysis

What are 4 important actions a nurse should take when a prenatal patient arrives to the ED and birth is imminent?

1: Identify multiple gestation 2: Preterm gestational age 3: Meconium-stained fluid (determine whether resuscitation will be needed) 4: Recent narcotic/drug use

If a pt with chronic HF who is taking diuretics, is experiencing constipation. What would be the best recommendation?

Increased consumption of fiber is the best recommendation. Diuretics may lead to dehydration; however, fluid intake is usually limited for pts with HF. This pt's history of HF is contraindicated to increase fluid intake due to potential fluid overload and increased workload on the heart.

A client of the Orthodox Jewish faith with a history of type 2 diabetes mellitus is hospitalized, recovering from a total right hip arthroplasty. At noon, the client consumed a lean roast beef sandwich with lettuce and mustard, carrot and celery sticks, and fresh fruit. What would be the most appropriate 2:00 PM snack for this client?

Individuals who practice Orthodox Judaism follow Kosher dietary laws. These regulations are strict regarding the consumption of certain animal products (eg, no pork, shellfish, fish without scales) and the separation of meat/poultry from dairy. When meat or poultry is consumed, at least 3-6 hours must pass before a dairy product is consumed. Certain foods, including fresh fruits and vegetables, grains, tea, and coffee, are considered neutral and can be consumed at any time. Hard-boiled eggs and blueberries are nondairy foods and would be an appropriate snack (Option 3). This choice also provides a combination of carbohydrates and protein, which would help in regulating blood glucose.

A client with borderline personality disorder says to the nurse, "You're the only one I trust around here. The others don't know what they are doing and they don't care about anyone except themselves. I only want to talk with you." What is the priority action for the client's nursing care plan?

Individuals with borderline personality disorder (BPD) live in fear of rejection and abandonment. To avoid abandonment, they use manipulation and control, often unconsciously, to prevent a person from leaving. The manipulative behavior may be of a positive nature, such as the use of flattery, or a negative nature, such as distancing from the other person. An individual with BPD may also engage in self harm or suicidal behaviors in an attempt to gain attention from the other person and keep that person from leaving. For this client, the nursing care plan must include the assignment of different staff members. This will help diminish the client's dependence on a particular individual and help the client learn to relate to more than one person.

The community health nurse teaches family members about measures to keep an Alzheimer's pt safe at home. What are 6 most important strategy for the nurse to include in the instruction?

Individuals with dementia may wander and become lost during any stage of the disease. The most effective strategy to prevent wandering is to make modifications to secure the environment. These include: - Placing locks above or below eye level on doors that lead to the outside. Clients with Alzheimer disease (AD) lose their peripheral vision; they cannot see objects unless they are directly in front of them or they purposely move their heads. - Adding a motion sensor or alarm that goes off when someone tries to exit - Placing a large stop sign on door exits - Disguising a door with a curtain or wall hanging - Using childproof doorknob covers - Placing a black mat or black strip by an exit. The client may perceive this as an impassable black hole due to changes in depth perception. <--------(WTF???!)

What is infant botulism and what age group is more predisposed?

Infant botulism is food poisoning that occurs after consuming Clostridium botulinum, a bacteria found in soil and animal products (eg, raw honey, milk). In infants, the bacteria often colonize the gastrointestinal tract and release an exotoxin that causes rapid, life-threatening paralysis. In addition to young age, absence of competitive bowel flora predisposes infants (age <1 year) to this infection. Therefore, infants should not be fed honey.

A nurse is evaluating a client's understanding about infant formula preparation. Which of the following client statements indicate proper understanding? Select all that apply.

Infant formula is readily available as ready-to-feed, concentrate, or powder. Parents should exactly follow the manufacturer's recommendations for preparation. Basic guidelines for preparation, safe storage, and handling of formula include: - Keep bottles, nipples, caps, and other parts as clean as possible (ie, boil or wash in dishwasher). - Wash the tops of formula cans (eg, concentrated formula) with hot water and soap prior to opening to prevent contamination. - Refrigerate any unused, prepared formula or unused, opened formula (eg, ready-to-feed, concentrated), but use within 48 hours or discard to reduce the risk of bacterial growth. - Warm bottles in a pan of hot water or under warm tap water for several minutes. - Test formula temperature on the inner wrist before serving to the infant (should feel lukewarm, not hot). **Any formula in a bottle left over after feeding should be discarded because the infant's saliva has mixed with it, which can foster bacterial growth.**

The nurse is walking through a mall parking lot and witnesses the collapse of a child. The child is not breathing and has a pulse of 50/min. After the nurse calls emergency services and delivers rescue breaths for 2 minutes, the child is still not breathing and is now pale with a pulse of 49/min. What is the nurse's next action?

Infants and children (age 1 year to puberty) often develop respiratory distress and bradycardia prior to cardiac arrest. After witnessing the collapse of a child who is not breathing but has a pulse, the nurse should contact emergency services and initiative rescue breathing. After two minutes of rescue breathing, if the pulse remains greater than or equal to 60/min and there are signs of poor perfusion (e.g. skin pallor), the nurse should initiate compressions because the heart isn't circulating blood and oxygen effectively. Initiating compression prior to cardiac arrest improves outcomes.

A community health nurse is preparing to administer influenza vaccines. Which clients can safely receive the live-attenuated, intranasal influenza vaccine? Select all that apply. 1. 4-month-old client who is receiving scheduled vaccinations 2. 3-year-old client who is afraid of needles 3. 24-year-old client who is 6 weeks postpartum 4. 32-year-old client who is pregnant at 12 weeks gestation 5. 45-year-old client with a history of HIV

Influenza (flu) is a viral, respiratory illness common during the winter months. Each year, a new influenza vaccine is created to help protect against specific viral strains. The Centers for Disease Control and Prevention and the Public Health Agency of Canada recommend that all clients age ≥6 months receive the influenza vaccine annually. The influenza vaccine is available as an inactivated vaccine (intramuscular/intradermal injection) or as a live-attenuated influenza vaccine (LAIV; intranasal spray) that contains a weakened form of the live flu virus. The LAIV is safe and effective for most healthy individuals age 2-49 years to receive, including breastfeeding women (Options 2 and 3). (Options 1, 4, and 5) There is a remote chance the LAIV may become infectious; therefore, the LAIV is contraindicated in susceptible populations (eg, immunocompromised; children age <2) and populations with severe potential complications (eg, pregnancy). For these individuals, the inactivated vaccine is safest.

A 65-year-old client with end-stage renal disease comes to the emergency department after missing 5 hemodialysis sessions. Serum potassium level is 7.5 mEq/L (7.5 mmol/L) and ECG shows tall, peaked T waves. Which prescription will immediately protect the client from experiencing dysrhythmias associated with hyperkalemia?

Intravenous calcium gluconate is administered to hyperkalemic clients with ECG changes (eg, peaked T waves). Calcium gluconate itself does not decrease the serum potassium level but temporarily stabilizes the myocardium by raising the threshold for dysrhythmia occurrence. Once the nurse stabilizes the client by administering calcium gluconate, other prescriptions may then be implemented to decrease serum potassium level (eg, intravenous regular insulin with dextrose, sodium polystyrene sulfonate, hemodialysis) (Option 1).

What is malignant hyperthermia (MH)?

Is a rare and life-threatening condition precipitated by certain medications used for anesthesia, including inhaled anesthetics (eg, desflurane, isoflurane, halothane) and succinylcholine (a paralytic used adjunctively for intubation and general anesthesia). Skeletal muscles become unable to control calcium levels, leading to hyper-metabolic state manifested by contracture and increased temp (105 F). Early signs of MH include tachypnea, tachycardia, and rigid jaw or generalized rigidity. As the condition progresses, the pt develops a high fever. Muscle tissue is broken down, leading to hyperkalemia, cardiac dysrhythmias, and myoglobinuria.

What neurotransmitter does Dopamine affect and what are the actions?

It affects the Alpha receptors and the Beta 1. Causes increase cardiac output; causing vasoconstriction in blood vessels; When low dosses are administered, it causes renal and mesenteric (in the bowl) vasodialation.

Why does Acute stress disorder (ASD) happen and what are at least 6 characteristics ?

It occurs following trauma or in an extremely stressful event characterized by negative mood, alt sense of reality, hyperactive sensory state, sleep disturbance, difficulty concentrating, and easily startled.

A nurse is evaluating the fetal monitoring strip of a laboring primigravida at 38 weeks gestation who is receiving an oxytocin infusion and has external fetal monitors and an intrauterine pressure catheter in place. Which of the following interventions should the nurse implement? Click on the exhibit button for additional information. Select all that apply.

Late decelerations occur after the onset of a uterine contraction and continue beyond its end. The lowest point (nadir) occurs near the end of the contraction before the fetal heart rate gradually returns to baseline. Late decelerations occur when fetal oxygenation is compromised (eg, uteroplacental insufficiency, uterine tachysystole, hypotension). Immediate steps to correct late decelerations include: Stopping oxytocin if it is being administered (Option 5) Repositioning the client to the left/right side Administering oxygen by face mask (Option 1) Administering an IV bolus of isotonic fluid (eg, lactated Ringer solution, 0.9% saline) as needed (Option 2) If late decelerations persist or variability is absent or minimal, the nurse should prepare for emergency delivery.

What is Leukorrhea in pregnant women and is it a normal finding and what about in newborns?

Leukorrhea (ie, whitish, mucoid vaginal discharge) increases dramatically during pregnancy. However, copious, clear vaginal discharge that is thin or watery could indicate leaking of amniotic fluid, especially in the third trimester. Assessing for rupture of membranes should be a priority. Non-purulent vaginal discharge (leukorrhea), and mild uterine withdrawal bleeding (pseudomenstruation) are benign transient findings commonly seen in newborns; these are physiologic responses to transplacental maternal estrogen exposure. Reassurance should be provided. Monitoring the amount, color, and consistency is the appropriate action (Option 3).

A nurse has completed teaching a client who is being discharged on lithium for a bipolar disorder. Which statement by the client indicates a need for further teaching? 1. "I need to drink 1-2 liters of fluid daily." (8%) 2. "I need to have my blood levels checked periodically." (3%) 3. "I should not limit my sodium intake." (49%) 4. "I should use ibuprofen for pain relief." (39%)

Lithium is a mood stabilizer most often used to treat bipolar affective disorders. It has a very narrow therapeutic serum range of 0.6-1.2 mEq/L (0.6-1.2 mmol/L). Levels >1.5 mEq/L (1.5 mmol/L) are considered toxic. Lithium toxicity usually occurs with the following: - Dehydration - Decreased renal function (eg, elderly clients) - Diet low in sodium - Drug-drug interactions (nonsteroidal anti-inflammatory drugs [NSAIDs] and thiazide diuretics) Lithium is cleared renally. Even a mild change in kidney function (as seen in elderly clients) can cause serious lithium toxicity. Therefore, drugs that decrease renal blood flow (eg, NSAIDs) should be avoided. Acetaminophen would be a better choice for pain relief (Option 4).

What should a lymph node feel like and what differentiates it from a malignant tumor?

Lymph nodes are not palpable in adults. However, a lymph node that is palpable, superficial, small (0.5-1 cm), mobile, firm, and non-tender is considered a normal finding. Post-op mastectomy: (It could easily be explained by relatively recent mastectomy (trauma) with resulting inflammation and lymph flow interference)

The client has increased intracranial pressure with cerebral edema, and mannitol is administered. Which assessment should the nurse make to evaluate if a complication from the mannitol is occurring?

Mannitol (Osmitrol) is an osmotic diuretic used to treat cerebral edema (increased intracranial pressure) and acute glaucoma. When administered, mannitol causes an increase in plasma oncotic pressure (similar to excess glucose) that draws free water from the extravascular space into the intravascular space, creating a volume expansion. This fluid, along with the drug, is excreted through the kidneys, thereby reducing cerebral edema and intracranial pressure. However, if a higher dose of mannitol is given or it accumulates (as in kidney disease), fluid overload that may cause life-threatening pulmonary edema results. An early sensitive indicator of fluid overload is new onset of crackles auscultated in the lungs. To prevent these complications, clients require frequent monitoring of serum osmolarity, input and output, serum electrolytes, and kidney function.

Which of the following diets would place a client at the highest risk for macrocytic anemia? 1. Lacto-ovo-vegetarian (13%) 2. Lacto-vegetarian (8%) 3. Macrobiotic (15%) 4. Vegan (61%)

Megaloblastic anemia is caused by vitamin B12 or folic acid deficiency. Vitamin B12 deficiency can also result in peripheral neuropathy and cognitive impairment. Vitamin B12 is formed by microorganisms and found only in animal foods; some plant foods may contain minimal amounts of vitamin B12 only if they accidentally contain animal particles. Natural sources of vitamin B12 include meat, fish, poultry, eggs, and milk; some breads and cereals may be fortified with vitamin B12 as well as some nutritional yeasts. Vegans are strict vegetarians; they exclude all animal products, including eggs, milk, and milk products, from the diet. They also may avoid foods that are processed or not organically grown, thereby eliminating potentially fortified food sources of vitamin B12. Individuals who practice any form of vegetarianism are at risk for vitamin B12 deficiency. A vegan diet, with its elimination of all animal products, poses the highest risk. A vitamin B12 supplement is recommended when dietary intake is inadequate.

What effect does sodium have on Lithium in the body and how does it affect toxicity level?

Na+ affects renal excretion of lithium. If Na+ is limited or depleted from the body (circulation) lithium is reabsorbed by the kidneys, increasing the possibility of toxicity

A client is taking morphine sulfate for acute pain. Which statement will best assist the client worried about nausea and vomiting while taking this medication?

Nausea and vomiting are expected side effects of opioid medications (eg, morphine sulfate) when the treatment is initiated. However, tolerance develops quickly and persistent nausea is rare. It is recommended that the client take an anti-emetic with the pain medication.

The nurse is reviewing phone messages from clients in a surgery clinic. Which client would be the priority to call back first? 1. Client 1 week postoperative appendectomy who has not had a bowel movement in 4 days (8%) 2. Client 8 days postoperative ileostomy placement who reports nausea, vomiting, and abdominal bloating (39%) 3. Client postoperative right below-the-knee amputation who is concerned about a new tingling sensation in the right foot (15%) 4. Client with a temperature of 101.2 F (38.4 C) who is scheduled for a shoulder arthroplasty the next morning (35%)

Nausea, vomiting, abdominal distension, and decreased stool production may signal a bowel obstruction or obstructed ileostomy. Bowel obstruction can lead to electrolyte disturbances, dehydration, bowel perforation and infection (eg, peritonitis), and/or tissue necrosis. It is urgent and potentially life-threatening. The client must be evaluated by the health care provider in a timely manner.

The nurse is caring for a client who had a near-drowning accident in cold weather. Which assessment finding indicates the most severe injury?

Near-drowning occurs when a client is under water and unable to breathe for an extended period. In a matter of seconds, major body organs begin to shut down from lack of oxygen and permanent damage results. Decerebrate posturing is a sign of severe brain damage. During assessment, the nurse would observe arms and legs straight out, toes pointed down, and the head/neck arched back. These assessment findings indicate that severe injury has occurred.

The nurse is preparing to change a negative-pressure wound therapy dressing on a client's pressure ulcer. Which actions are appropriate at this time? Select all that apply.

Negative-pressure wound therapy is the application of negative pressure to a wound to enhance bacteria and exudate removal. Negative pressure promotes healing by stimulating cell growth and vessel perfusion in the wound bed. Medications are administered preprocedure to prevent discomfort. After wound cleansing, a skin protectant is applied around the wound to prevent breakdown and promote an air-tight seal. A sterile foam dressing is cut to fit the wound shape and size and is placed in the wound bed. An occlusive dressing large enough to extend 1.2-2 inches (3-5 cm) beyond the wound edges is applied to create a seal. Then a vacuum-assisted closure unit is connected to create negative pressure. The foam dressing should compress when the device is turned on, indicating a proper seal and functioning equipment.

The nurse is evaluating a client's understanding of postcircumcision care for a 24-hour-old newborn. Circumcision was performed using the clamp method. Which statement by the client demonstrates a need for further teaching? 1. "Bleeding should be no larger than the size of a quarter." (7%) 2. "I should cleanse the glans with warm water occasionally." (18%) 3. "I should expect at least 2 wet diapers in the next 24 hours." (33%) 4. "Yellow exudate on the glans penis indicates infection." (40%)

Newborn circumcision is a procedure that removes the foreskin from the glans penis using a clamp (eg, Gomco) or plastic ring (eg, PlastiBell). Circumcision is typically performed near discharge to ensure that the newborn is stable. Circumcision care includes: - Washing hands before providing care. - Applying petroleum jelly to the glans penis at diaper changes (unless PlastiBell was used) for 3-7 days to prevent the exposed glans from adhering to the diaper until the site heals. The circumcision site typically heals within 7-10 days. - Expecting yellow exudate on the penis after the first day, a normal part of the healing process (Option 4). Exudate should not be removed forcefully and disappears in 2-3 days. Swelling, increasing redness, odor, or abnormal discharge may indicate infection.

Can live vaccines be given to children with Kawasaki disease why or why not?

No- Antibodies acquired from the IVIG therapy will remain in the body for up to 11 months and may interfere with the desired immune response to live vaccines. Therefore, live vaccines (eg, varicella, MMR) should be delayed for 11 months after IVIG administration as this therapy may decrease the child's ability to produce the appropriate amount of antibodies to provide lifelong immunity.

Can pregnant women take NSAIDs?

No- Nonsteroidal anti-inflammatory drugs (NSAIDs) (eg, ibuprofen, indomethacin, naproxen) are pregnancy category C (used only if potential benefit outweighs risk) in the first and second trimesters and pregnancy category D (Potential benefit may justify risk in severe circumstances) in the third trimester. NSAIDs must be avoided during the third trimester due to the risk of causing premature closure of the ductus arteriosus in the fetus. During the first and second trimesters, NSAIDs should be taken only if benefits outweigh risks and under the supervision of a health care provider (HCP).

After nurse draws blood from pt for lab specimen, should the nurse vigorously shake the specimen tube to mix obtained blood with anticoagulant solution?

No- The filled tube should be gently inverted 5-10 times to mix anticoagulant solution with the blood. Vigorously shaking the tube can cause hemolysis and false results.

Is pruiritus seen with measles?

No- maculopapular rashes are characteristics of measles not pruritis. The difference is that maculopapular rashes are not itching and pruritus does cause itching.

When a med surge nurse is floated and a pt is awaiting discharge, should that pt be assigned to that nurse?

No- the pt waiting to be discharged requires extensive discharge teaching about using a continuous passive motion device, weight-bearing restrictions and assistive devices, anticoagulation prophylaxis, and rehabilitation.

If a pt is hypoglycemic, can a UAP offer them orange juice why or why not?

No- this is because offering the pt juice is an intervention for treating hypoglycemia that is outside a UAP's scope of practice. ** UAP are able to take BG checks and report the hypoglycemia to the nurse**

Atrial fibrillation

Occurs when the normal rhythmic contractions of the atria are replaced by rapid irregular twitching of the muscular heart wall

What is the difference between S&S and causations?

Often times what causes something is the opposite of what the S&S are (Ex: diarrhea (an UP symptom) will cause a metabolic acidosis, causing body to shut down (Going DOWN), therefore will get a paralytic illius 'DOWN symptom')

What is overflow incontinence?

Overflow urinary incontinence is characterized by bladder distension and overfilling that results in frequent, involuntary dribbling of urine. Overflow incontinence can occur due to an impaired bladder muscle (eg, diabetic neuropathy, spinal cord injury) or urethral compression (eg, dilated bowel, uterine prolapse, enlarged prostate). Fluid restriction can lead to dehydration with concentrated urine, which irritates the bladder and increases the risk for urinary tract infection. Dehydration also contributes to constipation, which may worsen incontinence by compressing the bladder.Constipation leads to bowel distension, which compresses the bladder and worsens incontinence. Clients with overflow incontinence should increase dietary fiber intake to help bulk and soften the stool, thereby preventing constipation.

A nurse is preparing to administer oxytocin to induce labor in a pregnant client at term gestation. Which of the following nursing actions are appropriate during oxytocin infusion? Select all that apply.

Oxytocin is a high-alert medication commonly used for labor induction or augmentation. It should be administered via an electronic infusion pump (Option 4), which decreases medication errors, provides for accurate dosing, and prevents maternal hypotension associated with rapid oxytocin bolus. The nurse should evaluate and document the fetal heart rate and uterine contraction pattern every 15 minutes during the first stage of labor and every 5 minutes during the second stage (Option 2). Continuous electronic fetal heart rate monitoring, not intermittent auscultation, is necessary (Option 3). The nurse should also monitor maternal intake and output to identify fluid retention, which precedes water intoxication, a potential adverse reaction of oxytocin administration causing dilutional hyponatremia, convulsions, and death.

What is pulseless electrical activity (PEA) and in what kind LOC is the pt in?

PEA consists of any organized electrical activity observed on ECG in a patient with no central palpable pulse. A patient in PEA will be completely unconscious. When the monitor is attached, you will see a rhythm on the monitor. Normal sinus rhythm, bradycardia, and ventricular tachycardia are possible rhythms that you might see. Despite having a rhythm on the monitor, the patient will not have a palpable pulse or blood pressure.

When are PVCs life-threatening?

PVCs are usually not harmful in the client with a healthy heart. In the client with myocardial ischemia/infarction, PVCs indicate ventricular irritability and increase the risk for the rhythm to deteriorate into a life-threatening dysrhythmia (eg, ventricular tachycardia, ventricular fibrillation). The nurse should assess the client's physiological response, including apical-radial pulse.

The nurse is reviewing telemetry strips of clients. Which rhythm requires further assessment by the nurse?

Pacemakers are implanted in clients with bradycardia, heart block, or cardiomyopathy. Most pacemakers are demand pacemakers, which sense the intrinsic electrical activity of the heart and fire only when the client's heart rate falls below the set rate of the pacemaker. Failure to sense occurs when a pacemaker fails to recognize the intrinsic electrical activity of the heart and fires at inappropriate times during the cardiac cycle. If the pacemaker fires during myocardial repolarization (eg, within the T wave), life-threatening arrhythmias (eg, ventricular tachycardia, ventricular fibrillation) may occur (Option 3). Failure to sense is treated by increasing or lowering the sensitivity setting until the pacer senses appropriately. (Option 1) Pacer spikes occurring before every P wave indicate an atrial paced rhythm. The P wave may appear normal or abnormal; the QRS complex appears normal. (Option 2) Ventricular paced rhythms have a pacer spike before the QRS complex. The QRS complexes are often wide and distorted as the electrical impulse is generated in the ventricle (instead of the atrioventricular node) and does not follow the normal conduction pathway of the heart. (Option 4) Pacer spikes before every P wave and QRS complex indicate an atrioventricular (dual-chamber) paced rhythm.

The nurse assists with a staff education conference about appropriate nonpharmacological pain-management interventions for newborns and infants. Which of the following strategies should be included in the presentation? Select all that apply. 1. Administer an oral sucrose solution to a newborn during a circumcision procedure 2. Apply a cold pack to a newborn's heel 30 minutes before performing a heel stick 3. Assist the parent to hold a newborn skin-to-skin during an immunization injection 4. Offer a pacifier to an infant while performing venipuncture 5. Swaddle an infant while leaving one arm unwrapped during an IV dressing change

Painful procedures (eg, capillary heel sticks, immunizations) are frequently required to provide optimal care but may cause considerable stress or alterations in a client's status (eg, vital sign changes, instability) without proper management. Nonpharmacological pain management is a method for stopping or reducing the sensation of pain and may eliminate or decrease the need for pharmacological intervention. Appropriate nonpharmacological pain-management interventions for infants and newborns include: - Offering concentrated sucrose, if prescribed, which is associated with reduced indicators of pain (eg, presence and duration of crying, grimacing) (Option 1) - Assisting the parent to hold the infant skin-to-skin (kangaroo care), which provides sensory stimulation that is calming and reduces indicators of pain (Option 3) - Offering nonnutritive sucking interventions (eg, pacifiers), which help calm the infant during painful procedures (Option 4) - Swaddling the infant, which provides a sense of comfort and security and reduces the heart rate and incidences of crying (Option 5)

A nurse is caring for a client who is meeting with the palliative care team. After the meeting, the client's family asks for clarification about palliative care. Which statements about palliative care are accurate? Select all that apply.

Palliative care is a model of treatment that involves managing symptoms, providing psychosocial support, coordinating care, and assisting with decision making to relieve suffering and improve quality of life for clients and families facing serious illnesses. An interdisciplinary palliative assessment team often includes nursing staff, chaplains, social workers, therapists, and nutritionists who work together on a comprehensive treatment plan. This model of care has been found to decrease unnecessary medical interventions and reduce depressive symptoms. Families of clients who receive palliative care interventions also experience lower rates of prolonged grief and post-traumatic stress disorder.The main difference between palliative care and hospice is that clients receiving palliative care can receive concurrent curative treatment. Hospice care is only started once the client decides to forego curative treatment.

A hospitalized client is scheduled for a percutaneous kidney biopsy at 10 AM. At 8 AM, the nurse reviews the client's vital signs and most current serum laboratory results. Which finding is most important to report to the health care provider (HCP)?

Percutaneous kidney biopsy is an invasive diagnostic procedure. It involves inserting a needle through the skin to obtain a tissue sample that is then used to determine the cause of certain kidney diseases. The kidney is a highly vascular organ; therefore, uncontrolled hypertension is a contraindication for kidney biopsy as increased renal arterial pressure places the client at risk for post-procedure bleeding. Blood pressure must be lowered and well-controlled (goal <140/90 mm Hg) using antihypertensive medications before performing a kidney biopsy. **Only neurosurgery and ocular surgery require a platelet count >100,000/mm3 (100 x 109/L). Most other surgeries can be performed when the platelet count is >50,000/mm3 (50 x 109/L). Although the platelet count is low (normal 150,000-400,000/mm3 [150-400 x109/L]), it is not the most important finding to report to the HCP.**

The nurse is counseling a pregnant client who is HIV positive. Which information is appropriate to discuss?

Perinatal transmission of HIV infection can occur from mother to baby anytime during the antepartum, intrapartum, or postpartum periods. Maternal antiretroviral therapy (ART) during pregnancy is imperative for decreasing viral load (amount of virus detectable in maternal serum) and decreasing risk of transmission to the fetus.

The nurse assesses a client with left-sided pneumonia who has an intermittent, productive cough with copious amounts of thick, yellow sputum. Which of the following interventions help to facilitate secretion removal? Select all that apply. 1. Chest physiotherapy 2. Cough suppressant 3. Huff coughing technique 4. Pursed-lip breathing 5. Right side-lying position

Pneumonia is an inflammatory reaction in the lungs, often due to infection, that causes alveoli to fill with cellular debris and thick, purulent exudate (ie, consolidation), which may cause impaired ventilation and oxygenation. Interventions to facilitate secretion removal in clients with pneumonia include: - Performing chest physiotherapy (percussion, vibration, postural drainage) to loosen and break up thickened secretions (Option 1) - Assisting the client to perform huff coughing, which raises secretions from the lower to the upper airway for expectoration (Option 3) - Ensuring adequate hydration through increased oral fluid intake (≥2-3 L/day) and administration of prescribed IV fluids, which thins pulmonary secretions to promote improved secretion clearance - Positioning the head of the bed to 45-60 degrees (ie, Fowler position) to promote effective coughing and optimal lung expansion "Side-lying positioning is utilized in hypoxic clients with unilateral pneumonia to increase perfusion to the healthy lung by gravity and improve oxygenation by positioning the client with the unaffected (good) side down. However, side-lying position alone does not improve secretion clearance"

What is a Holter monitor?

Portable ECG monitor worn by patient for period of few hours to few days to assess heart and pulse activity as person goes through activities of daily living; used to assess patient who experiences chest pain and unusual heart activity during exercise and normal activities

What happens to the potassium of a pt who suffers burns?

Potassium, the predominant intracellular cation, is released when cellular damage occurs, resulting in hyperkalemia (potassium >5.0 mEq [5.0 mmol/L]). Clients with hyperkalemia experience muscle weakness, ECG changes (tall, peaked T waves, shortened QT interval), and cardiac arrhythmias.

A registered nurse is making pre-procedure phone calls to clients scheduled for cardiac pharmacologic nuclear stress testing the following day. Which instructions should the nurse give the clients? Select all that apply.

Pre-procedure client instructions include the following: Do not eat, drink, or smoke on the day of the test (NPO for at least 4 hours). Small sips of water may be taken with medications (Option 3). Avoid caffeine products 24 hours before the test (Option 2). Avoid decaffeinated products 24 hours before the test as these contain trace amounts of caffeine (Option 1). Do not take theophylline 24-48 hours prior to the test (if tolerated). If insulin/pills are prescribed for diabetes, consult the HCP about appropriate dosage on the day of the test. Hypoglycemia can result if the medicine is taken without food (Option 5). Some medications can interfere with the test results by masking angina. Do not take the following cardiac medications unless the HCP directs otherwise, or unless needed to treat chest discomfort on the day of the test: Nitrates (nitroglycerine or isosorbide) Dipyridamole Beta blockers (Option 4)

A client had a levonorgestrel-releasing intrauterine device placed during a well-woman visit. Which teaching is appropriate for the nurse to include? 1. "Avoid oil-based personal lubricants, which can damage the device's silicone." (14%) 2. "Notify the health care provider if the string feels longer or shorter after menses." (40%) 3. "Placement will need to be reassessed if you lose or gain significant weight." (34%) 4. "The device will provide protection from pregnancy for up to 10 years." (9%)

Priority teaching related to intrauterine devices (IUDs) for long-term contraception focuses on prevention of sexually transmitted infections, which increase the risk for pelvic inflammatory disease, and early recognition of a dislodged device, which places the client at risk for pregnancy. The nurse may use the acronym PAINS to discuss potential complications of IUDs. The client should assess the string position weekly for the first 4 weeks and then after each menses to ensure that the device remains in place. A longer, shorter, or missing string may indicate that the IUD is no longer in the uterus; the client should notify the health care provider and abstain from intercourse or use a barrier method (eg, condom) until placement is verified (Option 2).

A child's arm is burned from accidentally spilling boiling water on it, and the parent calls the clinic. The nearest emergency department is an hour away. Which instructions would be appropriate to give the parent? Select all that apply.

Proper emergency care immediately following a burn can prevent infection, hypothermia, and further tissue damage. Once the source of the burn is contained, the nurse teaches the client home care that can be given prior to arrival to the emergency department. Client teaching includes: - Soak area briefly in cool water to stop the burning process. - Remove any clothing or jewelry around the burn to avoid constriction as edema develops. This also allows for quick assessment of the burn by clinicians. Only a health care provider may remove clothing that is stuck to the burned area. - Cover with a clean, dry cloth to prevent contamination, further trauma, and hypothermia. **Placing ice on a burn or wrapping the area in ice can increase tissue damage and may cause hypothermia with large burns. No ice, ointments, creams, or butter should be placed on the open skin.**

How is IBS managed?

Restrict gas-producing foods (eg, broccoli, bananas, cabbage, onions); caffeine; alcohol; fermentable oligo-, di-, and monosaccharides and polys (FODMAPs) (eg,, honey, high-fructose corn syrup, wheat); and other gastrointestinal (GI) irritants (eg, spices, hot/cold food or drink, dairy product, fatty foods). Pt should gradually increase fiber intake (eg, whole grains, legumes, nuts, fruits, vegetables) as tolerated. Foods that are well tolerated include proteins, and bland foods.

The clinic nurse is asked by the mother of a 15-month-old, "I am worried about my child's thumb sucking and its effects on tooth alignment. What should I do?" What is the nurse's best response?

Rooting and sucking are a part of an infant's natural reflexes. Nonnutritive sucking assists in helping the infant to feel secure. Some parents become very concerned about their infants sucking fingers, thumbs, or a pacifier and try to stop the behavior. As a rule, if thumb sucking stops before the permanent teeth begin to erupt, misalignment of the teeth and malocclusion can be avoided. Parents should be taught that teasing and punishing a child for using a pacifier or sucking the thumb is not an effective method for getting the child to stop. This can increase the child's anxiety and cause the child to increase the behavior.

The clinic nurse provides teaching for the parent of a child diagnosed with scabies. Which instructions should the nurse include in the teaching plan? Select all that apply.

Scabies is a highly contagious skin infestation of the Sarcoptes scabiei mite. Scabies spreads easily via direct person-to-person contact (eg, skilled nursing facility, day care, prison). The pregnant female mite burrows into the outer skin layer to lay eggs and feces, leaving a superficial burrow track. Intense itching, especially at night, occurs due to the body's inflammatory response to the mite's eggs and feces. Treatment for scabies typically involves 1 or 2 applications of a scabicide cream (eg, 5% permethrin). For infants and children, permethrin should be massaged into all skin surfaces from the head to the feet, avoiding contact with the eyes (Option 2). Even after effective treatment, itching often continues for several weeks. All persons in close contact with the client during the lengthy 30- to 60-day incubation period (time from infestation to symptom onset) should also seek treatment (Option 1). To prevent reinfection, clothing and linens should be washed and dried on the hottest settings (Option 5).

A client is admitted to the labor and delivery unit with a diagnosis of severe preeclampsia. IV magnesium sulfate is prescribed. Which nursing measures should the nurse include in this client's plan of care? Select all that apply.

Seizures are a potential complication of worsening preeclampsia, also known as eclampsia. Seizure precautions should be in place for all clients with preeclampsia. Side rails should be padded and the bed kept in the lowest position to prevent trauma during a seizure. Functioning suction equipment and supplemental oxygen should be available at the bedside (Option 4). During a seizure, the nurse should turn the client to the left side to prevent aspiration and promote uteroplacental blood flow. After the seizure subsides, the nurse should suction any oral secretions and apply oxygen 8-10 L/min by facemask. Magnesium sulfate is a central nervous system (CNS) depressant commonly prescribed to prevent seizures in clients with preeclampsia. Deep tendon reflexes should be assessed hourly during administration (Option 1). Hyperreflexia or clonus may indicate impending seizure activity, whereas hyporeflexia may indicate magnesium toxicity. Calcium gluconate is the reversal agent administered in the event of magnesium toxicity and should be immediately available (Option 2). Environmental stimuli should be minimized to decrease risk for seizures. This may include limiting visitors and the number of caregivers entering/exiting the client's room (Option 5).

A client with advanced kidney disease has serum potassium of 7.1 mEq/L (7.1 mmol/L) and creatinine of 4.5 mg/dL (398 µmol/L). What is the priority prescribed intervention?

Severe hyperkalemia (potassium >7.0 mEq/L [7.0 mmol/L]) requires urgent treatment because cardiac muscle cannot tolerate very high potassium levels. Severe hyperkalemia increases the risk for life-threatening ventricular dysrhythmias (eg, ventricular tachycardia and fibrillation, asystole). IV administration of 50 mL 50% dextrose with 10 units of regular insulin is the priority intervention as it is most effective in reducing the potassium level quickly. The insulin temporarily shifts the potassium from the extracellular fluid back into the intracellular fluid. The dextrose prevents hypoglycemia associated with the increase of insulin in the body and can be eliminated if the client has hyperglycemia (Option 1). If the client has ECG changes (eg, tall peaked T waves), calcium gluconate should be given before insulin/dextrose. This will stabilize the cardiac muscle until the potassium level can be reduced with insulin/dextrose.

If a pt is on a nitroglycerin drip and angina symptoms are stable but reports a new onset of a headache, what should the nurse do?

Since headache is an expected side effect, the headache can be treated with acetaminophen or aspirin

An intervention to reduce the risk for drug interaction:

Since some pts see different HCPs and receive multiple prescriptions for different health problems (polypharmacy). Pts should be encouraged to bring all medications (prescription, over-the-counter, herbal supplements) take regularly and occasionally to each appointment so that potential drug interactions can be evaluated.

The nurse prepares to administer a prescribed dose of sodium polystyrene sulfonate to a client with hyperkalemia. Which action by the nurse is most important prior to administering the dose?

Sodium polystyrene sulfonate (Kayexalate) is used to treat mild to moderate hyperkalemia. Potassium is exchanged for sodium in the intestines and excreted in the stool, thereby lowering the serum potassium. In clients without normal bowel function (eg, post surgery, constipation, fecal impaction), there is a risk for intestinal necrosis. During sodium polystyrene sulfonate therapy, severe hypokalemia (palpitations, lethargy, cramping) can develop. Frequent monitoring of electrolyte status is required. Because potassium exchanges with sodium content of the resin, excess sodium absorption could put clients at risk of developing volume overload (water follows sodium). The client should be monitored for signs of fluid overload (eg, crackles, jugular venous distension, edema) and have daily weights and intake and output assessment.

The nurse is preparing to administer a sodium polystyrene sulfonate retention enema. Which explanation by the nurse best describes the purpose of this type of enema?

Sodium polystyrene sulfonate (Kayexalate) retention enema is a medicated enema administered to clients with high serum potassium levels. The resin in Kayexalate replaces sodium ions for potassium ions in the large intestine and promotes evacuation of potassium-rich waste from the body, thereby lowering the serum potassium level. Kayexalate can also be given orally and is much more effective. Kayexalate can rarely be associated with intestinal necrosis.

The nurse prepares to insert a large-bore nasogastric tube for gastric decompression. After obtaining equipment, the nurse identifies the client, performs hand hygiene, applies clean gloves, assesses nares, and selects a naris. Place the remaining steps in the correct order. All options must be used. 5. Measure, mark, and lubricate tube 4. Instruct client to extend neck back slightly 3. Gently insert tube just past nasopharynx 2. Ask client to flex head forward and swallow 1. Advance tube to the marked point 6. Verify tube placement and anchor

Steps for inserting a nasogastric tube for gastric decompression include the following: 1. Perform hand hygiene and apply clean gloves (no need for sterile gloves) 2. Place client in high Fowler's position 3. Assess nares and oral cavity and select naris 4. Measure and mark the tube 5. Curve 4-6" tube around index finger and release 6. Lubricate end of tube with water-soluble jelly 7. Instruct client to extend neck back slightly 8. Gently insert tube just past nasopharynx, aiming tip downward 9. Rotate tube slightly if resistance is met, allowing rest periods for client 10. Continue insertion until just above oropharynx 11. Ask client to flex head forward and swallow small sips of water (or dry if NPO) 12. Advance tube to marked point 13. Verify tube placement and anchor - use agency policy and procedure to verify placement by anchoring tube in place and obtaining an abdominal x-ray. Aspirating gastric contents and testing the pH may also give an indication of placement (pH should be 5.5 or below). Auscultation of inserted air is acceptable for confirming tube placement initially, but is not definitive as it is not an evidence-based method. Nothing may be administered through the tube until x-ray confirmation is obtained, or this may cause aspiration.

The nurse provides education for caregivers of a client with Alzheimer disease. Which instructions should the nurse include? Select all that apply.

Strategies for caring for clients with Alzheimer disease address progressive memory loss and declining ability to communicate, think clearly, and perform activities of daily living. Caregivers should also learn to manage clients' problematic behavior and mood swings. Therapeutic guidelines include: - Use distraction and redirection (eg, going for a walk) to manage agitation. - Speak slowly and use simple words and yes-or-no questions. - Do not try to rationalize with the client. - Use visual cues when giving directions. - Interact with the client as an adult, even as the client regresses to childlike affect and behavior; respect client dignity by avoiding use of pet names (eg, "honey," "sweetie," "darling"). - Break down complex activities into steps with simple instructions. - Decrease the client's anxiety by limiting the number of choices.

A student nurse asks why enteral (tube) feedings, rather than total parenteral nutrition (TPN), are being administered to a client with sepsis and respiratory failure. Which is the best response by the registered nurse? 1. "Enteral feedings have no complications." (1%) 2. "Enteral feedings maintain gut integrity and help prevent stress ulcers." (46%) 3. "Enteral feedings provide higher calorie content." (9%) 4. "Risk of hyperglycemia is lower with enteral feedings than with TPN." (42%)

Stress ulcers are a common complication in critically ill clients because the gastrointestinal tract is not a preferential organ. In the presence of hypoxemia, blood is shunted to the more vital organs, increasing the risk of stress ulcers. The early initiation of enteral feedings helps preserve the function of the gut mucosa, limits movement of bacteria (translocation) from the intestines into the bloodstream, and prevents stress ulcers. Enteral feedings are also associated with lower risk of infectious complications compared with TPN. However, the mortality is the same.

The nurse is educating a group of parents about ways to decrease the risk of sudden infant death syndrome. Which of the following recommendations should the nurse suggest? Select all that apply.

Sudden infant death syndrome (SIDS) is the unexpected, unexplained death of an infant age <1 year, occurring most frequently in those age <6 months during sleep/naps. The nurse should recommend that parents place their infant to sleep on the back in a safe place (eg, crib). The sleep surface (eg, mattress) should be firm with no loose or soft items (eg, blankets, toys, stuffed animals) to prevent suffocation. Environmental factors such as smoking may also increase the infant's risk for SIDS; therefore, parents should maintain a smoke-free environment (Option 4). In addition, breastfeeding and updated vaccinations help to keep infants healthy and are protective against SIDS (Options 1 and 3).

The nurse is assessing a 2-year-old who has a blistered sunburn across the back and shoulders. Which of the following parent statements indicates an appropriate understanding of care for sunburn? Select all that apply. 1. "I am allowing my child to play outdoors only very early in the morning and late in the evening since the sunburn." 2. "I am encouraging extra fluids since my child got sunburned." 3. "I have been giving my child acetaminophen to help relieve the pain." 4. "I have been placing cool, wet washcloths on my child's back." 5. "I have rubbed hydrocortisone cream on the area to help reduce inflammation and promote healing."

Sunburn is a painful inflammatory skin reaction resulting from overexposure to ultraviolet radiation (eg, natural sunlight, tanning beds). Sunburns may be classified as superficial (ie, red, painful) or partial-thickness (ie, blistering, weeping) burns. Severe sunburns may cause systemic symptoms such as fever, chills, nausea, and headache. Sunburns increase insensible fluid loss and place the client at an increased risk for dehydration. Sunburn prevention is important because sunburn may cause permanent skin damage and increases the risk of skin cancers. However, when minor sunburns occur, symptom management includes: - Protecting the burned area from further sun exposure (eg, avoid going outside during midday when the sun's rays are hottest) (Option 1) - Promoting increased fluid intake to avoid dehydration (Option 2) - Providing pain relief with over-the-counter analgesics such as ibuprofen or acetaminophen (Option 3) - Reducing inflammation and pain by taking tepid baths; using cool compresses; and applying soothing, protective lotions or gels (eg, aloe vera, calamine) to the sunburned area (Option 4)

What is Syndrom of inappropriate antidiuretic hormone (SIADH)?

Syndrome of inappropriate antidiuretic hormone (SIADH) is potential complication of head injury. In SIADH, the extra ADH leads to excessive water absorption by the kidneys. Low serum osmolality and low serum sodium are the result of increased total body water (dilution). As ADH is secreted and water is retained, urine output is decreased and concentrated, resulting in a high specific gravity.

The public health nurse provides care for a client on a directly observed therapy (DOT) program to treat tuberculosis (TB). Which option best describes the care the nurse provides on this program? 1. Follows the client until 3 sputum cultures are normal (34%) 2. Gives the client bus tokens or cab fare vouchers to attend scheduled clinic visits (2%) 3. Provides and watches the client swallow every prescribed medication (56%) 4. Screens all of the client's close contacts (6%)

TB is curable if the client completes the prescribed medication regimen. Noncompliance with the treatment plan is a major problem in treating TB due to the length of time drug therapy is required (usually about 6 months) and the associated unpleasant side effects. DOT is an effective patient-centered treatment strategy developed by the World Health Organization that increases compliance with drug therapy, prevents reinfection and the development of multi-drug resistant TB strains, and controls the spread of TB disease worldwide. The public health nurse provides and watches the client swallow every prescribed medication for at least the first 2 months of antitubercular medication therapy, preferably longer. Any designated person (ie, caregiver) can provide the medications and observe the client swallow them. This can take place in any designated area (eg, clinic, home, school, workplace).

If an 11-month-old is exposed to an individual with measles 2 days ago, what has to be done ASAP by the parents?

Take child into the clinic for the measles, mumps, rubella (MMR) vaccine. - The Centers of Disease Control and Prevention (CDC) recommends that the first dose of MMR vaccine be give to children between age 12-15 months to ensure optimal vaccine response. However, the vaccine is safe for children age <12 months; it could provide some protection or modify the clinical course of the disease if administered within 72 hours of the child's initial measles exposure. Immunoglobulin, if administered within 6 days of exposure, is also utilized as post-exposure prophylaxis.

What is teletherapy and what interventions should be implied?

Teletherapy (external beam radiation therapy). Teaching essential skin care standards to these clients is focused on preventing infection and promoting healing of the affected skin. Key measures of skin care that clients receiving teletherapy should take include: - Protect the skin from infection by not rubbing, scratching, or scrubbing Wear soft, loose-fitting clothing Use soft, cotton bed sheets and towels Pat skin dry after bathing, Avoid applying bandages or tape to the treatment area - Cleanse the skin daily by taking a lukewarm shower. Use mild soap without fragrance or deodorant. Do not wash off any radiation ink markings - Use only creams or lotions approved by the health care provider (HCP). Avoid over-the-counter creams, oils, ointments, or powders unless specifically recommended by the HCP as they can worsen any irritation. - Shield the skin from the effects of the sun during and after treatment. Avoid tanning beds and sunbathing. Wear a broad-brimmed hat, long sleeves, and long pants when outside. Use a sunscreen that is SPF 30 or higher - Avoid extremes in skin temperature. Avoid heating pads and ice packs.

What is the nitrazine test?

Testing vaginal secretions with a nitrazine pH test strip can help differentiate between amniotic fluid, which is alkaline, and normal vaginal fluids or urine, which are acidic. A yellow, olive, or green color suggests that amniotic membranes are intact. A bluish color suggests probable rupture of membranes (ROM). However, the presence of blood or semen may result in a false positive, as serum and prostatic fluid are alkaline. A client history of recent sexual intercourse should alert the nurse to notify the health care provider that nitrazine results may be falsely positive due to the presence of semen in the vagina.

What is the Romberg test and what is the prioritizing intervention?

The Romberg test, part of a focused neurologic examination, assesses clients' perceptions of their head in space (vestibular function) and body in space (proprioception). It is used to determine the reason for loss of coordination (ataxia). Clients are asked to stand with the feet together and hands at the sides of the body. They are then asked to close their eyes while ability to maintain balance is assessed. A loss of balance is considered to be a positive Romberg sign and indicates that ataxia is sensory in nature rather than cerebellar. Clients demonstrating a positive Romberg test are likely to have ataxia, or be prone to lose balance, and would require assistance with ambulation.

While caring for a client in skeletal traction, which tasks can the registered nurse (RN) delegate to experienced unlicensed assistive personnel (UAP) to help prevent immobility hazards? Select all that apply.

The UAP has the skills and knowledge to perform standard procedures to prevent immobility hazards for a client in traction (eg, pneumonia, pressure ulcers, foot drop, thromboembolism). When providing care for a stable client, the RN can safely delegate these tasks to the UAP: - Assist with active and passive ROM exercises after the client has been taught how to perform them by the RN or physical therapist. - Notify the RN of client reports of pain, tingling, or decreased sensation in the affected extremity - Remind the client to use the incentive spirometer after the client has been taught proper use by the RN or respiratory therapist. - Maintain proper use of pneumatic compression devices. - Remind the client to move frequently using the overhead trapeze

A nurse administers an intramuscular (IM) injection using the Z-track technique. Place the steps in chronological order. All options must be used.

The Z-track technique prevents tracking (leakage) of the medication into the subcutaneous tissue and is universally recommended for the administration of IM injections. Displacing the skin while injecting the medication, and then releasing the skin back to its normal position after removing the needle creates a zigzag track. The procedure for administering an IM injection using the Z-track technique includes these steps: 1. Pull the skin 1-1 ½" (2.5-3.5 cm) laterally away from the injection site. 2. Hold the skin taut with the nondominant hand, and insert the needle at a 90-degree angle - taut skin facilitates entry of the needle and this angle ensures that the needle will reach the muscle. 3. Inject the medication slowly into the muscle while maintaining traction - slow injection promotes comfort and allows time for tissue expansion to facilitate absorption of the medication. 4. Wait 10 seconds after injecting the medication and withdraw the needle while maintaining traction on the skin; this allows the medication to diffuse before needle removal and helps to prevent tracking. 5. Release the hold on the skin - this allows the tissue layers to slide back to their original position, sealing off the needle track. 6. Apply gentle pressure at the injection site, but do not massage as this can cause the medication to seep back up to the skin surface and cause local tissue irritation.

A client with a chronic kidney disease has blood laboratory values as shown in the exhibit. The nurse administers sodium polystyrene sulfonate by mouth per the health care provider's prescription. The nurse evaluates that the therapy is effective when which value is noted on the follow-up results? Click on the exhibit button for additional information. 1. Calcium 7.4 mg/dL (1.85 mmol/L) (3%) 2. Creatinine 4.0 mg/dL (353 µmol/L) (9%) 3. Phosphorus 3.9 mg/dL (1.26 mmol/L) (9%) 4. Potassium 4.9 mEq/L (4.9 mmol/L) (77%) Laboratory results: - Creatinine 4.5 mg/dL (398 µmol/L) - Potassium 5.9 mEq/L (5.9 mmol/L) - Calcium 6.3 mg/dL (1.57 mmol/L) - Phosphorus 5.2 mg/dL (1.68 mmol/L)

The client with kidney disease is at risk for both hyperkalemia (normal potassium 3.5-5.0 mEq/L [3.5-5.0 mmol/L]) and hyperphosphatemia due to reduced glomerular filtration rate. Untreated hyperkalemia may cause life-threatening cardiac arrhythmias. Sodium polystyrene sulfonate (Kayexalate) can be used to treat hyperkalemia. It works in the gastrointestinal tract to trade sodium for potassium, thereby eliminating excess potassium through the stool and reducing the serum potassium level.

The nurse is assisting a client who has a bedside needle liver biopsy scheduled. Which are the essential actions? Select all that apply.

The client's coagulation status is checked before the liver biopsy using PT/INR and PTT. The liver ordinarily produces many coagulation factors and is a highly vascular organ. Therefore, bleeding risk should be assessed and corrected prior to the biopsy. Blood should be typed and crossmatched in case hemorrhage occurs. After the procedure, frequent vital sign monitoring is indicated as the early signs of hemorrhage are rising pulse and respirations, with hypotension occurring later. The needle is inserted between ribs 6 and 7 or 8 and 9 while the client lies supine with the right arm over the head and holding the breath. **A full bladder is a concern with paracentesis when a trocar needle is inserted into the abdomen to drain ascites. An empty bladder may aid comfort, but it is not essential for safety.** The client must lie on the right side for a minimum of 2-4 hours to splint the incision site. The liver is a "heavy" organ and can "fall on itself" to tamponade any bleeding. The client stays on bed rest for 12-14 hours.

What is etonogestrel and ethinyl estradiol vaginal ring and how does it work?

The etonogestrel and ethinyl estradiol vaginal ring (NuvaRing) is a combined hormonal contraceptive. The client inserts the ring into the posterior vagina, though positioning is not crucial. Unlike some contraceptives that are placed vaginally (eg, diaphragm, cervical cap), the ring is not a barrier method and requires time for hormone absorption. For clients initiating contraception with the etonogestrel and ethinyl estradiol vaginal ring, abstinence or a barrier method (eg, condom) is necessary during the first 7 days of use until hormones produce their full contraceptive effect. If the ring is displaced (eg, during intercourse or bowel movements), it should be rinsed and placed back in the vagina within 3 hours; otherwise, backup contraception is required for 1 week.

The health care provider has just prescribed tetracycline for an adolescent with acne vulgaris. The client takes oral contraceptive pills. The clinic nurse should educate the teen about which topics? Select all that apply. 1. Not taking tetracycline with dairy products 2. Taking tetracycline at bedtime 3. Taking tetracycline with food 4. Using additional contraceptive techniques 5. Using sunblock

The following should be taught to clients taking tetracyclines (eg, tetracycline, doxycycline, minocycline): 1. Take on an empty stomach - for optimum absorption, tetracyclines should be taken 1 hour before or 2 hours after meals (Option 3) 2. Avoid antacids or dairy products - tetracyclines should not be taken with iron supplements, antacids, or dairy products as they bind with the drug and decrease its absorption (Option 1) 3. Take with a full glass of water - tetracyclines can cause pill-induced esophagitis and gastritis; the risk can be reduced by taking with a full glass of water and remaining upright after pill ingestion 4. Photosensitivity - severe sunburn can occur with tetracycline. The client should use sunblock (Option 5). **Medications such as tetracycline and rifampin can decrease the effectiveness of oral contraceptives; additional contraceptive techniques will be needed (Option 4).**

The nurse cares for a client who returns from the operating room after a tracheostomy tube placement procedure. Which of the following is the nurse's priority when caring for a client with a new tracheostomy? 1. Changing the inner cannula within the first 8 hours to help prevent mucus plugs (14%) 2. Checking the tightness of ties and adjusting if necessary, allowing 1 finger to fit under these ties (41%) 3. Deflating and re-inflating the cuff every 4 hours to prevent mucosal tissue damage (11%) 4. Performing frequent mouth care every 2 hours to help prevent infection (33%)

The immediate postoperative priority goal for a client with a new tracheostomy is to prevent accidental dislodgement of the tube and loss of the airway. If dislodgement occurs during the first postoperative week, reinsertion of the tube is difficult as it takes the tract about 1 week to heal. For this reason, dislodgement is a medical emergency. The priority nursing action is to ensure the tube is placed securely by checking the tightness of ties and allowing for 1 finger to fit under these ties. (Option 1) Changing of the inner cannula and tracheostomy ties is not usually performed until 24 hours after insertion; this is due to the risk of dislodgement with an immature tract. However, the dressing can be changed if it becomes wet or soiled. Suctioning can be performed to remove mucus and maintain the airway. (Option 3) The cuff is kept inflated to prevent aspiration from secretions and postoperative bleeding. Cuffs are not regularly deflated and re-inflated. The respiratory therapist should monitor the amount of air in the cuff several times a day to prevent excessive pressure and mucosal tissue damage.

Emergency medical service personnel are transporting a near-drowning victim who is currently hypothermic. Based on anticipated vital signs, the nurse needs to prepare for which interventions? Select all that apply. 1. Covering client with warm blankets 2. Logrolling the client from side to side frequently 3. Mechanical ventilation 4. Warmed blood administration 5. Warmed IV fluids

The initial management of a near-drowning victim focuses on airway management due to potential aspiration (leading to acute respiratory distress syndrome), pulmonary edema, or bronchospasm (leading to airway obstruction). Hypoxia is managed and prevented by ensuring a patent airway via intubation and mechanical ventilation as necessary (Option 3). Careful handling of the hypothermic client is important because as the core temperature decreases, the cold myocardium becomes extremely irritable. Frequent turning could cause spontaneous ventricular fibrillation and should not be performed during the acute stage of hypothermia. Continuous cardiac monitoring should be initiated (Option 2). There are passive, active external, and active internal rewarming methods. Passive rewarming methods include removing the client's wet clothing, providing dry clothing, and applying warm blankets. Active external rewarming involves using heating devices or a warm water immersion. Active internal rewarming is used for moderate to severe hypothermia and involves administering warmed IV fluids and warm humidified oxygen (Options 1 and 5). (Option 4) Unless blood loss has occurred from trauma during the near-drowning incident, administration of blood products is not indicated.

An emergency department nurse is sent to the scene of a massive motor vehicle collision. A client there reports neck pain. Which actions should the nurse perform at this time? Select all that apply. 1. Apply a hard cervical collar 2. Assess neck range of motion 3. Inspect client's respiratory pattern 4. Position client flat on firm surface 5. Use logrolling technique if moving client

The initial priorities for a client with a suspected cervical spine injury are to ensure a patent airway and immobilize the spine to prevent further injury. This includes applying a rigid hard collar, placing the client on a firm surface (eg, a backboard), and moving the client as a unit (logrolling) if required (Options 1, 4, and 5). A soft foam cervical collar does not provide immobilization. Further stabilization is achieved by taping down the client's head and using straps to immobilize the arms, especially if the client is not cooperating. After immobilizing the client, the nurse should obtain a baseline set of vital signs to monitor for neurogenic shock (eg, hypotension, bradycardia, poikilothermia [ie, inability to regulate body temperature]), a potential complication of spinal cord injury. The nurse should also assess the client's respiratory rate, pattern, and effort. Presence of abdominal breathing or increased work of breathing may indicate impending loss of airway and require prompt rapid-sequence intubation (Option 3).

A client was medicated with intravenous morphine 2 mg 2 hours ago to relieve moderate abdominal pain after appendectomy. The client becomes lethargic but arouses easily to verbal and tactile stimuli, and is oriented to time, place, and person. The pulse oximeter reading has dropped from 99% to 89% on room air. Which oxygen delivery device is the most appropriate for the nurse to apply?

The nasal cannula is the most appropriate oxygen delivery device to apply at this time because it is comfortable, used for the short term, inexpensive, and permits the client to eat and drink fluids. It can supply adequate oxygen concentrations of up to 44%. This client is most likely hypoventilating as a result of the opioid medication. The client is alert and oriented and able to follow directions. Because pain relief is effective according to the pain scale, the client should be able to breathe deeply through the nose, and the hypoxemia should reverse rapidly. (Option 2) The non-rebreather mask is used in emergencies, delivers high concentrations of oxygen (up to 90%-95%), requires a tight face seal, and is restrictive and uncomfortable. (Option 3) The simple face mask delivers a higher concentration of oxygen (40%-60%), is more uncomfortable and restrictive, must be removed to eat or drink, and is not appropriate at this time. It can be used if hypoxemia does not resolve. (Option 4) The Venturi mask is a more expensive device used to deliver a guaranteed oxygen concentration to clients with unstable chronic obstructive pulmonary disease. These clients cannot tolerate changes in oxygen concentration.

The student nurse is preparing to perform a heel stick on a neonate to collect blood for diagnostic testing. Which statement by the student nurse indicates a need for further education?

The neonatal heel stick (heel lancing) is used to collect a blood sample to assess capillary glucose and perform newborn screening for inherited disorders (eg, congenital hypothyroidism, phenylketonuria). Proper technique is essential for minimizing discomfort and preventing complications and includes: - Select a location on the medial or lateral side of the outer aspect of the heel. Avoid the center of the heel to prevent accidental insult to the calcaneus. Puncture should not occur over edematous or infected skin. - Warm the heel for several minutes with a warm towel compress or approved single-use instant heat pack to promote vasodilation. Cleanse the intended puncture site with alcohol. Sucrose and nonnutritive sucking on a pacifier may reduce procedural pain. - Use an automatic lancet, which controls the depth of puncture. Lancing the heel too deeply can result in penetration of the calcaneus bone, leading to osteochondritis or osteomyelitis. **An acceptable alternate method of blood collection in the neonate is venipuncture (ie, drawing blood from a vein). Venipuncture is considered less painful and often requires fewer punctures to obtain a sample, especially if a larger volume is needed.**

What is the priority action of a nurse if the pt's low tidal volume alarm does not resolve after troubleshooting it and pt's condition is deteriorating clinically? (eg, decreasing oxygen saturation)

The nurse should immediately disconnect the ventilator and manually ventilate the pt's lungs w/ a resuscitation bag device at 10-15 L/min oxygen until the ventilator alarm state can be resolved

Which symptoms should the nurse instruct the parent to assess for to determine if the child is having an anaphylactic reaction?

The nurse should instruct the parent to first assess for signs of swelling of the mouth, tongue, lips, and upper airway. The child will have wheezing and difficulty breathing next, followed soon by cardiovascular symptoms. These include lightheadedness due to hypotension, loss of consciousness, and cardiovascular collapse. An anaphylactic reaction is life-threatening and requires rapid assessment and intervention.

What fruit MUST be avoided when taking Calcium channel blockers and statins?

The nurse should intervene when the client talks about eating grapefruit. Grapefruit inhibits enzyme CYP3A4. The drugs that are metabolized by the same pathway would not be metabolized, resulting in higher drug levels and serious side effects. Calcium channel blocker (eg, nifedipine) use with grapefruit juice can cause severe hypotension; some statins (eg, simvastatin) may result in myopathy.

The nurse is preparing 7:00 AM medications for a client with a urinary tract infection and a history of heart failure and type 2 diabetes. Based on the information from the medical and medication records, which prescription should the nurse question before administering? Click on the exhibit for more information. 1. Furosemide (68%) 2. Glipizide (8%) 3. Levofloxacin (6%) 4. Potassium chloride (16%)

The nurse should question the prescription for furosemide (Lasix), a potent loop diuretic, before administering the medication. The client has a significant decrease in systolic blood pressure (50 mm Hg), a negative fluid balance of 2000 mL for 24 hours, hypernatremia (normal sodium, 135-145 mg/dL [135-145 mmol/L]), and a potassium level that is trending downward. These parameters indicate hypotonic dehydration, which is often caused by diuretic use. If the diuretic were administered, the fluid volume deficit would increase further.

The nurse prepares to exit the room of a client on airborne and contact isolation precautions. Place the following nursing actions in the correct order. All options must be used. 3. Place the call light within the client's reach 2. Exit the negative-pressure room and close the door 4. Remove the gown and gloves without contaminating hands 1. Discard the gown and gloves and perform hand hygiene 5. Remove the N95 respirator mask and perform hand hygiene

The order of removal for personal protective equipment (PPE) should be from most to least contaminated, because this reduces the risk of contaminating the nurse's skin and clothes. When exiting the room of a client on both contact and airborne precautions, the nurse should perform the following actions in order: 1. Place the call light within the client's reach and ensure that the client's bed is locked and in the lowest position. 2. Remove the gown and gloves (ie, contact isolation PPE) in order of most to least contaminated. The nurse can remove gloves and then gown, or alternately, can remove gown and gloves together. 3. Discard the gown and gloves and then perform hand hygiene. 4. Exit the negative pressure room and immediately close the door to prevent infectious airborne microorganisms from escaping into the hallway or isolation anteroom. 5. Remove and discard the N95 respirator mask and then perform final hand hygiene. Negative pressure rooms continuously filter air out of the room, creating a lower pressure gradient that prevents airborne microorganisms from escaping through the doorway. To prevent exposure to infectious airborne microorganisms, nurses should remove N95 respirator masks only after exiting the room.

A client with an acute head injury cannot accurately identify the sensation felt when the nurse touches the intact skin with a cotton ball or paper clip. The nurse is aware that the deficit reflects injury to which area of the brain?

The parietal lobe of the brain integrates somatic and sensory input. Injury to the parietal lobe could result in a deficit with sensation. The nurse would verify the client's injuries and documented imaging studies to confirm that this was an expected deficit and document it accordingly. If it is a new or unexpected deficit, the nurse should inform the health care provider immediately. The frontal lobe controls higher-order processing, such as executive function and personality. Injury to the frontal lobe often results in behavioral changes. The temporal lobe integrates visual and auditory input and past experiences. Temporal lobe injury clients cannot understand verbal or written language. The occipital lobe of the brain registers visual images. Injury to the occipital lobe could result in a deficit with vision.

A critically ill client receiving vasopressor therapy for hypotension requires continuous blood pressure monitoring via an arterial catheter. The nurse sets up the pressure monitoring system and correctly places the transducer at the phlebostatic axis. Where on the chest does the nurse mark this reference point?

The phlebostatic axis is an external anatomical point on the chest at the level of the atria of the heart (fourth intercostal space at the midaxillary line or midway point of the anterior posterior diameter of the chest). It is used as a reference point for correct placement of the zeroing point of the transducer when measuring continual arterial blood pressure (BP), central venous pressure (CVP) using a central line, and/or cardiopulmonary pressures via a pulmonary artery (Swan-Ganz) catheter. The nurse places the transducer and marks the chest at the phlebostatic axis, which helps to assure accuracy of measurement. After it is placed, the zero reference stopcock of the transducer is "leveled," or aligned with the level of the atrium, using a ruler or carpenter's level. If the zeroing stopcock is placed below this level, falsely high readings occur; if it is too high, falsely low readings are obtained. The phlebostatic axis is also used as a reference point for the upper arm when measuring BP indirectly using a noninvasive BP device or the auscultatory method with sphygmomanometer and stethoscope. If the upper arm is above or below this level, the BP reading will be inaccurate.

A client with a mandibular fracture who has the upper and lower teeth wired together begins to choke on excessive oral secretions. What is the nurse's immediate action?

The priority for a client with a mandibular fracture whose teeth have been wired together is maintaining a patent airway. If the client begins to choke on oral secretions, the nurse should immediately attempt to clear the airway by suctioning via the oral or nasopharyngeal route. If this intervention is ineffective, cutting the wires may be necessary. **Elevating the head of the bed is a preventive measure. Because the client is choking, the priority is suctioning secretions to clear the airway. The nurse should also turn the client to the side if the client has excessive oral secretions or begins to vomit to decrease the risk of aspiration.**

What is a lipoma?

Think about LIPO- which means fat. Benign, fatty masses and rarely become malignant. They are subcutaneous, have a soft doughy feel, and are mobile and asymptomatic. Tender nodes are usually also due to inflammation (not malignant). Masses that are hard and fixed, not soft and mobile, usually indicate malignancy.

A client with a 10-year history of methadone use for chronic leg pain is being treated with azithromycin for pneumonia. On the third hospital day, both medications are discontinued as the QT interval on EKG has lengthened, increasing arrhythmia risk. The client wants to be discharged against medical advice to return home and take the client's own medications to prevent going into withdrawal without the methadone. Which is the most appropriate nursing response?

This client, who has a decade of experience taking methadone for chronic pain, is afraid that suddenly stopping this medication may precipitate withdrawal. The client is trying to regain control and avoid this problem by leaving the hospital against medical advice. However, the client remains at risk of life-threatening arrhythmias. Therefore, the nurse should promote negotiation between the client and HCP to develop a plan of care that will address the concerns of each. The plan should advocate for the client to ensure that the concerns are addressed.

Should a post-op above the knee amputation (AKA) pt have their leg be elevated, eplain.

To prevent hip flexion contractures in clients with above-the-knee amputation, the residual limb should not be elevated, especially after 24 hours. Instead, edema should be managed using a figure eight compression bandage. The bandage should be worn at all times until the residual limb is healed, and care should be taken not to wrap it too tightly. Hip flexion contractures can also be avoided by placing the client in prone position with hip in extension for 30 minutes 3 or 4 times a day.

How should an arm sling be worn correctly?

To prevent injury and provide proper support of the affected extremity, the nurse should evaluate the proper fit of the sling by assessing for the following factors: -Elbow is flexed at 90 degrees to support the forearm, prevent swelling, and relieve shoulder pressure (Option 1) -Hand is held slightly above the level of the elbow, through adjustment of the neck strap, to prevent venous pooling and edema (Option 2) -Bottom of the sling ends in the middle of the palm with the fingers visible, to be able to assess circulation, sensation, and movement (Option 3) -Sling supports the wrist joint with the thumb facing upward or inward toward the body, to maintain proper alignment (Option 4) -Skin irritation, which can occur under the sling and around the neck if the strap is too tight

The nurse is caring for a client following a transsphenoidal hypophysectomy. Which clinical findings would the nurse recognize as signs that the client may be developing diabetes insipidus? Select all that apply. 1. Decreased serum sodium 2. Excess oral water intake 3. High urine output 4. Increased serum osmolality 5. Increased urine specific gravity

Transsphenoidal hypophysectomy is the surgical removal of the pituitary gland, an endocrine gland that produces, stores, and excretes hormones (eg, antidiuretic hormone [ADH], growth hormone, adrenocorticotropic hormone). Clients undergoing hypophysectomies are at risk for developing neurogenic diabetes insipidus (DI), a metabolic disorder of low ADH levels. ADH promotes water reabsorption in the kidneys. Therefore, loss of circulating ADH results in massive diuresis of dilute urine. Clinical manifestations associated with DI include: - Decreased urine specific gravity (<1.003) (Option 5) - Elevated serum osmolality (>295 mOsm/kg [295 mmol/kg]) (Option 4) - Hypernatremia (>145 mEq/L [145 mmol/L]) (Option 1) - Hypovolemia and potential hypotension - Polydipsia (Option 2) - Polyuria (2-20 L/day) (Option 3)

What is tumor lysis syndrome?

Tumor lysis syndrome (TLS), an oncologic emergency, occurs when cancer treatment successfully kills cancer cells, resulting in release of intracellular components (eg, potassium, phosphate, nucleic acids). Clients with TLS develop significant imbalances of serum electrolytes and metabolites.

The nurse is providing discharge teaching to a client newly diagnosed with ulcerative colitis. Which of the following statements by the client indicate that teaching has been effective? Select all that apply. 1. "I need to eat a diet high in calories and protein so that I avoid losing weight." 2. "I need to take multivitamins containing calcium daily." 3. "I should avoid consuming alcoholic beverages." 4. "I should drink at least 2 liters of water daily and more when I have diarrhea." 5. "I will keep a symptom journal to note what I eat and drink during the day."

Ulcerative colitis (UC) is a form of inflammatory bowel disease characterized by remitting periods of mucosal irritation in the large intestine, resulting in profuse, bloody diarrhea. Management of clients with UC often includes dietary interventions to reduce symptoms and prevent reoccurrence, malnutrition, and dehydration. Nutrition and hydration management: 1. Diets consisting of high-calorie, high-protein foods are recommended to prevent weight loss and muscle wasting (Option 1). 2. Multivitamins containing calcium are often prescribed to supplement nutrition and should be taken regardless of symptoms (Option 2). 3. Oral hydration is critical in UC as >10 liquid stools may occur daily during flares, placing clients at risk for dehydration. Instruct clients to drink at least 2 liters of water daily (Option 4). 4. Dietary triggers for UC vary greatly between individuals and may include dairy, nuts/legumes, cereal, alcohol, caffeine, and fatty and processed foods. Diet journaling is recommended to assist with identifying triggers (Option 5). 5. Caffeine, alcohol, and tobacco are gastric irritants that stimulate the intestine and should be avoided (Option 3).

The nurse admits a client with cirrhosis who has an upper gastrointestinal bleed from suspected gastroesophageal varices. Which new prescription should the nurse question? 1. Administer pantoprazole IV piggyback every 12 hours (5%) 2. Initiate continuous octreotide IV infusion (16%) 3. Insert and maintain a nasogastric tube (51%) 4. Maintain NPO status except for PO medications (25%)

Upper gastrointestinal bleeding (UGIB) is a potentially life-threatening condition commonly caused by bleeding gastroesophageal varices or peptic ulcers. Gastroesophageal varices are distended, fragile blood vessels within the stomach and/or esophagus that frequently occur secondary to cirrhosis. Due to the fragility of these veins, clients are closely monitored for variceal rupture. Rupture of gastroesophageal varices is an emergency complication that rapidly results in massive gastrointestinal bleeding, hypovolemic shock, and death. Variceal rupture commonly occurs due to a sudden increase in portal venous pressure (eg, coughing, straining, vomiting) and from mechanical injury (eg, chest trauma, consuming sharp/hard foods). In UGIB, nasogastric tube insertion may be prescribed for gastric decompression or evacuation. However, nasogastric tube insertion without visualization of the esophagus may traumatize and rupture varices, causing hemorrhage (Option 3).

What is high specific gravity?

Urine specific gravity is a laboratory test that shows the concentration of all chemical particles in the urine. Increases in specific gravity (hypersthenuria, i.e. increased concentration of solutes in the urine) may be associated with dehydration. The higher the number, the more concentrated the urine is.

VEAL CHOP

V- Variable C- Cord Comphression E- Early Decels H- Head Compression A- Accelerations O - OK L-Late Decels P - Placenta

What are the 4 characteristics that distinguish Tetralogy of Fallot?

V.O.R.P 1. Ventricular septal defect 2. Pulmonary stenosis 3. Overriding aorta 4. Right ventricular stenosis (right hypertrophy)

Where is the ICD lead system placed?

Via a subclavian vein to the endocardium, usually over the pectoral muscle subcutaneously on the patient's nondominant side.

What supplement can be consumed while being on a Factor Xa inhibitors med that cannot be consumed while being on Warfarin?

Vitamin K, found in many green, leafy vegetables

What are command hallucinations?

Voices that command the person to hurt self or others

What is the PRIMARY symptom of increased ICP in pts with or without VP shunts and should the HCP be contacted?

Vomiting may be a sign of increased ICP and would require that the HCP be contacted.

During shift change, the night nurse notices that the graduate nurse administered IV dopamine instead of the prescribed norepinephrine for a client with sepsis. What should the night nurse do first? 1. Administer the correct medication and obtain current vital signs (3%) 2. Alert the graduate nurse and complete an incident report (3%) 3. Assess the client and notify the health care provider (70%) 4. Discontinue the dopamine and inform the nursing supervisor (23%)

When a medication error occurs, client safety is the nurse's first priority. The nurse should assess the client immediately for any adverse effects and inform the healthcare provider (HCP) (Option 3). Before taking any other actions, the nurse must ensure that the client is stable. Following client stabilization, the error should be reported to the appropriate nursing authority (eg, supervisor, manager), and an incident or occurrence report should be filed within 24 hours.

When would be the only exception to immediately stop the infusion of Norepinephrine?

When extravasation occurs. Extravasation is the infiltration of a drug into the tissue surrounding the vein Norepinephrine (Levophed) is a vasoconstrictor and vesicant that can cause skin breakdown and/or necrosis if absorbed into the tissue. Pain, blanching, swelling, and redness are signs of extravasation. Norepinephrine should be infused through a central line when possible. However, it may be infused at lower concentrations via a large peripheral vein for up to 12 hours until central venous access is established.

Which procedures are appropriate for the nurse to use when obtaining an adult client's blood for a laboratory test? Select all that apply. 1. Avoid the arm on the affected side after a mastectomy 2. Do not make further attempts to draw blood if unsuccessful on first 2 attempts 3. If necessary to use an arm with IV infusing, draw proximal to infusion point 4. Insert the needle bevel up at a 15-degree angle to the skin 5. Obtain a finger capillary specimen from the middle of the finger pad

When performing phlebotomy, clean the site, "fix" or hold the vein taut, and then insert the needle bevel up at a 15-degree angle (no steeper than 30 degree). Some recommend bevel down for children. This will help prevent going through the vein completely. The Infusion Nurses Society (INS) identifies the standard of care as no more than 2 attempts by any 1 individual. If the nurse is unable to successfully draw blood after 2 attempts, a phlebotomist or a different nurse should be asked to complete the blood draw. The affected side of a client who has had a mastectomy (especially with lymph node removal) should not be used. It places the client at risk for infection and lymphedema.

Can a spiral femur fracture occur to a baby of about 3 months old if yes, how?

Yes, by applying pressure in opposite directions, which is an unlikely accidental injury in a non-ambulatory child

Vasoactive meds should always be discontinued...?

tapered SLOWLY to prevent hemodynamic instability

Insulin Onset Peak Duration Mnemonic

youtube.com/watch?v=pAhHxt663pU

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

Stop all resuscitation activity immediately. -Healthcare professionals will not be penalized for an honest mistake. However, resuscitation must end immediately after they are notified of the error. Failure to stop an erroneous code on a client with an advance directive in a timely fashion may result in legal. action.

What is Sumatriptan and when is it contraindicated?

Sumatriptan is a selective serotonin agonist prescribed to treat migraine headaches, which are thought to be caused by dilated cranial blood vessels. Triptan drugs, like sumatriptan, work by constricting cranial blood vessels, and clients should be instructed to take a dose at the first sign of a migraine to help prevent and relieve symptoms. Sumatriptan is contraindicated in clients with coronary artery disease and uncontrolled hypertension because its vasoconstrictive properties increase the risk of angina, hypertensive urgency, decreased cardiac perfusion, and acute myocardial infarction.

What can noisy breathing mean in a post-op thyroidectomy and what should be done?

Swelling in the surgical area at the base of the neck can be compressing the airway. Stridor and/or difficulty breathing in the pt should call for a rapid response

Can UAPs measure copression stalkings?

The UAP may apply compression stockings or devices, but the RN or LPN should measure the client to choose the appropriate size as this is beyond the UAP's scope of practice.

Which nursing instruction is the highest priority when teaching a 38-year-old female client newly diagnosed with stress incontinence?

The highest priority for a client newly diagnosed with stress incontinence is preventing skin breakdown and urinary tract infections through bladder training. Teaching the client to empty the bladder every 2 hours when awake and every 4 hours at night reduces these risks.

A client with end-stage renal disease, oxygen-dependent chronic obstructive pulmonary disease (COPD), and a Do Not Resuscitate (DNR) code status is admitted to the medical floor for COPD exacerbation. The nurse walks into the room and finds that the client is not breathing. What should the nurse do first?

The nurse has a medical order stating that the client should not be resuscitated. Therefore, the appropriate first action is to assess the apical pulse. Then the nurse should call the HCP. If the client's family members are present, the nurse should explain what is happening and make sure that they have support.

What is the most important post-laparoscopic cholecystectomy intervention?

The nurse should assist the client with early ambulation and deep breathing to facilitate dissipation of the CO2 used during surgery (Option 2). Early ambulation not only improves breathing but also decreases the risk of thromboembolism and stimulates peristalsis.

What does a low tidal volume alarm indicate in a ventilator and why does it happen?

The volume of air the ventilator is delivering is LOWER than the set volume. Most often due to a disconnection, loose connection, or leak in the circuit

What must a parent NEVER do when putting baby in a car seat?

Tucking blankets between the newborn and the harness or dressing the newborn in bulky coats or a sleep sack reduces the car seat's effectiveness

What is an important teaching for pt's using Glybruide?

Use sunscreen and protective clothing as serious sunburns can occur

How should a legally blind patient be assisted when ambulating?

Using the sighted guide technique- walk slightly ahead of the patient with the pt's hand resting on the nurse's elbow

How is ITP treated?

Usually resolves spontaneously without complications, and management is primarily supportive

If Capsaicin is used on hands, how long should it be before washing hands?

Wait at least 30 minutes after massaging the cream into the hands before washing them to ensure adequate absorption

When would otic medications be contraindicated?

When pt has a perforated eardrum

Breastfeeding contraindications

*NOT HEPATITIS* also, not latent TB. The infant should receive pyridoxine if mother is receiving Isoniazid. Breast feeding is contraindicated if the mother is receiving rifabutin or fluoroquinolone.

When on the phone with HCP, what should be said to let them know you do not understand their note?

- DO NOT: "You wrote your order incorrectly" - DO say: "I am having a hard time understanding your order"

What is Electroconvulsive therapy (ECT) and and what are 4 important pt teachings?

- ECT iduces a generalized seizure by passing an electrical current through electrodes applied to the scalp. Although the exact mechanism is unknown, 15-20-second seizures are proven effective in treating mood disorders (eg, major depression, bipolar disorder) and schizophrenia. Teachings include: 1. NPO status is required for 6-8 hrs prior to treatment except for sips of water with meds (muscle relaxers) 2. Anesthesia (eg, methohexital, propofol) and muscle relaxant (eg, succinylcholine) will be administered; clients are unconscious and feel no pain during the procedure. (DO NOT ADMINISTER ANTI-CONVULSIVE MEDS) 3. Driving is not permitted during the course of ECT treatment 4. Temporary memory loss and confusion in the immediate recovery period are common side effects of ECT

What are some symptoms that will be seen in pts with Acidosis (pH is DOWN)?

- Hyporeflexia - Bradycardia - Lethargy - Obtundent (Almost like lethargic, just remember that it is a DOWNER) - Paralytic illus - Coma - Respiratory arrest

What is agoraphobia?

- It is characterized by intense anxiety about being in a situation from which there may be difficulty escaping in the event of panic attack. A person with agoraphobia may avoid open spaces, closed spaces, riding in public or private transportation, going outside the home, bridges/tunnels, and crowds.

What is a patient with Shock syndrome and possible organ dysfunction assessed for in general and what 7 assessments should the nurse perform?

- Peripheral tissue perfusion: 1: Level of consciousness 2: Urine output 3: Capillary refill 4: Peripheral sensation 5: Peripheral pulses 6: Skin color 7: Extremity temp

What should the nurse be aware of if a patient is put on an unfractionated heparin drip and has unstable angina and CKD?

- aPTT should be monitored. Nurse should be aware that the normal aPTT is 25-35 seconds but in this case since the pt is on a drip, a therapeutic level is 1.5-2 times more. So, aPTT is 46-70 seconds.

What is the difference between Bright red blood with sputum vs. Blood-tinged sputum, on the NCLEX, this vocab will be present and each will mean something different?

-Bright red blood sputum: Hemorrhage - Blood-tinged sputum: A little bit of bleeding at site (USUALLY NORMAL)

What is the onset and the duration of Disulfiram?

-Onset: 2 weeks (takes 2 weeks to get out of system) -Duration: 2 weeks

What age does the anterior and posterior fontanelle fuse?

-Posterior fuses by age 2 months -Anterior fuses by age 18 months

How do non-selective Alpha blockers work on Alpha receptors?

-When Alpha 1 is blocked: VasoDIALATION occurs -When Alpha 2 is blocked: VasoCONSTRICTION occurs

What do all 3 "mean old -mycins" that are not part of that category have in common (their name)?

-thro-

What is the Lithium Carbonate therapeutic range?

0.6-1.2 mEq/L

What 2 priorities must be implemented if a Sinusoidal Fetal Heart Rate is present?

1. (PRIORITY) Notify HCP stat 2. Begin intrauterine resuscitation: positioning on L side, IV fluids, oxygen

What are 4 important interventions implemented before a prenatal pt with placenta accreta has a c-section and which one is PRIORITY, why?

1. 2 18-gauge IV's with a blood type and crossmatch- because the pt is at risk for hemorrhage 2. C-section history 3. Jewelry removal before surgery 4. Consent signed for a cesarean hysterectomy

Since placenta accreta causes life-threatening hemorrhage, when an attempt to separate the placenta, what 2 priority prevention must be taken in advanced?

1. 2 large-bore IV's (18-guage) 2. Blood type with cross-match

Interrupting this step of the renin-angiotensin-aldosterone system has following effects:

1. A shortage of angiotensin II results in an absence of the vasoconstrictive responses (orthostatic reflex, renal blood flow regulation) causing orthostatic hypotension. Clients may be more prone to experiencing orthostatic hypotension early in treatment with ACE inhibitors and should be taught ways to prevent it. 2. A shortage of aldosterone causes hyperkalemia. Aldosterone Saves Sodium and Pushes Potassium out of the body. 3. ACE inhibitors are contraindicated in pregnancy due to teratogenic effects on the fetus (eg, oligohydramnios, fetal kidney injury). **Nothing to do with HR**

What are 2 serious complications that can occur with diverticulitis and what can it result in?

1. Abscess formation (sack of pus) 2. Intestinal perforation It can result in diffused peritonitis, causing progressive pain in other quadrants of the abdomen, rigidity, guarding, rebound tenderness

What are the 3 phases of Kawasaki disease in children, along with a description of each?

1. Acute- Sudden onset of high fever that does not respond to antibiotics or antipyretics. The child can develop swollen feet, hands, lips, and the a red tongue (strawberry tongue) 2. Subacute- Skin peels from hands and feet 3. Convalescent- symptoms disappear slowly

What are 5 nursing interventions that prevent abdominal wound dehiscence and the reason for each one?

1. Administer stool softeners to prevent straining and constipation from post-op immobility and opioid pain meds 2. Administer antimetics to prevent straining from vomiting 3. Apply abd binder to provide hemostasis, support the incision, and reduce mechanical stress on wound 4. Monitor BG to maintain a tight glycemic control, adequate sugar lvls will promote wound healing 5. Splint the abd by holding a pillow or folded blanket against the wound for support when coughing and moving

What are the 6 ear irrigation steps for a pt with excess cerum?

1. Assess client for contraindications (eg, fever, ear infection). Use an otoscope to inspect the external ear canal. Verify that the tympanic membrane is intact and ensure there are no foreign bodies. 2. Explain the procedure to the client, including possible sensations (eg, vertigo, fullness, warmth). 3. Place the client in a side-lying or sitting position with the head tilted toward the affected ear. Place a towel and an emesis basin under the ear. 4. Verify that the irrigation solution is at body temperature (98.6 F [37 C]) to minimize discomfort. 5. Straighten the ear canal, pulling the pinna up and back for adults or down and back for children age ≤3 years. 6. Irrigate gently with a slow, steady flow of solution, directing the syringe tip toward the top of the ear canal. Avoid occluding the canal to prevent increased pressure and rupture of the tympanic membrane. Stop immediately if the client experiences severe pain, nausea, or dizziness.

What are the 5 steps a nurse should give to a pt with crutches following steps to ascend the stairs with modified tree-point gait?

1. Assume the tripod position and place body weight on the crutches while preparing to move the unaffected leg 2. Place the unaffected leg on the step 3. Transfer body weight from the crutches to the unaffected leg and then use the unaffected leg to raise the body up onto the step 4. Advance the affected leg and the crutches together up the step 5. Realign the crutches with unaffected leg on the step before repeating the process

What are the 4 most important travel instructions for a patient in their 3rd trimester?

1. Carry an updated copy of the prenatal record in case emergency medical care is necessary during travel 2. Increase fluid intake to prevent dehydration and reduce the risk of thrombus formation or preterm contractions (Increase fluid intake before and during the flight) 3. Secure the seat belt under the gravid abdomen and across the hips and, if available, place shoulder belts lateral to the uterus and between the breast to prevent complications from abd trauma (eg, placenta abruption) 4. Wear compression stockings and unrestrictive clothing to improve venous return and decrease the risk of thrombus. (When in plane, pregnant women should get up a few times at least to prevent trhombus)

4 characteristics of appropriate documentation include:

1. Data gathered by direct measurement (vital signs, wound measurements) 2. Observations (pt action, eg, crying, or observable assessments, eg, soiled with urine) 3. Client statements, documented as direct quotes 4. Detailed descriptions od nursing actions and interventions (eg, which health care provider was notified)

What is autonomy?

1. Deals with PATIENT (self determination) 2. Patient have the right to informed consent and full disclosure of treatment so they can make informed choices about their care 3. Right to privacy; freedom of choice - A pt is not "required" to have an advance directive

What are the 3 most common symptoms that Tetralogy of Fallot causes?

1. Decreased pulmonary blood flow 2. Mixing deoxy with oxy blood 3. Inadequate blood flow into the LEFT side of the heart (Systemic circulation)

What are 5 steps a nurse should follow before administering intermittent enteral feedings?

1. Elevate HOB to 30-45 degrees (keep it elevated 30-60 minutes afterwards) 2. Check tube placement marking at naris insertion site 3. Confirm tube placement (gastric aspirate pH) 4. Assess bowel function (Auscultate bowel sounds, measure gastric residual) to evaluate feeding tolerance 5. Flush tube with 30mL of water (and again after feeding)

What are the next 3 steps after a nurse reports suspected maltreatment?

1. Facilitate a complete physical evaluation (eg, skeletal survey, growth/development comparison, radiographic studies, neuro examination) 2. Doc facts and observations objectively, including history provided by the parent or caregiver and the time period from injury (using medial terms when possible) 3. Perform a review child-care practices with the caregiver

What are the 4 SSRI drugs?

1. Fluoxetine 2. Paroxetine 3. Sertaline 4. Citalopram

What S/S are exhibited by a pt in DKA?

1. Fruity/acetone smell of breath 2. Kussmaul respirations

What are 6 important interventions to decrease ICP?

1. HOB to 30 degrees to promote venous return from the head, which will decrease cerebral edema (DO NOT ELEVATE HEAD ON PILLOWS- will flex neck , decreasing venous draining, and increasing ICP) 2. Keep head and body mid line 3. Administer stool softener to prevent straining 4. Keep calm environment (dim lights) 5. Only suction when needed 6. Reduce metabolic demands (pain, seizures, hypoxia, fever) Treat fever aggressively, avoid shivering

What are the 9 steps a nurse should teach a female pt when doing a clean catch urine specimen for a urinalysis?

1. Hand hygiene 2. Open specimen container, leaving sterile side of lid facing upward to prevent contamination 3. Spread labia using the index finger and thumb of nondominant hand 4. Cleanse the vulva in a front-to-back motion using wipe once only 5. Initiate urinary stream to flush any remaining microorganisms from the urethral meatus 6. Pass the container into the stream for the collection of 30-60 mL 7. Remove the specimen container from the stream before urine stream ends and the labia are replaced to prevent contamination 8. Replace the sterile cap without contaminating it 9. Hand hygiene **Only 30-60 mL of urine is required for a culture and sensitivity urine test, and the specimen container does not need to be completely full. Furthermore, specimen collection should not be interrupted and restarted later, as this increases the chance of specimen contamination. It is not necessary to obtain the specimen from the day's first voided urine.**

What are 5 main S&S of cardiac tamponade?

1. Hypotension with narrowed pulse pressure 2. Muffled or distant heart tones 3. Jugular venous distension (venous fluid will back flow causing distension) 4. Pulsus paradoxus (Pulsus paradoxus refers to an exaggerated fall in a patient's blood pressure during inspiration by greater than 10 mm Hg) 5. Tachycardia

What are 2 initial treaments for Kawasaki disease and what should the nurse be monitoring constantly?

1. IV gamma globulin (IVIG) 2. Aspirin * IVIG creates high plasma oncotic pressure, and signs of fluid overload and pulmonary edema develop if too much is given at a time, they should be monitored for symptoms of heart failure (eg, decreased urinary output, additional heart sounds, tachycardia, difficulty breathing)

What are 6 nursing interventions for pts in skeletal traction?

1. Increase fluid intake (>2 L/day) 2. Weights hang freely 3. Monitoring pin insertion sites for infection 4. Frequent neuro checks (especially within the first 24 hrs of traction therapy) 5. Inspecting the rope for fraying (worn out) 6. Ensure proper alignment of the pt to facilitate union of the fractured bone

What are 4 other indications a pt is deemed incompetent to sign a consent for his/her own ECT therapy?

1. Inebriated 2. psychotic 3. delirious 4. Under influence of mind-altering meds

What nursing actions would represent appropriate care to an Ebola pt?

1. Keep doors closed at all times in their single room (Airborne precautions) 2. Maintain a log of everyone in and out of the pt's room, and all logged individuals are monitored for possible symptoms 3. Restrict visitors from entering the pt's room unless it is absolutely necessary (child is infected) 4. Sharps/needles are limited whenever possible 5. Outer gloves are first cleaned w/ disinfectant and removed then inner gloves are wiped between removal of every PPE (respirator, gown) and removed last

What are 3 main precautions to ensure safety, when caring for a pt undergoing brachytherapy?

1. Limit the time of exposure (30min/day). Cluster care and wear designated dosimeter badge 2. Maximize distance from the source (6 ft is recommended) 3. Use shield appropriately. Lead aprons typically shield the front of the body; turning the back to the pt is a risk for exposure

Caring for an intubated pt with continuous sedative infusion, what would be 4 interventions the nurse can use to prevent ventilator-acquired pneumonia?

1. Maintain HOB at 30-45 degrees (semi-Fowler) 2. Oral care with chlorohexidine mouthwash 3. Daily sedation vacations 4. Strict hand hygiene

What 3 measures should the nurse apply when TED hose are prescribed for the first time?

1. Measure length from heel to popliteal area (if knee length is prescribed) and circumference at the widest point of the calf 2. Ensure stockings are free of folds, rolls, or wrinkles 3. Discrete wounds should be covered with occlusive dressings

What are 3 additional steps needed in special circumstances; such as a person getting pulled out of a swimming pool (they have a transdermal patch)?

1. Moving the pt out of large bodies of water- the entire body does not have to be dry, it can still be used if the pt is in a puddle of water 2. Drying the chest area- for proper conduction 3. Removing trandermal med patches and wiping the chest of med residue before applying AED pads

What are 3 instructions a pt receives prior to a Crononary Arteriogram?

1. NPO 6-12 hrs prior 2. Pt may feel warm or flushed while contrast is being injected 3. Hemostasis (stability of blood/circulation) MUST be obtained from in the artery that was cannulated, compression and pt must lie flat for several hrs after procedure.

When prescribed Factor Xa inhibitors, what 3 medical regimen must the pt avoid?

1. Over-the-counter meds that increase bleeding (eg, NSAIDS, aspirin) 2. Other anticoagulants in conjunction with Factor Xa inhibitors meds 2. Supplements that can increase bleeding risk (containing garlic and ginger)

What are 3 disadvantages of using PPI for long term usage?

1. PPIs impair intestinal calcium absorption and therefore are associated with decreased bone density, which increases the possibility of fractures of the spine, hip, and wrist. 2. PPIs cause acid suppression that otherwise would have prevented pathogens from more easily colonizing the upper gastrointestinal tract. This leads to increased risk of pneumonias. 3. PPI use may also increase the risk for clostridium difficile-associated diarrhea (CDAD); currently the cause is unclear.

What are 5 misconceptions of contraindication to immunization?

1. Penicillin allergy 2. Mild illness (with or without elevated temp) 3. Mild site reactions (swelling, erythema, soreness) 4. Recent infections exposure 5. Current course of antibiotics

What are the 8 steps for instilling ear drops?

1. Perform hand hygiene and don clean gloves 2. Position pt side-lying with affected ear up (if not contraindicated) 3. Warm ear drops to room temp (using hands or water) to help avoid vertigo, dizziness, or nausea (internal ear is sensitive to temp extremes) 4. Pull pinna UP and BACK if pt is > 4yrs (Pull pinna DOWN and BACK in pt <3 yrs) 5. Hold dropper half an inch above ear canal 6. Apply gentle pressure to the tragus to facilitate the flow of the med 7. Tell pt to remain side-lying for 2-3 minutes 8. Place cotton ball loosely in pt's outermost ear canal for 15 minutes (only if needed)

What are 2 uses for Ginseng?

1. Promotes mental alertness 2. Enhances immune system

What are 2 absolute priority when treating asystole or PEA?

1. Providing continuous, high-quality CPR 2. Oxygen ventilation

What is the 1st step toward a PTSD resolution?

1. Pt's readiness (ability & willingness) to discuss the details of the traumatic event without experiencing high levels of anxiety.

What should be the first 2 things one does if a pt has S&S of infected CVC (central venous cath)?

1. Remove (discontinue) CVC asap to prevent continued exposure to infection 2. Blood cultures should be obtained before initiating antibiotic therapy, antibiotics can contaminate sample if used before

What are the 5 steps to perform a Huff cough to facilitate secretion removal in COPD pts?

1. Sit upright in a chair with feet spread shoulder-width apart and lean forward with shoulders relaxed; forearms supported on thighs or pillows; head and knees slightly flexed; and feet touching the floor. 2. Perform a slow, deep inhalation through the mouth or nose using the diaphragmatic muscle. 3. Hold breath for 2-3 seconds, keeping the throat open, and then perform a quick, forceful exhalation, creating an audible "huff" sound. 4. Repeat the "huff" once or twice more to expectorate any mucus. 5. Rest for 5-10 regular breaths and repeat as necessary until all mucus is cleared.

5 circumstances to report situations to professional authorities:

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

What are 5 instructions given to pts with pubic lice (crabs)?

1. Use lice treatment shampoo (1% permethrin) 2. Remove nits with fine nit comb, after shampooing 3. Wash and dry clothes, towels, and bedding with hot water and highest-heat dryer setting 4. Sexual partners should also receive pubic lice treatment 5. Pubic lice may be passed through close contact and sharing linens. All family members are at risk, so have them get screened.

What 2 types of heart activity is INDICATED for defibrillation and why?

1. Ventricular tachycardia (V-tach) (pulseless)- Most patients with this rhythm are unconscious and pulseless and defibrillation is needed to "reset" the heart so that the primary pacemaker (usually the Sinoatrial Node) can take over 2. Ventricular Fibrillation (V-fib)- Ventricular fibrillation (v-fib) is a common cause of out-of-hospital cardiac arrest. In this case, the heart quivers ineffectively and no blood is pumped out of the heart. On the monitor, v-fib will look like a frenetically disorganized wavy line. Ventricular fibrillation may be fine or coarse; coarse ventricular fibrillation is more likely to convert after defibrillation than fine v-fib. https://youtu.be/tO1Uh_GH8vk

What 4 nursing interventions can and should be done to PREVENT Tet spells?

1: Provide a calm environment, particularly on waking 2: Soothing and quieting the infant when crying or distressed 3: Swaddling or holding the infant during procedures or stress time 4: Providing frequent smaller feeds to reduce frustration

What 5 nursing interventions can be included in a care plan for a pt with acute mania?

1: Providing quiet environment 2: 1 to 1 interactions rather than group 3: Structured schedule of activities to help the client stay focused 4: Physical activity to help relieve stress 5: Setting limits such as picking clothes for them

The nurse is caring for a client who will have a copper intrauterine device (IUD) inserted. When reinforcing teaching related to the copper IUD, which of the following nurse statements are appropriate? Select all that apply.

A copper intrauterine device (IUD) is a form of long-acting, reversible contraception that causes an intrauterine inflammatory effect that impairs sperm mobility and prevents implantation of a fertilized egg. It is a highly effective contraceptive and is also used for emergency contraception. - IUD insertion commonly causes mild discomfort, cramping, and/or light vaginal bleeding. Ibuprofen is recommended before and after insertion for relief of cramping/pain. - Menstrual changes are also common among IUD users. For clients with copper IUDs, heavier bleeding and increased cramping during menses are the most common and expected side effects. - The client should check for the strings at least monthly to ensure that the IUD has not been expelled. **Unlike levonorgestrel IUDs, copper IUDs have an immediate contraceptive effect; backup contraception is not required. Condoms are recommended for clients who are at risk for sexually transmitted infections.**

The telemetry nurse reports the cardiac monitor rhythms of 4 clients to the medical unit nurse assigned to care for them. The nurse should assess the client with which rhythm first?

A demand ventricular electronic pacemaker set at 70/min delivers an impulse (fires) when it senses an intrinsic rate below the predetermined rate of 70/min. Failure to capture occurs when the pacemaker sends an impulse to the ventricle, but the myocardium does not depolarize (pacer spike with no QRS complex; no palpable pulse beat); this is usually associated with pacer lead (wire) displacement or battery failure. The malfunction can result in bradycardia (pulse <60/min) or asystole and decreased cardiac output; the nurse should perform an assessment and notify the health care provider immediately.

The nurse cares for a client scheduled for a percutaneous left kidney biopsy as an outpatient. Which intervention should the nurse include in the client's post-procedure care plan?

A kidney biopsy involves obtaining a tissue sample for pathological evaluation to determine the cause of certain kidney diseases (eg, nephritis, transplant rejection). The kidney has extensive vasculature (similar to the liver); therefore, bleeding from the biopsy site is the major complication following a percutaneous kidney biopsy. Before the procedure, the client must give informed consent and discontinue all anticoagulants (eg, heparin, warfarin, rivaroxaban) and antiplatelet agents (eg, aspirin, clopidogrel, nonsteroidal anti-inflammatory drugs) for at least one week. The client should be typed and crossmatched for blood (although the need for a transfusion is rare). Blood pressure should be well-controlled. After the procedure, the nurse should monitor vital signs at least every 15 minutes for the first hour as tachycardia, tachypnea, and hypotension can indicate blood loss. The nurse should also assess the puncture site dressing for bleeding (Option 4).

How is back labor relieved?

A laboring client may experience lower back pain with contractions, or "back labor," when the fetus is in the right occiput posterior (ROP) position. This variation of vertex presentation causes the fetal occiput to exert added pressure on the woman's sacrum during contractions. Positioning the woman on her hands and knees often helps decrease back pain and facilitates fetal rotation into an anterior position.

The nurse is admitting a pregnant client who is experiencing intense "back labor." The nurse suspects the fetus is in which position?

A laboring client may experience lower back pain with contractions, or "back labor," when the fetus is in the right occiput posterior (ROP) position. This variation of vertex presentation causes the fetal occiput to exert added pressure on the woman's sacrum during contractions. Positioning the woman on her hands and knees often helps decrease back pain and facilitates fetal rotation into an anterior position. (Option 2) This fetus is in the right occiput anterior (ROA) position, which is optimal for birth as it allows for rotation of the fetal head through the birth canal. (Option 3) This fetus is in the right occiput transverse (ROT) position. When the fetus remains in the OP or OT position, labor is often prolonged. Most fetuses in these positions will rotate spontaneously to the OA position during labor. Manual rotation may be attempted with persistent OP or OT position. (Option 4) Breech presentation, with the fetal feet or buttocks presenting first in the maternal pelvis, does not cause back labor. Potential complications from breech presentation include ineffective dilation of the cervix and increased risk of umbilical cord prolapse.

The nurse receives morning report on 4 clients who were admitted 24 hours earlier for injuries incurred in motor vehicle collisions. Which client should the nurse assess first? 1. Client with a fractured pelvis who has a large area of ecchymosis and bruising over the pelvic region (10%) 2. Client with a fractured tibia and leg cast who has pink skin under the cast edge and swollen toes (16%) 3. Client with a lung contusion who has an oxygen saturation of 90% and severe inspiratory chest pain (60%) 4. Client with a pneumothorax and a chest tube who has intermittent bubbling in the water-seal chamber (12%)

A lung contusion (bruised lung) caused by blunt force can occur when an individual's chest hits a car steering wheel. This injury is potentially life-threatening because bleeding into the lung and alveolar collapse can lead to acute respiratory distress syndrome. Clients should be monitored for 24-48 hours as symptoms (eg, dyspnea, tachypnea, tachycardia) are usually absent initially but develop as the bruise worsens. Inspiratory chest pain can lead to hypoventilation, and an oxygen saturation of 90% (normal: 95%-100%) indicates hypoxemia. Therefore, the nurse should assess this client with lung contusion first and then notify the health care provider as immediate interventions to decrease the work of breathing and improve gas exchange (eg, supplemental oxygen, medications, ventilatory support) may be necessary.

A graduate nurse is caring for a client with a triple-lumen peripherally inserted central catheter in the right arm. Which actions by the graduate nurse indicate that more education is needed? Select all that apply. 1. Flushing the line before and after each medication administration 2. Pausing the parenteral nutrition prior to drawing blood from a different port 3. Reinforcing a torn peripherally inserted central catheter line dressing with tape 4. Scrubbing the port with alcohol for 5 seconds before use 5. Taking the client's blood pressure in the left arm

A peripherally inserted central catheter (PICC) is a venous access device that is inserted via the cephalic or basilic vein and terminates in the superior vena cava. It is indicated for administration of noxious medications (eg, parenteral nutrition, chemotherapy), for long-term IV therapy, or in clients with poor venous access. Proper care and aseptic technique are important to maintain lumen patency and eliminate the risk of life-threatening central line-associated bloodstream infection (CLABSI). The nurse should inspect the insertion site for signs of infection (redness, drainage) and dressing integrity. Routine care includes sterile dressing changes every 48 hours with a gauze dressing or 7 days with a transparent semipermeable dressing (biopatch) as well as immediately if dressing is loose/torn, soiled, or damp. The line should be flushed before and after medication administration and per facility protocol (Option 1). Blood pressure and venipuncture should not be performed on the affected arm as compression of the vein can alter its integrity (Option 5). All infusing medications (except vasopressors) must be paused before drawing blood from the PICC to prevent false interpretation of the client's serum levels (Option 2).

A client is being discharged with a prescription for apixaban after being treated for a pulmonary embolus. Which clinical data is most concerning to the nurse? 1. Client eats a vegetarian diet (15%) 2. Client has chronic atrial fibrillation (20%) 3. Client takes indomethacin for osteoarthritis (48%) 4. Client's platelet count is 176 x103/mm3 (176 x109/L) (15%)

A pulmonary embolism (PE) occurs when the pulmonary arteries are blocked by a thrombus. Initial management of PE includes low-molecular-weight heparin (eg, enoxaparin, dalteparin) or unfractionated IV heparin. Once the PE is resolved, maintenance drug therapy often includes oral anticoagulants such as factor Xa inhibitors (eg, apixaban, rivaroxaban, dabigatran). Anticoagulants place the client at increased risk of bleeding, and the nurse should provide education regarding signs and symptoms of bleeding (eg, bruising; blood in the urine; black, tarry stools) and bleeding precautions (eg, use of an electric razor and soft-bristled toothbrush). Concurrent NSAID use (eg, indomethacin, ibuprofen, meloxicam) significantly increases the risk of bleeding. The nurse should discuss this risk with the health care provider prior to initiation of apixaban therapy (Option 3).

What is allergy immunotherapy injections (allergy shots)?

A shot that triggers an increase in the body's production of specific immunoglobulins to reduce the pt's allergy symptoms when exposed to specific allergens (eg, pollen, cat dander, dust mite).

The nurse is reviewing laboratory data of a client who is receiving warfarin therapy for atrial fibrillation. Today's INR is 5.0. What action should the nurse take? 1. Administer the next scheduled dose of warfarin (13%) 2. Anticipate infusing fresh, frozen plasma (3%) 3. Call the pharmacy to see if protamine is available (6%) 4. Request a prescription from the health care provider (HCP) for vitamin K (76%)

A therapeutic INR level is dependent on the reason the client is receiving the warfarin (an anticoagulant). Typically the therapeutic INR range should be 1.5-2 times the normal "control" value (INR of 2-3) for medical reasons such as deep vein thrombosis, atrial fibrillation, or stroke. An INR of 3 to 3.5 is desired for the client with a mechanical heart valve. An INR of 5.0 or higher places the client at risk for bleeding and requires a dosage adjustment of the warfarin or the administration of vitamin K as an antidote.

Which assessment findings should the nurse anticipate in a child with suspected acute otitis media (AOM)? Select all that apply.

AOM is an infection of the middle ear resulting from dysfunction of the Eustachian tube. OM typically occurs in infants and children age <2, often following a respiratory tract infection. Clinical manifestations of AOM include high fever (up to 104 F [40 C]), ear pain, irritability/restlessness, loss of appetite, and pulling on the affected ear. In AOM, the tympanic membrane will typically be bulging and very red. If the tympanic membrane ruptures from the buildup of fluid, the client will experience immediate pain relief and a gradually decreasing fever; purulent drainage may be observed in the external ear canal. **Severe pain experienced with direct pressure on the tragus or with pulling on the pinna is a manifestation of otitis externa, an infection of the outer ear. The pain associated with AOM is not affected by manipulation of the outer ear.**

The nurse is caring for a client with acute diverticulitis who has nausea, vomiting, and rates pain as 8 on a scale of 0-10. Which of the following interventions should be included in the plan of care? Select all that apply. Click the exhibit button for additional information.

Acute care for diverticulitis focuses on allowing the colon to rest and the inflammation to resolve. This includes: - NPO status: More acute cases require complete rest of the bowel; less severe cases may be handled at home, and clients may tolerate a low-fiber or clear liquid diet - IV fluids to prevent dehydration when NPO - Pain relief with IV medications to maintain NPO status: Opioids (eg, morphine sulfate) are indicated in moderate to severe cases of acute diverticulitis that require hospitalization - Preventing increased intra-abdominal pressure (eg, straining, coughing, lifting) to avoid perforation and rupture - Preventing increased intestinal motility by avoiding laxatives and enemas

What is Adalimumab (Humira), what is it used for and what is an adverse effect that should be reported to the HCP immediately?

Adalimumab (Humira) is a tumor necrosis factor (TNF) inhibitor, a biologic disease-modifying antirheumatic drug (DMARD) classified as a monoclonal antibody. Its major adverse effects are similar to those of other TNF inhibitor drugs (eg, etanercept [Enbrel], infliximab [Remicade]) and include immunosuppression and infection (eg, current, reactivated). An elevated white blood cell count in this client can indicate underlying infection and should be reported immediately.

What is Addison's disease?

Addison disease (primary adrenocortical insufficiency) is characterized by a deficiency in all three types of adrenal steroids (i.e., glucorcorticoids, androgens, mineralocorticoids), most commonly caused by an autoimmune response.

Explain Addison disease?

Addison disease, or primary adrenocortical insufficiency, is also described as hypofunction of the adrenal cortex. The adrenal gland is responsible for secretion of glucocorticoids, androgens, and mineralocorticoids. Bronze hyperpigmentation of the skin in sun-exposed areas is caused by an increase in adrenocorticotropic hormone (ACTH) by the pituitary in response to low cortisol (ie, glucocorticoid) levels. Clients with Addison disease may also have vitiligo, or patchy/blotchy skin, which is usually present when the etiology of the disease is an autoimmune problem. The immune cells are thought to destroy melanocytes which produce melanin (or brown pigment), resulting in a patchy appearance. Other common manifestations of Addison disease include the following: - Slow, progressive onset of weakness and fatigue - Anorexia and weight loss - Orthostatic hypotension - Hyponatremia and hyperkalemia - Salt cravings - Nausea and vomiting - Depression and irritability

What effect do anasthetic and sedating meds have in pts with Obstructive sleep apnea (OSA)?

Administration of general anesthesia or sedating medications (eg, opioids and benzodiazepines) can exacerbate OSA by decreasing pharyngeal muscle tone and increasing airway closure even further. Therefore, being on continuous positive airway pressure (CPAP) is very important in these clients, especially during sleep.

A client with metastatic esophageal cancer says, "I don't want to be kept alive being fed by a tube." What are the most appropriate ways for the nurse to ensure that this information is available to all who may need it for future decision-making? Select all that apply.

Advance care planning is a process that includes: - Considering treatments that may be needed in the future - Making decisions to guide future treatments, particularly if the client is no longer able to make own decisions - Ensuring that treatment decisions are legally documented on the appropriate forms, such as the advance directive, and in the medical record (Option 1) - Ensuring that advance directive documents are in the medical record so that they are available to HCPs who care for the client in the future (Option 3) - Ensuring that the health care proxy (or durable power of attorney for health care) has information and documentation to support that role if this person needs to make decisions for the client (Option 2)

When can compartment syndrome happen?

After an injury or trauma (yield, surgery), the vessels surrounding the injury site are compressed by swelling muscle and connective tissues. Muscle is encapsulated by a fibrous layer of fascia (a compartment), which does not yield to swelling, eventually restricting blood flow to the extremity

What is the BEST indicator that fluid resuscitation therapy is working for a pt that suffered from sever burns?

Aggressive fluid resuscitation to correct hypovolemia is a priority. Adequate urine output (at least 30 mL/hr, or 0.5 mL/kg/hr) depends on adequate renal perfusion and is the greatest indicator that fluid resuscitation therapy has effectively restored tissue perfusion.

How is intussusception in infancy treated with most successfully?

Air enema (pneumatic) enema

What is a medical emergency that can emerge in a pt with acute epiglottitis?

Airway obstruction

A client with an asthma exacerbation has been using her albuterol rescue inhaler 10-12 times a day because she cannot take a full breath. What possible side effects of albuterol does the nurse anticipate the client will report? Select all that apply. 1. Constipation 2. Difficulty sleeping 3. Hives with pruritus 4. Palpitations 5. Tremor

Albuterol is a short-term beta-adrenergic agonist used as a rescue inhaler to treat reversible airway obstruction associated with asthma. Dosing in an acute asthma exacerbation should not exceed 2-4 puffs every 20 minutes x 3. If albuterol is not effective, an inhaled corticosteroid is indicated to treat the inflammatory component of the disease. Albuterol is a sympathomimetic drug. Expected side effects mimic manifestations related to stimulation of the sympathetic nervous system, and commonly include insomnia, nausea and vomiting, palpitations (from tachycardia), and mild tremor.

The nurse is performing a physical assessment on a 2-year-old with cold symptoms and a fever at home of 101.7 F (38.7 C). The parent is concerned about the child's ability to cooperate during the examination. Place the components of assessment in the order the nurse would perform them. All options must be used.

Always complete the assessment by performing the least invasive parts first and then progressing to the most invasive. By first establishing a rapport with the parent (Option 2), the nurse will elicit the child's trust and cooperation. Playing with the child will help the child relax and perceive the nurse as less of a threat (Option 4). Measuring the child's height and weight should be performed next (Option 3). Auscultation of the heart and lungs should then be performed. Allowing the child to play with the equipment first will make this part of the assessment easier (Option 1). Taking vital signs can be difficult as a blood pressure cuff can be perceived as painful (Option 5); once the child is upset, it becomes difficult to continue with the assessment. A temperature of 101.7 F (38.7 C) is not serious in a child, especially if there are signs and symptoms of an upper respiratory infection.

The nurse receives report on 4 clients. Which client should be seen first?

Amyotrophic lateral sclerosis (ALS) is characterized by the progressive loss of motor neurons in the brainstem and spinal cord. Clients have spasticity, muscle weakness, and atrophy. Neurons involved in swallowing and respiratory function are eventually impaired, leading to aspiration, respiratory failure, and death. Care of clients with ALS focuses on maintaining respiratory function, adequate nutrition, and quality of life. There is no cure, and death usually occurs within 5 years of diagnosis. The client with ALS and worsening ability to speak (dysarthria) may also have dysphagia and respiratory distress; this client should be seen first.

What is Amyotrophic lateral sclerosis (ALS) and what are the 5 main symptom management interventions?

Amyotrophic lateral sclerosis (ALS, Lou Gehrig disease) is a debilitating neurodegenerative disease with no cure. ALS causes progressive degeneration of motor neurons in the brain and spinal cord. Physical symptoms include fatigue, progressive muscle weakness, twitching and muscle spasms, difficulty swallowing, difficulty speaking, and respiratory failure. Most clients survive only 3-5 years after the diagnosis as there is no cure. Treatment focuses on symptom management. Interventions include: 1. Respiratory support with noninvasive positive pressure (eg, bilevel positive airway pressure [BiPAP]) or invasive mechanical ventilation (eg, via tracheostomy) 2. Feeding tube for enteral nutrition 3. Medications to decrease symptoms (eg, spasms, uncontrolled secretions, dyspnea) 4. Mobility assistive devices (eg, walker, wheelchair) 5. Communication assistive devices (eg, alphabet boards, specialized computers)

12-lead ECG

An ECG provides a visual tracing of the heart's electrical activity. Lead V2 is one of the precordial leads (V1-V6) that is placed on the client's chest at the fourth intercostal space, to the left of the sternum. It views the anterior portion of the heart and may sometimes be referred to as an anterior lead. Visualization of electrical activity of the anterior portion of the heart allows the nurse to localize any damage to this area (eg, ST elevation in lead V2 may suggest an anterior wall myocardial infarction). Interference or baseline sway in the tracing indicates that the lead is not accurately capturing the heart's electrical activity. Interference appears as an irregular, scribbled tracing, and baseline sway is a wavelike shift of the tracing away from baseline. Artifact may be caused by electrical interference from other equipment, muscle tremors on the chest wall or diaphragm, client movement or respirations, or a poorly connected or damaged lead. Artifact can be limited by ensuring proper adhesion of leads to clean, dry skin; limiting client movement and talking; and moving away any items that may be a source of electrical interference.

What is immune thrombocytopenia (ITP)?

An acquired disorder in which antibodies cause decreased platelet survival and production

What is Kawasaki disease, what is affected specifically, and what can develop in some children who have this disease?

An autoimmune disease involving the inflammation of arterial walls (vasculitis). Coronary arteries are affected and some children develop coronary aneurysms.

A 75-year-old client is hospitalized with chronic obstructive pulmonary disease (COPD) exacerbation. The health care provider (HCP) initiates noninvasive positive airway pressure ventilation (NIPPV) with a bilevel positive airway pressure (BIPAP) device. Prescribed medications are shown in the exhibit. Which parameter is most important for the nurse to monitor frequently in this client? Click on the exhibit button for additional information. 1. Blood glucose level (37%) 2. Capillary refill time (10%) 3. Extremity swelling (6%) 4. Mental status (45%) Medication prescription - Albuterol and ipratropium: nebulizer, every 4 hours as needed - Levofloxacin: 750 mg IV, once daily - Methylprednisolone: 40 mg IV, every 8 hours - Enoxaparin: 40 mg subcutaneously, once daily

An exacerbation of COPD is characterized by the acute worsening of a client's baseline symptoms (eg, dyspnea, cough, sputum color and production). NIPPV is often prescribed short-term to support gas exchange in clients who have moderate to severe COPD exacerbations and acidosis (pH <7.3) or hypercapnia (PaCO2 >45 mm Hg). NIPPV can prevent the need for tracheal intubation and is administered until the underlying cause of the ventilatory failure is reversed with pharmacologic therapy (eg, corticosteroids, bronchodilators, antibiotics). BIPAP involves the use of a mechanical device and facemask in a conscious client who is breathing spontaneously. BIPAP delivers oxygen to the lungs and then removes carbon dioxide (CO2). CO2 retention causes mental status changes. If the client becomes drowsy or confused, it is likely that more CO2 is being retained than what BIPAP can remove; this should be reported to the HCP. Arterial blood gas evaluation should be obtained to determine CO2 level and BIPAP effectiveness. Altered mental status poses the greatest threat to a client's survival as it can lead to decreased protective reflexes (eg, gag, swallow, cough), periods of apnea, and airway compromise (Option 4).

A client comes to the emergency department following a bee sting. The client has a diffuse rash, hypotension, and throat tightness. One injection of IM epinephrine does not improve the client's condition. What action should the nurse take next? 1. Administer IV fluid bolus (7%) 2. Administer methylprednisolone (20%) 3. Prepare for emergency cricothyrotomy (14%) 4. Repeat IM epinephrine injection (57%)

Anaphylactic shock has an acute onset, and manifestations usually develop quickly (20-30 minutes). Circulatory failure and respiratory manifestations, including laryngeal edema (from inflammation) and bronchoconstriction (primarily from release of histamine), can lead to cardiac/respiratory arrest. The management of anaphylactic shock includes: 1. Ensure patent airway, administer oxygen 2. Remove insect stinger if present 3. IM epinephrine is the drug of choice and should be given to this client. Epinephrine stimulates both alpha- and beta-adrenergic receptors and dilates bronchial smooth muscle (beta 2) and provides vasoconstriction (alpha 1). The IM route (mid anterior lateral thigh) is better than the subcutaneous route. Repeat dose every 5-15 minutes. 4. Place in recumbent position and elevate legs 5. Maintain blood pressure with IV fluids, volume expanders or vasopressors 6. Bronchodilator (inhaled beta agonist) such as albuterol is administered to dilate the small airways and reverse bronchoconstriction 7. Antihistamine (diphenhydramine) is administered to modify the hypersensitivity reaction and relieve pruritus 8. Corticosteroids (methylprednisolone [Solu-Medrol]) are administered to decrease airway inflammation and swelling associated with the allergic reaction 9. Anticipate cricothyrotomy or tracheostomy with severe laryngeal edema

The nurse is assisting with procedural moderate sedation (conscious sedation) at a client's bedside. The unlicensed assistive personnel (UAP) comes to the door and indicates that the client in the next room needs the nurse right now. How should the nurse respond? 1. Ask the UAP to go back and ask the client what the current needs are (14%) 2. Ask the UAP to stay and take over while the nurse goes to check on the client in the next room (3%) 3. Tell the UAP to inform the client in the next room that the nurse will be there shortly (21%) 4. Tell the UAP to tell the charge nurse about the needs of the client in the next room (60%)

Answer: 4. Tell the UAP to tell the charge nurse about the needs of the client in the next room (60%) -With procedural moderate sedation at the bedside, the nurse takes on the role of an anesthetist. The nurse's role is to monitor the client's condition while the health care provider focuses on performing the procedure. The nurse should never leave the client during the procedure. The best response is to have an available nurse (the charge nurse) go assess and deal with the needs of the client next door.

The emergency department triage nurse is assessing 4 pediatric clients. Which client is a priority for further diagnostic workup and definitive care? 1. 1-year-old with ventriculoperitoneal shunt who has "lethargy" and pulse of 78/min (71%) 2. 3-year-old with history of meningocele who has unilateral ear pain and urinary incontinence (10%) 3. 6-year-old with muscular dystrophy who has "flu-like" symptoms and temperature of 100.4 F (38 C) (14%) 4. 8-year-old with history of cerebral palsy who has foot injury and spastic clonus (3%)

Answer: 1 A ventriculoperitoneal shunt is used to treat hydrocephalus and is usually placed at age 3-4 months. Blockage and infection are complications of shunt placement. Blockage results in signs of increased intracranial pressure (ICP). The normal pulse range for a 1-year-old is 100-160/min. A pulse of 78/min is considered bradycardia, a part of Cushing's triad (bradycardia, slowed respiration, widened pulse pressure).

The school nurse is speaking with the parent of a fourth grade student about a bed bug that was found on the child's sweater. The parent confirms that their home is infested but that the issue is being resolved. Which is the best action by the nurse? 1. Instruct the parent to launder the child's clothing and store it in tightly sealed plastic bags (55%) 2. Instruct the teacher of the child's classroom to use an insecticide spray (3%) 3. Send letters home to all of the children's parents informing them about the finding (27%) 4. Send the child home and prohibit school attendance until the infestation has been resolved (13%)

Answer: 1 Although full-blown bed bug infestations are uncommon in a school setting, a bed bug brought in on the clothing or possessions of one student could easily "hitch" a ride to another student's home and cause an outbreak there. The most important measure to prevent bed bugs from infesting other students' homes is to prevent the bugs from entering the school in the first place. Laundering clothing in hot water and using the highest temperature setting on a dryer will kill any bed bugs attached to clothes. The clothing should then be stored in tightly sealed plastic bags to prevent additional infestation (Option 1). (Option 2) A professional pest control company should be brought in to evaluate the classroom/school for bed bugs; treatment with an insecticide may or may not be necessary. (Option 3) Sending letters home to parents is premature at this point. After professional pest control personnel evaluate the classroom/school, letters can be sent to inform parents of the findings and any precautions that should be taken. (Option 4) Sending the child home is unnecessary and may be perceived as punitive and stigmatizing. Bed bugs do not inhabit humans; this child is not "infested" (seen in children with head lice).

A client's family member reports to the charge nurse that the nurses on the unit are not responding appropriately to the client's report of pain. What is the charge nurse's priority action? 1. Ask the client to rate current pain on a scale of 0-10 (44%) 2. Discuss the concerns with the nurse assigned to the client (29%) 3. Evaluate the client's medication administration record (22%) 4. Review the narcotic count and look for discrepancies (2%)

Answer: 1 Assessment is the first step in the nursing process, and it is always considered first when determining the nurse's priority action. Prior to investigating the family's concern regarding inadequate management of the client's pain, the charge nurse should assess the client's pain level on a subjective scale, such as the numerical pain intensity scale (Option 1). (Options 2, 3, and 4) Speaking with the nurse assigned to the client, evaluating the client's medication administration record, and reviewing the narcotic count in the medication dispensing system to look for discrepancies are all appropriate actions. However, the priority action is for the nurse to assess the client.

A nurse prepares to administer an intermittent enteral feeding via nasogastric tube to a client with a prescription for gastric residual checks before each feeding. The nurse obtains a gastric residual volume of 80 mL. Which action should the nurse perform next? 1. Collect gastric pH measurement (23%) 2. Delay feeding for at least 1 hour (11%) 3. Discard the gastric residual (3%) 4. Return residual and administer feeding (61%)

Answer: 1 Before administering intermittent (bolus) enteral feedings, the nurse must verify tube placement, such as with x-ray confirmation or gastric pH measurement. Ensuring that the tip of the feeding tube is correctly placed in the stomach or small intestine is essential because administration of enteral feeding through a misplaced tube may result in life-threatening aspiration (Option 1). (Option 2) Gastric residual volume (GRV) is one indicator of how well the client is tolerating enteral feedings. High GRV (eg, >500 mL) may indicate delayed gastric emptying and poor intestinal motility (ie, feeding intolerance), which is traditionally considered a risk factor for aspiration. The nurse should follow facility policy or contact the health care provider (HCP) to determine if feedings should be delayed for high GRV or other symptoms of intolerance (eg, gastric distension, nausea/vomiting). GRVs are traditionally checked every 4 hours with continuous feeding or before each intermittent feeding. However, some facilities no longer routinely check GRVs because recent evidence shows that this practice impairs calorie delivery and may be ineffective for predicting aspiration risk.

The same-day surgery nurse performs the preoperative assessment for a client with a history of coronary artery disease scheduled for an elective laparoscopic cholecystectomy. Which statement made by the client is critical to report to the health care provider (HCP) before the surgery? 1. "I didn't take the clopidogrel pill for my heart yesterday or today." (52%) 2. "I know I should stop smoking completely, but at least I didn't have a cigarette yesterday or today." (8%) 3. "I stopped taking my gingko biloba 2 weeks ago even though it really helps relieve leg cramps when I walk." (9%) 4. "I stopped taking naproxen for my arthritis pain 1 week ago and have been taking acetaminophen instead." (30%)

Answer: 1 Clopidogrel (Plavix) is an antiplatelet medication that should be discontinued 5-7 days before surgery to decrease the risk for excessive bleeding. The client took this drug 48 hours ago. Therefore, the nurse must notify the HCP. The surgery may be postponed due to the increased risk for intra- and post-operative bleeding (Option 1). (Option 2) All clients should try not to smoke for at least 24 hours before surgery to help prevent oxygenation problems. (Option 3) The client takes gingko biloba to relieve symptoms of intermittent claudication; it was discontinued 2 weeks ago because it can increase the risk for excessive bleeding. (Option 4) Nonsteroidal anti-inflammatory drugs (NSAIDS) such as naproxen (Naprosyn) should be discontinued 7 days before scheduled surgery as they can increase the risk for excessive bleeding. Acetaminophen can be taken to control pain up until surgery.

A client with schizophrenia is started on clozapine. Which periodic measurements take priority in this client? 1. Complete blood count and absolute neutrophil count (52%) 2. ECG and blood pressure (32%) 3. Fasting blood glucose and fasting lipid panel (7%) 4. Height, weight, and waist circumference (6%)

Answer: 1 Clozapine (Clozaril) is an atypical antipsychotic medication used to treat schizophrenia that has not responded to standard, more traditional treatment. Clozapine is associated with a risk for agranulocytosis (a potentially fatal blood disorder causing a dangerously low WBC count) and is therefore used only in clients with treatment-resistant schizophrenia. A client must have a WBC count of ≥3500/mm3 (3.5 × 109/L) and an absolute neutrophil count (ANC) of ≥2000/mm3 (2 × 109/L) before starting clozapine, so it is critical to obtain a baseline complete blood count and ANC. Because agranulocytosis is reversible if caught early, the client's WBC count and ANC must also be monitored regularly throughout the course of clozapine therapy (initially once a week) (Option 1). Clients should also contact the health care provider immediately if they develop fever or sore throat, which can indicate infection due to neutropenia.

The nurse is teaching a client about newly prescribed cyclosporine. Which client statement indicates a need for further teaching? 1. "I am going to a concert with my friends this weekend." (63%) 2. "I can use a hair removal cream for excess hair growth." (22%) 3. "I will need to check my blood pressure regularly at home." (6%) 4. "I will stop drinking grapefruit juice every morning." (7%)

Answer: 1 Cyclosporine is an immunosuppressant prescribed to manage rheumatoid arthritis (RA) and psoriasis, and to prevent transplant rejection. This medication inhibits the normal immune response by interfering with T cell response, which slows the progression of certain autoimmune diseases. Clients taking cyclosporine have an increased risk for infection and are instructed to avoid large crowds (eg, concerts, movie theaters) and known sick contacts (Option 1). It can take 1-2 months for the full effect of therapy and relief of symptoms from autoimmune disease (eg, joint stiffness in RA, psoriasis symptoms) to occur. This medication is for long-term use, and it is therefore important to monitor clients for adverse effects. The incidence of secondary malignancies (eg, skin cancer, lymphoma) is increased in these clients.

The nurse is providing teaching to a prenatal client about the 1-hour glucose challenge test that will be performed at the next visit. Which client statement indicates a need for further teaching? 1. "Fasting is required before the 1-hour glucose challenge test." (33%) 2. "One blood sample is obtained at the end of the test." (28%) 3. "The test includes drinking a 50-g glucose solution." (15%) 4. "The test's purpose is to screen for gestational diabetes, not diagnose it." (22%)

Answer: 1 Gestational diabetes mellitus (GDM) is diagnosed in clients who have impaired blood glucose (BG) regulation due to physiologic pregnancy changes (eg, rising BG levels, insulin resistance). GDM screening occurs at 24-28 weeks gestation. If GDM is diagnosed, management includes nutritional counseling and, if needed, pharmacologic therapy. Two-step GDM testing begins with a screening test: the 1-hour glucose challenge test (GCT). The 1-hour GCT can be performed any time of day and does not require fasting (Option 1). If the client's serum BG is <140 mg/dL (7.8 mmol/L), GDM is unlikely, and the client requires no further testing. If serum BG is ≥140 mg/dL (7.8 mmol/L), the client requires a 2- or 3-hour glucose tolerance test (GTT) to diagnose GDM. (Options 2 and 3) For the 1-hour GCT, the nurse draws one blood sample an hour after ingestion of a 50-g glucose solution (eg, glucola). In contrast, a 2- or 3-hour GTT requires the nurse to obtain fasting and hourly blood samples.

A client with a blood pressure (BP) of 250/145 mm Hg is admitted for hypertensive crisis. The health care provider prescribes a continuous IV infusion of nitroprusside sodium. Which of these is the priority goal in initial management of hypertensive crisis? 1. Decrease mean arterial pressure (MAP) by no more than 25% (52%) 2. Keep blood pressure at or below 120/80 mm Hg (19%) 3. Maintain heart rate (HR) of 60-100/min (10%) 4. Maintain urine output of at least 30 mL/hr (17%)

Answer: 1 Hypertensive crisis is a life-threatening emergency due to the possibility of severe organ damage. If not treated promptly, complications such as intracranial hemorrhage, heart failure, myocardial infarction (MI), renal failure, aortic dissection, or retinopathy may occur. Emergency treatment includes IV vasodilators such as nitroprusside sodium. It is important to lower the blood pressure slowly, as too rapid a drop may cause decreased perfusion to the brain, heart, and kidneys. This may result in stroke, renal failure, or MI. The initial goal is usually to decrease the MAP by no more than 25% or to maintain MAP at 110-115 mm Hg. The pressure can then be lowered further over a period of 24 hours. MAP is calculated by adding the systolic blood pressure (SBP) and double the diastolic blood pressure (DBP), and then dividing the resulting value by 3. MAP = (2 x DBP + SBP) / 3

The nurse is reviewing discharge instructions with the parents of a child who just had a tracheostomy. Which statement made by the parents indicates teaching has been effective? 1. "I will always travel with two tracheostomy tubes, one of the same size and one a size smaller." (58%) 2. "I will immediately change the tracheostomy tube if my child has difficulty breathing." (8%) 3. "I will provide deep suctioning frequently to prevent any airway obstruction." (21%) 4. "I will remove the humidifier if my child starts developing more secretions." (11%)

Answer: 1 In the event of an accidental decannulation or another urgent need to change a tracheostomy tube, the most important action is to quickly replace the tube as it is the client's only means to ventilate. Clients should always carry two spare tracheostomy tubes, one the same size and one a size smaller. If the tube is not easily replaced or is meeting resistance, the smaller tube should be used. (Option 2) Changing a tracheostomy tube is a high-risk procedure that should be done only if respiratory distress is noted and other interventions (eg, suctioning) have failed. Mucus plugs (ie, thickening and buildup of mucus due to dehydration) are one of the most common causes of respiratory distress. (Option 3) A tracheostomy should be suctioned frequently to maintain airway patency. However, deep suctioning should be reserved for clients in respiratory distress due to the risk of injury. Tracheostomy tubes should be suctioned to the specified depth using a measurement marked on the tube, to provide safe, effective suctioning.

A client with moderate Alzheimer disease is started on memantine. In evaluating the effectiveness of this medication, the registered nurse should assess the client for which of the following? 1. Improved ability to perform activities of daily living (77%) 2. Indications that disease progression has stopped (10%) 3. Rapid improvement in cognitive functioning (11%) 4. Reversal of the disease (0%)

Answer: 1 Memantine is used to ease the symptoms of moderate to severe Alzheimer disease (AD), thereby improving the quality of life for clients and caregivers. Memantine is an N-methyl-D-aspartate (NMDA) antagonist that works by binding to NMDA receptors, blocking the brain's NMDA glutamate pathways, and protecting brain cells from overexposure to glutamate (excess levels of glutamate contribute to brain cell death). Clients with moderate to severe AD may experience improvement in: - Cognition - memory, thinking, language - Daily functioning - dressing, bathing, grooming, eating - Behavioral problems - agitation, depression, hallucinations "Memantine does not cause rapid improvement of cognitive functioning; it usually takes weeks or months before such improvement is noticeable." ***QUICK TIP: ALL Q's THAT ARE ASKING WHAT THE OUTCOME OF A MED IS AFTER TAKING IT FOR A WHILE, THE ANSWER WILL AMOST ALWAYS BE IMPROVEMENT OF ADL's!***

The home health nurse reviews the serum laboratory test results for a client with seizures. The phenytoin level is 27 mcg/mL. The client makes which statement that may indicate the presence of dose-related drug toxicity and prompt the nurse to notify the health care provider? 1. "I am feeling unsteady when I walk." (30%) 2. "I am getting up to urinate about 4 times during the night." (4%) 3. "I have a metallic taste in my mouth when I eat." (25%) 4. "My gums are getting so puffy and red." (40%)

Answer: 1 Phenytoin (Dilantin) is an anticonvulsant drug used to treat generalized tonic-clonic seizures. The therapeutic serum phenytoin reference range is between 10-20 mcg/mL. Levels are measured when therapy is initiated, periodically throughout treatment to guide dosing until a steady state is attained (3-12 months), and if seizure activity increases. Early signs of toxicity include horizontal nystagmus and gait unsteadiness. These may be followed by slurred speech, lethargy, confusion, and even coma. Bradyarrhythmias and hypotension are usually seen with intravenous phenytoin.

The nurse is providing care to a 9-year-old client who is awaiting surgery. Which intervention is developmentally appropriate for this client's plan of care? 1. Discuss the procedure with the client using simple diagrams with correct anatomical terminology (62%) 2. Explore the client's perception of how the surgery will positively affect their future (14%) 3. Focus primarily on the client's feelings and concerns regarding surgical scar appearance (13%) 4. Provide initial education about the procedure to the client immediately before it is performed (9%)

Answer: 1 Planning care during a pediatric hospitalization requires the nurse to consider the child's stage of psychosocial and cognitive development. For the school-age child (age 6-12 years), developing a sense of industry (ie, confidence in skills and abilities) is a primary psychosocial need, and cognitive development is marked by concrete thinking (ie, based on actual objects or activities). During preprocedural education, the nurse should foster a sense of industry by involving the child in discussions about the procedure, interacting with the child directly, and using correct anatomical terminology. In addition, the use of simple diagrams helps to meet the child's need for concrete learning (Option 1).

What play behavior would the nurse be most likely to observe in a group of 4-year-old children? 1. Children playing and borrowing blocks from each other without directing others (28%) 2. Children playing and working together to build a castle out of blocks (29%) 3. Children playing next to each other with blocks, but not interacting (37%) 4. Children playing with blocks by themselves in separate areas of the room (5%)

Answer: 1 Play is an important developmental task of childhood and is an indication of physical, social, and emotional health. Preschoolers (age 3-6) enjoy associative play, in which they engage in similar activities or play with the same or similar items, but the play is unorganized without specific goals or rules. They often borrow items from each other without directing each other's play. Preschoolers also enjoy play involving motor activities and imaginative, pretend play. (Option 2) Cooperative play is common in school-age children (age 6-12). These children play with one another with a specific goal (eg, building a castle from blocks), often within a rigid set of rules. Cooperative play is likely too advanced for preschool-age children, as it involves more organizational skills. (Option 3) Parallel play is more common in toddlers (age 1-3). During parallel play, these children play next to each other and are happy to be in the presence of peers, but they do not play directly with one another. (Option 4) Solitary play is common in infants (birth to 1 year). Children at this stage are focused on their own activity and will play alone in the presence of others.

The emergency department nurse performs an admission assessment for a client with priapism of about 3 hours duration who also has sickle cell anemia. What assessment finding is of most concern and warrants immediate notification of the health care provider? 1. Bluish discoloration of the erect penis (66%) 2. Drank a 6-pack of beer 8 hours ago (4%) 3. Extreme penile pain rated as 9 on 0-10 scale (9%) 4. Has not voided for at least 6 hours (19%)

Answer: 1 Priapism is a sustained, painful erection often associated with sickle cell anemia, as the sickling (crescent shaping) of red blood cells can lead to penile vascular occlusion, erectile tissue hypoxia, and tissue necrosis. Bluish discoloration is of most concern as it can be a sign of ischemia to the penis.

Using SBAR (Situation, Background, Assessment, Recommendation/Request) to communicate with the health care provider, which statement should the nurse include to describe the situation? 1. "I'm calling about the client in 711 who has low blood pressure and is symptomatic." (48%) 2. "The client has a limited code status and requests no intubation or compressions." (4%) 3. "The client was admitted for acute respiratory failure and intubated on September 16." (10%) 4. "The client's blood pressure was 97/45 mm Hg an hour ago and is now 88/40 mm Hg." (36%)

Answer: 1 SBAR (Situation, Background, Assessment, Recommendation/Request) is a model used for communication and hand-off reporting. It allows for standardized, organized, and thorough communication among nurses, health care providers, and other personnel. The nurse should first state the situation, including the nurse's name, the client's name and room number, and a brief description of the concerning matter. (Options 2 and 3) The client's code status, admission date, and admitting diagnosis are important to include when describing the background, not the situation. (Option 4) Current vital signs or clinical findings are a key aspect of communicating the assessment, not the situation.

The nurse is caring for a client with scleroderma. Which assessment finding indicates the most serious complication of the disease and requires priority intervention? 1. Abrupt-onset hypertension and headache (38%) 2. Blue and cold fingertips (23%) 3. Dry cough and exertional dyspnea (15%) 4. Heartburn and difficulty swallowing (22%)

Answer: 1 Scleroderma is an overproduction of collagen that causes tightening and hardening of the skin and connective tissue. This is a progressive disease without a cure, and treatment is aimed at managing complications. Renal crisis is a life-threatening complication that causes malignant hypertension due to narrowing of the vessels that provide blood to the kidneys. Early recognition and treatment of renal crisis is needed to prevent acute organ failure. Even with treatment, this can be fatal. (Option 2) Raynaud phenomenon can develop secondary to scleroderma. It is characterized by vasospasm-induced color changes in the fingers, toes, ears, and nose. This requires urgent treatment (eg, immersing hands in warm water) but is not life-threatening. (Option 3) Pulmonary fibrosis is a progressive complication of scleroderma that is defined as scarring of lung tissue, which then causes reduced function, dry cough, and dyspnea. Some clients may be placed on oxygen. This is not immediately life-threatening. (Option 4) Heartburn and dysphagia (difficulty swallowing) are common symptoms associated with scleroderma. This is due to the disease process of internal scarring, and it is not life-threatening.

The nurse is caring for a client with bulimia nervosa. Which is the most important time for the nurse to monitor the client's behavior? 1. During 1-2 hours after each meal (84%) 2. During every meal (11%) 3. During the evening meal (0%) 4. During the overnight hours (3%)

Answer: 1 The eating behavior of a client with bulimia nervosa typically consists of binge eating followed by an inappropriate behavior to prevent weight gain, such as self-induced vomiting, exercise, and/or excessive use of laxatives. Although it is important to provide one-on-one supervision to a client with bulimia during every meal, it is most important to monitor the client's activities for 1-2 hours after each meal to prevent self-induced vomiting (Option 2). Clients with bulimia nervosa will often go to extreme lengths to engage in purging activity, especially at the beginning of a treatment program, as a way of gaining control. After mealtime, it may be necessary to restrict clients to the dayroom or a specified area with no bathroom privileges for a set period. Clients will also need to be monitored at all times for engaging in excessive exercise.

The clinic nurse cares for a 4-year-old who has been diagnosed with a pinworm infection. Which client symptom supports this diagnosis? 1. Anal itching that is worse at night (78%) 2. Intestinal bleeding with anemia (1%) 3. Poor appetite with weight loss (7%) 4. Red, scaly, blistered rings on skin (12%)

Answer: 1 The most common worm infection in the United States is pinworm, which is easily spread by inhaling or swallowing microscopic pinworm eggs, which can be found on contaminated food, drink, toys, and linens. Once eggs are ingested, they hatch in the intestines. During the night, the female pinworm lays thousands of microscopic eggs in the skinfolds around the anus, resulting in anal itching and troubled sleep. When the infected person scratches, eggs are transferred from the fingers and fingernails to other surfaces. Pinworm infection is treated with anti-parasitic medications. (Option 2) Hookworms (eg, Ancylostoma) are parasitic bloodsucking roundworms that are contracted from larvae in contaminated soil. They can infect the intestines, causing intestinal bleeding and anemia. (Option 3) Poor appetite, inadequate absorption of nutrients from food, and weight loss are symptoms associated with tapeworm infection (eg, Taenia solium). Tapeworm larvae are ingested when a person eats food that is contaminated with feces or undercooked meat from an infected animal. (Option 4) Ringworm is a skin infection caused by a fungus. It leads to red, scaly, blistered rings on the skin or scalp that grow outward as infection spreads. The fungus is easily spread by sharing hair care instruments and hats or via towels, linens, clothing, and sports equipment.

The nurse observes a nursing student performing chest compressions on an adult client. Which technique indicates that the student understands how to provide high-quality chest compressions during cardiopulmonary resuscitation? 1. Compressing the chest to a depth of at least 2 in (5 cm) (62%) 2. Pausing after each set of 15 compressions to allow for 2 rescue breaths (8%) 3. Placing the heel of the hand on the upper half of the client's sternum (10%) 4. Providing compressions at a rate of at least 80-100/min (18%)

Answer: 1 The primary goal of cardiopulmonary resuscitation (CPR) is adequate perfusion to the brain and vital organs. High-quality chest compressions for adults are at least 2 in (5 cm) deep to adequately pump blood but no more than 2.4 in (6 cm) deep to prevent unnecessary client injury (Option 1). The chest should recoil completely after each compression to allow complete refilling of the heart chambers, which promotes effective perfusion. (Option 2) Interruption of compressions should be minimized; at least 60% (preferably more) of the total resuscitation time should be made up of compressions. For adults (and in single-rescuer CPR for any age), a cycle of 30 compressions followed by 2 rescue breaths provides the best outcome. If the client has an advanced airway, continuous compressions and 10 breaths/min should be provided. (Option 3) Correct hand placement is in the center of the chest, on the lower half of the sternum (breastbone). Hand placement on the upper half of the sternum does not provide adequate perfusion. (Option 4) Studies have shown better client outcomes due to improved perfusion with a compression rate of 100-120/min.

After assessing 4 clients in the pediatric emergency department, the nurse should alert the health care provider to see which client first? 1. 4-month-old who is lethargic with fever and vomiting (68%) 2. 2-year-old who is alert and calm with an occasional barking cough (3%) 3. 8-year-old with cola-colored urine and generalized edema (24%) 4. 15-year-old who is withdrawn and having painful urination (3%)

Answer: 1 This child age <1 with fever, lethargy, and vomiting likely has sepsis or meningitis. Clients with suspected meningitis need to be seen immediately and require close monitoring (eg, level of consciousness, vital signs), isolation, spinal fluid cultures, and antibiotics (Option 1). Signs of meningitis in an infant include: - Fever or hypothermia - Poor feeding, vomiting - Altered level of consciousness (eg, restlessness, irritability, lethargy) - Increased intracranial pressure (bulging fontanelle [late sign], opisthotonic positioning [arching of the back with hyperextension of the neck]) (Option 2) Occasional barking cough without stridor is a sign of mild viral laryngotracheobronchitis (ie, croup). This client is stable and lower priority than a client with meningitis; however, the nurse should monitor for signs of deterioration (eg, stridor, lethargy, tachypnea) and have oxygen and emergency respiratory equipment available. (Option 3) Generalized edema and cola- or tea-colored urine (hematuria) indicates acute postinfectious glomerulonephritis, which occurs after infection with group A beta-hemolytic Streptococcus and is not emergent. Treatment is supportive (eg, bed rest, sodium restriction, diuretics) and may be delayed. (Option 4) Painful urination could signify a urinary tract infection and has less risk of becoming emergent than the other clients' conditions. The teenager's withdrawn behavior warrants further assessment (eg, for suspected abuse or depression), but this can be delayed.

When performing a head-to-toe assessment, the nurse has difficulty hearing the client's heart sounds. What should the nurse do to better auscultate the S1 and S2 heart sounds? 1. Ask the client to lean forward in a sitting position (33%) 2. Have the client inhale deeply and hold the breath (21%) 3. Instruct the client to raise the left arm over the head (8%) 4. Use the bell of the stethoscope instead of the diaphragm (36%)

Answer: 1 To auscultate the heart, the nurse should listen at each of the valve areas (aortic, pulmonic, tricuspid, mitral) and Erb's point in a Z pattern. The S1 and S2 heart sounds, as well as any adventitious sounds (eg, S3, S4, murmurs), should be identified. The rate and rhythm should also be assessed, listening for a full minute at the apex (apical pulse). If heart sounds are difficult to auscultate, the nurse can ask the client to either sit up and lean forward (best for aortic and pulmonic areas) or lie down on the left side (best for the mitral area). These positions move the heart closer to the chest wall. **(Option 2) Exhaling and holding the breath aid in auscultating heart sounds that are difficult to hear. Inhaling introduces more air into the lung, which may muffle heart sounds.**

The nurse receives report on a client with chronic atrial fibrillation who had an episode of torsades de pointes during the night. The client spontaneously converted back to the baseline rhythm of atrial fibrillation and is now stable. Which information should the nurse immediately report to the health care provider? 1. Client is scheduled to receive a dose of sotalol this morning (38%) 2. Client is scheduled to receive a dose of warfarin this afternoon (10%) 3. Client's magnesium level is 2.2 mEq/L (1.1 mmol/L) (46%) 4. Client's potassium level is 4.5 mEq/L (4.5 mmol/L) (4%)

Answer: 1 Torsades de pointes (ie, "twisting of the points") is a polymorphic ventricular tachycardia characterized by QRS complexes that change size and shape in a characteristic twisting pattern. Torsades de pointes may be the result of a prolonged QT interval (normal 0.34-0.43 sec or less than half the RR interval), usually due to medications or electrolyte imbalances. The nurse should review the client's medical record for any condition or medication that may prolong the QT interval and precipitate another episode of torsades de pointes, including: - Antiarrhythmics (eg, sotalol, amiodarone, ibutilide, dofetilide) (Option 1) - Macrolide antibiotics (eg, erythromycin, azithromycin) - Electrolyte abnormalities: Hypokalemia and hypomagnesemia (NOT HYPERmagnesemia)

A client in the emergency department is being discharged with a prescription for trimethoprim-sulfamethoxazole. Which statement by the client would indicate a need for further evaluation? 1. "I developed a whole-body rash while on glyburide." (47%) 2. "I drink at least 5 large bottles of water daily." (3%) 3. "I had to stop using lisinopril due to a bad cough." (19%) 4. "I have a birth control implant in place." (29%)

Answer: 1 Trimethoprim-sulfamethoxazole (Bactrim) is a sulfonamide antibiotic, commonly referred to as a sulfa drug. These antibiotics are prescribed to treat bacterial infections (eg, urinary tract infections). Contraindications include hypersensitivity to sulfa drugs, and pregnancy or breastfeeding. Glyburide is a sulfonylurea and has the potential to cause a sulfa cross-sensitivity reaction. Commonly used diuretics (eg, thiazides, furosemide) are also sulfa derivatives and can cause cross-sensitivity reaction. Although this reaction is uncommon, an alternate antibiotic, if possible, can be prescribed by the health care provider. (Option 2) Crystalluria is a potential adverse effect of sulfa medications. Clients should drink at least 2-3 L of water daily to prevent crystalluria. (Option 3) Angiotensin-converting enzyme inhibitors (eg, lisinopril) can produce an intractable cough. The only way to relieve this adverse effect is to discontinue the medication. There is no cross-reactivity with sulfa medications. (Option 4) Birth control implants (eg, IMPLANON, NEXPLANON) are progestin rods placed subdermally in the upper arm that provide contraception for up to 3 years. They are not contraindicated with concurrent trimethoprim-sulfamethoxazole use.

A client at 20 weeks gestation reports "running to the bathroom all the time," pain with urination, and foul-smelling urine. Which question is most important for the nurse to ask when assessing the client? 1. "Are you having any pain in your lower back or flank area?" (54%) 2. "Do you wipe from front to back after urinating?" (12%) 3. "Have you found that you urinate more frequently since becoming pregnant?" (1%) 4. "Have you had a urinary tract infection in the past?" (31%)

Answer: 1 Urinary tract infections (UTIs) are common during pregnancy due to physiologic renal system changes (eg, ureter dilation, urine stasis). Most UTIs are confined to the lower urinary tract (ie, cystitis, or bladder infection). Symptoms include urinary frequency, dysuria, urgency, foul-smelling urine, and a sensation of bladder fullness. Diagnostic testing includes urinalysis and urine culture. Oral antibiotics are required to appropriately treat cystitis. If cystitis goes unreported or untreated, the infection may ascend to the kidneys and cause pyelonephritis. During pregnancy, pyelonephritis requires IV antibiotics and hospitalization because of the increased risk of preterm labor. Therefore, priority assessment is to rule out indicators of pyelonephritis (eg, flank pain, fever) in clients who report UTI symptoms to ensure appropriate diagnosis and treatment (Option 1).

The nurse is participating in an obstetrical emergency simulation in which a client is hemorrhaging after birth due to uterine inversion. When describing interventions, which statement by the nurse indicates a need for further education? 1. "I will administer a rapid infusion of IV oxytocin before the inverted uterus is corrected." (78%) 2. "I will establish a second IV line with an 18-gauge catheter." (5%) 3. "I will initiate serial blood pressure monitoring every 3-5 minutes." (6%) 4. "I will notify anesthesia and operating room staff of the client's condition immediately." (8%)

Answer: 1 Uterine inversion is a rare, obstetrical emergency that occurs after birth when the uterine fundus collapses (partially or completely) into the uterine cavity, causing sudden hemorrhage, severe pelvic pain, and hypovolemic shock. Successful manual replacement of the inverted uterus through the vaginal canal by the health care provider (HCP) is the first step in resolving the inversion and requires a soft, uncontracted uterus. Tocolytics (eg, terbutaline) or inhaled anesthetics may be needed to assist with uterine relaxation. Uterotonic medications (eg, oxytocin, carboprost) must be delayed or discontinued until after the HCP has corrected the inversion (ie, manual uterine replacement) (Option 1). After uterine replacement, uterotonics are administered to reinforce its location in the pelvis and control further bleeding. If manual uterine replacement through the vagina is unsuccessful, emergency laparotomy (ie, replacement via abdominal incision) may be necessary; it is appropriate to notify surgical staff members who will be involved.

The nurse is preparing to discharge a client 4 days after colostomy placement. Which of the following findings are concerning and require further investigation? Select all that apply. 1. Areas of excoriation are noted on the skin surrounding the stoma. 2. No bowel sounds are present and the client reports nausea. 3. The client states, "I will call home health to come empty the pouch." 4. The client states, "There is a little gas in the colostomy bag." 5. The stoma is red, edematous, and smaller than the previous day.

Answer: 1, 2, 3 After colostomy placement, stomas should be beefy red and edematous. Stomas gradually shrink within a few days as inflammation subsides. There should be no separation of the stoma from the abdominal wall, unusual bleeding (eg, moderate to large amounts of blood in the ostomy pouch), or signs of inadequate circulation, including stoma ischemia (eg, pale, dusky) or necrosis (eg, dark red, purple, black). Appliances should be resized during the first several weeks to ensure proper fit and prevent skin breakdown (eg, excoriation) due to stool coming into contact with the skin (Option 1). Within 24 hours of surgery, clients should demonstrate signs of returning gastrointestinal motility (eg, nausea resolution, active bowel sounds, flatus). Nausea and absent bowel sounds may indicate postoperative ileus and should be reported to the health care provider (Option 2). After discharge, clients should change the pouch according to the manufacturer's instructions (every 5-10 days) and if the skin surrounding the stoma is irritated. Clients with a new ostomy who are unwilling to perform ostomy care may have disturbed body image and ineffective coping, requiring intervention (Option 3). ***(Option 5) An edematous, red stoma with subsiding inflammation shows adequate stoma healing.***

The nurse is caring for a client who began receiving continuous tube feeding a week ago. Which assessment findings suggest that the client is experiencing a tube feeding complication? Select all that apply. 1. 2 episodes of emesis 2. 3 episodes of brown, liquid stool today 3. 7-lb (3.18-kg) weight gain in 1 week 4. Low gastric residuals 5. Serum glucose of 110 mg/dL (6.1 mmol/L)

Answer: 1, 2, 3 Enteral tube feeding is the preferred route for providing nutrition to clients who cannot intake oral nutrition (eg, dysphagia, prolonged intubation). The nurse assesses tube feeding tolerance by monitoring for signs of potential complications: - Diarrhea: May occur if tube feeding formula is too concentrated (hyperosmolar) or administered too rapidly (Option 2). The presence of hyperosmolar feedings in the intestines causes the osmotic movement of water into the intestinal lumen, resulting in diarrhea. - Fluid overload: Manifested as rapid weight gain and peripheral edema; due to excess water flushes or too-dilute (hypo-osmolar) formula (Option 3) - Nausea and vomiting: Due to delayed gastric emptying or rapid administration (Option 1) **(Option 4) A low volume of gastric residuals suggests that the client has adequate gastric emptying and is tolerating tube feedings.** (Option 5) A serum blood glucose of 110 mg/dL (6.1 mmol/L) is an expected finding in a client receiving enteral nutrition. The recommended target serum glucose range for clients receiving nutritional support is 140-180 mg/dL (7.8-10.0 mmol/L). Hyperglycemia (>180 mg/dL [10.0 mmol/L]) would require intervention (eg, sliding scale insulin, alternate tube feeding formula).

The nurse suspects that a client with cirrhosis is developing hepatic encephalopathy based on which assessment findings? Select all that apply. 1. Breath has musty, sweet odor 2. Excessively sleepy 3. Flapping tremors when arms and hands are extended 4. Had 2 soft bowel movements in 24 hours 5. Pinpoint pupils

Answer: 1, 2, 3 Hepatic encephalopathy (HE), a potentially reversible disturbance in central nervous system function, results when the liver fails to detoxify the body of ammonia. Clients with cirrhosis or other forms of liver disease are at risk for developing HE. Clinical findings include: - Cognitive deficits - Confusion and disorientation, impaired thinking and judgment (eg, inability to perform basic math), loss of meaningful conversation - Mental status changes - Sleep disturbances and progressively altered level of consciousness, leading to coma if not effectively treated (Option 2) - Motor alterations - Asterixis (ie, flapping hand tremor when arms and hands are extended), hyperreflexia, apraxia (ie, inability to draw simple figures) (Option 3) - Fetor hepaticus (ie, musty, sweet odor to the breath) (Option 1) (Option 4) Constipation is a risk factor for HE. The lactulose goal in clients with cirrhosis or HE is to have 2-3 soft bowel movements a day. (Option 5) Constricted pupils are seen with use of opioids. Pupillary changes are not significant in HE.

The nurse has just completed discharge teaching for a client recently diagnosed with hypertension. Which of the following statements by the client indicate understanding of the Dietary Approaches to Stop Hypertension (DASH) diet? Select all that apply. 1. "I need to eat less red meat and more fresh vegetables." 2. "I'll limit drinking soda to only one at a time as an occasional treat." 3. "I'm going to replace potato chips with fruit during meals and snacking." 4. "I'm really going to miss drinking as much milk as I normally do." 5. "Taking the salt shaker off the table should be enough to reduce my sodium intake."

Answer: 1, 2, 3 The Dietary Approaches to Stop Hypertension (DASH) diet is often suggested to clients with hypertension due to its ability to reduce blood pressure. The diet focuses on elimination or reduction of foods and beverages high in sodium, sugar, cholesterol, and trans or saturated fats, which all contribute to increased blood pressure. The DASH diet focuses on: - Including fresh fruits and vegetables, and whole grains in the daily diet - Choosing fat-free or low-fat dairy products - Choosing meats lower in cholesterol (eg, fish, poultry) and alternate protein sources (eg, legumes) instead of red meats (Option 1) - Limiting intake of sweets, foods high in sodium (eg, potato chips, frozen meals, canned foods), and sugary beverages to the occasional treat (Options 2 and 3)

A client is diagnosed with septic arthritis of the knee. What manifestations does the nurse expect to find? Select all that apply. 1. Fever 2. Joint swelling with effusion 3. Limited range of motion 4. Moderate to severe pain 5. Numbness in the extremity

Answer: 1, 2, 3, 4 Septic arthritis (infectious arthritis) is acute joint inflammation due to an infection. Pathogens may enter the joint from the bloodstream (eg, current infection elsewhere in the body), direct penetration (eg, intraarticular injection), or infected adjacent tissue (eg, osteomyelitis). Septic arthritis can lead to irreversible joint damage if not treated promptly. Clinical manifestations of septic arthritis include: - Severe, pulsating pain, usually with sudden onset and exacerbated by movement - Erythema, warmth, effusion (ie, excess synovial fluid) - Limited range of motion due to swelling in the joint - Systemic immune response to the joint infection (eg, fever) (may not be present in elderly or immunocompromised clients) The goal of treatment is to limit joint destruction and promote pain relief. Management may include aspirating synovial fluid; immobilizing the joint; restricting weight bearing; and administering antibiotics, analgesics, and antipyretics.

The nurse is planning education for clients in group prenatal care who are entering the second trimester of pregnancy. Which of the following are appropriate for the nurse to include in second-trimester teaching? Select all that apply. 1. Anticipate light fetal movements around 16-20 weeks gestation 2. Expect to have an abdominal ultrasound for fetal anatomy evaluation 3. Gain about 1 lb (0.5 kg) per week if pre-pregnancy BMI was normal 4. Increase consumption of iron-rich foods like meat and dried fruit 5. Plan for gestational diabetes screening near the end of the second trimester

Answer: 1, 2, 3, 4, 5 The second trimester (14 wk 0 d to 27 wk 6 d) is a time of positive changes for many pregnant clients (eg, improved nausea) and when physical evidence of the pregnancy is noted (eg, increased fundal height). The nurse should prepare clients for expected physical changes and discuss prevention of potential complications. - Quickening, or a client's first perception of light fetal movement, is expected around 16-20 weeks gestation, depending on parity (Option 1). - Weight gain increases by approximately 1 lb (0.5 kg) per week if pre-pregnancy BMI has been normal (Option 3). - Increasing intake of iron-rich foods (eg, meat, dried fruit) and continuing prenatal vitamins both help to prevent anemia caused by increased fetal iron requirements after 20 weeks gestation (Option 4). - Preterm labor warnings and signs of preeclampsia should be reviewed beginning at 20 weeks gestation. The nurse should also discuss routine screening/diagnostic tests performed during the second trimester. - An ultrasound is performed around 18-20 weeks gestation to evaluate fetal anatomy and the placenta (Option 2). - Screening for gestational diabetes mellitus (GDM) occurs between 24-28 weeks gestation (ie, 1-hour glucose challenge test) (Option 5). GDM is a complication of pregnancy caused by hormonally related maternal insulin resistance.

The nurse is assisting the health care provider (HCP) with insertion of a central venous access device for a client scheduled to receive chemotherapy. Which nursing actions are appropriate? Select all that apply. 1. Applying a sterile, occlusive dressing to the site once insertion is completed 2. Asking family members to refrain from entering the room during the procedure 3. Donning a face mask and providing one to the HCP before the procedure 4. Infusing only normal saline until catheter placement is confirmed by x-ray 5. Verifying that the client has signed informed consent before the procedure begins

Answer: 1, 2, 3, 5 A central venous access device (CVAD) (eg, peripherally inserted central catheter, central venous catheter) is a catheter inserted into a large vein (eg, internal jugular, femoral) to administer medications, collect blood samples, or monitor central venous pressure. Sterile technique during insertion reduces the risk of central line-associated bloodstream infections. When assisting with CVAD placement, the nurse: - Limits traffic in and out of the room (Option 2) - Completes a safety checklist (eg, verifies consent and client identifiers) prior to the procedure (Option 5) - Assists the health care provider (HCP) in establishing a sterile field with maximal barrier precautions (eg, head-to-toe sterile drape, sterile gowns). All individuals in the room, including the nurse and HCP, must wear face masks (Option 3). - Maintains a sterile environment, monitors the client, and assists the HCP as needed - Places a sterile, occlusive dressing as soon as the CVAD is in place (Option 1) (Option 4) After insertion, the nurse should not inject or infuse anything through the CVAD until appropriate placement (ie, catheter tip in the superior vena cava) is confirmed via chest x-ray.

The nurse is performing an assessment on a 2-year-old with otitis media. Which of the following actions would be appropriate? Select all that apply. 1. Do not insert the speculum into the bony interior part of the ear canal 2. Encourage the parents to have the child vaccinated against influenza and pneumonia 3. Inspect the tympanic membrane for redness, bulging, and perforation 4. Pull the pinna up and back during the otoscopic examination 5. Wait until the end of the assessment to perform the otoscopic examination

Answer: 1, 2, 3, 5 Acute otitis media is caused by a blocked eustachian tube, which leads to a buildup of purulent fluid and inflammation in the middle ear. Manifestations include a red and bulging tympanic membrane, inner ear pressure (which can rupture the tympanic membrane if not treated), pain, and fever (Option 3). Clients also may have rhinorrhea, nausea, or vomiting. When assessing a toddler (age 1-3), the nurse should use the otoscope last because it often distresses clients in this age group, especially when pain is present (Option 5). The nurse should insert the speculum only as far as the outer cartilaginous part of the external auditory canal. Advancing the speculum into the bony interior part causes pain and could damage the tympanic membrane (Option 1). The nurse should educate the parents on how to avoid future occurrences of acute otitis media, which includes recommending influenza and pneumococcal conjugate vaccinations (Option 2). (Option 4) Children age <3 have a more horizontal external auditory canal than older children and adults. The nurse should pull the pinna down and back in infants and toddlers.

A nurse prepares a client for knee arthroscopy requiring general anesthesia. Which actions should the nurse complete? Select all that apply. 1. Encourage the client to void prior to surgery 2. Ensure that the client has been on NPO status 3. Place signed informed consents in the client's chart 4. Replace the current 20-gauge IV catheter with an 18-gauge 5. Witness that the correct surgery site is marked by the surgeon

Answer: 1, 2, 3, 5 Nursing responsibilities prior to surgery include assessment, client teaching, and communication with the health care provider. Client allergies and history are confirmed while baseline vital signs are collected. Other nursing preoperative responsibilities include: - Confirming that informed consent has taken place and signed documents are placed in the client's chart (Option 3). - Encouraging the client to void to reduce the risk of retention in the immediate recovery period (Option 1). - Ensuring that the client has been on NPO status to avoid aspiration during surgery and documenting when it started (Option 2). - Witnessing and documenting preoperatively that the correct surgical site is marked by the surgeon with a permanent marker. Verify this with the client, ensuring that surgery will take place on the correct side/site (Option 5). (Option 4) If an IV line has not been started, an 18-gauge catheter is preferred. However, if a functioning IV line is already present, a 20-gauge is acceptable. Blood products, if needed during surgery, can be transfused through a 20-gauge catheter if necessary.

The inpatient hospice nurse is caring for a Muslim client newly admitted with terminal cancer. Which of the following interventions would the nurse anticipate for this client? Select all that apply. 1. Arrange for health care workers of the same sex to provide care for the client 2. Coordinate with the registered dietician to provide halal meals 3. Reposition the immobile client to face the city of Mecca during daily prayer times 4. Restrict the number of visitors from the family to preserve the client's privacy 5. Upon death, provide the family with supplies for postmortem care

Answer: 1, 2, 3, 5 Spirituality, religious beliefs, and traditions are important to include in client care. Aspects of care for Muslim clients include: Facilitating client to face Kaaba in the holy city of Mecca, generally northeastward from North America, during prayer (Option 3) - Ritual daily prayers occur 5 times a day, and dying clients may pray more often. Modesty - Care providers should be the same sex as the client whenever possible (Option 1). The female client may require a hijab (traditional head covering) and/or gown to cover most of the body. Providing foods that are halal (lawful), or acceptable for consumption (eg, no pork) - Kosher and vegetarian meals are acceptable if a specific halal menu is unavailable (Option 2). During Ramadan, the sick and dying are not required to fast with other Muslims from dawn until sunset. If the client chooses to fast, meals and medications should be rescheduled accordingly. Postmortem care of the Muslim client involves ritual washing, usually performed by family members, in preparation for burial. Burial occurs quickly after death, sometimes the same day (Option 5). (Option 4) In Islam, the family is the most important unit, and family presence brings strength to the individual. Multiple visitors should be accommodated unless they interfere with care.

The nurse is caring for a child who has had a tonsillectomy. Which of the following are appropriate nursing interventions? Select all that apply. 1. Anticipate ear pain and give acetaminophen as needed 2. Educate parents to expect the child to develop bad breath postoperatively 3. Encourage the child to drink cold liquids through a straw 4. Notify the health care provider about frequent, increased swallowing 5. Use an oral suction device regularly to remove secretions from the back of the throat

Answer: 1, 2, 4 A tonsillectomy may be indicated in some cases of chronic tonsillitis, peritonsillar abscess, or obstructive sleep apnea. Postoperative bleeding is a primary concern after a tonsillectomy because the surgical site is not easily visualized and is vulnerable to irritation and trauma from swallowing and coughing. The nurse should observe for signs of postoperative bleeding (eg, frequent, increased swallowing or clearing of the throat; vomiting bright red blood) and notify the health care provider (Option 4). Expected postoperative findings include ear pain when swallowing (ie, referred pain from the throat) and low-grade fever (<101 F [38.3 C]); analgesics (eg, acetaminophen) may be administered as needed (Option 1). Superficial infection at the surgical site is common and causes white, fluid-filled exudate in the throat with halitosis (ie, bad breath); this is not concerning because it usually resolves spontaneously after 5-10 days (Option 2).

Which discharge teaching instructions should the nurse provide to the parents of a 2-year-old with group A streptococcal pharyngitis? Select all that apply. 1. Complete all the antibiotics even if your child is feeling better 2. Cool liquids and soft diet are recommended 3. Keep your child home from daycare for at least a week 4. Replace your child's toothbrush 24 hours after starting antibiotics 5. Throat lozenges may soothe your child's sore throat

Answer: 1, 2, 4 Pharyngitis caused by group A β-hemolytic Streptococcus is a contagious bacterial throat infection that can lead to renal (glomerulonephritis) or cardiac complications (rheumatic fever) if not treated. Children may refuse to eat due to pain. A soft diet and cool liquids (ice chips) should be offered rather than solid foods (Option 2). It is important to complete the full course of antibiotics to prevent reinfection and complications (Option 1). Toothbrushes should be replaced 24 hours after starting antibiotics; the bristles can harbor the bacteria and reinfection may occur (Option 4). Young children may have minor cold symptoms and still be infected. The health care provider should test siblings age <3. (Option 3) Children with streptococcal pharyngitis may return to school or daycare after they have completed 24 hours of antibiotics and are afebrile. (Option 5) Throat lozenges (like cough drops or like cough suppressants) can be given to older children but are a choking hazard in younger children. Acetaminophen or ibuprofen (liquid preparations) should be given for pain.

The medical-surgical nurse cares for a group of clients. Which client situations would prompt the nurse to notify the health care provider during the middle of the night? Select all that apply. 1. Client develops right-sided upper and lower extremity drift 2. Client found lying unconscious on the floor 3. Client has order for heparin with surgery planned for the morning 4. Client has serum sodium of 124 mEq/L (124 mmol/L) 5. Client refuses a prescribed, routine pain medication

Answer: 1, 2, 4 The nurse contacts the health care provider (HCP) for certain circumstances, regardless of the time of day. An emergent call is warranted if a client: - Falls - Deteriorates significantly or dies - Has critical laboratory results - Needs a prescription that requires clarification - Leaves against medical advice or runs away - Refuses key treatments in a relevant period The HCP should be called after the initiation of hospital protocols (eg, stroke, code blue) and after a concerning assessment finding (eg, significant change in vital signs, unilateral drift, change in level of consciousness, signs of trauma after a fall ) (Options 1 and 2).

A nurse is teaching a client with a surgically repaired undescended testis about testicular self-examination (TSE). Which instructions should be included in the teaching? Select all that apply. 1. Perform the examination during a warm bath or shower 2. Perform the examination monthly on the same day 3. Report if one testis is slightly larger than the other 4. Report if there is a hard mass over the testis 5. Use both hands to feel each testis separately

Answer: 1, 2, 4, 5 Testicular cancer is the most common form of cancer in men age 15-35. When diagnosed early, it is highly curable. Clients at high risk for developing a tumor (eg, history of undescended testis) are encouraged to perform a monthly TSE. Client instructions for a TSE include: - Perform TSE monthly on the same day (easy to remember) - Perform TSE while taking a warm shower or bath as warm temperatures will relax the scrotal tissue and make the testis hang lower in the scrotum - Use both hands to feel each testis separately Palpate each testicle gently, using the thumb and first 2 fingers - Check that the testicle is normally egg-shaped and movable with a smooth surface The clinical findings that should be reported to the health care provider include: - Painless, hardened lump on testes - Scrotal swelling or heaviness - Dull ache in pelvis or scrotum

The nurse provides teaching for a client newly diagnosed with Addison disease. Which of the following client statements indicate that teaching has been effective? Select all that apply. 1. "I may need more medication during times of extreme emotional stress." 2. "I should avoid being around people who are sick with colds or flu." 3. "I will begin decreasing the amount of sodium that I consume." 4. "I will have to take the prescribed medications for about a year." 5. "I will wear a medical alert bracelet to advise others of my diagnosis."

Answer: 1, 2, 5 Addison disease, also known as primary adrenal insufficiency, occurs when the adrenal glands are damaged and do not produce enough corticosteroids to support homeostasis. Levels of cortisol (a glucocorticoid that stimulates metabolism and immune response and increases blood pressure and blood glucose levels) and aldosterone (a mineralocorticoid that regulates reabsorption of sodium and potassium) are particularly deficient. Manifestations of Addison disease are often nonspecific (eg, fatigue, nausea, weight loss) and may not be evident until corticosteroid levels are low enough to cause life-threatening hypotension, hypoglycemia, and electrolyte imbalances (ie, Addisonian crisis). Self-care for Addison disease includes: - Adhering to life-long corticosteroid replacement therapy - Understanding that periods of stress, illness, and exertion require higher dosing of steroids (Option 1) - Avoiding illness and infection (eg, receiving vaccination, avoiding sick contacts) (Option 2) - Wearing a medical alert bracelet to notify others if an Addisonian crisis occurs (Option 5) - Carrying and learning to administer an emergency steroid injection (eg, dexamethasone, hydrocortisone) **(Option 3) Aldosterone deficiency causes hyponatremia and hyperkalemia. Clients should not restrict dietary sodium and may need increased sodium and water intake, especially during illness, on hot days, or during periods of increased exertion. The client should avoid excess intake of potassium (eg, supplements). (Option 4) There is no cure for Addison disease. Life-long hormone replacement is required to avoid life-threatening Addisonian crisis.**

The nurse prepares a client for scheduled surgery. Which actions are the nurse's legal responsibility with regard to informed consent? Select all that apply. 1. Acting as a witness that the client signed the consent form voluntarily 2. Documenting in the medical record the date and time the signature was obtained 3. Educating the client if there is a misunderstanding about the procedure 4. Explaining to the client the right to refuse surgery 5. Verifying that the client is competent to provide informed consent

Answer: 1, 2, 5 Written consent is required for invasive procedures and surgery. Clients must be informed of and competent to understand information about the procedure, alternate treatments, and risks. They must also be informed that they have the right to refuse the procedure or surgery. The nurse's role in informed consent is to witness that the client signed the consent voluntarily and was competent at the time of signing (Options 1 and 5). The nurse should ensure that the client received necessary information and has no remaining questions about the procedure. After obtaining the signature, the nurse should document in the client's medical record that the informed consent was given and the date/time of the signature (Option 2).

The nurse plans care for a pediatric client who has just undergone a cleft palate repair. Which of the following interventions should the nurse include in the plan of care? Select all that apply. 1. Assist and encourage caregivers to hold and comfort the child 2. Offer a pacifier in between feedings to promote the child's comfort 3. Position the child supine with an elevated head of bed after feedings 4. Remove elbow restraints per policy for skin and circulatory assessment 5. Use tongue blade and penlight to assess surgical site every 4 hours

Answer: 1, 3, 4 A cleft palate is a malformation of the roof (palate) of the mouth occurring from incomplete fusion of the palatine bones and maxilla during fetal development. Cleft palate causes an opening (cleft) in the mouth into the nasal cavity, which leads to difficulty in sucking and feeding. Clients with cleft palate typically undergo surgical repair between age 6-24 months. Postoperative nursing interventions for clients with a cleft palate repair include: - Implementing pharmacological and nonpharmacological pain management (eg, encouraging caregiver soothing), as uncontrolled pain leads to crying, which stresses the surgical site and promotes hemorrhage (Option 1) - Positioning the child in an upright, supine position, particularly after feedings, to prevent airway compromise and obstruction from secretions and/or feedings (Option 3) - Utilizing elbow restraints to prevent the child from disrupting the surgical site by placing hands or objects into the mouth, and monitoring skin and neurovascular status by removing elbow restraints per agency policy (Option 4)

A client with advanced osteoarthritis is admitted for right total knee arthroplasty. Which characteristic manifestations does the nurse expect to assess in this client? Select all that apply. 1. Crepitus with joint movement 2. Low-grade fever 3. Morning stiffness lasting 10 to 15 minutes 4. Pain exacerbated by weight-bearing activities 5. Positive serum rheumatoid factor

Answer: 1, 3, 4 Osteoarthritis (OA) is a degenerative disorder of the synovial joints (eg, knee, hip, fingers) that causes progressive erosion of the articular (joint) cartilage and bone beneath the cartilage. As the degenerative process continues, bone spurs (osteophytes), calcifications, and ulcerations develop within the joint space, and the "cushion" between the ends of the bones breaks down. Clinical manifestations of OA of the knee include: - Pain exacerbated by weight-bearing activities: Results from synovial inflammation, muscle spasm, and nerve irritation (Option 4) - Crepitus, a grating noise or sensation with movement that can be heard or palpated: Results from the presence of bone and cartilage fragments that float in the joint space (Option 1) - Morning stiffness that subsides within 30 minutes of arising (Option 3) - Decreased joint mobility and range of motion - Atrophy of the muscles that support the joint (eg, quadriceps, hamstring) due to disuse

During the admission assessment of a client with a small-bowel obstruction, the nurse anticipates which clinical manifestations? Select all that apply. 1. Abdominal distension 2. Absolute constipation 3. Colicky abdominal pain 4. Frequent vomiting 5. Pain during defecation

Answer: 1, 3, 4 Small-bowel obstruction can have mechanical or non-mechanical causes. Mechanical obstruction is commonly caused by obstruction of the bowel resulting from surgical adhesions, hernias, intussusception, or tumors. Paralytic ileus, a non-mechanical obstruction, may occur after abdominal surgery or narcotic use. When a small-bowel obstruction develops, fluid and gas collect proximal to the obstruction, producing rapid onset of nausea and vomiting (Option 4), colicky intermittent abdominal pain (Option 3), and abdominal distension (Option 1). The nurse should recognize symptoms of bowel obstruction quickly as delay could lead to vascular compromise, bowel ischemia, or perforation. Nursing management of an obstruction includes placing the client on NPO status, inserting a nasogastric tube, administering prescribed IV fluids, and instituting pain control measures. (Option 2) Symptoms of a large-bowel obstruction differ slightly from small-bowel obstruction and include gradual onset of symptoms, cramping abdominal pain, abdominal distension, absolute constipation, and lack of flatus. Constipation and decreased flatus resulting from small-bowel obstruction would occur later, as the stool and gas in the large colon would be expelled for a few days. (Option 5) Pain during defecation usually indicates a rectal problem such as inflammation, anal fissure, or thrombosed hemorrhoids.

Which of these instructions is appropriate teaching for a 60-year-old woman? Select all that apply. 1. Consume adequate sources of calcium and vitamin D and take supplements 2. Increase intake of food sources of iron and take supplements 3. Observe for unilateral leg swelling when taking hormone replacement therapy (HRT) 4. Remain upright for 30 minutes when taking a bisphosphonate 5. Vaginal spotting after menopause is a common, insignificant sign of aging

Answer: 1, 3, 4 The average age of menopause in the United States is 50-52. Major health risks of menopause include osteoporosis and heart disease. Bisphosphonates, such as alendronate (Fosamax), risedronate (Actonel), or ibandronate (Boniva), decrease bone resorption so that loss of bone density is minimized. They must be consumed in the morning, on an empty stomach, with at least 30 minutes before other drugs. The medication is taken with a full glass of water and the client must remain upright for at least 30 minutes to aid absorption and prevent esophageal irritation (Option 4). Adequate sources (both food and supplements) of calcium and vitamin D are required to build bone mass (Option 1). HRT can improve bone mass and prevent osteoporosis but is associated with increased risk of thrombotic complications (deep vein thrombosis, stroke, myocardial infarction) and some cancers (breast, uterine). Therefore, it is used only in clients who have disabling hot flashes. Unilateral leg swelling is a classic symptom of venous thromboembolism (Option 3). (Option 2) Anemia in older adults is usually not related to lack of iron intake, especially once menstruation has stopped. Excessive iron intake can lead to iron overload, and the risk of excess iron tends to be higher with aging. (Option 5) Postmenopausal bleeding or abnormal premenopausal bleeding is the most common symptom of endometrial cancer and requires follow-up.

A hospitalized client develops acute hemorrhagic stroke and is transferred to the intensive care unit. Which nursing interventions should be included in the plan of care? Select all that apply. 1. Administer PRN stool softeners daily 2. Administer scheduled enoxaparin injection 3. Implement seizure precautions 4. Keep client NPO until swallow screen is performed 5. Perform frequent neurological assessments

Answer: 1, 3, 4, 5 A hemorrhagic stroke occurs when a blood vessel ruptures in the brain and causes bleeding into the brain tissue or subarachnoid space. Seizure activity may occur due to increased intracranial pressure (ICP) (Option 3). During the acute phase, a client may develop dysphagia. To prevent aspiration, the client must remain NPO until a swallow function screen reveals no deficits (Option 4). The nurse should perform neurological assessments (eg, level of consciousness, pupillary response) at regular intervals and report any acute changes (Option 5). Preventing activities that increase ICP or blood pressure will minimize further bleeding. The nurse should: - Reduce stimulation, maintain a quiet and dimly lit environment, limit visitors - Administer stool softeners to reduce strain during bowel movements (Option 1) - Reduce exertion, maintain strict bed rest, assist with activities of daily living - Maintain head in midline position to improve jugular venous return to the heart

The nurse is teaching a client diagnosed with Raynaud phenomenon about ways to prevent recurrent episodes. Which instructions should the nurse include? Select all that apply. 1. Avoid excessive caffeine 2. Immerse hands in cold water 3. Practice yoga or tai chi 4. Refrain from using tobacco products 5. Wear gloves when handling cold objects

Answer: 1, 3, 4, 5 Raynaud phenomenon is a vasospastic disorder resulting in an episodic vascular response related to cold temperatures or emotional stress. It most commonly affects women age 15-40. Vasospasms induce a characteristic color change in the appendages (eg, fingers, toes, ears, nose). When vasoconstriction occurs, the affected appendage initially turns white from decreased perfusion, followed by a bluish-purple appearance due to cyanosis. Clients usually report numbness and coldness during this stage. When blood flow is subsequently restored, the affected area becomes reddened and clients experience throbbing or aching pain, swelling, and tingling. Acute vasospasms are treated by immersing the hands in warm water. Client teaching regarding prevention of vasospasms includes: - Wear gloves when handling cold objects (Option 5). - Dress in warm layers, particularly in cold weather. - Avoid extremes and abrupt changes in temperature. - Avoid vasoconstricting drugs (eg, cocaine, amphetamines, ergotamine, pseudoephedrine). - Avoid excessive caffeine intake (Option 1). - Refrain from use of tobacco products (Option 4). - Implement stress management strategies (eg, yoga, tai chi) (Option 3). If conservative management is unsuccessful, clients may be prescribed calcium channel blockers to relax arteriole smooth muscle and prevent recurrent episodes.

A nurse educator is developing materials for a hospital-wide campaign about zero tolerance for lateral violence and bullying among staff. Which actions will the nurse educator include in teaching about what staff members should do if they experience workplace violence? Select all that apply. 1. Document the interactions with the bully 2. Ignore the bully's comments, remarks, and allegations 3. Observe interactions between the bully and other colleagues 4. Report the violent incidents to the hospital administrator 5. Tell the bully you will not tolerate the unprofessional behavior

Answer: 1, 3, 5 Lateral violence (also known as horizontal violence) can be defined as acts of aggression carried out by a co-worker against another co-worker and designed to control, diminish, or devalue a colleague. These behaviors usually take the form of verbal abuse such as name-calling, unwarranted criticism, intimidation, and blaming. However, other acts, such as refusing to help someone, sabotage, exclusion, and unfair assignments, also fall under the category of lateral violence. Violence in the workplace should not be tolerated or ignored by either staff or management. Actions that staff members can take if they become victims of lateral violence include: - Documenting and keeping a file of all incidents (Option 1) - Reporting the incidents to the immediate supervisor - Letting the bully know that the behavior will not be tolerated (Option 5) - Observing interactions between the bully and other colleagues (may validate the victim's experiences and serve as a source of support) (Option 3) - Seek support from within the facility or from an external source

The nurse is providing discharge teaching to several clients with new prescriptions. Which instructions by the nurse are correct in regard to medication administration? Select all that apply. 1. Avoid salt substitutes when taking valsartan for hypertension 2. Take levofloxacin with an aluminum antacid to avoid gastric irritation 3. Take sucralfate after meals to minimize gastric irritation associated with a gastric ulcer 4. When taking ethambutol, notify the health care provider (HCP) of any changes in vision 5. When taking rifampin, notify the HCP if the urine turns red-orange

Answer: 1, 4 Both ACE inhibitors ("prils" - captopril, enalapril, lisinopril, ramipril) and angiotensin receptor blockers ("sartans" - valsartan, losartan, telmisartan) cause hyperkalemia. Salt substitutes contain high potassium and must not be consumed unless approved by the health care provider (HCP) (Option 1). Ethambutol (Myambutol) is used to treat tuberculosis but can cause ocular toxicity, resulting in vision loss and loss of red-green color discrimination. Vision acuity and color discrimination must be monitored regularly (Option 4). (Option 3) Sucralfate (Carafate, Sulcrate), prescribed to treat gastric ulcers, should be administered before meals to coat the mucosa and prevent irritation of the ulcer during meals. It should also be given at least 2 hours before or after other medications to prevent interactions that reduce drug efficacy.

A client with a history of degenerative arthritis is being discharged home following an exacerbation of chronic obstructive pulmonary disease. After reviewing the discharge medications, the nurse should educate the client about which topics? Select all that apply. Click on the exhibit button for additional information. 1. Dryness of the mouth and throat may occur 2. Ringing in the ears is an expected, transient side effect 3. The albuterol canister should not be shaken before use 4. The health care provider should be notified if stools are black and tarry 5. Tiotropium capsules should not be swallowed Discharge medications: - Albuterol: 2 puffs every 4-6 hours as needed - Prednisone: 40 mg PO daily - Naproxen: 220 mg PO twice daily - Tiotropium: 1 capsule inhaled daily

Answer: 1, 4, 5 A common side effect of tiotropium (Spiriva) and other anticholinergics (eg, ipratropium, benztropine) is xerostomia (dry mouth) due to the blockade of muscarinic receptors of the salivary glands, which inhibits salivation. Sugar-free candies or gum may be used to alleviate dry mouth and throat (Option 1). Tiotropium capsules should not be swallowed. These capsules are placed inside the inhaler device, and the capsule is pierced, allowing the client to inhale its contents (Option 5). Glucocorticoids (eg, prednisone), when taken in combination with aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) such as naproxen, can increase the risk of gastrointestinal ulceration and bleeding. The client should report black, tarry stools (ie, melena) to the health care provider as they could indicate gastrointestinal bleeding (Option 4). (Option 2) Tinnitus (ie, ringing in the ears) is an uncommon side effect of NSAID (eg, naproxen) use. Tinnitus is commonly associated with toxicity related to salicylate-containing NSAIDs (eg, aspirin) or aminoglycosides (eg, gentamicin, neomycin, tobramycin); its onset should be reported by a client taking these medications. The medication may need to be discontinued to prevent permanent hearing loss. (Option 3) The albuterol canister should be shaken prior to inhalation to ensure appropriate medication delivery.

The nurse is caring for a client in labor at 37 weeks gestation and notes a baseline fetal heart rate of 180 beats per minute. Which interventions should the nurse perform? Select all that apply. 1. Measure maternal blood pressure 2. Reassess fetal heart rate in an hour 3. Reduce IV fluid rate 4. Review medication administration record 5. Take maternal temperature

Answer: 1, 4, 5 Fetal tachycardia is defined as a baseline heart rate above 160 beats per minute. Tachycardia can be an early indicator of fetal hypoxia and acidosis. Other common causes include infection, maternal fever, maternal dehydration, maternal hypotension, and drug side effects. Maternal temperature should be taken to assess for fever, and blood pressure should be assessed to rule out hypotension (Options 1 and 5). Certain medications can lead to fetal tachycardia (eg, terbutaline, bronchodilators, decongestants), and the nurse should review the medication administration record to determine whether potential causative medications were administered recently (Option 4).

Which interventions does the nurse perform to promote normal rest and sleep patterns for a critically ill client? Select all that apply. 1. Dimming the lights at night 2. Increasing the level of continuous IV sedation during nighttime hours 3. Leaving the television on for diversion at night 4. Opening the window blinds/shades in the morning 5. Scheduling interventions and activities during the day when possible 6. Turning off equipment alarms in the client's room at night

Answer: 1, 4, 5 It is important to maintain the client's normal circadian rhythms in the intensive care unit (ICU). Interventions that help to maintain the normal sleep-wake cycle include dimming the lights at night, providing quiet and uninterrupted periods of sleep when possible, scheduling interventions and activities during the day, frequently reorienting the client as necessary, and opening the shades in the morning. Excessive stimuli and lack of sleep can predispose the client to delirium. (Option 2) Continuous IV sedation, if indicated, should be given at the lowest dose adequate for pain management. (Option 3) Unless the client is awake and chooses to have the television turned on, this extra stimulus is disruptive to sleep. (Option 6) Turning the alarms off in the client's room would pose a risk to safety, as the nurse may not be alerted to a change in condition or equipment failure. If possible, alarm parameters should be adjusted according to the client's routine to prevent unnecessary awakening.

A nurse cares for a frail, elderly client with osteoporosis in a nursing home. Which interventions are appropriate to include in the client's care plan to help prevent a hip fracture? Select all that apply. 1. Calcium supplements 2. Encourage bed rest 3. Use of full bed rails during the night 4. Vitamin D supplements 5. Weight-bearing exercises

Answer: 1, 4, 5 The primary treatment goal for elderly clients with osteoporosis is to prevent bone fracture, especially hip fracture. Teaching to increase bone mineral density and prevent bone loss (resorption) includes: - Bisphosphonate medication (eg, alendronate [Fosamax], risedronate [Actonel], zoledronic [Reclast]) - Calcium and Vitamin D supplementation (Options 1 & 4) - Smoking cessation and alcohol avoidance, as these increase bone resorption and contribute to falls - Weight-bearing exercise (eg, walking, dancing) and resistance training (eg, weights) ≥3 times a week for 30 minutes, as increasing mechanical stress on bone increases bone density (Option 5) Interventions to prevent falls and resulting hip fracture include: - Maintain bed in low and locked position - Ensure that call light and personal belongings are within reach - Orient client and ensure use of non-skid footwear, eyeglasses and hearing aids, and assist devices if needed - Keep environment well-lit and free of clutter (Option 2) A client should not be placed on bed rest solely for the prevention of falls. Immobilization actually increases fracture risk due to bone resorption, a condition called disuse osteoporosis. The nurse should encourage and assist with mobility and weight-bearing exercises to prevent muscle atrophy and bone resorption. (Option 3) The client may actually incur more injury from a fall if trying to climb over side rails to get out of bed. The nurse should utilize bed alarms if the client is prone to getting out of bed without assistance.

The nurse provides discharge instructions to a client at 14 weeks gestation who has received a prophylactic cervical cerclage. Which client statement indicates an understanding of teaching? 1. "I need to be on bed rest for the duration of my pregnancy." (18%) 2. "I will notify my health care provider if I start having low back aches." (41%) 3. "Pelvic pressure is to be expected after cerclage placement." (22%) 4. "The cerclage will be removed once my baby is at 28 weeks." (17%)

Answer: 2 A cervical cerclage is placed to prevent preterm delivery, usually in clients with histories of second trimester loss or premature birth. A heavy suture is placed transvaginally or transabdominally to keep the internal cervical os closed. Placement occurs at 12-14 weeks gestation for clients with a history of cervical insufficiency (ie, painless, premature cervical dilation and miscarriage or preterm delivery) or up to 23 weeks gestation if signs of cervical insufficiency (eg, short cervix) are noted. Discharge instructions include activity restriction and recognition of signs of preterm labor (eg, low back aches, contractions, pelvic pressure) and rupture of membranes (Option 2). (Option 1) Bed rest is usually recommended for a few days after the procedure. Long-term bed rest is individualized but uncommon and increases the risk for complications (eg, deep vein thrombosis). Pelvic rest (eg, avoiding sexual intercourse) is determined by the health care provider. (Option 3) Mild abdominal cramping following cerclage placement is common; however, regular contractions, pelvic pressure, and low back aches may indicate preterm labor. (Option 4) The cerclage remains in place until 36-37 weeks gestation. Early removal is indicated by rupture of membranes (to prevent infection) or preterm labor (to prevent damage to the cervix as it dilates).

The telemetry nurse reports the cardiac monitor rhythms of 4 clients to the medical unit nurse assigned to care for them. The nurse should assess the client with which rhythm first? 1. Atrial fibrillation with a pulse of 76/min in a client prescribed rivaroxaban (8%) 2. Bradycardia in a client with a demand pacemaker set at 70/min (38%) 3. First-degree atrioventricular block in a client prescribed atenolol (24%) 4. Sinus tachycardia in a client with gastroenteritis and dehydration (28%)

Answer: 2 A demand ventricular electronic pacemaker set at 70/min delivers an impulse (fires) when it senses an intrinsic rate below the predetermined rate of 70/min. Failure to capture occurs when the pacemaker sends an impulse to the ventricle, but the myocardium does not depolarize (pacer spike with no QRS complex; no palpable pulse beat); this is usually associated with pacer lead (wire) displacement or battery failure. The malfunction can result in bradycardia (pulse <60/min) or asystole and decreased cardiac output; the nurse should perform an assessment and notify the health care provider immediately.

A float nurse from labor and delivery is assigned to the cardiac care unit. Which client is most appropriate for the charge nurse to assign to the float nurse? 1. Client 3 days following a myocardial infarction who is on 6 L of oxygen and reports nausea (12%) 2. Client admitted for hypertensive crisis with blood pressure of 154/92 mm Hg on amlodipine PO (30%) 3. Client with a demand pacemaker set at 70/min who has a ventricular rate of 65/min (5%) 4. Client with angina at rest who has normal troponin levels and normal sinus rhythm on ECG (51%)

Answer: 2 A hypertensive crisis is an elevation in blood pressure (BP) >180 mm Hg systolic and/or >120 mm Hg diastolic with evidence of organ damage (eg, kidney damage, retinopathy). The goal of treatment is to slowly lower BP using IV antihypertensive medications (eg, vasodilators) to limit end-organ damage. Once the client's condition is stabilized, oral antihypertensives are prescribed and IV medications are titrated off. Float nurse assignments should be made on the basis of what is within the knowledge and skill of the generalist nurse. The float nurse can safely care for the client whose BP is controlled by oral medication, and has the knowledge and skill to assess vital signs (Option 2). (Option 1) The client with a history of myocardial infarction showing signs of reinfarction (eg, nausea, increased oxygen demands) may be unstable and should not be assigned to the float nurse.

A client at 38 weeks gestation is in latent labor with ruptured membranes and is receiving an oxytocin infusion for labor augmentation. The client is requesting IV pain medication. When administering an IV narcotic during labor, which nursing action is appropriate? 1. Discontinue the oxytocin infusion prior to giving the medication (21%) 2. Give the medication slowly during the peak of the next contraction (50%) 3. Hold until contractions are occurring at least every 4 minutes for an hour (19%) 4. Withdraw 5 mL of lactated Ringer from the IV tubing to dilute the medication (9%)

Answer: 2 Administration of IV narcotics (eg, nalbuphine, butorphanol, meperidine) during the peak of contractions can help decrease sedation of the fetus and subsequent newborn respiratory depression at birth (Option 2). Uteroplacental blood flow is significantly reduced during contraction peaks, and administration of IV medication at this time results in less medication crossing the placental barrier. In addition, a higher concentration of medication remains in the maternal vasculature, which increases the effectiveness of pain relief.

When caring for a client with a left radial artery catheter, which assessment data obtained by the nurse indicates the need to take immediate action? 1. Capillary refill of less than 3 seconds (4%) 2. Left hand cooler than right (77%) 3. Mean arterial pressure of 65 mm Hg (10%) 4. Pressure bag at 300 mm Hg (8%)

Answer: 2 Although the Allen's test is performed before cannulating the radial artery and determines the adequacy of ulnar artery blood flow, circulation to the extremity is monitored frequently. The nurse must assess color, capillary refill, sensation, temperature, and movement per institution policy. Impairment in any of these parameters must be reported immediately because it may indicate impaired circulation to the extremity, and removal of the catheter may be necessary.

A child is scheduled to have an electroencephalogram (EEG). Which statement by the parent indicates understanding of the teaching? 1. "I will let my child drink cocoa as usual the morning of the procedure." (7%) 2. "I will wash my child's hair using shampoo the morning of the procedure." (46%) 3. "My child may have scalp tenderness where the electrodes were applied." (35%) 4. "My child will not remember the procedure." (10%)

Answer: 2 An electroencephalogram (EEG) is a diagnostic procedure used to evaluate the presence of abnormal electrical discharges in the brain, which may result in a seizure disorder. The EEG can be done in a variety of ways, such as with the child asleep or awake with or without stimulation. Teaching for the parent includes the following: 1. Hair should be washed to remove oils and hair care products, and accessories such as ribbons or barrettes should be removed. Hair may need to be washed after the procedure to remove electrode gel. 2. Avoid caffeine, stimulants, and central nervous system depressants prior to the test. 3. The test is not painful, and no analgesia is required. (Option 1) Food and liquids are not restricted prior to an EEG except for caffeinated beverages. Cocoa contains caffeine. (Option 3) This test (EEG) is not painful as it only records brain electrical activity. Electrode gel is nonirritating to the skin. (Option 4) A routine EEG is not performed under sedation, and so the child should remember the procedure.

A client suffering from chronic kidney disease is scheduled to receive recombinant human erythropoietin and iron sucrose. The client's hemoglobin is 9.7 g/dL (97 g/L) and hematocrit is 29% (0.29). What is the appropriate nursing action? 1. Administer the erythropoietin in the client's ventrogluteal muscle (42%) 2. Check blood pressure prior to administering the erythropoietin (39%) 3. Hold the client's next scheduled iron sucrose dose (3%) 4. Hold the erythropoietin and inform the health care provider (15%)

Answer: 2 Anemia associated with chronic kidney disease is treated with recombinant human erythropoietin (Epogen/Procrit, epoetin). Therapy is initiated when hemoglobin is <10 g/dL (100 g/L) to alleviate the symptoms of anemia (eg, fatigue) and the need for blood transfusions. Therapy should be discontinued or the dose reduced for hemoglobin >11 g/dL (110 g/L) to prevent venous thromboembolism and adverse cardiovascular outcomes from blood thickened by high concentrations of RBCs. Hypertension is a major adverse effect of erythropoietin administration. Therefore, uncontrolled hypertension is a contraindication to recombinant erythropoietin therapy. Blood pressure should be well controlled prior to administering erythropoietin (Option 2).

A client comes to the emergency department with severe dyspnea and a cough. Vital signs are temperature 99.2 F (37.3 C), blood pressure 108/70 mm Hg, heart rate 88/min, and respirations 24/min. The client has a history of chronic obstructive pulmonary disease (COPD) and chronic heart failure. Which diagnostic test will be most useful to the nurse in determining if this is an exacerbation of heart failure? 1. Arterial blood gases (ABGs) (10%) 2. B-type natriuretic peptide (BNP) (54%) 3. Cardiac enzymes (CK-MB) (28%) 4. Chest x-ray (6%)

Answer: 2 BNP is a peptide that causes natriuresis. B-type natriuretic peptides are made, stored, and released primarily by the ventricles. They are produced in response to stretching of the ventricles due to the increased blood volume and higher levels of extracellular fluid (fluid overload) that accompany heart failure. Elevation of BNP >100 pg/mL helps to distinguish cardiac from respiratory causes of dyspnea.

A graduate nurse (GN) is caring for a client with right lower leg cellulitis that is seeping clear fluid. Which action by the GN requires intervention by the supervising nurse? 1. Applying a warm compress to the affected extremity (57%) 2. Maintaining the affected leg flat on the bed (30%) 3. Marking and dating the reddened areas (5%) 4. Wearing a gown and gloves while bathing the client (6%)

Answer: 2 Cellulitis is inflammation of the subcutaneous tissues that is typically caused by bacterial infection (eg, Staphylococcus aureus, group A Streptococcus) resulting from an insect bite, cut, abrasion, or open wound. Cellulitis is characterized by redness, edema, pain, and fever. Nurses caring for clients with cellulitis should ensure that the affected extremity is elevated when the client is sitting or lying down to promote lymphatic drainage. Flat or dependent positioning may worsen edema, which delays recovery and contributes to pain (Option 2). In addition, clients with weeping or draining wounds must be protected from prolonged exposure to moist or soiled linens as this exposure promotes tissue injury and infection. **(Option 1) Applying warm compresses promotes circulation to the area of infection, alleviates discomfort, and helps reduce edema.**

A nurse is caring for a homeless client who is moderately malnourished and suffering from pneumonia. The client needs a peripheral IV line for fluid administration. Which IV site should the nurse select to reduce the risk for infection? 1. Antecubital fossa (47%) 2. Dorsal surface of hand (34%) 3. Dorsum of foot (1%) 4. Lateral surface of wrist (15%)

Answer: 2 Clients most at risk for catheter-related bloodstream infections are those with compromised immune systems; therefore, this client is at high risk. The IV site chosen for catheter insertion can influence the infection risk. The risk is higher using the lower extremities compared to the upper extremities and using the wrist or upper arm compared to the hand. Unless the client is very old or very young, the hand is a good site as it is most distal, allowing future sites to be selected higher on the arm if needed.

A client at 32 weeks gestation goes into cardiac arrest. What is the nurse's best action while performing cardiopulmonary resuscitation for this client? 1. Compress chest at second intercostal space, right sternal border (14%) 2. Perform chest compressions slightly higher on the sternum (53%) 3. Place hands just below the diaphragm to perform chest compressions (6%) 4. Position client in the supine position for optimal compressions (26%)

Answer: 2 Common causes of sudden cardiac arrest in pregnant clients include embolism, eclampsia, magnesium overdoses, and uterine rupture. If cardiopulmonary resuscitation (CPR) is required, several modifications must be made to ensure efficacy of the rescue efforts. During pregnancy, the heart is displaced toward the left because the growing uterus pushes upward on the diaphragm, particularly in the third trimester. To accommodate this displacement, the hands should be placed on the sternum slightly higher than usual for chest compressions during CPR (Option 2). In addition, a gravid uterus can significantly compress the client's vena cava and aorta, thereby hindering effective blood flow during CPR. The uterus should be manually displaced to the client's left to reduce this pressure. The nurse can also place a rolled blanket or wedge under the right hip to displace the uterus. If return of spontaneous circulation (ROSC) does not occur after 4 minutes of CPR, emergency cesarean section is usually initiated. Delivery should occur within 5 minutes of initiating CPR.

A client with fibromyalgia refuses to take the prescribed drug duloxetine. When the nurse asks, why, the client responds, "Because I'm not depressed!" What is the nurse's most appropriate response? 1. "Depression is common with fibromyalgia, but a low dose of this drug can prevent it." (12%) 2. "It can relieve your chronic pain and help you sleep better at night." (58%) 3. "It helps to relieve the adverse effects of your other prescribed drugs." (11%) 4. "You have the right to refuse. I will notify your health care provider (HCP)." (17%)

Answer: 2 Fibromyalgia (FM) results from abnormal central nervous system pain transmission and processing. It is characterized by chronic, bilateral musculoskeletal axial pain (above and below the waist), multiple tender points, fatigue, and sleep/cognitive disturbances. Duloxetine (Cymbalta) is a serotonin-norepinephrine reuptake inhibitor that has both antidepressant and pain-relieving effects. It is used to relieve chronic pain that interferes with normal sleep patterns in clients with FM. With the restoration of normal sleep patterns, fatigue often improves as well (Option 2). Other effective drugs to treat the chronic pain associated with FM include pregabalin and amitriptyline (Elavil), an older tricyclic antidepressant drug.

The nurse prepares to administer morning medications to assigned clients. Which prescription should the nurse clarify with the health care provider? 1. Clopidogrel for client with history of stroke and platelet count of 154,000/mm3 (154 × 109/L) (12%) 2. Losartan for client with hypertension who is 8 weeks pregnant (61%) 3. Prednisone for client with herpes simplex lesions and Bell palsy (17%) 4. Tiotropium for client with pneumonia and chronic obstructive pulmonary disease (8%)

Answer: 2 Losartan is an angiotensin II receptor blocker (ARB) prescribed to treat hypertension. ACE inhibitors (eg, lisinopril, enalapril) and ARBs are teratogenic, causing renal and cardiac defects or death of the fetus. ARBs and ACE inhibitors have black box warnings that indicate contraindication in pregnancy. The nurse should not give an ARB to a pregnant client (Option 2). The health care provider should be notified so that an alternate antihypertensive may be prescribed that is safe to take during pregnancy (eg, labetalol, methyldopa). (Option 1) Antiplatelet agents (eg, clopidogrel) are prescribed to prevent thromboembolic events in clients with increased risk for stroke or myocardial infarction. Laboratory values are monitored periodically as these drugs increase bleeding time (normal, 2-7 minutes [120-420 seconds]) and, rarely, may lower platelet count (normal, 150,000-400,000/mm3 [150-400 × 109/L]) (Option 3) Bell palsy presents as acute onset of unilateral facial paralysis related to inflammation of the facial nerve (ie, cranial nerve VII) that may be triggered by a viral illness (eg, herpes simplex virus). Standard treatment includes corticosteroids (eg, prednisone) within 72 hours of symptom onset. (Option 4) Tiotropium is an inhaled anticholinergic drug that inhibits receptors in the smooth muscles of the airways. It is prescribed daily for the long-term management of bronchospasm in clients with chronic obstructive pulmonary disease.

The nurse on a medical-surgical unit prepares scheduled daily medications for a client and places them in a pill cup. After receiving the pill cup, the client states, "I take a whole tablet of metoprolol at home. Why did you cut this one in half?" What is the best response by the nurse? 1. "Do you know how many milligrams of metoprolol you normally take at home every day?" (34%) 2. "Show me which pill you're talking about so I can verify your prescriptions again." (53%) 3. "This is the same dose you received the past 3 days in the hospital, so we know it's safe to take." (0%) 4. "Your health care provider has prescribed a half-dose of metoprolol while you're in the hospital." (11%)

Answer: 2 Medications appear different when produced by different manufacturers, and the client's home medications may vary in color, size, or dosage per tablet. If a client expresses concern about a medication, the nurse should first compare the actual tablet with the client's current prescription (Option 2). (Option 1) Once the nurse verifies that the administered medications match the current prescriptions, the nurse can compare them with the client's home medications and explain any changes in prescriptions. In acute care settings, clients may be on different medication regimens than they are at home. Additional medications may be given in the hospital and some medications may be withheld or decreased/increased in dose (eg, antihypertensives are withheld if the client is hypotensive).

A 62-year-old client is scheduled for open abdominal aneurysm repair. What key assessment should be made by the nurse preoperatively? 1. Assess and compare blood pressure in each arm (12%) 2. Assess character and quality of peripheral pulses (62%) 3. Assess for presence or absence of hair on lower extremities (2%) 4. Assess for presence of bowel sounds (21%)

Answer: 2 Open aneurysm repair involves a large abdominal incision and requires cross-clamping the aorta proximally and distally to the aneurysm. Establishing baseline data is essential for comparison with postoperative assessments. The nurse should pay special attention to the character and quality of peripheral pulses and renal and neurologic status. Dorsalis pedis and posterior tibial pulse sites should be marked for easy location postoperatively. A decreased or absent pulse with cool, pale, mottled, or painful extremity postoperatively can indicate embolization or graft occlusion. Graft occlusion may require reoperation. **(Option 1) Comparison of blood pressures in each arm may be helpful in an assessment of an upper aortic dissection or congenital aortic coarctation, but not in assessing an abdominal aortic aneurysm.**

During a routine office visit, the nurse documents the list of current medications of a client with a history of hypertension. Which statement by the client would cause the most concern? 1. "I periodically take docusate sodium for constipation." (12%) 2. "I regularly take ibuprofen for chronic low back pain." (41%) 3. "I take hydrochlorothiazide to prevent swelling around my ankles." (29%) 4. "I take omeprazole daily to prevent heartburn." (17%)

Answer: 2 Over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen can cause cardiovascular side effects, including heart attack, stroke, high blood pressure, and heart failure from fluid retention. These drugs also decrease the effectiveness of diuretics and other blood pressure medications. The risks can be even higher in the client who already has cardiovascular disease or takes NSAIDs routinely or for a long time. In addition, long-term use of NSAIDs is associated with peptic ulcers and chronic kidney disease. These clients should use NSAIDs cautiously, at the lowest dose necessary and for a short time. The nurse should notify the health care provider that this client is routinely taking ibuprofen.

The nurse provides care for a client diagnosed with polycythemia vera. Which statement by the client would require immediate follow-up? 1. "I am trying to find makeup to cover my unattractive, ruddy facial complexion." (1%) 2. "I must have injured my leg in some way. It is sore, swollen, and red." (64%) 3. "I take a baby aspirin to relieve my occasional headaches." (29%) 4. "My skin itches so severely, and no lotion or cream seems to help." (5%)

Answer: 2 Polycythemia vera (PV) is a hematological disorder in which too many RBCs (and often WBCs and platelets) are produced, causing increased blood viscosity, venous stasis, and increased risk for thrombus formation. The nurse should teach clients with PV measures to prevent thrombus (eg, wearing graduated compression stockings, elevating legs when sitting, maintaining adequate hydration). Clients should also learn to monitor for and report signs and symptoms of thrombus (eg, redness, tenderness, or swelling in one leg). Reports of possible thrombus require immediate intervention to avoid serious injury (eg, stroke, pulmonary embolism) (Option 2). (Option 3) Occasional headaches or blurred vision can result from sluggish, viscous blood flow in the brain. Aspirin therapy is used for its antiplatelet and analgesic action. The nurse should assess the client's headaches; however, they are not the priority.

Which client is at the greatest risk for development of hospital-acquired pressure injuries? 1. 25-year-old client with quadriplegia, urosepsis, temperature of 101 F (38.3 C), and white blood cell count of 18,000/mm3 (18.0 x 109/L) (46%) 2. 50-year-old client with AIDS who is receiving norepinephrine infusion and has a weight loss of 20 lb (9.1 kg) in a month, prealbumin level <10 mg/dL (100 mg/L), and mean arterial pressure of 50 mm Hg (26%) 3. 80-year-old client 2 days post hip replacement with dementia, 2 Jackson-Pratt drains, and hemoglobin level of 14 g/dL (140 g/L) (23%) 4. 87-year-old client 2 days post open cholecystectomy (3%)

Answer: 2 Pressure injuries are areas of localized skin injury and underlying tissue caused by external pressure with or without friction and/or shearing. These result from ischemia and hypoxia of tissue following periods of prolonged pressure. Clients at greatest risk include older adults with limited movement and long bone (femur) or hip fractures, those with quadriplegia, and the critically ill. Clients with deficits in mobility and activity, incontinence, inadequate nutrition, chronic illness, renal failure, anemia, problems with oxygenation, edema, or infection are also at increased risk. This client (Option 2) has 5 risk factors: chronic illness and immune deficiency disease; significant weight loss; prealbumin <16 mg/dL (<160 mg/L), indicating inadequate nutrition and protein deficiency; hypotension (decreases perfusion pressure); and receiving norepinephrine (Levophed), a vasoconstrictor. These risks affect circulation, capillary perfusion pressure, and the ability to provide adequate nutrition to the cells.

The nurse is providing education to a client with a new prescription for progestin-only pills (POPs). Which statement about POPs is appropriate for the nurse to include? 1. "If you begin vomiting any time within 24 hours of taking the pill, take an additional pill." (1%) 2. "If you take your pill 3 or more hours after your usual time, use a backup contraceptive." (29%) 3. "In your pill pack, there are 21 days of progestin pills and 7 days of inactive iron pills." (28%) 4. "The use of POPs increases your risk of developing deep venous thrombosis." (40%)

Answer: 2 Progestin-only pills (POPs), a form of oral contraception, work by thickening cervical mucus (ie, hinders sperm motility), thinning the endometrium (ie, hinders implantation), and preventing ovulation. Cervical mucus changes last only approximately 24 hours, so the client must take the pill at the same time every day for it to be effective. If the pill is taken ≥3 hours late, a barrier method (eg, condom) is advised until the pill is taken correctly for 2 days (Option 2).

The acute care clinic nurse administers a prescribed narcotic for a client with renal colic and then discharges the client without ensuring that the client has a designated driver. The client is subsequently involved in a motor vehicle accident causing injury to self and others. Which ethical principle did the nurse violate? 1. Autonomy (4%) 2. Nonmaleficence (80%) 3. Paternalism (6%) 4. Veracity (8%)

Answer: 2 The nurse violated the ethical principle "nonmaleficence" (ie, do no harm). It is rare to see a nurse inflict intentional harm. However, problems do occur due to unintentional harm, which is usually a result of poor clinical judgment. Beneficence is a nurse's duty to promote good and do what is best for the client. (Option 1) Autonomy is allowing the clients to choose the direction of their care. This is accomplished with advanced directives along with informed consent and choices regarding proposed treatments. (Option 3) Paternalism is a type of beneficence whereby clients are treated as children. The nurse claims to know what is best for the client and coerces the client to act as the nurse wishes without considering the client's autonomy. (Option 4) Veracity refers to the duty to tell the truth. This principle should always be applied to client care and documentation.

A self-employed auto mechanic is diagnosed with carbon monoxide poisoning. Admission vital signs are blood pressure 90/42 mm Hg, pulse 84/min, respirations 24/min, and oxygen saturation 94% on room air. What is the nurse's priority action? 1. Administer 5 mg inhaled albuterol nebulizer treatment to decrease inflammatory bronchoconstriction (12%) 2. Administer 100% oxygen using a nonrebreather mask with flow rate of 15 L/min (48%) 3. Administer methylprednisolone to decrease lung inflammation from toxic inhalant (21%) 4. Titrate oxygen to maintain pulse oximeter saturation of >95% (17%)

Answer: 2 The purpose of hemoglobin (Hgb) is to pick up oxygen in the lungs and deliver it to the tissues. It must be able to pick up oxygen and release it in the right places. Carbon monoxide (CO) has a much stronger bond to Hgb than oxygen does. Consequently, CO displaces oxygen from Hgb, causing hypoxia that is not reflected by a pulse oximeter reading. The nurse's primary action is to administer highly concentrated (100%) oxygen using a nonrebreather mask at 15 L/min in order to reverse this displacement of oxygen.

A nurse on the telemetry unit observes the following rhythm on the monitor of a client admitted with coronary artery disease. What action should the nurse take first? Click the exhibit button for additional information. 1. Administer atropine 0.5 mg IV push (13%) 2. Measure the client's vital signs (50%) 3. Move the client back to bed from chair (10%) 4. Obtain a temporary pacemaker (25%)

Answer: 2 The rhythm shows that the client is experiencing a second-degree atrioventricular (AV) block, type 1. This is an intermittent block usually occurring at the level of the AV node characterized by a progressively lengthening PR interval until a QRS complex is dropped. AV block can be associated with myocardial ischemia (eg, coronary artery disease) or certain medications (eg, beta blockers, digoxin). Assess the client first for any evidence of symptoms associated with the rhythm (eg, hypotensive, dizzy, shortness of breath). Treatment is only indicated if the client is symptomatic. If the client is experiencing symptoms, atropine and temporary pacing may be indicated. If there are no associated symptoms, the nurse should continue to closely monitor the client and be ready to intervene if symptoms arise.

The nurse caring for a client in the intensive care unit reports a critical laboratory value of 120,000/mm3 (120 x 109/L) platelets, decreased from 300,000/mm3 (300 x 109/L) on admission. The health care provider says this is normal. The client is receiving heparin injections. Which nursing action would be the most appropriate? 1. Contact the appropriate certification and licensing board (3%) 2. Document the exchange in the chart (63%) 3. Report the incident to the hospital's legal team (29%) 4. Report the incident to the state medical board (3%)

Answer: 2 There are 2 forms of heparin-induced thrombocytopenia. The first form (platelets >100,000/mm3 [100 x 109/L]) normalizes within a few days. The second form (platelets <40,000/mm3 [40 x 109/L]) is a life-threatening autoimmune process that requires immediate heparin discontinuation. When in doubt of a clinician's judgment, the nurse should document these objections and report to the nursing supervisor.

A nurse is caring for a 6-year-old client with tonsillitis. Which further assessment finding requires immediate intervention? 1. Dry mucous membranes (13%) 2. Presence of trismus (39%) 3. Pulling at the ears (26%) 4. Sandpaper-like skin rash (20%)

Answer: 2 Trismus (inability to open the mouth due to a tonic contraction of the muscles used for chewing) may indicate a more serious complication of tonsillitis, a peritonsillar or retropharyngeal abscess (collection of pus). Other features include a "hot potato" or muffled voice, pooling of saliva, and deviation of the uvula to one side. This abscess can occlude the airway, making it a medical emergency. Surgical intervention (tonsillectomy or incision and drainage) is often required. In the meantime, maintaining an adequate airway is essential.

A laboring client with epidural anesthesia experiences spontaneous rupture of membranes, immediately followed by an abrupt change in the fetal heart rate. The nurse knows that considering the probable cause of the change in fetal heart rate, which action should be taken first? Click on the exhibit button for additional information. 1. Administer IV fluid bolus (3%) 2. Assess for umbilical cord prolapse (46%) 3. Notify the health care provider (11%) 4. Reposition client to alternate side (37%)

Answer: 2 Umbilical cord prolapse may occur after rupture of membranes if the presenting fetal part is not firmly applied to the cervix. Cord compression caused by a prolapsed cord will produce abrupt fetal heart rate deceleration, fetal bradycardia, and disruption of fetal oxygen supply. The priority action is to inspect the vaginal area and perform a sterile vaginal examination to assess for a prolapsed cord (Option 2). If a prolapsed cord is visualized or palpated, the nurse should then manually elevate the presenting fetal part off the umbilical cord, leave the hand in place, and call for help. (Option 1) Although IV fluid bolus is part of intrauterine resuscitation, in the presence of prolonged deceleration after rupture of membranes, the first action is to rule out a prolapsed cord.

The client has a dislocated shoulder and the nurse is assisting the health care provider with bedside procedural moderate sedation (conscious sedation). During the procedure, the client becomes restless and cries out "Help me!" What action should the nurse take first? 1. Administer midazolam per protocol (20%) 2. Check the client's pulse oximeter (51%) 3. Give more morphine per protocol (7%) 4. Open the airway with head tilt-chin lift (19%)

Answer: 2 When there is new, sudden onset of restlessness/agitation, the nurse should first think about oxygenation (or blood glucose). The desired level of sedation is level 3 on the Ramsay Sedation Scale, during which the client is drowsy but responds to a voice command.

The nurse is preparing an injection of IM haloperidol from a glass ampule. Which of the following actions by the nurse are appropriate? Select all that apply. 1. Attaches an 18-gauge injection needle to a syringe for withdrawal of medication 2. Breaks the ampule neck away from the nurse's body to prevent injury from the glass 3. Disposes of the empty glass ampule in a sharps container 4. Injects air into the glass ampule prior to withdrawing the medication 5. Rests and steadies the needle on the ampule's outer rim to withdraw medication

Answer: 2, 3 **Ensure that the filter needle does not touch the glass edges, which are not sterile, as this can introduce bacteria.**

The nurse is caring for a client with right upper quadrant pain and jaundice. The client's alanine aminotransferase /aspartate aminotransferase (ALT/AST) levels are 7 times the normal values. What questions would be most helpful regarding the etiology for these findings? Select all that apply. 1. Do you have black tarry stool? 2. Do you use intravenous (IV) illicit drugs? 3. How much alcohol do you typically drink? 4. Were you recently immunized for pneumonia? 5. What over-the-counter drugs do you take?

Answer: 2, 3, 4 ALT and AST are the enzymes released when hepatic cells are injured (hepatitis). There are smaller amounts in the cardiac, renal, and skeletal tissues, but ALT/AST are used to diagnose hepatic disorders. Besides viral hepatitis, liver injury can occur with excessive chronic alcohol intake (Option 3), some over-the-counter medications (eg, acetaminophen), and certain herbal and dietary supplements (Option 5). IV illicit drug use increases the risk for hepatitis B and C infection (Option 2). (Option 1) Black tarry stool (melena) is an expected finding from a gastrointestinal bleed (from the digested blood). Melena can be seen in clients with gastric or esophageal varices, which are often complications of hepatic disease (eg, cirrhosis). However, melena is not an etiology of liver injury. (Option 4) Immunizations do not cause liver damage. It is possible to get a small elevation with an intramuscular injection, but not values this high.

The nurse is preparing a client for a magnetic resonance cholangiopancreatography. Which statements by the client would require the nurse to obtain further assessment data? Select all that apply. 1. "I ate lunch about 4 or 5 hours ago." 2. "I got a rash the last time I had IV contrast." 3. "I had my last period 6 weeks ago." 4. "I have a hearing aid implanted in my ear." 5. "I smoked a cigarette about an hour ago."

Answer: 2, 3, 4 Magnetic resonance cholangiopancreatography (MRCP) is a noninvasive diagnostic test used to visualize the biliary, hepatic, and pancreatic ducts via MRI. MRCP uses oral or IV gadolinium (noniodine contrast material) and is a safer, less-invasive alternative to endoscopic retrograde cholangiopancreatography to determine the cause of cholecystitis, cholelithiasis, or biliary obstruction. The nurse must assess for contraindications before the procedure, including the presence of certain metal and/or electrical implants (eg, aneurysm clip, pacemaker, cochlear implant) or any previous allergy or reaction to gadolinium (Option 4). A client with a history of rash following prior IV contrast administration should be assessed to determine the type of contrast that caused the reaction. Although allergies to iodine-based contrast material are more common, the nurse must rule out a gadolinium allergy (Option 2). Pregnancy also is a contraindication for MRCP as gadolinium crosses the placenta and may adversely affect the fetus. Delayed/irregular menses may be a normal variation in some clients; however, delayed menses may indicate pregnancy and should be reported for further investigation prior to MRCP (Option 3).

A nurse is teaching the parent of a 6-year-old with a urinary tract infection (UTI) how to avoid repeat infections. Which statements by the parent indicate that the teaching has been effective? Select all that apply. 1. "I just bought my child new nylon panties." 2. "I will make sure my child does not hold urine." 3. "I will not give my child any more bubble baths." 4. "I will teach my child to wipe from the front to the back." 5. "I will use antibacterial soap for bathing my child."

Answer: 2, 3, 4 UTIs are one of the most common conditions in children, with a higher occurrence in girls (due to the short urethra and its close proximity to the vagina and anus). Girls should be taught to wipe from front to back; this will help minimize the chances of bacteria entering the urethra from the perianal area (Option 4). Urinary stasis (incomplete emptying of the bladder) is the most common contributing factor to UTIs; sedentary urine provides an ideal environment for bacterial growth. Constipation and straining increase the pressure on the bladder neck and may prevent the bladder from emptying completely. The child should be encouraged to drink plenty of fluids and use the restroom as soon as the urge to go is felt, which will decrease the risk of constipation and promote frequent urination. Avoiding "holding in" urine and voiding regularly help to prevent urinary retention and flush bacteria out of the urinary tract (Option 2). Scented soaps or commercially prepared bubble bath products should be avoided as they cause irritation to the urethra. Antibacterial soap should not be used for bathing a child as it may reduce the presence of normal flora. The bathtub should be filled with water only, and the hair should be washed last (Options 3 and 5).

The registered nurse and the practical nurse are collaborating to develop the plan of care for a newborn with esophageal atresia and tracheoesophageal fistula. Which of the following nursing interventions should be included? Select all that apply. 1. Educate the family about comfort care and hospice services 2. Insert a peripheral IV for administration of prescribed IV fluids 3. Instruct the parents not to breastfeed or bottle-feed the infant 4. Maintain continuous low suction of the proximal esophageal pouch 5. Position the infant supine and elevate the head of the bed

Answer: 2, 3, 4, 5 Esophageal atresia and tracheoesophageal fistula (EA/TEF) are congenital malformations; most commonly, the proximal (upper) esophagus ends in a blind pouch (ie, atresia) and the distal (lower) esophagus connects to the primary bronchus or trachea through a fistula. Fluids (eg, milk, saliva) accumulate in the proximal esophageal pouch, are aspirated into the trachea, and return to the mouth and nose, causing the client to cough, choke, and drool frothy saliva. Management of clients with EA/TEF is focused on preventing aspiration. Interventions include ensuring NPO status while awaiting surgery and positioning the infant supine with the head of the bed elevated at least 30 degrees (Options 3 and 5). Continuous or intermittent low suction of the proximal esophageal pouch is applied via a double-lumen catheter to keep the pouch clear of secretions and avoid aspiration (Option 4). IV fluids are administered to maintain hydration, and IV antibiotics may be prescribed to reduce the risk of pneumonia (Option 2).

The nurse reinforces teaching for a client newly diagnosed with primary open-angle glaucoma. Which of the following client statements indicate that teaching has been effective? Select all that apply. 1. "After a few months of using the eye drops, my vision will be near normal." 2. "I need to keep all follow-up appointments with my health care provider." 3. "I will check with my health care provider before using allergy or cold medications." 4. "I will need to use prescribed eye drops for the rest of my life." 5. "If I see colored halos around lights, I should notify my health care provider."

Answer: 2, 3, 4, 5 Primary open-angle glaucoma is a chronic condition in which aqueous humor does not drain properly, leading to elevated intraocular pressure (IOP) that causes optic nerve damage and progressive peripheral vision loss (eventually "tunnel vision"). Treatment focuses on minimizing vision loss and monitoring the IOP (eg, several times per year). Client teaching includes: - Taking prescribed eye drops (eg, prostaglandin analogs, beta-adrenergic blockers, alpha-adrenergic agonists, cholinergic agonists, carbonic anhydrase inhibitors) for life and on time (eg, every 12 hours) to control IOP (Option 4) - Keeping all appointments with the health care provider (HCP) for continual monitoring of IOP (Option 2) - Consulting the HCP before taking over-the-counter medications with anticholinergic properties (eg, allergy, cough, or cold medications) to avoid increasing the IOP (Option 3) - Reporting sudden eye pain, halos around lights, and abrupt onset of blurry vision because these may indicate acute angle-closure glaucoma, a medical emergency that requires immediate surgical intervention (Option 5)

The nurse cares for a client with a pulmonary embolism. Which of the following clinical manifestations would the nurse anticipate? Select all that apply. 1. Bradycardia 2. Chest pain 3. Dyspnea 4. Hypoxemia 5. Tachypnea 6. Tracheal deviation

Answer: 2, 3, 4, 5 Pulmonary embolism (PE) is a potentially life-threatening medical emergency occurring when a blood clot, fat or air embolus, or tissue (eg, tumor) travels via the venous system into the pulmonary circulation and obstructs blood flow into the lung. This prevents deoxygenated blood from reaching the alveoli, which leads to hypoxemia due to impaired gas exchange and cardiac strain due to congested blood flow in the pulmonary arteries. Clinical manifestations of PE range from mild (eg, anxiety, cough) to severe (eg, heart failure, sudden death). However, many clients initially have mild, nonspecific symptoms that are often misdiagnosed and inadequately managed, greatly increasing the likelihood of progression to shock and/or cardiac arrest. Clinical manifestations of PE include: - Pleuritic chest pain (ie, sharp lung pain while inhaling) (Option 2) - Dyspnea and hypoxemia (Options 3 and 4) - Tachypnea and cough (eg, dry or productive cough with bloody sputum) (Option 5) - Tachycardia - Unilateral leg swelling, erythema, or tenderness related to deep vein thrombosis

The labor and delivery nurse is caring for a client whose unborn child has been diagnosed with anencephaly. Which of the following nursing actions are appropriate for supporting the client in preparation for birth? Select all that apply. 1. Avoid bringing up the newborn's prognosis to prevent upsetting the client 2. Discuss the newborn's expected appearance with the client 3. Educate the client that grieving cannot truly begin until one cries 4. Explore the client's preferences for social and spiritual support 5. Remind the client of the ability to conceive again in the future

Answer: 2, 4 Anencephaly (ie, absence of a major portion of the fetal brain and skull) is incompatible with life. When caring for a client expecting the birth of a child with a poor prognosis, the nurse plays an important role in coordinating care and facilitating grief and psychological adjustment. Exploring the client's preferences for social (eg, family, friends) and spiritual (eg, chaplain, clergy) support helps the nurse accommodate the client's emotional and psychological needs and create a comforting setting (Option 4). To ease anxiety related to contact with the newborn, the nurse should offer to explain the newborn's expected appearance (ie, unique physical features) and potential bonding opportunities after birth (Option 2). (Option 1) Avoiding discussion of the client's unique situation invalidates the client's experience and does not facilitate the grieving process.

The nurse is performing a central line tubing change when the client suddenly begins gasping for air and writhing (twisting or squirming). Order the interventions by priority. All options must be used. 2. Clamp the catheter tubing 1. Administer oxygen as needed 4. Place the client in Trendelenburg position on the left side 3. Notify the health care provider (HCP) 5. Stay with the client and provide reassurance

Answer: 2, 4, 1, 3, 5 Leakage of more than 500 mL of air into a central venous catheter is potentially fatal. An air embolism in the small pulmonary capillaries obstructs blood circulation. A central venous catheter leaks air rapidly at 100 mL/sec. This client requires immediate intervention to prevent further complications (eg, cardiac arrest, death). The nurse should not delay emergency treatment, not even to stop and contact the HCP or the rapid response team (RRT). Priority interventions for active or suspected air embolism are as follows: 1. Clamp the catheter to prevent more air from embolizing into the venous circulation. 2. Place the client in Trendelenburg position on the left side, causing any existing air to rise and become trapped in the right atrium. 3. Administer oxygen if necessary to relieve dyspnea. 4. Notify the HCP or call an RRT to provide further resuscitation measures. 5. Stay with the client to provide reassurance and monitoring as the air trapped in the right atrium is slowly absorbed into the bloodstream over the course of a few hours.

The educator on a rehabilitation unit is teaching a graduate nurse (GN) about caring for clients who have had a stroke. Which of the following statements by the GN indicate correct understanding of the teaching? Select all that apply. 1. "Approach clients with visual impairment from the affected side when entering the room." 2. "Instruct clients with unilateral weakness to dress by donning clothes on the affected side first." 3. "Provide written instructions for activities of daily living to clients with receptive aphasia." 4. "Teach clients with left-sided neglect to turn their heads to scan the environment." 5. "Teach families of clients with right-sided stroke to expect impulsive behaviors."

Answer: 2, 4, 5 Clients with unilateral weakness from stroke may have limited mobility and control on the affected side. Clients being taught to dress independently should first clothe the affected side, which decreases the need for movement of impaired extremities and allows unrestricted use of unaffected limbs for assistance (Option 2). Unilateral neglect is an alteration in sensory perception that causes clients to ignore input from the affected side, leading to performing actions only on one side (eg, eating food on only the right side of the plate). Teaching clients to turn the head to fully scan the environment reduces the tendency to neglect one side (Option 4). Clients with right-sided cerebrovascular accidents tend to be impulsive and unaware of deficits. Teaching the client's family to expect disinhibition and emotional outbursts helps family members cope with the behavioral changes and reduces frustration during interactions (Option 5). (Option 1) The nurse should approach clients with unilateral blindness from the unaffected side to avoid startling the client. (Option 3) Receptive aphasia (ie, Wernicke aphasia) is impairment of verbal and written language comprehension. Visual aids and hand gestures may be more effective means of communication.

A client is being discharged after having a coronary artery bypass grafting (CABG) x 5. The client asks questions about the care of chest and leg incisions. Which instructions should the registered nurse include? Select all that apply. 1. Report any itching, tingling, or numbness around your incisions 2. Report any redness, swelling, warmth, or drainage from your incisions 3. Soak incisions in the tub once a week then clean with hydrogen peroxide and apply lotion 4. Wash incisions daily with soap and water in the shower and gently pat them dry 5. Wear an elastic compression hose on your legs and elevate them while sitting

Answer: 2, 4, 5 Incisions may take 4-6 weeks to heal. The nurse should instruct clients on how to care for their incisions; these instructions are as follows: - Wash incisions daily with soap and water in the shower. Gently pat dry (Option 4). - Itching, tingling, and numbness around the incisions may be present for several weeks due to damage to the local nerves (Option 1). - Tub baths should be avoided due to risk of introducing infection (Option 3). - Do not apply powders or lotions on incisions as these trap the bacteria at the incision (Option 3). - Report any redness, swelling, and increase in drainage or if the incision has opened (Option 2). - Wear a supportive elastic hose on the legs. Elevate legs when sitting to decrease swelling (Option 5).

The nurse is performing an assessment on a 39-week neonate an hour after a spontaneous vaginal delivery. What are common expected newborn findings? Select all that apply. 1. One artery and one vein in the umbilical cord 2. Plantar creases up the entire sole 3. Skin on the nose blanches to a yellowish hue 4. Toes fan outward when the lateral sole surface is stroked 5. White pearl-like cysts on gum margins

Answer: 2, 4, 5 The number of plantar creases on the bottom of the feet is indicative of the neonate's age. The more creases over the greater proportion of the foot, the more mature the neonate. The Babinski reflex is present at birth and disappears at 1 year. The toes hyperextend and fan out when the lateral surface of the sole is stroked in an upward motion. Absent Babinski or a weak reflex may indicate a neurological defect. Epstein's pearls are white, pearl-like epithelial cysts on gum margins and the palate. They are benign and usually disappear within a few weeks. (Option 1) The cord should be opaque or whitish-blue with two arteries and one vein and covered with Wharton's jelly. The presence of only one umbilical artery and vein is associated with heart or kidney malformation. The cord should also be assessed for bleeding. It will become dry and darker within 24 hours and detach from the body within 2 weeks.

The nurse is administering IV hydromorphone to a client every 3-4 hours as needed for postoperative pain. Which interventions should the nurse implement? Select all that apply. 1. Administer IV hydromorphone over 5-10 seconds 2. Administer PRN stool softener with daily medications 3. Hold hydromorphone if client is not practicing deep breathing exercises 4. Perform reassessment an hour after administration 5. Tell the client to call for assistance before getting out of bed

Answer: 2, 5 Opioid analgesics (eg, hydromorphone, morphine) are effective for controlling moderate to severe pain. Major side effects include sedation, respiratory depression, hypotension, and constipation. The client is at risk for falls from sedation or hypotension and should not get out of bed unassisted (Option 5). Slowed bowel motility persists throughout opioid use, and measures to prevent constipation (eg, administration of daily stool softeners) should be implemented (Option 2). (Option 4) The nurse should reassess pain and sedation level during the opioid's peak effect, which is 15-30 minutes after administration of IV hydromorphone.

The nurse develops a teaching plan for a client prescribed isoniazid, rifampin, ethambutol, and pyrazinamide to treat active tuberculosis (TB). Which of the following instructions associated with the adverse effects of rifampin is most important for the nurse to include? 1. Notify the health care provider if your urine is red (16%) 2. Take acetaminophen every 6 hours for drug-associated joint pain while taking this medication (9%) 3. Wear eyeglasses instead of soft contact lenses while taking this medication (70%) 4. You can stop taking the medications as soon as one sputum culture comes back normal (3%)

Answer: 3 Active TB is treated with combination drug therapy. Isoniazid causes hepatotoxicity and peripheral neuropathy. Rifampin (Rifadin) also causes hepatotoxicity. Therefore, baseline liver function tests should be obtained. Clients should be advised to watch for signs and symptoms of hepatotoxicity (eg, jaundice, anorexia). Ethambutol causes ocular toxicity, and clients will need frequent eye examinations. A teaching plan for a client prescribed rifampin includes these additional instructions: - Rifampin changes the color of body fluids (eg, urine, sweat) due to its body-wide distribution. Tears can turn red, making contact lenses appear discolored. Client should wear eyeglasses instead of soft contact lenses while taking this medication. - Women should use nonhormonal birth control methods while taking this drug as it can decrease the effectiveness of oral contraceptives.

The nurse receives new prescriptions for a client with right lower quadrant pain and suspected acute appendicitis. Which prescription should the nurse implement first? 1. Administer 0.25 mg hydromorphone IV push for pain (25%) 2. Draw blood for complete blood count and electrolyte levels (20%) 3. Initiate IV access and infuse normal saline 100 mL/hr (50%) 4. Obtain urine specimen for urinalysis (4%)

Answer: 3 Appendicitis is inflammation of the appendix and often results from obstruction by fecal matter. Appendiceal obstruction traps fluid and mucus typically secreted into the colon, causing increased intraluminal pressure and inflammation. As appendiceal intraluminal pressure and inflammation increase, blood circulation to the appendix is impaired, resulting in swelling and ischemia. These factors increase the risk for appendiceal perforation, a medical emergency, which may lead to peritonitis and sepsis. When prioritizing care of the client with appendicitis, the nurse should utilize the ABCs (ie, airway, breathing, circulation). Fluid resuscitation with IV crystalloids (eg, normal saline, lactated Ringer solution) is an important intervention aimed at preventing circulatory collapse resulting from fluid losses (eg, vomiting, diarrhea) and NPO status (Option 3). ^^^^^This is FIRST!

A newborn client is seen in the emergency department for vomiting. Which assessment finding indicates a possible emergency? 1. Frequent vomiting since birth (18%) 2. Tiny blood streaks in the vomit (24%) 3. Vomit that is green (28%) 4. Vomiting through the nose (28%)

Answer: 3 Bile made by the liver is green and is released into the duodenum on eating to aid digestion. When there is an obstruction in the intestines and stool cannot pass, it may come back up as green vomit. A bowel obstruction is an emergency that can lead to bowel rupture, peritonitis, and sepsis. (Option 1) Newborns vomit or spit up frequently as they adjust to eating and digesting food. They also have a loose lower esophageal sphincter that allows food to come up from the stomach easily. Hydration status and weight gain should be monitored. (Option 2) Tiny blood streaks may be noted due to rupture of pressured esophageal veins from frequent vomiting. This is not a cause for concern unless the vomit contains a large amount of blood or blood-streaked vomiting persists. Scant amounts seen in vomit can be normal. (Option 4) It is not uncommon for a newborn to have vomiting through the nose because the esophagus is connected to the nose and mouth. The vomit comes up through the esophagus and, if forceful enough, will come out of both orifices.

A client receives an injection of botulinum toxin type A for facial and neck rejuvenation. What complications of this procedure should the nurse be aware of for monitoring and teaching? 1. Abdominal rigidity and diarrhea (4%) 2. Back pain and urge incontinence (1%) 3. Difficulty swallowing and breathing (91%) 4. Difficulty walking and hand tremor (2%)

Answer: 3 Botulinum toxin type A (Botox) blocks neuromuscular transmission by inhibiting acetylcholine release from nerve endings. The drug is used for treating wrinkles, blepharospasm, and cervical dystonia. Complications are uncommon when Botox is used for cosmetic purposes but can be life-threatening if they occur. The toxin can also relax the muscles used for swallowing and breathing, resulting in dysphagia (aspiration risk) and respiratory paralysis. (Options 1 and 2) Botulism can be associated with constipation and urinary retention due to relaxation of smooth muscle. Unlike in Clostridium tetani infection (tetanus), painful rigidity and spasms of the neck, back, and abdominal muscles are absent.

The emergency department nurse receives report on 4 clients. Which client should the nurse assess first? 1. Client with acute cholecystitis who reports right shoulder pain (19%) 2. Client with gastroparesis who reports persistent nausea and vomiting (18%) 3. Client with intractable lower back pain who reports new urinary incontinence (44%) 4. Client with Ménière disease who reports increasing tinnitus (17%)

Answer: 3 Cauda equina syndrome is a disorder that results from injury to the lumbosacral nerve roots (L4-L5) causing motor and sensory deficits. The main symptoms are severe lower back pain, inability to walk, saddle anesthesia (ie, motor weakness/loss of sensation to inner thighs and buttocks), and bowel and bladder incontinence (late sign). Cauda equina syndrome is a medical emergency. Treatment requires urgent reduction of pressure on the spinal nerves to prevent permanent damage. This client displays characteristic late signs of cauda equine syndrome (ie, incontinence); therefore, the nurse should assess this client first.

The charge nurse is rounding on clients in restraints. Which of the following situations would require immediate intervention by the nurse? 1. Client in a belt restraint in the semi-Fowler position (18%) 2. Client in mitten restraints in the side-lying position (19%) 3. Client in soft wrist restraints in the supine position (36%) 4. Client in vest restraint in the high-Fowler position (25%)

Answer: 3 Clients in any form of restraints should not be in the supine position because it can cause aspiration, especially in those with altered mental status. Unless contraindicated, clients in restraints should be placed in the side-lying, semi-Fowler, or high-Fowler position to promote airway patency and expectoration of secretions or emesis. The supine position may also increase anxiety and agitation, especially in a restrained client. (Options 1 and 4) Belt and vest restraints are secured around the client's waist. A client in a belt or vest restraint can be safely placed in the side-lying, semi-Fowler, or high-Fowler position.

A home health nurse is visiting a 72-year-old client who had coronary artery bypass graft surgery 2 weeks ago. The client reports being forgetful and becoming teary easily. How should the nurse respond? 1. "Don't worry. You'll feel better in a few weeks." (0%) 2. "How well are you sleeping at night?" (45%) 3. "These symptoms can be common after major surgery. It will take 4-6 weeks to completely heal and start to feel normal again." (46%) 4. "You may be experiencing depression. I'll call the health care provider and see if we can get a prescription for an antidepressant." (7%)

Answer: 3 Clients who have undergone surgery (eg, coronary artery bypass graft) may experience some postoperative cognitive dysfunction (POCD). This may include memory impairment and problems with concentration, language comprehension, and social integration. Some clients may cry easily or become teary. The risk for POCD increases with advanced age and in clients with preexisting cognitive deficits, longer operative times, intraoperative complications, and postsurgical infections. POCD can occur days to weeks following surgery. Most symptoms typically resolve after complete healing has occurred. In some cases, this condition can become a permanent disorder (Option 3).

A client with a diagnosis of antisocial personality disorder was given a 2-hour pass to leave the hospital. The client returned to the unit 15 minutes past curfew and did not sign in. The next day, this behavior is brought up in a group meeting. The client says, "It's all the nurse's fault. The nurse was right there and did not remind me to sign in." What is the best response by the nurse? 1. "I'm sorry. I should have reminded you to sign in." (4%) 2. "It is not my fault that you forgot to sign in." (0%) 3. "It is your responsibility to sign in when you return from a pass." (72%) 4. "You were late coming back from your pass. Is that why you did not sign in?" (22%)

Answer: 3 Clients with antisocial personality disorder often disregard the rules, have a history of irresponsible behavior, and blame others for their behavior. They avoid responsibility for their own behavior and the consequences of their actions using numerous excuses and justifications. Nursing interventions include setting firm limits and making clients with antisocial personality disorder aware of the rules and acceptable behaviors. The nurse should require the client to take responsibility for his/her own behavior and the consequences of not following the rules and regulations of the unit.

The home health nurse visits a client with inflammatory bowel disease who recently underwent a total colectomy with ileostomy creation. Which statement by the client indicates that the client understands ileostomy care? 1. "I can irrigate the stoma daily to help regulate stool drainage." (23%) 2. "I change the ostomy appliance and bag every morning." (8%) 3. "I cut the appliance opening slightly larger than my stoma." (63%) 4. "I restrict how much I drink to make the stool drainage less watery." (5%)

Answer: 3 Clients with inflammatory bowel disease may undergo a total colectomy with ileostomy creation to control symptoms of chronic abdominal pain and diarrhea. Peristomal skin irritation is the most common ileostomy complication. Peristomal skin care and prevention or treatment of irritation include: - Cleansing peristomal skin with mild soap and water - Ensuring that the ostomy appliance fits well so that skin is protected from liquid stool drainage - Trimming the appliance opening to 1/8 inch (0.32 cm) larger than the stoma so that it "hugs" the stoma without touching stoma tissue (Option 3) (Option 1) Ileostomies are formed from small intestine that bypasses the colon, which results in incontinence of liquid stool that cannot be regulated with irrigation. Irrigation is used to achieve regular emptying of the colon in clients with descending colostomies. (Option 2) To prevent skin irritation, stoma appliances are changed only every 5-10 days. The bag is emptied whenever one-third full to prevent it from becoming heavy and pulling away from the skin. (Option 4) Clients with ileostomies are at risk for dehydration, hyponatremia, and hypokalemia due to increased fluid loss through liquid stool. Clients are encouraged to increase fluid intake.

Which of the following methods would the nurse use to collect a urine sample for culture and sensitivity testing in a 16-month-old client? 1. Apply a urine collection bag to the perineum (43%) 2. Aspirate a specimen from an indwelling catheter collection bag (8%) 3. Insert a sterile intermittent urinary catheter (37%) 4. Place cotton balls inside the diaper (10%)

Answer: 3 Culture and sensitivity testing is used to identify the causative agent of an infection and to determine the susceptibility of the infectious agent to various medications (eg, antibiotics). To ensure that the correct organism is identified, sterile technique is required when obtaining a sample to prevent contamination with microorganisms from the skin. Infants and toddlers who are not toilet trained are unable to control voiding, making it difficult to prevent contamination and determine the timing of urination; therefore, sterile intermittent catheterization is the most appropriate means of collecting a sterile urine specimen. (Option 1) A nonsterile specimen can be obtained by adhering a sterile urine collection bag around the genitalia inside the diaper. This method is appropriate for obtaining a sample for urinalysis or calculating intake and output; however, there is a high risk of contamination as the urine may come into contact with the perineum, making this method inappropriate for culture and sensitivity testing. (Option 4) Cotton balls are sometimes placed in the diaper to absorb urine while the infant voids. After the cotton balls are saturated, they are removed, and the urine is squeezed into a collection cup. This method has high likelihood of contamination and therefore cannot be used to obtain urine for culturing.

The nurse is caring for a client 1 hour after receiving the first electroconvulsive therapy treatment for severe major depressive disorder. The client reports a headache, is disoriented to place, and cannot recall the spouse's name. What is the appropriate nursing action? 1. Call the spouse to ask about memory problems prior to admission (1%) 2. Complete a full neurological examination and stroke assessment (34%) 3. Document the findings in the client's medical record (61%) 4. Request a prescription for a CT scan of the head (2%)

Answer: 3 Electroconvulsive therapy (ECT) is a psychiatric treatment in which a health care provider purposely induces a seizure to provide relief from symptoms of mental illness (eg, depressive or bipolar disorders) that has not responded to other therapies. Before the procedure, the client receives a general anesthetic, a bite block, and a muscle relaxant (eg, succinylcholine) to minimize post-procedure muscle soreness and to prevent injury. The health care provider applies an electric stimulus through electrodes attached to the client's head, causing a brief tonic-clonic seizure. During the seizure, the treatment team closely monitors electrical activity in the brain and heart with an electroencephalogram and ECG. Most clients require multiple ECT treatments that are typically administered several times per week over 3-4 weeks. The most common side effects of ECT are a headache as well as confusion and disorientation for several hours following the procedure and temporary memory loss that lasts for a few weeks. The nurse should reorient the client and document these findings in the client's medical record (Option 3).

The nurse is caring for a client with chronic kidney disease who has a scheduled dose of epoetin alfa. Which of the following laboratory results would cause the nurse to hold the medication and contact the health care provider? 1. Blood urea nitrogen: 26 mg/dL (9.3 µmol/L) (11%) 2. Creatinine: 2.5 mg/dL (221 µmol/L) (35%) 3. Hemoglobin: 13 g/dL (130 g/L) (31%) 4. Platelets: 120,000/mm 3 (120 × 109/L) (21%)

Answer: 3 Erythropoiesis-stimulating agents (ESAs) (eg, epoetin alfa [Epogen, Procrit], darbepoetin alfa [Aranesp]) are used to treat chronic anemia related to chronic kidney disease (CKD) or bone marrow suppression (chemotherapy). ESAs are synthetic forms of the naturally occurring hormone erythropoietin, which stimulates the production of red blood cells (ie, erythropoiesis) by the bone marrow. Erythropoietin is normally produced by the kidneys, so clients with CKD may develop anemia due to decreased erythropoietin production. ESAs are administered on a regular schedule (eg, once weekly) and may be self-administered subcutaneously at home or IV during hemodialysis as needed. A total of 2-3 months is required to reach a target hemoglobin level. ESAs are held if hemoglobin exceeds 11 g/dL (110 g/L) due to an increased risk of thrombotic events (eg, myocardial infarction, stroke) (Option 3). ESAs increase blood pressure and are contraindicated in clients with uncontrolled hypertension. **(Options 1, 2, and 4) Creatinine and blood urea nitrogen are expected to be elevated in clients with CKD. Laboratory results for creatinine, platelet, and blood urea nitrogen do not indicate the effectiveness of epoetin alfa.**

The emergency department nurse is caring for a client who requires gastric lavage for a drug overdose. Which action would be appropriate? 1. Lavage through a small-bore nasogastric tube (22%) 2. Place client in Trendelenburg position during lavage (4%) 3. Prepare intubation and suction supplies at the bedside (64%) 4. Wait an hour after gastric decompression to initiate lavage (8%)

Answer: 3 Gastric lavage (GL) is performed through an orogastric tube to remove ingested toxins and irrigate the stomach. GL is rarely performed as it is associated with a high risk of complications (eg, aspiration, esophageal or gastric perforation, dysrhythmias). GL is only indicated if the overdose is potentially lethal and if GL can be initiated within one hour of the overdose. Activated charcoal administration is the standard treatment for overdose, but it is ineffective for some drugs (eg, lithium, iron, alcohol). Intubation and suction supplies should always be available at the bedside during GL in case the client develops aspiration or respiratory distress (Option 3). (Option 1) GL is usually performed through a large-bore (36 to 42 French) orogastric tube so that a large volume of water or saline can be instilled in and out of the tube. (Option 2) During GL, clients should be placed on their side or with the head of bed elevated to minimize aspiration risk. (Option 4) GL should be initiated within one hour of overdose ingestion to be effective. The client's stomach should be decompressed first, but lavage should be initiated as soon as possible afterwards.

Four clients come to the emergency department simultaneously. Which client should the nurse see first for definitive care? 1. 6-month-old with a temperature of 101 F (38 C) who is rubbing the ears and being fussy (4%) 2. 10-day-old client with a red mark (stork bite) on the neck, the mother is concerned (1%) 3. A client who took a handful of amitriptyline pills, a tricyclic antidepressant drug (66%) 4. A client who tripped and hit the head but is alert with no loss of consciousness, currently takes warfarin (27%)

Answer: 3 In this scenario, a client with a drug overdose (OD) is the highest priority as the actual amount taken and its effects are unknown. In addition, clients who deliberately OD often consume other substances (eg, alcohol) that can potentiate the effect of the drug. OD is especially concerning for a tricyclic antidepressant (TCA) due to the effect this can have on the cardiovascular and central nervous systems (eg, dysrhythmias, seizures). TCA use for depression is an uncommon second-line treatment, but the drug class is used for neuropathic pain and sometimes bed-wetting (enuresis). A client with head trauma (a vascular area of the body) who is currently on an anticoagulant could have potential intracranial bleeding and should be treated next. The 6-month-old client is exhibiting classic signs of otitis media (eg, fever, ear pulling/rubbing). This infection of the middle ear is a common childhood illness, often in conjunction with an upper respiratory infection. The child should be treated third and will need antibiotics, but this is nonurgent. Antipyretics can be given for comfort by protocol or direct order from the health care provider while the child is still in the triage/waiting area. The 10-day old client's mark is a salmon-colored patch (nevus simplex or angel kiss); this is a developmental vascular abnormality that will disappear within 1 year. It is at the nape of the neck but can also be seen on the eyelid, upper lip, or between the eyes. The mother needs reassurance and teaching.

The nurse is performing assessments of several clients during routine prenatal visits. Which client should the nurse discuss with the health care provider first? 1. Client at 30 weeks gestation with darkened patches of skin on the face (6%) 2. Client at 32 weeks gestation with painless, flesh-colored bumps on the perianal area (54%) 3. Client at 34 weeks gestation with intense itching on the hands and feet that worsens at night but no rash (31%) 4. Client at 38 weeks gestation with stretch marks on the abdomen that have become reddened and pruritic (6%)

Answer: 3 Intrahepatic cholestasis of pregnancy is a liver disorder exclusive to pregnancy that manifests with intense, generalized itching but no rash. Itching often involves the hands and feet and worsens at night. This condition increases the risk of intrauterine fetal demise and requires priority assessment by the health care provider (Option 3). Management includes laboratory testing (eg, elevated bile acids), fetal surveillance (eg, biophysical profile, nonstress test), medication (ie, ursodeoxycholic acid), and labor induction around 37 weeks gestation. Intrahepatic cholestasis of pregnancy begins to resolve after birth.

The nurse is caring for a child with Kawasaki disease who is receiving IV immunoglobulin. The child's parent wants to know why this treatment is required. The nurse explains that this therapy is given to: 1. Fight the infection (47%) 2. Minimize rash (5%) 3. Prevent heart disease (36%) 4. Reduce spleen size (11%)

Answer: 3 Kawasaki disease (KD), also known as mucocutaneous lymph node syndrome, is characterized by ≥5 days of fever, bilateral nonexudative conjunctivitis, mucositis, cervical lymphadenopathy, rash, and extremity swelling. Coronary artery aneurysms are the most serious potential sequelae in untreated clients, leading to complications such as myocardial infarction and death. Echocardiography is used to monitor these cardiovascular complications. Intravenous immunoglobulin (IVIG) along with aspirin is used to prevent coronary aneurysms and subsequent occlusion. KD is one of the few pediatric illnesses in which aspirin therapy is warranted due to its antiplatelet and anti-inflammatory properties. However, parents should be cautioned about the risk of Reye syndrome. Cardiopulmonary resuscitation should also be taught to parents of children with coronary artery aneurysms. (Option 1) KD is a vasculitis of unknown etiology, but it is not an infectious process. Because the child will often have a similar clinical presentation to that of an infection (eg, persistent fever, inflammatory immune response), KD may be mistaken for a bacterial or viral illness. (Option 2) Polymorphous rash of the trunk and extremities is an expected finding in a child with KD. Cool compresses, unscented lotions, and loose-fitting clothing can minimize discomfort. IVIG is not given to control rash. (Option 4) Lymphadenopathy (usually a single palpable anterior cervical node >1.5 cm) and splenomegaly are included in the clinical presentation of KD. IVIG therapy is not indicated to reduce incidence of these findings.

A distraught parent informs the nurse of bleeding in a 1-day-old girl. What is an appropriate response by the nurse after assessing a small amount of bloody mucus in the newborn's diaper? 1. "Laboratory work will need to be completed to determine your newborn's hormone levels." (15%) 2. "The health care provider will prescribe a dose of medication to stop the bleeding." (1%) 3. "We will continue to monitor the amount, color, and consistency of the drainage." (77%) 4. "What visitors have been present since the baby was born?" (5%)

Answer: 3 Mammary gland enlargement, non-purulent vaginal discharge (leukorrhea), and mild uterine withdrawal bleeding (pseudomenstruation) are benign transient findings commonly seen in newborns; these are physiologic responses to transplacental maternal estrogen exposure. Reassurance should be provided. Monitoring the amount, color, and consistency is the appropriate action (Option 3). (Options 1 and 2) The blood-tinged mucus will cease within a few days after birth when hormone levels return to normal. No additional workup or medications are indicated. (Option 4) Pseudomenstruation is a physiological process and is not caused by trauma or abuse.

The nurse provides teaching about methotrexate to a 28-year-old client with rheumatoid arthritis. Which client statement indicates the need for further instruction regarding this drug? 1. "I know my resistance to germs will be lower, so I should get a flu shot this year." (23%) 2. "I should take precautions to prevent pregnancy while I take this medicine." (16%) 3. "I will have an eye examination every 6 months to check for damage caused by my medication." (38%) 4. "It will be a difficult change for me, but I will not have wine with dinner anymore." (21%)

Answer: 3 Methotrexate (Rheumatrex) is classified as a folate antimetabolite, antineoplastic, immunosuppressant drug to treat various malignancies and as a nonbiologic disease-modifying antirheumatic drug (DMARD) to treat rheumatoid arthritis and psoriasis. The client's statement about getting an eye examination every 6 months indicates that further teaching is necessary as these examinations are not indicated for clients prescribed methotrexate (Option 3). However, frequent eye examinations are required for clients prescribed the nonbiologic antimalarial DMARD hydroxychloroquine (Plaquenil) as it can cause retinal damage. (Option 1) Methotrexate is an immunosuppressant and can cause bone marrow suppression. Clients are at risk for infection. They should avoid crowded places and individuals with known infection and should receive appropriate killed (inactivated) vaccines (eg, influenza, pneumococcal). Live vaccines (eg, herpes zoster) are contraindicated.

The nurse notes muffled heart tones in a client with a pericardial effusion. How would the nurse assess for a pulsus paradoxus? 1. Check for variation in amplitude of QRS complexes on the electrocardiogram strip (7%) 2. Compare apical and radial pulses for any deficit (48%) 3. Measure the difference between Korotkoff sounds auscultated during expiration and throughout the respiratory cycle (26%) 4. Multiply diastolic blood pressure (DBP) by 2, add systolic blood pressure (SBP), and divide the result by 3; [(DBP x 2) + (SBP)]/3 (17%)

Answer: 3 Muffled heart tones in a client with pericardial effusion can indicate the development of cardiac tamponade. This results in the build-up of fluid in the pericardial sac, which leads to compression of the heart. Cardiac output begins to fall as cardiac compression increases, resulting in hypotension. Additional signs and symptoms of tamponade include tachypnea, tachycardia, jugular venous distension, narrowed pulse pressure, and the presence of a pulsus paradoxus. Pulsus paradoxus is defined as an exaggerated fall in systemic BP >10 mm Hg during inspiration. The procedure for measurement of pulsus paradoxus is as follows: 1. Place client in semirecumbent position 2. Have client breathe normally 3. Determine the SBP using a manual BP cuff 4. Inflate the BP cuff to at least 20 mm Hg above the previously measured SBP 5. Deflate the cuff slowly, noting the first Korotkoff sound during expiration along with the pressure 6. Continue to slowly deflate the cuff until you hear sounds throughout inspiration and expiration; also note the pressure 7. Determine the difference between the 2 measurements in steps 5 and 6; this equals the amount of paradox 8. The difference is normally <10 mm Hg, but a difference >10 mm Hg may indicate the presence of cardiac tamponade.

The nurse is documenting assessments of pregnant clients in the antepartum unit. Which client's assessment findings are most important to report to the health care provider? 1. Client at 28 weeks gestation with an asymptomatic systolic murmur (9%) 2. Client at 34 weeks gestation with 1+ edema of bilateral lower extremities (5%) 3. Client at 35 weeks gestation with painful genital lesions (53%) 4. Client at 39 weeks gestation with brownish, mucoid vaginal discharge (31%)

Answer: 3 Painful genital lesions can be indicative of an outbreak of genital herpes simplex virus (HSV) and are a priority assessment finding to report to the health care provider. Herpes in pregnant women can be transmitted to the infant in utero (congenital HSV), perinatally, or postnatally as a result of direct contact with virus particles shed from the infected vulva, vagina, cervix, or perineum. Neonatal HSV infection has serious morbidity (eg, permanent neurologic sequelae) and mortality. Immediate antiviral therapy (eg, acyclovir) should be initiated to treat the active infection. Vaginal birth is not recommended in the presence of active lesions; cesarean birth helps reduce the risk of transmission to the newborn (Option 3).

The emergency department nurse is assigned 4 clients. Which client needs to be seen first? 1. 1-week-old with redness and swelling at the umbilicus and temperature of 100.1 F (37.8 C) (8%) 2. 2-year-old with a cough and post-tussive emesis with a respiratory rate of 27/min (13%) 3. 9-year-old with recent pacemaker insertion with dizziness and purulent drainage at the incision site (44%) 4. 14-year-old who reports a dull and constant headache after hitting the head while ice skating (33%)

Answer: 3 Permanent pacemakers consist of a generator that is implanted subcutaneously in the chest and lead wires that terminate in the heart. Infection of the incision site can easily travel down the pacemaker lead wires into the heart, causing myocarditis and/or endocarditis. Infection may disrupt pacemaker function and result in failure to sense or pace that causes decreased cardiac output and life-threatening arrhythmias. Signs and symptoms of pacemaker malfunction (eg, hypotension, bradycardia, dizziness) and infection (eg, redness, fever, purulent drainage) should be assessed immediately (Option 3). ***(Option 4) This client needs to be evaluated second for possible concussion or hemorrhage; however, the client is currently alert and responsive.***

A client with polycythemia vera comes to the clinic for a monthly treatment. The nurse knows that treatment for this condition will consist of which of the following? 1. Blood transfusion (26%) 2. Fluid bolus (22%) 3. Phlebotomy (42%) 4. Steroid injection (9%)

Answer: 3 Polycythemia vera (PV) is a chronic myeloproliferative disorder in which the bone marrow produces an abnormally high number of RBCs. Although PV is an abnormality of the bone marrow, secondary polycythemia can occur in an individual with chronic hypoxemia, such as chronic obstructive pulmonary disease or chronic lung disease. The danger of PV is seen when the client develops blood clots—due to the increased viscosity of the blood, which makes the circulation sluggish—and decreased tissue perfusion. Treatment of PV usually includes periodic phlebotomy, the removal of 300-500 mL of blood through venipuncture, to reduce the RBC count and achieve a hematocrit <45%. Initially, clients may require phlebotomy every other day until the goal hematocrit is reached. Hematocrit is then monitored monthly, and additional blood draws are performed as necessary. (Option 2) Although an IV fluid bolus may be helpful in the short term to reduce blood viscosity, it is not a maintenance treatment for PV. Instead, the client should be encouraged to drink >3 L of fluid daily and avoid dehydration.

A client who gave birth vaginally with epidural anesthesia still has limited movement and strength of the right leg, and reports no urge to urinate at 2 hours postpartum. The nurse palpates the client's fundus 2 cm above the umbilicus and to the right. What should the nurse do next? 1. Assist the client to the bathroom in a wheelchair (42%) 2. Encourage the client to drink plenty of fluids (5%) 3. Perform in-and-out catheterization (39%) 4. Reassess for bladder distension hourly (12%)

Answer: 3 Postpartum urinary retention is commonly related to decreased bladder sensation (eg, due to regional anesthesia, prolonged labor, or perineal trauma) and postpartum diuresis. Urinary retention can cause bladder distension, which may be noted by a displaced and/or boggy uterus, or by a palpable bladder. If bladder distension cannot be resolved with spontaneous voiding, in-and-out (I&O) catheterization may be indicated, especially if the client: - Is unable to ambulate to the restroom or void into a bedpan (Option 3) - Has not voided within 6-8 hours after delivery or removal of the indwelling urinary catheter after cesarean delivery - Has difficulty emptying bladder completely (ie, voiding <100 mL frequently)

The nurse is caring for a client who, 30 minutes ago, underwent an ablation procedure for supraventricular tachycardia in the cardiac catheterization laboratory. The client has a dressing over the femoral insertion site with a small amount of oozing blood. Which action by the nurse causes the charge nurse to intervene? 1. Applies pressure above the femoral insertion site (22%) 2. Assesses bilateral pedal pulses frequently (3%) 3. Assists client to sit on the side of the bed to use the urinal (64%) 4. Reports client chest pain of 2 on a scale of 0-10 to health care provider (9%)

Answer: 3 Radiofrequency catheter ablation is an invasive procedure that may be used to treat clients with recurrent episodes of supraventricular tachycardia. A catheter is inserted through a large artery or vein (eg, femoral) and threaded to the heart. Radiofrequency waves are delivered to inactivate tissue in the area of the heart causing the dysrhythmia. After cardiac catheterization, clients must remain supine with the head of the bed at ≤30 degrees and the affected extremity straight to prevent bleeding from the catheter insertion site. The charge nurse should intervene if the nurse is assisting the client to sit on the side of the bed to use the urinal (Option 3).

The nurse is reinforcing teaching to the parent of a child diagnosed with ringworm. Which statement by the parent indicates a need for further teaching? 1. "Antifungal cream must be applied to all affected areas to eradicate ringworm from the body." (16%) 2. "Hand washing is very important as ringworm can be spread among humans and pets." (6%) 3. "My child has been infected by a worm and must be treated to rid it from the body." (54%) 4. "My child will be uncomfortable due to itching, but this is not a dangerous condition." (23%)

Answer: 3 Ringworm, or tinea corporis, is a fungal infection on the superficial keratin layers of the skin, hair, and/or nails. Ringworm is a misleading name as the condition is not caused by a worm infestation. However, it is highly contagious and spreads via contact. Management includes teaching appropriate hygiene (eg, washing hands after touching infected areas), limited contact with personal items (eg, hair brush), and treatment with the prescribed shampoos as well as topical and/or oral medications (eg, terbinafine [Lamisil], miconazole).

client with generalized anxiety disorder has received a new prescription for sertraline. The nurse should teach this client about which possible side effect? 1. Constipation (12%) 2. Sedation (31%) 3. Sexual dysfunction (50%) 4. Weight loss (4%)

Answer: 3 Selective serotonin reuptake inhibitors (SSRIs) are commonly used to treat major depression and anxiety disorders. SSRIs (eg, fluoxetine, paroxetine, citalopram, escitalopram, sertraline) are generally well tolerated except for sexual dysfunction. Clients often underreport this side effect. However, when asked specifically, over 50% of clients taking SSRIs may be experiencing some type of sexual dysfunction. This can be a decrease in sexual desire, arousal, or orgasm and may vary by gender. The nurse should discuss this with the client. The side effect may decrease or cease after a 2- to 4-week waiting period for the therapeutic effect, or the client may be able to switch to a different antidepressant medication (eg, bupropion). (Option 4) Weight gain is a common side effect of most SSRIs, especially with long-term therapy.

The nurse prepares to administer the prescribed 8 AM medications to 4 clients. The nurse should administer medication to which client first? 1. Client 2 days postoperative abdominal surgery who is to receive enoxaparin for venous thromboembolism prophylaxis (5%) 2. Client with hypertension who has a blood pressure of 196/98 mm Hg and is to receive IV hydralazine (21%) 3. Client with suspected sepsis who has a temperature of 102.3 F (39.1 C) and is to receive an initial dose of IV ceftazidime (36%) 4. Client with type 2 diabetes mellitus and blood sugar of 500 mg/dL (27.8 mmol/L) who is to receive subcutaneous regular insulin and insulin glargine (35%)

Answer: 3 Sepsis is a condition associated with a serious infection in the bloodstream. Evidence-based guidelines recommend the early administration of antibiotic therapy to reduce mortality. Cultures should be obtained quickly and antibiotics administered as soon as possible. Failure to treat early sepsis can lead to septic shock (persistent hypotension) and multiorgan dysfunction syndrome.

Four clients enter the emergency department at the same time. Which client should the nurse alert the health care provider to see first? 1. 6-year-old who is crying and reports a headache after hitting the head (26%) 2. 17-year-old who cannot raise arm above head after a football injury (11%) 3. 40-year-old with a first-degree burn and singed beard from a campfire (44%) 4. 70-year-old experiencing severe diarrhea and a poor appetite (17%)

Answer: 3 Singed facial hair may indicate a smoke inhalation injury from close proximity to a fire. Inhaled smoke causes injury to the airway and lung tissue, which may result in life-threatening pulmonary or tracheal edema. The nurse should assess for any indications of inhalation injury (eg, singed facial hair, hoarse voice, burned clothing around the chest and neck) and prepare for emergent intubation to protect the airway. ***(Option 1) A child who has a headache after a head trauma may have a concussion and will require a neurologic examination. This client is alert enough to verbalize pain and will likely be discharged with instructions to the parents to observe for changes in neurologic status.***

The registered nurse is counseling the parent of a child who was diagnosed with attention-deficit hyperactivity disorder and received a prescription for methylphenidate immediate-release tablet. Which statement by the parent demonstrates that teaching has been effective? 1. "An additive-free, low-sugar diet will reduce my child's symptoms." (21%) 2. "I can now manage my child's condition on my own." (3%) 3. "My child should not take the last daily dose after 6 PM." (74%) 4. "Once medication is started, I will not have to monitor my child anymore." (1%)

Answer: 3 Stimulant medications (eg, methylphenidate, dextroamphetamine, lisdexamfetamine) are first-line agents in the treatment of attention-deficit hyperactivity disorder (ADHD). Methylphenidate (Ritalin) is administered in divided doses 2 or 3 times daily, usually 30-45 minutes before meals. As a stimulant, methylphenidate may interfere with sleep and should be given no later than around 6 PM (Option 3). The sustained-release preparation should be given in the morning. The dosage in children is usually started low and titrated to the desired response.

The nurse provides discharge teaching for the parent of a child newly prescribed methylphenidate for attention-deficit hyperactivity disorder (ADHD). The nurse advises the parent that the child might experience which side effects? 1. Decreased blood pressure and growth delays (18%) 2. Heart palpitations and weight gain (16%) 3. Loss of appetite and restlessness (51%) 4. Trouble sleeping and a dry cough (14%)

Answer: 3 Stimulant medications are commonly used to treat ADHD in children and adults. Methylphenidate (Ritalin) and amphetamines (eg, dextroamphetamine, lisdexamfetamine) are the most commonly used stimulants. The major problems with stimulant medications include: 1. Decreased appetite and weight loss - can lead to growth delays 2. Cardiovascular effects - hypertension and tachycardia (particularly in adults) 3. Appearance of new or exacerbation of vocal/motor tics 4. Excess brain stimulation - restlessness, insomnia 5. Abuse potential - misuse, diversion, addiction

The nurse is caring for a client with non-Hodgkin lymphoma who is starting chemotherapy. What assessment findings alert the nurse that the client is developing the potential complication of tumor lysis syndrome? 1. Facial and upper body edema (10%) 2. Generalized edema and hyponatremia (12%) 3. Hyperkalemia and hyperuricemia (54%) 4. Hypotension and elevated lactic acid (23%)

Answer: 3 TLS may result in the following life-threatening conditions: - Hyperkalemia (eg, >5.0 mEq/L [5.0 mmol/L]) may progress to lethal dysrhythmias (eg, ventricular fibrillation) - Large amounts of nucleic acids (normally converted to uric acid and excreted by the kidneys) overwhelm the kidneys, leading to hyperuricemia and acute kidney injury from uric acid crystal formation - Hyperphosphatemia (eg, >4.4 mg/dL [>1.42 mmol/L]) can cause acute kidney injury and dysrhythmias TLS is best prevented by aggressive hydration and prophylactic allopurinol for hyperuricemia.

After talking to the client, the health care provider (HCP) tells the registered nurse that the client's signature is needed on the consent form that has been filled out. While the nurse is obtaining the signature, the client states, "I'm not clear on what is included in the low-fat diet that I'll be on after the cholecystectomy." What action should the nurse take? 1. Call the HCP to come and talk to the client (34%) 2. Refuse to witness the signature on the consent (1%) 3. Teach the client about a low-fat diet (64%) 4. Tell the client that the HCP will explain it later (0%)

Answer: 3 The HCP performing the surgery should explain the risks, benefits, and alternatives of the specific procedure to the client. However, the nurse can witness the client's signing of the consent form; this differs from "obtaining consent." If the client had a question about the procedure, or the risks, alternatives, or outcomes, then the HCP should be contacted to provide additional teaching to the client. However, an ordinary question about general care or health care teaching can be answered by the nurse as this is part of the nurse's role. (Options 1, 2, and 4) As the client is not asking about details related to the procedure, it is unnecessary for the HCP to return to talk to the client (unless the client specifically asks for this). The client's question does not interfere with the ability to legitimately sign consent for the procedure or with the nurse's witnessing of the client signing the consent form.

The nurse reinforces education to a female client about the use of a cervical cap to prevent pregnancy. Which statement by the client indicates a need for further teaching? 1. "I should apply spermicide to the cervical cap before inserting it." (13%) 2. "I should not use the cervical cap while I am on my period." (14%) 3. "I will remove and clean the cervical cap as soon as possible after intercourse." (47%) 4. "It is okay for me to insert the cervical cap several hours before I have sex." (24%)

Answer: 3 The cervical cap is a barrier method of contraception used with spermicide (eg, nonoxynol-9). The reusable, cup-shaped cap is placed over the cervix before intercourse to block sperm from the uterus. To allow time for sperm to die, the cap should remain in place for ≥6 hours after intercourse but should not remain for more than 48 hours (Option 3). The cap may remain in place for multiple acts of intercourse, but clients should confirm correct placement and insert additional spermicide into the vagina each time.

A client with a permanent pacemaker with continuous telemetry calls the nurse and reports feeling lightheaded and dizzy. The client's blood pressure is 75/55 mm Hg. What is the nurse's priority action? Click the exhibit button for additional information. 1. Administer atropine 0.5 mg IV (19%) 2. Administer dopamine 5 mcg/kg/min IV (10%) 3. Initiate transcutaneous pacing (35%) 4. Notify the health care provider (34%)

Answer: 3 The client is experiencing failure to capture from the permanent pacemaker with subsequent bradycardia and hypotension. Failure to capture appears on the cardiac monitor as pacemaker spikes that are not followed by QRS complexes. Pacemaker malfunction may be caused by a failing battery, malpositioned lead wires, or fibrosis at the tip of lead wire(s) preventing adequate voltage for depolarization. This client is symptomatic (eg, hypotension, dizziness) from insufficient perfusion. The nurse's priority is to use transcutaneous pacemaker pads to normalize the heart rate, stabilize blood pressure, and adequately perfuse organs until the permanent pacemaker is repaired or replaced (Option 3). Administer analgesia and/or sedation as prescribed as transcutaneous pacing is very uncomfortable for the client.

The nurse is caring for a client with an implantable cardioverter defibrillator (ICD). The client goes into ventricular tachycardia and is pulseless. The ICD has fired twice. What action should the nurse take? 1. Administer epinephrine 1 mg IV push (18%) 2. Deactivate the ICD with a magnet (5%) 3. Initiate chest compressions (66%) 4. Take no action and let the ICD work (9%)

Answer: 3 The client with an ICD that is firing is receiving electrical shocks from the internal defibrillator to interrupt the dysrhythmia. It is still imperative that the client receive chest compressions in the form of cardiopulmonary resuscitation (CPR) to provide circulation of blood to the vital organs. The nurse should implement the pulseless arrest algorithm, allowing 30-60 seconds for the ICD to complete its therapy cycle before applying external defibrillation pads/paddles.

An experienced nurse precepts a graduate nurse caring for a hospitalized client who has a prescription for a transfusion of packed red blood cells (RBCs) to be hung over 3 hours. Which statement by the graduate nurse indicates the correct rationale for asking the client to void prior to starting the transfusion? 1. "A drop in blood pressure is expected during the transfusion and getting up to void may cause a fall." (24%) 2. "Bedrest is required; therefore, voiding will prevent intermittent catheterization during the procedure." (15%) 3. "If a transfusion reaction occurs, it will be important to collect a fresh urine specimen to check for hemolyzed RBCs." (41%) 4. "The urine is collected and analyzed prior to starting the transfusion to assess the client's baseline results." (17%)

Answer: 3 The nurse should ask the client to void or empty the urinary catheter and discard urine prior to starting a blood transfusion. In the event of an acute hemolytic transfusion reaction, a fresh urine specimen should be collected and sent to the laboratory to analyze for hemolyzed RBCs. An acute hemolytic transfusion reaction is a life-threatening reaction in which the host's antibodies rapidly destroy the transfused RBCs and is generally related to incompatibility. Early signs of a hemolytic reaction include red urine, fever, and hypotension; late signs include disseminated intravascular coagulation and hypovolemic shock. The transfusion should be stopped immediately if any sign of transfusion reaction occurs. Starting the transfusion with an empty bladder will help ensure that any urine specimen collected after a reaction is reflective of the body's physiological processes after the blood transfusion has started (Option 4).

The nurse prepares to administer an IV infusion of potassium chloride through a peripheral vein to a client with hypokalemia. The health care provider's prescription states: IV potassium chloride 10 mEq (10 mmol)/100 mL 5% dextrose in water now, infuse over 30 minutes. What is the nurse's priority action? 1. Assess the patency of the peripheral IV site (24%) 2. Check the most current serum potassium level (33%) 3. Contact the health care provider to verify the prescription (39%) 4. Set the electronic IV pump to 100 mL/hr (2%)

Answer: 3 The recommended rates for an intermittent IV infusion of potassium chloride (KCl) are no greater than 10 mEq (10 mmol) over 1 hour when infused through a peripheral line and no greater than 40 mEq/hr (40 mmol/hr) when infused through a central line (follow facility guidelines and policy). If the nurse were to administer the medication as prescribed, the rate would exceed the recommended rate of 10 mEq/hr (10 mmol/hr) (ie, 10 mEq [10 mmol] over 30 minutes = 20 mEq/hr [20 mmol/hr]). A too rapid infusion can lead to pain and irritation of the vein and postinfusion phlebitis. Contacting the health care provider to verify this prescription is the priority action.

The nurse is caring for a client with a chest tube that was placed 2 hours ago for a pneumothorax. Where would the nurse expect gentle, continuous bubbling? 1. Air leak monitor (3%) 2. Collection chamber (4%) 3. Suction control chamber (41%) 4. Water seal chamber (50%)

Answer: 3 The suction control chamber (Section A) maintains and controls suction to the chest drainage system; continuous, gentle bubbling indicates that the suction level is appropriate. The amount of suction is controlled by the amount of water in the chamber and not by wall suction. Increasing the amount of wall suction would cause vigorous bubbling but does not increase suction to the client as excess suction is drawn out through the vent of the suction control chamber. Vigorous bubbling would increase water evaporation and therefore decrease the negative pressure applied to the system. The nurse should check the water level and add sterile water, if necessary, to maintain the prescribed level. (Option 1) The air leak monitor (Section C) is part of the water seal chamber. Continuous or intermittent bubbling seen here indicates the presence of an air leak. (Option 2) The collection chamber (Section D) is where drainage from the client will accumulate. The nurse will assess amount and color of the fluid and record as output. (Option 4) The water seal chamber contains water, which prevents air from flowing into the client. Up and down movement of fluid (tidaling) in Section B would be seen with inspiration and expiration and indicates normal functioning of the system. This will gradually reduce in intensity as the lung reexpands.

The nurse working on the inpatient psychiatric unit is preparing to administer 9:00 AM medications to a client. The medication administration record is shown in the exhibit. On assessment, the client is tremulous, exhibits muscle rigidity, and has a temperature of 101.1 F (38.4 C). Which action should the nurse take? Click on the exhibit button for additional information. 1. Give all medications, including acetaminophen, and reassess in 30 minutes (10%) 2. Hold the haloperidol, give acetaminophen, and reassess in 30 minutes (14%) 3. Hold the haloperidol and notify the health care provider (HCP) immediately (61%) 4. Hold the hydrochlorothiazide and notify the HCP immediately (13%)

Answer: 3 This client is exhibiting signs and symptoms of neuroleptic malignant syndrome (NMS), a rare but potentially life-threatening reaction. NMS is most often seen with the "typical" antipsychotics (eg, haloperidol, fluphenazine). However, even the newer "atypical" antipsychotic drugs (eg, clozapine, risperidone, olanzapine) can cause the syndrome. NMS is characterized by fever, muscular rigidity, altered mental status, and autonomic dysfunction (eg, sweating, hypertension, tachycardia). Treatment is supportive and is directed at reducing fever and muscle rigidity and preventing complications. Treatment in an intensive care unit (ICU) may be required. The most important intervention is to immediately discontinue the antipsychotic medication and notify the HCP for further assessment.

A client with a diagnosis of atrial fibrillation has just been placed on warfarin therapy. The registered nurse (RN) overhears a student nurse teaching the client about potential food-drug interactions. Which statement made by the student nurse requires an intervention by the RN? 1. "Do you take any nutritional supplements?" (7%) 2. "You will need to monitor your intake of foods containing vitamin K." (17%) 3. "You will not be able to eat green, leafy vegetables while taking this medication." (71%) 4. "Your blood will be tested at regular intervals." (4%)

Answer: 3 Warfarin (Coumadin) works by blocking the availability of vitamin K, which is essential for blood clotting. As a result, the clotting mechanism is disrupted, reducing the risk of a stroke, venous thrombosis, or pulmonary embolism. Sudden increases or decreases in the consumption of vitamin K-rich foods could inversely alter the effectiveness of warfarin. An increase in vitamin K could decrease the effectiveness of warfarin, placing the client at increased risk of blood clot formation; a decrease could increase the effectiveness of warfarin, placing the client at increased risk for bleeding. (Option 1) Many medications can interfere with warfarin metabolism. Nutritional supplements may contain vitamin K, and so any new medication or nutritional supplement should be approved by the health care provider. Cranberry juice, grapefruit, green tea, and alcohol may also interfere with the effectiveness of warfarin.

Prior to hospital discharge, the nurse discusses sexuality after childbirth with a client who had an uncomplicated vaginal birth with no perineal lacerations. Which client statement requires further teaching? 1. "I should avoid resuming sexual intercourse until after my vaginal bleeding has stopped." (17%) 2. "I should expect vaginal dryness and use water-soluble lubricants, especially if I'm breastfeeding." (25%) 3. "I will begin using condoms to prevent pregnancy once menses returns." (38%) 4. "I will try to feed my baby before my partner and I engage in sexual activity." (19%)

Answer: 3 Initiating an open discussion about sexual activity after childbirth allows the nurse to provide anticipatory guidance and recognize individual client concerns (eg, discomfort, fatigue, fear, body image). The nurse should plan to reinforce the use of contraception because many clients resume sexual activity before their postpartum checkup (4-6 weeks after birth), when contraception methods are usually prescribed. Ovulation may occur as early as 4 weeks after birth and before resumption of menses, especially in clients who formula feed. Clients should be encouraged to use a barrier contraceptive such as condoms to prevent pregnancy until another form of birth control can be prescribed (Option 3). (Option 1) Sexual activity may be resumed once lacerations/episiotomy are healed, and vaginal bleeding has stopped. For clients with no birth complications, risk of infection or bleeding is low at ≥2 weeks postpartum. (Option 2) Sexual arousal takes more time for most postpartum clients due to hormonal changes. Lactating clients may especially experience symptoms of estrogen deficiency (eg, vaginal dryness). Vaginal lubrication is recommended to increase comfort. (Option 4) Sexual activity may be inhibited by the couple's sense of responsibility for newborn needs. In addition, sexual arousal may stimulate leakage of breast milk. Feeding the newborn before sexual activity helps alleviate these concerns/distractions.

The nurse is caring for a client at 21 weeks gestation with reports of occasional, bothersome heartburn (pyrosis). Which of the following lifestyle changes should the nurse recommend? Select all that apply. 1. Avoid intake of dairy products 2. Drink large amounts of fluid with meals 3. Eat several small meals each day 4. Eliminate fried, fatty foods 5. Lie down on the left side after meals

Answer: 3, 4 Pyrosis, or heartburn, is common during pregnancy due to an increase of the progesterone hormone and uterine enlargement that displaces the stomach. Progesterone relaxes smooth muscles, resulting in esophageal sphincter relaxation. Gastric contents are then regurgitated, usually causing a burning sensation behind the sternum. The nurse should educate the client about lifestyle changes for reducing heartburn, such as: - Keep the head of the bed elevated using pillows - Sit upright after meals - Eat small, frequent meals (Option 3) - Avoid tight-fitting clothing - Eliminate common dietary triggers (eg, fried/fatty foods, caffeine, citrus, chocolate, spicy foods, tomatoes, carbonated drinks, peppermint) (Option 4) (Option 1) Dairy products do not typically lead to heartburn and are an important source of calcium during pregnancy.

The nurse provides discharge teaching for family members of a client going home following a suicide attempt. Which of the following instructions are appropriate for the nurse to include? Select all that apply. 1. "Avoid initiating discussion about suicide as this may increase risk for additional attempts." 2. "If the client hints at self-harm, redirect the conversation to positive subjects." 3. "Maintain a list of community resources and a suicide hotline for quick reference." 4. "Remove excess and unused medications, firearms, and knives from the home." 5. "Sudden positive outlook or calmness may indicate an impending suicide attempt."

Answer: 3, 4, 5 (Some options are logical which is why I left out the rationale for them) Recognizing that a client's sudden positive outlook or calmness may be a sign that the client has determined a plan for suicide and feels hopeful about having resolution (Option 5) **(Options 1 and 2) The client's risk for acting on suicidal thoughts may be reduced, not increased, when provided the opportunity to express thoughts and related feelings. All communication about self-harm should be addressed directly.**

The nurse in the oral surgery clinic reviews a client's medical record prior to surgery. Which will the nurse immediately report to the oral surgeon? Select all that apply. 1. Client is on a calorie-restricted diet for obesity 2. Creatinine is 1.3 mg/dL (115 µmol/L) 3. History of congenital heart disease 4. International Normalized Ratio of 2.5 5. Presence of prosthetic valve

Answer: 3, 4, 5 Clients with a history of congenital heart disease and those with prosthetic valves are at risk for developing infective endocarditis, an infection of the endothelial lining of the heart, with oral surgery and certain procedures (eg, dental work). These clients should receive prophylactic antibiotic therapy prior to any such procedure or surgery. Clients on warfarin therapy due to the presence of prosthetic valves or for other reasons will have a therapeutically elevated International Normalized Ratio (2.0-3.0) to inhibit blood clot formation. However, this will place these clients at risk for excessive bleeding during surgical procedures (Options 3, 4, and 5).

When monitoring an infant with a left-to-right-sided heart shunt, which findings would the nurse expect during the physical assessment? Select all that apply. 1. Clubbing of fingertips 2. Cyanosis when crying 3. Diaphoresis during feedings 4. Heart murmur 5. Poor weight gain

Answer: 3, 4, 5 Congenital heart defects that cause blood to shunt from the higher pressure left side of the heart to the lower pressure right side (eg, patent ductus arteriosus, atrial septal defect, ventricular septal defect) increase pulmonary blood flow. Left-to-right shunting results in pulmonary congestion, causing increased work of breathing and decreased lung compliance. Compensatory mechanisms (eg, tachycardia, diaphoresis) result from sympathetic stimulation. Clinical manifestations of acyanotic defects may include: - Tachypnea - Tachycardia, even at rest - Diaphoresis during feeding or exertion (Option 3) - Heart murmur or extra heart sounds (Option 4) - Signs of congestive heart failure - Increased metabolic rate with poor weight gain (Option 5)

The nurse has provided teaching to the parents of a 6-month-old child who is being discharged with a new prescription for a liquid iron supplement. Which statements by a parent indicate a need for additional instruction? Select all that apply. 1. "Our child might become constipated while taking this medication." 2. "Our child's stools might become black and tarry." 3. "We can give the dose with milk to prevent stomach irritation." 4. "We will administer the dose into the back of our child's cheek." 5. "We will administer the dose with meals to increase absorption."

Answer: 3, 5 At birth, a newborn will have enough iron (received during the last trimester of pregnancy) to last until approximately age 4 months. After this age, formula-fed infants usually receive adequate iron intake from iron-fortified formula, whereas breastfed infants may require supplementation until they begin eating iron-rich foods. Oral iron supplements should be given on an empty stomach between meals for best absorption (Option 5). If gastric irritation occurs, iron may be given with meals; however, this will decrease absorption. If the child is old enough, the supplements should be offered with citrus fruit juice as vitamin C will increase absorption. Milk products and antacids also decrease the absorption of oral iron and should be avoided for 2 hours following administration (Option 3). **(Options 1 and 2) Iron supplements may cause constipation and black or dark green, tarry stools. Parents should be taught not to be alarmed if these expected findings occur. (Option 4) Liquid iron supplements can stain teeth and so are administered with a medicine dropper toward the back of the infant's cheek. The dose may be diluted with water or juice to prevent staining and improve flavor. Older children should use a straw to take the supplement and drink water or juice after each dose.**

The clinic nurse evaluates the ongoing treatment plan for a client with major depressive disorder. Which of the following client statements indicate a positive response to treatment? Select all that apply. 1. "I am trying to force myself to eat more, but I have still lost 5 pounds." 2. "I have been getting about 13 hours of sleep at night, and I still feel tired." 3. "I joined a book club with some of the parents from my kids' school." 4. "Physical intimacy doesn't interest me like it used to, but my spouse is patient." 5. "This haircut and color are very different, but I think I like the new look."

Answer: 3, 5 Major depressive disorder (MDD) is a psychiatric disorder characterized by a persistently depressed mood or loss of interest in usual activities lasting for at least two weeks. Treatment for MDD includes the use of antidepressant medications, psychotherapy (eg, cognitive-behavioral therapy, group therapy), and sometimes electroconvulsive therapy. Positive outcomes associated with an effective treatment regimen may include: - Renewed interested in self-care (Option 5) - Increased social interaction (Option 3) - Planning for the future and finding purpose in life - Improved self-esteem (eg, verbalizing positive self-attributes) - Returning to normal daily activities (Options 1, 2, and 4) Hypersomnia (or insomnia), weight loss (or gain), and decreased libido are signs of MDD, which indicate that the client has not fully recovered.

It is 0700 and the nurse is caring for an 84-year-old client with dementia and a fractured hip. The client has been disoriented to time, place, and person since admission. The client moans frequently and grimaces when moving. He is prescribed morphine IV every 2 hours as needed for pain and was last medicated at 0530. He is scheduled for surgery at 1000 to repair the hip fracture, but the consent has not yet been signed. The client's spouse and child are to arrive at 0900. Which intervention should the nurse carry out first? 1. Administer pain medication (20%) 2. Call the health care provider to meet with the family to obtain informed consent (23%) 3. Complete the preoperative checklist (4%) 4. Perform the morning assessment (51%)

Answer: 4 (Incoming shift @ 0700) The morning shift assessment should be completed first to collect baseline assessment data (eg, vital signs, lung sounds, level of consciousness), assess pain, and collect necessary information for the preoperative checklist (Option 4). (Option 1) Pain medicine is not due until 0730 and can be administered after the initial assessment if necessary. (Option 2) The nurse should call the health care provider after the initial assessment (by 0730) and arrange for a meeting with family members at 0900 to obtain informed consent as the client is not capable of giving it. (Option 3) The preoperative checklist can be completed after consent is obtained.

The registered nurse (RN) is providing nursing care with a licensed practical nurse and unlicensed assistive personnel. The RN administers hydromorphone 1.5 mg IVP per STAT order to a client with severe abdominal pain. Three hours later, the client rates pain as a 9 on a scale of 0-10 and requests pain medication. What is the most appropriate action for the RN to take? 1. Administer the hydromorphone (17%) 2. Ask the licensed practical nurse to administer the medication (2%) 3. Ask the unlicensed assistive personnel to take repeat vital signs (22%) 4. Contact the health care provider (57%)

Answer: 4 A STAT order indicates that the medication should be given immediately and only one time. A new prescription for the medication must be acquired before the dose can be repeated. The most appropriate action is to contact the health care provider to request an as-needed prescription for pain medication.

What is the best activity for a school-aged child hospitalized for vaso-occlusive sickle cell crisis? 1. Finger painting (18%) 2. Playing a game of Chinese checkers in the activity room (16%) 3. Playing video games (12%) 4. Watching a favorite movie (52%)

Answer: 4 A child in vaso-occlusive sickle cell crisis will be experiencing a high level of pain due to the occlusion of small blood vessels from increased red blood cell sickling. Supportive and symptomatic treatment includes round-the-clock pain management with opioids, intravenous fluids for hydration, and bed rest to decrease energy expenditure and oxygen demand. Age-specific nonpharmacologic strategies should also be implemented to manage pain and help limit the amount of needed narcotic analgesia. For a school-aged child, such activities include distraction (watching TV, listening to music, reading), relaxation, guided imagery, warm soaks, positioning, and gentle massage. (Option 1) Finger painting is messy and best done in the activity room; it is not appropriate for a child confined to bed.

A school-age child is brought to the emergency department due to nausea, vomiting, and severe right lower quadrant pain. The child's white blood cell count is 17,000/mm3 (17.0 x 109/L). Which statement by the child is of most concern to the nurse? 1. "I am hungry and they will not let me eat." (5%) 2. "I don't like hospitals and I want to go home." (1%) 3. "I'm so tired." (15%) 4. "My belly doesn't hurt anymore." (77%)

Answer: 4 A child with acute-onset right lower quadrant abdominal pain, nausea, and vomiting and a high white blood cell count likely has acute appendicitis. Appendicitis is a serious condition that usually requires emergency surgery due to the risk of appendix rupture. The pain results from swelling and inflammation of the appendix. However, once the appendix ruptures, pain is relieved only temporarily and will return with full-blown peritonitis and sepsis.

The nurse caring for a terminally ill client asks if the client has an advance directive. The client states, "I already have a power of attorney." What is the best response by the nurse? 1. "A power of attorney (POA) is good to have in place. It sounds like you are on the right track." (7%) 2. "Great. Your POA can start to make decisions for you when you are no longer able to do so." (13%) 3. "Many people find a lawyer at this stage of life. A lawyer can help you get your affairs in order." (1%) 4. "There are many types of POAs. Let's clarify if your POA can make health care decisions for you." (77%)

Answer: 4 A power of attorney (POA) designates a representative to act on a person's behalf in the event that the individual becomes incapacitated. There are different types of POAs, including medical and financial. An advance directive or living will describes the client's health care decisions (eg, do not resuscitate). As part of an advance directive, the client may designate a representative to make health care decisions for the client - a durable POA for health care or POA for health care (Canada). This client's statement requires further clarification regarding what type of POA is in place (Option 4).

The nurse prepares a client for discharge following a vasectomy. The client asks, "When can I have sexual intercourse with my wife without using a condom?" What is the best response by the nurse? 1. "Discontinue alternative birth control after at least 5 ejaculations." (14%) 2. "There is no need to use alternative birth control following today's procedure." (15%) 3. "Use alternative birth control for 6 months following today's procedure." (19%) 4. "Use alternative birth control until cleared by the health care provider." (50%)

Answer: 4 A vasectomy is a surgical procedure performed for permanent male sterilization. During the procedure, the vasa deferentia (ie, ducts that carry sperm from the testicles to the urethra) are cut and sealed, preventing sperm from entering the ejaculate. The vasa deferentia are severed in the scrotum at the site before the seminal vesicles and prostate. As a result, the procedure should not affect the ability to ejaculate, amount and consistency of ejaculatory fluid, or other physiological mechanisms (eg, hormone production, erection, orgasm). Following a vasectomy, sperm continue to be produced but are absorbed by the body. Following the procedure, it can take several months for the remaining sperm to be ejaculated or absorbed. Alternative birth control should be used until the health care provider confirms that semen samples taken at a follow-up appointment are free of sperm; otherwise, pregnancy can occur (Option 4). (Options 1, 2, and 3) The length of time and number of ejaculations necessary to evacuate remaining sperm will vary. The only way to ascertain that the ejaculate no longer contains sperm is to test a client's semen samples.

The clinic nurse is reviewing telephone messages from four clients. Which client's call should the nurse return first? 1. Client who has just taken albuterol and reports a heart rate of 108/min and a coarse tremor in both arms (14%) 2. Client who is prescribed azithromycin and reports frequent, foul-smelling, liquid stools and abdominal cramping (14%) 3. Client who is prescribed metformin and reports a blood glucose of 284 mg/dL (15.76 mmol/L) and frequent urination (13%) 4. Client who takes amiodarone and reports a dry cough and increased dyspnea when walking around the house (58%)

Answer: 4 Amiodarone is an antiarrhythmic medication used to treat life-threatening arrhythmias that cannot be controlled with other medications. Amiodarone therapy is used only if other treatments have failed, as it has many toxic, adverse effects that may be severe. Pulmonary toxicity is a life-threatening adverse effect of amiodarone, which is believed to cause direct cellular damage and activation of an immune response in the lungs. Clients who develop pulmonary toxicity may report respiratory symptoms such as dry cough, pleuritic chest pain, and dyspnea. Clients with clinical manifestations of pulmonary toxicity require immediate intervention to prevent fatal, irreversible lung damage (Option 4).

The office nurse receives 4 telephone messages. Which client should the nurse call back first? 1. 28-year-old female client who fell on ice yesterday and has low back pain and spasm (0%) 2. 42-year-old male client who developed sharp, burning leg pain radiating from buttock to knee after lifting heavy weights (2%) 3. 65-year-old female client 10 days post spinal fusion who has increased persistent back pain and fever of 101.2 F (38.4 C) (46%) 4. 70-year-old male client with peripheral vascular disease who has acute-onset abdominal pain radiating to the low back (49%)

Answer: 4 An abdominal aortic aneurysm (AAA) is a blood-filled bulge in the abdominal aorta caused by weakening in the vessel wall due to increased pressure. Risk factors include male sex, age >65, coronary artery and peripheral vascular diseases, hypertension, and family and smoking history. AAA dissection (blood leakage into a vessel tear) or rupture may manifest as acute-onset abdominal pain radiating to the back and is typically associated with symptoms of hemorrhagic shock (eg, decreased systolic pressure; increased, weak pulses; pallor). This client's symptoms could indicate impending rupture, which can lead to life-threatening vascular hemorrhage. **Option 2) This client's pain is most likely radicular (irritation of the sciatic nerve) in origin. Although neurovascular evaluation for a herniated disk (L5-S1) is necessary, this is not a life-threatening condition.**

The nurse is teaching a client who is scheduled to have an inferior vena cava filter inserted via the right femoral vein. Which statement by the client requires further teaching? 1. "I need to make all health care providers aware of my filter before I have body scans." (9%) 2. "I need to stay active and avoid crossing my legs for extended periods when I get home." (9%) 3. "I should call the health care provider if I develop numbness, tingling, and swelling in my right leg." (3%) 4. "It is normal to have some chest or back discomfort for a few days after filter placement." (76%)

Answer: 4 An inferior vena cava filter is a device that is inserted percutaneously, usually via the femoral vein. The filter traps blood clots from lower extremity vessels (eg, embolus from deep venous thrombosis) and prevents them from migrating to the lungs and causing a pulmonary embolism (PE). It is prescribed when clients have recurrent emboli or anticoagulation is contraindicated. Clients should be questioned about and report any metallic implants (eg, vascular filters/coils) to the health care team prior to radiologic imaging, specifically MRI (Option 1). Physical activity should be promoted, and clients should avoid crossing their legs to promote venous return from the legs (Option 2). Leg pain, numbness, or swelling may indicate impaired neurovascular status distal to the insertion site and should be reported immediately (Option 3).(Option 4) Symptoms of PE (eg, chest pain, shortness of breath) and vascular injury (bleeding causing back pain) are not expected findings after the procedure and should be reported immediately.

A client with a C3 spinal cord injury has a headache and nausea. The client's blood pressure is 170/100 mm Hg. How should the nurse respond initially? 1. Administer PRN analgesic medication (2%) 2. Administer PRN antihypertensive medication (17%) 3. Lower the head of the bed (17%) 4. Palpate the client's bladder (62%)

Answer: 4 Autonomic dysreflexia is an acute, life-threatening response to noxious stimuli, which clients with spinal cord injuries above T6 are unable to feel. Signs and symptoms include hypertension, bradycardia, a pounding headache, diaphoresis, and nausea. It is essential that the nurse assess for and remove noxious stimuli to prevent a stroke (Option 4). Noxious stimuli may include: - Bladder distention (eg, obstructed urinary catheter, neurogenic bladder) - Fecal impaction - Tight clothing (eg, shoelaces, waistbands) (Options 1 and 2) Hypertension, headache, and nausea due to uncontrolled sympathetic activity will resolve once the cause is identified and removed. (Option 3) Lowering the head of the bed would increase blood pressure. The head of the bed should be raised to lower the blood pressure.

A nurse is preparing to administer a unit of packed red blood cells to a critically ill client. Two nurses have performed the verification process, and the unit label indicates that it is in-date and unexpired. On inspection, the nurse notices a large air bubble at the top of the bag. What is the appropriate action by the nurse at this time? 1. Call the blood bank to verify the expiration date and the safety of the blood for administration (6%) 2. Call the health care provider for further instruction and file an incident report (0%) 3. Proceed with administration as any air will be caught by the drip chamber of the tubing (24%) 4. Return the blood to the blood bank, notify them that air is present, and obtain a new bag (68%)

Answer: 4 Before a blood transfusion, the nurse should verify the client's identity, crossmatch the client's determined ABO blood-type and Rhesus (Rh) factor with the unit's blood group label, and verify the unit donor number and expiration date against the blood bank receipt. The nurse should also inspect the blood product for any signs of blood product contamination. Blood products are a protein- and sugar-rich medium for bacterial growth. Indications of contaminated blood include: - Green, black, white, or dusky discoloration - Accumulations of air - Evidence of clotting or presence of inclusions - Malodor Units exhibiting any of these signs should be returned to the blood bank (Option 4). (Option 1) Regardless of the expiration date, potentially contaminated blood products should be returned to the blood bank for investigation. (Option 2) It is not necessary to notify the health care provider unless there will be a critical delay in administration of the prescribed blood products or a contaminated product is administered. An incident report may be required later but is not the priority. (Option 3) Although air may be caught by the drip chamber, large accumulations of air or gasses in the bag often indicate a problem with the safety and freshness of the product. This blood should not be transfused.

The staff nurse is preparing a presentation about strategies to reduce horizontal violence. The nurse educator is reviewing the presentation beforehand. Which recommendation included in the presentation indicates a need for further teaching? 1. Creating a behavior code of conduct outlining communication (12%) 2. Creating a suggestion box for anonymously reporting bullying (35%) 3. Providing consistent education regarding bullying (3%) 4. Working toward diversification of staff age and gender (48%)

Answer: 4 Bullying, harassment, or disparaging behaviors between coworkers in the workplace, or horizontal violence, is an issue in nursing that results in job dissatisfaction, decreased productivity, anxiety, burnout, and decreased quality of care. Nurses must be aware of horizontal violence and work to eliminate disparaging practices in the work environment. Horizontal violence behaviors may be verbal (eg, belittling, gossiping, using a hostile tone of voice) and/or nonverbal (eg, ignoring, eye-rolling). Anonymous reporting (eg, suggestion boxes, tip lines) may encourage staff participation and identify aggressors (Option 2). Current trends and behaviors related to professionalism should be analyzed to work toward identifying solutions. All staff should receive education regarding the importance of a positive work culture and the facility's expectations for behavior and consequences of horizontal violence (Options 1 and 3). Addressing factors that increase stress in the workplace (eg, increased workload, high client-staff ratios, unfair scheduling) can reduce horizontal violence. ***(Option 4) Although gender and age diversity play a role in overall collaboration, diversification is not known to decrease workplace hostility and horizontal violence.***

The nurse is speaking to a client who takes desmopressin nasal spray for diabetes insipidus. Which statement by the client is most important for the nurse to report to the health care provider? 1. "I am tired of restricting my fluids but know I need to." (15%) 2. "I feel like I am beginning to get sick with a bad cold." (13%) 3. "I have been getting a lot of nasal pain with this spray." (12%) 4. "I have recently started to experience frequent headaches." (59%)

Answer: 4 Desmopressin is a medication often used to treat central diabetes insipidus, a disease characterized by reduced antidiuretic hormone (ADH) levels that may result in dehydration and hypernatremia. Desmopressin mimics the effects of naturally occurring ADH, which increases renal water resorption and concentrates urine. However, this effect also increases the risk for water intoxication from decreased urine output. Clients receiving desmopressin must have their fluid and electrolyte status closely monitored for symptoms of water intoxication/hyponatremia (eg, headache, mental status changes, weakness). The nurse should immediately notify the health care provider (HCP) of client reports of water intoxication symptoms, as severe hyponatremia may progress to seizure, neurologic damage, or death (Option 4).

In the intensive care unit, the nurse cares for a client who has been admitted with diabetic ketoacidosis. The client is on a continuous infusion of regular insulin at 5 units/hr via IV pump. Which action should the nurse expect to implement? 1. Check serum BUN and creatinine levels every hour (43%) 2. Discontinue insulin infusion when blood glucose is <350 mg/dL (19.4 mmol/L) (31%) 3. Increase insulin infusion rate when blood glucose level decreases (4%) 4. Initiate potassium IV when serum potassium is 3.5-5.0 mEq/L (3.5-5.0 mmol/L) (20%)

Answer: 4 Diabetic ketoacidosis (DKA) is an acute, serious complication generally due to lack of insulin in clients with type 1 diabetes. DKA is characterized by hyperglycemia, ketosis, and acidosis. Hyperglycemia causes osmotic diuresis, resulting in profound dehydration. Clients with DKA may initially develop hyperkalemia as a compensatory response to acidosis despite having a total body potassium deficit from urinary loss. Management of DKA includes fluid resuscitation, IV insulin, and hourly blood glucose monitoring. When serum glucose is <250 mg/dL (13.9 mmol/L), D5W is administered to prevent hypoglycemia until ketoacidosis is resolved. Hypokalemia often occurs with resolution of acidosis and administration of IV insulin, which shifts potassium from the intravascular to the intracellular space. Therefore, potassium is administered even when the client is normokalemic (3.5-5.0 mEq/L [3.5-5.0 mmol/L]) to prevent hypokalemia and subsequent life-threatening arrhythmias (Option 4).

An elderly client with diabetes comes to the clinic in winter reporting numbness of the feet. After removing the client's shoes and socks, the nurse notes that the feet are ice cold to the touch and appear waxy and pale. What is the appropriate nursing action? 1. Assist the client with ambulation to promote circulation (8%) 2. Bring the client warm blankets and a warm beverage (19%) 3. Massage the client's hands and feet to promote warming (4%) 4. Soak the client's lower legs in a warm water bath (67%)

Answer: 4 Frostbite occurs when vasoconstriction restricts blood flow, intracellular fluid freezes, and cell membranes rupture; tissue may appear pale, waxy, blue, or mottled. Clients with peripheral vascular problems (eg, advanced age, diabetes, smoking) are at a higher risk for developing frostbite. A warm water bath (eg, 98.6-102.2 F [37-39 C]) is administered to thaw and reestablish as much circulation to viable tissue as possible. Subsequent edema and/or superficial blistering may develop as the damaged tissue is rewarmed. Blisters are opened to reduce pressure and sterile dressings are applied. The client will need analgesics as the rewarming process is very painful. (Options 1 and 3) Manual friction (eg, massage, ambulation) applied to tissues affected by frostbite is contraindicated as it may further damage the tissues. **(Option 2) Comfort care (eg, warm blankets) may be provided after emergent interventions to salvage the client's lower extremities. However, the nurse should consult with the health care provider before providing food or drink to the client.**

When making assignments in the labor and delivery unit, the charge nurse should assign the most experienced newborn admit nurse to attend to the birth of which client? 1. Client with diet-controlled gestational diabetes (2%) 2. Client with mild preeclampsia and blood pressure averaging 140/90 mm Hg (12%) 3. Client with premature rupture of membranes 6 hours ago at 37 weeks gestation (9%) 4. Client with spontaneous rupture of membranes with greenish amniotic fluid (75%)

Answer: 4 Green amniotic fluid indicates that the fetus has passed its first stool (meconium) in utero. Meconium-stained amniotic fluid places the newborn at risk for meconium aspiration syndrome, a type of aspiration pneumonia. A skilled neonatal resuscitation team should be present at the birth of any newborn with meconium-stained fluid for immediate evaluation and stabilization (Option 4). Previously, endotracheal (ET) suctioning was recommended for nonvigorous newborns (eg, depressed respirations, decreased muscle tone, heart rate <100/min) born with meconium-stained fluid; however, recent guidelines indicate that routine ET suctioning is no longer necessary.

The nurse is providing first aid at an outdoor festival when a client reports dizziness and weakness. The client is flushed, sweating, nauseated, and slightly tachycardic. Which action is most appropriate at this time? 1. Call emergency medical services and place ice packs on the client's axilla and groin (24%) 2. Encourage the client to leave the venue to visit a health care provider (0%) 3. Evaluate whether the client may be intoxicated (15%) 4. Move the client to an air-conditioned booth and provide a cool sports drink (59%)

Answer: 4 Heat exhaustion is the result of prolonged exposure to excessive heat. Heat exhaustion manifests with elevated body temperature (hyperthermia), intravascular volume depletion, and electrolyte imbalance. Manifestations include dizziness, weakness, fatigue, sweating, flushing, nausea, tachycardia, and muscle cramping. If heat exhaustion is suspected, the client should be moved to cooler temperatures and provided a cool sports drink, another electrolyte-containing beverage (eg, Gatorade), or water (Option 4). The priority is to lower the body temperature to prevent heat stroke, a potentially fatal condition associated with mental status changes (ie, indicating brain damage) and additional organ damage (eg, kidney injury, rhabdomyolysis). If the client's temperature continues to rise after moving to cooler temperatures, ice packs placed on the axilla and groin may help to dissipate heat; further medical help may be necessary. (Option 2) The client should not leave until the symptoms subside, especially if driving. It is not necessary to have the client visit a health care provider if symptoms resolve.

The nurse is reinforcing teaching to a client with a hiatal hernia. Which statement by the client indicates that further teaching is needed? 1. "I need to raise the head of my bed on blocks by at least 6 inches." (11%) 2. "I will remain sitting up for several hours after I eat any food." (11%) 3. "If my reflux and abdominal pain don't improve, I might need surgery." (5%) 4. "Losing weight may reduce my reflux, so I plan to take a weight-lifting class." (71%)

Answer: 4 Hiatal hernia is a group of medical conditions characterized by abnormal movement of the stomach and/or esophagogastric junction into the chest due to a weakness in the diaphragm. Although hiatal hernias may be asymptomatic, many people experience heartburn, chest pain, dysphagia, and shortness of breath when the abdominal organs move into the chest. Symptoms of hiatal hernias are often exacerbated by increased abdominal pressure, which promotes upward movement of abdominal organs. Clients with hiatal hernias who are obese are often encouraged to lose excess weight by performing light activities (eg, short walks) because obesity increases abdominal pressure. However, nurses should teach clients to avoid activities that promote straining (eg, weight lifting), which increases abdominal pressure (Option 4). (Options 1 and 2) Sitting up for several hours after meals and sleeping with the head of the bed elevated at least 6 inches (15 cm) reduces upward movement of the hernia and decreases the risk of gastric reflux.

The nurse is providing education to a pregnant client diagnosed with symptomatic hypothyroidism regarding levothyroxine therapy during pregnancy. Which is appropriate teaching for the nurse to include? 1. After symptoms resolve, levothyroxine may be discontinued (5%) 2. Levothyroxine should be taken in the evening with a prenatal vitamin (8%) 3. Medication dose will remain the same throughout pregnancy (21%) 4. Symptoms should begin improving within 4 weeks of starting levothyroxine (65%)

Answer: 4 Hypothyroidism during pregnancy places clients at increased risk for other complications of pregnancy (eg, preeclampsia, placental abruption, preterm labor). Symptoms of hypothyroidism may include fatigue, cold intolerance, constipation, dry skin, and brittle hair/nails. Levothyroxine (Synthroid) is the first-line medication for treatment of hypothyroidism during pregnancy. The client may experience some relief of symptoms beginning approximately 3-4 weeks after initiating levothyroxine therapy (Option 4). Hormone levels are usually rechecked every 4-6 weeks until normal thyroid hormone levels are achieved. It may take up to 8 weeks after initiation to see the full therapeutic effect. (Option 1) Adequate levels of maternal thyroid hormones are important for fetal brain development, particularly during the first trimester. Levothyroxine should not be stopped during pregnancy, even if symptoms resolve. (Option 2) Prenatal vitamins containing iron can affect the absorption of levothyroxine and decrease its effectiveness. The nurse should instruct the client to take levothyroxine in the morning on an empty stomach, at least 4 hours before or after taking a prenatal vitamin. (Option 3) As the pregnancy advances, the client's dose of levothyroxine may need to be increased. Thyroid stimulating hormone (TSH) levels are closely monitored during pregnancy, and the client's dose is modified as needed to maintain normal levels.

The nurse assesses a client who is intubated and mechanically ventilated after a cerebrovascular accident. Which assessment finding is most important for the nurse to report to the health care provider? 1. Flaccid right hand and arm (9%) 2. Impaired gag reflex when suctioning (33%) 3. Presence of urinary incontinence (3%) 4. Rigid flexion of arms at the elbows (53%)

Answer: 4 In a cerebrovascular accident (CVA), blood flow in the brain is compromised due to either bleeding or occlusion of a blood vessel. After a CVA, mental status may continue to decline, especially within the first 24-48 hours. The nurse should immediately notify the health care provider of decorticate (flexion) posturing, which is characterized by arms rigidly flexed at the elbow, hands raised to the chest, and legs extended (Option 4). This posturing suggests worsening cerebral impairment (eg, increased intracranial pressure) that may be reversible with proper interventions. **(Option 2) An impaired gag reflex may indicate an impaired airway; however, a patent airway has already been established in an intubated and mechanically ventilated client. An impaired gag reflex can occur after intubation if sedation was required for placement of the endotracheal tube. (Option 3) Bladder dysfunction (eg, retention, incontinence) can be an expected finding in a client who has experienced a CVA, depending on the level of neurological impairment.**

A client presents to the emergency department with a stab wound to the chest. The nurse assesses tachycardia, tachypnea, and a sucking sound coming from the wound. Which of the following actions is priority? 1. Administer prescribed IV fluids (2%) 2. Apply supplemental oxygen via nonrebreather mask (16%) 3. Assist the health care provider to prepare for chest tube insertion (12%) 4. Cover the wound with petroleum gauze taped on three sides (68%)

Answer: 4 In a traumatic, or "open," pneumothorax, air rushes in through the wound with each inspiration, creating a sucking sound, and fills the pleural space. The lungs cannot expand, so the client develops respiratory distress and air hunger. Tachycardia and hypotension result from impaired venous return, as the heart and great vessels shift with each breath. A tension pneumothorax may also develop if air cannot escape the pleural space. The priority action in this medical emergency is to apply a sterile occlusive dressing (eg, petroleum gauze) taped on three sides, preventing inward air flow while allowing air to escape the pleural space.

The nurse cares for a child with bed bug bites. Which parent statement indicates that further teaching is required? 1. "I need to have the entire house treated by pest control to ensure the bed bugs are gone." (9%) 2. "I should concentrate on alleviating scratching as it can cause further complications." (6%) 3. "My other family members and pets are at risk of bed bug bites." (4%) 4. "This must have happened because I did not wash the bed sheets this week." (80%)

Answer: 4 It is a common misconception that bed bugs are drawn only to dirty environments. They can inhabit any environment and can travel and spread easily in clothing, bags, furniture, and bedding. Although they do not pose significant harm, bed bugs can cause an itchy red rash that can be uncomfortable and affect sleep. Bed bugs should be exterminated, especially in a home with children.

The nurse checks a client's blood pressure using an automatic, noninvasive machine. The nurse notes that the machine inflates for an unusually long amount of time, and the client reports intense pain in the arm with the cuff. The device suddenly stops inflation and displays an error message. Which action by the nurse is appropriate? 1. Place a soft washcloth under the cuff and repeat the measurement (0%) 2. Repeat the measurement after moving the cuff to the opposite arm (19%) 3. Repeat the measurement using a new cuff that is a size larger than the client needs (11%) 4. Send the machine for maintenance and repeat the measurement manually (68%)

Answer: 4 Malfunctioning health care equipment must be taken out of service to prevent client injury. If an automatic, noninvasive blood pressure (BP) machine malfunctions (eg, overinflates, displays error message), it may cause an inaccurate reading as well as pain and bruising to the client. The nurse should tag any malfunctioning piece of equipment and take it out of service until it can be checked by maintenance personnel (Option 4). The nurse should take the client's BP with a manual cuff so that the maximum inflation can be controlled. A BP cuff needs to be inflated only to approximately 30 mm Hg above the pressure at which the client's brachial pulse disappears. (Option 3) BP cuffs that are too small or too large for a client will affect the accuracy of the BP measurement. The nurse should always verify that the correct cuff size is being used.

The nurse reinforces teaching to a female client about taking misoprostol to prevent stomach ulcers. Which statement by the client would prompt further instruction? 1. "I can take this medication with food if it hurts my stomach." (7%) 2. "I must use a reliable form of birth control while taking this medication." (10%) 3. "I should continue to take my ibuprofen as prescribed." (44%) 4. "I will take this medicine with an antacid to decrease stomach upset." (37%)

Answer: 4 Misoprostol (Cytotec) is a synthetic prostaglandin that protects against gastric ulcers by reducing stomach acid and promoting mucus production and cell regeneration. It is often prescribed to prevent gastric ulcers in clients receiving long-term nonsteroidal anti-inflammatory drug (NSAID) therapy. Antacids, especially those that contain magnesium (eg, Gaviscon), can increase the adverse effects of misoprostol (eg, diarrhea, dehydration). If clients require therapy with antacids, they should choose one that does not contain magnesium (eg, calcium carbonate [Tums]) and contact the health care provider if adverse effects occur (Option 4).

Four clients in labor are requesting pain relief. The nurse understands that which client can safely receive a dose of IV butorphanol tartrate, an opioid agonist-antagonist, at this time? 1. Multipara at 6 cm dilation with recent heroin use (14%) 2. Multipara at 9 cm dilation with an urge to push (9%) 3. Nullipara at 3 cm dilation desiring to ambulate (32%) 4. Nullipara at 7 cm dilation moaning with contractions (43%)

Answer: 4 Opioid agonist-antagonist medications used in labor include butorphanol tartrate (Stadol) and nalbuphine hydrochloride (Nubain). Maternal adverse effects include sedation, dizziness, and nausea. Butorphanol tartrate crosses the placental barrier, peaking in 30-60 minutes; its duration of action is approximately 2-4 hours. If given near the time of birth, there is a risk for newborn respiratory depression, which may require naloxone (Narcan) to reverse the effects. IV opioids are safest for clients who will give birth 2-4 hours after administration so that the opioid effect has time to wear off before the birth. IV opioids are also best for clients in active labor or those with a well-established contraction pattern because opioid administration may slow labor progression in the latent phase (Option 4). **(Option 1) Although this client is in active labor, recent heroin use is a contraindication to opioid agonist-antagonists because of the risk for maternal and/or fetal withdrawal symptoms.**

The graduate nurse (GN) is inserting an oropharyngeal airway into a client emerging from general anesthesia. Which action by the GN causes the nurse preceptor to intervene? 1. Measures the oropharyngeal airway against the cheek and jaw angle before insertion (30%) 2. Rotates the device tip downward once it reaches the soft palate (21%) 3. Suctions secretions from the mouth and pharynx prior to device insertion (13%) 4. Tapes the external portion of the inserted oropharyngeal airway to the client's cheek (35%)

Answer: 4 Oropharyngeal airways (OPAs) are temporary artificial airway devices used to prevent tongue displacement and tracheal obstruction in clients who are sedated or unconscious. As consciousness and the ability to protect the airway return, the client often coughs or gags, indicating a need to remove the OPA; clients may also independently remove or expel it. Nurses caring for a client with an OPA must ensure that the device is easily removable from the client's mouth because an obstructed (eg, taped) OPA may cause choking and aspiration (Option 4).

The nurse is obtaining orthostatic vital signs on a client admitted for dehydration. The nurse measures the client's blood pressure and pulse using the left brachial site with the client lying supine and then sitting. Which action by the nurse is appropriate? Click on the exhibit button for additional information. 1. Assist the client to a standing position and measure a third set of vital signs (62%) 2. Place the client in reverse Trendelenburg position and take an apical pulse (3%) 3. Reassess the client's blood pressure in the supine position using the popliteal site (4%) 4. Return the client to a recumbent position and notify the health care provider (29%) Vital signs: Supine- Blood pressure: 153/83 mm Hg Heart rate: 70/min Sittting- Blood pressure: 119/70 mm Hg Heart rate: 95/min

Answer: 4 Orthostatic vital signs help assess the body's ability to compensate hemodynamically during postural changes. Changing position normally triggers vasoconstriction in the extremities to promote venous return. Without this response, hypotension and subsequent hypoperfusion of internal organs and the brain occur. Clients with impaired compensatory mechanisms (eg, hypovolemia, sepsis) may exhibit orthostatic hypotension, in which hypotension and/or neurologic impairment (eg, syncope) occur with position change. This increases the client's risk for falls. Orthostatic vital signs involve measuring the client's blood pressure (BP) and heart rate in the supine, sitting, and standing positions. Each measurement should be obtained after maintaining each position for 2 minutes. If any position change produces decreased systolic BP ≥20 mm Hg, decreased diastolic BP ≥10 mm Hg, and/or increased pulse ≥20/min from supine values, the nurse should discontinue assessment, place the client in a recumbent position, and notify the health care provider (Option 4).

The home health nurses visits a 72-year-old client with pneumonia who was discharged from the hospital 3 days ago. The client has less of a productive cough at night but now reports sharp chest pain with inspiration. Which finding is most important for the nurse to report to the health care provider? 1. Bronchial breath sounds (3%) 2. Increased tactile fremitus (13%) 3. Low-pitched wheezing (rhonchi) (11%) 4. Pleural friction rub (72%)

Answer: 4 Pleurisy is characterized by stabbing chest pain that usually increases on inspiration or with cough. It is caused by inflammation of the visceral pleura (over the lung) and the parietal pleura (over the chest cavity). The pleural space (between the 2 layers) normally contains about 10 mL of fluid to help the layers glide easily with respiration. When inflamed, they rub together, causing pleuritic pain. A pleural friction rub is auscultated in the lateral lung fields over the area of inflammation. The sound is produced by the 2 layers rubbing together and can indicate pleurisy, a complication of pneumonia. It is characterized by squeaking, crackling, or the sound heard when the palm is placed over the ear and the back of the hand is rubbed with the fingers. Complications of pneumonia are more prevalent in elderly clients with underlying chronic disease.

A client comes to the emergency department after being bitten by a bat. The nurse observes 2 small, nondraining puncture wounds resembling pinpricks on the fingertip. Which action should the nurse implement first? 1. Administer an intramuscular injection of human rabies vaccine (19%) 2. Administer an intramuscular tetanus toxoid vaccine if client not immunized within 5 years (11%) 3. Inject human rabies immunoglobulin into the proximal wound area (11%) 4. Scrub the wound with povidone-iodine solution or soap and water (57%)

Answer: 4 Rabies is caused by a virus present in the saliva of an infected animal (eg, bat, dog) and can be transmitted to a human through a bite, a scratch, or mucous membrane contact. Rabies affects the central nervous system, and can cause viral encephalitis with eventual death from cardiovascular and respiratory collapse if untreated. Clients with actual or suspected rabies exposure should receive rabies postexposure prophylaxis, including: (IN ORDER) 1. Immediate wound care: Aggressive scrubbing and cleaning with povidone-iodine solution or soap and water to decrease the viral count and the rabies transmission risk (Option 4) 2. Administration of tetanus toxoid vaccine (if the client is not current with immunizations): Tetanus is associated with a high mortality rate and can be transmitted through animal bites (Option 2) 3. Administration of the human rabies immunoglobulin: Provides passive immunity and is injected into the proximal wound area (Option 3) 4. Administration of the human rabies vaccine: Provides active immunity and is administered intramuscularly on the day of exposure and again on days 3, 7, and 14 postexposure (Option 1)

The client admitted to the psychiatric unit with severe anxiety is pacing rapidly in the room, crying, and hyperventilating. The client yells, "I can't believe you took my belongings! Where are you keeping them? This is so frustrating!" What is the appropriate response by the nurse? 1. "I understand that you are frustrated. I will give you some time to yourself to decompress." (8%) 2. "This is frustrating for me too. I wish I could give you your belongings right now, but I can't." (0%) 3. "Would you like to sit down so we can talk? Pacing like this will make you feel worse." (20%) 4. "Your belongings are locked in a safe place to ensure that they are protected while you are here." (70%)

Answer: 4 Severe anxiety impairs the ability to attend to stimuli in the environment other than the anxiety-producing event or factor. Physiological responses to anxiety include hyperventilation, palpitations, shortness of breath, and diaphoresis. Behavioral responses (eg, fixation on specific details, pacing) serve as coping mechanisms to manage anxiety. Unrelieved anxiety may become severe and escalate to a panic attack. The nurse should ensure safety and support the client with severe anxiety to prevent injury and escalation. The client is unable to attend to details, so the nurse should communicate in a calm, accepting manner; answer questions directly; and use simple statements (Option 4). (Option 1) Clients with severe anxiety are unable to attend to their own safety or needs. The nurse should not leave the client alone at this time.

The clinic nurse is listening to voicemail messages in the office. Which client should the nurse call back first? 1. Client started on capsaicin cream 2 days ago reports sudden burning in the eyes (18%) 2. Client started on carbidopa-levodopa a day ago reports dizziness on standing (6%) 3. Client started on hydroxyzine 3 days ago reports urinary difficulty and hesitancy (8%) 4. Client started on phenytoin a week ago reports blistered lesions on the face and trunk (65%)

Answer: 4 Stevens-Johnson syndrome is an immune-mediated reaction triggered by certain classes of medications (eg, sulfonamide antibiotics, allopurinol, anticonvulsants [eg, phenytoin]). Initial symptoms are nonspecific and flu-like (eg, fever, fatigue) and are followed by blistered lesions and skin detachment on the face, trunk, and palms (Option 4). Stevens-Johnson syndrome can cause fatal complications (eg, sepsis, multiple organ dysfunction) and requires immediate hospitalization and follow-up by the health care provider. Treatment includes prompt discontinuation of the causative medication and initiation of supportive care (eg, fluids, nutrition, wound care). (Option 1) Capsaicin cream (Zostrix) is a topical analgesic. Capsaicin, a component of hot peppers (eg, cayenne, jalapeño), can cause a burning sensation; therefore, clients are taught to wash their hands after application to avoid getting the cream in their eyes. (Option 3) Hydroxyzine (Atarax) is a commonly used, first-generation antihistamine similar to diphenhydramine (Benadryl) and chlorpheniramine. Anticholinergic side effects (eg, urinary retention, dry mouth, constipation, blurred vision) are common. This client needs to be called second.

A client with chronic heart failure calls the clinic to report a weight gain of 3 lb (1.36 kg) over the last 2 days. Which information is most important for the nurse to ask this client? 1. Diet recall for this current week (1%) 2. Fluid intake for the past 2 days (4%) 3. Medications and dosages taken over the past 2 days (8%) 4. Presence of shortness of breath, coughing, or edema (85%)

Answer: 4 The client with chronic heart failure is at risk for exacerbations that may require hospitalization. The priority for the nurse on the phone is to ascertain if the client is experiencing any physiological symptoms such as shortness of breath, coughing, or edema (Option 4). These could indicate fluid overload. This information can help the nurse direct the client to come in for further assessment, follow a protocol to make changes in medications/dosages, or restrict fluids.

A client was treated in the emergency department 2 days ago. The nurse makes a follow-up call to say that a culture shows that the client needs an antibiotic. The client's spouse answers the phone, says that the client is at work and doing fine, and that the client does not need the antibiotic. Which is a priority action for the nurse? 1. Call the prescription into the client's pharmacy (2%) 2. Document the spouse's statement in the client's chart (6%) 3. Notify the emergency department physician (8%) 4. Request that the spouse tell the client to call back (81%)

Answer: 4 The spouse does not have the authority to refuse the required medication for the client as the client is competent and has decision-making capacity. An informed refusal includes knowing the risks and benefits of the decision, including the potential of latent infection/damage in this case. If the client does not call back, the typical facility policy is to try to reach the client by phone 3 times, then by certified letter, and (depending on the seriousness of the result) then sending the police to contact the client. (Option 2) The statement and attempts for contact should be documented, but the first priority is client care.

The nurse receives report on 4 clients. Which client should be seen first? 1. 10-month-old with audible congestion and mucus-producing cough (37%) 2. 10-year-old with an active nose bleed who is applying pressure (12%) 3. 12-year-old with urinary frequency and burning, and fever (5%) 4. 15-year-old with painful right hip, fever, and limited range of motion (44%)

Answer: 4 This client is exhibiting localized (eg, pain, limited range of motion) and systemic infection symptoms (eg, fever), which may indicate septic arthritis. Possible causes include recent surgery, injections, trauma, or spread from adjacent infection (eg, cellulitis). A septic hip is considered a surgical emergency. The hip joint is prone to develop avascular necrosis (eg, damage to the femoral head) from compromised blood supply due to infection or injury (eg, fracture). This can result in sequelae that are significant in both the short term (eg, sepsis, death) and long term (eg, joint destruction). Management includes culturing synovial fluid and blood, giving antibiotics, and debriding the infected joint.

READ THE QUESTIONS VERY CAREFULLY: The nurse is caring for a pt admitted with incomplete fractures of right 5-7. The nurse notes shallow respirations, and the client reports deep pain on inspiration. What is the priority at this time? **Keep in mind this question is not asking about respiratory depression because what is causing the shallow breathing is the pain not something physiological like COPD for example**

Answer: Administer prescribed IV morphine- the focus is on the pain relief in order for the pt to be able to breath better. In this case, morphine will not depress breathing because the pt does not have an underling cause.

A 3-month-old infant has irritability, facial edema, a 1-day history of diarrhea with adequate oral intake, and seizure activity. During assessment, the parents state that they have recently been diluting formula to save money. Which is the most likely cause for the infant's symptoms?

Answer: Hyponatremia due to water intoxication Water intoxication (water overload) resulting in hyponatremia may occur in infants when formula is diluted to "stretch" the feeding to save money. Hyponatremia may also result from ingestion of plain water (eg, caregiver attempting to rehydrate an infant who has been ill). Infants have immature renal systems with a low glomerular filtration rate, which decreases their ability to excrete excess water and makes them susceptible to water intoxication. Symptoms of hyponatremia include irritability, lethargy, and, in severe cases, hypothermia and seizure activity. Breast milk and/or formula are the only sources of hydration an infant needs for the first 6 months of life. Formula should be prepared per the manufacturer's instructions.

A 1-year-old child who goes to day care is recovering from an episode of otitis media. Which intervention is most important for the nurse to recommend to the parents in order to prevent recurrence?

Answer: Smoking cessation by the parents -Otitis media (OM) is the inflammation or infection of the middle ear resulting from dysfunction of the eustachian tube. OM typically occurs in infants and children under age 2, sometimes following a respiratory tract infection. The eustachian tubes in infants and young children are short, straight, and fairly horizontal, which results in ineffective drainage and protection from respiratory secretions. Infants with exposure to tobacco smoke are at risk for OM due to the resulting respiratory inflammation. OM risk is also higher with activities such as using a pacifier or drinking from a bottle when lying down as these allow fluid to pool in the mouth and then reach the eustachian tubes.

The parent of a 15-month-old calls the nurse and says that the child developed a rash and mild fever after receiving a routine measles, mumps, rubella, and varicella (MMRV) vaccine in the pediatric clinic 5 days ago. What is the best response by the nurse?

Answer: What is the child's temp right now? Rationale: Some children have a mild reaction to the MMRV vaccine within 5-12 days after the first dose. Problems include low-grade fever, mild rash, swelling and erythema at the injection site, irritability, and restlessness. The rash should disappear in 2-3 days. Although rare, fever after MMRV vaccination can lead to febrile seizures. Therefore, it is important for the nurse to determine the child's temperature to evaluate the risk for a febrile convulsion. It would also be important for the nurse to instruct the parent to monitor the child's temperature and administer acetaminophen for a fever above 102 F (38.9 C).

A nurse is discharging a client who is receiving lithium for treatment of a bipolar disorder. It is most important for the nurse to provide which instruction to the client? 1. Avoid a high-potassium diet (22%) 2. Exercise regularly and maintain a high-fiber diet (5%) 3. Maintain oral hygiene (8%) 4. Report excessive urination and increased thirst (62%)

Answer:4 Lithium is a mood stabilizer most often used to treat bipolar affective disorders. It has a narrow therapeutic index (0.6-1.2 mEq/L [0.6-1.2 mmol/L]). Risk factors for lithium toxicity include dehydration, decreased renal function (in the elderly), diet low in sodium, and drug-drug interactions (eg, nonsteroidal anti-inflammatory drugs [NSAIDS] and thiazide diuretics). Chronic toxicity can result in: 1. Neurologic manifestations - ataxia, confusion or agitation, and neuromuscular excitability (tremor, myoclonic jerks) 2. Nephrogenic diabetes insipidus - polyuria and polydipsia (increased thirst) (Option 4) Clients should be educated about monitoring for these symptoms and obtaining serum lithium levels at regular intervals.

A nurse in the surgical admitting unit is preparing a client for elective coronary artery bypass surgery. Which statement by the client should the nurse report immediately to the health care provider (HCP)?

Antiplatelet medication (eg, prasugrel [Effient], clopidogrel [Plavix], ticagrelor [Brilinta]) are often prescribed to a client after a percutaneous coronary intervention such as angioplasty or stent placement. These agents should be stopped at least 5-7 days prior to the surgery to reduce the chance of intraoperative and postoperative bleeding. The nurse should immediately report to the HCP that the client is still taking prasugrel and took it the morning of the surgery. Unless the surgery is emergent, it will most likely be postponed at least a week.

A 45-year-old client with atrial fibrillation has been prescribed diltiazem. Which client outcome would best indicate that the medication has had its intended effect? 1. Atrial fibrillation is converted to sinus rhythm (42%) 2. Blood pressure is 126/78 mm Hg (17%) 3. No signs or symptoms of stroke (4%) 4. Ventricular rate decreased from 158/min to 88/min (35%)

Atrial fibrillation is characterized by disorganized electrical activity in the atria due to multiple ectopic foci. It leads to loss of effective atrial contraction and places the client at risk for embolic stroke as a result of the thrombi formed in the atria. During atrial fibrillation, the atrial rate may be increased to 350-600/min. The ventricular response can vary. The higher the ventricular rate, the more likely the client will have symptoms of decreased cardiac output (ie, hypotension). The treatment goals are to reduce the ventricular rate to <100/min and prevent stroke. Ventricular rate control is the priority. Medications used for rate control include calcium channel blockers (ie, diltiazem), beta blockers (ie, metoprolol), and digoxin.

What must a pt avoid and for how long before and after having CPT?

Avoid meals or snacks 1 hr before, during, and 2 hrs following CPT to prevent gastrointestinal upset.

A 7-month-old infant is admitted to the unit with suspected bacterial meningitis after receiving an initial dose of antibiotics in the emergency department. Frequent assessment of which of the following is most important in the plan of care?

Bacterial meningitis is inflammation of the meninges of the brain and spinal cord caused by infection. General manifestations in infants and children age <2 include fever, restlessness, and a high-pitched cry. One common acute complication of bacterial meningitis is hydrocephalus, an increase in intracranial pressure (ICP) resulting from obstruction of cerebrospinal fluid flow. Increased ICP can progress to permanent hearing loss, learning disabilities, and brain damage. Bulging/tense fontanels and increasing head circumference are important early indicators of increased ICP in children. Frequent assessment for developing complications is vital for any client with suspected bacterial meningitis.

The nurse answers a call light on a client not assigned to the nurse. The client, who was just admitted from the emergency department, requests a cup of coffee. What is the appropriate intervention?

Because the nurse is unfamiliar with the client, the prescriptions from the HCP should be reviewed before giving any fluids. It is common for clients admitted from the emergency department to be designated nothing by mouth (NPO) until appropriate diagnostics have been completed or in case of possible surgery. Caffeine would be questionable as it can interfere with certain diagnostic tests, such as nuclear cardiac studies.

The nurse is caring for a postpartum couplet and notices that the newborn is cyanotic and apneic, with a heart rate of 70/min. The nurse calls for help and begins resuscitation. Which position is appropriate for ventilating the newborn?

Before newborn resuscitation, the nurse should place the infant on the back with the neck slightly extended to promote adequate ventilation. Very slight neck extension, otherwise known as the neutral or sniffing position, ensures a patent airway. The nurse may need to place a blanket or towel roll under the newborn's shoulders to elevate the chest ¾-1 inch (2-2.5 cm) above the mattress. This technique may be particularly useful for maintaining the sniffing position during ventilation if the newborn has a large occiput from molding or edema (eg, caput succedaneum) (Option 1).

A client comes to the clinic for a follow-up visit after a Billroth II surgery (gastrojejunostomy). The client reports occasional episodes of sweating, palpitations, and dizziness 30 minutes after eating. Which nursing action is most appropriate?

Billroth II surgery (gastrojejunostomy) removes part of the stomach and shortens the upper gastrointestinal tract. After a partial gastrectomy, many clients experience dumping syndrome, which occurs when gastric contents empty too rapidly into the duodenum, causing a fluid shift into the small intestine. This results in hypotension, abdominal pain, nausea/vomiting, dizziness, generalized sweating, and tachycardia. To reduce the occurrence of symptoms, clients should avoid fluids with meals and lie down after eating to slow gastric emptying. An upright or sitting position increases the force of gravity, which increases the rate of gastric emptying.

The nurse caring for a client with left lobar pneumonia responds to an alarm from the continuous pulse oximeter. The client is short of breath with an oxygen saturation of 78%. After applying oxygen, the nurse should place the client in which position to improve oxygenation?

Blood flow in the lungs is partially influenced by gravity, meaning that blood flows in higher volumes to dependent parts of the lung. Therefore, a client with left lobar pneumonia should be positioned in right lateral position with the unaffected (good) lung down (eg, right lung) to increase blood flow to the lung most capable of oxygenating blood

What is blood dyscrasia?

Bone marrow suppression

What is the grey-turner sign and what is it a sign of?

Bruising of the flanks and retroperitoneal hemorrhage and is a bluish color

What happens first in pts who suffer from burn injuries?

Burn injuries cause tissue damage that leads to increased vascular permeability and fluid shifts (eg, second and third spacing). In the emergent phase after a burn (first 24-72 hours), fluid, proteins, and intravascular components leak into the surrounding interstitium, causing decreased intravascular oncotic pressure and decreased intravascular volume, and resulting in fluid shifts and hypovolemia.

How is denial treated?

By confronting it by pointing out the difference from what they say to what they do

The health care provider (HCP) has told a client to take over-the-counter (OTC) supplemental calcium carbonate 1000 mg/day for treatment of osteoporosis. Which instruction should the clinic nurse give the client? 1. Monthly calcium levels will need to be drawn (31%) 2. Stop vitamin D supplements when taking calcium (5%) 3. Take calcium at bedtime (15%) 4. Take calcium in divided doses with food (47%)

Calcium and vitamin D are essential for bone strength. Calcium carbonate (Caltrate) has the most available elemental calcium of OTC products and is inexpensive; it is therefore the preferred calcium supplement for most clients with osteoporosis. Calcium absorption is impaired when taken in excess of 500 mg per dose. Therefore, most clients should take supplements in divided doses (<500 mg per dose). These should be taken within an hour of meals as food increases calcium absorption. Constipation is a frequent side effect of calcium supplements, so clients should be advised to take appropriate precautions. Calcium carbonate and calcium acetate (PhosLo) are used to reduce serum phosphorous levels in clients with chronic kidney disease. In such cases, calcium should remain in the intestine and bind the phosphorous present in food; the calcium phosphorus product would then be excreted in stool. Therefore, these clients should take calcium supplements before meals.

What is vaginal candidiasis (Candida Albacans) and how is it treated?

Candida albicans (yeast) can colonize and cause infections of the vulvovaginal region. Vaginal candidiasis often causes itching and painful urination due to urine stinging the inflamed areas of the vulva. Assessment shows a thick, white, curd-like vaginal discharge and reddened vulvar lesions. Miconazole (Monistat), an antifungal cream commonly prescribed to treat vaginal candidiasis, is inserted high into the vagina using an applicator. It is best applied at bedtime so that it will remain in the vagina for an extended period. Sexual intercourse is avoided until the inflammation is resolved, typically for the duration of treatment, approximately 3-7 days. However, sexual activity is not a significant cause of infection or reinfection of candida, and partner evaluation is not needed. Trichomoniasis, syphilis, gonorrhea, and HIV are mainly sexually transmitted; therefore, partners should be evaluated and treated.

What is carboxyhemoglobin intoxication?

Carbon monoxide (CO) is a toxic inhalant that enters the blood and binds more readily to hemoglobin than oxygen does. When hemoglobin is saturated with CO, the pulse oximeter reading is falsely normal as conventional devices detect saturated hemoglobin only and cannot differentiate between CO and oxygen (eg, adequate o2 SAT). The diagnosis of CO poisoning is often missed in the emergency department because symptoms are nonspecific (eg, headache, dizziness, fatigue, nausea, dyspnea) and the pulse oximeter reading often appears within normal limits. A serum carboxyhemoglobin test is needed to confirm the diagnosis. Normal values are <5% in nonsmokers and slightly higher (<10%) in smokers. Pt requires administration of 100% oxygen to increase the rate at which CO dissipates from the blood to prevent tissue hypoxia and severe hypoxemia.

The charge nurse must assign a semi-private room to a client with diabetes mellitus admitted for IV antibiotic therapy to treat leg cellulitis. Which of the 4 room assignments is the best option for this client? 1. Room 1: Client 1 day postoperative laparoscopic cholecystectomy who is awaiting discharge (31%) 2. Room 2: Client with dementia and urinary incontinence wearing an external urine collection device (26%) 3. Room 3: Client with history of splenectomy 15 years ago, now admitted for pulmonary embolism (19%) 4. Room 4: Client with lupus nephritis who is prescribed treatment with azathioprine (21%)

Cellulitis is a common skin bacterial infection that is usually treated with IV antibiotics in clients with diabetes mellitus. Room 2 is the best assignment option for this client with cellulitis. The client with dementia and urinary incontinence who has an external urinary condom catheter is the least susceptible to infection compared to those in rooms 1, 3, and 4. (Option 1) The client who is 1 day postoperative laparoscopic cholecystectomy (surgical procedure with small incisions) is at increased risk for infection. The client with cellulitis should not be placed in room 1.

A nurse on a pediatric unit is admitting a school-aged child with suspected Reye syndrome. Which information obtained during the history taking is most consistent with this condition?

Children who develop Reye syndrome often have had a recent viral infection, especially varicella (chicken pox) or influenza. Clinical manifestations include fever, lethargy, acute encephalopathy, and altered hepatic function. Elevated serum ammonia levels are an expected laboratory finding. Acute encephalopathy manifests with vomiting and a severely altered level of consciousness; it can rapidly progress to seizures and/or coma. The risk of developing Reye syndrome increases if aspirin therapy is used to treat the fever associated with varicella or influenza. As a result of this awareness, there has been a significant increase in the use of acetaminophen or ibuprofen for fever management in children.

The nurse is caring for a client with cirrhosis of the liver. Which blood test values would the nurse typically anticipate to be elevated when reviewing the client's morning laboratory results? Select all that apply. 1. Albumin 2. Ammonia 3. Bilirubin 4. Prothrombin time 5. Sodium

Cirrhosis, the end stage of many chronic liver diseases, is characterized by diffuse hepatic fibrosis with replacement of the normal architecture by regenerative nodules. The resulting structural changes alter blood flow through the liver and decrease the liver's functionality. - Elevated bilirubin (jaundice) results from functional derangement of liver cells and compression of bile ducts by nodules. The liver has a decreased ability to conjugate and excrete bilirubin (Option 3). - Most coagulation factors are produced in the liver. A cirrhotic liver cannot produce the factors essential for blood clotting. As a result, coagulation studies (prothrombin time [PT]/International Normalized Ratio [INR] and activated partial thromboplastin time [aPTT]) are usually elevated (Option 4). - Ammonia from intestinal deamination of amino acids normally goes to the liver and is converted to urea and excreted by the kidney. This does not happen in cirrhosis. Instead, the ammonia level rises as the cirrhosis progresses; ammonia crosses the blood-brain barrier and results in hepatic encephalopathy (Option 2).

A client with newly diagnosed chronic heart failure is being discharged home. Which statement(s) by the client indicate a need for further teaching by the nurse? Select all that apply.

Client and family education is important for those with heart failure to prevent/minimize exacerbations, decrease symptoms, prevent target organ damage, and improve quality of life. The use of any nonsteroidal anti-inflammatory drugs (NSAIDS) is contraindicated as they contribute to sodium retention, and therefore fluid retention (Option 5). To monitor fluid status, clients are instructed to weigh themselves daily, at the same time, with the same amount of clothing, and on the same scale (Option 3). Weights should be recorded to allow for day-to-day comparisons to help identify early signs of fluid retention. (Option 1) Frozen meals are often high in sodium. Most heart failure clients are instructed to limit sodium intake. All foods high in sodium (>400 mg/serving) should be avoided.

The nurse on the medical unit finishes receiving the change of shift hand-off report at 7:30 AM. Which assigned client should the nurse see first? 1. Client with a gastrointestinal bleed, who is receiving a unit of packed red blood cells (43%) 2. Client with an ulcerative colitis flare-up has temperature 101 F (38.3 C) and abdominal cramping (17%) 3. Client with atrial fibrillation, on telemetry, prescribed warfarin, with an International Normalized Ratio (INR) of 3.2 (23%) 4. Client with chronic kidney disease scheduled for bedside hemodialysis at 8:00 AM, with a serum creatinine of 8.4 mg/dL (743 µmol/L) (15%)

Client with the gastrointestinal bleed receiving packed red blood cells (PRBCs) - the nurse should: Check the infusion device; flow rate; and IV site, tubing, and filter Collect baseline physical assessment data against which to compare subsequent assessments Assess for complications associated with the administration of PRBCs, which include fluid overload and an acute transfusion reaction; these can occur at any time during the transfusion (Option 1)

The nurse has received report on 4 clients at the start of the shift. Which client should the nurse assess first? 1. Client in body cast who reports abdominal pain and bloating (40%) 2. Client post mastectomy who reports numbness at the surgical site (7%) 3. Client post neck dissection who reports difficulty chewing (41%) 4. Client receiving antibiotics who reports new-onset vaginal itching (10%)

Clients with large body casts are at risk for bowel obstruction, which can be caused by decreased peristalsis or by cast syndrome (ie, superior mesenteric artery [SMA] syndrome). Cast syndrome is a rare complication of an overly tight cast that involves compression of the duodenum by the SMA. Immobilization of clients in body casts decreases peristalsis and may cause a paralytic ileus (ie, bowel obstruction). If severe, bowel obstruction can result in bowel ischemia. The nurse should immediately report symptoms of a bowel obstruction (eg, abdominal pain, distension, nausea, vomiting) (Option 1). If cast syndrome is suspected, the cast may have a window cut out over the abdomen to relieve pressure.

The nurse is evaluating a parent's understanding of home care management for a 2-week-old client after initial cast placement for treatment of congenital clubfoot. Which of the following statements by the parent indicate a correct understanding? Select all that apply. 1. "Cradling my baby in my arms may cause stress and damage to the cast." 2. "I will check my baby's toes several times a day to ensure that they are pink and warm." 3. "My baby should alternate between sleeping on the stomach and back." 4. "My baby will need to have a new cast applied weekly for 5-8 weeks." 5. "When I bathe or diaper my baby, I will be sure to keep the cast dry."

Clubfoot (ie, talipes equinovarus) is a congenital bone deformity and soft tissue contracture manifested by one or both feet being turned inward. The health care provider typically begins management of the deformity soon after birth by manipulation and stretching of the affected foot and placing a long-leg cast. Weekly recasting over 5-8 weeks (ie, Ponseti method) is necessary to gradually reposition the foot (Option 4). To maintain the correction after successful casting, the client commonly wears custom shoes secured to a bar brace. To prevent recurrence, long-term follow-up continues until the child attains skeletal maturity. The nurse should teach parents about cast care, which includes monitoring the client's circulation (eg, toes pink and warm) and keeping the cast dry during diapering and bathing to prevent skin irritation or infection (Options 2 and 5).

A nurse is caring for a 1-month-old client who is being evaluated for congenital hypothyroidism. The nurse should recognize which of the following as clinical manifestations of hypothyroidism in infants? Select all that apply. 1. Difficult to awaken 2. Dry skin 3. Frequent, loose stools 4. Hoarse cry 5. Tachycardia

Congenital hypothyroidism occurs when abnormal development of the thyroid gland causes complete or decreased secretion of thyroid hormone (TH). Untreated hypothyroidism can cause severe intellectual disability in infants if undetected. Screening occurs after birth for all infants in the United States and Canada to prevent disability and encourage early treatment (ie, levothyroxine). TH plays an important role in growth, development, and regulation of many bodily functions (eg, heat production, muscle tone, skin function, cardiac function, metabolism). Clinical manifestations in affected infants reflect the pathophysiology of decreased TH and may include: - Difficulty awakening, lethargy, or hyporeflexia due to alterations in central nervous system function (Option 1) - Dry skin due to alterations in skin function (Option 2) - Hoarse cry caused by swelling of the vocal cords due to fluid retention (Option 4) - Constipation due to slowed metabolism - Bradycardia due to the effect of TH on cardiac function

A nurse is participating in an obstetrical emergency simulation in which the health care provider announces shoulder dystocia. Which of the following interventions should the assisting nurse implement? Select all that apply. 1. Assist maternal pushing efforts by applying fundal pressure during each contraction 2. Document the time the fetal head was born 3. Flex the client's legs back against the abdomen and apply downward pressure above the symphysis pubis 4. Prepare for a forceps-assisted birth 5. Request additional assistance from other nurses immediately

Correct answer 2,3,5 Shoulder dystocia is an unpredictable obstetrical emergency that occurs during vaginal birth when the fetal head delivers but the anterior (top) shoulder becomes wedged behind or under the mother's symphysis pubis. Shoulder dystocia lasting ≥5 minutes is correlated with almost certain fetal asphyxia resulting from prolonged compression of the umbilical cord. Minimizing the time it takes to deliver the fetal body is essential for reducing adverse outcomes (eg, hypoxia, nerve injury, death). When shoulder dystocia occurs, the primary nursing interventions include: - Documenting the exact time of events (eg, birth of fetal head, shoulder dystocia maneuvers) (Option 2) - Verbalizing passing time to guide decision-making by the health care provider (eg, "two minutes have passed") - Performing maneuvers to relieve shoulder impaction (eg, McRoberts maneuver, suprapubic pressure) (Option 3) - Requesting additional help from staff (eg, nurses, neonatologist) immediately (Option 5)

The nurse cares for a client with Addison's disease who was involved in a motor vehicle accident and hospitalized for a fracture of the right femur. Which client information is most important to report to the primary health care provider (PHCP)? 1. Blood pressure change from 128/80 mm Hg to 90/50 mm Hg (64%) 2. Development of a 1st-degree atrioventricular (AV) block on electrocardiogram (ECG) (22%) 3. Reports of right femur pain of 7 on a scale of 1-10 (1%) 4. Vesicular breath sounds auscultated over the lung tissue (11%)

Correct answer: 1 Addison's disease is adrenocortical insufficiency or hypofunction of the adrenal cortex. A deficiency in all 3 classes of adrenal corticosteroids, including glucocorticoids, mineralocorticoids, and androgens, is present in Addison's disease. Addisonian crisis, or acute adrenocortical insufficiency, is a potentially life-threatening complication of Addison's disease. It can lead to shock and should be reported immediately to the PHCP. Addisonian crisis is triggered by stress, and its manifestations include the following: - Hypotension and tachycardia - Dehydration - Hyperkalemia and hyponatremia - Hypoglycemia - Fever - Weakness and confusion

The nurse is caring for a young adult who is considering becoming pregnant. The client expresses concern, stating, "One of my parents has Huntington disease, and I am afraid my child will get it." How should the nurse respond? 1. "Genetic counseling is recommended. You will receive a referral before you leave." (49%) 2. "Huntington disease inheritance requires both biological parents to carry the gene." (42%) 3. "There are other ways to grow your family. You should consider adoption." (0%) 4. "This disease occurs spontaneously and is not likely to affect your children." (7%)

Correct answer: 1 Huntington disease (HD) is an incurable autosomal dominant hereditary disease that causes progressive nerve degeneration, which results in impaired movement, swallowing, speech, and cognitive abilities. Chorea (involuntary, tic-like movement) is a hallmark sign. The onset of active disease is usually at age 30-50, and death from neuromuscular and respiratory complications typically occurs within 20 years of diagnosis. HD is confirmed by genetic testing. Clients who have a parent with HD and are considering having biological children should receive genetic counseling (Option 1). (Option 2) Autosomal dominant traits require only one copy of the affected gene (from one carrier parent) to manifest (eg, cause disease). (Option 3) Although adoption may be considered, the nurse's opinion is not appropriate or therapeutic for the client. After genetic testing and further education from a genetic counselor, the client can make an informed decision about starting a family.

A client with diabetes receiving peritoneal dialysis experiences chills and abdominal discomfort. The nurse assesses the client's abdomen by pressing one hand firmly into the abdominal wall. The client experiences pain when the nurse quickly withdraws the hand. The client's most recent blood glucose level is 210 mg/dL (11.65 mmol/L). What is the priority action by the nurse? 1. Collect peritoneal fluid for culture and sensitivity (48%) 2. Heat the remaining dialysate fluid and increase the dwell time (8%) 3. Place the client in high Fowler's position (23%) 4. Prepare to administer regular insulin intravenously (19%)

Correct answer: 1 Peritonitis is a common but serious complication of peritoneal dialysis that typically occurs as a result of contamination during infusion connections or disconnections. Typically, the earliest indication of peritonitis is the presence of cloudy peritoneal effluent. Later manifestations include low-grade fever, chills, generalized abdominal pain, and rebound tenderness. To detect rebound tenderness, one hand is pressed firmly into the abdominal wall and quickly withdrawn. Rebound tenderness is present when there is pain on removal, indicating inflammation of the peritoneal cavity. The nurse should collect peritoneal effluent from the drainage bag for culture and sensitivity (Option 1). Treatment of peritonitis is antibiotic therapy based on the culture results. Antibiotics may be added to dialysate, given orally, or administered intravenously.

The nurse reviews laboratory test results for a pregnant client at 32 weeks gestation. What is the nurse's best action based on these results? Click on the exhibit button for additional information. 1. Complete the client assessment and documentation (56%) 2. Draw another sample for repeat complete blood count (7%) 3. Prepare for transfusion of packed red blood cells (9%) 4. Request a prescription for iron supplementation (26%) Laboratory results: - Hemoglobin: 11.4 g/dL (114 g/L) - Hematocrit: 34% (0.34) - Red blood cells: 5.3 x 106/mm3 (5.3 x 1012/L) - White blood cells 14,000/mm³ (14.0 x 109/L) - Platelets 230,000/mm3 (230 x 109/L)

Correct answer: 1 Pregnant women experience a 40%-45% increase in total blood volume during pregnancy to meet the increased oxygen demand and nutritional needs of the growing fetus and maternal tissues. Because the increase in plasma volume is greater than the increase in red blood cells, a hemodiluted state called physiologic anemia of pregnancy occurs, and is reflected in lower hemoglobin and hematocrit values. It is also normal for the white blood cell count to increase during pregnancy; counts can be as high as 15,000/mm3 (15.0 x 109/L). These laboratory results are within the normal ranges for a pregnant client in the third trimester, and no intervention is required (Options 1 and 2).

A nurse is teaching home management to a client newly diagnosed with severe psoriasis. Which client statement indicates that further teaching is needed? 1. "Exposure to sunlight will worsen my psoriasis." (31%) 2. "I should avoid drinking alcohol." (8%) 3. "I should use moisturizing creams frequently." (51%) 4. "Stress can worsen psoriasis." (8%)

Correct answer: 1 Psoriasis is a chronic autoimmune disease that causes a rapid turnover of epidermal cells. Characteristic silver plaques on reddened skin may be found bilaterally on the elbows, knees, scalp, lower back, and/or buttocks. The goal of therapy is to slow epidermal turnover, heal lesions, and control exacerbations. There is no cure for psoriasis; disease management includes avoidance of triggers (eg, stress, trauma, infection), topical therapy (eg, corticosteroids, moisturizers), phototherapy (eg, ultraviolet light), and systemic medications, including cytotoxic (eg, methotrexate) and biologic (eg, infliximab) agents (Options 3 and 4). The client should avoid alcohol as it can worsen psoriasis (Option 2). In addition, the liver, kidneys, and bone marrow are specifically affected by the systemic medications commonly used to control psoriasis. (Option 1) Exposure to ultraviolet light (eg, phototherapy, sunlight) can help slow epidermal turnover and decrease exacerbations; however, there is a greater long-term risk of skin cancer. Therefore, frequent skin examinations by a health care provider are important.

The spouse of an immunocompromised client is diagnosed with influenza virus infection. The spouse asks the office nurse how long contact with the client should be avoided to prevent the infection from spreading. What is the nurse's most appropriate response? 1. "Avoid close contact for about a week." (61%) 2. "It's impossible to avoid contact with the client. Just wash your hands often." (27%) 3. "You are sick already, and so you are not contagious anymore." (2%) 4. "You don't have to worry as long as the client has received the influenza vaccination." (8%)

Correct answer: 1 The influenza virus has an incubation period of 1-4 days, with peak transmission starting at about 1 day before symptoms appear and lasting up to 5-7 days after the illness stage begins (Option 1). (Option 2) Influenza is transmitted by inhaling droplets that an infected individual exhales into the air when sneezing, coughing, or speaking. If contact with others is unavoidable, wearing a mask can offer some protection against virus transmission. (Option 3) Individuals with the influenza virus can transmit the virus during the incubation period and illness stage of the infection. It is not appropriate to assume that the spouse can no longer transmit the infection. (Option 4) Although vaccination provides immunity against influenza in about 2 weeks after inoculation, it does not offer complete protection against all virus strains. Therefore, close contact with others should be avoided during the illness stage, especially those with an impaired immune system.

A client who is 2 hours post aortic valve replacement is in the intensive care unit (ICU). The low pressure alarm for the client's radial arterial line sounds. Which action should the nurse take first? 1. Check for bleeding at tube connection sites (67%) 2. Perform a fast flush of the arterial line system (4%) 3. Re-level the transducer to the phlebostatic axis (16%) 4. Zero and re-balance the monitor and system (11%)

Correct answer: 1 The low pressure alarm could signal hypotension. The nurse's first action should be to check the client for evidence of hypotension and the cause. Arterial lines carry the risk of hemorrhage and are most likely to occur at connection sites of the tubing and catheter. A client can lose a large amount of arterial blood in a short period of time. The nurse should verify that these connections are tight on admission of the client to the ICU.

The nurse is caring for a client newly prescribed crutches. Which finding indicates the need for further teaching? 1. The axillary pads are torn and show signs of wear (65%) 2. The client has a 30-degree bend at the elbow when walking (8%) 3. The crutches and injured foot are moved simultaneously in a 3-point gait (16%) 4. There is a 3 finger-width space noted between the axilla and axillary pad (9%)

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

A client arrives at the clinic for a follow-up after an emergency department visit the night before. The client sustained an ulnar fracture, and a fiberglass cast was applied. Which of the following teachings related to cast care should the nurse reinforce? Select all that apply. 1. Contact the clinic if any hot areas or foul odors develop in the cast 2. Cover the cast with a plastic bag for bathing, and avoid getting the cast wet 3. Elevate the affected extremity above heart level for the first 48 hours 4. Expect some numbness and tingling of the fingers during the first week 5. Use only soft, padded objects to scratch the skin under the cast

Correct answer: 1,2,3 Casts (eg, fiberglass, plaster) are applied to immobilize fractured extremities during healing. Instructions for cast care include: - Report foul odors or hot areas (hot spots) in the cast, which may indicate infection (Option 1). - Avoid getting the cast wet, which may damage the cast and cause skin irritation/infection (Option 2). - Elevate the affected extremity above heart level for the first 48 hours to reduce edema (Option 3). - Regularly perform isometric and range of motion exercises to prevent muscle atrophy.

The clinic nurse is taking vital signs on a client who reports being fatigued every day and gaining weight lately despite not eating much. The nurse should also ask about which symptoms? Select all that apply. 1. Cold intolerance 2. Constipation 3. Fever 4. Menstrual irregularity 5. Night sweats 6. Tachycardia

Correct answer: 1,2,4 Fatigue and weight gain are classic manifestations of hypothyroidism. Features of hypothyroidism typically result from decreased metabolic rate and include cold intolerance, constipation, dry skin, irregular or prolonged menstrual periods, and mental slowing or difficulty concentrating.

A home health nurse is supervising a home health aide who is changing the dressing for a client with a chronic heel wound. Which actions by the aide indicate adherence to appropriate infection control procedures? Select all that apply. 1. Open a sterile container of 4 x 4's using the outermost corner to peel back the cover 2. Pull glove off over the soiled dressing to encase it before disposal 3. Save unused sterile 4 x 4's by taping original package shut for the next dressing change 4. Wash hands prior to putting on gloves and after removing them 5. Wrap soiled dressing in paper towels before disposing of it in the trash can

Correct answer: 1,2,4 The nurse is responsible for observing the home health aide periodically during delegated tasks. The aide should wash the hands prior to gloving and after glove removal (Option 4). Sterile dressing supplies should be opened prior to the dressing change; this should be done by carefully peeling from the outermost corner of the package to expose the contents without contaminating the sterile product (Option 1). A contaminated used dressing should be placed in impervious plastic or a paper bag before disposal in the household trash (Option 2). (Option 3) Unused sterile supplies should not be saved as it is not possible to ensure their sterility. (Option 5) Paper towels are not impervious and infectious waste from the dressing can seep through and into other items in the trash can.

Which procedures are appropriate for the nurse to use when obtaining an adult client's blood for a laboratory test? Select all that apply. 1. Avoid the arm on the affected side after a mastectomy 2. Do not make further attempts to draw blood if unsuccessful on first 2 attempts 3. If necessary to use an arm with IV infusing, draw proximal to infusion point 4. Insert the needle bevel up at a 15-degree angle to the skin 5. Obtain a finger capillary specimen from the middle of the finger pad

Correct answer: 1,2,4 When performing phlebotomy, clean the site, "fix" or hold the vein taut, and then insert the needle bevel up at a 15-degree angle (no steeper than 30 degree). Some recommend bevel down for children. This will help prevent going through the vein completely. The Infusion Nurses Society (INS) identifies the standard of care as no more than 2 attempts by any 1 individual. If the nurse is unable to successfully draw blood after 2 attempts, a phlebotomist or a different nurse should be asked to complete the blood draw. The affected side of a client who has had a mastectomy (especially with lymph node removal) should not be used. It places the client at risk for infection and lymphedema.

The nurse is caring for a female client newly diagnosed with epilepsy who has been prescribed phenytoin. Which of the following should the nurse include in client teaching? Select all that apply. 1. "Avoid drinking alcoholic beverages." 2. "Do not abruptly stop taking your phenytoin." 3. "Go to the emergency department every time a seizure occurs." 4. "Wear an epilepsy medical identification bracelet." 5. "You may need to start using a nonhormonal birth control method."

Correct answer: 1,2,4,5 Epilepsy is characterized by chronic seizure activity. Clients typically require lifelong anticonvulsant medication. The nurse should provide education about identifying and avoiding seizure triggers, such as excessive alcohol intake, sleep deprivation, and stress (Option 1). Practicing relaxation techniques (eg, biofeedback) may help reduce the number of episodes. The client should also be encouraged to wear an epilepsy medical identification bracelet in case of emergency (Option 4). Phenytoin (Dilantin), a hydantoin anticonvulsant, may decrease the effectiveness of some medications (eg, oral contraceptives, warfarin) due to stimulation of hepatic metabolism. An alternate, nonhormonal birth control method (eg, condoms, copper intrauterine device) should be used in addition to or instead of oral contraceptives (Option 5). Clients should discuss pregnancy plans with their health care provider, as phenytoin can cause fetal abnormalities (eg, cleft palate, heart malformations, bleeding disorders). Clients taking phenytoin should also receive education about practicing good oral hygiene as gingival hyperplasia is a potential complication. Anticonvulsants should not be stopped abruptly, as this increases the risk of seizure (Option 2).

A client is admitted to the labor and delivery unit with a diagnosis of severe preeclampsia. IV magnesium sulfate is prescribed. Which nursing measures should the nurse include in this client's plan of care? Select all that apply. 1. Assess deep tendon reflexes hourly 2. Ensure availability of calcium gluconate 3. Ensure bright lighting to prevent falls 4. Have supplemental oxygen at bedside 5. Limit visitors to minimize stimulation

Correct answer: 1,2,4,5 Seizures are a potential complication of worsening preeclampsia, also known as eclampsia. Seizure precautions should be in place for all clients with preeclampsia. Side rails should be padded and the bed kept in the lowest position to prevent trauma during a seizure. Functioning suction equipment and supplemental oxygen should be available at the bedside (Option 4). During a seizure, the nurse should turn the client to the left side to prevent aspiration and promote uteroplacental blood flow. After the seizure subsides, the nurse should suction any oral secretions and apply oxygen 8-10 L/min by facemask. Magnesium sulfate is a central nervous system (CNS) depressant commonly prescribed to prevent seizures in clients with preeclampsia. Deep tendon reflexes should be assessed hourly during administration (Option 1). Hyperreflexia or clonus may indicate impending seizure activity, whereas hyporeflexia may indicate magnesium toxicity. Calcium gluconate is the reversal agent administered in the event of magnesium toxicity and should be immediately available (Option 2). Environmental stimuli should be minimized to decrease risk for seizures. This may include limiting visitors and the number of caregivers entering/exiting the client's room (Option 5). (Option 3) Severe preeclampsia is associated with CNS irritability, and excessive stimulation should be avoided. Lights should be lowered to decrease visual stimuli and risk for seizures.

A nurse is precepting a new graduate nurse who is caring for a client with a paralytic ileus and a Salem sump tube attached to continuous suction. The preceptor should intervene when the graduate nurse performs which interventions? Select all that apply. 1. Checks for residual every 4 hours 2. Places client in semi-Fowler's position 3. Plugs the air vent if gastric content refluxes 4. Provides mouth care every 4 hours 5. Turns off suction when auscultating bowel sounds

Correct answer: 1,3 Continuous suction can be applied to decompress the stomach if a double lumen Salem sump tube is in place. The larger lumen is attached to suction and the smaller lumen (within the larger one) is open to the atmosphere. Checking for residual volume is not an appropriate intervention because the Salem sump is attached to continuous suction for decompression and is not being used to administer enteral feeding (Option 1). The air vent (blue pigtail) must remain open as it provides a continuous flow of atmospheric air through the drainage tube at its distal end (to prevent excessive suction force). This prevents damage to the gastric mucosa. If gastric content refluxes, 10-20 mL of air can be injected into the air vent. However, the air vent is kept above the level of the client's stomach to prevent reflux (Option 3). General interventions to maintain gastric suction using a Salem sump tube include: - Place the client in semi-Fowler's position to help keep the tube from lying against the stomach wall; this is done to help prevent gastric reflux (Option 2). - Provide mouth care every 4 hours as this helps to maintain moisture of oral mucosa and promote client comfort (Option 4). - Turn off suction briefly during auscultation as the suction sound can be mistaken for bowel sounds (Option 5). - Inspect the drainage system for patency (eg, tubing kink or blockage).

The nurse assesses a client with fever and productive cough for the last 10 days. Which findings support the presence of pneumonia? Select all that apply. 1. Coarse crackles 2. Hyperresonance 3. Pleuritic chest pain 4. Shortness of breath 5. Trachea deviating from midline

Correct answer: 1,3,4 Pneumonia is an acute infection of the lungs. Findings in a client with pneumonia include: - Crackles - Fine or coarse crackling sounds caused by air passing through alveoli and small airways obstructed with mucus (Option 1) - Fever, chills, productive cough, dyspnea, and pleuritic chest pain (Options 3 and 4) - Increased vocal/tactile fremitus - Transmission of palpable vibrations (fremitus) is increased when transmitted through consolidated versus normal lung tissue. - Bronchial breath sounds in peripheral lung fields - High-pitched, harsh sounds conducted through consolidated lung tissue, which are abnormal when heard in an area distant from where normally heard (ie, trachea); this finding can be an early sign of pneumonia. - Unequal chest expansion - Decreased expansion of affected lung on palpation - Dullness - Percussion of medium-pitched sounds over consolidated lung tissue (pneumonia) or fluid-filled space (eg, pleural effusion, a complication of pneumonia)

A nurse is preparing to administer an oxytocin IV infusion to a client for labor induction. The nurse recognizes that an oxytocin infusion may increase the client's risk for which of the following? Select all that apply. 1. Abnormal or indeterminate fetal heart rate patterns 2. Delayed breast milk production 3. Placenta previa 4. Postpartum hemorrhage 5. Uterine tachysystole

Correct answer: 1,4,5 Oxytocin (Pitocin) stimulates contraction of the uterine smooth muscle. It is commonly administered to induce or augment labor and to prevent postpartum hemorrhage. Oxytocin, a high-alert medication, is administered cautiously to avoid potential adverse effects, including: - Category II or III fetal heart rate (FHR) patterns (eg, late decelerations, bradycardia). - Abnormal or indeterminate FHR patterns are very common when using oxytocin and may occur because of reduced blood flow to the fetus during contractions (Option 1). - Emergency cesarean birth, which may be required due to persistent abnormal FHR pattern - Postpartum hemorrhage - Uterine atony and uterine fatigue may occur if the client experiences prolonged exposure to exogenous oxytocin (Option 4). - Water intoxication - Oxytocin has an antidiuretic effect when administered at high doses over prolonged periods. - Uterine tachysystole (ie, >5 contractions in 10 minutes) (Option 5) (Option 2) Endogenous oxytocin is excreted by the pituitary gland and triggers the milk ejection/let-down reflex. Administration of exogenous oxytocin (ie, synthetic oxytocin) has no known effect on milk production. (Option 3) Uterine stimulation from oxytocin increases the risk of placental abruption and uterine rupture. Placenta previa (ie, abnormal implantation of the placenta over the cervical os) is unrelated to oxytocin administration.

The nurse is assessing a client at 36 weeks gestation during a routine prenatal visit. Which statement by the client should the nurse investigate first? 1. "I am not sleeping as well due to cramps in my calves at night." (29%) 2. "I have noticed less kicking movements as the baby grows bigger." (49%) 3. "Over the last few weeks, I have not been able to wear any of my shoes." (17%) 4. "Sometimes I feel short of breath after walking up a flight of stairs." (3%)

Correct answer: 2 Fetal movement is a sign of fetal health and indicates an intact fetal central nervous system. Fetal movement may occur numerous times per hour during the last trimester of pregnancy, although the client may not perceive every movement. Multiple factors (eg, maternal substance abuse, medications, fasting, fetal sleep) can affect fetal movement. However, fetal movements should not decrease as the fetus increases in size. Decreased fetal movement is a potential warning sign of fetal compromise (ie, impaired oxygenation), which may precede fetal death (Option 2). The nurse prioritizes assessment of client reports of decreased fetal movement to evaluate fetal well-being (eg, nonstress test). (Option 1) Leg cramps commonly occur in the third trimester, especially at night, due to the weight of the gravid uterus applying pressure to nerves affecting calf muscles. Home interventions include stretching legs, massaging calves, and increasing fluid intake.

The graduate nurse (GN) is caring for a client at 20 weeks gestation with secondary syphilis. The client reports an allergic reaction to penicillin as a child but does not know what kind of reaction occurred. When discussing the client's potential treatment plan with the precepting nurse, which statement by the GN indicates an appropriate understanding? 1. "Doxycycline is an acceptable alternative to penicillin for treatment of syphilis during pregnancy." (47%) 2. "The client will require penicillin desensitization to receive appropriate treatment." (22%) 3. "The newborn can be treated after birth if antepartum treatment is contraindicated." (22%) 4. "Treatment is only effective if provided during the primary stage of syphilis." (8%)

Correct answer: 2 Syphilis is a sexually transmitted infection that crosses the placenta and may have teratogenic effects on fetal development. All pregnant clients are screened for syphilis at the initial prenatal visit, and high-risk clients are screened again during the third trimester and labor. Maternal manifestations of syphilis may vary depending on the time of diagnosis. The only adequate prenatal treatment is IM penicillin injection (ie, benzathine penicillin G). Expected outcomes include resolution of maternal infection and prevention or treatment of fetal infection. If a pregnant client has a penicillin allergy, the nurse should anticipate penicillin desensitization so that adequate treatment can be provided (Option 2).

A client with renal failure recently started dialysis and is unable to work due to ongoing health problems. The client's spouse has started working for a cleaning service to replace the lost income. The dialysis nurse notices that the client has become withdrawn and increasingly frustrated by small inconveniences when coming to dialysis. Which is the most appropriate first response by the nurse? 1. "How is your spouse's new job going?" (3%) 2. "I notice that you seem frustrated." (77%) 3. "It can take time to adjust to dialysis. We have a support group that can be helpful." (17%) 4. "It's normal to be angry when you can't work any longer." (0%)

Correct answer: 2 The client with chronic illness who is unable to work may experience depression, grief, loss, a feeling of inadequacy, or a loss of meaning and purpose in life. It can take time to adjust and accept the new roles, and this stress can increase a person's vulnerability to ongoing health problems. This client has gone from being the main source of income, or "breadwinner," to being someone who is unable to support the family. The client is now dependent on the spouse for financial stability and this is causing a strain. This type of role change can be particularly difficult for men who are used to providing for their families and for anyone who is well-established in a career. The nurse has noticed a change in the client's behavior but has not assessed the client to determine the factors contributing to this change. Assessment is needed before interventions can be planned. An open-ended reflective statement and nonverbal communication expressing acceptance and willingness to listen in the setting of a trusting relationship are appropriate to begin this assessment.

The nurse is preparing a nutritional teaching plan for a client planning to become pregnant. Which foods would best prevent neural tube defects? 1. Calcium-rich snacks (7%) 2. Fortified cereals (68%) 3. Organ meats (16%) 4. Wild salmon (7%)

Correct answer: 2 Women who are planning on becoming pregnant should consume 400-800 mcg of folic acid daily. Food options that are rich in folic acid include fortified grain products (eg, cereals, bread, pasta) and green, leafy vegetables (Option 2). Inadequate maternal intake of folic acid during the critical first 8 weeks after conception (often before a woman knows she is pregnant) increases the risk of fetal neural tube defects (NTDs), which inhibit proper development of the brain and spinal cord. Common NTDs are spina bifida and anencephaly (lack of cerebral hemispheres and overlying skull).

The nurse is preparing to administer medications to a client admitted with atrial fibrillation. The nurse notes the vital signs shown in the exhibit. Which medications due at this time are safe to administer? Select all that apply. Click on the exhibit button for additional information. 1. Diltiazem extended-release PO 2. Heparin subcutaneous injection 3. Lisinopril PO 4. Metoprolol PO 5. Timolol ophthalmic Vital signs - Temperature: 98.4 F (36.9 C) - Blood pressure: 124/78 mm Hg - Heart rate: 46/min and irregularly irregular - Respirations: 22/min

Correct answer: 2,3 Clients with atrial fibrillation can have either bradycardia (slow ventricular response) or tachycardia (rapid ventricular response). This client's vital signs are significant for bradycardia (heart rate [HR] <60/min). Therefore, medications that can decrease HR should be held and the health care provider (HCP) notified. The reason for holding the medication (HR 46/min) and an HCP contact note should be documented. Heparin is an anticoagulant; the subcutaneous injection is most commonly used to prevent deep venous thrombosis in hospitalized clients on bed rest. This medication will not affect the vital signs and is safe to administer (Option 2). Lisinopril, an ACE inhibitor, does not lower HR and is not contraindicated in clients with bradycardia (Option 3). The client is not hypotensive; therefore, lisinopril is safe to administer. (Option 1) Non-dihydropyridine calcium channel blockers (eg, diltiazem, verapamil) can decrease HR and should be held in clients with bradycardia. (Options 4 and 5) All beta blockers (eg, metoprolol, timolol, atenolol), including eye drops that can be absorbed systemically, can decrease the HR and should be held until the prescriptions can be clarified by the HCP.

The nurse is admitting a client with malnutrition related to anorexia nervosa. Which of the following actions are appropriate to include in the care of this client? Select all that apply. 1. Allow the client to continue to exercise per usual routine 2. Assist the client in reflecting on triggers of disordered eating 3. Maintain strict record of protein and calorie intake 4. Remain with the client for the duration of each meal 5. Weigh the client each morning prior to any oral intake

Correct answer: 2,3,4,5 Anorexia nervosa is a psychogenic eating disorder with potentially fatal physiological implications. Clients commonly become extremely underweight and protein-energy malnourished. Clients admitted for anorexia nervosa are typically in a crisis state, and the priority is restoring physiological integrity through appropriate weight gain and nutritional intake. Nursing care includes: - Assisting the client in reflecting on triggers for dysfunctional eating and fears and feelings related to gaining weight (Option 2) - Maintaining strict documentation of dietary protein and calorie intake to ensure healthy weight gain (Option 3) - Remaining with the client during and 1 hour following meals to ensure intake and prevent purging behaviors (Option 4) - Establishing a weekly weight-gain goal (typically 2-3 lb/wk [0.91-1.36 kg/wk]) - Weighing the client at the same time each morning (after voiding and before any oral intake) and wearing the same clothing to assess efficacy of nutritional support (Option 5) - Limiting physical activity initially and gradually increasing as oral intake improves - Not focusing on food initially, but encouraging participation in meal planning as the client nears target weight

The nurse is reviewing new prescriptions from the health care provider. Which prescription would require further clarification? 1. Atorvastatin for hyperlipidemia in a client with angina pectoris (9%) 2. Bupropion for smoking cessation in a client with emphysema (15%) 3. Cyclobenzaprine for muscle spasms in a client with hepatitis (54%) 4. Metronidazole for trichomoniasis in a client with Crohn disease (20%)

Correct answer: 3 Cyclobenzaprine (Flexeril) is a common, centrally acting skeletal muscle relaxant prescribed for muscle spasticity, muscle rigidity, and acute or chronic muscle pain/injury. Centrally acting muscle relaxants interfere with reflexes within the central nervous system (CNS) to decrease muscle spasm and rigidity. Like many medications, muscle relaxants are metabolized by the liver. The presence of liver disease (eg, hepatitis) decreases hepatic metabolism and can cause a buildup of medication, leading to medication toxicity and increased CNS depression (eg, weakness, confusion, drowsiness, lethargy). The prescription for a muscle relaxant would need to be clarified in a client with liver disease (Option 3). (Option 1) Atorvastatin (Lipitor) is a statin prescribed for hyperlipidemia. It is used for primary and secondary prevention of cardiovascular disease and would not warrant further clarification when used in a client with angina pectoris. (Option 2) Bupropion (Wellbutrin, Zyban) and varenicline (Chantix, Champix) are commonly prescribed for smoking cessation. Both bupropion and varenicline can cause serious neuropsychiatric effects (eg, depression, suicide); however, there is no contraindication for clients with emphysema. (Option 4) Metronidazole (Flagyl) is an antibiotic that can be used to treat a Trichomonas infection. There is no contraindication for its use in clients with Crohn disease.

The nurse is assessing a 3-year-old client in the emergency department and finds dyspnea, high fever, irritability, and open-mouthed drooling with leaning forward. The parents report that the symptoms started rather abruptly. The client has not received age-appropriate vaccinations. Which set of actions should the nurse anticipate? 1. 20-gauge needle insertion at the mid-axillary line for pleural aspiration (3%) 2. 4 L oxygen at 100% per nasal cannula with bilevel positive airway pressure (BPAP) ventilation standing by (30%) 3. Intubation in the operating room with a prepared tracheotomy kit standing by (46%) 4. Nebulized racemic epinephrine with pediatric anesthesiologist standing by (19%)

Correct answer: 3 Epiglottitis should be considered first in a 3-7-year-old child with acute respiratory distress, toxic appearance (eg, sitting up, leaning forward, drooling), stridor, and high-grade fever. Tachycardia and tachypnea are also present. This is a pediatric emergency and should be managed with endotracheal intubation; however, intubation of such clients is difficult, and preparation for possible tracheostomy is also standard. The complications of epiglottitis are serious and include sudden airway obstruction.

A nurse is admitting a child who has leukemia. Several rooms are available on the pediatric unit. Which client could share a room with this child? 1. A client recovering from a ruptured appendix (25%) 2. A client with cystic fibrosis (20%) 3. A client with minimal change nephrotic syndrome (49%) 4. A client with rheumatic fever (4%)

Correct answer: 3 Leukemia is characterized by unrestricted proliferation of abnormal white blood cells (lymphoblasts), resulting in depression of normal bone marrow activity. This disorder is the most common form of childhood cancer. Infection is a major concern due to neutropenia. In addition, anemia occurs due to decreased red blood cell production, and bleeding is common as a result of decreased platelet production. It would be appropriate for this client with leukemia to share a room with a client with minimal change nephrotic syndrome (MCNS). MCNS is a non-infectious condition of the glomeruli and poses no risk to a client with leukemia. (Option 1) Appendicitis is a result of viral or infectious processes and can lead to rupture of the appendix. A client recovering from a ruptured appendix poses a threat of infection to the child who has leukemia.

A client undergoing endotracheal intubation received IV sedation and succinylcholine. Shortly after respiratory status has been stabilized, the client becomes flushed and profusely diaphoretic and has a rigid jaw. Which medication should the nurse prepare to administer? Click the exhibit button for more information. 1. IM epinephrine (20%) 2. IV atropine (27%) 3. IV dantrolene (42%) 4. IV glucagon (9%) Vital signs: - Temperature: 105 F (40.6 C) - Blood pressure: 140/90 mm Hg - Heart rate: 150/min - Respirations: 28/min - O2 saturation: 98%

Correct answer: 3 Malignant hyperthermia (MH) is a rare and life-threatening condition precipitated by certain medications used for anesthesia, including inhaled anesthetics (eg, desflurane, isoflurane, halothane) and succinylcholine (a paralytic used adjunctively for intubation and general anesthesia). Skeletal muscles become unable to control calcium levels, leading to a hypermetabolic state manifested by contracture and increased temperature. Early signs of MH include tachypnea, tachycardia, and a rigid jaw or generalized rigidity. As the condition progresses, the client develops a high fever. Muscle tissue is broken down, leading to hyperkalemia, cardiac dysrhythmias, and myoglobinuria. MH requires emergent treatment with IV dantrolene to reverse the process by slowing metabolism. Succinylcholine should be discontinued. Other interventions include applying cooling blankets to reduce temperature and treating high potassium levels.

The nurse receives handoff report on 4 clients. Which client should the nurse assess first? 1. Client with chronic anxiety disorder taking buspirone and diphenhydramine who has a dry mouth (5%) 2. Client with chronic heart failure taking metoprolol and lisinopril who has dizziness when standing up (20%) 3. Client with major depressive disorder taking phenelzine and pseudoephedrine who has a headache (56%) 4. Client with type 2 diabetes taking metformin and lovastatin who has stomach upset and nausea (16%)

Correct answer: 3 Monoamine oxidase inhibitors (MAOIs) (eg, isocarboxazid [Marplan], phenelzine [Nardil], tranylcypromine [Parnate]) are often prescribed for depression. MAOIs deactivate an enzyme that breaks down norepinephrine, dopamine, and serotonin. Increased levels of norepinephrine can increase blood pressure. This increased norepinephrine level combined with certain medications that also increase blood pressure (eg, nasal decongestants [eg, pseudoephedrine, oxymetazoline]) may lead to hypertensive crisis, a complication that can result in hemorrhagic stroke and death. Headache is a common, early symptom of hypertensive crisis that should be evaluated immediately in clients taking MAOIs (Option 3).

Following the precipitous birth of a term newborn, what is the best action by the nurse while awaiting expulsion of the placenta and arrival of the health care provider? 1. Clean the perineal area (1%) 2. Gently pull on the cord (4%) 3. Keep the infant warm (57%) 4. Massage the fundus (36%)

Correct answer: 3 Precipitous birth occurs when the newborn is delivered ≤3 hours after the onset of contractions. In the event of precipitous labor, the nurse should be prepared to assist with the birth if the health care provider is unable to arrive in time. Immediately after the birth, the newborn should be dried and placed skin-to-skin on the mother's abdomen at uterine level to promote warmth; this prevents cold stress that can lead to newborn hypoglycemia or respiratory distress (Option 3). If the newborn is stable, the cord can be clamped and cut with sterile scissors after it has stopped pulsating or after the placenta has been expelled.

During a camping trip, a camp counselor falls and gets a small splinter of wood embedded in the right eye. What action should the volunteer camp nurse take first? 1. Gently flush the eye with cool water (45%) 2. Instill optic antibiotic ointment (2%) 3. Patch both eyes with eye shields (46%) 4. Remove the splinter using tweezers (5%)

Correct answer: 3 The camp nurse protects the injured eye using an eye shield (eg, small Styrofoam or paper cup), ensuring the shield does not touch the foreign body. The eyes work in synchrony with each other; therefore, the non-injured eye is patched to prevent further eye movement. The nurse also facilitates transport to the nearest emergency care center for assessment and treatment by an ophthalmologist. (Option 1) Flushing the eye with cool water is contraindicated as it may cause further damage by moving the splinter and/or introducing potential wound pathogens. (Option 2) Instilling optic antibiotic ointment would interfere with ophthalmologic medical examination. Optic antibiotic ointment may be prescribed by the health care provider to reduce the risk of infection once the object is removed from the eye.

The nurse is caring for a client with active pulmonary tuberculosis. Which elements of infectious disease precautions are mandatory for the nurse when providing routine care? Select all that apply. 1. Gown 2. Goggles or face shield 3. Hand washing 4. N95 particulate respirator 5. Surgical mask

Correct answer: 3,4 Isolation is mandatory for clients with conditions that involve airborne transmission, and rooms must use both negative air pressurization and high-efficiency particulate air (HEPA) filters to avoid contamination. A class N95 or higher particulate respirator must be worn during client care. All clients with symptoms consistent with a suspected airborne illness should be given a surgical mask to wear as soon as they are assessed during triage. Good hand hygiene is always the first and last element of infection control in any client care setting. (Options 1 and 2) Wearing a gown and face shield would be necessary only if the nurse suspected splash of body fluids from procedural client care, not from routine care such as assessment or medication administration. Contact precautions may also be necessary if the tuberculosis is extrapulmonary with draining lesions (eg, cutaneous tuberculosis).

A client diagnosed with end-stage renal disease comes to the dialysis clinic for treatment. Which actions should the nurse take to prepare the client for hemodialysis? Select all that apply. 1. Administer subcutaneous heparin to decrease clotting during dialysis 2. Administer the client's morning doses of carvedilol and lisinopril 3. Check the client's medical records to determine the last post-dialysis weight 4. Obtain a set of client vital signs and the client's current weight 5. Palpate the fistula in the client's arm for a thrill and auscultate for a bruit

Correct answer: 3,4,5 Prior to dialysis treatment, the nurse should assess the client's fluid status (weight, blood pressure, peripheral edema, lung and heart sounds), vascular access (arteriovenous fistula, arteriovenous grafts), and vital signs (Option 4). The amount of fluid removed (ultrafiltration) is determined by calculating the difference between the last post-dialysis weight and the client's current pre-dialysis weight (Option 3). After the client is connected to the dialysis machine, IV heparin is added to the blood from the client to prevent clotting that can occur when blood contacts a foreign substance. Giving subcutaneous heparin prior to initiation is not necessary (Option 1). (Option 2) During dialysis, excess fluid is removed, making the client prone to hypotension. In addition, medications are removed from the blood during hemodialysis, making them ineffective. Many medications that are taken once daily can be held until after the dialysis treatment to prevent their removal. If blood pressure medications are given prior to dialysis, the client can develop hypotension during the dialysis and then uncontrolled hypertension (decreased drug concentrations). (Option 5) Arteriovenous fistulas are created by anastomosing an artery to a vein; a thrill can be felt when palpating the fistula, and a bruit can be heard during auscultation when the fistula is functioning properly.

The clinic nurse reviews teaching provided to the parent of a child being considered for growth hormone replacement therapy at home. Which statement by the parent indicates that teaching has been effective? 1. "Treatment will be considered a success when my child grows at a rate equal to peers." (24%) 2. "Treatment will be required throughout my child's life." (26%) 3. "Treatment will begin when my child becomes an adolescent." (11%) 4. "Treatment will require a daily injection under my child's skin." (37%)

Correct answer: 4 A child who demonstrates a slow growth pattern will undergo diagnostic evaluation to determine the cause. If the cause is found to be growth hormone deficiency, the child may undergo growth hormone replacement therapy. The biosynthetic hormone is administered via subcutaneous injection on a daily basis. Despite replacement therapy, the child may still have a final height less than "normal." Treatment is most successful when diagnosis and replacement therapy begin early in the child's life. When to stop therapy is decided by the client, family, and provider. However, growth less than 1 inch (2.5 cm) per year and bone age of 14 years in girls and 16 years in boys are the criteria often used to stop therapy. (Option 1) Growth hormone replacement does not guarantee that a child will grow at a rate equal to peers. Treated children often remain shorter than their peers. (Option 2) Replacement therapy is not continued throughout a child's life. It is stopped when bone growth begins to cease or when the child, parents, and provider make the decision. (Option 3) Replacement therapy is most successful when treatment begins early, as soon as growth delays are noted.

The nurse is assessing a client who had an esophagogastroduodenoscopy 3 hours ago. The client is reporting increasing abdominal pain. Which clinical finding requires an immediate report to the health care provider? Click the exhibit button for additional information. 1. Blood pressure 108/72 mm Hg (20%) 2. Gag reflex has not returned (26%) 3. Sore throat when swallowing (4%) 4. Temperature 100.6 F (38.1 C) (47%)

Correct answer: 4 An esophagogastroduodenoscopy (EGD) involves passing an endoscope down the esophagus to visualize the upper gastrointestinal structures (eg, esophagus, stomach, duodenum). Perforation of the gastrointestinal tract is a life-threatening complication of EGD that can lead to peritonitis and sepsis. Signs of perforation include a sudden temperature spike, increasing pain/tenderness, restlessness, tachycardia, and tachypnea. The nurse should notify the health care provider immediately if the client develops a fever (Option 4). (Option 1) Post-procedure changes in blood pressure can be caused by sedation, blood loss, or sepsis. Although the client had a slight decrease in blood pressure, it has remained relatively consistent with the other blood pressure readings and does not require immediate notification of the health care provider. (Option 2) An EGD involves applying a topical anesthetic to the throat to pass the endoscope. It may take a few hours for the gag reflex to return. Absent gag reflex after a prolonged period (eg, 6 hours) should be reported to the health care provider.

A nurse is assisting with the care of a newborn during circumcision. Which is an appropriate intervention? 1. Apply a snug-fitting diaper following the procedure (17%) 2. Anticipate the use of clean technique during the circumcision (16%) 3. Offer oral fluids during the procedure (7%) 4. Wrap the newborn's upper body in a blanket restraint for the circumcision (58%)

Correct answer: 4 Application of a blanket restraint or the use of a special board prevents injury during circumcision. Swaddling and the use of non-nutritive sucking are nonpharmacologic approaches to manage pain during circumcision. (Option 1) A loose-fitting diaper is put on the newborn after circumcision to avoid irritation to the penis. (Option 2) Sterile technique is used during the surgical procedure of circumcision. (Option 3) The infant should not be fed during circumcision to prevent the risk of aspiration. A pacifier dipped in a concentrated sucrose solution is offered as a nonpharmacologic pain management technique.

During the shift report, the night charge nurse tells the day charge nurse that the night unlicensed assistive personnel (UAP) is totally incompetent. What is the best response for the day charge nurse to give? 1. Encourage the night nurse to provide the UAP with additional training (33%) 2. Indicate that it is the night nurse's job to deal with staff problems (1%) 3. Remind the night nurse that the UAP is doing the best job the UAP can (1%) 4. Suggest that the night nurse discuss concerns with the nurse manager (64%)

Correct answer: 4 Incompetency is a concern for client safety and quality care. The nurse manager is responsible for hiring/firing and setting up additional training times or experiences for staff. The situation should be discussed with the person who has 24/7 responsibility for the unit so that an appropriate response can be given to the night nurse's perceptions (Option 4).

A nurse cares for a client with impairment of cranial nerve VIII. What instructions will the nurse provide the unlicensed assistive personnel prior to delegating interventions related to the client's activities of daily living? 1. "Be aware of the client's shoulder weakness and provide support as needed." (10%) 2. "Ensure that the client sits upright and tucks the chin when swallowing food." (37%) 3. "Explain all procedures in step-by-step detail before performing them." (27%) 4. "Make sure the items needed by the client are within reach." (24%)

Correct answer: 4 The client has an impairment of cranial nerve (CN) VIII, the vestibulocochlear (or auditory) nerve. Symptoms of impairment may include loss of hearing, dizziness, vertigo, and motion sickness, which place the client at a high risk for falls. Therefore, when instructing the unlicensed assistive personnel (UAP) about helping the client with activities of daily living, the nurse emphasizes the need to keep items at the bedside within the client's reach (Option 4).

The parent of a 6-year-old calls the nurse and reports that the child was playing outside in the snow and the child's feet now appear red and swollen. What is the best response by the nurse? 1. "Bring the child to the health care provider's (HCP) office immediately." (20%) 2. "Give your child something warm to drink." (8%) 3. "Massage the child's feet gently until they warm up." (22%) 4. "Place the child's feet in warm water immediately." (49%)

Correct answer: 4 The clinical indications of a cold injury include redness and swelling of the skin (chilblains or pernio) and blanched skin with hardness of the affected area (frostbite). For any cold injury, it is important to re-warm the area as soon as possible to restore blood flow and reduce the risk of permanent tissue damage. The recommendation for re-warming is immersion of the affected area in warm water (104 F [40 C]) for about 30 minutes or until the area turns pink in cases of frostbite. The face and ears can be re-warmed with the application of warm facecloths (Option 4). Massaging a body part that has sustained a cold injury is contraindicated due to the risk of tissue injury.

An elderly client with a history of stable chronic obstructive pulmonary disease, alcohol abuse, and cirrhosis has a serum theophylline level of 25.8 mcg/mL (143 µmol/L). Which clinical manifestation associated with theophylline toxicity should worry the nurse most? 1. Alterations in color vision (9%) 2. Gum (gingival) hypertrophy (8%) 3. Hyperthermia (6%) 4. Seizure activity (75%)

Correct answer: 4 Theophylline has narrow therapeutic index and plasma concentrations >20 mcg/mL (111 µmol/L) are associated with theophylline drug toxicity. Toxicity can be acute or chronic. Conditions associated with chronic toxicity include advanced age (>60), drug interactions (eg, alcohol, macrolide and quinolone antibiotics), and liver disease. Acute toxicity is associated with intentional or accidental overdose. Symptoms of toxicity usually manifest as central nervous system stimulation (eg, headache, insomnia, seizures), gastrointestinal disturbances (eg, nausea, vomiting), and cardiac toxicity (eg, arrhythmia).

A client is admitted to the hospital for evaluation of suspected pulmonary tuberculosis (TB). The nurse assesses for which characteristic presenting signs and symptoms associated with TB disease? Select all that apply. 1. Dysuria 2. Jaundice 3. Low back pain 4. Night sweats 5. Purulent or blood-tinged sputum 6. Weight loss

Correct answer: 4,5,6 Mycobacterium tuberculosis is a gram-positive, acid-fast bacillus that is transmitted through the airborne route. TB is usually (85%) pulmonary but can also be extrapulmonary (eg, meninges, genitourinary, bone and joints, gastrointestinal). TB, regardless of location, commonly presents with constitutional symptoms, including: 1. Low-grade fever 2. Night sweats 3. Anorexia and weight loss 4. Fatigue Additional symptoms depend on the location of the infection. Pulmonary tuberculosis typically includes: 1. Cough 2. Purulent or blood-tinged sputum 3. Shortness of breath Dyspnea and hemoptysis are typically seen in the late stages. The classic manifestations of TB can be absent in immunocompromised clients and the elderly.

The nurse is providing discharge education for a postoperative client who had a partial laryngectomy for laryngeal cancer. The client is concerned because the health care provider said there was damage to the ninth cranial nerve. Which statement made by the nurse is most appropriate?

Cranial nerve IX (glossopharyngeal) is involved in the gag reflex, ability to swallow, phonation, and taste. Postoperative partial laryngectomy clients will need to undergo evaluation by a speech pathologist to evaluate their ability to swallow safely to prevent aspiration. Clients are taught the supraglottic swallow, a technique that allows them to have voluntary control over closing the vocal cords to protect themselves from aspiration. Clients are instructed to: 1. Inhale deeply 2. Hold breath tightly to close the vocal cords 3. Place food in mouth and swallow while continuing to hold breath 4. Cough to dispel remaining food from vocal cords 5. Swallow a second time before breathing

A client is brought to the emergency department with multiple trauma injuries. The nurse sees the client's Jehovah's Witness identification card. As part of providing culturally competent care, the nurse would anticipate the client accepting which of the following? Select all that apply. 1. Epoetin alfa 2. Fresh frozen plasma 3. Homologous packed red blood cells 4. Normal saline 5. Platelet transfusion

Culturally competent nursing care involves recognizing certain cultural and religious beliefs. A health-related belief of Jehovah's Witnesses is that transfusions containing blood in any form are not acceptable. Witnesses do not accept transfusions of whole blood or any of its 4 major components (ie, red cells, white cells, platelets, and plasma) (Options 2, 3, and 5). Shock prevention is a major concern in the setting of blood loss and can be accomplished with the use of non-blood volume expanders such as saline, lactated Ringer's, dextran, and hetastarch. These can be administered safely to clients who refuse blood products (Option 4). Recombinant human erythropoietin (eg, epoetin alfa) and IV iron are accepted by most Jehovah's Witnesses. These medications stimulate the bone marrow to produce more red blood cells, resulting in increased hematocrit and hemoglobin levels (Option 1).

A 3-month-old child with developmental dysplasia of the hip (DDH) is being fitted for a Pavlik harness. Which statement made by the parent indicates a need for further instruction?

DDH is instability or dislocation of the hip joint that may be present at birth or develop during the first few years of life. Nonsurgical treatment methods such as the Pavlik harness are most successful when initiated during the first 6 months of life. After this time, surgery is generally required. The Pavlik harness is the most common tool used to treat early DDH. It maintains the infant's hips in a slightly flexed and abducted position (ie, legs bent and spread apart), allowing for proper hip development (Option 4). Pavlik harnesses are typically worn for 3-5 months or until the hip joint is stable. The straps are assessed every 1-2 weeks by the health care provider (HCP) and adjusted as necessary to account for infant growth. However, parents should not alter the strap placements at home as incorrect positioning can lead to damage to the nerves or vascular supply of the hip (Option 2). Care of the infant wearing a Pavlik harness includes the following: Assess skin 2-3 times daily for redness or breakdown under the straps (Option 3) Dress the child in a shirt and knee socks under the harness to protect the skin Apply diapers underneath the straps to keep the harness clean and dry Leave the harness on at all times, unless otherwise indicated by the HCP (Option 1)

A client is diagnosed with diabetic ketoacidosis (DKA). The client reports frequent urination, thirst, and weakness. The nurse assesses a temperature of 102.4 F (39.1 C), fruity breath, deep labored respirations with a rate of 30/min, and dry mucous membranes. What is the priority nursing diagnosis (ND) at this time? 1. Deficient fluid volume related to osmotic diuresis (35%) 2. Imbalanced nutrition, less than body requirements related to inability to metabolize glucose (3%) 3. Ineffective breathing pattern related to the presence of metabolic acidosis (55%) 4. Ineffective health maintenance related to the inability to manage DM during illness (5%)

DKA is a life-threatening emergency caused by a relative or absolute insulin deficiency. The condition is characterized by hyperglycemia, ketosis, metabolic acidosis, and dehydration. The most likely contributing factors in this client include stress associated with illness and infection (elevated temperature) and inadequate insulin dosage and self-management. Deficient fluid volume related to osmotic diuresis secondary to hyperglycemia as evidenced by dry mucous membranes and client report of frequent urination, thirst, and weakness is the priority ND. Hyperglycemia leads to osmotic diuresis, dehydration, electrolyte imbalance, and possible hypovolemic shock and renal failure. Therefore, this condition requires rapid correction through the infusion of isotonic intravenous fluids and poses the greatest risk to the client's survival (Option 1).

What are signs that developmental dysplasia of the hip (DDH) is present in infants age <2-3 months (Strictly in this age group)?

Developmental dysplasia of the hip (DDH) is a set of hip abnormalities ranging from mild dysplasia of the hip joint to full dislocation of the femoral head. Manifestations in infants age <2-3 months include: - The presence of extra inguinal or thigh folds - Laxity of the hip joint on the affected side. Hip laxity/instability is tested through the Barlow and Ortolani maneuvers. However, these tests must only be performed by an experienced health care provider to avoid further hip injury. If DDH is not treated, these signs disappear after age 2-3 months due to the development of muscle contractures.

A client returns to the unit after receiving hemodialysis for the first time. The client vomits once, reports headache, and appears restless and disoriented. What is the priority intervention?

Dialysis disequilibrium syndrome (DDS) is a rare but potentially life-threatening complication that can occur in clients during the initial stages of hemodialysis (HD); it can be prevented by slowing the rate of dialysis. During HD, solutes (ie, urea) are removed more quickly from the blood than from the brain cells and cerebrospinal fluid, creating a concentration gradient that can lead to excess fluid in the brain cells and increased intracranial pressure. Characteristic neurologic manifestations include nausea and vomiting, headache, restlessness, change in mentation, and seizure activity. If DDS is suspected, the health care provider should be contacted immediately.

The nurse is monitoring a neonate 1 hour after spontaneous vaginal delivery. Which of the following are expected findings? Select all that apply. 1. Capillary glucose of 60 mg/dL (3.3 mmol/L) 2. Holosystolic murmur auscultated at fourth intercostal space 3. Respirations of 56 breaths per minute 4. Single transverse crease across palm of the hand 5. White papules on bridge of the nose

During pregnancy, the fetus stores large quantities of glycogen that are used during the transition to extrauterine life. As a result, glucose levels are decreased 1 hour after birth, then rise and stabilize within 2-3 hours. Optimal glucose levels are 70-100 mg/dL (3.9-5.6 mmol/L), but ≥40 mg/dl (2.2 mmol/L) is considered normal (Option 1). A hypoglycemic neonate (<40 mg/dl [2.2 mmol/L]) should be fed immediately. Infants of diabetic mothers are at increased risk for hypoglycemia due to excess intrauterine insulin produced in response to high maternal glucose levels. Normal newborn respiratory rate is 30-60 breaths per minute (Option 3). Breathing may be slightly irregular, diaphragmatic, and shallow. Milia (white papules) form due to plugged sebaceous glands and are frequently found on the nose and chin. They resolve without treatment within several weeks (Option 5). (Option 2) A holosystolic murmur (heard during entire systole phase) at the left lower **A holosystolic murmur (heard during entire systole phase) at the left lower sternal border is a classic sign of a ventricular septal defect (VSD). Although abnormal, most small VSDs close spontaneously within the first 6 months of life.**

A nurse is caring for a pregnant client at 27 weeks gestation after a motor vehicle collision with side airbag deployment. The client's blood type is O negative. Which laboratory test should the nurse anticipate?

During pregnancy, the mother and fetus have separate blood supply mechanisms. However, disruption of this separation can occur at delivery or when trauma results in fetomaternal hemorrhage (eg, placental abruption after a motor vehicle collision). If an Rh-negative mother (eg, O negative blood type) is exposed to Rh-positive fetal blood (if the father is Rh positive), the pregnant client develops antibodies to the Rh antigen (ie, Rh sensitization), placing the current fetus and all future pregnancies at risk for serious complications (eg, hemolytic anemia). An indirect Coombs test is performed to screen for Rh sensitization any time hemorrhage secondary to placental abruption is suspected (eg, maternal trauma) (Option 2). Rh immune globulin (eg, RhoGAM) is administered to all Rh-negative pregnant clients at 28 weeks gestation and within 72 hours postpartum, as well as after any maternal trauma, to prevent the development of permanent Rh antibodies. RhoGAM is not effective once sensitization has occurred.

How does endometrial cancer arise and what are the 3 main factors that increase the risk of getting it?

Endometrial cancer arises from the inner lining of the uterus and forms after the development of unregulated endometrial overgrowth (ie, hyperplasia). Although typically slow growing, it can metastasize to the myometrium (ie, uterine muscle tissue), cervix, and nearby lymph nodes and eventually beyond the pelvis. Many signs of endometrial cancer are nonspecific (eg, lower back or abdominal pain), but the hallmark symptom is abnormal uterine bleeding (eg, heavy, prolonged, intermenstrual, and/or postmenopausal bleeding). As with many cancers, the client's family and genetic history (eg, BRCA mutation carrier) are significant risk factors; however, prolonged estrogen exposure without adequate progesterone is the greatest risk factor for developing endometrial cancer. Factors increasing estrogen exposure and endometrial cancer risk include: - Conditions associated with infrequent or anovulatory menstrual cycles (eg, polycystic ovary syndrome, infertility, late menopause, early menarche) - Obesity - Tamoxifen (a medication given for breast cancer)

What is epididymitis?

Epididymitis is irritation and swelling of the epididymis, commonly caused by bacterial sexually transmitted infections (STIs), including gonorrhea and chlamydia. To avoid transmission of STIs and prevent complications (eg, infertility), assessing the client's sexual history and investigating possible STIs are the priority. Additional Information Physiological Adaptation NCSBN Client Need

The parent of a 5-year-old child calls the clinic to report the recurrence of a nosebleed for which the child was seen a week ago. Which of the following instructions should the nurse reinforce? Select all that apply. 1. Apply a cold cloth to the bridge of the nose 2. Apply pressure by pinching the nostrils together 3. Attempt to keep the child calm and quiet 4. Have the child lie down and turn to the left side 5. Take the child to the emergency department

Epistaxis (nosebleed) is a common and rarely serious nasal condition that can be caused by dry mucous membranes, local injury (eg, nose-picking), insertion of a foreign body, or rhinitis. Epistaxis usually involves the anterior nasal septum and often resolves spontaneously or with simple home management. Home management of epistaxis includes: - Prioritizing application of direct, continuous pressure to the soft, compressible area below the nasal bone for 5-15 minutes to promote clot formation (Option 2) - Holding a cold cloth or ice pack to the bridge of the nose to induce vasoconstriction and slow bleeding (Option 1) - Attempting to keep the client with epistaxis quiet and calm as emotional outbursts and noncooperation create a challenge to implementing interventions and stopping bleeding (Option 3)

Which statements related to ethical nursing practices are correct? Select all that apply. 1. Accountability is documenting that the nurse administered the wrong medication 2. Autonomy is informing the client of the decision the family made for the client 3. Confidentiality is respecting a client's request to keep suicidal ideation a secret 4. Justice is providing the same cardiac care to a homeless person as a businessperson 5. Nonmaleficence is reporting abuse for a client with Alzheimer disease

Ethical principles guide decision making and appropriate behavior. Justice is treating every client equally regardless of gender, sexual orientation, religion, ethnicity, disease, or social standing (Option 4). Accountability refers to accepting responsibility for one's actions and admitting errors (Option 1). Nonmaleficence means doing no harm. It also relates to protecting clients who are unable to protect themselves due to their physical or mental condition. Examples include infants/children, clients under the effects of anesthesia, and clients with dementia (Option 5). (Option 2) Autonomy is freedom for a competent client to make decisions for oneself, even if the nurse or family does not agree (eg, informed consent, advanced directive). The nurse can provide information and should respect the client's decisions. (Option 3) Confidentiality means that information shared with the nurse is kept in confidence unless permission is given to share or it is required by law to be shared to protect the client and/or community (eg, reportable infectious diseases). If a client discusses suicidal ideation with the nurse, it must be appropriately reported to protect the client from self-harm. Educational objective:

What is a fat embolism and what are the manifestations of it?

FES is a rare, but life-threatening complication that occurs in clients with long bone and pelvis fractures. It can also occur in nontrauma-related conditions, such as pancreatitis and liposuction. It usually develops 24-72 hours following the injury or surgical repair. There are no specific diagnostic tests to identify FES. However, the initial characteristic signs and symptoms include: - Respiratory problems (eg, dyspnea, tachypnea, hypoxemia) after a fat embolus travels through the pulmonary circulation and lodges in a pulmonary capillary, leading to impaired gas exchange and acute respiratory failure. This pathophysiology is similar to that of a pulmonary embolus (Option 5). - Neurologic changes (eg, altered mental status, confusion, restlessness), which occur due to cerebral embolism and hypoxia (Option 1). - Petechial rash (eg, pin-sized purplish spots that do not blanch with pressure), which appears on the neck, chest, and axilla due to microvascular occlusion. This defining characteristic differentiates a fat embolus from a PE (Option 4). - Fever (>101.4 F [38.6 C]), which is due to a cerebral embolism leading to hypothalamus dysfunction.

A 70-year-old female client with type 2 diabetes mellitus comes to the emergency department with diaphoresis, nausea, generalized weakness, and epigastric burning pain. Which intervention should the nurse implement first? 1. Administer 2 mg morphine IV (2%) 2. Assess fingerstick blood glucose (58%) 3. Draw blood for basic metabolic panel (2%) 4. Obtain a 12-lead electrocardiogram (37%)

Female, elderly, and diabetic clients tend to present with atypical symptoms of myocardial infarction (MI), such as diaphoresis, nausea, fatigue, or dyspnea, but may not always experience chest discomfort. Pain may be absent or atypical or may radiate to unusual locations (eg, jaw, back). Some clients may report pain as "indigestion" (epigastric burning or gas). The nurse should obtain a 12-lead electrocardiogram (ECG) on any client with atypical MI symptoms to assess for evidence of ischemia, injury, or infarction (Option 4). ST-segment elevation MI is life-threatening and requires rapid coronary intervention.

What are the classifications of burns?

First-degree (superficial) burns. First-degree burns affect only the outer layer of skin, the epidermis. The burn site is red, painful, dry, and with no blisters. Mild sunburn is an example. Long-term tissue damage is rare and often consists of an increase or decrease in the skin color. Second-degree (partial thickness) burns. Second-degree burns involve the epidermis and part of the lower layer of skin, the dermis. The burn site looks red, blistered, and may be swollen and painful. Third-degree (full thickness) burns. Third-degree burns destroy the epidermis and dermis. They may go into the innermost layer of skin, the subcutaneous tissue. The burn site may look white or blackened and charred. Fourth-degree burns. Fourth-degree burns go through both layers of the skin and underlying tissue as well as deeper tissue, possibly involving muscle and bone. There is no feeling in the area since the nerve endings are destroyed.

A client is 6 hours postoperative from hip surgery after receiving regional anesthesia and has epidural continuous anesthesia in place. Which is the most important reason for the nurse to contact the health care provider?

Fondaparinux (Arixtra), unfractionated heparin, and low molecular weight heparin (eg, enoxaparin, dalteparin) are anticoagulants commonly used for deep vein thrombosis and pulmonary embolism prophylaxis after hip/knee replacement or abdominal surgery. However, fondaparinux is not administered until more than 6 hours after any surgery, and anticoagulants are not given while an epidural catheter is in place.

A Muslim woman is admitted to the inpatient trauma unit after falling and sustaining a head injury. In providing culturally competent care for this client, which consideration is most important?

For the observant Muslim client, maintaining modesty is an important moral value. Covering up the body is essential when a Muslim woman is in the presence of a man who is not related to her, even if the man is a health care provider. Special provision should be made for female health care workers to provide care and examine Muslim women. If a female health care provider is not available, a female nurse or clinical staff person should be present. In addition, privacy screens should be used and room doors should be kept closed consistently.

The nurse preparing an educational seminar on sexually transmitted infections for female college students should advise that which 2 infections are leading causes of pelvic inflammatory disease and infertility?

Gonorrhea and chlamydia can lead to pelvic inflammatory disease (PID) and infertility. They are referred to as "silent infections" because many affected women show no symptoms. Infections of the fallopian tubes and uterus can lead to permanent damage and infertility. The Centers for Disease Control and Prevention recommend annual chlamydia and gonorrhea screening for all sexually active females age <25 and older females with risk factors. Both chlamydia and gonorrhea are treatable. The use of latex condoms is recommended to reduce the risk of contracting chlamydia and gonorrhea.

After morning report, the nurse must perform which action first when caring for assigned clients? 1. Administer IV bumetanide to a client with heart failure who has bilateral crackles and dyspnea (56%) 2. Hang the second unit of packed red blood cells for a client with a hemoglobin of 6 g/dL (60 g/L) (36%) 3. Replace the empty IV opioid medication syringe in a patient-controlled analgesia pump (5%) 4. Replace the heparin infusion bag that has 100 mL remaining and is infusing at 50 mL/hr (1%)

Heart failure involves the inability of the heart to pump blood effectively to meet the body's oxygen needs. The nurse should first administer the IV bumetanide (Bumex) or furosemide (Lasix) to promote diuresis and mobilize excess fluid in the systemic circulation and lungs. This is the priority action as it improves oxygenation and gas exchange in the lungs and helps relieve dyspnea.

A 59-year-old client comes to the clinic due to a blistering, linear rash on the left chest. The client reports itching and pain around the rash. What is the priority question for the nurse to ask the client?

Herpes zoster, or shingles, has a characteristic unilateral, linear pattern of fluid-filled blisters. Affected clients commonly report pain and itching. Herpes zoster infection is due to the varicella-zoster virus (VZV), which also causes chickenpox. After initial VZV infection (chickenpox) in early childhood, the virus remains dormant in the sensory nerves. Reactivation of VZV when the immune system is compromised (eg, aging, immunosuppression) results in the formation of lesions along the distribution of one or more such nerves (dermatomal distribution). Vaccination can prevent shingles. If this rash is determined to be due to shingles, the affected area should be covered to prevent the spread of infection. Therefore, it is a priority to ask if this client has had chickenpox. This client's linear rash has a dermatomal distribution that is characteristic of herpes zoster. These questions should be addressed, but assessing a history of chickenpox is the priority.

The nurse is caring for an infant diagnosed with Hirschsprung disease who is awaiting surgery. Which assessment finding requires the nurse's immediate action?

Hirschsprung disease (HD) occurs when a child is born with some sections of the distal large intestine missing nerve cells, rendering the internal anal sphincter unable to relax. As a result, there is no peristalsis and stool is not passed. These newborns exhibit symptoms of distal intestinal obstruction. They have a distended abdomen and will not pass meconium within the expected 24-48 hours. They also have difficulty feeding and often vomit green bile. Surgical removal of the defective section of bowel is necessary and colostomy may be required. A potentially fatal complication is Hirschsprung enterocolitis, an inflammation of the colon, which can lead to sepsis and death. Enterocolitis will present with fever; lethargy; explosive, foul-smelling diarrhea; and rapidly worsening abdominal distension.

A nurse is caring for a client at 12 weeks gestation who is admitted for hyperemesis gravidarum. Which clinical manifestation should the nurse expect?

Hyperemesis gravidarum (HG) is characterized by severe, persistent nausea and vomiting during pregnancy that usually leads to considerable weight loss (ie, ≥5% of prepregnancy weight), fluid and electrolyte imbalances (eg, hypokalemia), and nutritional deficiencies. Clients with HG may require hospitalization for IV fluid replacement and antiemetic therapy. Routine laboratory assessment for HG includes urinalysis dipstick testing to monitor the client's health status. Expected findings include an elevated urine specific gravity and ketonuria (Option 4). Urine specific gravity increases when urine is concentrated due to dehydration, and ketones are a by-product of the fat breakdown that occurs in starvation states.

The emergency department nurse cares for a client admitted with a diagnosis of hyperosmolar hyperglycemic state. The nurse understands which characteristics are commonly associated with this complication?

Hyperosmolar hyperglycemic state is a serious complication usually associated with type 2 diabetes. With this condition, clients are able to produce enough insulin to prevent diabetic ketoacidosis but not enough to prevent extreme hyperglycemia, osmotic diuresis, and extracellular fluid deficit. Because some insulin is produced, blood glucose rises slowly and symptoms may not be recognized until hyperglycemia is extreme, often >600 mg/dL (33.3 mmol/L). This eventually causes neurological manifestations such as blurry vision, lethargy, obtundation, and progression to coma. Because some insulin is present, symptoms associated with ketones and acidosis, such as Kussmaul respirations (hyperventilation) and abdominal pain, are typically absent

A client with heart failure is started on furosemide. The laboratory results are shown in the exhibit. The nurse is most concerned about which condition? Click on the exhibit button for additional information. 1. Atrial fibrillation (27%) 2. Atrial flutter (11%) 3. Mobitz II (7%) 4. Torsades de pointes (53%) Laboratory results: Sodium- 134 mEq/L (134 mmol/L) Potassium- 3.4 mEq/L (3.4 mmol/L) Chloride- 108 mEq/L (108 mmol/L) Magnesium- 0.9 mEq/L (0.45 mmol/L)

Hypomagnesemia (normal: 1.5-2.5 mEq/L [0.75-1.25 mmol/L]) causes a prolonged QT interval that increases the client's susceptibility to ventricular tachycardia. Torsades de pointes is a type of polymorphic ventricular tachycardia coupled with a prolonged QT interval; it is a lethal cardiac arrhythmia that leads to decreased cardiac output and can develop quickly into ventricular fibrillation. The American Heart Association recommends treatment with IV magnesium sulfate.

If a pt has a question about blood transfusion before signing a consent form for surgery, what happens to the legitimacy of the signature?

If the pt questions, it indicates an incomplete understanding of risk and would invalidate the signature.

What is the most critical complication with ectopic pregnancy, what S&S would show up?

If untreated, continued growth can lead to fallopian tube rupture, resulting in hemorrhage and hemodynamic compromise. Intra-abdominal bleeding can lead to referred shoulder pain, a classic sign of diaphragm irritation. Ruptured ectopic pregnancy requires emergency surgical intervention and hemodynamic support (eg, IV fluids, blood transfusion)

The nurse has provided teaching about home care to the parent of a 10-year-old with cystic fibrosis. Which of the following statements by the parent indicates that teaching has been effective? Select all that apply. 1. "Chest physiotherapy is administered only if respiratory symptoms worsen." 2. "I will give my child pancreatic enzymes with all meals and snacks." 3. "I will increase my child's salt intake during hot weather." 4. "Our child will need a high-carbohydrate, high-protein diet." 5. "We will limit our child's participation in sports activities."

In clients with cystic fibrosis (CF), a defective protein responsible for transporting sodium and chloride causes exocrine gland secretions to be thicker and stickier than normal. Viscous respiratory secretions accumulate, resulting in impaired airway clearance and a chronic cough. Clients eventually develop chronic lung disease, which predisposes them to recurrent respiratory infections. Pancreatic enzyme secretion, needed for digestion and absorption of nutrients, is also impaired because thick secretions block pancreatic ducts. Therefore, the client needs supplemental enzymes with all meals and snacks (Option 2). The client also requires multiple vitamins and a diet high in carbohydrates, protein, and fat to help meet nutritional requirements for growth (Option 4). Sweat gland abnormalities prevent sodium and chloride reabsorption, causing increased salt loss, dehydration, and hyponatremia during times of significant perspiration. Therefore, parents should increase the child's salt intake and fluids during hot weather, exercise, or fever (Option 3).

A client with primary hypothyroidism has been taking levothyroxine for a year. Laboratory results today show high levels of TSH. Which statement by the nurse to the client is appropriate?

In primary hypothyroidism, the thyroid is unable to synthesize enough T3 or T4, slowing the metabolic rate. In response to low circulating thyroid hormones, the pituitary continues to release TSH, resulting in high TSH levels. Levothyroxine (Synthroid), a thyroid hormone replacement drug, is commonly used to treat hypothyroidism. Levothyroxine dosing is adjusted to regulate circulating thyroid hormone levels; this creates a euthyroid (normal) state and TSH levels are decreased.

What are 5 common assessment findings on an infant with pyloric stenosis?

In pyloric stenosis, a hypertrophied pyloric muscle causes postprandial projectile vomiting secondary to an obstruction at the gastric outlet. An olive-shaped mass may be palpated in the epigastric area just to the right of the umbilicus. Emesis is nonbilious (formula in/formula out) and leads to progressive dehydration. Infants will be hungry constantly despite regular feedings. A hematocrit of 57% (0.57) is elevated and indicative of hemoconcentration caused by dehydration. Elevated blood urea nitrogen is also a sign of dehydration.

The nurse is providing nutritional teaching for a client with a new ileostomy. Which foods should the nurse instruct the client to avoid?

In the immediate postoperative period of an ileostomy, a low-residue diet (low-fiber) is prescribed to prevent obstruction of the narrow lumen of the small intestine and stoma (1-in [2.54-cm] diameter or less). After the ileostomy heals, the client reintroduces fibrous foods one at a time. The client is instructed to thoroughly chew food and monitor for changes in stool output. Foods to be avoided include: - High fiber: popcorn, coconut, brown rice, multigrain bread - Stringy vegetables: celery, broccoli, asparagus - Seeds or pits: strawberries, raspberries, olives - Edible peels: apple slices, cucumber, dried fruit

What are 3 HR value ranges classified as Fetal Bradycardia and how critical can they be?

1. 100-120 BPM: Mild, considered "okay" 2. 80-100 BPM: Nonreassuring- try to manage it with interventions and it occurs with congenital heart abnormalities, myocardial conduction defects, etc. 3. Below 80 BPM: sustained at 3 mins or longer, indicates severe hypoxia, baby must be delivered STAT

What are 3 HR value ranges are classified as Fetal Tachycardia and how critical can they be?

1. 160-180 BPM is mild 2. >180 BPM is considered severe 3. >200 BPM is usually caused by congenital anomolies rather than hypoxia alone

When should the Moro reflex be present and be gone by?

From 3-6 months

What is an example of dissociative symptom?

Altered sense of reality

Where are Beta 2 receptors located?

Located in Lungs: GI smooth muscle, Lungs, Uterus, Liver (LG LU)

What is justice?

Refers to treating all pts fairly (without bias)

What is meningeocele?

(Option 2) Meningocele is a saclike protrusion through a bony defect that contains meninges and cerebrospinal fluid; it is corrected with surgery. In some children, residual bowel and bladder incontinence can result despite surgery. If bowel and bladder control is obtained but incontinence reoccurs, the child should be evaluated for infection (a common complication). Although the child with ear pain (eg, otitis media) may need antibiotics, this is not urgent and the client with neurological signs is the priority.

What is Donepezil?

- AchE Inhibitor. - To treat mild to moderate Alzheimer's disease. - Do NOT give in pregnant/ breast-feeding women, in COPD/asthma pts and in pts with cardiovascular disease.

If pulse oximeter tracing is showing up erratic in a pt, what should be the FIRST thing the nurse does?

- When an electronic assessment reading is questionable, the nurse should always assess the pt first for possible etiology.

If there is a suspected positive TB test and induration is present, what would be the next 2 steps?

1. Sputum test 2. Chest X-ray

What 4 types of precautions should a pt with Ebola be under in a hospital?

1. Standard 2. Contact 3. Droplet 4. Airborne

In an ineffective breastfeeding situation, what 2 possible alternatives should be AVOIDED?

1. Supplemental formula feedings 2. Artificial nipples - Research demonstrates it interferes with mother's ability to exclusively breastfeed, DO NOT use formula as supplement if progression of breastfeeding is the goal

What 2 main signs should you be on the lookout when pt is given the "mean old -mycins"?

1. Tinnitus 2. Vertigo (dizziness)

At age 5, how many hrs of sleep do kids need?

11 hrs

Is decompensated heart failure systolic or diastolic?

ADHF, acute or subacute decompensation is in the context of chronic HF with reduced ejection fraction (also known as systolic HF)

What is the FHR baseline?

120-160 beats/min

What is Amiodrone's duration of action?

13-107 days

What could unexpected and projectile vomiting without feeling nauseated indicate in a pt with history if increased ICP?

It can indicate increased ICP. The vomiting can be associated with headaches and gets worse with lowered head position.

What 5 interventions should be implemented to prevent complications in a patient who was recently extubated in the ICU?

1: Place patient in high fowler position to maximize lung expansion and prevent secretion aspiration 2: Provide warmed, humidified oxygen immediatly after extubation via facemask 3: Oral care to decrease bacteria and contaminants 4: Give patient an incentive spirometer to promote cough and deep breathing (to expand alveoli and prevent atelectasis) 5: Keep them NPO until Speech Therapy evaluates them (swallow eval)

What 3 obstructions will set off a high pressure alarm?

3 kinds of obstructions: 1. kinks in tubing- it will increase resistance, so unkink it 2. water condensation in the tubing- to fix this problem one must empty the tubing 3. Mucus secretions in the airway- make pt turn cough deep breath first, if that did not work, then suction

What is an Implantable Cardioverter Defibrillator (ICD) and what is its capability?

It defibrillates life-threatening dysrhythmias. It also includes pacemaker capabilities such as overdrive pacing for rapid heart rhythms or back-up pacing for bradycardias.

What is a sign that a pt is less likely to currently commit suicide?

Pt articulate long-term personal goals and family milestones

What major symptom should be reported to the HCP ASAP?

Signs and symptoms of infection (eg, low-grade fever should be reported to the HCP immediately as infection can develop quickly and spread rapidly.

If Melatonin is being used to treat jet lag, when should Melatonin be taken first, when should you not take it and why?

Once destination is reached, avoid taking it during air travel because it may actually slow the recovery of jet lag

When does Acute Stress Disorder (ASD) and what characterizes it?

It happens following a traumatic or extremely stressful event and is characterized by intrusive memories of the event, negative mood, dissociative symptoms and reactivity symptoms

How often should an ostomy appliance be changed?

5-10 days

In a disaster triage, what are the characteristics of an Nonurgent (GREEN) case and what 3 examples display those characteristics?

Injuries requiring treatment but can wait for 2 hrs or longer. 1. Infections 2. Minor burns or lacerations 3. Closed fractures Tip to remember this: M.I.C likes the color green...

What is medical battery?

Intentional actions by medical staff that is legally defined as unacceptable or occurs without the person's consent. Does not have to be physical

If UAP raises all 4 rails on a pt's bed, what should the nurse do?

Intervene because all 4 rails up is considered a restraint

Does Levothyroxine sodium have to be taken on an empty stomach or with a meal?

It is best to take this medication first thing in the morning as it best absorbed on an empty stomach (1 hr before or 2 hrs after a meal).

What is Variability in a FHR strip and what is the baseline?

It is the way the HR dropes BPM 1. Minimal= <5 BPM 2. Moderate= 6-25 BPM 3. Marked= >25 BPM 4. Absent variability is VERY BAD

What does it mean if there is a low pressure alarm going off?

It is too easy for the machine to put air in the lungs

What kind of pts have an increased risk of uterine rupture and what are they recommended to do in order to avoid it?

Clients attempting vaginal birth after cesarean (VBAC) have a slightly increased risk for uterine rupture due to previous surgical scarring of the uterus. Clients desiring VBAC are usually encouraged to wait for spontaneous onset of labor rather than undergo induction and are monitored closely throughout labor and delivery.

If a pt in a semi-private room overhears the incoming nurse receive report from the neighbor, is it considered privacy violation?

A client overhearing report through a privacy curtain is inadvertent communication and is not considered a violation.

A client suffering from bladder prolapse and subsequent stress urinary incontinence has discussed treatment options with the health care provider (HCP). The nurse evaluates that the client understands support pessary use when the client makes which statement?

A pessary is a vaginal device that provides support for the bladder. Clients can remain sexually active while wearing a pessary. They are fitted for the proper type and size by an HCP in the office. Surgery is not required for pessary placement; clients who are able can insert and remove the pessary themselves (Option 1). If a pessary or other treatment (eg, pelvic muscle exercises, estrogen replacement therapy) is ineffective, reconstructive surgery may be indicated. (Option 3) Clients who are able to remove and reinsert the pessary on their own will have the choice to remove it weekly, possibly even nightly, for cleaning. Clients who are sexually active may prefer to remove the pessary prior to intercourse, although this is not necessary. When the client cannot remove the pessary regularly, removal by an HCP at 2- to 3-month intervals is recommended. (Option 4) Increased vaginal discharge is a common side effect. However, if an odor is present, the client should be instructed to notify the HCP to be treated for a possible infection.

When does the top of the fundus reach the umbilicus?

At 20-22 wks of gestation

Briefly explain NG insertion

During NG tube insertion, the tube sometimes slips into the larynx or coils in the throat, which can result in coughing and gagging. The nurse should withdraw the tube slightly and then stop or pause while the client takes a few breaths. After the client stops coughing, the nurse can proceed with advancement, asking the client to take small sips of water to facilitate advancement to the stomach. The client should not be asked to swallow during coughing or aspiration may occur. If resistance or obstruction occurs during tube advancement, the nurse should rotate the tube while trying to advance it. If resistance continues, the tube should be withdrawn and inserted into the other naris if possible.

Lumbar puncture positioning

During a lumbar puncture, the client is positioned side-lying, with the head, back, and knees flexed. A small pillow may be placed between the legs and under the head for comfort and to maintain the spine in a horizontal position. Following the procedure, the client will be positioned according to the health care provider's prescription (usually supine or with head of the bed elevated 30 degrees).

A pregnant client at 39 weeks gestation is brought to the emergency department in stable condition following a motor vehicle collision. The client, who is secured supine on a backboard, suddenly becomes pale with a blood pressure of 88/50 mm Hg. Which action should the nurse take first?

During stabilization of a pregnant client after trauma (eg, motor vehicle collision, fall), uterine displacement is the first step to address supine hypotension (due to aortocaval compression and decreased venous return to the heart) and promote blood circulation to the fetus. The client should be tilted laterally while strapped on the backboard to promote venous return and protect the client from further potential spinal injury.

What are early clinical manifestations of infant botulism?

Early clinical manifestations of infant botulism often include constipation, difficulty feeding, decreased head control, and diminished deep-tendon reflexes. It is essential to recognize symptoms early, because botulism progresses rapidly to respiratory failure and arrest.

What positioning must be avoided in pts with Shock?

High Fowler's (90 degrees) position, it will decrease BP even more.

What is the vest used to give CPT to pts with CF?

High-frequency chest wall oscillation (HFCWO)

What kind of surgery is done to reduce bleeding in a pt with placenta accreta while in C-section and why, what is the outcome of this this surgery?

Hysterectomy, with placenta left in to reduce blood loss. Pt will not be able to have children anymore

What about 3rd degree burns over 60% of the body, first phase?

Metabolic acidosis- causes dehydration

Is psychosis confronted?

NO- because psychosis is due to brain damage, so the pt will never learn what is real as appose to what is fantasy

What is the definition of preeclampsia?

New-onset hypertension with either proteinuria or end-organ dysfunction after 20th week of gestation (< 20 weeks suggests molar pregnancy).

Does organ donation leave obvious evidence on a pt, in case they want to have an open casket funeral for them?

No, they maintain the integrity and outward appearance of the body

What 4 factors can affect the SAT reading from a pulse ox?

Normal SpO2 for a healthy client is 95%-100%. Any factor that affects light transmission or peripheral blood flow can result in a false reading. Common causative factors of falsely low SpO2 include: 1. Dark fingernail polish or artificial acrylic nails 2. Hypotension and low cardiac output (eg, heart failure) 3. Vasoconstriction (eg, hypothermia, vasopressor medications) 4. Peripheral arterial disease

The nurse is preparing to administer a unit of packed red blood cells to a 16-year-old with blood loss anemia. The client currently has D5W infusing through a 20-gauge IV catheter. What action should the nurse take?

Normal saline (NS) is the only fluid that can be given with a blood transfusion. Dextrose solutions may lyse the red blood cells. All other IV solutions and medications may cause precipitation and are incompatible with blood. Blood transfusions should be infused through a dedicated IV line. If a transfusion must be started in an IV catheter currently in use, the nurse should discontinue the infusion(s) and tubing, and then flush the catheter with NS prior to connecting the blood administration tubing. After transfusion, the catheter should be cleared with NS before any other IV fluids are administered.

What is priority after nurse assess a pt with possible CS and why?

Notify HCP STAT after assessment- CS is a limb-threatening emergency and requires immediate surgery (fasciotomy)

A client had a percutaneous nephrolithotripsy 3 hours ago to remove left renal calculi. Since then, the indwelling urethral catheter has drained 125 mL of urine and the nephrostomy tube has drained 0 mL. The client now reports left flank pain radiating to the left groin along with severe nausea. What is the appropriate nursing intervention?

Percutaneous nephrolithotripsy involves the insertion of a needle and sheath through the skin into the pelvis of the kidney. A nephroscope is inserted through the sheath to break and remove kidney stones too large to remove with other methods. Post procedure, a temporary percutaneous nephrostomy tube may be placed to prevent obstruction by stone fragments and to promote healing of injured tissue; maintaining tube patency is critical. This client is experiencing left flank pain and has no drainage from the nephrostomy tube, which may indicate obstruction to urine flow in the left kidney that can lead to kidney injury (pressure atrophy). Gentle irrigation of the nephrostomy tube with a small volume of sterile normal saline (as prescribed or per protocol) using aseptic technique is the appropriate intervention. If tube paten

TORCH infections

Prenatal infex that lead to severe abnormalities = most common HEARING IMPAIRMENT & MR Toxoplasmosis Other = syphillis, varicella, HIV Rubella Cytomegalovirus Herpes Simplex

What is a spiral femur fracture how can it occur?

Pressure applied to leg in opposite directions (torsion)

What is Misoprostol (Cytotec)?

Prostaglandin analog that acts on the cervix to soften and dilate and on the uterine muscle to stimulate contractions

A pt post MI day 3 is having nausea and increased oxygen demands, what can this mean?

Pt is showing signs of reinfarction and may be unstable FYI: Pt like this should not be assigned to a nurse who is floating to a cardiac care unit

Why should we teach pts to avoid caffeine as a strategy to prevent constipation?

Pt should avoid it because it promotes diuresis and dehydration and may lead to constipation

As my pH goes, so does my...

Pt- meanings, as the pH goes up or down, so do his/her symptoms

What is aortic regurgitation and what is one KEY sign of it in a pt's pulse?

Pulses would be bounding in aortic regurgitation due to more blood being pumped each time (blood accumulation from regurgitation of the previous systole).

What if pH is UP and Bicarb is NORMAL?

Respiratory Alkalosis

What is Rotavirus and how is it acquired?

Rotavirus is a contagious virus and the leading cause of diarrhea in children less than 5 years old; it is also the cause of many nosocomial infections each year. Rotavirus is spread via the fecal-oral route. Because the virus lives easily outside a human host, transmission can occur through contact with food, toys, diapers, and hands. Meticulous handwashing and proper diaper disposal prevent the spread of the virus. Symptoms include foul-smelling, watery diarrhea that lasts 5-7 days and is often accompanied by fever and vomiting. Vaccination is available and must be given before the child is 8 months old. However, vaccinated children can still acquire Rotavirus as many strains are not covered by the vaccine. Because the virus can easily lead to dehydration, parents should be taught the symptoms (eg, lack of tears when crying, extremely fussy or sleepy, decreased urination, dry mucous membranes). Oral rehydration solutions should be used to combat dehydration

With loss, you?

SUPPORT

What are diverticula and what are they caused by?

Sac-like protrusions or outpouchings of the intestinal mucosa of the large intestine caused by increased intraluminal pressure (chronic constipation)

What is the goal of treatment in hypertensive crisis?

Slowly lower BP using IV anti-hypertensive meds to limit end-organ damage

If pregnant pt at 38 weeks shows up to ED complaining of bleeding, severe abd pain, and contracting, what should nurse do first?

These are signs of placenta abruption, when placenta prematurely detaches from the uterine wall. It is a priority to assess maternal vital signs and place a continuous fetal heart rate monitor

When cardiac tamponade happens, how does that hinder the workload of the heart?

The heart struggles to contract effectively against the fluid, and cardiac output can decrease drastically

Which client should the nurse assess first? 1. Client with atrial fibrillation with a new prescription for warfarin (5%) 2. Client with chronic obstructive pulmonary disease with an oxygen saturation of 91% (1%) 3. Client with postoperative pain rated 8 out of 10 (5%) 4. Client with third-degree heart block with a pulse of 42/min (86%)

Third-degree atrioventricular (AV) block, or complete heart block, occurs when electrical conduction from the atria to the ventricles is blocked, causing decreased cardiac output (eg, dizziness, syncope, mental status changes, heart failure, hypotension, bradycardia). The client with third-degree AV block is a high priority, as the client may decompensate to cardiogenic shock and even periods of asystole (Option 4). Treatment includes administration of atropine and temporary pacing (eg, transcutaneous) until a permanent pacemaker can be placed.

The nurse is caring for an adolescent client diagnosed with type 1 diabetes. The client exhibits hot, dry skin and a glucose level of 350 mg/dL (19.4 mmol/L). Arterial blood gases show a pH of 7.27. STAT serum chemistry labs have been drawn. Cardiac monitoring shows a sinus rhythm with peaked T waves, and the client has minimal urine output. What is the nurse's next priority action?

This client has diabetic ketoacidosis (DKA). All clients with DKA experience dehydration due to osmotic diuresis. Prompt and adequate fluid therapy restores tissue perfusion and suppresses the elevated levels of stress hormones. The initial hydrating solution is 0.9% saline infusion. **Insulin therapy should be started after the initial rehydration bolus as serum glucose levels fall rapidly after volume expansion.**

How can a nurse treat breakthrough pain?

To treat episodes of breakthrough pain, you can take a "rescue medication." This means a pain reliever that goes to work quickly and lasts for a short period of time. Usually breakthrough pain is treated with a short-acting opioid that is 5 to 20 percent of the dose you normally take to manage chronic pain

A nurse in a pediatric clinic is performing a physical examination of a 30-month-old child. Which finding requires further evaluation?

Weight gain slows during the toddler years with an average yearly weight gain of 4-6 lb (1.8-2.7 kg). By age 30 months, current weight should be approximately 4 times greater than birth weight. A toddler weighing 6 times the initial birth weight requires further evaluation. Family nutrition and meal habits should be discussed. (Option 1) A toddler achieves bowel and bladder sphincter control by age 24 months as bladder capacity increases. (Option 2) Chest circumference exceeds abdominal circumference after age 2, resulting in a taller and more slender appearance. (Option 4) Head circumference increases by 1 in (2.5 cm) during the second year and then slows to a growth rate of 0.5 in (1.25 cm) per year until age 5.

If a pt makes their advance directive outline choice but family changes their mind about it last minute, ex: pt is status DNR but fam wants CPR last minute, what should be done at this point?

When advance directive is placed, the pt's wishes are followed even if they conflict with the wishes of loved ones.

The nurse reads a journal article about a study using a new pain management protocol for clients with terminal cancer. What should the nurse first consider in determining whether the protocol is appropriate to implement on the unit?

When evaluating research for practice changes, the nurse must first determine if there is reasonable similarity between the nurse's unit population and the study population to expect equivocal results. This should be the initial consideration to ensure that the research is appropriate for a given setting. For instance, if the nurse cares for pediatric clients with acute pain, the protocol for adult clients with terminal cancer might not translate effectively or safely to those clients.

The clinic nurse is teaching a client about the advance directive form that needs to be completed. Which statement indicates that the client understands the information?

When the advance directive is completed, a copy should be placed in the client's medical record and copies should be given to everyone listed as health care proxies. The client should also keep a copy in a safe place.

What is the Moro reflex and what does it assess for?

When the newborn is quickly lowered simulating a fall and also can be assessed by making a sudden loud noise. This reflex indicates whether the CNS and brain of the baby is intact

Where should the top of the fundus be felt at 36 wks?

Xiphoid process

Can acute diverticulitis cause bleeding and where will it show up?

YES, in the stool and it will be bright red

If a pt with CKD is admitted with urosepsis and has a creatinine level of 4.0, can antibiotics be given and why or why not?

Yes, but only IV broad-spectrum antibiotics

Can iron deficiency anemia occur in toddlers who are overweight? why?

Yes, overweight toddlers who consume too much milk develop iron deficiency anemia due to the likely exclusion of iron-rich foods in favor of milk.

What does Low-pressure limit alarm on a ventilator indicate, is it a priority to assess?

Yes, positive pressure necessary to deliver a breath to the pt is decreased. Complications usually arise from the pt (loss of airway), artificial airway (cuff leak), and/or vent system (tubing disconnected).

Is informed consent required for Electroconvulsive therapy (ECT) and who should sign it for pt with mental illness?

Yes, pt who has a mental illness can give or withhold consent unless they have been deemed incompetent through legal proceedings

Are microwaves and ovens safe to use for people that have permanent pacemakers?

Yes, they do not interfere with the pacemaker

Is it normal for a pt to have a low grade fever following surgery or from post-op atelectasis?

Yes, within 24 hrs. Low-grade fever may occur following surgery (due to the release of inflammatory cytokines) or from postoperative atelectasis. The client should be encouraged to ambulate and deep-breathe.

Can UAPs empty surgical drain from bulb drain and document the output?

Yes- UAP can empty, measure, and record output from a surgical drain. However, the RN is responsible for assessing the drainage (eg, type, amount, odor, color) and maintaining the wound drainage device (Option 2).