July 18th
A client with active pulmonary tuberculosis is prescribed 4-drug therapy with ethambutol. The community health nurse instructs the client to notify the health care provider immediately if which adverse effect associated with ethambutol occurs? 1. Blurred vision 2. Dark colored urine 3. Difficulty hearing 4. Yellow skin
1. BLURRED VISION Ethambutol (Myambutol) is used in combination with other antitubercular drugs (eg, isoniazid, rifampin, pyrazinamide) to treat active tuberculosis. The client must have baseline and periodic eye examinations during therapy as optic neuritis is a potentially reversible adverse effect. The client is instructed to report signs of decreased visual acuity and loss of color (red-green) discrimination. (Options 2 and 4) Dark-colored urine and yellow skin can indicate the presence of hepatotoxicity, which is associated with many drugs used to treat tuberculosis (eg, isoniazid, pyrazinamide, rifampin). However, hepatotoxicity is not common with ethambutol. (Option 3) Difficulty hearing (tinnitus, subjective hearing loss) is an adverse reaction to streptomycin. Streptomycin, an aminoglycoside antibiotic, is a second-line drug sometimes used to treat multi-drug-resistant tuberculosis, with ototoxic and nephrotoxic adverse effects. Educational objective: Clients taking ethambutol must have baseline and periodic eye examinations during therapy as optic neuritis is a potentially reversible adverse effect.
The nurse who is caring for a 1-month-old with Tetralogy of Fallot will report which finding to the health care provider as a priority? 1. Hgb of 24.9 2. Murmur on heart auscultation 3. Oxygen saturation of 82% on room air 4. Poor weight gain
1. HGB OF 24.9 The normal range for hemoglobin in a 1-month-old is 12.5-20.5 g/dL (125-205 g/L). Hemoglobin of 24.9 g/dL (249 g/L) is diagnostic of polycythemia (elevated hemoglobin levels). Infants with cyanotic cardiac defects can develop polycythemia as a compensatory mechanism due to prolonged tissue hypoxia. Polycythemia will increase blood viscosity, placing an infant at risk for stroke or thromboembolism (Option 1). Clubbing is another manifestation of prolonged hypoxia. (Option 2) Cardiac murmur is expected in heart defects. This is not a priority to report. (Option 3) Tetralogy of Fallot (TOF) is a cyanotic cardiac defect. Infants with TOF will normally maintain oxygen saturations of 65%-85% until the defect is surgically corrected. (Option 4) Poor weight gain is common with congenital heart defects. This finding is not a priority. Feeding intolerance, tachypnea, and dyspnea usually indicate severe hypoxemia. Educational objective: Poor oxygenation can cause elevated levels of hemoglobin (polycythemia), which increase blood viscosity. Thickened serum puts infants at risk for stroke or thromboembolism. An infant with polycythemia must stay hydrated.
When a client diagnosed with acute urinary retention is emergently catheterized, the nurse should initially assess for which priority manifestation that may occur as a result of the catheterization? 1. Dysuria 2. Hypotension 3. Infection 4. Tachycardia
2. HYPOTENSION Acute urinary retention is best treated with rapid, complete bladder decompression rather than the intermittent urine drainage that is limited to 500 to 1000 mL at a time. Rapid decompression can be associated with hematuria, hypotension, and postobstructive diuresis (Option 2). However, these are rarely clinically significant if appropriate supportive care is administered, whereas inability to relieve the obstruction can be associated with infection and kidney injury (Option 3). (Option 1) Dysuria from catheterization can be treated with analgesics or antispasmodic medications. Maintaining perfusion and adequate blood pressure is the priority concern. (Option 4) With sudden release of bladder obstruction, cardiovascular autonomic activity occurs and the blood pressure and heart rate are reduced due to the excitation of the parasympathetic system. Educational objective: Acute urinary retention is best treated with rapid complete bladder decompression. The nurse should carefully assess for hypotension and bradycardia, which are potential complications.
When caring for a client with a left radial artery catheter, which assessment data obtained by the nurse indicates the need to take immediate action? 1. Cap refill less than 3 seconds 2. Left hand cooler than right 3. MAP of 65 4. Pressure bag at 300
2. LEFT HAND COOLER THAN RIGHT Although the Allen's test is performed before cannulating the radial artery and determines the adequacy of ulnar artery blood flow, circulation to the extremity is monitored frequently. The nurse must assess color, capillary refill, sensation, temperature, and movement per institution policy. Impairment in any of these parameters must be reported immediately because it may indicate impaired circulation to the extremity, and removal of the catheter may be necessary. (Option 1) Capillary refill of less than 3 seconds is an indicator of normal arterial circulation. (Option 3) A mean arterial pressure of 65 mm Hg is adequate to perfuse the vital organs. (Option 4) To maintain patency of the arterial blood pressure monitoring system, an intravenous bag of normal saline solution is placed in a pressure infuser device. The device is set to maintain continual pressure at 300 mm Hg. The pressure drops as the volume of solution in the bag decreases and can be pumped back up. This does not pose an immediate threat to the client. Educational objective: When caring for a client with a radial, brachial, or femoral arterial line in place, the nurse must be able to assess for complications. These include hemorrhage, infection, thrombus formation, and circulatory and neurovascular impairment.
The clinic nurse is caring for a 3-year-old client. Which task, if not observed or reported by the parents as accomplished, will cause the nurse concern? 1. Catches a ball at least 50% of the time 2. Copies a square with a crayon 3. Eats with a spoon 4. Hops on one foot
3. EATS WITH A SPOON Things that most children can do by a certain age are considered developmental milestones. These include the following areas of development: social/emotional, language/communication, cognitive, and physical. Each child develops in a unique pattern, and ages are considered as general guidelines for assessing development. Normally, a toddler develops the ability to use a spoon by 18 months. Therefore, a 3-year-old should be able to eat with a spoon. (Option 1) Catching a ball 50% of the time is a developmental expectation for a 4-year-old. (Option 2) A 4-year-old can copy or draw a square with a pencil or crayon. Copying shapes other than a circle is a developmental expectation for a 5-year-old. (Option 4) Hopping on one foot is a developmental expectation for a 4-year-old. Educational objective: A 3-year-old should be able to eat with a spoon.
The nurse reinforces teaching to a female client about taking misoprostol to prevent stomach ulcers. Which statement by the client would prompt further instruction? 1. I can take this med with food if it hurts my stomach 2. I must use a reliable form of birth control while taking this medication 3. I should ocntinue to take my ibuprofen as prescribed 4 .I will take this medicine with an antacid to decrease stomach upset
4. I WILL TAKE THIS MEDICINE WITH AN ANTACID TO DECREASE STOMACH UPSET Misoprostol (Cytotec) is a synthetic prostaglandin that protects against gastric ulcers by reducing stomach acid and promoting mucus production and cell regeneration. It is often prescribed to prevent gastric ulcers in clients receiving long-term nonsteroidal anti-inflammatory drug (NSAID) therapy. Antacids, especially those that contain magnesium (eg, Gaviscon), can increase the adverse effects of misoprostol (eg, diarrhea, dehydration). If clients require therapy with antacids, they should choose one that does not contain magnesium (eg, calcium carbonate [Tums]) and contact the health care provider if adverse effects occur (Option 4). (Option 1) Taking misoprostol with food can help decrease gastrointestinal side effects (eg, abdominal pain, cramping, diarrhea). (Option 2) Misoprostol is also used for labor induction and is classified as a pregnancy category X drug. Women of childbearing age must be educated on using reliable birth control and the possible sensation of uterine cramping while taking misoprostol. Clients who suspect they are pregnant must stop taking the medication and contact their health care provider immediately. (Option 3) The client can continue taking ibuprofen (an NSAID) with misoprostol because misoprostol is designed to reduce side effects of ibuprofen. Educational objective: Misoprostol prevents gastric ulcers in clients receiving long-term nonsteroidal anti-inflammatory drug therapy. It should not be taken with antacids but can be taken with food to reduce gastrointestinal upset. Women of childbearing age should be educated on using reliable birth control methods as misoprostol can induce labor.
A client with a C3 spinal cord injury has a headache and nausea. The client's blood pressure is 170/100 mm Hg. How should the nurse respond initially? 1. Administer analgesic 2. Administer antihypertensive 3. Lower head of bed 4. Palpate the pt's bladder
4. PALPATE THE PT'S BLADDER Autonomic dysreflexia is an acute, life-threatening response to noxious stimuli, which clients with spinal cord injuries above T6 are unable to feel. Signs and symptoms include hypertension, bradycardia, a pounding headache, diaphoresis, and nausea. It is essential that the nurse assess for and remove noxious stimuli to prevent a stroke (Option 4). Noxious stimuli may include: Bladder distention (eg, obstructed urinary catheter, neurogenic bladder) Fecal impaction Tight clothing (eg, shoelaces, waistbands) (Options 1 and 2) Hypertension, headache, and nausea due to uncontrolled sympathetic activity will resolve once the cause is identified and removed. (Option 3) Lowering the head of the bed would increase blood pressure. The head of the bed should be raised to lower the blood pressure. Educational objective: Autonomic dysreflexia is an acute, life-threatening response to noxious stimuli (eg, bladder distention, tight clothing) in clients with spinal cord injuries above T6. Signs and symptoms include hypertension, bradycardia, a pounding headache, diaphoresis, and nausea. The nurse must immediately identify and remove noxious stimuli to prevent a stroke and resolve symptoms.
A nurse in a clinic is talking with a parent about the onset of puberty in boys. What is the first sign of pubertal change that occurs? 1. Appearance of upper lip hair 2. Increase in height 3. Presence of axillary hair 4. Testicular enlargement
4. TESTICULAR ENLARGEMENT Testicular enlargement, including scrotal changes, is the first manifestation of puberty and sexual maturation. This typically occurs at age 9½-14. It is followed by the appearance of pubic, axillary, facial, and body hair. The penis increases in size and the voice changes. Some boys also experience an increase in breast size. Growth spurt changes of increased height and weight may not be apparent until mid-puberty. Educational objective: Sexual maturation in boys begins with an increase in testicular size, followed by changes in the scrotum, appearance of pubic, axillary, facial, and body hair, and voice changes.
A client's family presses the call button and reports that they are unable to wake the client. Place the nurse's next actions in the correct order. All options must be used.
-Attempt to shake the client awake -Call for help -Check for breathing and a pulse for 10 seconds -Begin chest compressions -Notify the health care provider The sequence of basic life support (BLS) for an unconscious, pulseless client includes: Verify unresponsiveness by tapping or gently shaking the client while calling by name or shouting, "Are you all right?" (Option 1). Activate the emergency response system by calling for help if in the hospital, or by calling 911 and obtaining an automated external defibrillator (AED) if outside the hospital (Option 3). The emergency response system should be activated for all unresponsive clients. This allows the nurse to quickly proceed with assessment of pulse and respirations without delaying to retrieve a defibrillator. Simultaneously check the carotid pulse and check the client for breathing for no more than 10 seconds (Option 4). Attempt cardiopulmonary resuscitation if no pulse is felt, starting with chest compressions (circulation, airway, breathing [CAB] sequence) (Option 2). Chest compression rate should be 100-120/min. Chest compression depth should be 2-2.4 in (5-6 cm). Notify the health care provider if not already on scene (Option 5). Educational objective: The sequence of basic life support includes assessing responsiveness by tapping or gently shaking the client, activating the emergency response system (eg, calling a code), simultaneously assessing pulse and breathing for no more than 10 seconds, initiating chest compressions if no pulse is felt, and notifying the health care provider.
The nurse is providing discharge teaching to several clients with new prescriptions. Which instructions by the nurse are correct in regard to medication administration? Select all that apply. 1. Avoid salt substitues when taking valsartan for hypertension 2. Take levofloxacin with an aluminum antacid to avoid gastric irritation 3. Take sucralfate after meals to minimize gastric irritation associated with a gastric ulcer 4. When taking ethanbutol, notify the HCP of any changes in vision 5. When taking rifampin, notify the HCP if the urine turns red orange
1 & 4 Both ACE inhibitors ("prils" - captopril, enalapril, lisinopril, ramipril) and angiotensin receptor blockers ("sartans" - valsartan, losartan, telmisartan) cause hyperkalemia. Salt substitutes contain high potassium and must not be consumed unless approved by the health care provider (HCP) (Option 1). Ethambutol (Myambutol) is used to treat tuberculosis but can cause ocular toxicity, resulting in vision loss and loss of red-green color discrimination. Vision acuity and color discrimination must be monitored regularly (Option 4). (Option 2) Levofloxacin (Levaquin) is a quinolone antibiotic. For this class of antibiotics, 2 hours should pass between drug ingestion and consumption of aluminum/magnesium antacids, iron supplements, multivitamins with zinc, or sucralfate. These substances can bind up to 98% of the drug and make it ineffective. (Option 3) Sucralfate (Carafate, Sulcrate), prescribed to treat gastric ulcers, should be administered before meals to coat the mucosa and prevent irritation of the ulcer during meals. It should also be given at least 2 hours before or after other medications to prevent interactions that reduce drug efficacy. (Option 5) Rifampin (Rifadin), used to treat tuberculosis, normally causes red-orange discoloration of all body fluids. The client should be alerted to expect this change but does not need to notify the HCP. Educational objective: The nurse should watch for vision changes with ethambutol. Potassium supplements or salt substitutes should not be given to a client taking an ACE inhibitor or angiotensin receptor blocker. Sucralfate must be given before meals to prevent irritation of the ulcer. Quinolone antibiotics should not be given with antacids or supplements that reduce drug efficacy. Rifampin commonly causes red-orange discoloration of body fluids.
A client is having a severe asthma attack lasting over 4 hours after exposure to animal dander. On arrival, the pulse is 128/min, respirations are 36/min, pulse oximetry is 86% on room air, and the client is using accessory muscles to breathe. Lung sounds are diminished and high-pitched wheezes are present on expiration. Based on this assessment, the nurse anticipates the administration of which of the following medications? Select all that apply. 1. Inhaled albuterol nebulizer 2. Inhaled ipratropium nebulizer 3. IV methylprednisone 4. Montelukast 5. Salmeterol
1, 2, & 3 Clinical manifestations characteristic of moderate to severe asthma exacerbations include tachycardia (>120/min), tachypnea (>30/min), saturation <90% on room air, use of accessory muscles to breathe, and peak expiratory flow (PEF) <40% of predicted or best (<150 L/min). Pharmacologic treatment modalities recommended by the Global initiative for Asthma (2014) to correct hypoxemia, improve ventilation, and promote bronchodilation include the following: Oxygen to maintain saturation >90% High-dose inhaled short-acting beta agonist (SABA) (albuterol) and anticholinergic agent (ipratropium) nebulizer treatments every 20 minutes Systemic corticosteroids (Solu-Medrol) (Option 4) Montelukast (Singulair) is a leukotriene receptor blocker with both bronchodilator and anti-inflammatory effects; it is used to prevent asthma attacks but is not recommended as an emergency rescue drug in asthma. (Option 5) A long-acting beta agonist (Salmeterol) is administered with an inhaled corticosteroid for long-term control of moderate to severe asthma; it is not used as an emergency rescue drug in asthma. Educational objective: Clinical manifestations characteristic of moderate to severe asthma exacerbations include tachycardia, tachypnea, saturation <90% on room air, use of accessory muscles of respiration, and PEF <40% predicted. Management includes the administration of high-dose inhaled SABA and ipratropium nebulizer, systemic corticosteroids, and oxygen to maintain saturation >90%.
The nurse plans care for a 3-year-old who was admitted with suspected pertussis infection. Which instructions will the nurse include in the plan of care? Select all that apply. 1. Institute droplet precautions 2. Monitor for signs of airway obstruction 3. Offer small amounts of fluids frequently 4. Place the child in a negative pressure isolation room 5. Request an order for cough suppressant
1, 2, & 3 Pertussis (whooping cough) is a very contagious communicable disease caused by the Bordetella pertussis bacteria. These organisms attach to the small hairs in the airway and release a toxin that causes swelling and irritation. Pertussis is spread from person to person by coughing, sneezing, and close contact. As a result, an affected client should be placed in standard (universal) and droplet isolation precautions when hospitalized. At first, symptoms similar to the common cold and a mild fever occur, but eventually these clients develop a characteristic violent, spasmodic cough. Coughing is so severe that the person is forced to inhale afterward, resulting in a distinctive, high-pitched "whooping" sound. Coughing episodes may continue until a thick mucus plug is expectorated and are sometimes followed by vomiting (posttussive emesis). Treatment consists of antibiotics and supportive measures. Humidified oxygen and adequate fluids will help loosen the thick mucus. Suction as needed is important in infants. Respiratory status should be monitored for obstruction. The client should be positioned on the left side to prevent aspiration if vomiting occurs. Vaccination against whooping cough is available, but some individuals will still develop the disease, although in a milder form. (Option 4) An airborne precaution such as placing the client in a negative pressure isolation room is needed for individuals with measles, tuberculosis, and varicella zoster (chicken pox) infections (airing MTV). (Option 5) Cough suppressants are not used as they are not very effective for pertussis. In addition, the child needs to cough up any mucus plugs that might develop to keep the airway clear. Educational objective: Pertussis can occur despite vaccination. Characteristic features include a cough lasting ≥2 weeks with ≥1 of the following: paroxysms of cough, inspiratory whooping sound, and posttussive vomiting. Clients need oral antibiotics, droplet precautions, and supportive measures (humidified oxygen and oral fluids).
A client with chronic kidney disease has a large pleural effusion. What findings characteristic of a pleural effusion does the nurse expect? Select all that apply. 1. Chest pain during inhalation 2. Diminished breath sounds 3. Dyspnea 4. Hyperrenonance on percussion 5. Wheezing
1, 2, & 3 A pleural effusion is an abnormal collection of fluid (>15 mL) in the pleural space that prevents the lung from expanding fully, resulting in decreased lung volume, atelectasis, and ineffective gas exchange. It is usually secondary to another disease (eg, heart failure, pneumonia, nephrotic syndrome). Pleural effusions are diagnosed by chest x-ray or CT scan. Thoracentesis can be performed to remove fluid from the pleural space and resolve symptoms. Clients commonly report dyspnea with a nonproductive cough, as well as pleural chest pain with respirations (Options 1 and 3). On assessment, clients have diminished breath sounds, dullness to percussion, decreased tactile fremitus, and decreased movement over the affected lung (Option 2). (Option 4) Fluid outside the lung interrupts the transmission of sound, resulting in decreased fremitus and dullness with percussion in pleural effusion. Percussion is hyperresonant in clients with pneumothorax. (Option 5) Wheezing indicates an obstructive process (eg, asthma, chronic obstructive pulmonary disease) and is not typical in pleural effusion. Educational objective: A pleural effusion is an abnormal collection of fluid (>15 mL) in the pleural space that prevents the lung from expanding fully, resulting in decreased lung volume, atelectasis, and ineffective gas exchange. Clients report dyspnea and pain with respirations and have diminished breath sounds with dullness to percussion over the affected area.
A registered nurse (RN), licensed practical nurse (LPN), and unlicensed assistive personnel are working on the unit. A client who is about to be discharged home with tube feedings needs care. Which responsibilities should the RN delegate to the LPN? Select all that apply. 1. Cleaning the skin surrounding the gastrostomy tube stoma 2. Crushing and administering metorpolol theough the gastrostomy tube 3. Programming the feeding pump to administer bolus feeding 4. Teaching pt about home enteral feedings 5. Weighing the pt using the bed scale
1, 2, & 3 Most routine nursing tasks in a stable client can be delegated to a licensed practical nurse (LPN). Routine ostomy care is an appropriate task for delegation to an LPN. The LPN may administer bolus or continuous tube feedings to a stable client. In addition, most medication administration is suitable for delegation to an LPN. However, advanced medication administration (eg, IV medications) must be performed by a registered nurse (RN) (Options 1, 2, and 3). (Option 4) Client education, nursing assessment, and advanced medication administration should always be performed by an RN. Procedural nursing tasks in an unstable client are also an RN responsibility. (Option 5) Routine activities of daily living (eg, positioning) are generally suitable to be delegated to unlicensed assistive personnel (UAP). Obtaining the client's weight may be delegated to UAP. Educational objective: The registered nurse is responsible for assessment, planning, evaluation, and teaching in the care of a client with a gastrostomy tube. The licensed practical nurse can administer tube feedings and medications and provide ostomy care in a stable client.
The nurse is reviewing anticipatory guidance with the parents of a 6-month-old infant with phenylketonuria. Which statements by the nurse are appropriate? Select all that apply. 1. A low phenylalaline diet is required 2. Meat and dairy products should not be introduced into the diet 3. Phenylketonuria is self limiting and usually resolves by adulthood 4. Special infant formula is required 5. Tyrosine should be removed from the diet
1, 2, & 4 Phenylketonuria (PKU) is one of a few genetic inborn errors of metabolism. Individuals with PKU lack the enzyme (phenylalanine hydroxylase) required for converting the amino acid phenylalanine into the amino acid tyrosine. As unconverted phenylalanine accumulates, irreversible neurologic damage can occur. A low-phenylalanine diet is essential in the treatment of PKU (Option 1). Phenylalanine cannot be entirely eliminated from the diet as it is an essential amino acid and necessary for normal development. The diet must meet nutritional needs while maintaining phenylalanine levels within a safe range (2-6 mg/dL [120-360 µmol/L] for clients age <12). There is no known age at which the diet can be discontinued safely, and lifetime dietary restrictions are recommended for optimal health (Option 3). Management of the client with PKU includes: Monitoring serum levels of phenylalanine Including synthetic proteins and special formulas (eg, Lofenalac, Phenyl-Free) in the diet (Option 4) Eliminating high-phenylalanine foods (eg, meats, eggs, milk) from the diet (Option 2) Encouraging the consumption of natural foods low in phenylalanine (most fruits and vegetables) (Option 5) Restriction of dietary tyrosine is not necessary. Tyrosine levels in clients with PKU may be normal or slightly decreased. Educational objective: Phenylketonuria requires lifetime dietary restrictions. Infants should be given special formulas (eg, Lofenalac). For children and adults, high-phenylalanine foods (eg, meats, eggs, milk) should be restricted and replaced with protein substitutes.
The clinic nurse is taking vital signs on a client who reports being fatigued every day and gaining weight lately despite not eating much. The nurse should also ask about which symptoms? Select all that apply. 1. Cold intolerance 2. Constipation 3. Fever 4. Menstrual irregularity 5. Night sweats 6. Tachycardia
1, 2, & 4 Fatigue and weight gain are classic manifestations of hypothyroidism. Features of hypothyroidism typically result from decreased metabolic rate and include cold intolerance, constipation, dry skin, irregular or prolonged menstrual periods, and mental slowing or difficulty concentrating. (Options 3, 5, and 6) Fever, tachycardia, and sweating are signs of hyperthyroidism, which is a hypermetabolic state, with signs and symptoms that are usually the opposite of those seen in hypothyroidism. The presenting symptoms of a hyperthyroid client would likely include weight loss despite an increased appetite and difficulty sleeping. Educational objective: Hypothyroidism is associated with symptoms of a low metabolic rate; hyperthyroidism causes symptoms of a high metabolic rate.
There has been a major community disaster. Stable clients need to be discharged to make more beds available for the victims. Which clients could be discharged safely? Select all that apply. 1. Diagnosed with endocarditis on antibiotics with a peripherally inserted central catheter line 2. History of MS with ataxia and diplopia 3. One day postoperative from a hemicolectomy 4. Reporting abdominal pain and coffee ground emesis 5. Taking warfarin with PT/INR 2x the normal value
1, 2, & 5 Ataxia and diplopia are expected signs/symptoms of multiple sclerosis. Two times the control value demonstrates that warfarin has reached a therapeutic level. The long-term antibiotic course (and follow-up lab work) can continue at home through the PICC line (Options 1, 2, and 5). (Option 3) Large intestine peristalsis does not return for up to 3-5 days. The client cannot be discharged until able to tolerate oral intake with normal elimination. The client has to at least be passing flatus. (Option 4) Coffee ground emesis indicates upper gastrointestinal bleeding. The etiology and treatment need to be determined before the client is discharged. Educational objective: Those who are stable for discharge include the client with multiple sclerosis with ataxia and diplopia, the client on warfarin (Coumadin) that has reached the therapeutic effect, and the client with a PICC line for a long-term antibiotic course.
The nurse assesses a client receiving peritoneal dialysis. Which assessment findings are most important for the nurse to report to the health care provider? Select all that apply. 1. Cloudy outflow 2. Low grade fever 3. Oliguria 4. Pruritus 5. Tachycardia
1, 2, & 5 During peritoneal dialysis (PD), a catheter is placed into the peritoneal cavity to infuse dialysate (dialysis fluid); the tubing is then clamped to allow the fluid to dwell for a specified period. After the dwell time, the catheter is unclamped and the fluid (effluent) drains out via gravity. Cloudy outflow (effluent), tachycardia, and low-grade fever are signs of peritonitis, an infection of the peritoneal cavity and a major concern with PD. Bloody fluid can indicate intestinal perforation or that the client may be menstruating. Brown effluent can indicate fecal contamination from perforation. All these findings need to be reported to the health care provider. (Option 3) Oliguria (very low urine output) is associated with acute or chronic kidney failure and is the reason the client is receiving peritoneal dialysis. It does not indicate a complication of PD. (Option 4) Pruritus (itching) is a common finding in clients with kidney failure, and may occur due to dry skin, neuropathy, or skin deposits of waste products (eg, urea, calcium-phosphate) that are normally removed via the kidney. PD can help relieve this symptom of kidney failure by filtering waste products. Educational objective: Peritonitis is a major complication of peritoneal dialysis. Signs of developing peritonitis are low-grade fever, tachycardia, and cloudy outflow (effluent). Bloody effluent can indicate intestinal perforation or that the client may be menstruating.
A community health nurse evaluates several clients' vaccination status. Which clients would the nurse recommend receive the influenza vaccine injection? Select all that apply. 1. 9 month with no known medical conditions 2. 5 year old with congenital heart defect 3. 23 year old recently diagnosed with HIV 4. 45 year old caretaker of elderly parent 5. 75 year old with end stage renal failure
1, 2, 3, 4, & 5 Influenza is a respiratory illness common during the cooler months of the year. Each year, a new influenza vaccine is created to help protect against specific viral strains. The Centers for Disease Control and Prevention and Public Health Agency of Canada recommend that all clients age ≥6 months receive the influenza vaccine annually unless the client has a life-threatening allergy to the vaccine or one of its ingredients. Special emphasis should be placed on vaccinating the following high-risk individuals: Clients with chronic conditions (eg, asthma, heart failure, cancer) may experience exacerbation of symptoms if infected (Options 2 and 5). Immunocompromised clients (eg, HIV) have decreased ability to fight infection (Option 3). Health care workers and caretakers are at greater risk for acquiring and transmitting infection to other clients (Option 4). Healthy children age 6-23 months and clients age ≥65 are at greatest risk for serious, flu-related complications (eg, pneumonia, dehydration) (Option 1). Pregnant clients are at increased risk for premature labor/delivery or influenza complications due to pregnancy-related physiologic changes. Educational objective: Annual vaccination during influenza season is recommended for all clients age ≥6 months without life-threatening allergy to the vaccine or its ingredients. High-risk groups include clients who have chronic conditions, those who work in health care settings or as caretakers, those age 6-23 months or ≥65, and pregnant clients.
A client indicates a desire to become pregnant. What are important preconception education topics for the nurse to provide for this client? Select all that apply. 1. Aim for a BMI<25 2. Avoid alcohol consumption and tobacco products 3. Ensure daily intake of 400-800 of folic acid 4. Obtain testing for rubella immunity 5. Schedule dental wellness appointment
1, 2, 3, 4, & 5 Preconception counseling and health care assess for risk factors and implement appropriate interventions to have a positive impact on a client's health and future pregnancies. Folic acid supplementation of at least 400 mcg per day is recommended to reduce the incidence of neural tube defects (Option 3). The impact of supplementation is greatest during the period of neural tube development (a month before pregnancy through the first trimester). Clients wanting to become pregnant should avoid alcohol, smoking/tobacco products, and illicit drugs (Option 2). There is no known safe amount of alcohol in pregnancy, so complete abstinence is recommended. Smoking is associated with fetal growth restriction, and clients should be encouraged to quit prior to pregnancy. Periodontal disease is associated with adverse pregnancy outcomes, including preterm birth and low birth weight. Dental problems should be identified and treated before pregnancy (Option 5). Clients who are not immune to rubella should be vaccinated and avoid pregnancy for at least 4 weeks after vaccination (Option 4). Obesity (BMI >30 kg/m2) during pregnancy is associated with increased risk for fetal/maternal complications (eg, birth defects, gestational diabetes, pregnancy-related hypertension, fetal macrosomia). Achieving a normal BMI (18.5-24.9 kg/m2) prior to pregnancy helps improve outcomes (Option 1). Educational objective: Preconception care involves folic acid supplementation, appropriate dental care and vaccinations, and avoidance of alcohol, smoking, and illicit drugs. Clients should also attempt to achieve normal weight (BMI of 18.5-24.9 kg/m2) before conceiving to improve outcomes.
A nurse on the antepartum unit is caring for a pregnant client at 30 weeks gestation who was admitted with reports of vaginal bleeding. A diagnosis of placenta previa was confirmed by ultrasound. What should the nurse tell the client to anticipate? Select all that apply. 1. Additional ultrasound around 36 weeks gestation 2. Clearance for sexua activity if bleeding stops 3. Discharge home if bleeding stops and fetal status is reassuring 4. Schedule c section birth before onset of labor 5. Weekly vaginal exams to assess for cervical change
1, 3, & 4 In placenta previa, the placenta is implanted over or very near the cervix. This causes placental blood vessels to be disrupted during cervical dilation and effacement, which may result in massive blood loss and maternal/fetal compromise. Because of the increased risk of hemorrhage if contractions result in cervical change, a cesarean birth is planned for after 36 weeks gestation and prior to the onset of labor (Option 4). A stable client with no active bleeding and reassuring fetal status may be discharged home and managed in an outpatient setting (Option 3). However, the client must be closely monitored and instructed to return to the hospital immediately if bleeding recurs. As pregnancy progresses, the placenta grows in size and can potentially migrate away from the cervical opening, resulting in complete resolution of the previa. Therefore, an additional ultrasound is usually performed around 36 weeks gestation to assess placental location (Option 1). (Options 2 and 5) Clients with placenta previa should be instructed to remain on pelvic rest. Vaginal examinations, douching, and vaginal intercourse are contraindicated due to the risk of disruption of the placental vessels and subsequent hemorrhage. Modified bed rest (ie, decreasing any physical activity that could cause contractions) is also recommended. Educational objective: Clients with placenta previa are at risk for hemorrhage. Vaginal examinations are contraindicated, and pelvic rest is recommended to prevent disruption of placental vessels. A cesarean birth is planned prior to onset of labor.
In the intensive care unit, the nurse cares for a client admitted with a head injury who develops syndrome of inappropriate antidiuretic hormone. Which data should the nurse expect with the onset of this condition? Select all that apply. 1. Decreased serum osmolality 2. High serum osmolality 3. High urine specific gravity 4. Increased urine output 5. Low serum sodium
1, 3, & 5 Syndrome of inappropriate antidiuretic hormone (SIADH) is potential complication of head injury. In SIADH, the extra ADH leads to excessive water absorption by the kidneys. Low serum osmolality and low serum sodium are the result of increased total body water (dilution). As ADH is secreted and water is retained, urine output is decreased and concentrated, resulting in a high specific gravity. (Options 2 and 4) Increased urine output is associated with diabetes insipidus (DI). In DI, ADH is suppressed, causing polyuria, severe dehydration, and high serum osmolality if the client is unable to drink enough to maintain a fluid balance. Educational objective: Syndrome of inappropriate antidiuretic hormone (SIADH) is a condition that results in increased ADH. Too much ADH causes increased total body water, resulting in a low serum osmolality and low serum sodium. As ADH is secreted and water is retained, urine output is decreased and concentrated, resulting in a high specific gravity.
In the intensive care unit, the nurse cares for a client who develops diabetes insipidus (DI) 2 days after pituitary adenoma removal via hypophysectomy. Which intervention should the nurse implement? 1. Administer desmopressin 2. Assess fasting blood glucose 3. Institute fluid restriction 4. Place the pt in the trendelenburg position
1. ADMINISTER DESMOPRESSIN Diabetes insipidus (DI) is a condition that occurs due to insufficient production/suppression of antidiuretic hormone (ADH). Neurogenic DI is a type of DI that results from impaired ADH secretion, transport, or synthesis. It sometimes occurs after manipulation of the pituitary or other parts of the brain during surgery, brain tumors, head injury, or central nervous system infections. DI is characterized by polydipsia (increased thirst) and polyuria (increased urine output) with low urine specific gravity (dilute urine). As a result, fluids should be replaced orally/intravenously to prevent dehydration (Option 3). ADH release is impaired in neurogenic DI. As a result, ADH replacement with vasopressin (Pitressin) can be used to treat DI. However, it also has vasoconstrictive properties. Therefore, desmopressin (DDAVP), an analog without vasopressor activity, is the preferred therapy. Clients on this treatment should be monitored for urine output, urine specific gravity, and serum sodium (to avoid hyponatremia due to excess DDAVP). (Option 2) DI is not associated with low/high blood glucose and should not be confused with diabetes mellitus (DM) as both DI and DM involve symptoms of excessive urination (polyuria). (Option 4) The Trendelenburg position (body laid flat and supine with feet higher than the head by at least 15-30 degrees) is contraindicated in most neurological conditions. Educational objective: DI occurs when there is insufficient production/suppression of ADH. It is characterized by polydipsia and polyuria with diluted urine. Oral and/or intravenous fluid replacement is imperative to prevent dehydration. DI is treated with ADH replacement drugs (eg, desmopressin acetate [DDAVP]). Clients should be monitored for urine output, urine specific gravity, and serum sodium.
A client who has been on long-term omeprazole therapy for gastroesophageal reflux disease is admitted to the hospital for a urinary tract infection. The nurse recognizes that this client is at highest risk for which complication due to omeprazole use? 1. C diff infection 2. Gait disturbances 3. Jaw necrosis 4. Tremor
1. CDIFF INFECTION Long-term use of proton pump inhibitors (PPIs) is common as these medications are available over the counter. PPIs impair intestinal calcium absorption and therefore are associated with decreased bone density, which increases the possibility of fractures of the spine, hip, and wrist. PPIs cause acid suppression that otherwise would have prevented pathogens from more easily colonizing the upper gastrointestinal tract. This leads to increased risk of pneumonias. PPI use may also increase the risk for clostridium difficile-associated diarrhea (CDAD); currently the cause is unclear. A safety alert has been issued by the US Food and Drug Administration (FDA) advising health care providers to consider CDAD for unresolved diarrhea in PPI users. This client would be receiving antibiotics for a urinary tract infection, further increasing the risk for C difficile infection (Option 1). (Option 2) Gait disturbance (ataxia) is commonly seen with phenytoin toxicity. (Option 3) Jaw necrosis is associated with long-term bisphosphonate (eg, alendronate, risedronate) therapy. (Option 4) Tremor is seen with lithium toxicity and albuterol (short-acting beta agonist) use. Educational objective: Long-term use of PPIs (Prazoles - omeprazole, lansoprazole, pantoprazole, rebeprazole) has been associated with decreased bone density (calcium malabsorption) and increased risk for C difficile-associated diarrhea and pneumonia.
Which components are used in determining the standards of professional nursing practice? Select all that apply. 1. Care given with good intentions to the best of one's own ability 2. Clinical practice statements of professional organizations 3. Health care institution's policies and procedures 4. Nurse practice act of the state or province 5. nurses usual custom and practice
2, 3, & 4 Standards of nursing practice and care are universal criteria that are used when determining if appropriate, professional care has been delivered. The definition of this minimum acceptable level of care reflects what reasonable, prudent, and careful nurses would do in specific circumstances. The state or province/territory boards of nursing help to regulate these standards. Sources used to define standard of care include statements from professional organizations, agency policies and procedures, textbooks, current literature, expert consensus, the Nurse Practice Act, and statutes from regulatory organizations (Options 2, 3, and 4). (Option 1) The standard of care includes objective criteria and does not consider intention. Guidelines are used in determining if duties were performed in an appropriate manner. A nurse can have good intentions but still fail to meet the standards of professional nursing practice. (Option 5) Standard of care is determined by objective, third-party authoritative/reasonably reliable sources. Nurses who are suspected of negligence, yet cannot provide documentation of the event in question, can testify about their interpretation of usual custom and practice as it relates to the incident. However, an individual's typical actions are not authoritative in determining the universal standard of nursing care and cannot replace the use of objective, authoritative, and predetermined standards of care. Educational objective: The standards of professional nursing practice and care are defined by what reasonable, prudent nurses would do in specific circumstances. These are based on objective, third-party authoritative sources, including literature, laws (Nurse Practice Act), and professional organizations.
The nurse is performing an assessment on a 2-day-old infant with suspected Hirschsprung disease. Which findings should the nurse anticipate? Select all that apply. 1. Bright red bleeding from anus 2. Distended abdomen 3. Has not passed stool 4. Nonbilious vomiting 5. Refusal to feed
2, 3, & 5 Hirschsprung disease occurs when a child is born with some sections of the distal large intestine missing nerve cells; this renders the internal anal sphincter unable to relax. As a result, there is no peristalsis and stool is not passed. Newborns exhibit symptoms of distal intestinal obstruction. They have a distended abdomen and will not pass meconium within the expected 24-48 hours. They will also have difficulty feeding and often vomit green bile. (Option 1) An infant with Hirschsprung disease will not have passed meconium. Bright red bleeding from the rectum would not occur. However, rectal bleeding could be a symptom of Meckel's diverticulum, a remnant of the umbilical cord that should have disintegrated at 8 weeks in utero but became an out pouch in the small intestine. (Option 4) Nonbilious vomiting is seen in conditions where the pathology is proximal to the pylorus (eg, hypertrophic pyloric stenosis). Bilious (green) vomiting is seen in conditions where the pathology is distal to the duodenum as the common bile duct drains at the duodenum. In Hirschsprung disease, the pathology is at the distal colon; green bilious vomiting is expected. Educational objective: Hirschsprung disease is caused by a lack of specialized nerve cells in portions of the distal large intestine; this renders the internal sphincter unable to relax. Infants with Hirschsprung disease will not pass meconium but will have distended abdomens and bilious emesis.
The nurse is assisting with cardiopulmonary resuscitation of a client in cardiac arrest. The rhythm in the exhibit is displayed on the cardiac monitor. Which medication administration should the nurse anticipate? Click the exhibit button for additional information. EXHIBIT: Torsaddes 1. Adenosine 2. Dopamine 3. Magnesium 4. Metorpolol
3. MAGNESIUM Torsades de pointes (ie, "twisting of the points") is a polymorphic ventricular tachycardia characterized by QRS complexes that change size and shape in a characteristic twisting pattern. Torsades de pointes is usually due to a prolonged QT interval (more than half the RR interval), which is the result of electrolyte imbalances, especially hypomagnesemia, or some medications. The first-line treatment is IV magnesium (Option 3). Treatment may also include defibrillation and discontinuation of any QT-prolonging medications. (Option 1) Adenosine is an antiarrhythmic used to treat supraventricular tachycardia. (Option 2) Dopamine is a vasopressor used to treat symptomatic hypotension. (Option 4) Metoprolol is a beta blocker used for heart rate control in tachyarrhythmias. Educational objective: Torsades de pointes is usually due to a prolonged QT interval, which is the result of electrolyte imbalances, especially hypomagnesemia, or some medications. First-line treatment is magnesium IV. Treatment may also include defibrillation and discontinuation of QT-prolonging medications.
A 64-year-old client is prescribed ciprofloxacin for a urinary tract infection (UTI). The nurse instructs the client to observe for and notify the health care provider (HCP) immediately about which of the following? 1. Brown colored urine 2. Hearing and balance problems 3. Pain in the achilles tendon area 4. Sunburn
3. PAIN IN THE ACHILLES TENDON AREA Use of fluoroquinolones (ciprofloxacin, levofloxacin, moxifloxacin, norfloxacin, ofloxacin), especially ciprofloxacin, places clients at increased risk for tendinitis and tendon rupture that most often occur in the Achilles tendon. This class of antibiotics carries a black box warning about this risk. The Food and Drug Administration recommends that at the first sign of tendon pain or swelling, clients should stop taking the fluoroquinolone, abstain from moving the affected area, and contact their HCP promptly for further evaluation and a change of antibiotic. (Option 1) Turning urine into a harmless brown color is a common side effect of nitrofurantoin, another antibiotic commonly used for UTI treatment. (Option 2) Hearing and balance problems (vertigo) result from aminoglycoside ototoxicity (eg, gentamicin). (Option 4) Ciprofloxacin can cause photosensitivity. The client should be instructed to avoid sun exposure and use sunscreen while taking the medication. Educational objective: Fluoroquinolones (ciprofloxacin) carry a black box warning citing an increased risk of tendinitis and rupture, especially of the Achilles tendon.
A nurse is caring for a 2-year-old child diagnosed with nephrotic syndrome who is in diapers and has red, edematous genitals. Which collection technique is appropriate for the nurse to obtain daily urine specimens for proteinuria testing with a urine dipstick? 1. Apply adhesive urine collection bag and wait for child to void 2. Intermittently cathterize the child every morning 3. Place cotton balls in a dry diaper; when wet, squeeze urine onto dipstick 4. Place urine dipstick in the child's diaper overnight and check results in morning
3. PLACE COTTON BALLS IN A DRY DIAPER; WHEN WET, SQUEEZE URINE ONTO DIPSTICK Nephrotic syndrome is characterized by massive proteinuria and hypoalbuminemia, which results in severe edema most evident in the abdomen, face, and perineum. Daily dipstick urinalysis determines the presence and pattern of urine protein loss to monitor for exacerbations. To collect a nonsterile urine specimen from a child who is not toilet trained, the nurse can place several cotton balls in a dry diaper and later squeeze urine onto a dipstick. The diaper is checked frequently and the sample collected and tested within 30 minutes of urination for the most accurate result. (Options 1 and 4) Children with nephrotic syndrome often have significant edema of the scrotum or labia. Placing a urine dipstick in the child's diaper or applying a standard adhesive urine collection bag around the genital area would cause further irritation and increased risk for skin breakdown. (Option 2) Children with nephrotic syndrome have a high risk for infection from immunosuppressive effects of corticosteroid therapy. Intermittent or continuous catheterizations are invasive procedures that may cause urinary tract infections. Urine cultures are the only specimen requiring sterile collection techniques (eg, clean catch, catheterization). Educational objective: Children with nephrotic syndrome often require daily urinalysis to monitor for proteinuria. Urine collection bags or dipsticks in the diaper risk breakdown of edematous skin. To collect a nonsterile urine specimen from a child in diapers, the nurse can place cotton balls in a dry diaper and later squeeze urine onto a dipstick.
A client is being discharged after having a stent placed in the left anterior descending coronary artery. The client is prescribed clopidogrel. Which client data obtained by the nurse would be concerning in relation to this new medication? Select all that apply. 1. BP of 140/84 2. HR of 98 3. Platelet of 200,000 4. Report of ginko biloba use 5. Report pf peptic ulcer disease
4 & 5 Antiplatelet agents (eg, clopidogrel, ticagrelor, prasugrel, aspirin) prevent platelet aggregation and are given to clients to prevent stent re-occlusion. They prolong bleeding time and should not be taken by clients with a bleeding peptic ulcer, active bleeding, or intracranial hemorrhage. Ginkgo biloba also interferes with platelet aggregation and can cause increased bleeding time. Antiplatelet agents and Ginkgo biloba should not be taken together. If this were to occur, this client would be at an increased risk for bleeding. This information should be reported to the prescribing health care provider before the client is discharged. (Option 1) This blood pressure is slightly elevated, but is unaffected by antiplatelet agents. (Option 2) Normal heart rate is between 60/min-100/min. (Option 3) This is a normal platelet count (150,000/mm3-400,000/mm3 [150-400 x 109/L]). Educational objective: If a client is prescribed clopidogrel, the nurse should be concerned about a history of peptic ulcer disease and Ginkgo biloba use. In this situation, the client would be at increased risk for bleeding. This data should be reported to the prescribing health care provider before the client is discharged.
The nurse is admitting a client with cholelithiasis and acute cholecystitis. Suddenly, the client vomits 250 mL of greenish-yellow stomach contents and reports severe pain in the right upper quadrant with radiation to the right shoulder. Which intervention would have the highest priority? 1. Administer promethazine 2. Infuse NS 3. Insert NGT to low suction 4. Maintain NPO status
4. MAINTAIN NPO STATUS The highest priority intervention for an actively vomiting client with cholelithiasis is maintenance of strict NPO status to avoid additional gallbladder stimulation. Additional collaborative interventions (see table) for cholecystitis should also be taken into account. (Option 1) Promethazine 25 mg suppository is the second priority. Promethazine promotes the relief of nausea and vomiting and minimizes further fluid loss. (Option 2) Obtaining fluid and electrolyte replacement with sodium chloride 100 mL/hr is the third priority and assists in the maintenance of fluid balance. (Option 3) Insertion of a nasogastric (NG) tube to low suction is the fourth priority. NG suction provides gastric decompression, alleviates nausea and vomiting, and promotes bowel rest. Educational objective: The highest priority intervention for an actively vomiting client with acute cholecystitis is maintenance of strict NPO status to avoid additional stimulation of the gallbladder. Additional priorities include management of nausea and vomiting, pain, fluid balance, and gastric decompression.
The nurse reinforces the physical therapist's teaching regarding the use of a cane when caring for a client with osteoarthritis of the left knee. Which client statement indicates the need for further teaching? 1. I will hold the cane on my right side 2. I will move the left leg forward after moving the cane 3. I will place the cane several inches in front of and to the side of my right foot 4. My cane should equal the distance from my waist to the floor
4. MY CANE SHOULD EQUAL THE DISTANCE FROM MY WAIST TO THE FLOOR Clients with one-sided weakness or injury, increased joint pressure, or poor balance can use a cane to provide support and stability when walking. Cane length should equal the distance from the client's greater trochanter to the floor as incorrect cane length can cause back injury. A cane measured from the waist would be too long to provide optimal support (Option 4). Teaching points to assist a client in appropriate use of a cane include: Hold the cane on the stronger side to provide maximum support and body alignment, keeping the elbow slightly flexed (20-30 degrees) (Option 1). Place the cane 6"-10" (15-25 cm) in front of and to the side of the foot to keep the body weight on both legs to provide balance (Option 3). For maximum stability, move the weaker leg forward to the level of the cane, so that body weight is divided between the cane and the stronger leg (Option 2). If minimal support is needed, the cane and weaker leg are advanced forward at the same time. Move the stronger leg forward past the cane and the weaker leg, so the weight is divided between the cane and the weaker leg. Always keep at least 2 points of support on the floor at all times. Educational objective: Clients should hold the cane on the stronger side to provide maximum stability. Cane length should equal the distance from the greater trochanter to the floor.
A client is admitted to the intensive care unit with suspected pheochromocytoma. The client's vital signs are temperature of 99.6 F (37.5 C), blood pressure (BP) of 200/110 mm Hg, heart rate of 110/min, and respirations of 20/min. The client is sweating profusely and reports a severe headache. Which prescription should the nurse implement first? 1. Draw labs to assess electrolyte panel 2. GIve acetaminophen for headache 3. Place a fan in the pt's room 4. Start nitroprusside infusion
4. START NITROPRUSSIDE INFUSION Pheochromocytoma is a condition caused by a tumor in the adrenal medulla. This results in excess release of catecholamines such as epinephrine and norepinephrine, leading to paroxysmal hypertensive crisis. Important points to note when caring for these clients include the following: Hypertension is difficult to treat and is often resistant to multiple drugs. The client should avoid activities that can precipitate a hypertensive crisis (eg, bending, lifting, Valsalva maneuver). Abdominal palpation should be avoided as manipulation of the adrenal gland and release of catecholamines can precipitate a hypertensive crisis. Hypertensive crisis puts the client at risk for stroke and so has the highest priority for treatment. Nitroprusside (Nitropress, Nipride) is a vasodilator given via infusion and can be titrated to keep the BP within a desired parameter. (Options 1, 2, and 3) Administration of acetaminophen and use of a fan may help relieve symptoms. Drawing an electrolyte panel is appropriate. However, these are not life-saving interventions and so are not the highest priority. Educational objective: Pheochromocytoma is a condition caused by a tumor in the adrenal medulla that causes release of catecholamines such as epinephrine and norepinephrine, resulting in paroxysmal hypertensive crisis. Hypertensive crisis puts the client at risk for stroke and should be treated promptly with intravenous nitroprusside or another vasodilator (eg, phentolamine, nicardipine). Abdominal palpation should be avoided in these clients.
The nurse is assessing a client who had an esophagogastroduodenoscopy (EGD) 2 hours ago. Which finding requires an immediate report to the health care provider? 1. BP drops from 122/88 to 106/72 2. Gag reflex has not returned 3. Sore throat when swallowing 4. Temp spike to 101.2
4. TEMP SPIKE TO 101.2 A sudden temperature spike 1-2 hours after an esophagogastroduodenoscopy (EGD) could be a sign of perforation or a developing infection. The nurse should notify the health care provider immediately. (Option 1) This blood pressure drop could be due to several things (sedation, blood loss, sepsis), but without any other symptoms indicating an emergency condition, it is still within the normal range. (Option 2) The gag reflex may take a few hours to return as the EGD involves applying a topical anesthetic to the throat. Absent gag reflex after a prolonged period (6 hours) would require reporting to the health care provider. (Option 3) A sore throat is expected after certain procedures (EGD, intubation) due to local irritation. Warm saline gargles could provide some relief. Educational objective: Fever after an esophagogastroduodenoscopy (EGD) or colonoscopy could be a sign of infection from perforation and should be reported.
A nurse is discussing parallel play with parents of toddlers. Which statement should be included in the discussion? 1. One toddler will take on a follower role 2. One toddler's choice of a toy determines the choices of others 3. The child may actively watch other children in the group 4. The children play without group goals
4. THE CHILDREN PLAY WITHOUT GROUP GOALS Parallel play is characteristic of the toddler years but is not limited to this age group. Parallel activities occur when children play independently near one another with no group organization or common goals (Option 4). Although they may share toys, each child remains primarily focused on their own activity rather than directly interacting with the others. (Option 1) Cooperative play is organized, requires the ability to follow rules, and involves a leader-follower approach to activities. One or two children direct the activity and assign roles. Cooperative play, which develops during the preschool years, is goal-oriented and may involve a formal game or task. (Option 2) In parallel play, toddlers may play with similar toys, but they are not directly led by the choices of another child. Such interaction occurs more often in associative play, when children begin to engage in more cooperative activities. (Option 3) Onlooker behavior is when an interested child sits and observes others at play but does not engage in an activity. Educational objective: Toddlers typically exhibit parallel play, during which they participate in various activities alongside one another but remain primarily independent. Parallel play is without group organization or common goals.
The nurse observes the rhythm displayed in the exhibit on the cardiac monitor of a client. The client is dizzy and diaphoretic and has a blood pressure of 80/60 mm Hg. What treatment does the nurse anticipate? Click on the exhibit button for additional information. 1. 500 ml NS bolus 2. Adenosine IVP 3.. Cardioversion 4. Transcutaneous paing
4. TRANSCUTANEOUS PACING This client is experiencing third-degree atrioventricular (AV) block, or complete heart block, which involves complete inhibition of impulse conduction from the atria to the ventricles, usually at the AV node or bundle of His. The atrial and ventricular rhythms are regular but unrelated to each other. A complete heart block results in bradycardia, decreased cardiac output, syncope, and possibly heart failure/shock. The client is typically symptomatic and requires immediate treatment with transcutaneous pacing until a permanent pacemaker can be inserted. Atropine, dopamine, and epinephrine can be used to increase heart rate and blood pressure until temporary pacing is available. (Option 1) A fluid bolus is warranted in a client who is hypotensive from hypovolemia; however, this client is hypotensive due to a cardiac rhythm disturbance and slow heart rate. (Option 2) Adenosine is given rapidly via IVP for treatment of rapid tachycardic rhythms such as paroxysmal supraventricular tachycardia (PSVT). (Option 3) Cardioversion is used in clients with tachydysrhythmias (eg, ventricular tachycardia with a pulse, supraventricular tachycardia (SVT), or atrial fibrillation with a rapid ventricular response) who have been unresponsive to medications or are hemodynamically unstable. Educational objective: A client in complete heart block is often bradycardic and hemodynamically unstable. Transcutaneous pacing should be used until a permanent pacemaker can be inserted. Atropine, dopamine, or epinephrine may be used to increase heart rate and blood pressure until temporary pacing is started.
The nurse is evaluating a client with liver cirrhosis who received IV albumin after a paracentesis to drain ascites. Which assessment finding indicates that the albumin has been effective? 1. Abdominal circumference reduced from admission recording 2. Flapping tremor no longer visible with arm extension 3. Shortness of breath no longer experienced in supine positinon 4. Vital signs remain within the pt's normal parameters
4. VITAL SIGNS REMAIN WITHIN THE PT'S NORMAL PARAMETERS Ascites is the accumulation of fluid in the peritoneal space that often occurs in clients with liver cirrhosis. Ascitic fluid increases abdominal pressure, resulting in weight gain, abdominal distension and discomfort, and shortness of breath. Paracentesis (ie, needle insertion through the abdomen into the peritoneum to remove ascitic fluid) is often performed to reduce symptoms of ascites. However, clients undergoing paracentesis must be monitored closely for hypotension as changes in abdominal pressure often result in systemic vasodilation. Clients may receive IV albumin (a colloid) after paracentesis, which increases intravascular oncotic pressure resulting in increased intravascular fluid volume. Albumin administration prevents hypotension and tachycardia by mitigating hemodynamic changes associated with paracentesis (Option 4). (Options 1 and 3) Decreased abdominal circumference and improved respiratory effort occur in clients with ascites after ascitic fluid is removed via paracentesis. Albumin does not directly reduce ascitic fluid volume. (Option 2) Asterixis (ie, flapping hand tremors during arm extension) occurs due to elevated blood ammonia levels. Lactulose is commonly used to treat asterixis as it promotes ammonia excretion. Albumin does not affect ammonia excretion. Educational objective: Clients undergoing paracentesis to alleviate symptoms related to ascites are at risk for hypotension due to changes in abdominal pressure. IV albumin increases intravascular fluid volume and may be used to prevent hypotension associated with paracentesis.
