ATI Exam 2- Missed Questions

A nurse is caring for an adolescent who has a superficial partial-thickness burn to the thigh. Which of the following actions should the nurse take? A. Prepare the adolescent for transport to a burn facility. ✔ B. Cleanse the affected area with tepid water. C. Scrub the affected area using a soft-bristle brush. x D. Administer morphine sulfate.

Correct Answer: B. Cleanse the affected area with tepid water. The nurse should cleanse the affected area with tepid water. Incorrect Answers: A. Minor burns do not require treatment at a burn center. They can be can be treated and managed in an outpatient setting. C. Gentle cleansing with tepid water is recommended for a superficial partial-thickness burn. D. Morphine sulfate is indicated for clients who have sustained moderate to major burns. Vital Concept: Management of Minor Burns Clean with mild soap and tepid water. Remove any debris from the wound. Gently remove dead skin. Place a sterile dressing over the wound. Apply antibacterial ointment to the affected area Ensure tetanus prophylaxis is up to date

Which of the following is an expected finding in an assessment of an 18-month-old child? ✔ A. Eats with a spoon B. Builds a 6-7 block tower C. Says sentences with 2-4 phrases x D. Grips crayons with fingers

Correct Answer: A. Eats with a spoon An 18-month-old should be able to meet the following milestones (see table below). Incorrect Answers: B. A 2-year-old normally has the fine motor skills to build a 6-7 block tower. An 18-month-old can build a tower of 3-4 blocks. C. An 18-month-old has at least a 10-word vocabulary but does not make phrases. A 2-year-old makes 2-3 word phrases. D. By the age of 3, a child can grip a crayon with fingers. An 18-month-old child uses a fist. Vital Concept: Developmental milestones at 18 months include throwing a ball overhand, jumping in place, and walking up and down stairs with help; building a 3-4 block tower, grabbing a crayon with the fist, and using a spoon and cup. An eighteen-month old toddler usually has a vocabulary of ten or more words.

The nurse is caring for a client who is undergoing an intravenous pyelogram. Arrange the following steps in proper chronological order for effective administration of the intravenous pyelogram. Assist with equipment application and setup Assist the client in positioning at the X-ray table Apply 10 lb. sandbag as needed Provide intravenous (IV) access using a large bore cannula Physician cleanses and anesthetizes the puncture site Doctor inserts needle and guide wires, advances catheter, and injects contrast medium Observe for itching or diaphoresis Assist the client in emptying bladder Doctor withdraws catheter and applies pressure to the puncture site for 5 minutes Apply pressure dressing or bandage over the insertion site Remove gloves and discard

Correct Answer: Assist the client in emptying bladder Assist with equipment application and setup Provide intravenous (IV) access using a large bore cannula Assist the client in positioning at the X-ray table Physician cleanses and anesthetizes the puncture site Doctor inserts needle and guide wires, advances catheter, and injects contrast medium Observe for itching or diaphoresis Doctor withdraws catheter and applies pressure to the puncture site for 5 minutes Apply pressure dressing or bandage over the insertion site Apply 10 lb. sandbag as needed Remove gloves and discard The implementation of an intravenous pyelogram is primarily used to visualize the renal pelvis, kidneys, ureters, and bladder. The client is instructed to have nothing by mouth after midnight and is usually given a cathartic on the evening before the test. In order to successfully implement this procedure, the following universal steps are taken: 1. Assist the client in bladder emptying, to prevent urination during the procedure. 2. Assist with equipment application and setup to ensure continuous implementation. 3. Provide IV (intravenous) access using large bore cannula for delivery of IV fluids. 4. Assist the client in positioning at the X-ray table for comfort and ease of access. 5. Doctor cleanses and anesthetizes the puncture site to avoid contamination and promote comfort. 6. Observe for itching or diaphoresis to evaluate signs of anaphylactic reaction to the injected medium. 7. Doctor inserts needle and guide wires, advances catheter, and injects contrast medium to visualize the urinary tract. 8. Doctor withdraws catheter and applies pressure on puncture site for 5 minutes to prevent bleeding. 9. Apply pressure dressing or bandage over insertion site to further blood clotting. 10. Apply 10-pound sandbag as needed to ensure that bleeding will not occur. 11. Remove gloves and discard as a safety precaution. Vital Concept: An intravenous pyelogram is a test of function of the urinary system. It is performed by administering iodine-based radiocontrast. The nurse should assess the client for shellfish allergy prior to the test. Peristaltic waves in the ureter indicate obstruction. After the test, the nurse should encourage the client to drink fluids to flush the radiocontrast dye from the system.

A nurse is providing discharge teaching about diet and fluid restrictions to a client who has a calcium oxalate kidney stone. Which instruction should the nurse include in the teaching? A. Increase intake of spinach. ✔ B. Limit sodium to no more than 2,300 mg/day. x C. Increase intake of vitamin C supplements. D. Limit consumption of high-purine foods.

Correct Answer: B. Limit sodium to no more than 2,300 mg/day. Increased sodium intake may result in urinary calcium excretion by decreasing calcium reabsorption. Incorrect Answers: A. Spinach is a food that is high in oxalate and, when combined with calcium, might result in calcium stone formation. C. Large doses of vitamin C can cause calcium stone formation. D. Foods that contain purine, such as organ meats and red wine, cause uric acid stone formation. Vital Concept: Stones that consist of calcium oxalate require a limitation of the client's dietary calcium intake to no more than 1,000 to 1,200 mg of calcium a day. Clients should avoid calcium supplements.

A nurse is reviewing snake bite management with a group of parents. Which of the following information should the nurse include in the teaching? x A. Apply ice as soon as possible after the bite occurs. B. Attempt to orally suck out the venom. ✔ C. Wash the bite area with soap and water. D. Perform passive range-of-motion exercises to facilitate circulation.

Correct Answer: C. Wash the bite area with soap and water. Washing the bite area with soap and water is part of the initial management for a snake bite. Management of a snake bite: Clean the area with soap and water. Cover with a clean dry dressing. Immobilize the area. Keep the child calm. Place the child in a reclined position. Remove restrictive clothing. Arrange for immediate transport to a medical facility. When possible and can be done safely, take a picture of the snake and bring it to the medical facility with the client so that it can be tested. Incorrect Answers: A. Ice is contraindicated because it slows the circulation to the area. B. While attempting to remove the venom is beneficial in some instances, a suction device should be used. D. When a snake bite occurs, the bite area should be immobilized. Vital Concept: Most snake bites occur while people attempt to handle a snake. Snakes that are kept as pets can also bite handlers. The best way to prevent snake bites is to avoid snakes.

A nurse is positioning a client who will undergo lumbar puncture. The nurse understands that a lumbar puncture is usually performed at which of the sites in the diagram below?

Correct Answer: A lumbar puncture is a procedure used to obtain cerebrospinal fluid from the subarachnoid space of the spinal canal for diagnosis of meningitis, encephalitis, and subarachnoid hemorrhage. It may also be performed to inject contrast material for imaging studies. The spinal cord ends at the level of the second lumbar vertebrae. Below the L2 vertebrae, the spinal nerves are gathered in the cauda equina. A lumbar puncture is performed at L3-L4 or L4-L5 because damage to the spinal cord is less likely to occur at this level. Informed consent must be obtained before the procedure. The nurse should assess the client for allergies to skin and local anesthetics and report any laboratory abnormalities to the healthcare provider. The nurse should advise the client that injection of the local anesthetic may result in a burning sensation and that it is important to remain still during the procedure. The client should empty the bladder before the procedure. The nurse will assist the client into the lateral recumbent position, with knees flexed and chin flexed to the chest, which widens the space between the vertebrae to facilitate insertion of the needle. The client's back is positioned at the edge of the bed or table. A lumbar puncture is a sterile procedure. After prepping and draping the client, the healthcare provider will inject a local anesthetic before introducing the spinal needle through the L3-L4 or L4-L5 vertebral interspace into the subarachnoid space. The client should be advised that the local anesthetic may cause a burning sensation. The nurse should encourage the client to breathe normally and remain still during the procedure. The healthcare provider will measure the CSF pressure and collect fluid for analysis. After the procedure, the nurse will clean and dress the puncture site and label the specimens to send immediately to the laboratory. The client should be assisted to the dorsal recumbent position with a pillow under the head. The client should remain flat for 4-24 hours, depending upon the provider's orders. The nurse should monitor the puncture site for leakage of CSF or formation of a hematoma and should monitor neurologic status at least every 4 hours for 24 hours after the procedure. The client should be encouraged to remain well hydrated to reduce the risk of spinal headache. The client should void within 8 hours of the procedure. The nurse will administer analgesics prescribed for pain. Vital Concept: The most common adverse effect associated with lumbar puncture is headache. Nursing interventions to reduce the risk of spinal headache include encouraging the client to remain flat for 4-24 hours after the procedure and ensuring the client remains well-hydrated. Other complications of lumbar puncture include hematoma at the puncture site, CSF leak, bleeding into the spinal canal, meningitis, abscess, pain from nerve root irritation, and transient urinary retention. Brain herniation is a serious but rare complication.

A nurse is developing a plan of care for a client with cancer who has a prescription for transcutaneous electrical nerve stimulation (TENS) for pain management. Which of the following actions should the nurse include in the plan? ✔ A. After applying electrodes, turn the knob until the client feels slight buzzing or tingling. B. Apply the TENS unit for no longer than 30 min. x C. Instruct the patient on how to adjust the voltage on the TENS unit. D. Avoid administering analgesics when using the TENS unit.

Correct Answer: A. After applying electrodes, turn the knob until the client feels slight buzzing or tingling. After applying electrodes, the nurse should turn the output knob until the client feels a tingling or buzzing. The intensity should be adjusted for client comfort. When using an older TENS unit, the nurse should apply a conductive gel before applying the electrodes from the TENS unit to the skin to provide good conduction between the electrode and the skin. Conductive gel may not be necessary for all TENS units, so the nurse should check the manufacturer's specifications. Incorrect Answers: B. TENS units can be applied for as long as is required and prescribed by the provider. C. The provider, nurse, or someone specially trained in TENS unit equipment should adjust the dial for voltage to be delivered to the client. D. The nurse can administer pain medication while the client is using the TENS unit. Vital Concept: Many clients who have cancer experience chronic pain. The use of non-pharmacologic methods of pain relief in combination with prescribed medications can improve client comfort. Transcutaneous electrical nerve stimulation (TENS) unit electrodes can be applied directly to the skin. The unit will send small electrical currents to the areas of pain to provide relief of symptoms. The therapy decreases pain levels by electrically stimulating local sensory fibers, which overrides the brain's ability to process pain messages from the affected area.

A healthcare prescriber has prescribed cefuroxime at 1.5 g in 50 mL normal saline over 30 minutes. If the drop factor is 60 gtt/mL at how many drops per minute should the nurse set the rate? (Record the numeric value only.) Fill in the blank

Correct Answer: 100 Cefuroxime is a second generation cephalosporin antibiotic used to treat respiratory, skin, soft tissue, urinary tract, and gynecological infections. It is also used for treatment of Lyme disease, meningitis, and sepsis. Cefuroxime should be used cautiously in clients with renal impairment. Adverse effects include pseudomembranous colitis and seizure. Probenecid increases blood levels of this drug by decreasing excretion. Cefuroxime is contraindicated in clients with cephalosporin or severe penicillin allergy. The calculation of flow rate in drops per minute is found using the following formula for intravenous flow rate: (Total volume x drop factor)/infusion time in minutes = drops per minute 50 mL = total volume Drop factor = 60 Infusion time = 30 minutes 50 x 60 = 3000 drops per minute/30 minutes = 100 drops per minute Vital Concept: The drop factor refers to the number of drops per mL. To find the drop rate/minutes, multiply the drop factor by the volume in mL and divided by the time of infusion in minutes.

A nurse is providing teaching to a client who has frequent urinary tract infections (UTIs). Which of the following statements by the client indicates an understanding of the teaching? ✔ A. "I will be sure to take the time to urinate at least every 4 hours." B. "I will take tub baths rather than showers when I think I'm getting an infection." x C. "I will make sure I drink a total of 50 ounces of water every day." D. "I will buy some new nylon underwear."

Correct Answer: A. "I will be sure to take the time to urinate at least every 4 hours." The nurse should instruct the client to void frequently during the daytime. The client should void as soon as the urge is felt, or at least every 2 to 4 hr. Doing so will flush the urethra and prevent bacteria from being retained and possibly ascending into the bladder. Incorrect Answers: B. The nurse should instruct a client who has frequent UTIs to shower rather than bathe in a bathtub. Sitting in a bathtub full of water allows any bacteria that might be present in the water to enter into the urethra. C. The nurse should instruct the client to drink at least six to ten 8-oz glasses of water daily. This amount ensures enough hydration to flush the bacteria out of the urinary system. To ensure adequate hydration, the nurse should recommend the client set a schedule for drinking small volumes of fluid frequently throughout the day. Increasing intake of food items, such as fruit, will also contribute to the client's fluid intake. D. The nurse should instruct the client to wear cotton underwear, rather than nylon underwear. Cotton fabric allows for more ventilation to the perineal area and helps to prevent a build-up of moisture, which could provide a medium for bacterial growth. Vital Concept: The nurse should teach clients who experience frequent UTIs about the importance of voiding after intercourse, emptying the bladder completely when voiding, keeping the perineal area clean, and avoiding constipation because pressure from the rectum can irritate the bladder. The nurse should also instruct clients about the importance of limiting caffeine intake because it can irritate the bladder. Female clients should also be instructed to wipe from front to back after voiding and defecating, avoid using perfumed perineal products, and avoid wearing tight-fitting clothing.

A nurse in a pediatric clinic is caring for an infant who has heart failure and is taking digoxin. Which of the following parent statements indicates a therapeutic response to the medication? A. "My baby is breathing easier than before." B. "My baby is taking longer naps now." C. "My baby is having fewer wet diapers since starting the medication." D. "My baby's heart rate is faster than it was before the medication."

Correct Answer: A. "My baby is breathing easier than before." The desired effect of digoxin is to increase cardiac output. The medication also should decrease venous pressure and pulmonary edema. Therefore, the nurse should identify this statement by the parent as indicating a therapeutic response to the medication. Incorrect Answers: B. The desired effect of digoxin is to increase cardiac output, which should decrease fatigue. C. The desired effect of digoxin is an increased urinary output due to improved cardiac output, which will increase the number of wet diapers. D. The desired effect of digoxin is to increase cardiac output, which will reduce the heart rate. Vital Concept: Manifestations of Heart Failure • Tachycardia • Anorexia • Pale extremities • Hypotension • Flaring nares • Orthopnea • Coughing • Wheezing • Weight gain • Periorbital edema • Distended neck veins

A nurse is caring for a client who weighs 165 pounds and is being treated for shock. The nurse is preparing a dopamine hydrochloride (Dopamine) infusion to start at 5mcg/kg/min. The nurse has prepared the following to infuse: dopamine 400 mg in 250 mL D5W. Which rate of infusion should the nurse choose? ✔ A. 14 milliliters per hour B. 16 milliliters per hour C. 22.5 milliliters per hour x D. 37.5 milliliters per hour

Correct Answer: A. 14 milliliters per hour The correct rate of infusion is 14 mL/hour. First, convert 165 lb. to kg by dividing 2.2(75). Then convert 400mg/250mL to mcg/mL by dividing 400mg/250mL and multiplying the result (1.6 mg/mL) by 1000 (1600 mcg/mL). Next, multiply the weight (75kg) by the ordered dose (5mcg/kg/min), and multiply the result (375 mcg/min) by 60. This equals 22,500mcg/hr. Calculate mL/hr by dividing 22,500 mcg/hr by 1600 mcg/mL. The appropriate rate is 14 mL/hr. Vital Concept: Dopamine is an agent used to treat shock. It can be prescribed at low doses (< 5 mcg/kg/min) or high-doses ( 5-20 mcg/kg/minute) At low doses, dopamine dilates renal and coronary arteries. High-dose dopamine has vasoconstriction properties. It also increases myocardial oxygen consumption. Headache is an early symptom of drug excess. The nurse will monitor blood pressure, peripheral pulses, and urinary output during the infusion. An infusion pump should be used for dopamine administration.

A nurse begins her shift on a med-surg unit after receiving a report on 4 clients. Which of the following should be her immediate priority? ✔ A. A client complaining of moderate to severe left upper quadrant pain after an endoscopic retrograde cholangiopancreatography (ERCP) B. A client with cramping abdominal pain 1 hour after a colonoscopy x C. A client admitted today with small bowel obstruction who has large amounts of green-brown drainage from a nasogastric tube D. A client who reports white stool 6 hours after a barium swallow

Correct Answer: A. A client complaining of moderate to severe left upper quadrant pain after an endoscopic retrograde cholangiopancreatography (ERCP) Correct Answer: A. A client complaining of moderate to severe left upper quadrant pain after an endoscopic retrograde cholangiopancreatography (ERCP) Pancreatitis is a complication of ERCP. During this diagnostic procedure, an endoscope is passed through the mouth and upper GI tract into the duodenum to allow assessment of the pancreatic and biliary ducts. The study is performed under fluoroscopy using a contrast medium to reveal strictures and obstructions or to perform a biopsy. During this procedure, dilation of strictures and removal of obstruction can also be performed. Irritation or perforation of the pancreatic or biliary duct during the procedure can result in pancreatitis. Symptoms include pain in the left upper quadrant or epigastric region, sometimes radiating to the back. Laboratory studies show a rapid increase in pancreatic enzymes amylase and lipase. Pancreatitis can be a life-threatening condition. Incorrect Answers: B. Crampy abdominal pain is a common effect of colonoscopy. C. A client with bowel obstruction is expected to have drainage of bile-colored drainage after a nasogastric tube is inserted and set to low wall suction. This client should be monitored for changes in electrolytes such as hypokalemia, metabolic alkalosis, and dehydration. D. After a barium swallow, barium contrast medium may affect the color of a client's stool for as long as 3 days. This is not an unexpected finding, but the nurse should remind the client to maintain adequate fluid intake to flush out the contrast medium. Vital Concept: When prioritizing client care, conditions that present a threat to survival or safety take precedence over other concerns. Medical conditions that require immediate attention should then be prioritized. When caring for clients who have undergone diagnostic or therapeutic procedures, the nurse should recognize the signs and symptoms associated with complications.

A nurse is caring for a client who has a new prescription for selegiline to treat major depressive disorder. Which of the following actions should the nurse take when administering the medication to the client? ✔ A. Apply the medication to dry skin on the client's upper thigh. B. Instruct the client to inhale the medication using a nebulizer. x C. Give the medication orally at bedtime to promote sleep. D. Inject the medication intramuscularly into a large muscle.

Correct Answer: A. Apply the medication to dry skin on the client's upper thigh. Selegiline, an MAOI, is only administered via transdermal route to treat depression. It can be administered orally to treat Parkinson's disease and other disorders. When administered transdermally, selegiline inhibits both monoamine oxidase-B (MAO-B) and monoamine oxidase-A (MAO-A). Incorrect Answers: B. Selegiline is not administered by inhalation. Selegiline should only be administered via transdermal route to treat depression. C. Selegiline is administered orally to treat Parkinson's disease as an adjunct to levodopa/carbidopa therapy. Selegiline should only be administered via transdermal route to treat depression. D. Selegiline is not administered intramuscularly. Selegiline should only be administered via transdermal route to treat depression. Vital Concept: The nurse should administer a selegiline transdermal patch by first asking the client if she has another patch in place and, if so, removing the existing patch to prevent overdose. The client should only wear one patch at a time. The nurse should then wash the application area carefully with soap and water, rinse thoroughly, and completely dry the area. Next, the nurse should check the dose of the patch because several strengths are available. The nurse should not remove the patch from its package until just before application. Lastly, the nurse should remove the liner from the back of the patch and then apply the patch to hairless, undamaged skin on the client's upper thigh, upper outer arm, chest, or back. The nurse should document the selected site on the client's medication record and ensure that the patch is placed on a different site the next day.

A nurse is planning care for a client who has anorexia nervosa and has been admitted for cardiac arrhythmias. Which of the following client goals should the nurse identify as the priority? ✔ A. Attain a weight that is greater than the 75th percent for ideal body weight. x B. Acknowledge misperceptions about body image. C. Verbalize having a sense of control over behaviors. D. Identify changes within the client's family unit that promote the client's autonomy.

Correct Answer: A. Attain a weight that is greater than the 75th percent for ideal body weight. A client who is less than 75% of their ideal body weight is at increased risk for systemic complications, including arrhythmias, electrolyte imbalances, cerebral atrophy, and renal failure. When using Maslow's hierarchy of needs, the nurse should determine the priority goal is to meet the physiological need for adequate nutrition. This means working with the client to attain an increase in weight. Incorrect Answers: B. A client who has anorexia nervosa can have a severely distorted body image, such as viewing themselves as fat despite obvious emaciation. Verbally acknowledging misperceptions about body image indicates that the client is achieving the need for a positive body image and self-esteem. However, there is another goal that is the priority. C. A client who has anorexia nervosa can experience obsessions, such as thinking constantly about food to the extent that food is concealed or hoarded. In addition, compulsive behaviors, such as hand washing, can also be present. Having the client feel a sense of control of behaviors is important because the client needs to attain the goal of safety. However, there is another goal that is the priority. D. Family members can experience a sense of powerlessness and guilt about the client's diagnosis. Family therapy works toward developing strategies for effective communication within the family and provides support for the client and the family members. The client's ability to identify changes that promote autonomy are important because this indicates the client is achieving the need for love and belonging. However, there is another goal that is the priority. Vital Concept: Priority setting involves establishing a sequence for addressing client needs. One framework that is often used for establishing priorities is Maslow's hierarchy of needs. The nurse should also recognize that priorities can change over time, so reassessment of client's needs is important.

When developing the teaching plan for a primiparous client who is bottle feeding her term neonate for the first feeding, which of the following instructions should the nurse include? ✔ A. Keep the nipple of the bottle full of formula while feeding B. All term babies have well-developed sucking skills x C. Burp the baby after 6 oz. of formula have been taken D. Propping of the bottle may make it easier to feed the baby

Correct Answer: A. Keep the nipple of the bottle full of formula while feeding Formula should fill the entire nipple of the bottle while the baby is sucking. This decreases the amount of air taken in by the baby prevents regurgitation: Not all babies at term are born with well-developed sucking skills. Incorrect Answers: B. Not all babies who are born full-term have well-developed sucking skills. C. A baby who is eating formula should be burped after eating 2 to 3 oz. at a time or more often if the baby stops eating in between or becomes fussy. D. The nurse should tell the parent to never prop a bottle. It will not cause the baby to get too much air but it can cause the baby to choke. It also results in dental decay. Vital Concept: The American Academy of Pediatrics recommends exclusively breastfeeding for the first six months of life. All women are not able to breastfeed and breastfeeding is contraindicated in some cases, including mothers with HIV or active tuberculosis. The energy requirement for infants in the first three months is 110 kcal/kg/day. Breast milk provides 67 kcal/100 ml. Most children receive formula at some point during the first year of life. Formula simulates the caloric content of breast milk. The type of formula is generally specified by the pediatrician. Most newborns should be fed every 3 to 4 hours. If the infant demonstrates adequate weight gain, he/she can be allowed to sleep through the night, but initially, most infants should be woken up for feedings during the night. Most infants require 6-8 feedings per 24 hours. Newborns usually drink 15-30 mL of formula at each feeding in the first day of life, with a gradual increase over the first week.

A nurse in a community center is providing an in-service to a group of parents of toddlers. Which of the following instructions should the nurse include about relieving airway obstruction caused by foreign objects? ✔ A. Push on the child's abdomen. B. Hyperextend the child's head to open the airway. C. Use a finger to check the child's mouth for objects. x D. Take the child to the hospital after witnessing the event.

Correct Answer: A. Push on the child's abdomen. To relieve airway obstruction on a conscious child, the parent should perform abdominal thrusts. Incorrect Answers: B. The nurse should teach the parent to position the child with the chin elevated, rather than hyperextended, to open the child's airway. C. Finger sweeps to check for an impaired airway are not performed, because this action can cause an object to be pushed further down into the child's throat. D. The nurse should instruct the parents to attempt to clear the child's airway according to the American Heart Association guidelines and to call 911. Attempting to independently transport the child to an emergency facility might delay treatment. Vital Concept: Prevention is the key to eliminating airway obstruction by foreign objects. The nurse should instruct parents to keep choking hazards, such as small toys and other objects, out of the reach of toddlers. Parents should be taught how to perform care during emergency situations. If airway obstruction is not relieved and the child becomes unconscious, CPR should be initiated, and emergency services should be notified by dialing 911.

A charge nurse on a labor and delivery unit is providing an inservice for staff about diagnostic tests used during pregnancy to measure fetal and maternal well-being. Which of the following examples will the charge nurse use as a common indication for non-stress test (NST) in a pregnant client? ✔ A. The client is 41 weeks gestation x B. The client is 39 years old C. The client's first child had Down syndrome D. The client had an abnormal ultrasound

Correct Answer: A. The client is 41 weeks gestation A non-stress test (NST) is a procedure that is performed by attaching a fetal monitor to a pregnant client and recording the fetal heart rate and activities; the mother pushes a button whenever she feels the baby move. Of the options provided, a NST would most likely be indicated for a pregnant client who is past her due date. Incorrect Answers: B. The client's age of 39 years puts her at higher risk of having a baby born with Down syndrome or another birth defect. This would warrant an amniocentesis, not an NST. C. This part of the client's history would most likely warrant an amniocentesis, not an NST. D. An abnormal ultrasound would not be followed with an NST; the client would most likely need an amniocentesis. Vital Concept: A fetal non-stress test is a simple, non-invasive test performed in pregnancies at > 28 weeks gestation. No stress is placed on the fetus during the test. One monitor is placed on the mother's abdomen to measure fetal heart rate and another is placed to measure contractions. Fetal movement, heart rate and the reactivity of the fetal heart rate to movement is measured for 20-30 minutes.

Which principle is most appropriate when maintaining a sterile field for a procedure? ✔ A. When adding items to a sterile field, drop small items from 6" directly above the sterile field B. Only turn away from the sterile field if a sterile item is to the left side of the room C. Sterile objects should not touch other sterile items x D. The sterile wrapper should be opened over the sterile field.

Correct Answer: A. When adding items to a sterile field, drop small items from 6" directly above the sterile field Maintaining a sterile field is essential to avoid contamination by microorganisms that can cause disease. When adding items to a sterile field or pouring a liquid into a sterile container, the nurse should hold the items 6 inches above the field before pouring or dropping small items onto the field to avoid contamination of the sterile field. Large objects can be directly placed onto a sterile field using sterile forceps or sterile gloves. Incorrect Answers: B. The back is considered contaminated and should not be turned toward the sterile field. C. Sterile objects in a sterile field can touch. D. The wrapper of a sterile package is opened away from the sterile field. Vital Concept: The area within one inch of the edge of the inner sterile wrapper is considered to be contaminated. Any sterile article that touches this area is considered contaminated and should be discarded. The nurse should hold the sterile package in one hand with the flaps up, away from the sterile field, grasping the outside edges of the wrapper with the free hand to protect the sterility of the package contents. The sterile package should be carefully unwrapped so the inside of the wrapper and the sterile object are not contaminated. The edges of the sterile wrapper should be opened back around the wrist so the wrists do not accidentally drag across the sterile field, with the wrapper covering the hand supporting the sterile object.

A male client with depression is encouraged by the nurse to participate in group activities. The client states, "I don't feel like doing any group activity today." What is the most appropriate response by the nurse? A. "You sound like you are in a bad mood today. Tell me more." ✔ B. "I heard you say you don't feel like doing any group activity today." x C. "You seem upset today. Tell me more." D. "I understand how you feel about groups. What would you like to do instead?"

Correct Answer: B. "I heard you say you don't feel like doing any group activity today." "I heard you say you don't feel like doing any group activity today" is a therapeutic statement as it restates what the client has said and implies understanding. It is accepting and non-judgmental. It also allows the client to review about what he said. Depressed clients find it hard to communicate their feelings and emotions; they often prefer to be left alone. Treatment for depression includes antidepressant medications and psychotherapy. Group dynamics and one-on-one interaction are daily activities that are components of the treatment regimen for depression. Therapeutic communication is an essential tool in engaging the client to continue and benefit from the treatment program. The nurse needs to be able to utilize appropriate communication technique for clients with depression. Incorrect Answers: A. "You sound like you are in a bad mood today. Tell me more" is not therapeutic because it imposes judgment and criticism on what the client's mood is. C. "You seem upset today. Tell me more" is not therapeutic because the client is not necessarily upset. D. "I understand how you feel about groups. What would you like to do instead?" is not therapeutic because there is no way of knowing or understanding the client's feelings about group activities unless the client states them. The statement prevents the client from verbalizing his feelings about the group. Vital Concept: Reflecting is a technique used in therapeutic communication in which all or part of the client's statement is repeated to encourage the client to continue. Repeating all or part of what the client has said may lead the client to more fully consider and expand upon the remark. Reflecting should not be overused, as the client may become annoyed if his statements are continually repeated back. Reflecting selective portions of the client's statement can be helpful if the nurse has some understanding of the client's underlying intent.

An RN and a licensed practical nurse (LPN) are receiving change-of-shift report on an assigned group of clients. Which of the following statements by the nurse giving report should indicate to the RN that she should assume total care for a client rather than assigning tasks to the LPN? x A. "The client has a chronic tracheostomy that requires suctioning." ✔ B. "The client's blood pressure and pulse have been fluctuating throughout the day." C. "The client discussed being depressed when the tracheostomy was first placed." D. "The client needs to have the ostomy appliance changed."

Correct Answer: B. "The client's blood pressure and pulse have been fluctuating throughout the day." The stability of a client's condition is a criterion to consider when delegating client care. To promote client safety, the RN should delegate tasks for more stable clients to the LPN. The RN should assume total care for a client who is experiencing irregular vital signs. Incorrect Answers: A. The RN should consider the state's Nurse Practice Act, facility policies, the skill level of the LPN, and the client's condition when delegating tasks. Tracheal suctioning is a task that is within the scope of practice for an LPN. C. The RN should consider the client's current condition rather than the client's history when delegating tasks. The client's history of depression is not a criterion to consider when delegating tasks to the LPN. D. The RN should ensure the LPN has the skill level to complete the task of changing the ostomy appliance and has access to the needed materials to complete the task. Changing the ostomy appliance is within the scope of practice for an LPN; therefore, the RN can delegate this task to the LPN. Vital Concept: The RN should consider the skill level and work load of the LPN when delegating tasks. She should communicate assignments clearly and be willing to support and assist the LPN if needed. The RN should remember that while tasks can be delegated, the RN is ultimately responsible for the care of the client.

A nurse is helping a client calculate his body mass index. After making the calculation, the nurse determines that the client's BMI is 24.9. This result would be classified as: A. Underweight ✔ B. A healthy weight x C. Overweight D. Obese

Correct Answer: B. A healthy weight A BMI of 24.9 is considered to be a healthy weight. <18.5 is underweight 18.5-24.9 is normal 25-29.9 is overweight 30-40 is obese >40 is morbidly obese Vital Concept: BMI measurement is calculated based on height and weight and correlated with percentage of body fat mass. It is a more accurate estimate of total body fat compared with body weight alone. Measurement of BMI is used to determine a person's risk for heart disease, high blood pressure, type 2 diabetes, gallstones, some types of cancer, and respiratory problems. Additional risk stratification can be achieved by measuring the waist circumference in conjunction with BMI. Abdominal obesity is an important risk factor for cardiovascular disease and metabolic disorders like diabetes mellitus. A waist circumference > 40 inches (102 cm) for men and > 35 inches (88 cm) for women is associated with increased risk.

A nurse is preparing to initiate IV therapy on a client. Which of the following solutions should the nurse identify as the best choice for preparing the client's skin at the insertion site? x A. Isopropyl alcohol ✔ B. Chlorhexidine C. Soap and water D. Povidone-iodine

Correct Answer: B. Chlorhexidine Evidence-based practice indicates the nurse should identify chlorhexidine as the best choice for skin preparation prior to IV insertion. Chlorhexidine is the antiseptic preferred by the Infusion Nurses Society (INS) to decrease peripheral catheter insertion site infections. Incorrect Answers: A. The nurse can use isopropyl alcohol to prepare the client's skin prior to initiating IV therapy; however, evidence-based practices indicates that the nurse should choose another solution. C. The nurse can use soap and water to cleanse the client's skin prior to initiating IV therapy; however, evidence-based practices indicates that the nurse should choose another solution. The nurse should follow soap and water cleansing with additional cleansing with an antiseptic solution. D. The nurse can use povidone-iodine to prepare the client's skin prior to initiating IV therapy; however, evidence-based practices indicates that the nurse should choose another solution. Vital Concept: A nurse who is responsible for initiating IV therapy should be able to identify the antiseptic of choice for preparing the IV insertion site. The nurse should gather this and all necessary supplies prior to going to the client's room. Other supplies needed can include: • Infusion set • Sterile parenteral solution • IV pole or infusion pump • Nonallergenic tape • Clean gloves • Tourniquet • IV catheter • Sterile gauze

The charge nurse is evaluating the knowledge and competencies of a nurse reliever. She asked the nurse reliever to explain the relationship of neurotransmitters to the symptoms of schizophrenia. Which of the following correlative statements is correct? x A. Too little dopamine causes hyperreflexia ✔ B. Deficiency in cholecystokinin causes avolition C. Excess acetylcholine produces acting-out behavior D. Deficiency in dopamine produces psychosis

Correct Answer: B. Deficiency in cholecystokinin causes avolition Neurotransmitters are believed to play a role in the manifestation of symptoms in clients with schizophrenia. These neurotransmitters include serotonin, dopamine, acetylcholine, cholecystokinin, glutamate, and aminobutyric acid. The nurse caring for a client with schizophrenia needs to understand how these neurotransmitters affect the client's behavior. Cholecystokinin excites the limbic neurons in the body. A deficiency in this type of neurotransmitter produces avolition and flat affect. Serotonin is a brainstem neurotransmitter that modulates mood and lowers aggressive tendencies. Elevated levels of serotonin cause psychotic symptoms in schizophrenia. Incorrect Answers: A. and D. Dopamine regulates motor behavior in the extrapyramidal tract. Elevated levels of dopamine produce psychosis, while insufficient levels produce movement disorders. C. Acetylcholine functions to transmit nerve impulses. A deficiency in acetylcholine produces confusion and acting-out behavior. Vital Concept: Schizophrenia is a group of severe, disabling psychiatric disorders characterized by withdrawal from reality, illogical thinking, delusions and hallucinations, and emotional, behavioral, or intellectual disturbance. These disturbances last for at least for six months. Functioning in work, interpersonal relationships, and self-care are markedly impaired. A client with acute schizophrenia will have difficulty distinguishing reality from fantasy. Their speech and behavior may frighten or mystify those around them. Avolition, flat affect, and anhedonia are negative symptoms of schizophrenia. Hallucinations and disordered thinking are positive symptoms.

A charge nurse is providing in-service education to staff about use of patient-controlled analgesia (PCA.) Which of the following should be included in the teaching? A. Family members should be instructed to push the PCA button if they perceive the client is having pain. ✔ B. PCA provides more consistent plasma levels of analgesia via small but frequent doses. C. The amount of analgesic used by clients with PCA is typically more than the amount given to clients who are receiving analgesics parenterally at prescribed intervals. x D. Meperidine and morphine are the most commonly prescribed analgesics for PCA.

Correct Answer: B. PCA provides more consistent plasma levels of analgesia via small but frequent doses. A PCA medication delivery system allows clients to administer safe doses of opioid medications in small amounts at frequent intervals with a "lockout" to prevent overdose. This results in a more consistent plasma level of analgesia than other methods of delivery such as dosing at defined intervals. Less medication is necessary to prevent onset of pain compared to treatment of acute onset of pain by PRN medication. If a PCA pump is not prescribed, around the clock medication should be administered at appropriate intervals. A PCA pump gives the client a measure of control over pain and its treatment. Only the client is permitted to administer the analgesic. A safety feature of PCA is that clients who are oversedated as a result of opioid analgesia will not be able to press the button to obtain additional doses of the drug. It is not necessary to wake stable clients during the night for assessment of pain or assessment of consciousness. Incorrect Answers: A. The client should be the only person who is permitted to push the PCA button to prevent an inadvertent overdose. C. Clients feel more control over their pain and have less time between the moment of need and medication delivery, and they often decrease the amount of pain medication as a result. D. Typically, morphine and hydromorphone are used in PCA systems, although any opioid can be administered by PCA. Vital Concept: Ideally, clients and their families should be instructed in use of the PCA system before surgery in cases of an elective procedure. Only clients should administer analgesic medications through the PCA, since sedation provides a feedback mechanism that prevents overdose. Stable clients using a PCA pump for administration of opioid analgesics do not require assessment for pain or level of consciousness when sleeping at night.

Which of the following instructions should the nurse include in the teaching? x A. Avoid crowds and sick individuals throughout the treatment regimen. ✔ B. Take a psoralen medication 2 hr before the scheduled light treatment. C. This treatment will occur daily for several weeks. D. Do not consume alcohol while undergoing this treatment regimen.

Correct Answer: B. Take a psoralen medication 2 hr before the scheduled light treatment. PUVA treatment involves the ingestion of a psoralen photosensitizing medication2 hr prior to the schedule exposure to ultraviolet A light. This time frame allows for skin exposure when the psoralen photosensitizing medication is at peak effectiveness. The light causes a change in the DNA of the epidermal cells and decreases replication. Incorrect Answers: A. This intervention is appropriate for clients who are receiving treatment for psoriasis with biologic agents such as etanercept, infliximab, and adalimumab. These medications suppress the immune system by blocking tumor necrosis factor (TNF) and increase the risk for contracting a serious infection. C. PUVA treatments are completed two to three times each week, not on consecutive days. If the client develops redness or edema of the skin, treatment can be interrupted until the symptoms subside. D. Alcohol consumption should be avoided when clients are treating psoriasis with systemic medications such as methotrexate or acitretin. Methotrexate can cause significant damage to the liver, even when prescribed in low dosages. The consumption of alcohol while taking acitretin greatly extends the half-life of the medication and increases the likelihood of adverse effects and toxicity. Vital Concept: Psoriasis is an autoimmune disorder that causes scaled skin lesions due to an overgrowth of epidermal cells. PUVA treatments are indicated for clients who have moderate to severe active psoriasis that is not responding to other treatments. The client is instructed to ingest a medication that increases photosensitivity 2 hr before the scheduled exposure to an ultraviolet A light source. This timing allows for light exposure during the peak photosensitive period. Clients should be instructed to wear dark glasses during the treatment and for the remainder of the day. Treatment sessions occur two to three times per week, but not on consecutive days. The client's skin should be monitored for any indications of redness or edema, and the treatment should be delayed if those are present.

A nurse is teaching a client who has seizures about going home with her new vagal nerve stimulator. Which of the following statements should the nurse include in the teaching? A. "You should use hypoallergenic lotion on your skin in the area of the device." B. "Notify your provider if you experience hiccups." ✔ C. "You should place the special magnet over the device when you feel an aura occurring." x D. "It is recommended that you use ultrasound diathermy for pain management."

Correct Answer: C. "You should place the special magnet over the device when you feel an aura occurring." The nurse should instruct the client to hold a specialized handheld magnet over the implantable device when an aura occurs. This practice has been shown to lessen the severity and duration of the seizure that follows. (See image below) Incorrect Answers: A. The nurse should instruct the client to that there are no restrictions on the type of skin lotion used on the skin near the device. The device is surgically implanted under the clavicle and connected to the vagus nerve in the cervical area. B. The nurse should instruct the client to monitor for complications that can develop following the placement of a vagal nerve stimulator such as infection at the surgical site, hoarseness, laryngeal spasms, cough, neck pain, dysrhythmias, dyspnea, and dysphagia. The client should inform the provider if any of these complications occur and should be instructed to seek immediate medical assistance for manifestations of laryngeal spasms, dysrhythmias, dyspnea, or dysphagia. D. The nurse should instruct the client to notify all health providers of the presence of the vagal nerve stimulator because exposure to MRI and ultrasound diathermy should be avoided as these disrupt the function of the nerve stimulator. The client should also avoid exposure to microwaves and shortwave radios for the same reason. Vital Concept: Nurses can provide both educational and emotional support to clients whose lives are impacted daily by seizure disorders. Because clients need to self-manage their conditions, the more information and coping strategies that nurses can provide, the better clients will be able to function and the less likely they will be to experience complications

A nurse is providing instructions concerning the proper use of crutches for a client who is non-weight-bearing for 4-6 weeks after an ankle injury. The nurse knows to provide instruction about which of the following crutch gaits? A. Any crutch gait that keeps weight off the affected side x B. 2-point gait ✔ C. 3-point gait D. 4-point gait

Correct Answer: C. 3-point gait The client can use the 3-point gait if able to bear all bodyweight on the unaffected leg. The weight is transferred between the 2 crutches and the unaffected leg. The nurse instructs the client to move the crutches (both) and the weaker leg forward and then to move the unaffected leg forward. Incorrect Answers: A. Crutch gaits involve alternating body weight on 1 or both legs and crutches. The standard gaits are the swing-through, swing-to-gait, 2-point, 3-point, and 4-point. The optimal gait depends on the client's ability to take steps, bear weight, and maintain balance while standing on both legs or only 1 leg and the ability to hold the body erect. B. The 2-point gait requires the client to move the left crutch and right foot forward together and then the right crutch and left foot forward together. D. This is an easy gait but requires the client to bear weight on both legs. Vital Concept: Crutch gaits involve transfer of body weight between one or both legs and the crutches. A client with an injury to a lower extremity can use a three-point gait with crutches if able to bear all body weight on the unaffected leg. A client must be able to bear weight on both legs in order to use a four-point crutch gait.

A nurse on a medical-surgical unit is observing a newly licensed nurse administer a medication to a client using the Z-track technique. Which of the following actions by the newly licensed nurse requires the nurse to intervene? x A. The nurse places a new needle on the syringe after withdrawing the medication from a vial. B. After cleansing the injection site, the nurse uses the nondominant hand to pull the tissue laterally 3 cm (1.2 in). ✔ C. After the medication is completely injected, the nurse immediately withdraws the needle. D. The nurse uses the dominant hand to inject the medication at a 90° angle.

Correct Answer: C. After the medication is completely injected, the nurse immediately withdraws the needle. After injecting the medication, the nurse should wait for 10 seconds before withdrawing the needle. Waiting 10 seconds allows the medication to disperse into the muscle tissue. This action reduces discomfort at the injection site and prevents the medication from seeping up the track of the needle. Incorrect Answers: A. The nurse should replace the needle after withdrawing the medication from a vial. This action prevents irritation to the subcutaneous tissue when the needle is injected into the skin. B. The nurse should take this action to reduce the escape of the medication into the subcutaneous tissue after the medication is injected. D. The nurse should inject the medication at a 90° angle. This action ensures that the medication reaches the client's muscle tissue. Vital Concept: The Z-track technique for intramuscular injection is used with medications that are very irritating to the tissue. The nurse should pull the skin and tissue taut and firmly holds them in this position while the needle is inserted and the medication is injected. The nurse should wait to remove the needle and release the tissue for ten seconds after injecting the medication. These steps encase the medication in the client's muscle tissue and prevent the medication from irritating subcutaneous tissue. Iron dextran is an example of a medication that should be administered using the Z-track technique. Policy at some facilities requires use of the Z-track technique for all medications administered intramuscularly.

Which of the following tasks should a nurse prioritize when caring for a client in the PACU who is one hour post-op total hip replacement? A. Assessment of urine cloudiness or pus in the catheter bag B. Placement of the abduction pillow ✔ C. Assessment of bloody drainage in a suction drainage device x D. Last dose of pain medication and assessment of client pain level

Correct Answer: C. Assessment of bloody drainage in a suction drainage device Complications of total hip replacement include dislocation of the prosthesis, bleeding, infection, and deep vein thrombosis. During the immediate postoperative period, the priority assessment is monitoring blood loss since this is a potentially life-threatening complication of surgery, particularly in the first few hours. Incorrect Answers: A. Cloudiness and pus in urine can be a sign of urinary tract infection in a client who has an indwelling urinary catheter, but it does not typically occur in the immediate postoperative period and is less of a priority than hemorrhage in the client in this scenario. B. An abduction pillow is placed between the legs of the client after total joint replacement of the hip to prevent adduction of the hip and dislocation of the prosthesis. Prevention of prosthesis dislocation is important but less critical than identification of post-operative hemorrhage. Hip dislocation should be prevented by positioning the client with more than 90 degrees of flexion at the hip. Other measures to reduce the risk of dislocation include use of an elevated toilet seat and a chair that does not recline. Signs of hip dislocation include shortening and internal rotation of the leg on the affected side. D. Pain control is always important, but hemorrhage is a priority. Many surgeons prescribe a patient-controlled analgesia device with programmed limits for dosage and dosing intervals, allowing clients to self-regulate analgesia as necessary. Vital Concept: In the immediate post-operative period, the client will be in the post-anesthesia care unit (PACU.) There are three phases of recovery in the PACU. Phase 1 is the immediate recovery phase. During phase 2, the nurse prepares the client for self/hospital care, Phase 3 is preparation for discharge. The PACU stay can be 4-6 hours, during which the client is closely monitored for hemorrhage and other potential complications of surgery. The client is discharged after regaining motor and sensory function and stable vital signs. Before discharge from the PACU, the client should be oriented and without evidence of complications.

The nurse receives the order written below on a client who has a bedside blood glucose level of 98. What is the most appropriate response? "Insulin Glargine 20u QD subcutaneously". A. Give the insulin as the blood glucose level is in a safe range to do so x B. Hold this insulin as it would not be safe to give the insulin with a blood sugar level of 98 ✔ C. Call the primary care provider to clarify the order D. Give half the insulin and notify the primary care provider

Correct Answer: C. Call the primary care provider to clarify the order The order should be clarified. In the order, there are two abbreviations that should not be used. Units should be spelled out as well as daily. U and QD are listed on the JCAHO Do Not Use Abbreviations list. Incorrect Answers: A, B, D. The insulin could be given since it is long-acting with a delayed onset and no peak. However, the order should be clarified prior to administration. There is no need to hold the insulin as it is long-acting. It is not appropriate to give half the dose and the order is inappropriate. This option is not an acceptable response to this order. Vital Concept: As a nurse, you must be aware of acceptable and unacceptable abbreviations. If you fail to do so, it could result in harm to the client and you would be personally responsible.

A nurse is changing a wound dressing for a client with tuberculosis who is on airborne precautions. When removing personal protective equipment (PPE) after completing this task, which of the following should the nurse remove first? A. Mask x B. Gown ✔ C. Gloves D. Eye protection

Correct Answer: C. Gloves Although airborne precautions do not usually require a gown, a gown should be used in any client care encounter when there is potential for contamination through contact with bodily fluids, as with a dressing change. By removing PPE in the correct order, the potential for contamination can be reduced. By removing the gloves first, the nurse can prevent contamination of other items, including non-contaminated materials. Removal of gloves should be performed by grasping the palmar surface of the first glove and pulling it off inside out. The fingers of the ungloved hand should be placed carefully under the next glove at the wrist, allowing the nurse to peel the second glove over the first glove. Both gloves should be discarded in an infectious waste container. In this situation, gloves are considered to be the most contaminated piece of PPE. When removing personal protective equipment after completion of a task for an individual under airborne precautions for infection, the nurse should initially remove gloves, then eye protection (face shield or goggles); the gown is removed next, followed by the mask. Removal of the mask after all other potentially contaminated PPE is removed will help prevent inhalation of airborne pathogens that may have contaminated other PPE. When removing other PPE, the nurse should avoid touching the surfaces most likely to be contaminated. For example, the gown can be removed by untying it and reaching inside when removing. Incorrect Answers: A. The mask is removed last to prevent inhalation of airborne pathogens that may have contaminated other PPE. B. The gown is removed after removing gloves and eye protection. C. Eye protection is removed after removing gloves. Vital Concept: After any client care task with potential for contamination through contact with body fluid, including wound care or dressing changes, the nurse should remove gloves first after completion of the task, to prevent contamination of other items. Gloves are considered the most contaminated item in this setting. They should be discarded in an infectious waste container.

A nurse is providing discharge teaching for a client who has a new prescription for valproate to treat bipolar disorder. Which of the following information should the nurse include in the teaching? x A. Thyroid function tests should be performed every 6 months while taking this medication. B. High calcium levels can result from long-term use of this medication. ✔ C. Liver function tests should be monitored while taking this medication. D. Low serum sodium levels can cause toxic levels of valproate.

Correct Answer: C. Liver function tests should be monitored while taking this medication. Liver dysfunction is a serious adverse effect occasionally associated with valproate. Liver function tests, including alanine aminotransferase (ALT), aspartate aminotransferase (AST), lactate dehydrogenase (LDH), ammonia, and bilirubin, should be monitored periodically to check for hepatic failure. The nurse should monitor the client for jaundice, nausea, upper right abdominal pain, and lethargy and report these to the provider. Manifestations of hyperammonemia, which can indicate severe hepatitis or cirrhosis, includes changes in level of consciousness and vomiting. Incorrect Answers: A. Hypothyroidism is a long-term risk for clients who take lithium, not valproate. B. Bleeding time can be prolonged while taking valproate and a low platelet count can occur, but calcium levels are not affected by this medication. D. Low serum sodium levels affect lithium levels, but serum sodium does not affect levels of valproate. Vital Concept: In addition to liver dysfunction, valproate can cause pancreatitis, which can be life-threatening. The nurse should monitor the client for manifestations of pancreatitis, such as loss of appetite, nausea, vomiting, and abdominal pain and report these findings to the provider. With acute pancreatitis, the onset of abdominal pain is often sudden in the epigastric region or left upper quadrant and can radiate to the left shoulder or flank.

A charge nurse on a medical-surgical unit receives a call about an 83-year-old female client who is being transferred from the ICU. The client was admitted to ICU with pneumonia requiring ventilator support, but is now breathing without mechanical ventilation. There are only 5 beds available on the medical-surgical unit, all in semi-private rooms. The charge nurse should assign the new client to a room with which of the following clients? A. A 45-year-old female diabetic client with a foot wound that has cultured positive for MRSA (methicillin-resistant Staphylococcus aureus) B. A 25-year-old female client with fever and diarrhea of undiagnosed etiology x C. A 31-year-old female client with symptoms suggestive of seasonal influenza ✔ D. A 75-year-old female client with new-onset atrial fibrillation who is being managed with medication

Correct Answer: D. A 75-year-old female client with new-onset atrial fibrillation who is being managed with medication This client poses no risk to a client recovering from pneumonia. The new client should be assigned to this room. Incorrect Answers: A. A client infected with MRSA should be on contact isolation and is not be a suitable roommate for a client recovering from pneumonia. B. This client has diarrhea that could be infectious in nature and is not a suitable roommate for a frail elderly client recovering from pneumonia. C. A client with possible influenza is not a suitable roommate. This client should be on droplet precaution isolation. Vital Concept: Conventional hygienic precautions, transmission precautions, and cohorting of clients according to presence or absence of specific pathogens should be implemented to reduce the spread of infection among immunocompromised and recovering clients in a healthcare facility.

A nurse is administering an enema to a client who is scheduled for gastrointestinal surgery. What should the nurse do when the client complains of abdominal cramps during the enema? A. Reduce the rate of the infusion B. Discontinue the enema and try again later x C. Lower the container below the level of the rectum ✔ D. Close the lumen of the tubing and wait until the discomfort subsides

Correct Answer: D. Close the lumen of the tubing and wait until the discomfort subsides Stopping the flow reduces cramping caused by distention of the intestinal lumen, which results from the volume of fluid instilled. Incorrect Answers: A. Reducing the infusion rate may still cause cramping. The nurse should temporarily stop the flow of the enema by clamping the tubing and waiting until the discomfort subsides. B. The nurse has been ordered to complete the enema and should not stop and try again later. She should instead temporarily stop the flow of the enema by clamping the tubing and waiting until the discomfort subsides. C. Lowering the container below the level of the rectum will only slow the flow of the enema solution, but may still cause cramping. Vital Concept: When administering an enema, the nurse will monitor the client for cramping as the enema solutions flows into the client's rectum. Abdominal muscle tension may indicate cramping. If cramping occurs while administering the enema, the nurse should stop the flow and ask the client to take several deep breaths. The enema may be continued when the cramping subsides and the client becomes comfortable again.

A nurse is providing care to a client who asks the nurse about taking gingko biloba to improve memory. The nurse should inform the client that this herbal supplement can cause a potential interaction with which of the following of the client's current medications? A. Loratadine x B. Prednisone C. Furosemide ✔ D. Ibuprofen

Correct Answer: D. Ibuprofen The nurse should inform the client that ibuprofen is an NSAID which can cause a potential interaction with gingko biloba. Taking ibuprofen and gingko biloba concurrently can increase the client's risk of bleeding. Incorrect Answers: A. Loratadine is an antihistamine and does not cause a potential interaction with gingko biloba. However, loratadine can interact with the herbal supplement valerian. B. Prednisone is a corticosteroid and does not cause a potential interaction with gingko biloba. However, prednisone can interact with the herbal supplement licorice. C. Furosemide is a loop diuretic and does not cause a potential interaction with gingko biloba. However, furosemide can interact with the herbal supplement aloe. Vital Concept: It is the nurse's responsibility to inform a client of potential interactions between medications they are currently taking or plan to take. This should include the use of herbal supplements and their potential interactions with other medications.

A nurse on a medical-surgical unit is delegating care for a group of clients. Which of the following specimens should the nurse delegate an unlicensed assistive personnel (UAP) to collect? A. Wound drainage for culture x B. Urine from an indwelling catheter C. Blood for an ABG test ✔ D. Random stool specimen

Correct Answer: D. Random stool specimen The nurse can delegate the collection of a random stool specimen to the AP because it does not require sterile technique or the skills of a licensed nurse. Incorrect Answers: A. Collecting drainage from a wound for culture requires the skills of a licensed nurse because it involves the use of sterile technique. Therefore, the nurse should not delegate this task to the AP. B. Urine from an indwelling catheter requires the skills of a licensed nurse because it involves the use of sterile technique. Therefore, the nurse should not delegate this task to the AP. C. Individuals who are specially trained to draw blood from a radial, brachial, or femoral artery, such as nurses, medical technicians, and respiratory therapists, should perform this task. Therefore, the nurse should not delegate this task to the AP. Vital Concept: The nurse should delegate tasks to the AP that do not require nursing assessment, evaluation, judgment, decision making, or problem solving skills. Tasks that require sterile technique or special skills should not be delegated to an AP. The nurse should consider each task prior to delegation to ensure the safety and quality of client care. The nurse should provide clear, concise communication regarding delegated tasks. The nurse should include what task is to be done for which client, when the task should be completed, the desired outcome of the task, outcomes that should be reported, and who will be available as a resource to the AP. The nurse who delegates a task is held accountable for the outcome and should intervene as needed to ensure safe and effective client care.

What is the priority action when a nurse is changing the ties on a recently placed tracheostomy tube that becomes accidentally dislodged when the client moves suddenly? x A. Replace the tube B. Call the healthcare provider to reinsert the tube C. Cover the stoma with a sterile dressing to prevent entry of infectious microorganisms ✔ D. Spread the opening by grasping the retention sutures

Correct Answer: D. Spread the opening by grasping the retention sutures A tracheostomy tube is placed through a surgical incision in the trachea, below the larynx, and inserted to extend into the trachea. The tube has an outer cannula with a flange that rests on the neck, allowing the tube to be secured with ties or tapes. The obdurator is used to insert the tube, after which it is removed. The obdurator should be kept at the bedside in case the tube becomes dislodged. Some tubes have an inner cannula that is removed for cleaning or (if disposable) may be replaced. In clients with a new or recently placed tracheostomy, the stoma may close quickly if the tube is dislodged. If accidental decannulation occurs, the nurse should pull the retention sutures placed on either side of the stoma, if there, to maintain patency. After calling for help, the nurse should reassure the client and encourage normal breathing. After the tracheostomy tube has been replaced, the nurse should tie it securely, leaving a finger breadth between the neck and the ties. To prevent the tube from dislodging when the ties are soiled or difficult to thread, the nurse can have an assistant hold the tracheostomy in place with a sterilely gloved hand. Incorrect Answers: A. The immediate priority is to maintain patency by grasping the retention sutures on either side of the stoma. Some facilities may permit the nurse to replace the tube, but that is not the initial priority. B. This action will delay the immediate intervention to maintain patency of the airway. C. The stoma must be left uncovered to allow air to enter. Vital Concept: The stoma can close quickly if a tracheostomy tube is dislodged from a newly placed tracheostomy. If accidental decannulation occurs, the nurse should pull the retention or "stay" sutures on either side of the stoma to maintain patency. The nurse should summon help and reassure the client, encouraging the client to breathe normally.

A nurse is instructing a client who will begin using a contraceptive sponge for birth control. Which of the following will maximize the efficacy of this form of birth control? x A. Spermicidal jelly should be inserted with the sponge. B. A new sponge must be placed every time the client has intercourse. C. The sponge must be removed immediately after intercourse. ✔ D. The sponge should be moistened with tap water until foamy prior to use.

Correct Answer: D. The sponge should be moistened with tap water until foamy prior to use. A contraceptive sponge is a small, round sponge made of polyurethane and impregnated with N-9 spermicide. The sponge fits over the cervix, and one size fits all. The concave side is placed over the cervix, and the opposite side has a loop that is used to remove the sponge. Cervical sponges should be moistened with water until foamy before insertion. The sponge provides up to 24 hours of protection for sexual intercourse, even if multiple instances occur. After the last instance of sexual intercourse, the sponge should remain in place for at least 6 hours. Women who use the sponge should be aware that use for longer than 23 to 30 hours increases the risk of toxic shock syndrome. The failure rate of this method of contraception in the first year of use is 12% among women who have never been pregnant and 24% among women with prior pregnancies. Incorrect Answers: A. The sponge contains a spermicide. B. The sponge provides contraception for multiple encounters over a 24-hour period. C. The sponge should be left in place for at least 6 hours after the last instance of sexual intercourse. Vital Concept: Contraceptive sponges are impregnated with spermicide and fit over the cervix. They are one-size-fits-all. Clients should be advised to moisten the sponge until foamy before insertion. The sponge should be left in place for at least six hours after sexual intercourse. They offer up to 24 hours of protection against conception, but the risk of toxic shock syndrome due to Staphylococcus aureus is increased when the sponge is left in place for longer than 23 hours.

The nurse is performing assessment of a client with stroke from vertebral artery of the brain. At what mark on the drawing is the artery situated?

Correct Answer: Stroke or cerebrovascular accident is a condition that occurs when an artery in the brain is obstructed. Blood supply is either diminished or totally blocked, resulting in a display of symptoms as the body reacts and adapts to the changes. Factors that can obstruct a brain artery include particles and blood clot. The major types of stroke are ischemic and hemorrhagic. When the vertebral artery (D on the graphic) of the brain is affected by this condition, the blood supply is cut off producing various symptoms such as pain in the face or eye, numbness and weakness of the face on the involved side, unstable gait and coordination, and dysphagia. The treatment modality for major stroke incident involves various members of the health care team, including the family, and involves medication such as blood thinners, thrombolysis, rehabilitation, and continuous assistance in ADL (activities of daily living). Vital Concept: The vertebral arteries arise from the subclavian arteries, one on each side of the body, They travel superiorly through the transverse foramen of the vertebrae. Inside the skull, the two vertebral arteries join to form the basilar artery at the base of the pons. The basilar artery is the main blood supply to the brainstem and connects to the Circle of Willis to potentially supply the rest of the brain if there is compromise to one of the carotids.

A nurse is caring for five clients. The nurse should identify that which of the following clients is at risk for developing a dysrhythmia? (Select all that apply.) A. A client who has metabolic alkalosis B. A client who has a total serum calcium level of 9.5 mg/dL C. A client who has an SaO2 of 96% D. A client who has COPD E. A client who had a stent placement in a coronary artery

Correct Answers: A. A client who has metabolic alkalosis D. A client who has COPD E. A client who had a stent placement in a coronary artery A client who has an acid-base imbalance, such as metabolic alkalosis, is at risk for dysrhythmias, such as atrial tachycardia, and premature ventricular contractions due to depressed respirations and hypokalemia. A client who has a lung disease, such as COPD, is at risk for a dysrhythmia, such as tachycardia, due to hypoxia. A client who has cardiac disease and underwent a stent placement is at risk for dysrhythmias, such as ventricular tachycardia, due to irritation of heart muscle. Incorrect Answers: B. A total serum calcium level of 9.5 mg/dL is within the expected reference range of 9.0 to 10.5 mg/dL and does not increase the client's risk for a dysrhythmia. C. A SaO2 of 96% is within the expected reference range of greater than or equal to 95 percent and does not increase the client's risk for a dysrhythmia. Vital Concept: The nurse should monitor clients for conditions that can precipitate dysrhythmias, such as hypoxia, fluid or electrolyte imbalances, use of certain medications, heart disease, or caffeine intake. The nurse should monitor a client who is experiencing dysrhythmias for manifestations of decreased cardiac output and fluid retention caused by decreased ventricular perfusion. Manifestations of decreased cardiac output can include a change in level of consciousness and cool skin. Manifestations of fluid retention can include neck vein distention and crackles or wheezes in the lungs. The nurse should check peripheral pulses and auscultate the client's heart for murmurs. The nurse should also frequently check the client's vital signs and obtain a 12-lead ECG.

A nurse is providing in-service training to a group of newly licensed nurses about caring for clients who are receiving enteral nutrition through continuous infusion. Which of the following instructions should the nurse provide in the training session? (Select all that apply.) A. Administer with an infusion pump. B. Measure gastric residual every two hours. C. Flush the feeding tube every four hours. D. Return the aspirated residual feeding into the stomach. E. Reassess tolerance if the residual volume is greater than the prescribed amount.

Correct Answers: A. Administer with an infusion pump. C. Flush the feeding tube every four hours. D. Return the aspirated residual feeding into the stomach. E. Reassess tolerance if the residual volume is greater than the prescribed amount. Administering continuous drip enteral nutrition using an infusion pump ensures the correct volume of the feeding is being infused. Flushing the feeding tube every four hours maintains patency. Returning the aspirated residual feeding into the stomach ensures that needed fluids, electrolytes, nutrients, and digestive enzymes are replaced. The client's tolerance of the amount and type of formula used should be reassessed if the residual volume is greater than the prescribed amount because this is an indication that the amount of formula being infused is not being digested. Types of Delivery Methods for Tube Feedings Delivery Method Description Cyclic feedings Constant rate of feeding over 8 to 20 hr, usually while sleeping. Keep head of the bed elevated more than 30 degrees to prevent aspiration. Continuous drip Commonly used to hospitalized clients. Given at a constant rate. Smaller residual volumes, lower risk for aspiration. Intermittent feedings Administered 4 to 6 times daily in equal portions over 30 to 45 minutes. Does not always require an infusion pump. One advantage is that they resemble normal nutrition intake. Bolus feedings A large volume of formula is delivered in the barrel of a syringe in a quick manner (5 to 15 minutes) every 3 to 4 hours. Incorrect Answers: B. The nurse should measure gastric residual every four to eight hours to determine if the formula is being digested. Vital Concept: Continuous tube feeding is the most common administration method for clients who receive enteral nutrition while hospitalized. The round-the-clock rate allows nutrient absorption and the most tolerance of any of the types of administration. The nurse should stop the feeding at least every four hours and add 30 milliters of warm water to keep the tube unclogged and assist with hydration needs.

The nurse is charting findings from a client with cirrhosis. Which of the following findings are specifically related to the client's diagnosis? (Select all that apply) A. Anemia B. Hypoglycemia C. Bruising D. Gynecomastia E. Bradycardia Graded Response: Incorrect

Correct Answers: A. Anemia C. Bruising D. Gynecomastia Cirrhosis is a condition commonly referred to as the end stage of chronic liver disease. Its occurrence is progressive, irreversible, and eventually leads to liver failure. It can be classified according to its cause such as alcoholic cirrhosis from alcoholic liver disease, biliary cirrhosis from obstructed biliary flow, and posthepatic cirrhosis from chronic hepatitis. Cirrhosis has symptoms such as anemia and bruising due to decreased synthesis of clotting factor and bleeding tendencies, gynecomastia due to altered sex hormone metabolism from the dysfunctional liver, asterixis due to accumulation of metabolic toxins and impaired excretion of ammonia, jaundice due to impaired bilirubin metabolism and excretion, edema or ascites due to increased pressure in the portal venous system, and esophageal varices due to portal hypertension. Incorrect Answers: B. Hypoglycemia occurs with increased insulin levels and is not commonly associated with cirrhosis. E. Bradycardia is not commonly associated with cirrhosis. Vital Concept: Cirrhosis of the liver is a chronic disease characterized by diffuse destruction and fibrotic regeneration of hepatic cells. As necrotic tissue becomes fibrotic, the disease alters liver structure and normal vasculature, impairs hepatic flow of blood and lymph, and causes hepatic insufficiency. The prognosis is better in noncirrhotic forms of hepatic fibrosis, which cause minimal hepatic dysfunction and don't destroy liver cells.

A charge nurse is conducting an in-service with a group of staff about comorbidities associated with eating disorders. Which of the following conditions should the nurse include in the discussion? (Select all that apply.) A. Anxiety B. Alcohol use C. Schizophrenia D. Breathing-related sleep disorder E. Depression

Correct Answers: A. Anxiety B. Alcohol use E. Depression Anxiety is a comorbid condition that is common in clients who have an eating disorder. Alcohol use is a comorbid condition that is common in clients who have an eating disorder, especially clients who have anorexia nervosa. Depression is a comorbid condition that is common in clients who have an eating disorder. Incorrect Answers: C. Bipolar disorders, not schizophrenia, are comorbid conditions that are common in clients who have an eating disorder. D. A breathing-related sleep disorder is not a comorbid condition that is associated with eating disorders. Vital Concept: The nurse should identify that comorbidities for anorexia nervosa can include depression, anxiety, obsessive-compulsive disorder, and the use of alcohol or other substances.

Which of the following findings are expected in a 3-year-old child with age-appropriate development? (Select all that apply.) A. Copies a circle B. Jumps rope C. Rides tricycle D. Brushes teeth E. Undresses without help

Correct Answers: A. Copies a circle C. Rides tricycle E. Undresses without help A 3-year-old child with proper growth development will be able to do the following: 1. Copy a circle 2. Build a bridge with 3 cubes 3. Less negativistic than a toddler with decreased tantrums 4. Learn from experience 5. Ride a tricycle 6. Walks backward and downstairs without assistance 7. Undress without help 8. Have up to at least 300 words and may have a vocabulary of as many as 900 words. Additionally, the child may invent an "imaginary" friend at this age. Vital Concept: Biological development includes the development of fine and gross motor skills. Psychosocial development includes the development of a sense of trust, language, and attachment. Early cognitive development tasks include tasks related to body image and gender identity. The Denver Developmental Screening Test and the revised edition, the Denver II, are used to formally evaluate child development. The Denver II is a series of 91 questions answered by parents. Only a subset of questions is asked for each age group. It is available for four age groups: 0-9 months, 9-24 months, 2-4 years, and 4-6 years.

A 5-month-old infant is brought to the ER with vomiting and diarrhea, which the mother states started 3 days ago. The nurse should conduct a focused assessment for which of the following? (Select all that apply.) A. Decreased or absent tearing B. Dry mucous membranes C. Sunken fontanel D. Clear, pale, yellow urine E. Bounding pulse

Correct Answers: A. Decreased or absent tearing B. Dry mucous membranes C. Sunken fontanel Clinical manifestations of dehydration include decreased tearing, dry mucous membranes, sunken fontanel, weight loss, behavioral changes, concentrated urine, and thready pulse. Incorrect Answers: D. Clear, pale urine is not associated with the symptoms of dehydration. Urine is concentrated and darker than usual. E. A bounding pulse would indicate too much circulatory fluid, but this child will be dehydrated. Vital Concept: Signs of dehydration in an infant include sleepiness, irritability, thirst, reduced elasticity in the skin, sunken eyes and fontanel; decreased or absent tears; dry mouth, and decreased number of wet diapers.

A nurse is caring for a client with Parkinson's disease who has a prescription for selegiline (Eldepryl). Which of the following is true about this medication? (Select all that apply) A. It causes dizziness B. It affects sleep patterns C. It is taken intravenously only D. It can be administered with MAOI (monoamine oxidase inhibitor) E. It is ototoxic F. It's best to administer when symptoms occur G. It can be combined with fluoxetine

Correct Answers: A. It causes dizziness B. It affects sleep patterns Selegiline (Eldepryl) is a drug prescribed for treatment of Parkinson's disease. It selectively inhibits the enzyme monoamine oxidase that inactivates dopamine in the brain. It can be administered alone or in combination with Levodopa as an adjunct therapy for Parkinson's disease. Common side effects are dizziness, dry mouth, insomnia or difficulty falling asleep, myalgia or muscle pain, rashes, nausea, and constipation. Adverse reactions from this type of drug include arrhythmia, dyspnea, chorea, and hallucinations. Selegiline should not be administered in combination with another MAOI (monoamine oxidase inhibitor) or fluoxetine, as the effects are strengthened and may lead to a toxic reaction. Selegiline is not ototoxic. It is prescribed after confirmation of the diagnosis to prevent further deterioration of dopaminergic neurons. It is administered orally and not intravenously. The nurse needs to educate the client about the side effects and benefits of taking this drug. Vital Concept: Parkinson's disease is a neurogenerative disorder that affects the dopaminergic neurons in the brain, usually in adults over the age of 60. Symptoms include tremors, bradykinesia, impaired postural reflexes and muscular rigidity. Individuals often have a shuffling gait and a mask-like facial expression with a "pill-rolling" tremor.

A nurse is assessing a client who has metabolic acidosis. Which of the following manifestations should the nurse expect? (Select all that apply.) A. Nausea and vomiting B. Kussmaul respirations C. Flushing D. Circumoral paresthesia E. Lethargy

Correct Answers: A. Nausea and vomiting B. Kussmaul respirations C. Flushing E. Lethargy Kussmaul respirations are a manifestation of metabolic acidosis. Lethargy is a manifestation of metabolic acidosis. Flushing and lethargy are manifestations of both metabolic and respiratory acidosis. Incorrect Answers: D. Circumoral paresthesia is a manifestation of respiratory alkalosis. Vital Concept: A nurse who is assessing the client who has metabolic acidosis should be able to identify the expected manifestations. The nurse should also be able to evaluate the blood gas results for this imbalance, including: • An arterial blood pH less than 7.35 • A sodium bicarbonate less than 22 mEq/L • A PaCO2 less than 38 mmHg with respiratory compensation

A nurse in the oncology unit is caring for a client who has developed disseminated intravascular coagulation (DIC) and is bleeding from her mucous membranes and venipuncture sites. Which of the following laboratory values indicates that the client's clotting factors are depleted? (Select all that apply.) A. Platelets 100,000 per cubic millimeter (mm3) B. Fibrinogen levels 57 milligrams per deciliter (mg/dL) C. Fibrin degradation products 4.3 micrograms per millimeter (mcg/mL) D. D-dimer 0.03 micrograms per millimeter (mcg/mL) E. WBC count 3,000 per cubic millimeter (mm3)

Correct Answers: A. Platelets 100,000 per cubic millimeter (mm3) B. Fibrinogen levels 57 milligrams per deciliter (mg/dL) The client's platelet count is less than the expected reference range of 150,000 to 400,000/mm³. In DIC, platelet levels are decreased, meaning clotting factors have become depleted. Clotting times of PT, aPTT, and thrombin time (TT) are all increased, which raises the risk of fatal hemorrhage. The client's fibrinogen level is less than the expected reference range of 60 to 100 mg/dL. In DIC, fibrinogen levels are decreased, meaning clotting factors have become depleted. Clotting times of PT, aPTT, and thrombin time (TT) are all increased, which raises the risk of fatal hemorrhage. Incorrect Answers: C. This fibrin degradation product level is less than the reference range of 0 to 5 micrograms per milliliter (mcg/mL) but would be significantly increased when DIC occurs. D. The client's D-dimer level is within the expected reference range of < 0.4 micrograms per milliliter (mcg/mL). In DIC, the D-dimer level would be increased. E. The WBC count reference range is 5,000 to 10,000/mm3. The client's WBC level is decreased; however, this is not an indicator of DIC. Vital Concept: Disseminated intravascular coagulation (DIC) is a potentially life-threatening condition that can be triggered in various ways, such as cancer, sepsis, trauma, and abruptio placentae. Hundreds of tiny clots form in the client's capillaries, causing obstruction and tissue ischemia. As clotting factors are used up, bleeding occurs, intensified by the anticoagulant properties of fibrin degradation products. Nursing care of the client who has DIC is complex and involves extensive care planning including the administration of oxygen, heparin, platelets and/or plasma, and antibiotics.

A nurse is providing medication teaching to a client who has Addison's disease and has been prescribed hydrocortisone. Which of the following instructions should the nurse include? (Select all that apply.) A. "Take the medication before meals." B. "Notify the provider of any illness or stress." C. "Report any episodes of weakness or dizziness." D. "Do not discontinue the medication suddenly." E. "Eat a high-sodium diet."

Correct Answers: B. "Notify the provider of any illness or stress." C. "Report any episodes of weakness or dizziness." D. "Do not discontinue the medication suddenly." Physical and emotional stress increases the need for hydrocortisone. The provider might increase the dosage when stress occurs. Weakness and dizziness are indications of adrenal insufficiency. The client should report these manifestations to the provider. Rapid discontinuation can result in adverse effects, including acute adrenal insufficiency. If hydrocortisone is to be discontinued, the dose should be tapered. Incorrect Answers: A. The client should take hydrocortisone with food to decrease gastrointestinal distress. E. Clients who have Addison's disease can have hyponatremia, but once placed on replacement therapy, this will be corrected. Steroids increase sodium retention and a high sodium diet is not needed. Vital Concept: Addison's disease, or adrenocortical insufficiency, is the inadequate production of cortical hormone. The nurse should recognize the manifestations of hypocortisolism, which are muscle weakness and fatigue, decreased appetite and gastrointestinal upset, darkened pigmentation of the skin, decreased blood pressure, and altered serum electrolytes (e.g., low blood glucose, low serum sodium, and high serum potassium levels).

A nurse is caring for an adolescent who has muscular dystrophy and is taking corticosteroids. Which of the following statements about corticosteroids should the nurse include in teaching? (Select all that apply.) A. Corticosteroids assist in controlling weight gain. B. Corticosteroids help to preserve respiratory functioning. C. Corticosteroids slow the progression of muscle weakness. D. Corticosteroids increase muscle bulk and power. E. Corticosteroids decrease the incidence of scoliosis.

Correct Answers: B. Corticosteroids help to preserve respiratory functioning. C. Corticosteroids slow the progression of muscle weakness. D. Corticosteroids increase muscle bulk and power. E. Corticosteroids decrease the incidence of scoliosis. Corticosteroids have been shown to preserve respiratory function. In addition to taking steroids, children are encouraged to participate in pulmonary exercises, such as deep breathing and incentive spirometer use. This further assists the child in preserving respiratory function. Prolonged steroid use, from 6 months to 2 years, has been shown to delay the progression of muscle weakness. Corticosteroid use has been demonstrated to increase muscle bulk and power, which leads to an increase in muscle strength. The incidence of scoliosis has been reported to be decreased in clients who have muscular dystrophy and take corticosteroids. Side Effects of Steroid Use Cushingoid facial appearance Increased facial hair Changes in skin characteristics (thinner, easily torn) Weight gain Fat deposit in back of neck giving "hump" appearance Mood swings Elevated blood pressure Elevated blood sugar Incorrect Answer: A. Weight gain is a side effect of steroid therapy. Vital Concept: Because of the physical changes that can occur with corticosteroids, it is important to review the side effects of the medication so parents and older children can anticipate changes and monitor for side effects.

A nurse is caring for a client who is pregnant and experiencing backaches. Which of the following measures should the nurse tell the client to take to help relieve backaches? (Select all that apply). A. Soak in a hot tub once a day. B. Perform Kegel exercises twice a day. C. Perform the pelvic rock exercise every day. D. Position the knees higher than the hips when sitting. E. Sleep in a supine position.

Correct Answers: C. Perform the pelvic rock exercise every day. D. Position the knees higher than the hips when sitting. Backache is a common discomfort of pregnancy. The client can alleviate this by performing pelvic rock or tilt exercises. These exercises stretch the muscles of the lower back and help relieve lower back pain. Sitting with both feet on the floor and the knees positioned higher than the hips will lessen the lumbar curvature that tends to increase during pregnancy and cause back discomfort. Incorrect Answers: A. The nurse should instruct the client to avoid the use of hot tubs or saunas during pregnancy. Prolonged and repeated elevation of body temperature can cause abnormalities in fetal development. B. Kegel exercises are performed to strengthen the perineal muscles and do not relieve backaches. E. Sleeping in a supine position can result in maternal supine hypotension. This position is not recommended, because it exerts pressure on the major blood vessels, such as the vena cava. Sleeping on the left side is recommended during pregnancy. Vital Concept: Backache is a common discomfort experienced during pregnancy due to the skeletal, muscular, and hormonal changes associated with pregnancy. The nurse should instruct the client about proper body mechanics and exercises to use during pregnancy. Pelvic tilt or rock exercises can help relax the muscles of the lower back and relieve some of the discomfort. The client can perform these exercises while standing, sitting in a chair, lying on the floor, or on their hands and knees. Other interventions, such as using a lumbar support pillow and sitting with knees higher than the hips, can lessen naturally increasing lumbar curvature and decrease discomfort. Interventions to prevent aggravating back discomfort during pregnancy include instructing the client about proper body mechanics. The client should use their leg muscles to lift objects off the floor while bending at their knees and using their feet as a base to maintain balance. To lift objects, the client should keep the object close to their chest and avoid raising the object above their chest.

A nurse is taking care of a client with diabetes who is on sliding scale insulin every six hours; a routine dose of twenty (20) units regular insulin is also ordered. The blood sugar check shows a blood glucose of 70. The scheduled 1200 dose of insulin is due and the lunch trays have not yet arrived. Wanting to keep on schedule, the nurse administers the insulin before lunch is served. When the meal tray is delivered an hour later, the client is diaphoretic, weak and unable to respond. A re-check of his blood glucose shows a reading of 30. After notifying the physician, what would be the most appropriate actions to take to care for this client?(Select all that apply.) A. Help client out of bed to ambulate B. Give him a soda to bring up his blood sugar C. Feed him protein to counteract the sugar in his bloodstream D. Give 1 amp of D50 intravenously E. Recheck blood glucose in 15 minutes after intitial treatment F. Monitor for symptoms of continued hypoglycemia, keeping physician notified

Correct Answers: D. Give 1 amp of D50 intravenously E. Recheck blood glucose in 15 minutes after intitial treatment F. Monitor for symptoms of continued hypoglycemia, keeping physician notified The client is unable to respond while in bed. Therefore, he will not be able to stand, and attempting to get him out of bed will result in injury to client and staff. Giving food or drink to an unresponsive client will most likely result in aspiration. In a responsive client, juice would be more appropriate than soda. It is quickly metabolized to bring blood glucose up. Adding protein, if possible, would help to slow sugar metabolism and achieve a more balanced and long-lasting therapeutic glucose level. In this case, oral treatment would be unsafe. 1 amp of D50 given by IV and recheck of blood glucose in 15 minutes is most appropriate. When the client is alert and stable, a snack consisting of juice, peanut butter or cheese may be in order. Blood glucose checks are usually ordered every 30 minutes to 1 hour for the next 3-4 hours after an extreme hypoglycemic event. Vital Concept: Sliding-scale dose is based on the pre-prandial blood sugar, which refers to the blood sugar level just before a meal. The higher the blood sugar, the more insulin prescribed. SSI therapy is most often used in hospitals and other healthcare facilities, because it's easy and convenient for the medical staff to administer. However, there is a greater risk of hypoglycemia if the client does not eat their meal after receiving a dose of insulin. Regular insulin injected subcutaneously results in levels of insulin that peak after about 90 minutes and then slowly dissipates in 4 to 6 hours; metabolic action of regular insulin peaks after 2 to 3 hours.

A nurse is administering an injection in the vastus lateralis in an adult. The nurse knows the injection should be administered in the area between two bony landmarks. One landmark is the lateral condyle of the femur. Select the other landmark used to locate the correct administration site for an intramuscular injection. Graded Response: Incorrect Question Feedback Correct Answer:

The vastus lateralis site is recommended for intramuscular injections in infants, but can also be used for adults. The site is located on the anterior lateral aspect of the thigh in infants. In adults, the site is located in the middle third of the area between two bony landmarks, the lateral femoral condyle and the greater trochanter of the femur. The injection can be given with the client in a sitting position or supine position. The ventrogluteal site is the preferred site for intramuscular injections in adults. Since there is a larger blood supply to muscles than to subcutaneous tissue, intramuscular injections are more rapidly absorbed. The muscles can accommodate a larger volume of fluid in an injection compared to SQ tissue. The size and length of the needle used for IM injection should be determined by taking into account the size of the muscle, the amount of overlying adipose tissue, the client age, and type of solution. Vital Concept: When choosing a site for intramuscular injection, the site should be located away from large blood vessels, nerves, and bone. Contraindications to use of a site include injury to the tissue or presence of overlying tissue pathology, including abscess, tenderness, or nodules

A nurse is caring for an adolescent who has a new diagnosis of Ewing's sarcoma. Which of the following actions should the nurse take? A. Measure total head circumference daily. B. Perform a detailed neurological assessment ✔ C. Spend time with the adolescent to answer any questions. x D. Use a Snellen chart to test the adolescent's visual acuity.

Correct Answer: C. Spend time with the adolescent to answer any questions. The nurse should be available to answer the adolescent's questions and to listen as they talk about their feelings. Incorrect Answers: A. Measuring head circumference is an assessment that is performed on children who have a brain tumor. B. An adolescent who is newly diagnosed with Ewing's sarcoma should have a detailed musculoskeletal assessment. D. Determining visual acuity using a Snellen chart is an assessment that is performed on children who have cranial tumors suspected of causing vision loss. Vital Concept: Ewing's Sarcoma vs. Osteosarcoma Ewing's Sarcoma Osteosarcoma Age at Diagnosis 10 to 20 years old 15 to 20 years old Part of bone involved Diaphysis Metaphysis Treatment Chemotherapy, surgery, radiation Chemotherapy, surgery

A nurse in the Emergency Department is caring for a client with a hemothorax. The physician plans to insert a right-sided chest tube. Place the following nursing interventions in the correct order: Assist the client to the correct position for placement. Check the physician's order and gather the chest tube supplies. Assist the provider with chest tube insertion. Move the drainage system unit so that it is below the level of the chest. Encourage the client to cough and deep breathe. Administer pain medications as required.

Correct Answer: Check the physician's order and gather the chest tube supplies. Assist the client to the correct position for placement. Assist the provider with chest tube insertion. Move the drainage system unit so that it is below the level of the chest. Administer pain medications as required. Encourage the client to cough and deep breathe. Tube thoracotomy (placement of a chest tube) is performed to drain air, blood, or fluid from the pleural space, a potential space formed between 2 layers of thin tissue that cover the lung. The outer layer, the parietal pleura, is attached to the chest wall. The inner layer, the visceral pleura, covers the lung and adjacent structures in the chest. The two layers adhere, with a small amount of pleural fluid in the space that serves as a lubricant. If blood, air, or fluid accumulate in the pleural space, the resulting pressure prevents the lung from expanding normally, resulting in dyspnea and abnormal oxygenation and ventilation. Hemothorax is a collection of blood in the pleural space that usually results from trauma to the chest. It can also occur spontaneously or after a surgical procedure in the thoracic cavity. Drainage of blood from the pleural space restores the normal negative pressure and allows the lung to re-expand. When placing a chest tube for pneumothorax, the tube is placed in at the 4th or 5th intercostal space in the mid-axillary line. When draining fluid or blood, the tube is placed at the sixth or seventh intercostal space in the posterior axillary line using sterile technique. Local anesthetic is used and procedural sedation may be administered if the client who is hemodynamically stable. The tube is connected to a sealed drainage system in order to prevent entry of air into the pleural space. Suction may be used in clients with hemothorax or large pleural effusion. Sterile dressing and rubber-tipped clamps should be kept with the client in case the tube becomes accidentally dislodged. If the tube becomes disconnected at the collecting system, the nurse should maintain a seal by submerging the end in an inch of sterile water or saline. If the tube becomes dislodged from the client, the nurse should immediately cover the wound with a dry sterile dressing on three sides. Vital Concept: When caring for a client with a chest tube, the nurse will monitor the client's vital signs, pulse oximetry, respiratory and cardiovascular status; maintain patency and integrity of the drainage system; observe the dressing site at least every 4 hours; monitor the client for discomfort and administer analgesics if indicated; and encourage deep breathing and coughing. The client should be repositioned every two hours to facilitate drainage. A rolled towel is placed beside the tubing when the client is lying on the side of the chest tube. The drainage system must remain in an upright position below the drainage site.

A nurse is providing teaching about home care to the parent of a child who is receiving radiation therapy. Which of the following information should the nurse include in the teaching? (Select all that apply.) A. Manifestations of infection B. Bleeding precautions C. Hand hygiene D. Skin care E. Airborne precautions

Correct Answers: A. Manifestations of infection B. Bleeding precautions C. Hand hygiene D. Skin care Radiation therapy destroys healthy WBCs, which increases the risk for infection. The nurse should include manifestations of infection in the teaching that the parent should be aware of. Radiation destroys healthy platelets, which increases the risk for bleeding. The nurse should include bleeding precautions in the teaching. Radiation destroys healthy WBCs, which increases the risk for infection. The nurse should include information about hand hygiene in the teaching. Children receiving radiation therapy can experience skin breakdown, which can lead to infection. The nurse should include information about skin care in the teaching. Incorrect Answer: E. Children who are receiving radiation therapy are at an increased risk for infection. However, they do not need to be placed on airborne precautions. Vital Concept: Skin care for children who are receiving radiation therapy: • Wear loose, comfortable clothing. • Avoid lotions while receiving treatment. • Avoid sun exposure during treatment. • Monitor for any signs of skin irritation or burns.