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The nurse is caring for a client scheduled for a bronchoscopy. The client asks what to expect during the recovery period. Which response by the nurse is most appropriate? A. "You may experience some sore throat and coughing for a few days after the procedure." [81%] B. "You'll need to avoid eating or drinking anything for at least 24 hours following the procedure." [8%] C. "You'll be discharged immediately after the procedure and can resume your normal activities." [10%] D. "Expect to have difficulty breathing for several days after the procedure." [1%]

Choice A is correct. After a bronchoscopy procedure, it's common for clients to experience some mild discomfort such as a sore throat and coughing due to irritation of the throat and airways from the scope. Providing this information prepares the client for what to expect during the recovery period and reassures them that these symptoms are expected. Choice B is incorrect. The client may need to avoid eating or drinking for a short period before the procedure to prevent aspiration, however, there is typically no need for prolonged fasting after a bronchoscopy procedure. Choice C is incorrect. After a bronchoscopy, clients typically require a period of observation to monitor for any immediate complications such as bleeding or respiratory distress before being discharged home. Choice D is incorrect. This is not expected. Significant difficulty breathing would be a cause for concern and should be promptly evaluated by a healthcare provider. ✓ A bronchoscopy is a medical procedure used to visualize the inside of the airways and lungs. It involves the insertion of a thin, flexible tube called a bronchoscope through the nose or mouth and into the airways. The bronchoscope has a light and a small camera at its tip, allowing the healthcare provider to examine the structures of the respiratory tract, including the trachea, bronchi, and bronchioles. ✓ Bronchoscopy can be performed using different types of bronchoscopes, including flexible bronchoscopes and rigid bronchoscopes. Flexible bronchoscopy, which is more commonly used, allows for easier maneuverability and visualization of the smaller airways. Rigid bronchoscopy, typically performed under general anesthesia, may be used for more complex procedures or in cases where a larger instrument is needed. ✓ Bronchoscopy is one of the most commonly performed invasive diagnostic p

The nurse is educating a client about the inactivated influenza vaccine (IIV). The nurse should plan to teach the client that Select all that apply. the IIV effectively prevents influenza or decreases the disease's severity. pregnant women can receive this vaccine. you may receive this vaccine if you are allergic to penicillin. the IIV contains a live virus. the vaccine is administered to newborns following delivery.

Choice A is correct. Although the influenza vaccine will not prevent 100% of the cases, it will help prevent or decrease symptoms in 70 to 80% of cases. If the client does get influenza, the severity of the symptoms will be diminished thanks to the vaccine. Choice B is correct. Those who are pregnant may receive the inactivated influenza vaccine (IIV). It is the Live attenuated influenza vaccine (LAIV) that should not be administered to those who are pregnant. The LAIV is licensed for ages 2-49. Choice C is correct. Penicillin allergy is not a contraindication to the administration of the influenza vaccine. Very few contraindications exist to receiving the influenza vaccine. Some contraindications include children younger than six months of age, individuals with a previous severe reaction to a prior influenza vaccine, and a history of Guillain-Barré syndrome. Egg allergy is not a contraindication to this vaccine being administered. Choice D is incorrect. The IIV is inactivated and does not contain a live virus. IIV is administered to infants starting at six months. Thus, the infant's caregivers must get vaccinated to prevent transmission to the newborn. Additional Info ✓ The influenza vaccine may be administered to those six months and older. ✓ Egg allergy is not an absolute contraindication to vaccine administration. ✓ A history of Guillain-Barré syndrome within 6 weeks of receiving an influenza vaccine is another contraindication to all influenza vaccines. ✓ Influenza vaccine may be coadministered with another vaccine such as COVID-19. ✓ IIV and LAIV are available. LAIV (live attenuated influenza vaccine) is administered via nasal mist. ✓ The LAIV is recommended for individuals who are immunocompetent aged 2 through 49.

The nurse is witnessing a client provide informed consent. The client is demonstrating which ethical principle? Correct A. Autonomy [83%] B. Justice [4%] C. Paternalism [2%] D. Veracity [10%]

Choice A is correct. By a client providing their consent, this is respecting their decision and, thus, their autonomy. This ethical principle exemplifies the client's self-determination and ability to make choices without interference or coercion. Choice B is incorrect. Justice refers to equality and providing care to all individuals regardless of insurance status, race, or religion. An example of justice could be the nurse starting a clinic, and clients will be seen on a first come, first serve basis. Choice C is incorrect. Paternalism refers to taking a course of action (or treatment) guided by someone else in the client's best interest. An example would be an organization requiring certain vaccines for healthcare staff. The decisions were made on behalf of others out of their best interest. Choice D is incorrect. Veracity refers to telling the truth and not being deceptive. The nurse should never give placebos or falsify documentation. ✓ The nurse's role during the informed consent process is to serve as the witness. ✓ The nurse should verify that the client has a general understanding of the procedure and that their consent is voluntary (not coerced). ✓ Informed consent should be witnessed for clients not under the influence of medication that may alter the CNS. ✓ Clients may withdraw their informed consent at any time.

The nurse observes a client clutching her abdomen and complaining of cramping, which is accompanied by sharp pain. Which of the following types of pain is the client experiencing? A. Cutaneous or superficial somatic [15%] B. Visceral [42%] C. Deep somatic [35%] D. Radiating [8%]

Choice A is correct. Cutaneous or superficial somatic pain originates from the skin or underlying tissues. It is often described as sharp, localized, and easily pinpointed. The client's behavior of clutching the abdomen and describing the pain as sharp aligns with the characteristics of cutaneous or superficial somatic pain. This type of pain is often well-defined and easily identifiable by the client, matching the description provided. Physical pain is either nociceptive or neuropathic. These two types of pain differ in the way they affect the client as well as in how they are treated. Nociceptive pain is the most common type of pain experienced. It occurs when pain receptors, which are called nociceptors, respond to stimuli that are potentially damaging, for example, as a result of noxious thermal, chemical, or mechanical stimuli. Nociceptive pain may occur as a result of trauma, surgery, or inflammation. Two types of nociceptive pain are visceral pain (i.e. pain originating from internal organs) and somatic pain (i.e. pain originating from the skin, muscles, bones, or connective tissue). Choice B is incorrect. Visceral pain is caused by the stimulation of deep internal pain receptors. It is most often experienced in the internal organs of the abdominal cavity, skull, or thorax. Visceral pain is not well localized and can be described as tight, pressure, deep squeezing, or aching pain. Choice C is incorrect. Deep somatic pain originates in the ligaments, tendons, nerves, blood vessels, and bones. It is localized and can be described as achy or tender. A fracture or sprain, arthritis, and bone cancer can cause deep bodily pain. Choice D is incorrect. Radiating pain starts at the origin but extends to other locations. ✓ The nurse should conduct a thorough assessment of the client's pain, including its location, intens

The nurse is caring for a client who has been physically violent towards staff. The nurse prepares to restrain the client using A. soft wrist restraints. [75%] B. mitten restraints. [6%] C. elbow restraints. [8%] D. waist belt restraint. [11%]

Choice A is correct. For a client exhibiting physical violence towards staff, the nurse may, as prescribed, choose to either chemically restrain or physically restrain the client. In this situation, the appropriate option is to seclude the individual or use soft wrist restraints. Another alternative for a violent client is the use of leather restraints attached to all four extremities, a decision to be determined by the provider and nursing staff. Choice B is incorrect. Mitten restraints would be appropriate if the client attempted to disconnect medical tubing or devices. This could be plausible if tethered to the frame, but mittens are more restrictive than necessary. Choice C is incorrect. Elbow restraints make removing a medical device near the face or neck difficult. It does not impede the removal of abdominal or urinary medical devices. Choice D is incorrect. Waist belt restraints would still allow the client to hit staff. This type of restraint is best utilized for confused or impulsive who are continually trying to get out of bed or a chair after repeated redirection. ✓ Soft wrist restraints are best utilized for clients becoming increasingly agitated, cannot be redirected with distraction, and keep trying to remove needed medical devices. This type of restraint may also be applied to the ankles. ✓ Elbow restraints make it difficult for a client to remove a medical device near the face or neck. It does not impede the removal of abdominal or urinary medical devices. ✓ Waist belt restraints are utilized for confused or impulsive clients who continually try to get out of bed or a chair after repeated redirection. ✓ Mitten restraints are only considered a restraint if they are tethered to an immovable object, and the client cannot remove it from their hand. This restraint is appropriate if the client attempts to di

The nurse is caring for a client who has sickle cell disease (SCD). Which prescription from the primary healthcare provider (PHCP) should the nurse anticipate? A. hydroxyurea [43%] B. methotrexate [31%] C. nortriptyline [13%] D. verapamil [12%]

Choice A is correct. Hydroxyurea is an effective treatment for SCD. This medication increases fetal hemoglobin and decreases hemoglobin S. By increasing fetal hemoglobin, the sickling effect can be reduced, and oxygen carrying capacity can be improved. Choices B, C, and D are incorrect. Methotrexate is a medication indicated to treat autoimmune conditions such as rheumatoid arthritis. Nortriptyline is a tricyclic antidepressant (TCA) with significant anticholinergic properties and would be detrimental to the management of SCD. Verapamil is a calcium channel blocker and is utilized in the management of hypertension and other vascular disorders. ✓ Hydroxyurea is an efficacious medication used in the management of sickle cell disease (SCD). ✓ This medication has been shown to decrease vaso-occlusive events and reduce hospitalization. ✓ Adversely, this medication increases the risk of leukemia, myelosuppression, alopecia, and other malignancies.

Intravenous therapies often consist of electrolyte replacement therapies. Select the electrolyte that is accurately paired with one of its functions. A. Sodium: The control and management of circulating blood volume. [66%] B. Bicarbonate: The regulation of extracellular fluid. [16%] C. Chloride: The regulation of plasma protein. [10%] D. Calcium: The metabolism of fats, carbohydrates, and proteins. [8%]

Choice A is correct. In addition to other functions, sodium controls and manages circulating blood volume, it maintains circulating blood volume, and it also is necessary for the transmission of nerve impulses. Choice B is incorrect. Bicarbonate regulates the body's acid-base balance and not the regulation of extracellular fluid. Choice C is incorrect. Chloride does not regulate plasma protein. Instead, it regulates acid-base balance and extracellular fluid balance. Choice D is incorrect. Calcium does not play a role in the metabolism of fats, carbohydrates, and proteins; however, calcium does play a role in blood clotting, the formation of teeth and bones, nerve impulse transmission, and controlling muscular contractions.

The nurse preceptor observes a newly hired nurse care for a client with a myxedema coma. It would require follow up by the nurse preceptor if the newly hired nurse is observed A. applying a cooling blanket to the client. [61%] B. requesting a prescription for hydrocortisone. [20%] C. removing the water pitcher from the bedside. [13%] D. placing an oral endotracheal tube at the bedside for potential use. [7%]

Choice A is correct. One of the clinical features of a myxedema coma is hypothermia. Passive warming of the client is an effective treatment measure for this emergency. Cooling the client would require follow-up as this would worsen the hypothermia. Choice B is incorrect. Immediate treatments for myxedema are hydrocortisone and levothyroxine. A corticosteroid is necessary to administer until adrenal insufficiency is excluded. The corticosteroid is also helpful in correcting the hyponatremia that is a feature of this condition. Choice C is incorrect. The client with a myxedema coma has a decreased mental status and is at risk for aspiration. The water pitcher should be removed from the bedside as IV fluids are given to restore the circulating volume. Choice D is incorrect. Advanced airway equipment such as an oral endotracheal tube should be available as severe hypoventilation may manifest with this condition. ✓ Myxedema coma is a severe form of hypothyroidism that causes an array of clinical manifestations, including - Decreased mental status Bradycardia Hyponatremia Hypoglycemia Hypotension Hypothermia ✓ Treatment is aimed at giving the client intravenous levothyroxine, corticosteroids, intravenous fluids with dextrose, rewarming, and mechanical ventilation, if necessary. ✓ Continuous and vigilant monitoring is essential to manage clients with myxedema coma effectively

The nurse is conducting a parenting class regarding nutrition for toddlers. Which of the following information should the nurse include? Select all that apply. "Whole milk can be offered to provide calcium and vitamin D." "Using food as a reward can be a positive incentive." "Good iron-rich food choices include melon and strawberries." "Roasted vegetables are preferred over fried vegetables." "Vitamin A rich foods should be given with iron to increase its absorption."

Choice A is correct. Plain cow milk (whole milk) or fortified unsweetened soy beverage can be offered at 12 months of age to help meet calcium, potassium, vitamin D, and protein needs. Flavored milk should be avoided until 24 months because they contain excessive sugars. Choice D is correct. Vegetables are an excellent source of fiber and are dense in vitamins. The healthy benefits of vegetables can be negated if they are fried. Roasting the vegetables are preferred. Choice B is incorrect. It is not advisable to use food as a reward. This manipulation can create an inferior relationship with food and create problems in a child's eating habits as they grow up. If children view food as a positive reward, they may expect treats whenever they do something right or complete a request. This can lead to poor nutrition; therefore, using food as a reward is inappropriate educational advice. Choice C is incorrect. Iron-rich foods include beef, lentils, and eggs. These foods are encouraged because iron-deficiency anemia may develop in toddlerhood. Choice E is incorrect. Vitamin C-rich foods (not vitamin A) are encouraged with iron because it enhances iron absorption. Examples of foods rich in vitamin C include citrus fruits, bell peppers, tomatoes, and sweet potatoes. Food encouraged in toddlerhood include - ✓ Roasted vegetables ✓ Ground lean meats ✓ Whole milk starting at 12 months of age ✓ Cereal with minimal sugar Additional guidelines for food intake include - ✓ Avoid caffeinated beverages until 24 months of age ✓ 100% fruit juice should be introduced into the diet starting at 12 months of age

A nurse is caring for a client with a central venous catheter (CVC) in place. Which action by the nurse is most effective in preventing central line-associated bloodstream infections (CLABSI)? A. Performing hand hygiene before and after any manipulation of the CVC. [95%] B. Monitoring the client's temperature every 4 hours. [1%] C. Administering prophylactic antibiotics. [4%] D. Ensuring the client maintains strict bed rest to prevent catheter movement. [0%]

Choice A is correct. Proper hand hygiene is essential in preventing healthcare-associated infections, including CLABSI. Healthcare providers must perform hand hygiene before and after any manipulation of the CVC to reduce the risk of introducing pathogens into the bloodstream. This practice helps maintain a clean environment around the catheter insertion site and minimizes the potential for contamination. Choice B is incorrect. Regular monitoring of the client's temperature is a proactive measure aimed at early detection of signs of infection, including CLABSI. However, while temperature monitoring is an essential aspect of infection surveillance, it does not directly prevent CLABSI. It should be complemented with other preventive measures, such as proper hand hygiene, to reduce the risk of infection transmission. Choice C is incorrect. Prophylactic antibiotics may be indicated in certain clinical situations to prevent infections, but their routine use for CLABSI prevention is not recommended. Overuse of antibiotics can lead to antimicrobial resistance and adverse effects on the client's microbiome. Additionally, prophylactic antibiotics do not address the underlying risk factors for CLABSI, such as inadequate catheter care practices. Choice D is incorrect. Strict bed rest is not recommended solely to prevent catheter movement. Immobilization can increase the risk of complications such as deep vein thrombosis and pressure ulcers. Instead, securing the CVC appropriately and providing instructions to the client on how to avoid excessive movement or manipulation of the catheter can help prevent dislodgement or accidental removal, reducing the risk of CLABSI. ✓ In addition to temperature monitoring, nurses should assess other signs of infection, such as increased heart rate, respiratory rate, and changes in mental status,

What is the best time to assess the respiratory rate of a young child? A. While the child is quietly sitting on the parent's lap [93%] B. While the child is crying [1%] C. While the child is playing in the playroom [1%] D. Immediately after assessing the child's blood pressure [5%]

Choice A is correct. Respirations are best determined while the child is sleeping or quietly awake. Choices B, C, and D are incorrect. When a child is playing or upset, respirations may increase because of the crying or activity. This could result in the appearance of a falsely abnormal finding.

The nurse is taking the history and physical of a woman who has just discovered that she is pregnant. This nurse knows that the purpose of asking a prenatal client about her history with rheumatic fever has the most to do with: Incorrect A. Cardiac stress related to a possible valvular lesion. [42%] B. Preventing transmission of this teratogenic condition to her infant. [33%] C. Preparing to deliver preventative antibiotics during labor and post-birth. [21%] D. Monitoring lung sounds for reoccurrence of the disorder. [4%]

Choice A is correct. Rheumatic fever can cause the formation of valvular lesions, which can lead to cardiac stress during pregnancy. Choice B is incorrect. A prenatal client with a history of rheumatic fever will not be at risk for passing on rheumatic fever to her infant. Choice C is incorrect. Preventative antibiotics would not be needed in this circumstance. Choice D is incorrect. Lung sounds are not relevant to a woman with a history of rheumatic fever.

The nurse is assessing a child with reports of right eye irritation, drainage, and itchiness. This client is at highest risk for developing A. conjunctivitis. [81%] B. amblyopia. [2%] C. nystagmus. [1%] D. ocular herpes. [15%]

Choice A is correct. This client is demonstrating classic manifestations of conjunctivitis. Conjunctivitis is characterized by Itching, burning, or scratchy eyelids. Additionally, the client has drainage to the affected eye(s), a common conjunctivitis finding. Choice B is incorrect. Amblyopia, also known as 'lazy eye,' is not an infectious process and is characterized by differences between the two eyes in their ability to focus. Choice C is incorrect. Nystagmus is also a condition that is not infectious and is characterized by repetitive and uncontrolled movements of the eye. Choice D is incorrect. Ocular herpes is a viral infection that does not produce drainage. This infection causes the development of vesicles. ✓ The clinical features of conjunctivitis are redness and swelling of the conjunctiva, eyelid edema, and discharge. ✓ Conjunctivitis may be viral (in most cases), bacterial, or allergic. ✓ Treatment is aimed at the underlying cause, which includes ophthalmic antibiotics for bacterial conjunctivitis. ✓ Symptomatic measures that can be taken to mitigate discomfort include intermittent wiping of the eye to remove debris (wipe inner canthus > outer). ✓ Additionally, for viral and bacterial causes, the nurse should stress the importance of meticulous hand hygiene to prevent the spread of the infection. ✓ The client should be instructed not to wear contact lenses during the infection.

The nurse is preparing to administer an intramuscular (IM) injection into the client's vastus lateralis. The nurse is correct in identifying the landmark by A. palpating to find greater trochanter and knee joints; divide the vertical distance between these two landmarks into thirds; inject into the middle third. [40%] B. locating the acromion process; inject only into the upper third of muscle that begins about two fingerbreadths below the acromion. [11%] C. locating the greater trochanter, iliac tubercle, and iliac crest; places palm over the greater trochanter, over iliac tubercle, along the ileum; inject into center of V formed by the fingers. [40%] D. displacing the skin by pulling the skin down or to one side about 1 inch with the non-dominant hand before administering the injection. [8%]

Choice A is correct. This is the appropriate anatomical landmark for giving an IM in the vastus lateralis. To locate the vastus lateralis, palpate to find greater trochanter and knee joints; divide vertical distance between these two landmarks into thirds; inject into the middle third. Choices B, C, and D are incorrect. Locating the acromion process is a landmark involved with giving an IM in the deltoid muscle. Locating the greater trochanter, iliac tubercle, and iliac crest is involved in giving an IM ventrogluteal. Displacing the skin by pulling the skin down or to one side about 1 inch is relevant to the Z-track technique, commonly used when giving an IM injection. This technique does not locate the appropriate anatomical location of the vastus lateralis. A key advantage of using the vastus lateralis is that an intramuscular (IM) injection may be given if the client is supine, side-lying, or sitting. Aspiration for routine injections into deltoid or vastus lateralis is not indicated because there are no large blood vessels in these locations.

The nurse has obtained assistance from a licensed practical/vocational nurse (LPN/VN). Which tasks would be appropriate for the RN to delegate to the LPN/VN? Select all that apply. performing tracheostomy care initiate a transfusion of packed red blood cells flushing a peripherally inserted central catheter (PICC) inserting an indwelling urinary catheter administer enteral feedings via nasogastric tube Titrate a medication

Choice A is correct. This task is appropriate for the registered nurse (RN) to delegate to the LPN/VN. Performing tracheostomy care includes cleaning around the stoma, replacing the disposable inner cannula, and replacing the dressing. This sterile procedure is necessary to prevent infection and to promote effective gas exchange. Choice D is correct. This task is appropriate for the RN to delegate to the LPN/VN. The task of inserting an indwelling urinary catheter is a sterile procedure within the scope of the LPN/VN. Choice E is correct. The task is appropriate for the RN to delegate to the LPN/VN. The LPN/VN may administer enteral feedings or medications via an NGT. Choice B is incorrect. The initiation of a transfusion of packed red blood cells falls under the responsibility of an RN. The LPN/VN may assist in data collecting on a client receiving blood products, but the RN must do the initiation. Choice C is incorrect. The flushing and management of a central line, such as a PICC line, is the responsibility of the RN. This responsibility may not be delegated to a LPN/VN. Choice F is incorrect. Titrating a medication involves adjusting the dosage based on a client's response, which requires critical thinking, complex decision-making, and a deep understanding of the client's condition. This task should be performed by an RN or a higher-level provider who has the education and training to assess the client's condition and make appropriate medication adjustments.

The newly hired nurse cares for a client bitten by a venomous snake in the left hand. Which of the following interventions by the newly hired nurse requires follow-up by the charge nurse? A. Applying a tourniquet proximal to the bite. [52%] B. Removing the client's wristwatch and jewelry. [7%] C. Establishing intravenous (IV) access. [5%] D. Obtaining a type and crossmatch for fresh frozen plasma (FFP). [36%]

Choice A is correct. Tourniquets should not be used in snake bites. The tourniquet impedes arterial blood flow and can be quite harmful to the extremity. The client should immobilize the affected extremity to decrease the absorption of the venom. Choices B, C, and D are incorrect. It would be appropriate to remove the jewelry and the wristwatch as these may impede the blood flow once the affected extremity swells (choice B). Establishing intravenous (IV) access and collecting laboratory tests such as PTT, PT/INR, platelets, and CPK are necessary (choice C). Snake venom may cause disseminated intravascular coagulation (DIC) and life-threatening bleeding; thus, obtaining this laboratory work is critical. PT and PTT are prolonged in DIC. An elevated CPK indicates rhabdomyolysis. If complications such as DIC arise, blood products are essential. Therefore, obtaining the type and crossmatch is necessary (choice D). A common blood product used to treat coagulopathy caused by snake venom is fresh frozen plasma (FFP). ✓ Venomous snake bites can be fatal if emergency treatment is not promptly obtained. ✓ The client should immobilize the affected extremity, remove any jewelry, and seek emergent care. ✓ The local poison control will determine antivenom treatment. ✓ The nurse should obtain vital signs, initiate intravenous (IV) therapy, collect laboratory work, and monitor for complications such as bleeding, neurovascular compromise, disseminated intravascular coagulation, rhabdomyolysis, shock, and renal failure. ✓ The nurse should also contact poison control for guidance on the client's care.

The nurse is caring for a client who has polycystic kidney disease (PKD). Which of the following would indicate the client is achieving treatment goals? A. Blood Pressure 128/63 mmHg [69%] B. Creatinine 2.3 mg/dL [0.6-1.2 mg/dL (53-106 mmol/L)] [15%] C. Proteinuria 2+ [6%] D. Sodium 132 mEq/L [136-145 mEq/L (mmol/L)] [10%]

Choice A is correct. Treatment goals for a patient with Polycystic Kidney Disease (PKD) include maintaining normotension, the glomerular filtration rate (GFR), and preventing sodium wasting, which is evidence of a decline in renal function. Hypertension is a cardinal finding in PKD, and if a client is achieving the treatment goals, they will maintain regulated blood pressure. Choice B is incorrect. An elevated creatinine indicates that kidney function is declining. This suggests a worsening of the condition. Choice C is incorrect. Proteinuria indicates damage to the glomerulus and worsening renal function. Choice D is incorrect. Hyponatremia indicates sodium loss in the urine, suggesting worsening renal functioning. This is evidence that the client is not meeting the treatment goals. ✓ Polycystic Kidney Disease is a genetic disorder manifested by fluid-filled cysts that grow on the kidneys. ✓ Additional findings in PKD include: • Abdominal or flank pain • Hypertension • Nocturia • Frequent urinary tract infections • Increased abdominal girth • Constipation • Hematuria (bloody urine) • Sodium wasting and inability to concentrate urine in the early stage • Progression to kidney failure with anuria

The nurse is caring for a client involuntarily admitted to the behavioral health unit. The client has been mailed a package. The nurse should perform which action? A. Provide the client with the package [43%] B. Open the package to review its content [31%] C. Provide the package upon discharge [15%] D. Determine if the sender is the client's next of kin [11%]

Choice A is correct. Under the patient bill of rights, the client has a right to confidentiality and privacy. The nurse should not open postal packages prior to giving them to the client. If the nurse is concerned that the client could be mailed something harmful, the nurse should request that they open the package up in front of them. Choices B, C, and D are incorrect. All of these options violate the client's right to privacy and confidentiality. Mail tampering is a crime, and the nurse is obligated to provide the client with dignity, privacy, and respect. This includes timely delivery of their mail. The Client Bill of Rights To courtesy, respect, dignity, and timely, responsive attention to his or her needs. To receive information from their physicians and to have opportunity to discuss the benefits, risks, and costs of appropriate treatment alternatives, including the risks, benefits and costs of forgoing treatment. Patients should be able to expect that their physicians will provide guidance about what they consider the optimal course of action for the patient based on the physician's objective professional judgment. Ask questions about their health status or recommended treatment when they do not fully understand what has been described and have their questions answered. To make decisions about the care the physician recommends and to have those decisions respected. A patient who has decision-making capacity may accept or refuse any recommended medical intervention. To have the physician and other staff respect the patient's privacy and confidentiality. To obtain copies or summaries of their medical records. To obtain a second opinion. To be advised of any conflicts of interest their physician may have in respect to their care. To continuity of care. Patients should be able to expect that their physician will co

The nurse prepares to insert a peripheral vascular access device (PVAD) in the client's cephalic vein. The nurse plans to align the catheter how many degrees above the targeted vein? A. 10-30 degrees [54%] B. 30-45 degrees [39%] C. 45-90 degrees [5%] D. 45-60 degrees [3%]

Choice A is correct. When the nurse plans to insert a peripheral vascular access device, the nurse should hold the vascular access device bevel up and align the catheter at a 10-30 degree angle. This is an appropriate angle because if the angle were higher than 30 degrees, the nurse would risk going through the vein and causing the client discomfort and a hematoma. The nurse should then observe for blood return in the catheter or flashback chamber of the catheter, indicating that bevel of needle has entered the vein. Once this blood return is observed, the nurse should then advance VAD approximately ¼ inch (0.6 cm) into vein to ensure it is in the tunica intima of the vein. Choices B, C, and D are incorrect. These angles are inappropriate when inserting a vascular access device. If the nurse does not insert the catheter at the appropriate angle, the nurse risks causing the client discomfort. ✓ When establishing a vascular access device, the nurse should consider the intention of the therapy and the duration ✓ It is highly preferred that a site be selected on the client's non-dominant arm ✓ To prevent skin injury, the nurse should consider using a blood pressure cuff instead of a tourniquet ✓ Good skin cleansing of at least thirty seconds is necessary to maintain an aseptic technique

A licensed practical/vocational (LPN/VN) nurse assists the behavioral health unit's registered nurse (RN). Which task can the RN appropriately delegate to the LPN/VN? A. Alcohol withdrawal screening on a client going through detoxification [7%] B. Medication administration to a client with a nasogastric tube [91%] C. Suicide assessment on a newly admitted client [1%] D. Educating a client on newly prescribed citalopram [1%]

Choice B is correct. An appropriate task the RN may delegate to the LPN/VN would be administering medications via nasogastric tube. This task is within the scope of the LPN/VN. Choices A, C, and D are incorrect. All of these tasks require the RN to complete. An alcohol withdrawal screening requires assessment and completion by the RN. Assessment is also required for a client requiring suicide screening. Finally, education about newly prescribed medications originates from the RN.

The nurse has just finished assisting the surgeon with inserting a chest tube in a client with a pneumothorax. Which assessment finding indicates that the procedure has produced its desired effect? A. Consolidation is seen in the chest x-ray. [10%] B. Clear breath sounds are auscultated bilaterally. [67%] C. There is rapid bubbling in the suction chamber of the chest drainage system. [21%] D. There is crepitus at the insertion site. [2%]

Choice B is correct. Bilateral breath sounds indicate that both the clients' lungs have expanded, which is the procedure's objective. A pneumothorax produces diminished or absent breath sounds in the affected lung. Once the chest tube has exerted its desired effect, the lung sounds should become clear. Choice A is incorrect. Consolidation occurs when fluid or exudates are present in the lungs, indicating pneumonia. This shows a deterioration in the status of the client. Choice C is incorrect. Rapid bubbling in the suction chamber indicates an air leak. This is not an indication that the treatment is effective, as this is a complication of the therapy. Choice D is incorrect. Crepitus indicates subcutaneous emphysema, indicating oxygen escape into the surrounding tissues. This complication is associated with a chest tube, not a therapeutic finding.

The nurse is caring for a child with varicella zoster. The nurse should implement which transmission-based precautions? A. Droplet precautions [21%] B. Airborne and contact precautions [50%] C. Contact and droplet precautions [21%] D. Contact precautions [8%]

Choice B is correct. Contact and airborne precautions will be implemented to prevent the spread of infection. The virus may spread by coming into contact with the lesions or inhalation of the vesicular fluid or aerosolized respiratory secretions. Precautions may be discontinued once all of the lesions have dried and crusted. Airborne and contact precautions require the following PPE: gloves, gown, and N95 mask/respirator. The room should have negative airflow, and the door must remain closed. Choices A, C, and D are incorrect. These transmission-based precautions are not used for varicella-zoster. ✓ It takes from 10 to 21 days after exposure to the virus for someone to develop varicella ✓ Varicella is highly contagious ✓ The virus can be spread from person to person by direct contact, inhalation of aerosols from vesicular fluid of skin lesions of acute varicella or zoster, and possibly through infected respiratory secretions that also may be aerosolized ✓ A person with varicella is considered contagious beginning one to two days before rash onset until all the chickenpox lesions have crusted

A nurse is caring for a client who underwent extensive reconstructive surgery following a severe burn injury. The client expresses distress over their altered appearance and avoids social interactions. Which nursing intervention is most appropriate to address the client's altered body image? A. Encourage the client to avoid looking at themselves in the mirror to minimize distress. [1%] B. Provide opportunities for the client to express their feelings and concerns about their appearance. [96%] C. Advise the client to focus solely on physical recovery and disregard their emotional state. [1%] D. Suggest the client wear clothing that conceals the surgical scars to avoid drawing attention. [2%]

Choice B is correct. Encouraging the client to express their feelings and concerns provides them with a safe space to discuss their altered body image. It promotes open communication and allows the nurse to evaluate the client's psychological well-being, facilitating the development of a therapeutic relationship. Choice A is incorrect. Avoidance may exacerbate the client's distress by preventing them from confronting and processing their feelings about their appearance. Choice C is incorrect. Ignoring or suppressing feelings related to altered body image can lead to increased psychological distress and may hinder the client's overall recovery. Choice D is incorrect. While wearing clothing that conceals surgical scars may provide temporary relief from social scrutiny, it does not address the underlying issues of altered body image. Moreover, it may reinforce feelings of shame or embarrassment about the client's appearance rather than promoting self-acceptance and body positivity. ✓ In a healthcare context, altered body image is commonly associated with conditions or treatments that lead to changes in physical appearance, such as scars, disfigurement, amputations, weight changes, or medical procedures like surgery. It can profoundly impact an individual's self-esteem, confidence, and overall well-being, affecting their social interactions, relationships, and quality of life. ✓ It's important for nurses to recognize that perceptions of body image and beauty standards vary across cultures and may influence the client's reaction to their altered appearance. ✓ Encouraging the client to engage in self-care activities that promote self-esteem and body positivity, such as relaxation techniques, mindfulness exercises, or engaging in hobbies and interests.

A nurse is working in a busy medical-surgical unit and has received report on the following four clients. The nurse should first see the client with A. A client who underwent surgery yesterday and is complaining of incisional pain at a level of 8/10 [2%] B. new-onset atrial fibrillation who is complaining of chest pain. [91%] C. diabetes who has a foot wound that appears infected and an oral temperature of 100.4° F (38 ° C) [3%] D. advanced Alzheimer's disease who is confused and has had a recent fall. [4%]

Choice B is correct. New-onset atrial fibrillation and complaint of chest pain indicate a potentially serious cardiac issue that requires immediate attention. Chest pain can be a symptom of myocardial infarction or unstable angina, which requires prompt assessment and intervention to help prevent further complications. Therefore, this client should be the nurse's first priority. Choice A is incorrect. Although pain management is essential, it is not the highest priority when compared to the other options, which involve acute or potentially life-threatening conditions. Choices C is incorrect. A client with a foot wound infection and a fever will require attention, however, not before a client that is experiencing acute chest pain with a cardiac rhythm change. Choice D is incorrect. The nurse would expect a client with advanced Alzheimer's to have a varying degree of confusion. The nurse would need to ensure that the client has the proper measures in place to prevent injury, if not already in place. However, the client possibly experiencing a myocardial infarction requires immediate attention. ✓ Chest pain is a common complaint and encompasses a broad differential diagnosis that includes several life-threatening causes. ✓ If the client's chest pain is severe, worsening, or accompanied by symptoms such as shortness of breath, diaphoresis, or lightheadedness, it should be treated as a medical emergency. ✓ Myocardial hypoxia produces angina ✓ One aspect of the conduction problems is that, when serum magnesium levels are low, intracellular potassium levels are also low. These changes alter the resting membrane potential in cardiac muscle cells, shortening the ST segment, prolonging the PR and QRS intervals, and triggering ectopic beats

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who reports trouble sleeping at night. Which question is most important for the nurse to ask? A. "What do you eat before you go to bed? [17%] B. "How many pillows do you sleep on at night?" [76%] C. "Have you always been a light sleeper?" [5%] D. "Is your partner snoring and keeping you awake?" [1%]

Choice B is correct. Orthopnea is shortness of breath that occurs when lying flat, causing the person to have to sleep propped up in bed or sitting in a chair. Asking the client how many pillows they use to sleep on is a way to assess if the client has been educated about measures to prevent orthopnea. COPD causes blocked or narrowed airways that make breathing more difficult. Clients may experience symptoms like wheezing, coughing, mucus production, and tightness in the chest. Smoking or exposure to harmful chemicals can cause COPD. Orthopnea is a common symptom of COPD clients. Choice A is incorrect. This question focuses on dietary habits, which may have relevance in some situations, but it is not the most pertinent when addressing respiratory distress during sleep. Choice C is incorrect. This question addresses the client's sleep patterns but does not directly address the potential impact of COPD on sleep. It is not as directly relevant to the respiratory distress reported. Choice D is incorrect. This question focuses on external factors affecting sleep but does not address the potential respiratory issues associated with COPD. It is less directly related to the client's primary concern. ✓ Beyond the number of pillows, assess the client for orthopnea, which is difficulty breathing while lying flat. This may provide additional insights into the severity of respiratory distress during sleep. ✓ Inquire further about the client's overall sleep quality, including the presence of any other sleep disturbances or interruptions. Understanding the broader context of the sleep experience can help identify contributing factors. ✓ There is a significant overlap between sleep apnea and COPD. Studies suggest that a substantial proportion of individuals with COPD also experience sleep apnea. The coexistence of these conditions ca

The nurse is caring for a prenatal client whose red blood cell levels have decreased since before pregnancy. The nurse believes that physiological anemia of pregnancy is likely occurring. This results from which of the following? A. Decrease in circulating red blood cells [18%] B. Increase in plasma [20%] C. Increase in iron demands from the body [61%] D. Decrease in heart size [1%]

Choice B is correct. Physiological anemia of pregnancy results from an increase in plasma volume, which is greater than the increase in red blood cell mass. This dilutional effect leads to a decrease in the concentration of red blood cells, causing a relative anemia. Choice A is incorrect. This option is not an accurate description of the physiological anemia of pregnancy. While the concentration of red blood cells may decrease, it is primarily due to the increase in plasma volume rather than a decrease in the number of circulating red blood cells. The total number of circulating red blood cells does not typically decrease. Choice C is incorrect. While iron demands increase during pregnancy to support the growing fetus and maternal tissues, physiological anemia is more directly related to changes in plasma volume rather than increased iron demands. Choice D is incorrect. Physiological anemia of pregnancy is not directly related to a decrease in heart size. The cardiovascular system undergoes changes to accommodate the increased demands of pregnancy, including an increase in blood volume. Additional Info ✓ While physiological anemia is primarily due to the increase in plasma volume, it's important for the nurse to assess the woman's iron status. Iron supplementation may be recommended to meet the increased demands of pregnancy and prevent iron deficiency anemia. ✓ Provide education on iron-rich foods and dietary sources of nutrients essential for red blood cell production. Encourage the woman to include foods such as lean meats, leafy green vegetables, legumes, and fortified cereals in her diet. ✓ Encourage the woman to actively engage in her prenatal care by attending regular check-ups, adhering to prescribed supplements or treatments, and communicating any concerns or changes in symptoms.

The nurse is discharging a client home who has pulmonary tuberculosis. To prevent disease transmission of the client's infection to others, the nurse should recommend that A. common household surfaces get disinfected with a bleach solution. [8%] B. your mouth should be covered with a tissue when you cough or laugh and dispose of it in a trash receptacle. [54%] C. hand hygiene should be performed frequently with soap and water. [30%] D. meals be served on disposable dishes and immediately discarded using gloves. [7%]

Choice B is correct. Pulmonary TB is only spread via aerosolized droplets. TB is not spread via contact with surfaces, handshakes, sitting on toilet seats, or dishes. The essential teaching point to a client with pulmonary TB is to instruct the client to exercise respiratory etiquette, such as covering your mouth with a tissue when you cough or laugh. The tissues should be disposed of in a trash can. The client is at the highest risk of transmitting TB while symptomatic. Once the client begins antitubercular medications, the risk of transmission drops after two to three weeks. Choice A is incorrect. Household surfaces such as countertops, door knobs, and faucets do not transmit TB. TB is only transmitted via aerosolized droplets. Choice C is incorrect. Hand hygiene is recommended, but it does not directly inhibit the transmission of TB. Thus, this is not the correct answer. Choice D is incorrect. Respiratory etiquette is a way to reduce transmission. Further, the client should be advised to wear a surgical mask in public. Disposable dishes are not used to prevent the transmission of pathogens. Disposable dishware and trays are not required for clients on airborne precautions. Regular dishware can be used for meals. ✓ Aerosolized droplets spread pulmonary tuberculosis, and it does not live on surfaces for transmission ✓ The nurse should strongly reinforce the necessity to adhere to antitubercular medication therapy that may last between six and nine months ✓ When the client is symptomatic is when they have the greatest risk of transmitting the infection to others

The nurse is assessing a 2-year-old client with the following symptoms: excessive drooling, stridor, difficulty swallowing, and difficulty speaking. Based on these assessment findings, which condition does the nurse suspect? A. Croup [6%] B. Epiglottitis [87%] C. Laryngotracheal bronchitis [7%] D. Bronchiolitis [1%]

Choice B is correct. The cardinal signs of epiglottitis are the "4 Ds" - drooling, dysphonia, dysphagia, and distress. Difficulty swallowing is dysphagia and difficulty speaking is dysphonia. Stridor is a high-pitched wheezing sound caused by disrupted airflow, hence the distress. This child is presenting with all of those cardinal symptoms and is therefore highly suspicious of epiglottitis. Choice A is incorrect. Croup is a respiratory infection presenting with a loud barking cough. It does not cause airway obstruction. Choice C is incorrect. Laryngotracheal bronchitis is another name for croup. The cardinal sign of this disorder is a loud, barking cough. It is sometimes described as a "seal-like" barking cough. It lasts 3-5 days and the child is typically febrile. Choice D is incorrect. Bronchiolitis is inflammation of the bronchioles or lower airway. It is characterized by a runny nose, fever, and cough. Children with bronchiolitis do not present with the signs of airway obstruction described; those are very specific to epiglottitis.

The nurse is preparing to sign a client's surgical consent form after the physician has explained the procedure to the client and family. As the client signs the form, she comments "I really didn't understand most of what the doctor said, but I have to have this procedure, so I want to sign." Which is the appropriate nursing action?A. Witness the document, as the client states she wants to sign it. [2%] B. Notify the physician or nursing supervisor. [83%] C. Call the OR to cancel the procedure and reschedule at a later date. [1%] D. Explain the information she did not understand. [14%]

Choice B is correct. The person (in this case, the doctor) responsible for performing the procedure has the responsibility to obtain the client's consent, providing a clear explanation about the procedure and all associated risks. When witnessing the client's signature, the nurse should confirm that the client understands the information about the procedure. If the client denies understanding, the nurse must then contact the physician or the nursing supervisor. Choice A is incorrect. The nurse has to witness the client's signature but even prior to that, she must confirm that the client understood the information about the procedure. Choice C is incorrect. The nurse must call the physician or nursing supervisor and inform them that the client did not understand the procedure information. Canceling the procedure is not necessary as something else needs to be done first. Choice D is incorrect. It is the responsibility of the person performing the procedure (in this case, the doctor) to obtain the client's consent, providing a clear explanation about the procedure and all associated risks. The nurse only needs to confirm if the client understood it.

The nurse is observing a student collect vital signs on a client. Which action by the student requires the nurse to intervene? Select all that apply. obtains the blood pressure with a cuff bladder width of at least 40% of arm circumference. places the BP cuff over the client's clothing garment. requests the client remove their hearing aid before obtaining a tympanic temperature. assesses the client's respirations after obtaining the pulse rate. obtains blood pressure by placing the client's upper extremity at the level of their heart. places the pulse oximeter probe on the client's finger that has edema.

Choice B is correct. This action by the student is incorrect and requires the nurse to intervene. The accuracy of blood pressure measurement may be skewed if the cuff is placed over clothes because it may impede blood pressure cuff fit and distort auscultatory sounds. The cuff should be snug over the client's skin. Choice F is correct. This action by the student is incorrect and requires the nurse to intervene. Pulse oximeter probes should be applied on an extremity that is non-edematous, has good peripheral blood flow, and is not obstructed by a blood pressure cuff (the cuff should be on the opposite side of the extremity where the pulse oximetry is being measured). Choice A is incorrect. This action by the student is correct and does not require the nurse to intervene. BP cuff size and selection are essential in obtaining an accurate reading. The width of the cuff is 40% of the circumference (or 20% wider than the diameter) of the midpoint of the limb on which the cuff is used to measure BP. Choice C is incorrect. This action by the student is correct and does not require the nurse to intervene. If the client has a hearing aid, it should be temporarily removed to allow the probe to fit. Obtaining a tympanic temperature is beneficial because it provides a rapid reading and is unaffected if the client consumes any food or fluid. Choice D is incorrect. This action by the student is correct and does not require the nurse to intervene. When obtaining a respiratory rate on an adult, it should occur immediately after obtaining the pulse. This assessment should be unknown to the client to prevent them from consciously or unintentionally altering their breathing pattern. Choice E is incorrect. This action by the student is correct and does not require the nurse to intervene. BP results can be inaccurate if the client's extrem

The nurse reviews a client's lipid panel who is being treated for hyperlipidemia with simvastatin. Which of the following actions should the nurse take based on the results? See the results in the exhibit. A. Review the client's most recent creatinine [10%] B. Assess the client's adherence to the prescribed medication [70%] C. Determine if the client is adhering to a low salt diet [9%] D. Document the results as within normal limits [12%]

Choice B is correct. This client is being treated for hyperlipidemia and still has suboptimal values. The triglycerides are high, along with the LDL-C. The first step is to assess whether the client is taking the medication as prescribed. Side effects and adverse reactions commonly deter a client from adhering to prescribed medication, and this should be assessed before going further in the process, such as notifying the prescriber of a potential dosage adjustment. Choice A is incorrect. Review the client's most recent creatinine: While kidney function is important to monitor, it is not directly related to the lipid panel results. Creatinine levels assess kidney function, not lipid levels. Choice C is incorrect. Determine if the client is adhering to a low-salt diet: Lipid panel results are not directly affected by sodium intake. While a healthy diet is essential, it is not the primary concern. The client should adhere to a low-fat diet as cholesterol comes from animal fat. Choice D is incorrect. Document the results within normal limits: The lipid panel results, especially total cholesterol, HDL, and LDL, are not within the normal range based on the provided reference values. Documenting them as within normal limits would be incorrect and could lead to inadequate management of the client's condition. ✓ Medications that may be hepatotoxic include, but are not limited to: Acetaminophen Antifungals (ketoconazole) Antiepileptics (valproic acid) Antituberculins (isoniazid) Statins (atorvastatin) Anabolic steroids Antiarrhythmics (amiodarone) ✓ Provide thorough education to the client about the importance of medication adherence. Explain the purpose of simvastatin, how it helps lower cholesterol, and the potential risks associated with uncontrolled hyperlipidemia. Emphasize the significance of following the prescribed dosa

A 12-year-old is diagnosed with a vaso-occlusive sickle cell crisis and complains of severe headaches. What should be the nurse's initial intervention? A. Give oxygen at 6 liters per minute via nasal cannula. [14%] B. Assess the client's neurologic status. [49%] C. Give an intravenous dose of morphine. [19%] D. Increase the client's IV rate. [18%]

Choice B is correct. This client with sickle cell crisis has a high risk of cerebrovascular accidents (CVA). Since the client has a severe headache, it is best to rule out a CVA before initiating all other interventions. Choice A is incorrect. Giving oxygen can help reduce the cells' sickling, but this is not the first intervention for the client's headache. Furthermore, oxygen-carrying capacity is reduced when the cells are actively sickling. Increasing oxygen content in the blood will not significantly improve the oxygen-carrying capacity in a non-hypoxemic sickle cell client. There is no indication that the client is hypoxemic. (Note: If the information is absent in the question stem, that vital is considered normal. When evaluating the questions, do not add additional information to the question stems on the NCLEX). Choice C is incorrect. The nurse must first assess to determine whether the pain is from what is expected with the disease process or whether it is a complication. Administering pain medications right away would mask the actual disease process. Choice D is incorrect. Hydration can help in decreasing the sickling of cells. Choice D indicates that IV hydration is already in place. In SCD, the client should be kept euvolemic. Hypervolemia should be avoided because it can cause additional problems that come from fluid overload. Increasing the IV hydration without assessing the volume status is not the first intervention for this client.

The nurse is teaching a parent of a 2-month-old client about car seat safety. Which of the following statements by the client would indicate further teaching? A. "I positioned my child's car seat at a 45-degree angle." [11%] B. "I notice my child is more comfortable after adding padding behind their back." [59%] C. "I place a blanket over the straps to keep my child warm." [17%] D. "I've placed the chest clip at the level of my child's armpit." [12%]

Choice B is correct. This statement requires follow-up. Blankets (or padding) behind the infant's (or child's) back while in the car seat are prohibited. Adding this padding creates slack in the harness, therefore creating the risk of the infant being able to eject from the seat during a crash. Choice A is incorrect. The car seat should be positioned at 45 degrees to prevent the infant from slouching. Choice C is incorrect. Bulky clothing or blankets can prevent a snug harness fit. Always buckle the infant (or child) in the seat first, then place coats or blankets over the harness. Choice D is incorrect. It is appropriate to place the chest clip at armpit level. This holds the harness straps on the child's chest and shoulders. When counseling a client about car seat safety, the nurse should provide the following information - ✓ Parents should not place an infant in the front seat of a car with a passenger-side airbag. ✓ Infants and toddlers should ride in a rear-facing child safety seat in the car's back seat until age two years or until they reach the highest weight or height recommended by the car seat manufacturer. ✓ Rolled blankets and towels may be needed between the groin and legs to prevent slouching and can be placed along the sides to minimize lateral movements. ✓ Placing the infant in a safety seat at a 45-degree angle will prevent slumping and airway obstruction. ✓ Padding is never placed underneath or behind the infant because it creates slack in the harness, leading to the possibility of the child's ejection from the seat in the event of a crash.

While teaching a client who has recently begun a vegan diet, the nurse should highly recommend supplementing with which of the following vitamins? A. Vitamin C [3%] B. Vitamin B12 [79%] C. Vitamin A [3%] D. Vitamin D [14%]

Choice B is correct. Vitamin B12 is abundantly present in food products of animal origin. These include eggs, poultry, dairy products, fish, and meat. No strict vegetarian source has sufficient vitamin B12 to meet the recommended daily allowance (RDA). Vegans refrain from consuming all animal products, including eggs and dairy. Therefore, vegans are at a very high risk of developing vitamin B12 deficiency. Vegans should be counseled to consume alternative sources of vitamin B12 such as vitamin B12 supplements foods fortified with vitamin B12 ( fortified nutritional yeasts, fortified cereals) to reduce the risk of B12 deficiency significantly. Choices A, C, and D are incorrect. Vegans are generally not more prone to vitamin A and C deficiencies than non-vegans. Vegans consume plenty of fruits and vegetables. Vitamin A ( Choice C) is present abundantly in carrots, apricots, sweet potatoes, and dark green leafy vegetables ( spinach, kale, and collard greens). Vitamin C ( Choice A) is present abundantly in fruits ( orange, apple, kiwi, etc.) and vegetables ( bell peppers, brussel sprouts, broccoli, and so on). While vitamin D ( Choice D) is not abundant in a vegan diet, there are still some good vegan sources, including mushrooms, spinach, and bananas. Also, vitamin D can be abundantly obtained from sunlight. Vegans may be more prone to vitamin D deficiency than non-vegans. However, the vegans' highest risk is for vitamin b12 deficiency, and the nurse should prioritize this recommendation. Vitamin B12 deficiency can lead to fatigue, dementia, glossitis ( tongue inflammation), macrocytic anemia ( anemia with large red blood cells), pancytopenia ( reduced blood counts along all cell lines, i.e., reduced red cells, white blood cells, and platelets ), and neurological manifestations ( neuropathy, paresthesias. tingling and nu

The nurse is admitting a new client and begins to review information regarding advanced directives. The client becomes agitated and refuses to discuss the issue or accept a handout about the topic. Which is the appropriate nursing action? A. Leave the handout on the client's bedside table instructing him that he must review the content. [3%] B. Document the client's refusal, using the client's own words, in quotes. [50%] C. Explain to the client that he must make decisions about accepting or refusing treatment while in the hospital. [16%] D. Request an assessment of the client's competency related to making decisions about advanced directives. [32%]

Choice B is correct. While the Self-Determination Act requires healthcare facilities to provide information about the client's right to refuse or accept treatment, the client has the right to withdraw that information. If the client declines verbal and written information about advanced directives, the nurse should document that information was offered and record the client's refusal, quoting the client's statements. Choice A is incorrect. The client has the right to autonomy and self-determination, including the refusal of information regarding advanced directives. Choice C is incorrect. The client is not required to have advanced directives in place while in the hospital. Choice D is incorrect. The client's refusal to accept information about advanced directives is not indicative of the client's level of competence. ✓ Respect for the client's autonomy is a fundamental principle of nursing ethics. Even if the client refuses to discuss advanced directives, it is essential to respect their decision and not pressure or coerce them into the discussion. ✓ While the client may refuse initially, their perspective may change over time. Nursing care involves ongoing assessment and reassessment. It may be appropriate to revisit the topic of advanced directives at a later time when the client is more receptive. ✓ Nurses should be familiar with the legal and ethical guidelines related to advanced directives in their jurisdiction. This knowledge can help inform their interactions with clients who may have questions or concerns about the topic.

The nurse is preparing a client for a renal ultrasound. Which of the following statements accurately describes the purpose of this procedure? A. It measures the concentration of potassium and sodium in the blood. [0%] B. It evaluates the function of the kidneys in producing red blood cells. [1%] C. It evaluates the size, shape, and location of the kidneys, as well as blood flow to the kidneys. [97%] D. It detects abnormal levels of urea in the bloodstream. [1%]

Choice C is correct. A kidney ultrasound is a noninvasive diagnostic exam used to evaluate the size, shape, and location of the kidneys, as well as blood flow to the kidneys. This imaging modality is particularly useful in detecting abnormalities such as cysts, tumors, obstructions, or other structural anomalies within or around the kidneys. Choice A is incorrect. A kidney ultrasound does not directly measure electrolyte levels. Instead, it primarily evaluates the structural aspects of the kidneys and blood flow to the kidneys. Choice B is incorrect. While the kidneys play a role in producing erythropoietin, a kidney ultrasound does not directly evaluate the function of the kidneys in producing red blood cells. Choice D is incorrect. Urea is a waste product that is removed from the blood by the kidneys, a kidney ultrasound does not directly detect urea levels in the bloodstream. ✓ Renal ultrasound is one of the most commonly performed imaging modalities for evaluating renal anatomy and function. It is estimated that millions of renal ultrasound examinations are conducted annually worldwide. ✓ It may be applicable for the nurse to ensure clients are comfortable during the ultrasound procedure by providing appropriate positioning and support. ✓ Renal ultrasound has a high diagnostic accuracy for detecting renal abnormalities, such as hydronephrosis, renal cysts, tumors, and renal artery stenosis. Studies have reported sensitivity and specificity values exceeding 90% for various renal pathologies.

The nurse is caring for a client with the following clinical data. Based on the clinical data, the nurse should clarify which prescription with the primary healthcare provider (PHCP)? See the image below. A. Urine analysis (UA) [4%] B. Head CT Scan [9%] C. Regular diet [78%] D. Ammonia level [8%]

Choice C is correct. A regular diet prescription should be questioned because of the client's medical history of diabetes mellitus and hypertension. The appropriate diet would be one restricted in carbohydrates and sodium. Thus, the nurse should follow up with the PHCP regarding this order. Choices A, B, and D are incorrect. A UA is a logical and plausible prescription for this client. Older adults may manifest infection as altered mental status. A CT scan should be obtained to rule out any structural abnormalities, such as infarcts. An ammonia level is useful to determine if the client has metabolic encephalopathy. The client has altered mental status, a cardinal feature of high ammonia levels. ✓ AMS may be caused by many reasons, including infections such as neurosyphilis, cystitis, brain injury, dementia, delirium, or a psychiatry pathology. ✓ The nurse must implement measures to keep the client safe such as fall precautions. The client with altered mentation is at increased risk of falling and self-injury.

The nurse is caring for a client scheduled for a thyroidectomy. The primary healthcare provider (PHCP) prescribes potassium iodide. The nurse understands that this medication is intended to do which of the following? A. Decrease the risk of agranulocytosis postoperatively. [11%] B. Prevent postoperative hypocalcemia. [22%] C. Reduce the size and vascularity of the thyroid. [59%] D. Decrease postoperative blood glucose levels. [8%]

Choice C is correct. For a client scheduled for thyroidectomy, potassium iodide-iodine (Lugol's solution) may be prescribed to decrease the risk of gland vascularity and surgical blood loss. A complication following thyroidectomy is significant blood loss, and having this medication taken 10 days before surgery will mitigate this risk. Choice A is incorrect. This medication does not decrease the risk of agranulocytosis. The antithyroid medications, especially methimazole, tend to cause agranulocytosis, and the client's white blood cell count should be monitored during therapy. Choice B is incorrect. Lugol's solution does not act to prevent postoperative hypocalcemia. Postoperative hypocalcemia is a concern following this surgery (injury to the parathyroid), however, the treatment for this would be postoperative prescribed calcium carbonate. Choice D is incorrect. Lugol's solution does not influence postoperative blood glucose levels. ✓ In hyperthyroid patients, iodine acutely inhibits hormonal secretion ✓ This medication is diluted in water or juice, and the client should take it with a straw to reduce the risk of teeth staining ✓ Potassium iodide-iodine (Lugol's solution) is indicated in the treatment for Preoperative preparation for thyroidectomy in Graves' disease Adjunctive therapy (one week after radioiodine or with thionamides) in Graves' disease Treatment of thyroid storm

The nurse is performing a follow-up visit on an adolescent recently prescribed guanfacine. Which of the following assessments indicates a therapeutic response to the medication? A. Euthymic mood [15%] B. Less social anxiety [23%] C. Improved academic performance [43%] D. No suicidal ideations [19%]

Choice C is correct. Guanfacine is an alpha2A-adrenergic receptor agonist and is approved to treat symptoms of attention deficit hyperactivity disorder (ADHD). The medication comes in an extended-release form to lessen the common side-effect of sedation. Guanfacine is efficacious for individuals with ADHD, especially if they possess motor hyperactivity and impaired concentration. The client reporting improving academic performance indicates that the client is receiving the therapeutic benefit of the medication, as individuals with ADHD usually have decreased work and scholastic performance. Choice A is incorrect. Euthymic mood is described as a mood without any disturbance (mania or depression). Guanfacine is not a mood-stabilizing medication. This would not be a therapeutic finding because it is irrelevant to the clinical indication. ADHD is not a mood disorder, as it is classified as a neurodevelopmental disorder. Choice B is incorrect. Less social anxiety would be a therapeutic finding if a client took a serotonergic drug such as paroxetine or citalopram. This medication would have no impact on the client's social anxiety. Choice C is incorrect. The client not reporting suicidal ideations would not be a relevant finding to guanfacine as this medication is indicated for ADHD. Medicines that may be used fo lessen suicidal ideations include lithium and clozapine. ✓ Guanfacine is indicated in the treatment of ADHD ✓ This medication is prescribed as either immediate or extended release ✓ Hypotension and sedation are the most common effects associated with this medication ✓ The client should be instructed to start this medication when they plan not to drive or do any tasks requiring high concentration ✓ The sedation side effect may lessen with time ✓ The client should not abruptly stop guanfacine because it tends to caus

The nurse notes that the 39-week pregnant client is experiencing placenta previa. Knowing the contexts surrounding this condition, the nurse refrains from performing which of the following standard procedures? A. Ultrasonography of the uterus [5%] B. Palpating the uterus to determine fetal arrangement [13%] C. Checking the cervix for dilation [77%] D. Placing the patient on the left side [4%]

Choice C is correct. If the prenatal client has a current case of placenta previa, the cervix should not be assessed for dilation. Placenta previa arises when the placenta develops in a problematic spot, close to or over the cervical os. To prevent bleeding or premature labor, women with placenta previa shouldn't have their cervix checked manually. Instead, an ultrasound may be performed. Choice A is incorrect. Ultrasounds may be used safely in women with placenta previa. Ultrasounds are the safest way to assess cervical dilation in a woman with this issue. Choice B is incorrect. If the physician requires, the nurse may safely palpate the abdomen and thus the uterus of a woman whose pregnancy is difficult because of placenta previa. Choice D is incorrect. Laying on her left side is an often-used position for pregnant women, including those with placenta previa. This position increases circulation to the fetus and is often a comfortable position for laboring women.

The nurse is assessing a client with schizophrenia who was recently prescribed lurasidone. Which questions by the nurse would be most appropriate in determining the presence of negative symptoms of schizophrenia? Select all that apply. "Have you found yourself more distracted than usual?" "Do you have any thoughts of harming yourself?" "You recently had a birthday party, how was it?" "Do you have any thoughts of harming others?" "It says here you enjoy playing tennis. Have you been playing recently?"

Choice C is correct. Negative symptoms of schizophrenia include anhedonia, avolition, alogia, affective flattening, or blunting. Reminding the client that they had a birthday party and how it was would provoke an emotional response (reminding them of a happy time, etc.). Those with affective blunting do not display emotion even when provoked with an emotionally charged line of questioning. Choice E is correct. One of the negative symptoms is anhedonia. Anhedonia is the loss of recreational and sexual interest and decreased relationships with friends/family. Inquiring about a client's previous hobby and asking if they have re-engaged with that hobby is an effective way of inquiring about this negative symptom. Choice A is incorrect. Schizophrenia may also have a bleak impact on cognition. Cognitive impairments of schizophrenia may include executive function, attention, working memory, and episodic memory. Choice B is incorrect. Inquiring if the client has suicidal ideations is necessary for any assessment. However, suicidal ideation is not a negative or positive symptom. Suicidal ideation is a separate assessment, and its relevance is not threaded to a positive or negative symptom. Choice D is incorrect. Inquiring if the client has homicidal ideations is necessary for any assessment. However, suicidal ideation is not a negative or positive symptom. Suicidal ideation is a separate assessment, and its relevance is not threaded to a positive or negative symptom. ✓ Schizophrenia is a psychotic disorder equally impacting males and females ✓ Most cases appear before 35 years of age ✓ Schizophrenia varies in severity ✓ Symptoms of schizophrenia include positive (delusions, hallucinations, illusions), negative (anhedonia, alogia, avolition), and cognitive (impaired episodic and working memory, inattention)

The nurse, in the emergency department, is caring for a child who swallowed a small toy. The child has trouble breathing but is conscious and not making any sounds. The nurse should immediately A. instruct the client to cough to clear the airway. [13%] B. apply a bag valve mask. [6%] C. perform abdominal thrusts. [73%] D. perform a blind finger sweep. [7%]

Choice C is correct. Performing abdominal thrusts should be the first action to relieve the obstruction. This action is essential because the child has trouble breathing and is not making any noise after swallowing a toy, which indicates choking. Since this client has an upper airway obstruction, performing a blind finger sweep is not recommended as it may cause the object to propel further down the airway. The nurse should only attempt a finger sweep if the object is visible. Choice A is incorrect. If the child is coughing after swallowing an object and can talk, the nurse should encourage the child to cough until the object comes out. If the child is coughing, abdominal thrusts should not be done because the cough reflex is more powerful than the abdominal thrusts. However, if the child is short of breath but conscious and still silent (not making noise) after swallowing an object, it indicates airway obstruction. In this case, the client is not making any noises - therefore, the nurse should not instruct them to cough to clear the object. Instead, the nurse should immediately intervene with abdominal thrusts. Choice B is incorrect. Applying a bag valve mask would not relieve the airway obstruction, and the nurse's initial concern is maintaining airway patency by removing the obstruction. Choice D is incorrect. The nurse should never perform a blind finger sweep if the object is not visible. This could cause the object to further dislodge in the airway and cause a complete blockade ✓ Abdominal thrusts are performed on children one year and older if they are choking. ✓ Manifestations of airway obstruction warranting immediate follow-up include the child in the tripod position, cyanosis, and unable to speak or cough. ✓ Five abdominal thrusts should be performed, and then the child should be reassessed to see if the ob

The nurse is assessing a client with a recent history of an above-the-knee amputation presenting with phantom limb pain. The nurse anticipates a prescription for A. aripiprazole [7%] B. oxycodone [59%] C. amitriptyline [23%] D. hydroxyzine [11%]

Choice C is correct. Phantom limb pain (PLP) is a form of complex pain syndrome that can be treated with medications such as pregabalin, gabapentin, amitriptyline, or propranolol. Amitriptyline is a tricyclic antidepressant (TCA), and its activity related to PLP may be associated with the blockade of serotonin-norepinephrine uptake. Choosing a non-opioid analgesic with proven efficacy is always critical before using an opioid analgesic. Choices A, B, and D are incorrect. Aripiprazole is an atypical antipsychotic not indicated in the management of PLP (choice A). Oxycodone is an opioid. While opioids may be effective for PLP-related pain, the use of opioid medications for long-term pain management is no longer recommended because their risks outweigh the benefits (choice B). A multimodal approach of medications from various classes is preferred. Hydroxyzine is a histamine antagonist commonly used to treat allergies and anxiety (choice D). ✓ Phantom limb pain (PLP) may occur after an above-the-knee amputation. It should be differentiated from other causes of stump pain. While acute stump pain is common following the amputation, it usually subsides over 1 to 3 weeks. If the pain persists beyond three weeks, it is considered chronic and may be secondary to stump ischemia, infection, neuroma formation, or phantom limb pain. Therefore, phantom limb pain is a diagnosis exclusion, i.e., the diagnosis is made only after excluding all the other causes of stump pain. ✓ The mechanism of phantom limb pain is not completely clear. However, most research indicates that this pain may be neuropathic in nature. This type of pain is often described as a burning, crushing, or cramping sensation. ✓ It is essential for the nurse to acknowledge the pain and refrain from being dismissive (for example, telling the client that their limb is no

The nurse supervises a student nurse assisting a client with left-sided weakness in performing activities of daily living. Which action by the student nurse requires the nurse to intervene? The student nurse A. puts the client's affected (weaker) arm in the shirt's sleeve first. [10%] B. places shoes with velcro straps on the client's feet. [6%] C. places the wheelchair as close to the bed as possible on the client's affected (weaker) side. [82%] D. places the hairbrush in the client's unaffected (stronger) hand. [3%]

Choice C is correct. Placing the wheelchair as close to the bed as possible on the client's affected (weaker) side requires follow-up because the client should be mobilized by having the wheelchair on their unaffected (stronger) side. This requires follow-up because the client is at risk of falling and injury. Choice A is incorrect. This action is appropriate, and the client should be instructed to use their unaffected (stronger) arm to dress the affected (weaker) side first. Choice B is incorrect. This action is appropriate. In lieu of using laces and frustrating the client, velcro straps on clothing and shoes are encouraged. Choice D is incorrect. The hairbrush should be placed on the client's stronger side so they can effectively comb their hair. ✓ The client should use the arm that is still mobile to put on clothing, starting with the affected side first. To undress, the client should start by taking off clothes from the unaffected side. ✓ Velcro shoes are preferred over shoes with laces. ✓ When mobilizing a client, they should be positioned on their unaffected (stronger) side to be transferred to a chair or wheelchair.

The nurse is caring for the following assigned clients. The nurse should initially follow-up with the client who A. is repeatedly washing their hands. [5%] B. talking over others during group therapy. [1%] C. yelling and shouting at others. [87%] D. is voluntarily admitted and requesting discharge. [7%]

Choice C is correct. The client yelling and shouting at other clients requires immediate intervention because this situation is hostile and warrants the nurse to de-escalate the situation before it intensifies. Choices A, B, and D are incorrect. A client repeatedly washing their hands is a feature of obsessive-compulsive disorder, and the nurse should not intervene unless the act threatens the client or others. Further, a client talking over others in therapy will require intervention, but this is not the immediate need as it is not a hostile situation. Finally, voluntarily admitted clients might request discharge, but this is a low-priority item compared to the client yelling at others. When prioritizing client needs, focus on ensuring that physiological, safety and security needs are met first. In this question, the client's safety and security needs are prioritized over the other needs.

After a patient experiences a motor vehicle accident (MVA) and suffers a complete spinal cord injury to L3, the nurses would assess for loss of motor function in the: A. Abdomen [9%] B. Arms [7%] C. Legs [80%] D. Chest [5%]

Choice C is correct. The level of injury in the spinal cord correlates with innervation on the skin according to the level of the dermatome. Choice A is incorrect. Innervation of the abdomen corresponds to T9 to T12 injury. Choice B is incorrect. Innervation of the arm correlates with C5 to T1. Choice D is incorrect. Injury to T1-T8 correlates with chest innervation.

The nurse is caring for a pediatric client reporting a sore throat that is inflamed with white patches on the tonsils. The nurse anticipates that the primary healthcare provider (PCHP) may order a A. sputum culture. [3%] B. extended respiratory virus panel. [6%] C. throat culture. [82%] D. complete blood count. [8%]

Choice C is correct. The nurse expects that a throat culture will be ordered to confirm a diagnosis of bacterial tonsillitis. Tonsilitis may be diagnosed by simple clinical presentation. However, a diagnostic tool to determine the causative bacterial would be a throat culture. Choice A is incorrect. A sputum culture would not be used for an individual with localized throat pain. A sputum culture would be used if a client has infectious disorders such as pneumonia or tuberculosis. Choice B is incorrect. The extended respiratory virus panel is a test sent to evaluate for the presence of some of the most common respiratory viruses, including influenza, RSV, adenovirus, parainfluenza, and rhinovirus. While this client may have a virus, the nurse suspects bacterial tonsillitis based on the symptoms and expects another diagnostic test to be ordered first. Choice D is incorrect. A complete blood count (CBC) is a test done to evaluate the different components present in a client's blood, such asThe nurse is observing a client ambulate with a walker. It would require follow-up by the nurse if the clienttheir red blood cells, white blood cells, and platelets. It can show if a client is anemic, has markers of infection, and much more. While this test could be ordered for many different reasons, it is not the test that will help confirm the suspected diagnosis of bacterial tonsillitis. The nurse expects another diagnostic test to be ordered first. ✓ When performing a throat culture, the client will stick out their tongue, and the nurse should sweep the swab near each tonsil. ✓ Avoid having the swab touch the tongue, teeth, and gums, as this may contaminate the sample. ✓ Label the specimen and send it to the lab for processing.

The nurse assesses a client receiving total parenteral nutrition (TPN) and fat emulsions. The nurse observes that the fat emulsion infusion is one hour behind schedule. The nurse should take which action? A. Adjust the infusion rate to make up the difference over the next hour, then revert the infusion rate back to the prescribed rate. [4%] B. Increase the infusion rate to ensure that the infusion finishes at the correct time. [1%] C. Ensure the fat emulsion infusion rate is infusing at the prescribed rate and maintain the rate at the prescribed rate. [84%] D. Stop the infusion and inform the primary health care provider (PHCP). [11%]

Choice C is correct. The nurse should confirm the fat emulsion infusion is infusing at the prescribed rate and subsequently maintain the prescribed rate until the infusion is complete. Choices A, B, and D are incorrect. Fat emulsions, parenteral nutrition (PN), or any other intravenous fluid should not be infused faster than the rate at which they are ordered. Doing so places the client at risk for fluid and/or fat overload. TPN and fat emulsions should be administered at the rate prescribed. The rate is usually printed on the product. Deviations from the ordered rate place clients at risk for fluid volume overload. Infusion rates should not be expedited to complete an infusion running behind schedule. There is no need to stop the infusion or contact the health care provider (HCP) based on the infusion being behind schedule. ✓ Typically, lipids (i.e., one fat emulsion infusion bag) should never hang for more than 12 hours. ✓ If lipids are added to a TPN infusion, they are typically given concurrently with the TPN. ✓ During TPN therapy, the client's electrolytes, liver function tests, and glucose levels are monitored closely.

The nurse reviews clinical data for a client 24 hours postpartum following a vaginal delivery. Which of the following findings would require follow-up by the nurse? A. Hematocrit 46% (0.46 L/L) [> 33%, 0.38-0.50 L/L] [2%] B. Creatinine 1.0 mg/dL (88.4 µmol/L) [0.6-1.1 mg/dL, 22-75 µmol/L] [1%] C. Platelets 90,000 mm3 (90 x 10⁹/L) [150,000-400,000 mm3, 130-380 × 10⁹/L] [70%] D. White blood cell 17,000 mm3 (17 x 10⁹/L) [5,000-10,000 mm3, 3.5-10.5 × 10⁹/L] [28%]

Choice C is correct. The platelet count is low and requires follow-up and notification to the primary healthcare provider (PHCP). The normal platelet count is 150,000-400,000 mm3, 130-380 × 10⁹/L. Causes of postpartum thrombocytopenia include exposure to certain medications, HELLP syndrome, preeclampsia, or disseminated intravascular coagulopathy. Thrombocytopenia can lead to an increased risk of bleeding, which is a concern postpartum, especially after a vaginal delivery. Choice A is incorrect. The hematocrit level is within the normal range (greater than 33% or 0.38-0.50 L/L) and does not require immediate follow-up. Choice B is incorrect. The creatinine level is within the normal range (0.6-1.1 mg/dL mg/dL, 22-75 µmol/L) and does not require immediate follow-up. Choice D is incorrect. The white blood cell count is elevated but can be a normal response to the stress of delivery. However, it should be monitored for signs of infection, but it does not necessarily require immediate follow-up unless there are other concerning symptoms. ✓ Normal postpartum findings include - A urinary output of up to 3000 mL/day may occur, especially on days 2 through 5 postpartum. Diaphoresis is a common postpartum finding White blood cell (WBC) count increases to as high as 30,000/mm3 during labor and the immediate postpartum period The hematocrit returns to normal limits 4 to 6 weeks postpartum The first stool usually occurs within 2 to 3 days postpartum. Constipation is common during the first bowel movement. Approximately 4.5 to 5.8 kg (10 to 13 lb) is lost during childbirth. This includes the weight of the fetus, placenta, amniotic fluid and blood lost during the birth An additional 2.3 to 3.6 kilograms (kg) (5 to 8 lb) are lost as a result of diuresis and 0.9 kg to 1.4 kg (2 to 3 lb) from involution and lochia by the end of the fi

The nurse is participating in a committee with the objective of promoting healthcare justice in the community. Which of the following recommendations should the nurse make to achieve the goal? A. Establishing interdisciplinary collaboration between nursing and nutritional services [15%] B. Providing more confidential waste containers at local drug stores [2%] C. Offering free telehealth offerings in underserved areas of the community [79%] D. Offering inpatient clients the ability to select their meal times [3%]

Choice C is correct. The premise of social justice is expanding access to affordable healthcare for all individuals. The nurse recommending health services for underserved areas is a way to improve health inequalities in the community. Another example would be the nurse endorsing expanding health services and eligibility for Medicaid. Choice A is incorrect. Establishing interdisciplinary collaboration between nursing and nutritional services does not focus on the community, as the focus is on two professional departments and no clear beneficiary. Providing more confidential waste containers at local drug stores relates to promoting confidentiality as this does not expand the offering of medical services. Offering inpatient clients the ability to select their meal times aligns with the nurse promoting autonomy. ✓ The primary focus of healthcare justice is the fair and equitable treatment of individuals. ✓ The goal is to expand access so all individuals can enjoy healthcare regardless of culture, gender, age, or income status. ✓ The nurse promoting programs and services targeting underserved areas are a prime example of promoting this type of justice.

The nurse is caring for an infant with suspected cystic fibrosis. When assessing the infant's stool, which of the following characteristics would support the diagnosis of cystic fibrosis? A. Small, hard, pellet-like stool [8%] B. Green, malodorous stool [17%] C. Oily, odorous, bulky stool [65%] D. Loose, yellow stool [11%]

Choice C is correct. This disease process frequently affects the pancreas, intestines, and hepatobiliary systems, resulting in the malabsorption of fats, fat-soluble vitamins, and protein in 85 to 95% of cystic fibrosis clients. As a result, gastrointestinal manifestations include the frequent passage of bulky, foul-smelling, oily stools. Choice A is incorrect. Small, hard, pellet-like stools are not characteristic stools produced by cystic fibrosis clients. Choice B is incorrect. Malodorous bowel movements are a clinical manifestation of cystic fibrosis clients; however, these bowel movements are not traditionally described as "green" in color. Choice D is incorrect. Loose, yellow bowel movements are not traditionally associated with cystic fibrosis clients. ✓ Cystic fibrosis is an inherited disease affecting primarily the gastrointestinal and respiratory systems. ✓ While universal newborn screening for cystic fibrosis is now standard in the United States, it is important to note that this screening tool cannot diagnose cystic fibrosis alone. When a newborn screening returns a positive result, it is followed by a sweat test to confirm the diagnosis. ✓ Despite advances in genetic testing, the sweat chloride test remains the standard for confirming a cystic fibrosis diagnosis in most cases because of the test's sensitivity, specificity, simplicity, and availability. ✓ Although most cases of cystic fibrosis are first identified by newborn screening, up to 10% of those with cystic fibrosis are not diagnosed until adolescence or early adulthood.

The nurse has attended a continuing education conference regarding medication administration and meal times. Which statement, if made by the nurse, would indicate correct understanding? A. Proton pump inhibitors (PPIs) should be given as the client eats their breakfast. [7%] B. Glucocorticoids should be given on an empty stomach to prevent gastrointestinal irritation. [7%] C. Rapid-acting insulins should be administered approximately 5-10 minutes before meals [73%] D. Levodopa-Carbidopa should be administered with a high-protein snack to enhance its absorption. [13%]

Choice C is correct. This is correct because rapid-acting insulin (lispro, aspart, glulisine) should be given within 5-10 minutes before a meal or while the client is actively eating. Choice A is incorrect. PPIs (omeprazole, pantoprazole) should not be given with a meal. The medication is intended to ameliorate esophageal reflux symptoms, and medications in this class are intended to be given 30 minutes before the main meal of the day. Choice B is incorrect. Glucocorticoids (prednisone) may cause GI irritation and cause ulcers. To minimize GI irritation, the client should take the medication with food and avoid concurrent use of NSAIDs. Choice D is incorrect. Levodopa-Carbidopa (Sinemet) is a medication used to treat Parkinson's disease. It should be administered on an empty stomach, preferably 30 minutes to 1 hour before meals, to maximize its absorption and effectiveness. Administering levodopa-carbidopa with a high-protein snack may decrease its absorption due to competition for transport across the blood-brain barrier, potentially reducing its therapeutic effects. ✓ The three rapid-acting insulins are lispro, aspart, and glulisine. ✓ The client needs to take this insulin 5-10 minutes before a meal or while actively eating. ✓ A rapid-acting insulin is utilized as correctional insulin before meals to prevent post-prandial hyperglycemia. ✓ This type of insulin is commonly loaded into an insulin pump.

The nurse is observing a client ambulate with a walker. It would require follow-up by the nurse if the client Correct A. advances the walker 6-10 inches. [14%] B. has their elbow flexed 15-30 degrees. [5%] C. tilts the walker forward to help stand up from a chair. [65%] D. advances the walker and then the affected leg. [15%]

Choice C is correct. This observation requires follow-up because when a client gets up from a chair to the walker, the arm rests of the chair should help the client stand to the walker. Tilting the walker could result in falling and serious injury. When clients get up from a chair to the walker, they should hold the chair's arm rests and push up using their arms. After they stand up, they should position their arms on the walker handles with an elbow bend of 15 to 30 degrees. Choices A, B, and D are incorrect. These observations reflect the effective use of a walker. The walker's height should be measured to the client's wrist crease, and the client should have elbow flexion of 15-30 degrees. As the client ambulates, they should lift the walker 6 to 10 inches and advance the affected leg first. ✓ The client with upper extremity weakness faces a challenge with walkers because they require the client to lift the device up and forward. ✓ Alternatively, walkers with wheels may be used; however, the walker can roll forward when weight is applied, causing the client to lose their balance. ✓ When a client uses a walker, the elbows should be flexed 15-30 degrees. ✓ When the client ambulates with a walker: They should advance the walker 6-10 inches Step into the walker with the weaker/affected leg first Then step into the walker with the stronger leg ✓ When a client gets up from a chair to their walker, they will position the walker in front of them and keep the weak leg slightly extended out, and place their hands on the arm rests of the chair. Once the hands are on the arm rests, they will ascend to the walker and finally position their hands on the walker and have the elbows flexed 15-30 degrees.

The nurse is teaching a group of students about tertiary prevention. Which of the following would be a form of tertiary prevention? Yearly fecal occult blood testing Testicular self exams Digital rectal exams Rehabilitation programs Support groups for chronic illness

Choice D and E are correct. Rehabilitation programs are considered tertiary prevention strategies. Support groups for a chronic illness are tertiary prevention as this enables individuals to share management strategies. Tertiary prevention focuses on maximizing the function of an individual and preventing further complications. Choices A, B, and C are incorrect. Yearly fecal occult blood testing is a screening. Therefore it is a secondary prevention strategy. Testicular self-exams are a screening. Therefore it is a secondary prevention strategy. Digital rectal exams are a screening. Therefore it is a secondary prevention strategy.

The nurse is caring for a client who developed a thyroid storm. The nurse should obtain a prescription for A. enalapril [24%] B. regular insulin [5%] C. levothyroxine [40%] D. dexamethasone [31%]

Choice D is correct. A thyroid storm is a medical emergency and is a complication of hyperthyroidism. Manifestations of a thyroid storm include fever, tachycardia, hypertension, and cardiac dysrhythmias. Emergent treatments for a thyroid storm include prescribed dexamethasone (corticosteroids inhibit the peripheral conversion of T4 into T3), propranolol (to reduce heart rate and blood pressure), and an antithyroid medication such as propylthiouracil. Choice A is incorrect. Enalapril is an ACE inhibitor and has no role in treating a thyroid storm. While this medication may ameliorate hypertension found with a thyroid storm, it is not the preferred drug because both tachycardia and hypertension are present in this endocrine emergency. Thus, the prescribed propranolol should be used. ACE inhibitors are preferred drugs for heart failure and hypertension. Choice B is incorrect. Regular insulin is not used in the management of a thyroid storm. Regular insulin is one of the two treatments for diabetic ketoacidosis. Choice C is incorrect. Levothyroxine is the treatment for hypothyroidism. Giving this medication would be catastrophic because it would further increase circulating thyroid levels. ✓ A thyroid storm is a medical emergency and is manifested by tachycardia, fever, hypertension, and restlessness ✓ Treatment is administering an array of medications including - IV corticosteroids to decrease the conversion from T3 to T4 IV antithyroid medications such as methimazole or propylthiouracil IV propranolol to treat the adrenergic symptoms ✓ Nursing care includes maintaining the client's airway, providing cooling blankets, and initiating continuous cardiac monitoring to detect any dysrhythmias ✓ Salicylates should not be given because they would increase circulating thyroid hormones

A nurse is conducting a dysphagia screening on a client who was recently extubated. Which assessment finding requires intervention? A. Slight cough after sipping water [6%] B. Hoarseness of voice during speech [17%] C. Complaint of throat discomfort when swallowing [11%] D. Presence of a wet, gurgling cough after drinking water [65%]

Choice D is correct. A wet, gurgling cough after drinking water is a concerning finding during a dysphagia screening post-extubation. It may indicate that the client is experiencing aspiration. The nurse should stop oral intake, keep the client in a safe position, and notify the healthcare provider for further evaluation and possible interventions, such as a formal swallow study or referral to a speech therapist for swallowing rehabilitation. Choice A is incorrect. A slight cough after sipping water is a common finding in post-extubation clients and may be indicative of a mild irritation in the airway. Choice B is incorrect. Hoarseness of voice after extubation is common due to irritation of the vocal cords from the endotracheal tube. While it should be documented and monitored, it does not require immediate intervention. Choice C is incorrect. While a complaint of mild throat discomfort when swallowing should be assessed and documented, it does not require immediate intervention. Mild throat discomfort could be a common post-extubation symptom due to the irritation caused by the endotracheal tube. ✓ After identifying the presence of a wet, gurgling cough after drinking water, the nurse should closely monitor the client's respiratory status and vital signs. This includes assessing for signs of respiratory distress, such as increased respiratory rate, decreased oxygen saturation, or abnormal breath sounds. ✓ Elevating the head of the bed to a semi-Fowler's or Fowler's position can help reduce the risk of aspiration and improve respiratory function. ✓ Aspiration during the dysphagia screening requires a more comprehensive evaluation of the client's swallowing function. The nurse should work with the healthcare provider to consult speech for further evaluation.

The nurse is reviewing vital signs for a client admitted with abdominal pain and has a medical history of chronic obstructive pulmonary disease (COPD). Which vital sign requires follow-up by the nurse? A. Blood pressure 130/70 mm Hg [4%] B. Respiratory rate 24 breaths/min [19%] C. Pulse oximetry 91% on room air [4%] D. Oral temperature of 101.1° F (38.4° C) [73%]

Choice D is correct. An elevated temperature indicates some form of infection. In a client with COPD, the common infections include bronchitis or pneumonia. Any respiratory infection may cause an exacerbation of COPD. A client who did not receive pneumonia or influenza vaccines is at increased risk of developing pneumonia and influenza. Monitoring for signs/symptoms of infection is a crucial nursing intervention. Fever increases respiratory workload and may precipitate a flare-up of COPD. Fever should be controlled, and the underlying etiology should be identified and treated promptly. The nurse should educate the client to receive the annual influenza vaccine and stay current on their pneumonia vaccine. Choices A, B, and C are incorrect. Although all the vital signs in these answer options are slightly elevated or in the upper limits of the normal range, they do not represent a cause for immediate concern. A blood pressure of 130/70 should be addressed. However, fever should be controlled, and the underlying infection should be treated promptly in a client with COPD. Mild to moderate tachypnea is expected in a client with COPD. In the absence of significant hypoxia with a saturation of less than 88%, supplemental oxygen should not be administered. A pulse oximetry of 91% on room air is within normal limits for an individual with COPD. The nurse should intervene if it declines to 88% while on room air.A nurse is caring for a client with a central venous catheter (CVC) in place.

The nurse is planning care for a client following a hematopoietic stem cell transplant. The nurse anticipates the primary healthcare provider (PHCP) will prescribe which medication? A. desmopressin [21%] B. montelukast [18%] C. zidovudine [23%] D. azithromycin [38%]

Choice D is correct. Azithromycin is a macrolide antibiotic used to treat and prevent many infections. The critical advantage of azithromycin is that it has significant lung penetration, making it an attractive option for treating and preventing pneumonia. Following a hematopoietic stem cell transplant, the client is at high risk for infection, and prophylactic antibiotics are commonly prescribed. Pulmonary infections, such as pneumonia, are a common infection, thus making azithromycin a plausible treatment option. Choice A is incorrect. Desmopressin does not have any utility in the management of hematopoietic stem cell transplants. This medication is commonly prescribed to treat neurogenic diabetes insipidus. Choice B is incorrect. Montelukast is a leukotriene modifier and is indicated in preventing exercise-induced asthma. This medication is designed to be taken by the client two hours before exercise to prevent an asthma exacerbation potentially triggered by exercise. Choice C is incorrect. Zidovudine has no role in the management of hematopoietic stem cell transplants. This antiviral is indicated in the treatment of human immunodeficiency virus. While a client may receive antivirals, it would not be zidovudine. Common prophylactic antivirals include acyclovir or valacyclovir. ✓ Azithromycin is a macrolide antibiotic ✓ Azithromycin has excellent pulmonary penetration, which makes it an effective antibiotic for pulmonary infections ✓ Common indications for azithromycin include pneumonia, sexually transmitted infections (Chlamydia trachomatis), rhinosinusitis, and streptococcal pharyngitis ✓ Azithromycin may be taken with or without food ✓ Diarrhea is the most common side-effect associated with this antibiotic

The nurse performs a focused assessment on a casted patient experiencing increased pain in the affected limb. The nurse notes pallor and swelling distal to the cast area. The patient reports increased pain upon passively moving the extremity. Which of the following fracture-related complications should the nurse be concerned about? A. Fat embolism [6%] B. Infection [2%] C. Pulmonary embolism [2%] D. Compartment syndrome [90%]

Choice D is correct. Compartment syndrome occurs when pressure increases in one area of the fascia groups around the muscle, causing a decrease in blood flow to the other parts of the affected limb. Compartment syndrome is identified by increasing pain in the affected limb, passive pain when moved, and pale swollen tissue distal to the site. Quick diagnosis is essential in compartment syndrome because permanent damage can occur to the tissue within 4 to 6 hours. Choice A is incorrect. A fat embolism is a complication of a fracture that occurs when a fat globule from the bone marrow is released into the blood system. This complication generally occurs within 48 to 72 hours after the injury. Choice B is incorrect. A disease related to a breach can occur at any time during the healing process. While infection, usually osteomyelitis, is a complication of a fracture, it results in red and swollen skin, an elevated temperature, and some pain. Choice C is incorrect. A pulmonary embolism can occur because of a fracture but presents with chest pain and shortness of breath rather than problems at the fracture site.

The nurse is caring for a client who is mechanically ventilated and receiving multiple intravenous medications. The client's family member is upset and overwhelmed by the client's clinical condition. Which therapeutic action would be appropriate for the nurse to take? A. Let the family member spend time alone with the client [20%] B. Reminiscence with the family member about the client [8%] C. Ask the family member if they would like to speak with pastoral care [9%] D. Explain the different types of medications and therapies the client is receiving [63%]

Choice D is correct. From the perspective of a family member, seeing a loved one receiving mechanical ventilation and multiple IV therapies can be overwhelming. The nurse must take an empathetic approach to the client's family, as this is a necessary caring behavior. Explaining to the family member the therapies the client is receiving can provide reassurance. It is the unknown that is likely causing the family member emotional distress, and explaining the current treatments would provide valuable information, thereby lessening anxiety. Choice A is incorrect. The nurse should not leave the client, and the nurse should respond to the family member with an empathetic approach. Choice B is incorrect. Reminiscing will not alleviate the family member's current emotional disposition. The nurse must focus on the here and now and review the current therapeutic modalities with the family member to ease the current emotion. Choice C is incorrect. Asking if the family member would like to speak with pastoral care would not address the family member's emotional state. The nurse should directly address the family member's concern, which is legitimate considering the client's current clinical condition. ✓ The caring behaviors of a nurse are what are central to the profession ✓ Examples of caring behaviors include active listening, empathy, therapeutic touch, advocacy, and client fidelity ✓ During periods of critical illness, the nurse must make themselves available to provide information about the client's condition

The parents of a 2-year old with Hirschsprung's disease are talking to the nurse in the family clinic. They ask the nurse about treatment options for Hirschsprung's disease; the nurse understands that the treatment of choice would be which of the following? A. A colostomy [42%] B. Senna concentrate [4%] C. Polyethylene glycol [13%] D. Pull-through procedure [40%]

Choice D is correct. In Hirschsprung's disease, the aganglionic section of the colon is removed, and the unaffected, functioning ends are attached to each other. In some cases, a Pull-through procedure is done, where a surgeon removes the segment of the large intestine lacking nerve cells and connects the first part to the anus. Choice A is incorrect. A colostomy is done to relieve symptoms of colonic obstruction. It is a temporary treatment for the condition until the client is old enough to undergo a colectomy. Choice B is incorrect. Hirschsprung's disease does not respond to medication due to the missing nerves in the colon. Choice C is incorrect. Hirschsprung's disease does not respond to medication due to the missing nerves in the colon.

The nurse in the intensive care unit is caring for a client being treated for necrotizing pancreatitis. Which of the following findings would indicate the client is experiencing a complication? A. periumbilical bruising [36%] B. abdominal pain rated 5/10 on the numerical rating scale [1%] C. white blood cell count 13,500 mm3 [5,000-10,000 mm3] [19%] D. decreased lung sounds in the left lower lung fields [43%]

Choice D is correct. Multiple complications of pancreatitis may occur, including left lower lung atelectasis or pleural effusion. Decreased lung sounds in the left lower lung field suggest atelectasis, especially considering the client has necrotizing pancreatitis. The cause of this lung injury is the massive inflammation associated with pancreatitis. Additionally, pancreatitis causes increased pulmonary microvascular permeability with protein-rich transudate spilling into the alveolar spaces, leading to decreased lung compliance. Extra abdominal complications pose a serious risk to a client with pancreatitis. Choice A is incorrect. The client has necrotizing pancreatitis, which is a severe form of pancreatitis. Manifestations of necrotizing pancreatitis include periumbical bruising (Cullen's sign) and bruising in the flank area (Grey-Turner sign). This is a finding consistent with necrotizing pancreatitis and not a complication. Choice B is incorrect. Abdominal pain in the epigastric region is a consistent finding with pancreatitis, which should be treated with prescribed opioids such as fentanyl. This is an expected finding and not a complication. Choice C is incorrect. Pancreatitis causes significant inflammation, which causes an individual to experience leukocytosis. This is an expected finding and not a complication. ✓ Acute pancreatitis may cause various complications, including hypovolemic shock, sepsis, paralytic ileus, pleural effusion, pneumonia, and disseminated intravascular coagulopathy. ✓ Early priorities in caring for acute pancreatitis include providing intravenous isotonic fluids to restore circulatory volume. Pain control should be provided with prescribed fentanyl, hydromorphone, or morphine. ✓ The nurse should put the client on nothing by mouth (NPO) status until an ileus has been ruled out and nau

The nurse is assessing the following clients. Which client is at greatest risk for decreased vascular perfusion? A. A 76-year-old female client with a history of alcohol abuse. [3%] B. A 76-year-old female client with a history of radon gas exposure. [7%] C. A 64-year-old male client with a history of cigarette smoking. [54%] D. A 64-year-old male client with hypotension. [36%]

Choice D is correct. Perfusion refers to the continuous supply of blood through the blood vessels to vital organs. The client with hypotension is at the highest risk for impaired vascular perfusion. Hypotension can result from various causes such as adrenal insufficiency, dehydration, hemorrhage, septic shock, obstructive shock, and cardiogenic shock. A Mean Arterial Pressure (MAP) greater than 65 mmHg is essential to maintain perfusion to vital organs. Prolonged hypoperfusion may lead to end-organ damage, such as renal failure and ischemic hepatitis. Therefore, the cause of hypotension must be identified and treated right away. Choice A is incorrect. Alcohol abuse can have various health consequences, including potential effects on the liver and cardiovascular system, but it does not specifically focus on vascular perfusion as the primary concern. Choice B is incorrect. Radon gas exposure primarily affects the respiratory system and can increase the risk of lung cancer. While lung cancer can indirectly impact vascular perfusion, it is not be the most immediate risk compared to hypotension. Choice C is incorrect. Cigarette smoking is a risk factor for various cardiovascular and respiratory diseases, including atherosclerosis and chronic obstructive pulmonary disease (COPD). These conditions can contribute to impaired vascular perfusion over time. However, hypotension is a more direct and immediate concern when assessing vascular perfusion. ✓ Assist in determining the underlying cause of hypotension. Hypotension can result from various factors, such as dehydration, medications, heart conditions, or sepsis. Identifying the cause is crucial for effective management. ✓ Frequent or even continuous monitoring of vital signs, including heart rate and respiratory rate, in addition to blood pressure may be needed. Changes in t

The clinic nurse assesses a 12-month-old infant and notes that the anterior fontanel remains slightly open. The infant's parent asks about the finding. What is the most appropriate response by the nurse? A. "I will contact the health care provider (HCP) immediately." [6%] B. "I need to examine your child further." [6%] C. "We will need to obtain an MRI on your child." [1%] D. "This is a normal finding on a child of this age." [87%]

Choice D is correct. The anterior fontanel typically closes anywhere between 12 to 18 months of age. Therefore, an assessment finding demonstrating the anterior fontanel remaining slightly open is considered normal, which would necessitate no further action for this client. The nurse should reassure the infant's parents. Choice A is incorrect. Notifying the health care provider (HCP) is unnecessary, as this is considered a normal assessment finding for a 12-month-old infant. Choice B is incorrect. Additional assessments based solely on this finding are not necessary. Choice C is incorrect. Ordering an MRI on this 12-month-old infant would be erroneous because an open anterior fontanel at 12 months of age is an expected finding, and placing unnecessary MRI orders is a waste of resources. Six fontanels (also commonly referred to as fontanelles) are present during infancy, with the most notable being the anterior and posterior fontanels. Typically, the posterior fontanel closes by two months of age, while the anterior fontanel fuses between 12 and 18 months. The purpose of fontanels is to facilitate the movement and molding of the newborn's cranium through the birth canal during labor. The primary cause of a sunken fontanel is due to dehydration. Conversely, a bulging fontanel occurs due to a rise in intracranial pressure, typically indicative of one or more of the following pathologies: hydrocephalus, hypoxemia, meningitis, trauma, or hemorrhage (of note, this is not an all-inclusive list).

The nurse is caring for a client, and their kosher meal has been delivered. The nurse should A. withhold any liquids until after the meal. [6%] B. assist the client in unwrapping the utensils. [4%] C. remove any condiments such as salt and pepper. [7%] D. allow the client to unwrap the utensils. [82%]

Choice D is correct. The kosher diet calls for the meals to be served on paper plates with plastic utensils that are sealed. Healthcare providers should not unwrap the utensils or transfer the food to another dish. Choice A is incorrect. Liquids may be served with the client's meal. However, the kosher diet prohibits dairy and meat from being consumed within the same meal. So, the liquid should be a non-dairy product if the client consumes meat. Choice B is incorrect. The nurse should not assist or touch the kosher meal in any way. This includes unwrapping utensils. Choice C is incorrect. Condiments are permitted to be served with the meal. The nurse does not need to remove them from the meal tray. ✓ Kosher meats are slaughtered a certain way, under the auspices of a rabbi, and all the blood is drained ✓ Animals that have split hooves and chew the cud, such as cows, bulls, sheep, lambs, and goats, are allowed. Pig (pork) is forbidden ✓ Certain poultry is allowed, such as chicken, goose, duck, and turkey, but all others are forbidden. Certain parts of permitted animals may not be eaten ✓ Fish with fins and scales can be eaten, meaning shellfish are prohibited ✓ Wine is allowed, but other alcoholic beverages are not ✓ The utensils, pots and pans, and cooking surfaces used for meat cannot be used for serving dairy

A nurse is providing education to a group of adolescents about the dangers of heroin use. Which of the following statements by one of the adolescents indicates a need for further clarification? A. "Heroin can lead to addiction and dependence, making it difficult to stop using." [1%] B. "Injecting heroin increases the risk of contracting blood-borne infections such as HIV and hepatitis." [3%] C. "Heroin can cause respiratory depression, which can be life-threatening." [3%] D. "Using heroin with friends at a party is safer than using it alone." [93%

Choice D is correct. Using heroin in any setting carries significant risks and dangers. While some individuals may mistakenly believe that using heroin with others provides a sense of safety or protection, the reality is that heroin use poses serious risks to health and safety regardless of the social context. Using heroin with friends does not mitigate the risks of overdose, respiratory depression, addiction, or other adverse effects associated with heroin use. Choice A is incorrect. Heroin is a highly addictive opioid drug that can lead to physical dependence and addiction with repeated use. Chronic heroin use can result in changes to the brain's reward system, leading to compulsive drug-seeking behavior and difficulty in stopping use. Choice B is incorrect. Injecting heroin with shared needles or other drug paraphernalia increases the risk of transmitting blood-borne infections such as HIV and hepatitis B and C. Sharing needles can lead to the direct exchange of contaminated blood between individuals, facilitating the spread of infectious diseases. Choice C is incorrect. Heroin is a central nervous system depressant that can suppress respiratory function, leading to shallow breathing, slowed heart rate, and potentially life-threatening respiratory depression. ✓ Treatment for heroin use disorder typically involves a combination of behavioral therapies, medication-assisted treatment (MAT), and support services. ✓ The overdose reversal drug used for heroin and other opioid overdoses is naloxone. Naloxone is a medication known as an opioid antagonist, meaning it works by rapidly binding to opioid receptors in the brain, displacing any opioids present, and reversing the effects of opioid overdose. Naloxone can quickly restore normal breathing in individuals experiencing opioid overdose, potentially saving their lives.

The nurse reviews a client's laboratory data. Which laboratory data requires follow-up? See the image below. Select all that apply.

Choices A and C are correct. These laboratory values require follow-up because they are not within normal limits. The labs depict hyponatremia [less than 135 mEq/L (mmol/L)] and hypocalcemia [less than 9 mg/dL (2.12 mmol/L)]. Causes of hyponatremia include dehydration, diuretics (especially thiazides), and SIADH. Causes of hypocalcemia include hypoparathyroidism, chronic renal failure, and vitamin D deficiency. Choice B is incorrect. These laboratory values are within normal limits and do not require follow-up by the nurse. Choice D is incorrect. These laboratory values are within normal limits and do not require follow-up by the nurse. Choice E is incorrect. These laboratory values are within normal limits and do not require follow-up by the nurse. ✓ Assess for signs and symptoms of hypocalcemia, including muscle cramps, paresthesia (tingling or numbness), and positive Chvostek's and Trousseau's signs. ✓ Monitor the client's fluid balance closely, ensuring proper hydration levels. Assess for signs of dehydration, such as dry mucous membranes, decreased skin turgor, and decreased urine output. ✓ Communicate effectively with the healthcare team, including physicians, dietitians, and pharmacists, to ensure a comprehensive approach to managing electrolyte imbalances.

The nurse is educating the parents of a child diagnosed with impetigo. Which of the following statements, if made by the parent, would indicate effective understanding? Select all that apply. "I should keep my child home from swim practice until the blisters heal." "The virus causing this condition may cause skin outbreaks from time to time." "My child should wear a mask in public to prevent others from getting sick." "I should not share my child's linens with anyone else in the house." "I should keep the draining blisters uncovered."

Choices A and D are correct. Impetigo is a skin condition caused by group A Streptococcus (GAS; Streptococcus pyogenes) or Staphylococcus aureus. The condition is highly contagious and spreads by contact with the vesicles. The vesicles should remain clean and dry, and swimming is prohibited because it allows for further disease transmission. Children can return to school 24 hours after beginning antimicrobial therapy if the affected area remains covered. Draining lesions should be kept covered. Linens are an effective way to transmit the bacteria, and they should not be shared and laundered daily to prevent reinfection. Choices B, C, and E are incorrect. Bacteria, not a virus, cause impetigo. This statement is incorrect because it references flare-ups of herpes which are treated with oral and topical antivirals such as valacyclovir. A mask is not necessary to prevent transmission because this pathogen is spread by contact, not droplets. The draining vesicles should always be kept clean and dry with a bandage. This is a pivotal step in disease transmission. ✓ Impetigo is a contagious skin condition that is caused by Staphylococcus aureus or Streptococcus pyogenes ✓ This condition is commonly found in young children and typically presents around the face, mouth, and then on the hands, neck, and extremities ✓ The lesions have drainage and then begin to crust ✓ Medical treatment is antibacterial ointments that should be applied via a sterile cotton tip applicator ✓ Nursing care focuses on educating the client on hand hygiene, pain control with warm compresses to the affected area, preventing transmission by not sharing linens, etc. ✓ The individual with impetigo should not go into any pools, hot tubs, or saunas to prevent further transmission ✓ The child may return to school if the vesicles are covered and antibiotic trea

The nurse supervises unlicensed assistive personnel (UAP) assist a bed-bound client with oral hygiene. Which action by the UAP requires follow-up? Select all that apply. Raises the head of the bed (HOB) to 15 degrees Positions the toothbrush bristles at a 45-degree angle to the gum line Performs hand hygiene and applies clean gloves Removes the towel and places it in a biohazard bag Applies moisturizing lubricant to the lips after brushing and rinsing

Choices A and D are correct. These actions by the UAP require follow-up. The head of the bed should ideally be elevated to between 30-45 degrees to facilitate effective oral hygiene and reduce the risk of aspiration. A lower angle may make it more difficult for the client to swallow properly and increase the risk of choking. Placing a towel used for oral hygiene in a biohazard bag is unnecessary unless it is saturated with blood or other potentially infectious materials. The towel used to protect the client's clothing during oral hygiene is typically considered regular linen and should be placed in a linen bag for laundering. Using a biohazard bag for non-contaminated items increases waste and may lead to confusion in waste management procedures. Choice B is incorrect. Positioning the toothbrush bristles at a 45-degree angle to the gum line effectively removes plaque and debris from both the teeth and the gum line, promoting good oral hygiene. Choice C is incorrect. Hand hygiene and glove use are essential infection control practices to prevent the spread of infection, especially when providing direct client care, such as oral hygiene assistance. Choice E is incorrect. Applying moisturizing lubricant helps prevent dryness and irritation of the lips, promoting overall oral comfort and health after oral hygiene procedures. ✓ According to research published in the Journal of Clinical Nursing, up to 90% of hospitalized clients experience oral health problems, and poor oral hygiene is associated with an increased risk of hospital-acquired infections (HAIs). These infections can lead to extended hospital stays, increased healthcare costs, and even mortality. ✓ Communicate with the client throughout the procedure, explaining each step and ensuring their comfort. Use clear, simple language and allow time for the client to res

The nurse is providing handoff report to the oncoming nurse. Which information should be included? Select all that apply. As needed (PRN) medications that were administered Normal assessment findings for the shift Normal laboratory results Scheduled medications that were administered Abnormal vital signs

Choices A and E are correct. Medications administered as needed should be included in the nursing handoff and abnormal vital signs. Nursing handoffs should accurately and quickly review the client's condition during the past shift. As needed, medications are administered for a change in the client's condition, and abnormal vital signs will require follow-up. Choices B, C, and D are incorrect. Normal assessment findings for the shift are not a necessary component of the nursing handoff. Reviewing all normal assessment findings would not only take too long but is not necessary information. Any changes in assessment findings, abnormal findings, and current problems should be included as they will likely require follow-up. The client's scheduled medications are not a necessary component of the nursing handoff. This information may be obtained from the medication administration record (MAR) by the oncoming nurse. Topics to include during the handoff report include - Following the ISBAR format (identify the client, situation, background, assessment abnormalities, and recommendations) Abnormal vital signs PRN medications administered Abnormal laboratory values Pending orders/diagnostic tests Change in condition Pertinent family dynamics Discharge plan

The nurse is assessing a client with infective endocarditis (IE). Which of the following would be an expected finding? Select all that apply. Fever Night sweats Osler nodes Cardiac murmur Syncope Weight loss

Choices A, B, C, D, and F are correct. Infective endocarditis (IE) is a serious condition that, if untreated, may lead to heart failure. Infectious symptoms are the hallmark of this condition, including fever, night sweats, chills, weight loss, headache, and malaise. Other physical manifestations that may be assessed with IE include a cardiac murmur, Janeway lesions (flat, reddened maculae on hands and feet), Roth spots (hemorrhagic lesions that appear as round or oval spots on the retina), and Osler nodes (on palms of hands and soles of feet). Choice E is incorrect. Syncope is not a clinical feature of IE. This would be associated if the client was to have a vasovagal reaction. ✓ Infective endocarditis occurs primarily in clients with injection drug use (IDU) and those who have had valve replacements, have experienced systemic alterations in immunity, or have structural cardiac defects. ✓ This condition is caused by the invasion of bacteria that enter the client through contaminated needles, oral cavity following dental procedures, and/or skin abscesses. ✓ Classic manifestations of IE include • Fever associated with chills, night sweats, malaise, and fatigue • Anorexia and weight loss • Cardiac murmur (newly developed or change in existing) • Petechiae • Splinter hemorrhages • Osler nodes (on palms of hands and soles of feet) • Janeway lesions (flat, reddened maculae on hands and feet) • Roth spots (hemorrhagic lesions that appear as round or oval spots on the retina) Positive blood cultures ✓ Treatment of IE is antibiotic therapy for several weeks. ✓ Complications include myocardial infarction, congestive heart failure, renal infarction, stroke, and septic arthritis.

The nurse is educating nursing students about factors that can influence cardiac output. Which of the following would cause an increase in cardiac output? Increased stroke volume Increased blood volume Increased sympathetic stimulation Administration of positive inotropic drugs Increased systemic vascular resistance (SVR).

Choices A, B, C, and D are correct. A is correct. Stroke volume refers to the amount of blood ejected by the left ventricle during each contraction. An increase in stroke volume would directly increase cardiac output, as it is one of the two factors determining cardiac output (Workman, 2021). B is correct. An increase in blood volume can lead to an increase in cardiac output. More blood volume can stretch the heart muscle fibers, leading to a more muscular contraction and stroke volume, thereby increasing cardiac output (Frank-Starling law) (Workman, 2021). C is correct. Sympathetic stimulation increases both heart rate and the force of myocardial contraction, which can increase cardiac output. This is part of the body's 'fight or flight' response (Workman, 2021). D is correct. Positive inotropic drugs, such as digoxin, increase the force of myocardial contraction. This can lead to increased stroke volume and cardiac output (Workman, 2021). Choice E is incorrect. E is incorrect. Increased systemic vascular resistance, or afterload, actually decreases cardiac output. Increased SVR means the heart must work harder to pump blood into the systemic circulation, which may decrease stroke volume and reduce cardiac output.

The nurse works with elderly clients. The nurse should recognize which of the following are physical changes associated with the aging client? Select all that apply. Pronounced wrinkles on the face Decreased size of the nose and ears Increased growth of facial hair Neck wrinkles Increased height

Choices A, C, and D are correct. Many changes occur in the aging body. With age, the loss of adipose tissue causes sagging skin and wrinkles. This is especially noticeable around the head and face. Wrinkles on the face become more pronounced and tend to take on the general "mood" of the client over the years. For example, laugh lines or wrinkles around the lips, cheeks, and eyes are usually more noticeable. Changes in hormone levels, especially the androgen-estrogen ratio, often cause an increase in the growth of facial hair in most older adults. As individuals age, they lose estrogen. When estrogen decreases and testosterone levels are unopposed clients will start to grow more hair where men have it, especially on the face. The aging process causes the platysma muscle to shorten, which contributes to neck wrinkles. Neck skin is very similar to facial skin. As clients age, they lose important dermal plumping factors like collagen, elastin, and glycosaminoglycans. These factors are gradually lost over time with the aging process and are also enhanced with environmental stressors like frequent exposure to UV light. Choice B is incorrect. The nose and ears of the aging client become more extended and broader. Over time, the nose and ears appear to grow in size due to gravity. As individuals age, gravity causes cartilage in the ear and nose to break down and sag which gives these features an elongated appearance. Choice E is incorrect. Typically, height decreases through the aging process. ✓ Aging skin looks thinner, paler, and clear (translucent). ✓ Pigmented spots, including age spots or "liver spots," may appear in sun-exposed areas. The medical term for these areas is lentigos. ✓ Changes in the connective tissue reduce the skin's strength and elasticity. It becomes thinner, loses fat, and no longer looks as plump and

During a newborn assessment, the nurse performs a variety of reflex assessments to evaluate the newborn's nervous system and overall health. Which of the following statements about reflexes in the newborn is true? Select all that apply. The Babinski reflex is also known as the startle reflex. A positive Babinski sign is normal in the newborn. The Moro reflex is demonstrated when the infant is startled and stretches out their arms in response. The Moro reflex is pathologic in the newborn. The tonic neck reflex is present at birth and is essential for sucking

Choices B and C are correct. A positive Babinski sign is when the toes splay outward after stroking the plantar surface of the foot. It is normal in the newborn but pathologic in the adult population (choice B). When a baby is startled and responds by suddenly stretching out his arms, this is the Moro reflex (choice C). Choices A, D, and E are incorrect. The Moro reflex is also known as the startle reflex, not the Babinski reflex (choice A). The Moro reflex is normal in newborns and is not pathologic (choice D). The tonic neck reflex is when the baby's head is turned to one side; the arm on that side will extend while the opposite arm will flex. Tonic neck reflex disappears around 4-6 months of age. The following are some common newborn reflexes that healthcare providers may assess: ✓Moro reflex: The Moro reflex is a startle reflex that occurs when the baby is startled by a sudden noise or movement. The baby will arch their back, extend their arms and legs, and then bring their arms together in front of their body. ✓Rooting reflex: The rooting reflex is a reflexive turning of the head and opening of the mouth when the baby's cheek or mouth is stroked. This reflex helps the baby find the breast or bottle for feeding. ✓Sucking reflex: The sucking reflex is triggered when the roof of the baby's mouth is stimulated. This reflex helps the baby feed and can also have a soothing effect. ✓Grasp reflex: The grasp reflex is a strong grip of the baby's hand when an object is placed in their palm. ✓Babinski reflex: The Babinski reflex is a response to the bottom of the baby's foot being stroked. The big toe will extend upward while the other toes fan out. ✓Stepping reflex: The stepping reflex is a walking-like motion that occurs when the baby's feet touch a flat surface.

The nurse is developing a plan of care for a client admitted to the mental health unit with significant paranoia. Which of the following should the nurse include in the client's plan of care? Select all that apply. Plan competitive activities with other clients. Maintain consistent caregivers. Establish a rapport using therapeutic touch. Involve the client in decision-making. Develop a plan of care that is unstructured. Immediately enroll the client in group therapy.

Choices B and D are correct. A client experiencing paranoia may be very conspiratorial, and while it is important to reinforce reality, it would be appropriate to acknowledge their feelings. Involving the client in the decision-making process and avoiding any surprises is essential. Consistent caregivers are recommended because this cements the therapeutic relationship with staff. Choice A is incorrect. Activities should be structured and non-competitive. Competition may enable hostility and decrease a client's self-esteem. Choice C is incorrect. Central to caring for a client experiencing paranoia is having a therapeutic relationship without touch. Touch may be misinterpreted and should not be used. The same may be said for direct eye contact. Direct eye contact may raise an individual's suspicion. Choice E is incorrect. The plan of care should always be structured and verbalized to the client. This reinforces a trusting relationship. Choice F is incorrect. While group therapy may be helpful, this should be done gradually and not right away. Individuals with paranoia may initially resist socialization. ✓ For a client experiencing paranoia, developing trust with the client may be difficult. ✓ Establishing a trusting relationship that does not involve therapeutic touch is important, as this may be misinterpreted. ✓ Avoiding direct eye contact is also beneficial because direct eye contact may be misinterpreted. ✓ If the client is concerned about poisoned food, provide prepackaged foods. ✓ Avoid talking in front of the client and avoid any secretive activities. ✓ It would be beneficial to establish a clear schedule of the tasks ahead of time and establish trust and expectations.

The nurse is caring for several infants in the NICU. Which of the following signs would the nurse recognize as indicative of heart failure in an infant? Select all that apply. Sudden weight loss Tachycardia Diaphoresis Fatigue Bradypnea

Choices B, C, and D are correct. Choice B is correct. Tachycardia is a sign of heart failure. The heart is not pumping effectively, and the cardiac output is therefore decreasing. As a result of decreased oxygen delivery to the tissues, the heart rate increases to compensate for the decreasing cardiac output. Choice C is correct. Diaphoresis is a sign of heart failure. Infants will become sweaty in heart failure; you can notice this, especially on their scalp, where healthy babies would not usually sweat. They are diaphoretic because their body works hard to compensate for the decrease in cardiac output due to heart failure. Choice D is correct. Fatigue is common in heart failure due to decreased cardiac output and, thereby, reducing oxygen delivery to the tissues. The infant's body demands more oxygen, and heart failure makes it difficult to keep up with the demand, so they get very fatigued. Choice A is incorrect. Weight gain, not loss, is a sign of heart failure in an infant. For infants experiencing heart failure, their hearts will not be pumping blood effectively. This means that fluid is not moving forward, and blood is backing up in the body. This backup of blood leads to many complications, one of which is weight gain. When there are sudden weight changes, think fluid, not fat. Cardiac problems most often cause fluid changes. Choice E is incorrect. Tachypnea, not bradypnea, would be an expected finding in an infant with heart failure. Breathing rate increases as the lungs must work harder to provide adequate oxygen to the body.

The nurse is caring for a client prescribed lithium. Which laboratory tests would be necessary for the nurse to monitor? Select all that apply. Liver function tests Creatinine Thyroid-stimulating hormone Sodium Potassium

Choices B, C, and D are correct. Essential labs to monitor while a client takes lithium include the lithium level, thyroid panel (lithium may cause hypothyroidism), creatinine (risk of nephrotoxicity), and sodium (hyponatremia may precipitate lithium toxicity). Choice A is incorrect. Lithium is not hepatically metabolized, and monitoring the liver function tests is irrelevant. Potassium levels would not influence lithium the way sodium does. Thus, sodium is the essential electrolyte to monitor. ✓ Lithium levels should be maintained between 0.6 - 1.2 mEq/L (mmol/L). The client should be educated on the following points - Lithium requires the client to maintain adequate fluid and salt. The client's failure to do so may result in lithium toxicity. Lab findings expected with lithium include leukocytosis and hypothyroidism (long-term use). The client should avoid medications such as diuretics, NSAIDs, and ACE inhibitors, as these medications may cause lithium toxicity. Lithium levels should be drawn twelve hours following the client's last dose. If not, this may falsely elevate the lithium level. ✓ Lithium toxicity signs and symptoms include nausea, vomiting, lethargy, confusion, delirium, coma, seizures, and hypotension. ✓ Lithium's Thyroid and parathyroid effects:

The nurse is teaching a group of nursing students infectious diseases that are reportable to the local health department. Which of the following conditions should be reported? Bacterial vaginosis Herpes simplex virus (HSV) Human immunodeficiency virus (HIV) Hepatitis A Syphilis Human Papilloma Virus infection (HPV)

Choices C, D, and E are correct. Infectious conditions are reportable to the local health department including Human immunodeficiency virus (Choice C), Hepatitis-A (Choice D) and Syphilis (Choice E). Other reportable conditions include chlamydia, pulmonary tuberculosis, rabies, chickenpox, influenza, and gonorrhea. Healthcare providers have the responsibility to report these to the state/local health departments. Choice A is incorrect. Bacterial vaginosis is a common infection that does not require reporting. Choice B is incorrect. Herpes simplex virus (HSV) is spread by multiple methods and thus is not reportable. Genital herpes need not be reported. Choice F is incorrect. Human Papillomavirus (HPV) is not a reportable disease. Human Papillomavirus (HPV) infection and other HPV-associated clinical conditions are not nationally notifiable or required by the CDC. Some states and jurisdictions require specific HPV associated conditions reported (cervical cancer, cervical pre-cancer) but not infection itself.

You are working in the emergency department when a patient with a suspected stroke arrives. According to the American Heart Association (AHA), all of the tasks listed below should be done for this patient. What is the correct sequence for these tasks?

Correct ordered sequence: According to the AHA's suspected stroke algorithm, the correct course for the treatment of the stroke patient is: General assessment and stabilization within 10 minutes of arrival at the ED. Neurologic evaluation by the stroke team within 25 minutes of entry to the ED. Obtain a CT scan of the head without contrast within 45 minutes of entry to the ED. The purpose of a non-contrast CT scan is to determine if there is intracranial hemorrhage (hemorrhagic stroke). If an ischemic stroke is suspected, determine if the patient is a candidate for fibrinolytic (thrombolytic, tPA) therapy using the fibrinolytic checklist. Administer rtPA within 60 minutes of entry to the ED (within 4.5 hours of symptom onset). Admit to the stroke unit within 3 hours of entry to the ED.

0855: Client was brought to the clinic by her husband, who reports that she has been falling frequently, having difficulty remembering things, and numbness and tingling in the lower extremities. Onset was 2 weeks ago, with the falling and memory impairment worsening over the past week. The client was hospitalized 3 weeks ago because she ran out of medication, and her atrial fibrillation was giving her 'palpitations and shortness of breath.' Since refilling her medication, she has had no palpitations, chest discomfort, or dyspnea. The client's husband reports that he is worried about his wife's drinking because it has increased from three beers a day to five or six. She reports that her last drink was four days ago. On assessment, the client is alert and oriented to person, place, and time. Some speech latency was noted in her response. Her gait is unsteady, and had to be assisted to the examination room. Pupils are e

Potential Conditions The client is experiencing Wernicke encephalopathy. Nystagmus, ataxia, and paresthesias of the lower extremities are classic findings. The client's escalation in her drinking is the cause of this encephalopathy which is due to a thiamine deficiency. Prompt treatment is necessary as some of the neurological impairments may be irreversible. Alcohol intoxication and delirium tremens (DTs) are unlikely. The client reported that her last drink was four days ago, and while ataxia and nystagmus may be consistent with both intoxication and DTs, the client's blood pressure and pulse are normal, which would be elevated during DTs. DTs also have an onset of 12-72 hours following the last drink. Finally, the client's neurological findings have occurred for some time, whereas acute intoxication would cause the symptoms to wax and wane. A stroke is unlikely. While the client's atrial fibrillation puts her at higher risk for a stroke, she has no strength deficits or vital sign abnormalities (besides the irregular pulse, which is expected in atrial fibrillation). A stroke usually causes pronounced hypertension. Further, the duration of symptoms denies the likelihood of a stroke, as the client's symptoms started three weeks ago. Finally, she has no impairment in their level of consciousness and denies any pain, including a headache which would likely be present with a hemorrhagic stroke. Actions to Take The nurse needs to obtain an order to start a vascular access device and obtain a prescription to administer parenteral thiamine. Administering the prescribed thiamine will hopefully alleviate the client's neurological impairments. Oral thiamine is not recommended, as parenteral replacement is necessary to treat the neurological impairments, which may be permanent if prompt treatment is not sought. Lorazepam is not

The nurse in the emergency department cares for a 45-year-old female The client reports significant fatigue that has worsened over the past eight weeks. Additionally, the client reports constipation, hair loss, and a 3-kilogram (6.6 pounds) weight gain. She reports missing work because of difficulty concentrating and persistent fatigue. The client is alert and fully oriented. She appears fatigued and reports dizziness when she moves quickly. Periorbital edema, various bruises, and facial swelling were noted on assessment. Peripheral pulses were intact and weak. The client denies any pain.

Potential Conditions This client is experiencing significant hypothyroidism and requires immediate treatment. The clinical features that the client is demonstrating supporting hypothyroidism included periorbital edema, fatigue, bradycardia, hypotension, weight gain, constipation, anemia, increased TSH and decreased T3/T4. While adrenal insufficiency may cause hypotension and fatigue, it would not alter the thyroid hormones. Graves' disease is the most common form of hyperthyroidism and manifests as tachycardia, weight loss, and heat intolerance. Lupus is an inflammatory condition marked by fatigue, muscle and joint pain, anemia, and changes to the integument. The client is not reporting any pain, and while she does have anemia, it is related to thyroid abnormalities. Cushing's syndrome would be excluded because while this does cause weight gain and edema, it would not be explained by the altered thyroid levels. Action to Take This client's hypothyroidism is significant and requires the nurse to obtain a prescription for levothyroxine. Additionally, the client has low blood pressure and endorses dizziness; this should prompt the nurse to keep the client safe and implement fall precautions. Obtaining urine cortisol levels would be done for issues with the adrenal (Addison's / Cushing's) and not for this client. Additionally, this client does have anemia, but a transfusion of packed red blood cells is indicated when the hemoglobin is 7 g/dL or less. Anemia is expected with hypothyroidism. Methimazole would be helpful for Graves' disease, which this client is not experiencing. Parameters to Monitor The client arrives both with bradycardia and low blood pressure. Monitoring the vital signs is essential. Further, the nurse must monitor the serum thyroid levels. This would prevent overmedication which would cause the client t

The nurse is reviewing data for a client who is establishing primary care Click to highlight the findings from the history and physical that are risk factors for type II diabetes mellitus

The client's risk factors for type II diabetes mellitus include - Being 52-year-old - Testing is indicated for individuals at any age if they have a BMI greater than 25 and have a first-degree relative with diabetes or show signs of metabolic syndrome. This client has evidence of metabolic syndrome (hypertension and hyperlipidemia), and therefore, his age is a risk factor. Testing for diabetes mellitus type II is more likely after the age of 45. Native American ethnicity - Native Americans and Alaskan Indians are at higher risk than any other racial and ethnic groups. High blood pressure and high cholesterol - Two prominent risk factors for diabetes mellitus. Body mass index of 28 - According to the BMI scale, this client is overweight. The client's medical history of testicular cancer is not a credible risk factor for diabetes mellitus. Further, the client reporting that they have stopped smoking is a mitigating factor for the development of diabetes. One glass of red wine three times a week is not a concern. The recommendation for alcohol consumption is no more than one drink a day for women and two drinks a day for men.

A client with a stroke is prescribed alteplase. The prescription is for 0.9 mg/kg. The client weighs 257 pounds. How many milligrams will this equal? Round your answer to the nearest whole number. Fill in the blank.

The first step is to convert the client's weight from pounds (lbs) to kilograms (kg) 257 lbs → 116.81 kg Next, multiply the prescribed dosage by the client's weight 0.9 mg x 116.81 kg = 105.129 mg Finally, take the answer and round it to the nearest whole number 105.129 mg = 105 mg The maximum dosage of alteplase is 90 mg. Thus, the nurse would only deliver this prescribed amount. However, when calculating the problem, it is essential to ascertain the dose for mg/kg first.

The nurse is caring for a client with congestive heart failure Using the ISBAR format, click to highlight the text that expresses the nurses' recommendation to the physician. 2030 - Client reported a cough and shortness of breath while resting. The onset of symptoms was sudden and not relieved, with the client being positioned with the head of the bed at 90 degrees. Vital signs were obtained: 156/98; P 108; RR 26/minute; Oxygen saturation 91% on room air. Lung sounds had crackles in all fields. A rapid response was called because of the unstable vital signs. Dr. Thomas Smith was notified to obtain diuretics and critical care monitoring orders.

The nurse notifying the physician to obtain orders is a recommendation. The nurse explicitly outlined specific orders necessary for this client's care. The client's situation is best described by his reports of coughing, shortness of breath, and rapid response being called. Vital signs and the breath sounds collected would be classified as the assessment.

The nurse is reviewing the medical record of a client who is pregnant at 35 gestational weeks Click to highlight the findings in the medical record that require follow-up

This client's findings that require follow-up include The nonreassuring results in this medical record are the positive contraction stress test and the nonreactive stress test. The fasting glucose of 125 mg/dL (normal should be less than 100 mg/dL) is elevated and requires follow-up. The fetal heart rate is average, between 110 and 160 beats per minute. ✓ A nonstress test is performed in the third trimester if the client has indications such as a high-risk pregnancy that may result in a stillbirth or complications such as fetal hypoxia ✓A reactive finding indicates fetal well-being; specifically, the fetal heart rate increased by 15 beats per minute, lasting for 15 seconds ✓ A nonreactive NST is non-reassuring and indicates decreased variability with an absence in a fetal heart rate acceleration ✓ A contraction stress test (CST) is indicated for high-risk clients in the third trimester. CST requires the client to have contractions either through oxytocin administration or nipple stimulation ✓ Positive (abnormal) indicates that late decelerations were present in the FHR in more than 50% of the contractions ✓ Negative (normal) indicates no late or variable decelerations were evident during the contractions. The normal fetal heart rate is 110 - 160