July 5th

A pediatric client is diagnosed with an acute asthma attack. Which immediate-acting medications should the nurse prepare to administer to this client? Select all that apply. 1. Albuterol 2. Ibuprofen 3. Ipratropium 4. Mentelukast 5. Tobramycin

1 & 3 Asthma is an inflammatory condition in which the smaller airways constrict and become filled with mucus. Breathing, especially on expiration, becomes more difficult. Pharmacologic treatment for acute asthma includes the following: Oxygen to maintain saturation >90% High-dose inhaled short-acting beta agonist (albuterol or levalbuterol) and anticholinergic agent (ipratropium) nebulizer treatments every 20 minutes Systemic corticosteroids (Solu-Medrol) to control the underlying inflammation. These will take some time to show an effect. (Option 2) Nonsteroidal anti-inflammatory agents (eg, ibuprofen, naproxen, indomethacin) and aspirin can worsen asthma symptoms in some clients and are not indicated unless necessary. (Option 4) Montelukast (Singulair) is a leukotriene (chemical mediator of inflammation) inhibitor and is not used to treat acute episodes. It is given orally in combination with beta agonists and corticosteroid inhalers (eg, fluticasone, budesonide) to provide long-term asthma control. (Option 5) Tobramycin is an aminoglycoside antibiotic. It is used in aerosolized form to treat cystic fibrosis exacerbation when Pseudomonas is the predominant organism causing lung infection. Educational objective: Inhaled corticosteroids and leukotriene inhibitors are typically used to achieve and maintain control of inflammation for long-term management of asthma. Quick-relief medications (eg, albuterol, ipratropium) are used to treat acute symptoms and exacerbations.

A client denies illicit drug use but has some suspicious behaviors. The client's neonate has a low birth weight. What other signs would lead the nurse to suspect neonatal abstinence syndrome? Select all that apply. 1. Irritability and restlessness 2. Meconium ileus and floppy tone 3. Microencephaly and cleft palate 4. Poor feeding and loose stools 5. Stuffy nose and frequent sneezing

1, 4, & 5 A pregnant client's repeated use of illicit drugs will cause dependence in the neonate. The abrupt withdrawal from the drug due to delivery can cause abstinence syndrome in the neonate. This is most commonly seen with opioid use, although other central nervous system depressant drug use (eg, benzodiazepines) can contribute. Manifestations include: Autonomic nervous system symptoms - stuffy nose, sweating, frequent yawning and sneezing, tachycardia, and tachypnea. Treatment includes swaddling and keeping nasal passages clear (Option 5). Central nervous system symptoms - irritability, restlessness, high-pitched crying, abnormal sleep pattern, and hypertonicity/hyperactive primitive reflexes. Treatment includes medication and protecting the skin (Option 1). Gastrointestinal symptoms - poor feeding, vomiting, and diarrhea. These are treated with small, frequent feedings (Option 4). (Option 2) Meconium ileus is classic for cystic fibrosis, a genetic disorder. Floppy muscle tone is typical for Down's syndrome, a genetic disorder. (Option 3) These signs are from exposure to teratogenic agents, especially during the first 8 weeks of gestation. Microcephaly is an effect of fetal alcohol syndrome or cytomegalovirus infection. Craniofacial defects, including cleft lip and palate (eg, congenital anomalies), can be caused by maternal anticonvulsant use (eg, valproic acid). Opioids are not teratogenic. Educational objective: Prenatal exposure to maternal illicit drug use results in abstinence syndrome in the neonate. Neonatal abstinence syndrome affects the autonomic nervous system (stuffy nose, frequent yawning), gastrointestinal tract (poor feeding, diarrhea), and central nervous system (irritability, restlessness, high-pitched cry).

Which statements involve acceptable use of an abbreviation, symbol, or dose designation in documentation? Select all that apply. 1. 2 cm x 3 cm x 1cm stage II decubitus noted on left shin 2. 4.0 u SSRI adminstered to cover capillary glucose of 160 mg/dl 3. Dose of .5 hydromorphone administered and the pt feels better 4. Maalox 5 ml PO administered pc as requested for c/o heartburn 5. Spouce voiced understanding of home urinary catheterization QID

1, 4, & 5 The Joint Commission (2004) and Institute for Safe Medication Practices prohibit error-prone or "dangerous" abbreviations, descriptions of symptoms, and dose designations in medical documentation. "Cm" (centimeters) and "II" (2) (eg, decubitus staging) are acceptable abbreviations/notations (Option 1). The abbreviations "ac" (before meals), "pc" (after meals), and "c/o" (complains of) are acceptable (Option 4). "QID" (4 times a day) is acceptable. Abbreviations that are not acceptable include "qd" (daily) and "q1d" (daily), which can be mistaken for "qid" (4 times a day), and "qod" (every other day), which can be mistaken for "qd" (daily) (Option 5). (Option 2) A trailing zero after the decimal point is not acceptable as it could be interpreted as 40 instead of 4 if the decimal point is not noted. The use of "u" for unit is not acceptable as it can be mistaken for the number 0 or 4 (eg, 4u seen as 40). "SSRI" (sliding-scale regular insulin) is not acceptable to indicate insulin as it can be mistaken for selective serotonin reuptake inhibitor. "Mg" for milligrams is acceptable. (Option 3) A zero must precede the decimal dose. If the decimal point is missed, ".5" could be mistaken for 5 mg. Educational objective: Acceptable abbreviations include "ac," "pc," "QID," and "cm." Unacceptable abbreviations include "qd," "q1d," and "qod"; "SSRI" for insulin; and "u" for units. There must be a zero before a decimal dose and no trailing zero after a decimal point.

The following 4 clients are brought to the emergency department triage nurse. The client with which of these signs should be a priority to be seen for immediate care? 1. A 2 year old has sclera visible above the iris (sunset eyes) 2. A 3 eyar old has a single transverse crease across the entire palm of the hand 3. A 6 month old breastfed pt had 8 wet diapers in the last 24 hours 4. A 9 month old pt's toes fan out and the big toe dorsiflexes when the foot sole is stroked

1. A 2 YEAR OLD HAS SCLERA VISIBLE ABOVE THE IRIS (SUNSET EYES) This is a sign of 6th cranial nerve palsy (paralysis of upward gaze) as a result of increased intracranial pressure/hydrocephalus. This is an acute, delayed sign and requires timely priority diagnosis and treatment. This sign is more likely to be noted after the fontanels have closed (posterior by 2 months and anterior by 18 months) and the pressure increases. (Option 2) This is the Simian crease that is seen in a client with Down syndrome. This is a chronic condition, and the acute condition in Option 1 is a priority. (Option 3) The normal range for the number of wet diapers is 6-10/day, or approximately 1 every 4 hours. Infants create 2 mL/kg/hr normal urine output. The number of wet diapers/day is one of the best indications of adequate fluid intake (hydration). (Option 4) This is a description of the Babinski reflex, which is present in children up to age 1 year. Its presence beyond age 1 can indicate neurologic disease. Educational objective: The presence of sunset eyes (sclera above iris) is a late sign of increased intracranial pressure and a priority. Simian crease is an expected finding in Down syndrome. The normal diaper count for a 6-month-old is 6-10 diapers/day. Infants have a positive Babinski reflex until age 1.

The nurse who is caring for a client with acute diverticulitis will immediately report which finding to the health care provider? 1. Abdominal pain has progressed to the left upper quadrant 2. Hgb of 11.2 3. Lying on side with knees drawn up to abdomen and trunk flexed 4. White blood cell count of 12,000

1. ABDOMINAL PAIN HAS PROGRESSED TO THE LEFT UPPER QUADRANT Diverticula are saclike protrusions or outpouchings of the intestinal mucosa of the large intestine caused by increased intraluminal pressure (chronic constipation). The left (descending, sigmoid) colon is the most common area for diverticula to develop. When these diverticula become inflamed (diverticulitis), the client may experience acute pain (usually in the left lower quadrant) and systemic signs of infection (eg, fever, tachycardia, nausea, leukocytosis). Complications that can occur in some clients are abscess formation (continuous fever despite antibiotics and palpable mass) and intestinal perforation resulting in diffuse peritonitis (progressive pain in other quadrants of the abdomen, rigidity, guarding, rebound tenderness). The client with peritonitis prefers to lie still and take shallow breaths to avoid stretching the inflamed peritoneum. Peritonitis is a potentially lethal complication and should be reported immediately. (Option 2) Clients with acute diverticulitis can bleed. Usually this bleeding is quite obvious, often with a large amount of bright red blood seen in the stool. This client's mild anemia is nonspecific and should not be given reporting priority over the peritoneal signs. (Option 3) This indicates fetal position and could be due to pain. Clients with peritonitis are expected to lie still as any movement worsens the pain. Peritonitis takes priority over the expected pain in diverticulitis. (Option 4) Leukocytosis is expected with acute diverticulitis. However this client's white blood cell count is only minimally elevated (upper limit of normal is 11,000/mm3 [11.0 x 109/L]) and is not a priority over possible peritoneal signs. Educational objective: Diverticulitis is caused by inflammation of diverticula (outpouchings) of the large intestine that can lead to abscess, perforation, peritonitis, and/or bleeding. Peritonitis is a potentially fatal complication that should be reported to the health care provider immediately.

A client with a ventriculoperitoneal shunt has a dazed appearance and grunting and has not responded to the caregiver for 10 minutes. Status epilepticus is suspected. Which nursing intervention should be performed first? 1. Administer rectal diazepam 2. Assess for enck stiffness and Brudzinski sign 3. Draw blood for laboratory studies 4. Transport the pt to CT for assessment of shunt malfunction

1. ADMINISTER FOR NECK STIFFNESS AND BRUDZINSKI SIGN This client is in status epilepticus, a serious and life-threatening emergency in which a client has been seizing for 5 minutes or longer. Grunting and a dazed appearance are 2 common signs. A client with hydrocephalus (abnormal collection of cerebrospinal fluid in the head) and a ventriculoperitoneal (VP) shunt is at a higher risk for seizures. Stopping seizure activity is the first nursing priority. IV benzodiazepines (diazepam or lorazepam) are used acutely to control seizures. However, rectal diazepam is often prescribed when the IV form is unavailable or problematic. Parents often get prescriptions for rectal diazepam and are advised to administer a dose before bringing a child to the emergency department. (Option 2) Stopping the status epilepticus is a priority over determining its cause through a neurologic assessment. Quickly obtaining the oxygen saturation level and managing the airway are priority assessments. (Option 3) Blood draw is needed for laboratory studies but is not a priority over stopping the seizure. (Option 4) A VP shunt drains excess fluid in the brain down to the abdomen, where it is absorbed by the body. A CT scan can accurately assess shunt malfunction. Any malfunction would need to be treated promptly to prevent future seizures and damage. Finding the cause of the seizure is important and should be done as soon as seizing has stopped. Educational objective: Status epilepticus is a serious condition that could result in brain damage and death. Quickly stopping the seizure is the first nursing priority as long as there is an adequate airway and the client is breathing. IV or rectal benzodiazepines (lorazepam or diazepam) are used to rapidly control seizures.

The nurse is assigned to care for a client who had a total hip replacement an hour ago. Which of the following should the nurse assess first? 1. Amount of drainage in suction drainage device 2. Pt's level of pain and last dose of pain medication 3. Proper placement of the abduction pillow 4. Urine in the catheter bag for presence of cloudiness or pus

1. AMOUNT OF DRAINAGE IN SUCTION DRAINAGE DEVICE Common complications following total hip replacement are bleeding, prosthesis dislocation, deep vein thrombosis, and infection. Total joint replacements carry a risk of serious blood loss; therefore, the nurse should check the drainage device and dressing frequently to monitor blood loss, especially during the first several postoperative hours. (Option 2) Pain is typically controlled via a patient-controlled analgesia device with a programmed dosage and lockout. The client's level of pain should be assessed, but assessing for hemorrhage is the priority. (Option 3) Following total hip replacement, the client will have an abduction pillow between the legs to prevent adduction of the affected leg. Adduction of the leg could potentiate dislocation of the prosthesis. It is important that the client not flex the affected hip more than 90 degrees, as this could dislocate the prosthesis. Therefore, the client should be provided elevated toilet seats and chairs that do not recline. The nurse should assess for signs of hip dislocation, including shortening and internal rotation of the leg. Although providing an abduction pillow is important, assessing for hemorrhage is the priority. (Option 4) Assessment of the urine in a postoperative client's catheter bag is important but is not priority in this situation. Educational objective: Orthopedic surgeries, particularly total hip replacement, can cause significant blood loss. Assessing the dressing and drainage device is a priority over positioning an abduction pillow and evaluating the client's pain and quality of urine.

The nurse is providing teaching to the parents of a child with Marfan syndrome. Which topic is the priority for the nurse to address? 1. Avoiding participation in contact sports 2. Informing the dentist of the child's condition 3. Monitoring for development of scoliosis 4. Scheduling annual eye examinations

1. AVOIDING PARTICIPATIONS IN CONTACT SPORTS Marfan syndrome is an autosomal dominant disorder affecting the connective tissues of the body. Abnormalities are mainly seen in the cardiovascular, musculoskeletal, and ocular systems. Clients with Marfan syndrome are very tall and thin, with disproportionately long arms, legs, and fingers. Cardiovascular manifestations of Marfan syndrome include abnormalities of the aorta and cardiac valves, including aneurysms, tears (dissection), and leaky heart valves that may require replacement or repair. Therefore, competitive or contact sports are discouraged due to the risk of cardiac injury and sudden death (Option 1). (Option 2) The client may also experience crowding of the teeth from a very high-arched palate. Preventive antibiotics prior to dental work may be needed to provide prophylaxis against infective endocarditis, especially in clients with an artificial valve replacement. However, this is not a priority. (Option 3) These clients have an increased risk for scoliosis, especially during the adolescent years of increased growth; therefore, the child should be monitored regularly for curvature of the spine. This is not a priority. (Option 4) Ocular problems (eg, lens dislocation [ectopia lentis], retinal detachment, cataracts, glaucoma) can be common for the child with Marfan syndrome. Annual eye examinations with an ophthalmologist are important to monitor for developing issues. Educational objective: Aortic root disease (ie, aneurysm, dissection) is the major cause of morbidity and mortality in Marfan syndrome. Therefore, competitive or contact sports are discouraged due to the risk of cardiac injury and sudden death.

Which client finding would be a contraindication for the nurse to administer dicyclomine hydrochloride for irritable bowel syndrome? 1. Bladder scan showing 500 mL urine 2. Hgb of 11 3. History of cataracts 4. Reporting frequent diarrhea today

1. BLADDER SCAN SHOWING 500 ML URINE Dicyclomine hydrochloride (Bentyl) is an anticholinergic medication. Anticholinergics are used to relax smooth muscle and dry secretions. Anticholinergic side effects include pupillary dilation, dry mouth, urinary retention, and constipation. Therefore, the classic contraindications are closed-angle glaucoma, bowel ileus, and urinary retention. The urge to urinate is normally present at 300 mL; pain is usually felt around 500 mL. This client has urinary retention and should not have the bladder smooth muscle further relaxed. (Option 2) Anticholinergic drugs do not affect the blood count. The normal reference range for hemoglobin is 11.7-15.5 g/dL (117-155 g/L) for females and 13.2-17.3 g/dL (132-173 g/L) for males. (Option 3) The common eye contraindication is narrow-angle glaucoma as it could worsen the condition. Cataracts are a clouding of the lens and are not related to drainage flow. (Option 4) Diarrhea is an expected finding with irritable bowel syndrome or other increased peristalsis and is a common reason for the drug to be prescribed. Anticholinergic drugs are contraindicated in the presence of a bowel ileus or atony as constipation is a side effect and further relaxation of the intestines could worsen these conditions. Educational objective: Anticholinergic drugs are contraindicated when smooth muscle relaxation is already a concern. Commonly cited contraindications include narrow-angle glaucoma, urinary retention (including benign prostatic hyperplasia), and bowel ileus/obstruction.

A client who is 2 hours post aortic valve replacement is in the intensive care unit (ICU). The low pressure alarm for the client's radial arterial line sounds. Which action should the nurse take first? 1. Check for bleeding at tube connection sites 2. Perform a fast flush of the arterial line system 3. Re-level the transducer to the phlebostatic axis 4. Zero and re-balance the monitor and system

1. CHECK FOR BLEEDING AT THE TUBE CONNECTION SITES The low pressure alarm could signal hypotension. The nurse's first action should be to check the client for evidence of hypotension and the cause. Arterial lines carry the risk of hemorrhage and are most likely to occur at connection sites of the tubing and catheter. A client can lose a large amount of arterial blood in a short period of time. The nurse should verify that these connections are tight on admission of the client to the ICU. (Option 2) A fast flush of the arterial line system (square wave test) should be performed after the nurse has ruled out a physiological cause of the low pressure alarm. This test helps to verify if the arterial line is functioning correctly. (Option 3) The transducer should be leveled to the client's phlebostatic axis to measure arterial pressure correctly. However, this should be done after the client has been checked for a physiological cause of the alarm. (Option 4) Zeroing the monitor should be done if measurement accuracy is questioned. However, this should be done after the client has been taken care of. Educational objective: A low pressure alarm for an arterial line can indicate the presence of hypotension or disconnected tubing. Hemorrhage can rapidly occur with a disconnected arterial catheter line. The nurse should check the client for the presence of hypotension and its causes before troubleshooting the system.

The nurse is teaching the parents of a toddler about health promotion. Which statement by one parent requires clarification? 1. If my child refuses a meal, I will wait a few minutes and try again 2. If bedtime brings on a temper tantrum, I will use a time out 3. I will plan the evening meal at least 15 minutes after a play period 4. I will offer my child options rather than asking yes or no questions

1. IF MY CHILD REFUSES A MEAL, I WILL WAIT A FEW MINUTES AND ASK AGAIN Toddlers exhibit behaviors associated with negativism and ritualism as they seek autonomy. Limiting opportunities for children to express a negative response ("no") helps them learn self-control and behavior modification. For example, the parent can avoid asking, "Do you want to have dinner?" and instead offer food options or say, "It's time for dinner." (Option 4) If the child refuses a meal, the parents should wait to offer food until the next snack time or mealtime; days of low intake are common as toddlers experience a slowing growth rate. It is important not to force the child to eat (Option 1). (Option 2) Bedtime temper tantrums are common in toddlers as they become more independent. Parents should learn to ignore the behavior, remain in the child's presence, and consider using time-outs as a management technique. (Option 3) When toddlers have been physically active immediately before mealtime, they may have difficulty sitting at the table and can be disruptive. Offering a 15- to 30-minute period to calm down promotes better eating habits. Educational objective: Toddlers display behaviors associated with negativism and ritualism as they seek autonomy. When teaching about toddler health promotion, the nurse should tell parents to avoid giving options that allow toddlers to say "no", refrain from forcing toddlers to eat, allow toddlers a 15- to 30-minute period to calm down before meals, and use time-outs for management of temper tantrums.

The nurse is preparing to administer medications to a client admitted with atrial fibrillation. The nurse notes the vital signs shown in the exhibit. Which medications due at this time are safe to administer? Select all that apply. Click on the exhibit button for additional information. 1. Diltiazem extended release PO 2. Heparin subcutaneous injection 3. Lisinopril PO 4. Metoprolol PO 5. Timolol opthalmic

2 & 3 Clients with atrial fibrillation can have either bradycardia (slow ventricular response) or tachycardia (rapid ventricular response). This client's vital signs are significant for bradycardia (heart rate [HR] <60/min). Therefore, medications that can decrease HR should be held and the health care provider (HCP) notified. The reason for holding the medication (HR 46/min) and an HCP contact note should be documented. Heparin is an anticoagulant; the subcutaneous injection is most commonly used to prevent deep venous thrombosis in hospitalized clients on bed rest. This medication will not affect the vital signs and is safe to administer (Option 2). Lisinopril, an ACE inhibitor, does not lower HR and is not contraindicated in clients with bradycardia (Option 3). The client is not hypotensive; therefore, lisinopril is safe to administer. (Option 1) Non-dihydropyridine calcium channel blockers (eg, diltiazem, verapamil) can decrease HR and should be held in clients with bradycardia. (Options 4 and 5) All beta blockers (eg, metoprolol, timolol, atenolol), including eye drops that can be absorbed systemically, can decrease the HR and should be held until the prescriptions can be clarified by the HCP. Educational objective: Medications that decrease the heart rate should be held in clients with bradycardia. These include beta blockers such as metoprolol and timolol (including eye drops) and some types of calcium channel blockers (eg, diltiazem, verapamil).

The nurse is caring for a client who had a laparoscopic cholecystectomy 3 days ago. The client's WBC count has increased from 11,200/mm3 (11.2 × 109/L) to 14,600/mm3 (14.6 × 109/L) over the last 24 hours. The nurse understands that which of the following assessment findings indicate potential infection? Select all that apply. 1. Pt rating left shoulder pain as 4 on a scale of 0-10 2. Greenish-gray drainage noted on surgical dressing 3. Productive cough with thick, green sputum 4. Stiff abdomen with rebound tenderness on palpation 5. Warm, reddened area around the incision site

2, 3, 4, & 5 Cholecystectomy (removal of the gallbladder) is performed through laparoscopic or open surgery. Signs of postoperative infection typically appear 3-7 days after surgery. Systemic signs may include fever, elevated WBC count, and fatigue. Some potential postoperative infections include: Pneumonia can occur when atelectasis (alveolar collapse) prevents clearing of secretions, promoting bacterial growth. Symptoms include cough with or without sputum, tachypnea, and shortness of breath. Postoperative incentive spirometry, ambulation, and cough/deep breathing exercises help keep alveoli open and prevent pneumonia (Option 3). Surgical site infections present with localized redness, warmth, swelling, and purulent drainage. Proper wound care and sterile dressing changes help prevent infection (Options 2 and 5). Urinary tract infections (UTIs), caused by the use of indwelling urinary catheters during surgery, can present with frequency, urgency, and dysuria. Prompt removal of catheters after surgery helps prevent UTIs. Peritonitis (peritoneal infection) presents with rebound tenderness, boardlike abdominal rigidity, and shallow breathing related to abdominal distension. Peritonitis may lead to sepsis and death if untreated (Option 4). (Option 1) Clients recovering from laparoscopic surgery may experience referred left shoulder pain during the first few postoperative days. This is due to diaphragmatic nerve irritation caused by the carbon dioxide used to inflate the abdomen during laparoscopic surgery. Educational objective: Some potential postoperative infections related to abdominal surgery include pneumonia, surgical site infection, and peritonitis. Signs of infection may include cough, tachypnea, and shortness of breath; warmth or redness around the incision; purulent incisional drainage; or rigid, painful abdomen.

The nurse is performing an assessment on a 39-week neonate an hour after a spontaneous vaginal delivery. What are common expected newborn findings? Select all that apply. 1. One artery and one vein in the umbilical cord 2. Plantat creases up the entire sole 3. Skin on the nose blanches to a yellowish hue 4. Toes fan outward when the lateral sole surface in stroked 5. White pearl-like cysts on gum margins

2, 4, & 5 The number of plantar creases on the bottom of the feet is indicative of the neonate's age. The more creases over the greater proportion of the foot, the more mature the neonate. The Babinski reflex is present at birth and disappears at 1 year. The toes hyperextend and fan out when the lateral surface of the sole is stroked in an upward motion. Absent Babinski or a weak reflex may indicate a neurological defect. Epstein's pearls are white, pearl-like epithelial cysts on gum margins and the palate. They are benign and usually disappear within a few weeks. (Option 1) The cord should be opaque or whitish-blue with two arteries and one vein and covered with Wharton's jelly. The presence of only one umbilical artery and vein is associated with heart or kidney malformation. The cord should also be assessed for bleeding. It will become dry and darker within 24 hours and detach from the body within 2 weeks. (Option 3) Jaundice is best assessed in natural lighting, with gentle pressure to the skin over a firm surface such as the nose, forehead, or sternum. It first appears on the face and extends to the trunk and eventually the entire body. Jaundice within the first 24 hours is pathological. It is usually related to problems of the liver. Jaundice after 24 hours is referred to as physiological jaundice and is related to the increased amount of unconjugated bilirubin in the system. Educational objective: Expected (normal) findings for a term newborn include plantar creases up the sole of the foot, presence of Babinski reflex, and Epstein's pearls.

The nurse is caring for a 72-year-old client 1 day postoperative colectomy. The nurse assesses an increased work of breathing, diminished breath sounds at the bases with fine inspiratory crackles, respirations 12/min and shallow, and pulse oximetry 96% on 2 L oxygen. There is no jugular venous distension or peripheral edema. Pain is regulated with client-controlled morphine. Which prescription does the nurse anticipate? 1. Bolus dose of IV morphine 2. Incentive spirometer 3. IV furosemide 4. Non rebreather mask

2. INCENTIVE SPIROMETER During the initial postoperative period, a client needs respiratory interventions to keep the lungs expanded and prevent atelectasis and postoperative pneumonia. Atelectasis is maximal during the second postoperative night. Clients can be asymptomatic or have increased work of breathing, hypoxia, and basal crackles. Postoperative pain, opioid respiratory depression, limited mobility, and reluctance to take a deep breath due to anticipated pain contribute to postoperative atelectasis. The elderly and postoperative abdominal and thoracic surgery clients are at increased risk for atelectasis. The incentive spirometer encourages the client to breathe deeply with maximum inspiration. This action improves ventilation and oxygenation by expanding the lungs, encourages coughing, and prevents or improves atelectasis. It is the most appropriate prescription for this client. (Option 1) In a client whose pain is regulated with client-controlled analgesia (eg, morphine), administration of a bolus dose is not indicated and may increase the risk for respiratory depression. (Option 3) Fine crackles in the lungs usually indicate atelectasis. The presence of coarse crackles, elevated jugular venous distension, and peripheral edema usually indicates volume overload (fluid in the alveoli). In addition, clients with fluid overload breathe at a rapid rate (tachypnea) rather than take slow, shallow breaths. IV furosemide (Lasix) is an appropriate intervention for volume overload but not for atelectasis. (Option 4) As-needed oxygen may be prescribed postoperatively, especially with blood loss. A non-rebreather mask, which has 100% oxygen, is not indicated in this client as the pulse oximeter shows 96% saturation, indicating adequate oxygenation. Educational objective: The incentive spirometer is a handheld, inexpensive breathing device. It encourages the client to breathe deeply with maximum inspiration, which improves ventilation and oxygenation and encourages coughing. The incentive spirometer is used to prevent or improve atelectasis in clients who are postoperative, have respiratory problems (eg, pneumonia), or have experienced trauma.

A student nurse initiates oxygen with a nonrebreather mask for a client with acute respiratory distress. While reassessing the client, the RN notices the reservoir bag is fully deflating on inspiration. What immediate action does the RN take to correct the problem? 1. Elevated the head of bed 2. Increases the oxygen flow 3. Opens both flutter valves on the mask 4. Tightens the face mask straps

2. INCREASES THE OXYGEN FLOW A nonrebreather mask is an oxygen delivery device used in a medical emergency. It consists of a face mask with an attached reservoir bag and a one-way valve between the bag and mask that prevents exhaled air from entering the bag and diluting the oxygen concentration. The liter flow must be high enough (up to 15 L/min) to keep the reservoir bag at least 2/3 inflated during inhalation and to prevent the buildup of carbon dioxide in the bag. (Option 1) Elevating the head of the bed allows for maximum chest expansion and promotes oxygenation. It does not inflate the reservoir bag on inhalation or affect the proper operation of the rebreather mask. (Option 3) Ports (exhalation valves) are located on each side of the mask and are covered with rubber discs that act as flutter valves. The valves close on inhalation to prevent entry of room air and open on exhalation to prevent reinhalation of exhaled air. The ports should be occluded when initiating the device to fill the reservoir with oxygen. (Option 4) The nonrebreather mask can deliver high concentrations of oxygen if the mask is secured tightly to the face with the head strap to minimize leaks. Tightness of the mask does not affect the filling or deflating of the reservoir bag. Educational objective: A nonrebreather mask is an oxygen delivery device used in a medical emergency. It can deliver up to 95%-100% oxygen concentration if properly maintained during use. Proper care of the device includes monitoring the reservoir bag to assure continual inflation during inhalation; monitoring the 2 exhalation (flutter) valves that cover the ports on each side of the mask; and keeping the mask secured to the face by adjusting the tightness of the head strap to minimize leaks.

The nurse is caring for a client admitted with abdominal pain, who has been diagnosed with somatic symptom disorder after a thorough evaluation finds no medical cause for the symptoms. Which intervention should the nurse include in the plan of care? 1. Advocate for an elimination diet to identify the cause of the symptoms 2. Limit time spent discussing physical symptoms with the pt 3. Reinforce negative examination results when pain medication is requested 4. When abdominal pain is mentinoned, remind pt that it is not real

2. LIMIT TIME SPENT DISCUSSING PHYSICAL SYMPTOMS WITH THE PT Somatic symptom disorder (SSD) is a psychological disorder that develops from stress, resulting in medically unexplainable physical symptoms (eg, abdominal pain) that disrupt daily life. Clients with SSD focus an excessive amount of time, thought, and energy on the symptoms, often seeking medical care from multiple health care providers. Nursing interventions focus on minimizing indirect benefits and developing client insight. To minimize the indirect benefits from being "sick" (secondary gains), the nurse should: Redirect somatic complaints to unrelated, neutral topics Limit time spent discussing physical symptoms (Option 2) To promote insight and healthy coping mechanisms, the nurse should assist the client to: Identify secondary gains (eg, increased attention, freedom from responsibilities) Recognize factors that intensify symptoms (eg, increased stress, reminders of a deceased family member) Incorporate appropriate coping strategies (eg, relaxation training, physical activity) (Option 1) An elimination diet would increase the client's focus on the symptoms and is inappropriate, as physiological causes have already been ruled out. (Option 3) The client's symptoms are real despite the lack of diagnostic findings. The nurse should administer analgesics as prescribed. (Option 4) Disputing the validity of the client's symptoms may increase the client's stress level and exacerbate symptoms. Educational objective: Somatic symptom disorder occurs when stress causes medically unexplainable physical symptoms that disrupt daily life. Nursing interventions include limiting discussion of symptoms and identifying secondary gains, factors that intensify symptoms, and coping strategies.

A client is being discharged on enoxaparin therapy following total knee replacement surgery. Which teaching instruction does the nurse include in the teaching plan? 1. Eliminate green, leafy. vitamin K rich vegetables from your diet 2. Mild bruising or redness may occur at the injection site 3. You can take over the counter drugs such as ibuprofen to relieve mild discomfort 4. You will need PT/INR assessmentsw at regular intervals while on enoxaparin therapy

2. MILD BRUISING OR REDNESS MAY OCCUR AT THE INJECTION SITE Enoxaparin (Lovenox) is a low molecular weight heparin (LMWH) that may be prescribed for up to 10-14 days following hip and knee surgery to prevent deep venous thrombosis. Discharge teaching for the client on enoxaparin therapy includes: Pinch an inch of skin upwards and insert the needle at a 90-degree angle into the fold of skin. Continue to hold the skin fold throughout the injection and then remove the needle at a 90-degree angle. Mild pain, bruising, irritation, or redness of the skin at the injection site is common. Do NOT rub the site with the hand. Using an ice cube on the injection site can provide relief (Option 2). Avoid taking aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and herbal supplements (Ginkgo biloba, vitamin E) without health care provider approval as these can increase the risk of bleeding (Option 3). Monitor complete blood count to assess for thrombocytopenia. (Option 1) Vitamin K-rich foods do not need to be eliminated from the diet during enoxaparin therapy; prothrombin time (PT) and international normalized ratio (INR) are not affected. However, PT and INR are decreased when a vitamin K antagonist (eg, warfarin [Coumadin]) is taken with vitamin K-rich foods. (Option 4) Routine coagulation studies (eg, PT, INR, partial thromboplastin time [PTT]) do not need to be monitored in a client who is taking enoxaparin. However, periodic assessment of complete blood count (CBC) is usually required to monitor for hidden bleeding and thrombocytopenia (especially in older clients with renal insufficiency). Educational objective: LMWH (Enoxaparin) requires monitoring of CBC (thrombocytopenia) but not coagulation studies. Administration of unfractionated heparin requires monitoring with PTT, whereas warfarin requires PT/INR monitoring. Clients on these medications should avoid aspirin and NSAIDs.

The clinic nurse speaks with the spouse of a client being treated for alcohol use disorder. Which statements by the spouse indicate codependence? Select all that apply. 1. I am focusing on my new hobby and my friends in the book club 2. I left and didn't awaken my spouse, who went back to sleep after turning off the alarm clock. 3. I try to get up early and keep the children from being too loud in the mornings 4. If I didn't get so stressed about my job, my spouse wouldn't drink so much 5. When my spouse was sick, I called and rescheduled clients so my spouse could rest

3, 4, & 5 Codependent behaviors are those that allow the codependent person to maintain control by fulfilling the needs of the addict first. Behaviors such as keeping the addiction secret, suffering physical or psychological abuse from the addict, not allowing the addict to suffer the consequences of actions, and making excuses for the addict's habit are hallmarks of codependency. If the addict isn't happy, the codependent person will try to make the addict happy. Codependent persons will focus all their attention on others at the expense of their own sense of self. Codependent spouses, friends, and family members keep the client from focusing on treatment; this behavior is counterproductive to both themselves and the client. (Option 1) This statement does not represent codependency but rather indicates that the spouse is focusing on the spouse's own growth and needs rather than the needs of others. (Option 2) This statement does not represent codependency; it indicates that the spouse is allowing the client to suffer the consequence of actions. Educational objective: Codependent spouses, friends, and family members can impede treatment progress of clients with substance use disorders. Codependent behaviors include making excuses for a client's drug/alcohol use, putting a client's needs before one's own, and not allowing a client to suffer the consequences of actions.

Which of these tasks are appropriate for the registered nurse (RN) to delegate to unlicensed assistive personnel (UAP)? Select all that apply. 1. Assign lunch times to the other UAP on the unit 2. Assist a pt with a new ostomy with bathing and changing pouches 3. Collect vital signs on a pt 4 hours after laparoscopic appendectomy 5. Record intake and output for a pt with metabolic alkalosis

3, 4, & 5 The UAP can be delegated tasks that do not require nursing judgment. Any task that involves the nursing process (assessment, diagnosis, planning, implementation, evaluation) requires the attention of the RN. The UAP may gather information (eg, vital signs, intake and output) about stable clients, assist stable clients with activities of daily living, and retrieve necessary supplies, but the RN retains accountability for all of the delegated actions and outcomes (Options 3, 4, and 5). The RN is also responsible for determining the competency level of the UAP prior to delegating tasks. (Option 1) Making staff lunch assignments is part of the management of the unit; therefore, the RN cannot delegate this task. The RN must ensure that there is adequate staff coverage to meet client needs during the assigned lunch times. (Option 2) UAPs can give bed baths to stable, appropriate clients. The client with a new ostomy requires assessment and teaching about cleaning and caring for the ostomy; therefore, an RN must perform this task. Educational objective: Client care that involves any part of the nursing process (assessment, diagnosis, planning, intervention, evaluation) can never be delegated to the licensed practical/vocational nurse or the UAP. The UAP can assist with basic care activities and collect data (eg, vital signs, intake and output) for stable clients. The RN is ultimately accountable for the care provided by the UAP.

A nurse is preparing an educational presentation on herbal supplements for the local community center. Saw palmetto is one herbal medicine being discussed. Which audience participants would find this information beneficial? 1. Pts diagnosed with heart failure 2. Pts experiencing major depressive disorder 3. Elderly pts with benign prostatic hyperplasia 4. Perimenopausal pts experiencing hot flashes

3. ELDERLY PTS WITH BENIGN PROSTATIC HYPERPLASIA Herbal preparations are not regulated by governmental agencies and are generally classified as food or dietary supplements. Manufacturers are therefore able to avoid the scientific scrutiny exercised when prescription drugs are readied for the market. Saw palmetto is one such herbal preparation, and clients most often use it to treat benign prostatic hyperplasia. (Option 1) Hawthorn extract is used to treat heart failure and in some countries (eg, Germany) is an approved treatment for this purpose. (Option 2) St John's wort has been used for centuries to treat depression. It may cause hypertension and serotonin syndrome when used with other antidepressants. (Option 4) Black cohosh is an herbal supplement often used by perimenopausal clients experiencing hot flashes. Educational objective: Saw palmetto, a herbal preparation, is often used to treat benign prostatic hyperplasia. St John's wort has been used for centuries to treat depression.

The postpartum nurse is assessing a client who gave birth by cesarean section 5 hours ago and is requesting pain medication. The client appears restless, has a heart rate of 110/min, and admits to recent onset of anxiety. What priority action should the nurse take? 1. Assess for lwoer extremity warmth and redness 2. Instruct the client in relaxation breathing techniques 3. Obtain oxygen saturation reading by pulse oximeter 4. Offer the pt prescribed PRN pain medication

3. OBTAIN OXYGEN SATURATION READING BY PULSE OXIMETER Pregnancy is a hypercoagulable state that provides protection from hemorrhage after birth, but also greatly augments risk of thrombus formation. Women who give birth by cesarean section are at particularly increased risk for deep venous thrombosis (DVT). Additional risk factors for DVT include obesity, smoking, and genetic predisposition. If unrecognized, DVT may progress to pulmonary embolism (PE), often characterized by anxiety/restlessness, pleuritic chest pain/tightness, shortness of breath, tachycardia, hypoxemia, and hemoptysis. The nurse's priority is rapidly identifying symptoms, assessing respiratory status, administering supplemental oxygen, and notifying the health care provider (HCP) (Option 3). (Option 1) Any redness, tenderness, or warmth in the lower extremities may indicate DVT, which should be reported to the HCP. However, the nurse's priority is addressing the client's current symptoms indicative of acute PE by assessing oxygenation. (Option 2) Although relaxation breathing techniques may be helpful for management of anxiety, this client's symptoms may be stemming from impaired oxygenation secondary to PE. (Option 4) Unmanaged pain can cause tachycardia; however, the additional findings of restlessness/anxiety may indicate PE. The nurse should first assess the client's oxygenation status, before administering requested pain medication. Educational objective: Pregnancy is a hypercoagulable state that increases risk for deep venous thrombosis and pulmonary embolism (PE). Signs and symptoms of PE include anxiety/restlessness, pleuritic chest pain/tightness, shortness of breath, tachycardia, hypoxemia, and hemoptysis. Priorities are rapid symptom identification, assessment of oxygenation, and notification of the health care provider.

The nurse is assessing 4 clients in the emergency department. Which client should the nurse prioritize for care? 1. Pt with liver cirrhosis and ascites who has increasing abdominal distention and needs therapeutic paracentesis 2. Pt with new-onset ascites from a suspected ovarian mass who needs paracentesis for diagnostic studies 3. Pt with ulcerative colitis who has feverm bloody diarrhea, and abdominal distention and needs an abdominal xray 4. Nursing home pt with dementia who has stool impaction and abdominal distention and needs stool disimpaction

3. PT WITH ULCERATIVE COLITIS WHO HAS FEVERM BLOODY DIARRHEA, AND ABDOMINAL DISTENTION AND NEEDS AN ABDOMINAL X RAY The client with ulcerative colitis who has abdominal distension, bloody diarrhea, and fever likely has toxic megacolon. This is a common, life-threatening complication of inflammatory bowel disease and is seen more frequently in ulcerative colitis than in Crohn disease. Toxic megacolon can also be associated with Clostridium difficile infection and other forms of infectious colitis. Severe colonic inflammation causes release of inflammatory mediators and bacterial products which contribute to colonic smooth muscle paralysis. Rapid colonic distension ensues, thinning the intestinal wall and making it prone to perforation. Imaging confirms the diagnosis. (Option 1) This client with liver cirrhosis and ascites needs periodic paracentesis for relief of distension in addition to diuretics (eg, spironolactone, furosemide) for advanced-stage disease. However, this client is not the priority. (Option 2) This client needs paracentesis for fluid cytology (eg, diagnostic paracentesis) to evaluate for malignancy. This client is not the priority. (Option 4) Clients with dementia have decreased mobility, drink less fluid (eg, impaired thirst, do not ask for water), and often take medications with anticholinergic properties. Such factors make these clients prone to severe constipation, and they often need manual disimpaction. This client is not the priority. Educational objective: Toxic megacolon is a common, life-threatening complication of inflammatory bowel disease. Clients present with abdominal pain/distension, bloody diarrhea, fever, and signs of shock (eg, hypotension, tachycardia).

The registered nurse supervises a student nurse who is caring for a client newly prescribed lithium for the treatment of bipolar disorder. Which action by the student indicates a need for further teaching? 1. Advises the pt to drink 2-3 liters of water each day 2. Instructs the pt to limit intake of cola, tea, coffee, and alcohol 3. Shows the pt how to carefully check food labels to follow a low-sodium diet 4. Teaches the pt that it may take up to several weeks for the drug to be effective

3. SHOWS THE PT HOW TO CAREFULLY CHECK FOOD LABELS TO FOLLOW A LOW-SODIUM DIET Lithium carbonate is a mood stabilizer used for the treatment of bipolar disorder. Lithium levels take some time to reach therapeutic levels, often up to a few weeks (Option 4). Clients will need to have their lithium levels carefully monitored when starting therapy, as the therapeutic range is narrow (0.6-1.2 mEq/L [0.6-1.2mmol/L]). Blood sodium levels affect the renal excretion of lithium, as lithium and sodium are excreted in a parallel mechanism by the kidney. If sodium intake is limited or the body is depleted of its normal sodium (eg, excessive perspiration, vomiting, diarrhea), lithium is reabsorbed by the kidneys, increasing the possibility of toxicity (Option 3). Therefore, clients on lithium must consume adequate sodium in the diet. Care should be taken to avoid dehydration, so diuretic medications and substances with a diuretic effect (eg, coffee, cola, tea, alcoholic beverages) must be limited or avoided, and clients are advised to drink 2-3 liters of water each day (Options 1 and 2). Educational objective: Clients initiating lithium therapy should be instructed that therapeutic effects may take several weeks to achieve. Clients taking lithium should maintain a normal dietary sodium intake, consume 2-3 liters of fluids per day, and be advised to avoid diuretics or products with diuretic effects (eg, coffee, cola, tea).

While turning a client, the nurse observes that the client's radiation implant has dislodged and is now lying on the linens. Which action by the nurse is appropriate? 1. Get the pt out of bed and away from the radiation source 2. Manually reinsert the implant and notify the HCP 3. Use long-handled forceps to secure the implant in a lead container 4. Wrap the implant in the linens and place it in a biohazard bag

3. USE LONG-HANDLED FORCEPS TO SECURE THE IMPLANT IN A LEAD CONTAINER An internal radiation implant (ie, brachytherapy) emits radiation in or near a tumor to treat certain malignancies. When caring for clients undergoing brachytherapy, the nurse should monitor closely for evidence of implant dislodgment. The dislodged implant emits radiation that can be dangerous to health care workers at the bedside. Long-handled forceps and a lead-lined container should be kept in the room of the client who has a radioactive implant in case of dislodgment. If dislodgment occurs, the nurse should first use long-handled forceps to place the implant in a lead-lined container to contain radiation exposure (Option 3). The nurse should also notify the health care provider (radiation oncologist). (Option 1) Containing the source quickly is a priority as the implant continues to emit radiation that could be dangerous to the staff coming to evaluate the client and clean the room. (Option 2) The nurse should not handle dislodged radiation implants without the use of forceps. Furthermore, device reinsertion should be performed only by the health care provider. (Option 4) Wrapping the implant in linens and placing it within a biohazard bag does not reduce radiation exposure. Educational objective: If an internal radiation implant has dislodged, the nurse should use long-handled forceps to place it in a lead-lined container to contain radiation exposure.

The nurse receives report for 4 clients in the emergency department. Which client should be seen first? 1. 30 year old with a spinal cord injury at L3 sustained in a motor cycle accident who reports lower abdominal pain and difficulty urinating 2. 33 year old with a seizure disorder admitted with phenytoin toxicity who reports slurred speech and unsteady gait 3. 65 year old with sus[ected brain tumor waiting to be admitted for biopsy who reports throbbing headache and had emesis of 250 ml 4. 70 year old with a fib and a clsoed head injury waiting for brain imaging who reports a headache and had emesis of 200 ml

4. 70 YEAR OLD WITH A FIB AND A CLOSED HEAD INJURY WAITING FOR BRAIN IMAGING WHO REPORTS A HEADACHE AND HAD EMESIS OF 200 ML A client with a neurological injury (eg, head trauma, stroke) is at risk for cerebral edema and increased intracranial pressure (ICP), a life-threatening situation. The client with atrial fibrillation may also be taking anticoagulants (eg, warfarin, rivaroxaban, apixaban, dabigatran), making a life-threatening intracranial bleed even more dangerous. The nurse should perform a neurologic assessment (eg, level of consciousness, pupil response, vital signs) immediately. (Option 1) Autonomic dysreflexia (eg, throbbing headache, flushing, hypertension) is a life-threatening condition caused by sensory stimulation that occurs in clients who have a spinal cord injury at T6 or higher. This is not the priority assessment as this client's injury is at L3. This client likely has acute urinary retention and needs catheterization. (Option 2) Phenytoin toxicity commonly presents with neurologic manifestations such as gait disturbance, slurred speech, and nystagmus. These are expected symptoms and therefore are not a priority. (Option 3) A brain tumor can also cause increased intracranial pressure; clients report morning headache, nausea, and vomiting. Dexamethasone (Decadron) can be prescribed short-term to decrease the surrounding edema. A tumor usually grows more slowly than a possible hematoma and is therefore not the priority assessment. Educational objective: Constant headache, decreased mental status, and sudden-onset emesis indicate increased intracranial pressure.

The nurse is teaching self-care management to a client experiencing an outbreak of genital herpes. Which statement by the client indicates a need for further teaching? 1. I will be sure we use condoms during intercourse as long as I have lesions 2. I will not touch the lesions to prevent spreading the virus to the other parts of my body 3. I will use a hair dryer on a cool setting to dry the lesions after taking a shower 4. I will use warm running water and mild soap without perfumes to wash the area

4. I WILL BE SURE WE USE CONDOMS DURING INTERCOURSE AS LONG AS I HAVE LESIONS Herpes simplex virus type 2 (HSV-2) is usually associated with genital herpes. Lesions are painful and appear as multiple small, vesicular lesions. Management strategies focus on disease spread, including autoinoculation (eg, fingers) and pain relief, and include: Avoid sexual activity when lesions are present as the virus spreads through contact with the lesion; barrier contraception is not sufficient during an outbreak (Option 1). After the outbreak has resolved, condoms should be used in future sexual encounters as transmission is possible even in the absence of active lesions. Keep the area with lesions clean and dry. Avoid use of perfumed soaps and bubble baths. Maintain proper hand hygiene and avoid touching the lesions to prevent spreading. Use sitz baths and oatmeal baths to provide comfort and relief of itching and burning. (Option 2) Vesicles contain numerous virus particles, leading to the possibility of self-inoculation. This can be prevented by avoidance of hand contact with lesions during an outbreak. (Option 3) Use of a hair dryer on a cool setting is an effective means of drying the lesions and promoting client comfort. (Option 4) Warm water provides symptomatic relief. Mild soap containing no perfumes reduces the risk of irritation to the area. Educational objective: Clients experiencing an outbreak of genital herpes should abstain from sexual activity when lesions are present and use condoms in future sexual encounters as transmission is possible even in the absence of active lesions.

A nurse in the emergency department cares for 4 clients with orthopedic injuries. Which client should the nurse assess first? 1. Pt who sustained a closed, incomplete ulnar fracture while playing sports 2. Pt with bilateral metacarpal fractures after falling out of bed 3. Pt with multiple myeloma who has a vertebral fracture and aching back pain 4. Pt with pain and obvious shoulder deformity reporting a "pins and needles" sensations

4. PT WITH PAIN AND OBVIOUS SHOULDER DEFORMITY REPORTING A "PINS AND NEEDLES" SENSATION Joint dislocations may become orthopedic emergencies because articular bone may compress surrounding vasculature, causing limb-threatening distal ischemia (Option 4). When a joint is dislocated, the articular tissues, blood vessels, and nerves are often traumatized by stretching. Signs of joint dislocation include pain, deformity, decreased range of motion, and extremity paresthesia. The nurse should frequently assess neurovascular status and provide analgesics until the dislocation can be reduced and immobilized. (Option 1) In incomplete greenstick fractures, the bone bends and cracks but remains in one piece. These fractures are most common in children, as their bones are soft and flexible. The nurse should provide analgesics and offer reassurance; however, the client with neurovascular impairment should be assessed first. (Option 2) Fractures of the bones of the hand (ie, metacarpals) are common in fall injuries, when the brunt of the fall is borne against the hands and fingers, resulting in hyperflexion or hyperextension. The nurse should provide analgesics; however, the client with neurovascular impairment should be assessed first. (Option 3) Pathologic vertebral compression fractures and pain are expected in clients with multiple myeloma. These clients commonly experience fractures of the vertebral column and spinal processes as the cancer weakens and decalcifies the vertebrae. This client should be evaluated next to rule out spinal cord involvement. Educational objective: Joint dislocations may constitute an orthopedic emergency. Because articular tissues, blood vessels, and nerves are stretched and compressed, neurovascular compromise may occur. Prolonged disruption of the vasculature and nerves may cause permanent injury and even loss of the distal extremity.

A major disaster involving hundreds of victims has occurred, and an emergency nurse is sent to assist with field triage. Which client should the nurse prioritize for transport to the hospital? 1. Pt at 8 weeks gestation with spotting and pulse of 90 min 2. Pt with a compound femoral fracture and an oozing laceration 3. Pt with fixed and dilated pupils and no spontaneous respirations 4. Pt with paradoxical chest movement throughout respirations

4. PT WITH PARADOXICAL CHEST MOVEMENT THROUGHOUT RESPIRATIONS Disaster triage is based on the principle of providing the greatest good for the greatest number of people. Clients are triaged rapidly using a color-coded system to categorize them from highest medical priority (emergent) to lowest (expectant). The client with flail chest (ie, paradoxical chest movement during respiration) from multiple fractured ribs is at risk for respiratory failure from impaired ventilation. In addition, mobile fractured ribs may puncture the pleura or vessels, causing hemothorax and/or pneumothorax at any time. Therefore, this client would be classified as emergent due to airway compromise, which requires immediate treatment (Option 4). (Option 1) Spotting at 8 weeks gestation may indicate complications of pregnancy (eg, miscarriage, ectopic pregnancy, hydatidiform mole). With stable vital signs, this client would be classified as nonurgent as the fetus is not at the age of viability and there is no evidence of risk to the mother's life. (Option 2) The client with a compound fracture and oozing laceration would be classified as urgent and require care within 2 hours to prevent life-threatening complications (eg, hemorrhagic shock). (Option 3) Absent respirations and fixed pupils indicate severe neurologic damage or death. Therefore, this client would be classified as expectant. Educational objective: During mass casualty events, the goal is the greatest good for the greatest number of people. Clients are triaged rapidly using a color-coded system that categorizes them from highest medical priority to lowest: red (emergent), yellow (urgent), green (nonurgent), and black (expectant).

A client at 38 weeks gestation is in labor and receiving an oxytocin infusion. The continuous fetal heart rate (FHR) monitor displays the strip shown in the exhibit. Which action by the nurse is most appropriate? Click on the exhibit button for additional information. 1. Discontinue oxytocin infusion 2. Place pt in the side lying position 3. Provide pxygen 10 L/min via face mask 4. Review medication adminstration record

4. REVIEW MEDICATION ADMINISTRATION RECORD This fetal heart strip shows 2 early decelerations, 3 accelerations, and minimal variability with a baseline FHR of 140/min. The baseline FHR is normal (110-160/min), and occasional accelerations and early decelerations are reassuring findings. In the presence of these findings, minimal variability may indicate temporary fetal sleep (usually <30 minutes) or central nervous system (CNS) depression. The nurse should first check the medication administration record for recently administered CNS depressants (eg, opioid analgesics). However, minimal or absent variability requires further assessment if accompanied by late decelerations, as it may indicate fetal hypoxemia or acidosis. (Options 1, 2, and 3) Late decelerations indicate utero-placental insufficiency and require nursing interventions to prevent complications. The nurse should place the client in a side-lying position to relieve pressure on the vena cava and place oxygen via face mask to increase placental perfusion. Late decelerations indicate that the fetus is not tolerating the contractions and oxytocin (Pitocin), a medication that stimulates contractions, should be stopped. Educational objective: FHR of 110-160/min, occasional accelerations, and early decelerations are components of a reassuring FHR pattern. Minimal variability usually indicates fetal sleep or the effects of CNS depressants. Late decelerations with minimal variability indicate utero-placental insufficiency and require further assessment and intervention.

The nurse assesses a client who has followed a vegan diet for several years. Which client statement indicates a potential nutritional deficiency? 1. I have some visual disturbances while driving at night 2. I have had trouble falling asleep over the past few months 3. Scaly patches of skin are developing on my elbows and knees 4. Sometimes my hands and feet get a tingling sensation

4. SOMETIMES MY HANDS AND FEET GET A TINGLING SENSATION Clients who follow a vegan diet eat only plant-based foods, omitting animal proteins (eg, meat, poultry, fish) and products (eg, dairy, eggs). Clients who are vegan are at risk for deficiency of vitamin B12 (cobalamin), which is primarily supplied by animal products. Chronic vitamin B12 deficiency may precipitate megaloblastic anemia and neurological symptoms across the entire nervous system, from peripheral nerves to the spinal cord and brain. Manifestations of chronic deficiency include: Peripheral neuropathy (eg, tingling, numbness) (Option 4) Neuromuscular impairment (eg, gait problems, poor balance) Memory loss/dementia (in cases of severe/prolonged deficiencies) Clients who follow a vegan diet are encouraged to take supplemental vitamin B12 to prevent severe neurological complications. In addition, clients are taught to incorporate vitamin B12-fortified foods (eg, cereals, grain products, soy and nut milks, meat substitutes). (Options 1, 2, and 3) Visual disturbances, difficulty sleeping, and scaly patches of skin are likely not complications of a nutritional deficiency related to a vegan diet. Educational objective: Clients following a vegan diet should be educated about vitamin B12 deficiency and the importance of supplementation and eating B12-fortified foods. Chronic vitamin B12 deficiency may precipitate megaloblastic anemia and neurological symptoms (eg, peripheral neuropathy, neuromotor impairment, memory loss).

The nurse is caring for a client with acute pancreatitis admitted 2 days ago. Which assessment finding is most concerning? 1. Blood glucose levels for the past 24 hours are >250 2. Pt is lying with knees drawn up to the abdomen to alleviate pain 3. Five large, liquid stools that are yellow and foul smelling 4. Tmperature of 102.2 with increasing abdominal pain

4. TEMPERATURE OF 102.2 WITH INCREASING ABDOMINAL PAIN Clients with acute pancreatitis are at risk for pancreatic abscess development. This mainly results from secondary infection of pancreatic pseudocysts or pancreatic necrosis. High fever, leukocytosis, and increasing abdominal pain may indicate abscess formation (Option 4). The abscess must be treated promptly to prevent sepsis. The health care provider should be notified immediately as antibiotic therapy and immediate surgical management may be required. (Option 1) Elevated blood glucose is an expected finding in clients with pancreatitis. Elevated blood glucose is associated with pancreatic dysfunction and may necessitate insulin administration, but this is not the most concerning finding. (Option 2) Clients with acute pancreatitis often report severe, burning midepigastric abdominal pain that radiates to the back. Clients may seek relief from pain by positioning themselves in the knee-chest position, which decreases intra-abdominal pressure. Pain relief interventions should be attempted, but this is not the priority. (Option 3) The client with pancreatitis may develop steatorrhea (eg, fatty, yellow, foul-smelling stools) due to a decrease in lipase production. Although fluid and nutritional status are important, this does not take precedence over a possible surgical emergency. Educational objective: Acute pancreatitis may cause severe midepigastric abdominal pain, elevated blood glucose levels, and steatorrhea. The nurse should watch closely for high fever, increasing abdominal pain, and leukocytosis as these findings may indicate infection of the necrosed pancreas or pancreatic abscess formation.

The clinic nurse reviews teaching provided to the parent of a child being considered for growth hormone replacement therapy at home. Which statement by the parent indicates that teaching has been effective? 1. Treatment will be considered a success when my child grows at a rate equal to peers 2. Treatment will be required throughout my child's life 3. Treatment will begin when my child becomes an adolescent 4. Treatment will require a daily injection under my child's skin

4. TREATMENT WILL REQUIRE A DAILY INJECTION UNDER MY CHILD'S SKIN A child who demonstrates a slow growth pattern will undergo diagnostic evaluation to determine the cause. If the cause is found to be growth hormone deficiency, the child may undergo growth hormone replacement therapy. The biosynthetic hormone is administered via subcutaneous injection on a daily basis. Despite replacement therapy, the child may still have a final height less than "normal." Treatment is most successful when diagnosis and replacement therapy begin early in the child's life. When to stop therapy is decided by the client, family, and provider. However, growth less than 1 inch (2.5 cm) per year and bone age of 14 years in girls and 16 years in boys are the criteria often used to stop therapy. (Option 1) Growth hormone replacement does not guarantee that a child will grow at a rate equal to peers. Treated children often remain shorter than their peers. (Option 2) Replacement therapy is not continued throughout a child's life. It is stopped when bone growth begins to cease or when the child, parents, and provider make the decision. (Option 3) Replacement therapy is most successful when treatment begins early, as soon as growth delays are noted. Educational objective: Growth hormone replacement is an option for children who are not growing according to accepted standards. The treatment should begin as soon as delays are noted and continue until bone growth begins to cease despite replacement therapy. Replacement is administered via subcutaneous injections.