July 8th

The nurse prepares to assist the health care provider with a lumbar puncture on a child with suspected meningitis. Place the procedural steps in the correct order. All options must be used.

-Check the medical record for parental consent -Gather the lumbar puncture tray and supplies -Have the child empty the bladder -Assist the child into the side-lying position with the knees drawn up -Label specimen vials as they are collected -Place a bandage on the insertion site

The nurse is providing nutrition counseling during a preconception visit to a client who does not eat green vegetables. In addition to a daily prenatal vitamin, which foods can the client add to the daily diet to decrease the risk of neural tube defects? Select all that apply. 1. Black beans and rice 2. Fortified breakfast cereal and milk 3. Medium baked sweet potato 4. Peanut butter on wholl wheat toast 5. Raw carrots with cheese dip

1, 2, & 4 Folic acid, or folate, is a water-soluble, B-complex vitamin necessary for red blood cell production. Pregnant women and those attempting pregnancy need a minimum of 400 mcg of folic acid per day to decrease the chance of fetal neural tube defects (eg, spina bifida, anencephaly). Most prenatal vitamins contain 400-800 mcg of folic acid; additional folic acid can come from the diet. Leafy green vegetables are the best dietary sources of folic acid. However, other appropriate food choices include cooked beans, rice, fortified cereals, and peanut butter, which provide at least 40 mcg folic acid per serving (Options 1, 2, and 4). (Option 3) Sweet potatoes provide vitamin A, vitamin C, and minerals to the diet but no folic acid. (Option 5) Raw carrots are a dietary source of vitamin A, vitamin C, and minerals, but not of folic acid. Educational objective: Folic acid is a B-complex vitamin that decreases the risk of fetal neural tube defects. Pregnant women require a minimum of 400 mcg of folic acid daily. Leafy green vegetables supply excellent dietary folic acid; alternate sources include beans, rice, peanut butter, and fortified cereals.

The nurse has provided education about proper use of an epinephrine auto-injector to a client with a history of a severe hypersensitivity reaction to bee stings. Which of the following client statements indicate that teaching has been effective? Select all that apply. 1. I may have a rapid heartbeat and palpitations after injecting the medication 2. I must call an ambulance or go to the nearest hospital following an injection 3. I should avoid storing my device in extremely hot or cold temperatures 4. The area to be injected should be cleansed with alcohol or soap and water 5. The medication in injected at a 90 degree angle

1, 2, 3, & 5 Epinephrine auto-injectors (EAIs) are devices used as an emergency treatment for anaphylactic reactions to allergens (eg, insect bites, foods, chemicals). Clients with a history of anaphylaxis must be properly educated on EAI use because delaying or failing to administer epinephrine is a frequent cause of death. Nurses educating clients on EAI use should include the following information: Administer injection at a 90-degree angle into the outer thigh at the first sign of an allergic reaction (Option 5) Hold the auto-injector in place for 10 seconds to ensure delivery of the entire dose Seek immediate medical care after an injection because anaphylactic reactions may resume when the effects of the epinephrine subside (ie, 10-20 minutes) (Option 2) Expect to experience tachycardia, palpitations, and/or dizziness after administration (Option 1) Store EAIs at room temperature in a dark place to prevent inactivation by heat or light, or device failure from cold (Option 3) (Option 4) Clients should be instructed to administer EAIs as quickly as possible if symptoms of anaphylaxis develop. Skin preparation is not necessary, and delaying administration to cleanse the injection site increases the risk of death from anaphylactic shock. Educational objective: Client education about use of epinephrine auto-injectors (EAIs) includes injecting the EAI into the outer thigh at a 90-degree angle at symptom onset; seeking immediate medical care after device use; storing EAIs in a dark place at room temperature; and understanding that tachycardia, palpitations, and dizziness may occur after injection.

The nurse is providing discharge teaching to a client newly diagnosed with ulcerative colitis. Which of the following statements by the client indicate that teaching has been effective? Select all that apply. 1. I need to eat a diet high in calories and protein so that I avoid losing weight 2. I need to take multivitamins containing calcium daily 3. I should avoid consuming alcoholic beverages 4. I should drinnk at least 2 liters of water daily and more when I have diarrhea 5. I will keep a symptom journal to note what I eat and drink during the day

1, 2, 3, 4, & 5 Ulcerative colitis (UC) is a form of inflammatory bowel disease characterized by remitting periods of mucosal irritation in the large intestine, resulting in profuse, bloody diarrhea. Management of clients with UC often includes dietary interventions to reduce symptoms and prevent reoccurrence, malnutrition, and dehydration. Nutrition and hydration management: Diets consisting of high-calorie, high-protein foods are recommended to prevent weight loss and muscle wasting (Option 1). Multivitamins containing calcium are often prescribed to supplement nutrition and should be taken regardless of symptoms (Option 2). Oral hydration is critical in UC as >10 liquid stools may occur daily during flares, placing clients at risk for dehydration. Instruct clients to drink at least 2 liters of water daily (Option 4). Dietary triggers for UC vary greatly between individuals and may include dairy, nuts/legumes, cereal, alcohol, caffeine, and fatty and processed foods. Diet journaling is recommended to assist with identifying triggers (Option 5). Caffeine, alcohol, and tobacco are gastric irritants that stimulate the intestine and should be avoided (Option 3). Educational objective: Ulcerative colitis (UC) is an inflammatory bowel disease that is managed with dietary interventions in addition to medication. Clients with UC should maintain a high-calorie, high-protein diet; drink at least 2 liters of water per day; take multivitamins as prescribed; maintain a symptom journal in relation to daily dietary intake; and avoid triggers.

The camp nurse conducts a class for incoming summer counselors on prevention of tick bites and associated complications. Which instructions should the nurse include? Select all that apply. 1. Avoid hiking through tall grass and wooded areas 2. Cover ticks found on the skin with petroleum jelly 3. Report bulls eye shaped rash or flu like symptoms 4. Use deet containing tick repellent on skin and clothing 5. Wear dark colored clothing

1, 3, & 4 Lyme disease develops after a bite from a tick infected with Borrelia burgdorferi. Initial symptoms are flu-like (eg, headache, fever, myalgia, fatigue). Many clients develop a bull's-eye rash; however, it is not always present. Any of these symptoms should be reported immediately to a health care provider (Option 3). The client will likely be prescribed antibiotics (eg, doxycycline, amoxicillin) to treat Lyme disease and prevent it from spreading to other organs (eg, heart, brain, joints). Clients are taught to prevent tick bites by avoiding tall grass and wooded areas and to hike in the center of the trail only (Option 1). Clients should use insect repellent and wear long pants tucked into boots or closed-toed shoes (Option 4). (Option 2) Covering ticks with petroleum jelly or nail polish is a folk remedy that actually increases the chance of infection by keeping the tick on the skin. Instead, clients should be taught to promptly and properly remove a tick using tweezers, being careful to grasp the tick close to the attachment site and not to crush it during removal. (Option 5) It is difficult to spot ticks on dark clothing; they are more visible on light-colored clothing. Educational objective: Clients should be taught to prevent tick bites by using insect repellent, wearing long pants with closed-toed shoes, and avoiding tall grass and wooded areas. Ticks should be removed with tweezers, keeping them intact. Flu-like symptoms and a bull's-eye rash (erythema migrans) should be reported immediately to the health care provider.

The unit is staffed with an experienced registered nurse, an experienced licensed practical nurse, and unlicensed assistive personnel (UAP). Which tasks can the charge nurse appropriately delegate to UAP? Select all that apply. 1. Apply protective skin ointment after perineal cleansing 2. Determine if a pt has adequate after administration of an analgesic 3. Document daily wright for a pt with congestive HF 4. Feed a pt who had a stroke 24 hours after admission 5. Perform passive range-of-motion exercised for a pt on a ventilator

1, 3, & 5 Unlicensed assistive personnel (UAP) are assigned tasks for stable clients by the registered nurse (RN), who directs and manages overall client care. The RN cannot delegate the nursing process. UAP can perform active and passive range-of-motion exercises (Option 5). Under the direction of the RN, UAP can apply protective ointment (such as zinc oxide) after cleaning a client (Option 1). UAP can obtain data but the RN is responsible for interpreting (evaluating) it. For example, UAP can obtain objective data such as the client's height and weight, but the RN will analyze this data to determine the need in the nursing care plan (eg, effect on drug dosing) (Option 3). (Option 2) UAP can collect data (eg, an objective pain score), but the RN is responsible for evaluating if the relief is adequate. The word "adequate" refers to the evaluation of treatment and is not part of UAP scope of practice. The RN may consider other aspects (eg, vital signs, body language) when making such evaluations, especially in a nonverbal client. (Option 4) A stroke is not considered stabilized until approximately 48 hours have passed without changes. The client's risk of losing the gag reflex is still high as the stroke could be evolving. UAP should feed only stable clients. Educational objective: Unlicensed assistive personnel (UAP) can perform passive range-of-motion exercises, apply protective ointment, and obtain objective data for stable clients under the direction of a registered nurse. However, UAP cannot feed clients with potential dysphagia or make evaluations about treatment effectiveness.

The nurse observes an ambulating client begin to experience a tonic-clonic seizure. Which nursing actions should be implemented immediately? Select all that apply. 1. Guide the pt to the floor and gently cradle the head 2. Insert a tongjue blade to prevent pt from the swallowing the tongue 3. Move the objects that may cause injury away from the pt 4. Physically restrain the pt to prevent injury 5. Place the pt in left lateral position 6. Remain with the pt, observe, and record the seizure activithy

1, 3, 5, & 6 Protecting the ambulating client from injury is the immediate priority. The nurse assists the client to the floor, cradles the head, and places the client in the left lateral position. Left lateral position is preferred to avoid the risk of aspiration. Hard or sharp objects should be removed from the client's environment to prevent injury. The nurse remains with the client until the seizure is over to assess seizure activity and postictal symptoms and to minimize injury. (Option 2) No objects should be placed in a client's mouth during a seizure. Following the seizure, the client may require assessment and maintenance of the airway, suctioning, and oxygen administration. (Option 4) Attempting to restrain a client during a seizure may cause injury to the client. Educational objective: Safety measures implemented during a seizure include positioning the client to protect from injury, maintaining a patent airway, and observing the seizure activity. During the seizure, the nurse does not restrain the client or place objects in the client's mouth.

The nurse caring for a client with pulmonary edema responds to the mechanical ventilator high-pressure alarm. The nurse would assess for which conditions that can trigger the high-pressure alarm? Select all that apply. 1. Biting the endotracheal tube 2. DIsconnected ventilator tubing 3. Endotrachea; tube ciff link 4. Excessive airway secretionns 5. Kinked ventilator tubing

1, 4, & 5 Mechanical ventilator alarms (eg, high- or low-pressure limit) alert the nurse to potential problems caused by a change in the client's condition, a problem with the artificial airway (eg, endotracheal or tracheostomy tube), and/or a problem with the ventilator. Peak airway pressure is the amount of pressure required to deliver a tidal volume. Any condition that increases the peak airway pressure can trigger the ventilator high-pressure limit alarm. When this alarm sounds, the nurse should assess for conditions that increase airway resistance and/or decrease lung compliance, such as: Excessive secretions: Obstruct the airway, increasing resistance (Option 4) Biting the endotracheal tube and kinked ventilator tubing: Air flow is obstructed, increasing resistance (Options 1 and 5) (Options 2 and 3) Any condition that decreases airway resistance (eg, tubing disconnect, extubation, endotracheal or tracheostomy tube cuff leak) can trigger the low-pressure limit alarm. Educational objective: When the mechanical ventilator high-pressure limit alarm sounds, the nurse should assess for causes of increased airway resistance in the client (eg, bronchospasm), artificial airway (eg, excessive secretions, biting the endotracheal tube), and/or ventilator system (eg, kinked tubing), as well as for causes of decreased lung compliance (eg, pneumothorax).

The nurse assessing a 2-year-old should expect the child to be able to perform which actions? Select all that apply. 1. Build a tower with blocks 2. Draw a square 3. Hop on foot 4. Say own name 5. Walk without help

1, 4, & 5 Nurses play an important role in identifying appropriate growth and development in all clients. Children who do not meet key developmental milestones for their age should be reported to the health care provider (HCP) to determine the need for further testing. Developmental milestones that a 2-year-old toddler should meet include: Motor skills: Walks alone, builds block towers, draws lines, kicks a ball Language: Knows 300+ words, uses 2- to 3-word phrases, states name Cognitive/social skills: Engages in parallel play, imitates others, exerts independence (Option 2) Normally, a child will develop the ability to draw or copy a square later during the preschool years (age 3-6). (Option 3) A 2-year-old client will not yet demonstrate the balance required for this activity. The ability to hop and stand on one foot for 5-10 seconds develops during the preschool years (age 3-6). Educational objective: Developmental assessment findings in 2-year-old clients include the ability to build block towers, say their own name, and walk without assistance. The nurse should notify the HCP if a child is not meeting age-appropriate developmental milestones so the child can be referred for further testing.

Four clients enter the emergency department at the same time. Which should the triage nurse see first? 1. 25 year old pt with sudden onset chest pain and HR of 110 2. 45 year old pt with type 2 diabetes who is traveling and has lost insulin glargine 3. 60 year old with pain , swelling, erythema, and warmth in the right leg 4. 70 year old pt with left lower abdominal pain

1. 25 YEAR OLD WITH SUDDEN ONSET CHEST PAIN AND HR OF 110 An ECG should be performed immediately on all adult clients with chest pain; all chest pain should be considered cardiac until proven otherwise. After the initial ECG, the client with chest pain will need to be placed on a cardiac monitor and assessed by the health care provider before the other 3 clients. (Option 2) This client will need a prescription renewal. Glargine (Lantus) is given once a day, typically in the evening, as basal insulin. The consequence of late administration is hyperglycemia. A single temporary rise in glucose will not have a significant negative impact. The damage to vessels in a diabetic client comes from long-term uncontrolled diabetes. The other clients are a higher priority. (Option 3) This client may have a deep vein thrombosis and will probably require anticoagulant therapy. However, this client is hemodynamically stable without evidence of active pulmonary embolism and can safely wait to be seen after the higher-risk client with chest pain. (Option 4) This client may have acute diverticulitis and should be seen urgently, but after the client with chest pain. Prioritization should be based on which client is most ill and not on advanced age. Educational objective: Chest pain in an adult, regardless of age, is a priority. It is important to not make assumptions based on client age, race, or nationality.

NCLEX-RN TEST - Whitney Young 00:35:06 50 of 50 Feedback Flash Cards8 A nurse cares for a client after cardiac catheterization. During assessment of the groin site, the nurse notices that the dressing is saturated with blood and a small trickle leaks down the client's leg. What should the nurse do first? 1. Apply direct manual pressure at and above the skin puncture site 2. Call the HCP to report active bleeding 3. Check the peripheral pulse distal to the catheterization site 4. Place a new pressure dressing over the catheterization site

1. APPLY DIRECT MANUAL PRESSURE AT AND ABOVE THE SKIN PUNCTURE SITE Cardiac catheterization helps assess and diagnose coronary artery disease (eg, coronary artery patency, atherosclerosis). A catheter is advanced to the heart through a vein (eg, femoral, antecubital) for right-sided heart catheterization or an artery (eg, brachial, femoral) for left-sided heart catheterization. After the procedure, a pressure dressing is applied and the client placed supine with the affected extremity flat for 2-6 hours to promote complete hemostasis. The nurse monitors vital signs, extremity integrity (eg, pulses, sensation, capillary refill), and dressings for indications of bleeding according to institution policy. If bleeding occurs, the nurse applies direct manual pressure to the vessel puncture site (ie, about 2.5 cm [1"] above the skin puncture site) to achieve hemostasis and keep the client hemodynamically stable (Option 1). The health care provider (HCP) should be notified, as the client may require further surgical intervention. (Option 2) When a client is actively bleeding post cardiac catheterization, the HCP should be notified; however, the nurse should first control the bleeding. (Option 3) The distal pulse is assessed routinely after cardiac catheterization to determine adequate blood flow to the extremities. However, the priority is to control active bleeding through manual pressure. (Option 4) A new pressure dressing may be applied after the bleeding has stopped and hemostasis has been achieved per HCP prescription. Educational objective: If bleeding occurs after cardiac catheterization, the nurse first applies direct manual pressure to control the bleeding.

The nurse prepares a 7-year-old client for an influenza injection. The nurse explains that the client will receive "medicine under the skin," and the client is visibly anxious. Which nursing intervention is appropriate? 1. Ask the child to count to 10 during the injection 2. Ask the parent to hold the child's arm tightly 3. Explain to the child that the injection will not hurt 4. Keep the injection needle out of the child;'s view

1. ASK THE CHILD TO COUNT TO 10 Children are often fearful of injections, exhibiting unpredictable and/or uncooperative behavior. The nurse should explain the procedure to the child using simple, age-appropriate language (eg, "medicine under the skin") to reduce anxiety. According to Piaget's cognitive developmental stages, school-age children develop concrete thought and may fear a loss of control. To improve the child's sense of control, the nurse should offer a specific, task-based coping technique (eg, counting aloud, deep breathing) (Option 1). (Option 2) A caregiver should hold or embrace a child during the injection process, with the child on the caregiver's lap or standing in front of a seated caregiver. Tightly holding the child's arms is extreme and may distress the child and caregiver. (Option 3) The child should be told the truth about pain that accompanies an injection. The nurse should use appropriate language, such as "the skin may hurt for a minute," and emphasize that the pain is quick and transient. (Option 4) Keeping objects that may alarm the child out of view is an appropriate intervention for a toddler but not for a school-age child. Hiding a procedural object from a 7-year-old will hinder rapport with the nurse and may heighten the child's anxiety. Educational objective: School-age children possess concrete thinking and fear loss of control. When administering an injection to a school-age child, the nurse should offer a specific, task-based coping technique (eg, instruct the child to count aloud or breathe deeply) to increase the child's sense of control and thereby reduce anxiety.

A nurse is assessing a client with type 2 diabetes mellitus who was recently started on pioglitazone. Which client data obtained by the nurse is most important to bring to the attention of the health care provider? 1. Bilateral pitting edema in ankles 2. BP is 140/88 3. Most recent HBA1c 6.7% 4. Retinal photcoagulation in right eye

1. BILATERAL PITTING EDEMA IN ANKLES Thiazolidinediones (rosiglitazone [Avandia] and pioglitazone [Actos]) are used to treat type 2 diabetes mellitus. These agents improve insulin sensitivity but do not release excess insulin, leading to a low risk for hypoglycemia (similar to metformin). These drugs can worsen heart failure by causing fluid retention and increase the risk of bladder cancer. Heart failure or volume overload is a contraindication to thiazolidinedione use. These medications also increase the risk of cardiovascular events such as myocardial infarction. (Option 2) The target blood pressure for a client with diabetes is <140/90 mm Hg. (Option 3) The goal HbA1c for diabetic clients is <7%. (Option 4) Diabetic retinopathy, a condition treated with retinal photocoagulation, is unrelated to thiazolidinedione use. If the client has a history of bladder cancer, then it should be reported. Educational objective: Thiazolidinediones (rosiglitazone [Avandia] and pioglitazone [Actos]) increase the risk of cardiovascular events (eg, mycoardial infarction, heart failure) and bladder cancer. Thiazolidinedione use increase insulin sensitivity but carries a low risk for hypoglycemia (similar to metformin).

The nurse is monitoring a client who is in active labor with a cervical dilation of 6 cm. Which uterine assessment finding requires an intervention by the nurse? 1. Contraction duration of 95 seconds 2. Contraction frequency of every 3 minutes 3. Contraction intensity of 45mmhg 4. Uterinw resting tone of 10 mmhg

1. CONTRACTION DURATION OF 95 SECONDS Uterine contractions decrease circulation through the spiral arterioles and the intervillous space, which can stress the fetus. Uterine contraction duration should not exceed 90 seconds. During the first stage of labor, duration should be 45-80 seconds. A duration exceeding 90 seconds can result in reduction of blood flow to the placenta due to uterine hypertonicity. (Option 2) Uterine frequency should be 2-5 contractions every 10 minutes. If contractions occur less than 2 minutes apart, fetal distress can occur as a result of uteroplacental insufficiency. (Option 3) In the first stage of labor, the intensity of uterine contractions should be 25-50 mm Hg. Intrauterine pressure of more than 80 mm Hg is a sign of hypertonicity of the uterus. (Option 4) Uterine resting tone of 20 mm Hg or less is considered acceptable. Uterine resting tone allows blood flow to the placenta and therefore the fetus, ensuring a well-oxygenated fetus. Educational objective: Uterine contractions during labor dilate and efface the cervix and cause descent of the fetus. The contraction duration should not exceed 90 seconds or occur less than 2 minutes apart. Excess resting tone, contraction duration, and frequency result in uteroplacental insufficiency.

The daughter of an 80-year-old client recently diagnosed with Alzheimer disease (AD) says to the nurse, "I guess I can anticipate getting this disease myself at some point." What is an appropriate response by the nurse? 1. Engaging in regular exercise decreases the risk of AD 2. Havig a family history of AD is not a risk factor 3. Try not to worry about this now as you can't do anything to prevent AD 4. You should avoid aluminum cans and cookware to prevent AD

1. ENGAGING IN REGULAR EXERCISE DECREASES THE RISK OF AD The development of Alzheimer disease (AD) is related to a combination of genetic, lifestyle, and environmental factors. Clients with AD are usually diagnosed at age ≥65. Early-onset AD is a rare form of the disease that develops before age 60 and is strongly related to genetics. Children of clients with early-onset AD have a 50% chance of developing the disease. For late-onset AD, the strongest known risk factor is advancing age. Having a first-degree relative (eg, parent, sibling) with late-onset AD also increases the risk of developing AD (Option 2). Trauma to the brain has been associated with the development of AD in the future. Brain trauma may be prevented by wearing seat belts and sports helmets and taking measures to prevent falls. Research suggests that healthy lifestyle choices (eg, smoking cessation, avoiding excessive alcohol intake, exercising regularly, participating in mentally challenging activities) reduce the risk for developing AD (Options 1 and 3). (Option 4) Research has failed to confirm that exposure to aluminum products (eg, cans, cookware, antiperspirant deodorant) is related to the development of AD. Educational objective: Research suggests that healthy lifestyle choices (eg, smoking cessation, avoiding excessive alcohol intake, exercising regularly, participating in mentally challenging activities) reduce the risk for developing Alzheimer disease.

A nurse is caring for a client who developed paralytic ileus after a stroke. The client reports nausea, abdominal discomfort, and distension; bowel sounds are absent. Which prescription does the nurse question? 1. Hydrododone 1 tab every 4 hours PRN for moderate pain 2. Increase continuous IV NS rate from 75 to 100 3. Insert NG tube and attach wall suction 4. Ondansetron 4 mg IVP every 4 hours PRN for nausea

1. HYDROCODONE 1 TAB EVERY 4 HOURS PRN FOR MODERATE PAIN Paralytic ileus is characterized by temporary paralysis of a portion of the bowel, which affects peristalsis and bowel motility. Signs and symptoms include abdominal discomfort, distension, and nausea/vomiting. Risk factors for paralytic ileus include: Abdominal surgery Perioperative medications (eg, anesthesia, analgesics) Immobility (eg, stroke) To prevent further abdominal distension and resulting nausea, the client should remain NPO. Nasogastric tube to wall suction may be necessary to decompress the stomach (Option 3). IV fluid and electrolyte replacement (eg, normal saline) may be necessary to correct losses that occur from nasogastric suction (Option 2). Nausea can be treated with prescribed antiemetics (eg, ondansetron, promethazine) (Option 4). (Option 1) The client should not take medications by mouth (due to NPO status), and opioid medications should be avoided as they prolong paralytic ileus. Instead, non-opioid IV analgesics (eg, ketorolac, ibuprofen, acetaminophen) should be administered as prescribed if the client is in pain. Educational objective: Opioid medications can worsen constipation and paralytic ileus and therefore should be avoided in high-risk clients (eg, stroke, post abdominal surgery).

A client with a 10-year history of methadone use for chronic leg pain is being treated with azithromycin for pneumonia. On the third hospital day, both medications are discontinued as the QT interval on EKG has lengthened, increasing arrhythmia risk. The client wants to be discharged against medical advice to return home and take the client's own medications to prevent going into withdrawal without the methadone. Which is the most appropriate nursing response? 1. I will ask the hCP to come talk with us so that we can develop a plan to prevent withdrawal while reducing your risk of heart problems 2. I will talk with the HCP about your concerns, butin the meantime it's important that you stay here 3. It's important that you stay in the hospital so that we can treat you quickly if you have problems 4. You have the right to make your own decisions, but you are at high risk of having heart problems if you go home right now

1. I WILL ASK THE HCP TO COME TALK TO US SO THAT WE CAN DEVELOP A PLAN TP PREVENT WITHDRAWAL WHILE REDUCING YOUR RISK OF HEART PROBLEMS When clients are hospitalized, they lose control of many things, including their medication management. This loss of control can be frightening for the client, especially one who has had control of medications for many years. This client, who has a decade of experience taking methadone for chronic pain, is afraid that suddenly stopping this medication may precipitate withdrawal. The client is trying to regain control and avoid this problem by leaving the hospital against medical advice. However, the client remains at risk of life-threatening arrhythmias. Therefore, the nurse should promote negotiation between the client and HCP to develop a plan of care that will address the concerns of each. The plan should advocate for the client to ensure that the concerns are addressed. Care planning should be a collaborative, shared process informed by the knowledge and preferences of the client and evidence-based recommendations by the HCP that are appropriate to the situation. (Option 2) This response is based on the idea of the nurse and HCP being in control, but it fails to include the client in the decision-making team. (Option 3) This statement provides a rationale for the client to remain in the hospital, but it does not address the client's concerns about going into withdrawal. (Option 4) This response is based on the idea of client autonomy, but it does not propose a solution to the problem. Educational objective: A plan of care should be developed collaboratively, informed by the client's knowledge, beliefs, and preferences, and the expertise and evidence-based recommendations of HCPs.

The nurse assesses several clients using the Glasgow Coma Scale. Which scenario best demonstrates a correct application of this scale? 1. The nurse applies pressure to the nail bed, and the pt tries to push the nurse's hand away. The nurse scores the motor response as "localization to pain". 2. The nurse asks the pt what days it is and the pt says ":banana". The nurse scores verbal reponse as "confused". 3. The nurse speaks with the pt and then the pt's eyes open. The nurse scores eye opening as "spontaneous". 4. The nurse walks in the room and the pt sates "hi honey, how are you?". The nurse scores verbal response as "oriented".

1. THE NURSE APPLIES PRESSURE TO THE NAIL BED, AND THE PT TRIES TO PUSH THE NURSE'S HAND AWAY. THE NURSE SCORES THE MOTOR RESPONSE AS "LOCALIZATION OF PAIN". The Glasgow Coma Scale is used to determine level of consciousness. The nurse follows a standardized assessment to determine the score of the client's eye opening response, verbal response, and ability to obey commands through a motor response. For the best motor response score, the nurse first verbally asks the client to obey a command. If there is no response, the nurse next uses noxious stimuli (eg, nail bed pressure) and records the physical response. If the client tries to remove the painful stimulus, it is recorded as "localizing" or moving toward the pain; whereas if the client retracts from the stimulus, it is recorded as "withdrawal" (Option 1). (Option 2) To ensure an accurate score in the verbal response category, the nurse must differentiate if the client is confused (eg, answers "1955" when asked the year) or if a client uses inappropriate words. (Option 3) To ensure an accurate eye opening score, the nurse must determine whether the client's eyes open spontaneously (eg, no prompting) or if a stimulus (eg, sound, pain) is needed. (Option 4) A social, verbal client is not necessarily oriented. The nurse must assess orientation by specifically asking clients to state their name, the time, and their location. Educational objective: The Glasgow Coma Scale is used to determine level of consciousness. The nurse follows a standardized assessment to determine the score of the client's eye opening response, verbal response, and ability to obey commands through a motor response.

The school nurse is called to the classroom to assist with a 7-year-old with attention-deficit hyperactivity disorder who is throwing books and hitting the other children. What is the best initial action for the nurse to take? 1. Administer a PRN dose of methyphenidate 2. Ask the child to blow up a baloon 3. Give the child a "time out" in a quiet place 4. Reinforce the consequences of disruptive behaviors

2. ASK THE CHILD TO BLOW UP A BALLOON A key feature of attention-deficit hyperactivity disorder (ADHD) is hyperactivity; however, some children with ADHD behave aggressively and have difficulty controlling anger, especially when frustrated or if unable to meet demands and challenges. An immediate intervention to help settle an out-of-control child is deep breathing. Taking slow, deep breaths relaxes the body, slows the heart rate, and distracts the child from inappropriate behaviors. Asking the child to blow up a balloon provides an easy mode of distraction and engages the child in a deep breathing exercise. After the child is calm, the nurse and the child can further discuss the disruptive behavior. Nursing interventions include the following: Stay calm and remove the child from the source of frustration/anger Assist the child in calming down with deep breathing exercises Discuss what precipitated the behavior and why the behavior is wrong Discuss acceptable ways of expressing anger and frustration Acknowledge that controlling anger is difficult Provide rewards for appropriate behavior Discuss the consequences of inappropriate behavior (Option 1) Methylphenidate is not used on a PRN basis; it is administered daily in 2-3 divided doses (or in sustained release form) 30-45 minutes before meals. (Option 3) Isolating the child is punitive and not therapeutic; instead, remove the child from the source of anger. (Option 4) Reminding the child of the consequences of inappropriate behavior is a valid intervention. However, the best action is to help the child calm down and relax first. Educational objective: The priority intervention for a child with ADHD who is engaging in aggressive behavior is to assist the child in calming down and gaining control. Deep breathing exercises are an easy and efficient approach to help the body and mind slow down and relax.

The emergency department nurse assesses a client involved in a motor vehicle accident who sustained a coup-contrecoup head injury. Which assessment finding is consistent with injury to the occipital lobe? 1. Decreased rate and depth of respirations 2. Deficits in visual perception 3. Expressive aphasia 4. Inability to recognize touch

2. DEFICITS IN VISUAL PERCEPTION A coup-contrecoup head injury occurs when the head strikes an object and the brain receives an injury under the area of impact (coup), after which it rebounds to the opposite side of the skull and sustains injury on that side as well (contrecoup). This type of injury is common in motor vehicle accidents and shaken baby syndrome. Visual processing occurs in the occipital lobe. (Option 1) The rate and depth of respirations are regulated by the medulla oblongata at the base of the brainstem. (Option 3) Expressive aphasia, the inability to express spoken words, occurs after a transient ischemic attack or stroke. This will occur if the frontal lobe (Broca aphasia) or temporal lobe (Wernicke aphasia) is injured. (Option 4) Inability to recognize being touched is indicative of injury to the parietal lobe of the brain. Educational objective: Coup-contrecoup head injuries are common in motor vehicle accidents and shaken baby syndrome. Damage to the occipital lobe of the brain during coup-contrecoup head injury will result in visual disturbances.

The nurse is reviewing prescriptions for the assigned clients. Which prescription should the nurse question? 1. Allopurinol for a pt who devbeloped tumor lysis syndrome from chemotherapy 2. Dicyclomine for a pt with a history of IBS who develops a postoperative paralytic ileus 3. IV morphine for a pt after percutaneous necrolithotripsy who reports the last bowel movement was 2 days ago 4. Levofloxacin for a pt with a UTI who has a history of anaphylaxis to penicillin drugs

2. DICYCLOMINE FOR A PT WITH A HISTORY OF IBS WHO DEVELOPS A POSTOPERATIVE PARALYTIC ILEUS Dicyclomine (Bentyl) is an anticholinergic/antispasmodic drug prescribed to manage symptoms of intestinal hypermotility in clients with irritable bowel syndrome. Dicyclomine is contraindicated in clients with paralytic ileus as it decreases intestinal motility and would exacerbate the condition (Option 2). The nurse should question this prescription and contact the health care provider. (Option 1) Tumor lysis syndrome occurs due to rapid lysis of cells and the resulting release of intracellular potassium and phosphorus into serum. Phosphorus binds to calcium, leading to hypocalcemia. The breakdown of cellular nucleic acids causes severe hyperuricemia. IV hydration and hypouricemic medications (eg, allopurinol) are prescribed to promote purine excretion and prevent acute kidney injury. (Option 3) Although opioids (eg, morphine) can cause constipation, symptoms can be managed with pharmacologic (eg, docusate sodium, sennoside) and nonpharmacologic interventions (eg, increased activity, increased fiber and fluid intake). Percutaneous nephrolithotripsy breaks and removes kidney stones, and can lead to severe pain. Therefore, pain medication is appropriate. (Option 4) Levofloxacin, a fluoroquinolone antibiotic prescribed to treat urinary tract infections, has no known cross-sensitivity to penicillin. However, cross-sensitivity with other fluoroquinolones can occur. Educational objective: Dicyclomine is an antispasmodic drug that decreases intestinal motility and is contraindicated in clients with paralytic ileus.

The nurse is performing an assessment on a neonate shortly after delivery. The nurse is most concerned about which assessment finding? 1. Bilateral rales found on lung auscultation 2. Dullness over bladder found on percussion 3. Ptosis of right eyelid found on facial inspection 4. Single testicle found on genital palpation

2. DULLNESS OVER BLADDER FOUND ON PERCUSSION Eyelids should sit above the pupils symmetrically with irises showing. Ptosis (drooping of the eyelid below the level of the pupil) could indicate paralysis of the oculomotor nerve. This finding warrants further investigation. At the time of birth, there should be no cranial nerve abnormalities. (Option 1) Crackles (rales) indicate fluid in the lungs and are expected immediately after birth. Rales will clear as the neonate transitions to extrauterine life. However, wheezes, stridor, or persistence of crackles after the first few hours of birth are abnormal and should be reported. (Option 2) Percussing dullness in the hypogastric area is a normal finding when the bladder is full. The neonate should void spontaneously within a few hours after birth. (Option 4) An undescended testicle (cryptorchidism) at birth is not concerning. Most undescended testes descend spontaneously by age 6 months. Educational objective: At the time of birth, there should be no cranial nerve abnormalities. Rales (crackles) indicate fluid in the lungs and will clear as the neonate transitions to extrauterine life. Most undescended testes descend spontaneously by age 6 months.

The nurse teaching the parents of a child diagnosed with cystic fibrosis will advise the parents to choose foods that satisfy which recommended diet? 1. GLuten free with added protein 2. High calorie, high protein, and high fat 3. High protein, low fat, low phosphate 4. High protein, low fat, low sodium

2. HIGH CALORIE, HIGH PROTEIN, HIGH FAT In cystic fibrosis (CF), a protein responsible for transporting sodium and chloride is defective and causes the secretions from the exocrine glands to be thicker and stickier than normal. These abnormal secretions plug smaller airway passages and ducts in the gastrointestinal (GI) tract. The thick secretions block pancreatic ducts, resulting in a deficient amount of pancreatic enzymes entering the bowel to aid in digestion and nutrient absorption. Clients require multiple vitamin supplements and supplemental pancreatic enzymes that are administered with meals. To meet the growth needs of clients with CF, a diet high in calories, fat, and protein is required. (Options 1, 3, and 4) A gluten-free diet is required for clients with celiac disease who cannot tolerate barley, rye, oats, or wheat (mnemonic: BROW). Low-phosphate diets are indicated for clients with certain kidney disorders. Low-sodium diets are indicated for volume overload states (eg, heart failure, ascites) and hypertension. Educational objective: Cystic fibrosis causes damage to the GI tract and pancreas, leading to impaired absorption of nutrients and resulting growth deficits. Clients must consume a diet high in calories, fat, and protein.

An elderly client reports shortness of breath with activity for the past 2 weeks. The nurse reviews the admission laboratory results and identifies which value as the most likely cause of the client's symptoms? 1. BNP 70 2. Hct 21% 3. Leukocytes 3,500 4. Platelets 105,000

2. Hct 21% Hematocrit (Hct) is the percentage of red blood cells (RBCs) in a volume of whole blood. Hct and hemoglobin (Hgb) values are related (approximately 3 x Hgb = Hct); when one value is decreased, the other is also. This client likely has hemoglobin of 7 g/dL (70 g/L) (normal, 13.2-17.3 g/dL [132-173 g/L] for males and 11.7-15.5 g/dL [117-155 g/L] for females). Hgb is a component of the RBC that carries oxygen to the body's tissues. A decrease in Hgb decreases oxygen-carrying capacity and transport to tissues. RBCs may be 100% saturated with oxygen at rest, but desaturation may occur with increased activity and oxygen demand in the presence of decreased Hct and Hgb. Manifestations associated with decreased oxygen transport include shortness of breath with activity, tachypnea, and tachycardia. (Option 1) Brain natriuretic peptide (BNP) >100 pg/mL (100 pmol/L) is considered elevated and indicates ventricular stretch (heart failure) as the cause of the dyspnea. This client has normal BNP levels, making heart failure an unlikely cause. (Option 3) The leukocyte count is decreased (normal, 4,000-11,000/mm3 [4.0-11.0 x 109/L]). Leukocytes play a role in protecting the body from disease. (Option 4) The platelet count is decreased (normal, 150,000-400,000/mm3 [150-400 x 109/L]). Platelets play a role in blood clotting. Educational objective: Hemoglobin is a component of red blood cells that carries oxygen to the body's tissues. In the presence of decreased hematocrit and hemoglobin, decreased oxygen-carrying capacity and transport occur. Manifestations associated with decreased oxygen transport include shortness of breath with activity, tachypnea, and tachycardia.

The student nurse and the registered nurse are caring for a mechanically ventilated client with an acute lung injury. Which statement by the student nurse indicates a need for further education? 1. I will auscultate the neck to assess for endotracheal cuff leaks 2. I will perform endotracheal sucioning after oral care 3. I will provide oral care and oral suctioning every 2 hours. 4. I will reposition the pt from side to side at least every two hours

2. I WILL PERFORM ENDOTRACHEL SUCTIONING ROUTINELY AFTER ORAL CARE Endotracheal (ET) suctioning improves ventilation in mechanically ventilated clients by removing mucus and secretions from the ET tube. Suctioning is performed based on clinical findings such as adventitious breath sounds, elevated peak airway pressure, coughing, or signs of acute respiratory distress. Frequent suctioning increases the risk of tracheal and bronchial trauma, bleeding, and hypoxia. Suctioning should be performed only when needed to reduce the risk for injury (Option 2). (Option 1) Auscultating the neck to monitor for an ET tube cuff leak is a standard component of respiratory assessment in mechanically ventilated clients. The presence of a cuff leak increases the risk of accidental extubation, impairs ventilation, and allows aspiration of secretions from the mouth and throat. (Option 3) Oral care with oral suctioning is performed every 2 hours to prevent ventilator-associated pneumonia (VAP). Secretions in the mouth and throat often contain bacteria that can cause pneumonia. (Option 4) Repositioning clients at least every 2 hours reduces the occurrence of VAP. Turning clients side-to-side promotes mobilization of secretions and prevents secretions from pooling in dependent areas of the lungs. Educational objective: Endotracheal suctioning in mechanically ventilated clients should be performed based on assessment findings such as adventitious breath sounds, elevated peak airway pressure, coughing, or acute respiratory distress. Suctioning should be performed only when needed to reduce the risk of lung trauma and hypoxia.

A client has potential radiation contamination from a disaster. The nurse should monitor for which of the following related to this contamination? Select all that apply. 1. Bitter almond smell on breath 2. Fever and raised skin pustules 3. Low blood cell count 4. Oral mucosal ulcerations 5. Vomiting and diarrhea

3, 4, & 5 Radiation damages the DNA, which causes cell destruction. Radiation (and chemotherapy) usually affects tissues with rapidly proliferating cells (eg, oral mucosa, gastrointestinal tract, bone marrow) first, followed by tissues with slowly proliferating cells (eg, cartilage, bone, kidney). As a result, early manifestations of radiation damage include oral mucosal ulcerations, vomiting/diarrhea, and low blood cell counts. The extent of radiation exposure can be monitored indirectly by measuring blood cell counts. (Option 1) A bitter almond smell on the client's breath is a classic sign of cyanide poisoning. (Option 2) Fever and raised skin pustules are signs/symptoms of smallpox, which is transmitted from person to person via respiratory droplets. Infection starts with fever, followed by a rash and then sharply raised pustules. Educational objective: Radiation contamination (and chemotherapy) affects rapidly proliferating (dividing) cells first, such as those of the oral mucosa, gastrointestinal tract, and bone marrow.

The nurse is caring for an adolescent client who just had placement of an external fixation device for long-term stabilization of a fractured tibia. Which interventions are appropriate to include in the client's plan of care? Select all that apply. 1. Check the pins every 4 hours and if these are loose, turn the bolt clockwise to tighten 2. Maintain bed rest until the device is removed 3. Notify the HCP immediately if drainage or increased pain occurs at the pin site 4. Perform neurovascular checks every 2-4 hours for 24 hours 5. Perform pin care with 1/2 strength hydrogen peroxide and NS solution every 4 hours

3, 4, & 5 An external fixator is a metallic device composed of metal pins (screws) placed into the bone to stabilize it; these are positioned above and below the fracture through small incisions in the skin and muscle. After the pins are placed, they are attached to an adjustable external rod or frame outside the skin. Infection of the pin tract is a major complication associated with the device. The nurse should notify the HCP immediately if there are signs or symptoms of infection (eg, drainage, pain, erythema, swelling, fever, pin looseness) at the pin sites. Prompt treatment with antibiotic therapy is necessary as a localized pin tract infection can progress to osteomyelitis, an infection of the bone (Option 3). Infection can also cause the pins to loosen, and this can lead to bone displacement. Therefore, the nurse should perform meticulous sterile pin care with 1/2-strength hydrogen peroxide and NSS or chlorhexidine solution, or as directed by institution policy and procedure (Option 5). Regular neurovascular assessment is important after fixator placement as inadvertent pin placement can compromise the integrity of nerves and vessels (Option 4). (Option 1) Loosening of the pins can compromise bone alignment and healing. The nurse should assess the pins regularly and notify the HCP if they are loose but should not turn the bolts to tighten. (Option 2) An external fixator device allows for early ambulation with the device in place, increases independence while maintaining bone immobilization, and prevents immobility hazards. If used long-term (>4 weeks), the fixator is removed when the bone is healed. Educational objective: Nursing interventions to prevent common complications (eg, infection, loosening of pins) associated with an external fixator include meticulous sterile pin care with an antimicrobial solution, regular assessment of pin tightness, and immediate HCP notification if pins are loose or there are signs of infection.

`The nurse reviews and reinforces an asthma action plan with a client who has moderate persistent asthma. Which statement by the client indicates an understanding of how to follow a plan appropriately when peak expiratory flow (PEF) readings are in the green, yellow, or red zones? 1. If I am in the green zone (80-100%) but am coughing, wheezing, and having more trouble breathing, I will not make any changes in my medications 2. If I am in the yellow zone (50-80%) and I return to the green zone after taking my rescue medication, I will not make any changes in my daily medicatoins 3. If I am in the yellow zone (50-80%), I will take my rescue medication every 4 hours for 1-2 days and call my HCP for follow up care 4. If I remain in the red zone, my lips are blie, and my PEF is still <50% of my personal best reading after taking my rescue medication, I will wait 15 minutes bofre calling an ambulance

3. IF I AM IN THE YELLOW ZONEW (50-80%), I WILL TAKE MY RESCUE MEDICATION EVERY 4 HOURS FOR 1-2 DAYS AND CALL MY HCP FOR FOLLOW UP CARE An asthma action plan is an individualized management plan developed collaboratively between the client and the HCP to facilitate self-management of asthma. It includes information on daily and long-term treatment, prescribed medicines and when to take them according to a zone system, how to manage worsening symptoms or attacks, and when to call the HCP or go to the emergency department. The action plan uses traffic signal colors to categorize into zones degrees of asthma symptom severity and airway obstruction (peak flow meter readings): Green zone indicates asthma is under control and PEF is 80%-100% of personal best. When in this zone, there is no worsening of cough, wheezing, or trouble breathing (Option 1). Yellow zone means caution; even on a return to the green zone after use of rescue medication, further medication or a change in treatment is needed (Option 2). Red zone indicates a medical alert and signals the need for immediate medical treatment if the level does not return to yellow immediately after taking rescue medications (Option 4). Educational objective: A peak flow meter uses traffic signal colors to categorize degrees of asthma symptoms. Green zone indicates asthma is under control. Yellow zone indicates caution, symptoms are getting worse, PEF is 50%-80% of personal best, and there is a need for further medication. Red zone indicates the need for emergency treatment if the level does not immediately return to yellow after taking rescue medications.

The clinic nurse interviews the parents of a 6-month-old about the child's diet and feeding schedule. Which parent statement causes the nurse the most concern? 1. Apples are a healthy food so we often make apple pie for our child 2. Chopped pears are one of our childs favorite foods 3. Oatmeal with fresh honey is our childs favorite breakfast 4. We have found TV dinners to be convenient as they have both meat and vegetables

3. OATMEAL IS OUR CHILD FAVORITE BREAKFAST Although more than one of these parent comments are concerning, the most concerning is feeding honey to a child under age 1 year. Honey (especially raw or wild) is not recommended for children under age 1 due to the risk for infant botulism. An infant under age 1 has an immature gut system that can allow Clostridium botulinum spores contaminated in honey to colonize the gastrointestinal tract and release toxin that causes botulism. Botulinum toxin produces muscle paralysis by inhibiting the release of acetylcholine at the neuromuscular junction. Infants often present with constipation, diminished deep tendon reflexes, and generalized weakness. Additional symptoms are lack of head control, difficulty in feeding, and decreased gag reflex, which can progress to respiratory failure. Isolation of the organism from the child's stool can take several days; therefore, diagnosis is usually made by history, and treatment with botulism immune globulin is started before laboratory results are known. (Option 1) Apple pie is not the best way to serve apples to a 6-month-old as the other ingredients add too much fat and sugar. This would need to be addressed but is not a priority over the use of honey. (Option 2) Raw fruits are appropriate for a 6-month-old. (Option 4) Although TV dinners contain meat and vegetables, they are not the best source of food for an infant due to the high sodium content. This would need to be addressed after the use of honey is addressed. Educational objective: Due to the risk of infant botulism, honey should not be given to children under age 1 year.

The nurse cares for a client diagnosed with type I diabetes mellitus who came to the emergency department with the acute complication of diabetic ketoacidosis (DKA). After checking the blood glucose, which prescription should the nurse implement first? 1. Insert an indwelling urinary catheter for accurate output calculation 2. Obtain serum potassium level results and report to the primary HCP 3. Prepare an insulin drip for IV infusion as prescribed 4. Start an IV line and infuse NS as prescribed

3. PREPARE AN INSULIN DRIP FOR IV INFUSION AS PRESCRIBED DKA is a life-threatening complication of type I diabetes characterized by hyperglycemia (>250 mg/dL) that results in ketosis, a metabolic acidosis. Glucose cannot be taken out of the bloodstream and used for energy without insulin. The body begins to break down fat stores into ketones, as it does in a state of starvation, causing a metabolic acidosis (low pH and low HCO3). The lack of insulin also results in increased glucose production in the liver, worsening the hyperglycemia. Hyperglycemia causes osmotic diuresis, and clients are severely dehydrated. The cardinal signs of dehydration are poor skin turgor, dry mucosal membranes, tachycardia, orthostatic hypotension, weakness, and lethargy. Despite laboratory values showing hyperkalemia on admission, clients with DKA have a net potassium deficiency and will need careful replacement after fluid resuscitation. (Option 1) Although it is important to insert an indwelling catheter to monitor fluid balance, rehydrating the client is a life-saving measure with higher priority. (Option 2) Although it is important to monitor serum potassium results before and during insulin administration, rehydrating the client is the highest priority. Dilution will also improve the hyperkalemia. (Option 3) The priority intervention in DKA is to start an IV infusion for bolus rehydration therapy with normal saline. This should occur before insulin infusion as insulin will result in water, potassium, and glucose entering the cells, worsening the dehydration and electrolyte imbalances. Educational objective: The severe hyperglycemia of diabetic ketoacidosis (DM1) and hyperosmolar hyperglycemic state (DM2) causes severe dehydration from an osmotic diuresis. IV normal saline resuscitation should be started before any other therapy

The nurse is caring for a 10-year-old diagnosed with osteomyelitis. What is the best activity the nurse can suggest to promote age-specific growth and development during hospitalization? 1. fantasy play with puppets 2. Invite freinds to come visit 3. Provide missed schoolwork 4. Watch favorite movie

3. PROVIDE MISSED SCHOOLWORK According to Erikson's stages of psychosocial development, school-age children deal with the conflict of industry versus inferiority. Attaining a sense of industry (competence) is the most significant developmental goal for children age 6-12. Parents should therefore be encouraged to provide a hospitalized child with missed school work on a regular basis. This will help the child keep up with school demands, learn new skills, cope with the stressors of hospitalization, and avoid a sense of inferiority. (Option 1) Fantasy play with puppets is more appropriate for a preschool-age child as imaginary play and magical thinking peak during this stage of development. (Option 2) Although school-age children enjoy spending time with friends, peer relationships are significantly more important during the adolescent period. (Option 4) Watching television is a good diversion for all hospitalized children, but it does not promote age-specific growth and development. Educational objective: According to Erikson's stages of psychosocial development, school-age children deal with the conflict of industry versus inferiority. During this stage, unlike other developmental stages, learning is a priority and completing school work provides a sense of accomplishment and satisfaction. It is therefore important that parents provide hospitalized school-age children with missed school work on a regular basis.

Several children are brought to the emergency room after a boating accident in which they were thrown into the water. The children are now 6 hours post admission to the clinical observation unit. Which client should the nurse evaluate first? 1. Pt who did not require CPR but now has a new oxygen requirement of 2 L via NC to maintain a saturation of 95% 2. Pt who did not require CPR but was coughing on arrival to the hospital and is now crying inconsolably and asking for the mother 3. Pt who received CPR for 2 minutes on the scene and whose RR has now dropped from 61-18 /min 4. Pt who was briefly submerged in water and received rescue breaths on the scene and is now irritable and refusing food and drink

3. PT WHO RECEIVED CPR FOR 2 MINUTES ON THE SCENE AND WHOSE RR HAS NOW DROPPED FROM 61-18/MIN Clients with morbidity related to immersion in water are described as having submersion injury. Even if an individual was submerged for a very brief time, it is possible that water may have been aspirated, which can lead to respiratory compromise. Observation for at least 6 hours is recommended as the majority of significant respiratory problems will manifest in this time period. A marked decrease in respiratory rate or increased work of breathing may indicate respiratory fatigue, and immediate intervention is needed (Option 3). Impending respiratory failure is the immediate priority. (Option 1) A new oxygen requirement is an important symptom; however, this child has good oxygen saturation with the nasal cannula and is therefore not the immediate priority. (Option 2) This child who is coughing and emotionally distressed should be seen and comforted by the nurse but is not the priority. (Option 4) Irritability can be an early sign of hypoxia in a toddler. This child should be assessed promptly but is not the immediate priority. Educational objective: Clients who have sustained submersion injury should be evaluated immediately and observed for at least 6 hours for new or worsening respiratory failure. Changes in respiratory pattern or rate, oxygen saturation, and level of consciousness can signal impending respiratory failure, which can be life threatening.

A client with a diagnosis of schizophrenia with catatonia has recently been admitted to the psychiatric unit. Which of the following is the priority nursing diagnosis? 1. Impaired social interaction 2. Impaired verbal communication 3. Risk for deficient fluid volume 4. Risk for impaired skin integrituy

3. RISK FOR DEFICIENT FLUID VOLUME A diagnosis of schizophrenia with catatonia can be made if the clinical features meet the criteria for a diagnosis of schizophrenia and include at least 2 of the following additional features: Immobility—the client remains in a fixed stupor or position for long periods Refuses to move about or engage in activities of daily living May have brief spurts of excitement or hyperactivity Remaining mute Bizarre postures—the client holds the body rigidly in one position Extreme negativism—the client resists instructions or attempts to be moved Waxy flexibility—the client's limbs stay in the same position in which they are placed by another person Staring Stereotyped movements, prominent mannerisms, or grimacing Clients with catatonic schizophrenia are unable to meet their basic needs for adequate fluid and food intake and are at high risk for dehydration and malnutrition. The priority nursing action is to anticipate the client's needs, and to ensure that the client is well hydrated and has adequate nourishment. Some clients will need total care. (Option 1) Impaired social interaction is also an appropriate nursing diagnosis in a client with catatonic schizophrenia. However, it is not a priority, especially during the early phases of the disease. (Option 2) The client's mutism makes the diagnosis of impaired verbal communication appropriate, and the nurse should gently encourage this client to talk without undue expectations or pressure. This is not the priority nursing diagnosis. (Option 4) If this client is in a bizarre or fixed posture, there may be a risk for decreased circulation and pressure ulcers. The nurse needs to encourage ambulation and/or provide range-of-motion exercises. Educational objective: Clients with catatonic schizophrenia are unable to meet their own needs for fluids, food, movement, and elimination and need assistance in performing basic activities of daily living. However, a priority diagnosis is deficient fluid volume.

A client with seizure activity is receiving a continuous tube feeding via a small-bore enteral tube. The nurse prepares to administer phenytoin oral suspension via the enteral route. What is the nurse's priority action before administering this medication? 1. Check renal function lab results 2. Flush tube with NS, not water 3. Stop the feeding for 1 to 2 hours 4. Take the BP

3. STOP THE FEEDING FOR 1 TO 2 HOURS Phenytoin (Dilantin) is an anticonvulsant drug commonly used to treat seizure disorders. Steady absorption is necessary to maintain a therapeutic dosage range and drug level to control seizure activity. The nurse's priority action is to stop the feeding for 1 to 2 hours before and after administering phenytoin as products containing calcium (eg, antacids, calcium supplements) and/or nutritional enteral tube feedings can decrease the absorption and the serum level of this drug. (Option 1) Unless clients have renal insufficiency, renal function tests are not routinely monitored during prescribed phenytoin therapy. Phenytoin is metabolized in the liver and can cause liver damage. Monitoring of liver function test during therapy is recommended. (Option 2) Flushing the tube with 30-50 mL of water before and after administering phenytoin is recommended to minimize drug loss and drug-drug incompatibility. Flushing with normal saline before and after drug administration is recommended in clients receiving intravenous (IV) phenytoin. (Option 4) BP is not usually affected in clients prescribed oral phenytoin therapy for seizure disorders. However, IV phenytoin can cause hypotension and arrhythmias. Educational objective: Phenytoin is an anticonvulsant drug commonly used to treat seizure disorders. Steady absorption is necessary to maintain a therapeutic dosage range and drug level to control seizure activity. Administration of phenytoin concurrent with certain drugs (eg, antacids, calcium) and/or enteral feedings can affect the absorption of phenytoin.

A client with Alzheimer disease becomes agitated during mealtime and throws a plate of food on the floor. Which of the following initial responses by the nurse are appropriate? Select all that apply. 1. Administer a dose of prescribed PRN haloderidol before the pt's behavior escalates further 2. Inform the pt that the HCP will be notified about the inappropriate behavior 3. Obtain another plate of food and ask the UAP to feed the pt 4. Redirect the pt from the table to assist in folding napkins for the flowwing day's meals 5. Use directy eye contact, smile, and say to the pt "I can see that you are upset;m you are safe here"

4 & 5 Clients with Alzheimer disease (AD) often exhibit behavioral problems (eg, agitation, resisting care) due to cognitive decline. Behavioral management techniques include: Acknowledgement of the client's emotions; this reduces feelings of isolation and being misunderstood (Option 5) Reassurance that the client will be kept safe from harm Distraction (eg, photographs, music, television) to divert the client's attention Redirection to simple tasks (eg, folding towels/napkins, stacking plates) (Option 4) (Option 1) Antipsychotic medications (ie, haloperidol, risperidone, olanzapine) are associated with increased mortality when used for agitation in clients with dementia. These medications should be used as a last resort after other measures have failed. (Option 2) Threatening to call the health care provider disrupts the nurse-client relationship and may worsen the client's agitation and behavioral problems. (Option 3) Offering activities that precipitated the behavior will likely worsen the agitation. Another meal can be offered after the client is calm. Educational objective: Behavioral management for agitated clients with Alzheimer disease includes acknowledging client feelings, reassuring safety, distracting, and redirecting. Antipsychotic medications increase mortality in clients with dementia and should be used only as a last resort.

The nurse is caring for a 72-year-old client with hypothyroidism admitted to the emergency department for altered mental status. The client lives alone but has not taken medications or seen a health care provider for several months. Which action is the priority? Click on the exhibit button for additional information. EXHIBIT: temp=95, BP=90/50, HR=50, RR=10, and O2=83% 1. Administer IV levothyrpxin 2. CHeck serum TSH, triidothyronine, and thyroxine 3. Place a warming blanket on the pt 4. Prepare for endotracheal intubation

4. PREPARE FOR ENDOTRACHEAL INTUBATION Myxedema coma refers to a state of severe hypothyroidism causing decreased level of consciousness (eg, lethargy, stupor) that may progress to a comatose state. Myxedema coma is characterized by hypothermia, bradycardia, hypotension, and hypoventilation. Hypoventilation may occur as a result of respiratory muscle fatigue and mechanical obstruction by an edematous tongue. Clients with signs of respiratory failure (eg, slow or shallow breathing, low oxygen saturation) require emergency endotracheal intubation and mechanical ventilation. The nurse should provide respiratory support (eg, ventilation with a bag-valve-mask) and prepare to assist with intubation (Option 4). (Option 1) Clients with myxedema coma require thyroid hormone replacement with IV levothyroxine to correct the hypothyroid state but only after respiratory status is secured. Improvement in clinical status may not occur for up to a week after initiation of hormone replacement. (Option 2) A serum thyroid panel (eg, TSH, triiodothyronine, thyroxine) is required to confirm hypothyroidism, and these measurements should be monitored during treatment; however, the nurse should ensure that the client is stable before reviewing laboratory values. (Option 3) A warming blanket should be placed on the client to treat hypothermia; however, respiratory support is the priority. Educational objective: Myxedema coma is a state of severe hypothyroidism and decreased level of consciousness that may progress to coma and respiratory failure. The nurse should provide respiratory support (eg, ventilation with a bag-valve-mask) and prepare to assist with intubation.

A nurse is caring for a client following a forceps-assisted vaginal birth. The client reports severe vaginal pain and fullness. On assessment, the nurse notices a firm, midline uterine fundus. Lochia rubra is light. Which diagnosis should the nurse anticipate? 1. Cervical lacerations 2. Inversion of the uterus 3. Uterine atony 4. Vaginal hematoma

4. VAGINAL HEMATOMA\A vaginal hematoma is formed when trauma to the tissues of the perineum occurs during delivery. Vaginal hematomas are more likely to occur following a forceps- or vacuum-assisted birth or an episiotomy. The client reports persistent, severe vaginal pain or a feeling of fullness. If the client had epidural anesthesia, pain may not be felt until the effects have worn off. Vaginal bleeding is unchanged. The uterus is firm and at the midline on palpation. If the hematoma is large, the hemoglobin level and vital signs can change significantly. In a client with epidural analgesia, a change in vital signs may be an important indicator of hematoma. (Option 1) Cervical lacerations should be suspected if the uterine fundus is firm and midline on palpation despite continued vaginal bleeding. The bleeding can be minimal to frank hemorrhage. Severe pain or a feeling of fullness is not associated with cervical lacerations. (Option 2) Complete inversion of the uterus presents with a large, red mass protruding from the introitus. (Option 3) Uterine atony presents with a boggy uterus on palpation and an increase in vaginal bleeding. Educational objective: Vaginal hematomas are formed following trauma to the tissues of the perineum during vaginal delivery (eg, vacuum- or forceps-assisted delivery, episiotomy). The client reports severe pain or a persistent feeling of fullness in the region. Assessment shows a firm, midline uterine fundus with minimal or unchanged vaginal bleeding.`

A nurse is assisting with the care of a newborn during circumcision. Which is an appropriate intervention? 1. Apply a snug fitting diaper following the procedure 2. Anticipate the use of clean technique during the circumcision 3. Offer oral fluids during the procedure 4. Wrap the newborn's upper body in a blanket restraint for the circumcision

4. WRAP THE NEWBORN'S UPPER BODY IN A BLANKET RESTRAINT FOR THE CIRCUMCISION Application of a blanket restraint or the use of a special board prevents injury during circumcision. Swaddling and the use of non-nutritive sucking are nonpharmacologic approaches to manage pain during circumcision. (Option 1) A loose-fitting diaper is put on the newborn after circumcision to avoid irritation to the penis. (Option 2) Sterile technique is used during the surgical procedure of circumcision. (Option 3) The infant should not be fed during circumcision to prevent the risk of aspiration. A pacifier dipped in a concentrated sucrose solution is offered as a nonpharmacologic pain management technique. Educational objective: During circumcision, the newborn is restrained in a wrapped blanket or placed on a special board to prevent injury. Non-nutritive sucking of a concentrated sucrose solution is offered for pain management.