July 10th

The charge nurse responds to a cardiac arrest with resuscitation in progress of an adult client. Which of the following actions by a resuscitation team member would cause the charge nurse to intervene? Select all that apply. 1. Chest compression are performed at a rate 70-80 2. Chest compressions are stopped for a 10 second pulse check every 2 minutes 3. Defibrillator pads are applied at the left and right sternal borders 4. Manual breaths are delivered at a rate of 2 breaths per 30 chest compressions 5. Resuscitation team is alerted to remain clear of pt before difibrillation

1 & 3 All members of the health care team must follow basic life support guidelines to perform cardiopulmonary resuscitation (CPR) for clients experiencing cardiac arrest. Essential components of adult CPR include: Chest compressions are performed at a rate of 100-120/min and a depth of 2.0-2.4 inches (5-6 cm), allowing complete chest recoil between compressions (Option 1). Defibrillator pads are placed on the right upper chest, just below the clavicle, and on the left lateral chest, near the anterior axillary line below the nipple line (Option 3). (Option 2) During CPR, compressions are paused every 2 minutes to assess the client's pulse. This pause should be no longer than 10 seconds to minimize delays between compression cycles. (Option 4) Manual breaths are administered at a rate of 2 breaths per 30 chest compressions in clients without advanced airways or once every 6 seconds without chest compression interruption with advanced airway placement. (Option 5) The team member managing the defibrillator should use firm verbal cues (eg, "stand clear!") to clear all team members from contact with the client, followed by visual confirmation before defibrillation. Educational objective: During cardiopulmonary resuscitation, chest compressions are performed at a rate of 100-120/min. Defibrillator pads are placed on the right upper chest and on the left lateral chest.

A client is admitted with an exacerbation of asthma following a respiratory viral illness. Which clinical manifestations characteristic of a severe asthma attack does the nurse expect to assess? Select all that apply. 1. Accessory muscle use 2. Chest tightness 3. High-pitched expiratory wheeze 4. Prolonged inspritory phase 5. Tachypnea

1, 2, 3, & 5 Asthma is an obstructive lung disease characterized by hyperreactive airways and chronic inflammation. Asthma exacerbations occur due to various triggers (eg, allergens, respiratory infection, exercise, cold air), resulting in edema, hypersecretion of mucus, and bronchospasm. Narrowing of the airways culminates in increased airway resistance, air trapping, and lung hyperinflation. In severe asthma, breath sounds may be diminished due to closure of bronchioles. Absent breath sounds in a client with asthma are a medical emergency. Clinical manifestations of an asthma exacerbation include: Accessory respiratory muscle use related to increased work of breathing and diaphragm fatigue (Option 1) Chest tightness related to air trapping (Option 2) Cough from airway inflammation and increased mucus production Diminished breath sounds related to hyperinflation High-pitched expiratory wheezing caused by narrowing airways (Option 3); wheezing may be heard on both inspiration and expiration as asthma worsens Tachypnea related to inability to take a full, deep breath (Option 5) (Option 4) Clients with obstructive lung disease (eg, asthma, chronic obstructive pulmonary disease) develop prolonged expiratory phase as a physiologic response to hyperinflation and trapped air. Educational objective: Asthma is an obstructive lung disease characterized by hyperreactive airways and chronic inflammation. Clinical manifestations of an asthma exacerbation include accessory respiratory muscle use, chest tightness, diminished breath sounds, high-pitched wheezing on expiration, prolonged expiratory phase, tachypnea, and cough.

A nurse is teaching a client about formula preparation for a newborn. Which statements by the client indicate proper understanding? Select all that apply. 1. I can add water to the formula if my baby wants to eat more frequently 2. I must wash the top of the concentrated formula can before opening it 3. I should't heat formula in the microwave for more than 1 minute 4. If my baby does not finish the bottle, the leftover milk should refrigerated 5. Prepared formula should be kept in the refrigerator and discarded after 48 hours

2 & 5 Infant formula is readily available in 3 forms: ready-to-feed, concentrated, and powder. Parents who feed their infants commercial formula should closely follow the manufacturer's recommendations for preparation, particularly if the product requires dilution or reconstitution. Parents should also adhere to basic guidelines for safe storage and handling. Key teaching points include: Keep bottles, nipples, caps, and other parts as clean as possible, either by boiling or washing in the dishwasher Wash the tops of formula cans prior to opening to prevent contamination (Option 2) Prepared formula or opened cans of ready-to-feed or concentrated formula should be kept in the refrigerator and discarded after 48 hours if unused (Option 5). There is a risk of bacterial growth after this time. Prepared bottles can be warmed by placing in a pan of hot water for several minutes Test temperature on the inner wrist before serving to the infant; formula should feel lukewarm, but never hot Never microwave formula as it can cause mouth burns (Option 3) (Option 1) Formula should never be diluted or concentrated. Dilution of the formula does not allow the infant to receive the appropriate amount of calories, vitamins, and minerals needed for normal growth and development. Overconcentration of the formula can cause excessive proteins and minerals to be ingested that exceed the excretory ability of the infant's immature kidneys. (Option 4) Any formula left in a bottle after a feeding should be discarded immediately because the infant's saliva has mixed with it. This will encourage bacterial growth. Educational objective: Parents who feed their infants commercial formula should follow the manufacturer's recommendations for preparation and storage. Formula should never be diluted, concentrated, or microwaved for infant safety. After preparation, unused prepared formula can be stored in the refrigerator for up to 48 hours.

The clinic nurse reinforces education about intimate partner violence for a group of graduate nurses. Which of the following are appropriate for the nurse to include? Select all that apply. 1. Intimate partner violence is most common in low income familes 2. Intimate partner violence is rare in same sex couples 3. The abusive partner often demonstrates jealousy and possessiveness 4. Victims may not leave due to financial concerns of harm by the abuser 5. Violence against a female often intensifies during pregnancy

3, 4, & 5 Intimate partner violence (IPV) is physically, emotionally, verbally, sexually, or economically abusive behavior inflicted by one partner against another in an intimate relationship, to maintain power and control. Nurses must be aware of the risk factors and signs of IPV to recognize victims of abuse and to intervene (eg, separating the victim from the abuser during the health history interview, providing information about community resources). Features of IPV include: The abusive partner exhibits intense jealousy and possessiveness (Option 3). The victim of IPV chooses to stay in the relationship for a variety of reasons (eg, fear for life, financial or child custody concerns, religious beliefs) (Option 4). The abuse begins or intensifies during pregnancy (Option 5). (Options 1 and 2) IPV occurs in all religious, socioeconomic, racial, and educational groups, and in both heterosexual and same-sex partnerships. Educational objective: Intimate partner violence (IPV) is abusive behavior inflicted by one partner against the other in an intimate relationship. IPV occurs in all religious, socioeconomic, racial, and educational groups, and in both heterosexual and same-sex partnerships. IPV often begins or intensifies during pregnancy. Victims often stay in the relationship due to fear, financial or child custody concerns, or religious beliefs, among other reasons.

A 3-month-old infant has irritability, facial edema, a 1-day history of diarrhea with adequate oral intake, and seizure activity. During assessment, the parents state that they have recently been diluting formula to save money. Which is the most likely cause for the infant's symptoms? 1. Hypernatremia due to diarrhea 2. Hypoglycemia due to dilute formula intake 3. Hypokalemia due to excess GI output 4. Hyponatremia due to water intoxication

4. HYPONATREMIA DUE TO WATER INTOXICATION Water intoxication (water overload) resulting in hyponatremia may occur in infants when formula is diluted to "stretch" the feeding to save money. Hyponatremia may also result from ingestion of plain water (eg, caregiver attempting to rehydrate an infant who has been ill). Infants have immature renal systems with a low glomerular filtration rate, which decreases their ability to excrete excess water and makes them susceptible to water intoxication. Symptoms of hyponatremia include irritability, lethargy, and, in severe cases, hypothermia and seizure activity. Breast milk and/or formula are the only sources of hydration an infant needs for the first 6 months of life. Formula should be prepared per the manufacturer's instructions. (Option 1) Hypernatremia may be caused by dehydration (eg, decreased oral intake, vomiting, diarrhea) and presents with similar neurological symptoms (eg, restlessness, seizures). The infant's history indicates adequate oral intake and signs of fluid overload (eg, facial edema), not dehydration. (Option 2) Hypoglycemia may present with irritability and seizures, but facial edema and recent history of over-diluting the formula should alert the nurse that water intoxication with hyponatremia is the most likely cause. (Option 3) Hypokalemia secondary to diarrhea may present with irritability, muscle weakness, and cardiac arrhythmias. Educational objective: Infants are susceptible to hyponatremia secondary to water intoxication, which can present with neurological symptoms (eg, lethargy, irritability, seizures). Breast milk and/or formula provide sufficient hydration for the first 6 months of life. Formula should not be diluted to save money.

What intervention is essential prior to starting a client on atorvastatin therapy? 1. Assessing for muscle strength 2. Assessing the pt's dietary intake 3. Determing if the ot is on digoxin therapy 4. Monitoring lever function tests

4. MONITORING LIVER FUNCTION TESTS Prior to starting therapy with statin medications (eg, rosuvastatin, simvastatin, pravastatin, atorvastatin), the client's liver function tests should be assessed. The drug is metabolized by the hepatic enzyme system and could cause drug-induced hepatitis and increased liver enzymes. Liver function tests should be assessed prior to the start of therapy. (Option 1) Statins can also cause muscle aches and, rarely, severe muscle injury (rhabdomyolysis). Clients should be educated to report the development of muscle pains while on therapy. Assessment of muscle strength is not necessary prior to starting therapy. (Option 2) Assessment of dietary intake prior to therapy is not essential. Dietary teaching would have been performed prior to determining that medication therapy was necessary. (Option 3) Atorvastatin may slightly increase serum digoxin levels; however, it is not essential to determine if the client is on this medication prior to starting therapy. Educational objective: Statin medications (eg, rosuvastatin, atorvastatin) can cause hepatotoxicity and muscle aches. Liver function tests should be assessed prior to the start of therapy.

A client has chronic obstructive pulmonary disease (COPD) exacerbation. The pulse oximeter shows a saturation of 86% on room air. The nurse assesses diminished lung sounds and low-pitched wheezing posteriorly, shallow respirations, respiratory rate of 32/min, and use of accessory muscles. What is the most appropriate oxygen delivery device for this client? 1. Nasal cannula 2. Non rebreather mask 3. Oxymizefr 4. Venturi mask

4. VENTURI MASK The Venturi mask is a high-flow device that delivers a guaranteed oxygen concentration regardless of the client's respiratory rate, depth, or tidal volume (TV). The adaptor or barrel can be set to deliver 24%-50% (varies with manufacturer) oxygen concentration. In the presence of tachypnea, shallow breathing with decreased TV, hypercarbia, and hypoxemia, it is the most appropriate oxygen delivery device for this client as rapid changes in inspired oxygen concentration can blunt the hypoxemic drive to breathe in clients with COPD. (Option 1) The nasal cannula can deliver adequate oxygen concentrations and is best for clients with adequate TV and normal vital signs. It is not the best choice in an unstable COPD client with varying TVs because the inspired oxygen concentration is not guaranteed. (Option 2) The non-rebreathing reservoir mask can deliver 60%-95% oxygen concentrations and is usually used short term. It is often used for clients with low saturations resulting from asthma, pneumonia, trauma, and severe sepsis; it is not the most appropriate device for a COPD client in this situation. (Option 3) An oxymizer is a nasal reservoir cannula-type device that conserves on oxygen use. Clients can be sustained on a prescribed oxygen level using much less oxygen (eg, 3 L/min nasal cannula is equivalent to 1 L/min oxymizer device) to reach the same saturation. It is not the best choice in an unstable COPD client with varying TVs as the inspired oxygen concentration is not guaranteed. Educational objective: Low-flow oxygen delivery devices (eg, nasal cannula, simple face mask) deliver oxygen concentrations that vary with breathing patterns. They are appropriate for clients who can tolerate varying concentrations (eg, stable COPD, type I respiratory failure [hypoxemic]). High-flow oxygen delivery devices (eg, Venturi mask, mechanical ventilator) deliver oxygen concentrations that do not vary with breathing patterns. They are appropriate for clients who cannot tolerate varying concentrations (eg, exacerbation COPD, type II respiratory failure [hypercarbic]).

During morning rounds, the nurse notices that a client admitted 3 days ago with hepatic encephalopathy is sleepy and confused. The client is scheduled for discharge later today. Which interventions are appropriate for the nurse to implement? Select all that apply. 1. Assess the pt's and movements with arms extended 2. Compare current mental status findings with those from previous shifts 3. Contact the HCP to request a blood draw for ammonia level 4. Encourage the pt to ambulate in the hallway 5. Hold the pt's morning dose of lactulose

1, 2, & 3 Hepatic encephalopathy is a serious complication of end-stage liver disease (ESLD) that results from inadequate detoxification of ammonia from the blood. Symptoms include lethargy, confusion, and slurred speech; coma can occur if this condition remains untreated. Asterixis, or a flapping tremor of the hands when the arms are extended with the hands facing forward, may also be noted in the client with encephalopathy. The client with ESLD exhibiting confusion and lethargy should be evaluated for worsening encephalopathy by assessing for asterixis and comparing current mental status and ammonia level to previous findings. If encephalopathy continues to worsen, medical treatment should include higher doses of lactulose and rifaximin, and discharge should be delayed until the client is stable. (Option 4) The client with lethargy and confusion is at risk for falling. Ambulation is not an appropriate intervention at this point. (Option 5) Lactulose is the primary drug used for hepatic encephalopathy treatment. It helps to excrete ammonia through the bowels as soft or loose stools. Lactulose should not be held if the client's hepatic encephalopathy continues to worsen. Educational objective: Hepatic encephalopathy is a serious complication of end-stage liver disease caused by high levels of ammonia in the blood. Assessment findings include confusion, lethargy, and asterixis; coma and death can occur if this condition remains untreated. Pharmacologic treatments include lactulose and antibiotics (eg, rifaximin). The client with worsening encephalopathy is not stable enough for discharge.

A hospitalized client with acute pancreatitis has nausea, vomiting, epigastric pain, and tachycardia. Laboratory results show elevated serum lipase levels. Which interventions would the nurse anticipate being prescribed for the client? Select all that apply. 1. Administer hydromorphone IV PRN for pain 2. Administer IV fluids 3. Insert NGT for suction 4. Maintain pt in a supine position with hob flat 5. Provide small, frequent high carb, high calorie meals

1, 2, & 3 Supportive care for symptom relief and prevention of complications are the major goals in clients with acute pancreatitis. These strategies include: NPO status - The client is maintained on NPO status as any ingestion of food will stimulate the excretion of pancreatic enzymes. A nasogastric tube is used to suction out gastric secretions; this will reduce nausea and lessen stimulation of the pancreas as these juices will move to the duodenum. Pain management - Intravenous opioids (eg, hydromorphone, fentanyl) are frequently utilized for pain management. Morphine can also be used; worsening pancreatitis due to increase in sphincter of Oddi pressure has not been proven in studies. IV fluids - Aggressive fluid replacement to prevent hypovolemic shock is critical. Inflammation of the pancreas releases chemical mediators that increase capillary permeability and cause third spacing (fluid going into empty spaces). (Option 4) The client should maintain positions that flex the trunk and draw the knees up to the abdomen (semi-Fowler's) to decrease tension on the abdomen. A side-lying position with the head elevated to 45 degrees will help relieve the pain even better. (Option 5) NPO status is maintained to inhibit stimulation of pancreatic enzymes. Educational objective: The major goals in acute pancreatitis are symptom management (eg, opioids, NPO status, nasogastric suction) and monitoring and prevention of complications (eg, IV fluids), giving the pancreas time to heal.

The health care provider (HCP) prescribes an oral iron suspension for 3 months for a 2-year-old with iron deficiency anemia. Which instructions should be given to the parent? Select all that apply. 1. Administer doses b/w meals 2. Administer doses with citrus juice 3. Obtain a full 3 month supply from the pharmacy 4. Place medicine at the back of the mouth 5. Report black, tarry stools to the HCP immediately

1, 2, & 4 Iron deficiency anemia, the most common chronic nutritional disorder, often occurs in toddlers due to insufficient intake of dietary iron or excessive consumption of milk. It is treated with increased consumption of iron-rich foods (eg, leafy green vegetables, red meats, poultry, dried fruit, fortified cereal) and oral iron supplementation. Key instructions for safe, effective administration of oral iron supplements include: Administer between meals - Concentrations of stomach acid are higher between meals, breaking down the iron to an easily absorbed state (Option 1) Give with citrus juice - Absorption is enhanced when taken with a good source of vitamin C, such as orange juice or other citrus fruit (Option 2) Place medicine at the back of the mouth - Liquid iron can cause temporary staining of the teeth. Using a dropper or straw to direct the iron toward the back of the mouth can reduce this risk (Option 4). Avoid giving with milk - Milk and other products with high amounts of calcium reduce adequate absorption of iron supplements Keep no more than a 1-month supply on hand - When ingested in extreme quantities, iron can be toxic or even lethal. Only short-term amounts should be stored in the home, in a child-proof location (Option 3). (Option 5) Black or green tarry stools are an expected effect of oral iron supplements and are considered an indicator of proper compliance. Educational objective: Oral iron supplements should be given between meals and consumed with citrus juice to promote absorption, and administered to the back of the mouth to prevent tooth staining. No more than a 1-month supply of supplements should be kept on hand to reduce the risk of accidental poisoning. Oral iron should not be taken with milk.

An older client comes to the outpatient clinic for a routine physical examination and health screening. Which findings does the nurse recognize as possible indications of colorectal cancer? Select all that apply. 1. Abdominal pain 2. Blood in the stools 3. Change in bowel habits 4. Low hgb level 5. Unexplained weight loss

1, 2, 3, 4, & 5 Colorectal cancer occurs most often in adults over age 50. Risk factors include history of colon polyps; family history of colorectal cancer; inflammatory bowel disease (eg, Crohn disease, ulcerative colitis); and history of other cancers (eg, gastric, ovarian). Symptoms of colorectal cancer may include: Blood in the stool (eg, positive occult blood, melena) from fragile, bleeding polyps or tumors (Option 2) Abdominal discomfort and/or mass (not common) (Option 1) Anemia due to intestinal bleeding, which may result in fatigue and dyspnea with exertion (Option 4) Change in bowel habits (eg, diarrhea, constipation) due to obstruction by polyps or tumors (Option 3) Unexplained weight loss due to impaired nutrition from altered intestinal absorption (Option 5) Colorectal cancer often goes unnoticed, as many of the symptoms are painless and nonspecific. Clients should be assessed for these symptoms and receive regular routine colorectal cancer screening tests (eg, occult blood test every year, colonoscopy every 10 years). Educational objective: Clients over age 50 should receive routine colorectal cancer screening for symptoms such as blood in the stool, anemia, abdominal discomfort, change in bowel habits, and weight loss. Symptoms result from intestinal polyps or tumors that cause intestinal bleeding, obstruction, and impaired intestinal absorption.

During the admission assessment of a client with a small-bowel obstruction, the nurse anticipates which clinical manifestations? Select all that apply. 1. Abdominal distention 2. Absolute constipation 3. Colicky abdominal pain 4. Frequent vomiting 5. Pain during defecation

1, 3, & 4 Small-bowel obstruction can have mechanical or non-mechanical causes. Mechanical obstruction is commonly caused by obstruction of the bowel resulting from surgical adhesions, hernias, intussusception, or tumors. Paralytic ileus, a non-mechanical obstruction, may occur after abdominal surgery or narcotic use. When a small-bowel obstruction develops, fluid and gas collect proximal to the obstruction, producing rapid onset of nausea and vomiting (Option 4), colicky intermittent abdominal pain (Option 3), and abdominal distension (Option 1). The nurse should recognize symptoms of bowel obstruction quickly as delay could lead to vascular compromise, bowel ischemia, or perforation. Nursing management of an obstruction includes placing the client on NPO status, inserting a nasogastric tube, administering prescribed IV fluids, and instituting pain control measures. (Option 2) Symptoms of a large-bowel obstruction differ slightly from small-bowel obstruction and include gradual onset of symptoms, cramping abdominal pain, abdominal distension, absolute constipation, and lack of flatus. Constipation and decreased flatus resulting from small-bowel obstruction would occur later, as the stool and gas in the large colon would be expelled for a few days. (Option 5) Pain during defecation usually indicates a rectal problem such as inflammation, anal fissure, or thrombosed hemorrhoids. Educational objective: Common symptoms of small-bowel obstruction include rapid onset of nausea and vomiting, colicky intermittent abdominal pain, and abdominal distension. Absolute constipation and lack of flatus are usually seen with large-bowel obstruction. Initial treatment of an obstruction includes placing the client on NPO status, inserting a nasogastric tube, administering IV fluids, and instituting pain control measures.

The nurse is caring for a client with a chest tube to evacuate a hemopneumothorax after a motor vehicle accident. The drainage has been consistently 25-50 mL/hr for the majority of the shift. However, over the past 2 hours there has been no drainage. Which actions should the nurse take? Select all that apply. 1. Auscultate breath sounds 2. Increase amount of suction 3. Instruct pt to cough and deep breathe 4. Milk the chest tube 5. Reposition the pt

1, 3, & 5 When chest drainage stops abruptly, the nurse must perform assessments and interventions to ascertain if this is an expected finding. Auscultating breath sounds (Option 1) helps the nurse detect whether breath sounds are audible in all lung fields, potentially indicating that the lung has re-expanded and there is no more drainage. Other interventions to facilitate drainage include having the client cough and deep breathe (Option 3) and repositioning the client (Option 5). If a client has been in one position for a prolonged period, drainage may accumulate and a position change may facilitate improved drainage. (Option 2) A change in suction level should be performed only after obtaining a health care provider (HCP) prescription. The nurse should perform the assessment of breath sounds, coughing and deep breathing, and client repositioning before notifying the HCP about a change in suction level. In general, suction above 20 cm H2O is not indicated. (Option 4) Milking chest tubes to maintain patency is performed only if prescribed. It is generally contraindicated due to potential tissue damage from highly increased pressure changes in the pleural space. Educational objective: The nurse should assess breath sounds, encourage coughing and deep breathing, and reposition the client who has a decrease in chest tube drainage.

The nurse is assessing a 4-year-old boy in a pediatric clinic. Which behaviors by the client would concern the nurse for possible Duchenne muscular dystrophy? Select all that apply. 1. Frequently trips and falls at home 2. Has painful knees and elbows in the morning 3. Places hands on the thighs to push up to stand 4. Suddenly rigidly extends the arms and legs 5. Walks on tiptoes and has disporoportionately large calves

1, 3, & 5 Duchenne muscular dystrophy is an X-linked recessive (carried by females and affecting males) disorder that causes the progressive replacement of dystrophin, a protein needed for muscle stabilization, with connective tissue. The proximal lower extremities and pelvis are affected first. In response to proximal muscle weakness, the calf muscles hypertrophy (pseudohypertrophy) initially and are later replaced by fat and connective tissue. Children with Duchenne muscular dystrophy raise themselves to a standing position using the classic Gower sign/maneuver (placing hands on the thighs to push up to stand) and walk on tiptoes (Options 3 and 5). Parents may also report frequent tripping and falling (Option 1). (Option 2) Joint pain that is worse in the morning is a symptom of juvenile idiopathic arthritis. Children with this type of arthritis also experience symptoms of joint swelling and stiffness, high fever, and skin rash. (Option 4) Rigid extension of the arms and legs is seen in the tonic phase of a tonic-clonic seizure. During this time, muscles become stiff, the jaw becomes clenched, and pupils can be fixed and dilated. Educational objective: Duchenne muscular dystrophy is an X-linked recessive disorder characterized by progressive replacement of muscle tissue with connective tissue. Classic signs include Gower sign/maneuver (placing hands on the thighs to push up to stand), enlarged calves, walking on tiptoes, and frequent tripping/falling.

nurse is caring for a client diagnosed with endometrial cancer who is receiving brachytherapy. Which interventions should the nurse implement while caring for this client? Select all that apply. 1. Cluster care to limit each staff member's time in the room to 30 minutes a shift 2. Instruct the pt to be up & around in the room but not to leave the room 3. Keep the door to the room closed as radiation is emitting constantly from the pt 4. Teach family members & visitors to stay at least 6 feet away from the pt 5. Use a lead apron when providing direct pt care to reduce exposure to radiation 6. Wear a radiation film badge while in the pt's room to monitor radiation exposure

1, 3, 4, 5, & 6 Internal radiation (brachytherapy) involves direct application of a radioactive implant to the cancerous site or tumor for a short time, usually 24-72 hours. This technique is used to treat cervical and endometrial cancer and delivers a high dose of radiation to the cancerous tissues with a limited dose to adjacent normal tissues. Implementation of the following nursing measures is vital as the client receiving brachytherapy emits radiation. Following the principles of time, distance, and shielding provides staff and visitors protection from exposure to radiation. Time spent near the radiation source is restricted. The guideline is to limit staff time spent in the room to 30 minutes per shift. Cluster nursing care to minimize exposure to the radiation source Rotate daily staff responsibilities to limit time spent in the client room All staff must wear a dosimeter film badge when assigned to care for a client receiving internal radiation No individuals who are pregnant or under age 18 may be in the room All staff and visitors must keep the maximum distance possible from the radiation source. Maintaining a distance of at least 6 feet is an established standard. Assign the client to a private room with a private bath Keep the door to the room closed Ensure that a sign stating, "Caution, Radioactive Material" is affixed to the door Instruct the client to remain on bedrest to prevent dislodgement of the implant Shielding with lead diminishes exposure to radiation. All staff providing nursing care that requires physical contact must wear a lead apron. (Option 2) The client receiving brachytherapy for endometrial cancer is instructed to remain on bedrest while the radiation implant is in place. If the implant dislodges from the vaginal cavity, the implant is never touched with the hands; instead, long-handled forceps are used to pick it up for placement in a lead container. Educational objective: Following the principles of time, distance, and shielding provides staff protection from exposure to internal radiation emissions. Staff should spend no more than 30 minutes in a client's room; should remain at least 6 feet away from the radiation source; and should wear lead aprons when providing direct client care.

A client arrives at the emergency department after being rescued from a burning building. Both arms and the entire chest are covered with dry, leathery, charred skin that does not blanch. What is the priority for the client's care? 1. Administration of IV LR 2. Antibiotic administration 3. Incision through the burned tissue 4. IV administration of analgesics

1. ADMINISTRATIONS OF IV LACTATED RINGERS The initial management of burn injuries is identical to the management of all trauma clients - airway, breathing and circulation (ABCs) must always be secured first. All burn victims should be treated initially with high-flow oxygen via a nonrebreather mask, although caregivers should maintain a low threshold for intubation in any client with physical evidence of thermal damage to the upper airway. Following severe thermal burns, clients require significant volume replacement to compensate for fluid lost through their wounds and for a potential injury-related systemic inflammatory response causing increased capillary permeability with extravascular shift of fluids. Aggressive fluid replacement is essential if more than 15% total body surface area (TBSA) is involved. This client has 36% burn area based on the "Rule of Nines." Fluids used typically include lactated Ringer's. The amount of fluid required for the first 24 hours is calculated using the Parkland formula (4 mL/kg of body weight for each percent of TBSA burned). One-half of the total amount is infused in the first 8 hours, ¼ of the total in the 2nd 8 hours, and ¼ of the total in the 3rd 8 hours. (Option 2) Burn clients are at high risk for infection due to lack of skin integrity, especially by Pseudomonas aeruginosa, but treatment in the acute setting should focus on restoration of ABCs. (Option 3) Wound care is important but maintaining adequate circulation is a priority. This client has no evidence of a circumferential burn requiring an escharotomy. Even if this procedure is needed, fluids would be the first priority as the fluid loss/shift can start as early as 20 minutes after a burn and fluid resuscitation is life-saving. (Option 4) Full-thickness or 3rd-degree burns involve destruction of nerves, so there is no pain. There may be some other partial-thickness or superficial burns that do have severe pain. Under ABCD prioritization, pain is "D" and would be after circulation for fluids. Educational objective: The initial management of burn injuries is identical to the management of all trauma clients - ABCs must always be secured first. Fluids such as lactated Ringer's are typically used.

An obese 85-year-old client, who is an avid gardener and eats only home-grown fruits, legumes, and vegetables, is admitted to the hospital with pneumonia after having an upper respiratory tract infection for a week. Which factor puts the client at greatest risk for developing pneumonia? 1. Advanced age 2. Environmental exposure 3. Nutritional deficit 4. Obesity

1. ADVANCED AGE Pneumonia is an inflammatory process in the alveoli and interstitium of the lung usually caused by an infectious or noninfectious agent. Any condition, such as advanced age (>65), that compromises the respiratory system's protective mechanical or immune mechanisms to maintain the sterility of the lower airway can increase the risk for pneumonia. (Options 2, 3, and 4) Working in the garden and being exposed to environmental factors (eg, pollen), eating a vegetarian diet, and obesity do not pose the greatest risks for development of pneumonia. Educational objective: Any condition that compromises the respiratory system's protective mechanical or immune mechanisms, which maintain the sterility of the lower airway, can increase the risk for pneumonia.

The nurse is preparing to administer morning medications to a client with type 2 diabetes mellitus and end-stage renal disease who is scheduled for dialysis today. Which medication should the nurse hold for clarification prior to administration? Click the exhibit button for more information. 1. Atenolol 2. Calcium acetate 3. Insulin lispro 4. Vitamin E

1. ATENOLOL Medication administration may require modification on days that clients are scheduled to receive dialysis. The nurse should consider whether the medication will be dialyzed out of the client's system or may create adverse effects during dialysis. Fluid is removed during dialysis, which may cause hypotension. Typically, antihypertensives are held before dialysis to prevent hypotension. In addition, some medications are dialyzed out of the client's system and should therefore be held until after dialysis. Commonly held medications are water-soluble vitamins (eg, vitamins B and C), antibiotics, and digoxin. (Option 2) Clients with chronic kidney disease have high phosphorus levels as the kidney is unable to filter the phosphate from the body; dialysis also does not filter it. Therefore, the client should still take phosphate binders prior to dialysis. Phosphate binders (eg, calcium containing [calcium carbonate and calcium acetate]) and non-calcium containing [sevelamer and lanthanum]) block absorption of ingested phosphate from the intestine and excrete it through feces. (Option 3) Lispro is a fast-acting insulin that should be given 15-30 minutes before meals. It is appropriate to give scheduled lispro with breakfast prior to dialysis. (Option 4) Vitamin E is a fat-soluble vitamin that is not affected by dialysis. It is given to some clients to prevent leg cramps that can be experienced by dialysis clients. Educational objective: Unless otherwise indicated by the health care provider, antihypertensives and other blood pressure-lowering medications (eg, furosemide), antibiotics, digoxin, and water-soluble vitamins (B, C, and folic acid) should be held prior to dialysis.

A client is prescribed long-term pharmacologic therapy with hydroxychloroquine to treat systemic lupus erythematosus. Which intervention related to the drug's adverse effects should the nurse include in the teaching plan? 1. Have an eye exam every 6 months 2. take the medication on an empty stomach 3. GTake bvitamin D and calcium supplements 4. Wear a medicaalert braceet

1. HAVE AN EYE EXAM EVERY 6 MONTHS Hydroxychloroquine (Plaquenil) is an antimalarial drug, but it is more commonly prescribed to reduce fatigue and treat the skin and arthritic (eg, joint inflammation, pain) manifestations of systemic lupus erythematosus (SLE). Hydroxychloroquine can also help to reduce lupus exacerbations in clients with inactive to mild disease, but several months can pass before its therapeutic effects become apparent. Although rare, serious adverse drug reactions such as retinal toxicity and visual disturbances can occur with hydroxychloroquine. Therefore, clients are instructed to undergo regular ophthalmologic examination every 6-12 months (Option 1). (Option 2) Hydroxychloroquine should be taken with food to decrease gastrointestinal upset (common side effect). (Option 3) Some clients with severe SLE are prescribed long-term corticosteroid (prednisone) therapy to prevent organ damage and are at risk for adverse reactions, such as accelerated osteoporosis. Osteoporosis is not an adverse reaction of hydroxychloroquine, and vitamin D and calcium supplementation is not required. (Option 4) There are no effects of hydroxychloroquine that would require wearing a MedicAlert bracelet. Educational objective: Hydroxychloroquine (Plaquenil) is used to treat the skin and arthritic manifestations of SLE. Taking the medication with food can help alleviate gastrointestinal upset. Serious adverse drug reactions include retinopathy and visual disturbances; therefore, regular ophthalmologic examination every 6-12 months is required.

The nurse reinforces teaching to a client with HIV during a follow-up clinic visit after being on antiretroviral drugs for the past 2 months. Which statement by the client indicates a need for further instruction? 1. I can stop taking these HIV drugs once my viral levels are undetectable 2. I need to get tested regularly for STIs becuase I am sexually active 3. I should use latex condoms and barriers when having anal, vaginal, or oral sex 4. I won't stop injecting, but I will use a needle exchange program

1. I CAN STOP TAKING THESE HIV DRUGS ONCE MY VIRAL LEVELS ARE UNDETECTABLE Antiretroviral therapy (ART) is a medication regimen consisting of multiple drugs for managing and preventing progression of HIV infections. ART impairs viral replication at multiple points, which leads to decreased viral loads and increased CD4+ (ie, helper T) cell counts. When educating clients about ART, it is critical to explain that treatment is lifelong and requires strict adherence (Option 1). Even clients with undetectable viral loads remain infected with HIV. The discontinuation of, or poor adherence to, ART results in the progression of HIV (which may lead to AIDS) and promotes viral drug resistance. (Option 2) Clients with HIV who are sexually active are at increased risk for sexually transmitted infections (STIs). Regular testing (≥1 time annually) and treatment for STIs are recommended. (Option 3) Latex or polyurethane barriers should be used during sex to prevent STI transmission, as nonbarrier contraception and natural skin condoms (eg, lambskin) offer poor protection against HIV and STI transmission. (Option 4) IV drug use is a common source of HIV infection. Although abstinence from IV drugs is preferred, clients who continue to use them should be instructed to avoid sharing needles and receive information about needle and syringe exchange programs. Educational objective: Clients with HIV must be educated to strictly adhere to prescribed antiretroviral therapy to prevent disease progression. Clients with HIV who are sexually active should seek testing for sexually transmitted infections and use latex condoms/barriers during sex. Clients with HIV should use a needle exchange program if using IV drugs.

The postoperative client on hydromorphone becomes hypoxic, and naloxone is administered per protocol. What is most important for the nurse to consider in the follow-up care of this client? 1. Pt's respiratory status 60 minutes later 2. Documenting the pt's hypoxic event 3. Obtaining an order for a different analgesic 4. Potential for drug-drug interaction now

1. PT'S RESPIRATORY STATUS 60 MINUTES LATER Hydromorphone duration of action is 3-4 hours. The effects of naloxone (Narcan) start to wane at 20-40 minutes after administration, and its duration of action is approximately 90 minutes. Therefore, depending on the hydromorphone dose, its duration of action can continue beyond the duration of the naloxone. Repeat naloxone doses may be necessary. (Option 2) Documentation is essential, but client care is more important than paperwork. (Option 3) Naloxone will reverse the effects of the narcotic in the body and, as long as it is in the body, will reverse the effects of any additional narcotic administered. This client will need a different class of analgesic at this time. However, adequate respiration/oxygenation as the naloxone wears off is more important. (Option 4) Naloxone is the reversal agent for narcotics, and a drug-drug interaction is not a concern. Educational objective: The half-life of naloxone (Narcan) is shorter than most narcotics. When naloxone is used to reverse the effects of narcotics, the nurse must monitor the client to ensure that the client does not fall again into excessive sedation and/or respiratory depression.

The nurse is participating in staff training about protecting clients' privacy and confidentiality. Which of the following incidents does the nurse recognize as a violation of client confidentiality? Select all that apply. 1. A visitor talking in the waiting room states that the pt has alcoholism 2. The LPN has the pt's report sheet in a pocket when going home 3. The CNA tells a pt that the hospital roommate went for a gallbladder test 4. The RN tells a visitor to wear a mask bc the pt is on isolation precautions 5. Two LPNs are discussing a possible cure for AIDS on a crowded elevator

2 & 3 The nurse is ethically and legally obligated to protect clients' privacy and maintain confidentiality of their medical information. Clients' health information should be shared only with other health care team members directly involved in those clients' care. Report sheets used by nursing staff often include clients' private health information and must be shredded at the end of the shift (Option 2). Without the client's permission, information about the diagnosis or diagnostic tests cannot be shared with a hospital roommate (Option 3). (Option 1) Health care staff are not required to censor visitor conversation in waiting rooms. (Option 4) Nurses are obligated to help protect visitors and others by instructing visitors to wear appropriate personal protective equipment. However, the nurse should not violate the client's privacy by sharing the client's diagnosis. (Option 5) Although discussion about specific client information is not permissible, general discussion about health care topics (eg, a potential cure for AIDS) is not a violation of clients' privacy. Educational objective: The nurse must protect clients' privacy and maintain the confidentiality of their medical information. Clients' health information should be discussed only with health care team members directly involved in those clients' care. Nurses must also ensure that documents containing clients' information are shredded after use.

The nurse provides education for caregivers of a client with Alzheimer disease. Which instructions should the nurse include? Select all that apply. 1. COmplete activities such as bathing and dressing as quickly as possible 2. Decrease the pt;s amxiety by limiting the number of choices offered 3. Redirect the pt if agitated by asking for help with a task or going for a walk 4. Remember to interact with the pt as an adult, regardless of childlike affect 5. Use open ended questions when communicating with the pt

2, 3, & 4 Strategies for caring for clients with Alzheimer disease address progressive memory loss and declining ability to communicate, think clearly, and perform activities of daily living. Caregivers should also learn to manage clients' problematic behavior and mood swings. Therapeutic guidelines include: Use distraction and redirection (eg, going for a walk) to manage agitation (Option 3). Speak slowly and use simple words and yes-or-no questions. Do not try to rationalize with the client. Use visual cues when giving directions. Interact with the client as an adult, even as the client regresses to childlike affect and behavior; respect client dignity by avoiding use of pet names (eg, "honey," "sweetie," "darling") (Option 4). Break down complex activities into steps with simple instructions. Decrease the client's anxiety by limiting the number of choices (Option 2). (Option 1) Allow plenty of time for task completion. The client cannot process information rapidly, and hurrying or rushing can cause agitation or anxiety. (Option 5) Ask questions that can be answered with yes, no, or very few words. Do not ask open-ended questions, which can overwhelm the client and cause increased stress and frustration. Educational objective: Caregivers for clients with Alzheimer disease should communicate with the client using yes-or-no questions and simple, step-by-step instructions; treat the client as an adult; limit the number of choices; and allow plenty of time for task completion. Agitated clients can be redirected with new activities (eg, going for a walk).

The emergency department nurse cares for a client admitted with a diagnosis of hyperosmolar hyperglycemic state. The nurse understands which characteristics are commonly associated with this complication? Select all that apply. 1. Abdominal pain 2. BG >600 3. History of type 2 diabetes 4. Kussmaul respirations 5. Neurological manifestations

2, 3, & 5 Hyperosmolar hyperglycemic state is a serious complication usually associated with type 2 diabetes. With this condition, clients are able to produce enough insulin to prevent diabetic ketoacidosis but not enough to prevent extreme hyperglycemia, osmotic diuresis, and extracellular fluid deficit. Because some insulin is produced, blood glucose rises slowly and symptoms may not be recognized until hyperglycemia is extreme, often >600 mg/dL (33.3 mmol/L). This eventually causes neurological manifestations such as blurry vision, lethargy, obtundation, and progression to coma. Because some insulin is present, symptoms associated with ketones and acidosis, such as Kussmaul respirations (hyperventilation) and abdominal pain, are typically absent (Options 1 and 4). Educational objective: Hyperosmolar hyperglycemic state differs from diabetic ketoacidosis in that it is typically associated with type 2 diabetes mellitus. Because these clients produce some insulin, severe hyperglycemia happens more slowly and is often not noted until neurological manifestations occur.

A client with a severe asthma exacerbation following influenza infection is transferred to the intensive care unit due to rapidly deteriorating respiratory status. Which clinical manifestations support the nurse's assessment of impending respiratory failure? Select all that apply. 1. Arterial pH 7.50 2. PaCO2 55 3. PaO2 58 4. Paradoxical breathing 5. Restlessness and drowsiness

2, 3, 4, & 5 Acute severe asthma exacerbations (status asthmaticus) occur when severe airway obstruction and lung hyperinflation (air trapping) persist despite aggressive treatment with bronchodilators and corticosteroid therapy. Clinical manifestations indicating impending respiratory failure include: PaCO2 ≥45 mm Hg (6.0 kPa): Indicates hypercapnia and hypoventilation resulting from fatigue and labored breathing. As initial tachypnea subsides and respiratory rate returns to normal, PaCO2 rises and respiratory acidosis develops (Option 2). PaO2 ≤60 mm Hg (8.0 kPa): Indicates hypoxemia resulting from increased work of breathing, decreased gas exchange (hyperinflation and air trapping), and inability of the lungs to meet the body's oxygen demand (Option 3) Paradoxical breathing (ie, abnormal inward movement of the chest on inspiration and outward movement on expiration): Indicates diaphragm muscle fatigue and use of respiratory accessory muscles (Option 4) Mental status changes (eg, restlessness, confusion, lethargy, drowsiness): Sensitive indicators of hypoxemia and hypoxia (Option 5) Absence of wheezing and silent chest (ie, no sound of air movement on auscultation): Ominous signs indicating severe hyperinflation and air trapping in the lungs Single-word dyspnea: Inability to speak >1 word before pausing to breathe due to shortness of breath (Option 1) Normal arterial pH is 7.35-7.45. A pH of 7.50 indicates alkalosis, which could be respiratory or metabolic. Clients with respiratory failure have respiratory acidosis (low pH and elevated pCO2). Educational objective: Clinical manifestations indicating impending respiratory failure in clients with asthma include hypercapnia, hypoxemia, paradoxical breathing, and mental status changes.

A client with obesity is diagnosed with pulmonary embolism (PE). Which assessment data would the nurse expect to find? Select all that apply. 1. Bradycardia 2. Chest pain 3. Chills and fever 4. Hypoxemia 5. Tachypnea 6. Tracheal deviation

2, 4, & 5 A pulmonary embolus is a blood clot that usually originates from the deep veins of the legs (>90%), travels to the pulmonary circulation, and obstructs a pulmonary artery or one of its branches, resulting in decreased perfusion in relation to ventilation and impaired gas exchange (hypoxemia). Clients are at risk for formation of venous thromboembolism (VTE) when the conditions detailed in Virchow's Triad are present. Clients at risk for PE include those with prolonged immobilization (eg, during hospitalization if not ambulatory), obesity, recent surgery, varicose veins, smoking, heart failure, advanced age, or history of VTE. The assessment data most characteristic of PE include: Dyspnea (85%) Pleuritic chest pain (60%) Tachycardia Tachypnea Hypoxemia (impaired gas exchange, decreased perfusion with normal alveolar ventilation, shunting) Apprehension and anxiety A more atypical presentation can be associated with a larger sized PE, and may include manifestations of cardiopulmonary compromise and hemodynamic instability (eg, right ventricular dysfunction, pulmonary hypertension, systemic hypotension, syncope, loss of consciousness, distended neck veins). (Option 1) A classic manifestation of PE is tachycardia to compensate for hypoxemia (not bradycardia). (Option 3) Chills and fever can indicate the presence of an infection and are not characteristic of PE. However, a low-grade fever without chills can occur 1-2 weeks after PE due to inflammation. (Option 6) Tracheal deviation is a symptom of tension pneumothorax. The trachea deviates from midline toward the unaffected side, away from the collapsed lung. Educational objective: Classic clinical manifestations of PE include dyspnea, pleuritic chest pain, tachycardia, tachypnea, hypoxemia, and feelings of apprehension and anxiety. Risk factors for PE include those detailed in Virchow's Triad (eg, hypercoagulability, venous stasis, and endothelial damage). Massive PE can cause syncope and hemodynamic instability.

The client is scheduled to have a cardiac catheterization. Which findings will cause the nurse to question the safety of the test proceeding? Select all that apply. 1. Elevated c reactive protein level 2. History of previous reaction to IV contrast 3. Prolonged PR interval on ECG 4. Serum creatinine of 2.5 5. Took metformin today for type 2 diabetes

2, 4, 5, Cardiac catheterization involves injection of iodine contrast using a catheter to examine for obstructed coronary arteries. Complications include: Allergic reaction: Clients with a previous allergic reaction to IV contrast may require premedication (eg, corticosteroids, antihistamines) or another contrast medium (Option 2). Clients with shellfish allergies were once believed to be at higher risk, but this has been disproved. Contrast nephropathy: Iodine-containing contrast can cause kidney injury, although this risk can be reduced with adequate hydration. However, clients with renal impairment (eg, serum creatinine >1.3 mg/dL [115 µmol/L]) should not receive IV contrast unless absolutely necessary (Option 4). Lactic acidosis: Metformin (Glucophage) with IV iodine contrast increases the risk for lactic acidosis. Metformin is usually discontinued 24-48 hours before exposure and restarted after 48 hours, when stable renal function is confirmed (Option 5). (Option 1) C-reactive protein, produced during acute inflammation, may reflect an elevated risk for coronary artery disease. However, it does not indicate an acute event and is not a safety concern for this procedure. (Option 3) First-degree atrioventricular block (ie, PR interval >0.20 second) may precede more serious conditions. However, clients are usually asymptomatic and do not require treatment except for stopping the causative medication (eg, beta blockers, digoxin). This would not prevent the test from proceeding. Educational objective: Cardiac catheterization uses IV contrast to assess for artery obstruction. Complications include allergic reactions, lactic acidosis, and kidney injury. Contrast is avoided in clients who had a previous allergic reaction to contrast agents, took metformin in the last 24 hours, or have renal impairment.

The home health nurse visits a client with hand osteoarthritis whose health care provider has recommended topical capsaicin for pain relief. Which instruction about capsaicin should the nurse provide the client? 1. Apply a heating pad or warm compress for 20 minutes after applying cream 2. Apply cream to hands and wait at least 30 minutes before washing them 3. Discontinue immediately if burning or stinging sensation occurs 4. Use only if oral pain medications have not been effective

2. APPLY CREAM TO HANDS AND WAIT AT LEAST 30 MINUTES BEFORE WASHING THEM Topical capsaicin cream (Zostrix) is an over-the-counter analgesic that effectively relieves minor pain (eg, osteoarthritis, neuralgia). The nurse should instruct the client to wait at least 30 minutes after massaging the cream into the hands before washing to ensure adequate absorption (Option 2). The client should avoid contact with mucous membranes (eg, nose, mouth, eyes) or skin that is not intact, as capsaicin is a component of hot peppers and can cause burning. When applying cream to other areas of the body (eg, knee), the client should wear gloves or wash hands immediately after application. (Option 1) The application of heat with capsaicin is contraindicated as heat causes vasodilation, which increases medication absorption and can possibly lead to a chemical burn. (Option 3) Local irritation (burning, stinging, erythema) is quite common and usually subsides within the first week of regular use. If the client experiences persistent pain, redness, or blistering, the cream should be discontinued and the health care provider notified. (Option 4) Topical capsaicin is often used concurrently with acetaminophen or nonsteroidal anti-inflammatory drugs (eg, naproxen, celecoxib) to effectively treat osteoarthritis pain. Capsaicin should be used regularly (3-4 times daily) for long periods (eg, weeks to months) to achieve the desired effect. Educational objective: The topical analgesic capsaicin relieves minor peripheral pain (eg, osteoarthritis, neuralgia) with regular use. Local irritation (burning, stinging, erythema) is quite common. The client should wait at least 30 minutes before washing the affected area to ensure adequate absorption.

A client comes to the emergency department with severe dyspnea and a cough. Vital signs are temperature 99.2 F (37.3 C), blood pressure 108/70 mm Hg, heart rate 88/min, and respirations 24/min. The client has a history of chronic obstructive pulmonary disease (COPD) and chronic heart failure. Which diagnostic test will be most useful to the nurse in determining if this is an exacerbation of heart failure? 1. ABGs 2. BNP 3. CKMB 4. Chest x ray

2. BNP BNP is a peptide that causes natriuresis. B-type natriuretic peptides are made, stored, and released primarily by the ventricles. They are produced in response to stretching of the ventricles due to the increased blood volume and higher levels of extracellular fluid (fluid overload) that accompany heart failure. Elevation of BNP >100 pg/mL helps to distinguish cardiac from respiratory causes of dyspnea. (Option 1) ABGs will be helpful in determining the client's oxygenation status and acid-base balance but will not determine whether the cause of the dyspnea is cardiac or respiratory. (Option 3) CK-MB is a cardiospecific isozyme that is released in the presence of myocardial tissue injury. Elevations are highly indicative of a myocardial infarction but not specific for heart failure. (Option 4) A chest x-ray can show heart enlargement in the case of heart failure and may show infiltrations in the lungs. Pneumonia can also exacerbate COPD and can be confused with heart failure infiltrates. Chest x-ray is not as specific to heart failure as the BNP lab test. Educational objective: Elevation of BNP to >100 pg/mL is seen in heart failure. It aids in the assessment of the severity of heart failure and helps distinguish cardiac from respiratory causes of dyspnea.

The nurse is performing a postpartum assessment 12 hours after the prolonged vaginal delivery of a term infant. Which assessment findings should be reported to the health care provider? 1. Complaints of discomfort during fundal palpation 2. Foul smelling lochia 3. Oral temp 100.1 4. White blood cell 24,000

2. FOUL SMELLING LOCHIA A foul odor of lochia suggests endometrial infection. This client has an increased risk of infection due to her prolonged labor, which involved multiple cervical examinations. The odor of lochia is usually described as "fleshy" or "musty." A foul smell warrants further evaluation. Other signs of endometrial infection are maternal fever, tachycardia, and uterine pain/tenderness. (Option 1) Palpation of the postpartum uterine fundus is commonly uncomfortable for the client. If the client complains of increasing pain, further evaluation is needed. (Option 3) Major signs and symptoms of endometrial infection include temperature above 100.4 F (38.0 C); chills; malaise; excessive uterine tenderness; and purulent, foul-smelling lochia. During the first 24 hours postpartum, the temperature is normally elevated; temperature above 100.4 F (38 C) requires further evaluation. (Option 4) The WBC count is normally elevated during the first 24 hours postpartum (up to 30,000/mm3 [30.0 x 109/L]). Leukocyte levels that are not decreasing require further evaluation. Educational objective: Signs of endometrial infection include elevated temperature, chills, malaise, excessive pain, and foul-smelling lochia. During the first 24 hours postpartum, temperature and WBC count are normally elevated. Fever and leukocyte counts that do not decrease require further evaluation.

The nurse is caring for a client who had surgery yesterday. When administering omeprazole, the client asks "What is that for? I don't take it at home." Which reply by the nurse is most appropriate? 1. Will prevent nausea by making your stomach empty faster 2. Helps prevent you from developing an ulcer due to the stress of surgery 3. Protects you from getting an infection while on antibiotics 4. Will treat your GERD

2. HELPS PREVENT YOU FROM DEVELOPING AN ULCER DUE TO THE STRESS OF SURGERY Omeprazole is a proton pump inhibitor (PPI) that suppresses the production of gastric acid by inhibiting the proton pump in the parietal cells of the stomach. In most hospitalized clients without a history of GERD or ulcers, PPIs are prescribed to prevent stress ulcers from developing during surgery or a major illness. Although evidence has shown that two-thirds of clients who receive PPIs do not need them, these medications are still widely prescribed in hospitalized clients. PPIs can be identified by their "-prazole" ending (eg, pantoprazole, lansoprazole, esomeprazole). (Option 1) Metoclopramide (Reglan) is not a PPI. It decreases postoperative nausea by promoting gastric emptying. (Option 3) PPIs may be associated with an increased risk of Clostridium difficile infection with antibiotic use. (Option 4) The client does not take this medication at home. The nurse is assuming that the client has a history of GERD rather than assessing for this condition first. Educational objective: PPIs such as omeprazole are often prescribed to hospitalized clients without GERD or ulcers to prevent stress ulcers from developing during surgery or a major illness.

In the intensive care unit, the nurse cares for a client who is being treated for hypotension with a continuous infusion of dopamine. Which assessment finding indicates that the infusion rate may need to be adjusted? 1. CVP of 6 2. HR of 120 3. MAP of 78 4. SVR of 900

2. HR OF 120 Dopamine (Intropin) is a sympathomimetic inotropic medication used therapeutically to improve hemodynamic status in clients with shock and heart failure. It enhances cardiac output by increasing myocardial contractility, increasing heart rate, and elevating blood pressure through vasoconstriction. Renal perfusion is also improved, resulting in increased urine output. The lowest effective dose of dopamine should be used as dopamine administration leads to an increased cardiac workload. Significant adverse effects include tachycardia, dysrhythmias, and myocardial ischemia. A heart rate of 120/min may indicate that the dopamine infusion needs to be reduced (Option 2). (Options 1, 3, and 4) These measurements fall within the respective reference ranges and do not indicate a need to adjust dopamine administration. Normal central venous pressure is 2-8 mm Hg; normal mean arterial pressure ([systolic blood pressure + (2 x diastolic blood pressure)]/3) is 70-105 mm Hg; and normal systemic vascular resistance is 800-1200 dynes/sec/cm-5. Educational objective: Dopamine is a sympathomimetic inotropic agent that increases heart rate, blood pressure, cardiac output, and urine output. Vital signs should be monitored closely in these clients as a higher dose can result in dangerous tachycardia and tachyarrhythmias.

A nurse is caring for a pregnant client at 27 weeks gestation after a motor vehicle collision with side airbag deployment. The client's blood type is O negative. Which laboratory test should the nurse anticipate? 1. Group B streptococcal sulture 2. Indirect coombs test 3. Rubella immunity titer 4. Serum alpha fetorotein

2. INDIRECT COOMBS TEST During pregnancy, the mother and fetus have separate blood supply mechanisms. However, disruption of this separation can occur at delivery or when trauma results in fetomaternal hemorrhage (eg, placental abruption after a motor vehicle collision). If an Rh-negative mother (eg, O negative blood type) is exposed to Rh-positive fetal blood (if the father is Rh positive), the pregnant client develops antibodies to the Rh antigen (ie, Rh sensitization), placing the current fetus and all future pregnancies at risk for serious complications (eg, hemolytic anemia). An indirect Coombs test is performed to screen for Rh sensitization any time hemorrhage secondary to placental abruption is suspected (eg, maternal trauma) (Option 2). Rh immune globulin (eg, RhoGAM) is administered to all Rh-negative pregnant clients at 28 weeks gestation and within 72 hours postpartum, as well as after any maternal trauma, to prevent the development of permanent Rh antibodies. RhoGAM is not effective once sensitization has occurred. (Option 1) Perineal group B streptococcal cultures are routinely obtained at 35-37 weeks gestation to determine the need for antibiotics during labor to prevent neonatal infection. (Option 3) Testing for rubella immunity is performed in the first trimester; nonimmune mothers receive the measles-mumps-rubella vaccine in the immediate postpartum period. (Option 4) Serum alpha-fetoprotein is a blood test to screen for fetal neural tube defects. Educational objective: Indirect Coombs testing screens for Rh sensitization in Rh-negative mothers. If the test results are positive, the fetus and subsequent pregnancies are at risk for serious complications. Rh immune globulin (eg, RhoGAM) is given at 28 weeks gestation and within 72 hours postpartum as well as any time there is maternal trauma.

The nurse reviews the external fetal monitoring tracing of a client receiving an oxytocin infusion for augmentation of labor. The obstetric provider asks to increase the infusion rate. Which action by the nurse is most appropriate at this time? Click on the exhibit button for additional information. 1. Increase the rate of oxytocin infusion as requested by the provider 2. Inform the provider that the oxytocin rate sshould not be increased at this time 3. Request that the charge nurse speak with the obstetric provider 4. Request to leave the rate unchanged, as the contraction pattern in adequate

2. INFORM THE PROVIDER THAT THE OXYTOCIN RATE SHOULD NOT BE INCREASED AT THIS TIME Uterotonic drugs (eg, oxytocin [Pitocin]) are used to induce or augment labor and to stop postpartum hemorrhage by promoting uterine contractions. Oxytocin must be administered via infusion pump and requires continuous electronic fetal monitoring as it is a high-alert medication. The nurse assesses and documents the fetal heart rate and contraction pattern every 15 minutes during the first stage of labor with oxytocin. Most oxytocin protocols dictate gradual titration to achieve contractions every 2-3 minutes. Tachysystole (ie, ≥5 contractions in 10 minutes) is a potential adverse effect of oxytocin. Excessive uterine contractions can decrease placental blood flow and compromise fetal oxygenation. Treatment of tachysystole may include decreasing or stopping oxytocin infusion and administering IV fluid bolus and/or tocolytic drugs (eg, terbutaline) (Option 2). (Option 1) The tracing shows excessive uterine contractions. Increasing the rate of oxytocin may further intensify the contractions and put the client at risk. (Option 3) The nurse should first independently communicate concerns to the provider. If the provider disagrees with the nurse's assessment, the charge nurse can then assist with communication. (Option 4) This response does not accurately communicate the client's status to the provider. Educational objective: Uterotonic drugs (eg, oxytocin) promote uterine contractions. If tachysystole (ie, ≥5 contractions in 10 minutes) develops, the client is at risk for decreased placental blood flow. The oxytocin infusion rate is decreased or discontinued.

The nurse is planning care for a child being admitted with Kawasaki disease and should give priority to which nursing intervention? 1. Apply cool compresses to the skin of the hands and feet 2. Monitor for a gallop heart rhythm and decreased urine output 3. Prepare a quiet, non stimulating envorinment 4. Provide soft foods and liberal amounts of clear liquid

2. MONITOR FOR A GALLOP HEART RHYTHM AND DECREASED URINE OUTPUT Kawasaki disease (KD) is a childhood condition that causes inflammation of arterial walls (vasculitis). The coronary arteries are affected in KD, and some children develop coronary aneurysms. The etiology of KD is unknown; there are no diagnostic tests to confirm the disease, and it is not contagious. KD has 3 phases: Acute - sudden onset of high fever that does not respond to antibiotics or antipyretics. The child becomes very irritable and develops swollen red feet and hands. The lips become swollen and cracked, and the tongue can also become red (strawberry tongue). Subacute - skin begins to peel from the hands and feet. The child remains very irritable. Convalescent - symptoms disappear slowly. The child's temperament returns to normal. Initial treatment consists of IV gamma globulin (IVIG) and aspirin. IVIG creates high plasma oncotic pressure, and signs of fluid overload and pulmonary edema develop if it is given in large quantities. Therefore, the child should be monitored for symptoms of heart failure (eg, decreased urinary output, additional heart sounds, tachycardia, difficulty breathing). (Option 1) During the acute phase (swollen hands and feet), skin discomfort can be eased with cool compresses and lotions. No treatment is needed in the subacute phase (skin peeling), but the new skin might be very tender. (Option 3) The child will be very irritable during the acute phase of KD. A non-stimulating, quiet environment will help to promote rest. After a KD episode, it is important for parents to understand that their child's irritability may last for up to 2 months and that follow-up appointments for cardiac evaluation are important. (Option 4) During the acute phase (painful swollen lips and tongue), the child should be given soft foods and clear liquids as these are tolerated best. Educational objective: Kawasaki disease causes inflammation of the arterial walls and can lead to scarring of the coronary arteries or development of coronary aneurysms. Treatment consists of aspirin and substantial infusion of IV gamma globulin. The affected child must be monitored for signs of heart failure.

The nurse is interviewing a non-English-speaking client. Which best practices will the nurse use when working with a professional medical interpreter for clients of limited English proficiency? Select all that apply. 1. Address the interpreter directly 2. Ask the pt's adult child to translate 3. Hold a preconference with the interpreter 4. Identify any gender or age preferences 5. Speak in short sentences

3, 4, & 5 Title IV of the Civil Rights Act of 1964 initiated national standards for appropriate care of culturally diverse clients. Clients with limited English proficiency have the right to receive medical interpreter services free of charge. When working with an interpreter, the nurse should apply the following best practices to maximize communication and understanding with the client: Address the client directly in the first person Speak in short sentences, pausing to allow the interpreter to speak (Option 5) Ask only one question at a time Avoid complex issues, idioms, jokes, and medical jargon Hold a pre-conference with the medical interpreter to review the goals of the interview (Option 3) Use a qualified professional interpreter whenever possible The nurse should avoid using interpreters from conflicting cultures (eg, Palestinian, Jewish) and be mindful of any cultural, gender, or age preferences (Option 4). (Option 1) The nurse should speak directly to the client, not the interpreter. (Option 2) A family member or friend may not have the vocabulary, knowledge, or skills to provide the best communication for the client. Untrained interpreters may omit or simplify critical pieces of information if they do not understand the terminology. Educational objective: When working with a medical interpreter, the nurse should apply best practices to maximize communication and understanding with the client. Key practices include speaking to the client directly; using short, simple sentences; avoiding the use of family members as interpreters; and being mindful of cultural, gender, or age preferences.

The charge nurse is making assignments for the oncoming shift. Which client assignments should be avoided by the nurse who is pregnant? 1. 2 year old pt who is combative on postoperative day 2 for tonisllectomy and adenectomy 2. 5 year old pt admitted for dehydration secondary to severe throat pain associated with group B strep 3. 9 year old pt with parvovirus b-19 infection admitted for observation after a febrile seizure 4. 14 year old pt with ALL who received intrathecal chemotherapy 4 days ago and was admitted for a blood transfusion

3. 9 YEAR OLD WITH PARVOVIRUS b 19 INFECTION ADMITTED FOR OBSERVATION AFTER A FEBRILE SEIZURE Parvovirus B-19 is a common childhood infection also known as "fifth disease." Infected clients display a characteristic "slapped cheek" rash on the face. Symptoms range in severity; however, most children do not require intervention. Transmission of the infection is usually through person-to-person contact, especially with respiratory secretions. Although rare, infection with parvovirus B-19 during pregnancy can cause fetal anomalies (eg, hydrops fetalis, stillbirth). It is recognized as a TORCH infection (Toxoplasmosis, Other [parvo-B19/varicella zoster], Rubella, Cytomegalovirus, Herpes simplex virus), a group of infections that cause fetal abnormalities. Delegation of this client to a pregnant nurse is inappropriate due to potential harm to the fetus. (Option 1) A combative toddler should not be a hazard to the pregnant nurse. Appropriate precautions should be taken to ensure safety around combative clients. (Option 2) Group A Streptococcus infection requires droplet precautions; however, it does not pose a perinatal infection risk. Group A Streptococcus may manifest as sore throat. (Option 4) Extreme caution should be taken while handling cytotoxic medications; however, intrathecal administration days prior to contact should not pose a risk to the pregnant nurse. The nurse should use standard precautions if contact with the client's blood or bodily fluids is anticipated. Educational objective: Clients with infectious diseases that can be transmitted to the fetus (eg, TORCH infections) should not be assigned to a pregnant nurse. These infections, including parvovirus B19, can cause severe anomalies in the developing fetus.

The risk management nurse is reviewing client records. Which nursing intervention could have contributed to a sentinel event? 1. Administered flumanezil to a pt who overdosed on lorazepam 2. Adminstered insulin/dextrose to a pt with a potassium level of 7.2 3. Administered warfarin to a pt with an INPR of 6 4. Initiated nitroprusside infusion in a pt with BP of 210/1123.

3. ADMINISTERED WARFARIN TO A PT WITH INR OF 6 A sentinel event is any unanticipated event in a health care setting that results in death or serious physical or psychological injury. Warfarin is an anticoagulant often used in clients with the following: Atrial fibrillation (to prevent clot formation and reduce the risk for stroke) Deep venous thrombosis and pulmonary embolism (to prevent additional clots) Mechanical heart valves (to prevent clot formation on valves) The International Normalized Ratio (INR) is a blood test used to monitor the effectiveness of warfarin therapy. The typical target INR is 2-3. In some instances (eg, mechanical heart valves), the therapeutic INR target is as high as 3.5. The higher the INR, the higher the bleeding risk. The nurse should not administer warfarin if the INR is over 4. (Option 1) Flumazenil is the appropriate antidote for a benzodiazepine overdose. (Option 2) Insulin quickly lowers serum potassium by pushing it intracellularly. Dextrose is given to prevent hypoglycemia. This is an appropriate action. (Option 4) Nitroprusside is a potent vasodilator often used for hypertensive urgencies. Educational objective: The target International Normalized Ratio (INR) for most conditions in which warfarin is used is normally 2-3 and is occasionally 3.5. The risk of bleeding increases as the INR rises.

A 12-month-old is found to have a moderately elevated blood lead level. Which of the following is the most serious concern for this child? 1. GI bleeding 2. Growth retardation 3. Neurocognitive impairment 4. Severe liver injury

3. NEUROCOGNITIVE IMPAIRMENT Lead poisoning still occurs in the United States, although not as often as in previous decades. A common source of exposure is lead-based paints found in houses built before 1978, when such paint was banned. Blood lead level (BLL) screenings are recommended at ages 1 and 2, and up to age 6 if not previously tested. Because lead poisoning particularly affects the neurological system, elevated BLLs (≥5 mcg/dL [0.24 µmol/L]) are dangerous in young children due to immature development of the brain and nervous system. A mild to moderate increase in BLL can manifest with hyperactivity and impulsiveness; prolonged low-level exposure can cause developmental delays, reading difficulties, and visual-motor issues. Extremely elevated BLLs can lead to permanent cognitive impairment, seizures, blindness, or even death. (Option 1) Gastrointestinal bleeding is a concern for clients with iron poisoning but has no link to lead toxicity. (Option 2) Although delays in physical growth can result from chronic lead toxicity, the danger of permanent damage to the neurological system is a higher priority, particularly for young children. Growth retardation more commonly occurs with chronic anemia or pituitary disorders. (Option 4) Lead poisoning is most threatening to the kidneys and neurological system; liver injury typically does not occur. Severe liver damage is closely associated with acetaminophen overdose or Reye syndrome. Educational objective: Lead poisoning can lead to many severe complications of the neurological system (eg, developmental delays, cognitive impairment, seizures). Elevated blood lead levels are particularly dangerous in young children due to immature development of the brain and nervous system.

A client is 48 hours post abdominal aneurysm repair. Which assessment by the nurse is cause for greatest concern? 1. DIminished breath sounds in bilateral lung bases 2. Hpoactive bowel sounds in all four quadrants 3. Urinary outout of 90 ml in the past 4 hours 4. Warm extremities with 1+ bilateral pulses

3. URINARY OUTPUT OF 90ML IN THE PAST 4 HOURS Renal perfusion status is monitored closely in a client who has had abdominal aneurysm repair. Hypotension, dehydration, prolonged aortic clamping during surgery, blood loss, or embolization can lead to decreased renal perfusion and potential kidney injury. The nurse should routinely monitor the client's blood urea nitrogen (BUN) and creatinine levels as well as urine output. Urine output should be at least 30 mL/hr. This client should have an output of at least 120 mL of urine in a 4-hour period. (Option 1) Diminished breath sounds in the lung bases are a common occurrence after surgery, especially in a client who has an abdominal incision that is painful with deep inspiration. The nurse should medicate the client for pain and encourage coughing, deep breathing, and use of an incentive spirometer. (Option 2) Hypoactive bowel sounds are typical after abdominal surgery as the bowel has been handled and manipulated. Clients often have a nasogastric tube for suction until bowel sounds return. The nurse should continue to monitor for bowel sounds and the presence of flatus. (Option 4) A decreased or absent pulse, together with cool, pale, or mottled extremities, would be cause for concern. This client has warm extremities. Pulses should be compared with preoperative status and can be verified with a Doppler if needed. Educational objective: The nurse should carefully monitor renal status in a client who has had abdominal aortic aneurysm repair. BUN, creatinine, and urine output should be assessed. Urine output of at least 30 mL/hr is expected.

The nurse evaluates the effectiveness of desmopressin use for diabetes insipidus in a client with a pituitary tumor. Which client assessment finding indicates that the medication is having the desired effect? 1. Appetite has improved 2. Blood glucose is 110 3. Urine output has decreased 4. Urine specific gravity is lower

3. URINE OUTPUT HAS DECREASED Diabetes insipidus (DI) results in low levels of antidiuretic hormone (ADH), which is produced by the hypothalamus and stored in the pituitary gland. The function of ADH is to concentrate urine by signaling the kidneys to retain water in the setting of thirst. When ADH levels are insufficient, the kidneys excrete large quantities of very dilute urine (polyuria). This causes hypernatremia (elevated serum sodium due to deficit of free water) and increased serum osmolality, which lead to excessive thirst (polydipsia). Desmopressin acetate (DDAVP) is a synthetic form of ADH, which can be administered intravenously, orally, or via nasal spray. Effectiveness of therapy with desmopressin would be manifested by decreased urinary output and increased urine specific gravity as the urine becomes less dilute (Option 3). (Option 1) A client's thirst, not appetite, is affected by DI. (Option 2) DI is related to water balance, but not to diabetes mellitus, a disorder of glucose metabolism. (Option 4) If desmopressin therapy is effective, the client's urine specific gravity will be higher due to the urine output decreasing and becoming less dilute. Educational objective: Use of desmopressin acetate (DDAVP) in clients with diabetes insipidus will lower urinary output and cause the urine specific gravity to increase.

A newborn client is seen in the emergency department for vomiting. Which assessment finding indicates a possible emergency? 1. frequent vomiting since birth 2. Tiny blood streaks in the vomit 3. Vomit that is green 4. Vomiting through the nose

3. VOMIT THAT IS GREEN Bile made by the liver is green and is released into the duodenum on eating to aid digestion. When there is an obstruction in the intestines and stool cannot pass, it may come back up as green vomit. A bowel obstruction is an emergency that can lead to bowel rupture, peritonitis, and sepsis. (Option 1) Newborns vomit or spit up frequently as they adjust to eating and digesting food. They also have a loose lower esophageal sphincter that allows food to come up from the stomach easily. Hydration status and weight gain should be monitored. (Option 2) Tiny blood streaks may be noted due to rupture of pressured esophageal veins from frequent vomiting. This is not a cause for concern unless the vomit contains a large amount of blood or blood-streaked vomiting persists. Scant amounts seen in vomit can be normal. (Option 4) It is not uncommon for a newborn to have vomiting through the nose because the esophagus is connected to the nose and mouth. The vomit comes up through the esophagus and, if forceful enough, will come out of both orifices. Educational objective: It is common for newborns to vomit frequently as they learn to eat and digest. Hydration status and weight gain should be monitored. Green vomit represents bile from the intestine, which could indicate a bowel obstruction.

The nurse assesses a pediatric client who was diagnosed with diarrhea caused by Escherichia coli. The nurse is most concerned with which finding? 1. Blood streaked stools 2. Pt drank fruit juice 3. Dry mucous membranes 4. Petechiae noted on the trunk

4. PETECHIAE NOTED ON THE TRUNK Hemolytic uremic syndrome (HUS) is a life-threatening complication of Escherichia coli diarrhea and results in red cell hemolysis, low platelets, and acute kidney injury. Hemolysis results in anemia, and low platelets manifest as petechiae or purpura. Therefore, the presence of petechiae in this client could indicate underlying HUS and needs further assessment. (Option 1) E coli bacteria infect people through contaminated food or water and attack the digestive system. Blood-streaked stool due to intestinal irritation is a common symptom associated with this illness. Treatment is aimed at preventing dehydration, and clients usually improve in about a week. (Option 2) Fruit juices are discouraged in acute diarrhea as they have high sugar (osmolality) and low electrolyte content. Continuing the client's normal diet (solid foods) is encouraged as it shortens the duration and severity of the diarrhea. (Option 3) Dry mucous membranes are a sign of dehydration, a common complication of any persistent diarrhea. Dehydration should be treated promptly, especially in children; however, as long as fluid is replenished, the condition is not life-threatening. Educational objective: Hemolytic uremic syndrome is a life-threatening complication of Escherichia coli diarrhea. Clinical features include anemia (pallor), low platelets (petechiae and purpura), and acute kidney injury (low urine output).

The nurse is reviewing laboratory data of a client who is receiving warfarin therapy for atrial fibrillation. Today's INR is 5.0. What action should the nurse take? 1. Administer the next scheduled dose of warfarin 2. Anticipate infusing fresh, frozen plasma 3. Call the pharmacy to see if protamine is available 4. Request a prescription from the HCP for vitamin K

4. REQUEST A PRESCRIPTION FROM THE HCP FOR VITAMIN K A therapeutic INR level is dependent on the reason the client is receiving the warfarin (an anticoagulant). Typically the therapeutic INR range should be 1.5-2 times the normal "control" value (INR of 2-3) for medical reasons such as deep vein thrombosis, atrial fibrillation, or stroke. An INR of 3 to 3.5 is desired for the client with a mechanical heart valve. An INR of 5.0 or higher places the client at risk for bleeding and requires a dosage adjustment of the warfarin or the administration of vitamin K as an antidote. (Option 1) The warfarin should not be administered with an INR of 5. The nurse should hold the dose until further instructions have been received by the HCP. (Option 2) Fresh, frozen plasma is considered when major bleeding is occurring related to warfarin overdose, but this is typically after the vitamin K has been administered. (Option 3) Protamine is the reversal agent for heparin overdoses. Educational objective: The nurse should hold a dose of warfarin for an INR over 4 and notify the HCP. Vitamin K may need to be administered for INRs of 5 or greater.

An elderly client with a history of stable chronic obstructive pulmonary disease, alcohol abuse, and cirrhosis has a serum theophylline level of 25.8 mcg/mL (143 µmol/L). Which clinical manifestation associated with theophylline toxicity should worry the nurse most? 1. Alterations in color vision 2. Gingival hypertrophy 3. Hyperthermia 4. Seizure activity

4. SEIZURE ACTIVITY Theophylline has narrow therapeutic index and plasma concentrations >20 mcg/mL (111 µmol/L) are associated with theophylline drug toxicity. Toxicity can be acute or chronic. Conditions associated with chronic toxicity include advanced age (>60), drug interactions (eg, alcohol, macrolide and quinolone antibiotics), and liver disease. Acute toxicity is associated with intentional or accidental overdose. Symptoms of toxicity usually manifest as central nervous system stimulation (eg, headache, insomnia, seizures), gastrointestinal disturbances (eg, nausea, vomiting), and cardiac toxicity (eg, arrhythmia). (Option 1) Alteration in color perception and visual changes are commonly seen with digoxin toxicity. (Option 2) Gum hypertrophy is seen with phenytoin toxicity. (Option 3) Hyperthermia and tinnitus are often seen with aspirin overdose. Educational objective: Theophylline plasma concentrations >20 mcg/mL (111 µmol/L) are associated with theophylline drug toxicity. Seizures (central nervous system stimulation) and cardiac arrhythmias are the most serious and lethal consequences.

A nurse reviews the most current serum laboratory results for assigned clients. Which result is the highest priority to report to the health care provider? 1. Albumin of 3.0 in a pt with heptatis 2. BNP of 400 in a pt with HF 3. Magnesium of 1.7 in a pt with alcohol withdrawal 4. Sodium of 120 in a pt with small cell lung cancer

4. SODIUM OF 120 IN A PT WITH SMALL CELL LUNG CANCER Syndrome of inappropriate antidiuretic hormone secretion (SIADH) is often caused by the ectopic production of ADH by a malignant lung tumor (eg, lung cancer). Increased ADH leads to increased water reabsorption and intravascular volume, which results in dilutional hyponatremia. Severe neurologic dysfunction (eg, confusion, seizures) can occur when serum sodium drops below 120 mEq/L (120 mmol/L) (normal: 135-145 mEq/L [135-145 mmol/L]). Therefore, hyponatremia is the highest priority to report as it poses the greatest threat to survival. Hyponatremia requires immediate evaluation and treatment (eg, seizure precautions, fluid restriction, intravenous hypertonic saline) by the health care provider. (Option 1) Albumin (normal: 3.5-5.0 g/dL [35-50 g/L]) is a protein formed in the liver. Hepatocytes lose the ability to synthesize albumin when the cells are diseased. Hypoalbuminemia (<3.5 g/dL [<35 g/L]) should be expected in this client. (Option 2) B-type natriuretic peptide (BNP) (normal: <100 pg/mL [100 pmol/L]) is a substance secreted from the cardiac ventricles in response to increases in ventricular pressures and volume. Therefore, BNP is a marker for heart failure and is elevated in clients with both stable and decompensated heart failure. BNP is an expected finding in this client. (Option 3) Clients in alcohol withdrawal usually require magnesium supplements. Hypomagnesemia (<1.5 mEq/L [<0.75 mmol/L]) results from poor dietary intake, malnutrition, and increased renal excretion, and is common in clients with chronic alcoholism. This finding is within normal limits (normal: 1.5-2.5 mEq/L [0.75-1.25 mmol/L]). Educational objective: Malignant lung tumors are a common cause of syndrome of inappropriate antidiuretic hormone secretion (SIADH). When serum sodium drops below 120 mEq/L (120 mmol/L), immediate intervention is necessary to prevent severe neurologic dysfunction. Fluid restriction is recommended for clients with SIADH.

The flight nurse assesses an alert and oriented client at an industrial accident scene who was impaled in the abdomen by a pair of scissors. Which nursing action is the immediate priority on arrival at the scene? 1. Insert a large bore IV line & infuse NS 2. Obtain blood for type and crossmatch and hgb 3. Remove constrictive clothing to enhance circulation 4. Stabilize the scissors witrh sterile bulky dressings

4. STABILIZE THE SCISSORS WITH STERILE BULKY DRESSINGS A sharp object that pierces the skin and lodges in the body may result in penetrating trauma to nearby tissue and organs. Common types of impaled (embedded) objects include bullets or blast fragments from firearms as well as sharp objects such as scissors, nails, or knives. The embedded object creates a puncture wound and then controls potential bleeding by putting pressure on the wound. First responders should not manipulate or remove the impaled object. Manipulation or removal may cause further trauma and bleeding; therefore, stabilization of the object is the first priority to prevent it from moving during initial client assessment (Option 4) and later during transport to a health care facility where skilled trauma care is available. Exception to the rule: First responders (EMS providers) may remove the impaled object if it obstructs the airway and prevents effective cardiopulmonary resuscitation. (Option 1) An IV line may be inserted and fluids begun on scene after stabilization of the object and initial assessment. (Option 2) Blood may be drawn after stabilization of the object and initial assessment. (Option 3) Clothing may be removed on scene after stabilization of the object and initial assessment. Educational objective: An impaled object should not be manipulated or removed at the scene as further trauma and bleeding of soft tissue and surrounding organs may occur. The embedded object is stabilized on scene to allow for initial client assessment and later transport to a health care facility where skilled trauma care is available.

A client presents to the emergency department with alcohol intoxication. Assessment shows nystagmus, ataxia, and confusion. The client's breath smells of alcohol. Which prescription from the health care provider should the nurse implement first? 1. Blood draw for liver function tests 2. D5 1/2 NS 3. Folic acid, IV 4. Thiamine, IV

4. THIAMINE, IV Clients with alcoholism can have hypoglycemia. They can also have thiamine (vitamin B1) deficiency related to poor nutrient intake (a healthy diet contains enough thiamine) and alcohol-induced suppression of thiamine absorption. Thiamine deficiency can result in Wernicke encephalopathy (WE). Untreated WE can lead to death or neurologic morbidity (Korsakoff psychosis). In the setting of alcoholism, administered glucose is oxidized by using all the existing thiamine in the body; this can worsen thiamine deficiency, which in turn can precipitate the development of WE in a previously unaffected individual. Because the signs of alcohol intoxication and WE are similar, all intoxicated clients should be given IV thiamine before or with IV glucose (Options 2 and 4). (Option 1) A blood draw for liver functions tests to rule out alcoholic hepatitis is important but not a priority. (Option 3) Clients with alcoholism usually have additional nutritional deficiencies (eg, folic acid, magnesium). Magnesium and multiple vitamins should also be given to these clients. However, thiamine is the essential vitamin to administer before or with IV glucose in a client with suspected alcoholism. Educational objective: IV thiamine is given before or with IV glucose to a client with alcohol intoxication to prevent Wernicke encephalopathy. Clients with alcoholism often have thiamine deficiency.

The nurse is caring for a client with an inflammatory bowel disease exacerbation. The client is prescribed sulfasalazine. Which finding would require a priority follow-up by the nurse? 1. Elevated erhythrocyte sedimentation rate 2. Hgb 10.5 3. Urine with yellow-orange discoloration 4. Urine specific gravity 1.035

4. URINE SPECIFIC GRAVITY 1.035 Sulfasalazine (Azulfidine) contains sulfapyridine and aspirin (5-ASA) and is used as a topical gastrointestinal anti-inflammatory and immunomodulatory agent in inflammatory bowel disease (IBD). When the 5-ASA is combined with the sulfa preparation, the drug does not become absorbed until it reaches the colon. Dehydration is a risk with IBD as the client can have up to 20 diarrheal stools a day. The client usually does not feel thirsty until after there is a fluid volume deficit. Sulfa can crystallize in the kidney if the client is dehydrated. Normal urine specific gravity is 1.003-1.030. Elevated specific gravity can indicate concentrated urine and be a sign of dehydration (Option 4). (Option 1) Due to the inflammatory nature of IBD, erythrocyte sedimentation rate, C-reactive protein, and white blood cells can be elevated. This is an expected finding during an exacerbation. (Option 2) Mild to moderate anemia (normal hemoglobin 13.2-17.3 g/dL [132-173 g/L] for males, 11.7-15.5 g/dL [117-155 g/L] for females) is common with most chronic inflammatory conditions (eg, rheumatoid arthritis, IBD) as the body cannot use the available iron in bone marrow with active inflammation. In addition, IBD exacerbation usually includes bloody stools, resulting in blood loss iron deficiency anemia. This needs follow-up but is not a priority. (Option 3) Yellow-orange discoloration of the client's skin and urine is an expected side effect from the drug. Educational objective: Dehydration is a concern with sulfasalazine and most other "sulfa" medications due to the risk of crystal formation in the kidney. It is also a potential complication of inflammatory bowel disease.

A client is diagnosed with carpal tunnel syndrome (CTS). Teaching for this client is primarily focused on which of the following? 1. No caffeine and smoking 2. Repetitive hand exercises 3. Use of elastic compression 4. Use of hand splint

4. USE OF HAND SPLINT Carpal tunnel syndrome (CTS) is caused by compression of a median nerve within the carpal tunnel at the wrist. Any swelling in the canal puts pressure on the nerve and produces pain and paresthesia in the median nerve distribution (first 3½ digits). These symptoms are often worse at night when the wrists are flexed during sleep. The most commonly used conservative treatment is wrist splinting, particularly at nighttime. Splinting of the wrist prevents excessive flexion or extension, which could narrow the carpal tunnel. (Option 1) Caffeine and tobacco products do not affect CTS. (Options 2 and 3) Repetitive hand exercises and elastic compression would make the symptoms worse by narrowing the carpal tunnel. Educational objective: Carpal tunnel syndrome (CTS) is caused by compression of a median nerve at the wrist. Nighttime wrist splinting is most beneficial.