NCLEX 1

The nurse is reviewing new arterial blood gas results for a client with an exacerbation of chronic obstructive pulmonary disease. The client's serum pH is 7.45. Which result noted by the nurse is a priority to report to the health care provider? 1. HCO3− of 35 mEq/L (35 mmol/L) 2. Hemoglobin of 19 g/dL (190 g/L) 3. PaCO2 of 67 mm Hg (8.91 kPa) 4. PaO2 of 52 mm Hg (6.92 kPa)

1, 3. Clients with COPD chronically retain CO2, resulting in respiratory acidosis. This client's results are consistent with compensated respiratory acidosis in which renal resorption of HCO3− increases to normalize serum pH. 2. Clients with COPD often experience chronic hypoxia and may demonstrate a compensatory increase in hemoglobin (ie, polycythemia) to promote maximal oxygen transport. 4. CORRECT: PaO2 <60 mm Hg (7.98 kPa) in a client with COPD indicates significant hypoxemia, which requires the nurse to contact the health care provider for additional interventions (eg, oxygen, positive-pressure ventilation) (Option 4).

A client comes to the emergency department with crushing substernal chest pain. Which interventions should the nurse complete? Select all that apply. 1. Administer morphine 2. Check blood pressure and heart rate 3. Draw blood specimen 4. Obtain a 12-lead ECG 5. Position client in the supine position

1, 2, 3, 4. CORRECT: The nurse should rapidly assess (eg, vital signs, heart and lung sounds, pain) and intervene (eg, 2 large-bore IV lines, morphine, oxygen, nitroglycerin, aspirin) for the client with acute chest pain. Upright positioning improves ventilation and reduces pressure on the heart. The nurse should obtain a 12-lead ECG, chest x-ray, and blood work (eg, cardiac markers), and place the client on continuous cardiac monitoring. 5. Unless contraindicated the client should be placed in an upright, seated position (not supine); upright positioning improves ventilation and reduces pressure on the heart.

After addressing a group of young adults about sexual health and hygiene, the nurse recognizes that teaching regarding genital warts and the human papillomavirus (HPV) has been effective when hearing which client statements? Select all that apply. 1. "Genital warts that have been treated are at risk of recurrence." 2. "I should begin Pap testing as soon as I am sexually active." 3. "I should receive the HPV vaccine series even if I am already sexually active." 4. "Infection with HPV increases my risk of cervical cancer." 5. "Using condoms during sex will eliminate the risk of spreading the virus."

1, 3, 4. CORRECT: Genital warts can be treated (eg, topical podophyllin, cryotherapy, laser surgery) but may recur at any time. High-risk HPV strains (types 16 and 18) increase risk of cervical, oral, and genital cancers. The HPV vaccine helps prevent HPV infection and is most effective if taken before becoming sexually active. However, current guidelines suggest that even teens and young adults (age ≤26) who have already become sexually active may benefit from HPV vaccination 2. The majority of clinical organizations recommend that cervical cancer screening (Pap testing) be initiated at age 21, regardless of sexual history. In women age <21, HPV infection rarely progresses to malignancy. Overdiagnosis and treatment of potentially benign HPV infections can lead to negative reproductive outcomes in the future (eg, pregnancy loss, preterm birth). 5. Barrier methods (eg, condoms) can reduce the risk of HPV transmission. However, abstinence is the only definitive way to eliminate the risk of contracting STIs.

The nurse auscultates the lung sounds of a client with shortness of breath. Then, the nurse notifies the HCP about the adventitious sounds heard. Which medication prescription should the nurse anticipate for coarse crackles? 1. Albuterol 2. Bumetanide 3. Guaifenesin 4. Methylprednisolone

1, 4. Clients with asthma or chronic obstructive pulmonary disease (eg, emphysema) develop wheezing due to bronchospasm. Bronchodilators (eg, albuterol, ipratropium) and systemic corticosteroids (eg, methylprednisolone) may be prescribed to these clients. 2.CORRECT: Coarse crackles (loud, low-pitched bubbling) are heard primarily during inspiration and are not cleared by coughing. The sound is similar to that of Velcro being pulled apart. Coarse crackles may be confused with fine crackles (eg, atelectasis), which have a high-pitched, popping sound. Coarse crackles are present when fluid or mucus collects in the lower respiratory tract (eg, pulmonary edema, pulmonary fibrosis). During heart failure, the left ventricle fails to eject enough blood, causing increased pressure in the pulmonary vasculature. As a result, fluid leaks into the alveoli (pulmonary edema). Loop diuretics (eg, bumetanide, furosemide) treat pulmonary edema by reducing intravascular fluid volume through significant increase of fluid excretion by the kidneys 3. Clients with acute upper respiratory infections or chronic bronchitis (ie, inflammation of the upper airways) may be prescribed guaifenesin to loosen and improve the expectoration of mucus. Clients with chronic bronchitis typically develop rhonchi (ie, sonorous wheezes), which are continuous, low-pitched adventitious breath sounds that resemble moaning or snoring.

A nurse is caring for a client with unstable angina. After 5 minutes on a nitroglycerin IV infusion, the client reports relief of chest pain but a new dull, throbbing headache. What is the appropriate nursing action? 1. Decrease the infusion rate and reassess the client's report of pain 2. Document the finding and administer prescribed acetaminophen 3. Notify the health care provider and request a CT scan of the head 4. Stop the infusion immediately and notify the health care provider

1, 4. If the headache becomes severe or persistent despite acetaminophen, the HCP may temporarily decrease the dose. The nurse should not arbitrarily stop the infusion or decrease the rate. 2. CORRECT: Nitroglycerin is a potent vasodilator used to treat acute coronary syndrome. Headache is an expected side effect that decreases with continued therapy and can be treated with aspirin or acetaminophen. A headache is not concerning unless it is severe or persistent and/or accompanied by severe hypotension or signs of increased ICP 3. Nitroglycerin therapy can precipitate increased intracranial pressure (ICP). Additional signs of increased ICP (eg, decreased level of consciousness, vomiting, Cushing triad) should be reported to the HCP. A CT scan of the head is not indicated at this time.

The nurse is reinforcing education about lifestyle choices to help reduce symptoms for a client with gastroesophageal reflux disease. Which of the following statements by the client indicate a correct understanding? Select all that apply. 1. "I have switched from coffee to decaffeinated herbal tea in the mornings." 2. "I plan to join a smoking-cessation program." 3. "I prefer to eat three large meals a day and avoid snacking." 4. "I prop myself up on a couple of pillows when I go to sleep." 5. "I will switch to low-fat dairy products and avoid high-fat foods."

1, 5. CORRECT: Avoiding GERD triggers such as caffeine, alcohol, nicotine, high-fat foods, chocolate, spicy foods, peppermint, and carbonated beverages may help prevent GERD and associated symptoms 2. CORRECT: Discontinuing the use of tobacco products may help prevent GERD and associated symptoms Refraining from eating at bedtime and/or lying down immediately after eating 3. Clients with GERD should eat small, frequent meals with sips of water or fluids to help facilitate the passage of stomach contents into the small intestine and help prevent reflux from an overly full stomach during and after meals. 4. CORRECT: Sleeping with the head of the bed elevated may help prevent GERD and associated symptoms

When caring for a client with ulcerative colitis, which nursing activities are appropriate for the registered nurse to delegate to the licensed practical nurse? Select all that apply. 1. Administer a blood transfusion 2. Administer a prescribed suppository 3. Discuss dietary modifications with the dietitian 4. Monitor for a change in bowel sounds 5. Remind the client to track daily weights

1. A blood transfusion may be necessary, depending on the severity of symptoms. LPNs cannot initiate a blood transfusion, but they can monitor the client for adverse effects. 2. CORRECT: . It is within the LPN's scope of practice to administer medications via most routes, including topically via the rectum (eg, suppositories) 3. A low-residue, high-protein, high-calorie diet, along with daily vitamin and mineral supplements, is encouraged to meet the nutritional and metabolic needs of the client with UC. However, collaboration is part of the planning process and cannot be delegated. 4. CORRECT: Clients with UC typically have hyperactive bowel sounds. LPNs can monitor assessment findings after the initial assessment by an RN 5. CORRECT: Frequent diarrhea may cause weight loss and electrolyte imbalances; therefore, the client should be taught to measure daily weights. The registered nurse (RN) cannot delegate tasks requiring clinical judgment (eg, initial teaching, assessment, planning, evaluation). However, a licensed practical nurse (LPN) can reinforce teaching already provided by the RN

A nurse receives change-of-shift report on 4 clients. Which client should the nurse assess first? 1. Client who experienced a transient ischemic attack 2 days ago and is due to receive scheduled aspirin 2. Client who had a subdural hemorrhage 36 hours ago and is requesting a breakfast tray 3. Client with a bowel resection receiving total parenteral nutrition who had 4,800 mL of urine output during the last shift 4. Client with a stroke receiving tissue plasminogen activator whose Glasgow Coma Scale changed from 9 to 13

1. A client experiencing a transient ischemic attack has stroke-like symptoms that later resolve. Such clients are often placed on prophylactic antithrombotic treatment (eg, aspirin, clopidogrel) to prevent future strokes. This client requires scheduled medication but is not an immediate priority. 2. A client with a subdural hemorrhage should be frequently assessed for neurological changes and early symptoms of increased intracranial pressure (eg, headache, nausea). A verbal request for breakfast indicates that the client is stable and therefore does not require immediate attention. 3. CORRECT: TOTAL PARENTERAL NUTRITION (TPN) may be prescribed for clients with dysfunction of the gastrointestinal tract (eg, short bowel). GLUCOSE (dextrose) is a primary component of TPN solutions; therefore, the nurse should monitor blood glucose and assess for symptoms of HYPERGLYCEMIA (eg, polydipsia, POLYURIA, headaches, blurred vision). A urine output of 4,800 mL during a shift may indicate hyperglycemia. Symptomatic clients should be assessed and treated immediately as hyperglycemia can lead to SEIZURES, COMA, or DEATH. 4. Tissue plasminogen activator is administered to clients with ischemic strokes to dissolve clots in the brain. A Glasgow Coma Scale change from 9 to 13 demonstrates improving neurological status.

The nurse in an ambulatory surgery center triages telephone messages from clients. Which client should the nurse call back first? 1. Client who had a colonoscopy with polypectomy who reports abdominal cramping and a small amount of rectal bleeding 2. Client who had a lumbar laminectomy with spinal fusion 3 days ago who reports straining to have a bowel movement 3. Client who underwent laparoscopic inguinal hernia repair yesterday who reports difficulty urinating 4. Client who underwent placement of an arteriovenous graft who reports a temperature of 100.9 F

1. A small amount of rectal bleeding and abdominal cramping is expected following a colonoscopy as the bowel contracts to expel the air inserted during the procedure. Following a colonoscopy, clients should notify the HCP of severe abdominal pain, distension, and excessive bleeding, which may indicate bowel perforation. 2. Following surgery, constipation can occur due to decreased ambulation and narcotic pain medications. The client may require a stool softener to reduce straining. 3. Anesthesia and opioid analgesics may cause postoperative urinary retention for up to 3 days following surgeries, especially abdominal or pelvic surgeries. This client should be instructed on measures to aid voiding (eg, standing) and may need to come to the clinic for bladder ultrasound or straight catheterization. 4. CORRECT: Arteriovenous (AV) graft placement involves surgical connection of an artery and a vein using a synthetic material to graft a hemodialysis access site. Postoperative infection of an AV graft may cause thrombosis, graft failure, or systemic infection. Fever in a postoperative client may indicate infection of the graft site, which warrants immediate notification of the HCP; this client may require antibiotics and surgical removal of the graft

The nurse is caring for a pediatric client with osteomyelitis. Prior to the nurse administering IV antibiotics, the client's parent states, "We don't believe in antibiotics. Healing comes from within, and medications are toxic to that process." What is the nurse's priority response? 1. "Please tell me how medications are toxic to the healing process." 2. "Please tell me your understanding of your child's condition." 3. "What type of healing practices would you prefer for your child?" 4."Without this medication, your child can get worse and could die."

1. Asking about beliefs regarding medications in general may help in developing a teaching plan. However, it is more important to educate the parent about this child's specific and immediate need for antibiotics. 2. CORRECT: IV antibiotics are necessary for treating osteomyelitis (infection of the bone), and without them, the client is at risk for potentially life-threatening complications (eg, sepsis). Parental refusal of necessary medication for a minor creates an ethical dilemma. The nurse's first response should be assessment of a parental knowledge deficit regarding the client's condition. The nurse should ask open-ended questions, allowing the parent to demonstrate knowledge. With education and proper understanding of the condition, the parent may consent to the necessary treatment 3. Preferred healing practices are an important aspect of spiritual assessment; however, the priorities are to obtain parental consent for and initiate necessary treatment. Spiritual and cultural elements may be appropriate to include after physical needs (eg, IV antibiotics) are met. 4. Although true, this statement is inflammatory and would likely cause the situation to deteriorate, possibly leading to total refusal of care by the parent. It is most effective and important to respectfully assess parental knowledge and educate parents to obtain consent.

The nurse in the emergency department is assessing telemetry strips for assigned clients. Which client tracing is a priority for the nurse to assess? 1. Atrial fibrillation 2. First-degree heart block 3. ST-segment elevation 4. Premature ventricular contraction

1. Atrial fibrillation is characterized by an irregularly irregular rhythm with P waves replaced by fibrillatory waves, resulting in ineffective atrial contraction. Clients are at increased risk for clot formation (long-term), which can cause a stroke or pulmonary embolism; however, signs of cardiac injury take priority. 2. First-degree heart block is characterized by a prolonged PR interval. Clients are usually asymptomatic and do not require immediate assessment. 3. CORRECT: An ST-segment elevation myocardial infarction (STEMI) occurs when at least one of the coronary arteries is completely occluded. The ST segment is the portion of the ECG between the QRS complex and the T wave. Prompt treatment (eg, percutaneous coronary intervention, thrombolytics) is needed to restore myocardial oxygen supply and limit myocardial damage. 4. Premature ventricular contractions are early contractions of the ventricles that originate from an ectopic focus and result in a wide, distorted QRS complex. They are usually not harmful and can occur as a response to stimulants (eg, caffeine, nicotine, alcohol) or electrolyte imbalances.

A nurse is teaching an inservice regarding prevention of venous thromboembolism. Which nursing interventions should be included in the teaching? Select all that apply. 1. Administer scheduled anticoagulants 2. Apply sequential compression devices 3. Elevate the legs with pillows behind the knees 4. Have clients ambulate regularly as tolerated 5. Instruct clients to point and flex the feet in bed

1. CORRECT: Administration of anticoagulants (eg, enoxaparin), usually prescribed in clients with a moderate or high risk of VTE (eg, postsurgical) unless contraindicated (eg, active bleeding) 2. CORRECT: Application of compression devices or antiembolism stockings to limit venous stasis 3. Elevating the legs while in bed promotes venous return by gravity. However, the nurse should ensure that any pillows used to elevate the legs do not place pressure directly behind the knees, as pressure on the posterior knees compresses leg veins. Clients should also avoid crossing the legs to prevent pressure on the back of the knees. 4. CORRECT: Frequent ambulation, 4-6 times daily as tolerated, to improve circulation and promote venous return 5. CORRECT: Foot and leg exercises (eg, extend and flex the feet and knees) to promote venous return by activating calf muscles

A new nurse is providing hospice care for a terminally ill client who reports dyspnea. Which intervention would cause the charge nurse to intervene? 1. Administering oxygen via a nonrebreather mask 2. Administering prescribed morphine PRN 3. Providing a portable fan to improve air flow in the room 4. Providing relaxation strategies such as music and guided imagery

1. CORRECT: Nonrebreather masks are used to deliver high concentrations of oxygen in emergency situations. They require a tight face seal, which is uncomfortable and may cause claustrophobia and increased anxiety. High-flow oxygen can paradoxically decrease respiratory drive and cause carbon dioxide retention, further worsening the perception of dyspnea. 2, 3, 4. Terminally ill clients often experience dyspnea (air hunger). Initial interventions to reduce the perception of dyspnea include administering prescribed opioids to decrease respiratory effort, providing low-flow oxygen by nasal cannula, implementing comfort measures, and relieving anxiety.

The nurse is preparing to administer insulin lispro at 1700 to a client with type 1 diabetes mellitus whose blood glucose level was 245 mg/dL at 1645. During what time frame is the client at highest risk for hypoglycemia? 1. 1730-2000 2. 1900-2200 3. 2000-0700 4. 2100-0500

1. CORRECT: Rapid-acting insulins (eg, aspart, lispro) peak quickly, often within 30 minutes to 3 hours of administration. Therefore, the client who receives insulin lispro at 1700 is at highest risk for hypoglycemia from 1730-2000 2. Insulin glargine is a long-acting insulin that does not have a peak effect. The peak effect of regular insulin, which is short acting, is 2-5 hours. Clients who receive regular insulin at 1700 would be most at risk for hypoglycemia from 1900-2200. 3. Insulin detemir, a long-acting insulin, takes peak effect in 3-14 hours. Clients who receive insulin detemir at 1700 would be most at risk for hypoglycemia from 2000-0700. 4. Insulin NPH, an intermediate-acting insulin, takes peak effect in 4-12 hours. Clients who receive insulin NPH at 1700 are most at risk for hypoglycemia from 2100-0500.

The nurse is caring for an African American client with disseminated intravascular coagulation. Which locations are best to assess for the presence of petechiae? 1. Buccal mucosae and conjunctivae of the eyes 2. Nail beds of the fingers and toes 3. Palms of the hands and soles of the feet 4. Skin over the sacrum and behind the heels

1. CORRECT: Skin assessment of dark-skinned clients can be challenging as dark pigmentation makes it difficult to detect color changes. To best assess for petechiae in a dark-skinned client, the nurse should observe the buccal mucosae or conjunctivae. 2. The nail bed of the finger is the best location to assess dark-skinned clients for cyanosis, a blue discoloration that may occur with hypoxemia (ie, decreased blood oxygen). Petechiae generally do not occur in the nail bed. 3. The palms of the hands and soles of the feet are ideal locations for assessing other skin color changes that may occur in dark-skinned clients, such as jaundice (ie, yellowing of the skin due to increased bilirubin in the blood). However, these are not ideal locations to assess for petechiae in a dark-skinned client. 4. Over the sacrum and behind the heels are common locations for pressure injury formation; skin here typically appears dark, especially in dark-skinned clients.

The health care provider has explained the risks and benefits of a planned surgical procedure and asks the nurse to witness the client's signature on the consent form. Which situation would affect the legitimacy of the signature? 1. Client asks whether a blood transfusion will be required during surgery 2. Client expresses a fear of postoperative pain 3. Client received a dose of hydrocodone for pain 12 hours ago 4. Client wishes to wait to sign the consent until the spouse is present

1. CORRECT: To provide informed consent, a client must be a mentally competent adult; understand the explained procedure, risks, benefits, and alternatives; and sign voluntarily without coercion. Before witnessing a client's signature, the nurse should ensure that the client meets these criteria. A client question regarding the need for a blood transfusion during surgery indicates an incomplete understanding of risk and would invalidate the signature 2. Fears about the recovery process do not indicate confusion about the procedure itself. Fear about postoperative pain is an opportunity for the nurse to provide teaching and emotional support. 3. Narcotics and other medications (eg, some antiemetics) can cause sedation and impairment. The client can provide informed consent only after the effects of sedating medications have worn off. The duration of action for hydrocodone is 4-6 hours; a client who received a dose 12 hours ago would no longer be impaired from the medication. 4. Many clients wish to have family members present during the preoperative period to offer emotional support. The need for family presence does not invalidate an informed consent signature unless clients are mentally incompetent and require a legal next of kin to make medical decisions on their behalf.

The nurse reinforces teaching to a client recently diagnosed with urge incontinence. Which of the following client statements about self-management strategies indicate that teaching has been effective? Select all that apply. 1. "I drink diet cola with meals because it contains fewer calories than regular soda." 2. "I have an appointment with a nutritionist to help me manage my diet so that I can lose my excess weight." 3. "I joined a smoking cessation support group at the community center." 4. "I plan to do my daily Kegel exercises when I am riding the train to and from work." 5. "I will make sure to urinate every 2 hours to reduce urgency and have fewer accidents."

1. Clients with UI should avoid bladder irritants such as drinks that contain caffeine and artificial sweeteners because these ingredients can exacerbate UI symptoms 2. CORRECT: Losing excess weight to reduce pressure on the pelvic floor 3. CORRECT: Avoiding dietary bladder irritants (eg, caffeine, nicotine, artificial sweeteners, citrus juices, alcohol, carbonated drinks) 4. CORRECT: Performing pelvic floor exercises (eg, Kegel) to strengthen the pelvic muscles and help prevent urinary leakage 5. CORRECT: Using bladder training, such as voiding every 2 hours while awake and gradually lengthening the intervals between voiding

The nurse is reinforcing education with a client with Marfan syndrome who is recovering from an aortic root repair and mechanical aortic valve replacement via sternotomy and is prescribed warfarin. Which of the following statements by the client indicate appropriate understanding of teaching? Select all that apply. 1. "Because I have a mechanical valve, I will not need antibiotics for dental procedures." 2. "I will have to have my spouse lift and carry heavy objects for me for several months." 3. "I will need to take the prescribed warfarin for the rest of my life." 4. "If I gain 3 lb (1.36 kg) or more in a week, I will need to tell my health care provider." 5. "My usual razor blades will need to be replaced with an electric shaver."

1. Clients with mechanical heart valves are at high risk for infective endocarditis because bacteria can adhere to and proliferate on components of the valve. The client should receive prophylactic antibiotics before invasive respiratory and dental procedures, including routine dental cleanings 2, 3, 4, 5. CORRECT: The client should avoid lifting heavy objects to prevent disruption of the sternotomy sutures/wires. Anticoagulant therapy (eg, warfarin) will be needed for life after a mechanical valve replacement to prevent thromboembolic events (eg, stroke) and valve thrombosis. Signs and symptoms of heart failure (eg, weight gain ≥3 lb in a week) should be reported immediately because they may indicate valve failure. Bleeding precautions (eg, using an electric shaver) should be initiated because anticoagulant therapy increases the risk of uncontrolled bleeding.

A nurse in the cardiac intensive care unit receives report on 4 clients. Which client should the nurse assess first? 1. Client 2 months post heart transplant with sustained sinus tachycardia of 110/min at rest 2. Client 3 hours post coronary artery stent placement via femoral approach and reporting severe back pain 3. Client receiving IV antibiotics for infective endocarditis with a temperature of 101.5 F (38.6 C) 4. Client who had coronary bypass graft surgery 3 days ago and has swelling in the leg used for the donor graft

1. During a heart transplant, the donor heart is cut off from the autonomic nervous system (denervated), which alters the heart rate during rest and exercise after the transplant. The transplanted heart is expected to be tachycardic (eg, 90-110/min). 2. CORRECT: Percutaneous coronary intervention via the femoral approach places the client at increased risk for retroperitoneal hemorrhage, which is exacerbated by anticoagulants. Back pain, hypotension, flank ecchymosis (Grey-Turner sign), hematoma formation, and diminished distal pulses can be early signs of bleeding into the retroperitoneal space and require immediate intervention. 3. Infective endocarditis is often associated with cardiac valve disease and requires long-term antibiotic therapy (4-6 weeks). Characteristic manifestations include fever, myalgia, chills, joint pain, anorexia, and petechiae. 4. Some clients notice swelling in the leg used for donor venous graft (interruption of blood flow). Elevating the leg and wearing compression stockings can help decrease symptoms.

The primary nurse is preparing a client with atrial fibrillation for scheduled cardioversion. What action by the primary nurse requires the charge nurse to intervene? 1. Assembles equipment and obtains a prescription for preprocedural IV sedation 2. Ensures that defibrillator is programmed as prescribed and synchronize function is off 3. Uses clippers to remove the client's chest hair prior to placing defibrillation pads 4. Verifies that the client has provided informed consent and that documentation is signed

1. During nonemergency cardioversion of a hemodynamically stable client, a sedative (eg, midazolam) is often administered for client comfort. 2. CORRECT: Synchronized cardioversion uses a specifically timed, low-energy electrical impulse to momentarily disrupt the electrical cardiac cycle and "reset" the heart to a slower, regular rhythm. Tachyarrhythmias (eg, atrial fibrillation or flutter) with a pulse may be managed with cardioversion. Cardioversion requires the defibrillator's synchronize function to be activated so that the shock is delivered during the R wave. Failing to enable the synchronize feature may result in delivery of a potentially lethal, asynchronous shock. 3. Removing chest hair and ensuring that the chest is clean and dry improves defibrillator pad adherence. 4. If the cardioversion is elective and not an emergency, the client should sign a consent form. The nurse can assist with preparing the form and witnessing the client's signature.

A nurse hears various alarms sounding from different client rooms. Which alarm will the nurse address first? 1. Distal occlusion alarm on an infusion pump infusing heparin 2. Low-pressure limit alarm on a ventilator 3. Monitor alarm for a low respiratory rate of 11 breaths/min 4. Occlusion alarm on a continuous enteral feeding pump

1. Heparin is used to treat thromboembolic conditions (eg, pulmonary embolism); however, a brief interruption is not life-threatening. A distal occlusion alarm indicates that there is an obstruction to the flow of medication that occurs distal to the infusion pump (eg, between the infusion pump and the client). Causes include infiltration, clotting, displaced IV catheter, kinked tubing, and/or client positioning. 2. CORRECT: A low-pressure limit alarm on the ventilator is triggered when the amount of positive pressure necessary to deliver a breath to the client is decreased. A decrease in resistance to airflow occurs due to complications that arise in the client (eg, loss of airway), artificial airway (eg, cuff leak), and/or ventilator system (eg, tubing disconnect). All of these conditions impair airway and ventilation; therefore, addressing this alarm is the highest priority 3. The client with a low respiratory rate alarm should be assessed second. A low respiratory rate alarm may be caused by client factors (eg, sedation, shallow breathing) or equipment error (eg, malposition of ECG leads). 4. An occlusion alarm on the enteral feeding pump requires intervention, however; this is not a priority action. Possible causes include kinked tubing, food or medication blockage, or client positioning.

A nurse is preparing to administer a unit of packed red blood cells to a client with hemoglobin of 7 g/dL (70 g/L). The unit secretary retrieved the blood 25 minutes ago. When entering the client's room, the nurse notes that the client's IV is not patent and is unsuccessful at inserting the new IV. What should the nurse do next? 1. Have another nurse attempt to restart the IV 2. Notify the health care provider of the delay 3. Place the blood in the unit refrigerator 4. Return the blood to the blood bank

1. It is reasonable for the nurse or another nurse to attempt to restart the IV. However, this takes time, so the blood should be returned to the blood bank first. 2. If the client has symptoms related to the low hemoglobin level (<11.7 g/dL in female and <13.2 g/dL in male clients), such as low blood pressure, the HCP should be notified. This would occur after the blood is sent back to the blood bank and attempts to restart the IV have occurred. 3. Blood products should not be placed in the unit refrigerator as the temperature cannot be precisely regulated. 4. CORRECT: Blood products should not be left at room temperature for >30 minutes before a transfusion is started. Leaving blood out at room temperature for a prolonged period increases the likelihood of bacterial growth. If the start of the transfusion is delayed, the blood should be returned to the blood bank, where it can be refrigerated at a precise temperature

The nurse prepares to administer potassium chloride to a client through a peripherally inserted IV line. What are the appropriate nursing interventions related to administration of this medication? Select all that apply. 1. Administer as IV bolus 2. Assess IV site frequently 3. Assess renal function laboratory results and urine output 4. Place client on cardiac monitor 5. Verify that IV pump infusion is not >10 mEq/hr (10 mmol/hr)

1. KCl is never administered by IV push or as a fluid bolus. KCl is always diluted and given via infusion pump. 2. CORRECT: Potassium is a vesicant; therefore, the IV insertion site should be monitored frequently for extravasation to prevent tissue necrosis 3. CORRECT: Renal function should be assessed as clients with impaired renal function are unable to excrete potassium and other electrolytes effectively, potentially leading to toxicity. To assess renal function, the nurse should monitor renal function laboratory results (eg, blood urea nitrogen, creatinine) and urine output 4. CORRECT: Clients receiving KCl IV should have periodic cardiac monitoring during therapy, as changes in potassium levels can cause cardiac rhythm disturbances and rapid infusion can cause cardiac arrest 5. CORRECT: The maximum infusion rate of KCl through a peripheral line is 10 mEq/hr (10 mmol/hr) and the maximum concentration is 40 mEq/L (40 mmol/L). Higher rates and concentrations require a CVC

The health care provider (HCP) prepares to place a fetal scalp electrode (FSE) to monitor the fetus of a laboring client. Which information is most important for the nurse to communicate to the HCP before FSE placement? 1. Amniotic fluid is meconium stained 2. Client is HIV positive 3. External fetal monitor shows late decelerations 4. Fetal presenting part is at +1 station

1. Meconium-stained amniotic fluid may indicate fetal distress but is not a contraindication to FSE placement. 2. CORRECT: Placement of a fetal scalp electrode may be necessary when strict, continuous fetal heart rate monitoring is required. The nurse should be aware of the client's cervical dilation (≥2-3 cm), membrane status, and history of bloodborne infections (eg, hepatitis B, HIV) prior to electrode placement. 3. Late decelerations suggest impaired fetal oxygenation and are an indication for FSE placement. 4. It is helpful if the fetal presenting part is engaged (ie, 0, +1, or +2 station) to facilitate proper placement, but it is not required.

The nurse assists with medication reconciliation for a client visiting the clinic for a follow-up appointment. Which medication reported by the client requires further investigation? Click the exhibit button for additional information. Medical health history: hypertension, coronary artery disease, chronic stable angina Surgical health history: Coronary artery bypass with stent 1. 0.3 mg of nitroglycerin sublingual PRN 2. 10 mg of ezetimibe PO once daily 3. 20 mg of lisinopril PO once daily 4. 200 mg of celecoxib PO once daily

1. Sublingual nitroglycerin may be prescribed to alleviate an exacerbation of acute angina in a client with a history of chronic stable angina. Nitrates promote coronary vasodilation, thereby improving blood flow and relieving ischemic chest pain. 2. Ezetimibe inhibits cholesterol absorption from the small intestine, which reduces the risk of atherosclerosis and helps to treat coronary artery disease 3. ACE inhibitors (eg, lisinopril, enalapril, captopril) are prescribed to treat hypertension. These medications interfere with the conversion of angiotensin I to angiotensin II, which lowers blood pressure by reducing vasoconstriction and promoting sodium excretion. ACE inhibitors 4. CORRECT: NSAIDs (eg, naproxen, ibuprofen, celecoxib) are used for their analgesic, antipyretic, and anti-inflammatory properties. However, they increase the risk of thrombotic events (eg, myocardial infarction [MI], stroke), especially in clients with cardiovascular disease (eg, coronary artery disease). The nurse should investigate why a client with a history of cardiovascular disease is taking an NSAID and alert the HCP of its use

A client with type 1 diabetes has prescriptions for NPH insulin and regular insulin. At 7:30 AM, the client's blood glucose level is 322 mg/dL (17.9 mmol/L), and the client's breakfast tray has arrived. What action should the nurse take? Click on the exhibit button for additional information. 1. Administer 25 units of NPH insulin now and then 12 units of regular insulin after the morning meal 2. Administer 37 units of insulin: 25 units of NPH insulin and 12 units of regular insulin in 2 separate injections 3. Administer 37 units of insulin: 25 units of NPH mixed with 12 units of regular insulin in the same syringe, drawing up the NPH into the syringe first 4. Administer 37 units of insulin: 25 units of NPH mixed with 12 units of regular insulin in the same syringe, drawing up the regular insulin first

1. The two insulins can be safely given together before the meal as regular insulin has a rapid onset of action, whereas NPH has a slower onset but longer duration. 2. The insulins can be given as two separate injections; however, this increases client discomfort and infection risk. 3. Regular insulin should be drawn up first to avoid contaminating the regular insulin vial with NPH insulin (mnemonic - RN: Regular before NPH). 4. CORRECT: NPH insulin and regular insulin may be safely mixed and administered as a single injection. Regular insulin should be drawn into the syringe before intermediate-acting insulin to avoid cross-contaminating multidose vials (mnemonic - RN: Regular before NPH).

The nurse on the antepartum unit is performing shift assessments of several pregnant clients. Which client assessment is the priority to report to the health care provider? 1. Client with gestational diabetes mellitus reporting dysuria 2. Client with hyperemesis gravidarum with a blood pressure of 90/48 mm Hg 3. Client with oligohydramnios and a reactive fetal nonstress test 4. Client with preeclampsia with 3+ reflexes and 2 beats of clonus

1. Clients with gestational diabetes mellitus are more susceptible to infection (eg, urinary tract infection, vaginal yeast infection). Although the client's report of dysuria may indicate a urinary tract infection, the assessment findings do not indicate immediate risk. 2. Hyperemesis gravidarum usually affects clients in the first trimester and is characterized by severe nausea and vomiting that can lead to dehydration, hypotension, electrolyte imbalances, and nutritional deficits. This client should be assessed for further symptoms of hypotension (eg, dizziness, blurry vision) before notifying the HCP 3. Oligohydramnios indicates low amniotic fluid, which may lead to umbilical cord compression and fetal compromise. However, a reactive nonstress test is a reassuring finding. 4. CORRECT: Clients with preeclampsia are at risk for developing preeclampsia-associated seizure activity (eg, ECLAMPSIA) as a result of increased central nervous system irritability. The presence of NEUROLOGIC MANIFESTATIONS (eg, HYPERREFLECIA, clonus) may indicate worsening preeclampsia and can precede SEIZURE ACTIVITY . This client is at the most immediate risk of harm and is the priority to report to the HCP. To assess for CLONUS, the nurse firmly dorsiflexes the foot with 1 hand while supporting the leg and ankle with the other hand. The abnormal finding of positive clonus is identified when RHYTHMIC, JERKING "BEATS" OF THE FOOT are present as the foot is released and allowed to fall back into plantar flexion.

The nurse helps a client with end-stage renal disease and a serum potassium level of 5.2 mEq/L (5.2 mmol/L) to plan menu choices. Which items would be best to include in the meal plan? 1. Black beans and rice, sliced tomatoes, half a cantaloupe 2. Grilled chicken sandwich on white bread, applesauce 3. Hamburger patty on whole wheat bun, carrot sticks, chocolate pudding 4. Poached salmon, green peas, baked potato, strawberries

2. CORRECT: The kidneys' ability to excrete potassium is compromised in clients with end-stage renal disease. These clients should avoid foods high in potassium (eg, green leafy and cruciferous vegetables; legumes; melons; bananas; strawberries; milk and milk products; most beef, fish, and shellfish; and whole grains) to maintain normal serum potassium levels

The nurse is preparing to don sterile gloves before suctioning a client's tracheostomy. Place the steps of donning sterile gloves in the correct order. All options must be used. 1. Open the inner glove package by folding back the edges 2. Perform hand hygiene, and remove the outer glove package.. 3. Place dominant hand fingers under cuff on outside of nondominant glove. 4. Pull on dominant hand glove. 5. Pull on nondominant hand glove. 6. Use nondominant hand to grasp cuff on inside of dominant hand glove.

2. Perform hand hygiene, and remove the outer glove package.. 1. Open the inner glove package by folding back the edges 6. Use nondominant hand to grasp cuff on inside of dominant hand glove. 3. Place dominant hand fingers under cuff on outside of nondominant glove. 4. Pull on dominant hand glove. 5. Pull on nondominant hand glove.

The nurse is preparing to administer a continuous dopamine infusion at 5 mcg/kg/min. The client weighs 187 lb and the available medication contains 400 mg of dopamine in 250 mL of D5W. At what rate in milliliters per hour (mL/hr) should the nurse program the infusion pump? Record the answer using a whole number.

16 Prescribed = 5mcg dopamine / kg & min Available = 400 mg dopamine / 250 mL Required = mL / hr (5 mcg dopamine / kg & min) --> (60 min / hr) --> (kg / 2.2 lbs) --> (187 lbs / ___ ) --> (mg dopamine / 1000 mcg dopamine) --> (250 mL / 400 mg dopamine) = 15.93 mL dopamine /hr

The nurse is caring for an adult client who is in soft wrist restraints. Which nursing actions should be included in the plan of care? Select all that apply. 1. Offer fluids, nutrition, and toileting every 2 hours and as needed 2. Perform neurovascular assessment every hour 3. Reassess client's continued need for restraints every 12 hours 4. Release restraints to perform range of motion exercises every 2 hours 5. Remove restraints for a trial discontinuation every 4 hours

1, 2, 4. CORRECT: Facilities may determine the frequency of client monitoring; however, general guidelines include: performing hourly neurovascular checks (eg, pulses, color, skin temperature, sensation, movement), briefly releasing restraints for skin integrity assessment and range of motion exercises every 2 hours, and offering fluids, nutrition, and toileting every 2 hours and as needed 3. Restraints should be a last resort and discontinued as soon as possible. The nurse should regularly reassess (eg, every hour) the client's continued need for restraints. 5. Once restraints are discontinued, a new prescription is required to reapply them. Trial discontinuations are not permitted.

The nurse is performing a medication reconciliation during a clinic visit with a client recently prescribed lithium. Which of the client's home medications is the priority to clarify with the health care provider? 1. Acetaminophen 2. Hydrochlorothiazide 3. Metformin 4. Sulfadiazine

1, 4. Acetaminophen and sulfa antibiotics (eg, sulfadiazine) do not interact with lithium and are safe for the client to take. 2. CORRECT: Lithium is a mood stabilizer used to treat bipolar affective disorders. Medications such as thiazide diuretics, nonsteroidal anti-inflammatory drugs, and antidepressants can cause elevated lithium levels, which increases the risk of toxicity. 3. Lithium levels are not affected by antidiabetic medications such as metformin; however, lithium has been known to increase serum glucose levels. This may necessitate a dose adjustment of the antidiabetic medications. The client's blood glucose should be monitored, but this effect is not the most concerning at this time.

The nurse is caring for a client with tracheal cancer. At 9:00 PM, an on-call health care provider (HCP) rounds on the client and is alarmed to find the client bradypneic, hypotensive, and somnolent. The HCP requests that the nurse give the client naloxone. Which of the following is the best action by the nurse? Progress Notes: - 1300 Palliative care HCP progress notes: Efforts to shrink tumor unsuccessful. Family conference held with client regarding poor prognosis and quality of life. Client desires to receive comfort measures only. Code status changed to do not resuscitate - 1905 Nurse shift assessment: Client groaning, drooling, dyspnea, respiratory rate 29, wheezes and stridor on auscultation, pain 9/10 Medications: - Lorazepam: 2-4 mg IVP, q2h PRN for agitation and nausea - Morphine sulfate: 1 mg/mL IVPB, titrate dose every 5 minutes as needed for pain and dyspnea (continuous) - Scopolamine: 1.5 mg transdermal q72h (2100) 1. Approach the client's family to discuss whether to give naloxone in light of the client's wishes 2. Call the palliative HCP who prescribed the morphine sulfate to discuss the change in prescription 3. Describe the client's assessment data and plan of care, and do not give naloxone 4. Place the morphine infusion on standby and obtain the naloxone prescription

1. The client and family already decided to withdraw treatment and pursue palliation; approaching the family about whether to intervene is inappropriate and may cause undue grief and guilt. 2. Before escalating the situation by calling the palliative HCP, the nurse should explain the client's status and wishes. If the on-call HCP insists that naloxone be given, the nurse should notify the charge nurse or supervisor. 3. CORRECT: Clients at the end of life should be relieved of pain and discomfort according to the ethical principles of beneficence (doing good) and nonmaleficence (doing no harm). As a client advocate, the nurse should be actively involved in ensuring that unwanted or unwarranted treatment and client suffering are minimal. The client has requested a natural death without resuscitative efforts. Other HCPs (eg, on-call HCPs) may be unaware of the client's status or recent changes to the plan of care; therefore, the nurse should inform the on-call HCP of the changes and should not give the naloxone 4. Naloxone rapidly reverses the effects of opioid medications (eg, morphine). The resulting pain and discomfort for this client oppose nursing standards of care, violate the client's wishes, and are harmful to the client.

The nurse is performing a home visit for a child with cystic fibrosis who had a percutaneous endoscopic gastrostomy (PEG) tube placed 6 weeks ago. During inspection of the PEG tube, the nurse should correctly recognize which finding as expected? 1. External gastrostomy tube bumper is secured tightly to, and pressing against, the skin 2. Gastrostomy tube movement of 0.2 in (0.5 cm) is noted when the client coughs 3. Increased amounts of red, bumpy tissue are near the stoma compared to previous assessment 4. Resistance is felt when rotating the tube during cleaning

1. The external gastrostomy tube bumper should always rest loosely above the skin. Bumpers that tightly press against the abdomen promote tissue breakdown from pressure and friction. 2. CORRECT: An expected finding that indicates appropriate device function is slight in-and-out movement of the PEG tube (ie, ≤0.25 in [≤ 0.6 cm]), especially when coughing. PEG tubes are secured loosely against the skin, which allows the tube to move, thereby preventing device-related pressure injuries. 3. Granulation tissue (ie, red or pink skin with a bumpy texture) is an expected finding near the stoma and indicates wound healing. However, large or increasing amounts indicate abnormal healing or injury to the stoma. 4. Resistance when rotating a PEG tube often indicates adherence of the device to underlying tissues, which requires surgical revision of the device by the health care provider.

The nurse precepting a graduate nurse (GN) reviews age-related changes that increase older adult clients' risk for respiratory infections. Which of the following statements by the GN indicate a correct understanding? Select all that apply. 1. "The ability to cough forcefully decreases." 2. "The chest wall may become less flexible." 3. "The immune system response is diminished." 4. "The mucous membranes become drier." 5. "The number and motility of cilia decrease."

ALL CORRECT: With aging, mucus becomes thicker and more difficult to clear because the mucous membranes produce and secrete less mucus. Costal cartilage becomes calcified, reducing lung compliance and expansion. The respiratory muscles become weaker and the cough is less forceful. The number of respiratory cilia is decreased, and they become less effective in their brushing motion. All these changes reduce the body's ability to clear mucus and pathogens. The immune system of older adults is also diminished as the function and quality of lymphocytes (ie, T cells, B cells) are altered and respiratory defenses (eg, mucus clearance) are impaired. The older adult's dry mucous membranes are also more vulnerable to respiratory pathogens and infection.

A 2-month-old infant is admitted with respiratory syncytial virus and bronchiolitis. Which interventions would the nurse anticipate? Select all that apply. 1. Administer antipyretics 2. Initiate IV fluids 3. Keep the head of the bed flat 4. Maintain isolation precautions 5. Suction as needed

1, 2, 4, 5. CORRECT: Interventions for severe RSV infection are supportive, including providing supplemental oxygen and suctioning to support oxygen exchange and clear the airway, elevating the head of the bed to improve diaphragmatic expansion and promote secretion clearance, administering antipyretics to reduce fever and provide comfort, and initiating IV fluids to correct dehydration due to fever, tachypnea, or poor oral intake. RSV is transmitted via direct contact with respiratory secretions. Contact isolation is required, and droplet precautions are added if within 3 ft (0.91 m) of the client, depending on facility policy.

A client with emphysema arrives at the clinic for a routine follow-up visit. Which manifestations are characteristic of emphysema? Select all that apply. 1. Activity intolerance 2. Barrel chest 3. Hyperresonance on percussion 4. Stridor 5. Tracheal deviation

1, 2, 3. CORRECT: Emphysema is characterized by alveolar wall destruction. Lung tissues lose elasticity (recoil) due to permanently enlarged, "floppy" alveoli. This causes hyperinflation of the lungs (air trapping), manifested by hyperresonance on percussion and prolonged expiration. Hyperinflation of the lungs causes the client to develop a barrel-shaped chest. Hyperinflated lungs also prevent the client from meeting oxygen demands during increased activity, leading to activity intolerance and anxiety Pursed lip breathing ("puffing"), accessory muscle use, and the tripod position (leaning forward with hands on the knees) are seen during exertion and as the disease progresses. 4. Stridor (harsh, high-pitched breathing) is due to obstruction or constriction of the large (upper) airway (eg, aspiration of a foreign object, anaphylaxis, epiglottitis). Stridor indicates life-threatening airway compromise and requires prompt intervention. It is not a manifestation of emphysema. 5. Tracheal deviation occurs with a tension pneumothorax, not emphysema. When an injury causes air to become trapped in the pleural space, intrapleural pressure increases and pushes on the heart and great vessels. This causes a mediastinal shift that manifests externally as tracheal deviation.

The nurse is caring for a client with a central venous catheter (CVC) who reports feeling nauseated and chilled. The nurse notes that the CVC insertion site is red and inflamed and that the client has a temperature of 102 F (38.8 C). Which new prescription from the health care provider should the nurse implement first? 1. Administer ondansetron 4 mg IV push PRN for nausea or vomiting 2. Document the occurrence and notify the hospital's epidemiology team 3. Initiate the first dose of IV piperacillin/tazobactam via a new peripheral IV 4. Obtain blood cultures and discontinue the central venous catheter

1, 2. Administering medications for comfort, completion of documentation, and facility-based report protocols should be done as soon as possible. However, to prevent progression to sepsis, treatment of a suspected CRBSI should not be delayed. 3. Initiation of antibiotics is essential in treating infection and preventing its progression. However, the nurse should first draw blood cultures and remove the CVC, if possible. 4. CORRECT: When caring for a client with signs of a central line-related bloodstream infection, the nurse should obtain blood cultures and remove the device, if possible, before beginning antibiotic therapy. Other nursing interventions (eg, symptom management, documentation) should be done after initiating treatment of the infection.

A nurse is reading a client's tuberculin skin test 48 hours after placement and notes an 11-mm area of induration. The client is a recent immigrant from Nigeria and reports no symptoms. Which actions would be appropriate by the nurse? Select all that apply. 1. Ask the client about a history of bacille Calmette-Guérin vaccine 2. Document the negative response in the client's medical record 3. Have the client return in a week to receive a second injection 4. Obtain a prescription for a chest x-ray from the health care provider 5. Place the client in droplet precautions and wear a surgical mask during care

1, 4. CORRECT: Prior administration of the bacille Calmette-Guérin vaccine can produce a false positive tuberculin skin test (purified protein derivative [PPD] reaction). Positive PPD reactions in clients who are asymptomatic need further evaluation with chest x-ray.

A client is receiving packed red blood cells intravenously through a double-lumen peripherally inserted central catheter (PICC) line. During the transfusion, the nurse receives a new prescription to begin amphotericin B IVPB. What is the nurse's best action? 1. Administer amphotericin B through the unused lumen of the PICC line 2. Insert a peripheral IV line to begin infusion of amphotericin B 3. Interrupt the blood transfusion to infuse amphotericin B, then resume after infusion 4. Wait 1 hour after transfusion finishes before administering amphotericin B

1, 2. Although starting a peripheral IV line or using the unused lumen of the peripherally inserted central catheter line would prevent mixing the drug with the blood products, it would not help distinguish the onset of potentially fatal sequela from either component 3. Transfusions should not be interrupted after initiation except in cases of transfusion-related reactions or fluid overload. In addition, interrupting and restarting transfusions increases the risk for infection. Blood products should be transfused within 4 hours of removal from refrigeration. 4. CORRECT: At least one hour should be allowed between completion of a blood transfusion and administration of amphotericin B. The adverse effects of a transfusion-related reaction and an adverse reaction from amphotericin B are similar, and the observation time allows the nurse to distinguish the triggering event if symptoms develop.

The nurse is reviewing client phone messages. Which client should the nurse call back first? 1. Client asking whether to take the morning dose of phenytoin before surgery the next day 2. Client taking dabigatran who reports heavier bleeding with her menstrual cycle 3. Client taking metronidazole who reports abdominal cramping and diarrhea 4. Client who has taken the last dose of insulin glargine and needs a refill

1. Missing a dose of phenytoin (Dilantin), an antiseizure medication, could precipitate seizure activity. The client should be instructed to take the medication as prescribed with a small sip of water; however, this client does not take priority over one with active bleeding. 2. CORRECT: Dabigatran (Pradaxa) is a thrombin inhibitor anticoagulant often prescribed to prevent thrombotic events in clients with atrial fibrillation, pulmonary embolism, and deep vein thrombosis. Clients taking dabigatran are at increased risk for bleeding and hemorrhage. Clients with signs of abnormal bleeding (eg, bruising; blood in the urine, sputum, vomitus, or stool; epistaxis; heavy menstrual bleeding [menorrhagia]) should be prioritized as prompt intervention and treatment may be required 3. Gastrointestinal upset is a common side effect of many antibiotics, including metronidazole (Flagyl). Abdominal discomfort may be relieved by taking the medication with food or a glass of milk. 4. This client requires a refill of insulin to prevent hyperglycemic episodes but is not a priority over a client with active bleeding. Glargine is long-acting insulin that works for 24 hours.

Which client situation would be classified as an adverse event, requiring the nurse to complete an incident report? Select all that apply. 1. Cerebrospinal fluid sample is sent to the laboratory labeled as a urine sample 2. Client who has a hemoglobin of 6 g/dL (60 g/L) refuses recommended blood products 3. Nurse does not report potassium result of 6.5 mEq/L (6.5 mmol/L) to health care provider 4. Postpartum client who is post epidural anesthesia falls while ambulating to the bathroom 5. Provider prescribes 5,000 units of heparin, nurse gives 1 mL (10,000 units/mL) of heparin

1, 3, 4, 5. CORRECT: Adverse events are unforeseen or unintended outcomes that result in harm, or have the potential to cause harm, and require the completion of incident reports. Examples of client incidents include falls, mislabeled laboratory specimens, medication administration errors, and communication errors. 2. Under the ethical principle of autonomy, the client has the right to refuse any recommended medical treatment, even if doing so could result in potential harm to the client.

A nurse is performing cardiopulmonary resuscitation (CPR) on an adult at a swimming pool. A bystander brings the automated external defibrillator (AED). The nurse notes that the victim is wet, lying in a small pool of water, and wearing a transdermal medication patch on the upper right chest. What is the most appropriate action at this time? 1. Do not use the AED and continue CPR until paramedics arrive 2. Move the client away from the pool of water before applying AED pads 3. Remove the transdermal patch and wipe the chest dry before using the AED 4. Wipe the chest dry and apply the AED pads over the transdermal patch

1. The AED is used as soon as it is available; its use should not be delayed. 2. The entire body does not need to be completely dry; the chest should be quickly wiped, as this is where the electrical current travels. The AED can still be used if the client is damp or lying in a small puddle of water. 3. CORRECT: An automated external defibrillator (AED) is used as soon as possible for improved outcomes. The chest should be clean and dry, and any medication patches should be removed before applying the AED pads 4. AED pads should not be placed over medication patches as this interferes with conduction and can burn the skin.