July 16th

The nurse is teaching a group of clients diagnosed with diabetes mellitus. Which lesson regarding foot care should be included? Select all that apply. 1. Cut toenails straight across and file along the curves of the toes 2. Rub feet vigorously with a towel after bathing to ensure dryness 3. Use a mild foot powder on perspiring feet 4. Use cotton or lamb's wool to separate overlapping toes 5. Use an over the counter corn removal kit to remove corns or calluses

1, 3, & 4 Individuals with type I or II diabetes mellitus are at increased risk for developing an infection or ulcer on their feet. This is due to the chronic complication of peripheral neuropathy, which results from nerve damage in the extremities. Instructions for diabetic foot care include: Wash feet daily with warm water and mild soap; test water temperature with thermometer beforehand. Gently pat feet dry, particularly between the toes (Option 2). Use lanolin to prevent dry and cracked skin, but do not apply between the toes. Inspect for abrasions, cuts, or sores. Have others inspect the feet if eyesight is poor. To prevent injury, use cotton or lamb's wool to separate overlapping toes. Cut toenails straight across and use a nail file to file along the curves of the toes. Avoid going barefoot and wear sturdy leather shoes. Use mild foot powder to absorb perspiration and wear clean, absorbent socks with seams aligned (Options 1, 3, and 4). Avoid using over-the-counter products (eg, iodine, alcohol, strong adhesives) on cuts or abrasions (Option 5). To improve circulation, do not sit with legs crossed or for extended periods, avoid tight-fitting garments, and perform daily exercise. Report other types of problems such as infections or athlete's foot immediately. Educational objective: Individuals with type I or II diabetes mellitus are at increased risk for developing an infection or ulcer on their feet due to the chronic complication of peripheral neuropathy. Clients should keep feet clean, dry, and free from irritation.

A nurse is caring for a school-age client who has fever, somnolence, and a skin rash from suspected meningococcal meningitis. Which interventions should be implemented for this client? Select all that apply. 1. Allow the pt to self-position 2. Have the pt wear a mask at all times for 24 hours 3. Keep the pt on NPO status 4. Minimize the environmental stimuli 5. Place the pt in a negative airflow rooms

1, 3, & 4 Nursing care for a child with known or suspected meningococcal meningitis includes key safety and comfort measures. Droplet precautions are initiated because this form of meningitis is easily transferred through secretions. Precautions should be continued for 24 hours after initiation of antibiotic therapy. Clients with somnolence or other altered level of consciousness should be kept on NPO status to prevent aspiration (Option 3). Comfort measures include promoting a quiet environment, minimizing stimuli in the room, and allowing the client to self-position (Options 1 and 4). Due to nuchal rigidity, most clients prefer to lie with the head of the bed slightly raised and without a pillow, or in a side-lying position. (Option 2) Under droplet precautions, the nurse should wear a mask when caring for the client. However, the client does not need to wear a mask unless transportation outside the room (eg, to perform an imaging study) is necessary. (Option 5) A negative airflow room would be used for a client under airborne precautions (eg, active tuberculosis). A client with known or suspected meningitis requires droplet precautions. Educational objective: Nursing care for a client with suspected meningococcal meningitis includes implementing safety measures such as droplet precautions and NPO status (for somnolence), and promoting comfort by minimizing stimuli, raising the head of the bed slightly, and removing the pillow. Droplet precautions should continue for 24 hours after initiation of antibiotic therapy.

A client with throat cancer receives radiation therapy to the head and neck. Which strategies are appropriate to increase oral intake? Select all that apply. 1. Avoid irritants such as acidic; spicy foods 2. Discourage the use of topical analgesics 3. Encourage liquid nutritional supplements 4. Perform oral hygiene once a day 5. Use artificial saliva to control dryness

1, 3, & 5 Radiation therapy to the head and neck can decrease a client's oral intake due to the development of mucositis (ie, inflammation of the mouth, esophagus, and oropharynx) and xerostomia (ie, dry mouth). These adverse side effects affect speech, taste, and ability to swallow and can have a significant impact on the client's nutritional status. The nurse teaches the client to: Avoid irritants such as spicy, acidic, dry, or crumbly foods; coffee; and alcohol (Option 1). Consume supplemental nutritional drinks (eg, Ensure), which are often easier to swallow (Option 3). Use artificial saliva to manage xerostomia and the production of thick saliva due to altered salivary gland function (Option 5). Sipping water throughout the day is equally effective and less expensive. (Option 2) Topical anesthetics (eg, lidocaine) have been found to increase comfort and improve oral intake in clients with mucositis due to radiation therapy. (Option 4) Clients on radiation therapy need to maintain more frequent (eg, before and after meals, at bedtime) oral hygiene (eg, using soft toothbrush, rinsing with baking soda solution) due to the drying effects of mucositis. Educational objective: Radiation therapy to the head and neck can cause mucositis (ie, inflammation of the mouth, esophagus, and oropharynx) and xerostomia (ie, dry mouth), leading to decreased nutrition. Care includes avoiding irritants, consuming supplements, using artificial saliva or sipping water, and performing frequent oral hygiene.

A nurse is discussing the fine motor abilities of a 10-month-old infant with the infant's parent. Which are developmentally appropriate skills for an infant of this age? Select all that apply. 1. Grasps a small doll by the arm 2. Stacks 3 wooden blocks 3. Transfers small objects from hand to hand 4. Turns single pages in a book 5. Uses a basic pincer grasp

1, 3, & 5 Fine motor skills of infants develop around the ability to grasp and pick up objects. By 3 months, infants will reflexively grasp a rattle placed in their hand. At 5 months, they are able to voluntarily clasp it with their palm. Around 7 months, infants are able to transfer an object from one hand to the other. By 8-10 months, infants have replaced the palmar grasp with a crude pincer grasp (use of thumb, index, and other fingers) to pick up round oat cereal and other finger foods. By 11 months, this develops into a neat pincer grasp (use of thumb and index finger). (Options 2 and 4) By 12 months, infants may attempt to turn multiple book pages at once, and they also begin attempts to stack 2 blocks. These skills require finer muscle control than is expected of a 10-month-old. Educational objective: Fine motor skills of infants develop around the ability to grasp objects. Voluntary grasping with the palm begins around 5 months, followed by the ability to transfer an object between hands by 7 months and the development of a crude pincer grasp (using the thumb, index, and other fingers) around 8-10 months.

A hospitalized client develops acute hemorrhagic stroke and is transferred to the intensive care unit. Which nursing interventions should be included in the plan of care? Select all that apply. 1. Administer PRN stool softeners daily 2. Administer scheduled enoxaparin injection 3. Implement seizure precautions 4. Keep pt NPO until swallow screen is performed 5. Perform frequent neurological assessments

1, 3, 4, & 5 A hemorrhagic stroke occurs when a blood vessel ruptures in the brain and causes bleeding into the brain tissue or subarachnoid space. Seizure activity may occur due to increased intracranial pressure (ICP) (Option 3). During the acute phase, a client may develop dysphagia. To prevent aspiration, the client must remain NPO until a swallow function screen reveals no deficits (Option 4). The nurse should perform neurological assessments (eg, level of consciousness, pupillary response) at regular intervals and report any acute changes (Option 5). Preventing activities that increase ICP or blood pressure will minimize further bleeding. The nurse should: Reduce stimulation, maintain a quiet and dimly lit environment, limit visitors Administer stool softeners to reduce strain during bowel movements (Option 1) Reduce exertion, maintain strict bed rest, assist with activities of daily living Maintain head in midline position to improve jugular venous return to the heart (Option 2) Enoxaparin is an anticoagulant used to prevent venous thromboembolism (VTE). Anticoagulants are contraindicated in clients with hemorrhagic stroke; the nurse should question any prescriptions that increase risk for bleeding. A client with hemorrhagic stroke should instead receive nonpharmacologic interventions (eg, compression stockings) to prevent VTE. Educational objective: A hemorrhagic stroke occurs when a blood vessel ruptures in the brain and causes bleeding. The nurse should perform frequent neurological assessments, keep the client NPO, maintain seizure precautions and strict bed rest, and limit any activity that may increase bleeding (eg, anticoagulant administration) or intracranial pressure (eg, stimulation, straining during bowel movements).

The parent of a 21-day-old male infant reports that the infant is "throwing up a lot." Which assessments should the nurse make to help determine if pyloric stenosis is an issue? Select all that apply. 1. Assess the parent's feeding technique 2. Check for family history of gluten enteropathy 3. Check for history of physiologic hyperbilirubinemia 4. Check if the vomiting is projectile 5. Compare current weight to birth wieght

1, 4, & 5 In pyloric stenosis, there is gradual hypertrophy of the pylorus until symptom onset at age 3-5 weeks. It is common in first-born boys and the etiology is unclear. Pyloric stenosis presents with postprandial projectile vomiting (ejected up to 3 feet) followed by hunger (eg, "hungry vomiter"). This is clearly distinguished from the "wet burps" infants have due to a weak lower esophageal sphincter. The emesis is nonbilious as the obstruction is proximal to the bile duct. Infants have poor weight gain and are often dehydrated (eg, sunken fontanelle, decreased skin turgor, delayed capillary refill). The amount of milk consumed (particularly with bottle feedings) along with the mother's technique (mainly adequate burping) should be assessed to ensure there is no excessive air swallowing or overfeeding as an etiology. (Option 2) At times, formula intolerance or allergy is suspected initially when the infant first starts vomiting. However, celiac disease or gluten enteropathy is related to intolerance to gluten, a protein in barley, rye, oats, and wheat (BROW). Clients with celiac disease cannot eat these foods. A 3-week-old infant would only consume milk; this history would not be a factor at this time. (Option 3) Physiological hyperbilirubinemia occurs due to the newborn's immature liver that is unable to metabolize hemoglobin byproducts. This is a "normal" finding that is unrelated to pyloric stenosis. Educational objective: Pyloric stenosis is a hypertrophy of the pyloric sphincter that eventually causes complete obstruction. Classic signs include projectile nonbilious vomiting, an olive-shaped right upper quadrant mass, weight loss, dehydration, and/or electrolyte imbalance (metabolic alkalosis).

Which infant is most likely to require oral iron supplementation at this time? 1. 2 month old born at 34 weeks gestation who is bottle fed with breast milk 2. 4 month old at term who is breast-fed exclusively 3. 6 month old born at term who is formula fed 4. 7 month old who is breast fed and was recently started on solid foods

1. 2 MONTH OLD AT 34 WEEKS GESTATION WHO IS BOTTLE FED WITH BREAST MILK Iron is necessary for adequate hemoglobin production. Chronic iron deficiency can lead to anemia, decreased immune function, and delays in growth and development. During gestation, iron received from the mother is stored in the hemoglobin, liver, spleen, and bone marrow of the fetus. Although iron stores typically last 5-6 months in term infants, preterm infants and infants born in multiples exhaust their iron stores by 2-3 months. Iron must then be acquired through dietary sources (eg, iron-fortified formula) or oral supplements. Exclusively breast-fed infants can receive supplements of oral iron drops as breast milk contains low levels of iron. After transitioning to solid foods, infants can obtain iron from fortified infant cereal and iron-rich foods. (Option 2) Infants born at term who are exclusively breast-fed do not typically require additional iron until about age 6 months, which is when many are started on solid foods fortified with iron. (Option 3) Current recommendations state that all infants fed exclusively with formula should receive iron-fortified formula, so it is unlikely that this infant needs further supplementation. (Option 4) Infants often begin the transition to solid foods with fortified infant cereal. Although adequate intake should be confirmed, this infant is not likely to require supplements at this time. Educational objective: Premature infants require iron supplementation by age 2-3 months, which is when maternal iron stores are depleted. Appropriate sources include oral iron drops if breastfeeding or iron-fortified formula.

Four clients are seen by the emergency department nurse. Which client is a priority for treatment and definitive care? 1. 7 day old fussy infant with a rectal temperature of 100.6 and 6 wet diapers today 2. Pt receiving radiation therapy who has 6 in arm laceration that is not actively bleeding 3. Pt with purulent drainage and crusting of the eyelid with vision unaffected 4. New parent who is crying and overwhelmed, and denies suicidal ideation

1. 7 DAY OLD FUSSY INFANT WITH A RECTAL TEMPERATURE OF 100.6 AND 6 WET DIAPERS TODAY Infants <30 days old have immature immune systems and a blunted response to infection. The 7-day-old infant is at high risk for bacteremia. Infectious manifestations are often subtle at this age (eg, fever can be the only symptom), although some infants may have hypothermia, lethargy, poor feeding, or decreased urine output. Rectal temperature >100.4 F (38.0 C) or <96.8 F (36.0 C) is a "red flag" in a neonate. (Option 2) The client receiving radiation therapy is stable, and there is 6- to 8-hour window in which to safely close the wound. This is not a high-risk client. (Option 3) Bacterial conjunctivitis (pink eye) presents with conjunctival erythema; thick, purulent drainage; and "crusted" eyelids. The client will receive antibiotic drops or ointment, warm soaks/cool compresses, and infection control. Pink eye is highly contagious but not emergent. (Option 4) The parent has postpartum blues/depression and is not emergent. This client can be counseled or provided resources later after the infant with fever is seen. Educational objective: Infectious manifestations are often subtle in neonates (eg, fever can be the only symptom), although some may have hypothermia, lethargy, poor feeding, or decreased urine output. Rectal temperature >100.4 F (38.0 C) or <96.8 F (36.0 C) is a "red flag" in a neonate.

The nurse in the intensive care unit cares for a client with primary adrenocortical insufficiency (Addison's disease). The client reports nausea and abdominal pain. The blood pressure suddenly drops from 120/74 mm Hg to 88/48 mm Hg, heart rate increases from 80 to 100/min, and the client appears confused. Which action should the nurse take first? 1. Administer as needed does of hydrocortisone IV 2. Complete a head to toe assessment to identify any sources of infection 3. Document the findings in the pt's electronic medical record 4. Take blood pressure sitting and standing to assess for orthostatic hypotensionn

1. ADMINISTER AS NEEDED DOSE OF HYDROCORTISONE iv Addison's disease is adrenocortical insufficiency or hypofunction of the adrenal cortex. Addisonian crisis or acute adrenocortical insufficiency is a potentially life-threatening complication. Clients report nausea, vomiting, and abdominal pain. Signs of addisonian crisis include hypotension, tachycardia, dehydration, hyperkalemia, hyponatremia, hypoglycemia, fever, weakness, and confusion. Priority emergency management of addisonian crisis includes shock management, with fluid resuscitation using 0.9% normal saline and 5% dextrose; and administration of high-dose hydrocortisone replacement IV push. (Options 2, 3, and 4) Assessment and documentation are important components of the nursing process, but emergency treatment of an addisonian crisis is the priority action. Educational objective: Addisonian crisis is a potentially life-threatening complication of Addison's disease and commonly presents with abdominal pain, hypotension, and hypoglycemia. Emergency management includes shock management with fluid resuscitation using 0.9% normal saline and 5% dextrose, and administration of high-dose hydrocortisone replacement IV push.

A staff nurse complains to the charge nurse that another nurse was rude today. Which is the best initial response by the charge nurse to the complaining nurse? 1. Encourage the nurse to speak to the other employee about the incident 2. Have both employees meet with the charge nurse and discuss their issues 3. Offer to ocunsel the other employees about the employee's innapropriate behavior 4. Tell the nurse to tell the offending employee that the nurse will not tolerate insolence

1. ENCOURAGE THE NRUSE TO SPEAK TO THE OTHER EMPLOYEE ABOUT THE INCIDENT Assertive communication involves speaking directly to the person with whom there is a conflict. People should use "I" statements, indicate how they felt when the incident occurred, and communicate how they would like to be spoken to in the future. (Choice 2) Supervisors should initially encourage employees to work out their differences. This is an option if there is a repeated pattern of conflict or the action was egregious. (Choice 3) The charge nurse did not witness the incident and should hear both sides before deciding if something is inappropriate. (Choice 4) This is a more aggressive response. In this case, the receiving nurse may have misperceived the other employee's behavior. A better response would involve telling the offending employee how the nurse perceived the behavior rather than allowing the situation to escalate into hostile behavior or confrontation. Educational objective: Assertive communication should be encouraged initially when there is interpersonal conflict. The involved parties should speak directly with each other, using "I" statements.

The nurse is giving a presentation at a community health event. The nurse should provide which instruction on how to prevent botulism? 1. Boil water if unsure of its source 2. Discard canned food with a bulging end 3. Keep milk cold 4. Wash hands

2. DISCARD CANNED FOOD WITH A BULGING END Botulism is caused by the gastrointestinal absorption of the neurotoxin produced by Clostridium botulinum. The neurotoxin blocks acetylcholine at the neuromuscular junction, resulting in muscle paralysis. The organism is found in the soil and can grow in any food contaminated with the spores. Manifestations include descending flaccid paralysis (starting from the face), dysphagia, and constipation (smooth muscle paralysis). The main source is improperly canned or stored food. A metal can's swollen/bulging end can be caused by the gases from C botulinum and should be discarded. The infant form of botulism can occur in children under age 1 year if they eat honey, particularly raw (wild) honey. The immature gut system in these children makes them more susceptible. (Option 1) Contaminated water is boiled to prevent infestation with Giardia, which can cause gastrointestinal disease but is not related to botulism. (Option 3) Keeping dairy at room temperature can cause it to spoil, which would then cause gastroenteritis if ingested. Most serious illnesses are prevented through pasteurization. This is not related to botulism. (Option 4) Escherichia coli infections result from ingestion of food or water that is contaminated by feces. This can be related to improper handwashing or undercooking meat and is not related to botulism. Educational objective: Botulism is a result of ingesting improperly canned or stored food. Food in a can with a bulging end should not be used. Children under age 1 year should not be given honey as their immature gut system makes them prone to developing infant botulism.

A nurse is teaching a postpartum client about cord care for the newborn. Which statement by the client indicates a need for further teaching? 1. I can expect the cord to turn black in a few days 2. I should let the cord fall off by itself in about 1-2 weeks 3. I should use a cotton swab to gently apply alcohol to the cord 4. I will fold the diaper below the cord to allow the cord to dry

3. I SHOULD USE A COTTON SWAB TO GENTLY APPLY ALCOHOL TO THE CORD The primary goal of cord care is to keep the cord stump clean and dry to facilitate healing and reduce infection risk. Additional teaching points regarding cord care include: Keep the cord stump open to air when possible to allow for adequate drying. Do not apply antiseptics (eg, alcohol, triple dye, chlorhexidine) to the cord stump, which can cause skin irritation (Option 3). Report any signs of infection (eg, redness, purulent drainage, swelling) to the health care provider. (Option 1) The umbilical cord is usually clamped and cut a few minutes after birth. The clamp is left in place until the cord begins to dry, usually around 24 hours after birth. The remaining cord stump begins to shrivel and turn black in 2-3 days. (Option 2) The cord usually separates spontaneously from the umbilicus around 1-2 weeks after birth. Parents should be instructed to not pull on the cord stump or attempt to hasten cord separation, which could result in bleeding or other complications. (Option 4) The diaper should be folded below the cord to keep the cord dry and prevent contamination with urine or feces. Educational objective: The primary goal of cord care is to keep the cord stump clean and dry. Parents should keep the umbilical area dry, not apply antiseptics to the stump, and report any signs of infection.

The nurse plans to start an IV line on a female client hospitalized with pneumonia. The nurse reviews the electronic medical record for relevant information and learns that the client is right-handed and has a history of a left-sided mastectomy with lymph node removal. Which site is best for the nurse to select for the client's IV line? 1. Basilic vein of the left forearm 2. Cephalic vein of the right antecubital space 3. Median vein of the right forearm 4. Radial vein of the left wrist

3. MEDIAN VEIN OF THE RIGHT FOREARM The client's medical history should be reviewed prior to starting an IV line so that the nurse can identify any contraindications to specific anatomical sites. Lymph node removal during a mastectomy may affect lymphatic fluid drainage on the affected side and cause lymphedema or other complications such as infection, venous thromboembolism, or trauma to the affected arm. The nurse must avoid any needlesticks, IV insertions, or blood pressure measurements in the affected arm (Options 1 and 4). The nondominant side is preferred when no medical contraindications exist. However, in this case, the right forearm is best because the client had a left-sided mastectomy (Option 3). Other considerations when selecting IV sites include avoidance of areas that have obstructed blood flow, dialysis sites, areas distal to old puncture sites, bruised areas, painful areas, or areas with skin conditions or signs of infection. (Option 2) The antecubital space should be avoided when possible (except for emergency insertion) as it inhibits mobility and may be positional. Educational objective: The nurse should review the client's medical record and assess for contraindications to IV sites, including impaired lymphatic drainage (prior mastectomy), arteriovenous fistula or graft (used for hemodialysis), and areas distal to old puncture sites.

During a camping trip, a camp counselor falls and gets a small splinter of wood embedded in the right eye. What action should the volunteer camp nurse take first? 1. Gently flush the eye with cool water 2. Instill optic antibiotic ointment 3. Patch both eyes with eye shield 4. Remove the splinter using tweezers

3. PATCH BOTH EYES WITH EYE SHIELDS The camp nurse protects the injured eye using an eye shield (eg, small Styrofoam or paper cup), ensuring the shield does not touch the foreign body. The eyes work in synchrony with each other; therefore, the non-injured eye is patched to prevent further eye movement. The nurse also facilitates transport to the nearest emergency care center for assessment and treatment by an ophthalmologist. (Option 1) Flushing the eye with cool water is contraindicated as it may cause further damage by moving the splinter and/or introducing potential wound pathogens. (Option 2) Instilling optic antibiotic ointment would interfere with ophthalmologic medical examination. Optic antibiotic ointment may be prescribed by the health care provider to reduce the risk of infection once the object is removed from the eye. (Option 4) The nurse should not attempt to remove a foreign body embedded in the eye. An ophthalmologist, a health care provider who specializes in the surgical and nonsurgical evaluation and treatment of eye conditions, should remove the embedded object as soon as possible. Educational objective: When a foreign body becomes accidentally embedded in the eye, both eyes should be shielded to prevent eye movement and additional injury. The nurse should immediately refer the client to an ophthalmologist for further evaluation and treatment.

The nurse is caring for a client with chronic, stable angina. The client takes the long-acting nitrate isosorbide mononitrate. Which client outcome indicates that the drug is effective? 1. Pt is able to shower, dress, and fix hair without any chest pain 2. Pt reports a reduction in stress level and anxiety 3. Pt reports being able to sleep through the night 4. Pt's BP is 128/78 and HR 82

1. PT IS ABLE TO SHOWER, DRESS, AND FIX HAIR WITHOUT ANY CHEST PAIN Long-acting nitrates are used to reduce the incidence of anginal attacks. Nitrates are effective if the client is able to do activities without the incidence of chest pain. The client should be taught to report any increase in chest pain and how to manage headaches, a common side effect of nitrates. (Options 2 and 3) A reduction in stress level and anxiety, and being able to sleep through the night are positive outcomes for any client with cardiovascular disease. However, these outcomes are not directly related to long-acting nitrate use. (Option 4) Nitrates are vasodilators and may decrease the client's blood pressure, which is a positive outcome but not the primary reason for taking the medication. This client is taking the medication for angina. Educational objective: The ability to perform activities without chest pain is a desirable client outcome of long-acting nitrate use. The nurse would want to assess for this outcome in clients taking these medications.

A nurse is reviewing the laboratory values for a 3-year-old client with nephrotic syndrome. The nurse interprets the results to most clearly reflect which physiologic process related to nephrotic syndrome? Click on the exhibit button for additional information. EXHIBIT: albumin=2.0, total cholesterol= 275, protein=3+ 1. Glomerular injury 2. Hepatic impairment 3. Inherited hypercholesterolemia 4. Malnutrition

1. GLOMEREULAR INJURY Nephrotic syndrome is a collection of symptoms resulting from various causes of glomerular injury. Below are the 4 classic manifestations of nephrotic syndrome: Massive proteinuria - caused by increased glomerular permeability Hypoalbuminemia - resulting from excess protein loss in the urine Edema - specifically periorbital and peripheral edema and ascites; caused by low serum protein and albumin as fluid is pulled into interstitial spaces and body cavities Hyperlipidemia - related to increased compensatory protein and lipid production by the liver Additional symptoms include decreased urine output, fatigue, pallor, and weight gain. The most common cause of nephrotic syndrome in children is minimal change nephrotic syndrome, which is generally considered idiopathic. Less common secondary causes may be related to systemic disease or infection, such as glomerulonephritis, drug toxicity, or acquired immunodeficiency syndrome. (Option 2) Ascites and edema are often associated with liver disease. However, these symptoms result from fluid shifts related to hypoalbuminemia in nephrotic syndrome. (Option 3) Lipid levels (normal total cholesterol <200 mg/dL [5.2 mmol/L]) can increase with nephrotic syndrome as the liver produces increased lipids and proteins to compensate for protein loss. (Option 4) Although low serum albumin (normal 3.5-5.0 g/dL [35-50 g/L]) could result from malnutrition, hypoalbuminemia in nephrotic syndrome is related to massive proteinuria (negative to trace protein on urinalysis is usually considered normal). Educational objective: Nephrotic syndrome is a collection of symptoms resulting from glomerular injury. The 4 characteristic manifestations are proteinuria, edema, hypoalbuminemia, and hyperlipidemia.

The nurse is assessing a client diagnosed with tuberculosis who started taking rifapentine a week ago. Which statement by the client warrants further assessment and intervention by the nurse? 1. I do not want to get pregnant, so I restarted my oral contraceptive last month 2. I have been taking m medication with breakfast every morning 3. I should alert my HCP if I notice yellowing of the skin 4. Since I started this medicine, my saliva has become a red-orange color

1. I DO NOT WANT TO GET PREGNANT, SO I RESTARTED MY ORAL CONTRACEPTIVE LAST MONTH Rifapentine (Priftin), a derivative of rifampin, is an antitubercular agent used with other drugs (eg, isoniazid) as a combination therapy in active and latent tuberculosis infections. Both rifampin and rifapentine reduce the efficacy of oral contraceptives by increasing their metabolism; therefore, this client will need an alternate birth control plan (non-hormonal) to prevent pregnancy during treatment (Option 1). (Option 2) Rifapentine should be taken with meals for best absorption and to prevent stomach upset. (Option 3) Hepatotoxicity may occur; therefore, liver function tests are required at least every month. Signs and symptoms of hepatitis include jaundice of the eyes and skin, fatigue, weakness, nausea, and anorexia. (Option 4) Rifapentine may cause red-orange-colored body secretions, which is an expected finding. Dentures and contact lenses may be permanently stained. Educational objective: Clients taking rifampin or rifapentine (Priftin) as part of antitubercular combination therapy should be taught to prevent pregnancy with non-hormonal contraceptives, notify the health care provider of any signs or symptoms of hepatotoxicity (eg, jaundice, fatigue, weakness, nausea, anorexia), and expect red-orange-colored body secretions.

Which client does the nurse assess first after receiving morning report? 1. Pt 1 day opstoperative with IV PCA who reports burning at the IV site 2. Pt with a bowel obstruction prescribed continuous nasogastric suction who was admitted yesterday 3. Pt with Afib and an irregular heart rate of 94 4. Pt with dementia and cdiff who was oncontinent of liquid stool

1. PT 1 DAY POST OP WITH IV PCA WHO REPORTS BURNING AT THE IV SITE

The emergency department nurse cares for a client whose college roommate reports recent changes in the client's behavior. Which behaviors and clinical data meet the criteria for involuntary admission to the mental health unit? Select all that apply. 1. Pt has been sleeping on the floor in the den rather than the bed 2. Pt has refused food and water for 4 days and has poor skin turgor 3. Pt has repeatedly mumbles, "I must kill them before they get me" 4. Marijuana was found in the ot's personal belongings 5. The HCP makes a diagnosis of schizophrenia

2 & 3 Clients have the right to refuse hospital admission and treatment. However, all states and provinces have laws and procedures for involuntary admission that require clients to receive inpatient treatment for a psychiatric disorder against their will. The legal criteria for involuntary admission include: The individual appears to be an imminent danger to self or others (Option 3). The individual has a grave disability (ie, is unable to adequately care for basic needs [food, clothing, shelter, medical care, personal safety]) as a result of a mental illness (Option 2). Clients also have the right to the least restrictive environment in which treatment can be provided in a safe manner. Involuntary commitment is generally used as a last resort in dealing with a client whose illness is so severe that judgment and insight in deciding to refuse treatment are markedly impaired. (Option 1) Sleeping on the floor may be outside the client's normal behavior but does not meet the criteria for involuntary admission. (Option 4) Possession of marijuana does not meet the criteria for involuntary admission. (Option 5) The diagnosis of a mental illness alone does not justify the need for involuntary commitment. Educational objective: Clients with a mental illness have the right to refuse treatment, including inpatient hospitalization. Clients can be involuntarily admitted for psychiatric treatment if they pose an imminent danger to themselves or others or if they are gravely disabled and unable to meet their own basic needs.

A nurse in the emergency department is caring for a homeless client just brought in with frostbite to the fingers and toes. The client is experiencing numbness, and assessment shows mottled skin. Which interventions should be included in the client's plan of care? Select all that apply. 1. Apply occlusive dressings 2. Elevate affected extremities after rewarming 3. Massage the areas to increase circulation 4. Provide adequate analgesia 5. Provide continuous warm water soaks

2, 4, & 5 Frostbite involves tissue freezing, resulting in ice crystal formation in intracellular spaces that causes peripheral vasoconstriction, reduced blood flow, vascular stasis, and cell damage. Superficial frostbite can manifest as mottled, blue, or waxy yellow skin. Deeper frostbite may cause skin to appear white and hard and unable to sense touch. This can eventually progress to gangrene. Treatment of frostbite should include the following: Remove clothing and jewelry to prevent constriction. Do not massage, rub, or squeeze the area involved. Injured tissue is easily damaged (Option 3). Immerse the affected area in water heated to 98.6-102.2 F (37-39 C), preferably in a whirlpool. Higher temperatures do not significantly decrease rewarming time but can intensify pain (Option 5). Avoid heavy blankets or clothing to prevent tissue sloughing. Provide analgesia as the rewarming procedure is extremely painful (Option 4). As thawing occurs, the injured area will become edematous and may blister. Elevate the injured area after rewarming to reduce edema (Option 2). Keep wounds open immediately after a water bath or whirlpool treatment and allow them to dry before applying loose, nonadherent, sterile dressings (Option 1). Monitor for signs of compartment syndrome. Educational objective: Care of the client with frostbite focuses on preventing further injury and reducing pain. This includes removing items that can cause constriction or sloughing; no massaging or rubbing of the injured area; providing warm water soaks and analgesia; elevating injured areas; applying loose, nonadherent, sterile dressings; and monitoring for compartment syndrome.

A client with unstable angina and chronic kidney disease is receiving a continuous infusion of unfractionated heparin. Which value for activated partial thromboplastin time (aPTT) would indicate to the nurse that the heparin therapy is at an optimal therapeutic level? 1. 30 seconds 2. 35 seconds 3. 60 seconds 4. 85 seconds

3. 60 SECONDS Unfractionated heparin is used as an anticoagulant in unstable angina. It prevents the conversion of fibrinogen to fibrin and prothrombin to thrombin, both components of clot formation. The aPTT is a laboratory test that characterizes blood coagulation. It is used to monitor treatment effects of clients receiving heparin. The normal aPTT is 25-35 seconds. Heparin infusions are titrated to obtain a therapeutic value of aPTT, typically 1.5-2 times the normal value. Therapeutic value for aPTT is 46-70 seconds. The nurse would evaluate the aPTT for a therapeutic value and make adjustments in the rate of infusion of the heparin as needed. (Options 1 and 2) These are normal aPTT levels for clients not being anticoagulated. (Option 4) This aPTT is too high. This client is at risk for bleeding. The heparin should be titrated down based on the heparin drip protocol. Educational objective: The nurse caring for a client receiving a heparin infusion should monitor the aPTT and follow the heparin infusion protocol for titration. A therapeutic level is 1.5-2 times normal, or an aPTT of 46-70 seconds.

A laboring client reports feeling the need to have a bowel movement and begins vomiting. The nurse notes that the client's legs are trembling. What cervical examination finding would the nurse most expect this client to have? 1. 2 cm, 50%, and -2 station 2. 6 cm, 70%, and -1 station 3. 7 cm, 80%, and 0 station 4. 8 cm, 100% effaced, and +1 station

4. 8 CM, 100%, AND +1 STATION The end of the first stage of labor (8-10 cm dilation) is commonly referred to as the "transition phase" of labor. This period is often characterized by perineal/rectal pressure due to fetal descent, which the client may perceive as an urge to have a bowel movement. The maternal ischial spines are designated as the "0 station" landmark. During this period, descent of fetal station below the maternal ischial spines (ie, +1 station or greater) often results in nausea and vomiting and trembling or shivering (Option 4). Other maternal signs of the end of the first stage include increased pain, fear, irritability, anxiety, and self-doubt in the ability to birth. The client may require more assertive direction and emotional support during this period. (Option 1) Cervical dilation of 0-5 cm denotes the early/latent phase of labor. During this phase, pain is usually well managed. Although possibly apprehensive, the client is usually able to maintain focus and follow directions. For these reasons, the latent phase is the best time to provide client education. (Options 2 and 3) Cervical dilation of 6-7 cm denotes the start of the active phase of labor. During this period, apprehension and pain increase, and the ability to follow instruction decreases. The client's demeanor is more serious. Pain management, reassurance, and encouragement are priorities. Educational objective: Signs of the end of the first stage of labor ("transition phase") include perineal/rectal pressure, nausea and vomiting, trembling/shivering, increased pain, fear, irritability, and self-doubt. Laboring clients may require more assertive direction and additional emotional support during this period.

The nurse teaches a client about the use of regular and neutral protamine Hagedorn (NPH) insulin. Which statement by the client indicates that further teaching is needed? 1. I will always check my blood glucose prior to using the sliding scale 2. I will eat breakfast 30 minutes after taking my morning NPH and regular insulin 3. I will use a new insulin syringe each time I give myself an injection 4. I will use the sliding scale to determine my NPH dose 4 times a day

4. I WILL USE THE SLIDING SCALE TO DETERMINE MY NPH DOSE 4 TIMES A DAY The Institute for Safe Medication Practices has labeled insulin a high-alert medication. These types of medication can be safe and effective when administered or taken according to recommendations. However, errors in administration may cause death or serious illness. NPH is an intermediate-acting insulin with a duration of 12-18 hours; it is generally prescribed 2 times daily (morning and evening). Regular insulin and other rapid-acting insulins (lispro, aspart, glulisine) are typically used with a sliding scale for tighter control of blood glucose throughout the day. These are generally taken before meals and at bedtime. (Options 1, 2, and 3) These are correct statements and indicate the teaching objective was completed successfully. Educational objective: NPH is an intermediate-acting insulin with a duration of 12-18 hours and typically prescribed twice a day.

The nurse teaches a parent how to administer an oral liquid medication to a 2-month-old client. The nurse knows that the parent understands the teaching when the parent does which of the following? 1. Allows the pt to sip the medication from a cup 2. Expels the medication from a dropper onto the back of the tongue 3. Mixes the medication in the infant's bottle of formula 4. Using a syringe, administers the medication in small amounts into the back of the cheek

4. USING A SYRINGE, ADMINSTERS THE MEDICATION IN SMALL AMIUNTS INTO THE BACK OF THE CHEEK Using a syringe to measure the medication is the most accurate technique to ensure that the proper amount of medication is being administered. The correct procedure for administering oral medication to an infant is to place small amounts of the medication at the back of the cheek, allowing time for the infant to swallow each amount. This technique decreases the risk for choking and ensures that all the medication is consumed. (Option 1) Although cup feeding may be a method used to feed infants in specific cases, medication administration requires a more accurate measurement. A syringe can provide an accurate measurement and decrease the risk of waste due to the infant's spitting or drooling. (Option 2) Infants have a decreased gag reflex. Dispensing medication onto the back of the tongue would increase the risk for aspiration of the medication. (Option 3) It is very important for the infant to receive the entire dose of the medication. Medication should never be mixed in a bottle of formula as the infant may not consume the entire amount. Educational objective: The extrusion reflex and a decreased gag reflex in infants less than 4 months old increase the risk for choking and aspiration. Instilling the medication using a syringe at the back of the cheek decreases the risk for choking and ensures that the correct amount of medication is consumed.

A nurse on the telemetry unit is preparing client medications in the medication room at the nurse's station. The nurse should perform which actions to be consistent with client safety practices related to medication administration? Select all that apply. 1. Check lab values before administering 2. Compare medication, dosage, and route to prescription orders prior to administration 3. Discard any unlabeled medications 4. Open unit dose packages and place medications in dispensing cup to the bedside 5. Wear gloves to handle unopened individual unit dose medication packages

1, 2, & 3 The nurse must follow the 6 rights of medication administration: The right client The right medication The right dose The right time The right route The right documentation Additionally, one of the National Patient Safety Goals (NPSGs) is to "improve the safety of using medications." This includes labeling all medications as soon as prepared, discarding any medications that are found unlabeled, and taking extra care for clients who take anticoagulant drugs. (Option 4) Individual dose packages should be opened at the client's bedside and should be placed in a medication cup only immediately prior to administration. (Option 5) Gloves are generally not required during medication preparation or handling of unopened packages or vials, although hand hygiene should be performed both prior to preparation or handling and again prior to administration. The nurse should wear gloves during medication administration when coming into contact with a route that is potentially contaminated by blood or body fluids (eg, administering intramuscular or subcutaneous injections, accessing a closed IV tubing system, placing a pill into a client's mouth using fingers). Educational objective: The nurse should follow the 6 rights of medication administration when preparing and administering drugs to a client. Additionally, the NPSGs of improving the safety of using medications should be followed, including labeling all medications, discarding medications found unlabeled, and taking extra care for clients taking anticoagulant drugs.

A laboring client weighing 187 lb is 5 cm dilated and having contractions every 2-3 minutes. The client rates the pain at 7 out of 10. Nalbuphine hydrochloride 10 mg/70 kg IV push × 1 is prescribed by the health care provider. Nalbuphine hydrochloride 10 mg/1 mL is available. How many milliliters does the nurse administer? Record your answer using one decimal place.

1.2 Weight in kg = Weight (lb) = 187 lb = 85 kg 2.2 2.2 Desired dose = Prescribed amount (mg/kg) x Weight (kg) = (10 mg / 70 kg) x 85 kg = 12.1428 mg Dose to administer = Desired (mg) x Quantity (mL) = 12.1428 mg x 1 mL = 1.214 mL (round down 1.2 mL) Available (mg) 10 mg The client is in active labor with an established contraction pattern and pain in the severe range. This is considered a safe time in labor to administer pain medication. The usual dose of nalbuphine hydrochloride is 10-20 mg, and the dose prescribed is within the normal dose range for labor. The nurse must convert the client's weight to kilograms (1 kg = 2.2 lb) and then determine the desired dose in milligrams. Finally, the nurse must calculate the dose to be administered in milliliters. Educational objective: The usual and safe dose of nalbuphine hydrochloride is 10-20 mg/70 kg of body weight given intramuscularly or by IV push. The nurse should convert weight to kilograms and then calculate the dose in milliliters based on the client's body weight and using the 2 formulas: Desired dose = Prescribed amount (mg/kg) x weight (kg) Dose to administer = Desired (mg) x Quantity (mL) Available (mg)

The nurse is assessing a client with a possible diagnosis of peripheral artery disease. Which client statement is consistent with the diagnosis? 1. At the end of the day, my shoes and socks are tight 2. I have a slow-healing sore right above my ankle 3. My legs ache when I stand for extended periods 4. When I sit down to rest and elevate my legs, the pain increases

4. WHEN I SIT DOWN TO REST AND ELEVATE MY LEGS, THE PAIN INCREASES Peripheral artery disease (PAD [previously called peripheral vascular disease]) refers to arteries that have thickened, have lost elasticity due to calcification of the artery walls, and are narrowed by atherosclerotic plaques (made up of fat and fibrin). Pain due to decreased blood flow is the most common symptom of PAD. Cramping pain in the muscles of the legs during exercise, known as intermittent claudication, is usually relieved with rest. However, with critical arterial narrowing, pain can be present at rest and is typically described as "burning pain" that is worsened by elevating the legs and improved when the legs are dependent. Skin becomes cool, dry, shiny, and hairless (due to lack of oxygen). Ulcers and gangrene occur usually at the most distal part of the body, where circulation is poorest. Clients should be advised that a progressive walking program will aid the development of collateral circulation. (Options 1, 2, and 3) Chronic venous insufficiency refers to inadequate venous blood return to the heart. Too much venous blood remains in the lower legs, and venous pressure increases. This increased venous pressure inhibits arterial blood flow to the area, resulting in inadequate supply of oxygen and nutrients to area cells and the development of stasis ulcers, which are typically found around the medial side of the ankle. By the end of the day or after prolonged standing, the legs become edematous with dull pain due to venous engorgement. The skin of the lower leg becomes thick with a brown pigmentation. Educational objective: The pain of peripheral artery disease is arterial in nature and results from decreased blood flow to the legs. It is made worse with leg elevation. Arterial ulcers are formed at the most distal end of the body. Venous ulcers form over the medial malleolus, and compression bandaging is needed to reduce the pressure.

The charge nurse on the cardiac floor is orienting a new graduate nurse. The charge nurse describes various roles of the interdisciplinary team. In which situations would the nurse "case manager" be consulted? Select all that apply. 1. Facilitating communication between HCPs 2. Obtaining health information from the pt's nursing home 3. Reconcilitation of home medications 4. Referral for home health after discharge 5. Visiting the pt daily while hospitalized

1, 2, & 4 Case management involves assessing, planning, facilitating, and advocating for client health services to accomplish cost-effective quality client outcomes. This is done through communication and use of available resources. A professional nurse often serves in the case manager role. The case manager in the hospital setting assesses client needs, decreases fragmentation of care (Option 2), helps to coordinate care and communication between HCPs (Option 1), makes referrals, ensures quality standards are being met, and arranges for home health or placement after discharge (Option 4). (Option 3) Case managers typically do not provide direct client care. Medication reconciliation should be done between the primary nurse directly caring for the client and the HCP. (Option 5) Case managers often make daily rounds to the nursing department to review documentation in the client's chart but do not necessarily visit the client personally. Educational objective: The nurse providing direct client care should be familiar with the nurse case manager role as part of the interdisciplinary team. The goal of the nurse case manager is to facilitate provision of quality care across a continuum, decrease fragmentation of care across various settings, and contain costs.

The mental health nurse is planning care for a client newly admitted with dissociative identity disorder. Which interventions will the nurse include? Select all that apply. 1. Develop a trusting relationship with each of the alternate identities 2. Encourage the pt to journal about feelings and dissociation 3. Explain to the pt in detail the events of missing memories and lost time 4. Listen for expressions of self harm from the alternate identities 5. teach grounding techniques such as breathing to hinder dissociation

1, 2, 4, & 5 Dissociative identity disorder is a condition in which 2 or more identities alternately control the client's behavior. The alternate identities likely develop as a response to abuse or traumatic events and serve to protect the client from stressful memories. The client may not be aware of the alternate identities and may be confused by "lost time" and gaps in memory. Switching between identities occurs as a reaction to stress and individual triggers. The goal of treatment is to integrate the identities into one personality while maintaining safety. The client should journal about feelings and dissociation triggers and use a grounding technique (eg, deep breathing, rubbing a stone, counting coins) to counter dissociative episodes (Options 2 and 5). Identities may be volatile and should be monitored for indications of harm to self or others (Option 4). The nurse should attempt to form trusting, therapeutic relationships with each identity to explore feelings and facilitate identity integration (Option 1). (Option 3) Dissociation and memory gaps are protective mechanisms. Forcing the client to hear or attempt to recall memories may result in distress and regression. Allow clients to recall memories at their own pace. Educational objective: When caring for clients with dissociative identity disorder, the nurse should establish relationships with each identity, listen for expressions of self-harm, allow clients to recall memories at their own pace, encourage journaling about feelings and dissociation triggers, and teach grounding techniques to counter dissociative episodes.

The client is brought to the emergency department after falling off a roof and landing on his back. A T1 spinal fracture is diagnosed. The client's blood pressure is 74/40 mm Hg, pulse is 50/min, and skin is pink and dry. What nursing action is a priority? 1. Administer IV normal saline 2. Determine if urinary occult blood is present 3. Perform a neurological assessment 4. Verify that there is no stool impaction

1. ADMINISTER IV NORMAL SALINE This presentation is classic for neurogenic shock, a distributive shock. Vascular dilation with decreased venous return to the heart is present due to loss of innervation from the spine. Classic signs/symptoms are hypotension, bradycardia, and pink and dry skin from the vasodilation. Neurogenic shock usually occurs in cervical or high thoracic injuries (T6 or higher). Systolic blood pressure should remain at 80 mm Hg or above to adequately perfuse the kidneys. Administration of fluids is a priority to ensure adequate kidney and other organ perfusion. (Option 2) Testing for the presence of blood in the urine is important in determining if kidney damage has occurred, but circulation stability is a priority. (Option 3) A neurological assessment is essential, but circulation stability is a priority ("C before D" [disability]). (Option 4) Bladder and stool impaction are etiologies for autonomic dysreflexia and generally occur in a client with a high-level fracture at T6 or above with a stimulation below the fracture. Autonomic dysreflexia is a medical emergency that presents with severe headache, hypertension, piloerection, and diaphoresis. It is seen weeks to years after the injury. Educational objective: Neurogenic shock/distributive shock can occur from vasodilation soon after spinal injury. Classic symptoms are hypotension, bradycardia, and pink and dry skin. The hypotension must be treated with isotonic fluids to maintain vital organ perfusion.

The nurse assesses a client with benign prostatic hyperplasia. Which client statement requires further assessment? 1, I have a burning sensation when I urinate 2. I have been having some dribbling after I finish urinating 3. I missed 3 days of finasteride while on the trip last week 4. I was awakened 3 times last night by the need to urinate

1. I HAVE A BURNING SENSATION WHEN I URINATE Benign prostatic hyperplasia (BPH) is an abnormal prostate enlargement that most commonly affects male clients age >50. The prostate gradually enlarges and compresses the urethra, causing voiding problems. Symptoms include urinary urgency, frequency, and hesitancy, dribbling urine after voiding, nighttime frequency (nocturia), and urinary retention. Treatment includes lifestyle changes and medications that shrink or slow growth of the prostate, and symptom management interventions (eg, voiding schedule, avoidance of caffeine and antihistamines). Surgical prostate resection may be required. Clients with BPH have increased risk for urinary tract infection (UTI) because of incomplete bladder emptying and urine retention. Symptoms of UTI are often similar to those of BPH; however, burning sensation with urination and cloudy/foul-smelling urine are specific UTI symptoms that require further assessment and treatment (Option 1). (Options 2 and 4) Dribbling after urination and nocturia are expected findings with BPH. (Option 3) Finasteride (Proscar) is a medication that inhibits further growth of the prostate. Appreciable differences in prostate size are noticed only after several months of therapy. Missing three doses would not cause immediate or long-term adverse effects. Educational objective: Clients with benign prostatic hyperplasia (BPH) have increased risk for urinary tract infections (UTI) due to incomplete bladder emptying and urine retention. Symptoms of UTI that differ from those of BPH include burning sensation with urination and cloudy/foul-smelling urine.

The nurse is providing education to several first-trimester pregnant clients. Which client requires priority anticipatory teaching? 1. Pt who gardens and eats homegrown vegetables 2. Pt who has gained 4 lb from pregnancy wieght 3. Pt who has noticed a thing, milky weight vaginal discharge 4. Pt who practices yoga and swims in a pool 3 times a week

1. PT WHO GARDENS AND EATS HOMEGROWN VEGETABLES Toxoplasmosis is a parasitic infection caused by Toxoplasma gondii, which may be acquired from exposure to infected cat feces or ingestion of undercooked meat or soil-contaminated fruits/vegetables. Pregnant clients who contract toxoplasmosis can transfer the infection to the fetus and potentially cause serious fetal harm (eg, stillbirth, malformations, blindness, mental disability). Pregnant clients should be advised to take precautions when gardening and thoroughly wash all produce to decrease exposure risk. (Option 2) Weight gain recommendations vary by prepregnancy BMI. A 1.1- to 4.4-lb (0.5- to 2.0-kg) weight gain in the first trimester and approximately 1 lb (0.5 kg) per week thereafter is normal and expected for women with a healthy BMI. (Option 3) Leukorrhea is a thin, milky white vaginal discharge that is normal during pregnancy and is due to increased levels of progesterone and estrogen. If discharge changes color, becomes malodorous, or causes itching/burning, further investigation is needed. (Option 4) Exercise, particularly low-impact activities such as walking, swimming, and yoga, is recommended during pregnancy. Contact sports or activities with a risk for falls (eg, soccer, downhill skiing) should be avoided to prevent abdominal injuries. Educational objective: Toxoplasmosis is a parasitic infection acquired by exposure to infected cat feces or ingestion of undercooked meat or soil-contaminated fruits/vegetables. Pregnant clients who contract toxoplasmosis may transfer the infection to the fetus and potentially cause serious fetal harm. Pregnant clients should take precautions when gardening and thoroughly wash all produce to decrease exposure risk.

A client was prescribed phenytoin 100 mg orally 3 times a day a month ago. The serum phenytoin level is 32 mcg/mL and the nurse notifies the health care provider (HCP). Which action is anticipated from the HCP? 1. Administer phenytoin as prescribed 2. Decrease phenytoin daily dose 3. Increase phenytoin daily dose 4. Repeat serum phenytoin level in 2 hours

2. DECREASE PHENYTOIN DAILY DOSE Phenytoin (Dilantin), an anticonvulsant drug, is used to treat generalized tonic-clonic seizures. The therapeutic serum phenytoin reference range is 10-20 mcg/mL. In the presence of an elevated reference range (32 mcg/mL), if no seizure activity is observed, the nurse would anticipate the HCP to prescribe a decreased daily dose. The nurse will continue to monitor for signs of toxicity (eg, ataxia, nystagmus, slurred speech, decreased mentation). (Options 1 and 3) The serum phenytoin level is elevated, so administering the prescribed dose or increasing the dose can raise the level and further increase the risk for drug-induced toxicity. (Option 4) Repeating the serum phenytoin level in 2 hours will not result in a significant change as the average half-life of the drug is 22 hours. Educational objective: Phenytoin (Dilantin) is used to treat generalized tonic-clonic seizures. Common symptoms of phenytoin-induced toxicity involve the central nervous system (eg, nystagmus, ataxia, slurred speech, decreased mentation) and can occur when phenytoin plasma levels exceed the therapeutic reference range (10-20 mcg/mL).

During a routine office visit, the nurse documents the list of current medications of a client with a history of hypertension. Which statement by the client would cause the most concern? 1. I periodically take ducosate sodium for constipation 2. I regularly take ibuprofen for chronic low back pain 3. I take hydrochlorothiazide to prevent swelling around my ankles 4. I take omeprazole daily to prevent heartburn

2. I REGULARLY TAKE IBUPROFEN FOR CHRONIC LOW BACK PAIN Over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen can cause cardiovascular side effects, including heart attack, stroke, high blood pressure, and heart failure from fluid retention. These drugs also decrease the effectiveness of diuretics and other blood pressure medications. The risks can be even higher in the client who already has cardiovascular disease or takes NSAIDs routinely or for a long time. In addition, long-term use of NSAIDs is associated with peptic ulcers and chronic kidney disease. These clients should use NSAIDs cautiously, at the lowest dose necessary and for a short time. The nurse should notify the health care provider that this client is routinely taking ibuprofen. (Option 1) Taking docusate sodium occasionally for constipation is appropriate. (Option 3) Hydrochlorothiazide is a weak diuretic and is commonly used to treat hypertension. (Option 4) Omeprazole for heartburn is appropriate for this client. Educational objective: NSAIDs may cause heart attack, stroke, high blood pressure, and possible heart failure after long-term use. NSAIDs decrease the effectiveness of diuretic and blood pressure medications. Long-term use is also associated with chronic kidney disease and peptic ulcers.

A nurse is caring for a client 1 day after a left-sided mastectomy with lymph node dissection. Which nursing intervention is the priority in caring for this client? 1. Apply an ice pack to the left shoulder 2. Elevate the affected arm on apillow 3. Help the pt ambulate frequently 4. Obtain pneumatic compression sleeve

2. ELEVATE THE AFFECTED ARM ON A PILLOW After a mastectomy, an important goal is restoring function in the client's affected arm. Measures to promote function are initiated immediately after surgery. Elevating the affected arm to heart level (eg, on a pillow) is crucial to reduce fluid retention and prevent lymphedema in the affected arm (Option 2). Hand and arm exercises are implemented gradually, beginning with finger flexion and extension. These activities maintain muscle tone, prevent contractures, and improve lymph and blood circulation, which promote function and also prevent lymphedema. The return of full range of motion in the affected arm is desired within 4-6 weeks. Additional nursing care for clients after a mastectomy includes keeping the client in semi-Fowler position and placing a sign over the bed that specifies, "No blood pressure, venipuncture, or injections on left arm," as these actions could cause lymphedema. (Option 1) Ice reduces inflammation, swelling, and pain. Although this reduces discomfort, it does not directly contribute to restoring arm function and is not the priority. (Option 3) Frequent ambulation is not the priority in the initial postoperative period as it does not facilitate lymph drainage or help restore arm function. (Option 4) Pneumatic compression devices may be used to facilitate lymph drainage when lymphedema is present. Elevating and exercising the arm help prevent lymphedema from developing and are priority in this client. Educational objective: A priority goal for a client following a mastectomy is restoring function in the affected arm. Elevation of the arm and institution of arm exercises begin immediately following surgery to prevent lymphedema.

The nurse admits a postoperative client following weight loss surgery. Which prescription should the nurse question? 1. Begin a sugar free, clear liquid diet 2. Insert NGT for uncontrolled mausea 3. Place pt in low fowlers position during mealtimes 4. Start morphine via patient-controlled analgesia

2. INSERT NGT FOR UNCONTROLLED NAUSEA Bariatric surgery for weight loss involves a surgical modification of the client's stomach and/or small intestine to restrict the client's intake. Postoperative nursing care focuses on managing pain and nausea and monitoring for complications (eg, infection, fluid and electrolyte imbalance, dumping syndrome, anastomotic leak). Nasogastric tubes are contraindicated after gastric surgery due to potential disruption of the surgical site, which can cause hemorrhage and anastomotic leak (Option 2). Postoperative nausea would be controlled using IV antiemetics. (Option 1) Clients are placed on a clear liquid diet for the first 48-72 hours after bariatric surgery to promote healing. The diet is restricted to low-carbohydrate (eg, sugar-free) liquids to decrease the risk of dumping syndrome, rapid emptying into the small intestines that causes unpleasant vasomotor symptoms (eg, sweating, dizziness, cramping, diarrhea). (Option 3) After bariatric surgery, low Fowler position is preferred during mealtimes as it slows gastric emptying, reducing the risk of dumping syndrome. (Option 4) Morphine and patient-controlled analgesia pumps are commonly used to manage pain after bariatric surgery. Educational objective: Nasogastric tube placement is contraindicated after gastric surgery due to the potential for disturbing the surgical site, which can result in hemorrhage and anastomotic leak.

A female client with liver cirrhosis and chronic anemia is hospitalized for a deep venous thrombosis. The client is receiving a heparin infusion and suddenly develops epistaxis. Which laboratory value would indicate that the heparin infusion needs to be turned off? 1. Hct of 30% 2. PTT of 110 3. Platelet ocunt of 80,000 4. PT of 11

2. PPT OF 110 Heparin is an anticoagulant that helps prevent further clot formation. It is titrated based on a partial thromboplastin time (PTT). The therapeutic PTT target is 1.5-2.0 times the normal reference range of 25-35 seconds. A PTT value >100 seconds would be considered critical and could result in life-threatening side effects. Common sentinel events that result from heparin drips include epistaxis, hematuria, and gastrointestinal bleeds. (Option 1) A normal hematocrit for a female is 35%-47% (0.35-0.47). In a client with a history of chronic anemia, a hematocrit of 30% (0.30) may be an expected finding. (Option 3) A normal platelet count is 150,000-400,000/mm3 (150-400 x 109/L). In a client with a history of liver cirrhosis, a platelet count of 80,000/mm3 (80 x 109/L) would be anticipated. An episode of bleeding rarely occurs with a platelet count >50,000 mm3 (50 x 109/L). (Option 4) A normal prothrombin time is 11-16 seconds, and so a level of 11 seconds would not be concerning. Educational objective: Heparin infusions require close monitoring by the nurse. The partial thromboplastin time is the laboratory value required to accurately monitor the therapeutic effects of heparin.

There has been an explosion at a local chemical plant. A private car arrives at the emergency department with 4 victims whose clothes are saturated with a strong-smelling liquid. The victims are wheezing. The nurse should implement which intervention first? 1. Assessing the pt's respiratory systems 2. Decontaminating the pts 3. Donning personal protective equipment 4. Providing oxygen by NC

3. DONNING PERSONAL PROTECTIVE EQUIPMWNT Nursing priorities when implementing a chemical contamination emergency response plan include the following: Restricting other clients, staff, and bystanders from the victims' vicinity to protect non-affected individuals and the health care facility from the contaminant Donning personal protective equipment to protect the nurse when providing care (Option 3) Decontaminating the clients outside the facility before initiating treatment. If the chemical is not removed, it will continue to cause respiratory distress; contaminated clothing is left outside the facility to reduce the risk of contaminating staff and other clients (Option 2). Assessing and providing treatment of symptoms. Initial treatment is for the symptoms (eg, wheezing), regardless of the specific cause (Options 1 and 4). Educational objective: The nurse should always protect other clients, staff, and the health care facility first in a chemical contamination. Personal protective equipment should be put on before decontamination. Victims should be decontaminated outside the facility before care is administered.

The nurse working on the inpatient psychiatric unit is preparing to administer 9:00 AM medications to a client. The medication administration record is shown in the exhibit. On assessment, the client is tremulous, exhibits muscle rigidity, and has a temperature of 101.1 F (38.4 C). Which action should the nurse take? Click on the exhibit button for additional information. 1. Give all medications, including acetaminophen, and reassess in 30 minutes 2. Hold the haloperidol, give acetaminophen, and reassess in 30 minutes 3. Hold the haloperidol and notify the HCP immediately 4. Hold the hydrochlorothiazide and notify the HCP immediately

3. HOLD THE HALOPERIDOL AND NOTIFY THE HCPM IMMEDIATELY This client is exhibiting signs and symptoms of neuroleptic malignant syndrome (NMS), a rare but potentially life-threatening reaction. NMS is most often seen with the "typical" antipsychotics (eg, haloperidol, fluphenazine). However, even the newer "atypical" antipsychotic drugs (eg, clozapine, risperidone, olanzapine) can cause the syndrome. NMS is characterized by fever, muscular rigidity, altered mental status, and autonomic dysfunction (eg, sweating, hypertension, tachycardia). Treatment is supportive and is directed at reducing fever and muscle rigidity and preventing complications. Treatment in an intensive care unit (ICU) may be required. The most important intervention is to immediately discontinue the antipsychotic medication and notify the HCP for further assessment. (Option 1) Administering acetaminophen may be appropriate, but it is more important to discontinue the haloperidol and notify the HCP immediately. (Option 2) Due to the life-threatening nature of NMS, the HCP should be informed immediately. The HCP may order muscle enzymes, administer IV fluids/medications, and move the client for close monitoring (eg, to the ICU). (Option 4) Hydrochlorothiazide is a diuretic commonly used for hypertension. It does not cause NMS symptoms. Educational objective: NMS is characterized by fever, muscle rigidity, altered mental status, and autonomic dysfunction. The most important intervention is to discontinue the antipsychotic medication.

The nurse provides discharge instructions to a client with cirrhosis who has portal hypertension, ascites, and esophageal varices. Which statement by the client indicates that the teaching was effective? 1. I may have one alcoholic drink a day, but no more 2. I may take aspirin instead of acetaminophen for fever or pain 3. I should avoid straining while having a bowel movement 4. I should eat a protein and sodium restricted diet

3. I SHOULD AVOID STRAINING WHILE HAVING A BOWEL MOVEMENT Cirrhosis is a progressive, degenerative disease caused by destruction and subsequent disordered regeneration of the liver parenchyma. Clients with cirrhosis suffer from various complications (eg, ascites, varices, encephalopathy) that will progressively intensify without lifestyle modifications. (Option 1) Alcoholism is one of the leading causes of cirrhosis. All clients with alcoholism should abstain from drinking to prevent further liver damage. (Option 2) Aspirin and ibuprofen (a nonsteroidal anti-inflammatory drug [NSAID]) may cause gastrointestinal bleeding. Clients with esophageal varices or portal hypertension have an increased risk of bleeding and should avoid these medications. They should contact the health care provider regarding any pain or fever. (Option 4) Although a low-sodium diet is important to prevent worsening hypertension and ascites, a low-protein diet is not usually recommended. Many clients with cirrhosis suffer from protein-calorie malnutrition; therefore, an intake of 1.2-1.5 g/kg of protein a day is commonly prescribed. Educational objective: Clients with cirrhosis should eat a high-calorie, high-carbohydrate, low-sodium, and low-fat diet; moderate protein intake is recommended. They should avoid hepatotoxic substances (eg, alcohol, acetaminophen) and medications (NSAIDs) that increase bleeding risk and reduce activities that increase intraabdominal pressure.

The client recently admitted to the assisted living center has impaired vision related to primary open-angle glaucoma. Select the graphic that best illustrates the effects of glaucoma on the client's vision. 1. Spots in vision 2. Reduced center of vision 3. Reduced outer ring of vision 4. Blurry vision

3. REDUCED OUTER RING OF VISION Primary open-angle glaucoma (POAG) is an eye condition characterized by an increase in intraocular pressure and gradual loss of peripheral vision (ie, tunnel vision). The signs/symptoms of POAG develop slowly and include painless impairment of peripheral vision with normal central vision, difficulty with vision in dim lighting, increased sensitivity to glare, and halos observed around bright lights. POAG can lead to blindness if left untreated. (Option 1) Retinal detachment is separation of the retina from the underlying epithelium that allows fluid to collect in the space. The signs/symptoms include sudden onset of light flashes, floaters, cloudy vision, or a curtain appearing in the vision. (Option 2) Age-related macular degeneration is a degenerative eye disease that brings about the gradual loss of central vision, leaving peripheral vision intact. (Option 4) A cataract is cloudiness (ie, opacity) of the lens that may occur at birth or more commonly in older adults. The signs/symptoms of a cataract include painless, gradual loss of visual acuity with blurry vision; scattered light on the lens producing glare and halos, which are worse at night; and decreased color perception. Educational objective: Primary open-angle glaucoma is characterized by an increase in intraocular pressure and gradual loss of peripheral vision (ie, tunnel vision).

The nurse is monitoring a client following a radiofrequency catheter ablation. The nurse notes that the P waves are not associated with the QRS complexes on the cardiac monitor. Which intervention is most appropriate at this time? Click on the exhibit button for additional information. 1. Call a code and begin chest compressions 2. Call the rapid response team and prepare for cardioversion 3. Document the findings in the chart and continue to monitor 4. Notify the cardiologist and prepare for temporary pacing

4. NOTIFY THE CARDIOLOGIST AND PREPARE FOR TEMPORARY PACING Radiofrequency ablation is performed through transvenous cardiac catheterization to ablate (ie, burn) electrical pathways causing supraventricular or ventricular tachydysrhythmias. Ablation performed near the atrioventricular (AV) node can damage conduction, causing varying degrees of AV block. Third-degree AV block, or complete heart block, occurs when electrical conduction from the atria to the ventricles is blocked, causing decreased cardiac output (eg, dizziness, syncope, mental status changes, heart failure, hypotension, bradycardia). On ECG, third-degree AV block presents as a regular rate and rhythm with disassociated P waves and QRS complexes. This type of AV block requires temporary or permanent pacing to restore electrical conduction and hemodynamic stability. (Option 1) The client's pulse and hemodynamic stability (eg, responsiveness) should be assessed before calling a code. Most complete heart blocks can be managed with temporary followed by permanent pacing. (Option 2) The rapid response team can be initiated depending on the client's condition. However, cardioversion is performed for ventricular or supraventricular tachydysrhythmias but is not indicated in heart block. (Option 3) Third-degree AV block is a life-threatening condition and requires intervention. Educational objective: Third-degree AV block results in disassociation of atrial and ventricular contraction due to blocked electrical conduction pathways. Temporary or permanent pacing is necessary to stabilize the client.

The nurse is preparing to administer an antibiotic to a child with a severe respiratory infection. The prescription reads: 7.5 mg/kg every 24 hours divided into 2 doses, to be given by mouth in liquid form. Recommended dosage is 250-500 mg every 24 hours. The client weighs 78 lb. The pharmacy has supplied the drug in 125 mg/5 mL. How many mL should the client receive for each dose? Record your answer using one decimal place.

5.3 1. Calculate weight in kg 78 lb ÷ 2.2 = 35.4545 kg 2. Calculate the total dose in mg the client should receive in 24 hr 35.4545 kg x 7.5 mg/kg = 265.9088 mg 3. Determine if the ordered dosage is safe 265.9088 mg falls in the safe range of 250-500 mg/24 hr 4. Calculate the 2 individual dosages to be given in a 24-hr period 265.9088 mg ÷ 2 doses = 132.9544 mg 5. Calculate the amount of medication the client will receive in mL for each dose 132.9544 mg x 5 mL ÷ 125 mg = 5.3182 mL (round down 5.3 mL) Educational objective: Correct dosage calculations are very important for all age groups. However, due to lower body weight and immaturity of body systems, an incorrect drug calculation could be more harmful in a child than in an older person.

What is the priority when caring for a 6-month-old diagnosed with atopic dermatitis? 1. Encouraging use of humidifier 2. Exploration of family feelings 3. Instruction regarding hypoallergenic diet 4. Prevention of scratching

4. PREVENTION OF SCRATCHING Atopic dermatitis, also known as eczema, is a chronic skin disorder characterized by pruritus, erythema, and dry skin. In infants, red, crusted, scaly lesions may also be present. It is commonly first diagnosed before age 1 year. The exact cause is unknown, although it is associated with an impaired skin barrier that allows penetration of allergens, leading to an immune response. The primary goals of management are to alleviate pruritus and keep the skin hydrated to prevent scratching. Scratching leads to the formation of new lesions and predisposes to secondary infections. Important measures to prevent scratching include cutting and filing nails short, placing gloves or cotton stockings over the hands, not wearing rough fabrics or woolen clothing, and applying moisturizer. These measures would have an immediate effect in preventing scratching. (Option 1) A room humidifier may improve skin hydration and comfort in clients with excessively dry skin. However, comfort measures are not as crucial as immediate prevention of scratching (eg, gloves or cotton stockings placed over the hands). (Option 2) Having an infant with severe atopic dermatitis may be a source of anxiety or stress for parents. Although it may be beneficial to explore the psychosocial effects on the family, prevention of scratching is a higher priority as it can lead to secondary infection. (Option 3) Many clients with atopic dermatitis are also diagnosed with food sensitivities that aggravate the condition and require a hypoallergenic diet. However, nutritional education is a lower priority than infection prevention. Educational objective: Atopic dermatitis (eczema) is a chronic skin disorder manifested in infants by pruritus, dry skin, and red, crusted, scaly lesions. The priority management is to prevent scratching as this would promote formation of new lesions and predispose to secondary infections.