1-N

The nurse is drawing a blood specimen from the client's right basilic vein. The client cries out and reports a shooting, severe "pins and needles" sensation in the arm. The nurse should take what action next? 1. Apply ice locally 2. Apply lidocaine/prilocaine cream 3. Reassure the client 4. Withdraw the needle

Withdraw the needle The preferred site for venipuncture when collecting blood specimens is the antecubital fossa's median cubital vein. The basilica vein lies close to the brachial nerve and artery. Nerve injury may be occurring when a client has severe, shooting pain radiating down the arm during venipuncture. If a client reports shooting pain, withdraw the needle and avoid probing.

The nurse is providing hospice care to a terminally ill client who is reporting dyspnea. Which interventions should the nurse implement at this time?

Dyspnea (air hunger) is a common symptom in terminally ill clients. Dyspnea is subjective, and management depends on the client's clinical condition and reported symptoms. Initial interventions focus on decreasing respiratory effort and the perception of dyspnea, as well as relieving anxiety. Interventions for hospice clients include: Administering opioids (eg, morphine, fentanyl), which are prescribed to relieve dyspnea (Option 2) Providing low-flow oxygen by nasal cannula, which may improve psychological comfort and ease feelings of apprehension Allowing frequent periods of rest to minimize exhaustion and dyspnea Administering anxiolytics (eg, lorazepam) for anxiety associated with dyspnea Assisting with relaxation strategies (eg, music, guided imagery) (Option 5) Placing a fan in the room to improve airflow near the client, which decreases the perception of dyspnea (Option 4)

Furosemide

Furosemide is the primary diuretic used in children, particularly in those with congenital heart disease when fluid overload is a frequent problem.

Insulin

Insulin is a high-risk medication (eg, can cause severe hypoglycemia), and exact dosages are critical.

The nurse inserts a urinary catheter into a female client who has not voided for 6 hours. No urine is returned. What action should the nurse take next?

Leave the catheter in place and insert a new catheter higher up in the perineal area. Urine output would be expected as this client has not voided for 6 hours (obligatory amount is at least 30 mL x 6 = 180 mL). The most common explanation is that the catheter was unintentionally inserted into the vagina. The nurse should leave that catheter as a landmark and insert a new sterile catheter into the urethra which is located above the vagina.

Naloxone

Naloxone is given to the client to reverse respiratory depression resulting from maternal opioid use during the 1-4 hours prior to birth.

The nurse is performing an admission assessment on an elderly client with Alzheimer disease (AD). The nurse should do which of the following when communicating with the client?

When speaking with AD clients, use clear and simple explanations. When communicating with clients who have hearing loss, speak loudly, stand close to the person, and touch the person before speaking.

amoxicillin administration for otitis media in infant

can be given with or without food. give medicine when baby is hungry makes it more likely for baby to swallow it -give full course of antibiotics as prescribed -stroking infant cheek will open the infants mouth allowing for administration of medicine

The community health nurse is preparing to teach a group of African American women about prevention of diseases common to their ethnic group. Based on the incidence of disease within this group, which disorders should the nurse plan to discuss? Select all that apply. 1. Cervical cancer 2. Hypertension 3. Ischemic stroke 4. Osteoporosis 5. Skin melanoma

1. Cervical cancer 2. Hypertension 3. Ischemic stroke The incidence of cervical cancer is higher among Hispanics, American Indians, and African Americans. The mortality rate for cervical cancer among African American women is twice as high as that for white American women (Option 1). African Americans have the highest incidence of hypertension in the world, and this condition is more prevalent among the women than men in this ethnic group. The mortality rate for hypertension among African American women is higher than that for white American women (Option 2). African Americans have a higher incidence of ischemic stroke than whites or Hispanics. Risk factors for stroke are related to an increased rate of hypertension, diabetes mellitus, and sickle cell anemia (Option 3). (Option 4) White and Asian women have a higher incidence of osteoporosis than African Americans, but the disease affects all ethnic groups. (Option 5) Melanoma of the skin is more common in people who are of white ancestry, light-skinned, and over age 60 with frequent sun exposure. The incidence of melanoma is 10 times higher in white Americans than African Americans.

A nurse is preparing a client for below-the-knee amputation surgery. Which actions should the nurse complete? Select all that apply. 1. Administer a preoperative IV antibiotic 2. Ensure that the correct limb to be amputated is marked appropriately 3. Place a red "no known allergies" bracelet on the client 4. Place operative permits in the client's chart 5. Replace the current 20G IV catheter with an 18G IV catheter

1 2 4 The Joint Commission's National Patient Safety goals include preventing mistakes in surgery. The goals state, "Make sure that the correct surgery is done on the correct patient and at the correct place on the patient's body." The correct surgical site is marked preoperatively with a permanent marker (Option 2). A measure by The Centers for Medicare & Medicaid and the Joint Commission states that a prophylactic antibiotic is to be given within 1 hour prior to surgical incision (Option 1). It is also a standard of practice for the nurse to ensure that appropriate operative permits have been signed and placed on the client's chart (Option 4). (Option 3) A red allergy band should be placed on the client only if the client has an allergy. (Option 5) If the client does not have an IV line started, an 18G would be preferable. However, if the client has a functioning IV line present, then a 20G is most likely acceptable. Blood can be transfused through a 20G if necessary.

Which statements involve acceptable use of an abbreviation, symbol, or dose designation in documentation? Select all that apply. 1. "2 cm x 3 cm x 1 cm stage II decubitus noted on left shin." 2. "4.0 u SSRI administered to cover capillary glucose of 160 mg." 3. "Dose of .5 mg hydromorphone administered and the client feels 'better.'" 4. "Maalox 5 mL administered pc as requested for c/o heartburn." 5. "Spouse voiced understanding of home urinary catheterization QID."

1,4,5, The Joint Commission (2004) and Institute for Safe Medication Practices list prohibited or error-prone "dangerous" abbreviations, symptoms, and dose designations that should be avoided. Cm (centimeters) and decubitus staging are acceptable abbreviations/notations (Option 1). The abbreviations ac (before meals), pc (after meals), and c/o (complains of) are acceptable (Option 4). QID, 4 times a day, is acceptable. Not acceptable are qod (every other day) as it can be mistaken as qd (daily); qd (daily) as it can be mistaken as qid; and q1d (daily) as it can be mistaken as qid (Option 5). (Option 2) A trailing zero after the decimal point is not acceptable as it could be interpreted as 40 instead of 4 if the decimal point is not noted. The use of u for unit is not acceptable as it can be mistaken for the number 0 or 4 (eg, 4u seen as 40). SSRI (sliding-scale regular insulin) is not acceptable to indicate insulin as it can be mistaken for selective serotonin reuptake inhibitor. Mg for milligrams is acceptable. (Option 3) A zero must precede the decimal dose. If the decimal point is missed, the .5 could be mistaken as 5 mg. Educational objective:

The health care provider prescribes intravenous fluid resuscitation for a client in hypovolemic shock. The nurse should anticipate the rapid infusion of which intravenous solution initially? 1. 0.9% Sodium chloride 2. 5% Albumin 3. Dextrose 5% and lactated Ringer's 4. Dextrose 5% and water

1. 0.9% Sodium chloride Normal saline is the fluid of choice for rapid correction of hypotension in most situations, including hypovolemic and septic shock. It can be administered in large quantities rather rapidly and is inexpensive. (Option 2) When 5% albumin, a colloid solution, is infused into the intravascular space, it mobilizes fluid from the extravascular tissues into the extracellular vascular space. Although it is equally effective in expanding intravascular fluid volume, it is expensive and not the initial fluid of choice. It can be used in clients with low intravascular protein (albumin) content and hypotension but increased fluid in extravascular tissues (eg, cirrhosis with ascites). (Option 3) When dextrose 5% and lactated Ringer's, a hypertonic solution, is infused into the intravascular space, it mobilizes fluid from the extravascular tissue into the extracellular vascular space. Although it may be used to expand fluid volume, it is not the initial intravenous fluid of choice. (Option 4) When the dextrose in dextrose 5% and water is metabolized, a hypotonic solution is left. In large volumes, it can cause shift of the fluid into the extravascular compartment, which may cause further hypotension in clients with low blood pressure. Hypotonic solutions (0.45% saline or dextrose 5% and water) are typically used to treat hypernatremia.

The nurse is administering a pink pill to a hospitalized medical-surgical client. The alert, oriented client says, "This is a pill I haven't seen before." What follow-up action should the nurse take next? 1. Check the health care provider's prescription in the medical record 2. Explain that the health care provider has prescribed the medication 3. Look up the medication in the pharmacology reference 4. Teach the client about the purpose of the medication

1. Check the health care provider's prescription in the medical record Safe medication administration is conducted according to 6 rights: Right client using 2 identifiers Right medication Right dose Right route Right time Right documentation When a mentally competent client questions a drug administration, the safest option is to first check the prescription to verify the 6 rights of medication administration (Option 1). If an error is ruled out (eg, different brand, new order) the nurse should follow up with appropriate teaching. (Option 2) The nurse must first verify all aspects of proper medication administration. If they are correct, the nurse should provide appropriate teaching on why the health care provider prescribed the medication. Explaining that the nurse is just following orders is rarely the correct answer. (Option 3) A pharmacology reference can verify information about the medication but will not confirm that the client is the correct recipient. Acceptable identifiers include first and last name, medical record number, and birth date. (Option 4) The nurse can teach the client about the purpose of the medication after the 6 rights have been verified.

The nurse observes an ambulating client begin to experience a tonic-clonic seizure. Which nursing actions should be implemented immediately? Select all that apply. 1. Guide the client to the floor and gently cradle the head 2. Insert a tongue blade to prevent client from swallowing the tongue 3. Move objects that may cause injury away from the client 4. Physically restrain the client to prevent injury 5. Place the client in left lateral position 6. Remain with the client, observe, and record the seizure activity

1.Guide the client to the floor and gently cradle the head 3. Move objects that may cause injury away from the client 5. Place the client in left lateral position 6.Remain with the client, observe, and record the seizure activity Protecting the ambulating client from injury is the immediate priority. The nurse assists the client to the floor, cradles the head, and places the client in the left lateral position. Left lateral position is preferred to avoid the risk of aspiration. Hard or sharp objects should be removed from the client's environment to prevent injury. The nurse remains with the client until the seizure is over to assess seizure activity and postictal symptoms and to minimize injury. (Option 2) No objects should be placed in a client's mouth during a seizure. Following the seizure, the client may require assessment and maintenance of the airway, suctioning, and oxygen administration. (Option 4) Attempting to restrain a client during a seizure may cause injury to the client.

Which steps should the nurse take to decompress the stomach for a client with abdominal distension and vomiting after insertion of a large-bore nasogastric (NG) tube? Select all that apply. 1. Connect the blue pigtail air vent to suction 2. Flush the tubing with water regularly 3. Leave the blue pigtail air vent open to air 4. Plug the blue pigtail lumen to prevent leakage 5. Use an adaptor to connect main NG lumen to suction tubing

2 3 5 The term decompression is used to describe the removal of air or secretions from the stomach. An NG tube can facilitate the removal of secretions when it is connected to suction. After NG insertion, the nurse should connect the main lumen of the NG tube (using a small white teardrop-shaped adaptor) to the suction apparatus. The blue pigtail lumen is the air vent that facilitates removal of air or secretions from the stomach. The nurse should never connect the air vent to suction, use it for flushing, or clamp/plug it (Options 1 and 4). If plugged, the tube may adhere to the side of the stomach or esophagus and cause tissue breakdown. Regular flushing of the NG tube with water prevents clogging and allows the suction apparatus a clear pathway to decompress the suction.

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?" 2. "I notice that you seem frustrated." 3. "It can take time to adjust to dialysis. We have a support group that can be helpful." 4. "It's normal to be angry when you can't work any longer."

2. "I notice that you seem frustrated." 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. (Option 1) This response ignores the client's feelings and closes off an opportunity to assess the client's emotional state and the role change brought on by illness and the spouse's new job. (Option 3) The source of the client's behavior change is not apparent at this point, so further assessment is needed. It is premature to intervene by recommending a support group. (Option 4) The nurse is assuming that the client is angry about inability to work, but the client has not said this. Further assessment is needed to understand the client's emotions and their source.

The nurse plans to start an IV line to infuse 2 units of packed red blood cells for a stable 42-year-old client with a gastrointestinal bleed. Which IV catheter size is best? 1. 14-gauge 2. 18-gauge 3. 20-gauge 4. 22-gauge

2. 18-gauge When selecting catheter size, the need for rapid fluid administration and the type of fluid administered versus client discomfort should be assessed. A lower IV catheter gauge number corresponds to a larger bore IV catheter. A 14-gauge (large-bore) catheter may be used for administering fluids and drugs in an emergency or prehospital setting, or for hypovolemic shock (Option 1). In somewhat stable adult clients who require large amounts of fluids or blood, an 18-gauge catheter is preferred. (Options 3 and 4) A 20-22-gauge catheter is sufficient for administering general IV fluids and medications to adult clients; a 20-gauge is acceptable for blood transfusion. However, 20-22-gauge is not preferred for blood administration. A 24-gauge catheter is recommended for children and some older adults with small, fragile veins.

A young Spanish-speaking client is experiencing a spontaneous abortion (miscarriage). Which illustrates the best use of an interpreter to explain the situation to the client? Select all that apply. 1. Ask the client to nod so the nurse can confirm the client understands the situation 2. Attempt to use a female interpreter to avoid gender sensitivity 3. Make good eye contact with the client (rather than the interpreter) when speaking 4. Preferably use a personal friend or relative to facilitate client privacy under HIPAA 5. Teach about one intervention at a time and in the order it will occur

2. Attempt to use a female interpreter to avoid gender sensitivity 3. Make good eye contact with the client (rather than the interpreter) when speaking 5. Teach about one intervention at a time and in the order it will occur Clients from many cultures will be more responsive if the interpreter is the same gender, especially when the condition is highly personal or sensitive (Option 2). The nurse should maintain good eye contact when communicating with the client. The interpreter should translate the client's words literally. Communication is with the client, not the interpreter. The nurse should use basic English rather than medical terms, speak slowly, and pause after 1-2 sentences to allow for translation (Option 3). Providing simple instructions about upcoming actions in the order they will occur will be easier for the client to understand. For example, the nurse can indicate that there will be surgery and then a follow-up visit as opposed to, "You'll follow up with the health care provider after your procedure" (Option 5). (Option 1) The nurse should obtain feedback to be certain that the client understands. This feedback should extend beyond nodding as some people nod to indicate that they are listening or nod in agreement to "save face" even though they do not understand. It is better to use a tactic such as having the client repeat back information (which is then translated into English). (Option 4) Using a fee-based agency or language line is preferred if an appropriate bilingual employee is not available. The client may not want the friend/relative to know about this personal situation, or the person may not be able to adequately translate medical concepts and/or understand client rights.

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 2. Check the client's pulse oximeter 3. Give more morphine per protocol 4. Open the airway with head tilt-chin lift

2. Check the client's pulse oximeter 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. (Option 1) Adequate oxygenation should be established first before administering additional benzodiazepine for sedation. (Option 3) Oxygenation should be assessed before administering additional narcotics for pain. Change in the level of consciousness (restlessness/agitation or lethargy/sedation) can be an indication of excess medication and should be assessed before administering additional drugs. (Option 4) If the client is speaking, the airway is open. Opening the airway would be an initial response if there is new onset of snoring respirations (the tongue falling back due to relaxation and blocking the airway). Normal respirations should be effortless and quiet.

The nurse caring for a client with a single-lumen jugular central venous catheter (CVC) plans to administer 3 mL of an intravenous (IV) push medication through the CVC. Which size syringe is best for the nurse to choose when preparing the medication? 1. 1 mL 2. 3 mL 3. 10 mL 4. 30 mL

3. 10 mL A 10 mL syringe is generally preferred for administering medications through a CVC. The smaller the syringe, the greater the amount of pressure per square inch (PSI) exerted during injection. If the pressure produced by the IV push is too high, it can damage the CVC. A damaged CVC may result in complications for the client, including embolism or malfunction. A 1 mL or 3 mL syringe may cause too much pressure (Options 1 and 2). The nurse should always consult the specific manufacturer guidelines and facility policy when caring for a CVC. (Option 4) The nurse would have difficulty accurately drawing up precisely 3 mL of medication in a 30 mL syringe, which is too big for most IV pushes.

A nurse is caring for a group of clients on a medical surgical unit. Which client is most at risk for contracting a nosocomial infection? 1. 51-year-old client who received a permanent pacemaker 48 hours ago 2. 60-year-old client who had a myocardial infarction 24 hours ago 3. 74-year-old client with stroke and an indwelling urinary catheter for 3 days 4. 75-year-old client with dementia and dehydration who is on IV fluids

3. 74-year-old client with stroke and an indwelling urinary catheter for 3 days A nosocomial infection occurs in a hospital (hospital-acquired) or other health care setting and is not the reason for the client's admission. Many nosocomial infections are caused by multidrug resistant organisms. These infections occur 48 hours or more after admission or up to 90 days after discharge. Clients at greater risk include young children, the elderly, and those with compromised immune systems. Other risk factors include long hospital stays, being in the intensive care unit, the use of indwelling catheters, failure of health care workers to wash their hands, and the overuse of antibiotics. The most common nosocomial infection is urinary tract infection, followed by surgical site infections, pneumonia, and bloodstream infections. The 74-year-old client is most at risk due to age and the presence of the urinary catheter. The nurse will need to be on high alert for this complication and should follow infection control procedures diligently. (Option 1) This client does have a surgical incision, which poses a risk for infection. However, this client is younger and does not have any underlying chronic condition to compromise the immune system. (Option 2) This client does not fall in the category of elderly and has no surgical incision or indwelling catheters other than a possible IV site. (Option 4) This client is at risk due to age and presence of an IV catheter. However, the risk is not as high as the client with the urinary catheter.

The nurse receives report on 4 clients. Which client should the nurse assess first? 1. Client with end-stage renal disease receiving hemodialysis who reports fever with chills and nausea 2. Client taking ibuprofen for ankylosing spondylitis who reports black-colored stools 3. Client with altered mental status who is not following commands starts vomiting 4. Client with acute diverticulitis receiving antibiotics who reports increasing abdominal pain

3. Client with altered mental status who is not following commands starts vomiting This client with altered mental status and not following commands is at risk for aspiration and airway compromise from vomiting. This client should be assessed first; the client needs to be placed in the lateral position with head elevated and may need emergent intubation if airway cannot be protected. (Option 1) Clients receiving hemodialysis are at risk for bloodstream infections. Blood cultures need to be obtained from a client with a bloodstream infection, and antibiotics would then be administered. This is not a priority over airway compromise. (Option 2) Clients with ankylosing spondylitis often take nonsteroidal anti-inflammatory drugs to control back pain and are at risk of developing gastric ulcers. They can cause melena (black stools). The client needs further assessment of orthostatic vital signs and hemoglobin level. This is not a priority over airway compromise. (Option 4) Clients with acute diverticulitis (inflammation of the diverticula) are at risk for perforation, which can be manifested by increasing abdominal pain, rigidity, guarding, and rebound tenderness (peritoneal signs). This client needs further assessment, but this is not a priority over airway compromise.

A child on the playground is experiencing an anaphylactic reaction. The school nurse arrives with an EpiPen. The weather is cold and the child is wearing several layers of clothing. How should the nurse proceed with the EpiPen? 1. Inject into the upper arm where the sleeve can be pulled up 2. Inject into the most accessible vein 3. Inject through the clothing into thigh and hold in place for 10 seconds 4. Take the child inside, remove excess clothing, and inject into the thigh

3. Inject through the clothing into thigh and hold in place for 10 seconds The EpiPen is designed to be administered through clothing with a swing and firm push against the mid-outer thigh until the injector clicks. The position should be held for 10 seconds to allow the entire contents to be injected (Option 3). The site should be massaged for an additional 10 seconds. Timing is essential in the delivery of epinephrine during an anaphylactic reaction. The nurse should administer the medication immediately on the playground without removing the child's clothing. Any delays can cause client deterioration and make maintenance of a patent airway difficult (Option 4). (Option 1) The EpiPen should be injected into the mid-outer thigh, not the upper arm. (Option 2) IV epinephrine is not administered outside the hospital setting. It requires cardiac monitoring and is indicated in clients with profound hypotension (shock) or those who do not respond to intramuscular epinephrine and fluid resuscitation.

A client with multiple co-morbidities, including chronic obstructive pulmonary disease, diabetes, and chronic kidney disease, has just been told by the health care provider of the need to start dialysis. The client is in tears and says to the nurse, "I don't know what I'm going to do; everything was so overwhelming before, and now this." Which is the best response by the nurse? 1. "But you need the dialysis to stay alive." 2. "I hope that a kidney donor will be found for you very soon." 3. "It won't be so bad; you might even feel better with dialysis." 4. "Tell me more about what has been overwhelming for you."

4. "Tell me more about what has been overwhelming for you." It is not unusual for clients to feel overwhelmed when managing one or more chronic illnesses. Day-to-day self management includes engaging in activities that maintain and promote physical health, adhering to prescribed medications and treatments, keeping multiple health care appointments, making decisions about health care, and coping with the impact of the illness on physical and social functioning. In this situation, the client felt overwhelmed even before receiving the news about the deteriorating kidney disease requiring dialysis. To help the client plan strategies for self-care and coping with health conditions, it is important for the nurse to identify past barriers to self care and assess aspects of the client's health that were most difficult to manage. Exploring a topic or idea with such words as "Tell me more about..." or "Let's discuss..." is a communication technique that will promote a therapeutic interaction with the client. (Option 1) This may be a true statement; however, it does not explore the client's feelings of being overwhelmed. (Option 2) This does not explore the client's feelings of being overwhelmed and does not facilitate a discussion of how the client might be able to manage illnesses in the future. (Option 3) This is a non-therapeutic statement that dismisses the client's sense of being overwhelmed.

The nurse prepares to care for a client being admitted with a confirmed diagnosis of Middle East respiratory syndrome. Which personal protective equipment will the nurse use when providing care to the client? 1. Gloves and gown 2. Gloves and mask 3. Gown and N95 respirator 4. Gown, gloves, N95 respirator, and eye protection

4. Gown, gloves, N95 respirator, and eye protection Middle East respiratory syndrome (MERS) is a viral respiratory illness caused by the coronavirus (MERS-CoV). Symptoms include fever, cough, and shortness of breath that often worsen and cause death in many of those afflicted. The incubation period is 5-6 days but can range from 2-14 days. How the virus spreads is not fully understood, but it is thought to spread via respiratory secretions. Because it has easily spread to those who care for infected persons, the Centers for Disease Control and Prevention recommends the use of standard, contact, and airborne precautions with eye protection when caring for clients with MERS. (Options 1, 2, and 3) These options do not provide enough protection as each is missing a vital element that is recommended when caring for a client with MERS.

A client newly returned to the unit after knee surgery asks the nurse for assistance to a chair. What action should the nurse implement first? 1. Ask another nurse to help 2. Delegate the task to unlicensed assistive personnel 3. Premedicate the client for pain 4. Verify the client's activity prescription

4. Verify the client's activity prescription A client newly admitted from a surgical procedure may have activity restrictions or bed rest prescribed for a certain period. Before assisting the client to the chair, the nurse needs to verify the activity level prescribed by the health care provider. Getting the client out of bed too early could cause injury to the surgical site or result in a fall. (Option 1) A client who had knee surgery will likely be unable to bear any weight on the affected limb. Depending on the client's size, it may be prudent for the nurse to get additional help. This could be requested after the activity prescription has been verified. (Option 2) Assistance with ambulation is often delegated to unlicensed assistive personnel (UAP); however, the nurse should verify the prescription first. It would also be prudent to have the UAP assist the nurse as this is the client's first time up after surgery. (Option 3) The nurse should assess the client's pain level before providing pain medication.

A legally blind client is being prepared to ambulate 1 day after an appendectomy. What is the most appropriate action by the nurse? 1. Arrange for the client's service dog to come to the health care facility as soon as possible 2. Describe the environment in detail so the client can ambulate safely with a cane 3. Instruct the unlicensed assistive personnel to walk beside the client and lead by the hand 4. Walk slightly ahead of the client with the client's hand resting on the nurse's elbow

4. Walk slightly ahead of the client with the client's hand resting on the nurse's elbow On the first postoperative day, the nurse assists the client with ambulation to evaluate alertness, pain level, signs of orthostatic hypotension, problems with gait or mobility, and ability to ambulate safely. The nurse also considers pre-existing limitations to ambulation such as the use of assistive aids (eg, sighted guides, canes, guide dogs). Clients who used any ambulatory assistive aids before surgery require postoperative evaluation prior to ambulatory independence. When walking with a client who is legally blind, the nurse uses the sighted-guide technique by walking slightly ahead of the client with the client holding the nurse's elbow. The nurse should describe the environment while ambulating the client. (Option 1) The service dog may be brought to the hospital to assist in ambulation once the nurse has determined the client can ambulate safely. (Option 2) After evaluation by the nurse, the client may be allowed to use a cane to ambulate around the nursing unit. (Option 3) Instructing the unlicensed assistive personnel to ambulate the client is an inappropriate assignment for a client who is 1 day postoperative and legally blind. Nursing assessment is required to determine if the client is able to ambulate safely.

The nurse finds a client on the floor in the client's room. Based on the documentation shown in the exhibit, the nurse made an incorrect entry in the client's medical record at what time?

All incidents, accidents, or occurrences that cause actual or potential harm to a client, employee, or visitor must be reported. The person who witnesses an unusual occurrence or event must file an incident report in the institution's computer documentation system using an electronic form. Alternately, a paper form may be completed and filed. The purposes of the report are to inform risk management of the occurrence, allowing them to consider changes that might prevent similar incidents, and to notify administration of a potential litigation claim. The nurse should not document that an incident report was filed, or refer to the incident report in the medical record.

A nurse is assisting with the care of a newborn during circumcision. Which is an appropriate intervention?

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.

The nurse is caring for a client who performs frequent self-urinary catheterizations. Which client assessments would indicate a potential for a latex allergy?

The greatest risk factor for latex allergy is long-term multiple exposures to latex products. Powdered latex gloves were banned in the 1990s, and the incidence of latex allergy is decreasing. It is estimated that 73% of clients with spina bifida have a sensitivity to latex. This can be a result of frequent exposure to latex during their lifelong care. A classic screening question is whether the lips swell when blowing up balloons (which have latex in them). Another is if your hands itch and/or burn after wearing rubber gloves (Option 5). Some proteins in rubber are similar to plant-derived food proteins. Therefore, certain foods may cause a latex-food syndrome in clients with an allergy to latex. Common foods include bananas, avocados, tomatoes, chestnuts, kiwis, potatoes, peaches, grapes, and apricots (Option 3).

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?

"If a transfusion reaction occurs, it will be important to collect a fresh urine specimen to check for hemolyzed RBCs." 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).

Which emergency department clients cannot be allowed to sign out against medical advice (AMA)? Select all that apply. 1. Client who drank 1 bottle of vodka 2 hours ago 2. Client who hears voice commands to kill the employer 3. Client with ST elevation on electrocardiogram tracing 4. A pregnant 14-year-old client with vaginal spotting 5. Client who insists on being the embodiment of Jesus Christ

1 2 5 The client must be competent to sign out AMA. This includes not being impaired by drugs or alcohol. Adults can be incompetent due to unconsciousness, altered consciousness, mental illness, or chemical influence. The client who drank 1 bottle of vodka is intoxicated and the client who insists on being the embodiment of Jesus Christ is not in touch with reality. The client who hears voices has psychotic symptoms and is potentially homicidal. Clients cannot be allowed to leave AMA if they are a danger to themselves or others. If a competent adult leaves AMA, documentation must include discussion about the risks of the client's decision and the client's understanding of these risks ("informed refusal"). Reasonable steps should be taken to obtain the client's signature. However clients cannot be held against their will for refusing to sign. This process should be witnessed and documented. (Option 3) Clients have right to sign out AMA even if it is not within their best health interests to do so. The clients leaving AMA can and should have normal discharge instructions and the knowledge that they can return at any time. (Option 4) A underage client can be considered an adult (an emancipated minor) for consent purposes without parental involvement. Common criteria for an emancipated minor include marriage, membership in the armed forces, living apart from one's parents, financial independence, pregnancy/parenthood, or a court decision.

A client with suspected foot osteomyelitis is scheduled for magnetic resonance imaging (MRI). Which assessment findings should the nurse notify the health care provider (HCP) about before the test? Select all that apply. 1. Cardiac pacemaker 2. Colostomy 3. Retained metal foreign body in eye 4. Total hip replacement 5. Transdermal testosterone patch

1 3 4 Clients must be screened for contraindications before exposure to the magnetic field (MRI), as it can damage implanted devices or metallic implants. Absolute contraindications can preclude testing, and relative contraindications can pose a hazard to the client's devices or implants, affect the quality of the images, or cause discomfort. Therefore, the imaging HCP determines the client's eligibility for MRI. Absolute contraindications: Cardiac pacemaker (Option 1) Implantable cardioverter defibrillator (ICD) Cochlear implant Retained metallic foreign body, especially in organs such as the eye (Option 3) Relative contraindications: Prosthetic heart valve Metal plate, pins, brain aneurysm clip, or joint prosthesis (Option 4). Some of these devices have nonferrous MRI-safe materials and should be verified. Implanted device (eg, insulin pump, medication port) Other factors that can affect the client's eligibility include inability to remain supine for 30-60 minutes and claustrophobia (sedation can be prescribed, open MRI machine can be used). (Option 2) A colostomy is not a contraindication for MRI. (Option 5) Transdermal metal-containing medication patches (clonidine, nicotine, scopolamine, testosterone, or fentanyl) are not a contraindication for MRI. However, these must be removed before and replaced after testing.

The nurse auscultates rhonchi in a client with a tracheostomy tube and performs endotracheal suctioning to clear the secretions. Which nursing interventions are most appropriate to limit the risks associated with suctioning? Select all that apply. 1. Apply suction only while withdrawing catheter 2. Instill sterile normal saline to loosen secretions 3. Limit aspiration time to 10 seconds with each suction pass 4. Maintain sterile technique throughout suctioning procedure 5. Pre-oxygenate with 100% oxygen

1. Apply suction only while withdrawing catheter 3. Limit aspiration time to 10 seconds with each suction pass 4. Maintain sterile technique throughout suctioning procedure 5. Pre-oxygenate with 100% oxygen Endotracheal suctioning is performed to maintain a patent airway if a client cannot mobilize secretions independently. Inserting a catheter into the airway compromises the sterility of the lower airway and increases the risk for infection. Suctioning removes oxygen in addition to secretions, placing the client at risk for hypoxemia. High suction levels or the contact of the catheter with the trachea can cause trauma, such as barotrauma, damage to tracheal mucosa, and microatelectasis. In order to decrease the occurrence of these complications: Use strict sterile technique throughout suctioning process. Pre-oxygenate with 100% oxygen (hyperoxygenation) for 3-4 breaths. Aspirate during withdrawal of catheter only, limiting each suction pass to 10 seconds. Allow client 4-5 recovery breaths between suction passes to replenish oxygen. (Option 2) Instilling 5-10 mL of sterile normal saline solution (NSS) is thought to help loosen thick secretions and stimulate cough. Although saline lavage is a common practice in some facilities, the installation of NSS into the airway prior to suctioning is not recommended. It can dislodge bacteria, causing increased bacterial colonization, and can stimulate excessive coughing.

The nurse is caring for a client on a mechanical ventilator. The settings on the ventilator have just been changed, and the standing prescription is to draw arterial blood gases 30 minutes after a ventilator change. In anticipation of this blood draw, what intervention should the nurse implement? 1. Avoid suctioning the client 2. Pre-oxygenate the client 3. Raise the head of the bed 4. Reduce the amount of sedation medication

1. Avoid suctioning the client Arterial blood gases (ABGs) indicate the acid-base balance in the body and how well oxygen is being carried to the tissues. It is common to measure ABGs after a ventilator change to assess how well the client has tolerated it. Factors such as changes in the client's activity level or oxygen settings, or suctioning within 20 minutes prior to the blood draw can cause inaccurate results. Unless the client's condition dictates otherwise, the nurse should avoid suctioning as it will deplete the client's oxygen level and cause inaccurate test results. (Option 2) Pre-oxygenation should occur prior to suctioning and possibly before position changes. It will affect ABG results. (Option 3) The head of the bed should be maintained at 30 degrees or higher in an intubated client to prevent aspiration and allow for adequate chest expansion. This position will not affect ABG results. (Option 4) If a client is being weaned from the ventilator, sedation may be reduced. A client with reduced sedation may become anxious and have an increased activity level; these could affect the ABG results.

A client who lives alone had a total laryngectomy for laryngeal cancer 3 months ago. The client has a tracheoesophageal puncture (TEP) to enable speech and tells the nurse, "It's a good thing it's cold outside, so I can keep the hole in my neck covered up with a scarf. I don't know what I'll do when the weather gets warmer." What is the most appropriate nursing diagnosis? 1. Disturbed body image 2. Impaired verbal communication 3. Ineffective coping 4. Ineffective self-health maintenance

1. Disturbed body image Body image is a person's attitude about the actual or perceived structure or function of one's body. A variation from what is considered normal (eg, being a mouth breather) can result in a disturbance or dissatisfaction with one's physical self. Disturbed body image is related to the presence of the laryngectomy stoma (secondary to laryngeal cancer) and altered verbal communication, as evidenced by negative feelings about having to keep the "hole in my neck covered up" and the presence of the TEP. (Option 2) This client has a TEP and is able to speak and communicate. (Option 3) This client is at risk for ineffective coping related to lack of a support system due to living alone. However, the client is now demonstrating the ability to manage stress and problem solve (eg, wearing a scarf). There are no assessment data to support ineffective coping as a problem at this time. (Option 4) Ineffective self-health maintenance refers to the inability to identify, manage, and/or seek help maintaining one's health. Common related factors include cognitive impairment, adverse personal habits (eg, drug and alcohol abuse, poor diet), lack of access to care, and ineffective coping. This client does not currently exhibit any such factors to support this nursing diagnosis.

The nurse on the IV therapy team is making rounds in the intensive care unit on clients with central venous catheters. Which central line should be removed earliest to prevent infection? 1. Femoral line inserted in emergency department post cardiac arrest 48 hours ago 2. Internal jugular line inserted 6 days ago in operating room 3. Peripherally inserted central catheter line with one lumen occluded that was placed 2 weeks ago 4. Subclavian line with slight redness at anchor suture sites inserted in intensive care unit 72 hours ago

1. Femoral line inserted in emergency department post cardiac arrest 48 hours ago In adult clients, central venous access sites in the upper body (internal jugular or subclavian) are preferred to minimize the risk of infection. Access sites in the inguinal area (femoral) are easily contaminated by urine or feces, and it is difficult to place an occlusive dressing over these sites. A central venous catheter (CVC) should be placed where aseptic technique can be applied. The site should be assessed daily for signs/symptoms of infection (eg, redness, swelling, drainage). The duration of CVC placement should be based on clinical need and judgment that there is no evidence of infection. (Option 2) Although this site has been in use for 6 days, it is a preferred site; the CVC was inserted in the operating room, where surgical asepsis was easily accomplished. The site can be used as long as there is a clinical need and no evidence of infection. (Option 3) Peripherally inserted central catheter (PICC) lines can be left in for weeks or months. The occlusion of one lumen does not necessitate removal of the catheter. (Option 4) The subclavian vein is a preferred site for a CVC. Although slight redness is present at the suture sites, it is not located at the insertion site. The femoral line is still at higher risk for infection.

The nurse is caring for a client on droplet precautions who has a prescription for a CT scan. When transporting the client to radiology, the nurse should ensure that the transporter uses protective equipment correctly to reduce the environmental spread of infection when the client is outside the room. Which instruction should the nurse give the transporter? 1. Have the client wear a mask 2. Have the client wear gloves 3. Wear a mask 4. Wear an isolation gown

1. Have the client wear a mask Droplet precautions are used to prevent transmission of respiratory infection. These precautions include the use of a mask and a private room. When the client is in the room, staff should wear masks and follow standard precautions. The client on droplet precautions should wear a mask at all times when outside the hospital room. (Option 2) Gloves are not required as part of droplet precautions. Standard precautions should guide the use of gloves in clients on droplet precautions. (Option 3) The transporter does not need to wear a mask outside of the client's room as long as the client keeps a mask on to prevent transmission of infection. (Option 4) An isolation gown is not required for droplet precautions.

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

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 4. Wash hands prior to putting on gloves and after removing them 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.

The emergency department nurse would administer a prescribed isotonic crystalloid solution to which client? 1. 25-year-old with a closed-head injury and signs of increasing intracranial pressure (ICP) 2. 45-year-old with acute gastroenteritis and dehydration 3. 68-year-old with chronic renal failure and hypertensive crisis 4. 60-year-old with seizures and serum sodium of 112 mEq/L

2. 45-year-old with acute gastroenteritis and dehydration Acute gastroenteritis is associated with nausea, vomiting, diarrhea, and dehydration. An isotonic crystalloid intravenous (IV) solution (eg, 0.9% normal saline, lactated Ringer's) has the same tonicity as plasma and when infused remains in the vascular compartment, quickly increasing circulating volume. It is appropriate to correct the extracellular fluid volume deficit (dehydration) in this client. (Option 1) A hypertonic, rather than isotonic, solution would be infused in clients with ICP. Increasing circulating volume would only further increase ICP. (Option 3) Isotonic solutions can exacerbate fluid overload in chronic renal failure and increase blood pressure. (Option 4) Clients with severe hyponatremia and neurologic manifestations need rapid correction of hyponatremia with hypertonic saline (3% saline).

The charge nurse is notified that a client is being admitted with a diagnosis of active shingles with a disseminated rash. Which room assignment is most appropriate for this client? 1. A private room with contact and droplet precautions 2. A private room with negative airflow and contact and airborne precautions 3. A private room with positive airflow and airborne precautions 4. A semi-private 2-bed room with standard precautions

2. A private room with negative airflow and contact and airborne precautions Shingles (herpes zoster) is a reactivation of the varicella-zoster (chicken pox) virus. It is more likely to occur when a client's immune system is compromised by disease (eg, HIV infection) or treatments (eg, chemotherapy). Shingles lesions that are open may transmit the infection by both air and contact. The client with disseminated shingles that are not crusted over will require contact precautions, airborne precautions, and a negative airflow room to prevent transmission of the infection to others in the hospital. Negative airflow pulls air from the hospital environment into the room, and the air from the hospital room then goes directly to the outside rather recirculating to the rest of the hospital. Localized shingles require only standard precautions for clients with intact immune systems and contained/covered lesions. (Option 1) Negative airflow and airborne precautions are also required in addition to contact precautions. Droplet precautions are not necessary. (Option 3) Positive airflow would pull fresh air from outside into the hospital room, and then the air from the room would circulate throughout the rest of the hospital. It is not appropriate for this type of infection. Instead, positive airflow would be used for protective isolation in a client who is immunocompromised. (Option 4) A semi-private room is not appropriate for this client with a communicable illness. Standard precautions are used for localized shingles in clients with intact immune systems and contained/covered lesions.

All of these events are occurring at the same time. Which one should the registered nurse deal with first? 1. A health care provider (HCP) is asking to speak to the nurse 2. A visitor is seen lying on the hallway floor 3. A client is requesting an analgesic for pain rated an "8" on a 1-10 scale 4. The intravenous (IV) pump is beeping on a client who is receiving blood

2. A visitor is seen lying on the hallway floor The nurse must deal with the visitor on the floor first, either by approaching/assessing the visitor or asking another nurse/charge nurse to deal with it urgently. The visitor could have fallen and hit the head. Responsiveness must be established and the need for any life-saving measures (eg, providing respirations or compression) must be ruled out. Visitor status does not matter, this individual is on hospital property and the nurse is obligated to respond. (Option 1) The nurse can speak to the HCP after dealing with this emergency. (Option 3) An analgesic can be administered after assessing the client and confirming that a medication has been ordered; however, a person needing potential life-saving measures is a priority. (Option 4) Although this is an urgent need and the nurse should assess the site/pump (not delegate for someone else to just push the button to silence the alarm), potential life-saving measures take priority. The IV line will not occlude waiting a few minutes to be dealt with.

A client on hospice home care is taking sips of water but refusing food. Family members appear distressed and insist that the personal care worker "force feed" the client. What is the priority nursing action? 1. Explain to the family that this is a normal physiological response to dying 2. Explore the family's thoughts and concerns about the client's refusal of food 3. Recommend a feeding tube 4. Tell the family that "force feeding" the client could cause the client to choke on the food

2. Explore the family's thoughts and concerns about the client's refusal of food When a terminally ill person refuses food, family members often become upset and frustrated in their roles of nurturers and caregivers; they may feel personally rejected. Refusal of food is associated with "giving up" and is a reminder that their loved one is dying. It is not uncommon for family members to believe that a client would get stronger by eating instead of refusing food. The registered nurse needs to explore family members' concerns and fears and listen as they express their feelings. The nurse can help them identify other ways to express how they care. The nurse should also provide education about the effects of food and water during all stages of the illness. (Option 1) Families and caregivers need to understand the effects of food and water in all stages of a terminal illness; however, it is more important to first explore the family's feelings and concerns. (Option 3) Although it is not unusual for a client to be admitted to hospice with a feeding tube already in place, tubes are generally not placed after a client begins receiving hospice services. (Option 4) This is a true statement, but it is not the priority nursing action.

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." 2. "How well are you sleeping at night?" 3. "These symptoms can be common after major surgery. It will take 4-6 weeks to completely heal and start to feel normal again." 4. "You may be experiencing depression. I'll call the health care provider and see if we can get a prescription for an antidepressant."

3. "These symptoms can be common after major surgery. It will take 4-6 weeks to completely heal and start to feel normal again." 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). (Option 1) The client will most likely feel better in a few weeks, but this statement is not therapeutic and does not really provide any useful information. (Option 2) This is good information for the nurse to have, but it does not directly relate to the client's issues of forgetfulness and becoming teary often. (Option 4) Two weeks postoperative is most likely too early for a diagnosis of depression. Depression can occur after a major illness or surgery, but antidepressants would be considered only for persistent symptomsClients 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). (Option 1) The client will most likely feel better in a few weeks, but this statement is not therapeutic and does not really provide any useful information. (Option 2) This is good information for the nurse to have, but it does not directly relate to the client's issues of forgetfulness and becoming teary often. (Option 4) Two weeks postoperative is most likely too early for a diagnosis of depression. Depression can occur after a major illness or surgery, but antidepressants would be considered only for persistent symptoms

The nurse is preparing to care for a client with acute myelogenous leukemia who is going through induction chemotherapy. The client's laboratory results are shown in the exhibit. Which intervention would be a priority for this client? Click on the exhibit button for additional information. 1. Administer erythropoietin injection 2. Minimize venipunctures and avoid intramuscular injections 3. Place sequential compression devices (SCDs) to the legs 4. Provide a private room and neutropenic precautions

4. Provide a private room and neutropenic precautions The client's laboratory results show severe neutropenia, with a reduced white blood cell count (normal 4,000-11,000/mm3 [4.0-11.0×109/L]) and reduced absolute neutrophil count (normal 2200-7700/mm3 [2.2-7.7 ×109/L]). Protection against infection is the most important goal for this client. The following neutropenic precautions are indicated: A private room Strict handwashing Avoiding exposure to people who are sick Avoiding all fresh fruits, vegetables, and flowers Ensuring that all equipment used with the client has been disinfected

A client has a subclavian vein central venous access device (CVAD). The nurse attempts to flush the catheter with 0.9% normal saline solution using a 10-mL syringe, but meets resistance, is unable to aspirate blood, and suspects an occlusion. What is the nurse's next most appropriate action? 1. Flush and lock with heparinized saline flush 2. Flush with 0.9% normal saline using a 5-mL syringe 3. Notify the health care provider (HCP) 4. Reposition the client

4. Reposition the client Catheter occlusion is the most common complication associated with a CVAD. A kinked tubing, catheter malposition, medication precipitate, or thrombus can cause occlusion. Flushing the CVAD maintains patency. Inability to flush or aspirate blood indicates a lumen occlusion. The nurse attempts to identify a mechanical, nonthrombotic problem that can include a clamped catheter, kinked intravenous (IV) tubing, obstructed IV filter, or catheter malposition. The next most appropriate nursing action is to reposition the client (ie, head, arm) as the catheter can be resting against a vessel wall. The nurse then reaccesses the device. (Option 1) Locking a catheter creates a column of fluid inside the lumen that maintains patency. Most manufacturers of needleless connectors for IV catheters recommend flushing and locking catheters with 0.9% normal saline solution only. Administering multiple heparin flushes before and after IV medications increases the risk for bleeding and heparin-induced thrombocytopenia. The Centers for Disease Control and Prevention recommends avoiding heparin for routine catheter flushing and locking. However, it is important for the nurse to follow institution guidelines as heparinized saline must be prescribed by the HCP if it is not included in the policy and procedure for flushing a CVAD. (Option 2) Never flush with a syringe smaller than 10 mL as it causes increased intraluminal pressure that can damage the catheter. Never apply force when flushing because it can damage the catheter and dislodge a thrombus. If any resistance is felt, stop flushing. (Option 3) If still unable to flush and aspirate blood from the lumen after first ruling out a mechanical problem, notify the HCP. A prescription for a medication (ie, alteplase) to dissolve a fibrin sheath or thrombus may be required.

An adult client has developed diarrhea 24 hours after the initiation of total enteral nutrition via nasogastric tube. The client is receiving a hypertonic formula. What is the best nursing action? 1. Dilute the formula with water 2. Discontinue the tube feeding 3. Send a stool sample to the lab for culture and sensitivity 4. Slow the rate of administration of the feeding

4. Slow the rate of administration of the feeding Most clients tolerate hypertonic and isotonic enteral formulas without complications. However, because of their higher osmolality, hypertonic formulas sometimes cause nausea, vomiting, or diarrhea, especially during the initiation of total enteral nutrition. The gastrointestinal tract will pull fluid from the surrounding intra- and extravascular compartments to dilute the formula, making it similar to body fluid osmolality. This process is similar to dumping syndrome and may cause temporary diarrhea with cramps, nausea, and vomiting. Slowing down the rate of administration of total enteral nutrition will usually alleviate these problems. The feeding can gradually progress to the established goal rate. (Option 1) Diluting enteral formulas is not necessary. This practice may increase the risk of intolerance secondary to microbial contamination. A diluted formula supports microbial growth better than a full-strength formula. Diluting total enteral nutrition may also be detrimental because the client may receive inadequate nutrition; it will take a larger volume of fluid to provide the same number of calories and protein. (Option 2) It is not necessary to discontinue the feeding; the client needs nutrition support. (Option 3) Sending a stool sample for culture and sensitivity would be appropriate if bacterial contamination or a bacterial infection is suspected as the cause of the diarrhea. It is not the best nursing action in this situation.

The nurse caring for a client with tuberculosis (TB) transports the client to the radiology department for a chest x-ray. The nurse ensures that the client uses which personal protective equipment when out of the negative-pressure room? 1. Isolation gown, surgical mask, goggles, and gloves 2. Isolation gown and surgical mask 3. N95 respirator mask 4. Surgical mask

4. Surgical mask Clients with airborne infections such as TB, measles, or chickenpox (varicella) are confined to a negative-pressure room except when traveling to various departments for essential diagnostic procedures or surgery. While being transported through the health care facility, the client on airborne transmission-based precautions wears a surgical mask to protect health care workers (HCWs) and other clients from respiratory secretions. (Options 1 and 2) The client on airborne transmission-based precautions must wear a surgical mask to contain exhaled respiratory secretions. The other personal protective equipment is not necessary. (Option 3) The Centers for Disease Control and Prevention recommends that HCWs who transport clients wear N95 respirator masks as protection against exposure to airborne droplets. N95 respirator masks protect HCWs by removing particles from inhaled air. The client is already infectious and does not require protection from inhaled air.

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 2. Ask the UAP to stay and take over while the nurse goes to check on the client in the next room 3. Tell the UAP to inform the client in the next room that the nurse will be there shortly 4. Tell the UAP to tell the charge nurse about the needs of the client in the next room

4. Tell the UAP to tell the charge nurse about the needs of the client in the next room 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. (Option 1) This action would place the UAP in the role of assessing and prioritizing, which is beyond the scope of the UAP's practice. In addition, the nurse must stay in the room and cannot meet the other client's need as a result. (Option 2) Taking on the role of assessing/monitoring (related to anesthesia) and/or administering additional intravenous drugs during the procedure is beyond the scope of the UAP's practice. (Option 3) The UAP has already communicated that the client's need is urgent. The client should not be kept waiting without further assessment to evaluate the situation.

An elderly client with end-stage renal disease who has refused dialysis is admitted to a long-term care facility for rehabilitation following hospitalization. The next day, the client becomes agitated and says to the nurse, "I've got to get back home to my things. I have so much to do." Which is the most likely interpretation of this client's behavior? 1. The client has been admitted to the facility without the client's consent 2. The client is becoming delirious and should be assessed for infection 3. The client is concerned that someone might steal possessions 4. The client wants to take care of business before imminent death

4. The client wants to take care of business before imminent death This client with advanced renal failure who decides not to start dialysis treatments may have only a few weeks to live. Toxins will build up in the body and soon lead to increased weakness and cognitive decline. This client knows there is a limited time left to live and wants to ensure that possessions will be taken care of appropriately after the client's death (Option 4). (Option 1) The client has probably been admitted to the facility due to concerns about safe management at home. However, the statement does not indicate that the client has been admitted against the client's will. (Option 2) Clients with end-stage renal disease are at risk for delirium due to a buildup of toxins, which may manifest as agitation and statements about needing to go somewhere. However, the nurse should not automatically assume that the client is delirious. Instead, it is important to assess the client's concern with an open mind so that appropriate interventions can be planned. (Option 3) The client's statement about having "so much to do" suggests that this is not the concern prompting the behavior.

An 8-year-old hospitalized due to a bowel obstruction is to be discharged home with a temporary colostomy. The parents' primary language is Vietnamese and their English proficiency is very limited. What is the best approach for the nurse to use when instructing the parents on how to care for the child at home? 1. Demonstrate the procedure using simple English phrases 2. Give the parents written instructions with picture illustrations 3. Tell the parents to have a friend or relative come in to translate 4. Use an interpreter via the telephone interpretation service

4. Use an interpreter via the telephone interpretation service Effective teaching can be accomplished only with effective communication, which can be compromised by language barriers, cultural differences, and low health literacy. When an interpreter is necessary, using a translator who is skilled in medical terminology is the best approach to provide accurate information (Option 4). Hearing instructions and information in one's primary language decreases the risk of adverse clinical consequences. When a professional medical translator is unavailable, language lines, telephone systems, and remote video interpreting services can be used. Translation by family members and friends should only be used as a last resort and only with the permission of the client, especially in situations where sensitive information needs to be communicated (Option 3). Children should not be used as translators except in an emergency situation when there are no other options. (Option 1) This client's parents have very limited English language proficiency; this approach will not be effective in providing instructions about the child's care at home. (Option 2) Providing written materials without verbal teaching does not give the client (or the client's legal guardian) the chance to ask questions, nor does it give the nurse the opportunity to assess the client's understanding of the given information.

Which interventions should the nurse perform when assisting the health care provider with removal of a client's chest tube? Select all that apply. 1. Ensure the client is given an analgesic 30-60 minutes before tube removal 2. Instruct the client to breathe in, hold it, and bear down while the tube is being removed 3. Place the client in the Trendelenburg position 4. Prepare a sterile airtight petroleum jelly gauze dressing 5. Provide the health care provider with sterile suture removal equipment

A chest tube is removed when drainage is minimal (<200 mL/24 hr) or absent, an air leak (if present) is resolved, and the lung has reexpanded. The general steps for chest tube removal include: Premedicate the client with analgesic (eg, IV opioid, nonsteroidal anti-inflammatory drug [ketorolac]) 30-60 minutes before the procedure to promote comfort as evidence indicates that most clients report significant pain during removal (Option 1). Provide the health care provider (HCP) with sterile suture removal equipment (Option 5). Instruct the client to breathe in, hold it, and bear down (Valsalva maneuver) while the tube is removed to decrease the risk for a pneumothorax. Most HCPs use this technique to increase intrathoracic pressure and prevent air from entering the pleural space (Option 2). Apply a sterile airtight occlusive dressing to the chest tube site immediately; this will prevent air from entering the pleural space (Option 4). Perform a chest x-ray within 2-24 hours after chest tube removal as a post-procedure pneumothorax or fluid accumulation usually develops within this time frame. (Option 3) The client should be placed in semi-Fowler's position or on the unaffected side to promote comfort and facilitate access for tube removal.

The charge nurse on the orthopedic unit has 4 semiprivate room beds available. Which room should the nurse assign to a client being transferred from the post anesthesia recovery unit following a total knee replacement? 1. Room 1 - client in skeletal traction following a fracture of the femur, who has erythema at the pin sites 2. Room 2 - client with cellulitis and osteomyelitis following blunt trauma of the tibia 3. Room 3 - client with compartment syndrome following a crush injury, who is 1 day post fasciotomy 4. Room 4 - client with a long leg cast following open reduction of a fractured tibia

A client who is postoperative total knee replacement is at risk for infection. No postoperative client should be assigned to a room with a client who has an actual infection or the potential for infection. This client should be assigned to room 4 as the client with the cast has the lowest potential risk for infection (Option 4). (Option 1) This client has erythema at the pin sites; this can be a sign of infection, a complication of skeletal traction. (Option 2) This client has cellulitis, a bacterial infection of the skin, and osteomyelitis, an infection of the bone. (Option 3) This client has a fasciotomy wound, which is usually kept open for several days to relieve the pressure in the myofascial compartment. This client is a potential source of infection and is susceptible to infection as well.

The nurse prepares to assist the health care provider with a lumbar puncture on a child with suspected meningitis. Place the procedural steps in the correct order. All options must be used

A lumbar puncture (spinal tap) is a sterile procedure used to gather a specimen of cerebrospinal fluid (CSF) for diagnostic purposes (eg, meningitis). A needle is inserted into the vertebral spaces between L3 and L4 or L4 and L5, and a sample of CSF is drawn. The nurse's role when assisting with a lumbar puncture includes the following: Verify informed consent Gather the lumbar puncture tray and needed supplies Explain the procedure to older child and adult Have client empty the bladder Place client in the appropriate position (eg, side-lying with knees drawn up and head flexed or sitting up and bent forward over a bedside table) Assist the client in maintaining the proper position (hold the client if necessary) Provide a distraction and reassure the client throughout the procedure Label specimen containers as they are collected Apply a bandage to the insertion site Deliver specimens to the laboratory

While preparing to insert a peripheral IV line, the nurse notices scarring near the client's left axilla. The client confirms a history of left breast cancer and modified radical mastectomy. Which actions should the nurse take?

A modified radical mastectomy includes removal of axillary lymph nodes that are involved in lymphatic drainage of the arm. Any trauma (eg, IV extravasation) to the arm on the operative side can result in lymphedema, characterized by painful and lengthy swelling, as normal lymphatic circulation is impaired by scarring. Therefore, starting an IV line in this arm is contraindicated. The nurse should insert the IV line into the most distal site of the unaffected side (Option 2). For client safety, it is also important to ensure documentation of the mastectomy history, place a restricted extremity armband on the affected arm, and place a sign above the client's bed notifying hospital staff of necessary mastectomy precautions (eg, no blood pressure measurements, venipuncture, or IV lines) (Options 3 and 4). In general, venipuncture is contraindicated in upper extremities affected by: Weakness Paralysis Infection Arteriovenous fistula or graft (used for hemodialysis) Impaired lymphatic drainage (prior mastectomy)

Albumin

Albumin may be given after paracentesis to prevent volume depletion.

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 2. Instruct the teacher of the child's classroom to use an insecticide spray 3. Send letters home to all of the children's parents informing them about the finding 4. Send the child home and prohibit school attendance until the infestation has been resolved

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).

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.

The charge nurse is planning assignments for the day. Which clients will require the nursing staff to institute contact precautions? Select all that apply. 1. 38-year-old with methicillin-resistant Staphylococcus aureus 2. 42-year-old with Clostridium difficile diarrhea 3. 69-year-old with pertussis infection 4. 72-year-old with vancomycin-resistant Enterococcus 5. 80-year-old with influenza

Infections caused by methicillin-resistant Staphylococcus aureus(MRSA), C difficile, vancomycin-resistant Enterococcus (VRE), and scabies require contact precautions to be used. Contact precautions include: Placing client in private room (preferred) or cohorting clients with the same infection Using dedicated equipment (must be disinfected when removing from room) Wearing gloves when entering room Perform proper hand hygiene before exiting room (use soap and water or alcohol-based hand rubs for MRSA and VRE, but only soap and water for C difficile and scabies) Wearing gown with client contact and removing before leaving room Place door notice for visitors Having client leave room only for essential clinical reasons (ie, tests, procedures). If an x-ray is needed, try to arrange for a portable one. (Option 3) Clients with pertussis infection (whooping cough) need droplet precautions. (Option 5) Influenza requires droplet precautions.

Net intake and output

Net intake and output is calculated by subtracting total output from total intake. To calculate a client's net intake and output, all values must be converted to milliliters (mL). Key conversions include 1 cup = 8 ounces, 1 ounce = 30 mL, and 1 cup = 240 mL.

The nurse recognizes that which factors place a client at increased risk for falls?

Positive orthostatic vital signs (eg, rise in pulse of ≥20/min) indicate increased risk of syncope and falls (Option 3). Osteoarthritis of the knees limits joint mobility, increasing the risk for falls. Presence of IV therapy, wet floors, rooms congested with furniture, and improper toilet seat or bed height are factors that increase this risk (Option 4). Carbidopa/levodopa (Sinemet) is an antiparkinson medication. Parkinson disease increases the risk of falls due to gait abnormality (eg, shuffling gait). Carbidopa/levodopa (Sinemet) may also cause dizziness, involuntary movements, and orthostatic hypotension, further increasing the risk for falls (Option 5). The use of an ambulatory aid such as a cane, walker, or crutches indicates a balance/gait problem and places the client at higher risk of falling (Option 6). (Option 1) Fall risk does not increase until age >65-75. (Option 2) Ovarian cancer does not inherently affect cognition and neurologic or muscular function and is therefore not a risk for falling. Advanced disease with weakness, perhaps from the treatment, could constitute a risk for a fall.

The nurse performs nasogastric (NG) tube insertion using a large-bore NG tube on a hospitalized client with a gastrointestinal bleed. During insertion, after the tube passes the nasopharynx, the client begins to cough and gag. Which action should the nurse take first? 1. Ask the client to take several small sips of water 2. Continue to slowly advance the tube until placement is reached 3.Gently remove the tube and reinsert in the other naris if possible 4. Pull back on the tube slightly and then pause to give the client time to breathe

Pull back on the tube slightly and then pause to give the client time to breathe 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 (Option 2), asking the client to take small sips of water to facilitate advancement to the stomach (Option 1). 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 (Option 3).

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?

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).

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

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: Pull the skin 1-1 ½" (2.5-3.5 cm) laterally away from the injection site (Option 4). 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 (Option 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 (Option 2). 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 (Option 6). Release the hold on the skin - this allows the tissue layers to slide back to their original position, sealing off the needle track (Option 5). 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 (Option 1).

The student nurse is preparing to perform a heel stick on a neonate to collect blood for diagnostic testing.

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 (Option 1). 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 (Option 3). Cleanse the intended puncture site with alcohol. Sucrose and nonnutritive sucking on a pacifier may reduce procedural pain (Option 2). 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 (Option 4).

A client who is 24-hours postoperative bowel resection is receiving IV opioids for severe pain. The nurse reviews the health care provider's (HCP's) prescription to discontinue the continuous IV fluids and advance the diet from clear liquids to regular diet as tolerated. What is the nurse's most appropriate action?

The nurse identifies severe pain as a major problem because if it is not controlled adequately, the client is less likely to move or breathe deeply and more likely to develop postoperative complications (eg, venous thrombosis, atelectasis, pneumonia). The nurse should discontinue the IV infusion and apply a saline lock adaptor to maintain IV access (without clotting). The HCP's prescription to lock the IV catheter is implied, as the client is currently receiving IV opioids.

The nurse initiates prescribed intravenous (IV) therapy on an 86-year-old hospitalized client. Which life span concept(s) should be considered when initiating IV therapy and caring for an older adult receiving IV therapy?

The nurse must consider several life span changes that occur with aging when initiating IV therapy and caring for IV infusions in the older adult. Important considerations include the following: The age-related cardiovascular and renal function changes that can occur in the elderly, such as a mild increase in the size and thickness of the heart, prolonged filling time, and declined glomerular filtration rate, may put the client at risk for rapid development of hypervolemia. Use of an infusion pump is recommended, even in clients with dementia, as they are at increased risk for fluid imbalance (Option 1). Older adults with fragile veins are at increased risk for IV infiltration; therefore, the site should be monitored carefully by the nurse every 1-2 hours. Fragile skin may tear easily; use nonporous tape, skin protectant solutions, and minimal tourniquet pressure. Because hearing and visual impairments may pose a problem for client education, the nurse should speak clearly and face the client when speaking. Use the smallest gauge catheter (24-26 gauge) indicated for the client's therapy as veins are more fragile. Consider vein sites to promote client independence (non-dominant arm, avoiding back of the hand). Use a 5-15-degree angle on insertion as veins of the elderly are usually more superficial (Option 5).

For which client is it most important for the nurse to provide teaching on ways to prevent the spread of the condition?

Tinea corporis (ringworm) is a fungal infection of the skin often transmitted from one person to another or from an infected animal to a human. It appears as a scaly, pruritic patch that is often circular or oval in shape. It is highly contagious and can be spread via items such as grooming tools, hats, towels, and bedding. Tinea corporis often spreads via shared athletic equipment or in athletic locker rooms due to the proximity of infected gear. This condition is treated with topical antifungals (eg, tolnaftate, haloprogin, miconazole, clotrimazole).

A client with right-sided weakness becomes dizzy, loses balance, and begins to fall while the nurse is assisting with ambulation. Which nursing actions would best prevent injury to the client and nurse while guiding the client to a horizontal position on the floor? 1. Step behind client with arms around waist, squat using the quadriceps, and lower client to the floor 2. Step in front of client, brace knees and feet against the client's, and assist to the floor gently 3. Step slightly behind client with feet apart, extend one leg, and let client slide against it to the floor 4. Step 12 inches behind the client, support under axillae, tighten back, and lower client to the floor

To prevent injury to the nurse and the client if the client is falling, the nurse uses good body mechanics to try to break the fall and guide the client to the floor if necessary. These actions include: Step slightly behind the client and place the arms under the axillae or around the client's waist Place feet wide apart with knees bent - creates a broad base of support, provides stability, and reduces the risk for back injury to the nurse Place one foot behind the other and extend the front leg - allows the nurse to bring the client backward by using the leg muscles to rock backward while supporting the client's weight Let the client slide down the extended leg to the floor - lowers the client gently to the floor while keeping the client's head protected from injury (Options 1 and 4) These actions do not provide close proximity to the client, a broad base of support, or a lower center of gravity to increase the nurse's stability and help prevent back injury. (Option 2) These actions are appropriate for helping a client rise from the bed or chair but not for assisting a falling client to the floor.

collecting a urine sample for urinalysis and culture

Urine specimens must be collected aseptically from the port located on the catheter tubing of an indwelling urinary catheter. To collect a urine specimen: Clean the collection port with an alcohol swab Aspirate urine with a sterile syringe Use aseptic technique to transfer the specimen to a sterile specimen cup

A nurse is reviewing the most recent laboratory results of a client on the telemetry floor. The client is currently asymptomatic, and the telemetry monitor indicates sinus rhythm. Which of the following critical values is most likely due to laboratory error?

With the exception of clients in end-stage renal disease, a serum potassium value >6.5 mEq/L (6.5 mmol/L) in any client who is walking and talking should raise the suspicion of an erroneously elevated serum potassium (pseudohyperkalemia) from poor hematology technique, hemolysis, or clotting. A serum potassium level of 7.0 mEq/L (7.0 mmol/L) would normally constitute a life-threatening electrolyte imbalance that would cause severe weakness or paralysis, unstable arrhythmias, and eventual cardiac arrest. An assessment would focus on evaluating cardiac symptoms and muscle strength and be reported to the health care provider (HCP). In this case, it is likely that a repeat blood draw would be prescribed. Pseudohyperkalemia can be avoided on the repeat blood draw by using heparin-impregnated hematology vials to prevent clotting, minimal use of a tourniquet and fist clenching, and use of a larger gauge needle for the sample. (Option 1) This blood urea nitrogen (BUN) value is elevated (normal 6-20 mg/dL [2.1-7.1 mmol/L]) and could be related to kidney damage or dehydration. Therefore, it is not the most likely erroneous result. (Option 2) Similar to the BUN level, this creatinine value is significantly elevated (normal 0.6-1.3 mg/dL [53-115 µmol/L]). Further nursing assessment is indicated, with documentation and involvement of the HCP in evaluating the impact of this kidney damage on the client's health. (Option 4) This sodium value is high (normal 135-145 mEq/L [135-145 mmol/L]) and requires further exploration. The nursing assessment should be documented and reported to the HCP.

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

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). (Options 3 and 4) The health care provider is responsible for explaining all aspects of the procedure, ensuring that the client has a correct understanding of the procedure and its potential risks, providing the names/qualifications of those who will be involved, describing available alternate treatments, and reinforcing that the client has the right to refuse the procedure. The health care provider should be contacted if the client does not have a correct understanding of the procedure. The nurse should not try to explain procedures as he/she could be held liable for giving incorrect/incomplete information.

pt with trach. how to reduce risk of aspiration pneumonia

partially or fully deflate the cuff, have pt sit upright- chin should be flexed toward chest, (hyperextension increases risk of aspiration) , monitor for a wet cough or voice quality, monitor vital signs