NCLEX Need to Know

How is acute otitis media treated?

with antibiotics (amoxicillin) --if symptoms do not clear up within 48-72 hours, follow-up with the HCP to determine if a different antibiotic is necessary

Describe school-age play

with others with a common goal at hand --cooperative play

How should the client be positioned when assessing for jugular venous distension?

with the HOB at 30-45 degree angle

What should you do if you have obtained pulsating blood when drawing labs?

withdraw the needle and apply pressure for 5 minutes ---pulsating bright red blood indicates that an artery was accessed

Define Duchenne muscular dystrophy

x-linked recessive disorders that causes progressive replacement of dystrophin with connective tissues

The nurse should plan to teach which client about the need for prophylatic antibiotics prior to dental procedures? -client who had a large anterior wall myocardial infarction with subsequent heart failure -client who had a mitral valvuloplasty repair -client with a mechanical aortic valve replacement -client with mitral valve prolapse with regurgitation

-client with a mechanical aortic valve replacement --Clients with any form of prosthetic material in their heart valves or who have unrepaired cyanotic congenital heart defect or prior history of IE should take prophylatic antibiotics prior to dental procedures to prevent development of IF

A nurse is screening clients at a community health event. Which of the following client statements should the nurse recognize as a warning sign of cancer? SATA -"for the past few years, I get a productive cough in the winter that goes away in spring" -"I occasionally have heartburn an hour after I eat fried foods and sausage" -"Last month when I was doing my breast self-examination, I noticed a marble-sized lump" -"My mole is itchy, and the borders have become uneven with a blackish to bluish color" -"Recently I have noticed that my bowel movements appear black"

-"Last month when I was doing my breast self-examination, I noticed a marble-sized lump" -"My mole is itchy, and the borders have become uneven with a blackish to bluish color" -"Recently I have noticed that my bowel movements appear black" -- A client report of occasional indigestion after specific triggers may indicate gastroesophageal reflux disease. However, indigestion that is persistent or chronic indigestion may indicate cancer.

The nurse is providing education to a 32-year-old female client diagnosed with human papillomavirus. Which client statement indicates a need for further instruction? -"I can transmit the virus when I don't have symptoms" -"I know the virus can be spread through oral sex" -"I need to have a Papanicolaou test on an annual basis" -"My partner won't get HPV as long as we use a condom"

-"My partner won't get HPV as long as we use a condom" --HPV is associated with genital warts and cervical cancer. Condoms used during sex decrease, but do not completely eliminate, the risk of transmission. Prevention includes vaccination against HPV, preferably before sexual activity begins, and safe sex practices.

Recommended criteria to consider when determining to call the rapid response team

--any provider worried about the condition of the client --or an acute change in any of the following: --- heart rate <40 or >90 mm Hg ---systolic blood pressure <90 mm Hg ---respiratory rate <8 or >28/min --- oxygen saturation <90 despite oxygen ---urine output <50 mL/4 hours ---level of consciousness

During assessment of a client with decerebrate posturing, what might be seen?

--arms and legs straight out --toes pointed down --head/neck arched back

What foods should a client with an ileostomy avoid?

--foods high in fiber (popcorn, coconut, brown rice, multigrain bread) -stringy vegetables (celery, broccoli, asparagus) -seeds or pits (strawberries, raspberries, olives) -Edible peels (apple slices, cucumber, dried fruit)

The steps to the modified Allen's test

--instruct the client to make a tight fist --occlude the radial and ulnar arteries using firm pressure --instruct the client to open the first; the palm will be white if both arteries are sufficiently occluded. --release the pressure on the ulnar artery; the palm should turn punk within 15 seconds as circulation is restored to the hand, indicating patency of the ulnar artery

Common symptoms of phenytoin drug-induced toxicity

--mainly involves the CNS -ataxia -nystagmus -slurred speech -decreased alertness

Significant adverse effects of dopamine includes

--tachycardia --dysrhythmias --myocardial ischemia

The nurse receives report on 4 clients. Which client should be seen first? -10-month-old with audible congestion and mucus-producing cough -10-year-old with an active nose bleed who is applying pressure -12-year-old with urinary frequency and burning, and fever -15-year-old with painful right hip, fever, and limited range of motion

-15-year-old with painful right hip, fever, and limited range of motion --This client is exhibiting localized and systemic infection symptoms, which may indicate septic arthritis. Possible causes include recent surgery, injections, trauma, or spread from adjacent infection. A septic hip is considered a surgical emergency. The hip joint is prone to develop avascular necrosis from compromised blood supply due to infection or injury. This can result in sequelae that are significant in both the short term and long term. Management includes culturing synovial fluid and blood, giving antibiotics, and debriding the infected joint.

What are examples of hypotonic crystalloid solutions?

-2.5% dextrose and water -0.45% NaCl

Language skills of 2 year old

-300+ words -forms phrases of 2-3 words -states own name

The nurse is making rounds on a medical-surgical floor. Which client should the nurse see first? -32 year old admitted for opioid withdrawal reporting severe generalized body pains -34 year old started on blood transfusion 10 minutes ago who reports chills, itching, and back pain -42 year old admitted with acute pyelonephritis who needs a first dose of IV antibiotics -67 year old admitted with hepatic encephalopathy who needs a first dose of lactulose

-34 year old started on blood transfusion 10 minutes ago who reports chills, itching, and back pain --acute transfusion reaction is a priority as it can be life-threatening if not immediately stopped and supportive care initiated. If untreated, hypotension, vascular collapse, respiratory distress, and DIC ensue quickly.

What angle should subcutaneous injections be administered?

-90 degreesif there are 2 inches of subcutaneous tissue to grasp --45 degrees if only 1 inch of subcutaneous tissue can be grasped

What is the scope of practice for a UAP?

-Activities of daily living -hygiene -linen change -routine, stable vital signs -documenting input/output -positioning

Classic S/S of Duchenne muscular dystrophy

-Gower maneuver (place hands on thighs to push up to stand) -enlarged calves -walking on tiptoes -frequent tripping/falling

S/S often experienced with myopia

-HA -dizziness -decreased school performance --people will often hold objects near their face

The pediatric nurse receives reports on 4 clients. Which client should the nurse see first? -a 2 month old awaiting evaluation for possible hip dislocation; parents are at the bedside -a 6 year old just returned from a bronchoscopy; a parent is at the bedside -a 7 year old just returned from a noncontrast abdominal CT scan; no parents are at the bedside -an 11 year old scheduled for ear surgery today; no parents are at the bedside

-a 6 year old just returned from a bronchoscopy; a parent is at the bedside --When deciding which client to see first, the nurse should apply the ABC's (airway, breathing, circulation) guideline to problems that clients may have or could develop

A nurse is admitting a child who has leukemia. Several rooms are available on the pediatric unit. Which client could share a room with this child? -a client recovering from a ruptured appendix -a client with cystic fibrosis -a client with minimal change nephrotic syndrome -a client with rheumatic fever

-a client with minimal change nephrotic syndrome --MCNS is a non-infectious condition of the glomeruli and poses no risk to a client with leukemia

What should the nurse provide a school-aged child when hospitalized?

-a daily schedule. Children at this age have a grasp on the concept of time.

Nurses performing negative-pressure wound therapy dressing changes should:

-administer prophylactic analgesics to prevent discomfort -apply a skin protectant to intact skin around the wound to promote an air0tight seal when the adhesive film dressing is placed -ensure negative pressure is present by observing the compression of the foam dressing when the device is turned on

5th stage of Erickson's developmental task --task

-adolescence --identity vs role diffusion

What are some potential complications of IV idoinated contrast?

-allergic reaction (premedication with corticosteroids or antihistamines) -lactic acidosis (discontinue metformin 24-48 hrs before and start 48 hours after to prevent acidosis) -contrast-induced nephropathy (can cause AKI in clients with renal impairment)

What support surfaces should be used to prevent pressure ulcers?

-alternating pressure -avoid donut-type devices and synthetic sheepskins -heel protection -mattress -overlay

S/S of hemolytic uremic syndrome

-anemia (pallor) -low platelets (petechiae; purpura0 -AKI (decreased U/O)

18 month growth and development

-anterior fontanelle usually closed -walks backward -climbs stairs -scribbles -builds 3-block tower -oral vocab is 10 or more words -great at mimicry

Drugs that increase warfarin effect (increases bleeding)

-antibiotics/antifungal agents -amiodarone -thyroid hormone -omeprazole -SSRI's -cranberry juice, ginkgo biloba, vitamin E

Nursing priority for a marked decrease in mediastinal chest tube drainage?

-assessment for cardiac tamponade S/S. --no S/S? troubleshoot and contact the doc.

The RN is caring for multiple clients on a medical-surgical unit and has finished the morning assessment. Which task is appropriate for the nurse to delegate to the UAP? -apply a collagenase dressing to a client's pressure ulcer for wound debridement -assist a client 1 day postoperative hip fracture repair to the bathroom -feed a client through a gastrostomy tube after elevating the head of the bed -offer orange juice to a client if the blood glucose level is <70 mg/dL

-assist a client 1 day postoperative hip fracture repair to the bathroom

The RN is working with UAP. Which task can the RN safely delegate to the UAP? -assisting a 2-day postoperative hip arthroplasty client with morning care -collecting a urine specimen for culture and sensitivity from a client with a Foley cath -initial change of colostomy bag for a client who is 1-day postoperative colostomy -refilling the empty enteral feeding container with tube feeding

-assisting a 2-day postoperative hip arthroplasty client with morning care

Social/cognitive skills of 3 year old

-associative play -toilet trained (except for wiping)

Steps to ascending the stairs with modified three-point gait

-assume the tripod position and place body weight on the crutches while preparing to move the unaffected leg -place the unaffected leg onto the good step -advance the affected leg and the crutches together up the step -realign the crutches with the unaffected leg on the step before repeating the process.

gross motor developmental milestones in 1 month old

-attempts to hold head up when in prone position

Ways to prevent lithium toxicity?

-avoid sodium depletion -eat regular diet -drink adequate fluids

Disease management of psoriasis involves

-avoidance of triggers: stress, trauma, infection -topical therapy: corticosteroids, moisturizers -phototherapy: UV lights -systemic medications: cytotoic and biologic agents

Key interventions for prevention of otitis media

-avoiding exposure to tobacco smoke -obtaining routine immunizations -discontinuing use of pacifier after 6 months of age

language developmental milestone for 6-9 month old

-babbles and imitates sounds -may say "mama" or "dada"

SE of methotrexate

-bone marrow suppression (results in anemia, leukopenia, thrombocytopenia) -hepatotoxicity (avoid alcohol) -GI irritation --avoid live vaccines, crowds, people with known infections

Major S/E of beta blockers

-bradycardia -bronchospasm -hypotension -depression -impotence

What are early indicators of increased ICP in children?

-bulging/tense fontanels -increased head circumference

The clinic nurse performs an admission assessment on a client diagnosed with systemic lupus erythematosus. Which characteristic cutaneous manifestation of SLE would the nurse most likely assess? -butterfly shaperash -petechiae -pruritus -urticaria

-butterfly shape rash ---The characteristic cutaneous manifestation of SLE is a flat or raised red rash that forms a butterfly shape accross the bridge of the nsoe and cheeks

The nurse is caring for a client admitted for a seizure disorder. The nurse witnesses the client having a tonic-clonic seizure with increasing salivation. Which actions should the nurse take? SATA -call for help -hold down the client's arm -insert a tongue depressor to move the tongue -preparing for suctioning -turn the client on the side

-call for help -preparing for suctioning -turn the client on the side --During an active seizure, the nurse should call for additional help, turn the client on the side if possible, and have suction equipment ready to clear any excessive secretions that may block the airway. However, during an active seizure it is dangerous to attempt to insert anything in the client's mouth, especially if the teeth are clenched. The client should not be restrained as this could cause an injury.

social/cognitive developmental milestone for 4-5 month old

-calmed by parents voice

What nutrition techniques should be used to prevent pressure ulcers?

-calorie counting (30-35 kcal/kg/day) -enteral nutrition -high-protein nutritional supplements -deficiency assessment

three month growth and development

-can hold rattle -head held erect and steady -follows objects to 180 degrees -smiles in mother's presence -laughs audibly

Clinical manifestations of hypovolemic shock

-change in LOC -tachycardia with thready pulse -cool,clammy skin -oliguria -tachypnea

What can cause neutropenia?

-chemotherapy -medications (clozapine, methimazole)

inclusion criteria for thrombolytic therapy in clients with acute MI

-chest pain less than 12 hours -EKG findings indicating acute ST-elevation -NO absolute contraindications

Steps to drawing up multiple insulins

-clean both vial tops with alcohol swabs -inject air into the NPH insulin vial without touching the needle to the solution -withdraw the needle from the NPH insulin vial and inject air into the regular insulin vial -invert the regular vial and withdraw the regular solution into the syringe -insert the needle into the NPH insulin vial and withdraw the solution

The nurse has just received shift report. Which client should be seen first? -client 1 day post-op abdominal aortic aneurysm repair who has hypoactive bowel sounds in all 4 quadrants -client 2 days post-op BKA who reports same-leg foot pain rated as 7 -client with DVT who is up to use the bathroom for the second time -client with Raynaud's phenomenon who reports throbbing, tingling, and swelling of fingers in both hands

-client 2 days post-op BKA who reports same-leg foot pain rated as 7 --The client with BKA is experiencing phantom limb pain, pain/tingling felt in a missing portion of a limb. It is real pain that many amputees experience immediately following surgery and that sometimes becomes chronic. --Because the bowels have been manipulated in AAA surgery, hypoactive sounds are common for several days afterwards

Nausea and vomiting in which client is of greatest concern to the nurse? -client postoperative ophthalmic surgery -client receiving chemotherapy -client with Meniere disease -client with severe gastroenteritis

-client postoperative ophthalmic surgery --Vomiting can cause an increase in intraocular pressure, damage to the blood vessels and retina, and potential permanent vision loss. Antiemetic medication is administered as needed following ophthalmic surgery to prevent vomiting

The nurse receives a report on the assigned clients for the shift. Which client should the nurse assess first? -1 day postoperative client with lower abdominal pain and no urine output for 6 hours -an elderly client with blood pressure 190/88 mm Hg who is asymptomatic -client with hepatitis C virus who has alanine aminotransferase/aspartate aminotransferase values 4 times the normal value -client who underwent thyroidectomy yesterday and now has positive Trousseau's sign

-client who underwent thyroidectomy yesterday and now has positive Trousseau's sign --Trousseau's sign indicates hypocalcemia. This is a known risk after a thyroidectomy as the parathyroid gland can be inadvertently removed during the surgery due to its very small size. Acute hypocalcemia can cause tetany, laryngeal stridor, seizures, and cardiac dysrhythmias. Assessing this client is a priority over pain or expected findings. --Client 1 likely has postoperative urinary retention and needs to be evaluated as soon as possible, but is not life-threatening.

which client should the nurse assess first? -client with A-fib with a new prescription for warfarin -client with COPD with an oxygen saturation of 91% -client with postoperative pain rated 8 out of 10 -client with 3rd degree heart block with a pulse of 42/min

-client with 3rd degree heart block with a pulse of 42/min

The charge nurse in an intensive care unit is rounding and reviewing hemodynamic data for clients in the unit. Which client requires immediate intervention? -client who is septic due to pneumonia with central venous pressure of 6 mm Hg -client who recently underwent a coronary artery bypass graft with cardiac output of 5 L/min -client with GI bleed and mean arterial pressure of 58 mm Hg -client with an adrenal gland tumor and blood pressure of 168/95 mm Hg

-client with GI bleed and mean arterial pressure of 58 mm Hg --MAP of at least 60 mm Hg is required to adequately perfuse vital organs; however, MAP >70 mm Hg is optimal. Without intervention, MAP <60 mm Hg may progress to tissue ischemia, organ damage, and death. CVP of 6 mm Hg and CO of 5 L/min are within normal limits. Blood pressure of 168/95 is an elevated reading requiring further assessment. However, low MAP is the highest priority due to the risk for tissue ischemia

The nurse is managing an assigned team. The following clients have family members reporting a concern. Which client should the nurse see first? -client who has a migraine is reporting 10/10 pain and nausea -client who is postictal after a seizure is drowsy and confused -client with ALS experiencing dysarthria -client with a GCS score of 9 is no longer responding when called

-client with a GCS score of 9 is no longer responding when called --Declining neurological status threatens the airway and breathing; therefore, the client with the GCS of 9 is the highest priority. A GCS score of 8 or lower is classified as a coma. Dysarthria is a typical symptom of ALS.

The charge nurse must assign a room for a client who was transferred from a long-term care facility and is scheduled for extensive surgical debridement to remove infected tissue from an unstageable pressure injury. Which room assignment is the most appropriate for this client? -client with multiple myeloma who is being treated with corticosteroids -client with diabetes mellitus and osteomyelitis receiving IV antibiotics -client with a GI bleed who has an NG tube -client with influenza with a high fever who is receiving oseltamivir

-client with a GI bleed who has an NG tube --the most appropriate room assignment is with a client who is least susceptible to infection.

CN IV

Trochlear

What precautions are used for measles?

airborne precautions (negative-pressure room; N95)

What does it mean if there is bubbling in the water seal chamber?

an air leak is present

Fine motor developmental milestone for 1 month old

maintains hands in fisted position

What is the gold standard for assessing ventilation?

measurement of forced vital capacity (FVE)

Define peak expiratory flow

measures how much air a person can exhale.. --expected to increase after treatment

Function of acetylcysteine

medication that can be inhaled to help loosen thick respiratory secretions

age appropriate toys for birth-2 months

mobiles 8-10 inches from face

How should levothyroxine be administered?

orally on an empty stomach (best absorbed this way)

A client is admitted to the ICU with diabetic ketoacidosis. The client is most likely to exhibit which of the following arterial blood gas results? --pH 7.26, PaCO2 56 mm Hg, HCO3 3 mEq/L --pH 7.30, PaCO2 30 mm Hg, HCO3 15 mEq/L --pH 7,40, PaCO2 40 mm Hg, HCO3 24 mEq/L --pH 7.58, PaCO2 48 mm Hg, HCO3 44 mEq/L

pH 7.30, PaCO2 30 mm Hg, HCO3 15 mEq/L --The arterial blood gas result most consistent with diabetic ketoacidosis is metabolic acidosis or partially compensated metabolic acidosis.

Mottling is characterized by...?

patches of pink, pale, and cyanotic skin --indicative of poor perfusion

Describe the aural phase of a seizure

period before the seizure when the client may experience visual or other sensory changes. Not all clients experience or can recognize a prodromal or aural phase before the seizure

Lansoprazole is what drug classification?

proton pump inhibitor --used to treat ulcer disease, erosive esophagitis, andgastroesopahgeal reflux disease.

What most often causes acute glomerulonephritis?

recent streptococcal infection

Define myopia

reduced visual acuity when viewing objects at a distance

What is phenytoin used to treat?

seizures

Manifestations of croup

stridor, a high-pitched inspiratory breath sound

Describe the acute phase of Kawasaki disease?

sudden onset of higher fever with no response to antibiotics/antipyretics --child is irritable; red/swollen feet/hands; swollen/cracked lips; red tongue

When a client is unable to make decision, who is legally able to make the decisions for the client?

the healthcare proxy.

What is the task associated with the first stage in Erickson's developmental tasks (infancy)?

trust vs. mistrust

Spinal accessory nerve assessment

turn head and lift shoulder to resistance

Optic nerve assessment

visual acuity and visual fields

The nurse is making assignments for the next shift. Which client should the nurse assign to the new nurse coming out of orientation? -client diagnosed with chronic anemia receiving iron via IV route -client newly admitted for uncontrolled diabetes mellitus type 2 with blood glucose >600 mg/dL -client undergoing ultrafiltration for congestive heart failure -client with a prescription for routine hemodialysis who has chronic renal failure

-client with a prescription for routine hemodialysis who has chronic renal failure

Which client is most appropriate for the charge nurse in the postpartum unit to assign to the float nurse from the ICU? -client experiencing fever and pain with mastitis -client preparing for discharge after cesarean birth -client showing disinterest in caring for the newborn -client with hysterectomy after postpartum hemorrhage

-client with hysterectomy after postpartum hemorrhage --the client with blood loss leading to a hysterectomy would require close observation of hemodynamic status. Signs could be subtle, and the nurse floating from ICU would have the assessment skills needed to recognize any changes.

Handoff report typically includes:

-clients name, location, age, gender, healthcare provider, and diagnoses -client's current baseline measurements, treatment plan, goals, and response to treatment -priority and outstanding tasks and changes from previous days

Factors increasing estrogen exposure and endometrial cancer risk includes:

-conditions associated with infrequent or anovulator menstrual cycles (polycystic ovary syndrome, infertility, late menopause, early menarche) -obesity -tamoxifen

The nurse is making follow-up phone calls to clients who had cataract surgery with intraocular lens implantation the previous day. The nurse receives which client report that requires priority intervention? -blurry vision in the affected eye -constipation -itching in the affected eye -sleeping on 2 pillows at night

-constipation --Following cataract surgery, the client should be instructed to avoid coughing, sneezing, lifting over 5 lbs, bending, rubbing the eye, or straining during bowel movements for several days to prevent increased intracocular pressure. IT is common for the client to experience itching, photophobia, and mild pain for several days following surgery

The registered nurse is providing nursing care with a licensed practical nurse and unlicensed assistive personnel. The RN administers hydromorphone 1.5 mg IVP per STAT order to a client with severe abdominal pain. Three hours later, the client rates pain as a 9 on a scale of 0-10 and requests pain medication What is the most appropriate action for the RN to take? -administer the hydromorphone -ask the licensed practical nurse to administer the medication -ask the unlicensed assistive personnel to take repeat vital signs -contact the healthcare provider

-contact the healthcare provider --A STAT order indicates that the medication should be given immediately and only one time. A new prescription for the medication must be acquired before the dose can be repeated. The most appropriate action is to contact the healthcare provider to request an as-needed prescription for pain medication

common SE of sulfasalazine

-crystalluria with kidney injury -yellow-orange skin and urine discoloration -photosensitivity -folic acid deficiency (take 1 mg/daily) -agranulocytosis -Stevens-Johnson syndrome (stop taking medication if rash develops)

indicators for treatment effectiveness for hospital acquired-pneumonia

-decreased WBC on CBC with differential -improvement of infiltrates on chest x-ray -improvement of oxygenation and S/S

Describe stage 3 (severe) stage of Alzheimer disease

-decreased mobility -dependent on others for ADLs -no recognition of self or previously familiar people -fragmented memory

What are the 4 types of medical management errors?

-diagnostic -treatment -preventive -other

common S/E of the varicella immunization

-discomfort -redness -vesicle at injection site

What might a low tidal volume alarm be caused by?

-disconnection -loose connection -leak

The nurse is caring for a client who needs an indwelling urinary catheter inserted for urinary retention. Which tasks would be appropriate to delegate to the UAP? SATA -document output from the urinary collection bag -hold adipose tissue out of the way during catheter insertion -monitor color of the urine after the nurse has assessed it -reinforce education about the purpose of the urinary catheter -secure the catheter to the client's thigh with an anchor

-document output from the urinary collection bag -hold adipose tissue out of the way during catheter insertion -secure the catheter to the client's thigh with an anchor

Major S/E of Angiotensin-Converting enzyme inhibitors (ACE-I)

-dry cough -hypotension -reflex tachycardia -hyperkalemia -angioedema

common SE of anticholinergic medications

-dry mouth -constipation -mild dizziness -pupillary dilation -urinary retention

Characteristics of enterocolitis

-explosive, foul-smelling diarrhea -fever -worsening abdominal distension

Pts with infective endocarditis often present with what type of symptoms?

-fever -arthralgias -weakness -fatigue

What are symptoms of Middle East respiratory syndrome (MERS)?

-fever -cough -SOA

Clinical manifestations of esophageal atresia and tracheoesophageal fistula

-frothy saliva -coughing -choking -drooling -distended abdomen --infant may develop apnea/cyanosis while feeding --the greatest risk is aspiration

Herbal supplements that increase bleeding

-gingko biloba -garlic -gingseng -ginger -feverfew

one month growth and development

-head lags -turns head side to side when prone -lifts head momentarily from bed

Long term complications of bacterial meningitis

-hearing loss -disabilities -brain damage

Fetal effects of syphilis during pregnancy

-hepatomegaly -jaundice -hemolytic anemia -decreased platelets -long bone abnormalities -failure to thrive

Fetal effects of syphilis

-hepatomegaly -jaundice -hemoytic anemia -decreased platelets -long bone abnormalities -failure to thrive

Nursing interventions for a blood transfusion reaction include

-immediately stopping transfusion and disconnecting tubing -maintain IV access with NS using new tubing -notify HCP and blood bank -monitor VS -recheck labels, numbers, and client's blood type -treat symptoms -collect blood and urine specimens to evaluate for hemolysis -return blood and tubing set to blood bank for additional testing -complete necessary facility paperwork

S/E of phenytoin

-increased body hair -rash -folic acid depletion -decreased bone density (osteoporosis) -gingival hyperplasia

Characteristics of primary open-angle glaucoma

-increased in intraocular pressure -gradual loss of peripheral vision (tunnel vision) --symptoms develop slowly

What are some risks associated with hormone replacement therapy?

-increased risk of thrombotic complications (DVT, stroke, MI) -cancer (breast and uterine)

to prevent air embolism when discontinuing a CVC, the nurse should:

-instruct the client to lie in a supine position to increase CVP and decrease the possibility of air getting into the vessel -instruct client to bear down or exhale. NEVER inhale -apply air-occlusive dressing to help prevent a delayed air embolism. =pull the line cautiously and never pull harder if there is resistance

positive outcome of 7th stage of Erickson's developmental tasks --negative outcome

-involved with established family; expands personal creativity and productivity --demonstrates lack of interests, commitments; peroccupation with self-centered concerns

S/S of increased ICP

-irritability -fever -high-pitched cry (infant) -pupillary reactions -sunset eyes -dilated scalp veins -poor feeding (infants) -vomiting -bulging fontanelles (infants)

S/S of hyponatremia in infants

-irritability -lethargy -hypothermia (severe) -seizure activity (severe)

S/S of shaken baby syndrome

-lethargy -vomiting -seizures -irritability -inability to eat -inconsolable crying

Define Splenic sequestration crisis

-life-threatening emergency that occurs when "sickled" RBC's get trapped in the spleen, resulting in splenomegaly

A client has potential radiation contamination from a disaster. The nurse should monitor for which of the following related to this contamination? SATA -bitter almond smell on breath -fever and raised skin pustules -low blood cell counts -oral mucosal ulcerations -vomiting and diarrhea

-low blood cell counts -oral mucosal ulcerations -vomiting and diarrhea ---Radiation changes the DNA, which causes cell destruction. Radiation usually affects tissues with rapidly proliferating cells first,followed by tissues with slowly proliferating cells. 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.

The nurse notes muffled heart tones in a client with a pericardial effusion. How would the nurse assess for a pulsus paradoxus? -check for variation in amplitude of QRS complexes on the electrocardiogram strip -compare apical and radial pulses for an deficit -measure the difference between Korotkoff sounds auscultated during expiration and throughout the respiratory cycle -multiple diastolic blood pressure by 2, add systolic pressure, and divide the result by 3.

-measure the difference between Korotkoff sounds auscultated during expiration and throughout the respiratory cycle --Muffled heart tones in a client with pericardial effusion can indiciate the development of cardiac tamponade. This results in the build-up of fluid in the pericardial sac, which leads to compression of the heart. Cardiac output begins to fall as cardiac compression increases, resulting in hypotension. additional signs and symptoms of tamponade include tachycardia, jugular venous distention, narrowed pulse pressure, and the presence of a pulsus paradoxus. Pulsus paradoxus is defined as an exaggerated fall in systemic BP >10 mm Hg during inspiration.

Procedures to prevent transmission of infection

-meticulous hand hygiene -use of disposable gloves during collection and handling of specimen -proper and immediate transport of specimen to the lab -avoiding placing specimen in clean areas (nursing station)

7th stage of Erickson's developmental tasks ---task

-middle adulthood --generativity vs stagnation

What is priority treatment for a child experiencing acute diarrhea?

-monitor for dehydration --treatment is accomplished with oral rehydration solutions and early reintroduction of the child's normal diet

The RN, LPN, and UAP are assigned a client who is being transferred from the PACU. Which tasks are the most appropriate to delegate to the LPN? SATA -assess the client on admission -measure vital signs and pulse oximetry -monitor pain level and administer pain medications -receive verbal report from the PACU nurse -reposition client every 2 hours -titrate oxygen based on unit protocols

-monitor pain level and administer pain medications -titrate oxygen based on unit protocols

COPD symptoms during the day

-morning HA -irritability -excessive sleepiness

How do you calculate mean arterial pressure?

-multiple diastolic blood pressure by 2, add systolic pressure, and divide the result by 3.

Need for spinal immobilization (think NSAIDS)

-neurological examination (focal deficits include numbness and decreased strength) -significant traumatic mechanism of injury -altertness (client may be disoriented or have an altered LOC) -intoxication (client could have impaired decision-making ability or lack awareness of pain) -distracting injury (another significant injury could distract the client from spinal pain) -spinal examination (point tenderness over the spine or neck pain on movement may be present)

An admitted ED client is waiting for an ICU bed to be available for transfer to the inpatient unit. The Ed is very crowded today. The ICU resident is currently too busy to request that an ICU client be transferred to telemetry so the bed can be available; the resident will be able to do so in about 6 hours. What action should the ED charge nurse take first? -call the telemetry unit manager -notify the nursing supervisor -send the client to ICU to "hold: the client in the hallway -wait until the resident has time to request the transfer

-notify the nursing supervisor --it is important to move the client to the ICU and for the ED to continue to care for incoming clients. The nursing supervisor, who serves as an "officer" of the facility, can help resolve interdepartmental issues when it is necessary for a higher authority to intervene and expedite processes.

S/S of lithium toxicity

-occurs when lithium is >1.5 -N/V -diarrhea -neurologic findings -ataxia -sluggishness -confusion -agitation -neuromuscular excitability (chronic)

Describe Broca's aphasia

-occurs when there is damage to the frontal lobe -clients demonstrate effortful and sensible speech that is short in sentences -they have retained ability to comprehend speech, resulting in frustrations when trying to speak

Standard fall risk precautions includes

-orientation to room and call light -call light within reach -bed in lowest position -uncluttered room -nonslip socks/shoes -well-lit room -belongings within reach

Characteristics of myasthenia crisis

-oropharyngeal and respiratory muscle weakness -respiratory failure

What repositioning techniques should be used to prevent pressure ulcers?

-pad bony prominences -pad medical devices -lift, do not pull -limit chair time -minimize shearing and frictional forces -turn every 2-4 hours

S/S of primary open-angle glaucoma

-painless impairment of peripheral vision with normal central vision -difficulty with vision in dim lighting -increased sensitivity to glare -halos observed around bright lights

General interventions to maintain gastric suction using a Salem sump tube includes

-place client in semi-Fowler's position (helps keep the tube from lying against the stomach wall to help prevent gastric reflux) -provide mouth care every 4 hours to help maintain moisture of oral mucosa and promote client comfort -turn off suction briefly during auscultation as the suction sound can be mistaken for bowel sounds -inspect the drainage system for patency

The nurse is caring for a client who has undergone a colonscopy. Which client assessment finding should most concern the nurse? -abdominal cramping -frequent, watery stools -positive rebound tenderness -recurring flatus

-positive rebound tenderness --A risk of a colonscopy is perforation. Signs of perforation include abdominal pain (with shoulder tip pain), positive rebound tenderness, guarding, abdominal distension, tenesmus, and/or board-like abdomen. Another potential complication is rectal bleeding.

The nurse is caring for a client with a hx of tonic-clonic seizures. After a seizure lasting 25 seconds, the nurse notes that the client is confused for 20 minutes. The client does not know the current location, does not know the current season, and has a HA. The nurse documents the confusion and HA as which phrase of the client's seizure activity? -aural phase -ictal phase -postictal phase -prodromal phase

-postictal phase --During this phase, the client may experience confusion while recovering from the seizure. The client may also experience a HA. Postictal confusion can help identify clients by differentiating seizures from syncope. In syncope, there will be only a brief loss of consciousness without prolonged post-event confusion.

A student nurse prepares to change a large wet-to-damp sterile wound dressing and uses a disposable moisture-proof sterile drape to set up the sterile field. The precepting nurse intervenes when the student performs which action? -holds the package 6 inches above the sterile field and drops the sterile gauze onto the field -opens the sterile gauze package with ungloved hands -places the sterile gauze dressings within 2 inches from the edge of the sterile drape -pours sterile normal saline solution into a sterile basin from a bottle opened 30 hours ago

-pours sterile normal saline solution into a sterile basin from a bottle opened 30 hours ago ---the sterility of an opened bottle of sterile saline cannot be guaranteed. Some institutions policies permit recapped bottles of solution to be reused within 24 hours of opening, and some require disposal of the remaining solution. Therefore, the nurse should intervene when the student uses sterile saline from a bottle that was opened >24 hours ago.

The most common clinical manifestations of any form of lymphoma

-presence of at least one painless, enlarged lymph node often found in neck, underarm, or groin

S/E of amiodarone

-pulmonary toxicity --symptoms= dry cough, dsypnea, pleuritic chest pain

What are age appropriate toys for a toddler?

-push-pull toys -low rocking horses -dolls -stuffed animals

drug class and function of palifermin (Kepivance)

-recombinant human keratinocyte growth factor --prevents oral mucositis in clients diagnosed with hematologic malignancies

A housekeeping employee tells the staff nurse of having a headache and asks for acetaminophen. How should the nurse respond? -ask about liver disease and give acetaminophen from the nurse's personal supply -assess the employee's blood pressure -check for allergies to drugs before giving acetaminophen from hospital stock -refer employee to the employee health provider

-refer employee to the employee health provider --although acetaminophen is an over-the-counter drug, the nurse should not give it without a prescription. By doing so, the nurse would be functioning outside the job description. There has not been a proper assessment and a legal caregiving relationship will be established by administering the medication.

nursing interventions before a seizure

-remove potential sources of injury -place padding -keep oxygen at the bedside -assess therapeutic level of antiepileptic drugs -identify seizure triggers

Nursing priorities when implementing a chemical contamination emergency response plan includes:

-restricting other clients, staff and bystanders from the victims' vicinity to protect non-affected individuals -donning personal protective equipment -decontaminating the clients outside the facility before initiating treatment -assessing and providing treatment of symptoms.

What is the fourth stage of Erickson's developmental tasks? --task?

-school-age --industry vs inferiority

define sunset eyes

-sclera is available above the iris -it is a late sign of increased ICP

Social/cognitive abilities of 10-12 month old

-separation anxiety -searches for hidden objects

The nurse reviews the assigned clients' laboratory results and medication administration records. Which finding is the highest priority for the nurse to follow-up with the healthcare provider? -gram-negative infection and positive blood cultures in a client prescribed tobramycin -serum B-type natriuretic peptide 650 pg/mL in a client prescribed furosemide -serum potassium 5.7 mEq/L in a client prescribed spironolactone -serum sodium 132 mEq/L in a client prescribed IV normal saline solution at 175 mL/hr

-serum potassium 5.7 mEq/L in a client prescribed spironolactone --This client who was prescribed spironolactone, a potassium-sparing diuretic that counteracts the potassium loss caused by other diuretics, has high serum potassium. The continuation of this medication puts this client at risk for life-threatening hyperkalemia-induced cardiac dysrhythmias. This finding is of highest priority.

What must be monitored for in a child with rotavirus?

-severe dehydration (S/S include lack of tears when crying, extremely fussy/sleepy, decreased urination, and dry mucous membranes)

manifestations of tumor lysis syndrome

-severe electrolyte abnormalities (increased potassium, phosphorus, and uric acid with decreased calcium) -AKI -cardiac arrhythmias

Mannitol accumulation results in...

-significant volume expansion -dilutional hyponatremia -pulmonary edema

7 month growth and development

-sits for short periods using hands for support -transfers toys hand to hand -fear of strangers begins to appear -lability of mood -responds to name

social/cognitive developmental milestone for 2-3 month old

-smiles in response to smiling/talking -recognizes faces

Examples of potassium-sparing diuretics

-spironolactone -triamterene -eplerenone

gross motor skills of 2 year old

-stairs by themselves one step at a time -runs without falling -kicks ball

Teaching topics for clients on anticoagulants

-take medications same time daily -avoid activities that may cause injury/bleeding -avoid aspirin and NSAIDs -limit alcohol consumption -avoid changing eating habits (increase vitamin K intake) -consult doc before taking herbal supplements (ginkgo) -wear medical alert bracelet

Preprocedure instructions for a barium enema includes

-taking a cathartic (magnesium citrate, polyethylene glycol) to empty the stool from the colon -follow a clear liquid diet the day before the procedure to aid in bowel preparation and to prevent dehydration; avoid red/purple liquids -do not eat or drink anything 8 hour before the test -expect to be placed in various positions during the procedure. Abdominal cramping and the urge to defecate may be experienced

S/S of Marfan Syndrome

-tall and thin in appearance with disportionately long arms, legs, and fingers -flat feet -arachnodactyly -joint hypermobility -kyphosis and/or scoliosis -inward or downward protrusion of breastbone -ectopia lentis

What are serious SE of tamoxifen?

-thromboembolic event (DVT, PE, stroke) -endometrial cancer

Fine motor skills of 18 month old

-towers 3-4 blocks high turns 2-3 pages at a time -scribbles -uses cup/spoon

Fine motor skills for 2 year old

-towers 5 to 6 blocks -turns one page at a time -draws line

Risks for tumor lysis syndrome

-tumors with high burden or rapid turnover -cytotoxic chemotherapy or immunotherapy initiation

What increases the risk for Reye Syndrome?

-use of aspirin therapy for a fever. Acetaminophen or ibuprofen is preferred

30 month growth and development

-walks on tiptoe -jumps with both feet -builds 8-block tower -stands on one foot -has sphincter control for toilet training

Gross motor skills of 3 year olds

-walks up stairs with alternating feet -pedals tricycle -jumps forward

What is a normal urine output?

0.5-1 mL/kg/hr or >30 mL/hr

An experienced nurse precepts a graduate nurse caring for a hospitalized client who has a prescription for a transfusion of packed red blood cells to be hung over 3 hours. Which statement by the graduate nurse indicates the correct rationale for asking the client to void prior to starting the transfusion? -"A drop in blood pressure is expected during the transfusion and getting up to void may cause a fall" -"Bedrest is required; therefore, voiding will prevent intermittent catheterization during the procedure" -"If a transfusion reaction occurs, it will be important to collect a fresh urine specimen to check for hemolyzed RBCs" -"The urine is collected and analyzed prior to starting the transfusion to assess the client's baseline results"

"If a transfusion reaction occurs, it will be important to collect a fresh urine specimen to check for hemolyzed RBCs" ---The nurse should ask the client to void or empty the urinary catheter and discard urine prior to starting a blood transfusion. In the event of an acute hemolytic transfusion reaction, a fresh urine specimen should be collected and sent to the laboratory to analyze form hemolyzed RBCs. An acute hemolytic transfusion reaction is a life-threatening reaction in which the host's antibodies rapidly destroy the transfused RBCs and is generally related to incompatibilty. Early signs of a hemolytic reaction include red urine,fever, and hypotension; late signs include disseminated intravascular coagulation and hypovolemic shock. The transfusion should be stopped immediately if any sign of transfusion reaction occurs.

The student nurse observes the respiratory therapist preparing to draw an arterial blood gas from the radial artery. The RT performs the Allen's test and the student asks why this test performed the blood sample is drawn. Which statement made by the RT is most accurate? --"The Allen's test is done to determine if capillary refill is adequate" --"The Allen's test is done to determine if the radial pulse is palpable" --"The Allen's test is done to determine the patency of the ulnar artery" --"The Allen's test is done to determine the presence of a neurologic deficit"

"The Allen's test is done to determine the patency of the ulnar artery" --The radial artery site at the wrist is preferred for collecting an arterial blood gas sample because it is near the surface, is easy to palpate and stabilize, and has good collateral supply from the ulnar artery. The patency of the ulnar artery can be confirmed with a positive modified Allen's test. If the Allen's test is positive, the arterial blood gas can be drawn; if negative and the palm does not return to a pink color, an alternate site must be used.

A legally blind client is being prepared to ambulate 1 day after an appendectomy. What is the most appropriate action by the nurse? -arrange for the client's service dog to come to the healthcare facility as soon as possible -describe the environment in detail so the client can ambulate safely with a cane -instruct the unlicensed assistive personnel to walk beside the client and lead by the hand - walk slightly ahead of the client with the client's hand resting on the nurse's elbow

- walk slightly ahead of the client with the client's hand resting on the nurse's elbow --On the first postoperative day, the nurse assists the client with ambulation to evaluate alertness, pain level, signs of orthostatic hypotension, problems with gait or mobility, and ability to ambulate safely. The nurse also considers pre-existing limitations to ambulation such as the use of assistive aids. Clients who used any ambulatory assistive aids before surgery require postoperative evaluation prior to ambulatory independence. When walking with a client who is legally blind, the nurse uses the sighted-guide technique by walking slightly ahead of the client with the client holding the nurse's elbow. The nurse should describe the environment while ambulating the client. The service dog may be brought to the hospital to assist in ambulation once the nurse has determined the client can ambulate safely. After evaluation by the nurse, the client may be allowed to use a cane to ambulate around the nursing unit. Instructing the unlicensed assistive personnel to ambulate the client is an inappropriate assignment for a client who is 1 day postoperative and legally blind. Nursing assessment is required to determine if the client is able to ambulate safely.

The student nurse verbalizes the procedure for obtaining a wound culture to the nurse preceptor. Which of the following statements by the student indicate a correct understanding? SATA -" I will apply the prescribed bacitracin ointment after collecting the wound culture" -"I will cleanse the wound by gently flushing it with normal saline" -"I will obtain a sample of the drainage accumulated since the last dressing change" -"I will perform hand hygiene and apply new gloves before obtaining the wound culture" -"I will swab the wound from the outermost margin toward the center"

-" I will apply the prescribed bacitracin ointment after collecting the wound culture" -"I will cleanse the wound by gently flushing it with normal saline" -"I will perform hand hygiene and apply new gloves before obtaining the wound culture" --wound cultures are used to identify microorganisms and select appropriate antibiotics. The nurse should assess and clean the wound, swab from the wound center toward the outer margin, and avoid contamination to prevent misidentification of microorganisms

The clinic nurse is assessing the client's understanding of tiotropium, which has been prescribed for chronic obstructive pulmonary disease. Which statement indicates that the client has a correct understanding of this medication? -"A capsule holds the powdered medication that I have to put in a special inhaler" -"I do not need to rinse my mouth with water after taking tiotropium" -"Tiotropium helps control my COPD by reducing inflammation in my airway"

-"A capsule holds the powdered medication that I have to put in a special inhaler" --tiotropium is a long-acting, 24-hour, anticholinergic, inhaled medication used to control COPD. It is administered most commonly using a capsule-inhaler system called the HandiHaler. The powdered medication dose is contained in a capsule. The client places the capsule in the inhaler device and pushes a button on the side of the device, which pokes a hole in the capsule. As the client inhales, the powder is dispersed through the hole. Unlike most inhaled medications, tiotropium looks like an oral medication because it comes in a capsule. Therefore, it is important to teach the client proper administration prior to the first dose, emphasizing that the capsule should not be swallowed and that the button on the inhaler must be pushed to allow for medication dispersion, During future appointments, the nurse should assess the client's ability to use this medication correctly. Client's should rinse the mouth after using tiotropium and inhaled steroids to remove any medication remaining in the mouth, which decreases the risk of developing thrush. Tiotropium is a controller medication for COPD with a peak effect of approximately 1 week; therefore, it should not be used as a rescue medication. Anticholinergic inhaled medications do not reduce inflammation in the airway. Instead, they relax the airway by blocking parasympathetic bronchoconstriction. They also help dry up airway secretions.

The nurse assesses for cancer risk factors during a screening event at a gastroenterology clinic. Which of the following client statements include risk factors for esophageal cancer? SATA -"A few years ago, I switched from smoking cigarettes to smoking cigars 1 or 2 times a week" -"I am proud that I was able to lose 10 lb, but I'm still considered obese for my height" -"I drink 3 or 4 beers nightly to relax, but I did switch to light beer recently" -"I have struggled with daily episodes of acid reflux for years, especially at nighttime" -"I snack on a lot of salted foods like popcorn and peanuts"

-"A few years ago, I switched from smoking cigarettes to smoking cigars 1 or 2 times a week" -"I am proud that I was able to lose 10 lb, but I'm still considered obese for my height" -"I drink 3 or 4 beers nightly to relax, but I did switch to light beer recently" -"I have struggled with daily episodes of acid reflux for years, especially at nighttime" --Esophageal cancer is a rare, rapidly malignancy of the esophageal lining with a low 5-year survival rate. Squamous cell carcinoma usually develops in the upper part of the esophagus, whereas adenocarcinoma usually develops in the lower part. Major risk factors include smoking and excessive alcohol consumption. Barrett esophagus is also a significant risk factor for esophageal cancer; this condition occurs when the distal portion of the esophagus develops precancerous changes. Obesity and uncontrolled gastroesophageal reflux disease contribute to the development of Barrett esophagus.

The nurse is caring for an adolescent newly diagnosed with a chlamydial infection. After administering a one-time dose of azithromycin, the nurse understands that which of the following client statements indicate a correct understanding of client teaching? SATA -"A long-term consequence of an untreated chlamydial infection is infertility" -"I can resume sexual intercourse tomorrow, as I already received the antibiotic" -"I can still spread the infection, even if I do not have any of the symptoms" -"I should have screening yearly for chlamydia even if I do not have symptoms" -"I will make sure my partner gets checked and treated to prevent reinfection"

-"A long-term consequence of an untreated chlamydial infection is infertility" -"I can still spread the infection, even if I do not have any of the symptoms" -"I should have screening yearly for chlamydia even if I do not have symptoms" -"I will make sure my partner gets checked and treated to prevent reinfection" --Clients should be taught to abstain from sexual intercourse for 7 days after initiation of drug therapy.

The community health nurse provides an education program about risk factors for prostate cancer. Which of the following statements by program attendees indicate that teaching has been effective? SATA -"African American men have a higher risk for prostate cancer than other men" -"Eating large amounts of red meat may increase my risk for prostate cancer" -"I should avoid taking NSAIDs to prevent prostate cancer" -"My father had prostate cancer, so I have an increased risk for it" -"My risk for prostate cancer increases as I become older"

-"African American men have a higher risk for prostate cancer than other men" -"Eating large amounts of red meat may increase my risk for prostate cancer" -"My father had prostate cancer, so I have an increased risk for it" -"My risk for prostate cancer increases as I become older" ---Long-term use of NSAIDs can be a protective factor against certain types of cancer. However, before regularly taking NSAIDs, clients should speak with their healthcare providers because NSAIDs can increase the risk for adverse effects.

The nurse teaching a client with newly diagnosed Sjogren's syndrome how to self-administer ophthalmic lubricating ointment medication. Which statement that the client makes indicates the need for further teaching? -"After applying the ointment, I'll tightly close my eyes and rub the lid for 2-3 minutes" -"I'll squeeze a thin strip of ointment on my lower eyelid, from the inner to the outer edge" -"I'll tilt my head back, pull my lower lid down, and look upward when administering the ointment" -"I'll use my ointment at bedtime and my eye drops during the day"

-"After applying the ointment, I'll tightly close my eyes and rub the lid for 2-3 minutes" --Ophthalmic lubricants replace tears and add moisture to the eyes. They are prescribed to treat dry eyes, a common symptom in clients with Sjogren's syndrome, an autoimmune disorder. Administering an ophthalmic ointment by tightly closing the eyes and rubbing the lid for 2-3 minutes can squeeze the ointment out of the eye and cause injury. The client is taught to gently close the eyes for 2-3 minutes to distribute the medication after applying the ointment.

A client who has been prescribed several medications asks, "Can I take over-the-counter (OTC) medications with my prescriptions?" Which of the following statements by the nurse is appropriate? SATA -"Always ask the healthcare provider or pharmacist before taking OTC medications" -"Ingredients in some OTC medications may interact with prescription medications" -"It is best to avoid OTC medications, but herbal and supplement products are usually safe" -"Remember to discuss all medications, herbs, and supplements you take with you healthcare providers" -"Taking OTC medications can sometimes hide symptoms of a serious disease or illness"

-"Always ask the healthcare provider or pharmacist before taking OTC medications" -"Ingredients in some OTC medications may interact with prescription medications" -"Remember to discuss all medications, herbs, and supplements you take with you healthcare providers" -"Taking OTC medications can sometimes hide symptoms of a serious disease or illness" ---OTC medications are available without a prescription and are used to treat common illnesses. It is estimated that nearly four times as many health conditions are independently managed with OTC medications as are managed under supervision of a healthcare provider. Prior to taking OTC medications, the client should talk with a HCP or pharmacist, particularly if already taking prescribed medications. Even when taken as directed by the OTC medication label, interactions and adverse effects may occur when used in combination with prescription medications. All medications, herbal products, and supplements must be discussed with HCPs so that they can be reconciled and considered before changing or adding new treatments. When OTC medications are used to manage symptoms, the diagnosis and treatment of serious underlying medical conditions may be delayed.

A nurse is making a presentation on skin cancer prevention with special focus on melanoma at a community health forum. Which statements should the nurse include? SATA -"Apply a broad-spectrum sunscreen before and during outdoor sports" -"Apply sunscreen a few minutes before starting outdoor activities" -"Reapply sunscreen after swimming, even if waterproof sunscreen was used earlier" -"serious sunburns can occur even on overcast days" -"Use tanning beds for <15 minutes for a base tan that is less likely to burn"

-"Apply a broad-spectrum sunscreen before and during outdoor sports" -"Reapply sunscreen after swimming, even if waterproof sunscreen was used earlier" -"serious sunburns can occur even on overcast days" ---To prevent sunburn, instruct clients to avoid sun exposure from 10 am to 4 pm, wear protective clothing, use sunscreen properly, and avoid non-solar exposure to ultraviolet radiation

A 25-year-old client is about to undergo a unilateral orchiectomy for treatment of testicular cancer. The client says to the nurse, "I'm so worried that my future spouse is going to call off our engagement." What is the best response by the nurse? -"Are you concerned about how the surgery will affect your sexuality" -"if you are concerned about infertility, you could always bank your sperm" -"The cancer is at an early stage. You are going to be fine" -"What have you and your future spouse discussed about your condition?"

-"Are you concerned about how the surgery will affect your sexuality"

The charge nurse in the telemetry unit has delegated the task of giving a bed bath to a male Arab client who practices traditional Islamic customs. Which communication to the female nursing assistant demonstrates appropriate cultural sensitivity to this client? -"Ask the client's wife if she would like to give the bed bath" -"Do not make eye contact with the client during the bath" -"The client may prefer for you not to talk to him during the bath" -"Touching the head is a sign of disrespect; let the client wash his own face"

-"Ask the client's wife if she would like to give the bed bath" --To provide culturally competent care, it is important for the nurse to realize that in many Arab cultures, a man is not allowed to be alone with a woman other than his wife. It may also be inappropriate for a female healthcare worker to physically care for him; however, in some instances, direct physical care from the opposite sex is allowed if a third party is present.

The nurse is caring for a female client newly diagnosed with epilepsy who has been prescribed phenytoin. Which of the following should the nurse include in client teaching? SATA -"Avoid drinking alcoholic beverages" -"Do not abruptly stop taking your phenytoin" -"Go to the ED every time a seizure occurs" -"Wear an epilepsy medical identification bracelet" -"You may need to start using a nonhormonal birth control method"

-"Avoid drinking alcoholic beverages" -"Do not abruptly stop taking your phenytoin" -"Wear an epilepsy medical identification bracelet" -"You may need to start using a nonhormonal birth control method" --epilepsy is characterized by chronic seizure activity. Clients typically require lifelong anticonvulsant medication. The nurse should provide education about identifying and avoiding seizure triggers, such as excessive alcohol intake, sleep deprivation, and stress. Practicing relaxation techniques may help reduce the number of episodes. The client should also be encouraged to wear an epilepsy medical identification bracelet in case of emergency. Phenytoin, a hydration anticonvulsant, may decrease the effectiveness of some medications due to stimulation of hepatic metabolism. An alternate, nonhormonal birth control method should be used in addition to or instead of oral contraceptives. Clients should discuss pregnancy plans with their healthcare provider, as phenytoin can cause fetal abnormalities. Clients taking phenytoin should also receive education about practicing good oral hygiene as ginigval hyperplasia is a potential complication. Anticonvulsants should not be stopped abruptly, as this increases the risk of seizure.

Which instructions should the nurse include when providing discharge teaching to a client with PUD due to H. pylori infection? SATA -"Avoid foods that may cause epigastric distress such as spicy or acidic foods" -"It is best if you refrain from consuming alcohol products" -"Report black tarry stools to your HCP immediately" -"Take our amoxicillin, clarithromycin, and omeprazole for the next 14 days" -"you may take over the counter drugs such as aspirin if you have mild epigastric pain"

-"Avoid foods that may cause epigastric distress such as spicy or acidic foods" -"It is best if you refrain from consuming alcohol products" -"Report black tarry stools to your HCP immediately" -"Take our amoxicillin, clarithromycin, and omeprazole for the next 14 days" --Treatment for H. pylori includes antibiotics and proton-pump inhibitors for acid suppression. The recommended initial treatment is 7-14 days of triple-drug therapy with omeprazole, amoxicillin, and clarithromycin. NSAIDs should be avoided as they inhibit prostaglandin synthesis, increase gastric secretion, and reduce the integrity of the mucosal barrier.

The nurse educator is completing a staff education conference about prenatal carrier screening. Which statement by a participant indicates a correct understanding of the genetic inheritance for cystic fibrosis? -"Both parents must be carriers of the abnormal gene for offspring to have the disorder" -"Female offspring are most often affected by the inheritance pattern of cystic fibrosis" -"If the female partner is a carrier, only male offspring will have the disorder" -"The inheritance pattern for cystic fibrosis does not skip generations"

-"Both parents must be carriers of the abnormal gene for offspring to have the disorder" --Carrier screening offers clients who are unaffected by a genetic disorder the option to discover whether they possess an abnormal gene that may affect health outcomes of future offspring. This type of genetic testing is frequently offered preconceptionally/prenatally to guide pregnancy decision-making. Cystic fibrosis follows an autosomal recessive inheritance pattern, meaning that offspring must receive two abnormal genes to be affected with the disorder.

Which statement is most important to emphasize when teaching a 40-year-old female client newly diagnosed with fibrocystic breast changes? -"Breast changes that are not related to your cycle should be reported to your provider" -"If your breasts become sore during the month, you may take ibuprofen as needed" -"Schedule yearly clinical breast examinations with your health care provider" -"These cysts are benign, and research shows that they do not increase the risk of cancer"

-"Breast changes that are not related to your cycle should be reported to your provider" --One of the most common benign breast disorders is fibrocystic breast changes. Fibrocystic changes correlate to estrogen/progesterone hormone fluctuations during the menstrual cycle. Clients may report cysts, nodules, or lumps that are more tender, swollen, and/or noticeable prior to menses. The condition typically resolves after menopause. The nurse instructs the client on breast self-awareness and emphasizes that any noncyclic breast changes and should be immediately reported to the healthcare provider.

A 2-year-old who swallowed of adult cough syrup is being discharged from the emergency department. The parents says to the nurse, "From now on, I'm going to store all medicines in my top dresser drawer." Which is the best response by the nurse? -"Can you lock your dresser drawer?" -"Make sure all of your medicines have childproof caps" -"That sounds like a safe place" -"You need to keep an eye on your child at all times"

-"Can you lock your dresser drawer?" --The most important strategy to prevent accidental drug overdoses in children is teaching parents and caregivers to keep medicines out of sight, in a locked drawer or cabinet. Parents/caregivers should also be advised to put drugs away after each use

The nurse is caring for a client with suspected pelvic inflammatory disease (PID). When the nurse is obtaining the client's health history, which of the following questions would provide pertinent data about the client's risk factors for PID? SATA -"Are you currently taking oral contraceptives" -"At what age did you experience your first menstrual cycle?" -"Do you engage in sexual intercourse with multiple partners?" -"Have you ever been diagnosed with a sexually transmitted infection?" -"Have you recently had an abortion or pelvic surgery?"

-"Do you engage in sexual intercourse with multiple partners?" -"Have you ever been diagnosed with a sexually transmitted infection?" -"Have you recently had an abortion or pelvic surgery?" --PID is a leading cause of ectopic pregnancy and infertility. The nurse assessing a client with suspected PID should assess for risk factors such as a history of PID or sexually transmitted infections; number of sexual partners; condom use during sexual intercourse; and recent abortion, pelvic surgery, or placement of an intrauterine device.

The HCP orders a small bowel follow-through for a client. Which instructions should the nurse include when teaching the client about this test? -"After the test, you may notice your stools are tarry black for a few days" -"During the test, a series of x-rays will be taken to assess the function of the small bowel" -"The HCP will use an endoscope to visualize your small bowel" -"Your examination is scheduled for 8am. Please drink all of the polyethylene glycol by midnight"

-"During the test, a series of x-rays will be taken to assess the function of the small bowel" --an SBFT examines the anatomy and function of the small intestine using x-ray images taken in succession. Barium is ingested, and x-ray images are taken every 15-60 minutes to visualize the barium as it passes through the small intestine. Using this technique, decreased motility, increased motility, fistulas, or obstructions are identified.

It is the first day on the job for the newly hired UAP. Which of the following illustrate appropriate delegation instructions for the RN to give the UAP? SATA -"Elevate the right leg on two pillows" -"Measure client for compression stockings" -"Please let me know what the urine looks like" -"Tell me what the client eats at lunch" -"Verify wrist restraints are on correctly"

-"Elevate the right leg on two pillows" -"Tell me what the client eats at lunch" --Assign a new UAP specific tasks that do not require specialized knowledge or skills. The UAP can gather data, but should not be asked to assess/analyze/evaluate or measure client for compression devices. --telling the UAP to let the RN know what the urine looks like is an assessment that the RN should perform. However, the RN is allowed to ask for specific data, such as the amount or if there is a presence of blood clots.

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

-"Engaging in regular exercise decreases the risk of AD" --The development of Alzheimer disease is related to a combination of genetic, lifestyle, and environmental factors. Clients with AD are usually diagnosed at ages greater than 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 with late-onset AD also increases the risk of developing AD. 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 reduce the risk for developing AD.

A student nurse asks why enteral (tube) feedings, rather than total parenteral nutrition (TPN) are being administered to a client with sepsis and respiratory failure. Which is the best response by the RN? -"enteral feedings have no complications" -"Enteral feedings maintain gut integrity and help prevent stress ulcers" -"Enteral feedings provide higher calorie content" -"Risk of hyperglycemia is lower with enteral feedings than with TPN"

-"Enteral feedings maintain gut integrity and help prevent stress ulcers" --Stress ulcers are a common complication in critically ill clients because the GI tract is not a preferential organ. In the presence of hypoxemia, blood is shunted to the more vital organs, increasing the risk of stress ulcers. The early initiation of enteral feedings helps preserve the function of the gut mucosa, limits movement of bacteria from the intestines into the bloodstream, and prevents stress ulcers. Enteral feedings are also associated with lower risk of infectious complications compared with TPN. However, the mortality is the same. --complications associated with eneteral feedings include aspiration, tube displacement, hyperglycemia, diarrhea, abdominal distension, enteral tube misconnections, and clogged tubes. -caloric and metabolic needs can usually be met adequately using enteral feedings or TPN. Multiple enteral or TPN formulas are available to meet individual client needs. If metabolic demands are not being met using enteral feedings along. TPN can be added. -illness-related stress hyperglycemia occurs in clients receiving both enteral feedings and TPN.

The nurse is obtaining a client's health history during a routine physical and wellness examination. Which of the following statements by the client should cause the nurse to suspect potential Hodgkin lymphoma? SATA -"For the past few weeks, I have noticed a pretty regular fever, but I do not have chills or feel bad" -"I have had a lump in my underarm for several weeks. I have not thought much about it because it doesn't hurt" -"My weight has gone down a lot in the past month. I have not changed my diet or exercise regimen, but it has been nice" - "Recently, my skin has been very itchy. I have had allergies in the past, but this feels different" -"Sometimes when I wake up, I find I have sweat so much while sleeping that I need to change the sheets"

-"For the past few weeks, I have noticed a pretty regular fever, but I do not have chills or feel bad" -"I have had a lump in my underarm for several weeks. I have not thought much about it because it doesn't hurt" -"My weight has gone down a lot in the past month. I have not changed my diet or exercise regimen, but it has been nice" - "Recently, my skin has been very itchy. I have had allergies in the past, but this feels different" -"Sometimes when I wake up, I find I have sweat so much while sleeping that I need to change the sheets" ---Lymphoma is a form of cancer that begins in the body's lymphatic system and is characterized by abnormal growth of lymphocytes. It is usually classified within two major subtyps, Hodgkin lymphoma and non-Hodgkin lymphoma and is further identified by numerous subcategories. To be diagnosed with Hodgkin lymphoma, malignant Reed-Sternberg cells must be found in the lymphatic tissue. Furthermore, Hodgkin lymphoma tends to follow a predictable path of metastasis, whereas NHL tends to be more widely disseminated. The most common clinical manifestation of any form of lymphoma is the presence of at least one painless, enlarged lymph node, often in the neck, underarm, or groin. Clients may also present with or develop fever; significant, unexplainable, and/or unintentional weight loss and/or drenching night sweats typically associate with a poor prognosis.

The nurse educates the caregiver of a client with Alzheimer disease about maintaining the client's safety. Current symptoms include occasional confusion and wandering. Which of the following responses by the caregiver show correct understanding? SATA -"Grab bars should be installed in the shower and beside the toilet" -"I will place a safe return bracelet on the client's wrist" -"Keyed deadbolts should be placed on all exterior doors" -"Medications will be placed in a weekly pill dispenser" -"Throw rugs and clutter will be removed from the floors"

-"Grab bars should be installed in the shower and beside the toilet" -"I will place a safe return bracelet on the client's wrist" -"Keyed deadbolts should be placed on all exterior doors" -"Throw rugs and clutter will be removed from the floors" --all medications should be out of the client's reach or locked away. A confused person may not remember the day of the week and take more or less medication than prescribed.

The nurse cares for an elderly client with type II diabetes who was diagnosed with diabetic retinopathy. Which statement by the client requires the most immediate action by the nurse? -"Half of my vision looks like it's being blocked by a curtain" -"I have to use reading glasses to see small print" -"My vision seems cloudy and I notice a lot of glare" -"The colors don't seem as bright as they used to be"

-"Half of my vision looks like it's being blocked by a curtain" --Chronic hyperglycemia can cause microvascular damage to the retina, leading to diabetic retinopathy, the most common cause of new blindness in adults. A partial retinal detachment may be painless and cause symptoms such as curtain blocking part of the visual field, floaters or lines, and sudden flashes of light

A 14-year-old is seen in the STD outpatient department and diagnosed with gonorrhea. The client tells the nurse of having sexual relations with only a 19-year-old partner. What is the best response by the nurse? -"Has your partner been evaluated and treated by a healthcare provider?" -"I have to report your situation to local law enforcement" -"One of your parents will need to consent to your treatment" -"You should use a condom when you have sex"

-"Has your partner been evaluated and treated by a healthcare provider?" --To avoid re-infection with gonorrhea, it is essential that the client's partner be tested and treated. During the visit, the nurse should counsel the client about the importance of partner evaluation and treatment and the likely recurrence of the infection if the partner refuses to be treated. The client should avoid sexual relations until treatment is completed and the client and partner no longer have symptoms.

A 78-year-old client recovering from a hip fracture tells the home health nurse, "I haven't had much of an appetite lately and have been really tired. I'm worried I'm not eating enough" Which question is the priority for the nurse to ask? -"Are you able to prepare your own meals?" -"Are you feeling lonely or depressed" -"Have you lost any weight unintentionally" -"How many meals do you eat each day?"

-"Have you lost any weight unintentionally" --Malnutrition occur when there is insufficient nutrient intake to meet body needs and relates to multiple factors. Malnutrition may impair critical physiological processes and can have rapid and potentially lethal implications. Therefore, nurses should frequently assess clients for malnutrition, particularly those at increased risk. Assessing for malnutrition involves collecting dietary data, lab values, physical measurements, and hx of recent weight loss. Reports of weight loss, especially unintentional, are critical findings often indicative of malnutrition. In addition, weight loss of greater than 5 percent in 1 month or greater than 10 percent in 6 months may indicate serious conditions.

A 55 yer-old client on a medical-surgical unit has just received a diagnosis of pancreatic cancer. The client says to the nurse, "Is this disease going to kill me?" What is the best response by the nurse? -"Hearing this diagnosis must have been difficult for you. What are your thoughts?" -"we will do everything possible to prevent that from happening" -"Well, we're all going to die sometime" -"You should concentrate on getting better rather than thinking about death"

-"Hearing this diagnosis must have been difficult for you. What are your thoughts?" --The stress of receiving a life-threatening diagnosis often causes clients to feel very vulnerable. There is a tendency to keep feelings and concerns closed off; clients may not be able to express how distressed they fell or find the right words to express feelings and concerns. In asking, "Is this disease going to kill me?", the client is most likely not looking for a direct yes or no answer. This would immediately close off the conversation and create a missed opportunity for a meaningful engagement and communication with the nurse. It is more likely that this question is being asked to provide an opening for further discussion about the meaning of this devastating diagnosis as well as the client's thoughts and feelings.

The nurse is caring for a hospitalized client. Which are the best examples of narrative documentation to provide legal malpractice protection for the nurse after an adverse event? SATA -"Client found on floor this morning at 6:50 AM. No verbalized symptoms. I think client tripped over a cord. Client instructed on safety during ambulation" -"Client reports that IV pole hit head at 7:30 AM. Denies pain. IV pole removed for client safety. Will continue to monitor. Healthcare provider notified" -"Heparin infusion running at 15 units/kg/hr at 7:15 AM; infusion rate adjusted to prescription of 12 units/kg/hr. Labs drawn at 7:20 AM, a PTT 65 sec. HCP notified; will draw labs again at 1:20 PM" -"IV site in right hand is red and swollen at 9:30 AM. IV removed, bleeding controlled, and warm compress administered at 9:40 AM. Will reassess for swelling and pain every hour" -"Package of green leaves found in client drawer at 1:00 PM. Client acting suspicious at 2:00 PM. HCP notified. Will call security. Client has multiple tattoos and piercings"

-"Heparin infusion running at 15 units/kg/hr at 7:15 AM; infusion rate adjusted to prescription of 12 units/kg/hr. Labs drawn at 7:20 AM, a PTT 65 sec. HCP notified; will draw labs again at 1:20 PM" -"IV site in right hand is red and swollen at 9:30 AM. IV removed, bleeding controlled, and warm compress administered at 9:40 AM. Will reassess for swelling and pain every hour"

The nurse is assessing a 2-year-old who has a blistered sunburn across the back and shoulders. Which of the following parent statements indicates an appropriate understanding of care for sunburn? SATA -"I am allowing my child to play outdoors only very early in the morning and late in the evening since the sunburn" -"I am encouraging extra fluids since my child got sunburned" -"I have been giving my child acetaminophen to help relieve the pain" -"I have been placing cool, wet washcloths on my child's back" -"I have rubbed hydorcortisone cream on the area to help reduce inflammation and promote healing"

-"I am allowing my child to play outdoors only very early in the morning and late in the evening since the sunburn" -"I am encouraging extra fluids since my child got sunburned" -"I have been giving my child acetaminophen to help relieve the pain" -"I have been placing cool, wet washcloths on my child's back" ---Sunburn is a painful inflammatory skin reaction that results from overexposure to ultraviolet radiation. Care for minor sunburn is symptomatic and involves protecting the burn from further sun exposure, increasing fluid intake, taking mild oral analgesics, and applying cool compresses and soothing lotions.

The nurse teaches safety precautions of home oxygen use in a client with emphysema being discharged with a nasal cannula and portable oxygen tank. Which client statement indicates the need for further teaching? SATA -"I can apply Vaseline to my nose when my nostrils feel dry from the oxygen" -"I can cook on my gas stove as long as I have a fire extinguisher in the kitchen" -"I can increase the liter flow from 2 to 6 liters a minute whenever I feel short of breath" -"I should not polish my nails when using my oxygen" -"I should not use a wool blanket on my bed"

-"I can apply Vaseline to my nose when my nostrils feel dry from the oxygen" -"I can cook on my gas stove as long as I have a fire extinguisher in the kitchen" -"I can increase the liter flow from 2 to 6 liters a minute whenever I feel short of breath" --Safety precautions for home oxygen use include the following: no smoking, electrical devices in good condition and plugs grounded; avoid volatile, flammable products and materials that generate static electricity; staying at least 5-10 feet away from open sources of flame; keeping fire extinguishers readily available; and regularly testing smoke detectors.

The nurse is teaching a client with newly diagnosed lactose deficiency about dietary management. Which statements by the client indicate a correct understanding of this condition? SATA -"I can still eat cheese and yogurt as long as they don't make me feel sick" -"I should take a daily calcium and vitamin D supplement" -"Most diary products should be eliminated from my diet, but ice cream is okay" -"My lactose enzyme supplement should be taken with meals containing dairy" -"This means that I have developed an allergy to milk"

-"I can still eat cheese and yogurt as long as they don't make me feel sick" -"I should take a daily calcium and vitamin D supplement" -"My lactose enzyme supplement should be taken with meals containing dairy" --clients with lactase deficiency experience varying degrees of gastroinestinal symptoms after ingesting milk products, including flatulence, diarrhea, bloating, and cramping. This is due to a deficiency of the enzyme lactase, which is required for digestion of lactose. Treatment includes restricting lactose-containing foods in the diet. These clients may also take lactase enzyme replacement to decrease symptoms. Supplementation of calcium and vitamin D is recommended due to insufficient intake of fortified milk. Milk and ice cream contain the highest amounts of lactose and should be restricted depending on the client's individual tolerance. Some dairy products, including aged cheeses and live-culture yogurts, contain little to no lactose and can be tolerated by most clients with lactase deficiency. --Lactase deficiency is not an immune reaction (allergy) to milk products. Rather, the GI symptoms are due to a deficiency of the enzyme lactase and the resultant inability to digest lactose.

The nurse provides home care education to a client newly diagnosed with von Willebrand disease. Which of the following client statements demonstrate correct understanding of the education? SATA -"I can use a humidifier to help prevent nosebleeds" -"I need to avoid contact sports such as soccer or hockey" -"I should use a soft-bristled toothbrush and floss carefully" -"I will call my healthcare provider if I soak a menstrual pad every hour" -"I will take naproxen to decrease inflammation if I am injured"

-"I can use a humidifier to help prevent nosebleeds" -"I need to avoid contact sports such as soccer or hockey" -"I should use a soft-bristled toothbrush and floss carefully" -"I will call my healthcare provider if I soak a menstrual pad every hour" --Von Willebrand disease is a genetic bleeding disorder caused by a deficiency of von Willebrand factor,which plays an important role in coagulation. Intranasal desmopressin or topical therapies may be prescribed to stop minor bleeding, whereas major bleeding may require replacement of vWF. Clients should wear medical identification bracelets in case of emergency.

A client with diabetes mellitus is admitted to the surgical unit after a vaginal hysterectomy. The client received 6 units of regular insulin subcutaneously and metoprolol 50 mg by mouth in the post-anesthesia care unit. Which statement by the unlicensed assistive personnel would require immediate action by the nurse? -"I changed the client's perineal pad 3 times in the last 2 hours" -"I have been encouraging the client to exercise the legs while in bed" -"I thought you should know the client voided 500 mL of straw-colored urine" -"I just took the client's vital signs, which are blood pressure 108/60 mm Hg, pulse 58, and respirations 12"

-"I changed the client's perineal pad 3 times in the last 2 hours" --The nurse should take immediate action when a client recovering from a vaginal hysterectomy saturates more than one perineal pad in an hour. The nurse should further assess the client and report these findings and excessive vaginal bleeding to the healthcare provider.

The same-day surgery nurse performs the preoperative assessment for a client with a history of coronary artery disease scheduled for an elective laparoscopic cholecystectomy. Which statement made by the client is critical to report to the healthcare provider before the surgery? -"I didn't take the clopidogrel pill for my heart yesterday or today" -"I know I should stop smoking completely, but at least I didn't have a cigarette yesterday or today" -"I stopped taking my gingko biloba 2 weeks ago even though it really helps relieve leg cramps when I walk" -"I stopped taking naproxen for my arthritis pain 1 week ago and have been taking acetaminophen instead"

-"I didn't take the clopidogrel pill for my heart yesterday or today" --Plavix is an antiplatelet medication that should be discontinued 5-7 days before surgery to decrease the risk for excessive bleeding. The client took this drug 48 hours ago. Therefore, the nurse must notify the HCP. The surgery may be postponed due to the increased risk for intra and postoperative bleeding. All clients should try not to smoke for at least 24 hours before surgery to help prevent oxygenation problems. The client takes gingko biloba to relieve symptoms of intermittent claudication; it was discontinued 2 weeks ago because it can increase the risk for excessive bleeding. NSAIDs such as naproxen should be discontinued 7 days before scheduled surgery as they can increase the risk for excessive bleeding. Acetaminophen can be taken to control pain up until surgery

The nurse is preparing a client for magnetic resonance cholangiopancreatography. Which statements by the client would require the nurse to obtain further assessment data? SATA -"I ate lunch about 4 or 5 hours ago" -"I got a rash the last time I had IV contrast" -"I had my last period 6 weeks ago" -"I have a hearing aid implanted in my ear" -"I smoked a cigarette about an hour ago"

-"I got a rash the last time I had IV contrast" -"I had my last period 6 weeks ago" -"I have a hearing aid implanted in my ear" ---MRCP is a noninvasive diagnostic test used to visualize the biliary, hepatic, and pancreatic ducts via MRI. MRCP uses oral or IV gadolinium and is a safer, less-invasive alternative to endoscopic retrograde cholangiopancreatography. to determine the cause of cholecystitis, cholelithiasis, or biliary obstruction. The nurse must assess for contraindications before the procedure, including the presence of certain metal and/or electrical implants or any previous allergy or reaction to gadolinium. A client with a history of rash following prior IV contrast administration should be assessed to determine the type of contrast that caused the reaction. Although allergies to iodine-based contrast material are more common, the nurse must rule out a gadolinium allergy. Pregnancy also is a contraindication for MRCP as gadolinium crosses the placenta and may adversely affect the fetus. Delayed/irregular menses may be a normal variation in some clients; however, delayed menses may indicate pregnancy and should be reported for further investigation prior to MRCP.

The nurse is preparing to discharge a client who is stable following a head injury. Which statement by the client indicates a need for further discharge instructions? -"I have a leftover prescription at home I can use if I have pain" -"I will cancel the wine tasting I have planned for this weekend" -"I will have someone drive me home and will take a couple of days off work" -"I will have someone stay with me and make sure I am okay"

-"I have a leftover prescription at home I can use if I have pain" --Opioid pain medications should be avoided following a head injury; therefore, the nurse should clarify what medication the client has at home. Any change in LOC, dizziness, nausea, or other side effects of opioids could be misinterpreted as symptoms of a worsening condition related to the head injury. Clients are typically advised to use non-narcotic or nonsteroidal anti-inflammatory pain medications. The client should also avoid driving, using heavy machinery, playing contact sports, or taking hot baths for 1-2 days.

A client comes to the ED with diplopia and recent onset of nausea. Which statement by the client would indicate to the nurse that this is an emergency? -"I am very tired, and it's hard for me to keep my eyes open" -"I don't feel good, and I want to be seen" -"I have not taken my blood pressure medicine in over a week" -"I have the worst headache I've ever had in my life"

-"I have the worst headache I've ever had in my life" --a ruptured cerebral aneurysm is a surgical emergency with a high mortality rate. Cerebral aneurysms are usually asymptomatic unless they rupture; they are often called "silent killers" as they may go undetected for many years before rupturing without warning signs. The distinctive description of a cerebral aneurysm rupture is the abrupt onset of "the worst headache of my life" that is different from previous HAs. Immediate evaluation for a possible ruptured aneurysm is critical for any client experiencing a severe HA with changes in or loss of consciousness, neurologic deficits, diplopia, seizures, vomiting, or a stiff neck. Early identification and prompt surgical intervention help increase the chance for survival

The home health nurse teaches an elderly clients with dysphagia some strategies to help limit repeated hospitalizations for aspiration pneumonia. Which statement indicates that the client needs further teaching? -"I have to remember to raise my chin slightly upward when I swallow" -"I have to remember to swallow 2 times before taking another bite of food" -"I should avoid taking OTC cold medications when I'm sick" -"I should sit upright for at least 30-40 minutes after I eat"

-"I have to remember to raise my chin slightly upward when I swallow" --Dysphagia increases the risk for aspiration of oropharyngeal secretions, gastric content, food, and/or fluid into the lungs. Aspiration of foreign material into the lungs increases the risk for developing aspiration pneumonia. Interventions to help decrease aspiration and resulting aspiration pneumonia in susceptible clients includes: swallowing 2 times before taking another bite of food in order to clear food from the pharynx; thickening liquids to assist swallowing;avoiding OTC cold medications due to antihistamine cold preparation having anticholinergic properties, such as drowsiness and decreasing saliva production; sitting upright for at least 30-40 minutes after meals to allow gravity to move food/fluid through the tract, decrease gastroesophageal reflux, and decrease risk for aspiration; brushing teeth and using antiseptic mouthwash before and after meals to reduce bacterial count.

The nurse is caring for a client who is participating in a research study (randomized controlled trial) of a new medication. Which statement indicates that the client has an appropriate understanding of the study and reason for participation? -"I changed my mind, but once in you're stuck" -"I hope others will be helped through my involvement" -"I know I will get new medication by being in this study" -"If I don't participate, my healthcare provider will be upset"

-"I hope others will be helped through my involvement" --Research with human subjects is reviewed by institutional research boards to ensure ethical principles are followed. The research participant cannot be deceived and must participate voluntarily knowing the risks and purpose of the study; confidentiality must be maintained. Clients in research studies often have altruistic motives. They know they may achieve no personal gain, but others could benefit from their participation. All clients should receive safe, quality care whether they participate in the study or not. Due to randomization, the client has no guarantee of receiving a medication that is more effective rather than the placebo. This misconception should be clarified.

The nurse provides care for a client diagnosed with polycythemia vera. Which statement by the client would require immediate follow-up? -"I am trying to find makeup to cover my unattractive, ruddy facial complexion" -"I must have injured my leg in some way. It is sore, swollen, and red" -"I take a baby aspirin to relieve my occasional headaches" -"My skin itches so severely, and no lotion or cream seems to help"

-"I must have injured my leg in some way. It is sore, swollen, and red" ---Polycythemia vera is a hematological disorder in which too many RBCs are produced, causing increased blood viscosity, venous stasis,and increased risk for thrombus formation. The nurse should teach clients with PB measures to prevent thrombus. Clients should also learn to monitor for and report signs and symptoms of thrombus. Reports of possible thrombus require immediate intervention to avoid serious injury.

The nurse is reinforcing teaching about ulcer prevention with a client newly diagnosed with peptic ulcer disease. Which of the following client statements indicate appropriate understanding of teaching? SATA -"I need to avoid taking medicines like ibuprofen without a prescription" -"I should avoid drinking excess coffee or cola" -"I should enroll in a smoking cessation program" -"I should reduce or eliminate my intake of alcoholic beverages" -"I will eliminate whole wheat foods, like breads and cereals, from my diet"

-"I need to avoid taking medicines like ibuprofen without a prescription" -"I should avoid drinking excess coffee or cola" -"I should enroll in a smoking cessation program" -"I should reduce or eliminate my intake of alcoholic beverages" --Peptic ulcer disease is characterized by ulceration of the protective layers of the esophagus, stomach, and/duodenum. Mucosal "breaks" allow digestive enzymes and stomach acid to digest underlying tissues, leading to potential gastrointestinal bleeding and perforation. Risk factors for PUD include GI H. pylori infections, genetic predisposition, chronic NSAID (aspirin, ibuprofen, naproxen) use, stress, and diet/lifestyle choices. Nurses educating clients with PUD about ulcer prevention should focus on modifiable risk factors (NSAIDs; caffeine; smoking; alcohol; and meal timing). Chronic use of NSAIDs can damage the gastric mucosa and delay ulcer healing. Cola, tea, and coffee should be avoided as they stimulate stomach acid secretion. Tobacco increases secretion of stomach acid and delays ulcer healing. Eating multiple small meals throughout the day or eating shortly before sleeping may actually worsen PUD by increasing stomach acid secretion.

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? SATA -"I need to eat a diet high in calories and protein so that I avoid losing weight" -"I need to take multivitamins containing calcium daily" -"I should avoid consuming alcoholic beverages" -"I should drink at least 2 liters of water daily and more when I have diarrhea" -"I will keep a symptom journal to note when I eat and drink during the day"

-"I need to eat a diet high in calories and protein so that I avoid losing weight" -"I need to take multivitamins containing calcium daily" -"I should avoid consuming alcoholic beverages" -"I should drink at least 2 liters of water daily and more when I have diarrhea" -"I will keep a symptom journal to note when I eat and drink during the day"

The nurse is reinforcing education about lifestyle modifications for a client diagnosed with Meniere disease. Which statement by the client indicates a need for further teaching? -"I need to enroll in a smoking cessation program" -"I need to restrict the amount of potassium in my diet" -"I will lie down and avoid walking unassisted during acute attacks" -"I will limit the amount of caffeine and alcohol that I consume"

-"I need to restrict the amount of potassium in my diet" --Meniere disease results from excess fluid accumulation in the inner ear. Attacks involve severe vertigo, nausea, and hearing loss. Clients with Meniere disease should be taught to adhere to a low-sodium diet; eliminate tobacco products; limit caffeine and alcohol; and limit or avoid exacerbating factors.

Client call lights come on while the UAP sits at a desk and reads a magazine. When the nurse asks the UAP to answer the lights, the UAP says, "Those aren't my clients". What is the best response by the nurse? -"Would you mind answering the lights anyways?" -"I need you to answer the lights because we want to provide good client care" -say nothing and answer the lights, but write up a disciplinary action -tell the UAP that this is unacceptable and speak to the nurse manager

-"I need you to answer the lights because we want to provide good client care" --the nurse should use assertive communication techniques to deal with a staff member directly and immediately by telling rather than asking for certain actions. The nurse should not attack the individual's character or initially make threats and should not avoid the issue by just performing the action itself.

A client with renal failure recently started dialysis and is unable to work due to ongoing health problems. The client's spouse has started working for a cleaning service to replace the lost income. The dialysis nurse notices that the client has become withdrawn and increasingly frustrated by small inconveniences when coming to dialysis. Which is the most appropriate first response by the nurse? -"How is your spouse's new job going?" -"I notice that you seem frustrated" -"It can take time to adjust to dialysis. We have a support group that can be helpful" -"It's normal to be angry when you can't work any longer"

-"I notice that you seem frustrated" --The client with chronic illness who is unable to work may experience depression, grief, loss, a feeling of inadequacy, or a loss of meaning and purpose in life. It can take time to adjust and accept the new roles, and this stress can increase a person's vulnerability to ongoing health problems. This client has gone from being the main source of income to being someone who is unable to support the family. The client is now dependent on the spouse for financial stability and this is causing a strain. This type of role change can be particularly difficult for men who are used to providing for their families and for anyone who is well-established in a career. The nurse has noticed a change in the client's behavior but has not assessed the client to determine the factors contributing to this change. Assessment is needed before interventions can be planned. An open-ended reflective statement and nonverbal communication expressing acceptance and willingness to listen in the setting of a trusting relationship are appropriate to begin this assessment

The long-term care nurse is caring for a client diagnosed with macular degeneration. Which client statement supports this diagnosis? -"I have been seeing small flashes of light" -"I have trouble threading my sewing needle. I have to hold it far away to see it" -"I notice that my peripheral vision is becoming worse" -"I see a blurry spot in the middle of the page when I read"

-"I see a blurry spot in the middle of the page when I read" ---Macular degeneration is a progressive, incurable eye disease that occurs when the central portion of the retina deteriorates, giving rise to distortion or loss in the center of the visual field. Macular degeneration has two different etiologies. Dry macular degeneration involves ischemia and atrophy of the macula that results from blockage of the retinal microvasculature. Wet macular degeneration involves the abnormal growth of new blood vessels in the macula that bleed and leak fluid, eventually destroying the macula. Progression of macular degeneration may be slowed with smoking cessation, intake of specific supplement, laser therapy, and injection of antineoplastic medications. Risk factors for macular degeneration include advanced age, family history, hypertension, smoking, and long-term poor intake of carotenoid-containing fruits and vegetables

The nurse is educating a client recently diagnosed with anaphylatic allergy to latex. Which statement made by the client indicates that the client understood the condition correctly? -"I do not need to worry about my allergy when I am outside of a health care environment" -"I just need to check labels to ensure products do not contain latex and I will be fine" -"I should always carry my Epi-pen in case I have difficulty breathing" -"I should take better care of myself and eat healthy foods like bananas and chestnuts"

-"I should always carry my Epi-pen in case I have difficulty breathing" --Anaphylaxis is a medical emergency and any client with a history of severe allergic reaction should always carry an Epi-Pen. Epinephrine injections is the only option for treating anaphylaxis.

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

-"I should avoid straining while having a bowel movement" --Cirrhosis is a progressive, degenerative disease caused by destruction and subsequent disordered regeneration of the liver parenchyma. Clients with cirrhosis suffer from various complications that will progressively intensify without lifestyle modifications. --although a low-sodium diet is important to prevent worsening hypertension and ascites, a low-protein diet is not usually recommended. Many clients with cirrhosis suffer from protein-calorie malnutrition; therefore, an intake of 1.2-1.5 g/kg of protein a day is commonly prescribed

The nurse is providing discharge teaching for a client who suffered full-thickness burns. Which statement by the client demonstrates a need for further instruction on the rehabilitation phase of a burn injury? -"I should avoid using lotion to prevent infection" -"I should perform range-of-motion exercises daily" -"I will avoid direct sun exposure for at least 3 months" -"I will wear pressure garments to minimize scars"

-"I should avoid using lotion to prevent infection" --The rehabilitation phase begins after the clients wounds have fully healed and lasts about 12 months. The initiation of this phase depends on the extent of the burns and the client's ability to care for themselves.

The pediatric nurse is reinforcing education about medication administration to the parents of a 4-year-old client. Which statement made by the parents demonstrate correct understanding? SATA -"I can mix the medication in a bowl of my child's favorite cereal" -"I should give another dose if my child vomits after taking the medication" -"I should measure liquid medications using an oral syringe" -"I will encourage my child to help me as I prepare the medication" -"I will place my child in time-out if the medication is refused"

-"I should measure liquid medications using an oral syringe" -"I will encourage my child to help me as I prepare the medication" --For pediatric clients, liquid medications should be measured with oral syringes, which have small, well-defined increments and provide accuracy for small doses. Household measuring devices are inaccurate due to variability of size and differences in measuring methods. Pediatric clients may refuse medication due to a fear of unpleasant taste. Preschool children typically start to take initiative and affirm power over the environment. Encouraging participation promotes initiative and cooperation by giving the child a sense of control. The child may not finish eating food mixed with medication and would receive only a partial dose. Parents should notify the HCP if the child vomits after oral medication administration; additional medication may cause an overdose, as some medication may have been absorbed. Preschool children respond best to positive reinforcement and rewards as incentives for desired behavior

The nurse is reinforcing instructions to a client on collection of a sputum specimen for culture and sensitivity. Which of the following client statements indicate that teaching has been effective? SATA -"I should rinse my mouth with water before collecting the sputum" -"I will be careful not to touch the inside of the specimen cup or lid" -"I will inhale deeply a few times and then cough forcefully" -"It is best to collect the sputum mid-day when my secretions are loose" -"It is helpful if I am sitting upright when I collect sputum"

-"I should rinse my mouth with water before collecting the sputum" -"I will be careful not to touch the inside of the specimen cup or lid" -"I will inhale deeply a few times and then cough forcefully" -"It is helpful if I am sitting upright when I collect sputum" ---Collection of a sputum specimen by expectoration is a sterile procedure that requires the client to breathe deeply and cough effectively. The nurse should instruct the client to rinse the mouth with water before collecting the sputum sample to reduce bacteria in the mouth and prevent specimen contamination by oral flora; to sit upright before specimen collection to promote cough strength during collection; inhale deeply several times, and cough prior to expectorating. The client should avoid touching the inside of the sterile container or lid. Sputum should be collected in the morning to improve sample quality.

The nurse is reinforcing instructions to a client being discharged from the clinic with a diagnosis of acute prostatitis. Which statement by the client indicates an understanding of the instructions? -"Having sex will make the infection worse" -"I enjoy iced tea, so I will drink more to stay hydrated" -"I should take ciprofloxacin until I feel better" -"I should take docusate to prevent straining"

-"I should take docusate to prevent straining" --Prostatitis is inflammation of the prostate gland, usually caused by a bacterial infection. Symptoms include rectogenital pain, burning, urinary hesitancy, and/or urinary urgency. Management of prostatitis includes antimicrobial and anti-inflammatory medications. Alpha-adrenergic blockers help relaxes the bladder and prostate. Suprapubic catheterization may be necessary for urinary retention in severe cases of acute prostatitis. Urethral catheterization is contraindicated due to the risk of exacerbating pain and urethral inflammation.

The nurse in the outpatient clinic is speaking with a client diagnosed with cerebral arteriovenous malformation. Which statement would be a priority for the nurse to report to the health care provider? -"I got short of breath this morning when I worked out" -"I have cut down on smoking to 1/2 pack per day" -"I haven't been feeling well, so I have been sleeping a lot" -"I took an acetaminophen in the waiting room for this bad headache"

-"I took an acetaminophen in the waiting room for this bad headache" --An arteriovenous malformation is a tangle of veins and arteries that is believed to form during embryonic development. The tangled vessels do not have a capillary bed, causing them to become weak and dilated. AVMs are usually found in the brain and cause seizures, headaches, and neurologic deficits. Treatment depends on the location of the AVM, but blood pressure control is crucial. Clients with AVMs are at high risk for having an intracranial bleed as the veins can easily rupture because they lack a muscular layer around their lumen. Any neurologic changes, sudden severe headache, nausea, and vomiting should be evaluated immediately as these are usually the first symptoms of a hemorrhage. --The report of dyspnea may prompt further evaluation depending on the type of exercise performed, but it is not the priority. Clients with AVMs should avoid smoking to prevent hypertension. Reports of not feeling well and sleeping a lot may be related to the HA and possible hemorrhage, but this alone would not prompt a call to the HCP.

The nurse is caring for a client with immune thrombocytopenic purpura. Which client statements indicate a need for further teaching? SATA -"I use a soft-bristle toothbrush and mild mouth rinse" -"I enjoy walking and wear nonskid footwear for safety" -"I use a safety razor and gentle shaving cream" -"Sometimes I get constipated, so I have been taking docusate" -"When I have a headache, I take over-the-counter ibuprofen"

-"I use a safety razor and gentle shaving cream" -"When I have a headache, I take over-the-counter ibuprofen" ---Clients with immune thrombocytopenicpurpura have low platelet counts and an increased risk of bleeding. Appropriate care for clients with ITP includes safe exercise; using stool softeners, electric razors, and soft-bristle toothbrushes, and avoiding nonsteroidal anti-inflammatory drugs.

The public health nurse conducts a program at the community senior citizen center about preventing falls at home. Which statement made by a participant indicates that further education is needed? -"I bought a new nightlight for the hallway to the bathroom" -"I feel so much more secure wearing my electronic fall alert device" -"I walk in my stockings at home because it helps to relieve my bunion pain" -"My daughter helped me secure the small, thin rug in my kitchen with strong tape"

-"I walk in my stockings at home because it helps to relieve my bunion pain" --Walking barefoot or while wearing stockings increases the risk of slipping on slick surfaces. Shoes or slippers with non-skid soles should be worn inside and outside of the home.

A client with a 10 year hx 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 the EKG have lengthened, increased 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? -"I will ask the HCP to come take with us so that we can develop a plan to prevent withdrawal while reducing your risk of heart problems" -"I will take with the HCP about your concerns, but in the meantime, it's important that you stay here" -"It's important that you stay in the hospital so that we can treat you quickly if you have problems" -"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"

-"I will ask the HCP to come take with us so that we can develop a plan to prevent withdrawal while reducing your risk of heart problems" --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.

Which statement made by the client demonstrates a correct understanding of the homecare of an ascending colostomy? -"I will avoid eating foods such as broccoli and cauliflower" -"I will empty the pouch when it is one-half full of stool" -"I will irrigate the colstomy to promote regular bowel movements" -"I will restrict my fluid intake to 2,000 mL of fluid a day"

-"I will avoid eating foods such as broccoli and cauliflower" --A colostomy is a surgical procedure that creates an opening in the abdominal wall for the passage of stool to bypass an obstructed or diseased portion of the colon. Stool drains through the intestinal stoma into a pouch device secured to the skin. Colostomies can be performed on any part of the colon. Depending on the location of the colostomy, characteristics of the stool will vary, with the stool becoming more solid as it passes through the colon. Proper care of the ostomy and pouching device in clients with a colostomy includes ensuring sufficient fluid intake, preventing gas and odor, and changing the pouching system when it becomes one-third full to prevent leaks.

The clinic nurse provides teaching for a client scheduled for a barium enema the next day. Which statement by the client shows a need for further instruction? -"I can expect chalky-white stool after the procedure" -"I cannot eat or drink 8 hours before the procedure" -"I may have abdominal cramping during the procedure" -"I will avoid laxatives after the procedure"

-"I will avoid laxatives after the procedure" --A barium enema, or lower gastrointestinal series, uses fluoroscopy to visualize the colon outlined by contrast to detect polyps, ulcers, tumors, and diverticula. This procedure is contraindicated for clients with acute diverticulitis as it may rupture inflamed diverticula and cause subsequent peritonitis.

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

-"I will be sure we use condoms during intercourse as long as I have lesions" --Avoid sexual activity when lesions are present as the virus spreads through contact with the lesion; barrier contraception is not sufficient during an outbreak.

The clinic nurse is reviewing the plan of care with a client who has phenylketonuria and plans to become pregnant this year. Which statement from the client requires the nurse to intervene? -"I will consume more high-protein, iron-rich foods, such as meat and eggs, before and during pregnancy" -"I will use a special, low-phenylalanine formula for infant feeding if my baby is also diagnosed with PKU" -"It would be beneficial for my partner and I to have genetic counseling even though he does not have PKU" -"My baby will need to have adequate milk intake after birth to help ensure the screening test for PKU is accurate"

-"I will consume more high-protein, iron-rich foods, such as meat and eggs, before and during pregnancy" --PKU is characterized by deficiency or absence of an enzyme required to metabolize phenylalanine, an amino acid found in protein foods. High levels of phenylalanine can cause intellectual disability by interfering with brain growth and development, which is particularly concerning for the developing fetus and infant. Clients with PKU should follow a low-phenylalanin diet before and during pregnancy to prevent potential teratogenic effects. Avoiding high-protein foods helps to maintain phenylalanine levels in a safe range. If the newborn is also diagnosed with PKU, special formulas with low-phenylalanine will likely be required. Exclusive breastfeeding may pose harm to the newborn with PKU because phenylalanine is transferred via breastmilk.

The clinic nurse is teaching a client about the advance directive form that needs to be completed. Which statement indicates that the client understands the information? -"I will get this notarized as soon as I can" -"I will give a copy of this to my daughter, who is listed as my healthcare proxy" -"I'll put this on my fridge, so no one will give me CPR" -"You and my daughter can witness this for me"

-"I will give a copy of this to my daughter, who is listed as my healthcare proxy" --An advance directive is placed in the client's medical record and copies are given to healthcare proxies. Two witnesses are required for completion of the advance directive, but they should not be the healthcare proxies listed in the document.

A client with a history of headaches is scheduled for a lumbar puncture to assess the cerebrospinal fluid pressure. The nurse is preparing the client for the procedure. Which statement by the client indicates a need for further teaching by the nurse? -"I may feel a sharp pain that shoots to my leg, but it should pass soon" -"I will go to the bathroom and try to urinate before the procedure" -"I will need to lie on my stomach during the procedure" -"The physician will insert a needle between the bones in my lower spine"

-"I will need to lie on my stomach during the procedure" --CSF is assessed for color, contents, and pressure. Normal CSF is clear and colorless, and contains a little protein, a little glucose, minimal white blood cells, no red blood cells, and no microorganisms. Normal CSF pressure is 60-150 mm H20. Abnormal CSF pressure or contents can help diagnose the cause of headaches in complicated cases. CSF is collected via lumbar puncture or ventriculostomy. Prior to a lumbar puncture, clients are instructed as follows: empty the bladder before the procedure; the procedure can be performed in the lateral recumbent position or sitting upright to help widen the space between the vertebrae and allow easier insertion of the needle; a sterile needle will be inserted between L3/4 or L4/5 interspace; pain may be felt radiating down the left, but it should be temporary. After the procedure, the client is instructed to lie flat with no pillow for at least 4 hours to reduce the chance of spinal fluid leak and resultant headache and increase fluid intake for at least 24 hours to prevent dehydration.

The nurse reinforces education to a female client about the use of a cervical cap to prevent pregnancy. Which statement by the client indicates a need for further teaching? -"I should apply spermicide to the cervical cap before inserting it" -"I should not use the cervical cap while I am on my period" -"I will remove and clean the cervical cap as soon as possible after intercourse" -"It is okay for me to insert the cervical cap several hours before I have sex"

-"I will remove and clean the cervical cap as soon as possible after intercourse" --The cervical cap is a barrier method of contraception used with spermicide. The reusable, cup-shaped cap is placed over the cervix before intercourse to block sperm from the uterus. To allow time for sperm to die, the cap should remain in place for > 6 hours after intercourse but should not remain for more than 48 hours. The cap may remain in place for multiple acts of intercourse, but clients should confirm correct placement and insert additional spermicide into the vagina each time.

The nurse is teaching general skin care guidelines to a client receiving teletherapy (external beam radiation therapy). Which statements does the client make that indicate proper understanding of the teaching? SATA -"I may apply an ice pack to the treatment site if it begins to burn" -"I will rub baby oil after each treatment to prevent dry skin" -"I will use extra measures to protect my skin from sun exposure" -"I will wash the treatment site with lukewarm water and mild soap" -"I will wear soft, loose-fitting clothing

-"I will use extra measures to protect my skin from sun exposure" -"I will wash the treatment site with lukewarm water and mild soap" -"I will wear soft, loose-fitting clothing" --Clients receiving teletherapy often experience significant effects to the skin of the treatment area. Teaching essential skin care standards to these clients is focused on preventing infection and promoting healing of the affected skin

A client is 1-day postoperative abdominoplasty and is discharged to go home with a Jackson-Pratt (JP) closed-wound system drain in place. The nurse teaches the client how to care for the drain and empty the collection bulb. Which statement indicates that the client needs further instruction? -"I'll empty the JP bulb when it is totally full so that I don't have to unplug it so many times" -"I'll pull the plug on the JP bulb and pour the drainage into the measurable specimen cup" -"I'll squeeze the JP bulb from side-to-side so I hold it in my hand" -"While the JP bulb is totally compressed, i'll clean the spout with alcohol and replace the plug'

-"I'll empty the JP bulb when it is totally full so that I don't have to unplug it so many times" --A closed-wound drain device is used to prevent fluid buildup at the surgical wound site and promote healing. Empty the device every 4-12 hours unless it is 1/2 to 2/3 full before then. Drainage tube patency and negative pressure in the reservoir (bulb) must be maintained to provide adequate drainage.

A client is being discharge home after an open radical prostatectomy. Which statement indicates a need for further teaching? -"I will drink lots of water" -"I will try to walk in my driveway twice a day" -"I will wash around my catheter twice a day" -"If I get constipated, I will use a suppository"

-"If I get constipated, I will use a suppository" --Following open radical prostatectomy, any rectal interventions such as suppositories or enemas must be avoided to prevent stress on the suture lines and problems with healing in the surgical area. The client should not strain when having a bowel movement for these reasons. Therefore, interventions to prevent constipation are an important part of postoperative care and discharge teaching. Prevention of constipation is particularly important while the client remains on opioid analgesics, which can cause constipation.

The nurse is providing education to a client with a new prescription for progestin-only pills (POPs). Which statement about POPs is appropriate for the nurse to include? -"If you begin vomiting any time within 24 hours of taking the pill, take an additional pill" -"If you take your pill 3 or more hours after your usual time, use a backup contraceptive" -"In your pill pack, there are 21 days of progestin pills and 7 days of inactive iron pills" -"The use of POPs increases your risk of developing deep venous thrombosis"

-"If you take your pill 3 or more hours after your usual time, use a backup contraceptive" --Progestin-only pills ,a form of oral contraception, work by thickening cervical mucus, thinning the endometrium, and preventing ovulation. Cervical mucus changes last only approximately 24 hours, so the client must take the pill at the same time every day for it to be effective. If the pill is taken > 3 hours late, a barrier method is advised until the pill is taken correctly for 2 days. An additional POP should be taken if diarrhea or vomiting occurs within 3 hours of the last dose. In a POP pack, there are no inactive pills. The client does not take a break from the hormone to menstruate.

During a routine clinic visit, the nurse is providing education to a 24-year-old female client with Marfan syndrome and aortic root dilation. Which statement made by the nurse is appropriate? -"Call the healthcare provider to stop your beta blocker if pregnancy occurs" -"If you plan to become pregnant, it is best to wait a few years and plan it at an older age" -"It is important to consistently use a reliable form of birth control" -"Your condition is not inheritable to your future children"

-"It is important to consistently use a reliable form of birth control" --Marfan syndrome is a connective tissue disorder that causes visual and cardiac defects and a distinct long, slender body type. In Marfan syndrome with aortic vessel involvement, the root of the aorta is dilated or weakened, increasing the risk of aortic dissection and aortic rupture. Increases in blood volume and cardiac workload that occur during pregnancy may worsen aortic root dilation and further increase the risk of aortic dissection/rupture. Pregnancy in clients with Marfan syndrome, especially those with aortic root dilation, poses a high risk of maternal mortality. Clients should be instructed about the importance of consistently using reliable birth control methods to prevent pregnancy. Clients with Marfan syndrome considering pregnancy should be counseled to complete childbearing in early adulthood because aortic root dilation and the risk of aortic dissection/rupture increase with time.

The primary health care provider prescribes a 24-hour urine collection for a client with suspected Cushing syndrome. Which instructions should the nurse give the client regarding this test? SATA -"A continuous urinary catheter must be inserted for this test and the urine will collect in an attached bag" -"Keep the urine collection container in the refrigerator or a cooled ice chest when it is not in use" -"Only daytime urine should be collected in the container as cortisol levels are higher in the morning" -"Record the time the urine collection is started and then empty the bladder into the toilet so that the start time coincides with an empty bladder" -"you will be given a dark plastic jug containing a powder that absorbs into the urine that you will collect in the jug"

-"Keep the urine collection container in the refrigerator or a cooled ice chest when it is not in use" -"Record the time the urine collection is started and then empty the bladder into the toilet so that the start time coincides with an empty bladder" -"you will be given a dark plastic jug containing a powder that absorbs into the urine that you will collect in the jug" ---a 24-hour urine is collected to test for increased cortisol levels when evaluating for Cushing syndrome. The client should be taught to collect the urine in a dark jug issued by the lab, start time and then empty the bladder and discard the 1st urine, and collect all the urine for 24 hours; it is kept in the refrigerator or ice chest with a secure lid. Exactly 24 hours after start time, empty bladder once more into the collection container. Use a dark jug containing a special powder to protect urine from light during collection. The powder helps preserve the urine and adjusts its acidity.

The nurse is eating lunch in the hospital cafeteria, which is crowded with visitors and other staff. A healthcare provider approaches the nurse and asks, "How is my client Mrs. Jones in Room 312 doing?" Which response by the nurse is appropriate? -"I don't know because I am off duty right now" -"Let's step away from the crowd to discuss it" -"Mrs. Jones was fine when I last checked on her during rounds" -"You will have to talk with the nurse caring for her while I am on break"

-"Let's step away from the crowd to discuss it" --The nurse is ethically and legally obligated to protect clients' privacy and maintain confidentiality of their medical information. If another staff member asks a question about a client's medical information in an open area with visitors, the nurse should first move the conversation to a secure area. Answering the question will promote further conversation, making it likely that the client's privleged healthcare information will be discussed and overheard by others. The best response is to suggest changing the location of the conversation so that the information can be discussed privately. It is appropriate to direct questions about the client to the currently assigned nurse; however, this response violates the client's privacy by confirming the client's presence in the hospital. It is best to make the conversation private before sharing any information

The nurse is reinforcing teaching to a client with a hiatal hernia. Which statement by the client indicates that further teaching is needed? -"I need to raise the head of my bed on blocks by at least 6 inches: -"I will remain sitting up for several hours after I eat my food" -"If my reflux and abdominal pain don't improve, I might need surgery" -"Losing weight may reduce my reflux, so I plan to take a weight-lifting class"

-"Losing weight may reduce my reflux, so I plan to take a weight-lifting class" --Hiatal hernia is a group of medical conditions characterized by abnormal movement of the stomach and/or esophagogastric junction into the chest due to a weakness in the diaphragm. although hiatal hernias may be asyptomatic, many people experience heartburn, chest pain, dysphagia, and shortness of breath when the abdominal organs move into the chest. Symptoms of hiatal hernias are often exacerbated by increased abdominal pressure, which promotes upward movement of abdominal organs. Clients with hiatal hernias who are obese are often encouraged to lose excess weight by performing light activities because obesity increases abdominal pressure. However, nurses should teach clients to avoid activities that promote straining. --sitting up for several hours after meals and sleeping with the head of the bed elevated at least 6 inches reduces upward movement of the hernia and decreases the risk of gastric reflux.

A nurse cares for a client with impairment of cranial nerve VIII. What instructions will the nurse provide the UAP prior to delegating interventions related to the client's activities of daily living? -"Be aware of the client's shoulder weakness and provide support as needed" -"Ensure that the client sits upright and tucks the chin when swallowing food" -"Explain all procedures in step-by-step detail before performing them" -"Make sure the items needed by the client are within reach"

-"Make sure the items needed by the client are within reach" --The client has an impairment of the vestibulocochlear nerve. Symptoms of impairment may include loss of hearing, dizziness, vertigo, and motion sickness, which place the client at a high risk for falls. Therefore, when instructing the UAP about helping the client with ADL's, the nurse emphasizes the need to keep items at the bedside within the client's reach. --weakness of the shoulder muscle occurs with impairment of CN XI, the spinal accessory nerve. Dysphagia may occur with impairment of CN IX (glossopharyngeal) and XN X (vagus), not CN VIII. Impairment of visual acuity occurs with disorders affecting CN II (optic).

While delegating to the UAP, the RN should utilize the 5 rights of delegation. The "right direction and communication" related to the task is one of those rights. Which statement best meets that standard? -"I need for you to take vital signs on all clients in rooms 1-10 this morning" -"Mr Wu's blood pressure has been low. Please take his vital signs first and let me know if his systolic blood pressure is <100" -"Mrs. Jones fell out of bed during the night. Be sure you keep a close eye on her this shift" -"Would you please make sure Mr. Garcia in bed 8 ambulates several times?"

-"Mr Wu's blood pressure has been low. Please take his vital signs first and let me know if his systolic blood pressure is <100" -The RN should communicate directions to the delegate that include any unique client requirements and characteristics as well as clear expectations on what to do, what to report, and when to ask for assistance. The time frame for option one should be more specific. The instruction in option two to "keep a close eye" on the client leaves the UAP too much room for interpretation. Instructions in option 4 are too broad and do not provide a specific time frame, as well and lacks the method needed to accomplish the task.

The healthcare provider prescribes clomiphene for 5 days, beginning on the fifth day of menses, for treatment of infertility. After the nurse provides medication teaching, which client statement would indicate a need for further teaching? -"Clomiphene increase my risk of having more than one baby, such as twins or triplets" -"Hot flashes, mood swings,nausea, and headache are possible side effects of this medication" -"My partner and I should have sexual intercourse on the days that I am taking the medication" -"This medication will help my body release eggs and increase my chance of becoming pregnant"

-"My partner and I should have sexual intercourse on the days that I am taking the medication" --Clomiphene is a selective estrogen receptor modulator that is used as a first-line treatment for infertility for women and works by stimulating ovulation. This medication blocks estrogen receptors in the hypothalamus and pituitary, which causes the release of hormones that stimulate the ovaries to release an egg. The medication is taken orally for 5 days early in the menstrual cycle. Ovulation typically occurs 5-9 days after completing the medication. Therefore, it is necessary for the client to understand the importance of engaging in frequent sexual intercourse 5 days after completing the medication for the best chance of successful conception.

The nurse employed in a woman's healthcare clinic would be most concerned about which client statement? -"I recently noticed a small, round, painless, mobile lump in my left breast while showering" -"Last night while breastfeeding, my nipples were cracked and my breasts were painful" -"My right breast is red and warm with little tiny indented areas on the surface of the skin" -"Sometimes during my cycle, I notice breast nodules that are movable and feel soft to the touch"

-"My right breast is red and warm with little tiny indented areas on the surface of the skin" --The nurse would be most concerned about the client who describes symptoms of inflammatory breast cancer. In this aggressive form of cancer, breast lymph channels are blocked by cancer cells,creating breast tissue that becomes red, warm, and has an orange peel,pitting appearance on the skin surface. The nurse would be most concerned about this client and make an immediate referral to the healthcare provider for examination and evaluation.

The nurse is caring for a client with absence seizures. The UAP asks if the client will "shake and jerk" when having a seizure. Which response from the nurse is the most helpful? -"No, absence seizures can look like daydreaming or staring off into space" -"No, you are wrong. Don't worry about that" -"Yes, so please let me know if you see the client do that" -"You don't have to monitor the client for seizures"

-"No, absence seizures can look like daydreaming or staring off into space" --Absence seizures are brief periods of staring; there is no evidence of tonic-clonic activity or postictal confusion. The UAP should be educated about absence seizures when involed in the care of such clients.

The nurse is providing teaching about contraception to a group of clients. Which statement by the nurse is appropriate to include? -"Backup contraception is required for the first 3 months after initiation of oral contraceptives" -"Diaphragm contraceptive devices, when used with spermicide, also provide protection from HIV infection" -"OTC emergency contraceptives should be taken within 3 days of unprotected intercourse" -"Use of an intrauterine device should be avoided in sexually active adolescent clients"

-"OTC emergency contraceptives should be taken within 3 days of unprotected intercourse" --Emergency contraception prevents pregnancy after unprotected intercourse. OTC EC pills should be taken within 3 days of unprotected sexual intercourse. If taken after 3 days, levonorgestrel will not harm an established pregnancy but may be less effective. Copper intrauterine device insertion and oral ulipristal require a prescription and offer EC for up to 5 days after unprotected intercourse. --Backup contraception is required for 7 days after starting oral contraceptives; however, it is not required if the pill pack is started on the first day of menses.

The RN is caring for a postoperative client with a Hemovac drain. Which task is inappropriate for the RN to ask the experienced UAP to perform? -"Please change the sterile dressing on the Hemovac drain insertion site when you bathe the client" -"Please measure the Hemovac drainage at 2:00 PM and let me know how much there was" -"Please record the amount of the Hemovac drainage on the intake and output record at the end of the shift" -"Please remember to compress the Hemovac device immediately after emptying to restore negative pressure, as you were taught"

-"Please change the sterile dressing on the Hemovac drain insertion site when you bathe the client" --Although the UAP can perform procedures that require observing principles of infection control and transmission of microorganisms, the UAP should not change sterile dressings or perform drain care. That is the responsibility of the RN.

The caregiver of a toddler calls the clinic because the child has accidentally ingested one capsule of amitriptyline found in the medicine cabinet. The caregiver states that the child appears to be acting normally. Which response by the nurse is appropriate? -"give syrup of ipecac immediately and proceed to the hospital" -"Please go directly to the nearest emergency department for evaluation" -"Stay home and monitor the child closely for any symptoms" -"You should come immediately to the clinic with the pill bottle"

-"Please go directly to the nearest emergency department for evaluation" --Amitriptyline is a tricyclic antidepressant that can produce cardiac toxicity ad neurological disturbances by altering cholinergic pathways, sodium channels, and calcium channels, causing symptoms such as arteroventricular block, hypotension, cardiac arrest, and seizure. TCAs have a narrow therapeutic index and rapid onset of action, so ingestion of even a small amount may be life-threatening for a toddler. Symptoms of toxicity are usually evident within hours of ingestion, but cardiac failure can develop days after. Neurological and hemodynamic assessments, as well as ECG monitoring in an emergency department setting is recommended.

The RN is supervising a graduate nurse providing postoperative teaching for a male client after an inguinal hernia repair. Which statement by the GN would cause the RN to intervene? -"Elevate your scrotum and apply an ice bag to reduce swelling" -"Practice coughing to clear secretions and prevent pneumonia" -"Stand up to use the urinal if you have difficulty voiding" -"Turn in bed and perform deep breathing every 2 hours"

-"Practice coughing to clear secretions and prevent pneumonia" --An inguinal hernia is the protrusion of abdominal contents through the inguinal canal, which appears as a bulge in the lateral groin. Herniation occurs spontaneously or results from increased intraabdominal pressure. Inguinal hernias occur most commonly in male clients and are usually repaired with minimally invasive surgery. If intestinal strangulation develops, the client requires emergency treatment to prevent bowel ischemia or perforation. Strangulation symptoms include abdominal distension, severe pain, N/V. To prevent hernia reoccurrence after surgical repair, the client is taught to avoid activities that increase intraabdominal pressure for 6-8 weeks. If sneezing or coughing are unavoidable, the client should splint incisions and keep the mouth open while sneezing.

The nurse is assessing the cranial nerves and begins testing the facial nerve (cranial nerve VII). Which direction should the nurse give the client to test this cranial nerve? -"close your eyes and identify this smell" -"Follow my finger with your eyes without moving your head" -"Look straight ahead and let me know when you can see my finger" -"Raise your eyebrows, smile, and frown"

-"Raise your eyebrows, smile, and frown" --This cranial nerve is tested by assessing exaggerated facial movements. The client is directed to raise the eyebrows, furrow the eyebrows, draw up the cheeks in a large smile, pull the cheeks down in a frown, and open the lips to show the teeth. Any asymmetrical movements are documented, and if unexpected, the healthcare provider is notified.

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

-"Sometimes my hands and feet get a tingling sensation" --Clients who follow a vegan diet eat only plant-based foods, omitting animal proteins and products. Clients who are vegan are at risk for deficiency of vitamin B12, which is primarily supplied by animal products. Chronic vitamin B12 deficiency may precipitate megaloblastic anemia and neurological symptoms across the entire nervous system, from peripheral nerves to the spinal cord and brain. Manifestations of chronic deficiency includes peripheral neuropathy, neuromuscular impairment, memory loss/dementia. Clients who follow a vegan diet are encouraged to take supplemental vitamin B12 to prevent severe neurological complications. In addition, clients are taught to incorporate vitamin B12 fortified foods.

The clinic nurse is assessing a previously healthy 60-year-old client when the client says, "my hand has been shaking when I try to cut food. I did some research online. Could I have Parkinson's disease?" Which response from the nurse is the most helpful? -"It can't be Parkinson's disease because you aren't old enough" -"Make sure you tell the physician about your concerns" -"Parkinson's disease does not cause that kind of hand shaking" -"Tell me more about your symptoms. When did they start?"

-"Tell me more about your symptoms. When did they start?" --Parkinson's disease is a chronic, progressive neurodegenerative disorder that involves degeneration of the dopamine-producing neurons. Damage to dopamine neurons makes it difficult to control muscles through smooth movement. PD is characterized by a delay in initiation of movement (bradykinesia), increased muscle tone (rigidity), resting tremor, and shuffling gait. The most helpful response by the nurse is the one that acknowledges the concern of the client and also asks for more information. The nurse should assess for additional information and perform a more focused physical assessment given this new information.

An adult diagnosed with celiac disease 3 weeks ago was placed on a gluten-free diet. The client returns for ambulatory care follow-up, reports continuation of symptoms, and does not seem to be responding to therapy. Which is the best response by the nurse? -"I will refer you to the dietitian" -"It should take about 6-8 weeks before you see improvement in your symptoms" -"Tell me what you had to eat yesterday" -You must not be following your diet"

-"Tell me what you had to eat yesterday" --The client with celiac disease continues to have symptoms. An assessment of the client's food intake must be obtained to determine if it includes foods that contain gluten, a protein in barley, rye oats, and wheats (BROW). The most common reason for non-responsiveness to a gluten-free diet in clients with celiac disease is that gluten has not been entirely eliminated from their food intake. --most people experience dramatic relief of GI symptoms within a few days of eliminating gluten from their diet.

An experienced nurse precepts a graduate nurse in the intensive care unit while caring for a client with a right subclavian triple-lumen central venous catheter. Which statement by the graduate nurse indicates understanding of the CVC? -"All 3 lumens come together, so all drugs infused through the CVC must be compatible" -"It is used to provide enteral nutrition to the client who cannot eat" -"Sterile gloves must be worn when administering drugs through the CVC" -"The lumen hub should be cleaned thoroughly with antiseptic prior to drug administration"

-"The lumen hub should be cleaned thoroughly with antiseptic prior to drug administration" --A central line or central venous catheter is inserted by the healthcare provider in a "central" vein and is used to administer fluids, medications, and parenteral nutrition and for hemodynamic monitoring.

A student nurse is preparing to administer the hepatitis B vaccine to a newborn. Which statement by the student nurse requires the preceptor to provide further teaching? -"A 5/8 inch, 25 gauge needle is appropriate for intramuscular injection in newborns" -"I will clean the injection site with an antiseptic swab before administration" -"I will draw the medication into a 1-mL syringe" -"The medication should be administered into the deltoid muscle"

-"The medication should be administered into the deltoid muscle" --IM injections are commonly administered to newborns shortly after birth or before discharge. The vastus lateralis muscle in the anterolateral middle portion of the thigh is the preferred site for IM injections in newborns and infants. The deltoid muscle is an inappropriate injection site for newborns due to inadequate muscle mass. For IM injections, the needle length should be 5/8 inch for newborns and 5/8 to 1 inch for infants; these lengths are adequate for reaching the muscle mass while avoiding underlying tissues. A 22- to 25-gauge needle is appropriate for clients age <12 months. The medication should be administered using aseptic technique; cleaning the site with an antiseptic solution is appropriate. A 1-mL syringe should be used to measure very small doses in 0.01-mL increments for newborns, infants, and small children. Pediatric medication dosages can be very small and should be measured to two decimal places.

A home health nurse is visiting a 72 year-old client who had coronary artery bypass graft surgery 2 weeks ago. The client reports being forgetful and becoming teary easily. How should the nurse respond? -"Don't worry. You'll feel better in a few weeks" -"How well are you sleeping at night?" -"These symptoms can be common after major surgery. It will take 4-6 weeks to completely heal and start to feel normal again" -"You may be experiencing depression. I'll call the healthcare provider and see if we can get a prescription for an antidepressant"

-"These symptoms can be common after major surgery. It will take 4-6 weeks to completely heal and start to feel normal again" --Clients who have undergone surgery may experience some postoperative cognitive dysfunction. This may include memory impairment and problems with concentration, language comprehension, and social integration. Some clients may cry easily or become teary. The risk for POCD increases with advanced age and in clients with preexisting cognitive deficits, longer operative times, intraoperative complications, and postsurgical infections. POCD can occur days to weeks following surgery. Most symptoms typically resolve after complete healing has occurred. In some cases, this condition can become a permanent disorder.

The nurse is providing discharge education for a postoperative client who had a partial layrgnectomy for laryngeal cancer. The client is concerned because the healthcare provider said there was damage to the ninth cranial nerve. Which statement made by the nurse is most appropriate? -"I will ask the healthcare provider to explain the consequences of your procedure" -"This is a common complication that will require you to have a hearing test every year" -"This is a common complication; your healthcare provider will order a consult for the speech pathologist" -"This is the reason you are using a special swallowing technique when you eat and drink"

-"This is the reason you are using a special swallowing technique when you eat and drink" --CN IX (glossopharyngeal) is involved in the gag reflex, ability to swallow, phonation, and taste. Postoperative partial laryngectomy clients will need to undergo evaluation by a speech pathologist to evaluate their ability to swallow safely to prevent aspiration. Clients are taught the supraglottic swallow, a technique that allows them to have voluntary control over closing the vocal cords to protect themselves from aspiration.

The nurse enters a client's room and finds that the client and spouse are crying. The spouse states that the healthcare provider just diagnosed the client with Alzheimer disease. What is the best response by the nurse? -"Do you have any questions about the diagnosis?" -"There are medications available to treat Alzheimer disease" -"This new diagnosis must be frightening for you" -"we can help you make decisions about your care"

-"This new diagnosis must be frightening for you" --When clients and families are faced with significant life changes, the nurse should support the process of coping by encouraging emotional expression. The nurse provides support by expressing empathy, actively listening, and encouraging therapeutic communication

The nurse provides discharge instructions to a client one day after laparoscopic cholecystectomy. Which statement by the client indicates that further teaching is required? -"I can resume a regular diet but will avoid fatty foods for several weeks after surgery" -"I can return to work within a week of surgery" -"I will report to the HCP if my temperature is higher than 101 F" -"Tomorrow I can remove the puncture she bandages and take a bath"

-"Tomorrow I can remove the puncture she bandages and take a bath" --A laparoscopic cholecystectomy is the safest and most commonly used procedure for gallbladder removal. A laparoscope and grasping forceps are inserted through small punctures made in the abdomen. The procedure is associated with decreased postoperative pain, better cosmetic results, shorter hospital stays, and fewer days for recovery versus the open technique. postoperative teaching includes a low-fat diet (recommended). A regular diet can be resumed after a few weeks, although weight loss is often recommended. Resume normal activity slowly, as tolerated. Most individuals can return to work within a week. Dressings can be removed the day after surgery and showering is permitted at this time.

The nurse prepares a client for discharge following a vasectomy. The client asks "When can I have sexual intercourse with my wife without using a condom?" What is the best response by the nurse? -"Discontinue alternative birth control after at least 5 ejaculations" -"There is no need to use alternative birth control following today's procedure" -"Use alternative birth control for 6 months following today's procedure" -"Use alternative birth control until cleared by the health care provider"

-"Use alternative birth control until cleared by the health care provider" --A vasectomy is a surgical procedure performed for permanent male sterilization. During the procedure, the vasa deferentia are cut and sealed, preventing sperm from entering the ejaculate. The vasa deferentia are severed in the scrotum at the site before the seminal vesicles and prostate. As a result, the procedure should not affect the ability to ejaculate, amount and consistency of ejaculatory fluid, or other physiological mechanisms. Following a vasectomy, sperm continue to be produced but are absorbed by the body. Following the procedure, it can take sever months for the remaining sperm to be ejaculated or absorbed. Alternative birth control should be used until the healthcare provider confirms that semen samples taken at a follow-up appointment are free of sperm.

A 28-year-old client is seeking advice from the nurse about why she has not been able to conceive. The client is discouraged and states that she has been "trying to get pregnant for 4 months." Which statement by the nurse is best? -"Adoption or surrogacy are options for those who are unable to conceive" -"Consider talking to your HCP about fertility-enhancing medications that can help you conceive more quickly" -"There is no cause for concern unless you haven't been able to conceive for 1 year" -"Using an OTC urine ovulation detector kit to time sexual intercourse may improve your chances of conceiving"

-"Using an OTC urine ovulation detector kit to time sexual intercourse may improve your chances of conceiving"

The student nurse is preparing to perform a heel stick on a neonate to collect blood for diagnostic testing. Which statement by the student nurse indicates a need for further education? -"I can perform the stick on either the medial or lateral side of the outer aspect of the heel" -"Sucrose and a pacifier can help alleviate the infant's pain and stress during the puncture" -"The heel area should be warmed for 3-5 minutes prior to puncture" -"Venipuncture should be reserved only for failed heel sticks because it is more painful"

-"Venipuncture should be reserved only for failed heel sticks because it is more painful" ---To perform a neonatal heel stick, select a location on the medial or lateral side of the outer aspect of the heel to avoid insult to the calcaneus bone. Provide comfort measures, warm the selected puncture site to promote vasodilation, cleanse with alcohol, and puncture using an automatic lancet. An acceptable alternate method of blood collection in the neonate is venipuncture. It is considered less painful and often requires fewer punctures to obtain a sample, especially if a larger volume is needed.

A client who was placed in restraints appears in the hallway an hour later and states "I'm Houdini. I can get out of anything. There could be trouble now." Which of the following is the best response to this client? -"How are you feeling now?" -"How did you manage to get out of the restraints?" -say nothing but signal to other staff that assistance is needed -"What kind of trouble are you thinking about?"

-"What kind of trouble are you thinking about?" --A client at high risk for violence, self-directed or other-directed, may need to be placed in restraints as a last resort. Frequent monitoring and assessment through observation and use of therapeutic communication techniques will help determine if a client is ready to have restraints removed.

The nurse provides discharge teaching for a client who is newly diagnosed with diabetes mellitus. Which statement by the client regarding sick-day rules indicates a need for further teaching? -"I will make sure that I monitor my blood glucose more frequently when I am sick" -"I will make sure to notify my health care provider when I am sick" -"When I am sick and not eating, I will not take my insulin until my appetite improves" -"When I am sick, I will drink 8-12 ounces of fluid every hour I am awake

-"When I am sick and not eating, I will not take my insulin until my appetite improves" --stress caused by illness, injury, or surgery causes increased secretion of corticosteroids that may result in impaired glycemic control and acute hyperglycemia in clients with diabetes mellitus. IF blood glucose is not controlled, the client can develop life-threatening ketoacidosis or hyperosmolar states. Therefore, the nurse should instruct clients with DM about sick-day DM management to detect and act on potentially dangerous hyperglycemic stats. Most importantly, the nurse should teach the client to frequently check blood glucose and to take insulin as prescribed during illness, even if there is no oral intake or it is poor, to avoid hyperglycemia and possible diabetic ketoacidosis.

The nurse iscaring for a client with increased ICP. Which statement by the UAP would require immediate intervention by the nurse? -"I will raise the HOB so it is easier to see the TV" -"I will turn down the lights when I leave" -"Let me move your belongings closer so you can reach them" -"You should do deep breathing and coughing exercises"

-"You should do deep breathing and coughing exercises" --Clients with elevated ICP should avoid anything that increases intrathoracic or intraabdominal pressure as these also indirectly increases ICP. These activities include straining, coughing, and blowing the nose. Respiratory interventions, if needed, may include deep breathing and incentive spirometry in the absence of coughing. The HOB should be maintained at 30 degrees, high enough to allow for CSF drainage, but low enough to maintain cerebral perfusion pressure. Clients should have minimal stimuli, including no bright lights or multiple visitors, so stimulation can increase ICP.

A client with multiple sclerosis is voicing concerns to the nurse about incoordination when walking. Which of the following instructions by the nurse would be most appropriate at this time? -"Avoid excess stretching of your lower extremities" -"Build strength by increasing the duration of daily exercise" -"Let me speak with you HCP about getting a wheelchair" -"You should keep your feet apart and use a cane when walking"

-"You should keep your feet apart and use a cane when walking" --Multiple sclerosis is a progressive, demyelinating disease of the central nervous system that interrupts nerve impulses, causing a variety of symptoms. Symptoms may vary, but muscle weakness, spasticity, incoordination, loss of balance, and fatigue are usually present, causing impaired mobility and risk for fall and injury. Walking with the feet apart increases the support base, improving steadiness and gait. Assistive devices, such as a cane or walker, are usually required as demyelination of the nerve fibers progresses. --fatigue is a common symptom with MS. Rather than increasing the duration, clients should balance exercise with rest. Clients should also exercise when the weather is cool and stay hydrated; dehydration and extremes in temperature cause symptom exacerbation.

A nurse is teaching home management to a client newly diagnosed with severe psoriasis. Which client statement indicates that further teaching is needed? -"exposure to sunlight will worsen my psoriasis" -"I should avoid drinking alcohol" -"I should use moisturizing creams frequently" -"Stress can worsen psoriasis"

-"exposure to sunlight will worsen my psoriasis" --Psoriasis is a chronic autoimmune disease that causes a rapid turnover of epidermal cells. Characteristic silver plaques on reddened skin may be found bilaterally on the elbows, knees, scalp, lower back, and/or buttocks. The goal of therapy is to slow epidermal turnover, heal lesions, and control exacerbations. There is no cure for psoriasis. Disease management includes avoidance of triggers, topical therapy, phototherapy, and systemic medications, including cytotoxic and biologic agents. The client should avoid alcohol as it can worsen psoriasis. In addition, the liver, kidneys, and bone marrow are specifically affected by the systemic medications commonly used to control psoriasis

The nurse is caring for a young adult who is considering becoming pregnant. The client expresses concern, stating, "One of my parents has Huntington disease, and I am afraid my child will get it." How should the nurse respond? -"genetic counseling is recommended. You will receive a referral before you leave" -"Huntington disease inheritance requires both biological parents to carry the gene" -"There are other ways to grow your family. You should consider adoption" -"This disease occurs spontaneously and is not likely to affect your children"

-"genetic counseling is recommended. You will receive a referral before you leave" --Huntington disease is an incurable autosomal dominant hereditary disease that causes progressive nerve degeneration, which results in impaired movement, swallowing, speech, and cognitive abilities. Chorea is a hallmark sign. The onset of active disease is usually at age 30-50, and death from neuromuscular and respiratory complications typically occurs within 20 years of diagnosis. HD is confirmed by genetic testing. Clients who have a parent with HD and are considering having biological children should receive genetic counseling. --autosomal dominant traits require only one copy of the affected gene to manifest.

An adolescent client is brought to the emergency department after being in a serious motor vehicle crash. The client is undergoing cardiopulmonary resuscitation. The nurse calls the family to inform them to come to the hospital and a family member asks how the client is doing. Which is an example of the ethical principle of beneficence when responding to the client's family? -"he is critically ill and we are caring for his needs" -"His heart has stopped and we are attempting to revive him" -"I don't know how he is doing but you need to come" -"I will have the healthcare provider talk to you once you arrive"

-"he is critically ill and we are caring for his needs" --beneficence is the ethical principle of doing good. It involves helping to meet the client's emotional needs through understanding. This can involve withholding information at times. Stating that the client is critically ill and is being cared for meets the ethical principle of veracity but also avoids overwhelming the family before they travel to the hospital. The nurse does not want the family to be too distressed to process the situation and arrive safely.

The graduate nurse is reinforcing education on sitting on and standing up from a chair to a client with crutches. Which instruction by the graduate nurse would cause the supervising nurse to intervene? -"hold a crutch in each hand on both sides when standing up from a chair" -"Move to the edge of the chair before standing and use your unaffected leg to rise" -"Touch the back of your unaffected leg to the chair before preparing to sit" -"use an armrest or seat for assistance when lowering your body into a chair

-"hold a crutch in each hand on both sides when standing up from a chair" --Clients have prescribed crutches after a musculoskeletal injury must understand appropriate device use to facilitate independent ambulation, promote wound healing, and prevent injury. When educating a client to rise from sitting, the nurse instructs the client to hold the hand grips of both crutches in the hand on the affected side, move to the chair's edge, and hold the armrest with the hand on the unaffected side. The client then uses the crutches, armrest, and unaffected leg for support when rising. To sit, the client backs up to the chair and moves both crutches into the hand on the affected side. The client holds the armrest with the other hand and lowers the body.

The nurse assessing a client's pain would expect the client to make which statement when describing the abdominal pain associated with appendicitis? -"my pain is a burning sensation in my upper abdomen" -"my pain is an 8 out of 10 and on my left side below my belly button" -"my pain is excruciating in my lower abdomen above my right hip" -"my pain is intermittent in my abdomen and right shoulder"

-"my pain is excruciating in my lower abdomen above my right hip" --The appendix is a bling pouch located at the junction of the ileum of the small intestine and the beginning of the large intestine. When infected or obstructed, the appendix becomes inflamed, causing acute appendicitis. Clients with acute appendicitis attempt to decrease pain by preventing increased intraabdominal pressure and lying still with the right leg flexed. --Pain in the left lower quadrant is associated with diverticulitis. Other signs/symptoms include a palpable, tender abdominal mass and systemic symptoms of infection.

A healthy 50 year old client asks the nurse, "What must I do in preparation for my screening colonscopy?" Which statements by the nurse correctly answer the client's question? SATA -"no food or drink is allowed 8 hours prior to the test" -"Prophylactic antibiotics are taken as prescribed" -"Smoking must be avoided after midnight" -"The day prior to the procedure your diet will be clear liquids" -"You will drink polyethylene glycol as directed the day before"

-"no food or drink is allowed 8 hours prior to the test" -"The day prior to the procedure your diet will be clear liquids" -"You will drink polyethylene glycol as directed the day before" --The instructions prior to a nuclear gastric emptying scan include teaching the client to avoid smoking the day of the examination as delay of gastric emptying occurs with tobacco use. Smoking cessation per se has no role in colonoscopy.

A client is scheduled for coronary artery bypass surgery in the morning. In the middle of the night, the nurse finds the client wide awake. The client demonstrates symptoms of extreme anxiety and tells the nurse about wanting to refuse the surgery. Which statement by the nurse would be most appropriate? -"Please try not to worry, you have an excellent surgeion" -"tell me about how you feel about your surgery" -"Why are you considering refusing the surgery?" -"You have the right to make your own decisions and can refuse the surgery

-"tell me about how you feel about your surgery" ---This is the most appropriate statement to encourage the client to express the source of anxiety. Using an open-ended question enables the client to take control of the conversation and direct it to concerns about the surgery. The nurse can then address the specific concerns identified and provide individualized explanations and support.

The ICU nurse is caring for a client who has just been extubated. Which interventions are appropriate at this time? SATA --administer prescribed oral narcotics for throat pain --administer warmed, humidified oxygen via facemask --give the client ice chips to moisten the mouth --provide mouth care with oral sponges --start the client on incentive spirometer

--administer warmed, humidified oxygen via facemask --provide mouth care with oral sponges --start the client on incentive spirometer ----Recently extubated clients are at high risk for aspiration, airway obstruction, and respiratory distress. To prevent complications, clients are placed in high Fowler position to maximize lung expansion and prevent aspiration of secretions. Warmed, humidifies oxygen is administered immediately after extubation to provide high concentrations of supplemental oxygen without drying out the mucosa. Oral care is provided to decrease bacteria and contaminants, as well as promote comfort. Clients are instructed to frequently cough, deep breathe, and use an incentive spirometer to expand alveoli and prevent atelectasis.

An ED nurse is sent to the scene of a massive motor vehicle collision. A client there reports neck pain. Which actions should the nurse perform at this time? SATA --apply a hard cervical collar --assess neck range of motion --inspect client's respiratory pattern --position client flat on the firm surface --use logrolling technique if moving client.

--apply a hard cervical collar --inspect client's respiratory pattern --position client flat on the firm surface --use logrolling technique if moving client. --The initial priorities for a client with a suspected cervical spin injury are to ensure a patent airway and immobilize the spine to prevent further injury. This includes applying a rigid hard collar, placing the client on a firm surface, and moving the client as a unit (logrolling) if required. A soft foam cervical collar does not provide immobilization. Further stabilization is achieved by taping down the client's head and using straps to immobilize the arms, especially if the client is not cooperating. After immobilizing the client, the nurse should obtain a baseline set of vital signs to monitor for neurogenic shock (hypotension, bradycardia, poikilothermia), a potential complication of spinal cord injury. The nurse should also assess the client's respiratory rate, pattern, and effort. Presence of abdominal breathing or increased work of breathing may indicate impending loss of airway and require prompt rapid-sequence intubation. Movement of the neck/upper extremities should be avoided until cervical spine injury is ruled out with imaging, which is done after the spine is immobilized with a hard collar.

The nurse is preparing to defibrillate a client who suddenly went into ventricular fibrillation. Which steps are essential prior to delivering a shock? SATA --apply defibrillator pads --call out and look around to ensure that everyone is "all clear" --continue chest compressions until ready to deliver shock --ensure adequate IV sedation has been given --ensure that the synchronization button is turned on

--apply defibrillator pads --call out and look around to ensure that everyone is "all clear" --continue chest compressions until ready to deliver shock ---IV sedation is not necessary to defibrillation as the client is already unconscious. It is often given prior to elective synchronized cardioversion to ease anxiety and decrease pain. Synchronized cardioversion delivers a shock on the R wave of the QRS complex and would not be appropriate for a client in Vfib.

An intoxicated client not wearing a seatbelt drives into a metal barricade near the entrance to the ED. The client's head has hit the windshield and the client is unconscious. What nurse actions are appropriate? SATA --assess the client for a carotid pulse --determine the client's GCS --maintain airway with head-tilt/chin-life maneuver --place a hard cervical collar on the client --remove the client from the car onto a backboard.

--assess the client for a carotid pulse --determine the client's GCS --place a hard cervical collar on the client --remove the client from the car onto a backboard. ----The transference of kinetic energy to the client's body from an opposing force during sudden deceleration causes bodily injury. If the client is not wearing a seatbelt during an automobile crash, the client may strike the windshield, causing blunt-force trauma to the head, neck, or spine. The unconscious client should first be assessed for adequate breathing and the presence of a pulse. Using a rigid cervical collar, cervical spine immobilization must be maintained throughout the client assessment to minimize further injury. The client should be removed and placed on a backboard after the cervical spine has been stabilized. The nurse should also perform Glasgow Coma Scale scoring to determine the level of neurological impairment. If a client with possible spinal injuries is not breathing, or if the airway is occluded, the nurse should use the jaw-thrust technique. The head-tilt/chin-life maneuver may hyperextend the neck, compromising the cervical spine.

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? SATA --biting endotracheal tube --disconnected ventilator tubing --endotracheal tube cuff leak --excessive airway secretions --kinked ventilator tubing

--biting endotracheal tube --excessive airway secretions --kinked ventilator tubing --Mechanical ventilator alarms alert the nurse to potential problems caused by a change in the client's condition, a problem with the artificial airway, and/or 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. Any condition that decreases airway resistance (tube disconnect, extubation, endotracheal or tracheostomy tube cuff leak) would trigger the low-pressure limit alarm.

The charge nurse responds to a cardiac arrest with resuscitation in progress of an adult client. Which of the following actions by a resuscitation team member would cause the charge nurse to intervene? SATA --chest compressions are performed at a rate of 70-80/min --chest compressions are stopped for a 10-second pulse check every 2 minutes --defibrillator pads are applied at the left and right sternal borders --manual breaths are delivered at a rate of 2 breaths per 30 chest compressions --resuscitation team is alerted to remain clear of client before defibrillation

--chest compressions are performed at a rate of 70-80/min --defibrillator pads are applied at the left and right sternal borders ---Chest compressions are performed at a rate of 100-120/min and a depth of 2.0-2.4 inches, allowing complete chest recoil between compressions. Defibrillatory pads are placed on the right upper chest, just below the clavicle, and on the left lateral chest, near the anterior axillary line below the nipple line.

Appropriate use of indwelling catheters

--clients with urinary obstruction or retention, or a need for strict intake and output in critically ill clients -perioperative use for surgical procedures such as urologic surgery or prolonged surgeries, or when large doses of fluid or diuretics are given during surgery -during prolonged immobilization when bedrest is essential -to improve end-of-life comfort -to facilitate healing of an open perineal or sacral wound in continent clients

Emergency medical service personnel are transporting a near-drowning victim who is currently hypothermic. Based on anticipated vital signs, the nurse needs to prepare for which interventions? SATA --covering client with warm blankets --logrolling the client from side to side frequently --mechanical ventilation --warmed blood administration --warmed IV fluids

--covering client with warm blankets --mechanical ventilation --warmed IV fluids ---The initial management of near-drowning victim focuses on airway management due to potential aspiration, pulmonary edema, or bronchospasm. Hypoxia is managed and prevented by ensuring a patent airway via intubation and mechanical ventilation is necessary. Careful handling of the hypothermic client is important because as the core temperature decreases, the cold myocardium becomes extremely irritable. Frequent turning could cause spontaneous ventricular fibrillation and should not be performed during the acute stage of hypothermia. Continuous cardiac monitoring should be initiated. Unless blood loss has occurred from trauma during the near-drowning incident, administration of blood products is not indicated.

A nurse in the emergency department is caring for a homeless client just brought in with frostbite to the fingers and toes. The client is experiencing numbness, and assessment shows mottled skin. Which interventions should be included in the client's plan of care? SATA --apply occlusive dressings after rewarming --elevate affected extremities after rewarming --massage the areas to increase circulation --provide adequate analgesia --provide continuous warm water soaks

--elevate affected extremities after rewarming --provide adequate analgesia --provide continuous warm water soaks ---Frostbite involves tissue freezing, resulting in ice crystal formation in intracellular spaces that causes peripheral vasoconstriction, reduced blood flow, vascular stasis, and cell damage. Superficial frostbite can manifest as mottled, blue, or waxy yellow skin. Deeper frostbite may cause skin to appear white and hard and unable to sense touch.

Interventions to reduce the risk of ventilator-associated penumonia

--elevating HOB 30-45 degrees --providing oral care with antiseptic solutions and suctioning subglottic secretions --performing scheduled daily sedation vacations and maintaining appropriate client sedation levels --practicing strict hand hygiene

What is the mechanism of action of dopamine?

--enhance cardiac output by increasing myocardial contractility, increasing heart rate, and elevating blood pressure through vasoconstriction

Acute care for diverticulitis

--focuses on allowing the colon to reset and inflammation to resolve --NPO status --IV fluids to prevent dehydration --pain relief through IV medications --prevention of increased intraabdominal pressure --prevention of increased intestinal motility by avoiding laxatives and enemas

The nurse cares for an intubated client on mechanical ventilation with worsening cerebral edema from increased intracranial pressure (ICP). Which nursing interventions help reduce ICP? SATA --clustering as many interventions as possible when providing care --hyperventilating before suctioning --maintaining a quiet, dark environment --maintaining the head in a neutral midline position --suctioning for 30 seconds to remove endotracheal tube secretions at regular intervals

--hyperventilating before suctioning --maintaining a quiet, dark environment --maintaining the head in a neutral midline position ---Most nursing activities increase intracranial pressure in brain injuries. The goal is to reduce ICP while managing basic client needs. During interventions, ICP should not exceed 25 mm Hg and should return to baseline within a few minutes. Metabolic demands (pain, straining, agitation, shivering, fever, hypoxia) increase blood supply and raise ICP. The nurse should suction a maximum of 10 seconds and only as necessary to remove secretions. Prolonged suctioning increases ICP.

Which nursing interventions are appropriate for managing the care of a client receiving mechanical ventilation and continuous IV sedation? SATA --maintain the HOB at 30-45 degrees --mute ventilator alarms at night to allow the client to rest --pause sedation daily to assess weaning readiness --perform oral care with chlorhexidine solution --place a manual resuscitation bag at the bedside

--maintain the HOB at 30-45 degrees --pause sedation daily to assess weaning readiness --perform oral care with chlorhexidine solution --place a manual resuscitation bag at the bedside ---Although the client should have a quiet environment at night, ventilator alarms should never be muted, as they may indicate life-threatening complications

The nurse is caring for an 11-month-old child in the pediatric hospital. Which of these child's findings would be a common criterion to activate the rapid response team? SATA --new-onset right-sided paralysis of extremities --pulse rate sustained at 120/min --respirations continued at 38/min --sudden inability to be aroused to an awake state --temperature of 101.3 degrees F

--new-onset right-sided paralysis of extremities --sudden inability to be aroused to an awake state ---Rapid response teams are formed as a means to get critical care specialists to the bedside of clients who are not in a critical care unit when acute, significant changes occur in their condition. Each institution sets its own criteria, but it usually includes acute changes in heart rate, systolic blood pressure, respiratory rate, oxygen saturation, level of consciousness, and/or urine output.

A nurse is caring for an intubated client receiving a continuous sedative infusion. Which interventions by the nurse reflect correct understanding of preventing ventilator-acquired pneumonia? SATA --elevated the HOB 30-45 degrees --performing hourly in-line endotracheal suctioning --practicing strict hand hygiene --providing frequent oral care with chlorhexidine --scheduling daily sedation vacations

--practicing strict hand hygiene --providing frequent oral care with chlorhexidine --scheduling daily sedation vacations --elevated the HOB 30-45 degrees ---Mechanically ventilated clients are at risk for developing ventilator-associated pneumonia due to sedation and impairment of natural defenses by artificial airways.

Treatment of frostbite includes:

--remove clothing and jewelry to prevent constriction --do not massage, rub, or squeeze the area involved. --immerse the affected area in water heated to 98.6-102.2, preferably in a whirlpool. Higher temperatures do not significantly decrease rewarming time, but can intensify pain. --avoid heavy blankets or clothing to prevent tissue sloughing --provide analgesia as the rewarming procedure is extremely painful --as thawing occurs, the injured area will become edematous and may blister. Elevated injured area after rewarming to reduce edema --keep wounds open immediately after a water bath and allow them to dry before applying LOOSE, nonadherent sterile dressings --monitor for signs of compartment syndrome

Which would be the appropriate client criteria for activating a rapid response team at the hospital? SATA --GCS score of 9 throughout the shift --heart rate remaining at 58 beats/min for more than 1 hour --postoperative pain rated at 10 --respiratory rate maintaining an increase to 30 breaths/min --sustained change in level of consciousness for 10 minutes

--respiratory rate maintaining an increase to 30 breaths/min --sustained change in level of consciousness for 10 minutes ---The rapid response team is activated to marshal additional experienced and specialized resources for an acute need to try to prevent a client from deterioration into a code/arrest situation. The team has critical care expertise to provide immediate attention to unstable clients in noncritical care units and usually consists of a respiratory therapist, a critical care nurse, and a physician or advanced practice registered nurse.

Steps to perform defibrillation include:

--turn on defibrillator --place defibrillator pads on the client's chest --charge defibrillator. Chest compressions should continue until defibrillator has charged and is ready to deliver the shock -before delivering the shock, ensure that the area is "all clear". Confirm that no personnel are touching the client, bed, or any equipment attached to the client. --deliver the shock --immediately resume chest compressions

A nurse is caring for 4 clients. Which prescription by the healthcare provider would the nurse question and seek further clarification before administering? -0.45% sodium chloride solution for a client with severe gastroenteritis who had 12 episodes of diarrhea and vomiting in the past 4 hours -IV bolus of 1000mL 0.9% sodium chloride solution for a client in anaphylaxis due to a food allergy -IV bolus of 1000 mL 0.9% sodium chloride solution for a client with diabetic ketoacidosis who has a serum glucose level of 650 mg/dL -IV mannitol 25% solution for a client with a closed head injury who is exhibiting signs of increased intracranial pressure

-0.45% sodium chloride solution for a client with severe gastroenteritis who had 12 episodes of diarrhea and vomiting in the past 4 hours --the nurse should question the administration of a hypotonic IV solution to replace gastrointestinal tract fluid losses as this would create a concentration gradient and shift fluid out of the intravascular compartment into the interstitial tissue and cells, worsening the client's fluid volume deficit. Isotonic IV solutions have the same osmolality as plasma and are administered to expand intravascular fluid volume. These solutions replace fluid losses commonly associatedwith vomiting and diarrhea, burns, and traumatic injury. Anaphylaxis causes increased capillary permeability, leaking intravascular fluid into free spaces; this places the client at risk for hypotension. Therefore, isotonic solutions should be given to this client (client 2). Extreme hyperglycemia in a client with diabetic ketoacidosis results in osmotic diuresis and dehydration. The immediate initial treatment is IV fluid resuscitation with isotonic 0.9% sodium chloride to replace fluid losses, stabilize vital signs, reestablish urine output, and dilute the serum glucose concentration before initiating insulin therapy. A client with head trauma is at risk for increased intracranial pressure due to inflammation and cerebral edema. IV mannitol is an osmotic diuretic that reduces cerebral edema by pulling water from the cerebral cells into the vasculature.

What are examples of isotonic crystalloid solutions?

-0.9% NaCl -LR

The healthcare provider prescribes intravenous fluid resuscitation for a client in hypovolemic shock. The nurse should anticipate the rapid infusion of which intravenous solution initially? -0.9% sodium chloride -5% albumin -Dextrose 5% and lactated Ringer's -Dextrose 5% and water

-0.9% sodium chloride --Isotonic solutions are used for immediate fluid resuscitation in clients with hypovolemic shock

The charge nurse in the medical-surgical unit is evaluating client safety. Which actions by UAP would require the nurse to intervene? SATA -1 UAP repositioning a client who is 8 hours postoperative total hip replacement - 1 UAP using a gait belt to transfer a partial weight-bearing client from the bed to a chair - 2 UAPs repositioning a client who is sedated and has been on the left side for 2 hours -2 UAPs using the log-rolling technique to move a client with a cervical collar -3 UAPs using a draw sheet to move a client who weighs 220 lbs up in bed

-1 UAP repositioning a client who is 8 hours postoperative total hip replacement -2 UAPs using the log-rolling technique to move a client with a cervical collar --The client who is 8 hours postoperative total hip replacement requires assessment prior to repositioning as the client is at risk for hip dislocation. A wedge may be needed to maintain abduction; nursing judgment is required.

describe administration of tetracycline

-1 hour before or 2 hours after meals -with plenty of water -DO NOT take with dairy or within 2 hrs of antacids -increased risk for photosensitivity

The nurse is preparing to administer an IM immunization to a 6-month old infant. Which needle length and injection site would be the most appropriate to minimize a local reaction to the vaccine components? -3/8 inch needle in the anterolateral thigh -5/8 inch needle in the ventrogluteal muscle -1 inch needle in the anterolateral thigh -1.5 inch needle in the ventrogluteal muscle

-1 inch needle in the anterolateral thigh --The needle length and injection site for IM injections are dependent on a client's age and muscle mass. The vastus lateralis muscle in the anterolateral middle portion of the thigh is the preferred IM injection site for newborns and infants. Selection of the most appropriate needle length is an important factor in ensuring immunization success and minimizing local reactions to vaccine components. If the needle is too short, the IM vaccine is injected into subcutaneous fat, resulting in vaccine failure due to poor mobilization of the antigen within adipose tissue. Infants typically require a 1 inch needle for IM injections. The ventrogluteal area in an infant does not have enough muscle mas for use and is not recommended until at least age 3.

The nurse is caring for a client who weighs 450 lb 2 days after bariatric surgery. The client is pleasant, cooperative, and able to fully bear weight. What would be the most appropriate method for transferring this client safely? -1-person safely standby with walker -2-person full-body sling lift -2-person standing-assist lift -4-person full-body sling lift

-1-person safely standby with walker --When determining the most appropriate method to transfer a client safely, the nurse should assess whether the client can bear weight and whether the client is cooperative. This client is able to bear weight despite having a heavy body and can cooperate during the transfer. Therefore, such clients should be encouraged to do so as much as they can for themselves, anticipating discharge in the near future. It is appropriate to transfer this client with 1 person standing by for safety. If the client was unable to bear weight fully, more assistance would be needed. The number of caregivers providing assistance during the transfer of a heavier client should be increased to promote safety for the client and staff.

Therapeutic INR range

-1.5 or 2 times the normal control value (2-3) for clients w/ DVT, A-fib, stroke -3-3.5 for mechanical heart valve

Language skills of 18 month old

-10+ words -identifies common objects

The nurse in the ED receives report on 4 clients. Which client should be seen first? -5-year-old with an accidental epinephrine auto-injector stick and a heart rate of 124/min -7-year-old who is crying, has vaginal lacerations and bruising, and has a heart rate of 118/min -10-year-old with a large, draining abscess on the left buttock and a temperature of 101.2 F -14-year-old who is lethargic after playing a football game and has a temperature of 104.1 F

-14-year-old who is lethargic after playing a football game and has a temperature of 104.1 F --Heatstroke occurs when excessive environmental heat exposure and/or overexertion cause hyperthermia and depletion of fluid and electrolytes, specifically sodium. Eventually, hypothalamic thermoregulation fails and sweating production stops, causing a rapid elevation of core temperature. Risk for permanent neurological injury or death from heatstroke is related directly to the degree and duration of hyperthermia. Treatment involves stabilization of ABCs and rapid cooling interventions. Antipyretics are ineffective as hyperthermia is unrelated to the inflammatory process.

The nurse assesses 4 clients in the ED. Which client should the nurse prioritize first? -12-year-old with right lower quadrant abdominal pain that started in the periumbilical region -14-year-old with severe scrotal pain; right testis is tender, swollen, and more elevated than the left -16-year-old with sickle cell disease who has excruciating generalized body pain -34-year-old with sudden-onset, right-sided flank pain radiating to the right groin

-14-year-old with severe scrotal pain; right testis is tender, swollen, and more elevated than the left --Testicular torsion is an emergency condition in which blood flow to the testis has stopped. The testicle rotates and twists the spermatic cord, inititally causing venous drainage obstruction that leads to swelling and severe pain. Arterial blood supply is subsequently interrupted, resulting in testicular ischemia and necrosis, which require surgical removal of the testis. The condition can be diagnosed with ultrasound. There is a short time frame in which testicular torsion can be treated, generally 4-6 hours, making this condition a priority. --right lower quadrant pain referred from the periumbilical area is a classic sign of appendicitis. If left untreated, the appendix could perforate and release bacteria into the abdomen, causing peritonitis, a more serious condition. surgery is usually required within 24 hours. This client should receive prompt attention, but is not priority. Clients with sickle cell disease have episodes of sickle cell crisis, in which the sickle-shaped cells occlude the blood vessels. This decreased blood flow is responsible for the generalized body pain. This client should be treated emergently with pain medications and IV fluids, but is not priority. Sudden-onset, right-sided flank pain radiating to the groin is classic for renal stones. Kidneys stones are very painful, but in most cases, cause no permanent damage unless a stone completely blocks kidney flow. This client is not a priority over the client with testicular torsion

The nurse performs admission assessments on 4 clients. Which client assessment information is most concerning and needs priority care? -17 year old with suspected meningococcal meningitis who has a fever of 103 F, HA with photophobia, and stiff neck -36 year old who is an IV drug user with cellulitis of the arm, a fever of 103.2 F, and foul-smelling drainage from self-injection sites -45 year old with diabetes mellitus and osteomyelitis of the foot who has a fever of 100.9 F and a serum glucose of 295 mg/dL -76 year old with chronic bronchitis who has a fever of 101 F and a productive cough of thick green mucus

-17 year old with suspected meningococcal meningitis who has a fever of 103 F, HA with photophobia, and stiff neck --Characteristics of meningococcal meningitis include fever, HA, nuchal ridigity, photophobia, N/V, and changes in mental status. If any of these are present, prompt testing and initiation of antibiotic therapy immediately following the LP are critical as this is a life-threatening medical emergency.

drug class and function of isoniazid

-1st line antitubular drug --used for latent/active TB

A large-scale community disaster occurs and clients must share hospital rooms due to the rapid influx of new victims. Which room assignments are appropriate in this situation? SATA -2 clients on contact isolation, one with vancomycin-resistant enterococci infection and another with methicillin-resistant Staphylococcus infection -2 clients with C diff, one in the stool and the other in a wound -a client in sickle cell disease crisis and a client with streptococcal pneumonia -a client who had abdominal surgery today and a client with universal precautions -a young client in Buck's traction with an elderly client with Parkinson's disease

-2 clients with C diff, one in the stool and the other in a wound -a client who had abdominal surgery today and a client with universal precautions -a young client in Buck's traction with an elderly client with Parkinson's disease --when clients must be housed together in less than idea circumstances, those infected with the same causative pathogens can be placed together. However, a client who is infectious should not be placed with an immunosuppressed client. Every client in the hospital is on universal precautions; therefore, there should be no concern about placing a vulnerable post-operative client in the same room where standard precautions are being taken for another client. In a disaster setting, clients of different age groups can be placed in the same room together so long as both are stable and noninfectious.

The nurse is triaging clients from the waiting room. The care of which client is a priority? -2 year old who ingested a button battery approximately 30 minutes ago and is asymptomatic -4 year old who started crying and suddenly wont use the left arm after being swung by the arms -child with cerebral palsy and a baclofen pump who has increased muscular spasms -child with osteogenesis imperfecta who walks in reporting being hit on the front of the head with a baseball

-2 year old who ingested a button battery approximately 30 minutes ago and is asymptomatic --foreign body aspiration can be life-threatening depending on the object's location, type, and size. Up to 50% of children with foreign body ingestion are asymptomatic at the beginning. alkaline batteries can be corrosive to the esophageal and intestinal mucosa; if ingested, they must be removed emergently by endoscopy as perforation can occur. --osteogenesis imperfecta is a condition in which bones are brittle and fracture easily. Head trauma indicates a possible skull fracture and alerts the need to assess for intracranial hemorrhage. This child is walking, meaning that bleeding is unlikely, but still requires evaluation at some point.

Which client in the ED should the nurse see first? -2 year old with fever and sore throat who is restless and drooling -6 year old with appendicitis who has right lower quadrant pain and vomiting -9 year old with immune thrombocytopenia who has generalized petechiae -17 year old with cystic fibrosis who is coughing up thick, blood-tinged sputum

-2 year old with fever and sore throat who is restless and drooling --Acute epiglottitis is a life-threatening emergency due to possible airway obstruction from severe swelling of the epiglottis. Symptoms include fever, sore throat, stridor, drooling, restlessness, and tripod positions. The nurse should prepare to assist with emergent endotracheal intubation. --if left untreated, the inflamed appendix may rupture, causing peritonitis, major abscess, or partial bowel obstruction. The client with acute appendicitis may require antibiotic administration and emergent surgical appendectomy. Although appendicitis is an emergent condition, a client with impending airway obstruction is more critical.

The clinic nurse educator is developing a teaching plan for the following 6 clients. The nurse should instruct which client to avoid the Valsalva maneuver when defecating? SATA -22 year old man with a head injury sustained during a college football game -30 year old woman recently hospitalized for reconstructive augmentation mammoplasty -56 year old man 2 weeks post myocardial infarction -68 year old woman recently diagnosed with pancreatic cancer -74 year old man with portal hypertension related to alcohol-induced cirrhosis -82 year old woman 1 week post cataract surgery

-22 year old man with a head injury sustained during a college football game -56 year old man 2 weeks post myocardial infarction -74 year old man with portal hypertension related to alcohol-induced cirrhosis -82 year old woman 1 week post cataract surgery --The Valsalva maneuver involves holding the breath while bearing down the perineum to pass a stool. Straining to have a bowel movement is to be avoided in clients recently diagnosed with increased intracranial pressure, stroke, or head injury as straining increases intra-abdominal and intrathoracic pressure, which raises the intracranial pressure. The vagus nerve is stimulated when bearing down; this temporarily slows the heart and decreases cardiac output, leading to potential cardiac complications in clients with heart disease. Straining increases intra-abdominal and intrathoracic pressure and should be avoided in clients diagnosed with portal hypertension related to cirrhosis due to the risk of variceal bleeding. The maneuver increases intraocular pressure and is contraindicated in clients with glaucoma and recent eye surgery.

Four clients enter the ED at the same time. Which should the triage nurse first see? -25 year old client with sudden-onset chest pain and heart rate of 110/min -45 year old client with type 2 diabetes who is traveling and has lost insulin glargine -60 year old client with pain, swelling, erythema, and warmth in the right leg -70 year old client with left lower abdominal pain and diarrhea for 2 days

-25 year old client with sudden-onset chest pain and heart rate of 110/min --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 HCP before the other 3 clients. --The client with pain, swelling ,erythema, and warmth in the right leg 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.

The nurse assesses 4 clients. Which assessment finding requires the nurse's priority action? -26 year old with splenectomy reports a HA and chills -40 year old with immune thrombocytopenia purpura has petechiae on the arms -60 year old with marked anemia reports SOA when ambulating -68 year old with polycythemia vera has a hematocrit of 66%

-26 year old with splenectomy reports a HA and chills --the spleen is part of the immune system and functions as a filter to purify the blood and remove specific microorganisms that cause infections. Overwhelming postsplenectomy bacterial infection or rapid-onset sepsis are major lifelong complications in a client without a functioning spleen. A minor infection can quickly become life-threatening, and so any indicator of infection such as a low-grade fever, chills, or HA needs immediate intervention. --ITP is an autoimmune condition in which clients have abnormal platelet destruction with a count of <150,000/mm3. ITP is associated with an increased risk of bleeding. A common manifestation of ITP includes petechiae, which are pinpoint flat, red or brown microhemorrhages under the skin caused by leakage of RBCs and is expected.

The nurse is reviewing the history of four female clients. The nurse should recommend a Pap test to screen for cervical cancer in which client? -17-year-old who reports being sexually active for 2 years and uses condoms -26-year-old whose last Pap test screening at age 21 was negative -51-year-old who had a hysterectomy with cervix removal for benign reasons and whose previous pap tests were negative -72-year-old with a history of regular Pap test screening whose previous Pap tests were negative

-26-year-old whose last Pap test screening at age 21 was negative --Pap testing for cervical cancer allows early detection of cervical dysplasia and is initiated at age >21, regardless of sexual activity history. Women who have had their uterus and cervix removed for reasons unrelated to cervical cancer and th ose age >65-70 may usually discontinue screening. Women age 21-29 should be screened with Pap testing every 3 years in the United States

The student nurse completes a clinical rotation in the ED. The instructor knows the student is able to prioritize care appropriately when the student visits which client first? -9-year-old crying with pain and swelling of the left ankle after a popping sound while playing soccer -29-year-old with neck swelling and increased pain 2 days after thyroidectomy -43-year-old with blood glucose of 423 mg/dL, dehydration, and trace ketones in urine -72-year-old who is incontinent with acute altered mental status and is yelling at staff

-29-year-old with neck swelling and increased pain 2 days after thyroidectomy --Swelling of the neck and increased pain after a thyroidectomy may indicate hematoma formation or increased tissue inflammation. These complications have a high priority due to potential inference with airway patency. The nurse should assess for S/S of airway compromise and suction equipment should be available to clear the airway of secretions, and a trachestomy tray should be at the bedside in case an emergency trach is required. --acute altered mental status in an elderly client may indicate infection. Diagnostic testing to identify the source of the altered mental status; however, airway complications and circulatory compromise have a higher priority. This client should be seen third.

The nurse receives report on 4 pediatric clients in the ED. Which client should be seen first? -3 week old with fever who is sleeping more than usual and refuses to feed -4 month old who has painless, new-onset, bilateral testicular swelling -8 month old who ingested a bottle of children's bubble soap 30 minutes ago -2 year old with fever, runny nose, cough, and sore throat for the past 2 days

-3 week old with fever who is sleeping more than usual and refuses to feed --sepsis neonatorum is a medical emergency. Newborns may not exhibit obvious signs of infection but instead may have elevated temperature or be hypothermic. subtle changes such as irritability, increased sleepiness, and poor feeding should be considered red flags. Blood, urine, and cerebrospinal fluid cultures should be obtained immediately and broad-spectrum antibiotics started. --the 4 month old has signs of hydrocele, a fluid-filled testicular mass. Most hydroceles resolve before the first birthday and are not a medical emergency. Children's bubble soap is non-toxic and is not a priority. The 2 year old likely has an upper respiratory viral or bacterial infection. This localized infection is not a priority over generalized/bloodstream infection

The nurse will anticipate administration of isotonic IV fluids in which clients? SATA -14-day-old client has urine output of 2 mL/kg/hr with flat fontanel -3-month-old client with diarrhea has a capillary refill of 4 seconds and mottling in lower extremities -8-year-old client has serum sodium of 131 and blood urea nitrogen of 15 mg/dL -client is having contractions every 10 minutes and will be receiving an epidural analgesic -client received a bolus of IV fluid for hyperemesis gravidarum, and urine output is 80 mL/4 hour and pulse is 120/min

-3-month-old client with diarrhea has a capillary refill of 4 seconds and mottling in lower extremities -client is having contractions every 10 minutes and will be receiving an epidural analgesic -client received a bolus of IV fluid for hyperemesis gravidarum, and urine output is 80 mL/4 hour and pulse is 120/min ---Isotonic IV fluids expand only the extracellular fluid and are used as fluid replacement for fluid volume deficit. Commonly examples are NS and LR. Capillary refill indicates adequate circulation and perfusion. Normal capillary refill time is less than 3 seconds, and a delay can be an indication of dehydration. Mottling is characterized by patches of pink, pale, and cyanotic. Clients in labor usually receive 500-1,000 mL of isotonic fluids prior to an epidural anesthesia as vasodilation below the epidural site can occur and result in hypotension. Up to 40% of these clients may experience hypotension after an epidural anesthesia. The preadministration of IV fluids can lessen hypotension. Hyperemesis gravidarum is severe vomiting that can result in dehydration. Despite being given some fluids, this client still needs additional fluids. Minimal obligatory urine output is 30mL/hr or 120 mL/4 hr. Urine output is the best indicator of adequate rehydration. Tachycardia with pulse of 120/min indicates dehydration unless there is another clear etiology. Uirnary output of 2 ml/kg/hr and a flat fontanel are normal findings in an infant. Normal serum sodium in children is 138-145. Hyponatremia often results from excess fluids. There would be no need to give this client (option 3) additional fluids. Normal BUN in children is 5-18 mg/dL and BUN is elevated with dehydration or a need for fluid. The range provided for client (option 3) is normal and does not indicate that additional fluids are required.

Multiple clients present to the ED. Which client should the triage nurse prioritize for diagnostic testing and definitive care? -26-year-old IV drug user reporting fever and right arm redness and swelling -32-year-old kidney transplant reporting low-grade fever and generalized body pains -69-year-old with diverticulosis reporting left lower quadrant pain and fever -74-year-old with right knee replacement reporting fever and right knee swelling

-32-year-old kidney transplant reporting low-grade fever and generalized body pains --The kidney transplant client is likely immunosuppressed by steroids and anti-rejection drugs. In general, organ transplant clients will have a blunted response to infection, such as a low-grade fever. This client has systemic symptoms, which may indicate a serious underlying infection. Some of these clients develop fulminant sepsis within a few hours if the antibiotics are delayed. As a whole, management of systemic S/S takes priority over that of localized S/S

The charge nurse is planning assignments for the day. Which clients will require the nursing staff to institute contact precautions? SATA -38 YO with MRSA -42 YO with C-diff -69 YO with pertussis infection - 72 YO with vancomycin-resistance Enterococcus -80 YO with influenze

-38 YO with MRSA -42 YO with C-diff - 72 YO with vancomycin-resistance Enterococcus --Clients with multidrug-resistant organisms, C-diff diarrhea, and scabies require nursing staff to implement contact precautions

The charge nurse on a pediatric unit recognizes that it is acceptable for which pair of clients to be assigned to a semi-private room? -4 year old girl in Buck traction and 5 year old boy post laparoscopic appendectomy -6 year old girl with varicella and 7 year old girl with measles -9 month old boy with rotavirus infection and 8 month old boy with salmonella infection -14 year old girl with sickle cell anemia and 13 year old girl with periorbital cellulitis.

-4 year old girl in Buck traction and 5 year old boy post laparoscopic appendectomy --Although placing pediatric clients of different sexes in a semi-private room is not ideal, the charge nurse must prioritize client room assignments based on client safety. At ages 4 and 5, the male-female pair can room together. The client in Buck traction does not have a transmittable illness. The client post laparoscopic appendectomy is also not infectious. A client with sickle cell anemia is at risk for infection due to spleen dysfunction and a client with periorbital cellulitis has an infection-therefore they should not share a room.

What is a normal blood uric acid level in males? females?

-4.4-7.6 mg/dL -females= 2.3-6.6 mg/dL

The nurse is caring for 4 clients requiring IV fluid therapy. For which client should the nurse anticipate the need for isotonic crystalloid administration? -25-year-old with a closed-head injury and signs of increasing intracranial pressure -45-year-old with acute gastroenteritis and dehydration -60-year-old with seizures and serum sodium of 112 mEq/l -68-year-old with chronic renal failure and hypertensive crisis

-45-year-old with acute gastroenteritis and dehydration --Isotonic fluid therapy is used to treat clients with extracellular fluid deficits. Clients at risk for cerebral swelling (increased intracranial pressure, hyponatremia) require hypertonic fluid administration to decrease cellular swelling. Isotonic fluid administration may cause fluid overload in clients with renal failure.

The nurse is caring for several clients in a women's health clinic. Based on the data collected, which client's history is most concerning for an increased risk of endometrial cancer? -40-year-old client who has been taking hormonalbirth control pills for the past 10 years -45-year-old client who reports a history of an ectopic pregnancy with a ruptured ovary and two preterm births -47-year-old client with polycystic ovary syndrome, obesity, and a history of unsuccessful infertility treatments -60-year-old client who recently had a colposcopy after testing positive for a high risk type of human papillomavirus

-47-year-old client with polycystic ovary syndrome, obesity, and a history of unsuccessful infertility treatments --Endometrial cancer arises from the inner lining of the uterus and forms after the development of unregulated endometrial overgrowth. Although typically slow growing, it can metastasize to the myometrium, cervix, and nearby lymph nodes and eventually beyond the pelvis. Many signs of endometrial cancer are nonspecific but the hallmark symptom is abnormal uterine bleeding. As with many cancers, the client's family and genetic history are significant risk factors; however, prolonged estrogen exposure without adequate progesterone is the greatest risk factor for developing endometrial cancer.

How long does it take MMR vaccine reactions to occur and what symptoms are present?

-5-12 days after vaccination administration --mild fever --rash --irritability --restlnessness --swelling/erythema at injection site

Four clients with different skin alterations comes to the ER. Which client should the nurse advise that the HCP see first? -8 year old client who uses corticosteroid inhaler who has white patches on the tongue -50 year old client who developed a smooth, red, pinpoint rash after taking sulfa -60 year old client with pain and crusted blisters along the back -70 year old client who has erythema with a small pustule at the hair follicle

-50 year old client who developed a smooth, red, pinpoint rash after taking sulfa --Petechiae and purpura can be a sign of blood dyscrasia, including thrombocytopenia due to a severe drug response. This systemic symptom takes priority over a more localized dermatological presentation.

Which client is at the greatest risk for development of hospital-acquired pressure injuries? -25-year-old client with quadriplegia, urosepsis, temperature of 101 F, and white blood cell count of 18,000/mm3 -50-year-old client with AIDS who is receiving norepinephrine infusion and has a weight loss of 20 lb in a month, prealbumin level <10 mg/dL, and mean arterial pressure of 50 mm Hg -80-year-old client 2 days post hip replacement with dementia, 2 Jackson-Pratt drains, and hemoglobin level of 14 g/dL -87-year-old clients 2 days post open cholecystectomy

-50-year-old client with AIDS who is receiving norepinephrine infusion and has a weight loss of 20 lb in a month, prealbumin level <10 mg/dL, and mean arterial pressure of 50 mm Hg --Pressure injuries are areas of localized skin injury and underlying tissue caused by external pressure with or without friction and/or shearing. These result from ischemia and hypoxia of tissue following periods of prolonged pressure. Clients at greatest risk include older adults with limited movement and long bone or hip fractures, those with quadriplegia, and the criticall ill. Clients with deficits in mobility and activity, incontinence, inadequate nutrition, chronic illness, renal failure, anemia, problems with oxygenation, edema, or infection are also at increased risk.

The primary care provider's office nurse must return telephone calls concerning 4 clients. Which client has the most emergent situation and requires and immediate call back? -28 year old woman is requesting antibiotic to be called to pharmacy due to another bladder infection -55 year old man who takes trazodone is reporting a painful erection of 3 hours duration -78 year old man with sinusitis who takes pseudoephedrine is having difficulty voiding -84 year old man with prostate cancer and spine metastasis is requesting increased pain medication

-55 year old man who takes trazodone is reporting a painful erection of 3 hours duration --priapism is a prolonged, painful erection caused by trapping of blood in the penile vasculature that can lead to erectile tissue hypoxia and necrosis. The condition is usually idiopathic, secondary to prescription medications or a preexisting medical condition. The nurse should return this call first as the condition is a medical emergency that can result in permanent erectile dysfunction; it requires urgent treatment in the ED.

A nurse in the gynecology clinic is reviewing client histories. Which report would be most concerning to the nurse? -25-year-old client who reports a fish-like vaginal odor for the past month -30-year-old client with an intrauterine device who reports heavy bleeding with menses -40-year-old client with endometriosis who reports persistent pain during intercourse -60-year-old client who reports bloating and pelvic pressure for the past 2 months

-60-year-old client who reports bloating and pelvic pressure for the past 2 months --Ovarian cancer results in more deaths than any other gynecologic cancer. Symptoms are often subtle and may include abdominal bloating; pelvic pain or pressure; abdominal girth increase; earl satiety; abdominal/back/leg pain;urinary urgency/frequency;and gastrointestinal disturbances.Due to the lack of routine screening and reports of vague symptoms, ovarian cancer may not be diagnosed until an advanced stage. A fish-like vaginal odor is often caused by bacterial vaginosis, an overgrowth of vaginal bacterial flora. This condition is not usually serious and is treated with oral or vaginal antibiotics.

A client tells the nurse of wanting to lose 20 lb in time for the client's daughter's wedding, which is 16 weeks away. How many calories will the client have to eliminate from the diet each day to meet this goal? -450 kcal/day -625 kcal/day -860 kcal/day -1,000 kcal/day

-625 kcal/day --A reduction or energy expenditure of 3,500 calories will result in a weight loss of 1 lb. To lose 20 lb, the client needs to reduce intake by a total of 70,000 kcal. Over a period of 16 week, this results in 625 kcal/day. Adding an exercise regimen to the client's daily routine will facilitate additional weight loss and/or reduce the need for severe caloric restriction.

The nurse triaging clients in the emergency department. Which client needs to be seen first? -18 year old female with fever, suprapubic pain, and dysuria -21 year old male with diffuse abdominal pain and a rigid abdomen -64 year old male with a pulsatile mass in the perumbilical area and back pain -75 year old with nausea, fever, and left lower quadrant pain

-64 year old male with a pulsatile mass in the perumbilical area and back pain --Abdominal aneurysms may present with a pulsatile mass in the periumbilical area slightly to the left of the midline. A bruit may be auscultated over the site. Back/abdominal pain can be present due to compression of nearby anatomical sites r nerve compression from an expanding/rupturing abdominal aortic aneurysm (AAA). Rupture of an abdominal aneurysm can quickly cause exsanguination and death. Fever, suprapubic pain, and dysuria in a young female client indicate a UTI. Diffuse pain and a rigid abdomen indicate peritonitis, which is not life-threatening. Fever and left lower quadrant pain in an elderly client are usually due to acute diverticulitis.

The nurse receives report on 4 clients. Which client conditions require priority assessment? -34-year-old with acute pericarditis reporting left-sided chest pain that is worse with inspirations -54-year-old post right femoropopliteal bypass surgery reporting sudden-onset severe right foot pain -64-year-old post hip replacement reporting sudden-onset right-sided chest pain and dyspnea -70-year-old with pneumonia; rapid, irregular pulse of 140/min; and blood pressure of 130/86 mm Hg

-64-year-old post hip replacement reporting sudden-onset right-sided chest pain and dyspnea --Clients who are bedridden, have undergone major surgery, or are taking estrogen-containing contraceptive pills are at high risk of developing DVT's. This condition can result in subsequent embolus and life-threatening pulmonary embolism. When blood flow is blocked to certain parts of the lung, the area can become infarcted, resulting in chest pain, shortness of breath, and cough. These clients require immediate anticoagulation to prevent extension of the blood clot.

The nurse assistant reports vital signs on 4 clients. Which client should be a priority for the nurse to assess? -28 year old with infective endocarditis and heart rate of 105/min -45 year old with acute pancreatitis and sinus tachycardia of 120/min -65 year old with tachycardia of 110/min after liver biopsy -74 year old on diltiazem drip with atrial fibrillation and heart rate of 115/min

-65 year old with tachycardia of 110/min after liver biopsy --the liver is a highly vascular organ and bleeding is a major complication. Tachycardia is an early sign of internal hemorrhage. --tachycardia can be caused by underlying infection and can resolve with the treatment of endocarditis. Pancreatitis is a very painful condition and sinus tachycardia is expected. Atrial fibrillation is commonly treated with CCB such as diltiazem. The dosage needs to be adjusted to achieve a goal heart rate of <100/min, but is not life-threatening.

A nurse is assigned to multiple clients. Which client should the nurse reassess as a priority after administering IV morphine for pain relief? -22 year old with sickle cell anemia admitted for acute pain crisis -26 year old with pneumonia reporting sharp right side chest pain on deep inspiration -55 year old who is 1 day postoperative bowel resection reporting pain at the incision site -67 year old with obstructive sleep apnea reporting pain at the fractured right tibia

-67 year old with obstructive sleep apnea reporting pain at the fractured right tibia --Obstructive sleep apnea is characterized by partial or complete airway obstruction that occurs from relaxation of the pharyngeal muscles, airway closure, and lack of airflow. This leads to repeated episodes of apnea and hypopnea, resulting in hypoxemia and hypercapnia. Administration of general anesthesia or sedating medications can exacerbate OSA by decreasing pharyngeal muscle tone and increasing airway closure even further. Therefore, being on continuous positive airway pressure is very important in these clients, especially during sleep. The nurse should assess LOC, lung sounds, vital signs, and pulse oximeter readings, and then compare these with the client's baseline measurements. The nurse should also continue to monitor respiratory status as IV morphine peaks in 20 minutes and has a duration of 3-4 hours. --the 22 year old with sickle cell crisis will likely need large doses of narcotics due to increased tolerance from prior use. The nurse needs to assess the pain and any complications from narcotic use, but is not priority.

The office nurse receives 4 telephone messages. Which client should the nurse call back first? -32 year old woman with a temperature of 100.4 F who reports feeling achy following a flu shot yesterday -50 year old man who reports right shoulder pain and difficulty raising the arm above the head after playing baseball 3 days ago -68 year old woman with left-sided jaw pain, dizziness, and nausea who thinks it is an infection related to routine teeth cleaning yesterday -72 year old woman with urge incontinence who started taking solifenacin 2 days ago and reports constipation and very dry mouth

-68 year old woman with left-sided jaw pain, dizziness, and nausea who thinks it is an infection related to routine teeth cleaning yesterday --older individuals, diabetic clients, and women may have atypical angina symptoms rather than the characteristic crushing, substernal type of chest pain. These symptoms include atypical pain, SOA, indigestion, nausea, dizziness, and cold sweats. This client reports symptoms thought to be related to a dental problem, but the nurse needs to gather more information. The symptoms can indicate a cardiac medical emergency that requires immediate evaluation and intervention. --Solifenacin is a cholinergic antagonist prescribed to treat symptoms associated with an overactive bladder. Common expected adverse effects include dry mouth and constipation.

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

-7 day old fussy infant with a rectal temperature of 100.6 F and 6 wet diapers today --Infants <30 days old have immature immune systems and a blunted response to infection. The 7-day old infant is at high risk for bacteremia. Infectious manifestations are often subtle at this age, although some infants may have hypothermia, lethargy, poor feeding, or decreased urine output. pink eye is highly contagious, but is not emergent.

The nurse in the pediatric client is triaging telephone messages. The nurse should call the parent of which child first? -2 year old with bilateral tympanostomy tubes who has a small piece of plastic in the right outer ear -4 year old post adenotonsillectomy who is now reporting ear pain -6 year old with strep throat who needs a note to return to school 24 hours after starting antibiotics -7 year old 5 days post tonsillectomy who wants to return to soccer practice today

-7 year old 5 days post tonsillectomy who wants to return to soccer practice today --This child is at highest safety risk. Postoperative hemorrhage from tonsillectomy is uncommon, but may occur up to 14 days after surgery. During the healing process, white scabs will form at the surgical sites. Sloughing then occurs approximately 7 days after the procedure, increasing the risk for bleeding. Caregivers should be taught to observe for signs of bleeding. --Clients often report ear pain following adenotonsillectomy due to irritation of the 9th cranial nerve in the throat, causing referred pain to the ears. This is a normal finding.

Several clients check into the emergency department at the same time. Which client should be seen first? -8 month old with persistent vomiting and diarrhea for several days -5 year old who has a foreign body in the right naris -7 year old who is restless after tonsillectomy surgery 3 days ago -9 year old with a second-degree burn to the arm who is crying inconsolably

-7 year old who is restless after tonsillectomy surgery 3 days ago --A client who is status post tonsillectomy and adenoidectomy is at risk for hemorrhage up to 14 days after surgery. Because of the location of the surgery, hemorrhage can lead to life-threatening airway compromise. The client who had a tonsillectomy 3 days ago has signs of hemorrhage should be seen first. Signs and symptoms of hemorrhage after tonsillectomy and adenoidectomy include restlessness, frequent swallowing or throat-clearing, vomiting of blood, and pallor. Persistent vomiting and diarrhea in an 8-month old would warrant concern for dehydration. IV fluid resuscitation may be required. This client, with potential circulatory compromise, should be seen second. A second-degree burn is not full thickness and is not considered life threatening. This client needs treatment for pain and infection prevention and should be seen third.

A category 4 hurricane has disrupted a rural local health care system, creating a significant increase in ED admissions. Which client would the nurse assess first? -55 year old with type 2 diabetes mellitus complaining of a headache after being involved in a minor motor vehicle accident -45 year old with type 1 diabetes mellitus with a blood glucose of 690 mg/dL complaining of abdominal pain and fatigue -7 year old with status asthmaticus and an oxygen saturation of 89% -34 year old with gestational diabetes, 11 weeks pregnant, who has not been able to "hold anything down" due to nausea and vomiting over the past 2 days

-7 year old with status asthmaticus and an oxygen saturation of 89% --The child with status asthmaticus is at risk for rapid deterioration of respiratory status and respiratory failure. The clinical finding of decreased oxygen saturation indicates mild-to-moderate status asthmaticus. -the clinical findings of fatigue, abdominal pain, and blood glucose level of 690 mg/dL indicate developing diabetic ketoacidosis. This client is at risk of life-threatening hemodynamic instability and needs immediate treatment. However, this client is second in priority.

The nurse receives report for 4 clients in the ED. Which client should be seen first? -30 year old with a spinal cord injury at L3 sustained in a motor cycle accident who reports lower abdominal pain and difficulty urinating -33 year old with a seizure disorder admitted with phenytoin toxicity who reports slurred speech and unsteady gait -65 year old with suspected brain tumor waiting to be admitted for biopsy who reports throbbing headache and had emesis of 250 mL -70 year old with atrial fibrillation and a closed-head injury waiting for brain imaging who reports a headache and had emesis of 200 mL

-70 year old with atrial fibrillation and a closed-head injury waiting for brain imaging who reports a headache and had emesis of 200 mL --A client with a neurological injury is at risk for cerebral edema and increased intracranial pressure, a life-threatening situation. The client with atrial fibrillation may also be taking anticoagulants, making a life-threatening intracranial bleed even more dangerous. The nurse should perform a neurologic assessment immediately.

The occupation health nurse administers an intradermal tuberculin skin test (TST) to a healthcare worker. The site must be assessed for a reaction afterward. The nurse instructs the HCW to return in how many hours? -12 hours -24 hours -36 hours -72 hours

-72 hours --TST is the standard method for conducting TB surveillance of HCWs and involves injection of purified protein derivative solution under the first layer of skin of the forearm ad evaluation of the injection site 48-72 hours later. The healthcare practitioner inspects and palpates the site to determine if a local skin reaction has occurred. Induration indicates a positive test, which means that the individual has been exposed to TB, has developed antibodies, and is infected with TB bacteria. Further testing is needed to determine the presence of latent TB infection or active TB disease. Presence of symptoms, positive sputum culture, and chest x-ray abnormalities confirm active TB

A nurse is caring for a group of clients on a medical surgical unit. Which client is most at risk for contracting a nosocomial infection? -51 YO client who received a permanent pacemaker 48 hours ago -60 YO client who had a myocardial infarction 24 hours ago -74 YO client with stroke and an indwelling urinary catheter for 3 days -75 YO client with dementia and dehydration who is on IV fluids

-74 YO client with stroke and an indwelling urinary catheter for 3 days --A noscomial infection occurs in a hospital or other healthcare setting and is not the reason for the client's admission. Many nosocomial infections are caused by multidrug resistant organisms. These infections occur 48 hours or more after admission or up to 90 days after discharge. Clients at greater risk include include young children, the elderly, and those with compromised immune systems. Other risk factors include long hospital stays, being in the intensive care unit, the use of indwelling catheters, failure of healthcare workers to wash their hands, and the overuse of antibiotics. The most common nosocmial infection is urinary tract infection, followed by surgical site infections, pneumonia, and bloodstream infections. The 74 YO client is most at risk due to age and the presence of the urinary catheter. The nurse will need to be on high alert for this complication and should follow infection control procedures diligently. Client 4 is at risk due to age and presence of an IV catheter. However, the risk is not at high as the client with the urinary catheter

The charge nurse on a med-surg step-down unit is responsible for making assignments. Which client is most appropriate to assign to a new graduate nurse who is still in orientation? -65 year old client 1 day postoperative left femoral-popliteal bypass graft surgery with a diminished pedal pulse -66 year old client admitted for hypertensive crisis 2 days ago; blood pressure currently 180/102 mm Hg; reports headache and blurred vision -75 year old client with an ischemic stroke transferred from the ICU 1 hour ago; unresponsive with right-sided paralysis -78 year old with diabetes and cellulitis of the left foot; requires frequent dressing changes due to excessive drainage

-78 year old with diabetes and cellulitis of the left foot; requires frequent dressing changes due to excessive drainage --The RN makes assignments according to staff members' experience, knowledge, and skill level. The more experienced nurse is assigned to clients who are less stable and require more in-depth analysis of assessment data to implement and plan care. The less experienced graduate nurse is assigned to more stable clients who require basic nursing care

The charge nurse in the coronary care unit must transfer a client to the medical unit to accommodate another acutely ill client from the ER. The nurse suggests the transfer of which client to the HCP? -52 year old with unstable angina and chest pain at rest who has had 3 normal serum troponin I levels -60 year old with new-onset atrial fibrillation of 140/min who is receiving a continual IV infusion of diltiazem -65 year old admitted last night for third-degree heart block who is awaiting permanent pacemaker placement -78 year old with end-stage heart failure and ejection fraction of 15% whose family is requesting palliative care

-78 year old with end-stage heart failure and ejection fraction of 15% whose family is requesting palliative care --Palliative and end-of-life care for end-stage heart failure focuses on client-centered interventions to provide symptom and pain relief and psychological and spiritual support, rather than on curative interventions. The client with end-stage heart failure, a terminal illness, would be most appropriate to transfer as palliative care can be provided in any healthcare setting.

The charge nurse in the ER assigns a client to a new nurse who has been off orientation for a week. which client assignment is most appropriate? -3 year old with a temperature of 102.4 who had a seizure at home 30 minutes ago and is very irritable -8 year old with a closed fracture of the clavicle following a fall who is talkative and rates pain as a "2" on the 0-10 FACES pain scale -32 year old with asthma who has an upper respiratory tract infection and a peak expiratory flow rate that is 45% of personal best -72 year old prescribed antibiotics 3 days ago to treat acute sinusitis who reports shortness of breath and has a rash

-8 year old with a closed fracture of the clavicle following a fall who is talkative and rates pain as a "2" on the 0-10 FACES pain scale --A fractured clavicle is not uncommon in children <10 years and is usually treated conservatively. A new nurse should be competent in performing the basic skills needed to care for a client with a musculoskeletal injury. A client who has a severely reduced peak expiratory flow rate needs emergency intervention and is not an appropriate assignment

The nurse is caring for the assigned clients on a pediatric inpatient unit. Which client is the priority? -8 year old with sickle cell crisis who has sudden-onset unilateral arm weakness -11 year old with viral meningitis requesting pain medication for headache -male child scheduled for surgery for intussusceptio who has reddish mucoid stool -male child with hemophilia who has hemarthrosis and is receiving desmopressin

-8 year old with sickle cell crisis who has sudden-onset unilateral arm weakness --Children can have strokes. Ischemic strokes are more common in children with sickle cell disease. Other causes can include carotid abnormalities/dissection. The most common presentation of an ischemicstroke is the sudden onset of numbness or weakness of an arm and/or leg. These are handled with a similar emergent approach as for stroke in an adult. Children may require exchange blood transfusion to prevent the stroke from worsening. Intussusception occurs when one portion of the intestine prolapses and then telescopes into another. It is frequent cause of intestinal obstruction during infancy. Onset is abrupt, initially with pain and brown stool. The condition then progresses to bilious emesis, palpable abdominal mass, and stools with a red, "currant jelly" appearance due to blood and mucus. This is an expected finding for this condition, and surgery is already scheduled to assess it.

Which client is most at risk for hospital-acquired methicillin-resistant Staph aureus? -15 YO student athlete in the ER with a fractured femur -46 YO with a large abdominal incision and 2 peripheral IV lines -72 YO who received a permanent pacemaker 24 hours ago -80 YO with COPD who is on a ventilator

-80 YO with COPD who is on a ventilator --Clients at highest risk for hospital-acquired MRSA are older adults and those suppressed immunity, long history of antibiotic use, or invasive tubes or lines. Clients in the ICU are especially at risk for MRSA. the 80 year old client with COPD in the ICU on the ventilator has several of these risk factors. COPD is a chronic illness that can affect the immune system, and clients experience exacerbations that may require frequent antibiotic and corticosteroid use. This client is elderly and also has an invasive tube from the ventilator.

The nurse is performing beginning of shift assessments on 4 clients. Which client's assessment findings should the nurse immediately report to the HCP? -36 year old client with alcohol withdrawal who is receiving IV lorazepam every 3 hours for agitation and has a blood pressure of 190/98 mm Hg -56 year old client with stable angina who has chest and jaw pain relieved with nitroglycerin, blood pressure of 98/70 mm Hg, and dizziness when getting up -60 year old client with chronic kidney disease who has a blood pressure of 168/88 mm Hg, serum creatinine level of 5.0 mg/dL, and reports nausea and itching -82 year old client with a pressure injury who has a change in mental status, temperature of 96.4, pulse of 110/min, and blood pressure of 96/72 mm Hg

-82 year old client with a pressure injury who has a change in mental status, temperature of 96.4, pulse of 110/min, and blood pressure of 96/72 mm Hg --sepsis is an exaggerated response to an infection in the bloodstream, often originating from a local infection (pressure injury) that results in potentially life-threatening organ impairment. Older adults are at increased risk for sepsis due to normal, age-related decreases in the immune and inflammatory response. Because of altered immune function, older adults often do not develop typical signs of infection. Instead, nurses must observe for and immediately report atypical indicators of infection (altered mental status, hypothermia, leukopenia) because early identification and intervention reduce mortality. -chronic use of central nervous system depressants (alcohol) causes a reflexive increase in catecholamine production (epinephrine). During alcohol withdrawal, hypertension, agitation, and anxiety occur because catecholamine production is no longer inhibited. Clients with stable angina often experience orthostatic hypotension, an adverse effect of nitrate drugs. Clients with CKD commonly experience nausea and pruritus due to buildup of nitrogenous wastes in blood. Elevated creatinine is an expected finding in CKD. Hypertension does require intervention by the nurse after management of infection and sepsis.

The nurse is reviewing phone messages from clients in a surgery clinic. Which client would be the priority to call back first? -client 1 week postoperative appendectomy who has not had a bowel movement in 4 days -Client 8 days postoperative ileostomy placement who reports nausea, vomiting, and abdominal bloating -client postoperative right BTK amputation who is concerned about a new tingling sensation in the right foot -client with a temp of 101.2 who is scheduled for a shoulder arthroplasty the next morning

-Client 8 days postoperative ileostomy placement who reports nausea, vomiting, and abdominal bloating --N/V, abdominal distension, and decreased stool production may signal a bowel obstruction or obstructed ileostomy. Bowel obstruction can lead to electrolyte disturbances, dehydration, bowel perforation and infection/tissue necrosis. It is urgent and potentially life-threatening --active infection is a relative contraindication for elective surgical procedures and this client should be called back for assessment and likely rescheduling of the surgery, but is not priority over a client with bowel obstruction.

The nurse in a women's health clinic is returning client phone calls. Which client would be the priority to call first? -client 4 days post cesarean delivery who has not had a bowel movement since surgery -client who gave birth vaginally a few days ago who states, "They want to hurt my baby" -Client who gave birth vaginally recently who states, "I think I am experiencing incontinence" -client's spouse who is concerned that the client wants to sleep instead of care for the baby

-Client who gave birth vaginally recently who states, "I think I am experiencing incontinence" --Postpartum psychosis is a rare but serious perinatal mood disorder. Research suggests a multifactorial etiology, including genetic predisposition and hormone fluctuation after birth. Risk factors include history of bipolar disorder and previous discontinuation of mood-stabilizing medications. Signs appear within 2 weeks after birth and include hallucinations, delusions, paranoia, severe mood changes, delirium, and feelings that someone will harm the baby. Postpartum psychosis is a psychiatric emergency requiring hospitalization, pharmacologic intervention, and long-term supportive care. Women exhibiting signs of postpartum psychosis are at increased risk of suicide and infanticide, and their assessment should take priority to ensure the safety of mother and baby. --post-surgical constipation is caused by narcotic and anesthetic administration, decreased ambulation, and manipulation of the bowels during surgery. Fluids, fiber, ambulation, and stool softeners should be encouraged. --Urinary incontinence can occur after vaginal birth due to neuromuscular trauma and can improve with pelvic floor exercises.

The nurse assesses and reviews the laboratory results for 4 clients. Which client's fever is of highest priority and should be reported to the HCP immediately? -client newly diagnosed with Hodgkin Lymphoma scheduled for chemotherapy who has a fever of 100.9 and white blood cell count of 6,000/mm3 -client with acute cholecystitis scheduled for laparoscopic surgery wo has a fever of 102 F and white blood cell count of 13,000/mm3 -client with C. diff infection receiving metronidazole who has a fever of 101 F and white blood cell count of 18,000/mm3 -Client with colon cancer receiving chemotherapy who has a fever of 100.4 F and white blood cell count of 1,500/mm3

-Client with colon cancer receiving chemotherapy who has a fever of 100.4 F and white blood cell count of 1,500/mm3 --A common adverse effect of chemotherapy is bone marrow suppression and immunosuppression. A decreased neutrophil count, termed neutropenia, increases the client's susceptibility to infection. A fever can signal an infection and, in the presence of neutropenia, can rapidly develop into life-threatening sepsis. Even a low-grade fever should be taken seriously in these clients. --Hodgkin lymphoma is a malignant cancer of the lymphatic system. Expected early manifestations include painless enlarged lymph nodes, fatigue, fever, weight loss, and drenching night sweats. The client's white blood cell count is within normal limits --acute cholecystitis involves inflammation of the gallbladder. Expected manifestations include right upper quadrant pain that can radiate to the right shoulder, N/V, fever, and leukocytosis. The client is scheduled for surgery and is likely on antibiotics. --C. diff is a toxin-producing bacterium that proliferates in the lower gastrointestinal tract. expected manifestations include diarrhea, fever, and leukocytosis. Frist-line pharmacologic treatment includes metronidazole (Flagyl) and oral vancomycin.

The nurse is preparing to administer a unit of packed red blood cells to a 16-year-old with blood loss anemia. The client currently has D5W infusing through a 20-gauge IV catheter. What action should the nurse take? -attach the blood transfusion set to the port closest to the client on the existing IV tubing -discontinue the 20-gauge IV catheter and restart an 18-gauge IV catheter -Discontinue the D5W,flush the IV catheter with normal saline, and start the transfusion -run the blood transfusion as an IV piggyback through the infusion pump

-Discontinue the D5W,flush the IV catheter with normal saline, and start the transfusion --NS is the only fluid that can be given with a blood transfusion. Dextrose solutions may lyse the red blood cells. All other IV solutions and medications may cause precipitation and are incompatible with blood. Blood transfusions should be infused through a dedicated IV line. If a transfusion must be started in an IV catheter currently in use, the nurse should discontinue the infusion and tubing, and then flush the catheter with NS prior to connecting the blood administration tubing. After transfusion, the catheter should be cleared with NS before any other IV fluids are administered.

The nurse reads a journal article about a study using a new pain management protocol for clients with terminal cancer. What should the nurse first consider in determining whether the protocol is appropriate to implement on the unit? -did the study have institutional review board approval? -Do the characteristics of the sample population match those of the nurse's unit? -What are the credentials of the study's researcher? -What was the financial support provided for the study?

-Do the characteristics of the sample population match those of the nurse's unit? --When evaluating research for practice changes, the nurse must first determine if there is reasonable similarity between the nurse's unit population and the study population to expect equivocal results. This should be the initial consideration to ensure that the research is appropriate for a given setting. For instance, if the nurse cares for pediatric clients with acute pain, the protocol for adult clients with terminal cancer might not translate effectively or safely to those clients. Other aspects of the study to evaluate include whether all clinically relevant outcomes were addressed, if the benefits outweigh any potential harm or costs, and if the protocol resulted in improved care.

The nurse is caring for a client with right upper quadrant pain and jaundice. The client's ALT/AST levels are 8 times the normal values. What questions would be most helpful regarding the etiology for these findings? SATA -do you have black tarry stool? -Do you use IV illicit drugs? -How much alcohol do you typically drink? -Were you recently immunized for pneumonia? -What OTC drugs do you take?

-Do you use IV illicit drugs? -How much alcohol do you typically drink? -What OTC drugs do you take? --ALT and AST are the enzymes released when hepatic cells are injured (hepatitis). There are smaller amounts in the cardiac, renal, and skeletal tissues, but ALT/AST are used to diagnose hepatic disorders. Besides viral hepatitis, liver injury can occur with excessive chronic alcohol intake, some OTC medications (acetaminophen), and certain herbal and dietary supplements. IV illicit drug use increases the risk for hepatitis B and C infection.

A nurse prepares a client for knee artheroscopy requiring general anesthesia. Which actions should the nurse complete? SATA -Encourage the client to void prior to surgery -ensure that the client has been on NPO status -place signed informed consents in the client's chart -replace the current 20-gauge IV catheter with an 18-gauge -witness that the correct surgery site is marked by the surgeon

-Encourage the client to void prior to surgery -ensure that the client has been on NPO status -place signed informed consents in the client's chart -witness that the correct surgery site is marked by the surgeon --When preparing a client for surgery, the nurse needs to ensure that informed consent has taken place and signed documents are in the chart. The nurse also witnesses that the correct operative site is marked and verified by the client and ensures that the client is NPO and voids prior to surgery. If an IV line has not been started, an 18-gauge catheter is preferred. However, if a functioning IV line is already present, a 20-gauge is acceptable. Blood products, if needed during surgery, can be transfused through a 20-gauge catheter if necessary.

A client was struck on the head by a baseball bat during a robbery attempt. The nurse gives this report to the oncoming nurse as shift change and conveys that the client's current GCS score is a "10". Which client assessment is most important for the reporting nurse to include? -belief that the current surroundings are a racetrack -GCS score was "11" one hour ago -recent vital signs show blood pressure of 120/80 mm Hg and pulse of 82/min -reported allergy to penicillin and vancomycin

-GCS score was "11" one hour ago --The GCS quantities the LOC in a client with acute brain injury by measuring eye opening, verbal response, and motor response. The maximum score on the GCS is 15 and the lowest is 3. If a client is trending for deterioration, this should always be noted in neurological assessments. A numerical decline of a single number in 1 hour is significant. A criticism of the GCS score is that it is not that precise. --although it is important to be aware of allergies, the oncoming nurse can find that information on the chart if these medications are offered.

The nurse is teaching about cervical cancer prevention during a women's health conference. Which of the following factors should be taught as risks for cervical cancer? SATA -HIV -HPV -multiple sex partners -nulliparity -sexual activity before age 18

-HIV -HPV -multiple sex partners -sexual activity before age 18 -HPV is the most common sexually transmitted infection and is a primary risk factor for cervical cancer. Other cervical cancer risk factors include sexual activity at an early age, multiple sexual partners, and weakened immune system function.

Risk factors for cervical cancer

-HPV infection -hx of STI -early onset of sexual activity -multiple or high-risk sexual partners -immunosuppression -oral contraceptive use -low socioeconomic status -tobacco use

Examples of dead vaccines

-Haemophilus influenzae Type B -Hepatitis B -pneumococcal conjugate

A new nurse attends a risk management class on the indications and legal implications of using chemical restraints to maintain client safety. Which prescription should the nurse question before administering? -Haloperidol for a client with a fall history who keeps getting out of bed without assistance -Lorazepam for a client who is in alcohol withdrawal and is extremely agitated -Olanzapine for a client with schizophrenia who is exhibiting violent behavior -Propofol for a client who is intubated and receiving mechanical ventilation

-Haloperidol for a client with a fall history who keeps getting out of bed without assistance ---Medications that are standard treatments for specific conditions are not considered chemical restraints. The nurse should question a chemical restraint prescription that may not be medically necessary for a client's safety. Although this client is at risk of injury from falling, the use of a psychotropic drug is not considered the standard treatment for a client with a history of falls who keeps getting out of bed without assistance. The least restrictive method to ensure client safety should be tried first before administering a chemical restraint.

The nurse moves a finger in a horizontal and vertical motion in front of the client's face while directing the client to follow the finger with the eyes. Which cranial nerves is the nurse assessing? SATA -II -III -IV -V -VI

-III -IV -VI

treatment for Kawasaki disease

-IV Gamma globulin (IVG) and aspirin --monitor for HF d/t an increase in plasma oncotic pressure and fluid overload (from IVG)

A client with ascites due to cirrhosis has increasing shortness of breath and abdominal pain. The healthcare provider requests that the nurse prepare the client for paracentesis. Which nursing actions would the nurse implement prior to the procedure? SATA -educate client about the procedure and obtain informed consent -initiate NPO status 6 hours prior to the procedure -Obtain baseline vital signs, abdominal circumference, and weight -place client in high Fowler position or as upright as possible -request that the client empty the bladder

-Obtain baseline vital signs, abdominal circumference, and weight -place client in high Fowler position or as upright as possible -request that the client empty the bladder --Paracentesis is performed to remove excess fluid from the abdominal cavity or to collect a specimen of ascitic fluid for diagnostic testing. Paracentesis is not a permanent solution for treating ascites and is performed only if the client is experiencing impaired breathing or pain due to ascites. Prior to a paracentesis, nursing actions include verifying that the client received necessary information to give consent and witness informed consent; instruct the client to void to prevent puncturing the bladder; assess the client's abdominal girth, weight, and vital signs; place the client in the high Fowler position or as upright as possible.

The RN is developing a nursing care plan for a client who has just undergone surgery for treatment of ulcerative colitis with the creation of a permanent ileostomy. What is the priority outcome for this client? -the client will contact the United Ostomy Associated of America -The client will look at and touch the stoma -The client will read the materials provided on ostomy care -the client will verbalize methods to control gas and odor

-The client will look at and touch the stoma --A client who has undergone ostomy surgery must become independent in self-care. This requires adaptation to a significant alteration in body image and dealing with a number of psychosocial issues that are associated with a change in appearance and the loss of bowel control. The client looking at and touching the stoma is an indication that the client has accepted or begun to accept the change in body image and functioning and can begin participating in self-care.

The nurse cares for a group of clients in the medical surgical unit. The client with which diagnosis and condition requires the most immediate assistance by the nurse? -post cholecystectomy, reporting incision pain of a 5 on a scale of 1-10 -post open reduction of the right femur, reporting nausea -Type 1 diabetes mellitus with a blood glucose of 55 mg/dL -Type 2 diabetes mellitus with a blood glucose of 250 mg/dL

-Type 1 diabetes mellitus with a blood glucose of 55 mg/dL --hypoglycemia is the most life-threatening condition listed. It occurs when the proportion of insulin exceeds the glucose in the blood. Counterregulatory hormones are then released and the ANS is activated, causing multiple hypoglycemia-associated symptoms, including increased heart rate, shakiness, sweating, hunger, anxiety, and pallor. The lack of glucose in the brain is also responsible for other symptoms, including disorientation, impaired vision and speech, seizures, and coma. However, most clients respond rapidly to the correction of hypoglycemia.

A nurse has received report from the off-going shift that a client is confused and has been identified as a high risk for falls. The nurse shares this information with the UAP. Which finding by the nurse requires intervention? -UAP has attached a bed alarm to the client's gown and bed -UAP has been making hourly rounds on the client -UAP has lowered the bed and raised all 4 side rails -UAP has placed a fall risk ID bracelet on the client's wrist

-UAP has lowered the bed and raised all 4 side rails --placing the client's bed in the lowest position is appropriate, but raising all 4 side rails is considered a form of restraint. Having all 4 side rails up may actually increase clients' risk for falls as they may try to climb up and over the rails. Raising 2-3 side rails is appropriate. The nurse should lower at least one side rail and communicate to the UAP that having all 4 up is inappropriate.

The clinic nurse receives multiple phone calls regarding client status. Which call should the nurse return first? -a 3 year old diagnosed with Kawasaki disease 2 weeks ago developed skin peeling -a 7 year old has had a high fever, cough, and sore throat for the past 2 days -a 14 year old with asthma controlled with a corticosteroid inhaler developed oral white patches -a 16 year old diagnosed with mononucleosis 10 days ago reports abdominal pain

-a 16 year old diagnosed with mononucleosis 10 days ago reports abdominal pain --Infectious mononucleosis is caused by the Epstein-Barr virus. Spleen rupture is a serious complication of infectious mononucleosis that can occur spontaneously and present with sudden onset of left upper quadrant abdominal pain. The 16 year old client should be taken to ER for close monitoring of hemoglobin levels, supportive care to prevent hemorrhagic shock, and possible surgery. Skin peeling is expected in the subacute stage of Kawasaki disease. Corticosteroid inhalers can cause oral thrush.

Which pediatric presentation in the ER should the nurse follow up for possible abuse and mandatory reporting? -a 2 month old who rolled off the changing table and is now lethargic -a 3 month old with flat bluish discoloration on the buttock that the mother says has been present since birth -a 3 year old with forehead bruises that the mother says come from running into a table -a 4 year old who pulled boiling water off the stove and has splattered burns on the arms

-a 2 month old who rolled off the changing table and is now lethargic --infants do not start rolling until 4 months of age and normally roll front to back at 5 months. This explanation for the injury does not fit the growth capacity of the child. -congenital dermal melanocytosis are an expected finding. These are seen on the lower back and/or buttock more often in AA, Asian, Hispanic, and NA infants.

The nurse assesses 4 children in the clinic. Which assessment finding requires the nurse's priority action? -a 3-month-old with fever, vomiting, high-pitched cry, and irritability -a 9-month old with diarrhea who is refusing fluids and cries without tears -an 11-month old with cold symptoms and an abdominal breathing pattern -an 18-month old who cries with the caregiver leaves

-a 3-month-old with fever, vomiting, high-pitched cry, and irritability --infants with underlying infection and increased intracranial pressure will be very irritable and have a fever and high-pitched cry. Other signs of increased ICP include changes in pupillary reaction, sunset eyes, dilated scalp veins, poor feeding, vomiting, and bulging fontanelles. The 3 month old needs to be seen first due to the potential for bacterial meningitis. The absence of tears when crying indicates moderate dehydration.

Four children are brought to the ED. Which child should be assessed first? -a 13-month old who ingested an unknown quantity of children's multivitamins -a 15-month-old with a fever of 100.5 F after being vaccinated -a 3-year-old with a forehead laceration and colorless nasal drainage -a 4-year-old with enlarged lymph nodes who is crying in pain

-a 3-year-old with a forehead laceration and colorless nasal drainage --Clear, colorless fluid draining from the nose or ears after head trauma is suspicious for CSF leakage. When the drainage is clear, dextrose testing can be used to determine if the drainage is CSF. However, the presence of blood would make this test unreliable as blood also contains glucose. This child is at risk for intracerebral bleeding and meningitis. Vascular compromise may occur with even minimal head trauma; therefore, the nurse should evaluate any changes in LOC and temperature as well as assess the head and neck for subcutaneous bleeding. The nurse should anticipate a CT scan of the head and neck and prophylactic antibiotics.

The nurse receives a report on 4 clients. Which client should the nurse assess first? -a 29 year old heroin user admitted for arm cellulitis 24 hours ago has abdominal cramps and is restless -a 34 year old admitted with femur fracture 24 hours ago is confused and has Sp02 of 91% -a 65 year old admitted with serum sodium of 125 mEq/L 8 hours ago is confused -a 78 year old admitted for UTI 6 hours ago is disoriented to time and place

-a 34 year old admitted with femur fracture 24 hours ago is confused and has Sp02 of 91% --Clients with pelvic or long-bone fractures are at risk for the development of life-threatening fat embolism syndrome. Respiratory distress, mental status changes, and petechiae are the classic manifestations. --Moderate hyponatremia can cause altered mental status and can lead to seizures if it becomes severe. This client needs treatment and should be the second priority.

The nursing team consists of a RN, a LPN, and 2 UAPs. The nurse considers the assignment appropriate if the LPN is assigned to care for which pediatric client? -a 1 day old with tracheoesophageal fistula scheduled for surgical repair today -a 6 month old who had diaphragmatic hernia repair 5 days ago -a 12 ear old newly admitted with productive cough and white blood cell count of 15,000/mm3 -a 16 year old admitted for uncontrolled diabetes experiencing Kussmaul breathing

-a 6 month old who had diaphragmatic hernia repair 5 days ago --the RN should delegate stable clients with expected outcome to the LPN. The RN cannot delegate any techniques or procedures that involve evaluation, teaching, or assessment methods.

The nurse is caring for pediatric clients in an acute care setting. Which of these clients should the nurse see first? -a 1-day post tubal myringotomy client with purulent tympanic drainage -a 4-day post valve replacement client with a temperature of 102 F and petechiae -a 10-day old client with a patent ductus arteriosus who has a continuous murmur -a 6-year old client with epiglottitis who is drooling and has a severe sore throat

-a 6-year old client with epiglottitis who is drooling and has a severe sore throat --Epiglottitis refers to inflammation of the epiglottis that may result in life-threatening airway obstruction. Haemophilus influenza type b was the most common cause, but the incidence has decreased dramatically with widespread Hib vaccination. Symptoms begin with abrupt onset of high-grade fever and a severe sore throat, followed by the 4 D's: drooling, dysphonia, dysphagia, and distressed airway. Children are typically toxic-appearing and may be tripoding with inspiratory stridor. This client should be assessed first due to being unstable from an airway disorder. The client has a respiratory illness and is drooling, which indicates respiratory distress.

The nurse is working on a busy medical-surgical unit and is responding to the client call lights. Which statement would be the priority to assess first? -a 65 year old female client recently started on celecoxib says, "I am having some nausea and my upper back and shoulder are hurting quite a bit." -A client's child says, "My parent has been here for 2 days without anything to eat or drink." -A paraplegic client with multiple stage 4 pressure ulcers says, "I have had a bowel movement and need to be cleaned up." -A postoperative client says, "I am very nauseous and just thew up. This pain medicine is making me really sick."

-a 65 year old female client recently started on celecoxib says, "I am having some nausea and my upper back and shoulder are hurting quite a bit." --Celecoxib, a COX-2 inhibitor, has a black box warning for increased risk of cardiovascular complications. Myocardial infarction symptoms, which can be vague in female clients, include nausea and upper back and shoulder pain. These symptoms would be the priority to assess first, and immediate testing would be warranted.

The clinical coordinator RN on a surgical unit makes assignments for the staff of RN, LPN, and graduate nurse. Which assignment is most appropriate for a new graduate nurse? -a 36 year old client with postoperative venous thromboembolism who is to be started on the institution's intravenous heparin therapy protocol this morning -a 56 year old client with newly diagnosed cancer, scheduled for a total laryngectomy this morning, who is now refusing surgery -a 68 year old client with multiple sclerosis, 2 days postoperative open cholecystectomy with recurrent mucous plugs, who is scheduled for a bronchoscopy this morning -an 80 year old client, 3 days postoperative colectomy with peritonitis, who was mentally alert before and develops new-onset confusion this morning

-a 68 year old client with multiple sclerosis, 2 days postoperative open cholecystectomy with recurrent mucous plugs, who is scheduled for a bronchoscopy this morning --When assigning clients to the appropriate staff member, the RN must consider the individual client needs and the skills of the staff member. The more experienced RN is assigned to the client with the more complex physiologic and psychologic needs, who requires a more advanced level of nursing skill. The new graduate nurse is assigned to the client who less complex needs, who requires basic nursing skills, such as measurement of vital signs and basic physical assessment.

The nurse receives report for clients on the neurology floor. Which client is important for the nurse to assess first? -25 year old client with multiple sclerosis who had bladder incontinence last night -a 37 year old client with Gullain-Barre syndrome who has "0" deep tendon patellar reflexes -a 58 year old client with Parkinson disease who is drooling -a 78 year old client with dementia who has new-onset agitation and confusion

-a 78 year old client with dementia who has new-onset agitation and confusion --new-onset agitation is a change in mental status for someone with dementia and requires assessment. It is possible for a client to develop delirium in addition to dementia. Delirium is a sign of a different issue, such as worsening infection/condition, fluid and electrolyte imbalance, or drug-drug interaction. --drooling, lack of blinking, mask-like facial expressions, and lack of swinging arms with walking are expected findings of Parkinson disease. This loss of autonomic movements results from alterations of the basal ganglia and extrapyradmidal portion of the central nervous system.

Which client is at greatest risk for pulmonary embolism? -a client 6 hours postoperative cesarean section - a client in atrial fibrillation -a client with a subdural hematoma -a client with pneumonia

-a client 6 hours postoperative cesarean section --Death from pulmonary embolism is often attributed to a missed diagnosis. Nurses must recognize any condition or situation that predisposes a client to venous stasis, hypercoagulability of blood, and endothelial damage, as these factors increase the risk for PE.In atrial fibrillation, stasis and turbulence of blood increases risk of thrombus formation. Once mobilized, emboli can get trapped in blood vessels, causing ischemia. Smaller vasculature and increased blood flow in the brain increases the probability of a stroke, rather than PE>

The post-anesthesia care unit nurse is caring for 4 clients during the immediate postoperative period. Which client would be the priority for the nurse to see first? -a client post cholecystectomy reporting increased nausea -a client post myomectomy with mild oozing of blood from the surgical site -a client post spinal surgery requesting additional pain medication -a client post transurethral resection of the prostate with reddish-pink drainage

-a client post cholecystectomy reporting increased nausea --Postoperative clients are at an increased risk for vomit aspiration due to nausea and an altered LOC. These clients should be placed on their side and should receive antiemetics to prevent potential airway and breathing complications. Mild oozing of blood from the surgical site is normal during the postoperative period. Pain control after surgery is important for client recovery- see this client second. After transurethral resection of the prostate, continuous bladder irrigation for 24-36 hours flushes out small clots and prevents obstruction. Reddish-pink drainage is expected.

The RN is discussing care of shared clients with LPN. Which of the following clients require intervention by the RN? SATA -a client receiving a blood transfusion who reports severe anxiety and has a blood pressure 90/60 mm Hg and pulse 110/min -a client receiving oral metoprolol whose heart rate has decreased to 60/min after administration -a client whose blood pressure decreased from 130/8- mm Hg to 110/70 mm Hg following administration of 1 mg hydromorphone IV -a client whose blood pressure was 90/65 mm Hg before prescribed oral nifedipine was administered -a client whose pulse increased from 70/min to 100/min after albuterol administration

-a client receiving a blood transfusion who reports severe anxiety and has a blood pressure 90/60 mm Hg and pulse 110/min -a client whose blood pressure was 90/65 mm Hg before prescribed oral nifedipine was administered --Nurses caring for clients receiving blood products should immediately intervene upon signs of transfusion reaction (anxiety, hypotension, tachycardia). Clients should be monitored for hemodynamic instability if blood pressure medications are administered during hypotension. Opioids may cause decreased blood pressure due to histamine release.

A blizzard is predicted to hit a large city within a few hours. The home care nurse is prioritizing and revisiting the schedule and estimates that 3 home visits can be made before the blizzard hits. Which clients should the nurse see first? SATA -a client who fell and hit the head but refuses to go to the ED -a client who is due for a maintenance dose of cyanocobalamin -a client who needs pre-filled insulin syringes -a client who was discharged from the hospital yesterday after heart failure treatment -a client with a stage 3 pressure injury in need of a dressing change

-a client who fell and hit the head but refuses to go to the ED -a client who needs pre-filled insulin syringes -a client with a stage 3 pressure injury in need of a dressing change --in this scenario, it is unknown when home care visits will resume due to severe inclement weather. The high-priority clients are those who are at risk for harm if a scheduled visit cannot be made in 24 hours or more. The client who fell could have sustained a head injury and needs assessment. The client in need of pre-filled insulin syringes could become hyperglycemic if insulin is unavailable. The client with the stage 3 pressure injury has a scheduled dressing change for a serious wound and tis should not be postponed.

The charge nurse on a telemetry unit is training a new RN. The charge nurse assists the new RN in prioritizing assessments of multiple clients. Which client should be assessed first? -a client in atrial fibrillation with an INR of 4.0 who has a warfarin dose due -a client who had coronary artery bypass surgery 2 days ago, has a temperature of 99 F, and has a dose of vancomycin due -a client who is 48 hours post myocardial infarction, is experiencing ventricular bigeminy, and has a dose of amiodarone due -a client whose NPO status has just been discontinued after 8 hours and who is anxious to drink fluids

-a client who is 48 hours post myocardial infarction, is experiencing ventricular bigeminy, and has a dose of amiodarone due --Ventricular bigeminy is a rhythm in which every other heartbeat is a PVC. PVC's in the presence of a MI indicate ventricular irritability and increase the risk for a more serious dysrhythmia. Possible causes of ventricular bigeminy include electrolyte imbalances and ischemia. After assessing the client's vital signs, the nurse should assess potassium and magnesium levels and apical-radial pulse, administer the scheduled amiodarone, and notify the HCP. --the client with AF should be seen after the MI client. Vital signs are stable, but the INR should be lower (normal 2.0-3.0 for AF). The nurse should assess for signs of bleeding and notify the HCP; the scheduled dose of warfarin should likely be held.

A clinic nurse is reviewing charts for clients who have appointments later in the day. Which of the following clients should the nurse recognize as appropriate recipients of a prescription of emtricitabine/tenofovir? SATA -a client who reports current recreational IV drug use -a client with a latent tuberculosis infection -a female client whose spouse has HIV -a male client who has intercourse with men and women -a phlebotomist at an outpatient blood bank

-a client who reports current recreational IV drug use -a female client whose spouse has HIV -a male client who has intercourse with men and women --HIV is a viral infection of CD4 cells that results in progressive immune system impairment. It is most frequently transmitted via blood, unprotected sexual contact, shared needles, and parenteral equipment, or perinatally from mother to child. Primary prevention and modification of risky behaviors are essential health care strategies for HIV because there is no known cure. Preexposure prophylaxis is a preventive strategy in which antiretroviral therapy is prescribed for clients whose risk for contracting HIV is high. Entricitabine/tenofovir (Truvada) is a commonly used combination therapy for PrEP in high-risk individuals (clients using recreational IV drugs, clients whose spouses have HIV, men who have sex with men). PrEP should be combined with other prevention methods such as safer sex practices, regular HIV testing and counseling for risk reduction. -Tuberculosis infection does not increase the risk of contracting HIV. However, HIV infection places clients at risk for opportunistic infections. Antiretroviral therapy can lower the risk for opportunistic infections in clients with HIV.

Four clients comes to the ED simultaneously. Which client should the nurse see first for definitive care? -6 month old with temperature of 101 F who is rubbing the ears and being fussy -10 day old client with a red mark on the neck, the mother is concerned -a client who took a handful of amitriptyline pills, a tricyclic antidepressant drug -a client who tripped and hit the head but is alert with no loss of consciousness, currently takes warfarin

-a client who took a handful of amitriptyline pills, a tricyclic antidepressant drug --A client with a drug overdose is the highest priority as the actual amount taken and its effects are unknown. In addition, clients who deliberately OD often consume other substances that can potentiate the effect of the drug. OD is especially concerning for a TCA due to the effect this can have on the cardiovascular and central nervous systems. TCA use for depression is an uncommon second-line treatment, but the drug class is used for neuropathic pain and sometimes bed-wetting. --a client with head trauma who is currently on an anticoagulant could have potential intracranial bleeding and should be treated next.

A nurse on a medical surgical unit receives a report on multiple clients. Based on this report, which client should the nurse assess first? -a client who underwent a colon resection 3 hours ago and is bleeding -a client who was rescued from a burning building and shows evidence of smoke inhalation -a client with gastroenteritis who is throwing up large amounts of vomit -a client with peritonitis who has pain level of "8" on a scale from 1-10

-a client who was rescued from a burning building and shows evidence of smoke inhalation --Smoke inhalation is the leading cause of death in burn clients as it causes thermal injury to the upper airways, chemical injury to the tracheobronchial tree, and carbon monoxide and/or cyanide poisoning. Clients should receive 100% oxygen to displace carbon monoxide and cyanide from hemoglobin. Intubation is indicated if there is evidence of upper airway edema with respiratory distress. An obstructed airway can lead to cardiac arrest if not treated immediately.

Which client with an endocrine problem is most appropriate for the charge nurse to delegate to the LPN? -a client experiencing Addisonian crisis with a prescription for hydrocortisone -a client with Cushing syndrome who needs intermittent urinary catheterization -a client with DKA on insulin IV infusion -A client with thyrotoxicosis and new onset atrial fibrillation

-a client with Cushing syndrome who needs intermittent urinary catheterization --The charge nurse should assign the most stable clients to the LPN

There has been a large-scale community disaster and clients must be roomed together at the hospital. Who are appropriate roommates in light of infection risk principles? SATA -a client diagnosed with varicella and a client with pertussis -a client placed in an airborne infection isolation room and a client with heart failure -a client receiving chemotherapy and a client with COPD coughing yellow sputum -a client with PID and a client with coffee ground emesis -two clients diagnosed with tuberculosis

-a client with PID and a client with coffee ground emesis -two clients diagnosed with tuberculosis --For infection control, clients with same organisms can be placed together. Infectious clients cannot be placed with immunosuppressed or at-risk clients. -Varicella requires airborne precautions. Pertussis requires droplet precautions. Both precautions and organisms are different, thus the clients could cross-infect each other. An AIIR in indicated when the client has an organisms transmitted by the airborne route. No other client should be in the room with a client with this type of infection, especially one with a significant co-morbidity. Chemotherapy causes bone marrow suppression with immunosuppression. Although the client may not need reverse or protective isolation, an infectious client should not be placed with this client. Yellow sputum typically indicates bacterial infection.

Which of the these clients should the nurse assess first? -A client who has SOB from moderate pleural effusion and is waiting for thoracentesis -a client who just had a long leg cast applied and has severe pain despite a dose of morphine -a client with cellulitis who is receiving a first dose of IV antibiotics and has throat tightness -a sickle cell crisis client who has severe bone pain despite a dose of morphine

-a client with cellulitis who is receiving a first dose of IV antibiotics and has throat tightness --First-level priorities include issues of airway, breathing, cardiac and circulation, and vital signs, respectively. Anaphylactic reactions are potentially fatal medical emergencies that must be treated immediately. Compartment syndrome prevents perfusion and can cause tissue death and limb loss. Stable clients awaiting procedures are assessed last.

The nurse is caring for clients on a busy medical-surgical unit. Which client would be priority to assess first? -a client with an ileostomy bag that has leaked stool all over -a client with COPD, diminished breath sounds, and SpO2 of 91% -a client with DVT who missed the last warfarin dose -a client with sepsis who is developing petechiae

-a client with sepsis who is developing petechiae --Clients with sepsis are at risk for developing DIC, a condition that initially causes clotting within the microvessels. Platelets and clotting factors are consumed in clotting and become unavailable for body use, leading to bleeding complications. The initial clotting also disrupts blood flow to extremities and organs. Signs of DIC include frank external bleeding, signs of internal bleeding, and respiratory distress.

The charge nurse is notified that a client is being admitted with a diagnosis of active shingles with a disseminated rash. Which room assignment is most appropriate for this client? -a private room with contact and droplet precautions -a private room with negative airflow and contact and airborne precautions -a private room with positive airflow and airborne precautions -a semi-private 2-bed room with standard precautions

-a private room with negative airflow and contact and airborne precautions --Shingles is a reactivation of the varicella-zoster virus. It is more likely to occur when a client's immune system is compromised by disease or treatments. Shingles lesions that are open may transmit the infection by both air and contact. The client with disseminated shingles that are not crusted over will require contact precautions, airborne precautions, and a negative airflow room to prevent transmission of the infection to others in the hospital. Negative airflow pulls air from the hospital environment into the room, and the air from the hospital room then goes directly to the outside rather than recirculating to the rest of the hospital. Localized shingles require only standard precautions for clients with intact immune systems and contained/covered lesions.

The nurse completes a neurological examination on a client who has suffered a stroke to determine if damage has occurred to any of the cranial nerves. The nurse understands that damage has occurred to cranial nerve IX based on which assessment finding? -a tongue blade is used to touch the client's pharynx; gag reflex is absent -only one side of the mouth moves when the client is asked to smile and frown -the absence of light touch and pain sensation on the left side of the client's face -when the client shrugs against resistance, the left shoulder is weaker than the right

-a tongue blade is used to touch the client's pharynx; gag reflex is absent --Cranial nerve IX (glossopharyngeal) and X (vagus) are related to the movement of the pharynx and tongue. To evaluate cranial nerves X and IX, the nurse assesses for the presence of a gag reflex and symmetrical movements of the uvula and soft palate, and listens to voice quality. A tongue blade can be used to touch the posterior pharyngeal wall to assess for a gag reflex. Asking the client to say "ah" will allow assessment of the uvula and soft palate. Harsh or brassy voice quality indicates dysfunction with the vagus nerve.

All of these events are occurring at the same time. Which one should the registered nurse deal with first? -a HCP is asking to speak to the nurse -a visitor is seen lying on the hallway floor -a client is requesting an analgesic for pain rated an "8" on a 1-10 scale -the IV pump is beeping on a client who is receiving blood

-a visitor is seen lying on the hallway floor --the nurse must deal with the visitor on the floor first, either by approaching/assessing the visitor or asking another nurse/charge nurse to deal with it urgently. The visitor could have fallen and hit the head. Responsiveness must be established and the need for any life-saving measures must be ruled out. Visitor status does not matter, this individual is on hospital property and the nurse is obligated to respond. --Although blood transfusions are urgent and the nurse should assess the site/pump, potential life-saving measures take priority.

During the admission assessment of a client with a small-bowel obstruction, the nurse anticipates which clinical manifestations? SATA -abdominal distension -absolute constipation -colicky abdominal pain -frequent vomiting -pain during defecation

-abdominal distension -colicky abdominal pain -frequent vomiting --Small-bowel obstruction can have mechanical or non-mechanical causes. Mechanical obstruction is commonly caused by obstruction of the bowel resulting from surgical adhesions, hernias, intussuscpetion, or tumors. Paralytic ileus, a non-mechanical obstruction, may occur after abdominal surgery or narcotic use. When a small-bowel obstruction develops, fluid and gas collect proximal to the obstruction, producing rapid onset of N/V; colicky intermittent abdominal pain, and abdominal distension. The nurse should recognize symptoms of bowel obstruction quickly as delay could lead to vascular compromise, bowel ischemia, or perforation. Nursing management of an obstruction includes placing the client on NPO status, inserting a NG tube, administering prescribed IV fluids, and instituting pain control measures.

An older client comes to the outpatient clinic for a routine physical examination and health screening. Which findings does the nurse recognize as possible indications of colorectal cancer? SATA -abdominal pain -blood in the stools -change in bowel habits -low hemoglobin level -unexplained weight loss

-abdominal pain -blood in the stools -change in bowel habits -low hemoglobin level -unexplained weight loss --Colorectal cancer occurs most often in adults over age 50. Risk factors include history of colon polyps; family history of colorectal cancer; inflammatory bowel disease; and history of other cancers. --Symptoms of colorectal cancer may include blood in stool from fragile, bleeding polyps or tumors; abdominal discomfort and/or mass; anemia due to intestinal bleeding, which may result in fatigue and dyspnea with exertion; change in bowel habits due to obstruction by polyps or tumors; unexplained weight loss due to impaired nutrition from altered intestinal absorption. Colorectal cancer often goes unnoticed, as many of the symptoms are painless and nonspecific. Clients should be assessed for these symptoms and receive regular routine colorectal cancer screening tests.

The nurse who is caring for a client with acute diverticulitis will immediately report which finding to the healthcare provider? -abdominal pain has progressed to the left upper quadrant -hemoglobin of 11.2 g/dL -lying on the side with knees drawn up to abdomen and truck flexed -white blood cell count of 12,000/mm3

-abdominal pain has progressed to the left upper quadrant --Diverticula are saclike protrusions or outpouchings of the intestinal mucosa of the large intestine caused by increased intraluminal pressure. The left colon is the most common area for diverticula to develop. When these diverticula become inflamed, the client may experience acute pain and systemic signs of infection. Complications that can occur in some clients are abscess formation and intestinal perforation resulting in diffuse peritonitis. The client with peritonitis prefers to lie still and take shallow breaths to avoid stretching the inflamed peritoneum. Peritonitis is a potentially lethal complication and should be reported immediately.

A school nurse observes a 3-year-old begin to choke and turn blue while eating lunch. What should be the nurse's initial action? -abdominal thrusts -back blows and chest thrusts -blind sweep of the child's mouth -call 911 for an ambulance

-abdominal thrusts --The Heimlich maneuver is the primary rescue intervention for children over age 1 with a foreign body airway obstruction causing respiratory distress. Back blows and chest thrusts are appropriate interventions for a choking infant under age 1. Blind sweeping of a child' mouth should not be attempted

What are 2 core symptoms of autism?

-abnormalities in social interactions -communication and patterns of behavior, interests, or activities that can be restricted and repetitive.

The emergency nurse is triaging clients. Which report is most concerning and would be given priority for definitive diagnosis and care? -abrupt, tearing, moving back pain and epigastric pain -severe lower back pain after lifting heavy boxes -sharp calf ache with ambulation that improves with rest -unilateral leg swelling with 2+ pitting edema after an airplane trip

-abrupt, tearing, moving back pain and epigastric pain --An aortic dissection occurs when the arterial wall intimal layer tears and allows blood between the inner and middle layers Clients with ascending aortic dissections typically have chest pain, which can radiate to the back. Descending aortic dissection is more likely associated with back pain and abdominal pain. It is frequently abrupt in onset and described as "worst ever", "tearing", or "ripping" pain. Hypertension is a contributing factor. Extending dissection from uncontrolled hypertension can cause cardiac tamponade or arterial rupture, which is rapidly fatal. Emergency treatment includes surgery and/or lowering the blood pressure. --severe lower back pain after lifting heavy boxes is likely due to disc herniation. Some clients may report radiculopathy pain radiating down the leg below the knee. While uncomfortable, this is not life-threatening. --this is a description of intermittent claudication in the lower extremity due to peripheral artery disease. It is an ischemic muscle pain related to exercise that resolves with rest. --This is a description of a DVT resulting from immobility during a flight. The embolization of DVT can cause life-threatening pulmonary embolism, but is not currently life- threatening

The nurse is caring for a client with scleroderma. Which assessment finding indicates the most serious complication of the disease and requires priority intervention? -abrupt-onset hypertension and headache -blue and cold fingertips -dry cough and exertional dyspnea -heartburn and difficulty swallowing

-abrupt-onset hypertension and headache --Scleroderma is a progressive disease without a cure and treatment is aimed at managing complications. Renal crisis is a life-threatening complication that causes malignant hypertension due to narrowing of the vessels that provide blood to the kidneys. Early recognition and treatment of renal crisis is needed to prevent acute organ failure.

The post-anesthesia care unit nurse receives report on a client after abdominal surgery. What sounds would the nurse expect to hear when auscultating the bowel? -absent bowel sounds -borborygmi sounds -high pitched and gurgling sounds -swishing or buzzing sounds

-absent bowel sounds --Auscultation of abdominal sounds during physical assessment includes bowel and cardiovascular components. Bowel sounds are normally intermittent, high-pitched, gurgling sounds that can be auscultated with the diaphragm of the stethoscope in all 4 quadrants. Cardiovascular bruits are rarely benign and usually arterial narrowing or dilation. Procedures that require bowel manipulation cause a temporary halting of peristalsis for the first 24-48 hours, resulting in absent bowel sounds. For bowel sounds to be considered absent, the nurse must auscultate for 2-5 minutes in each quadrant. Peristalss will usually return in the small intestine in 24 hours, but the large intestine may be delayed 3-5 days. Other procedures requiring general anesthesia, late stages of mechanical obstruction, and peritonitis may cause absent bowel sounds.

treatment for varicella-zoster virus? (chickenpox)

-acetaminophen for fever and pain -cool oatmeal baths -topical antihistamines for itching -if the client is immunocompromised, they should receive antiviral therapy (acyclovir)

The nurse prepares a client for scheduled surgery. Which actions are the nurse's legal responsibility with regard to informed consent? SATA -acting as a witness that the client signed the consent form voluntarily -documenting in the medical record the date and time the signature was obtained -educating the client if there is a misunderstanding about the procedure -explaining to the client the right to refuse surgery -verifying that the client is competent to provide informed consent

-acting as a witness that the client signed the consent form voluntarily -documenting in the medical record the date and time the signature was obtained -verifying that the client is competent to provide informed consent --The HCP is responsible for explaining all aspects of the procedure, ensuring that the client has a correct understanding of the procedure and its potential risks, providing the names/qualifications of those who will be involved, describing available alternative treatments, and reinforcing that the client has the right to refuse the procedure. The HCP should be contacted if the client does not have the correct understanding of the procedure. The nurse should not try to explain procedures as he/she could be held liable for giving incorrect information.

The nurse is caring for a client who has a postoperative paralytic ileus following a bowel resection for colon cancer. The client is receiving patient-controlled analgesia with morphine. Which nursing diagnoses are appropriate to include in the client's care plan? SATA -acute pain -dysfunctional gastric motility -imbalanced nutrition, less than body requirements -ineffective self-health management -risk for infection

-acute pain -dysfunctional gastric motility -imbalanced nutrition, less than body requirements -risk for infection

The nurse is caring for a client at risk for aspiration pneumonia due to a stroke. What nursing actions help prevent this potential complication during hospitalization? SATA -add a thickening agent to the fluids -avoid administering sedating medications before meals -place the client in an upright position during meals -restrict visitors who show signs of illness -teach the client to flex the neck while swallowing

-add a thickening agent to the fluids -avoid administering sedating medications before meals -place the client in an upright position during meals -teach the client to flex the neck while swallowing --aspiration pneumonia develops when aspirated material causes an inflammatory response and provides a medium for bacterial growth. At-risk conditions include cognitive changes, difficulty swallowing, compromised gag reflex, and tube feeding.

The nurse is reinforcing discharge instructions with a client following a partial gastrectomy. Which of the following instructions should the nurse include to prevent dumping syndrome? SATA -add high-protein foods to diet -consume high-carbohydrate meals -eat small, frequent meals -increase intake of fluids with meals -lie down after eating

-add high-protein foods to diet -eat small, frequent meals -lie down after eating --Following a partial gastrectomy, many clients experience dumping syndrome, which occurs when gastric contents empty too rapidly into the duodenum, causing a fluid shift into the small intestine. This results in hypotension, abdominal pain, N/V, dizziness, generalized sweating, and tachycardia. The symptoms usually diminish over time. --avoid meals high in simple carbohydrates because these may trigger dumping syndrome --avoid consuming fluids with meals to reduce the risk of dumping syndrome.

Prevention of DVT recurrence

-adequate fluid intake -limit caffeine/alcohol -elevate legs when sitting -dorsiflex feet often -partake in exercise programs -change positions frequently -stop smoking -avoid restrictive clothing -if overweight, consult with dietician

After morning report, the nurse must perform which action first when caring for assigned clients? -administer IV bumetanide to a client with heart failure who has bilateral crackles and dyspnea -hang the second unit of packed red blood cells for a client with a hemoglobin of 6 g/dL -replace the empty IV opioid medication syringe in a patient-controlled analgesia pump -replace the heparin infusion bag that has 100 mL remaining and is infusing at 50 mL/hr

-administer IV bumetanide to a client with heart failure who has bilateral crackles and dyspnea --Heart failure involves the inability of the heart to pump blood effectively to meet the body's oxygen needs. The nurse should first administer the IV bumetanide (Bumex) or furosemide to promote diuresis and mobilize excess fluid in the systemic circulation and lungs. This is the priority action as it improves oxygenation and gas exchange in the lungs and helps relieve dyspnea. The second unit of packed red blood cells is required to raise the hemoglobin to increase the blood's oxygen-carrying capacity, but it is not as urgent as improving gas exchange in the lungs.

A hospitalized client develops acute hemorrhagic stroke and is transferred to the intensive care unit. Which nursing interventions should be included in the plan of care? SATA -administer PRN stool softeners daily -administer scheduled enoxaparin injection -implement seizure precautions -keep client NPO until swallow screen is performed -perform frequent neurological assessments.

-administer PRN stool softeners daily -implement seizure precautions -keep client NPO until swallow screen is performed -perform frequent neurological assessments. --a hemorrhagic stroke occurs when a blood vessel ruptures in the brain and causes bleeding into the brain tissue or subarachnoid space. Seizure activity may occur due to increased intracranial pressure. During the acute phrase, a client may develop dysphagia. To prevent aspiration, the client must remain NPO until a swallow function screen reveals no deficits. The nurse should perform neurological assessments at regular intervals and report any acute changes. Preventing activities that increase ICP or blood pressure will minimize further bleeding. The nurse should reduce stimulation by maintaining a quiet and dimly lit environment and limit visitors; administer stool softeners to reduce strain during bowel movements; reduce exertion, maintain strict bed rest, and assist with activities of daily living; maintain head in midline position to improve jugular venous return to the heart --enoxaparin is an anticoagulant used to prevent venous thromboembolism. Anticoagulants are contraindicated in clients with hemorrhagic stroke; the nurse should question any prescriptions that increase risk for bleeding. A client with hemorrhagic stroke should instead receive nonpharmacologic interventions to prevent VTE.

The nurse is delegating client care tasks to a LPN and UAP. Which of the following assignments are most appropriate to assign to the LPN? SATA -administer a client's daily dose of subcutaneous insulin glargine -administer a scheduled oral analgesic to a 2 days postoperative client -complete an admission nursing interview for a client admitted for elective hysterectomy -reinforce teaching on self-administration of insulin to a client with diabetes mellitus -tally the shift's intake and outputs for the entire unit

-administer a client's daily dose of subcutaneous insulin glargine -administer a scheduled oral analgesic to a 2 days postoperative client -reinforce teaching on self-administration of insulin to a client with diabetes mellitus --administration of insulin by LPN varies by state legislation

Steps to performing wound irrigation

-administer analgesic 30-60 minutes before the procedure to allow medication to reach therapeutic effect -don a gown and mask with face shield to protect from splashing fluid and sterile gloves to maintain surgical asepsis and prevent infection -fill a 30-60 mL sterile irrigation syringe with the prescribed irrigation solution -attach an 18 or 19-gauge needle or angiocatheter to the syringe and hold 1 inch above the area -use continuous pressure to flush the wound, repeating until drainage is clear -dry the surrounding wound area to prevent skin breakdown and irritation

An unaccompanied 16 year old girl comes to the ER with severe abdominal pain and vomiting. The client has a temperature of 102.2 F and a pulse of 120/min and is lethargic. The client's parents are out of town, and no guardians can be reached. How should this client's care be handled? -administer care unit the parents or guardians can be reached -admit the client but without giving care until the parents or guardians can be reached -perform a pregnancy test to see if the client qualifies as an emancipated minor -provide health care and follow-up advice but do not give any direct care

-administer care unit the parents or guardians can be reached --An underage client whose parents or guardians cannot be contacted and who needs emergency care should receive all necessary medical care until a parent or guardian can be reached to provide consent.

A postoperative client with obesity and diabetes mellitus has an abdominal incision and is at risk for poor wound healing, Which interventions should the nurse include in the plan of care to promote wound healing and prevent dehiscence? SATA -administer docusate PO daily -administer ondansetron IV PRN for nausea -apply an abdominal binder -implement caloric restriction to promote weight loss -monitor blood sugar to maintain tight glucose control

-administer docusate PO daily -administer ondansetron IV PRN for nausea -apply an abdominal binder -monitor blood sugar to maintain tight glucose control --Dehiscence is a complication of poor wound healing that occurs when the edges of a surgical wound fail to approximate and separate. Dehiscence is associated with factors that impair circulation, tissue oxygenation, and wound healing and with mechanical stress on the wound.

A client who suffered a burn injury has received fluid resuscitation and is now diuresing, indicating the end of the emergency phase. Which prescription is the highest priority at this time? -administer enteral feedings at the return of bowel sounds -assist the client in activities of daily living as tolerated -contact the client's religious advisor for spiritual support -educate the client's family about dressings and medications

-administer enteral feedings at the return of bowel sounds --The nurse should consider Maslow's Hierarchy of Needs to determine the importance of various interventions. This client is in the acute phase of burn management continues to have increased physiological needs. Clients with burns have increased metabolism and calorie requirements that must be met for healing to occur. The nutrition needed for healing increases proportionally with he percentage of burned tissue. Therefore, providing proper nutrition as soon as possible is the highest priority.

A hospitalized client with acute pancreatitis has nausea, vomiting, epigastric pain, and tachycardia. Laboratory results show elevated serum lipase levels. Which interventions would the nurse anticipate being prescribed for the client? SATA -administer hydromorphone IV PRN for pain -administer intravenous fluids -insert a nasogastric tube for nasogastric suction -maintain client in a supine position, with head of bed flat -provide small, frequent, high-carbohydrate, high-calorie meals

-administer hydromorphone IV PRN for pain -administer intravenous fluids -insert a nasogastric tube for nasogastric suction --Supportive care for symptom relief and prevention of complications are the major goals in clients with acute pancreatitis. NPO status is maintained to prevent stimulation of excretion of pancreatic enzymes. A NG tube is used to suction out gastric secretions; this reduces nausea and lessens stimulation of the pancreas. IV opioids are frequently utilized for pain management. Aggressive fluid replacement to prevent hypovolemic shock is critical. Inflammation of the pancreas releases chemical mediators that increase capillary permeability and cause third spacing. --the client should maintain positions that flex the trunk and draw the knees up to the abdomen to decrease tension on the abdomen. A side-lying position with the head elevated to 45 degrees will help relieve the pain even better.

Which actions by an RN are reportable to the state board of nursing? SATA -administer hydromorphone without a prescription -being habitually tardy to work -documenting an intervention that was not performed -stealing narcotics -walking off duty in the middle of a shift

-administer hydromorphone without a prescription -documenting an intervention that was not performed -stealing narcotics -walking off duty in the middle of a shift --Clients receiving IV heparin should maintain therapeutic clotting times, avoid developing embolic events, and remain free from signs of heparin-induced thrombocytopenia. Clients having undergone a carotid endarterectomy, a surgical procedure removing plaque from carotid arteries, would be expected to show no evidence of hemorrhage or neurological impairment. Clients receiving IV furosemide, a loop diuretic, should maintain adequate blood pressure and avoid developing symptoms of electrolyte imbalance. A femoral-popliteal angioplasty is a surgical procedure to restore perfusion to the legs of clients with peripheral arterial disease. After the procedure, the client should be able to ambulate without evidence of extremity ischemia.

The nurse is caring for a client with acute diverticulitis who has N/V and rates pain as 8 on a scale of 0-10. Which of the following interventions should be included in the plan of care? -administer morphine sulfate as prescribed for pain control -insert a rectal tube to protect the client's skin from diarrhea -instruct the client to avoid straining -maintain NPO status -start IV infusion of normal saline

-administer morphine sulfate as prescribed for pain control -instruct the client to avoid straining -maintain NPO status -start IV infusion of normal saline --Diverticulosis is a condition in which saclike protrusions develop in the large intestine, caused by increased intraabdominal pressure and/or chronic constipation. When diverticula become infected and inflamed, the individual has diverticulitis.

The RN is working with a LPN and UAP. A client has just returned to the cardiac unit after a percutaneous coronary intervention. Which actions are most appropriate for the RN to assign to the LPN. SATA -administer oral pain medication for the client's chronic lower back pain -assist the client with the use of a urinal post-procedure -monitor for bleeding at the catheter insertion site every 15 minutes -perform the initial post-procedure vital sign measurements -review the ECG monitor for dysrhythmias

-administer oral pain medication for the client's chronic lower back pain -monitor for bleeding at the catheter insertion site every 15 minutes --In the client who has had a percutaneous coronary intervention, after initial assessment and comparison to pre-procedure baseline, the RN may assign the tasks of medication administration, monitoring of neurovascular status of the involved extremity, and checking for bleeding at the catheter insertion site to the LPN.

The nurse cares for a client with ulcerative colitis who is having abdominal pain and greater than 10 bloody stools per day. Which of the following interventions should be included in the client's plan of care? SATA -administer prescribed analgesic medications as needed -encourage the client to discuss feelings about illness -initiate strict, hourly intake and output monitoring -investigate the client's compliance with the medication regimen -offer the client high-protein foods during meals and snacks

-administer prescribed analgesic medications as needed -encourage the client to discuss feelings about illness -initiate strict, hourly intake and output monitoring -investigate the client's compliance with the medication regimen -offer the client high-protein foods during meals and snacks --Ulcerative colitis is a chronic inflammatory bowel disease characterized by bouts of bloody diarrhea, abdominal pain, anorexia, and anemia. Nurses caring for clients with UC should provide pain management, promote adequate nutrition and hydration, address psychosocial needs, and evaluate client compliance with treatment.

A nurse is caring for a client admitted to the intensive care unit for toxic epidermal necrolysis. Which interventions should be included in this client's care plan? SATA -administer prescribed eye lubricants on schedule -apply sterile, moist dressings and ointments to denuded areas of skin -implement reverse isolation precautions and strict aseptic technique -keep room temperature warm to prevent shivering -provide gentle massage as needed to relieve pain

-administer prescribed eye lubricants on schedule -apply sterile, moist dressings and ointments to denuded areas of skin -implement reverse isolation precautions and strict aseptic technique -keep room temperature warm to prevent shivering --toxic epidermal necrolysis is an acute skin disorder, most commonly associated with a medication reaction that results in widespread erythema, blistering, epidermal shedding, keratoconjunctivitis, and skin erosion. It is a severe form of Stevens-Johnson syndrome. The major cause of death related to toxic epidermal necrolysis is sepsis; therefore, infection prevention is critical

The nurse is preparing to change a negative-pressure wound therapy dressing on a client's pressure ulcer. Which of the following actions are appropriate at this time? SATA -administer prescribed pain medication 30 minutes before the procedure -apply skin protectant to intact skin surrounding the wound -apply the foam dressing to the wound bed using clean technique -cut the foam dressing slightly larger than the size of the wound -ensure that the foam dressing shrinks after the device is turned on

-administer prescribed pain medication 30 minutes before the procedure -apply skin protectant to intact skin surrounding the wound -ensure that the foam dressing shrinks after the device is turned on ---negative pressure wound therapy is used to treat acute and chronic wounds with impaired healing. It promotes wound healing and approximation by using negative pressure to remove fluid, exudate, and infectious organisms and encourages circulation of blood to the wound bed. In negative-pressure wound therapy, a sterile foam dressing is cut to fit in the wound, placed in the wound bed, and then covered with an occlusive dressing to create a seal. A vacuum-assisted closure unit is then connected to creative negative pressure.

A client with a ventriculoperitoneal shunt has a dazed appearance and grunting and has not responded to the caregiver for 10 minutes. Status epilepticus is suspected. Which nursing intervention should be performed first? -administer rectal diazepam -assess for neck stiffness and Brudzinski sign -draw blood for lab studies -transport the client to CT for assessment of shunt malfunction

-administer rectal diazepam --This client is in status epilepticus, a serious and life-threatening emergency in which a client has been seizing for 5 minutes or longer. Grunting and a dazed appearance are 2 common signs. A client with hydrocephalus and a ventriculoperitoneal shunt is at a higher risk for seizures. Stopping seizure activity is the first nursing priority. IV benzodiazepines are used acutely to control seizures. However, rectal diazepam is often prescribed when the IV form is unavailable or problematic. Parents often get prescriptions for rectal diazepam and are advised to administer a dose before bringing a child to the emergency department. --a VP shunt drains excess fluid in the brain down to the abdomen, where it is absorbed by the body. A CT scan can accurately assess shunt malfunction. Any malfunction would need to be treated promptly to prevent future seizures and damage. Finding the cause of the seizure is important and should be done as soon as seizing has stopped.

The risk management nurse is reviewing client records. Which nursing intervention could have contributed to a sentinel event? -administered flumazenil to a client who overdosed on lorazepam -administered insulin/dextrose to a client with potassium level of 7.2 mEq/L -administered warfarin to a client with INR of 6.0 -initiated nitroprusside infusion in a client with blood pressure of 210/112 mm Hg

-administered warfarin to a client with INR of 6.0 --a sentinel event is any unanticipated event in a health care setting that results in death or serious physical/psychological injury. The target INR for most conditions in which warfarin is used is normally 2-3.

The RN and practical nurse are caring for a client who was admitted to the medical unit last night with a moderate asthma exacerbation and an upper respiratory infection. Which tasks are appropriate for the RN to delegate to the PN? SATA -administering albuterol metered dose inhaler medication -auscultating lung sounds to determine the response to a bronchodilator -checking oxygen saturation with the pulse oximeter -measuring morning peak expiratory flow with the client's peak flow meter -teaching the client about a newly prescribed inhaled corticosteroid

-administering albuterol metered dose inhaler medication -checking oxygen saturation with the pulse oximeter -measuring morning peak expiratory flow with the client's peak flow meter

The RN is planning care to prevent venous thromboembolism in several clients. Which tasks can the RN delegate to the licensed practical nurse? SATA -administering enoxaparin subcutaneously to a client in skeletal traction -applying sequential compression devices to a client with limited mobility -evaluating partial thromboplastin time in a client receiving heparin -measuring a client with chronic heart failure for compression stockings -teaching a client with a new prescription for warfarin about bleeding precautions

-administering enoxaparin subcutaneously to a client in skeletal traction -applying sequential compression devices to a client with limited mobility -measuring a client with chronic heart failure for compression stockings

When caring for a client with pneumonia, which nursing activities are most appropriate for the RN to delegate to the LPN working under RN supervision? SATA -administering metered-dose inhaled medications -monitoring lung sounds -evaluating use of the incentive spirometer -nasotracheal suctioning to collect a sputum specimen -teaching the importance of fluid intake

-administering metered-dose inhaled medications -monitoring lung sounds -nasotracheal suctioning to collect a sputum specimen

An RN, LPN, and UAP are caring for a client who is 1-day postoperative gastric bypass surgery. Which pain management-related tasks should the RN delegate to the LPN? SATA -administering oral pain medication -assessing characteristics of pain -measuring vital signs before and after analgesic administration -monitoring pain level using a numeric scale -providing discharge teaching about pain management

-administering oral pain medication -monitoring pain level using a numeric scale --The RN is responsible for assessing pain characteristics, developing the care plan, evaluating the effectiveness of the care plan, and providing initial and discharge teaching. A LPN may monitor pain level and administer pain medication.

Interventions to prevent abdominal wound dehiscence includes:

-administering stool softeners to prevent straining and constipation from postoperative immobility and opioid pain medications -administering antiemetics as needed for nausea to prevent straining that can occur with vomiting -applying a abdominal binder to provide hemostasis, support the incision, and reduce mechanical stress on the wound when coughing and moving -monitoring blood sugar to maintain tight glycemic control fasting glucose to decrease infection risk and promote wound healing. -splinting the abdomen by holding a pillow or folded blanket against the wound for support when coughing and moving

Interventions and prescriptions for a client with sepsis and meningitis may include:

-administering vasopressors -obtaining relevant labs and blood cultures prior to administering antibiotics -administer empiric antibiotics, preferably within 30 minutes of admission -prior to lumbar puncture, obtain a head CT scan as increased ICP or mass lesions may contraindicate an LP due to the risk of brain herniation -assist with a lumbar puncture for CSF examination and cultures. CSF is usually purulent and turbid in clients with bacterial meningitis.

The nurse is caring for aclient with hemophilia admitted for a facial laceration and hemarthrosis of the left knee after falling at home. Which of the following actions by the nurse are appropriate? SATA -administers coagulation factor replacement IV push -administers ibuprofen PO PRN for pain -applies ice packs to the affected joint hourly for 15 minutes -elevates the affected leg in the extended position -performs neurologic assessment every 30 minutes for 6 hours

-administers coagulation factor replacement IV push -applies ice packs to the affected joint hourly for 15 minutes -elevates the affected leg in the extended position -performs neurologic assessment every 30 minutes for 6 hours. --for acute bleeding, clients with hemophilia are treated with supplemental IV clottingfactors. Hemarthrosis is managed with rest, ice,compression, and elevation, and the affected joint should remain extended to prevent contractures. NSAIDs increased bleeding risk and should be avoided for clients with hemophilia.

Contraindications for misoprostol

-administration of another uterotonic simultaneously (oxytocin) -previous uterine surgery (c-section) -abnormal fetal heart rate patterns -uterine tachysystole (>5 contractions in 10 minutes)

How are febrile seizures treated?

-administration of antipyretics every 6 hours -additional cooling methods (cool, damp compress to the forehead, increased air circulation, wear loose/minimal clothing) --MUST avoid shivering

Management of moderate-to-severe asthma exacerbations

-administration of high-dose inhaled SABA (albuterol) -ipratropium nebulizer -systemic corticosteroids -oxygen to maintain O2 sat >90%

The RN is performing triage at the pediatric emergency department. Which client should be seen first? -child with HX of cystic fibrosis has new yellow sputum and cough today -crying infant with fiery redness and moist papules in the diaper region -grace-school client with swollen ecchymotic ankle after playing basketball -adolescent client with abdominal pain, heart rate 120/min, and respirations 26/min

-adolescent client with abdominal pain, heart rate 120/min, and respirations 26/min --The client with abdominal pain has abnormal vital signs, which is a sign of systemic condition. Adult criteria apply to adolescent clients in terms of physiological S/S.

What nursing care related to peripherally inserted IV catheters can reduce the incidence of catheter-related infections? SATA -after insertion, secure the catheter with a sterile, semi-permeable dressing -clean ports with an alcohol swab prior to accessing the catheter system -prior to insertion, apply chlorhexidine, using friction, to the venipuncture site -prior to insertion, shave excess hair over the selected venipuncture site -replace or remove the venous catheter every 48 hours

-after insertion, secure the catheter with a sterile, semi-permeable dressing -clean ports with an alcohol swab prior to accessing the catheter system -prior to insertion, apply chlorhexidine, using friction, to the venipuncture site ---The nurse should select an IV catheter site on an upper extremity, preferably the hand or forearm. To reduce the incidence of catheter-related infections, the selected site should be cleaned with antiseptic solution using friction and then allowing to air-dry completely. Chlorhexidine is preferred as it achieves an antimicrobial effect within 30 seconds,whereas povidine-iodine takes >2 minutes. After insertion, the catheter hub should be secured with a narrow strip of sterile tape to prevent accidental removal or excessive back-and-forth motion, which can introduce microorganisms into the vein. In addition, a sterile, transparent, semipermeable dressing should be used to secure the catheter hub to reduce infection risk and allow visualization of the site. When the catheter is accessed, the needleless port should be cleansed with an alcohol swab to kill externally colonized microorganisms

Clinical manifestations of Serotonin Syndrome

-agitation -diaphoresis -tachycardia -autonomic instability/HTN -diarrhea -hyperactive bowel sounds -tremor -mydriasis -hyperreflexia

S/S of serotonin syndrome

-agitation -diaphoresis -tachycardia -mydriasis (Dilated pupils) -hyperreflexia -tremor -clonus -diarrhea/hyperactive bowels -autonomic instability -HTN

A nurse is making a home visit when a fire starts in the client's kitchen trash can. The client has a fire extinguisher. The nurse should take which actions to properly operate the fire extinguisher? SATA -aim the nozzle at the base of the fire -pull out the pin on the handle -shake the canister prior to use -squeeze the handle to spray -sweep the spray from side to side

-aim the nozzle at the base of the fire -pull out the pin on the handle -squeeze the handle to spray -sweep the spray from side to side ---A small fire can quickly become very dangerous. During an emergency situation, such as a fire, anxiety can narrow a person's focus, causing hesitation or difficulty in responding to the situation, especially when operation of unfamiliar equipment is involved. The mnemonic PASS is often used to help people remember the steps used in operating a fire extinguisher.

complications of mononucleosis

-airway obstruction (d/t swollen lymph nodes) -severe abdominal pain (d/t splenic rupture)

S/E of midazolam

-airway occlusion -apnea -hypotension -oxygen desaturation with resultant respiratory arrest

What can cause thrombocytopenia?

-alcohol use -HIV infection -medications (heparin)

The nurse is conducting an educational community outreach program on melanoma screening. Which statement by a resident would indicate the need for further education? -abrupt changes in the size or color of a mole are warning signs -all new growths and pigmentations must be biopsied to rule out cancer -melanoma can occur as any color -melanoma does not always occur as a new mole

-all new growths and pigmentations must be biopsied to rule out cancer --Client education on early detection of skin cancer is important as most cases of malignant melanoma are discovered by the client. A full medical workup of every mole is unnecessary. Routine self-evaluation followed by medical assessment of questionable growths is sufficient. Clients with advanced age or reduced mobility may need to see a dermatologist for a full body skin survey.

The nurse is providing postmortem care for a client who has died after a long hospitalization. The client had a do-not-resuscitate prescription in place at the time of death, Which of the following interventions should the nurse include during postmortem care in preparation for transfer to the funeral home? SATA -allow family members to assist with care -call the medical examiner for an autopsy -gently close the client's eyes -place a pad under the perineum -remove the client's dentures

-allow family members to assist with care -gently close the client's eyes -place a pad under the perineum --postmortem care involves preparing the body for presentation to the family and includes hygiene and positioning.

The hospice nurse is providing end-of-life care to a client who is experiencing anorexia and cachexia. Which interventions are appropriate? SATA -allow the client to refuse food if not feeling hungry -ask if the client is experiencing any pain or nausea -involve the client in meal planing and food selection -plan for loved ones to share mealtimes with the client -provide oral care before and after meals to alleviate dry mouth

-allow the client to refuse food if not feeling hungry -ask if the client is experiencing any pain or nausea -involve the client in meal planing and food selection -plan for loved ones to share mealtimes with the client -provide oral care before and after meals to alleviate dry mouth ----managing anorexia during end-of-life care includes involving the client in meal planning/food selection; including friends/family at meals; offering preferred foods when the client is hungry; providing frequent oral care; administering antiemetics, analgesics, and appetite stimulants, and allowing the client to refuse food or drink.

Which tasks can the registered nurse safely delegate to the UAP? SATA -ambulate an oxygen-dependent client to the bathroom -assist the client with dentures to perform oral suctioning after the client's meal -document pulse oximetry of a client with chronic obstructive pulmonary disease -instruct a client with pneumonia on use of the incentive spirometer -turn and reposition a client with pneumonia

-ambulate an oxygen-dependent client to the bathroom -assist the client with dentures to perform oral suctioning after the client's meal -document pulse oximetry of a client with chronic obstructive pulmonary disease -turn and reposition a client with pneumonia

The nurse is caring for a client with cirrhosis of the liver. Which blood test values would the nurse typically anticipate to be elevated when reviewing the client's morning laboratory results? SATA -albumin -ammonia -bilirubin -prothrombin time -sodium

-ammonia -bilirubin -prothrombin time --Cirrhosis, the end stage of many chronic liver disease, is characterized by diffus hepatic fibrosis with replacement of the normal architecture by regenerative nodules. The resulting structural changes after blood flow through the liver and decrease the liver's functionality. Elevated bilrubin results from functional derangement of liver cells and compression of bile ducts by nodules. The liver has a decreased ability to conjugate and excrete bilirubin. Most coagulation factors are produced in the liver. A cirrhotic liver cannot produce the factors essential for blood clotting. As a result coagulation studies (PT, INR, PTT) are usually elevated. Ammonia from intestinal deamination of amino acids normally goes to the liver and is converted to urea and excreted by the kidney. This does not happen in cirrhosis. Instead, the ammonia level rises as the cirrhosis progresses; ammonia crosses the blood-brain barrier and results in hepatic encephalopathy. --albumin holds water inside the blood vessels. In cirrhosis, the liver is unable to syntehsize albumin, so hypoalbuminemia would be expected. This is the primary reason that fluid leaks out of the vascular spaces into interstitial spaces. The kidneys perceive this as low perfusion and try to reabsorb both sodium and water. The large amount of water in the body results in a dilutional effect.

The clinic nurse receives phone calls about the following 4 clients. Which call should the nurse return first? -a 6 month old who received the diphtheria, tetanus, acellular pertussis vaccine 18 hours ago and developed fever of 102 F and injection site redness. -an 11 month old with inconsolable crying and drawing up of the legs toward the abdomen -a 4 year old diagnosed with right lung pneumonia 2 days ago who has chest pain when breathing deeply -a 15 year old whose eyes are red and itchy and have a yellow discharge

-an 11 month old with inconsolable crying and drawing up of the legs toward the abdomen --inconsolable crying and drawing up of the legs toward the abdomen in a child age 6-26 months could indicate intussusception or some other abdominal pathology (appendicitis). Additional findings in intussusception include stools that have mucus and blood, often called "currant jelly" stools, and vomiting. Intussusception occurs when one section of bowel telescopes over another, which can block the passage of intestinal contents, interrupt blood supply,. and cause intestinal tears. It is an emergency and the client should be brought to the ED for further evaluation. --mild to moderate fever and local reactions are common after diphtheria, tetanus, acellular pertussis injections. Severe allergic reaction and encephalopathy are the most serious reactions that require priority attention.

Which issue would a unit quality improvement committee address? -a 10% decrease in client satisfaction in the registration process -a nurse who made 3 medication errors in the past quarter -an increase in catheter-associated urinary tract infections -staff perception of hospital laboratory personnel incivility

-an increase in catheter-associated urinary tract infections --A unit quality improvement committee assesses process standards (guidelines, systems, and operations) and clinical issues on a specific unit that affect delivery of client care and client outcomes. The committee implements a process to improve performance if the standards are not being met.

After receiving the shift report, the nurse should assess which infant first? -an infant born 6 hours ago after 38 weeks gestation who has a respiratory rate of 52/min -an infant born 12 hours ago who is jittery and has a blood glucose level of 40 mg/dL -an infant with bilateral crackles who was delivered vaginally 30 minutes ago -an infant wrapped in a warm blanket 15 minutes ago due to a temperature of 97.7 F

-an infant born 12 hours ago who is jittery and has a blood glucose level of 40 mg/dL --a normal blood glucose range for an infant is 40-60 mg/dL within the first 24 hours after delivery. A blood glucose level <40 indicates hypoglycemia. Symptoms include jitters, cyanosis, tremors, pallor, poor feeding, retractions, lethargy, low oxygen saturation, and seizures.

A client with suspected foot osteomyelitis is scheduled for an MRI. Which findings should the nurse notify the healthcare provider about before the test? SATA -aneurysm clip -cardiac pacemaker -colostomy -retained metal foreign body in eye -transdermal testesterone patch

-aneurysm clip -cardiac pacemaker -retained metal foreign body in eye --Clients must be screened for contraindications before exposure to a magnetic field as it can damage implanted devices or metallic implants. Absolute contraindications can preclude testing, and relative contraindications can post a hazard to the client's devices or implants, affect the quality of the images, or cause discomfort. Other factors that can affect the client's eligibility include inability to remain supine for 30-60 minutes and claustrophobia; however, these concerns are often controllable.

What drug class is commonly used for overactive bladder?

-anticholinergic medications

drugs commonly associated with orthostatic hypotension

-antihypertensives (BB; alpha blockers) -antipsychotics (olanzapine, risperidone) -antidepressants (SSRI's) -diuretics (furosemide, hydrochlorothiazide) -vasodilator meds (nitroglycerine, hydralazine) -narcotics (morphine)

According to Beers criteria, which drugs should be avoided/administered cautiously in elderly population?

-antipsycotics (amitriptyline) -anticholinergics -antihistamines -antihypertensives -benzodiaepines (lorazepam) -diuretics -sliding insulin scales

8 month growth and development

-anxiety with strangers -regular patterns of elimination -sits unsupported -beginning pincer grasp -makes consonant sounds -responds to word "no"

Assessment of a client with a history of stroke reveals that the client understands and follows commands but answers questions with incorrect word choices. The nurse documents the presence of which communication deficit? -aphasia -apraxia -dysarthria -dysphagia

-aphasia --Aphasia refers to impaired communication due to a neurological condition. The term aphasia is interchangeable with dysphasia, although aphasia is used more commonly. Receptive aphasia refers to impaired comprehension of speech and writing. A client with receptive aphasia may speak full sentences, but the words do not make sense. The nurse should speak clearly, as simple "yes" or "no" questions, and use gestures and pictures to increase understanding. Expressive aphasia refers to impaired speech and writing. A client with expressive aphasia may be able to speak short phrases but will have difficulty with word choice. The nurse should listen without interrupting and give the client time to form words. A client may have one type of aphasia or a combination of both, and the severity will vary with the individual.

A client admitted 3 days ago with upper GI bleed underwent an endoscopic procedure to stop the bleeding. The client is started on a clear liquid diet today. Which foods are appropriate for the nurse to offer the client? SATA -apple juice -cherry popsicle -chicken broth -frozen yogurt -unsweetened tea -vanilla ice cream

-apple juice -chicken broth -unsweetened tea --A client recovering from abdominal surgery first consumes ice chips after demonstrating adequate bowel function. After ice chips, postoperative diet progression continues to clear liquids, full liquids, soft diet, and then regular diet. -popsicles are part of a clear liquid diet. However, red dyes in clear liquids should not be given to clients with recent GI bleeding. If a client vomits, the vomitus may appear red and falsely lead the nurse to believe that the client is bleeding. It is important to implement prudent nursing judgment and fully consider the client's condition when making care decision. -frozen yogurt and vanilla ice cream are appropriate food choices for a client on a full liquid diet.

A client is diagnosed with right-sided Bell's palsy. What instructions should the nurse give this client for care at home? SATA -apply a patch to the right eye at night -avoid driving -chew on the left side -maintain meticulous oral hygiene -use a cane on the left side

-apply a patch to the right eye at night -chew on the left side -maintain meticulous oral hygiene --Bell's palsy is an inflammation of cranial nerve VII that causes motor and sensory alterations. Clients are usually managed as outpatients, with corticosteroids to reduce inflammation, and taught eye/oral care. In Bell's palsy, the eyelids do not close properly. This may result in eye dryness and risk of corneal abrasions. However, weakness of the lower eyelid may cause excessive tearing due to overflow in some clients. Facial muscle weakness results in poor chewing and food retention. --Client teaching should include using glasses during the day and wearing a patch at night to protect the exposed eye; using artificial tears during the day as needed to prevent excess drying of the cornea; chew on the unaffected side to prevent food trapping; soft diet is recommended; maintain good oral hygiene after every meal to prevent problems from accumulated residual food.

A client diagnosed with head and neck cancer has developed mouth sores related to external radiation therapy. The nurse teaches the client to use which of the following oral hygiene practices? SATA -apply a water-soluble lubricating agent to moisturize mouth tissues -brush teeth with a soft-bristle toothbrush -cleanse the mouth with normal saline after meals and at bedtime -do not drink hot liquids or eat foods that are spicy or acidic -rinse with alcohol-based antiseptic mouthwash to decrease mouth odor -use palifemin as prescribed to alleviate oral pain

-apply a water-soluble lubricating agent to moisturize mouth tissues -brush teeth with a soft-bristle toothbrush -cleanse the mouth with normal saline after meals and at bedtime -do not drink hot liquids or eat foods that are spicy or acidic --Measures to minimize oral mucositis from chemoradiotherapy include rinsing the mouth with normal saline, brushing with a soft-bristle toothbrush, using a water-soluble lubricating agent, avoidance of hot liquids and spicy/acidic foods, and application of prescribed viscouslidocaine.

Basic steps for suppository administration include:

-apply clean gloves and position the client appropriately based on age and size -lubricate the tip of the suppository with water-soluble jelly -insert the suppository past the internal sphincter using the fifth finger if the child is under 3 years -angle suppository and guide it along the rectal wall. The suppository should remain in contact with the rectal mucosa to ensure systemic absorption. -hold the buttocks together for several minutes, or until the urge to defecate has passed, to prevent immediate expulsion -if a BM occurs within 10-30 minutes, observe for the presence of the suppository

The nurse admits an 80-year-old client with an altered level of consciousness and left-sided weakness following a recent stroke. The client is dehydrated from multiple episodes of diarrhea. Which interventions should the nurse implement to prevent falls? SATA -apply color-corded, non-slip socks to the client's feet -move the client to a room closer to the nurses' station -place a bedside commode to the right of the client -raise all bed rails before leaving the room -use a bed alarm to alert staff when the client gets up

-apply color-corded, non-slip socks to the client's feet -move the client to a room closer to the nurses' station -place a bedside commode to the right of the client -use a bed alarm to alert staff when the client gets up --Many falls are associated with bathroom urgency/frequency. Fall risk precautions include placing the client in a room near the nurses' station, placing a bedside commode by the client's stronger side, applying nonslip socks, and using a bed alarm.

A client diagnosed with cirrhosis is experiencing pruritus. Which strategies are appropriate for the nurse to teach the client to promote comfort and skin integrity? SATA -apply cool, moist washcloths to the affected areas -keep the fingernails trimmed short to minimize skin scratching -take a hot bath or shower to alleviate itching sensations -use skin protectant or moisturizing cream over unbroken skin -wear cotton gloves or long-sleeved clothing to avoid scratching

-apply cool, moist washcloths to the affected areas -keep the fingernails trimmed short to minimize skin scratching -use skin protectant or moisturizing cream over unbroken skin -wear cotton gloves or long-sleeved clothing to avoid scratching ---Cholestyramine may be prescribed to increase the excretion of bile salts in feces, thereby decrease pruritus. it is packaged in powdered form, must be mixed with food or juice, and should be given 1 hour after all other medications.

The nurse provides an in-service for hospital staff on how to prevent pressure injuries in clients with limited mobility. Which instructions are appropriate for the nurse to include? SATA -apply moisture barrier cream to dry skin -clean perineal area after incontinent episodes -massage bony prominences frequently -place foam-padded seat cushions on chairs -reposition clients in bed every 6 hours

-apply moisture barrier cream to dry skin -clean perineal area after incontinent episodes -place foam-padded seat cushions on chairs --Pressure injuries develop from external pressure compressing capillaries and underlying soft tissue, or from friction and shearing forces. The nurse should assess every client's risk for pressure injuries upon admission at least once daily during hospitalization.

A male client has terminal metastatic disease. He arrives at the ED with respirations of 6/min and an advance directive indicating to withhold resuscitative efforts. What should the nurse's response be? -apply oxygen at 2 L by nasal cannula -ask the client if he wants to change his mind -ask the spouse what she wants done -determine who has medical power of attorney

-apply oxygen at 2 L by nasal cannula --Because the client has indicated specific desires, these should be honored. This is especially true as the client has a terminal condition/ Oxygen can provide comfort and is not resuscitative when given by nasal cannula.

The nurse should teach a client receiving a clonidine patch to...

-apply patch to a dry hairless area on the upper arm or chest -wash hands before and after application -rotate sites with each new patch application -discard patch away from children or pets with sticky folded together -never wear more than 1 patch at a time -never stop using the patch abruptly

A client diagnosed with hypertension has been prescribed a clonidine patch. Which instructions should the nurse include? SATA -apply patch to the upper arm or chest -fold used patches in half with sticky sides together before discarding -remove patch if dizziness occurs when getting up -rotate sites each time a new patch is applied -shave hair before applying patch

-apply patch to the upper arm or chest -fold used patches in half with sticky sides together before discarding -rotate sites each time a new patch is applied --Clonidine is a potent antihypertensive agent and is available as a transdermal patch. The patches should be replaced every 7 days and can be left in place during bathing

The unit is staffed with an experienced RN, an experienced LPN, and UAP. Which tasks can the charge nurse appropriately delegate to the UAP? SATA -apply protective skin ointment after perineal cleansing -determine if a client has adequate relief after administration of an analgesic -document daily weight for a client with congestive heart failure -feed a client who had a stroke 24 hours after admission -perform passive range-of-motion exercises for a client on a ventilator

-apply protective skin ointment after perineal cleansing -document daily weight for a client with congestive heart failure -perform passive range-of-motion exercises for a client on a ventilator

The nurse is suctioning the artificial airway of a conscious client. Which actions demonstrate correct technique? SATA -apply suction for no longer than 5-10 seconds -insert catheter with low, intermittent suction applied -set suction higher than 130 mm Hg for thick, copious secretions -wait at least 1 minute between suction passes -withdraw catheter immediately if client begins coughing

-apply suction for no longer than 5-10 seconds -wait at least 1 minute between suction passes --The process of suctioning a client's airway removes oxygen in addition to the secretions; therefore, the client should be preoxygenated with 100% O2, and suction should be applied for no more than 10 seconds during each pass to prevent hypoxia. The nurse must wait 1-2 minutes between passes for the client to ventilate to prevent hypoxia. In addition, deep, rebreathing should be encouraged. The suction catheter should be no more than half the width of the artificial airway and inserted without suction. The nurse should don sterile gloves if the client does not have a closed suction system in place. Suction should be set at medium pressure as excess pressure will traumatize the mucosa and can cause hypoxia. Clients usually cough as the catheter enters the trachea, and this helps loosen secretions. The catheter should be advanced until resistance is felt and then, to prevent mucosal damage, retracted 1 cm before applying suction

The nurse is caring for a client in the postanesthesia care unit following a gastroduodenostomy. Which of the following nursing interventions are appropriate? SATA -applying bilateral sequential compression devices -encouraging splinting of the incision with a pillow when coughing -keeping the client NPO until bowel sounds return -maintaining supine positioning at all times -repositioning and irrigating a clogged nasogastric tube

-applying bilateral sequential compression devices -encouraging splinting of the incision with a pillow when coughing -keeping the client NPO until bowel sounds return --A gastroduodenostomy involves removing the distal two-thirds of the stomach with anastomosis of the remaining stomach to the duodenum. Following a partial gastrectomy, clients should remain NPO until bowel sounds return. Once tolerated, consumption of small, frequent meals will help prevent the occurrence of dumping syndrome. Postoperative clients are at risk for developing venous thromboembolism due to reduced mobility levels and require VTE prophylaxis. Clients are also at risk for hypoventilation and respiratory compromise due to sedation, pain, and immobility. Encourage clients to turn, cough, and deep breathe while splinting the surgical site to prevent development of atelectasis. --in the postoperative period, the nurse should elevate the head of the bed to improve ventilation and reduce the risk of aspiration. Only clients who experience dumping syndrome should lay supine for a short period after eating.

The nurse is caring for a mechanically ventilated client with a tracheostomy tube in the ICU. What client care tasks can the nurse safely delegate to the UAP? SATA -applying moisturizing solution to the oral mucosa and lips -cleaning the area around tracheostomy stoma with normal saline -educating the family to maintain the head of the bed at least 30 degrees -obtaining and documenting respiratory rate and pulse oximetry readings -performing passive and active range-of-motion exercises

-applying moisturizing solution to the oral mucosa and lips -obtaining and documenting respiratory rate and pulse oximetry readings -performing passive and active range-of-motion exercises --when caring for a ventilated client, nurses may consider delegating the following tasks to UAP: vital sign measurement, oral care, personal hygiene, blood glucose testing, passive/active range-of-motion exercises, and measurement of urine/drainage output

The nurse is caring for a postoperative client who has D5W/O.45% NS with 10 mEq potassium chloride infusing through a peripheral IV catheter. What are appropriate reasons for the nurse to change the site? SATA -area around the insertion site feels cool to the touch -client report mild arm discomfort since the infusion was started -edema is observed on the dependent side of the involved arm -intraoperative peripheral IV catheter is placed in the left antecubital region -serous fluid leaks from the site despite secure connections

-area around the insertion site feels cool to the touch -edema is observed on the dependent side of the involved arm -serous fluid leaks from the site despite secure connections ---peripheral IV catheter sites should be changed no more frequently than every 72-96 hours unless signs of complications develop. The nurse should check for signs of infiltration by assessing the insertion site and areas dependent from it. Potassium is a known irritant to veins and discomfort is not a sign of infiltration. Locations where flexion occurs are generally avoided; however, these sites may be required for certain medications or situations.

A client with blunt head injury is admitted for observation, including hourly neurologic checks. At 01:00 AM, the client reports a headache; the nurse obtains a normal neurologic assessment and administers the PRN acetaminophen. At 02:00 AM, the client appears to be sleeping. Which action should the nurse take? -arouse the client and ask what the current month is -document "relief apparently obtained" and recheck at 03:00 AM -let the client sleep but verify respiratory rate -wake the client up and check for paresthesia

-arouse the client and ask what the current month is --Serial neurologic assessments are important as neurologic abnormalities are often initially subtle, making it important to note the trend. Interventions for neurologic issues are most effective when made early. The client is admitted due to the need for serial neurologic assessments by a professional nurse, and that is the priority. --although pain relief has probably been achieved, this option does not involve any neurologic assessment. One of the early signs of increased ICP is change in LOC.

The nurse reinforces education about safety modifications in the home for the spouse of a client diagnosed with Alzheimer disease. What instructions should the nurse include? SATA -arrange furniture to allow for free movement -keep frequently used items within easy reach -lock doors leading to stairwells and outside areas -place an identifying symbol on the bathroom door -provide a dark room free of shadows for sleeping

-arrange furniture to allow for free movement -keep frequently used items within easy reach -lock doors leading to stairwells and outside areas -place an identifying symbol on the bathroom door --When a client with Alzheimer disease is being cared for in the home, the caregiver should be instructed regarding safety modifications to ease the burden of caregiving and promote the client's independence and dignity

A home health nurse visits a client with Alzheimer disease. The caregiver appears frustrated and reports that the client has been persistently restless and agitated. Which nursing action is the priority at this time? -ask about the client's recent bowel and bladder habits -assess the home for sources of excessive noise -provide information about respite and adult day care -review behavior-management techniques with caregiver

-ask about the client's recent bowel and bladder habits --Alzheimer disease is a form of dementia that causes a progressive decline of cognitive and physical abilities. Behavioral changes (agitation, aggression) often result from the client's inability to identify a stressor. Stressors may include pain or problems with elimination or eating. The nurse's priority must be identifying and solving problems related to the client's basic physiological needs according to the Maslow hierarchy of needs

The nurse is caring for a client with liver cirrhosis who was admitted for cellulitis of the leg. Which assessments would the nurse perform to determine if the client's condition has progressed to hepatic encephalopathy? SATA -ask if the client knows what day it is -ask the client to extend the arms -assess for telangiectasia -determine if the conjunctiva is jaundiced -note amylase and lipase serumlevels

-ask if the client knows what day it is -ask the client to extend the arms --hepatic encephalopathy is a frequent complication of liver cirrhosis. Precipitating factors include hypokalemia, constipation, GI hemorrhage, and infection. It results from accumulation of ammonia and other toxic substances in blood. Clinical manifestations of HE range from sleep disturbances to lethargy and coma. Mental status is altered and clients are not oriented to time, place, or person. A characteristic clinical finding of HE is presence of asterixis (flapping tremors of the hands). It is assessed by having the client extend the arms and dorsiflex the wrists. Another sign is fetor hepaticus (musty, sweet odor of the breath) from accumulated digestive byproducts. --Spider angiomas, gynecomastia, testicular atrophy, and palmar erythema are expected findings in cirrhosis due to altered metabolism of hormone in the liver. --jaundice occurs when bilirubin is 2-3 times the normal value. Jaundice can occur in hepatitis and tends to worsen in cirrhosis due to increasing functional derangement. It is not related specifically to encephalopathy. --amylase and lipase are enzymes from pancreatic tissue. Alanine aminotransferease and aspartate aminotransferase are liver enzymes. They would be elevated with hepatitis and are not unique to cirrhosis or HE. Elevated ammonia levels would be more specific to cirrhosis

The nurse is caring for a client who had a stroke two weeks ago and has moderate receptive aphasia. Which interventions should the nurse include in the plan of care to help the client follow simple commands regarding activities of daily living? SATA -ask simple questions that require "yes" or "no" answers -if the client becomes frustrated, seek a different care provider to complete ADL -remain calm and allow the client time to understand each instruction -show the client pictures of ADL or use gestures -speak slowly but loudly while looking directly at the client

-ask simple questions that require "yes" or "no" answers -remain calm and allow the client time to understand each instruction -show the client pictures of ADL or use gestures --Receptive aphasia refers to impairment or loss of language comprehension that is caused by a neurological condition. The terms "aphasia" and "dysphasia" can be used interchangeably as both refer to impaired communication; however, "aphasia" is more commonly used. When assisting a client with receptive aphasia to complete activities of daily living, the nurse should avoid completing tasks for the client and should instead encourage independence using appropriate communication techniques.

A nurse delegates a tasks to the UAP. The UAP states, "I can't do that." Which is the best initial response for the nurse to make? -ask the UAP the reason for the response -do the task, but discuss the UAP's response with the manager -ignore the UAP's initial response and repeat the delegation request -remind the UAP of the importance of teamwork

-ask the UAP the reason for the response --The nurse should first assess in management situations. The UAP may not have the skills or abilities to do the task or the availability if doing something else. The nurse may need to reprioritize the tasks that the UAP has been delegated or provide additional instructions/education. However, finding out the reason for the response is the first step.

During the charge nurse's morning rounds, a client says, "I hope you will take better care of me than the nurse I had last night." What should be the charge nurse's initial response? -apologize for the previous nurse's treatment -ask the client to describe what happened last night -explain that the night nurse was probably busy -reassure the client that things will be better today

-ask the client to describe what happened last night -the first step in management issues is assessment. The charge nurse must first determine what happened before deciding the next course of action. The client could have misperceived certain actions.

Before examining the infant of a Mexican American mother, the nurse compliments the child's outfit. The mother becomes visibly distressed. What is the best next action for the nurse to take? -ask the mother's permission to touch the child's hand -interview the mother about the reason for bringing the child to the clinic -reassure the mother that there is no reason for distress -suggest postponing the examination until the mother calms down

-ask the mother's permission to touch the child's hand --Many Latin Americans believe in "mal de ojo", a cultural belief in an illness thought to be manifested in children by vomiting, fever, and crying. It is believed to be caused when a stranger admires a child without touching the child at the same time or immediately afterward. Asking the mother about the reason for bringing the child to the clinic will not relieve the mother's distress.

Ear irrigation steps

-assess client for contraindications -verify the tympanic membrane is intact and no foreign bodies present -explain the procedure to the client, including possible sensations -place the client ina side-lying or sitting position with the head tilted toward the affected ear. Place a towel an emesis basin under the ear. -verify that the irrigation solution is at body temperature -straighten the ear canal, pulling the pinna up and back for adults or down and back for children less than 3 years of age -irrigate gently with a slow, steady flow of solution, directing the syringe tip toward the top of the ear canal. -repeat as tolerated until the ear canal is clear or the prescribed amount is instilled -document the type, temperature, and volume of solution; exudate characteristics; response to the irrigation; and client teaching

The nurse is preparing to infuse 2 units of packed red blood cells to a client with a gastrointestinal bleed. Which actions should the nurse take? SATA -assess client's vital signs -infuse both units simultaneously -obtain a Y tubing set and prime with normal saline -plan to remain with client during the 1st 14 minutes of transfusion -set infusion pump to delivery unit over 30-45 minutes -spike filtrated intravenous tubing with dextrose 5% water

-assess client's vital signs -obtain a Y tubing set and prime with normal saline -plan to remain with client during the 1st 14 minutes of transfusion --always verify blood products, type and crossmatch results, and client identifiers with another nurse prior to transfusion. Obtain vital signs before, during, and after blood administration. Use Y tubing primed with NS and an IV pump for administration. Watch for transfusion reaction and stop the transfusion immediately if a reaction occurs.

Describe care associated with wearing Pavlik harness

-assess skin 2-3 times for redness/breakdown under straps -dress child in a shirt and knee socks under harness to protect skin -apply diapers underneath straps to keep harness clean/dry -leave harness on at all times, unless otherwise stated by HCP

During shift change, the night nurse notices that the graduate nurse administered IV dopamine instead of the prescribed norepinephrine for a client with sepsis. What should the night nurse do first? -administer the correct medication and obtain current vital signs -alert the graduate nurse and complete an incident report -assess the client and notify the HCP -discontinue the dopamine and inform the nursing supervisor

-assess the client and notify the HCP --When a medication error occurs, client safety is priority. The nurse should assess the client immediately for any adverse effects and inform the HCP. Before taking any other actions, the nurse must ensure that the client is stable. Following client stabilization, the error should be reported to the appropriate nursing authority and an incident or occurrence report should be filed within 24 hours. --Discontinuing dopamine without providing another medication for hemodynamic stabilization may harm the client. The nursing supervisor should be informed after client stabilization.

Ten minutes after an infusion of packed red blood cells is initiated through a central venous catheter, the client has shortness of breath and slight chest tightness. What initial actions would be appropriate for the nurse to complete? SATA -assess the client's breath sounds -flush the blood IV tubing with normal saline -notify the heathcare provider -remove the CVC -stop the infusion of PRBCs

-assess the client's breath sounds -notify the heathcare provider -stop the infusion of PRBCs --If an adverse blood transfusion reaction is suspected, the first action is to stop the infusion. An infusion of normal saline through a different port for the CVC is typically started. A client assessment and notification of the HCP are also required.

During a home visit, the community health nurse observes bruises in various stages of healing on the extremities and torso of an elderly client. The client explains that the bruises are from bumping into furniture and the wall in the wheelchair. What is the priority nursing action? -ask the client to explain the bruises on the torso -assess the client's general hygiene and nutritional status -report the bruises to the client's health care provide -talk to the client's child about the injuries

-assess the client's general hygiene and nutritional status --The client's injuries are inconsistent with the explanation given in that bumping into furniture could explain bruising on the extremities but does not account for the bruises on the torso. In addition, the bruises are in various stages of healing, which suggests that the injuries occurred over multiple occasions. The nurse's findings are suggestive of elder abuse but not conclusive. Further assessment is needed to confirm the nurse's suspicions and to determine the extent of the abuse. The nurse will assess the client for general hygiene, clothing, nutritional and hydration status, presence of other injuries, inappropriate medication administration, signs of depression, and other statements by the client suggesting neglect. During the assessment and client interview, the nurse will need to maintain a neutral, nonjudgmental attitude to facilitate a trusting nurse-client relationship. Asking the client to explain the bruises on the torso is a "why" type of question, places the client on the defensive, and does not facilitate a trusting nurse-client relationship. Reporting the bruises to the HCP is an appropriate nursing action but is not the priority. The nurse needs additional information. Talking to the client's child and/or other family members may be an appropriate nursing action, but the nurse needs more information.

During morning rounds, the nurse notices that a client admitted 3 days ago with hepatic encephalopathy is sleepy and confused. The client is scheduled for discharge later today. Which interventions are appropriate for the nurse to implement? SATA -assess the client's hand movements with the arms extended -compare current mental status findings with those from previous shifts -contact the HCP to request a blood draw for ammonia level -encourage the client to ambulate in the hallway -hold the client's morning dose of lactulose

-assess the client's hand movements with the arms extended -compare current mental status findings with those from previous shifts -contact the HCP to request a blood draw for ammonia level --Hepatic encephalopathy is a serious complication of end-stage liver disease that results from inadequate detoxification of ammonia from the blood. Symptoms include lethargy, confusion, and slurred speech; coma can occur if this condition remains untreated. Asterixis, or a flapping tremor of the hands when the arms are extended with the hands facing forward, may also be noted in the client with encephalopathy. The client with ESLD exhibiting confusion and lethargy should be evaluated for worsening encephalopathy by assessing for asterixis and comparing current mental status and ammonia level to previous findings. If encephalopathy continues to worsen, medical treatment should include higher doses of lactulose and rifaximin, and discharge should be delayed until the client is stable. --Lactulose is the primary drug used for hepatic encephalopathy treatment. It helps to excrete ammonia through the bowels as soft or loose stools. Lactulose should not be held if the client's hepatic encephalopathy continues to worsen.

A client with end-stage liver disease is admitted for a transplant workup. The client's spouse states that the client has not stopped drinking alcohol and may be unable to quit for 6 months before the transplant. Which is the most appropriate action for the nurse to implement? -ask the transplant team to place a palliative care referral so the client can learn about the option of hospice instead of transplant -assess the client's motivation to make the necessary self-care changes before and after the transplant -schedule a meeting to enlist the help of family members in encouraging the client to stay sober until the transplant -tell the nurse manager that the client may not be an appropriate transplant candidate

-assess the client's motivation to make the necessary self-care changes before and after the transplant --The client may not be an appropriate transplant candidate due to his alcohol use. However, additional facts are needed to determine the new situation as the only information obtained came from the client's spouse. The nurse should assess the client's drinking habits and motivation to stop drinking before and after the transplant by speaking with the client directly. In addition, a transplant requires many other self-care regimens. The nurse should be alert for indicators of the client's ability to take prescribed medications, follow dietary restrictions, and attend medical appointments.. The information obtained from this assessment should be communicated to the interdisciplinary team members responsible for determining transplant eligibility.

What is the priority nursing action when parents state that their infant "cries all the time"?

-assess the pattern, quality, and frequency of the child's cry to help determine if the crying is normal or a sign of a more serious condition

The UAP assists a client with cirrhosis who underwent paracentesis 4 hours ago. The UAP reports to the nurse that the client was lightheaded and unsteady while ambulating to the chair. Which action should the nurse implement first? -ask the UAP to take a set of vital signs -assess the symptoms reported by the UAP -hold the prescribed diuretic medications -instruct the UAP to assist the client to bed

-assess the symptoms reported by the UAP --paracentesis is a procedure that involves removal of excess fluid from the peritoneal cavity and is performed to relieve dyspnea and discomfort related to increased intra-abdominal pressure and fluid volume. Hypovolemia is an associated complication related to intravascular fluid shifts that occur during and post-procedure and also to high volume peritoneal fluid removal. The nurse should first validate the presence of light-headedness and unsteady gait, monitor vital signs, and assess for manifestations of hypovolemia, as decreased circulating volume can lead to hemodynamic instability

The nurse is planning care for a client admitted with newly diagnosed quadriplegia (tetraplegia). Which intervention will the nurse prioritize? -assess vital capacity and total volume once per shift and PRN -perform passive range of motion exercises on affected joints every 4 hours -provide time during each shift for the client to express feelings -turn the client every 2 hours throughout the day and night

-assess vital capacity and total volume once per shift and PRN --Quadriplegia occurs when the lower limbs are completely paralyzed and there is complete or partial paralysis of the upper limbs. This is usually due to injury of the cervical spinal cord. Depending on the area of injury and extent of cord edema, the airway can be adversely affected. The priority assessment for this client is the status of the airway and oxygenation. The nurse should frequently assess breath sounds, accessory muscle use, vital capacity, tidal volume, and arterial blood gas values.

Which tasks can the registered nurse appropriate delegate to the UAP? SATA -assist the RN with ambulating a client 1-day post chest tube placement -measure wound drainage from a bulb drain and document it on the output flow sheet -monitor for redness and swelling at the IV insertion site and report back to the nurse -return an unused unit of packed red blood cells to the blood bank -take family members to the waiting room after a client goes into surgery

-assist the RN with ambulating a client 1-day post chest tube placement -measure wound drainage from a bulb drain and document it on the output flow sheet -return an unused unit of packed red blood cells to the blood bank -take family members to the waiting room after a client goes into surgery --UAP may perform clerical and clinical tasks related to the care of stable clients under the direction of the RN.

The RN and LPN are caring for a client with an established colostomy. Which nursing actions may the RN delegate to the LPN? SATA -assess perfusion of the stoma tissue -assist the client in changing the ostomy pouch -auscultate the client's bowel sounds -develop a plan of care to prevent skin breakdown -monitor the color of ostomy drainage

-assist the client in changing the ostomy pouch -auscultate the client's bowel sounds -monitor the color of the ostomy drainage --Tasks requiring initial assessment, initial or discharge education, care planning, or care of an unstable client require the clinical judgment of the RN and may not be delegated. The LPN may perform basic care activities of the client with an established ostomy, perform specific assessments, monitor RN findings, and reinforce education.

The nurse is caring for a hospitalized client with a diagnosis of thyrotoxicosis. Which of the following actions can be delegated to UAP? SATA -administer artificial tears if the client reports eye dryness -assist the client to bathe and change the bed linens to maintain client comfort -lower the room temperature and provide cool cloths on request -reinforce to the client that fever is expected with thyrotoxicosis -return a call to the client's family telling them the client's condition is unchanged

-assist the client to bathe and change the bed linens to maintain client comfort -lower the room temperature and provide cool cloths on request

The nurse has been assigned to the staging area of a disaster response to an act of terrorism that deployed a caustic chemical agent. A client comes to the triage area with burns to the skin, severe pain, and visible chemical residue. What is the nurse's priority action? -assess skin to determine severity of burns and wounds -assign client to a cot with other similarly triaged clients -assist the client to the designated showering area -prepare supplies to establish IV access

-assist the client to the designated showering area --Decontamination is a priority nursing action for clients who have been exposed to a chemical or radioactive agent. During a mass casualty disaster, the nurse should assist clients with complete decontamination before providing care. Decontamination limits further client injury and prevents exposure to other clients and staff.

The nurse is caring for a client in soft wrist restraints. Which tasks can the nurse safely delegate to the UAP? SATA -assist the client with using the bedpan -check pulses and sensation of extremities -observe skin for signs of impairment -perform ROM exercises -turn and reposition the client in bed

-assist the client with using the bedpan -perform ROM exercises -turn and reposition the client in bed --Nurses may delegate to UAP tasks that relate to basic hygiene; tasks of daily living; measurement and documentation of vital signs; documentation of I & O; and validated technical skills. Activities requiring assessment may be performed only by the nurse

Which guiding principle is suitable for dealing with a disaster scenario involving radiation contamination? -assess for copious secretions to determine exposure -assist the victims farthest from the source first -assist the victims with the most severe symptoms first -monitor for diplopia to determine extent of exposure

-assist the victims farthest from the source first --the key aspects related to radiation exposure are time and distance. The greater the distance, the less dosage received. Acute radiation syndrome has the following phases: prodromal, latent, manifest, and recovery or death. Initially, all victims will appear well; however, the damage is mainly internal, leads to cell destruction, and manifests later on. Victims farthest away from the radiation source are the most salvageable. In this scenario, the principle of disaster nursing is to do the most good for the most people with the available resources.

While caring for a client in skeletal traction, which tasks can the RN delegate to experienced unlicensed assistive personnel to help prevent immobility hazards? SATA -assist with active and passive range of motion exercises -change bed linens while logrolling the client from side to side -check the color and temperature of the affected extremity -remind the client to use the incentive spirometer -reapply pneumatic compression device after bathing the client

-assist with active and passive range of motion exercises -remind the client to use the incentive spirometer -reapply pneumatic compression device after bathing the client --Logrolling this client would require multiple staff members and would not be recommended. Clients in traction are instructed to lift themselves using the overhead trapeze.

After performing a physical assessment and obtaining vital signs for a client immediately after a laparoscopic cholecystectomy, which nursing intervention is the priority? -apply anti-embolism stockings -assist with early ambulation -offer stool-softeners -provide low-fat foods

-assist with early ambulation --postoperative nursing care after a laparoscopic cholecystectomy focuses on prevention of complications. Carbon dioxide is used to inflate and expand the abdominal cavity during laparoscopic procedures to allow insertion of surgical instruments and better visualization of the abdominal organs. CO2 can initiate the phrenic nerve and diaphragm, causing shallow breathing and referred pain to the right shoulder. The nurse should assist the client with early ambulation and deep breathing to facilitate dissipation of the CO2 used during surgery. Early ambulation not only improves breathing but also decreases the risk of thromboembolism and stimulates peristalsis. --stool softeners may prevent postoperative constipation caused by surgical anesthetics and opioids, which contribute to decreased peristalsis. However, early ambulation is more important due to promoting bowel motility and reduces constipation.

The RN is caring for a postoperative client who becomes short of breath on the night of surgery and initiates the prn prescription for oxygen at 3 L/min by NC. The client makes frequent requests to use the bathroom during the night. Which tasks can be delegated to the UAP? SATA -assisting the client the bathroom -deciding if supplemental oxygen is necessary when the client is ambulating -documenting vital signs in the EMR -notifying the nurse immediately if the client's respirations exceed 20/min -reapplying the nasal cannula if it accidentally comes off

-assisting the client the bathroom -documenting vital signs in the EMR -notifying the nurse immediately if the client's respirations exceed 20/min -reapplying the nasal cannula if it accidentally comes off

The postpartum nurse receives report on 4 mother-baby couplets. Which tasks can be delegated to UAP? SATA -assisting the mother with morning hygiene -demonstrating neonate bathing technique -documenting intake and output on the monitor -evaluating caregiver interaction with the neonate -obtaining an axillary temperature on the neonate -swaddling the neonate after diaper changes.

-assisting the mother with morning hygiene -documenting intake and output on the monitor -obtaining an axillary temperature on the neonate -swaddling the neonate after diaper changes. --The RN is responsible for any care requiring clinical judgment. UAPs can assist with ADL's, documenting intake and output, positioning, and taking the vital signs of stable clients.

Client instructions for using a volume-oriented SMI device

-assume a sitting or high Fowler position, which optimizes lung expansion, and exhale normally. -while holding the device at an even level, seal the lips tightly on the mouthpiece to prevent leakage o air around it -inhale deeply through the mouth until the piston is elevated to the predetermined level of tidal volume. The piston is visible on the device and helps provide motivation -hold the breath for at least 2-3 seconds as this maintains maximal inhalation -exhale slowly to prevent hyperventilation -breathe normally for several breaths before repeating the process -cough at the end of the session to help with secretion expectoration

There has been a community disaster with multiple victims. Stable clients must be released to make room for the victims. Which clients would the nurse recommend as stable for discharge? SATA -acute head injury with GCS of 12 -admitted with cirrhosis of liver with oozing esophageal varices -asthma exacerbation with peak flow at 85% of personal best -DVT on IV heparin with platelets 40,000/mm3 -myasthenia gravis with ptosis in the evening

-asthma exacerbation with peak flow at 85% of personal best -myasthenia gravis with ptosis in the evening --normal GCS is 15; score of 12 indicates impairment requiring further care; the varices oozing blood are at risk for rupture and/or increasing ammonia; normal platelet count is 150,000-400,000. A potential complication of heparin therapy is thrombocytopenia. The client is at risk for paradoxical thrombosis and rarely bleeding.

The nurse is teaching the home health client how to perform colostomy irrigation. Which client action reveals that further teaching is required? -attaches an enema set to the irrigation bag, lubricates it, gently inserts it into the stoma, and holds it in place. -fills irrigation container with 500-1000 mL of lukewarm tap water and flushes the irrigation tubing -hands the irrigation container on a hook at the level of the shoulder approximately 22 inches above the stoma -slowly opens the roller clamp, allowing the irrigation solution to flow, but clamps the tubing when cramping occurs

-attaches an enema set to the irrigation bag, lubricates it, gently inserts it into the stoma, and holds it in place. --A colostomy is a surgical procedure that creates an opening in the abdominal wall for the passage of stool to bypass an obstructed or diseased portion of the colon. Stool drains through the intestinal stoma into a pouch device secured to the skin. Clients with a descending or sigmoid colostomy drain stool that is more formed and similar to a normal bowel movement. Although less common, some clients choose to irrigate their colostomy in order to create a bowel regimen that allows them to wear a smaller pouch or a dressing over the stoma. When irrigated daily, the client gains increased control over the passage of stool. --a cone-tip applicator is used to instill the irrigation solution into the stoma. An enema set should never be used to irrigate a colostomy. A cone-tip applicator is specifically made to avoid damage to the sensitive colostomy opening.

A nurse is caring for a 3-month-old client with a new trahceostomy. Which findings would indicate a need for suctioning? SATA -audible gurgling -heart rate 105/min -increased irritability -oxygen saturation -respiratory rate 30/min

-audible gurgling -increased irritability -oxygen saturation --Assessment findings that indicate a need for suctioning include: decreased oxygen saturation; altered mental status (irritability, lethargy); increased heart rate (normal infant range: 90-160); increased respiratory rate (normal: 30-60); increased work of breathing (flared nostrils, use of accessory muscles); adventitious breath sounds (crackles, wheezes, rhonchi); pallor, mottled, or cyanotic skin coloring

Which actions are appropriate for the RN to delegate to an experienced LPN? SATA -administer heparin continuous infusion to a client with a venous thromboembolism -auscultate bowel sounds 2 days after repair of an inguinal hernia -discuss concerns about last shift's care with an irate family member -monitor flow rate and drainage in a client receiving bladder irrigation -teach kegel exercises after a client has a catheter removed

-auscultate bowel sounds 2 days after repair of an inguinal hernia -monitor flow rate and drainage in a client receiving bladder irrigation --Under the direction of the RN, the LPN can perform higher-level skills within the scope of practice defined by the state. Appropriate tasks include administering routine medications for expected needs, monitoring RN findings, and performing focused assessments.

The client has increased intracranial pressure with cerebral edema, and mannitol is administered. Which assessment should the nurse make to evaluate if a complication from the mannitol is occurring? -auscultate breath sounds to assess for crackles -monitor for >50 mL/hr urine output -monitor GCS increasing from 8/15 to 9/15 -press over the tibia to assess for pitting edema

-auscultate breath sounds to assess for crackles --Mannitol is an osmotic diuretic used to treat cerebral edema and acute glaucoma. When administered, mannitol causes an increase in plasma oncotic pressure that draws free water from the extravascular spaced into the intravacular space, creating a volume expansion. This fluid, along with the drug, is excreted through the kidneys, thereby reducing cerebral edema and intracranial pressure. However, if a higher dose of mannitol is given or it accumulates, fluid overload that may cause life-threatening pulmonary edema results. An early sensitive indicator of fluid overload is new onset of crackles auscultated in the lungs. To prevent these complications, clients require frequent monitoring of serum osmolarity, input and output, serum electrolytes, and kidney function. --urine output would be expected to increase from the diuretic effect of mannitol and is not a complication.

6 month growth and development

-average weight gain of 3-5 oz per week -can hold bottle -can turn from back to stomach -early ability to distinguish and recognize parents and strangers -can chew and bite

The nurse should encourage the following healthy sleep habits

-avoid caffeine, nicotine, and alcohol within 4-6 hours of sleep -exercise daily but avoid exercise or strenuous activity within 4-6 hours of sleep -avoid going to bed hungry or eating a heavy meal just before bed -practice relaxation techniques if stress is causing insomnia

A client with throat cancer receives radiation therapy to the head and neck. Which strategies are appropriate to increase oral intake? SATA -avoid irritants such as acidic, spicy foods -discourage the use of topical analgesics -encourage liquid nutritional supplements -perform oral hygiene once a day -use artificial saliva to control dryness

-avoid irritants such as acidic, spicy foods -encourage liquid nutritional supplements -use artificial saliva to control dryness --Radiation therapy to the head and neck can cause mucositis and xerostomia, leading to decreased nutrition.Care includes avoiding irritants, consuming supplements, using artificial saliva or sipping water, and performing frequent oral hygiene. Clients on radiation therapy need to maintain more frequent oral hygiene due to the drying effects of mucositis.

The nurse is reviewing discharge teaching for a client who had surgical repair of a retinal detachment. Which of the following instructions are appropriate for the nurse to include in the teaching? SATA -avoid rubbing or scratching the affected eye -avoid straining when having a bowel movement -expect occasional flashes of light during recovery -report any sudden pain to the healthcare provider -rest the eyes by refraining from reading and writing

-avoid rubbing or scratching the affected eye -avoid straining when having a bowel movement -report any sudden pain to the healthcare provider -rest the eyes by refraining from reading and writing ---Retinal detachment is separation of the sensory retina from the underlying pigment epithelium. Clients experiencing retinal detachment may report a gradual, curtain-like loss of the visual field. Traumatic retinal detachment may also result in abrupt vision loss. Retinal detachment requires emergency surgery to attempt to restore vision. Surgical repair involves rebinding the choroid and retina. After repair, interventions focus on promoting retinal reattachment.

The clinic nurse reinforces teaching to a client with systemic lupus erythematosus. Which instructions will the nurse include? SATA -avoid annual influenza vaccination -avoid situations that cause physical and emotional stress -avoid sun exposure and ultraviolet light when possible -notify the healthcare provider if you have fever -use antibiotic soap to cleanse skin rashes

-avoid situations that cause physical and emotional stress -avoid sun exposure and ultraviolet light when possible -notify the healthcare provider if you have fever ---Systemic lupus erythematosus is an autoimmune disorder that results in inflammation and damage to many body parts. Symptoms vary widely among affected individuals, but most experience painful/swollen joints, extreme fatigue, skin rashes, and kidney problems. The symptoms typically appear for periods of time alternating with periods of remission. There is no cure for SLE, but it can be treated with immunosuppressants or immunomodulators. Pneumonia and annual influenza vaccinations are recommended for those with SLE as they are more susceptible to infections. These individuals should avoid contact with sick people and report fever to their healthcare provider. Both physical and emotional stress can exacerbte SLE. Therefore, clients should follow a healthy lifestyle. Balanced exercise with alternating periods of rest is recommended. Sunlight is known to worsen the rash of SLE and should be avoided when possible; protective clothing and sunscreen application are recommended during periods of sun exposure. The rash of SLE should be cleansed only with mild soap. Harsh soap and chemicals should be avoided.

Which procedures are appropriate for the nurse to use when obtaining an adult client's blood for a laboratory test? SATA -avoid the arm on the affected side after a mastectomy -do not make further attempts to draw blood if unsuccessful on first 2 attempts -if necessary to use an arm with IV infusion, draw proximal to infusion point -insert the needle bevel up at a 15-degree angle to the skin -obtain a finger capillary specimen from the middle of the finger pad

-avoid the arm on the affected side after a mastectomy -do not make further attempts to draw blood if unsuccessful on first 2 attempts -insert the needle bevel up at a 15-degree angle to the skin --While performing phlebotomy, clean the site, "fix: or hold the vein taut, and then insert the needle bevel up at a 15-degree angle. Some recommend bevel down for children. This will help prevent going through the vein completely. The Infusion Nurses Society identifies the standard of care as no more than 2 attempts by any 1 individual. If the nurse is unable to successfully draw blood after 2 attempts, a phlebotomist or a different nurse should be asked to complete the blood draw. The affected side of a client who has had a mastectomy should not be used. It places the client at risk for infection and lymphedema.

Postoperative teaching after retinal detachment repair involves...

-avoiding activities that increase intraocular pressure -reporting sudden pain, flashes of light, vision loss, or bleeding (indicates detachment or infection) -avoiding focused activities that can cause rapid eye movements and increase risk of detachment -wearing an eye patch or shield as directed to prevent rubbing/scratching of the eye -ensuring appropriate positioning as instructed by surgeon.

Describe cervical cap

-barrier method of contraception used with spermicide -inserted several hours before intercourse and should be left in place for ATLEAST 6 hours after intercourse

What skin care should be provided to prevent pressure ulcers?

-barriers to incontinence -hydration -moisturizer

Where can children with cow's milk allergy obtain calcium and vitamin D?

-beans, dark greens, calcium-fortified cereal/juices (calcium) -fish, egg yolks, and vitamin D-fortified foods (vitamin D)

High fall risk precautions

-bed alarm -high fall risk signs -room close to nurses' station -color-coded socks and wristbands

Which client condition is concerning and requires further nursing assessment and intervention? SATA -before liver biopsy, pulse is 80/min and BP is 120/80 mm Hg; 1 hour afterwards, pulse is 112/min and BP is 90/60 mm Hg -before lumbar puncture, pulse is 100/min and BP is 140/86 mm Hg; 1 hour afterwards, pulse is 80/min and BP is 126/82 mm Hg -client with coronary artery disease on metoprolol; pulse is 62/min -elderly client with black stools; pulse is 112/min -neonate crying inconsolably at feeding time; pulse is 160/min

-before liver biopsy, pulse is 80/min and BP is 120/80 mm Hg; 1 hour afterwards, pulse is 112/min and BP is 90/60 mm Hg -elderly client with black stools; pulse is 112/min --The liver is very vascular, which places it at risk for internal bleeding after a tissue sample is removed for biopsy. Liver dysfunction typically results in coagulopathy as many coagulation factors are synthesized in the liver, thereby increasing the risk for bleeding. Early signs of blood loss/shock are tachypnea, tachycardia, and agitation. A later sign is hypotension. Black stools indicates slow upper gastrointestinal bleeding; tachycardia may indicate significant blood loss. --The change in vital signs from preprocedure of lumbar puncture to post-procedure most likely reflects decreased anxiety. This client's vital signs are within normal range. Lumbar puncture does not produce bleeding serious enough to make a client hypotensive

What is the positive outcome of the third stage in Erickson's developmental task? --negative outcome?

-begins to evaluate own behavior; learns limits on influence in the environment --demonstrates fearful, pessimistic behaviors; lacks self-confidence

language developmental milestones for 4-5 month old

-begins to laugh -makes some consonant sounds

Beliefs on death for children ages 6-9 years

-believes death is reversible -thoughts may include magical thinking and fantasy (hopes that someone dies)

Which situations would require the nurse to obtain a prescription for physical restraints? SATA -belt restraint used for a confused client who keeps trying to get out of bed but is on bed rest -elbow restraints used temporarily for a toddler while drawing blood -full padded side rails in the raised position for a client during a seizure -long leg immobilizer used for a client with a fractured femur -soft ankle restraint to prevent bleeding at the femoral site following cardiac catheterization

-belt restraint used for a confused client who keeps trying to get out of bed but is on bed rest -soft ankle restraint to prevent bleeding at the femoral site following cardiac catheterization --A physical restrain is a device or method used to immobilize or limit physical mobility or body movement to prevent falls, injury to self or others, or removal of medical devices. The client situation, rather than the device, determines whether it is classified as a restraint, Prescribed orthopedic immobilizers and protective devices used temporarily during routine procedures or examinations are not considered physical restraints and do not require authorization for use from a healthcare provider. Restraints should be used only after less invasive methods have failed and must be discontinued at the earliest time possible once it is safe to do so. The belt restraint is applied at the waist and tied to the bed frame under the mattress with straps using a quick-release knot. It is used to protect a confused or disoriented client who is on bred rest. Although the client can turn, it is considered a restraint because it restricts physical mobility and confines the client to the bed involuntarily. Soft limb restraints immobilize one or more extremities and are used for the prevention of falls or attempted removal of devices. Following aprocedure requiring sedation, clients may require restraints to protect them from disrupting a surgical site or medical device until they are alert enough to follow instructions independently. Limb restraints should be applied loosely enough that 2 fingers can be inserted underneath the secured restraint. The nurse should closely monitor the peripheral neurovascular status and skin integrity of a client's restrained extremity. Elbow restraints used a protective device to temporarily immobilize a child to perform a medical, diagnostic or surgical procedure are not considered a physical restraint. The use of full padded side rails in the raised position for clients during a seizure protects them from immediate injury; these are not considered a restraint. An orthopedic leg immobilizer used to restrict movement and maintain a client's extremity in proper alignment is prescribed for therapeutic purposes and is not considered a restraint.

Describe growth hormone replacement therapy

-best started early in the child's age -involves the administration of a biosynthetic version of a growth hormone subcutaneously -child may still have a less than normal height after treatment -cessation of treatment usually occurs when growth is less than 1 inch per year and bone age is 14 in girls and 16 in body

5 month growth and development

-birth weight is doubled -takes objects presented to him/her -teething may begin -smiles at mirror image

12 month growth and development

-birth weight usually tripled -needs help while walking -eats with fingers -usually says 3-5 words -sits from standing position without assistance

A client arrives at the emergency department on a cold winter day. The client is calm, alert, and oriented with a respiratory rate of 20/min and a pulse oximeter reading of 78%. The nurse suspects that the client's pulse oximeter reading is inaccurate. Which factors could be contributing to this reading? SATA -black fingernail polish -cold extremities -elevated WBC count -hypotension -peripheral arterial disease

-black fingernail polish -cold extremities -hypotension -peripheral arterial disease ---Any factor that affects light transmission or peripheral blood flow can cause a falsely low reading for oxygen saturation on pulse oximeter. Common causes include dark nail polish, hypotension, low cardiac output, vasoconstriction (hypothermia or vasopressor medications) , and peripheral arterial disease.

The nurse assessing a client with an upper GI bleed would expect the client's stool to have which appearance? -black tarry -bright red bloody -light gray "clay-colored" -small, dry, rocky-hard masses

-black tarry --black tarry --As blood passes through the GI tract, digestion of the blood ensures, producing the black tarry appearance. Bright red bloody stool would indicate a lower GI hemorrhage. Decreased bile flow into the intestine due to biliary obstruction would produce a light gray "clay-colored" stol. Small, dry, rocky-hard masses are an indication of constipation. Inactivity, slow peristalsis, low intake of fiber in the diet, decreased fluid intake, and some medications may contribute to constipation.

What are the risks associated with long-term use of ketorolac?

-bleeding -gastrointestinal ulcers -kidney injury

The nurse understands that which of these body substances are modes of transmission for hepatitis B? SATA -blood -feces -semen -urine -vaginal secretions

-blood -semen -vaginal secretions --Viral hepatitis isa disease of the liver characterized by inflammation, necrosis,and cirrhosis. One of the most common viral strains that causes hepatitis is hepatitis B. The transmission of hepatitis B is primarily through contact with blood, semen, and vaginal secretions, commonly through unprotected sexual intercourse and intravenous illicit drug use. Infants born to infected mothers are also at risk for vertical transmission of hepatitis B. Although kissing, sneezing, sharing drinks/utensils, and breastfeeding are not known routes of transmission, hepatitis B could possibly be transmitted through saliva entering the bloodstream via sharing a toothbrush or receiving a bite. Hepatitis B has an insidious onset of illness, and clients may be asymptomatic carriers. Early symptoms are often nonspecific. Hepatitis B may produce jaundice, weight loss, clay-colored stools, and thrombocytopenia in late stages of illness. An effective vaccine is widely available for hepatitis B.

The nurse is preparing to administer 40 mg of IV furosemide. Prior to administering the medication, the nurse should assess which parameters? SATA -blood pressure -blood urea nitrogen -liver enzymes -potassium -white blood cell count

-blood pressure -blood urea nitrogen -potassium --Loop diuretics are used to treat fluid retention, such as that found in clients with heart failure or cirrhosis. When administering loop diuretics, the nurse can expect the client's kidneys to excrete a significant amount of water and potassium. When potassium is excreted at a fast rate, the client could develop hypokalemia, medical emergency that can result in other life-threatening complications such as heart arrhythmias, as well muscle cramps and weakness. Blood pressure should also be assessed prior to administration of loop diuretics as excess diuresis may cause intravascular volume depletion that results in low blood pressure. A client with baseline hypotension may develop a critically low blood pressure. Excess diuresis can also affect kidneys, and the blood urea nitrogen and creatinine levels can become elevated as well. Therefore, these levels should be assessed.

The emergency department nurse performs an admission assessment for a client with priapism of about 3 hours duration who also has sickle cell anemia. What assessment finding is of most concern and warrants immediate notification of the healthcare provider? -bluish discoloration of the erect penis -drank a 6-pack of beer 8 hours ago -extreme penile pain rated as 9 on a 0-10 scale -has not voided for atleast 6 hours

-bluish discoloration of the erect penis --Priapism is a sustained, painful erection that lasts for more than 2 hours. Common associated clinical manifestations includes intense pain, rigid penis, difficulty voiding, and anxiety/embarassment. Bluish discoloration is of the most concern as it can be a sign of ischemia to the penis.

The nurse is managing assigned clients on the evening shift. Which client presentation is a priority? -blunt head trauma with projectile vomiting -hx of alzheimer disease with agitation -hx of carpal tunnel syndrome with hand numbness -hx of third cranial nerve pathology with double vision

-blunt head trauma with projectile vomiting --A client with a TBI from blunt force can have delayed symptoms if there is bruising in the brain and subdural hematoma/cerebral edema develops. A subdural hematoma is typically a slower venous bleed, and symptoms appear 24-48 hours later. S/S are similar to those if increased ICP and include change in LOC, projectile vomiting, ataxia, ipsilateral pupil dilation, and seizures. Brain herniation can occur if the condition is not recognized and treated.

What symptoms are included in Cushing's triad?

-bradycardia -widening pulse pressure -irregular respirations (Cheyne-Stokes)

The nurse is preparing an injection of IM haloperidol from a glass ampule. Which of the following actions by the nurse are appropriate? SATA -attaches an 18-gauge injection needle to a syringe for withdrawal of medication -breaks the ampule neck away from the nurse's body to prevent injury from the glass -disposes of the empty glass ampule in a sharps container -injects air into the glass ampule prior to withdrawing the medication -rests and steadies the needle on the ampule's outer rim to withdraw medication

-breaks the ampule neck away from the nurse's body to prevent injury from the glass -disposes of the empty glass ampule in a sharps container --When preparing medication from a glass ampule, the nurse breaks the ampule away from the body and discards it in the sharps container. The nurse withdraws medication using a filter needle to prevent the injection of glass shards, avoids touching the needle to contaminated ampule edges, and avoids injecting air to prevent spillage

The ED nurse is assessing a client brought in after a car accident in which the client's head hit the steering column. Which assessment findings would indicate that the triage nurse should apply spinal immobilization? SATA -breath smells of alcohol -client disoriented to place -client reports eyes burning -history of multiple sclerosis -point tenderness over spine

-breath smells of alcohol -client disoriented to place -point tenderness over spine --Indications for spinal immobilization include abnormal neurological findings, significant mechanism of injury, change in orientation or LOC, intoxication, distracting injury, and point tenderness over the spine.

The nurse is caring for a client after a motor vehicle accident. The client's injuries include 2 fractured ribs and a concussion. The nurse notes which of the following as expected neurological changes for the client with a concussion? SATA -asymmetrical pupillary constriction -brief loss of consciousness -headache -loss of vision -retrograde amnesia

-brief loss of consciousness -headache -retrograde amnesia --A concussion is considered a minor traimatic brain injury and results from blunt force or an acceleration/deceleration head injury. These clients should be observed closely by family members and not participate in strenuous or athletic activities for 1-2 days. Rest and a light diet are encouraged during this time. The following manifestations indicate more serious brain injury and are not expected with simple concussion: Worsening headaches and vomiting; sleepiness and/or confusion; visual changes; weakness or numbness of part of the body.

The nurse is providing nutritional teaching for a client with a new ileostomy. Which foods should the nurse instruct the client to avoid? SATA -bananas -broccoli with cheese -multigrain bagel -popcorn -spaghetti with sauce

-broccoli with cheese -multigrain bagel -popcorn --An ileostomy is a surgically created opening in the abdominal wall that connects the small intestine to the external abdomen. Stool from the small intestine bypasses the colon and exits through the ileostomy. Functions of the colon do not occur, resulting in liquid stool that drains into an external ostomy appliance attached to the skin. In the immediate postoperative period of an ileostomy, a low-residue diet is prescribed to prevent obstruction of the narrow lumen of the small intestine and stoma. After the ileostomy heals, the client reintroduces fibrous foods one at a time. The client is instructed to thoroughly chew food and monitor for changes in stool output.

The night nurse receives a call at 4 AM from the lab regarding a client's blood cultures that have tested positive for bacteria. Which action by the nurse is appropriate at this time? -call the answering service and speak to the HCP now -document the results of the culture in the client's medical record -leave a message on the HCP phone -speak to the HCP on rounds in the morning

-call the answering service and speak to the HCP now --Critical lab results require immediate communication with HCP

The nurse witnessed a signed inform consent for an inguinal hernia repair surgery. During the procedure, the surgeon discovers a secondary ventral hernia that also requires repair. Which action should the nurse perform? -add the secondary hernia to the consent form that the client signed before the procedure -call the client's medical power of attorney to provide consent for the additional procedure -document that an additional hernia was found and that it will require surgery at a later time -witness an additional consent after both procedures are complete and the client is awake

-call the client's medical power of attorney to provide consent for the additional procedure --the nurse is responsible for witnessing the client's signature and ensuring that the client is competent and understands information provided by the surgeon. Clients unconscious or under the influence of mind-altering drugs cannot provide consent. If the sedated client requires procedures not listed on the consent form, the client's medical power of attorney, legal guardian, or next of kin should be contacted so that the surgeon can explain the situation and obtain consent.

A nurse cares for a client on life-support who has been declared brain dead. Which intervention is appropriate at this time? -ask the family members about their plans for the funeral services -call the local organ procurement services representative -discontinue nursing care and provide postmortem care -remove life support as requested by the spouse and family

-call the local organ procurement services representative --local organ procurement services are notified for every client death, per hospital protocol. If the client is deemed appropriate as a donor, then OPS collaborate with hospital staff in approaching the client's family about organ donation. Cardiac support continue as organ donation is discussed and/or performed. Life support is withdrawn only if the client is not a candidate for donated due to physiological reasons or the client/family does not consent.

Risk associated with thiazolidinediones and pioglitazone

-can worsen HF d/t fluid retention -increases risk for bladder cancer

The nurse assesses a newly admitted adult client on a neurological inpatient unit. Which assessment findings require immediate follow-up by the nurse? SATA -cannot flex the chin toward the chest -eyes move in opposite direction of head when head is turned to side -new onset of right arm drift -pupils 8 mm in diameter bilaterally -toes point downward when side of foot is stimulated

-cannot flex the chin toward the chest -new onset of right arm drift -pupils 8 mm in diameter bilaterally --the neck should be supple and able to be flexed toward the chest. Nuchal rigidity requires follow-up due to possible meningeal irritation related to infection. A new-onset of unilateral drift of a limb could indicate a stroke. The nurse assesses for other stroke-like symptoms, activates the facility stroke protocol, and notifies the HCP accordingly. Normal pupils are 3-5 mm in diameter. Pupil dilation can be the result of medication use of neurological causes. --oculocephalic reflex is an expected finding indicating an intact brainstem. It is tested by rotating the head and watching for the eyes to move simultaneously in the opposite direction.

What should you monitor for in clients being administered ziprasidone hydrochloride?

-cardiac effects (prolonged QT intervals) -hypotension -seizure activity --alcohol interacts with ziprasidone and increases the risk for potential adverse effects

Absolute contraindications for MRI

-cardiac pacemaker -implantable cardioverter defibrillator -cochlear implant -retained metallic foreign body, especially in organs such as the eye

What tissues are made with slow proliferating cells?

-cartilage -bone -kidney

Which of the following drug administrations should be reported as a practice error? SATA -cephalexin administered; client has hx of anaphylaxis from penicillins -hydromorphone 2 mg administered; client reports pruritus -immunization for 3-month-old administered in ventrogluteal site -oral niacin administered; client has facial flushing -warfarin administered; client at 12 weeks gestation

-cephalexin administered; client has hx of anaphylaxis from penicillins -immunization for 3-month-old administered in ventrogluteal site -warfarin administered; client at 12 weeks gestation ---do not administer warfarin if the client is pregnant. Intramuscular injections are given in the vastus lateralis to children age <7 months. Penicillins and cephalosporins can have across-sensitivity response. Narcotic-induced pruritus is not a true allergy.

The community health nurse is preparing to teach a group of African American women about prevention of diseases common to their ethnic group. Based on the incidence of disease within this group, which disorders should the nurse plan to discuss? SATA -cervical cancer -hypertension -ischemic stroke -osteoporosis -skin melanoma

-cervical cancer -hypertension -ischemic stroke ---African Americans have the highest incidence of hypertension in the world as well as increased incidence of stroke and cervical cancer. Whites have a high incidence of osteoporosis and skin cancer.

The nurse is caring for a client with Bell palsy. Which of the following assessment findings does the nurse expect? SATA -change in lacrimation on the affected side -electric shock-like pain in the lips and gums -flattening of the nasolabial fold -inability to smile symmetrically -severe pain along the cheekbone

-change in lacrimation on the affected side -flattening of the nasolabial fold -inability to smile symmetrically

The unit implemented a quality improvement program to address client pain relief. Which set of criteria is the best determinant that the goal has been met? -chart audits found clients' self-reported pain scores improved by 10% -number of narcotics used on the unit increased by 20% -positive comments on returned client satisfaction surveys increased by 30% -survey found that 90% of the nurses believed clients had better pain control

-chart audits found clients' self-reported pain scores improved by 10% --Measurements should be objective, rather than subjective. Evidence-based criteria should be used, if applicable. These survey results are objective, restrospective measurements of a positive change.

A nursing unit implements a quality improvement process of written reminders to ameliorate incentive spirometer use in postoperative client. What is the best indicator that the client goal for this process has been met? -chart audits indicate that client incidence of nosocomial pneumonia decreased by 20% -documentation shows that 100% of nurses attended an inservice seminar on the topic -nurses report an increased number of written reminders given to appropriate clients -surgeons who admit to the unit report increased satisfaction with current client IS use

-chart audits indicate that client incidence of nosocomial pneumonia decreased by 20% --The effectiveness of an intervention should be determined by objective measurable outcomes that can be correlated with the intervention. It should not be based only on personal opinion or staff activities.

The nurse on the telemetry unit is preparing client medications in the medication room at the nurse's station. The nurse should perform which actions to be consistent with client safety practices related to medication administration? SATA -check laboratory values before administering anticoagulants -compare medication, dosage, and route to prescription orders prior to administration -discard any unlabeled medications -open unit dose packages and place medications in a dispensing cup to take to the bedside -wear gloves to handle unopened individual unit dose medication packages

-check laboratory values before administering anticoagulants -compare medication, dosage, and route to prescription orders prior to administration -discard any unlabeled medications --The nurse must follow the 6 rights of medication administration. Additionally, one of the National Patient Safety Goals is to "improve the safety of using medications". This includes labeling all medications as soon as prepared, discarding any medications that are found unlabeled, and taking extra care for clients who take anticoagulant drugs. Individual dose packages should be opened at the client's bedside and should be placed in a medication cup only immediately prior to administration. Gloves are generally not required during medication preparation or handling of unopened packages or vials, although hand hygiene should be performed both prior to preparation or handling and again prior to administration.

A postoperative client who is receiving continuous enteral feedings via a nasoenteric tube becomes dyspneic with a productive cough, and the nurse auscultates crackles and diminished breath sounds in lung bases. Which action is appropriate at this time? -administer an inhaled bronchodilator -check marked insertion depth of the tube -request a prescription for a diuretic -start the client on incentive spirometry

-check marked insertion depth of the tube --a nasoenteric tube is passed through the nares into the duodenum or jejunum when it is necessary to bypass the esophagus and stomach. Nasoenteric tubes have a decreased risk of aspiration compared with nasogastric tubes; however, a nasoenteric tube can become dislodged to the lungs, causing aspiration of enteral feedings. If a client with a feeding tube develops signs of aspiration pneumonia, the feeding should be stopped immediately and tube placement checked. Some facilities use capnography to determine placement; if a senor detects exhaled carbon dioxide from the tube, it is in the client's airway and must be removed immediately. An inhaled bronchodilator may be prescribed to treat aspiration pneumonia, but the priority is to stop the feeding and check tube placement to prevent additional aspiration. Crackles may be heard with fluid overload, aspiration, or pneumonia. A diuretic would be appropriate if a client is experiencing pulmonary edema from fluid overload. Incentive spirometry promotes expansion of the lungs and resolves atelectasis, but is not the priority.

A client with end-stage renal disease, oxygen-dependent COPD, and a DNR code status is admitted to the medical floor for COPD exacerbation. The nurse walks in to the room and finds that the client is not breathing. What should the nurse do first? -activate the code system -call the HCP stat -check the apical pulse -check the blood pressure

-check the apical pulse --the nurse has a medical order stating that the client should not be resuscitated. Therefore, the appropriate first action is to assess the apical pulse. Then the nurse should call the HCP. If the client's family members are present, the nurse should explain what is happening and make sure that they have support.

The nurse practicing on a medical surgical unit cares for a client with type 1 diabetes mellitus. Which action should the nurse delegate to the experienced UAP? -assess the client for S/S of hypoglycemia -check the blood glucose before meals and report it to the primary nurse -teach the client to cut toenails straight across and file with rounded curves of the toes -update the care plan to include client's preference for nighttime diabetic snack

-check the blood glucose before meals and report it to the primary nurse

A client receiving total parenteral nutrition complains of nausea, abdominal pain, and excessive thirst. What is the best action from the nurse to take? -assess the client's vital signs -check the client's blood glucose -report the findings to the HCP -slow down the rate of infusion

-check the client's blood glucose --A complication of total parenteral nutrition is hyperglycemia, as evidenced by excessive thirst, increased urination, abdominal pain, headache, fatigue, and blurred vision. The development of hyperglycemia is related to the following: excessive dextrose infusion; a low tolerance for dextrose in critically ill clients due to the inflammatory response and the resulting production of counterregulatory hormones; high infusion rate; administration of medications such as steroids; infection. Interventions to resolve TPN-associated hyperglycemia include reducing the amount of carbohydrate in the TPN solution, slowing down the infusion rate, and administering subcutaneous insulin.

The client has a dislocated shoulder and the nurse is assisting the healthcare provider with bedside procedural moderate sedation (conscious sedation). During the procedure, the client becomes restless and cries out "help me" What action should the nurse take first? -administer midazolam per protocol -check the client's pulse oximeter -give more morphine per protocol -open the airway with head tilt-chin lift

-check the client's pulse oximeter ---When there is a new, sudden onset of restlessness/agitation, the nurse should first think about oxygenation or blood glucose. The desired level of sedation is level 3 on the Ramsay Sedation Scale, during which the client is drowsy, but responds to a voice command. If the client is snoring, opening the airway should be considered

The nurse is administering a pink pill to a hospitalized medical-surgical client. The alert, oriented client says, "This is a pill I haven't seen before." What follow-up action should the nurse take next? -check the healthcare provider's prescription in the medical record -explain that the healthcare provider has prescribed the medication -look up the medication in the pharmacology reference -teach the client about the purpose of the medication

-check the healthcare provider's prescription in the medical record -When a mentally competent client questions a drug administration, the safest option is to first check the prescription to verify the 6 rights of medication administration. If an error is ruled out, the nurse should follow up with appropriate teaching. Explaining that the nurse is just following orders is rarely the correct answer. A pharmacology reference can verify information about the medication, but will not confirm that the client is the correct recipient. Acceptable identifiers include first and last name, medical record number, and birth date.

A 55-year-old male client has a 16-Fr indwelling urethral catheter with a 5-mL balloon inserted to relieve postoperative urinary retention. The nurse observed urine leaking from the insertion site, past the catheter. What is the nurse's first action? -check the urethral catheter and drainage tubing -irrigate the catheter with 30 mL of sterile NS -notify the HCP -remove and reinsert the next-larger-size catheter

-check the urethral catheter and drainage tubing --The nurse's first action should be to assess for a mechanical obstruction by inspecting the catheter tubing. If these interventions fail, the nurse should then notify the HCP. Irrigation is usually avoided as pus or sediment can be washed back into the bladder; however, it is sometimes prescribed to relieve an obstruction to urine flow. If there is a discrepancy in expected urine output compared with fluid intake, a blockage is suspected and a bladder scan is then performed to confirm the presence of urine in the bladder.

A nurse precepting a new graduate nurse who is caring for a client with a paralytic ileus and a Salem sump tube attached to continuous suction. The preceptor should intervene when the graduate nurse performs which interventions? SATA -checks for residual every 4 hours -places client in semi-Fowler's position -plugs the air vent if gastric content refluxes -provides mouth care every 4 hours -turns off suction when auscultating bowel sounds

-checks for residual every 4 hours -plugs the air vent if gastric content refluxes --Continuous suction can be applied to decompress the stomach if a double lumen Salem sump tube is in place. The larger lumen is attached to suction and the smaller lumen is open to the atmosphere. Checking for residual volume is not an appropriate intervention because the Salem sump is attached to continuous suction for decompression and is not being used to administer enteral feeding. The air vent must remain open as it provides a continuous flow of atmospheric air through the drainage tube at its distal end (to prevent excessive suction force). This prevents damage to the gastric mucosa. If gastric content refluxes, 10-20 mL of air can be injected into the air vent. However, the air vent is kept above the level of the client's stomach to prevent reflux.

The nurse is planning teachnig for a client newly diagnosed with Sjogren's syndrome. Which measures will the nurse include in the teaching plan? SATA -chewing sugar-free gum or using artificial saliva -scheduling regular dental examinations -showering with lukewarm water and avoiding harsh soaps -using over-the-counter decongestants to alleviate nasal symptoms -using over-the-counter lubricants to ease vaginal dryness

-chewing sugar-free gum or using artificial saliva -scheduling regular dental examinations -showering with lukewarm water and avoiding harsh soaps -using over-the-counter lubricants to ease vaginal dryness ---Clients with Sjogren's syndrome need measures to combat the effects of damaged moisture-producing glands. These include eye drops, sugar-free candy or artificial saliva, vaginal lubricants, frequent dental examinations, lukewarm showers with mild soap, and avoiding decongestants.

The nurse in the ED receives 4 clients. Which client should the nurse see first? -child who is confused and irritable and whose parent claims 2 glyburide pills are missing -child with an abscess on the buttock that is red, swollen, and warm to the touch -child with immune thrombocytopenia who fell off a bike and reports shoulder pain -child with low-grade fever, barking cough, and runny nose who has mild retractions

-child who is confused and irritable and whose parent claims 2 glyburide pills are missing --Glyburide is used to treat diabetes mellitus, and it can cause significantly low blood sugar if ingested by a client who does not have diabetes, especially a child. Based on the symptoms the child is exhibiting, hypoglycemia is likely. This client requires immediate intervention as severe hypoglycemia can result in coma and/or death. --immune thrombocytopenia can be a serious condition due to the risk for bleeding. A client with this condition should be assessed for internal bleeding following an injury, especially to the head. Shoulder pain is not a symptom associated with life-threatening bleeding, thus the client is not a priority.

The triage nurse has one isolation room left in the emergency department. Which priority client should be assigned to this room? -child with chickenpox for the past 14 days; all lesions are crusted and dried -child with impetigo who has been on antibiotics for 3 days -child with leg rash secondary to poison ivy exposure -child with suspected pertussis who has paroxysms of coughing

-child with suspected pertussis who has paroxysms of coughing ---paroxysms of rapid coughing that lead to vomiting are a key feature of pertussis infection. Pertusis is a highly contagious disease and requires droplet precautions. It can be deadly if contracted in infancy before vaccination is started. Chickenpox is no longer contagious after the lesions have crusted and dried, but this process can take as long as 3 weeks. Impetigo is no longer contagious after 24 hours of antibiotics. Poison ivy rash is not considered contagious

What are the indicators of a child's readiness for toilet training?

-child's ability to express the urge to defecate/urinate -understanding simple commands -can pull clothing up/down -walks to and sits on toilet

The nurse is reviewing lifestyle and nutritional strategies to help reduce symptoms in a clinet with newly diagnosed gastroesophageal reflux disease. Which strategies should the nurse include? SATA -choose foods that are low in fat -do not consume any foods containing dairy -eat three large meals a day and minimize snacking -limit or eliminate the use of alcohol and tobacco -try to avoid caffeine, chocolate, and peppermint

-choose foods that are low in fat -limit or eliminate the use of alcohol and tobacco -try to avoid caffeine, chocolate, and peppermint --GERD occurs when chronic reflux of stomach contents causes inflammation of the esophagus mucosa. The lower esophageal sphincter normally prevents stomach contents from entering the esophagus. Any factor that decreases the tone of the lower esophageal sphincter (caffeine, alcohol) delays gastric emptying (fatty foods) or increases gastric pressure (large meals) can precipitate GERD.

The nurse supervisor tells the psychiatric nurse to go to the telemetry unit as the unit is short staffed and has 2 clients with cardiac arrest. The nurse is not familiar with this client population and does not want to go. What is the best response by the psychiatric nurse? -clarify the skills/knowledge that the nurse is able/unable to perform -read the policy and procedure book for the unit before providing care -refuse to go due to concerns about client safety -tell the supervisor to send someone else instead

-clarify the skills/knowledge that the nurse is able/unable to perform --When a nurse is asked to care for clients in an unfamiliar population, the duties to be performed and the nurse's limitations in skills or knowledge of specialized care should be clarified. Refusing to go can result in disciplinary action, including termination

An RN, LPN, and UAP are working on the unit. A client who is about to be discharged home with tube feedings needs care. Which responsibilities should the RN delegate to the LPN? SATA -cleaning the skin surrounding the gastrostomy tube stoma -crushing and administering metoprolol through the gastrostomy tube -programming the feeding pump to administer a prescribed bolus feeding -teaching the client about home enteral feeding and gastrostomy tube care -weighing the client using the bed scale

-cleaning the skin surrounding the gastrostomy tube stoma -crushing and administering metoprolol through the gastrostomy tube -programming the feeding pump to administer a prescribed bolus feeding

A nurse is preparing to insert a peripheral IV catheter dons clean gloves, applies a tourniquet to the client's arm, and immediately identifies a site for venipuncture. What are the remaining steps that the nurse should take? (5 steps)

-cleanse selected site while using an antiseptic swab -anchor vein by holding skin taut -insert needle bevel-side up until blood return is observed -advance catheter hub while retracting stylet -remove stylet and attach extension or infusion

A 7-year-old client receives a scalp laceration to the back of the head while on a playground, and the new nurse prepares to irrigate the wound. Which actions by the new nurse would require the experienced nurse to intervene? SATA -administers the prescribed analgesic 30 minutes before irrigating the wound -cleanses the wound from the most to the least contaminated area -obtains a 10-mL syringe and a 27-gauge needle -reviews the child's most recent immunization record -uses continuous pressure to irrigate and repeats until drainage is clear

-cleanses the wound from the most to the least contaminated area -obtains a 10-mL syringe and a 27-gauge needle --Before an open wound is closed, irrigation is performed to wash out debris and bacteria to ensure appropriate wound healing. This is important for wounds obtained in an outdoor environment as contamination with soil or dirt greatly increases the risk of infection. Immunization history is reviewed to determine tetanus vaccination status. Typically, a tetanus vaccination is administered if the client has not had one within the last 5-10 years, depending on the contamination level of the wound.

Which client does the nurse assess first after receiving morning report? -client 1 day postoperative with IV patient-controlled analgesia who reports burning at the IV site -client with a bowel obstruction prescribed continuous nasogastric suction who was admitted yesterday -client with atrial fibrillation and an irregular heart rate of 94/min -client with dementia and C diff who was incontinent of liquid stool

-client 1 day postoperative with IV patient-controlled analgesia who reports burning at the IV site --The nurse assesses the client who reports burning at the PCA IV site first. The analgesia runs through a special PCA administration set that is attached to the PCA pump. It is attached to a running IV line, which is on its own infusion pump, to flush the PCA drug through the IV line each time a dose is administered. If the IV line infiltrates the subcutaneous tissue or the catheter becomes occluded, the PCA drug can back up into the primary tubing each time a dose is administered, resulting in inadequate pain control. In addition, burning can indicate phlebitis, which causes vessel wall injury and can lead to thrombophlebitis.

The charge nurse on the telemetry unit is making client assignments. Which client is appropriate to assign to the LPN? -client 2 days after aortic valve surgery who needs a urinary catheter reinserted due to inability to void -client being discharged after deep vein thrombosis who needs teaching on how to self-administer enoxaparin injections -client who has just been admitted to the telemetry unit from the ED with a rule-out myocardial infarction -client with a nitroglycerin infusion with prescription to titrate to keep systolic blood pressure <150 mm Hg; currently is 110/62 mm Hg

-client 2 days after aortic valve surgery who needs a urinary catheter reinserted due to inability to void --the charge nurse should assign the most stable and predictable client to the LPN. Clients who are less predictable and stable require clinical assessment and judgment and should be assigned to an RN.

A nurse receives the following change-of-shift morning report for the assigned clients/ Which client should the nurse assess first? -client 1 day postop with fine inspiratory crackles in the lung bases on auscultation who is to ambulate for the first time this morning -client 1 day postop with serosanguineous drainage on the abdominal surgical dressing and temp of 100.4 F -client 2 days postop receiving intermittent epidural bolus analgesia who now reports incisional pain as a 4 on a 0-10 scale -client 2 days postop receiving fluids infusing at 125 mL/hr, with a foley catheter and urine output of 100 mL during the last 8 hours

-client 2 days postop receiving fluids infusing at 125 mL/hr, with a foley catheter and urine output of 100 mL during the last 8 hours --This client is becoming oliguric. The nurse should take vital signs to assess for hypotension, which can result in decreased renal perfusion, prerenal failure, and acute kidney injury, and assess for bladder distention and foley catheter patency before notifying the HCP. Auscultating fine crackles in the base of the lungs is common 1 day postop and is usually related to ateletctatsis caused by hypoventilation.

The nurse receives report on 4 clients. Which client should the nurse see first? -client 2 hours post foot amputation surgery has a surgical dressing saturated with bright red blood -client scheduled for whirlpool bath in 20 minutes has the dressing on the infected foot ulcer fall off -client with arteriovenous graft for hemodialysis access has new-onset pain and redness at graft site -client with urinary retention and infection receiving antibiotics is confused and trying to pull out Foley catheter

-client 2 hours post foot amputation surgery has a surgical dressing saturated with bright red blood --Serosanguineous drainage is expected after a surgical procedure, but a dressing saturated with sanguineous drainage indicates excessive blood loss with possible hemorrhage; it should be reported immediately to the healthcare provider for evaluation. Treatment with a pressure dressing to provide hemostasis, cauterization of a bleeding vessel, or fluid replacement may be necessary. Dialysis grafts are prone to infection and is not an immediate life-threatening condition.

The nurse on the orthopedic unit receives information during evening report. Which client should the nurse assess first? -client 3 hours postoperative tibial fracture repair who reports severe pain and pressure under the cast and is requesting opioids every hour -client 6 hours postoperative rotator cuff repair with a sling immobilizer who has moderate swelling and tinging of the hand and fingers -client 8 hours postoperative total knee arhtorplasty who has 2 closed wound suction drains and a total output of 200 mL sanguineous drainage -male client 1 day postoperative total hip replacement prescribed enoxaparin who has a hematocrit of 37% and hemoglobin of 12.5 g/dL

-client 3 hours postoperative tibial fracture repair who reports severe pain and pressure under the cast and is requesting opioids every hour --Compartment syndrome results from swelling and increased pressure within a confined space. It is most common with lower extremity injuries but can also occur in the arm. Pressure from bleeding/edema can exceed capillary perfusion pressure and lead to decreased perfusion and tissue ischemia below the site of increased pressure. Early manifestations include increasing pain unrelieved by opioids or elevation, pain with passive motion, pallor, and paresthesia due to nerve compression and ischemia. If the pressure is not relieved within 4-6 hours of onset, irreversible nerve and muscle injury can occur.

The nurse has received report on the following clients. Which client should the nurse assess first? -client 4 hours postop colon resection who has a blood pressure of 90/74 mm Hg -client receiving palliative care who has Cheyne-Stokes respiration with 20-second periods of apnea -client with anemia and hemoglobin level of 7 g/dL who has a pulse of 110/min after ambulation -client with diabetic keotacidosis who has rapid, deep respirations at a rate of 32/min

-client 4 hours postop colon resection who has a blood pressure of 90/74 mm Hg --Postop hypotension can be a manifestation of bleeding, hypovolemia, and sepsis. changes in VS can indicate decreased cardiac output and altered tissue perfusion.

The nurse receives report on 4 assigned clients. Which client should the nurse assess first? -client 1 hour post laparoscopic cholecystectomy for gallstones who reports right shoulder pain -client 4 hours post tracheostomy who has a small amount of pink drainage on the tracheotomy dressing -client 48 hours post abdominal hysterectomy who is ambulatory and reports aching in the right leg -client 3 days post open gastric bypass who reports fever and foul-smelling discharge at the surgical site

-client 48 hours post abdominal hysterectomy who is ambulatory and reports aching in the right leg --Nurse should first assess the client showing symptoms of DVT. If a DVT is suspected, early diagnostic testing and treatment with anticoagulant therapy are critical to prevent clots from traveling to the pulmonary circulation and causing pulmonary embolism.

The nurse receivees report on 4 clients. Which client should the nurse see first? -client admitted 12 hours ago with acute asthma exacerbation who needs a dose of IV methylprednisolone -client admitted 2 days ago with congestive heart failure who is reporting shortness of breath and had an extra dose of furosemide prescribed recently -client admitted with intestinal obstruction who is reporting abdominal pain and distention and needs nasogastric tube placement -client who had cardiac valve surgery 8 days ago but was readmitted with a sternal wound infection and needs antibiotics and a dressing change

-client admitted 2 days ago with congestive heart failure who is reporting shortness of breath and had an extra dose of furosemide prescribed recently --Although it is not a STAT order, an extra dose of furosemide was precribed for the client with congestive heart failure. The SOB is most likely due to a change in fluid status, and this client is the priority. Furosemide works immediately and should be given urgently. Even though the client is experiencing asthma exacerbation, steroids do not show their effects immediately. These drugs control underlying inflammation, but take several hours/days to take effect. Drugs that provide immediate relief to a patient with asthma exacerbation includes albuterol or ipratropium.

The nurse receives the hand-off shift report on assigned clients. Which information is most concerning and prompts the nurse to assess that client first? -client 1 day post colon resection who is receiving continual epidural morphine and reports severe itching -client admitted 2 hours ago with gastroenteritis who has been vomiting for 36 hours and has muscle cramps and weakness -client who has received IV bumetanide for 3 days for heart failure and experiences dizziness when standing up -client with acute poststreptococcal glomerulonephritis who is receiving antibiotics and has gross hematuria

-client admitted 2 hours ago with gastroenteritis who has been vomiting for 36 hours and has muscle cramps and weakness --The nurse should assess first the newly admitted client with gastroenteritis as prolonged vomiting increases the risk for dehydration, acid-base and electrolyte disturbances, and potential cardiac dysrhythmias. The client is exhibiting manifestation of hypokalemia, including muscle cramps and muscle weakness. Hypokalemia can lead to dangerous cardiac arrhythmias. --a histamine-related reaction is an expected adverse effect associated with the administration of epidural morphine, so this client does not need to be assessed first.

The nurse is reviewing new laboratory values. Which client would be the priority to report to the HCP? -client 2 days after a hip arthroplasty with a WBC count of 12,000 -client admitted for cocaine overdose with a creatine kinase of 30,000 U/L -client admitted for end-stage renal disease with a creatine of 3.6 mg/dL -client in heart failure exacerbation with a brain natriuretic peptide of 600 pg/mL

-client admitted for cocaine overdose with a creatine kinase of 30,000 U/L --Rhabdomyolysis occurs when muscle tissue is damaged and myoglobin is released into the blood, usually after an injury from overexertion, dehydration, severe vasoconstriction, heat stroke, or trauma. Acute kidney injury can occur when myoglobin overwhelms the kidneys' filtration ability. As myoglobin is excreted, the urine becomes very dark and is described as being a cola-brown color. Severely elevated creatine kinase levels, typically > 15,000 U/L are observed with severe muscle damage and can be a precursor to kidney injury. Forced saline diuresis with IV fluids is necessary to prevent permanent kidney damage.

A float nurse from labor and delivery is assigned to the cardiac care unit. Which client is most appropriate for the charge nurse to assign to the float nurse? -client 3 days following a myocardial infarction who is on 6 L of oxygen and reports nausea -client admitted for hypertensive crisis with blood pressure of 154/92 mm Hg on amlodipine -client with a demand pacemaker set a 70/min who has ventricular rate of 65/min -client with angina at rest who has normal troponin levels and normal sinus rhythm on ECG

-client admitted for hypertensive crisis with blood pressure of 154/92 mm Hg on amlodipine --a hypertensive crisis is an elevation in blood pressure >180 mm Hg systolic and/or >120 mm Hg diastolic with evidence of organ damage. The goal of treatment is to slowly lower BP using IV antihypertensive medications to limit end-organ damage. Once the client's condition is stabilized, oral antihypertensives are prescribed and IV medications are titrated off. Float nurse assignments should be made on the basis of what is within the knowledge and skill of the generalist nurse. The float nurse can safely care for the client whose BP is controlled by oral medication and has the knowledge and skill to assess vital signs. Unstable angina is a medical emergency that requires specialist-level monitoring and intervention.

The nurse has just received report. Which client should the nurse assess first? -client admitted from coronary angiography in the past hour with back pain -client with DVT on heparin drip at 1250 units/hr with an aPTT of 60 seconds -client with a head injury and GCS of 14 -postoperative day 2 coronary artery bypass graft client with incisional pain rated 6 on pain scale

-client admitted from coronary angiography in the past hour with back pain --Post-procedure care of a client who has undergone heart catheterization should focus on evaluating hemodynamics. The client should also be assessed several times per hour for active bleeding, hematoma, or pseudoaneurysm formation at incision site. The first hour after cardiac catheterization requires assessment every 15 minutes. Any report of back or flank pain should be assessed for retroperitoneal bleeding as back pain, tachycardia, and hypotension may be the only indication of internal bleeding. Internal bleeding after cardiac catheterization is particularly dangerous due to frequent use of anticoagulant prescriptions in these clients. --A heparin infusion is used for a client with DVT. An aPTT of 60 indicates a therapeutic value. The therapeutic range for a client on anticoagulation is usually 46-70 seconds.

The nurse has received report on 4 clients. Which client should the nurse see first? -client admitted this morning with acute pyelonephritis whose IV line is infiltrated -client scheduled for surgery in 2 hours who has questions about the procedure -client who had a colostomy yesterday and now has a leaking colostomy bag -client with total hip replacement 3 days ago who reports no bowel movement in 2 days.

-client admitted this morning with acute pyelonephritis whose IV line is infiltrated --Acute pyelonephritis is a severe bacterial infection of the kidney that causes it to swell. It can lead to permanent scarring of the kidney and can be life-threatening. Initial treatment includes vigorous parenteral IV fluids and IV antibiotics. This client's needs are the priority as treatment is dependent on patent IV access.

The nurse is evaluating a return demonstration by the client of a dry dressing change. Which action by the client would cause the nurse to intervene? -client applies sterile adhesive dressing over gauze without touching the wound bed -client applies sterile gauze moistened with sterile saline to wound surface -client cleanses site with a sterile saline swab in a spiral pattern from the center out -client removes old dressing with clean gloves and checks site for signs of infection

-client applies sterile gauze moistened with sterile saline to wound surface --Prior to discharge, the nurse evaluate the client's ability to perform home wound care. When performing a simple dry dressing change, the client should: don clean gloves and perform hand hygiene before and after removing the old dressing; cleanse the wound bed using sterile saline by moving from "clean" to "dirty" or from the center of the wound outward; thoroughly dry the wound and surrounding skin using sterile gauze to prevent maceration of underlying tissues; monitor the site for signs of infection; apply dry, sterile gauze over the wound bed

The medical-surgical nurse cares for a group of clients. Which client situations would prompt the nurse to notify the HCP during the middle of the night? SATA -client develops right-sided upper and lower extremity drift -client found lying unconscious on the floor -client has order for heparin with surgery planned for the morning -client has serum sodium of 124 mEq/L -client refuses a prescribed, routine pain medication

-client develops right-sided upper and lower extremity drift -client found lying unconscious on the floor -client has order for heparin with surgery planned for the morning -client has serum sodium of 124 mEq/L --The nurse should notify the HCP, regardless of the time, for acute client deterioration, critical lab values, falls, or death. Other reasons include prescription clarification and the client leaving against medical advice or refusing a key treatment.

A nurse on the medical surgical unit has just received report. Which client should be seen first? -client 1 day post femoral-popliteal bypass grafting who has an IV antibiotic due now -client diagnosed with DVT yesterday who reports some chest discomfort and cough -client with HTN and BP 180/92 mm Hg who reports a HA -client on fall precautions who just called the nurses' station for assistance in using the bathroom immediately

-client diagnosed with DVT yesterday who reports some chest discomfort and cough --This client is showing potential S/S of PE, a life-threatening condition. The nurse should elevate the HOB, administer oxygen, and assess the client.

The nurse has received report on 4 clients at the start of the shift. which client should the nurse assess first? -client in body cast who reports abdominal pain and bloating -client post mastectomy who reports numbness at the surgical site -client post neck dissection who reports difficulty chewing -client receiving antibiotics who reports new-onset vaginal itching

-client in body cast who reports abdominal pain and bloating --clients with large body casts are at risk for bowel obstruction, which can be caused by decreased peristalsis or by cast syndrome. Cast syndrome is a rare complication of an overly tight cast that involves a compression of the duodenum by the SMA. Immobilization of clients in body casts decreases peristalsis and may cause a paralytic ileus. If severe, bowel obstruction can result in bowel ischemia. The nurse should immediately report symptoms of a bowel obstruction. If cast syndrome is suspected, the cast may have a window cut out over the abdomen to relieve pressure. --antibiotics disrupt normal vaginal flora and may precipitate the development of a yeast infection, which present with vaginal discharge and itching. A client reporting this needs to be assessed, but is not priority.

Which client does the nurse assess first after receiving the morning report? -client has cellulitis from injecting heroin; threatening to leave against medical advice if more morphine is not given right now -client is 1 day postoperative colectomy; night nurse medicated client with morphine 15 minutes ago -client is 2 days postoperative open gastric bypass surgery; now reporting nausea and dry heaving -client is 3 days postoperative total knee replacement; waiting to be discharged

-client is 2 days postoperative open gastric bypass surgery; now reporting nausea and dry heaving --Vomiting and dry heaving place increased mechanical stress on surgical wound edges and increase the risk for wound dehiscence and evisceration. Obese clients who have undergone extensive abdominal surgery are especially vulnerable. Therefore, the nurse should first assess the client who is nauseated and dry heaving and administer an antiemetic medication. --the client trying to leave against medical advice is the second priority. --the nurse must follow-up 30 minutes after morphine is administered.

The nurse is caring for a client diagnosed with Broca aphasia due to a stroke. Which of the following deficits would the nurse correctly attribute to Broca aphasia? SATA -client coughs and gasps when swallowing food and liquids -client is easily frustrated while attempting to speak -client is unable to understand speech and is completely nonverbal -client misunderstands and inappropriately responds to verbal instruction -client's speech is limited to short phrases that require effort

-client is easily frustrated while attempting to speak -client's speech is limited to short phrases that require effort --Broca aphasia is a nonfluent aphasia resulting from damage to the frontal lobe. Clients with Broca aphasia can comprehend speech but demonstrate speech difficulties. The speech pattern often consists of short, limited phrases that make sense but display great effort and frequent omission of smaller words. Clients with Broca aphasia are aware of their deficits and can become frustrated easily. Clients with Wernicke aphasia are unaware of their speech impairment. --Wernicke aphasia involves the inability to comprehend the spoken and/or written words

After receiving report, which client should the nurse assess first? -client on a heparin infusion with platelet count of 86,000/mm3 -client with dehydration with blood urea nitrogen of 24 mg/dL -client with myelodysplastic syndrome with white blood cell count of 2,000/mm3 -client with sickle cell disease with hemoglobin of 7.9 g/dL and hematocrit of 24%

-client on a heparin infusion with platelet count of 86,000/mm3 --thrombocytopenia is a serious complication of heparin products. Regardless of its cause, thrombocytopenia usually results in bleeding complications. However, in heparin-induced thrombocytopenia usually leads to paradoxical venous and/or arterial thrombosis and less commonly in bleeding. The mechanism for thrombosis is unclear. The danger of HIT is risk of organ damage from local thrombi and/or embolization, leading to stroke and/or pulmonary embolism. HIT occurs over several days. The nurse should monitor platelet levels of clients on heparin and report a decrease of >50% from baseline or a drop below 150,000/mm3 to the HCP.

Which client incident would be classified as an adverse event that requires an incident/event/irregular occurrence/variance report? SATA -client admitted with white blood cell count of 28,000 mm3 and dies from sepsis -client receives 1 mg morphine instead of prescribed 0.5 mg morphine -client refuses pneumonia vaccination and contracts pneumonia -nurse did not report client's new hemoglobin result of 6 g/dl to oncoming nurse -provider was not notified of client's positive blood culture results

-client receives 1 mg morphine instead of prescribed 0.5 mg morphine -nurse did not report client's new hemoglobin result of 6 g/dl to oncoming nurse -provider was not notified of client's positive blood culture results --Adverse events are injuries caused by medical management rather than a client's underlying condition. Types of errors include diagnostic, treatment, preventive, and failure of communication, equipment, or other systems.

A client sustained a concussion after falling off a ladder. What are essential instructions for the nurse to provide when the client is discharged from the hospital? SATA -client should abstain from alcohol -client should remain awake all night -client should return if having difficulty walking -responsible adult should be taught neurological examination -responsible adult should stay with the client

-client should abstain from alcohol -client should return if having difficulty walking -responsible adult should stay with the client --A neurological assessment should be performed by a clinician. The responsible adult is taught the general indicative symptoms.

What is required for contact precautions?

-client should be placed in a private room or semi-private with another client with the same infection -dedicate equipment for client -wear gloves when entering the room -perform excellent hand hygiene before exiting the room -wear gown with client contact and remove it before leaving the room -place door notice for visitors -ensure client leaves the room only for essential clinical reasons

Which emergency department clients cannot be allowed to sign out against medical advice? SATA -client in sickle cell crisis receiving oxygen via face mask -client who drank a 1 L bottle of vodka 2 hours ago -client who hears voice commands to kill a coworker -client with mania who has not eaten in 5 days -client with ST elevation on ECG monitoring

-client who drank a 1 L bottle of vodka 2 hours ago -client who hears voice commands to kill a coworker -client with mania who has not eaten in 5 days

The oncoming nurse is receiving report on 4 clients. Which should be the priority assessment? -client who had a carotid endarterectomy that day with a blood pressure of 160/88 mm Hg -client who is 1 day post bowel resection with absent bowel sounds -client with a pulse of 100/min who has hx of atrial fibrillation -client with pancreatitis whose total parenteral nutrition is almost finished

-client who had a carotid endarterectomy that day with a blood pressure of 160/88 mm Hg --A carotid endarterectomy is a surgical procedure that removes atherosclerotic plaque from the carotid artery. clients with carotid artery disease are at increased risk for transient ischemic attack and stroke. Post-surgical risks include cerebral ischemia and infarction as well as bleeding. Blood pressure is closely monitored during the first 24 hours post surgery. HTN may strain the surgical site and trigger hematoma formation, which can cause hemorrhage or airway obstruction. Systolic blood pressure is maintained at 100-150 mm Hg to ensure adequate cerebral perfusion and avoidance of hemorrhage or strain. It can take 24-48 hours for peristalsis to return after bowel surgery due to manipulation of the bowels and anesthesia.

The unit secretary notifies the nurse that 4 clients called the nurses' station reporting pain. Which client should the nurse assess first? -client who had a foot amputation today reporting left shoulder pain radiating down the arm -client who has acute pancreatitis reporting severe, continuous, penetrating abdominal pain -client who has multiple myeloma reporting deep pelvic pain after walking down the hall -client who has sickle cell disease reporting severe pain in the arms and upper back

-client who had a foot amputation today reporting left shoulder pain radiating down the arm --Clients undergoing lower-extremity amputation may experience surgical site pain or phantom limb pain. However, shoulder pain radiating down the arm is an unexpected finding following an extremity amputation and may indicate myocardial ischemia. Women, older adults, or clients with diabetes may have atypical presentations other than chest pain during a MI.

The RN prepares to give out client care assignments. Which client is appropriate for the RN to assign to the LPN? -client admitted 3 hours ago with suspected acute pancreatitis -client who had a total right hip replacement 2 days ago -client who had a total thyroidectomy 2 hours ago -client with alcohol withdrawal syndrome

-client who had a total right hip replacement 2 days ago --The LPN should be assigned to clients who are medically stable and have expected outcomes. LPNS should not be assigned to clients who require complex care and clinical judgment and have potential negative outcomes. Teaching, assessment, clinical judgment, and evaluation of a client are the responsibility of the RN and should never be delegated to the LPN.

The nurse reviews the most current laboratory results of assigned clients. Which result should the nurse report to the healthcare provider immediately? -client who has cellulitis of the leg with a white blood cell count of 13,000/mm3 -client who has chronic kidney injury with a hematocrit of 28% and hemoglobin of 9 g/dL -client who has type 2 diabetes mellitus with a 2-hour postpranial serum glucose of 165 mg/dL -client who is 1 month post kidney transplant with a urinalysis showing WBC's and bacteria

-client who is 1 month post kidney transplant with a urinalysis showing WBC's and bacteria ---Clients who have undergone kidney (or organ) transplantation are prescribed immunosuppressant drugs to help prevent organ rejection and are therefore at increased risk for developing infection. The nurse should notify the HCP immediately of any signs or symptoms of an infection. Cellulitis is a bacterial infection that causes inflammation of the subcutaneous tissues. An increased WBC count would be expected in this client. Clients with chronic kidney injury have a decreased level of the hormone erythropoietin, resulting in decreased erythrocyte production. Decreased hematocrit and hemoglobin levels would be expected. An elevated postprandial serum glucose would be expected in a client with type 2 diabetees mellitus, so notifying the HCP is not necessary.

After receiving the hand-off nurse-to-nurse evening shift report, which client should the nurse assess first? -client who is 3-days postoperative bowel resection, now reports shortness of breath and chest pain -client with is 3-days postoperative right knee surgery, now reports fever, cough, and shortness of breath -client who was transferred from the post-anesthesia care unit (PACU) 15 minutes ago -client with a kidney stone who is requesting pain medication for severe flank pain

-client who is 3-days postoperative bowel resection, now reports shortness of breath and chest pain --The nurse should assess the postoperative client who had the bowel resection and is currently reporting shortness of breath and chest pain first. Abdominal surgery can cause engorgement of the large vessels in the pelvis leading to venous stasis and increased risk for PE. Therefore, this client's problem poses the greatest threat to survival and requires immediate attention. --Client 3-days postoperative right knee surgery likely developed postoperative pneumonia. Though pneumonia needs to be assessed and treated as soon possible, it is not as life-threatening as acute PE.

The nurse on the medical unit finishes receiving the change of shift repot at 7:30 AM. Which assigned client should the nurse see first? -client with GI bleed, who is receiving a unit of packed RBCs -client with an ulcerative colitis flare-up has temp of 101 F and abdominal cramping -client with A-fib, on telemetry, prescribed warfarin, with an INR of 3.2 -client with CKD scheduled for bedside hemodialysis at 8 AM, with a serum creatinine of 8.4 mg/dL

-client with GI bleed, who is receiving a unit of packed RBCs --The nurse should first check the client with the GI bleed to check the infusion device; flow rate; and IV site while also collecting baseline physical assessment data and assess for any complications --Secondly, the client with CKD to perform a baseline assessment before dialysis is initiated. The nurse should prepare the client by making sure the client eats breakfast and administer morning medications. --Thirdly, the nurse should assess the client with ulcerative colitis. -Finally, the nurse assesses the client with A-fib. The monitor tech will alert the nurse if there are any dysrhythmias. The goal INR is 2-3 for a-fib, but a 3.2 is expected when adjusting the warfarin dose

A nurse receives information in a change of shift report. Which client is the priority? -client prescribed levothyroxine to treat hypothyroidism who reports nervousness, sweating, and insomnia -client receives intravenous antibiotics for bacterial pneumonia who reports cough with blood-tinged sputum -client with a femoral external fixator who has a temperature of 100.9 F and redness and pain around the pin sites -client with chronic pancreatitis who reports upper abdominal pain and voluminous, foul-smelling, fatty stools

-client with a femoral external fixator who has a temperature of 100.9 F and redness and pain around the pin sites --External fixation stabilizes bone by inserting metal pins through skin into the bone and attaching them to a metal rod outside the skin. The nurse should assess this client first as any S/S of an infection warrant immediate evaluation and treatment. Localized pin tract infection can progress to osteomyelitis, a serious bone infection that requires long-term treatment with antibiotics. --the dose of levothyroxine may need to be adjusted as the client is now exhibiting manifestations of hyperthyroidism

The nurse in a pulmonary clinic triages telephone messages left by several clients. Which client should the nurse call back first? -client with a hx of asthma who reports scoring a peak flow of 45% of personal best -client with a pneumothorax who reports scant, clear drainage from the Heimlich valve -client with active TB reporting dark red orange urine after starting rifampin -client with COPD with an oxygen saturation of 90%

-client with a hx of asthma who reports scoring a peak flow of 45% of personal best --Peak expiratory flow rate is the peak velocity of exhaled air during forced exhalation. Clients with asthma use a peak flow meter to monitor their PEFR and determine their level of asthma control. An optimal PEFR is determined by recording the client's personal best peak flow number during 2 weeks of well-controlled asthma symptoms. Guided by their personal best, clients are taught asthma self-care using peak flow "zones" Green is good and >80%. Yellow requires intervention is is 50-79%. Red zone is bad and requires emergency medical care. Red zone is deemed anything less than 50% of personal best

The nurse receives report on 4 clients. Which client should be seen first? -client with a hx of chronic HTN exhibiting epistaxis and blurred vision -client with a unilateral, pulsating HA reporting sensitivity to light -client with episodes of vomiting and abdominal cramps following a outdoor party -client with multiple sclerosis reporting blurred vision and right arm weakness

-client with a hx of chronic HTN exhibiting epistaxis and blurred vision --Hypertensive encephalopathy is a medical emergency caused by a sudden elevation in blood pressure creating cerebral edema and increased ICP. Triggers of HE include an acute exacerbation of pre-exisintg hypertension, drug use, MAOI-tyramine interaction, head injury, and pheochromocytoma. The client may report severe HA, visual impairment, anxiety, confusion, and observed epistaxis, seizures, or coma. HE may precipitate life-threatening complications such as myocardial infarction, hemorrhagic stroke, and acute kidney injury. The client with a hx of chronic HTN and active signs of increased ICP requires immediate assessment and treatment. --The client with multiple sclerosis may have recurrent exacerbations, including symptoms of blurred vision, focal weakness, and/or sensory abnormalities.

Which client assignment is most appropriate for the nruse on an orthopedic unit to assign to a float nurse from a general medical unit? -client 1 day postop with external fixators to stabilize a complex fracture of the wrist -client 3 days post knee replacement surgery awaiting discharge -client who is scheduled for an above-the-knee amputation today -client with a long leg cast applied yesterday morning to treat a fractured ankle

-client with a long leg cast applied yesterday morning to treat a fractured ankle --This client is the most stable and appropriate assignment for the float nurse. This client requires the nurse to perform basic pain, peripheral vascular and peripheral neurologic assessments, which should be familiar to a nurse who works on a general medical unit. The client scheduled for an amputation requires preoperative teaching and psychological support specific to this type of surgery. Therefore, this client should be assigned to a nurse who is familiar with preparing clients for orthopedic surgery.

The nurse receives morning report on 4 clients who were admitted 2 hours earlier for injuries incurred in motor vehicle collisions. Which client should the nurse assess first? -client with a fracture pelvis who has a large area of ecchymosis and bruising over the pelvic region -client with a fractured tibia and leg cast who has pink skin under the cast edge and swollen toes -client with a lung contusion who has an oxygen saturation of 90% and severe inspiratory chest pain -client with pneumothorax and a chest tube who has intermittent in the water-seal chamber

-client with a lung contusion who has an oxygen saturation of 90% and severe inspiratory chest pain --A lung contusion caused by blunt force can occur when an individual's chest hits a car steering wheel. This injury is potentially life-threatening because bleeding into the lung and alveolar collapse can lead to acute respiratory distress syndrome. Clients should be monitored for 24-48 hours as symptoms are usually absent initially but develop as the bruise worsens. Inspiratory chest pain can lead to hypoventilation, and an oxygen saturation of 90% indicates hypoxemia. Therefore, the nurse should assess this client with lung contusion first and then notify the HCP as immediate interventions to decrease the WOB and improve gas exchange may be necessary.

Which client should the nurse assess first after receiving the hand-off morning report? -client 1 day postoperative exploratory abdominal laparotomy who has a nasogastric tube and absent bowel sounds in 4 quadrants -client with a peripherally inserted central catheter who has a 5-com increase in external catheter length since yesterday -client with chronic diarrhea from malabsorption syndrome who is receiving 10% dextrose in water via a peripheral IV line -client with type 2 diabetes mellitus who is scheduled for discharge and has a hemoglobin A1C level of 9%

-client with a peripherally inserted central catheter who has a 5-com increase in external catheter length since yesterday --A PICC is inserted via the basilic or cephalic veins into the superior vena cava. The nurse should measure and document the external length of the PICC during dressing changes. A change in the length of the external portion of the catheter can indicate migration of the tip of the catheter from its original position. The nurse should hold IV fluids and medications, secure the PICC to prevent further movement, and notify the healthcare provider for x-ray evaluation of catheter tip placement. --after abdominal surgery, placement of a nasogastric tube to decompress the stomach and the absence of bowel sounds for 24-72 hours due to postoperative paralytic ileus would be expected. The client with malabsorption syndrome is unable to digest and absorb nutrients by the GI tract. Peripheraly parenteral nutrition with 10% dextrose is expected treatment. Hemoglobin A1C level of 9% is above the recommended level and reflects inadequate glycemic control, which can be expected in a client with diabetes.

The nurse receives report on 4 clients. Which client should the nurse assess first? -client 1 day postoperative receiving PCA with morphine who reports itching and nausea -client receiving maintenance IV NS with labeled tubing indicating that tubing was changed 48 hours ago -client with a pulmonary embolus receiving continuous heparin infusion and warfarin who has an INR of 1.9 -client with a resistant bacterial infection receiving IV vancomycin who reports discomfort at the peripheral IV site

-client with a resistant bacterial infection receiving IV vancomycin who reports discomfort at the peripheral IV site --Phlebitis is an inflammation of a vein. Common manifestations include pain, swelling, warmth at the site, and redness extending along the vein. Causes include irritating drugs, catheter movement within the vein, or bacteria. If signs of phlebitis are present, immediate removal of the catheter is necessary as phlebitis can lead to thrombophlebitis and emboli or a bloodstream infection. --itching and nausea are common and expected adverse effects associated with the administration of opioids. Histamine blockers and an antiemetic can provide relief. --EBP recommend changing a continuous IV peripheral tubing administration no earlier than every 72 hours unless it becomes contaminated. Intermittent infusion and hypertonic solutions require more frequent changes (4-24 hours). --parenteral and oral anticoagulant medications are administered concurrently until the INR reaches a therapeutic range of 2-3, at which time the heparin infusion can be discontinued and the warfarin continued.

A nurse working in the office of a healthcare provider must respond to client telephone messages. The nurse should return which call first? -client with a left shoulder sling due to a fractured clavicle, reports nausea after taking oxycodone -client with a right leg cast applied yesterday for a fractured ankle, reports tinging in the right foot -client with diabetes, reports having taken the usual dose of insulin this morning and is now vomiting -client with fibromyalgia who is prescribed amitriptyline for sleep, reports continued insomnia

-client with a right leg cast applied yesterday for a fractured ankle, reports tinging in the right foot --The nurse should first call the client with tingling in the right foot. Musculoskeletal injuries and immbolization devices can cause neurologic or vascular damage to the extremity distal to the injury. Paresthesia is an early sign of neurovascular impairment. It would be important for the client to report to the HCP for immediate evaluation. Clients with diabetes are usually able to take the prescribed insulin dose when ill, and some clients may need a higher dose. Illness is a physiologic stressor and can increase blood glucose level. On the other hand, if the oral intake is low, blood sugars can be low and insulin may need to be reduced. While it is important to instruct the client to check glucose levels and repeat every 4 hours, reporting glucose levels above or below target range to the HCP, it is not the most important call.

The nurse on the neurotrauma unit receives report on 4 clients. Which client should the nurse assess first? -client in neurogenic shock from a spinal cord injury, with pulse of 56/min, blood pressure of 120/60 mm Hg, and warm/pink skin -client with a concussion from closed-head injury due to a fall, GCS score of 15, HA, and memory loss -client with a subdural hematoma, pulse of 48/min, blood pressure of 190/90 mm Hg, and a pupil that reacts slowly to light -client with central diabetes insipidus from a head injury, hypernatremia, and urine output of 210 mL/hr

-client with a subdural hematoma, pulse of 48/min, blood pressure of 190/90 mm Hg, and a pupil that reacts slowly to light --A subdural hematoma is caused by bleeding into the subdural space and is the result of blunt force head trauma. It is life-threatening, as increased pressure from the hematoma on the brain can lead to decreased cerebral perfusion and herniation. Assessing for signs of increased intracranial pressure, including change in level of consciousness, Cushing triad (HTN, bradycardia, and irregular respirations), ipsilateral pupil dilation, HA, and vomiting, is critical as surgery to evacuate the hematoma and relieve the pressure may be necessary. --central diabetes insipidus results from head trauma. Damage to the hypothalamus or pituitary gland leads to decreased antidiuretic hormone secretion, resulting in increased serum osmolality. Treatment is necessary, but polyuria and hypernatremia due to dehydration are expected manifestations.

A nurse working in the office of a HCP receives 4 telephones messages. Which client call should the nurse return first? -client with acute sinusitis prescribed azithromycin 3 days ago now has hives -client with chronic low back pain requests an oxycodone medication prescription refill -client with fever of 100 F has aching and itching at site after getting a flu shot yesterday -client with newly diagnosed asthma has palpitations after using an albuterol rescue inhaler

-client with acute sinusitis prescribed azithromycin 3 days ago now has hives --The first phone call the nurse should return is to the client with acute sinusitis. Hives can be a manifestation of hypersensitivity to the macrolide antibiotic azithromycin. Anaphylaxis is a potential complication, and the drug should be discontinued immediately. Anaphylaxis poses the greatest threat to survival.

After making initial rounds on all the assigned clients by 8AM, which client should the nurse care for first? -client 1 day postoperative who was medicated with tramadol 50 mg orally 1.5 hours ago -client 1 day postoperative with pink-colored urine after transurethral resection of the prostate -client scheduled for discharge today who needs instruction on how to change a sterile dressing -client with adenocarcinoma scheduled for a lobectomy at 9 AM who was restless and awake all night

-client with adenocarcinoma scheduled for a lobectomy at 9 AM who was restless and awake all night --Not being able to sleep the night before surgery is a common manifestation of anxiety and fear; these emotions can negatively affect recovery. For this reason, it is important to identify and listen to the client's concerns, teach the client about what to expect following surgery, and provide emotional support to help alleviate the fear and anxiety. The nurse can provide for the physical preparation of the client and complete the preoperative checklist as well. --Tramadol 50-100 mg orally every 4-6 hours is prescribed for moderate-to-severe postoperative pain. The client was medicated 1.5 hours ago. The drug onset is 1 hour, the peak is 2-3 hours, and the duration is 4-6 hours. Therefore, this client is most likely stable at this time and does not need care

The nurse receives the following information in the hand-off report. Which client should the nurse assess first? -client with a paralytic ileus following a colon resection who has abdominal distension, no audible bowel sounds, and nausea -client with alcoholic cirrhosis who has coffee ground nasogastric drainage, blood pressure of 90/60 mm Hg, and pulse of 110/min -Client with bacterial peritonitis following surgery for a ruptured appendix who is receiving IV tobramycin and has a temp of 101 F -Client with dysphagia and a sore throat who has a NG tube to administer contrast media for an abdominal CT scan

-client with alcoholic cirrhosis who has coffee ground nasogastric drainage, blood pressure of 90/60 mm Hg, and pulse of 110/min --The nurse should first assess the client with alcoholic cirrhosis, as this condition is associated with gastritis, clotting abnormalities, and esophageal varices that increase the risk for hemorrhage. Hypotension and tachycardia in the presence of blood loss can indicate hypovolemia. --A paralytic ileus is a non-mechanical intestinal obstruction that can occur following abdominal surgery. Expected manifestations include absent or hypoactive bowel sounds due to the lack of bowel motility and peristalsis, and abdominal distension and nausea due to the accumulation of gas and fluids in the bowel.

The nurse receives report on 4 clients. Which client should the nurse assess first? -client with end-stage renal disease receiving hemodialysis who reports fever with chills and nausea -client taking ibuprofen for ankylosing spondylitis who reports black-colored stools -client with altered mental status who is not following commands starts vomiting -client with acute diverticulitis receiving antibiotics who reports increasing abdominal pain

-client with altered mental status who is not following commands starts vomiting --This client with altered mental status and not following commands is at risk for aspiration and airway compromise from vomiting. This client should be assessed first; the client needs to be placed in the lateral position with head elevated and may need emergent intubation if airway cannot be protected.

The nurse receives report on 4 clients. Which client should be seen first? -client with amyotrophic lateral sclerosis experiencing increased dysarthria -client with COPD reporting increasing leg edema -client with strep throat and fever of 102 on antibiotics for 12 hours -client with urolithiasis reporting wavelike flank pain and nausea

-client with amyotrophic lateral sclerosis experiencing increased dysarthria --ALS is characterized by the progressive loss of motor neurons in the brainstem and spinal cord. Clients have spasticity, muscle weakness, and atrophy. Neurons involved in swallowing and respiratory function are eventually impaired, leading to aspiration, respiratory failure, and death. Care of clients with ALC focuses on maintaining respiratory function, adequate nutrition, and quality of life. There is no cure, and death usually occurs within 5 years of diagnosis. The client with COPD and peripheral edema may have cor pulmonale, or right-sided heart failure, from vasoconstriction of the pulmonary vessels.

The nurse is planning to assess 4 assigned clients. Which client situation is of greatest concern and warrants immediate assessment? -client scheduled for hemodialysis in an hour who has a serum creatinine level of 9.2 and refuses to take prescribed medications -client taking diphenhydramine for urticaria who reports difficulty urinating and increasing lower abdominal pain -client with an infected venous leg ulcer prescribed IV vancomycin who has a dressing saturated with yellow, foul-smelling drainage -client with an inguinal hernia who rates abdominal pain as 10 on a 0-10 scale and reports bloating, nausea, and vomiting

-client with an inguinal hernia who rates abdominal pain as 10 on a 0-10 scale and reports bloating, nausea, and vomiting --An inguinal hernia is a protrusion of intraperitoneal contents through a weakened area in the abdominal wall. Clients may experience dull pain exacerbated by exercise or straining and a palpable bulge on assessment. A hernia is reducible if the organs can be returned to the peritoneal cavity by applying pressure to the bulge; and incarcerated, if they cannot. Manifestations of a mechanical bowel obstruction are caused by compressed loops of bowel incarcerated by the hernia. Subsequent bowel ischemia and strangulation can lead to infection and death. Immediate evaluation and urgent surgical intervention are critical.

The nurse is triaging victims at the site of a mass casualty incident. Which victim should be seen first? -client with a head injury and fixed, dilated pupils -client with an open right femur fracture and palpable pedal pulses -client with full-thickness burns covering 85% total body surface area -client with shallow lacerations over legs and arms

-client with an open right femur fracture and palpable pedal pulses

The nurse receives news of a local mass shooting. Stable clients need to be discharged to make room for newly admitted clients. Which client would the nurse identify as safe to recommend for discharge? -client on chemotherapy who started antibiotics today for cellulitis of the leg -client with asthma exacerbation who has not required oxygen or a nebulizer in 12 hours -client with diabetes who has nausea, abdominal pain, and vomiting -client with ulcerative colitis and diarrhea who has developed fever and vomiting

-client with asthma exacerbation who has not required oxygen or a nebulizer in 12 hours --a client with acute exacerbation may require treatment in the ER or hospitalization for oxygen, inhaled bronchodilators, and corticosteroids. The client can likely be discharged home when respiratory status has stabilized and continue the previous home regimen of inhaled bronchodilators and corticosteroids. --clients who have received chemotherapy may be immunocompromised due to neutropenia. An immunocompromised client is at greater risk of sepsis from an infection. Close monitoring and antibiotic therapy is required

The nurse receives handoff of care report on four clients. Which client should the nurse assess first? -client 1 day post-thoracotomy wedge resection who has subcutaneous emphysema at the chest tube insertion site -client with asthma who reports SOA following an albuterol nebulizer treatment 15 minutes ago -client with COPD exacerbation who is receiving bi-level positive airway pressure therapy and has a pulse oximetry reading of 90% -client with leg cellulitis following a spider bite who needs the IV restarted to initiate prescribed antibiotics

-client with asthma who reports SOA following an albuterol nebulizer treatment 15 minutes ago --Asthma exacerbations may require repeat nebulization every 20 minutes, or continuous nebulization for one hour, to relieve severe bronchoconstriction until the administered corticosteroids take effect and start to reduce the inflammation. The nurse should assess the client for wheezing, decreased breath sounds, use of accessory muscles to breathe, capillary refill, respiratory rate, and pulse oximeter reading and pulse. --subcutaneous emphysema is air that leaks into the tissue surrounding the chest tube insertion site. The amount is usually small and reabsorbs spontaneously. The nurse should auscultate for lung sounds, assess for a popping sound, and palpate the site for a crackling sensation, but is not priority.

The nurse reviews the laboratory results for 4 assigned clients. Which result is most important for the nurse to report to the HCP? -client with atrial fibrillation receiving warfarin for 7 days with an INR of 1.3 -client with chronic bronchitis who has a hematocrit of 56% and hemoglobin of 10 g/dL -client with C. diff infection who has a white blood cell count of 15,000/mm3 -client with sepsis receiving gentamycin who has a creatinine of 0.6 mg/dL

-client with atrial fibrillation receiving warfarin for 7 days with an INR of 1.3 --The client with A-fib is at increased risk for the development of atrial thrombi due to blood stasis, which can embolize and lead to an ischemic brain attack. The INR is a measurement used to assess and monitor coagulation status in clients receiving anticoagulation therapy. The therapeutic INR level for a client receiving warfarin to treat A-fib is 2-3. The subtherapeutic INR of 1.3 is the most important result to report as the client is at increased risk for a stroke and dose adjustment is needed.

Four clients were involved in a major highway motor vehicle accident. Which client requires priority care? -client with blood pressure of 90/70 mm Hg and deviated trachea -client with concussion who was unconscious for 5 minutes -client with grossly swollen upper thigh and blood pressure of 80/60 mm Hg -client with pain at the thoracic spine and complete paralysis of both legs

-client with blood pressure of 90/70 mm Hg and deviated trachea --tension pneumothorax causes marked compression and shifting of mediastinal structures, including the heart and great vessels, resulting in reduced cardiac output and hypotension, resulting in a life-threatening emergency. The client should have emergency large-bore needle decompression, followed by chest tube placement, to relieve the compression on the mediastinal structures. --clients who have a head injury and lose consciousness are at high risk of intracranial injury (bled). This client would likely need a CT scan to assess for further damage, but is not the priority. A grossly swollen upper thigh likely represents a femur fracture with extensive bleeding. It requires intervention, especially IV fluids and surgical correction. However, this is second priority. Thoracic spine pain and leg paralysis likely represent injury to the spinal cord. Precautions such as a hard cervical collar and backboard should be used to prevent further injury. This client requires further testing and treatment, but is not priority.

The nurse receives the change of shift report for assigned clients at 7 AM. Which client should the nurse assess first? -client with change in level of consciousness who fell in the nursing home -client with chronic headaches who is scheduled for an MRI at 9 AM -client with COPD and pulse oximeter reading of 90% -client with heart failure and 3+ pitting edema of the lower extremities

-client with change in level of consciousness who fell in the nursing home --Change in LOC is a high priority problem as it can indicate a neurologic deficit that can be associated with a closed head injury. At the beginning of the shift, the nurse must perform a basic neurologic assessment. This is done to obtain the baseline data against which subsequent assessments can be compared and to assess for indicators of increased ICP.

Which ED client would be allowed to leave against medical advice after the risks are discussed with the primary HCP? -5 year old client with meningitis whose parent refuses antibiotics -client who tried to commit suicide by taking a handful of acetaminophen an hour ago -client with UTI who is disoriented to time and place -client with coffee-ground emesis from chronic use of high-dose aspirin

-client with coffee-ground emesis from chronic use of high-dose aspirin --to leave AMA, a client must have the risks explained and be able to understand them. Issues that can make a client ineligible to leave AMA include danger to self or others, lack of consciousness, altered consciousness, mental illness, being under chemical influence, or a court decision. Despite it not being within the client's best interest to leave with a GI bleed, they can. --Parents may not refuse life; limb; or organ saving treatment on behalf of their minor child for religious or personal reasons; they can make that decision only for themselves.

The charge nurse must assign a semi-private room to a client with diabetes mellitus admitted for IV antibiotic therapy to treat leg cellulitis. Which of the 4 room assignments is the best option for this client? -client 1 day postoperative laparoscopic cholecystectomy who is awaiting discharge -client with dementia and urinary incontinence wearing an external urine collection device -client with hx of splenectomy 15 years ago, now admitted for PE -client with lupus nephritis who is prescribed treatment with azathioprine

-client with dementia and urinary incontinence wearing an external urine collection device --The client with dementia and urinary incontinence who has an external urinary condom catheter is the least susceptible to infection compared to the other clients.

Multiple clients arrive at the ED. Which client should the triage nurse prioritize for the HCP to see first? -client at 24 weeks gestation, showing no signs of labor, with cough productive of yellow phlegm -client with dementia arriving with new-onset restlessness and confusion -client with epilepsy who had a seizure earlier but is now alert and oriented -client with newly deformed forearm with normal circulation and sensation, pain rated 8/10

-client with dementia arriving with new-onset restlessness and confusion --Clients with dementia are expected to be alert, with a gradual development of symptoms showing cognitive decline. The sudden onset of a new behavior may indicate delirium caused by infection or another serious etiology and is considered a priority. --The client who had a seizure earlier is now stable. The nurse can maintain a safe environment until the client is seen, but the client with dementia and behavior changes is the priority.

A nurse in the ED assesses 4 clients. Based on the laboratory results, which client is the highest priority for treatment? -client with abdominal pain, respirations 28/min, and blood alcohol level 80 mg/dL -client with chronic obstructive pulmonary disease, pH 7.34, pO2 86 mm Hg, pCO2 38 mm Hg, and HCO3 30 mEq/L -client with dull headache, pulse oximeter reading 95%, and serum carboxyhemoglobin level 20% -client with emesis of 100 mL coffee-ground gastric contents and serum hemoglobin 15 g/dL

-client with dull headache, pulse oximeter reading 95%, and serum carboxyhemoglobin level 20% --Carbon monoxide is a toxic inhalant that enters the blood and binds more readily to hemoglobin than oxygen does. when hemoglobin is saturated with CO, the pulse oximeter reading is falsely normal as conventional devices detect saturated hemoglobin only and cannot differentiate between CO and oxygen. The diagnosis of CO poisoning is often missed in the ED because symptoms are nonspecifci. A serum carboxyhemoglobin test is needed to confirm the diagnosis. Normal values are <5% in nonsmokers and slightly higher in smokers. This client with CO poisoning is the highest priority for treatment and requires immediate administration of 100% oxygen to increase the rate at which CO dissipates from the blood to prevent tissue hypoxia and severe hypoxemia.

The nurse on the medical-surgical unit receives report on assigned clients. Which client warrants immediate attention? -client experiencing abdominal cramps two hours after colonscopy -client reporting white stools 8 hours after barium swallow study -client with epigastric pain after endoscopic retrograde cholangiopancreatography -client with small bowel obstruction with copious, greenish-brown drainage from the nasogastric tube

-client with epigastric pain after endoscopic retrograde cholangiopancreatography --ERCP is a procedure in which an endoscope is passed through the mouth into the duodenum to assess the pancreatic and biliary ducts. Using fluoroscopy with contrast media, the ducts can be visualized and treatments including removal of obstructions, dilation of strictures, and biopsies can be performed. Perforation or irritation of these areas during the procedure can cause acute pancreatitis, a potentially life-threatening complication after an ERCP. S/S include acute epigastric or left upper quadrant pain, often radiating o the back, and a rapid rise in pancreatic enzymes.

The nurse is caring for an assigned team of clients. Which client is the priority for the nurse at this time? -client admitted with Gullian-Barre syndrome yesterday is paralyzed to the knees -client admitted with multiple sclerosis exacerbation has scanning speech -client with epilepsy puts on call light and reports having an aura -client with fibromyalgia reports pain in the neck and shoulders

-client with epilepsy puts on call light and reports having an aura --An aura is a sensory perception that occurs prior to a complex or generalized seizure. The client will most likely have a tonic-clonic seizure soon, and the nurse should attend to this client first to ensure safety measures are in place.

The nurse receives handoff of care report on four clients. Which client should the nurse assess first? -client who had an appendectomy today and reports severe nausea and 8 out of 10 pain -client with a diabetic foot ulcer who has current blood glucose level of 301 mg/dL -client with fever of unknown origin whose arterial blood gas reveals PaCO3 30 mm Hg -client with persistent diarrhea who has continuous lactated Ringer solution IV infusing at 125 mL/hr

-client with fever of unknown origin whose arterial blood gas reveals PaCO3 30 mm Hg --systemic inflammatory response syndrome is a pathophysiologic response mediated by the release of large quanities of inflammatory cytokines from the inflammatory cascade. Overwhelming release of inflammatory cytokines triggers vasodilation and capillary leakage, leading to hypotension and impaired end-organ perfusion. SIRS may occur in response to trauma, tissue ischemia, infection, and shock and can rapidly progress to hemodynamic instability, respiratory failure, and multiorgan dysfunction. Clinical manifestations of SIRS include fever or hypothermia, tachycardia, leukocytosis or leukopenia, and tachypnea. Clients who develop multiple symptoms of SIRS require aggressive fluid resuscitation and treatment to address possible causes as SIRS may be life-threatening. --a client with persistent diarrhea should have both total intake and output and recent electrolyte levels assessed, but signs of SIRS should be addressed first.

Which client should the charge nurse assign to the room closest to the nurses' station? -client with a Salem sump tube to continuous suction who is deaf -client with gastroenteritis and dementia who wanders -client with herpes zoster under airborne isolation precautions -client with sickle cell crisis who requires frequent intravenous opioids.

-client with gastroenteritis and dementia who wanders --When assigning rooms, the nurse should consider infection control, physical location, acuity level, and individual client safety needs. Cognitive impairment and fluid and electrolyte disturbances pose the greatest risks to a client's safety.

Which client is most appropriate for the charge nurse on a cardiac step-down unit to assign to the float registered nurse from a med-surg unit? -client who just returned to the unit after coronary angioplasty and placement of stent -client with a-fib scheduled for electrical cardioversion this afternoon -client with heart block scheduled for pacemaker placement this afternoon -client with heart failure and deep vein thrombosis receiving an IV infusion of heparin

-client with heart failure and deep vein thrombosis receiving an IV infusion of heparin

After the nurse receives the change-of-shift report, which client should the nurse assess first? -client with asthma who has SOA and high-pitched expiratory wheezing -client with diabetes and a stasis leg ulcer dressing saturated with serosanguineous drainage -client with heart failure who is SOA and coughing up pink frothy sputum -client with left pleural effusion and absent breath sounds in the left base

-client with heart failure who is SOA and coughing up pink frothy sputum --This client has developed acute pulmonary edema, a potentially life-threatening condition. This client's status has deteriorated from baseline and is potentially the most hemodynamically unstable.

A major earthquake has occurred. Local gas lines and water pipes are breaking with resulting fires and flooding in collapsed buildings. Multiple victims arrive at the triage area. Which client should the nurse care for first? -client with charred, leathery skin over entire back, chest, and legs -client with cool skin, shivering from sitting in water until rescued -client with diabetes who was unable to take prescribed insulin today -client with high-pitched, crowing inspiratory respirations

-client with high-pitched, crowing inspiratory respirations --during mass casualty events, the goal is the greatest good for the greatest number of people. Clients are triaged rapidly using a color-coded system that categorizes them from highest medical priority to lowest. The client with stridor, which typically occurs from constricted or blocked upper airways, is at risk for impending respiratory failure due to a compromised airway. This client is classified as emergent. --Clients with wet clothing or cold water immersion are at risk for hypothermia, but can easily be self-managed by provision of warm, dry blankets; this client is nonemergent.

The nurse receives the assigned clients for today on a neurology unit. The nurse should check on which client first? -client with hx of head injury whose GCS changes from 13 to 14 -client with hx of myasthenia gravis who had ptosis in the evening -client with hx of T2 spinal injury who has diaphoresis, pulse 54/min, and hypertension -client with hx of transverse myelitis with 2+ bilateral lower extremity muscle strength

-client with hx of T2 spinal injury who has diaphoresis, pulse 54/min, and hypertension --autonomic dysreflexia is a massive, uncompensated cardiovascular reaction by the sympathetic nervous system in a spinal injury at T6 or higher. Due to the injury, the parasympathetic nervous system cannot counteract the SNS stimulation below the injury. Classic triggers are distended bladder or rectum. Classic manifestations include severe hypertension, throbbing HA, marked diaphoresis above the level of injury, bradycardia, piloerection, and flushing. This is an emergency condition requiring immediate intervention. Management includes raising the head of the bed and then treating the cause

The nurse reviews the serum laboratory results of assigned clients. Which results are most important to report to the HCP? SATA -client with a malignancy prescribed filgrastim has neutropenia -client with acute osteomyelitis prescribed vancomycin has leukocytosis -client with acute pancreatitis prescribed hydromorphone has an elevated lipase level -client with hypertension prescribed candesartan has hyperkalemia -client with peritonitis prescribed tobramycin has an elevated creatinine level

-client with hypertension prescribed candesartan has hyperkalemia -client with peritonitis prescribed tobramycin has an elevated creatinine level --Potassium-sparing diuretics, ACE inhibitors, and angiotensin II receptor blockers cause hyperkalemia. Therefore, those should be held in clients with underlying hyperkalemia. Aminoglycosides are used to treat serious infections. The nurse should monitor renal function and peak and trough levels, and report an elevated creatinine level to the HCP as it is a major adverse effect that can indicate reversible nephrotoxicity. --Neutropenia increases a client's susceptibility to infection. Filgrastim is used to increase the neutrophil count in clients with certain malignancies and in those undergoing chemo. Acute osteomyelitis, an infection of the bone, is characterized by local and systemic manifestations of infection, increased erythrocyte sedimentation rate, fever and involves long-term antibiotic therapy. Acute pancreatitis is an acute inflammation of the pancreas, characterized by abdominal pain and elevated levels of amylase and lipase, which are digestive enzymes produced by the pancreas. The pain is treated with opioids.

The emergency department nurse receives report on 4 clients. Which client should the nurse assess first? -client with acute cholecystitis who reports right shoulder pain -client with gastroparesis who reports persistent nausea and vomiting -client with intractable lower back pain who reports new urinary incontinence -client with Meniere disease who reports increasing tinnitus

-client with intractable lower back pain who reports new urinary incontinence --Cauda equina syndrome is a disorder that results from injury to the lumbosacral nerve roots causing motor and sensory deficits. The main symptoms are severe lower back pain, inability to walk, saddle anesthesia, and bowel/bladder incontinence (late sign). Cauda equina syndrome is a medical emergency. Treatment requires urgent reduction of pressure on the spinal nerves to prevent permanent damage. This client displays characteristic late signs of cauda equine syndrome; therefore, this client is of the most priority.

The emergency department nurse is assigned to triage. Which client should the nurse assess first? -client who smokes who has intermittent leg pain that is worse with walking and eases with rest -client with diabetes mellitus who has temperature of 100.7 -client with leg swelling and calf pain who was on a 15-hour flight 2 days ago -client with pain, edema, and redness in the leg following a dog bite 1 hour ago

-client with leg swelling and calf pain who was on a 15-hour flight 2 days ago --Life-threatening physiological problems are the highest priority followed by less threatening problems. Unilateral edema and calf pain could be signs of a VT, a high-priority circulation problem in which a lower-extremity clot may dislodge, travel, and cause life-threatening complications. Prolonged immobilization increases the risk for DVT. A client with leg pain during activity that is relieved by rest may have intermittent claudication, a classic sign of peripheral artery disease.

The nurse receives handoff report on 4 clients. Which client should the nurse assess first? -client with chronic anxiety disorder taking buspirone and diphenhydramine who has a dry mouth -client with chronic heart failure taking metoprolol and lisinopril who has dizziness when standing up -client with major depressive disorder taking phenelzine and pseudoephedrine who has a HA -client with type 2 diabetes taking metformin and lovastatin who has stomach upset and nausea

-client with major depressive disorder taking phenelzine and pseudoephedrine who has a HA --MAOIs are often prescribed for depression. MAOIs deactivate an enzyme that breaks down norepinephrine, dopamine, and serotonin. Increased levels of norepinephrine can increase blood pressure. This increased norepinephrine level combined with certain medications that also increase blood pressure may lead to hypertensive crisis, a complication that can result in hemorrhagic stroke and death. Headache is a common, early symptom of hypertensive crisis that should be evaluated immediately in clients taking MAOIs.

A nurse working in a neurology clinic receives the following telephone messages. Which client should the nurse call back first? -client prescribed sumatriptan who has throbbing left temple pain preceded by an aura -client taking carbidopa-levodopa who has dizziness when rising from a sitting or lying position -client with myasthenia gravis who has a fever and increasing difficulty swallowing -client with trigeminal neuralgia who reports burning cheek pain after eating ice cream

-client with myasthenia gravis who has a fever and increasing difficulty swallowing --Myathenia gravis is an autoimmune disease of the neuromuscular junction resulting in fluctuating muscle weakness. Autoantibodies are formed against the acetylcholine receptors, so fewer receptors are available for acetylcholine to bind. It is treated with pyridostigmine, which increases the amount of acetylcholine at the synaptic junction, augmenting neuromuscular signals and improving muscle strength. Infection, undermedication, and stress can precipitate a life-threatening myasthenic crisis, which is characterized by oropharyngeal and respiratory muscle weakness and respiratory failure. This client's infection and increasing difficulty swallowing indicate the need for immediate intervention. -Sumatriptan is prescribed for moderate to severe, acute migraine headaches that are characterized by severe pulsatile, throbbing unilateral head pain with or without auras, photophobia, nausea, and vomiting. The client with uncontrolled migraine headaches requires a change in treatment regimen. --trigeminal neuralgia is characterized by intermittent severe, unilateral facial pain precipitated by light touch, hot or cold foods, chewing, and swallowing.. This client may require a change in treatment regimen for improved pain relief.

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

-client with paradoxical chest movement throughout respirations --Disaster triage is based on the principle of providing the greatest good for the greatest number of people. The client with flail chest from multiple fractured ribs is at risk for respiratory failure from impaired ventilation. In addition, mobile fractured ribs may puncture the pleura or vessels, causing hemothorax and/or pneumothorax at any time. Therefore, this client would be classified as emergent due to airway compromise

The nurse receives report on 4 clients. Which client should the nurse assess first? -client with cellulitis of the right foot, medicated with hydromorphone IV 1 hour ago, reports pain as 6 on a scale of 0-10 -client with chronic kidney disease with hemoglobin 8 g/dL and hematocrit 24% reports shortness of breath with activity -client with heart failure exacerbation and a large pleural effusion with serum sodium of 132 mEq/L reports HA -client with pneumonia and asthma, who just received nebulized albuterol, now appears to be resting after a sudden decrease in wheezing

-client with pneumonia and asthma, who just received nebulized albuterol, now appears to be resting after a sudden decrease in wheezing --The client with pneumonia and asthma is at risk for problems related to airway management and should be assessed first. Clients with symptomatic asthma will receive inhaled beta agonists; however, even after medication, it is a priority to assess this client's lung sounds, work of breathing, and LOC to determine respiratory status. A sudden decrease in wheezing may signal the development of silent chest, where airflow is rapidly reduced due to increased bronchial constriction. Dilutional hyponatremia is expected in a client with heart failure due to excess fluid and cause fatigue and HA. Change in LOC and seizures can occur with sodium <120 mEq/L, but a borderline low level does not require immediate attention.

A LPN is discussing assessment findings for several older adult clients with the RN. Which client is priority for the RN to assess? -client taking metoprolol who has a pulse of 54/min and blood pressure of 154/82 mm Hg -client who has chronic obstructive pulmonary disease with an oxygen saturation of 92% -client with 345 mL of gastric residual volume aspirate from a PEG tube before an enteral feed -client with pneumonia who is receiving IV fluids and has a new S3 heart sound

-client with pneumonia who is receiving IV fluids and has a new S3 heart sound --An S3 heart sound is made when blood from the atrium is pumped into a noncompliant ventricle. S3 is heard after S2. It may be present as a normal finding in young adults. However, a new S3 in older adults is a significant finding as it may indicate development of volume overload or heart failure. These conditions require prompt intervention as they may rapidly progress to life-threatening events. This client may be receiving excessive IV fluids that are causing volume overload. --Repeated high gastric residual volumes in clients receiving enteral feedings may indicate delayed stomach emptying and require adjustment to prevent N/V or abdominal distension

The L & D nurse is floated to a medical-surgical floor for a shift. Which client is most appropriate for the charge nurse to assign to this L&D nurse? -client with occluded arteriovenous fistula receiving IV heparin infusion -client with cirrhosis and ascites who requires bedside paracentesis -client with diabetes who is one day postoperative below-the-knee amputation -client with pyelonephritis who is febrile and receiving IV antibiotics

-client with pyelonephritis who is febrile and receiving IV antibiotics --A float nurse should be assigned to clients who require care similar to the nurse's usual client population. Clients requiring care from a nurse with specialized knowledge should not be assigned to a float nurse.

Which client finding is most important for the nurse to follow up? -client with distinct liver edge even with right costal margin -client with pyelonephritis who has costovertebral angle tenderness -client with rash that has purplish blotches that do not blanch -client with spinal cord injury whose toes point downward with the Babinski test

-client with rash that has purplish blotches that do not blanch --Purpura refers to reddish-purple blotches on the skin that do not blanch with pressure due to bleeding underneath the skin. Further assessment must be done to evaluate for a potentially serious etiology, such as blood dyscrasia.

The nurse receives a hand-off report from the night shift nurse. Which client should the nurse assess first? -client with anemia who began receiving a unit of packed red blood cells one hour ago -client with hemoglobin of 7 g/dL who needs to be started on IV iron therapy -client with seizure activity who received lorazepam 20 minutes ago -client with suspected leukemia scheduled for a bone marrow biopsy in 1 hour

-client with seizure activity who received lorazepam 20 minutes ago --This client is at increased risk for injury, aspiration, and airway obstruction. The nurse should obtain baseline neurological vital signs against which to compare subsequent findings and to evaluate the client's response to lorazepam. The client requires a safe environment, so the nurse should also ensure that fall and seizure precautions have been initiated. --hemoglobin of 7 g/dL is not life-threatening and many clients can tolerate this level.

The charge nurse on the medical-surgical unit must assign a room for an immediate post-operative nephrectomy client. Which room assignment is the best option for this client? -client with diabetes mellitus and CKD who is on hemodialysis and has a serum glucose level of 265 mg/dL -Client with chronic HIV infection and overwhelming fatigue who has a CD4+ cell count of 200/mm3 -Client with cellulitis of the leg due to spider bite who has a white blood cell count of 13,000/mm3 -client with severe epistaxis due to a traumatic nasal fracture who has a platelet count of 85,000/mm3

-client with severe epistaxis due to a traumatic nasal fracture who has a platelet count of 85,000/mm3 --This client does not place the immediate post-operative client at increased risk for infection. --A client with diabetes mellitus and advanced CKD may have infectious complications due to increased susceptibility to infection resulting from an altered immune response and decreased leukocyte function due to hyperglycemia.

A pediatric nurse is floated to an adult medical surgical unit. Which client assignment would be most appropriate for the pediatric nurse? -client with alcohol withdrawal who needs IV lorazepam every 2 hours -client with emphysema and an oxygen saturation of 89% on room air -client with sickle cell crisis requiring IV morphine every 2 hours -client with type 2 diabetes mellitus who needs discharge teaching

-client with sickle cell crisis requiring IV morphine every 2 hours --The most appropriate assignment for the pediatric nurse is the client with sickle cell anemia requiring IV morphine every 2 hours. Sickle cell anemia is a common disorder in children and the pediatric nurse would be familiar with the assessment, plan of care, and treatment of clients with sickle cell crisis. --alcohol withdrawal is predominantly a disease of adults. A pediatric nurse would have little experience managing clients with delirium tremens. Emphysema is a COPD not commonly seen in pediatric clients since it occurs later in life due to long-term smoking. Type 2 diabetes mellitus is increasing in incidence in the pediatric population. However, discharge teaching would be performed better by a nurse from the adult medical surgical unit who has more experience with the disease and discharge paperwork.

The night charge nurse is making assignments for the next shift. Which client is most appropriate to assign to a nurse with less than a year of experience who is floated from the orthopedic unit the medical unit? -client newly admitted for an evolving ischemic stroke -client newly diagnosed with diabetes mellitus who needs insulin administration teaching -client with exacerbation of chronic obstructive pulmonary disease with a new tracheostomy -client with sickle cell crisis who requires frequent IV opioid medication for pain

-client with sickle cell crisis who requires frequent IV opioid medication for pain --The float nurse is familiar with the policies and procedures for pain assessment and administering opioid medications, which should be the same on non-specialty units within the same facility.

The nurse receives handoff of care report on four clients. Which client should the nurse assess first? -client with Graves disease who has a heart rate of 110/min and blood pressure of 122/85 mm Hg -client with pneumonia and temperature of 101.8 F who is unable to receive antibiotics due to an occluded IV catheter -client with sickle cell disease whose pain rating has increased from 3 to 9 on a scale of 0-10 over the last hour -client with type 2 diabetes whose fingerstick glucose level is 220 mg/dL

-client with sickle cell disease whose pain rating has increased from 3 to 9 on a scale of 0-10 over the last hour --when caring for clients with sickle cell disease, it is important to observe for indicators of sickle cell crisis. Severe, acute pain is a common symptom of SCC due to impaired capillary blood flow and tissue ischemia. Without prompt recognition and intervention, vasoocclusion may lead to irreversible tissue damage and death

The night nurse receives the hand-off report on assigned clients. Which client should the nurse assess first? -client with acute kidney injury scheduled for hemodialysis in the morning has a urine output of 200 mL for the past 8 hours -client with an indwelling urinary catheter who is 1 day postoperative prostatectomy reports severe bladder spasms -client with an urethral stent placed this morning after laser lithotripsy reports burning on urination and hematuria -client with spinal cord injury requiring intermittent catheterization reports a throbbing HA and nausea

-client with spinal cord injury requiring intermittent catheterization reports a throbbing HA and nausea --Autonomic dysreflexia can occur in any individual with a spinal cord injury at or above T6. The condition causes an exaggerated sympathetic nervous system response resulting in uncontrolled hypertension. Common triggers include bladder or rectum distention and pressure ulcers. Characteristic manifestations include acute onset of throbbing HA, nausea, and blurred vision; HTN and bradycardia; and diaphoresis and skin flushing above the level of the injury. It is a medical emergency that requires immediate intervention to remove the precipitating trigger.

4 clients comes to the ER and are assessed by the triage nurse. Which client should be prioritized for more definitive care? -client with HX of gout who has severe pain in the right foot -client with HX of migraines reporting HA and photophobia -client with severe epigastric pain radiating to the back after an alcohol binge -client with sudden onset of the "worst HA of my life"

-client with sudden onset of the "worst HA of my life" --This is a classic description of a subarachnoid hemorrhage and requires emergency evaluation due to high mortality.

The nurse prepares to administer the prescribed 8 AM medications to 4 clients. The nurse should administer medication to which client first? -client 2 days postoperative abdominal surgery who is to receive enoxaprin for venous thromboembolism prophylaxis -client with hypertension who has a blood pressure of 196/98 mm Hg and is to receive IV hydralazine -client with suspected sepsis who has a temp of 102.3 F and is to receive an initial dose of IV ceftazidime -client with type 2 diabetes mellitus and blood sugar of 500 mg/dL who is to receive subcutaneous regular insulin and insulin glargine

-client with suspected sepsis who has a temp of 102.3 F and is to receive an initial dose of IV ceftazidime --Sepsis is a condition associated with a serious infection in the bloodstream. EBP guidelines recommend the early administration of antibiotic therapy to reduce mortality. Cultures should be obtained quickly and antibiotics administered as soon as possible. Failure to treat early sepsis can lead to septic shock and multiorgan dysfunction syndrome. --The client with high blood pressure needs treatment, but the condition is not life-threatening

For which client is it most important for the nurse to provide teaching on ways to prevent the spread of the condition? -client with eczema on upper torso -client with oral candidiasis -client with psoriasis on hands -client with tinea corporis

-client with tinea corporis --Tinea Corporis is a fungal infection of the skin often transmitted from one person to another or from an infected animal to human. It appears as a scaly, pruritic patch that is often circular or oval in shape. It is highly contagious and can be spread via items such as grooming tools, hats, towels, and bedding. Tinea corporis often spreads via shared athletic equipment or in athletic locker rooms due to the proximity of infected gear.

The nurse is assessing 4 clients in the ED. Which client should the nurse prioritize for care? -client with liver cirrhosis and ascites who has increasing abdominal distension and needs therapeutic paracentesis -client with new-onset asscites from a suspected ovarian mass who needs paracentesis for diagnostic studies -client with ulcerative colitis who has fever, blood diarrhea, and abdominal distension and needs an abdominal x-ray -nursing home client with dementia who has stool impaction and abdominal distension and needs stool disimpaction.

-client with ulcerative colitis who has fever, blood diarrhea, and abdominal distension and needs an abdominal x-ray --The client with ulcerative colitis who has abdominal distension, blood diarrhea, and fever likely has toxic megacolon. This is a common, life-threatening complication of inflammatory bowel disease and is seen more frequently in ulcerative colitis that in Crohn disease. Toxic megacolon can also be associated with C. difficile infection and other forms of infectious colitis. Severe colonic inflammation causes release of inflammatory mediators and bacterial products which contribute to colonic smooth muscle paralysis. Rapid colonic distension ensues, thinning the intestinal wall and making it prone to perforation. Imaging confirms the diagnosis --This client with liver cirrhosis and ascites need periodic paracentesis for relief of distension in addition to diuretics for advanced-stage disease. This client is not priority. --this client needs paracentesis for fluid cytology to evaluate for malignancy, but is not priority. --clients with dementia have decreased mobility, drink less fluid, and often take medications with anticholinergic properties. Such factors make these clients prone to severe constipation, and they often need manual disimpaction but this does not make the client priority.

A client with AIDS treated for intractable seizures is transferred from the ICU to the medical unit. There are 4 semiprivate room beds available. Which room assignment does the charge nurse choose as the best option for this client? -client with C. Diff -Client with fever of unknown origin -client with bacterial pneumonia -client with upper GI bleed

-client with upper GI bleed --this client does not place the immunocompromised client with AIDS at increased risk for infection

Which situations would prompt the healthcare team to use the client's advance directive to make a decision regarding care? SATA -client diagnosed with lumbar spinal cord compression has paraplegia -client's Glasgow Coma Scale score is 3 -client is refusing a life-saving treatment due to religious beliefs -client with intracerebral hemorrhage has aphasia -oriented client has cancer and is on a ventilator

-client's Glasgow Coma Scale score is 3 -client with intracerebral hemorrhage has aphasia --Advance directives take effect when the client is unable to speak for him/herself due to such conditions as mental incapacity. Aphasia involves the inability to express thoughts and comprehend language due to brain dysfunction and includes both verbalizing and writing

What is the scope of practice for an RN?

-clinical assessment -initial client education -discharge education -clinical judgment -initiating blood transfusion

S/S of cataract

-cloudiness of the lens -painless, gradual loss of visual acuity with blurry vision -scattered light on the lens producing glares and halos -decreased color perception

A nurse prepares to administer an intermittent enteral feeding via nasogastric tube to a client with a prescription for gastric residual checks before each feeding. The nurse obtains a gastric residual volume of 80 mL. Which action should the nurse perform next? -collect gastric pH measurement -delay feeding for atleast 1 hour -discard the gastric residual -return residual and administer feeding

-collect gastric pH measurement --Before administering intermittent enteral feedings, the nurse must verify tube placement, such as with x-ray confirmation or gastric pH measurement. Ensuring that the top of the feeding tube is correctly placed in the stomach or small intestine is essential because administration of enteral feeding through a misplaced tube may result in life-threatening aspiration. Gastric residual volume is one indicator of how well the client is tolerating enteral feedings. High GRV may indicate delayed gastric emptying and poor intestinal motility, which is traditionally considered a risk factor for aspiration. The nurse should follow facility policy or contact the HCP to determine if feedings should be delayed for high GR or other symptoms of intolerance.

A client with diabetes receiving peritoneal dialysis experiences chills and abdominal discomfort. The nurse assesses the client's abdomen by pressing one hand firmly on the abdominal wall. The client experiences pain when the nurse quickly withdraws the hand. The client's most recent blood glucose level is 210 mg/dL. What is the priority action by the nurse? -collect peritoneal fluid for culture and sensitivity -heat the remaining dialysate fluid and increase the dwell time -place the client in high Fowler's position -prepare to administer regular insulin intravenously

-collect peritoneal fluid for culture and sensitivity --Peritonitis is a common but serious complication of peritoneal dialysis that typically occurs as a result of contamination during infusion connections or disconnections. Typically, the earliest indication of peritonitis is the presence of cloudy peritoneal effuent. Later manifestations include low-grade fever, chills, generalized abdominal pain, and rebound tenderness. To detect rebound tenderness, one hand is pressed firmly into the abdominal wall and quickly withdrawn. Rebound tenderness is present when there is pain on removal, indicating inflammation of the peritoneal cavity. The nurse should collect peritoneal effuent from the drainage bag for culture and sensitivity. Treatment of peritonitis is antibiotic therapy based on the culture results. Antibiotics may be added to dialysate, given orally, or administered intravenously.

Which of these tasks are appropriate for the RN to delegate to the UAP? SATA -assign lunch times to the other UAP on the unit -assist a client with a new ostomy with bathing and changing pouches -collect vital signs on a client 4 hours after laparoscopic appendectomy -pick up an intravenous antibiotic from the pharmacy -record intake and output for a client with metabolic alkalosis

-collect vital signs on a client 4 hours after laparoscopic appendectomy -pick up an intravenous antibiotic from the pharmacy -record intake and output for a client with metabolic alkalosis --Client care that involves any part of the nursing process can never be delegated to the LPN or UAP. The UAP can assist with basic care activities and collect data for stable clients. The RN is ultimately accountable for the care provided by the UAP.

A client is admitted with a lower urinary tract infection from an obstructing ureteral stone. Which tasks can the RN delegate to the experienced UAP? SATA -assisting the client is completing a health history form -collecting a urine specimen for culture and sensitivity -instructing the client to strain urine when voiding -measuring and documenting urine output -monitoring the color and characteristics of urine output

-collecting a urine specimen for culture and sensitivity -measuring and documenting urine output

The male client had a hemiclectomy. The client is refusing to wear the prescribed sequential compression devices. What is most important for the nurse to communicate to the client? -an appropriate form must be signed, verifying refusal -complications, including death, could result -the client will be billed for the equipment regardless -the surgeon will be informed of the refusal

-complications, including death, could result --Just as there is informed consent, there is informed refusal. The client should be made aware of all the possible complications when making a decision, and this should be documented. The nurse should try to work with the client to get at least partial compliance when it is in the client's best interest.

While receiving prenatal records with a client and her partner, the nurse notes documentation in the medical record indicating that the client is G2P0. However, the client denies a previous pregnancy. Which action by the nurse is appropriate? -adjust documentation to indicate that the client is a G1P0 -ask the client and partner about a previous miscarriage or abortion -confirm the obstetric history when the client is alone -explain the importance of accurate information to the client and partner

-confirm the obstetric history when the client is alone --The nurse should be cautious of discussing obstetric history with a client in front of the partner or family and not assume that others have knowledge of the client's past pregnancies. If there is a discrepancy between what the client discloses in the interview and the medical record, the information should be clarified when the client is alone to maintain confidentiality.

A client on a medical-surgical unit is receiving heparin therapy. Platelet levels decreased from 230,000/mm3 2 days ago to 80,000/mm3 today. Which nursing actions are appropriate? SATA -confirm validity of platelet result with new blood specimen -hold the scheduled morning dose of heparin -notify the HCP of the platelet count -obtain a full set of vital signs -request change of prescription for heparin to enoxaparin

-confirm validity of platelet result with new blood specimen -hold the scheduled morning dose of heparin -notify the HCP of the platelet count -obtain a full set of vital signs ---The nurse should suspect heparin-induced thrombocytopenia in a client who is receiving or has recently received heparin and has a sudden reduction of >50% in platelet count. The nurse should stop heparin immediately, assess vital signs and neurovascular status, draw blood for repeat testing, and report findings to the HCP. Clients who are suspected of having HIT or who have a history of HIT should never receive heparin or low-molecular-weight heparni. Only non-heparin anticoagulants may be given

S/S of infant botulism

-constipation -difficulty feeding -decreased head control -diminished deep tendon reflexes

What should the nurse assess for before administering kayexalate?

-constipation -signs of impaction -recent bowel patterns

A nurse is preparing to administer 2 continuous IV medications concurrently via a 20-gauge IV. What is the nurse's priority action? -assess the condition of the IV site -check 2 client identifiers before administering medications -consult a medication guide for compatibility -wash hands prior to administering medications

-consult a medication guide for compatibility --The priority when administering 2 IV medications concurrently is to determine drug compatibility. Incompatible drugs given through the same IV line will deteriorate or form a precipitate. This change is visualized through either a color change, a clouding of the solution, or the presence of particles. If 2 or more drugs are not compatible, the nurse may consider inserting a second IV or consulting the pharmacists and the healthcare provider to determine the safest and most beneficial plan for the client.

The nurse learns that an Orthodox Jewish client has not started taking recently prescribed diltiazem extended-release capsules. The client states "I cannot take the medication in this form." What is the nurse's first action? -ask the healthcare provider to prescribe a different CCB -consult with the pharmacist to see if an alternate form of the drug is available -open the capsule and sprinkle the medication in a cup of applesauce -warn the client about the dangers of uncontrolled hypertension

-consult with the pharmacist to see if an alternate form of the drug is available ---Members of the Orthodox Jewish faith observe strict dietary laws that dictate whether certain foods and medications are considered kosher. Most capsules are created in gelatin, a substance made from the collagen of animals, which is generally considered nonkosher. The nurse should first ask the pharmacist if an equivalent, gelatin-free form of the medication is available. If no alternate form is available, the client may want to consult with a rabbi as laws may be relaxed for those who are ill.

Which of these instructions is appropriate teaching for a 60-year-old woman? SATA -consume adequate sources of calcium and vitamin D and take supplements -increase intake of food sources of iron and take supplements -observe for unilateral leg swelling when taking hormone replacement therapy -remain upright for 30 minutes when taking a bisphosphonate -vaginal spotting after menopause is a common, insignificant sign of aging

-consume adequate sources of calcium and vitamin D and take supplements -observe for unilateral leg swelling when taking hormone replacement therapy -remain upright for 30 minutes when taking a bisphosphonate --A postmenopausal woman is at risk for osteoporosis and heart disease. Clients should remain upright after taking a bisphosphonate and consume calcium and vitamin D for bone health. Clotting disorder is a risk with HRT. Intermittent vaginal spotting after menopause can be a sign of endometrial cancer. Anemia in older adults is usually not related to lack of iron intake, especially once menstruation has stopped. Excessive iron intake can lead to iron overload, and the risk of excess iron tends to be higher with aging.

Self-care for Meniere disease

-consuming a low-sodium diet to decrease the potential for fluid excess within the inner ear. -limiting/avoiding aggravating substances and stimuli -adhering to prescribed therapies for relief of symptoms -avoiding sudden changes in the position of the head -participating in vestibular rehabilitation therapy -Implementing safety measures during attacks

The nurse is feeding a confused client via a small-bore nasoenteric tube. The nurse observes the client pulling at the tube and then notices an increase in external tube length from the original exit mark. After immediately stopping the feeding, which action is appropriate for the nurse to take next? -advance the tube to the original exit mark, check gastric aspirate pH, and resume feeding -contact the HCP to request a prescription for hand mitts -contact the HCP to request an x-ray to verify tube placement -reinsert the guide wire and advance the tube to its original exit mark

-contact HCP to request an x-ray to verify tube placement --A feeding tube is marked with indelible ink at the exit site (nare). If the external length of the tube changes, the nurse should contact the HCP and request a prescription for a repeat x-ray to determine tube location before resuming administration of enteral feedings and medications. Even if bedside methods to determine placement are used (gastric aspirate pH and appearance) advancing the tube to the original marking does not guarantee correct placement. Tube feedings should not be resumed after tube dislodgment without x-ray verification. A prescription for hand mitts to keep a confused client from disrupting enteral nutrition may be appropriate if other less restrictive interventions are ineffective or unavailable. Once removed, the guide wire should never be reinserted while the tube is in place as it can protrude and damage both the tube and the client's mucosa

The nurse prepares to administer an IV infusion of potassium chloride through a peripheral vein to a client with hypokalemia. The health care provider's prescription states: IV potassium chloride 10 mEq/100 mL 5% dextrose in water now, infuse over 30 minutes. What is the nurse's priority action? -assess the patency of the peripheral IV site -check the most current serum potassium level -contact the healthcare provider to verify the prescription -set the electronic IV pump to 100 mL/hr

-contact the healthcare provider to verify the prescription\ --The recommended rates for an intermittent IV infusion of potassium chloride are no greater than 10 mEq over 1 hour when infused through a peripheral line and no greater than 40 mEq/hr when infused through a central line. If the nurse were to administer the medication as prescribed, the rate would exceed the recommended rate of 10 mEq/hr over 30 minutes = 20 mEq/hr. A too rapid infusion can lead to pain and irritation of the vein and postinfusion phlebitis. Contacting the healthcare provider to verify this prescription is the priority action.

S/S of acute appendicitis

-continuous pain that begins in the periumbilical region and then moves to the right lower quadrant centering at McBurney's point -anorexia, N/V -rebound tenderness and guarding

Treatment of tumor lysis syndrome

-continuous telemetry -aggressive electrolyte monitoring/treatment

Inappropriate use of indwelling urinary catheters

-convenience or replacement for nursing care when the client is elderly, confused, incontinent, or voids frequently -for obtaining a urine culture when the client can follow instructions and void voluntarily -postoperatively for prolonged periods when other appropriate indications are not present

Growth and development of 3 year old

-copies a circle -builds bridge with 3 cubes -undresses without help -900 word vocab -uses sentences

What clients is sumatriptan contraindicated?

-coronary artery disease and uncontrolled HTN --it can cause HTN urgency, angina, decreased cardiac perfusion, and acute myocardial infarction

Characteristic features of pertussis

-cough that lasts more than 2 weeks with one or more symptoms: -paroxysms of cough -inspiratory whooping sounds -posttussive vomiting

Interventions involved in the rehabilitation phase of burns

-counseling or other psychosocial support -gentle massage with water-based lotion to alleviate itching and minimize scarring -planning for reconstructive surgery -Pressure garments to prevent hypertrophic scars and promote circulation -range-of-motion exercises to prevent contractures -sunscreen and protective clothing to prevent sunburns and hyperpigmentation

What are expected findings during assessment of a client with pneumonia

-crackles -increase tactile/vocal fremitus -unequal chest expansion -bronchial breath sounds in peripheral areas --clients often report fever, chills, productive cough, dyspnea, and pleuritic chest pain

10 month growth and development

-crawls well -pulls self to standing position with support -brings hands together -vocalizes on or two words

Which group of food selections would be the best choice for a client advancing to a full liquid diet 3 days after bariatric surgery? -apple juice, mashed potatoes, chocolate pudding -chicken broth, low-fat cheese omelet, strawberry ice cream -creamy wheat cereal, blended cream of chicken soup, protein shake -low-fat vanilla yogurt, smooth peanut butter, vegetable juice

-creamy wheat cereal, blended cream of chicken soup, protein shake --Bariatric surgery reduces stomach capacity. A client's bariatric postoperative diet is restricted to foods that are low in simple carbohydrates and high in nutrients. After gastric surgery, consumption of simple carbohydrates can lead to dumping syndrome. The client will tolerate only small meals of clear liquids at first, advance to full liquids 24-48 hours after surgery and then progress gradually to solid foods as the gastrointestinal tract heals. Small, frequent meals are recommended to avoid overstretching of the pouch and to prevent N/V and regurgitation. The best food choices for a bariatric full liquid diet are cream soups, refined cooked cereals, sugar-free drinks, and low-sugar protein shakes and dairy foods.

A nurse is preparing a presentation about behavioral modifications to support weight loss for clients at an obesity clinic. Which of the following points should the nurse include in the teaching plan? SATA -avoid social gatherings that occur in restaurants or around meals -create multiple small goals with rewards for achievement -identify a list of desired outcomes not directly related to weight loss -perform anxiety-reducing activities rather than using food to cope with stress -utilize visual cues such as motivational quotes to encourage positive behavior

-create multiple small goals with rewards for achievement -identify a list of desired outcomes not directly related to weight loss -perform anxiety-reducing activities rather than using food to cope with stress -utilize visual cues such as motivational quotes to encourage positive behavior --avoiding social activities in a food setting promotes isolation and negative perceptions. Clients who struggle to make healthy choices in these settings should plan ahead for what will be eaten or bring a separate meal.

The nurse reviews the serum laboratory results of a client who was seen in the clinic 2 days ago for worsening joint pain from a flare of systemic lupus erythematosus. Which result is of greatest concern and prompts the nurse to notify the healthcare provider? -creatinine of 1.8 mg/dL -elevated erythrocyte sedimentation rate -positive antinuclear antibody titer -white blood cell count of 3,600/mm3

-creatinine of 1.8 mg/dL --increased creatinine, BUN, and abnormal urinalysis can indicate the presence of lupus nephritis, a potentially serous complication of SLE. Early recognition and aggressive immunosuppressive treatment are essential to preserve renal function and prevent irreversible kidney damage. An elevated erythrocyte sedimentation rate can indicate the presence of an active inflammatory process and would be expected in a client with an inflammatory disease such as SLE, especially during a disease flare. A positive antinuclear antibody titer indicates the presence of AAs, which the body produces against it own DNA and nuclear material. This would be expected in a client diagnosed with SLE. Anemia, mild leukopenia, and thrombocytopenia are often present in SLE

The nurse is providing handoff-of care report to the oncoming nurse for a client admitted with pneumonia that morning. Which information is most important for the nurse to communicate about the client during handoff report? - chest x-ray showed lung infiltrates; WBC count is 14,000/mm3 -client's spouse was acting rudely toward the nurse earlier -current respirations are 24/min; pulse oximetry is 93% on 2 L/min -intravenous line is infusing with no signs of infiltration

-current respirations are 24/min; pulse oximetry is 93% on 2 L/min --Handoff report should include objective information related to the client's current condition. It is especially important to include baseline measurements that may not be documented in the medical record so that the oncoming nurse can prioritize care.

The nurse is caring for a client with a balloon tamponade tube in place due to bleeding esophageal varices. The client suddenly develops respiratory distress, and the nurse finds that the tube has been partially pulled out. Which intervention should be the nurse's priority? -contact the HCP -cut the tube with scissors -increase gastric suction level -place the client in high Fowler position

-cut the tube with scissors --A balloon tamponade tube (Sengstaken-Blakemore or Minnesota) is used to temporarily control bleeding from esophageal varices. It contains 2 balloons and 3 lumens. The gastric lumen drains stomach contents, the esophageal balloon compresses bleeding varices above the esophageal sphincter, and the gastric balloon compresses from below. A weight is attached to the external end of the tube to provide tension and hold the gastric balloon securely in place below the esophageal sphincter. Airway obstruction can occur if the balloon tamponade tube becomes displaced and a balloon migrates into the oropharynx. Scissors are kept at the bedside as a precaution; in the event of airway obstruction, the nurse can emergently cut the tube for rapid balloon deflation and tube removal.

What disorders follow the autosomal recessive inheritance pattern?

-cystic fibrosis -phenylketonuria -Tay-Sachs disease -sickle cell disease

A client with a blood pressure of 250/145 mm Hg is admitted for hypertensive crisis. The healthcare provider prescribes a continuous IV infusion of nitroprusside sodium. Which of these is the priority goal in initial management of hypertensive crisis? -decrease mean arterial pressure by no more than 25% -keep blood pressure at or below 120/80 mm Hg -maintain heart rate of 60-100/min -maintain urine output of at least 30 mL/hr

-decrease mean arterial pressure by no more than 25% --Hypertensive crisis is a life-threatening emergency due to the possibility of severe organ damage. If not treated promptly, complications such as intracranial hemorrhage, heart failure, myocardial infarction, renal failure, aortic dissection, or retinoathy may occur. Emergency treatment includes IV vasodilators such as nitroprusside sodium. It is important to lower th blood pressure slowly, as too rapid a drop may cause decreased perfusion to the brain, heart, and kidneys. This may result in stroke, renal failure, or MI. The initial goal is usually to decrease the MAP by no more than 25% or to maintain MAP at 100-115 mm Hg. The pressure can then be lowered further over a period of 24 hours. MAP is calculated by adding the systolic blood pressure and double the diastolic blood pressure, and then dividing the resulting value by 3. A blood pressure of 120/80 mm Hg is too low for an initial goal and could result in organ damage.

The nurse provides education for caregivers of a client with Alzheimer disease. Which instructions should the nurse include? SATA -complete activities such as bathing and dressing as quickly as possible -decrease the client's anxiety by limiting the number of choices offered -redirect the client if agitated by asking for help with a task or going for a walk -remember to interact with the client as an adult, regardless of childlike affect -use open-ended questions when communicating with the client

-decrease the client's anxiety by limiting the number of choices offered -redirect the client if agitated by asking for help with a task or going for a walk -remember to interact with the client as an adult, regardless of childlike affect --Caregivers for clients with Alzheimer disease should communicate with the client using yes or no questions and simple, step-by-step instruction; treat the client as an adult; limit the number of choices; and allow plenty of time for task completion. Agitated clients can be redirected with new activities.

Clinical manifestations of DI

-decreased urine specific gravity -elevated serum osmolality -hypernatremia -hypovolemia and potential hypotension -polydipsia -polyuria

Clinical manifestations associated with diabetes insipidus

-decreased urine specific gravity -increased serum osmolality -polydispsia -hypernatremia -hypovolemia -potential hypotension -polyuria

The nurse is assigned to care for a hospitalized confused client with an indwelling urinary catheter. On entering the client's room, the nurse notes the client pulling at the catheter and grimacing in pain. Blood is trickling from the client's meatus and the urine in the drainage bag is pink. Which action should the nurse take first? -collect a urine specimen and send to the lab -deflate the balloon on the urinary catheter -remove the catheter by gently pulling from the urethra -use a sterile 4X4 pad to absorb the blood around the meatus

-deflate the balloon on the urinary catheter --Because signs of traumatic injury are present, the nurse should follow steps to remove the catheter before further complications such as obstruction occur. A urine specimen can be collected after the balloon is deflated or after the catheter is removed if needed. The meatus should be cleaned after balloon deflation.

The nurse is discharging a client with emphysema who is on continuous oxygen. The case manager alerts the nurse that the home oxygen will not be delivered until 2 hours later. What action should the nurse take? -ask if the client can go without the oxygen for 2 hours -delay discharge until the oxygen is delivered -notify the HCP to see what action should be taken -send a hospital oxygen tank home with the client

-delay discharge until the oxygen is delivered --a client should not be allowed to leave until essential home supplies and equipment have been made available for a safe discharge.

What are examples of diagnostics medical errors?

-delay in diagnosis -failure to employ indicates tests -failure to act on results of monitoring

S/E associated with methylphenidate

-delayed growth and development -increased blood pressure --affects dopamine and norepinephrine levels

What is the typical injection site for intramuscular injections?

-deltoid -vastus lateralis -ventrogluteal

What does St. John's wart treat? Symptoms it may cause?

-depression -can cause HTN and serotonin syndrome when taken with other antidepressants

The nurse observes a client who is postoperative left total knee replacement use a cane. Which action by the client indicates an understanding of the correc technique when walking down the stairs? -descends with the cane on the step first, followed by the left leg, and then the right leg -descends with the cane on the first step, followed by the right leg, and then the left leg -descends with the left leg on the step first, followed by the cane, and then the right leg -descends with the right leg on the first step, followed by the left leg, and then the cane

-descends with the cane on the step first, followed by the left leg, and then the right leg --To prevent falls when descending the stairs using a cane, the client should lead with the cane, follow with the weaker leg, and then step down with the stronger leg.

medications used for enuresis in children greater than 5 years of age

-desmopressin (reduces urine production during sleep) -tricyclic antidepressant (help improve bladder capacity)

A client with a T4 spinal cord injury has a severe throbbing headache and appears flushed and diaphoretic. Which priority interventions should the nurse perform? SATA -administer an analgesic as needed -determine if there is bladder distension -measure the client's blood pressure -place the client in the Sims' position -remove constrictive clothing

-determine if there is bladder distension -measure the client's blood pressure -remove constrictive clothing --Clients with a high (T6 or above) spinal cord injury are at risk for autonomic dysreflexia. It is an uncompensated sympathetic nervous system stimulation. Classic signs include hypertension, throbbing headache, diaphoresis above the level of injury, bradycardia, ploerection, flushing, and nausea. This is life-threatening condition that requires immediate intervention to prevent complications. Clients with a spinal cord injury should have their blood pressure checked when they report a headache, The most common cause of autonomic dysreflexia is bladder irritation due to distension. The client needs to be catheterized or the possibility of a kink in the existing catheter must be assessed. Bowel impaction can also be a cause; a digital rectal examination should be performed. Constrictive clothing should be removed to decrease skin stimulation. --HAs associated with autonomic dysreflexia are typically due to severe hypertension and often resolve after blood pressure has been treated. --the client should have the head of the bed elevated 45 degrees or higher Fowlers to lower blood pressure. The Sims' position is flat and side-lying.

Priority nursing actions when caring for a client who recently experienced sexual assault

-determine whether the client has bathed, showered, or douched -educate victim on recommendation for a pelvic exam to collect evidence -obtain date of last menstrual period and current method of birth control -perform head-to-toe assessment to identify physical injuries -thoroughly document all injuries on a body map -provide prophylactic therapies for sexually transmitted infections and pregnancy.

S/S of primary open-angle glaucoma

-develop slowly -painless impairment of peripheral vision -normal central vision - difficulty with vision in dim light -increased sensitivity to glare -halos observed around bright lights

Priority concerns for clients with cystic fibrosis

-development of respiratory infections -chronic hypoxemia -nutritional deficiencies -abnormal growth (FTT)

What is the positive outcome of the 4th stage of Erickson's developmental tasks? --task?

-develops a sense of confidence; uses creative energies to influence the environment --demonstrates feelings of inadequacy, mediocrity, and self-doubt

What are some examples of hypertonic solutions?

-dextrose 5% and 0.9% NaCl -5% dextrose and lactated ringer -colloid solutions (dextran, albumin

There has been a major community disaster. Stable clients need to be discharged to make more beds available for the victims. Which clients could be discharged safely? SATA -diagnosed with endocarditis on antibiotics with a PICC line -history of multiple sclerosis with ataxia and diplopia -one day postoperative form a hemicolectomy -reporting abdominal pain with coffee ground emesis -taking warfarin with PT/INR 2X control value

-diagnosed with endocarditis on antibiotics with a PICC line -history of multiple sclerosis with ataxia and diplopia -taking warfarin with PT/INR 2X control value --These clients are all stable and are experiencing typical symptoms. Large intestine peristalsis does not return for up to 3-5 days after hemicolectomy. This client cannot be discharged until they are able to tolerate oral intake with normal elimination. Coffee ground emesis indicates upper GI bleeding. Etiology and treatment need to be determine before the client is discharged.

symptoms of dumping syndrome

-diaphoresis -cramping -weakness -diarrhea within 30 minutes of eating

examples of anticholinergic medications

-dicyclomine -hydrochloride -oxybutynin -solifenacin

The nurse is assessing a client with advanced amyotrophic lateral sclerosis. Which of the following assessment findings does the nurse expect? SATA -diarrhea -difficulty breathing -difficulty swallowing -muscle weakness -resting tremor

-difficulty breathing -difficulty swallowing -muscle weakness --Amyotrophic lateral sclerosis is a debilitating neurodegenerative disease with no cure. ALS causes progressive degeneration of motor neurons in the brain and spinal cord. Physical symptoms include fatigue, progressive muscle weakness, twitching and muscle spasms, difficulty swallowing, difficulty speaking, and respiratory failure. Most clients survive only 3-5 years after the diagnosis as there is no cure.

A client is diagnosed with a small thoracic aortic aneurysm during a routine chest x-ray and follows up 6 months later with the HCP. Which assessment data is most important for the nurse to report to the HCP? -blood pressure of 140/86 mm Hg -difficulty swallowing -dry, hacking cough -low back pain

-difficulty swallowing --Difficulty swallowing is the most important symptom to report to the HCP. A thoracic aortic aneurysm can put pressure on the esophagus and cause dysphagia. The development of this symptom may indicate that the aneurysm has increased in size and may need further diagnostic evaluation and treatment. --low back pain would be a concern if the client had a hx of abdominal aortic aneurysm.

A client admitted with acute myocardial infarction suddenly displays air hunger, dyspnea, and coughing with frothy, pink-tinged sputum. What would the nurse anticipate when auscultating the breath sounds of this client? -bronchial breath sounds at lung periphery -clear vesicular breath sounds at lung bases -diffuse bilateral crackles at lung bases -stridor in upper airways

-diffuse bilateral crackles at lung bases --Acute-onset dyspnea and cough productive of pink, frothy sputum indicate severe pulmonary edema, likely a complication from myocardial infarction. Pink sputum results from ruptured bronchial veins due to high back pressure. The mix of blood and airway fluids creates the pink tinge. On assessment, crackles can be heard at the lung bases.

What are some signs of aspiration pneumonia?

-diminished or adventitious lung sounds (crackles, wheezing) -dyspnea -productive cough

Which interventions does the nurse perform to promote normal rest and sleep patterns for a critically ill client? SATA -dimming the lights at night -increasing the level of continuous IV sedation during nighttime hours -leaving the television on for diversion at night -opening the window blinds/shades in the morning -scheduling interventions and activities during the day when possible -turning off equipment alarms in the client's room at night

-dimming the lights at night -opening the window blinds/shades in the morning -scheduling interventions and activities during the day when possible --it is important to maintain the client's normal circadian rhythms in the ICU. Interventions that help to maintain the normal sleep-wake cycle include dimming the lights at night, providing quiet and uninterrupted periods of sleep when possible, scheduling interventions and activities during the day, frequently reorienting the client as necessary, and opening the shades in the morning. Excessive stimuli and lack of sleep can predispose the client to delirium. Continuous IV sedation, if indicated, should be given at the lowest dose adequate for pain management. Unless the client is awake and chooses to have the television turned on, this extra stimulus is disruptive to sleep. Turning the alarms off in the client's room would pose a risk to safety, as the nurse may not be alerted to a change in condition or equipment failure. If possible, alarm parameters should be adjusted according to the client's routine to prevent unnecessary awakening.

The nurse is teaching a parent of an infant about administration of an oral medication. What should be included in the teaching? SATA -add the medication to the bottle of formula before feeding -direct liquid medication toward the inside of the infant's cheek -hold the infant in a semi-reclining position during administration -measure and administer the medication using an oral syringe -open the infant's mouth by gently pinching the nose shut

-direct liquid medication toward the inside of the infant's cheek -hold the infant in a semi-reclining position during administration -measure and administer the medication using an oral syringe --Giving oral medications to infants requires specialized techniques for safe administration. A plastic, disposable oral syringe can be used for accurate dosing and ease of delivery. Oral medication should be administered with the infant in a semi-reclining position, which is similar to the feeding position. This position promotes comfort, prevents aspiration, and may be better controlled by the nurse if the infant resists the medication. Liquid medications administered by oral syringe should be directed toward the back and inside of the infant's cheek. The medication should be dispensed slowly in small amounts, allowing the infant to swallow between squirts to prevent aspiration. Medications are never mixed in a bottle of infant formula as this can affect the taste and the infant may then refuse the formula in the future. Pinching the nose shut during medication administration may cause aspiration. The infant's mouth should be opened by applying gentle pressure to the chin or cheeks.

The nurse is giving a presentation at a community health event. The nurse should provide which instruction on how to prevent botulism? -boil water if unsure of its source -discard canned food with a bulging end -keep milk cold -wash hands

-discard canned food with a bulging end --Botulism is caused by the GI absorption of the neurotoxin produced by Clostridium botulinum. The neurotoxin blocks acetylcholine at the neuromuscular junction, resulting in muscle paralysis. The organism is found in the soil and can grow in any food contaminated with the spores. Manifestations include descending flaccid paralysis, dysphagia, and constipation. The main source is improperly canned or stored food. A metal can's swollen/bulging end can be caused by the gases from C botulinum and should be discarded. The infant form of botulism can occur in children under age 1 year if they eat honey, particularly raw honey. The immature gut system in these children makes them more susceptible.

The nurse is caring for a client with bacterial meningitis, identified as Neisseria meningitidis who has a stage 4 pressure injury. What personal protective equipment is most appropriate for the nurse to wear when performing a dressing change? SATA -disposable gown -face shield -gloves -N95 respirator -surgical mask

-disposable gown -face shield -gloves -surgical mask --Bacterial meningitis and many respiratory illnessesare transmitted through large droplets of secretions spread into the air by coughing, sneezing, or talking. These droplets can land on surfaces up to 6 feet away from the client. Droplet precautions for routine care require the use of a surgical mask, as the highest risk of transmission is through inhalation of droplets. Wearing a face shield, gown, and gloves is required if there is a risk of splash or contact with body fluids from procedural client care. Dedicated medical equipment should remain in the room to limit spread of infection. For client care involving airborne precautions, a class N95 or higher respirator must be used instead of a surgical mask to avoid potential exposure to aerosolized particles. Surgical masks are rated only for barrier protection from droplet splashing and for filtration of large respiratory particles

S/S associated with Hirschsprung disease

-distended abdomen -inability to pass meconium within 24-48 hrs -difficulty feeding -green bile vomit

Characteristics of Fifth disease

-distinctive red rash on cheeks ("slapped face"), eventually travels to the extremities -general malaise -joint pain

What are the most significant manifestations of hyperkalemia?

-disturbances in cardiac conduction -development of potentially life-threatening cardiac dysrhythmias

What medications do NSAIDs decrease effectiveness?

-diuretics -blood pressure meds --therefore NSAIDs should not be taking if the client has medications for HTN

Common SE of tricyclic antidepressants

-dizziness -drowsiness -dry mouth -constipation -photosensitivity -urinary retention -blurred vision

Education for long-term corticosteroid use

-do not abruptly discontinue (can lead to Addisonian crisis) -report S/S to HCP (infection) -increase dose during times of stress -report S/S of hyperglycemia (increased urine/hunger/thirst) -maintain a diet high in calcium/protein and low in fats/simple carbs -see optomotrist yearly (d/t risk of cataracts) -eat before taking corticosteroids (can cause gastric irritation) -recognize S/S of Cushing Syndrome and report to HCP -develop a regular exercise program

During change-of-shift report, the nurse going off duty notes that the nurse coming on has an alcohol smell on the breath and slurred speech. What actions are most important for the nurse to take? SATA -do not continue the handoff report with the oncoming nurse -document the incident according to facility policy -notify the charge nurse -say nothing but watch for impaired behavior -tell the oncoming nurse that he/she is not fit for duty

-do not continue the handoff report with the oncoming nurse -document the incident according to facility policy -notify the charge nurse --an impaired nurse cannot safely give care regardless of the reason for impairment. If impairment is suspected, the nurse has a duty to take action that will both protect the client and ensure that the impaired individual receives assistance. The charge nurse should be notified, the incident documented, and the nurse not allowed to give care while impaired. Confronting the impaired nurse in a hostile manner does nothing to protect the client and offers no support to the nurse. Confrontation may be necessary if the client is in immediate danger.

The nurse is drawing blood from a client's peripheral vein for laboratory specimens. Which of the following are correct nursing actions? SATA -do not leave the tourniquet on more than 1 minutes while looking for a vein -draw the specimen while the skin is still wet with the alcohol prep -if pulsating red blood is noted, withdraw the needle and apply pressure for 5 minutes -use a highly visible vein on the ventral side of the client's wrist -vigorously shake the specimen tube to mix obtained blood with anticoagulant solution

-do not leave the tourniquet on more than 1 minutes while looking for a vein -if pulsating red blood is noted, withdraw the needle and apply pressure for 5 minutes ---When performing phlebotomy for a laboratory specimen, allow the cleansed area to air dry, do not use the veins on the ventral side of write (due to risk for nerve injury and risk of arterial access), position the tourniquet for no more than 1 minute at a time, and invert the tube gently 5-10 times to mix the solution with blood. Insertion in an artery will cause pulsation; if this happens, immediately remove the needle and apply pressure for 5 minutes.

The nurse caring for a client in the ICU reports a critical lab value of 120,000/mm3 platelets, decreased from 300,000/mm3 on admission. The HCP says this is normal. The client is receiving heparin injections. Which nursing action would be the most appropriate? -contact the appropriate certification and licensing board -document the exchange in the chart -report the incident to the hospital's legal team -report the incident to the state medical board.

-document the exchange in the chart --When in doubt of a clinician's judgment, the nurse should document these objections and report to the nursing supervisor.

A nurse educator is developing materials for a hospital-wide campaign about zero tolerance for lateral violence and bullying among staff. Which actions will the nurse educator include in teaching about what staff members do if they experience workplace violence? SATA -document the interactions with the bully -ignore the bully's comments, remarks, and allegations -observe interactions between the bully and other colleagues -report the violent incidents to the hospital administrator -tell the bully you will not tolerate the unprofessional behavior

-document the interactions with the bully -observe interactions between the bully and other colleagues -tell the bully you will not tolerate the unprofessional behavior --Lateral violence in the workplace should not be tolerated or ignored. Victims can take action against bullying, including documenting and reporting incidents, standing up to the bully in a professional way, and seeking support. The chain of command should be followed when reporting of lateral violence. If the immediate supervisor takes no action, the employee can move up the chain.

A client with metastatic esophageal cancer says, "I don't want to be kept alive being fed by a tube." What are the most appropriate ways for the nurse to ensure that this information is available to all who may need it for future decision-making? SATA -document this communication in the EMR -encourage the client to discuss this decision with the healthcare proxy -facilitate completion of an advance directive that reflects the client's decision -obtain a signed informed consent from the client -tell the HCP that the client needs a DNR order

-document this communication in the EMR -encourage the client to discuss this decision with the healthcare proxy -facilitate completion of an advance directive that reflects the client's decision --An advanced directive is used to communicate a client's wishes when the client is not able to communicate them him/herself. The nurse can advocate for the client by ensuring that expressed wishes are communicated in the advance directive and medical record and by encouraging the client to share this information with the appointed health care proxy.

nursing considerations after seizure

-document timing and symptoms -remain with client -perform neurological assessment -assess for physical injury

The nurse is contributing to the plan of care for a client who has active varicella with open, moist lesion. Which of the following actions are appropriate to include in the plan of care? SATA -don gown, gloves, and N95 respirator when entering the client's room -ensure that pregnant staff members are not assigned to care for this client -place single-use, disposable thermometer and stethoscope in the room -place the client in a private room with negative air pressure -request discontinuation of isolation precautions once all lesions are dry and crusted.

-don gown, gloves, and N95 respirator when entering the client's room -ensure that pregnant staff members are not assigned to care for this client -place single-use, disposable thermometer and stethoscope in the room -place the client in a private room with negative air pressure -request discontinuation of isolation precautions once all lesions are dry and crusted. Varicella-zoster virus is transmitted through airborne particles or contact with open vesicles. For chickenpox and disseminated shingles, the nurse should use precautions for both airborne isolation and contact isolation until vesicles have crusted.

There has been an explosion at a local chemical plant. A private car arrives at the emergency department with 4 victims whose clothes are saturated with a strong-smelling liquid. The victims are wheezing. The nurse should implement which intervention first? -assessing the clients' respiratory systems -decontaminating the clients -donning personal protective equipment -providing oxygen by nasal cannula

-donning personal protective equipment --The nurse should always protect other clients, staff, and the healthcare facility first in a chemical contamination. Personal protective equipment should be put on before decontamination. Victims should be decontaminated outside the facility before care is administered

A nurse is caring for a homeless client who is moderately malnourished and suffering from pneumonia. The client needs a peripheral IV line for fluid administration. Which IV site should the nurse select to reduce the risk for infection? -antecubital fossa -dorsal surface of hand -dorsum of foot -lateral surface of wrist

-dorsal surface of hand --Clients most at risk for catheter-related bloodstream infections are those with compromised immune systems; therefore, this client is at high risk. The IV site chosen for catheter insertion can influence the infection risk. The risk is higher using the lower extremities compared to the upper extremities and using the wrist or upper arm compared to the hand. Unless the client is very old or very young, the hand is a good site as it is most distal, allowing future sites to be selected higher on the arm if needed. The antecubital fossa is commonly selected in emergency situations due to its size and ease of cannulation but is problem prone for longer-term needs as it is in the bend of the elbow. Bending of the arm can move the catheter, causing irritation at the insertion site and increasing infection risk. The foot is not typically accessed in adults without a specific healthcare provider prescription. It is occasionally used in emergency situations; however,veins in the legs and feet may have decreased venous return, and complications can lead to thrombophlebitis or deep vein thrombosis. The radial vein is present on the later side of the wrist but is in close proximity to several nerves, which could cause severe pain or nerve damage.

5 year old growth and development

-dresses without help -beginnings of cooperative play -gender-specific behavior -skips on alternate feet -ties shoes

Client education for allopurinol

-drink a full glass of water with each dose -increase overall fluid intake

A client with a history ofmdiverticular disease is being discharged after an episode of acute diverticulitis. Which instructions should be included in the discharge teaching plan to reduce the risk of future episodes? SATA -drink plenty of fluids -exercise regularly -follow a low-residue diet -include whole grains, fruits, and vegetables in the diet -increase intake of red meat

-drink plenty of fluids -exercise regularly -include whole grains, fruits, and vegetables in the diet --Diverticular disease of the colon is a condition in which there are sac-like protrusions in the large intestine. Diverticulosis is characterized by the presence of these protrusions: the client is asymptomatic and may not even be aware of the condition. Diverticulitis occurs when diverticula become infected and inflamed. Complications of diverticulitis include abscess, fistula formation, intestinal obstruction, peritonitis, and sepsis. Diverticular bleeding occurs when a blood vessel next to one of these pouches bursts; this may cause blood in the stool. The etiology of diverticular disease has been liked to chronic constipation, a major cause of excess intracolonic pressure. Preventing constipation may help reduce to risk of diverticula forming and becoming inflamed. Measures to prevent constipation include a diet high in fiber daily intake of at least 8 glasses of water or other fluids, and exercise. A fiber supplement such as psyllium or bran may be advised. In the past, clients have been taught to avoid consuming seeds, nuts, and popcorn; however, current evidence does not indicate that avoidance of these foods will prevent an episode of diverticulitis. --a low-residue diet, which avoids all high-fiber foods, may be used in treating acute diverticulitis. However, after symptoms have resolved, a high-fiber diet is resumed to prevent future episodes. --increased consumption of red meat and other high-fat foods can increase the risk of diverticulitis.

Symptoms of Sjogren's syndrome

-dry skin and rashes -chronic dry cough -vaginal dryness and painful intercourse

During the immediate postoperative period after a colostomy, which stoma appearance requires the nurse to contact the HCP immediately? -brick red with slight moisture noted -dusky with moderate edema present -pink with slight oozing of blood -rosy with no stool produced

-dusky with moderate edema present --A colostomy is a surgical procedure that creates an opening in the abdominal wall for the passage of stool to bypass an obstructed or diseased portion of the colon. The stoma should be pink to brick red, indicating vascularity and viability. Minor bleeding and oozing may occur and mild to moderate swelling is normal for 2-3 weeks after surgery. In the immediate postoperative period, stool will be absent. If the bowel is cleansed prior to surgery, the draining of stool will be delayed by several days. Otherwise, stool appears when peristalsis resumes.

S/S of PE

-dyspnea -hypoxemia -tachypnea -cough -chest pain -hemoptysis -tachycardia -syncope -hemodynamic instability

A client is admitted to the medical surgical floor with a hemoglobin level of 5.0 g/dL. The nurse should anticipate which findings? SATA -coarse crackles -dyspnea -pallor -respiratory depression -tachycardia

-dyspnea -pallor -tachycardia ---A normal hemoglobin level for an adult male is 13.2-17.3 g/dL and female is 11.7-15.5 g/dL. A client with severe anemia will have tachycardia, which will maintaincardiac output. The cardiovascular system must increase the heart rate and stroke volume to achieve adequate perfusion. Shortness of breath may occur due to an insufficient number of red blood cells. The respiratory system must increase the respiratory rate to maintain adequate levels of oxygen and carbon dioxide. Pallor occurs from reduced blood flow to the skin. Respiratory depression does not occur with anemia, but may occur post-administration of a narcotic or during oversedation.

24 month growth and development

-early efforts at jumping -builds 6-7 block tower -turns book pages one at a time -300-word vocab -obeys easy commands -parallel play

The nurse is developing teaching materials for a client diagnosed with ulcerative colitis. The client will receive sulfasalazine. Which of the following instructions are included in the discharge teaching plan? SATA -avoid small, frequent meals -can have a cup of coffee with each meal -eat a low-residue, high-protein, high-calorie diet -increase fluid intake to at least 2000 mL/day -medication should be continued even after the resolution of symptoms -take daily vitamin and mineral supplements

-eat a low-residue, high-protein, high-calorie diet -increase fluid intake to at least 2000 mL/day -medication should be continued even after the resolution of symptoms -take daily vitamin and mineral supplements --A low-residue, high-protein, high-calorie diet, along with daily vitamin/mineral supplements is encourage to meet the nutritional and metabolic needs of the client with ulcerative colitis. The low-residue diet limits trauma to the inflamed colon and may lessen symptoms. Easily digested foods such as enriched breads, rice, pastas, cooked vegetables, canned fruits, and tender meats are included in the diet. Raw fruits and vegetables, whole grains, highly seasoned foods, fried foods, and alcohol are avoided. The well-balanced diet includes at least 2000-3000 mL/day of fluid to maintain fluid and electrolyte balance and hydration. --Small, frequent meals are encouraged to lessen the amount of fecal material present in the GI tract and to decrease stimulation --caffeine, alcohol, and tobacco are gastric irritants that stimulate the intestine and should be avoided

A client at 32 weeks gestation has been diagnosed with syphilis. The client expresses to the nurse her belief that antibiotic therapy is harmful and refuses treatment. What is the nurse's appropriate response at this time? -educate the client about potential fetal harm or death if antibiotics are refused -explain that the fetus's right to receive appropriate treatment is prioritized during pregnancy -express respect for the client's beliefs and discuss natural treatment alternatives -inform the client about the symptoms of a Harisch-Herxheimer reaction,which may potentially occur after treatment

-educate the client about potential fetal harm or death if antibiotics are refused --Nurses have an ehtical responsibility to respect the pregnant client's authority to make decisions for herself and on behalf of her fetus, authority known as the principle of autonomy. A client's autonomy and right to make decisions do not change during pregnancy.The nurse should assist the client by providing education about the need for treatment and the consequences of refusing treatment for herself and the fetus,which ensures that the client's refusal of treatment is an informed decision. Syphilis is a STI that crosses the placenta. Refusing treatment for syphilis may cause fetal harm or death. The only adequate treatment available during pregnancy is an IM penicillin injection. Treatment should resolve the maternal infection and prevent or successfully treat fetal infection.

The nurse is precepting a new graduate nurse who is administering a prefilled enoxaparin injection to an obese client. Which action by the graduate nurse indicates the need for further education from the nurse preceptor? -discourages the client from rubbing the injection site after the injection -ejects the air bubble from the prefilled syringe before administration -inserts the needle and injects the medication at a 90-degree angle -selects an injection site on the left lateral side of the abdomen

-ejects the air bubble from the prefilled syringe before administration --Low-molecular-weight heparins are anticoagulants commonly used for prevention and treatment of deep venous thrombosis and pulmonary embolism. LMWH is administered subcutaneously and is often available in a prefilled syringe, which contains an air bubble to ensure delivery of the entire dose. During injection, the air bubble follows the medication out of the syringe, ensuring that no medication is left behind. The nurse should not expel the air bubble prior to administration as this could result in an incomplete dose and medication error. After subcutaneous injection, the client should not rub the injection site as this increases bruising and the risk for hematoma. A 90-degree angle is appropriate for a subcutaneous injection in an obese client. In general, subcutaneous injections are administered at a 90-degree angle if 2 inches of tissue can be grasped or a 45-degree angle if only 1 inch of tissue can be grasped. Subcutaneous anticoagulants are best absorbed when administered in the lower part of the right or left lateral abdominal wall away from the umbilicus.

A nurse is caring for a client 1 day after a left-sided mastectomy with lymph node dissection. Which nursing intervention is the priority in caring for this client? -apply an ice pack to the left shoulder -elevate the affected arm on a pillow -help the client ambulate frequency -obtain a pneumatic compression sleeve

-elevate the affected arm on a pillow --After a mastectomy, an important goal is restoring function in the client's affected arm. Measures to promote function are initiated immediately after surgery. Elevating the affected arm to heart level is crucial to reduce fluid retention and prevent lymphedema in the affected arm. Hand and arm exercises are implemented gradually, beginning with finger flexion and extension. These activities maintain muscle tone, prevent contractures, and improve lymph and blood circulation, which promote function and also prevent lymphedema. The return of full range of motion in the affected arm is desired within-6 weeks.Additional nursingcare for clients after a mastectomy includes keeping the client in semi-Fowler position and placing a sign over the bed that specifies, "no blood pressure, venipuncture, or injections on left arm"

The nurse will implement which nursing actions when caring for a client recently diagnosed with a hiatal hernia? SATA -elevate the head of the hospital bed -instruct the client to avoid tobacco and caffeine -offer small, frequent, low-fat meals -provide a girdle to reduce the hernia -teach the client to avoid lifting or straining

-elevate the head of the hospital bed -instruct the client to avoid tobacco and caffeine -offer small, frequent, low-fat meals -teach the client to avoid lifting or straining --Conditions that increase intraabdominal pressure and weaken the muscles of the diaphragm may allow a portion of the stomach to herniate through an opening in the diaphragm, causing a hiatal hernia. A sliding hernia occurs when a portion of the upper stomach squeezes through the hiatal opening in the diaphragm. A paraesophageal hernia occurs when the gastroesophageal junction remains in place but a portion of upper stomach folds up along the esophagus and forms a pocket. Paraesophgeal hernias are a medical emergency. Although hiatal hernias may be asymptomatic, many clients experience signs and symptoms commonly associated with gastroesophageal reflux disease, including heartburn, dysphasia, and pain caused by increased intraabdominal pressure or supine positioning. Interventions to reduce herniation includes: diet modifications, lifestyle changes, avoiding lifting or straining, elevated the HOB approximately 30 degrees. --wearing a girdle or tight clothes increases intrabdominal pressure and should be avoided

The nurse plans discharge teaching for a client newly diagnosed with polycythemia vera. Which actions will the nurse include in the teaching plan? SATA -elevate the legs and feet when sitting -increase dietary intake of foods rich in iron -increase fluid intake during exercise and hot weather -increase water temperature to reduce post-bath itching -report swelling or tenderness in the legs

-elevate the legs and feet when sitting -increase fluid intake during exercise and hot weather -report swelling or tenderness in the legs --Clients with polycythemia vera are at risk of developing thrombosis and should be taught preventive measures and symptoms to report. They should take measures to prevent dehydrate, and avoid iron-rich foods and hot showers/baths. Increasing intake of iron-containing foods and supplements can further increase hemoglobin production and is not recommended. Clients with PV need periodic phlebotomy to remove excess blood.

Clinical manifestations of heat exhaustion

-elevated body temperature -intravascular volume depletion -electrolyte imbalances -dizziness -weakness -fatigue -sweating -flushing -nausea -tachycardia -muscle cramping

9 month growth and development

-elevates self to sitting position -creeps on hands/knees -develops preference for dominant hand -rudimentary imitative expression -responds to parental anger

Nursing interventions to control ICP

-elevating the head of the bed to 30 degrees with the head/neck in a neutral position to reduce venous congestion. --administer stool softeners to reduce the risk of straining --manage pain well while monitoring sedation --manage fever (cool sponges, ice, antipyretics) while preventing shivering --ensuring adequate oxygenation --hyperventilating and preoxygenating the client before suctioning; reducing CO2 by hyperventilation induces vasoconstriction and reduces ICP

common causes of sudden cardiac arrest in pregnant clients?

-embolism -eclampsia -magnesium overdoses -uterine rupture

The nurse is assigned to care for clients with assistance from UAP. Which of the following tasks are appropriate for the nurse to assign to UAP? SATA -emptying a urinary drainage bag and recording output volume -emptying and verifying the patency of an accordion drain -escorting a disgruntled family member off the unit -providing perineal care around an indwelling urinary catheter -reapply bilateral sequential compression devices

-emptying a urinary drainage bag and recording output volume -providing perineal care around an indwelling urinary catheter -reapply bilateral sequential compression devices

The nurse is caring for a client newly diagnosed with mild Alzheimer disease. Which action should the nurse prioritize at this time when teaching the client and family? -demonstrate behavioral management techniques to caregivers -encourage the client to make an advance directive before cognitive decline worsens -inform the client that mentally stimulating activities can slow disease progression -provide information about local adult daycare programs

-encourage the client to make an advance directive before cognitive decline worsens --due to the progressive course of AD, it is important to discuss advance directives while the client can make informed decisions.

Key nursing interventions to alleviate separation anxiety

-encourage the presence of favorite items -establish a daily routine -provide opportunities for play -facilitate phone calls with parents -provide support when child is upset

The nurse educates a group of clients in the infertility clinic about risk factors contributing to infertility. Which factors should the nurse include in the teaching? SATA -BMI of 22 kg/m2 -endometriosis -maternal age > 35 -polycystic ovarian syndrome -recurrent chlamydial infections

-endometriosis -maternal age > 35 -polycystic ovarian syndrome -recurrent chlamydial infections ---Infertility is the inability to conceive after unprotected intercourse for > 12 months. Female fertility declines as women age, with the first significant decrease seen after age 35.Hormonal dysfunction can cause ovarian cysts and anovulatory cycles which impair fertility. Some sexually transmitted infections may be asymptomatic in females, which can delay treatment. Untreated or recurrent infections cause inflammation, scarring, and damage to the reproductive tract, leading to infertility. Endometriosis is characterized by endometrial tissue depositing outside the uterus. These endometrial lesions can result in chronic inflammation, pelvic pain, menstrual cycle abnormalities, and infertility.

A comatose client in the intensive care unit has an indwelling urinary catheter. Which action(s) should the nurse implement to reduce the incidence of catheter-associated urinary tract infections? SATA -cleanse periurethral area with antiseptics every shift -ensure each client has a separate container to empty collection bag -keep catheter bag below the level of the bladder -routinely irrigate the catheter with antimicrobial solution -use sterile technique when collecting a urine specimen

-ensure each client has a separate container to empty collection bag -keep catheter bag below the level of the bladder -use sterile technique when collecting a urine specimen --Routine catheter care to prevent healthcare catheter-associated UTIs includes routine hand hygiene, cleansing the perineal area with soap and water routinely, keeping the catheter bag below the bladder and off the ground, keeping the catheter and tubing free of kinks and facilitating urine into the bag, and using sterile technique when collecting urine specimens.

The nurse plans to administer 9:00am medications via the NG route to a client with an NG tube. The nurse contacts the PHCP to clarify which prescriptions that are contraindicated using this route? SATA -enteric-coated ibuprofen 200-mg tablet -extra-strength acetaminophen 500-mg tablet -metoprolol extended-release 50-mg tablet -sulfamethoxazole double-strength 800-mg tablet -tamsulosin 0.4-mg slow-release capsule

-enteric-coated ibuprofen 200-mg tablet -metoprolol extended-release 50-mg tablet -tamsulosin 0.4-mg slow-release capsule --enteric-coated drugs have a barrier coating that dissolves at a slower rate to protect the stomach from irritant effects. Crushing enteric-coated medications disrupts the barrier coating and may cause stomach irritation. In addition, the particles from the coating may clog the NG tube, particularly small-bore NG tubes. Slow-, extended-, or sustained-release drug formulations are designed to dissolve very slowly within a specific time frame. Crushing these medications alters this property and introduces the risk of adverse effects from toxic blood levels due to more rapid drug absorption. Therefore, the nurse should first contact the PHCP for clarification

Fatal complication of Hirschsprung's disease?

-enterocolitis, which is characterized by explosive, foul-smelling diarrhea, fever, and worsening abdominal distension

Symptoms of Meniere disease

-episodic attacks of vertigo (associated with N/V), tinnitus, hearing loss, and aural fullness

11 month growth and development

-erect standing posture with support -walks holding onto furniture -drops objects and expects it to be picked up -plays peek-a-boo -shakes head for "no"

What are examples of treatment medical errors?

-error in performance of procedure, treatment, dose -avoidable delay

The nurse is caring for a client following a transsphenoidal hypophysectomy. Which clinical findings would the nurse recognize as signs that the client may be developing diabetes insipidus? SATA -decreased serum sodium -excess oral water intake -high urine output -increased serum osmolality -increased urine specific gravity

-excess oral water intake -high urine output -increased serum osmolality --Transphenoidal hypophysectomy is the surgical removal of the pituitary gland, an endocrine gland that produces, stores, and excretes hormones. Clients undergoing hypophysectomies are at risk for developing neurogenic diabetes insipidus, a metabolic disorder of low ADH levels. ADH promotes water reabsorption in the kidneys; therefore, loss of circulating ADH results in massive diuresis of dilute urine.

positive outcome of the second stage of Erickson's developmental task? --negative outcome?

-exercises self-control and influences the environment directly --demonstrates defiance and negativism

Strategies that can help reduce falls in the home environment

-exercising regularly for 30 minutes 3 times/week (increase strength, balance, coordination, and flexibility) -maintaining a well-lit, clutter-free environment -using grab bars and non-ski bath mats in the bathroom -wearing shoes/slippers with non-skid soles both inside and outside of the home -periodically reviewing medications and side effects with a pharmacist and HCP -getting regular vision exams -wearing an electronic fall alert device.

Postprocedure instructions for a barium enema includes

-expect the passage of chalky, white stool until all barium contrast has been expelled -take a laxative to assist in expelling the barium. Retained barium can lead to fecal impaction -drink plenty of fluids to promote hydration and eat a high-fiber diet to prevent constipation.

A client is seen in the clinic for the third time for a nonhealing, infected diabetic foot ulcer. The client is able to verbalize the correct procedure for wound care but reports not adhering to the ordered routine at home. What intervention does the nurse prioritize to promote proper self care? -assess the client's feelings about placement at a skilled nursing facility for care -educate the client on the risks of tissue death if not properly cared for at home -explore the client's ability and motivation to perform care at home -provide the client with the supplies needed to change dressings as recommended

-explore the client's ability and motivation to perform care at home --Self care is a critical component of health. However, barriers to self care are multifactorial. The nurse must assess for adequate knowledge and ability to perform self-care activities and the desire to complete such activities. Once the barriers have been identified, the nurse can work with the client to create an individualized plan to meet healthcare needs

A client on hospice home care is taking sips of water but refusing food. Family members appear distressed and insist that the personal care worker "force feed" the client. What is the priority nursing action? -explain to the family that this is a normal physiological response to dying -explore the family's thoughts and concerns about the client's refusal of food -recommend a feeding tube -tell the family that "force feeding" the client could cause the client to choke on the food.

-explore the family's thoughts and concerns about the client's refusal of food --It is very common for family members to become distressed when a terminally ill loved one refuses food. The nurse needs to explore theirs fears and concerns and help them identify other ways to express how they care. The nurse should also provide education about the effect of food and water during all stages of the illness.

A speeding driver sustained a closed-head injury in an acceleration/deceleration accident from striking a tree front end first. Based on the coup-countrecoup phenomenon, which assessments are most likely to be affected related to the involved areas of the brain? -expressive speech, vision -light touch, hearing -sense of position, graphesthesia -weber tuning fork test, cranial nerve

-expressive speech, vision --Coup-contrecoup injury occurs when a body in motion stops suddenly, causing contusions of brain tissue as the brain moves back and forth within the skull. First, the soft tissue strikes the hard skull in the same direction as the momentum (coup). As the body bounces back, the brain strikes the opposing side of the skull (contrecoup). When the forward collision occurred, the frontal lobe most likely suffered the primary impact (coup). Executive function, memory, speech, and voluntary movement are controlled by the frontal lobe. The contrecoup most likely injured the occipital lob, where vision is processed.

A nurse is assessing a 58-year-old client with blurred vision and reduced visual fields. Which manifestation is of most concern to the nurse? -difficulty adjusting to dimmed lights -extreme eye pain -gradual loss of peripheral vision -opaque appearance of lens

-extreme eye pain --Acute angle-closure glaucoma is a form of glaucoma that requires immediate medical intervention. Glaucoma disorders are characterized by increased intraocular pressure due to decreased outflow of the aqueous humor resulting in compression of the optic nerve that can lead to permanent blindness.

The nurse is caring for a 50-year-old client in the clinic. The client's annual physical examination revealed a hemoglobin value of 10 g/dL compared to 13 g/dL a year ago. What should be the nurse's initial action? -encourage intake of over-the-counter iron pills -encourage intake of red meat and egg yolks -facilitate a screening colonoscopy -facilitate another blood test in 6 months

-facilitate a screening colonoscopy --Early signs of colorectal cancer are usually nonspecific and include fatigue, weight loss, anemia, and occult gastrointestinal bleeding. Clients shouldhave regular screening colonscopy for colon cancer starting at age 50 if their risk is average or earlier if their risk is high. Colorectal screening can also include fecal occult blood test or fecal immunochemical test annually. New-onset anemia should be taken seriously at this client's age, and colon cancer must be ruled out. The etiology of anemia must be determined prior to recommending treatment.

A client in the mental health unit picks up a fire extinguisher and throws it at a nurse standing by the nurses' station. What is the most important intervention by the nurse? -facilitate immediate removal of people from the area -inform the client that the client cannot act that way -pull the fire alarm to get additional immediate help -state that the nurse can see the client is upset

-facilitate immediate removal of people from the area --When a situation is out of control, safety is the primary concern. The nurse and everyone else should leave the area, and security should be called immediately.

The charge nurse on the cardiac floor is orienting a new graduate nurse. The charge nurse describes various roles of the interdisciplinary team. In which situations would the nurse "case manager" be consulted? SATA -facilitating communication between HCP -obtaining health information from the client's nursing home -reconciliation of home medications -referral for home health after discharge -visiting the client daily while hospitalized

-facilitating communication between HCP -obtaining health information from the client's nursing home -referral for home health after discharge --Case management involves assessing, planning, facilitating, and advocating for client health services to accomplish cost-effective quality client outcomes. This is done through communication and use of available resources. A professional nurse often serves in the case manager role. The case manager in the hospital setting assesses client needs, decreases framentation of care, helps to coordinate care and communication between HCPs, makes referrals, ensures quality standards are being met, and arranges for home health or placement after discharge.

The nurse is participating in a staff presentation to review risk factors for skin cancer. Which of the following risk factors should the nurse include? SATA -family history of skin cancer -high number of moles -history of severe adolescent acne -immunosuppressant medication use -outdoor occupation

-family history of skin cancer -high number of moles -immunosuppressant medication use -outdoor occupation --skin cancers are most often linked to damage of skin cells DNA by overexposure to ultraviolet radiation. The three most common types of skin cancer are squamous cell carcinoma, basal cell carcinoma, and melanoma. Melanoma grow rapidly and are highly metastatic, making them the deadliest form of skin cancer. Basal cell and squamous cell carcinomas generally have a much lower risk of metastasis. Clients should be taught to avoid overexposure to sunlight, perform monthly skin checks with the ABCDE assessment, and immediately report any abnormal findings to their healthcare provider. Early detection and treatment significantly improve outcomes.

Client instructions for a small bowel follow-through (SBFT)

-fast 8 hours prior to the examination -test lasts 60-120 minutes, but if obstruction or decreased motility is present, it can take longer -drink plenty of fluids after the examination to facilitate barium removal. Chalky stools may be present 24-72 hours after the examination. If brown stools do not return after 72 hours or abdominal pain or fullness is present, contact HCP.

Which of the following tasks would the charge nurse on a surgical unit assign to the UAP? -assisting a client in ambulating to the bathroom for the first time following surgery? -explaining why using the incentive spirometer is important to a client with postoperative pneumonia -feeding a client with dementia who has a blood sugar of 70 mg/dL -taking vital signs every 15 minutes on a client who was just transferred from the post-anesthesia recovery unit

-feeding a client with dementia who has a blood sugar of 70 mg/dL

non-modifiable breast cancer risk facotrs

-female sex -age >50 -first-degree relative with history of breast cancer -BRCA1 and BRCA2 genetic mutations -personal history of endometrial or ovarian cancer -menarche before age 12 or menopause after age 55

The nurse on the IV therapy team is making rounds in the intensive care unit on clients with central venous catheters. Which central line should be removed earliest to prevent infection? -femoral line inserted in emergency department post cardiac arrest 48 hours ago -internal jugular line inserted 6 days ago in operating room -peripherally inserted central catheter line with one lumen occluded that was placed 2 weeks ago -subclavian line with slight redness at anchor suture sites inserted in intensive care unit 72 hours ago.

-femoral line inserted in emergency department post cardiac arrest 48 hours ago --In adult clients, central venous access sites in the upper body are preferred to minimize the risk of infection. Access sites in the inguinal area are easily contaminated by urine or feces, and it is difficult to palce an occlusive dressing over these sites. A central venous cathter should be placed where aseptic technique can be applied. The site should be assessed daily for signs/symptoms of infection. The duration of CVC placement should be based on clinical need and judgment that there is no evidence of infection. Peripherally inserted central catheter lines can be left in for weeks or months. The occlusion of one lumen does not necessitate removal of the catheter.

S/S of mononucleosis

-fever -fatigue -sore throat -splenomegaly -hepatomegaly -swollen lymph nodes

Clinical manifestations of bacterial meningitis

-fever -severe HA -N/V -nuchal rigidity -photophobia -altered mental status -S/S of increased ICP --the priority treatment is fluid resuscitation

Clinical manifestations of bacterial meningitis in infants less than two years of age

-fever or possible hypothermia -irritable -frequent seizures -high-pitched crying -poor feeding/vomiting -nuchal rigidity -bulging fontanelle (not always present) --common acute complication is hydrocephalus

Which are correct understandings of applying nursing ethical principles? SATA -autonomy is requiring the client to have an advance directive -beneficence is withholding prognosis from a client due to family wishes -fidelity is administering medication as prescribed to the client -justice is telling the client the truth that the biopsy is positive -nonmaleficence is refusing to give report to a nurse who is impaired

-fidelity is administering medication as prescribed to the client -nonmaleficence is refusing to give report to a nurse who is impaired --Ethical principles guide the nurse in making appropriate decisions and acting accordingly. They speak to the essence but not to the specifics of the law. Fidelity is exhibiting loyalty and fulfilling commitments made to oneself and others. It includes meeting the expected responsibilities of professional nursing practice and provides the basis of accountability. Nonmaleficence means to do no harm and relates to protecting clients from danger when they are unable to do so themselves due to a mental/physical condition and from a nurse who is impaired.

The nurse is caring for a client with a hx of HAs. The client has talked to the nurse, smiled at guests, and maintained stable vital signs. The nurse notes the following changes in the client's status. Which assessment finding is critical to report to the HCP? -blood pressure 136/88 mm Hg -flat affect and drowsiness -poor appetite -respiratory rate 12/min

-flat affect and drowsiness --The level of consciousness is the most important, sensitive, and reliable indicator of the client's neurological status. Changes in the level of consciousness can represent increased intracranial pressure and reduced cerebral blood flow. Changes in vital signs usually do not appear until intracranial pressure has been elevated for some time, or they may be sudden in cases of head trauma.

The nurse is counseling a client with obesity who is starting a weight reduction diet. The client reports consuming 4-5 regular cola beverages daily. Which of the following beverages should the nurse recommend as healthier substitutes? SATA -commercial fruit juice -flavored club soda -fresh vegetable juice -sports beverages -unsweetened tea

-flavored club soda -fresh vegetable juice -unsweetened tea --Sugary beverages, such as regular soft drinks, are key contributors to the excess consumption of calories and the obesity epidemic. Individuals who are attempting to lose weight should consume beverages with nutritional value and little-to-no caloric value, such as water, club soda, unsweetened tea/coffee, fresh vegetable juice, an nonfat/low-fat milk. A 12-oz serving in a typical can of regular cola-type beverage contains around 140 calories. For this client, the consumption of 5 cola beverages daily is contributing 255,500 kcal per year and accounts for 73 lb. This client could lose 73 lbs in a year simply by substituting zero-calorie beverages for cola.

When preparing medication from a glass ampule, the nurse ensures safety and prevents contamination during medication administration by:

-flicking upper stem of the ampule with a fingernail several times to ensure removal of medication from the ampule neck -using sterile gauze to break the ampule neck away from the nurse's body to prevent injury from glass shards -setting the ampule on a flat surface or inverting it to withdraw the medication -disposing of the ampule in a sharps container

A client with a nasogastic tube is prescribed intermittent bolus enteral feedings with routine gastric residual checks. Which of the following actions by the nurse are appropriate? SATA -discard aspirated gastric residual in a biohazard container -flush the nasogastric tube before and after administering the feeding -place the client is the semi-Fowler position -Start the feeding after obtaining a gastric residual volume of 75 mL -start the feeding when the gastric residual has pH of 6

-flush the nasogastric tube before and after administering the feeding -place the client is the semi-Fowler position -Start the feeding after obtaining a gastric residual volume of 75 mL --When administering bolus enteral feedings, the nurse should elevate the head of the bed to 30-45 degrees and keep it elevated for 30-60 minutes afterwards to decrease aspiration risk. Many institutions require the nurse to hold feeding if the client must remain supine. Feeding tubes should be flushed before and after feedings to keep the tube patent. Gastric residual volumes are traditionally checked every 4 hours with continuous feeding or before each bolus feeding. Per facility policy, enteral feedings may be held for high GRV to reduce aspiration risk. Low GRV indicates that the client is tolerating feedings well. Some facilities no longer routinely check GRVs because recent evidence shows that the procedure may not truly indicate aspiration risk and actually impairs calorie delivery. Regardless of GRV checks, the nurse should closely monitor clients for symptoms of intolerance, which may indicate that feedings should be held or reduced in volume.

The nurse working in an intensive care unit cares for a client with a left triple lumen subclavian central venous catheter. The nurse should call the primary health care provider for clarification prior to implementation when recognizing that which prescription is an error? -administer intravenous total parenteral nutrition at 50 mL/hr -change occlusive central line dressing every 7 days -flush unused lumens of the CVC with 1,000 units heparin every 12 hours -use distal port of CVC to monitor central venous pressure

-flush unused lumens of the CVC with 1,000 units heparin every 12 hours --Most CVC lumens require anticoagulation in the form of a heparin flush to maintain patency and prevent clotting when not in use. The nurse should check the institution's protocol and the HCP prescription to determine the correct dose. Doses of 2-3mL containing 10 units/mL are the standard of care for flushing a CVC. Doses of 1,000-10,000 units are given for cases of venous thromboembolisml therefore, this prescription is an error and should be clarified by the nurse. The CDC recommend that a single-dose vial or prefilled syringe be used to reduce infection risk. Heparin is a high-alert medication.

The nurse is reviewing a client's preoperative questionnaire, which indicates a religious preference with spiritual needs concerning surgery scheduled later today. Which action is most appropriate at this time? -ask the client when a spiritual leader or clergy member is coming to visit -document the response and notify the healthcare provider and perioperative team -follow up with the client regarding the nature of the spiritual or religious practices -notify the hospital chaplain and tell the client that the chaplain will come by to assist

-follow up with the client regarding the nature of the spiritual or religious practices --Spiritually and religious beliefs are often integral parts of a client's life and can be therapeutic in the management of illness. Some studies have found that clients who engage in regular spiritual or religious practices have shorter recovery times, better coping mechanisms, and improved health outcomes. Spiritual, cultural, or religious needs should be accommodated within the plan of care. During the nursing process, the nurse should first assess the client's needs to best address them. By following up with the client regarding the questionnaire and asking about the specific nature of spiritual needs or religious practices, the nurse can effectively assist the client and create an appropriate plan of care.

A client is admitted to the hospital for chemotherapy complications. Laboratory results show an absolute neutrophil count of 450 cells/mm3. What information contained in the admission history of this client will need to be addressed during discharge education? -eats steamed vegetables daily -enjoys eating grilled shrimp weekly -gardens as hobby -takes a bath daily and applies moisturizer

-gardens as hobby --This client has a very low absolute neutrophil count; having <500 cells/mm3 indicates severe neutropenia and increases the risk of infection. All risks for infection should be minimized in a client with neutropenia. Soil contains many pathogens, including Aspergillus fungus, which could expose this client to infection. Gardening and contact with fresh flowers and plants should be avoided when a client is at increased risk for infection. In addition, the client's room should not have standing water. Strict hand-washing is recommended. The client should be placed in a private room while in the hospital and all visitors should wear a mask

What drug classification and use is sulfasalazine?

-gastroinestinal anti-inflammatory --treated IBD

Steps for performing the procedure for a client with a disposable inner cannula

-gather supplies to the bedside, then place client in semi-Fowler's position, if not contraindicated, to promote lung expansion and oxygenation and prevent aspiration of secretions -don personal protective equipment to maintain universal precautions. Ausculate lungs and suction secretions if necessary -remove soiled dressing and also remove clean gloves -don sterile gloves; remove old disposable cannula and replace with a new one. -clean around stoma with sterile water or saline, dry and replace sterile gauze pad to remove dried secretions, and dry around stoma well to limit the growth of microorganisms.

treatment for dental avulsion when not able to immediately get to the dentist

-gently rinse tooth and reinsert the tooth into the gingival socket --if reimplantation is not possible, the tooth should be placed in a commercially prepared solution/cold milk/sterile saline

A client with terminal cancer arrives in the ED unresponsive and in respiratory distress. The client's sister is the legal medical power of attorney. Both the client's spouse and sister are present. Which action by the nurse is appropriate at this time? -ask the spouse about the client's wishes -get directions about care from the client's sister -prepare for emergency intubation -request that the sister provide a living will

-get directions about care from the client's sister --Advance directives are legal documents that allow clients to make decisions about their future medical treatment in case the client later becomes medically incompetent. The most common forms are living will and medical power of attorney. A living will declares the client's wishes related to specific situations. A medical POA allows the client to designated a specific decision-making individual who can advocate for the client as needed and can be flexible in changing circumstances. --A client's spouse is typically the primary decision maker. However, clients have the right to declare any specific individual who they trust as their agent with medical POA, and the agent becomes the final decision maker.

The nurse is providing postoperative care to a client returning from a hemorrhoidectomy. Which action is the priority for the nurse to perform? -administer docusate and teach the client to avoid straining during defecation -give pain medications and instructions related to pain control -remove the rectal dressing and check the client for bleeding -teach the client how to self-administer a sitz bath 2-3 times daily

-give pain medications and instructions related to pain control --hemorrhoids are caused by increased anorectal pressure. Clients may experience symptoms such as rectal bleeding, pain, pruitus, and prolapse. Although removal of hemorrhoids is a minor procedure, the pain associated with it is due to spasms of the anal sphincter and is severe.

The nurse removes personal protective equipment (PPE) after completing a wound dressing change for a client in airborne transmission-based precautions. Which PPE should the nurse remove first? 1. Face shield/goggles 2. Gloves 3. Gown 4. Mask/respirator

-gloves ---The proper removal of personal protective equipment limits self-contamination. Gloves should be removed first and promptly after use to prevent contamination of other items or noncontaminated materials

The nurse caring for a client diagnosed with HIV uses which infection prevention and control measures? SATA -gloves when contact with body fluids is anticipated -gloves when starting an intravenous line -gown, gloves, face shield, and googles for every client encounter -hand hygiene before and after providing client care -N95 respiratory mask and face shield

-gloves when contact with body fluids is anticipated -gloves when starting an intravenous line -hand hygiene before and after providing client care --Hand hygiene is performed before and after providing client care. HIV is a blood-borne virus, and standard precautions are sufficient protection against viral transmission. The nurse wears gloves when anticipating exposure to blood or body fluids. Isolation gowns are applied if the nurse if the nurse anticipates splashing of body fluids on clothing. A face shielfd and goggles are applied if splashing in the eyes is a possibility. The nurse should always don gloves when starting an intravenous line.

The nurse preparing an educational seminar on sexually transmitted infections for female college students should advise that which 2 infections are leading causes of pelvic inflammatory disease and infertility? -genital herpes and HIV -gonorrhea and chlamydia -human papillomavirus and syphilis -year and trichomoniasis

-gonorrhea and chlamydia --Gonorrhea and chlamydia can lead to pelvic inflammatory disease and infertility. They are referred to as "silent infections" because many affected women show no symptoms. Infections of the fallopian tubes and uterus can lead to permanent damage and infertility. The centers for Disease Control and Prevention recommend annual chlamydia and gonorrhea screening for all sexually active females age <25 and older females with risk factors. Both chlamydia ad gonorrhea are treatable. The use of latex condoms is recommended to reduce the risk of contracting chlamydia and gonorrhea.

The nurse prepares to care for a client being admitted with a confirmed diagnosis of Middle East respiratory syndrome. Which personal protective equipment will the nurse use when providing care to this client? -gloves and gown -gloves and mask -gown and N95 respirator -gown, gloves, N95 respirator, and eye protection

-gown, gloves, N95 respirator, and eye protection --MERS is a viral respiratory illness caused by the coronavirus. Symptoms include fever, cough, and shortness of breath that often worsen and cause death in many of those affected. The incubation period is 5-6 days but can range from 2-14 days. How the virus spreads is not fully understood, but it is thought to spread via respiratory secretions. Because it has easily spread to those who care for infected persons, the CDC recommends the use of standard, contact, and airborne precautions with eye protection when caring for clients with MERS.

The nurse teaching a group of clients about celiac disease will include which meal in the teaching plan? -baked salmon with rice, steamed vegetables, and dinner roll -breaded pork chops, corn on the cob, and steamed snow peas -grilled chicken, green beans, and mashed potatoes -spaghetti with italian tomato sauce and meatballs

-grilled chicken, green beans, and mashed potatoes --Celiac disease is an autoimmune disorder in which chronic inflammation caused by gluten damages the small intestine. It is important to teach this client that all gluten-containing products should be eliminated from the diet (wheat, barley, rye, and oats); rice, corn, and potatoes are gluten free and allowed in their diet; processed foods may contain "hidden" sources of gluten; clients will need to be gluten-free for the rest of their lives; eating even small amounts of gluten will damaged the intestinal villi, even if they do not experience symptoms. --marinated and breaded protein sources should be avoided

The pediatric nurse is preparing to administer an acetaminophen suppository to an 11-month-old with pyrexia. Which actions are appropriate? SATA -advance past the external sphincter only -guide suppository along the rectal wall -hold buttocks together firmly after insertion -position client supine with knees and feet raised -use gloved fifth finger for insertion

-guide suppository along the rectal wall -hold buttocks together firmly after insertion -position client supine with knees and feet raised -use gloved fifth finger for insertion ---Pediatric administration of rectal suppositories is similar to the adult technique, with a few key modifications due to the small size of a child's colon and varying developmental needs. Age-appropriate explanations and/or distractions should be implemented to reduce distress. Toddlers and infants may benefit from distraction with a toy; preschoolers and older children can be instructed to take deep breaths or count during the procedure.

A football player is brought to the emergency department after a helmet-to-helmet collision without loss of consciousness or signs of external trauma. Which clinical finding warrants immediate intervention? -hairnet-like effect across vision -loss of memory about the collision -temporal headache -tongue laceration oozing blood

-hairnet-like effect across vision --Retinal detachment is a separation of the retina from the posterior wall of the eye, and may result from blunt-force trauma. If not promptly recognized and treated, permanent blindness may occur. Signs of detachment include lighting flashes or floaters and a curtain-like or gnats/hairnet/cobweb effect throughout the field of vision.

The nurse is caring for an adult client at the clinic who asks the nurse to look at a "black skin lesion". What assessment findings would be a classic indication of a potential malignant skin neoplasm? SATA -blanches with manual pressure -half of the lesion is raised and half is flat -history of prurlent drainage -lesion is the size of a nickle -various color shades are present

-half of the lesion is raised and half is flat -lesion is the size of a nickle -various color shades are present ---The examination for skin cancer follows the ABCDE rule: Asymmetry, Border irregularity, Color changes and variation; Diameter of 6 mm or larger; Evolving

The nurse is caring for a client with active pulmonary tuberculosis. Which elements of infectious disease precautions are mandatory for the nurse when providing routine care? SATA -gown -goggles or face shield -hand washing -N95 particulate respirator -surgical mask

-hand washing -N95 particulate respirator --Isolation is mandatory for clients with conditions that involve airborne transmission, and rooms must use both negative air pressurization and high-efficiency particulate air (HEPA) filters to avoid contamination. A class N95 or higher particulate respirator must be worn during client care. All clients with symptoms consistent with a suspected airborne illness should be given a surgical mask to wear as soon as they are assessed during triage. Good hand hygiene is always the first and last element of infection control in any client care setting. Wearing a gown and face shield would be necessary only if the nurse suspected splash of body fluids from procedural client care, not from routine care such as assessment or medication administration. Contact precautions may also be necessary if TB is extrapulmonary with draining lesions. For client care involving airborne precautions, a class N95 or higher respirator must be used in lieu of a surgical mask to avoid potential exposure to aerosolized particles. Surgical masks are rated for barrier protection for droplet splashing and filtration of large respiratory particles only. Clients should be given surgical masks during their transportation.

A client is receiving an infusion of total parenteral nutrition with 20% dextrose through a central line at 75 mL/hr. The nurse responds to the client's IV pump alarm, which indicates that the bag is empty. The new bag is not expected to arrive from the pharmacy for an hour. What is the most appropriate nursing action? -hang 0.9% normal saline until new bag arrives, then increase TPN to 150 mL/hr for 1 hour -hang 10% dextrose in water until the new bag arrives, then resume TPN at 75 mL/hr -hang dextran in saline until the new bag arrives, then resume TPN at 75 mL/hr -hang lactated Ringer's until the new bag arrives, then resume TPN at 75 mL/hr

-hang 10% dextrose in water until the new bag arrives, then resume TPN at 75 mL/hr --TPN is administered via central venous catheter to meet the nutritional needs of clients who cannot digest nutrients via the GI tract. The nurse should hang 10% dextrose in water at the same infusion rate of 75 mL/hr until the new bag arrives. If the 20% dextrose solution is temporarily replaced with an infusion lacking dextrose, the pancreas will continue to produce insulin in response to the residual glucose, which may cause hypoglycemia. --dextran in saline solution is a colloid use to expand intravascular volume in clients with hypovolemia. It can cause fluid overload and is not an appropriate action.

A highly intoxicated client was brought to the ED after found lying on the sidewalk. On admission, the client is awake with a pulse of 70/min and blood pressure of 160/80 mm Hg. An hour later, the client is lethargic, pulse is 48/min, and blood pressure is 200/80 mm Hg. Which action does the nurse anticipate taking next? -administer atropine for bradycardia -administer nifedipine for hypertension -have CT scan performed to rule out an intracranial bleed -perform hourly neurologic checks with Glasgow coma scale

-have CT scan performed to rule out an intracranial bleed --Cushing's triad is related to increased ICP. Early Signs include change in level of consciousness. Later signs include bradycardia, increased systolic blood pressure with a widening pulse pressure and slowed irregular respirations. Cushing's triad is a later sign that does not appear until the ICP is increased for some time. It indicates brain stem compression. The client's intoxication could blunt an accurate history or presentation of a head injury --atropine is used to stimulate the sinoatrial node in bradycardia with systemic symptoms. An ECG should be obtained prior to administering atropine. --Nifedipine is a CCB that is a potent vasodilator. However, all components must be considered in this scenario as to the etiology of the HTN rather than just treating that sign

An elderly client visits the clinic for an annual examination, which includes updating the client's advance care plan. When assessing the client's advance care planning needs, which topics should the nurse discuss? SATA -financial power of attorney -health care proxy -life insurance beneficiary -living will -safe deposit box

-health care proxy -living will --financial power of attorney form can help clients having difficulty managing financial affairs and needing someone to help, but is not part of the advance care planning process.

The nurse is teaching about the importance of dietary fiber at a community health fair. Which health benefits of consuming a fiber-rich diet should the nurse include in the teaching plan? SATA -helps prevent colorectal cancer -improves glycemic control -promotes weight loss -reduces risk of vascular disease -regulates bowel movements

-helps prevent colorectal cancer -improves glycemic control -promotes weight loss -reduces risk of vascular disease -regulates bowel movements --Dietary fiber is composed of indigestible complex carbohydrates that absorb and retain water, which increases stool bulk and makes stool softer and easier to pass. Consuming a diet high in fiber-rich foods improves stool elimination, which helps prevent constipation and decreases the risk of colorectal cancer. --fiber-rich foods tend to have a low glycemic load, and are nutrient dense, yet have lower caloric density. Clients may also experience increased satiety as fiber absorbs water and produces fullness. This may help reduce caloric intake, improve blood glucose control, and promote weight loss. --fiber binds to cholesterol in the intestines, which reduces serum cholesterol levels by decreasing the amount of dietary cholesterol that enters the bloodstream. Decreasing serum cholesterol levels helps reduce vascular plaque buildup and atherosclerosis. A high intake of fiber-rich foods directly correlates with a reduced risk of vascular diseases, including coronary artery disease and stroke.

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? -brain natiuretic peptide 70 pg/mL -hematocrit 21% -Leukocytes 3,500//mm3 -platelets 105,000/mm3

-hematocrit 21% --Hematocrit 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.

Describe diet for a client with cystic fibrosis

-high calorie -high fat -high protein

The nurse in the oral surgery clinic reviews a client's medical record prior to surgery. Which will the nurse immediately report to the oral surgeon? SATA -client is on a calorie-restricted diet for obesity -creatinine is 1.3 mg/dL -history of congenital heart disease -international normalized ratio of 2.5 -presence of prosthetic valve

-history of congenital heart disease -international normalized ratio of 2.5 -presence of prosthetic valve --Clients with a history of congenital heart disease and those with prosthetic valves are at risk for developing infective endocarditis, an infection of the endothelial lining of the heart, with oral surgery and certain procedures. These clients should receive prophylatic antibiotic therapy prior to any such procedure or surgery. Clients on warfarin therapy due to the presence of prosthetic valves or for other reasons will have a therapeutically elevated international normalized ratio to inhibit blood clot formation. However, this will place these clients at risk for excessive bleeding during surgical procedures.

The nurse administers lactulose to a client diagnosed with cirrhosis and hepatic encephalopathy. Which nursing action is inappropriate when administering this medication? -assess mental status and orientation -give on an empty stomach for rapid effect -hold if 3 soft stools occur in a day -mix with fruit juice to improve flavor

-hold if 3 soft stools occur in a day --Hepatic encephalopathy is a reversible neurological complication of cirrhosis caused primarily by increased ammonia levels in the blood. Normally, ammonia created in the intestines is converted to urea in the liver and excreted in the kidneys. However, in the presence of liver damage, blood is shunted around the liver portal system and ammonia is able to cross the blood-brain barrier, leading to neurological dysfunction. Lactulose is the most common treatment for hepatic encephalopathy. Lactulose is not digested or absorbed until it reaches the large intestines where it is metabolized, producing an acidic environment and a hyperosmotic effect. In this acidic environment, ammonia is converted to ammonium and excreted rapidly. Lactulose can be given orally with water, juice, or milk or it can be administered via enema. For faster results, it can be administered on an empty stomach. The desired therapeutic effect of lactulose is the production of 2-3 soft bowel movement each day; therefore, the dose is titrated until the therapeutic effect is achieved. This therapeutic dose should not be held but instead should be maintained until the desired outcomes are reached. The client's electrolyte levels should be closely monitored during therapy as lactulose is a laxative that can cause dehydration, hypernatremia, and hypokalemia.

The nurse is working in a busy ED and is assigned 4 clients. Which client should the nurse see first? -client receiving cyclophosphamide reporting bloody urine -client who reports severe N/V after chemotherapy -client with an elbow abrasion and a lip laceration possibly requiring sutures -homeless client who appears drowsy with a temperature of 95 F

-homeless client who appears drowsy with a temperature of 95 F --The client with a low body temperature and drowsiness needs immediate intervention to prevent and/or reverse physiologic compromise. Sins of hypothermia include a core temperature less than 95 F, mental status changes, shivering, and impaired coordination. Alterations in acid-base balance, coagulation values, and cardiac function may also occur. Hypothermia can lead to cardiac and respiratory failure and coma. Homeless clients are at higher risk for hypothermia from exposure to the elements, infections, and poorly managed chronic health conditions. The nurse should anticipate a workup for sepsis and various types of shock, in addition to environmental factors, while addressing this client's hypothermia. --hemorrhagic cystitis is a well-known complication of cyclophosphamide. The client is instructed to drink plenty of fluids. This client may need IV hydration and other preventive measures. Bleeding is usually minimal and occasionally requires a blood transfusion, but is rarely life threatening.

Risk factors for Pelvic inflammatory disease (PID)

-hx of PID -multiple sexual partners -previous STI -unprotected sexual intercourse -placement of an intrauterine device within the past 3 weeks -recent abortion or pelvic surgery

Client education with prostatitis

-hydrate with CLEAR liquids -complete full course of antibiotics -engage in sexual intercourse or masturbation to reduce discomfort (use condoms) - take stool softeners as prescribed to reduce straining during defecation -take sitz baths to help relieve symptoms

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? -hydrocodone 5/325 mg 1 tab every 4 hours PRN for moderate pain -increase continuous IV normal saline rate from 75 to 100 mL/hr -insert nasogastric tube and attach to wall suction -ondansetron 4 mg IVP every 4 hours PRN for nausea

-hydrocodone 5/325 mg 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. S/S include abdominal discomfort, distension, and N/V. Risk factors include abdominal surgery, perioperative medications, and immobility. 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. IV fluid replacement may be necessary to correct losses that occur from nasogastric suction. Nausea is treated with prescribed antiemetics. --The client should not take medications by mouth and opioid medications should be avoided as they prolong paralytic ileus.

Mild-to-moderate increase in the blood lead levels can cause

-hyperactivity/impulsiveness -prolonged low-level exposure causing potential developmental delays, reading difficulties, and visual-motor issues

What are the most specific characteristic signs/symptoms of malignant hyperthermia?

-hypercapnia --generalized muscle rigidity (jaw, trunk, extremities) --hyperthermia (later sign)

Clinical manifestations indicating impending respiratory failure in clients with asthma

-hypercapnia -hypoxemia -paradoxical breathing -mental status changes

A client admitted with severe acute pancreatitis. While obtaining the client's blood pressure, the nurse notices a carpal spasm. What laboratory result would the nurse assess in response to this symptom? -decreased albumin -elevated troponin -hyperkalemia -hypocalcemia

-hypocalcemia --Pancreatitis is an acute inflammation of the pancreas that results in autodigestion. The most common causes are cholelithiasis and alcoholism. Classic presentation includes severe epigastric pain radiating to the back due to the retroperitoneal location of the pancreas. The pancreatic enzymes (amylase and lipase) are elevated. Serious complications to monitor for include hyperglycemia, hypovolemia, latent hypoxia or acute respiratory distress syndrome, peritonitis, and hypocalcemia. Pancreatitis can cause hypocalcemia, but the etiology is unclear. Chvostek's (facial twitching) and Trousseau's (carpal spasm) signs are an indication of hypocalcemia from the decrease in threshold for contraction. Sustained muscle contraction and decreased cardiac contractility are concerns related to hypocalcemia.

S/S of splenic sequestration crisis

-hypotension -rapidly enlarging spleen

Steps for administering a continuous enteral feeding

-identify the client using 2 identifiers and explain the procedure to the client. Perform hand hygiene and apply clean gloves -elevate the HOB > 30 degrees and keep it elevated for at least 30 minutes after feeding to minimize the risk of aspration -validate tube placement by checking the gastric pH as well as assessing the external tube length and comparing it with the measruement at the time of insertion. The tube should be marked at the nostril with a permanent marker during the initial x-ray validation -check gastric residual volume -flush the tube with 30 mL of water after checking residual volume, every 4-6 hrs during feeding, and before/after medication administration -administer the prescribed enteral feeding solution by connecting the tubing and setting the rate on the infusion pump.

Methods to verify tube placement includes

-imaging (x-ray is standard protocol) -gastric content pH testing (typically used to assess for displacement after initial x-ray verification) -air auscultation (not an evidence-based method for placement verification)

Describe stage 1 (mild) stage of Alzheimer disease

-immediate recall affected, distant memories preserved -gets lost easily -trouble remembering words and common objects -difficulty finding words, repetitive -cognitive impairment with progressive decline

The RN delegates to the UAP the ambulation of a client. The RN observes the UAP place the client's Foley bag on the IV pole at the level of the client's chest during the ambulation down the length of the hallway. what action should the RN take initially? -discuss the need for UAP inservice education with the nurse manager -give praise to the UAP for encouraging the client to walk the entire hallway -immediately lower the bag and speak privately to the UAP -let the UAP complete assigned tasks and speak to the UAP at the end of the shift

-immediately lower the bag and speak privately to the UAP --The Foley bag is too high and needs to be lowered. When observing a provider making an error, the RN should immediately intervene to stop any potential harm to the client. It is important to timely correct a staff member who is making a mistake to help ensure that the error is not repeated. Correction of staff should always be done privately, not in front of the client.

The graduate nurse cares for several poststroke clients. Which of the following nursing interventions are appropriate? SATA -implement fall precautions for the client with cerebellar stroke -increase lighting for the client with cranial nerve VII affected -initiate swallow precautions for the client with cranial nerves IX and X affected -place spoon within field of vision for the clinet with homonymous hemianopsia -speak louder in front of the client who has receptive aphasia

-implement fall precautions for the client with cerebellar stroke -initiate swallow precautions for the client with cranial nerves IX and X affected -place spoon within field of vision for the client with homonymous hemianopsia --Strokes causes different neurological deficits depending on the location of the affected area within the brain and the extent of injury. Cerebellar deficits affect balance and equilibrium; fall precautions are appropriate. Cranial nerves IX and X control the gag and swallowing mechanisms, making swallow precautions necessary. Blindness in the same half of each visual field, homonymous hemianopsia, is suspected when clients ignore objects on one side. Initially, the nurse assists, but the client must learn to turn the head to scan the environment. --a stroke affecting cranial nerve VII, the facial nerve, can cause an asymmetrical smile or inability to raise one eyebrow. Increased light is unnecessary as vision is not affected. --clients experiencing receptive aphasia, impair comprehension of speech and writing, typically have injury to the Wernicke area of the brain, located in the left temporal lob. The nurse would not speak louder as this does not aid comprehension.

Key points for continuous subcutaneous insulin infusion therapy?

-important to check blood glucose levels four times a day -administration education on how to give a bolus dose at mealtimes to cover carb intake -how to administer supplemental bolus dose to correct hyperglycemia -the importance for balancing diet and exercise to avoid excess weight gain

What are the best indicators of treatment effectiveness during an acute asthma attack?

-improvement in oxygen saturation -peak expiratory flow

Manifestation of Bell palsy

-inability to completely close the eye on affected side -alteration in tear production d/t weakness of lower eyelid muscle -flattening of the nasofabial fold on the side of the paralysis -inability to smile/frown symmetrically

Manifestations of Bell palsy includes

-inability to completely close the eye on the affected side -alteration in tear production due to weakness of the lower eyelid muscle -flattening of the nasolabial fold on the side of the paralysis -inability to smile or frown symmetrically

The nurse is caring for a client diagnosed with Gullian-Barre syndrome after a recent GI illness. Monitoring for which of the following is a nursing care priority for this client? -diaphoresis with facial flushing -hypoactive or absent bowel sounds -inability to cough or lift the head -warm, tender, and swollen leg

-inability to cough or lift the head --GBS is an acute, immune-mediated polyneuropathy that is most often accompanied by ascending muscle weakness and absent deep-tendon reflexes. Many clients have a hx of antecedent respiratory tract or GI infection. Lower-extremity weakness progresses over hours to days to involve the thorax, arms, and cranial nerves. However, neuromuscular respiratory failure is the most life-threatening complication. Early signs indicating impending respiratory failure includes inability to cough, shallow respirations, dyspnea and hypoxia, and inability to lift the head or eye brows. Assessing the client's pulmonary function by serial spirometry is also recommended. Measurement of forced vital capacity is the gold standard for assessing ventilation; a decline in FVC indicates impending respiratory arrest requiring endotracheal intubation.

Huntington disease

-incurable autosomal dominant disease that causes progressive nerve degeneration, which results in impaired movement, swallowing, speech, and cognitive abilities. --clients who have a parent with this disease should receive genetic counseling

When might water intoxication resulting in hyponatremia occur?

-infants receiving formula that is diluted with water --infants are unable to excrete excess water due to their immature renal systems with a low glomerular filtration rate

The emergency nurse admits a client who was rescued from a burning building. The client's arms and chest are covered with dry, leathery, charred skin that does not blanch. Which new prescription should the nurse implement first? -administer 50-100 mcg fentanyl IV push q30min, PRN for pain -apply topical bacitracin ointment to burn wounds, twice daily -infuse 150 mL/hr lactated ringer solution IV continuously -obtain equipment and prepare client for escharotomy

-infuse 150 mL/hr lactated ringer solution IV continuously ---Burn injuries are caused by direct tissue damage from exposure to caustic sources. These injuries may be life-threatening, depending on the extent of tissue injury and organ damage. To prioritize the initial management of burn injuries, nurses should use the ABCs. Circulatory compromise is common after sustained a burn, as extensive tissue injury combined with the systemic inflammatory response cuases increased capillary permeability, fluid and electrolyte shifts, and decreased intravascular volume. These intravascular losses begin rapidly after a burn and may lead to hypovolemic shock and death. Therefore, the nurse should prioritize initiation of fluid resuscitation

An adult client with altered mental status and fever has suspected bacterial meningitis with sepsis. Blood pressure is 80/60 mm Hg. Which prescribed intervention should the nurse implement first? -administer IV antibiotics -infuse bolus of IV normal saline -prepare to assist with lumbar puncture -transport client for head CT scan

-infuse bolus of IV normal saline --Meningitis is an inflammation of the meninges covering the brain and spinalcord. The key clinical manifestations of bacterial meningitis includes fever, severe HA, N/V, and nuchal rigidity. Other symptoms include photophobia, altered mental status, and other signs of increased ICP. In a hypotensive client with sepsis, the priority of care is fluid resuscitation to increase the client's blood pressure.

An adolescent client seen in the ambulatory care center is going on a one-week fasting regimen of water and juice to jump start weight loss. The nurse's response is based on an understanding of which of the following? -fasting for 7 days is not likely to cause health problems -fasting spares protein in favor of fat metabolism -fasting will help control hunger pangs in the long term -initial weight loss during fasting is primarily from fluid loss

-initial weight loss during fasting is primarily from fluid loss

The nurse receives new prescriptions for a client with right lower quadrant pain and suspected acute appendicitis. Which prescription should the nurse implement first? -administer 0.25 mg hydromorphone IV push for pain -draw blood for CBC and electrolyte levels -initiate IV access and infuse normal saline 100 mL/hr -obtain urine specimen for urinalysis

-initiate IV access and infuse normal saline 100 mL/hr --Appendicitis is inflammation of the appendix and often result from obstruction by fecal matter. Appendiceal obstruction traps fluid and mucus typically secreted into the colon, causing increased intraluminal pressure and inflammation. As appendiceal intraluminal pressure and inflammation increase, blood circulation to the appendix is impaired, resulting in swelling and ischemia. These factors increase the risk for appendiceal perforation, a medical emergency, which may lead to peritonitis and sepsis. When prioritizing care of a client with appendicitis, the nurse should utilize the ABCs. Fluid resuscitation with IV crystalloids is an important intervention aimed at preventing circulatory collapse resulting from fluid losses and NPO status. --blood and urine samples often are prescribed to assist with treatment and care decisions. However, the nurse should prioritize circulatory status over obtaining lab specimens.

The nurse is admitting a client from the post-anesthesia care unit who just received a permanent atrioventricular pacemaker for a complete heart block. Which action should the nurse implement first? -assess incision for bleeding or hematoma formation -auscultate bilateral anterior and posterior lung sounds -initiate continuous cardiac monitoring -reestablish IV fluids and postoperative antibiotics

-initiate continuous cardiac monitoring --When the client arrives in the post-anesthesia care unit after pacemaker placement, the nurse should attach the cardiac monitor to assess the function of the pacemaker. If the atrioventricular pacemaker is working properly, pacer spikes should be visible prior to the P waves and QRS complexes. If the pacemaker is not working properly, the HCP should be contacted immediately. The nurse should also assess for mechanical capture by palpating the client's pulse rate and comparing it with the electrical rate displayed on the cardiac monitor, and check the client's vital signs to assess stability following the procedure.

A client comes to the emergency department reporting alkaline drain cleaner splashed into the eye. The conjunctiva of the affected eye is erythematous, and the client reports a burning sensation. What action is appropriate at this time? -administer PO analgesic medication -cover the affected eye with an eye patch -initiate continuous eye irrigation -perform a Snellen vision test

-initiate continuous eye irrigation --Ocular chemical burns require emergency care to prevent permanent vision loss. Alkali burns are particularly dangerous as they will quickly penetrate deep into the eye, causing severe, irreversible damage. Fr all types of ocular chemical burns, copious eye irrigation with sterile saline or water should begin immediately to flush the chemical irritant out of the eye. Irrigation is continued until the pH of the eye returns to normal (6.5-7.5) , which typically takes 30-60 minutes.

The nurse is planning care for a client experiencing an acute attack of Meniere disease. Which action is a high priority to include in the plan of care? -initiate fall precautions -keep the emesis basin at bedside -provide a quiet environment -start intravenous fluids

-initiate fall precautions --Clients with Meniere disease can have severe vertigo, tinnitus, hearing loos, and aural fullness. It is a priority for the nurse to institute safety measures, such as fall precautions, for these clients. they will require a salt-restricted diet.

A visiting family member of a hospitalized client reports sudden onset of a HA and numbness in half of the body. The visitor asks the nurse to take a blood pressure reading. what is the most appropriate response by the nurse? -encourage the visitor to lie down and see if symptoms change -initiate protocol to assist the visitor to the ED -proceed to take the visitor's blood pressure -suggest that the visitor call the HCP

-initiate protocol to assist the visitor to the ED --Providing care establishes a legal caregiver obligation/relationship between the nurse and the visitor. In the event of a visitor emergency, the nurse should refrain from actions that establish this relationship and instead implement facility protocol to help get the visitor promptly to the ED.

The nurse admits a client with cirrhosis who has an upper gastrointestinal bleed from suspected gastroesophageal varices. Which new prescription should the nurse question? -administer pantoprazole IV piggyback every 12 hours -initiate continuous octreotide IV infusion -insert and maintain a nasogastric tube -maintain NPO status except for PO medications

-insert and maintain a nasogastric tube --Upper GI bleeding is a potentially life-threatening condition commonly caused by bleeding gastroesophageal varices or peptic ulcers. Gastroesophageal varices are distended, fragile blood vessels within the stomach and/or esophagus that frequently occur secondary to cirrhosis. Due to the fragility of these veins, clients are closely monitored for variceal rupture. Rupture of gastroesophageal varices is an emergency complication that rapidly results in massive GO bleeding, hypovolemic shock, and death. Variceal rupture commonly occurs due to a sudden increase in portal venous pressure and from mechanical injury. In upper gastrointestinal bleeding, nasogastric tube insertion may be prescribed for gastric decompression or evacuation. However, nasogastric tube insertion without visualization of the esophagus may traumatize and rupture varices, causing hemorrhage. --Octreotide may be used to help control upper GI bleeding related to bleeding gastroesophgeal varices, as it reduces portal venous pressure, which reduces bleeding.

The nurse is caring for a client after a lumbar puncture. Which client assessment is most concerning and requires a nursing response? -consumes 600 mL liquid over 4 hours -insertion site dressing saturated with clear fluid -observed lying in the right-sided Sim's position -reports a HA rated 6/10

-insertion site dressing saturated with clear fluid --Elevated ICP is a contraindication to performing a lumbar puncture. The client is placed in the fetal position or sitting and leaning over a table. Continued leaking fluid indicates that the site did not seal off and a blood patch is required. --The client should lie flat for atleast 4 hours. The prone or supind position is recommended to help prevent a HA. --5%-30% of clients have the common complication of HA. It is thought to be a result of leakage of fluid through the dural puncture site. The symptom is treated and is normally self-limiting.

The nurse observes a student nurse administer ear drops to an elderly client to help loosen cerumen. The nurse intervenes when the student performs which action? -instills ear drops at room temperature -instills ear drops with dropper by occluding the ear canal -places a cotton ball loosely in outermost auditory canal after the instillation -pulls pinna up and back and instills drops

-instills ear drops with dropper by occluding the ear canal --Otic medications are used to treat infection, soften cerumen for later removal, and facilitate removal of an insect trapped in the ear canal. They are contraindicated in a client with a perforated eardrum.

The nurse is changing the dressing, injection caps, and IV tubing of a client who is receiving total parenteral nutrition through a right peripherally inserted central venous catheter. The nurse should implement what actions to prevent complications during this procedure? SATA -instruct the client to hold the breath when changing the injection caps and tubing -instruct the client to keep the head to the right side during the dressing change -perform hand hygiene before and after the procedure -place the client in the Trendelenburg position before the procedure -wear sterile gloves and a surgical mask when changing the dressing

-instruct the client to hold the breath when changing the injection caps and tubing -perform hand hygiene before and after the procedure -wear sterile gloves and a surgical mask when changing the dressing --Peripherally inserted central venous catheters are commonly used for long-term antibiotic administration, chemotherapy treatments, and nutritional support with total parenteral nutrition. Complications related to the PICC are occulsion of the catheter, phlebitis, air embolism, and infection due to bacterial contamination. Prior to a central line dressing change, the nurse performs hand hygiene. The central line dressing changes is performed using sterile technique with the nurse wearing a mask to prevent contamination of the site with microorganisms or respiratory secretions. During injection cap and tubing changes, the client is instructed to hold their breath to prevent air from entering the line, traveling to the heart, and forming an air embolism. If an air embolism is suspected, the client should be placed in the Trendelenburg position (head down) on the left side, causing any existing air to rise and become trapped in the right atrium

The school nurse is speaking with the parent of a fourth grade student about a bedbug that was found on the child's sweater. The parent confirms that their home is infested but that the issue is being resolved. Which is the best action by the nurse? -instruct the parent to launder the child's clothing and store it in tightly sealed plastic bags -instruct the teacher of the child's classroom to use an insecticide spray -send letters home to all of the children's parents informing them about the finding -send the child home and prohibit school attendance until the infestation has been resolved.

-instruct the parent to launder the child's clothing and store it in tightly sealed plastic bags ---Although full-blown bed bug infestations are uncommon in a school setting, a bed bug brought in on the clothing or possessions of one student could easily "hitch" a ride to another student's home and cause an outbreak there. The most important measure to prevent bed bugs from infesting other students' homes is to prevent the bugs from entering the school in the first place. Laundering clothing in hot water and using the highest temperature setting on a dryer will kill any bed bugs attached to clothes. The clothing should then be stored in tightly sealed plastic bags to prevent additional infestation.

The nurse is assisting the healthcare provider with a lumbar puncture in the client's room. The unit secretary calls over the room intercom and tells the nurse that the lab is on the phone with a critical value report for one of the nurse's other clients. What action should the nurse take? -Ask the unit secretary to write down a message from the lab personnel -instruct the unit secretary to have the charge nurse receive the report -leave the room to talk to the lab on the phone and then return immediately -tell the unit secretary to have lab personnel send a written result

-instruct the unit secretary to have the charge nurse receive the report --A critical value is a result that is significantly abnormal and requires the nurse to contact a provider immediately to initiate appropriate interventions. The nurse should delegate the task to the charge nurse so appropriate interventions can be initiated while the nurse finishes the sterile procedure. This is the option with the least client risk. Timely reporting of critical results is part of the international patient safety goals. A written report may never be received or the nurse may forget to look for it.

The nurse teaches a client diagnosed with iron-deficiency anemia about iron-rich foods. Which meal dose the client choose to indicate that teaching has been effective? -chicken salad with lettuce on French bread, chocolate pudding, and milk -fat-free yogurt, carrot sticks, apple slices, and diet soda -Ham, steamed carrots, green beans, gelatin dessert, and iced tea -kale salad with boiled eggs and dried fruit, a brownie, and orange juice

-kale salad with boiled eggs and dried fruit, a brownie, and orange juice --Clients with iron-deficiency anemia should be taught to eat iron-rich foods such as meats, shellfish, eggs, green leafy vegetables, broccoli, dried fruits, dried beans, brown rice, and oatmeal.

A client has been admitted with a catheter-associated, vancomycin-resistant enterococcal bacteremia. Which interventions should the nurse implement? SATA -keep dedicated equipment for client -perform hand hygiene before exiting the room -place a "no visitors" sign on the client's door -wear a face mask when in the room -wear an isolation gown when providing direct care

-keep dedicated equipment for client -perform hand hygiene before exiting the room -wear an isolation gown when providing direct care --In addition to standard precautions, the client infected with multidrug-resistant organisms will require contact precautions. The client with MRSA or VRE are allowed to have visitors. However, these individuals will need instructions from the nursing staff about hand hygiene and the use of gloves and gowns and their disposal prior to leaving the client's room. A sign should be placed on the client's door to inform visitors about these precautions. A face mask is required for droplet precautions, not contact precautions.

A client with stroke symptoms has a blood pressure of 240/124 mm Hg. The nurse prepares the prescribed nicardipine intravenous infusion solution correctly to yield 0.1 mg/mL. The nurse then administers the initial prescription to infuse at 5 mg/hr by setting the infusion pump at 50 mL/hr. What is the nurse's priority action at this time? -assess hourly urinary output -increase pump setting to correct administration rate to 100 mL/hr -keep systolic blood pressure above 170 mm Hg -monitor for a widening QT interval

-keep systolic blood pressure above 170 mm Hg --A client with an acute stroke presentation requires "permissive hypertension" during the first 24-48 hours to allow for adequate perfusion through the damaged cerebral tissues. However, the blood-brain barrier is no longer intact once the blood pressure is greater than 220/120 mm Hg. Therefore, "mild" lowering is required, usually to a systolic pressure that is not below 170 mm Hg. Nicardipine is a prototype of nifedipine and is a potent calcium channel blocking vasodilator. It takes effect within 1 minute of IV administration. It is essential to monitor that the blood pressure is not being lowered too quickly or too slowly as this would extend the stroke. Hypotension can occur with or without reflex tachycardia. The drug must be discontinued if hypotension or reflex tachycardia occurs. --widening of the QT interval can increase the risk of life-threatening torsades de pointes. It is most commonly seen with haloperidol, methadone, ziprasidone, and erythromycin. However, this is not an expected complication of nicardipine.

A client with Ebola was just admitted to the unit. Which actions by the nurse would represent appropriate care of this client? SATA -ensuring the client wears a N95 respirator at all times -keeping the door the client's room closed at all times -maintaining a log of everyone in and out of the client's room -removing both pairs of gloves before removing gown and mask -restricting visitors from entering the client's room

-keeping the door the client's room closed at all times -maintaining a log of everyone in and out of the client's room -restricting visitors from entering the client's room --Ebola is an extremely disease with a high mortality rate. Clients require standard, contact, droplet, and airborne precautions. The client is placed in a single-client airborne isolation room with the door closed. Visitors are prohibited unless absolutely necessary for the client's well-being. For disease surveillance, a log is maintained of everyone entering or exiting the room, and all logged individuals are monitored for symptoms. Procedures and use of sharps/needles are limited whenever possible. There are currently no medications or vaccines approved by the Food and Drug Administration to treat Ebola. Prevention is crucial.

Interventions to promote safety when using crutches in the home includes:

-keeping the environment free of clutter and remove scatter rugs to reduce fall risk -look forward and not down at the feet, when walking to maintain an upright position -use a small backpack, fanny back, or shoulder bag to hold small personal items -wear rubber or non-skid slippers/shoes without laces -rest crutches upside down on the axilla crutch pads when not in use to prevent them from falling and becoming a trip hazard -keep crutch rubber tips dry and replace them if worn to prevent slipping.

Barriers to self-care include

-knowledge (lack of experience, cognitive abilities) -skills/supplies (lack of dexterity, experience, financial barriers) -motivation (lack of assumed threat to health, denial, hopelessness)

The nurse is caring for a client who performs frequent urinary self-catheterizations. Which of the following client assessments would indicate a potential for a latex allergy? SATA -history of angioedema with lisinopril -history of epilepsy -known allergy to avocados and bananas -known allergy to shellfish -lip swelling when blowing up balloons

-known allergy to avocados and bananas -lip swelling when blowing up balloons --Latex allergy is an exaggerated immune reaction to exposure to latex-containing products. Risk factors include swelling, hives, or itching after exposure to common latex-containing products; certain food allergies (banana, avocado, tomato) and a history of multiple latex exposures.

psychosocial risk factors for failure to thrive

-lack of structured mealtimes -domestic violence -negative attitudes towards food -poverty

A client recovering at home following a left total knee replacement 7 days ago is using a can to go up and down the stairs under the supervision of the home health nurse. Which client action indicates a need for further instruction? -faces forward when going up and down the stairs -holds the cane with the right hand -leads with left leg,follows next with cane, and finally right leg when going up the stairs -places full weigh on left leg when going down the stairs

-leads with left leg,follows next with cane, and finally right leg when going up the stairs --Clients who have had total knee replacement surgery can typically bear full weight by the time of discharge. To reduce the risk of falls, the client should hold the cane on the stronger side and face forward when going up and down the stairs, To ascend the stairs, the client should first step up with the stronger leg, next bear weight on that leg and move the cane, and finally step up with the weaker leg.

The nurse is caring for a client in the immediate postoperative period following a carotid endarterectomy. The client is drowsy with slurred speech. Which assessment finding would cause the nurse to notify the HCP immediately? -diminished gag reflex after endotracheal tube removal -increased agitation level and pulling at linens -left arm drift during bilateral arm extension -responds to verbal commands with eyes closed

-left arm drift during bilateral arm extension --a carotid endarterectomy is a surgical procedure performed to remove plaque from the carotid artery to improve cerebral perfusion. The nurse must closely assess for signs of new or worsening alterations in neurologic status, as surgical manipulation of arteries and blood flow increases the risk of stroke. Monitoring the client's neurologic status post-operatively can --diminished gag reflex is common after anesthesia and endotracheal tube removal. The gag reflex should return as the client awakens. Individuals recovering from anesthesia may have alterations in mood or affect that will resolve as anesthesia wears off. Drowsiness and somnolence during purposeful interactions are expected after anesthesia.

The nurse assesses a client with suspected acute pancreatitis and anticipates the client reporting pain in which anatomical area? -left flank radiating to the left groin area -left upper quadrant radiating to the back -periumbilical area shifting to the right lower quadrant -right upper quadrant radiating to the right shoulder

-left upper quadrant radiating to the back --The client with acute pancreatitis will report a sudden onset of unrelenting, severe pain in the left upper quadrant or midepigastric area of the abdomen that often radiates to the back. The pain is referred to the back as the pancreas is a retroperitoneal organ. Pain improves with leaning forward and worsens with lying flat. The pain is often preceded or made worse by a high-fat meal. N/V are common due to severe pain. Clients are at risk of developing hypovolemia (third spacing of fluids), acute respiratory distress syndrome (due to intense systemic inflammatory response), and hypocalcemia (necrosed fat binding calcium) --kidney stones cause sudden, excruciating pain in the flank, back, or lower abdomen due to stretching of the ureter. The pain will radiate to the groin area --appendicitis presents as periumbilical pain progressing to the right lower quadrant. Tenderness at McBurney's point is present as pressure is applied, and rebound tenderness occurs when pressure is released. -Cholecystitis causes pain in the right upper quadrant that often radiates to the right shoulder area.

The charge nurse in the cardiac intensive care unit responds to a client room where a resuscitation effort is in progress. The client's immediate family member refuses to leave the room. How should the charge nurse handle the situation? -call security to escort the family member to the waiting room have the family member stand or sit in an area that is not in the staff's way -inform the family member that relatives are not allowed in rooms during emergency situations -let the family member stay and assign a staff person to explain what is happening

-let the family member stay and assign a staff person to explain what is happening --The nurse should support a family member who wants to present during the resuscitation of a client. The family member should be allowed to sit or stand in an area that is out of the way of the resuscitation team. A staff member should be assigned to stay with the family member to explain the interventions taking place.

An ED nurse is assigned to triage. Which client should the nurse assess first? -five year old with a superficial leg laceration -lethargic 3 month old with diarrhea for the past 12 hours -seven year old with a elevated temp of 101 F and hematuria -17 year old with severe, acute abdominal pain

-lethargic 3 month old with diarrhea for the past 12 hours --Triaging clients involves decision-making about whose needs/problems are most urgent and create the greatest risk to survival. Two popular frameworks can assist the nurse in making these decisions and setting priorities. In the "first, second, and third" priority level framework, the priority needs progress from the most immediate (first) to the least (third) level of risk. The include: ABCs and IV (first); mental status changes, acute pain, unresolved medical issues, acute elimination problems, abnormal lab values, and risk (second); longer-term issues such as health education, rest, and coping (third)

A female client is admitted to the emergency department after a motor vehicle collision. The client is unresponsive and on a mechanical ventilator. Which actions should the nurse perform? SATA -locate and remove any medication patches -locate possible medical alert band or necklace -remove rings and jewelry and lock in a secure location -remove tampon and replace with menstrual pad -take out contacts if no presence of eye trauma

-locate possible medical alert band or necklace -remove rings and jewelry and lock in a secure location -remove tampon and replace with menstrual pad -take out contacts if no presence of eye trauma --The unconscious client requires a thorough head-to-toe assessment on admission to assess for foreign objects, devices, or belongings that have potential for harm. Medication patches should not be removed without first consulting the healthcare provider. Clients are often prescribed transdermal patches for chronic conditions. Removing and discarding a medication patch without additional information may harm the client.

During assessment of a client who had major abdominal surgery a week ago, the nurse notes that the incision has dehisced and evisceration has occurred. The nurse stays with the client while another staff member gets sterile gauze and saline. How should the nurse position the client while waiting to cover the wound? -low Fowler's position with knees bent -prone to prevent further evisceration -side-lying lateral position -supine with head of the bed flat

-low Fowler's position with knees bent --wound evisceration is the protrusion of internal organs through the wall of an incision. It typically occurs 6-8 days after surgery and is more common in clients who have had abdominal surgery, those with poor wound healing, and those who are obese. IT is considered a medical emergency. The nurse should remain with the client while calling for help. The HCP should be notified immediately and supplies brought to the room by another staff member. The wound should be covered with sterile normal saline dressings. While the nurse remains in the room, the client should be positioned in low Fowler's position with the knees bent.. This position lessens abdominal tension on the suture line and can prevent further evisceration. The client should be prepared for immediate return to surgery.

Home management of nephrotic syndrome

-low sodium diet with attractive foods -infection prevention -fluid restriction for severe edema -monitoring for weight gain and proteinuria to detect release

When assessing a client with cholelithiasis and acute cholecystitis, which findings might the nurse note during the health history and physical examination? SATA -flank pain radiating to the groin -high-protein food ingestion before the onset of pain -low-grade fever with chills -pain at the umbilicus -right upper quadrant pain radiating to the right shoulder

-low-grade fever with chills -right upper quadrant pain radiating to the right shoulder --cardinal symptoms of acute cholecystitis from cholelithiasis include pain in the RUQ with referred pain to the right shoulder and scapula. Clients often report fatty food ingestion 1-3 hours before the initial onset of pain. Associated symptoms include low-grade fever, chills, N/V, and anorexia. During an acute attack, inflammation of the mucous lining and wall of the gallbladder occurs as a result of gallstone obstruction of the cystic bile duct. The inflammation and increased pressure in the gallbladder from the blocked bile duct results in Murphy's sign; palpation over the RUQ causes pain and inability to take a deep breath. Laboratory results show leukocytosis. --it is not dietary protein but food with significant fat content that signals the gallbladder to contract, emptying bile into the duodenum to help digestion. Gallstones normally harmlessly floating around the gallbladder are squeezed into the bile duct, causing the pain of biliary colic. Gallstones stuck further down the bile duct may become colonized by a bacterial infection.

home management instructions for pulmonary artery disease

-lower extremities below heart when sitting/lying down -engage in moderate exercise (30-45 minutes) -perform daily skin care (apply lotion) -maintain warmth w/ blankets/socks -stop smoking -avoid tight clothing and stress -take prescribed vasodilators/antiplatelets

A 70-year old client is admitted to the hospital with a lower GI bleed. After assisting the client back to bed, the nurse finds approximately 600 mL of frank red blood in the commode. The client is now pale and diaphroetic and reports dizziness. Which action should the nurse perform first? -check the vital signs -draw blood for hemoglobin and hematocrit -lower the head of the bed -maintain an IV line with normal saline

-lower the head of the bed --Acute blood loss is a medical emergency, and the nurse needs to carry out interventions rapidly. Lowering the head of the bed or placing the client in the supine position maintains blood perfusion to the brain and other vital organs. This can be done quickly to help stabilize the client before performing other interventions. --assessing and recording vital signs is appropriate after lowering the head of the bed --monitoring hemoglobin and hematocrit levels is appropriate to assess to severity of blood loss and need for possible blood transfusion. Blood loss typically takes a few hours to reflect on the client's laboratory report; thus, not a priority. --ensuring IV access and continuing fluid administration is appropriate. This maintains fluid volume due to blood loss and corrects or reduces potential for hypovolemic shock. Not a priority and can be done after lowering the head of the bed

The nurse is caring for a client with newly prescribed hearing aids. Which of the following actions by the client indicate proper use and care of hearing aids? SATA -keeps hearing aids clean by rinsing them with water -lowers television volume when talking with nurse -places hearing aids on food tray when not in use -turns volume completely down prior to insertion of aid into the ear -verifies that battery compartment is closed before insertion

-lowers television volume when talking with nurse -turns volume completely down prior to insertion of aid into the ear -verifies that battery compartment is closed before insertion --The nurse should ensure that clients with hearing aids understand proper hearing aid use and care. Principles of hearing aid care include: turning volume off and ensuring the battery compartment is shut before insertion; minimizing background noise; cleaning the aids with a soft cloth; keeping the aids in a safe, dry place; and not immersing them in water

The nurse recognizes that which factors place a client at increased risk for falls? SATA -age of 50 -diagnosis of ovarian cancer -lying pulse 80/min, standing pulse 110/min -osteoarthritis of knees -takes carbidopa/levodopa -uses a cane to ambulate

-lying pulse 80/min, standing pulse 110/min -osteoarthritis of knees -takes carbidopa/levodopa -uses a cane to ambulate ----Falls risk does not increase until ages greater than 65-75.

The nurse assesses a client 5 minutes after initiating a blood transfusion. The client has shortness of breath, itching, and chills. The nurse immediately turns of the transfusion and disconnects the tubing at the catheter hub. What action should the nurse take next? -check vital signs -maintain IV access with normal saline -notify the HCP -recheck identification labels and numbers

-maintain IV access with normal saline --During a blood transfusion reaction, the nurse should immediately stop the transfusion and initiate normal saline to maintain IV access and prevent hypotension and vascular collapse.

The nurse is admitting a client with choleslithasis and acute cholecystitis. Suddenly, the client vomits 250 mL of greenish-yellow stomach contents and reports severe pain in the right upper quadrant with radiation to the right shoulder. Which intervention would have the highest priority? -administer promethazine 25 mg suppository -infuse normal saline 100 mL/hr -insert nasogastric tube to low suction -maintain NPO status

-maintain NPO status --the highest priority intervenetion for an actively vomiting with cholelithiasis is maintenance of strict NPO status to avoid additional gallbladder stimulation. Additional collaborative interventions for cholecystitis should also be taken into account. --Promethazine 25 mg suppository is the second priorty. Promethazine promotes the relief of nausea and vomiting and minimizes further fluid loss.

A client is brought to the ED by emergency medical services with a flaccid right arm and leg and lack of verbal response. The stroke alert team is initiated. The nurse takes which priority action? -determine onset of symptoms -ensure that the client has 2 large-bore IV lines -maintain patent airway -prepare for head CT scan

-maintain patent airway --A flaccid extremity and change in verbal ability are symptoms of a stroke, which is considered an emergency. Clients with stroke symptoms are immediately triaged using a special team and set of tools to determine the correct course of action with the goal of preventing further brain damage. In any emergency, the first priority nursing action is to maintain a patent airway. Depending on the mechanism of injury, the symptoms may include changes in airway clearance, which is a priority. The nurse, or another member of the ED or stroke alert team, will prepare the client for an immediate head CT scan to rule out a hemorrhagic stroke and determine the location and extent of the injury. This person will also ensure that the client has 2 large-bore IV lines for rapid infusion of fluids or medications as needed.

Tasks performed for postmortem care

-maintain standard or isolation precautions in place at the time of death -gently close the client's eyes -remove tubes and dressings per policy, unless an autopsy or organ harvest is pending -straighten and wash the body and change the linens. Handle the body carefully, as tissue damage and bruising occur easily after circulation has ceased -leave dentures in place, or replace if removed, to maintain the shape of the face -place a pad under the perineum to absorb any stool or urine leaking from relaxed sphincters -place a pillow under the head to prevent blood from pooling and discoloring the face -remove equipment and soiled linens from the room -give client's belongings to a family member or send with the body.

A client calls the primary care clinic reporting diarrhea for 4 days and a low grade fever. What instruction is most important for the nurse to give to the client? -encourage client to eat bulk-forming foods such as whole grain bread -encourage rest, fluids, and acetaminophen for the fever -make an appointment for the client with the healthcare provider today -take 2 tablets of loperamide followed by 1 tablet after each loose stool.

-make an appointment for the client with the healthcare provider today --Most bouts of diarrhea are self-limiting and lasts <48 hours. Clients experiencing diarrhea that lasts >48 hours or accompanied by fever or bloody stools should be evaluated by a HCP. Causes may include infectious agents, dietary intolerances, malabsorption syndromes, medication side effects, or laxative overuse. The HCP will need to assess for dehydration and electrolyte imbalances and identify underlying causes of the diarrhea that may require further treatment. -Instructions on eating bulk-forming foods may be helpful with diarrhea but does not address the underlying problem causing the diarrhea and fever. -Instructions on rest, fluids, and acetaminophen are helpful and would be the primary choice if the diarrhea had been occurring <48 hours without other symptoms.

The pediatric clinic nurse reinforces culturally competent care at an in-service. Which finding would be inappropriate to include as a common dermatologic effect of alternative medicine therapies? -blistered with a garlic scent near the wrists -circular bruised blemishes on the back -markings appearing to be human bites on the arms -well-like linear lesions on the back

-markings appearing to be human bites on the arms --The culturally competent nurse is aware that some alternative medicine practices of nondominant cultures in North America can present with dermatologic findings. Markings that appear to be human bites would require further follow-up as these are not common in alternative medicine. Although nurses should be aware of various cultural practices, any marks consistent with child abuse should be reported to the appropriate authorities

The nurse is preparing a client who had Roux-en-Y gastric bypass for discharge from the hospital. What information should the nurse plan to include related to the prevention of dumping syndrome? -meals should be small and low in carbohydrate content -fluids should be encouraged with each meal -take a multivitamin with iron and calcium supplements daily -you will need to take your cobalamin injection monthly

-meals should be small and low in carbohydrate content --A RYGB procedure uses a small proximal portion of the stomach to create a gastric pouch that is anastomosed to the Roux limb of the small intestine, bypassing most of the stomach and a portion of the duodenum. Dumping syndrome, the rapid emptying of gastric contents into the small intestine, is a potential complication. The presence of a large quantity of hyperosmolar intestinal contents causes fluids to shift out of the vascular system into the intestines, leading to symptoms such as N/V, diarrhea, weakness, and hypotension. To prevent dumping syndrome, clients should eat multiple small meals, eat a low-carbohydrate diet, and separate their consumption of food and fluids.

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

-median vein of the right forearm --The client's medical history should be reviewed prior to starting an IV line so that the nurse can identify any contraindications to specific anatomical sites. Lymph node removal during a mastectomy may affect lymphatic fluid drainage on the affected side and cause lymphedema or other complications such as infection, venous thromboembolism, or trauma to the affected arm. The nurse must avoid an needlesticks, IV insertions, or blood pressure measurements in the affected arm. The nondominant side is preferred when no medical contraindications exist. However, in this case, the right forearm is best because the client has a left-sided mastectomy. Other dialysis sites, areas distal to old puncture sites, bruised areas, painful areas, or areas with skin conditions or signs of infection.

What are some examples requiring unit quality improvement?

-medications prescribed STAT not being available in a timely manner -catheter-associated bacterial infections are increasing within the unit

Proper hearing aid use and care includes

-minimize distracting sounds during conversation to enhance effectiveness -turn the volume off prior to insertion, then gradually turn up the volume to a comfortable level -to adjust to the new hearing aids, initially wear them for a short time and gradually increase length of wear time -do not wear the hearing aids when using hair dryers or heat lamps -regularly check that the battery compartment is clean, the batteries are inserted correctly, and the compartment is shut before insertion -remove the battery at night and when the aid is not in use to extend battery life

Special techniques to utilize when caring for a patient with dysphagia includes:

-modification of food consistency (pureed, mechanically altered, soft) -thickened liquids -having client sit upright at 90-degree angle -placing food on the stronger side of the mouth to aid in bolus formation -tilting the neck slightly to assist with laryngeal elevation and closure of the epiglottis

The nurse is caring for a client with an acute ischemic stroke who has a blood pressure of 178/95 mm Hg. The HCP prescribes as-needed antihypertensives to be given if the systolic pressure is >200 mm Hg. Which action by the nurse is most appropriate? -give the antihypertensive medication -monitor the blood pressure -notify the HCP -question the prescription

-monitor the blood pressure --An ischemic stroke is a loss of brain tissue perfusion due to blockage in blood flow. Elevated blood pressure is common and permitted after a stroke and may be a compensatory mechanism to maintain cerebral perfusion distal to the area of blockage. This permissive hypertension usually autocorrects within 24-48 hours and does not require treatment unless the hypertension is extreme (Systolic pressure >220 mm Hg or diastolic blood pressure >120 mm Hg) or contraindicated due to the presence of another illness requiring strict blood pressure control. A blood pressure of 178/95 mm Hg should be monitored, along with the client's other vital signs and status.

What is the focus of care for a client with acute glomerulonephritis?

-monitoring blood pressure, specifically blood pressure, and fluid status. --salt should be avoided in the diet

What is the scope of practice for an LPN/LVN?

-monitoring findings of RN -reinforcing education -routine procedures -most medication administrations -ostomy care -tube patency and enteral feeding -specific assessments ( lung sounds, bowel sounds, neurovascular checks)

Common S/E of clomiphene

-mood swings -nausea -hot flashes -HA

Describe Amyotrophic lateral sclerosis

-motor neuron degeneration in the brain and spinal cord occur, resulting in fatigue, progressive muscle weakness, twitching, and muscle spasms, difficulty swallowing, difficulty speaking, and respiratory failure. --most people live 3-5 years

Fine motor developmental milestone for 6-9 month old

-moves objects between hands -uses crude pincer grasp

S/S of cardiac tamponade

-muffled heart tones -compression of the heart increases, resulting in hypotension -tachypnea -tachycardia -jugular vein distention -narrowed pulse pressure -presence of pulsus paradoxus

The nurse is caring for a client in the medical-surgical unit who has delirium according to the Confusion Assessment Method assessment tool. Which of the following assessment findings are likely contributing to the client's delirium? SATA -multiple doses of IV hydromorphone administered in the past 12 hours -serum sodium of 123 mEq/L -SpO2 of 82% on room air -temperature of 103.1 F -urine culture positive for gram-positive cocci in chains

-multiple doses of IV hydromorphone administered in the past 12 hours -serum sodium of 123 mEq/L -SpO2 of 82% on room air -temperature of 103.1 F -urine culture positive for gram-positive cocci in chains --Nursing interventions include treating the underlying cause as prescribed to resolve delirium, maintaining a safe environment, reorienting the client frequently, promoting a regular sleep cycle, providing familiar items from hone, and encouraging family and friends to stay with the client.

Treatment for fibromyalgia

-muscle relaxers (cyclobenzaprine) -narcotic analgesics (tramadol, hydrocodone) -NSAIDs (ibuprofen, naproxen, celecoxib) -neuropathic pain relievers (pregabalin, gabapentin0 -antidepressants= SSRIs (fluoxetine, duloxetine) -tricyclic antidepressants (amitriptyline)

Indications for spinal immobilization (think NSAIDs)

-neurological exam; experiences numbness and decreased strength -significant traumatic mechanism of injury -alertness (disoriented or decreased LOC) -intoxication (impaired decision making; lack of awareness to pain) -distracting illness/injury (another significant injury could distract from spine injury) -spinal exam (point tenderness over spine or neck pain on movement)

The nurse receives report on the assigned team of clients on the oncology unit. All are receiving chemotherapy. Which client should the nurse check on first? -alopecia and oral mucositis noted on assessment -morning hemoglobin result is 8 g/dL -new-onset back pain and weakness in legs -persistent vomiting and potassium result is 3.4 mEq/L

-new-onset back pain and weakness in legs --A new onset finding is more concerning than chronic or expected findings. There is a risk of spinal cord compression from a metastatic tumor in the epidural space. The classic symptoms are localized, persistent back pain; motor weakness; and sensory changes. There can also be autonomic dysfunction, reflected by bowel or bladder dysfunction. Neurologic changes are a priority because the symptoms are subtle and time sensitive for permanent negative outcomes. Bone is a common site for metastasis due to its vascularity. This is the highest risk of the 4 options.

Thrombotic thrombocytopenic purpura is suspected due to the client's current platelet count of 2,000/mm3. Which client sign or symptom is the most concerning and requires immediate further nursing action? -current oozing epistaxis -ecchymosis on leg since yesterday -new-onset confusion -reported history of hematuria

-new-onset confusion --A priority assessment in a client with low platelets is any change in level of consciousness. This can indicate intracranial bleeding and increased intracranial pressure.

The acute care clinic nurse administers a prescribed narcotic for a client with renal colic and then discharges the client without ensuring that the client has a designated driver. The client is subsequently involved in a motor vehicle accident causing injury to self and others. Which ethical principle did the nurse violate? -autonomy -nonmaleficence -paternalism -veracity

-nonmaleficence --Nonmaleficence is the ethical principle of doing no harm

Client teaching for von Willberand disease includes:

-notify HCP of signs of bleeding -use a humidifier or nasal spray to keep mucosa moist, reducing nosebleeds -avoid aspirin and NSAIDs -maintain gum integrity to minimize bleeding -report heavy menstrual bleeding, which can be managed with hormonal therapies and intranasal desmopressin

The nurse assesses a client who is 2 days postoperative breast reconstruction surgery. The client has 2 closed-suction Jackson Pratt bulb drains in place. There is approximately 10 mL of serosanguineous fluid in each one. One hour later, the nurse notices the bulbs are full of bright red drainage and measures a total output of 200 mL. What is the nurse's priority action? -notify the HCP -open the collection bulb to release excessive negative pressure -record the amount in the output record as wound drainage -reposition the client on the right side

-notify the HCP --Although it depends on the type of surgical procedure performed, about 80-120 mL of serosanguineous or sanguineous drainage per hour for the first 24 hours following surgery can be expected. The nurse should notify the HCP if the drainage in the Jackson-Pratt closed-wound drainage device changes from serosanguineous to sanguineous and if the amount increases significantly after the first 24 hours following surgery.

A client is admitted to the hospital for severe HAs. The client has a hx of increased ICP, which has required lumbar punctures to relieve the pressure by draining cerebrospinal fluid. The client suddenly vomits and states, "That's weird, I didn't even feel nauseated." Which action by the nurse is the most appropriate? -document the amount of emesis -lower the head of the bed -notify the HCP -offer anti-nausea medication

-notify the HCP --Unexpected and projectile vomiting without nausea can be a sign of increased ICP, especially in the client with a hx of increased ICP. The unexpected vomiting is related to pressure changes in the cranium. The vomiting is related to pressure changes in the cranium. The vomiting can be associated with HA and gets worse with lowered head position. The most appropriate action is to obtain a full set of vital signs and contact the HCP immediately.

The nurse is caring for a debilitated client with a percutaneous endoscopic gastrostomy tube that was inserted 3 days ago for the long-term administration of enteral feedings and medications. While the nurse is preparing to administer the feeding, the tube becomes dislodged. What is the most appropriate intervention? -insert a Foley catheter into the existing tract and inflate the balloon -insert a small-bore nasointestinal tube to administer feedings and medications -notify the HCP who inserted the PEG tube -reinsert the PEG tube into the existing tract immediately

-notify the HCP who inserted the PEG tube --A PEG is a minimally invasive procedure performed under conscious sedation. Using endoscopy, a gastrostomy tube is inserted through the esophagus into the stomach and then pulled through an incision made in the abdominal wall. To keep it secured, the PEG tube has an outer bumper and an inner balloon or bumper. The tube's tract begins to mature in 1-2 weeks and is not fully established until 4-6 weeks. It begins to clsoe within hours of tube dislodgement. The nurse should notify the HCP who placed the PEG tube as early dislodgement (less than 7 days from placement) requires either surgical or endoscopic replacement. --the insertion of a Foley catheter or immediate reisertion of the PEG tube should not be attempted because the tube's tract is only 3 days old (immature). A reinserted tube could be placed inadvertently into the peritoneal cavity, leading to serious consequences such as peritonitis and sepsis. Therefore, these are not the most appropriate interventions. --Small-bore nasointestinal tubes are used for short-term rather than long-term administration of enteral feedings. They are prone to clogging from enteral feedings, undissolved medications, and inadequate tube flushes. They can also kink, coil, and become dislodged by coughing and may require frequent reinsertion. Therefore, they are not the most appropriate intervention.

The 70-year-old client with type 2 diabetes and hypertension is scheduled for ureteral stent removal in 2 hours. The preoperative protocol ECG is done in the inpatient unit, and results indicate a "possibly acute" ST segment elevation. What action is most important for the nurse to take? -document the test results on the preoperative checklist -notify the healthcare provider about the test results -place the printed ECG in the front of the chart -report the results to the surgical nurse to tell the surgeon

-notify the healthcare provider about the test results --this is a high-risk client and the acute, new, significant finding needs further evaluation and possible intervention before undergoing the stress of surgery. In addition, clients with a long history of diabetes often have associated neuropathy and may not experience the chest pain typical of myocardial infarction, known as silent MI. As a result, the nurse must ensure that the healthcare provider is made aware of this client's new findings in a timely manner

The nurse is caring for a 4 year old child in the ER who has a 104 F temperature, is obtunded, and has a positive Kernig's sign. The parents are refusing antibiotics and any treatment. The parents state that their religious belief is to trust in just prayer and believe the child will receive divine healing. What action does the nurse anticipate? -assisting the parents in signing AMA papers -discharging the child if parents have power of attorney papers -notifying the hospital administration about the situation -reassuring the parents that their decision will be respected under the principle of autonomy

-notifying the hospital administration about the situation --A competent adult has the right to make any decisions regarding the client's health care, even if the provider does not believe it is in the client's best interest. However, parents do not have the right to place their minor child in a life-threatening position. Parents have legal authority to make choices about their child's health care, but not when they do not permit life-saving treatment or when there is a potential conflict of interest, such as child abuse or neglect. The hospital will seek court-appointed custody to treat this child who is seriously ill with dangerously high temperature and signs of severe neurologic deficit. Bacterial meningitis presents with high fever, change in LOC, nuchal rigidity, and meningeal signs. Ethical principle of autonomy is deciding for oneself. In this case, the child's best interest is priority and the legal authority takes precedent

A client is hospitalized for a broken leg. The client has a hx of breast cancer and is receiving outpatient chemotherapy; the last infusion was about a week ago. Which staff members can safely care for this client? SATA -nurse floated from another medical-surgical floor -nurse who is 24 weeks pregnant -nurse with erythematous rash and honey-color crusts on the hands -UAP who just received yearly injectable flu vaccination -UAP with a cold

-nurse floated from another medical-surgical floor -nurse who is 24 weeks pregnant -UAP who just received yearly injectable flu vaccination --clients who are immunosuppressed from chemotherapy should not be cared for by a HCP who is infectious

Which of the following are violations of protected clinical health information? SATA -client overhears the nurse give report on the client's roommate through the room curtain -nurse calls a client by the first and last name in the public waiting room -nurse gives a pregnancy result to the client's partner without the client's permission -nurse tells the transporting tech that the client has breast cancer -UAP tells a discharged client, "You take care now"

-nurse gives a pregnancy result to the client's partner without the client's permission -nurse tells the transporting tech that the client has breast cancer --The HIPAA and PIPEDA requirements related to protected health information include not giving results to a spouse without permission or telling a client diagnosis to an employee who does not need to know it. It is not a violation to call clients by their names, have information overheard inadvertently, or indicate well wishes. A client overhearing report through a privacy curtain is inadvertent communication and is not considered a violation

correct order for assessing infants

-observe -auscultate -palpate -perform traumatic procedures (examine eyes, ears, mouth) --LAST is moro reflex

What can cause leakage of urine from the insertion site of an indwelling urinary catheter?

-obstruction (clots/sediment) -kinking/compression of catheter tubing -bladder spasms -improper catheter siz

The nurse admits a client who fell of a 20 ft ladder. On arrival in the ED, the client is arousable but lethargic. What is the nurse's priority action? -ask about client's chronic medical conditions -assess for level and duration of pain -obtain a GCS score -perform a head-to-toe assessment

-obtain a GCS score --After trauma to a client, the nurse performs an emergency or trauma assessment that includes a primary and secondary survey. The primary assessment determines the status of the airway, breathing, and circulation. Next, the nurse evaluates disability of neurological function using the GCS. The GCS measures the client's LOC by assessing the best eye opening response, best verbal response, and best motor response. The lower the GCS score, the higher the risk for the client to develop complications.

The nurse is planing care for a client with suspected stroke who has just arrived at the ED with slurred speech, facial drooping, and right arm weakness that began 1 hour ago. Which of the following interventions should the nurse anticipate including in the initial plan of care? SATA -arrange for a speech pathologist consult -discuss community resources with family -obtain a STAT CT scan of the head -perform a baseline neurologic assessment -prepare to initiate alteplase within the next 3 hours

-obtain a STAT CT scan of the head -perform a baseline neurologic assessment -prepare to initiate alteplase within the next 3 hours --Strokes may be either ischemic or hemorrhagic. Ischemic stroke occurs when circulation to parts of the brain is interrupted by occlusion of cerebral blood vessels by a thrombosis or embolus. Hemorrhagic stroke occurs when a cerebral blood vessel ruptures and bleeds into the cranial vault. Both types of stroke result in brain tissue death without prompt treatment. A client with stroke symptoms must have an immediate CT scan or MRI of the head to determine the type and location of the stroke. Determining exactly when symptoms began is essential for diagnosis and planning treatment. Thrombolytic therapy is used to dissolve blood clots and restore perfusion to brain tissue in clients with an ischemic stroke unless contraindicated. It must be administered within 4.5 hours from onset of symptoms. A baseline neurologic assessment is essential for tracking ongoing neurologic symptoms that indicate improvement or complications which guide later treatments. --Consultation with a speech pathologist and providing the family with information about community resources are important later but not during the initial phase of stroke management.

Which nursing interventions would the nurse implement when caring for a client newly diagnosed with acute, viral hepatitis B? SATA -offer small, frequent meals to prevent nausea -promote rest periods between periods of activity -provide a diet high in fat and low in carbs -teach the client not to share razors or toothbrushes with others -teach the client to abstain from drinking alcohol

-offer small, frequent meals to prevent nausea -promote rest periods between periods of activity -teach the client not to share razors or toothbrushes with others -teach the client to abstain from drinking alcohol --Hepatitis is often caused by infection, toxins, or trauma resulting in impairment of liver function. Nursing interventions for clients with acute viral hepatitis includes: alternate periods of rest and activity to reduce metabolic demands and avoid fatigue; avoid hepatotoxins as they worsen injury to liver cells; medications metabolized in the liver should be used cautiously to allow hepatocytes to head; encourage a low fat, small, frequent meals to decrease nausea and promote intake in clients with anorexia--anorexia is lowest in the morning so promote eating a larger breakfast; provide oral care and avoid extremes in food temperature to increase appetite; promote water consumption and diets adequate in carbohydrates and calories; hepatitis B is transmitted through sexual contact and infected blood, therefore a condom should be used during sexual intercourse; clients should not share razors or toothbrushes

The nurse is caring for a 2-year-old who is refusing oral antibiotics. What is the nurse's next action? -ask the healthcare provider to switch to IV antibiotics -hide the antibiotic in the child's favorite food or beverage -offer the child a choice of orange or apple juice with the antibiotic -tell the child that the medication tastes just like candy

-offer the child a choice of orange or apple juice with the antibiotic --The need for control is common during the toddler stage of psychosocial development, and administering oral medications can be challenging. The nurse should offer the toddler limited choices and avoid questions that require a yes or no response. Medication should not be referred to as candy as this increases the risk for a toxic ingestion.

A nurse is caring for a client with blindness due to diabetic retinopathy. Which interventions should the nurse implement for this client? SATA -ask a family member about the client's preferences for room arrangement -offer the client an elbow to hold, and walk a half-step ahead for guidance -say"goodbye" when leaving the room to help orient the client -speak slowly and slightly louder so the client can understand -use a clock-face pattern to explain food arrangement on the client's meal tray

-offer the client an elbow to hold, and walk a half-step ahead for guidance -say"goodbye" when leaving the room to help orient the client -use a clock-face pattern to explain food arrangement on the client's meal tray ---When caring for a client who is blind, the nurse should create a safe therapeutic environment and foster client independence by orienting the client to the surroundings, announcing room entry and exit, guiding the client by offering an elbow and walking slightly in front, using a clock-face description to orient the client to the location of objects, and asking the client directly about preferences.

Symptoms of ovarian cancer

-often subtle --bloating --early satiety --urinary symptoms (pressure on bladder and pelvic pressure)

Treatment of pertussis

-oral antibiotics -droplet precautions -supportive measures (humidified O2 and oral fluids)

What are some rapidly proliferating cells commonly first affected by radiation and chemotherapy?

-oral mucosa -GI tract -bone marrow

Describe cooperative play. At what age does this occur?

-organized, rule-oriented, leader/follower relationship --school-aged

Standard fall risk precautions

-orientation to room and call light -call light within reach -bed in lowest position -uncluttered room -nonslip socks or shoes -well-lit room -belongings within reach

Long-term use of PPIs (-zole) is associated with what type of symptoms?

-osteoporosis -C. diff infection -pneumonias --clients should be encouraged to increased calcium and vitamin D intake

Pharmacologic treatment for acute asthma

-oxygen to maintain saturation >90% -high-dose inhaled short-acting beta agonist (albuterol or levalbuterol) -anticholinergic agent (ipratropium) -nebulizer treatments Q 20 minutes -systemic corticosteroids (Solu-medrol) to control inflammation

A client with a C3 spinal cord injury has a HA and nausea. The client's blood pressure is 170/100 mm Hg. How should the nurse respond initially? -administer PRN analgesic medication -adminsiter PRN antihypertensive medication -lower the HOB -palpate the client's bladder

-palpate the client's bladder --Autonomic dysreflexia is an acute, life-threatening response to noxious stimuli, which clients with spinal cord injuries above T6 are unable to feel. Signs and symptoms include hypertension, bradycardia, a pounding headache, diaphoresis, and nausea. It is essential that the nurse assess for and remove noxious stimuli to prevent a stroke. Noxious stimuli may include bladder distention, fecal impaction, and tight clothing.

The nurse is caring for an elderly client after hips replacement surgery. The client is distressed because he has not had a bowel movement in 3 days. Which action by the nurse would be most appropriate? -administer the prescribed as-needed milk of magnesia -ask dietary services to add more fruits and vegetables to the client's tray -notify the healthcare provider -perform a focused abdominal assessment

-perform a focused abdominal assessment ---Constipation may be a side effect of anesthesia, pain medication, physiological stress, and/or immobility. The nurse's first priority is to assess the client and then use measures that promote normal bowel function. The HCP is contacted if the focused abdominal assessment indicates a potential complication, such as postoperative ileus,

Steps for removing an indwelling catheter include the following

-perform hand hygiene -ensure privacy and explain the procedure to the client -apply clean gloves -place a waterproof pad underneath the client -remove any adhesive tape or device anchoring the catheter -follow specific manufacturer instructions for balloon deflation -loosen the syringe plunger and connect the empty syringe hub into the inflation port -deflate the balloon by allowing water to flow back into the syringe naturally, removing all 10 mL -remove the catheter gently and slowly; inspect to make sure it is intact and fragments were not left in the client -if any resistance is met, stop the removal procedure and consult with the urologist for removal -empty and measure urine before discarding the catheter and drainage bag in the biohazard bin or according to hospital policy -remove gloves and perform hand hygiene

The general steps for preparing the sterile field for a wet-to-damp dressing change:

-perform hand hygiene -open a sterile gauze package that has a partially sealed edge with ungloved hands by grasping both sides of the edge, one with each hand, and pull them apart while being careful not to contaminate the gauze. -hold the inverted opened gauze package 6 inches above the waterproof sterile field so it does not touch the field, and then drop the gauze dressing onto the sterile field -place the sterile dressings on the sterile field 2 inches from the edge; the 1 inch margin at each edge is considered unsterile because it is in contact with unsterile surfaces -use sterile NSS from a recapped bottle that was opened <24 hours ago

The nurse is drawing a blood specimen from a client's central line. Identify the steps necessary to prevent transmission of infection while performing this procedure? SATA -discard the first 6-10 mL of blood drawn from the line -flush the line with sterile normal saline before and after collection -perform hand hygiene -place the specimen in a biohazard bag -scrub the catheter hub with antiseptic prior to use

-perform hand hygiene -place the specimen in a biohazard bag -scrub the catheter hub with antiseptic prior to use --Blood and bodily fluids are considered hazardous materials and must be placed in containers identifying them as biohazards. This alerts staff to take the necessary precautions to prevent infection transmission when handling the specimen. An appropriate antiseptic scrub of the catheter hub prior to use inhibits microorganism entry and prevents transmission of infection to the client. When drawing a blood specimen from a central line, the nurse should discard the first blood drawn to prevent an inaccurate lab result, but this will not prevent the transmission of infection. Flushing the line prior to specimen collection will clear any previous infusions and assist in checking patency. It is important to flush the line after collection to remove blood and prevent clotting. Neither action prevents infection transmission.

Steps to administering otic medications

-perform hand hygiene -position the client side-lying with the affected ear up -pull pinna up and back -administer prescribed number of ear drops -instruct the client to remain side-lying for 2-3 minutes -place cotton ball loosely in the outer ear canal for 15 minutes

General procedure for emptying the JP drainage device

-perform hand hygiene -pull the plug on the bulb (opens the device) -pour the drainage into a small, calibrated container -empty the device every 4-12 hours (unless 1/2 or 2/3 full) ----as the small capacity bulb fills, the amount of negative pressure in the bulb decreases. -compress the empty bulb by squeezing it from side-to-side with 1 or 2 hands until it is totally collapsed. -clean the spout on the bulb with alcohol and replace the plug when it is totally collapsed to restore negative pressure.

Steps for inserting a NG tube for gastric decompression includes:

-perform hand hygiene and apply clean gloves -place client in high Fowler's position -assess nares and oral cavity and select naris -measure and mark the tube -curve 4-6 inches tube around index finger and release -lubricate end of tube with water-soluble jelly -instruct client to extend neck back slightly -gently insert tube just past nasopharynx, aiming tip downward -rotate tube slightly if resistance is met, allowing rest periods for client -continue insertion until just above oropharynx -ask client to flex head forward and swallow small sips of water -advance tube to marked point -verify tube placement and anchor.

Wound cultures are obtained through:

-perform hand hygiene and apply clean gloves. -remove the old dressing. remove and discard gloves -perform hand hygiene and apply sterile gloves -assess wound bed. Cleanse wound bed and surrounding skin with NS -remove and discard gloves. perform hand hygiene and apply clean gloves. -gently swab the wound bed with a sterile swab from the wound center toward the outer margin. -avoid contact with skin at the wound edge as it can contaminate the specimen with skin flora -place swab in sterile specimen container; avoid touching the swab to the outside of the container -apply prescribed topical medication after obtaining cultures to prevent interference with microorganism identification -apply new dressing -remove and discard gloves and perform hand hygiene. -label specimen and document the procedure

Steps for reconstituting powdered medication for parenteral administration

-perform hand hygiene and don clean gloves -withdraw an amount of air from the vial equal to the prescribed amount of diluent to create negative pressure that will be equalized when the diluent is injected into the vial. -inject the appropriate diluent into the vial. -roll the vial between the palms of the hands to gently mix the solution. Avoid shaking the vial as bubbles may develop. -withdraw the reconstituted medication from the vial into a sterile syringe for administration. -verify the dosage by checking the prepared medication against the medication administration record and medication label -label the syringe with the medication name and dosage to prevent medication errors at the bedside

Correct clean catch collection method for a female client

-perform hand hygiene and open the specimen container, leaving the sterile side of the collection lid positioned upward to prevent contamination -spread the labia using the index finger and the thumb of the nondominant hand so that the specimen cup can be held with the dominant hand -cleanse the vulva in a front-to-back motion with provided antiseptic wipes, using a new towelette with each wipe to prevent contamination -initiate the urinary stream to flush any remaining microorganisms from the urethral meatus before passing the container into the stream for the collection of 30-60 mL of urine -remove the specimen container from the stream before the urinary flow ends and the labia are released to prevent contamination -replace the sterile cap without contaminating it and repeat hand hygiene

The UAP notifies the charge nurse that the client told the UAP that the client is feeling short of breath. What should the charge nurse do first? -activate a rapid response team -ask the UAP to take vital signs and report back -notify the client's assigned LPN to assess the client -personally go and auscultate the client's lung

-personally go and auscultate the client's lung --when an RN receives a report of a client complaint that is potentially ominous from a staff member of lesser qualifications, the RN should personally assess the client. This is the primary nursing assessment that will be use to decide if an urgent need exists and a change in the nursing plan of care is needed.

A client with polycythemia vera comes to the clinic for a monthly treatment. The nurse knows that the treatment for this condition will consist of which of the following? -blood transfusion -fluid bolus -phlebotomy -steroid injection

-phlebotomy --Treatment of PV usually includes periodic phlebotomy, the removal of 300-500 mL of blood through venipuncture, to reduce the RBC count and achieve a hematocrit <45%. Initially, clients may require phlebotomy every other day until hematocrit is reached. Hematocrit is then monitored monthly, and additional blood draws are performed as necessary.

A homeless man known to have chronic alcoholism and who has not eaten for 8 days in undergoing nutritional rehabilitation via oral and enteral feedings. Which of the following findings would indicate that the client is developing refeeding syndrome? -phosphorus 2.0 mg/dL, potassium 2.9 mEq/L, magnesium 1.0 mEq/l -phosphorus 4.0 mg/dL, potassium 3.5 mEq/L, magnesium 2.0 mEq/L -random blood glucose 60 mg/dL, sodium 120 mEq/L, calcium 7.0 mg/dL -random blood glucose 100 mg/dL, sodium 140 mEq/dL, calcium 10.0 mg/dL

-phosphorus 2.0 mg/dL, potassium 2.9 mEq/L, magnesium 1.0 mEq/l --Refeeding syndrome is a potentially lethal complication of nutritional replenishment in significantly malnourished clients and can occur with oral, enteral, or parenteral feedings. After a period of starvation, carbohydrate-rich nutrition stimulates insulin production along with a shift of electrolytes from the blood into tissue cells for anabolism. The key signs of refeeding syndrome are rapid declines in phosphorus, potassium, and/or magnesium. Other findings may include fluid overload, sodium retention, hyperglycemia, and thiamine deficiency.

What are examples of when an incident report would be required?

-physical, verbal, or sexual assault occurs in the health facility -clients falls, with or without occurring injuries -staff or visitor falls, regardless of acceptance/refusal of treatment -failure to obtain/intervene upon results of diagnostic procedures -inadequate/delayed diagnosis and monitoring -delay, omission, or incorrect performance/administration of prescribed therapies/medications -hospital equipment failure

The nurse prepares to administer IV albumin to a client with severe liver disease who has a low serum albumin level of 1.5 g/dL. Which characteristic finding associated with hypoalbuminemia should the nurse anticipate assessing? -altered mental status -easy bruising -loss of body hair -pitting edema

-pitting edema --Oncotic pressure is a form of osmotic pressure exerted by plasma proteinsin the blood that pulls water into the circulatory system. Albumin is a large plasma protein that remains in the vascular compartment. Albumin plays a role in maintaining intravascular oncotic pressure and prevents fluid from leaking out of the vessels. Clients with severe liver disease can develop hypoalbuminemia because the liver manufactures albumin, and damaged hepatocytes are unable to synthesize it. When serum albumin is low, oncotic pressure decreases and fluid leaks from the intravascular compartment into the interstitial spaces, causing pitting edema of the lower extremities, periorbital edema, and ascites. --all other options are manifestations of liver disease. Altered mental status is due to elevated serum ammonia levels. Easy bruising is caused by an inability to produce prothrombin and other clotting factors. Loss of body hair is due to altered hormone metabolism.

The nurse is caring for a client with cirrhosis. Assessment findings include ascites, peripheral edema, SOA, fatigue, and generalized discomfort. Which interventions would be appropriate for the nurse to implement to promote the client's comfort? SATA -encourage adequate sodium intake -place client in semi-Fowler position -place client in Trendelenburg position -provide alternating air pressure mattress -use music to provide a distraction

-place client in semi-Fowler position -provide alternating air pressure mattress -use music to provide a distraction --In a client with cirrhosis and ascites, discomfort is often due to pressure of the fluid on the surrounding organs. SOA occurs due to the upward pressure exerted by the abdominal ascites on the diaphragm, which restricts lung expansion. Positioning the client in semi-Fowler or Fowler position can promote comfort, as this position can reduce the pressure on the diaphragm. In semi-Fowler position, the head of the bed is elevated 30-45 degrees. Side-lying with the head elevated can also be a position of comfort for the client with ascites as it allows the heavy, enlarged abdomen to rest on the bed, reducing pressure on internal organs and allowing for relaxation. Meticulous skin care is a priority due to the increased susceptibility of skin breakdown from edema, ascites, and pruitus. It is important to use a specialty mattress and implement a turning schedule of every 2 hours. A distraction can take the client's mind off the current symptoms and may also help promote comfort in many different situations. Some of these distractions include listening to music, watching television, playing video games, or taking part in hobbies. --Client with ascites and peripheral edema should decrease their fluid or sodium intake, not increase. In Trendelenburg position, the bed is tilted with the head lower than the legs. This position is contraindicated in the client with ascites, as it may exacerbate SOA by causing the abdominal ascites to push upward on the diaphragm, restricting lung expansion.

Steps for suctioning the tracheostomy tube

-place client in semi-fowler position, if not contraindicated, to prevent hypoxemia and microatelectasis -preoxygenate with 100% oxygen to prevent hypoxia and microatelectasis -insert the catheter gently the length of the airway without applying suction to prevent mucosal tissue damage. -withdraw the catheter slightly if resistance is felt at the carina to prevent mucosal tissue damage -apply intermittent suction while rotating the suction catheter during withdrawal to prevent mucosal tissue damage. Limit suction time to 5-10 seconds with each suction pass to prevent mucosal tissue damage and limit hypoxia.

The procedure for measurement of pulsus paradoxus:

-place client insemirecumbent position -have client breath normally -determine SBP using manual BP cuff -inflate BP cuff to at least 20 mm Hg above the previously measured SBP -deflate the cuff slowly, noting the first Korotkoff sound during expiration along with the pressure -continue to slowlu deflate the cuff until you hear sounds throughout inspiration and expiration; note the pressure -determine the difference between the two measurements in steps 5 and 6; this equals the amount of paradox -the difference is normally <10 mm Hg, but the difference > 10 mm Hg may indicate the presence of cardiac tamponade.

A nurse is caring for a 2-year-old child diagnosed with nephrotic syndrome who is in diapers and has red, edematous genitals. Which collection techniques is appropriate for the nurse to obtain daily urine specimens for proteinuria testing with a urine dipstick? -apply adhesive urine collection bag around the genital areas and wait for the child to void -intermittently catheterize the child every morning to avoid contaminating the specimen -place cotton balls in a dry diaper; when wet, squeeze urine onto dipstick -place urine dipstick in the child's diaper overnight and check result in the morning

-place cotton balls in a dry diaper; when wet, squeeze urine onto dipstick ---Children with nephrotic syndrome often require daily urinalysis to monitor for proteinuria. Urine collection bags or dipsticks in the diaper risk breakdown of edematous skin. To collect a nonsterile urine specimen from a child in diapers, the nurse can place cotton balls in a dry diaper and later squeeze urine onto a dipstick.

The nurse has unlicensed assistive personnel caring for a client with an acute attack of Meniere disease. Which action by the UAP will require follow-up by the nurse? -assist the client in ambulating to the bathroom -dim the room lights -place the bed in low position with all side rails up -turn off the television

-place the bed in low position with all side rails up --Safety is a priority for the client experiencing an acute attach of Meniere disease. Fall precautions include placing the bed in low position, raising 2 or 3 side rails, and assisting the client with arising and ambulating. Vertigo can be minimize by staying in a quiet, dark room without a television or flickering lights.

All nursing staff on the medical unit are responsible for implementing a new interdisciplinary fall prevention protocol. Which tasks are appropriate for the RN to delegate to the UAP to promote client safety? SATA -orient the client to the bedside unit and explain the call bell system on admission -place the bedside commode as close to the bed as possible -remind the client to change position slowly -report observations of changes in client's condition immediately -report whether client is using correct gait and balance while ambulating with walker

-place the bedside commode as close to the bed as possible -remind the client to change position slowly -report observations of changes in client's condition immediately

When exiting the room of a client on both contact and airborne precautions, the nurse should perform the following actions in order:

-place the call light within the client's reach and ensure that the client's bed is locked and in the lowest position -remove the gown and gloves in order of most to least contaminated. The nurse can remove gloves, then gown or alternately. -discard the gown and gloves and then perform hand hygiene -exit the negative pressure room and immediately close the door to prevent infectious airborne microorganisms from escaping into the hallway or isolation anteroom -remove and discard the N95 respirator mask and then perform final hand hygiene

A nurse is evaluating an acutely ill client with suspected meningitis. The nurse should take what action first? -check for Kernig's and Brudzinski's signs -establish IV access -place the client on droplet precautions -prepare the client for lumbar puncture

-place the client on droplet precautions --The client with suspected bacterial meningitis should be placed on droplet precaution isolation until the causative agent has been identified and appropriate treatment is initiated. Meningococcal meningitis and Haemophilus influenzae type B meningitis are highly transmissible to others, and the client must remain on droplet isolation until these can be ruled out. Precautions can usually be discontinued 24 hours after beginning antibiotic therapy. Viral meningitis and other types of bacterial meningitis usually do not require droplet precautions.

Contact precautions includes:

-placing client in private room or cohorting clients with the same infection -using dedicated equipment -wearing gloves when entering room -perform proper hand hygiene before exiting room -wearing gown with client contact and removing before leaving room -place door notice for visitors -having client leave room only for essential clinical reasons

An 86-year-old client with diabetes and gastroparesis has had repeated hospitalizations for aspiration pneumonia following a stroke and is now hospitalized with altered LOC. Which nursing action is most appropriate to decrease the client's risk for developing aspiration pneumonia. -assessing client's breath sounds every 2 hours -placing client in the side-lying position in bed -titrating client's oxygen to maintain saturation greater than 93% -turning and repositioning the client every 2 hours

-placing client in the side-lying position in bed --Clients with decreased LOC may not be alert enough to protect their own airways; therefore, a side lying or lateral position is used to decrease the risk for developing aspiration pneumonia. If vomiting were to occur, this position promotes drainage of emesis out of the mouth instead of down the pharynx where it can be aspiration into the lungs. Maintaining an upright position during and after meals will allow remaining food particles to clear from the pharynx. --assessing breath sounds can help identify the presence of pneumonia but does not prevent the client from aspirating. Turning and repositioning every 2 hours helps to prevent stasis of secretions in the lungs but does not prevent the client from aspirating.

A nurse is preparing to perform postmortem care on a client who recently died from metastatic cancer. No family members were present at the time of death. What interventions can be delegated to experienced UAP? SATA -notifying the family of the client's death -placing dentures in the client's mouth -positioning a pillow beneath the client's head -transporting the client to the morgue -washing the client's body

-placing dentures in the client's mouth -positioning a pillow beneath the client's head -transporting the client to the morgue -washing the client's body

Describe solitary play and at what age children perform this type of play

-plays alone, but enjoys the presence of others -interest is centered on their own activity --occurs at infancy

describe parallel play and at what age do children perform this?

-plays alongside, but not with one another --characteristic of toddlers, but can occur in other age groups

What respiratory complications can clients with acute pancreatitis develop?

-pleural effusions -atelectatsis -ARDS (most severe) --these conditions occurs when pancreatic enzymes and cytokines are released from the pancreas into circulation and cause local/systemic inflammation

clinical manifestations of pulmonary embolism

-pleuritic chest pain -dyspnea -hypoxemia -tachypnea -cough -tachycardia -unilateral leg swelling --tachycardia occurs d/t heart trying to compensate for hypoxemia

The nurse is caring for a client with severe chronic obstructive pulmonary disease COPD). The nurse anticipates which laboratory results for this client? -anemia -neutropenia -polycythemia -thrombocytopenia

-polycythemia --The client with severe COPD will have a chronically low oxygen level, hypoxemia. To compensate, the body produces more red blood cells to carry needed oxygen to the cells.

Which of these are correct nursing actions related to client positioning? SATA -position client in high Fowler's for a paracentesis related to end-stage cirrhosis -position client on left side after liver biopsy -position client on side with head, back, and knees flexed after lumbar puncture -position client Trendelenburg on left side if air embolism is suspected -position client with arm raised above head for chest tube placement

-position client in high Fowler's for a paracentesis related to end-stage cirrhosis -position client Trendelenburg on left side if air embolism is suspected -position client with arm raised above head for chest tube placement ---Abdominal paracentesis is used to remove ascitic fluid from the peritoneal cavity in end-stage liver disease. The client should be positioned in high Fowler's or sat upright to facilitate the flow of fluid to the bottom of the peritoneal cavity, where the needle will be inserted. The client should void prior to the procedure to decrease the risk of bladder puncture. In the event of an air embolus, the head of the bed should be lowered and the client should be positioned on the left side; this will cause the air to rise to the right atrium. The healthcare provider should be notified immediately and the nurse should remain with the client. Chest tube insertion should be performed with the client's arm raised above the head on the affected side. If possible, the head of the bed should be raised 30-60 degrees to reduce risk of injury to the diaphragm.

Steps for indwelling urinary catheter insertion for the female client

-position the client supine with knees flexed and hips slightly externally rotated -perform hand hygiene and open a sterile catheterization kit -apply sterile gloves and place a sterile drape underneath the client's buttocks -remove the protective covering from the catheter, lubricate the catheter tip, and pour antiseptic solution over cotton balls or swab sticks while maintaining sterility of gloves and sterile field -use the nondominant hand to gently spread the labia.The nondominant hand is now contaminated. -use the dominant hand to cleanse the labia and urinary meatus with antiseptic-soaked cotton balls or swab sticks. Cleanse in an anteroposterior direction. Use a new swab for each swipe to avoid transferring bacteria between areas. Cleanse the labia majora first, then the labia minora, and lastly the urinary meatus -use the dominant hand to insert the catheter until urine return is visualized in the tubing and then advance it an additional -hold the catheter in place with the nondominant hand, and then use the dominant hand to inflate the balloon

The RN is caring for a client with TB who is on airborne isolation precautions. The RN can delegate which tasks to the experienced UAP? SATA -alert the x-ray department about maintaining airborne isolation precautions -explain to the client why the client must wear a mask during transport to another department -post signs for airborne isolation precautions on the client's door and stock necessary equipment -remind visitors to wear a respirator mask and keep the door closed while in the client's room -talk with the family about the reasons for airborne isolation precautions in the client

-post signs for airborne isolation precautions on the client's door and stock necessary equipment -remind visitors to wear a respirator mask and keep the door closed while in the client's room --The RN is responsible for appropriate communication with other departments and providing instruction to clients and their families, but can delegate a UAP to post signs on the door pertaining to isolation precautions as well as stock necessary equipment, and remind visitors to wear a respirator mask when entering the client's room.

two months growth and development

-posterior fontanelle closes -diminished tonic neck and moro reflexes -able to turn from side to side -eyes begin to follow moving objects -social smile first appears

The nurse is caring for a client with end-stage liver failure from hepatitis C who is being seen in the clinic for worsening ascites. The client is treated in the infusion center with IV albumin, IV furosemide, and oral spironolactone. The following day the nurse checks the client's labs. Which of the following lab findings is most important for the nurse to communicate to the HCP? -albumin 2.5 g/dL -INR 1.4 -potassium 3.0 mEq/L -sodium 131 mEq/L

-potassium 3.0 mEq/L --The client with cirrhosis is at risk of hepatic encephalopathy. Hypokalemia, high protein intake, GI bleeding, constipation, hypovolemia, and infection can precipitate hepatic encephalopathy. Use of furosemide can cause hypokalemia, which must be corrected immediately to prevent the precipitation of hepatic encephalopathy and dangerous arrhythmias --a low albumin level of 2.5 g/dL is common in liver failure due to decrease protein synthesis. The lower limit for serum albumin is 3.5 g/dL and there is no treatment to correct it. --elevated prothrombin time and INR are common with liver disease or cirrhosis.

A nurse is reviewing the most recent laboratory results of a client on the telemetry floor. The client is currently asymptomatic and the telemetry monitor indicates sinus rhythm. Which of the following critical values is most likely due to laboratory error? -blood urea nitrogen of 60 mg/dL -creatinine of 4.0mg/dL -potassium of 7.0 mEq/L -sodium of 155 mEq/L

-potassium of 7.0 mEq/L --With the exception of clients in end-stage renal disease, a serum potassium value >6.5 mEq/L in any client who is walking and talking should raise the suspicion of an erroneously elevated serum potassium (pseudohyperkalemia) from poor hematology technique, hemolysis, or clotting. A serum potassium level of 7.0 mEq/L would normally constitute a life-threatening electrolyte imbalance that would cause severe weakness or paralysis, unstable arrhythmias, and eventual cardiac arrest. An assessment would focus on evaluating cardiac symptoms and muscle strength and be reported to the HCP. In this case, it is likely a repeat blood draw would be prescribed. Pseudohyperkalemia can be avoided on the repeat blood draw by using heparin-impregnanted hematology vials to prevent clotting, minimal use of a tourniquet and fist clenching, and use of a larger gauge needle for the sample.

The nurse cares for a client with an exacerbation of inflammatory bowel disease. The client tells the nurse about being infected with TB 10 years ago, but never being medicated. Which prescription is of concern and prompts the nurse to notify the healthcare provider? -lansoprazole -metronidazole -prednisone -sulfasalazine

-prednisone ---A client with latent TB infection has a positive TST, is symptomatic, and cannot transmit the disease to others. Malignancy, immunosuppressant medications (prednisone), chemotherapy, and prolonged debilitating disease can convert LTBI to active disease.

Risk factors for iron deficiency anemia in pediatrics

-premature birth -cow's milk before 1 year -excessive milk intake in toddlers

The general steps for chest tube removal

-premedicate the client with analgesic 30-60 minutes before the procedure to promote comfort as evidence indicates that most clients report significant pain during removal. -provide the HCP with sterile suture removal equipment -place the client in the Semi-Fowler position or on unaffected side to promote comfort and facilitate access for tube removal -instruct client to breath in, hold it, and bear down while the tube is removed to decrease the risk for a pneumothorax. -apply a sterile airtight occlusive dressing to the chest tube site immediately to prevent air from entering the pleural space -perform a chest x-ray within 2-24 hours after chest tube removal as a post-procedure pneumothorax or fluid accumulation usually develops within this time frame

Which prescription should the nurse question when caring for a hospitalized client diagnosed with acute diverticulitis? -metronidazole 500 mg IV every 8 hours -nasogastric tube to suction -NPO -prepare for barium enema in AM

-prepare for barium enema in AM --Diverticular disease of the colon occurs when saclike protrusions form in the large intestine. When diverticula become infected and inflamed, the client has diverticulitis. Acute care for diverticulitis focuses on allowing the colon to rest and the inflammation to resolve.This includes IV antibiotic therapy, NPO status, NG suction, IV fluids, and bed rest.

A charge nurse is monitoring a newly licensed registered nurse. What action by the new nurse would warrant intervention by the charge nurse? -administers hydromorphone 1 mg to a client who rates pain at 7 on a 1 to 10 scale -notifies physician of occasional premature ventricular beats in a client with myocardial infarction -positions a postoperative pneumonectomy client on the affected side -prepares to administer IVPB potassium chloride via gravity infusion for a client with hypokalemia

-prepares to administer IVPB potassium chloride via gravity infusion for a client with hypokalemia --Treatment of hypokalemia may require an IV infusion of potassium chloride. The infusion rate should not exceed 10 mEq/hr. Therefore, IVPB KCL must be given via an infusion pump so the rate can be regulated. The charge nurse would need to intervene if the new nurse was attempting to administer IVPB KCL via gravity infusion instead of a pump. With the complete removal of the lung in a pneumonectomy, the client should be positioned on the surgical side to promote adequate expansion and ventilation of the remaining lung.

Manifestations of developmental dysplasia of the hip (DDH) in infants <2-3 months of age

-presence of extra inguinal/thigh folds -laxity of the hip joint on the affected side --test using Barlow and Ortolani maneuvers

absolute contraindications to thrombolytics

-prior intracranial hemorrhage -structural cerebrovascular lesion (arteriovenous malformation; aneurysm) -ischemic stroke within 3 months -active bleeding or bleeding diathesis -significant head trauma within 3 months

Classic S/S of pyloric stenosis

-projectile nonbilious vomiting -olive-shaped right upper quadrant mass -weight loss -dehydration -electrolyte imbalance (metabolic alkalosis)

preventative measures for Developmental Dysplagia of the hip (DDH)

-proper swaddling with hips bent up and out (hips flexed and abducted) -avoiding seats/carriers that hold legs straight and together (hips extended and adducted)

Relative contraindications for MRI

-prosthetic heart valve -metal plate, pin, brain aneurysm clip, or joint prosthesis -implanted device (insulin pump, medication port)

What clients require antibiotic prophylaxis before dental work?

-prosthetic valve replacement -repaired valves -hx of infectious endocarditis

Nursing interventions during a seizure

-protect client's head from injury -place client is rescue position (left lateral) -insert nothing into the mouth -do NOT restrain limbs or torso

Key measures of skincare that clients receiving teletherapy should take includes:

-protecting skin from infection (no rubbing, scratching, or scrubbing) -cleanse skin daily with lukewarm water and mild soap -use creams or lotions approved by HCP only -shield the skin from effects of sun during/after treatment -avoid extremes in skin temperature (no heating/ice packs)

What should be performed by the nurse when using an interpreter?

-provide a same-sex interpreter, who is NOT a family member, but a trained professional -speak slowly and directly to the client, providing direct eye contact with the client -provider information in the sequence it will occur -obtain feedback of comprehension beyond merely nodding

A graduate nurse is caring for a client with acute appendicitis who is awaiting surgery. Which action by the graduate nurse would require the precepting nurse to intervene? -administers morphine IV PRN for pain -initiates continuous normal saline IV -provides a heating pad for abdominal discomfort -teaches client about prescribed strict NPO status

-provides a heating pad for abdominal discomfort --Appendicitis is inflammation of the appendix often resulting from obstruction by fecal matter. Appendiceal obstruction traps fluid and mucus typically secreted into the colon, causing increased intraluminal pressure and inflammation As appendiceal intraluminal pressure and inflammation increase, blood circulation to the appendix is impaired, resulting in swelling and ischemia. These factors increase the risk for appendiceal perforation, a medical emergency, which many lead to peritonitis and sepsis. Appendicitis is often treated surgically via removal of the appendix. Nurses caring for clients with appendicitis should avoid interventions that increase intestinal blood circulation, gut motility, or appendiceal intraluminal pressure. The application of heat to the abdomen increases intestinal circulation and the risk for appendiceal perforation.

The nurse performs nasogastric tube insertion using a large-bore NG tube on a hospitalized client with a gastrointestinal bleed. During insertion, after the tube passes the nasopharynx, the client begins to cough and gag. Which action should the nurse take first? -ask the client to take several small sips of water -continue to slowly advance the tube until placement is reached -gently remove the tube and reinsert in the other naris if possible -pull back on the tube slightly and then pause to give the client time to breath

-pull back on the tube slightly and then pause to give the client time to breath --During NG tube insertion, the tube sometimes slips into the larynx or coils in the throat, which can result in coughing and gagging. The nurse should withdraw the tube slightly and then stop or pause while the client takes a few breaths. After the client stops coughing, the nurse can proceed with advancement, asking the client to take small sips of water to facilitate advancement to the stomach. The client should not be asked to swallow during coughing or aspiration may occur. If resistance or obstruction occurs during tube advancement, the nurse should rotate the tube while trying to advance it. If resistance continues, the tube should be withdrawn and inserted into the other naris if possible.

What are the steps for administering an IM injection using the Z-track technique?

-pull skin 1-1.5 inches laterally away from the injection site. -hold skin taut with nondominant hand -insert needle at 90-degree angle. The taunt skin facilitates entry of needle and angle ensures reaching the muscle -inject medication slowly into the muscle while maintaining traction -wait 10 seconds after injecting the medication and withdraw the needle while maintaining traction on the skin (allows medication to diffuse before needle removal and help prevent tracking) -release the hold on to the skin (allows tissue layers to slide back to their original position, sealing off the needle tract) -apply gentle pressure at injection site without massaging.

A nurse in a pediatric clinic is preparing to administer ear drops to a 5-year-old. Which is an appropriate action by the nurse? -have the child sit upright with the child tilted down -pull the pinna upward and back -remove the medication from the refrigerator just before use -touch the dropper to the entrance of the ear canal

-pull the pinna upward and back --When administering otic medication to children age 3 and older, the pinna is pulled upward and back to straighten the ear canal. The child is placed in a prone or supine position with the head turned to the appropriate side, and the medication is allowed to drop against the wall of the canal.

UAP reports 4 situations to the RN. Which situation warrants the nurse's intervention first? -client on a 24hour urine collection had a specimen discarded by mistake -client and family request clergy to administer last rites -puncture-resistant sharps disposal container on the wall is full -client with diabetes mellitus has an 8AM fingerstick glucose of 80 mg/dL

-puncture-resistant sharps disposal container on the wall is full --healthcare workers are required to abide by OSHA standards and regulations to reduce work-related injuries and exposure to bloodborne pathogens. A sharps disposal container should not be overfilled and should be replaced on a regular basis to reduce the risk for a needle stick during disposal. --if any urine is discarded by accident during a 24-hour collection test, the procedure must be restarted. A new container will need to be labeled with the appropriate times and date, but no immediate interaction required. --the nurse will arrange for a visit from clergy to administer the last rites, a religious ceremony for roman Catholic clients who are extremely ill, but this does not require prompt intervention --a fingerstick glucose of 80 mg/dL is normal and requires no intervention unless the client received insulin and refuses or is unable to eat.

At 8 AM, medications are prescribed for assigned clients. Which medication should the nurse administer first? -acetylsalicylic acid for a client with a hx of coronary artery disease and ischemic stroke -metformin for a client with serum glucose of 285 mg/dL who is scheduled for a CT scan with contrast -morphine sulfate for a client with terminal lung cancer who has chronic bone pain -pyridostigmine for a client with myasthenia gravis exacerbation who reports difficulty swallowing

-pyridostigmine for a client with myasthenia gravis exacerbation who reports difficulty swallowing --Myasthenia gravis is a chronic, neurologic autoimmune disorder that involves damage to acetylcholine receptors at the neuromuscular junctions, which results in skeletal muscle weakness. The ocular and facial muscles, along with those responsible for chewing and swallowing, are affected initially; however, weakness can progress to the respiratory muscles. Pyridostigmine is a first-line drug that inhibits acetylcholine breakdown and is prescribed to temporarily increase muscle strength in clients with MG. It is the priority medication as difficulty swallowing indicates weakness of the muscles involved in swallowing and increases aspiration risk.

The healthcare provider writes a prescription for hydromorphone 10 mg intravenous push every 2 hours prn for the post-operative client. The usual recommended dose is 0.2-1 mg every 2-3 hours prn. What action should the nurse initially take? -administer the medication and monitor client frequently -ask a nursing colleague if this drug amount is used -check hydromorphone dose that the client had previously -question the prescription with the prescriber

-question the prescription with the prescriber --When a medication prescription is outside the safety range, the nurse must question/clarify the prescription with the prescriber and not administer the drug automatically.

The nurse is admitting a client who had mastectomy 6 months ago and is scheduled for elective surgery. During the physical assessment, the nurse notices a 0.5 cm mobile, firm, nontender lymph node in the upper arm. What action should the nurse take? -anticipate the scheduling of a biopsy -apply ice to the node -reassure the client that it is an expected finding -request an antibiotic

-reassure the client that it is an expected finding --A lymph node that is superficial, palpable, small (<1 cm), mobile, firm, and nontender is a normal finding. Hard and fixed nodes are most concerning as they are likely due to malignancy. Tender nodes usually indicate inflammation/infection

What are signs of infections within wounds?

-redness -warmth -purulent drainage

Describe stage 2 (moderate) stage of Alzheimer disease

-reduced ability to perform ADLs -behavioral changes (argues easily, anxious, depressed) -paces and wanders -needs close supervision

A graduate nurse is caring for a client with a triple-lumen peripherally inserted central catheter in the right arm. Which action by the graduate nurse indicate that more education is needed? SATA -flushing the line before and after each medication administration -pausing the parenteral nutrition prior to drawing blood from a different port -reinforcing a torn peripherally inserted central catheter line dressing with tape -scrubbing the port with alcohol for 5 seconds before use -taking the client's blood pressure in the left arm

-reinforcing a torn peripherally inserted central catheter line dressing with tape -scrubbing the port with alcohol for 5 seconds before use ---Peripherally inserted central catheter lines provide central venous access for clients who require long-term medication administration or infusion of noxious substances. Maintaining the line integrity with aseptic technique and routine care is important for continued use and prevent of central line-associated bloodstream infections. Dressings that no longer occlude the insertion site must be changed immediately. Loose corners may be temporarily reinforced with tape. The nurse should scrub the hub with alcohol or chlorhexidine for 10-15 seconds.

The nurse is caring for an agitated client with dementia who is pulling at the oxygen and IV tubing. Wrist restraints are applied after less-restrictive safety measures have been ineffective. Which actions are appropriate to protect the client from injury? SATA -attach wrist restraint straps to the upper side rails -position the client supine to keep restraint straps taut -release restraints at regular intervals and assess behavior -use a square knot to tie restraint straps to the bed -use gauze to pad bony prominences under restraints

-release restraints at regular intervals and assess behavior -use gauze to pad bony prominences under restraints --when caring for a client in restraints, the nurse should implement these interventions at regular intervals, according to agency policy (typically Q2 H): provide skin care and ROM exercises; ensure basic needs are being met; assess skin integrity and neurovascular status of restrained extremities; pad bony prominences under restraints, if necessary, to protect skin; determine the need for continued restraint by releasing restraints briefly and assessing clients reactions. Restraint straps should be attached to areas that move with the bed frame. Areas that do not move with the base or move independently of the frame should never be used. Supine positioning increases aspiration risk as the client may be unable to self-reposition if vomiting occurs. Side-lying or semi-Fowler position promotes drainage of emesis or oral secretions. Restraint straps should be tied in a quick-release knot, in case of emergency, and never a square knot.

What are the steps to administering ophthalmic medications?

-remove secretions from the eyelid by wiping from the inner to outer canthus -pull lower eyelid downward, have client look upward, and instill drops into the conjunctival sac -apply pressure to the lacrimal duct if medication has systemic effects (beta blockers, timolo maleate)

The nurse precepts a nursing student caring for a client with glaucoma and observes the student administer timolol maleate, an ophthalmic medication. Which student action indicates that further instruction is needed? -instructs client to close eyelid and move eye around; applies pressure to the lacrimal duct for 30-60 seconds -pulls lower eyelid down gently with thumb and forefinger against bony orbit to expose the conjunctival sac -removes dried secretions with moistened sterile gauze pads by wiping from the outer to inner canthus -rests hand on client's forehead and holds dropper 1-2 cm above the conjunctival sac

-removes dried secretions with moistened sterile gauze pads by wiping from the outer to inner canthus --To administer opthalmic medications, follow these steps: remove secretions from the eyelid by wiping from the inner to outer canthus; pull lower eyelid downward, have client look upward, and instill drops into the conjunctival sac; apply pressure to the lacrimal duct if medication has systemic effects (beta blockers, timolo maleate)

The registered nurse observes a graduate nurse who is inserting a small-bore nasojejunal feeding tube. Which action by the graduate nurse requires intervention by the registered nurse? -asking the client to take small sips of water during insertion -marking the tube at the exit point from the naris -removing the stylet before the x-ray is performed -stopping insertion of the tube while the client is coughing

-removing the stylet before the x-ray is performed ---After placing a new, small-bore nasoenteric feeding tube, the nurse should obtain an x-ray to verify tube placement and should leave the styletin place until tube placement is verified. The nurse should never reinsert a stylet into a nasoenteric tube. The nurse should stop advancing when the client is inhaling or coughing to avoid inserting the tube into the airway and then continue advancing when the client is able to swallow again.

A client is being discharged after having a coronary artery bypass (CABG) X 5. The client asks questions about the care of chest and leg incisions. Which instructions should the registered nurse include? SATA -report any itching, tingling, or numbness around your incisions -report any redness, swelling, warmth, or drainage from your incisions -soak incisions in the tub once a week then clean with hydrogen peroxide and apply lotion -wash incisions daily with soap and water in the shower and gently pat them dry -wear an elastic compression hose on your legs and elevate them while sitting

-report any redness, swelling, warmth, or drainage from your incisions -wash incisions daily with soap and water in the shower and gently pat them dry -wear an elastic compression hose on your legs and elevate them while sitting ---The nurse should instruct the client with chest and leg incisions from CABG to wash them daily with soap ad water in the shower. In addition, the client must b instructed not to apply any powders or lotions to the incisions, to report any redness, swelling or increase in drainage, and to wear an elastic compression hose on the legs.

A 3-month-old client infant is treated in the emergency department for a spiral femur fracture. The parent reports that the infant sustained the injury after rolling off the bed. What is the priority nursing action? -document a description of the injury -question the mother about where the infant sleeps -report the injury per facility protocol -separate the mother from the infant

-report the injury per facility protocol --The parent's account of this injury is inconsistent with the developmental milestones of a 3-month-old infant, as the muscles required for rolling over do not develop until age 4-5 months. Additionally, spiral femur fractures indicate that pressure was applied to the leg in opposite directions, which is unlikely accidental injury in a nonambulatory child. Fractures in young children, especially non-ambulatory infants, are always of concern and suspicious of child abuse. The nurse's priority is to report suspected child maltreatment to the appropriate authorities following facility protocol as required by law. After reporting suspected maltreatment, the nurse should: facilitate a complete physical evaluation, document facts and observations objectively, using medical terms when possible. Include the history provided by the parent or caregiver and the time period from inury occurrence to evaluation, and perform a review of child-care practices with the caregiver.

The nurse is caring for a client with C.Diff. Which of the following infection control measures by the nurse are appropriate? SATA -applies sterile gloves before performing client care -ensures surgical masks are worn by staff in the client's room -request that the client be assigned to a single-client room -uses alcohol-based sanitizers for hand hygiene -wears a single-use, disposable gown during client care

-request that the client be assigned to a single-client room -wears a single-use, disposable gown during client care ---C. Diff is a highly infectious bacteria requiring contact isolation precautions, including a single-client room assignment if available, disposable gowns and clean gloves, and hand hygiene with soap and water. Surgical masks are not necessary unless performing client care with the possibility of body fluid splashing

A client was treated in the ED 2 days ago. The nurse makes a follow-up call to say that a culture shows that the client needs an antibiotic. The client's spouse answers the phone, says that the client is at work and doing fine, and that the client does not need the antibiotic. Which is a priority action for the nurse? -call the prescription into the client's pharmacy -document the spouse's statement in the client's chart -notify the ED physician -request that the spouse tell the client to call back

-request that the spouse tell the client to call back --the spouse does not have the authority to refuse the required medication for the client as the client is competent and has decision-making capacity. An informed refusal includes knowing the risks and benefits of the decision, including the potential of latent infection/damage in this case. If the client does not call back, the typical facility policy is to try to reach the client by phone 3 times, then by certified letter, and then sending the police to contact the client.

interventions for amyotrophic lateral sclerosis

-respiratory support (Bipap or mechanical ventilation) -feeding tube -medications to decrease symptoms -mobility assistive devices -communication assistive devices

Interventions for amyotrophic lateral sclerosis involves?

-respiratory support with noninvasive positive pressure (BiPAP) or mechanical ventilation -feeding tube for enteral nutrition -medications to decrease symptoms -mobility assistive devices (walker and wheelchair) -communication assistive devices (alphabet boards, specialized computers)

The nurse is obtaining orthostatic vital signs on a client admitted for dehydration. The nurse measures the client's blood pressure and pulse using the left brachial site with the client lying supine and then sitting. Which action by the nurse is appropriate. Blood Pressure: Supine = 153/83; sitting= 119/70 Heart Rate: Supine = 70/min; Sitting = 95/min -assist the client to a standing position and measure a third set of vital signs -place the client in reverse Trendelenburg position and take an apical pulse -reassess the client's blood pressure in the supine position using the popliteal site -return the client to a recumbent position and notify the healthcare provider.

-return the client to a recumbent position and notify the healthcare provider. ---Orthostatic vital signs involve measuring the client's blood pressure and heart rate in the supine, sitting, and standing position. Each measurement should be obtained after maintaining each position for 2 minutes. IF any position change produces decreased systolic BP >20 mm Hg, decreased diastolic BP >10 mm Hg, and/or increased pulse >20/min from supine values, the nurse should discontinue assessment, place the client in a recumbent position, and notify the healthcare provider. It is unsafe to assist the client to a standing position after identifying orthostatic hypotension, as a syncopal event may occur and the client may fall.

Drugs that decrease warfarin effect (decreases bleeding)

-rifampin -carbamazepine -oral contraceptives -gingseng -ST. John's wort -Vitamin K-rich foods (spinach, broccoli, or liver)

What are the 6 rights of medication administration?

-right client (using 2 identifiers) -right medication -right dose -right route -right time -right documentation

The nurse is caring for a client who has homonymous hemianopsia following an acute stroke. Which nursing diagnosis is the most appropriate for this client? -risk for ineffective airway maintenance -risk for knowledge deficit -risk for poor fluid intake -risk for self-neglect

-risk for self-neglect --Cerebral vascular accidents can cause visual and perceptual deficits depending on which part of the brain is affected. Clients with changes in visual field or perception of their body in space can be at risk for safety-related injuries. Homonymous hemianopsia is a loss in half of the visual field on the same side. For example, the client may lose the left side of the visual field in both eyes. A client unable to see the left side of the body is at a higher risk for neglecting that side or being unable to eat food placed on the left side of a plate. These clients are at higher risk for injury because they are unable to incorporate full visual field input. They are taught to turn the head and scan to the side with the visual field deficit to reduce the risk for injury and self-neglect.

four month growth and development

-rolls back to side -brings objects to mouth -evidence of pleasure in social contact -drooling -moro reflex absent after 3-4 months

Treatment of intussusception

-saline or air enema --the nurse must monitor for a normal brown stool and notify HCP immediately to stop all plans for surgery

The nurse assesses a client with a burn on the arm and finds that the area is red, moist, and covered in shiny, fluid-filled vesicles. Which burn stage does the nurse document? -first degree -second degree -third degree -fourth degree

-second degree --second degree burns appear as moist or weeping wounds with blisters and shiny, fluid-filled vesicles. Pain is moderate or severe.

A new graduate nurse is preparing to administer the following analgesics to clients with postoperative pain. Which situation would require intervention by the precepting nurse? -chooses to administer 60 mcg of the prescribed 50-100 mcg of IV fentanyl for the first dose -dilutes hydromorphone with 5 mL of normal saline and injects IV push over 2 minutes -injects 1 mg of morphone sulfate undiluted via IV push over 5 minutes -selects a 25-gauge 1/2 inch needle to inject ketorolac intramuscularly

-selects a 25-gauge 1/2 inch needle to inject ketorolac intramuscularly --Ketorolac is an NSAID analgesic administered for short-term relief of mild to moderate pain. Usage should not exceed 5 days due to adverse effects. Ketorolac IM should be administered into a large muscle using the Z-track method to mitigate burning and discomfort. A 1 to 1.5 inch needle is recommended to inject medication into the proper muscular space in average-weight individuals. Selecting a smaller first dose is appropriate if the nurse is unsure of how the client will respond to the medication. If needed, the larger amount can be given the next time a dose is requested or an additional one-time dose can berequested from the healthcare provider if breakthrough pain occurs. Hydromorphone IV push, given undiluted or diluted with 5 mL of sterile water or NS should be administered slowly over 2-3 minutes. Undiluted morphine IV push should be administered slowly over 4-5 minutes

What are the major complications associated with toxic epidermal necrolysis?

-sepsis -fluid and electrolyte imablance -hypothermia -ophthalmic issues

The nurse reviews the most current laboratory results for assigned clients. Which finding is the highest priority for the nurse to report to the HCP? -CD4+ cell count of 500/mm3 in a client with oral candidiasis and HIV who is receiving fluconazole orally -hemoglobin A1c of 7.3% in a client with community-acquired pneumonia and type 2 diabetes who is receiving IV levofloxacin -platelet count of 148,000/mm3 in a client with a venous thrombosis who is receiving a continuous heparin infusion -serum glucose of 68 mg/dL in a client with radiation enteritis who is receiving total parenteral nutrition

-serum glucose of 68 mg/dL in a client with radiation enteritis who is receiving total parenteral nutrition --The target range for glucose in clients receiving nutritional support is 140-180 mg/dL. Hypoglycemia can be due to slowing the rate of the infusion. Although it occurs less frequently in clients receiving total parenteral nutrition than hyperglycemia does, hypoglycemia can lead to life-threatening complications. Therefore, the serum glucose of 68 mg/dL is the laboratory finding of highest priority for the nurse to report to the HCP.

The hospitalized client with anorexia nervosa is started on nutrition via enteral and parenteral routes. Which client assessment is the most important for the nurse to check during the first 24-48 hours of administration? -serum albumin level and body weight -serum potassium and phosphate -symptoms of dumping syndrome -white blood cell count and neutrophils

-serum potassium and phosphate --Refeeding syndrome is a potentially fatal complication of nutritional rehabilitation in chronically malnourished clients. The client's lack of oral intake results in the pancreas making less insulin. After the client receives food or IV fluids with glucose, insulin secretion is increased, leading to phosphorous, potassium, and magnesium shifting intracellularly. Phosphorus is the primary deficient electrolyte as it is required for energy. Hypophosphatemia causes muscle weakness and respiratory failure. Deficiencies in potassium and magnesium potentiate cardiac arrythmias. Therefore, aggressive initiation of nutrition without adequate electrolyte repletion can quickly precipitate cardiopulmonary failure. --Daily weights and periodic serum albumin level are indicated to evaluate the efficacy of nutritional replenishment, but is not the most important --dumping syndrome is seen after surgery for stomach cancer or bariatric surgery, which results in decreased storage area in the stomach. It is not seen with anorexia

The nurse is providing care for a client with Alzheimer disease who often becomes angry and agitated 20 mintues or more after eating. The client accuses the nurse of not providing food, saying "I'm hungry. You didn't feed me". The nurse should take which action? -give the client gentle reminders that the client has already eaten -say that the client can have a snack in a couple of hours -serve the client half of the meal initially and off the other half later -take a picture of the client having a meal and show it when the client becomes upset.

-serve the client half of the meal initially and off the other half later --Most clients with Alzheimer disease experience eating and nutritional problems throughout the course of their disease. During the earlier stages, it is common for clients to forget that they have eaten recently. The best approach is for caregivers to give clients something to eat when they say they are hungry. Smaller meals throughout the day, along with low-calorie snacks, are effective strategies for clients who forget that they have eaten. --showing a picture of the client having a meal is confrontational and will have no meaning to the client.

Gross motor developmental milestone for 6-9 month old

-sits without help -begins to crawl -may pull up to stand

An adult client has developed diarrhea 24 hours after the initiation of total enteral nutrition via nasogastric tube. The client is receiving a hypertonic formula. What is the best nursing action? -dilute the formula with water -discontinue the tube feeding -send a stool sample to the lab for culture and sensitivity -slow the rate of administration of the feeding

-slow the rate of administration of the feeding ---Most clients tolerate hypertonic and isotonic enteral formulas without complications. However, because of their higher osmolality, hypertonic formulas sometimes cause N/V or diarrhea, especially during the initiation of total enteral nutrition. The gastrointestinal tract will pull fluid from the surrounding intra and extravascular compartments to dilute the formula, making it similar to body fluid osmolality. This process is similar to dumping syndrome and may cause temporary diarrhea with cramps, N/V. Slowing down the rate of administration of total enteral nutrition will usually alleviate these problems. The feeding can gradually progress to the established goal rate.

A nurse reviews the most current serum lab results for assigned clients. Which result is the highest priority to report to the HCP? -albumin of 3.0 g/dL in a client with chronic hepatitis -B-type natriuretic peptide of 400 pg/mL in a client with heart failure -magnesium of 1.7 mEq/L in a client with alcohol withdrawal -sodium of 120 mEq/L in a client with small lung cancer

-sodium of 120 mEq/L in a client with small lung cancer --Malignant lung tumors are a common cause of SIADH. When serum sodium drops below 120 mEq/L, immediate intervention is necessary to prevent severe neurologic dysfunction. Fluid restriction is recommended for clients with SIADH. --clients in alcohol withdrawal usually require magnesium supplements. Hypomagnesemia results from poor dietary intake, malnutrition, and increased renal excretion, and is common in clients with chronic alcoholism. This finding is within normal limits.

A HCP is screaming, "Why didn't you get surgery scheduled sooner!?", at the nurse in the hallway. People in the hallway are staring. What is the best initial reaction by the nurse? -firmly indicate that the HCP cannot speak to the nurse in that manner -immediately apologize and attempt to fix the situation -say nothing and let the HCP vent frustrations -state that the conversation needs to take place in private and walk to a room

-state that the conversation needs to take place in private and walk to a room --when there is inter-staff disagreement, it is important to not have a public "show". The first action should be to take the conflict "off stage". Rather than suggest and wait, the nurse should immediately lead and go to a private area. That way the disruptive person has to either follow the nurse or stop talking because there is no longer an audience. Once in private, the nurse can acknowledge the HCP's concern and work to resolve the issue.

The nurse is reinforcing education to a client with irritable bowel syndrome who is experiencing diarrhea. Which of these meals selected by the client indicates an understanding of diet management? -beans, yogurt, and a fruit cup -beef, broccoli, and a glass of wine -eggs, a bagel, and black coffee -steak, tomato basil soup, and cornbread

-steak, tomato basil soup, and cornbread --IBS is a common, chronic bowel condition caused by altered intestinal motility. Peristaltic action is affected, causing diarrhea, constipation, or a combination of both. Management focuses on reducing diarrhea or constipation, abdominal pain, and stress. Clients can manage symptoms with diet, medications, exercise, and stress management. To manage IBS, clients should restrict gas-producing foods, caffeine, alcohol, and other GI irritants. Clients should gradually increase fiber intake as tolerated. Foods that are generally well tolerated include proteins, breads, and bland foods.

A client with a 10-year history of unipolar major depression has relapsed and is now hospitalized. The client is currently on phenelzine and weighs 115 lb but weighed 150 lb 3 months prior to admission. Which foods would be best for this client? -crackers and cheddar cheese -hard-boiled egg with tomatoes -steamed fish and potatoes -tortilla chips with avocado dip

-steamed fish and potatoes --reduced appetite and significant, unintentional weight loss are included in the diagnostic criteria for unipolar major depression. A 35 lb weight loss within 3 months is a 23% change in this client's usual body weight and is considered severe weight loss. The client needs a diet high in calories and protein to promote adequate nutrition and weight gain. In addition, the client has a diagnosis of depression and may have a low energy level; providing foods that are easier to chew and swallow may be better choices for promoting intake.

A client with right-sided weakness becomes dizzy, loses balance, and begins to fall while the nurse is assisting with ambulation. Which nursing actions would best prevent injury to the client and nurse while guiding the client to a horizontal position on the floor? -step behind client with arms around waist, squat using the quadriceps, and lower client to the floor -step in front of client, brace knees and feet against the client's, and assist to the floor gently -step slightly behind client with feet apart, extend one leg, and let client slide against it to the floor -step 12 inches behind the client, support under axillae, tighten back, and lower client to the floor

-step slightly behind client with feet apart, extend one leg, and let client slide against it to the floor --To prevent injury to the nurse and the client if the client is falling, the nurse uses good body mechanics to try to break the fall and guide the client to the floor if necessary. These nursing actions can help prevent injury if a client is falling while the nurse is assisting with ambulation; steps slightly behind the client with feet wide apart and knees bent; place arms under the axillae or around the client's waist; place one leg behind the other and extend the front leg; and let the client slide down the extended leg to the floor

Routine care of peripherally inserted central catheter lines includes:

-sterile dressing changes every 48 hours with a gauge dressing OR every 7 days with a transparent semipermeable dressing. --dressing changes if dressing is loose/torn, soiled, or damp -flushing the line before and after medication administration and per facility protocol -performing blood pressure and venipuncture on opposite arm -pausing infusing medications before drawing blood from the PICC to prevent false interpretation of the client's serum levels.

Typical appearance of Parkinson disease

-stooped posture -masked facial expression -rigidity -forward tilt of trunk -reduced arm swinging -flexed elbows and wrists -slightly flexed hips and knees -trembling of extremities -shuffling, short-stepped gait

The nurse is administering cleansing enemas to a client the night before bowel surgery. During instillation of the enema, the client reports cramping and pain. What action should the nurse take? -have the client take slow, deep breaths -stop infusing the solution for 30 seconds, then resume at a slower rate -tell the client the process will not take much longer -withdraw the tube approximately 2 cm and continue the infusion

-stop infusing the solution for 30 seconds, then resume at a slower rate --The rapid infusion of an enema solution may cause intestinal spasms that result in a feeling of fullness, cramping, and pain. If the client reports any of these symptoms, instillation should be stopped for 30 seconds and then resumed at a slower rate. Slow infusion will also decrease the likelihood of premature ejection of the solution, which would not allow for adequate bowel evacuation. Having the client take slow, deep breaths may be helpful, but the infusion should be stopped first.

Interventions to manage norepinephrine extravasation

-stop infusion immediately and disconnect the IV tubing -use syringe to aspirate the drug from IV catheter and remove while aspirating -elevate extremity above the heart to reduce edema -notify HCP and obtain prescription for phentolamine (Regitine)

If signs of a transfusion reaction occur, the nurse should:

-stop the transfusion immediately -using new tubing, infuse normal saline to keep the vein open -continue to monitor hemodynamic status and notify the healthcare provider and blood bank -administer any emergency or prescribed medications to treat the reaction; these may include vasopressors, antihistamines, steroids, or IV fluids -collect a urine specimen to be assessed for a hemolytic reaction -document the occurrence and send the remaining blood and tubing set back to the blood bank for analysis.

Management of anaphylatic shock includes:

-stopping infusion causing the reaction and call for help -ensure patent airway -administer oxygen via high-flow non-rebreather mask (prepare for intubation) -give epinephrine intramuscularly. -maintain blood pressure with normal saline IV fluids -administer adjunctive therapies (bronchodilators, antihistamines, corticosteroids) -continue to reassess vital signs for any changes

What is contraindicated in clients who have had an open radical prostatectomy?

-straining -suppositories -enemas

Life-threatening complications associated with infective endocarditis

-stroke (resulting in paralysis on 1 side) -spinal cord ischemia (results in paralysis of both legs) -ischemia to extremities (results in pain, pallor, and cold foot/arm) -intestinal infection (results in abdominal pain) -splenic infarction (results in left upper quadrant pain)

The nurse in the student health center at a large university received student telephone messages. Which return telephone call is the priority? -student who feels well but is concerned about possible exposure to viral meningitis at an off-campus party 2 weeks ago -student who was in a baseball tournament yesterday and is now unable to lift the arm past the waist due to extreme shoulder pain -student who woke from a deep sleep in an unfamiliar dormitory room and is panic-stricken with severe vaginal pain -student with itchy, cottage-cheese-like vaginal discharge who is sexually active and worried about having a STI

-student who woke from a deep sleep in an unfamiliar dormitory room and is panic-stricken with severe vaginal pain --Sexual assault is a medical emergency requiring a thorough head-to-toe physical examination by a specially trained healthcare provider to identify and treat injuries.

The nurse has received report on the following pediatric clients. Which action should the nurse perform first? -administer water enema to the 2 year old with intussusception who has severe abdominal pain -call the HCP about the 4 year old with leukemia who has a low-grade fever -measure head circumference of the 3 month old with ventriculoperitonal shunt placement -suction the 3 month old with bronchiolitis who is irritable and scheduled for a feeding

-suction the 3 month old with bronchiolitis who is irritable and scheduled for a feeding --bronchiolitis is a lower respiratory tract infection most commonly caused by respiratory syncytial virus. It causes inflammation and obstruction of the lower respiratory tract. Depending on the severity of the infection, infants with bronchiolitis can experience mild cold symptoms or respiratory distress. The infant will have difficulty feeding and can become dehydrated. Medical care is supportive and includes suctioning, oxygen, and hydration. The infant with irritability may be exhibiting signs of hypoxia. --Chemotherapy can result in neutropenia and immunosuppression. Even a low-grade fever should be taken seriously as it can result in lethal sepsis. The client needs cultures and empiric antibiotics, but is not priority over the client with bronchiolitis.

S/S of retinal detachment

-sudden onset of light flashes -floaters -cloudy vision or curtain appearing in vision

Manifestations of acute angle-closure glaucoma

-sudden onset of severe eye pain -reduced central vision -blurred vision -ocular redness -report of seeing halos around lights

Manifestations of acute-angle closure glaucoma

-sudden onset of severe eye pain -reduced central vision -blurred vision -ocular redness -report of seeing halos around lights --this condition is a medical emergency

During the shift report, the night shift nurse tells the day charge nurse that the night UAP is totally incompetent. What is the best response for the day charge nurse to give? -encourage the night nurse to provide the UAP with additional training -indicate that it is the night nurse's job to deal with staff problems -remind the night nurse that the UAP is doing the best job the UAP can -suggest that the night nurse discuss concerns with the nurse manager

-suggest that the night nurse discuss concerns with the nurse manager --Incompetency is a concern for client safety and quality care. The nurse manager is responsible for hiring/firing and setting up additional training times or experiences for staff. The situation should be discussed with the person who has 24/7 responsibility for the unit so that an appropriate response can be given to the night nurse's perceptions

What medication is used for mild-to-moderate chronic inflammatory rheumatoid arthritis and inflammatory bowel disease?

-sulfasalazine (a sulfonamide) -DMARD

drug class of misoprostol -function

-synthetic prostaglandin --protects against ulcers by reducing stomach acid and promoting mucus production and cell regeneration

Early signs of malignant hyperthermia

-tachypnea -tachycardia -rigid jaw or generalized rigidity --will develop HIGH fever as the condition develops.

A charge nurse suspects that the UAP is falsifying the documentation of clients' capillary glucose results rather than performing the test. What is the best action by the charge nurse to handle this situation? -ask a client if the UAP has performed the test -discuss the importance of task completion and accurate documentation in a staff meeting -give the UAP a verbal warning not to falsify data -take a client's capillary glucose personally and compare it to the recorded result

-take a client's capillary glucose personally and compare it to the recorded result --When deliberate inaccurate documentation is suspected, gather evidence before confronting the staff member. One way of doing this is by checking the data personally and comparing it to what has been documented.

The clinic nurse is caring for an elderly client who is overweight and being treated for hypertension. What is most important for the nurse to emphasize to prevent a stroke (acute brain attack)? -consume a low-fat, low-salt diet -do not smoke cigarettes -exercise and lose weight -take prescribed antihypertensive medications

-take prescribed antihypertensive medications --risk factors for stroke include diabetes, high cholesterol, hypertension, smoking, obesity, older age, and genetic susceptibility. The single most important modifiable risk factor is hypertension. Stroke risk can be reduced up to 50% with appropriate treatment of hypertension. Because clients often experience side effects from the antihypertensive medications and do not feel bad with untreated hypertension, they may not realize that it is essential to continue the medications. The nurse should therefore emphasize this point.

Describe how to administer pancreatic enzyme supplements

-take with or just before every meal -swallow whole or sprinkle onto acidic foods -NEVER crush or chew (they are enteric coated) -do NOT take with milk

Techniques to prevent pill-induced esophagitis when taking potassium tablets

-take with plenty of water -sit upright after ingestion -take before/during meals to prevent gastric upset

The graduate nurse is inserting an oropharyngeal airway into a client emerging from general anesthesia. Which action by the graduate nurse causes the nurse preceptor to intervene? -measures the oropharyngeal airway against the cheek and jaw angle before insertion -rotates the device tip downward once it reaches the soft palate -suctions secretions from the mouth and pharynx prior to device insertion -tapes the external portion of the inserted oropharyngeal airway to the client's cheek

-tapes the external portion of the inserted oropharyngeal airway to the client's cheek ---Oropharyngeal airways are temporary artificial airway devices used to prevent tongue displacement and tracheal obstruction in clients who are sedated or unconscious. As consciousness and the ability to protect the airway return, the client often coughs or gags, indicating a need to remove the OPA. Clients may also independently remove or expel it. Nurses caring for a client with an OPA must ensure that the device is easily removable from the client's mouth because an obstructed OPA may cause choking and aspiration. Appropriate OPA size should be measured prior to insertion because an inappropriate size could push the tongue back and cause airway obstruction. The OPA should be measured with the fiange next the to client's cheek. With correct size, the OPA curve reaches the jaw angle. When inserting an OPA, the nurse should initially suction the upper airway to remove secretions. The OPA is then inserted with the distal end pointing upward toward the roof of the mouth to prevent tongue displacement and tracheal obstruction. Once the OPA reaches the soft palate, the nurse rotates the OPA tip downward toward the esophagus, which pushes the tongue forward and maintains airway patency.

After talking to the client, the HCP tells the RN that the client's signature is needed on the consent form that has been filled out. While the nurse is obtaining the signature, the client states "I'm not clear on what is included in the low-fat diet that I'll be on after the cholecystectomy" What action should the nurse take first? -call the HCP to come and talk to the client -refuse to witness the signature on the consent form -teach the client about a low-fat diet -tell the client that the HCP will explain it later

-teach the client about a low-fat diet --the HCP performing the surgery should explain the risks, benefits, and alternatives of the specific procedure to the client. However, the nurse can witness the client's signing of the consent form; this differs from "obtaining consent." If the client had a question about the procedure, or the risks, alternatives, or outcomes, then the HCP should be contacted to provide additional teaching to the client. However, an ordinary question about general care or health care teaching can be answered by the nurse as this is part of the nurse;s role.

A client comes to the clinic for a follow-up visit after a Billroth II surgery (gastrojejunostomy). The client reportsoccasional episodes of sweating, palpitations, and dizziness 30 minutes after eating. Which nursing action is most appropriate? -check serum blood glucose for hypoglycemia -ensure that the client consumes fluids with meals -take the client's blood pressure while lying and standing -teach the client to lie down after eating

-teach the client to lie down after eating --Billroth II surgery removes part of the stomach and shortens the upper GI tract. After a partial gastrectomy, many clients experience dumping syndrome, which occurs when gastric contents empty too rapidly into the duodenum, causing a fluid shift into the small intestine. This results in hypotension, abdominal pain, N/V, dizziness, generalized sweating, and tachycardia. To reduce to occurrence of symptoms, clients should avoid fluids with meals and lie down after eating to slow gastric emptying. An upright or sitting position increases the force of gravity, which increases the rate of gastric emptying.

The nurse is caring for a client with acute pancreatitis admitted 2 days ago. Which assessment finding is most concerning? -blood glucose levels for the past 24 hours are >250 mg/dL -client is lying with knees drawn up to the abdomen to alleviate pain -five large, liquid stools that are yellow and foul-smelling -temperature of 102.2 F with increasing abdominal pain

-temperature of 102.2 F with increasing abdominal pain --Clients with acute pancreatitis are at risk for pancreatic abscess development. This mainly results from secondary infection of pancreatic pseudocysts or pancreatic necrosis. High fever, leukocytosis, and increasing abdominal pain may indicate abscess formation. The abscess must be treated promptly to prevent sepsis. The HCP should be notified immediately as antibiotic therapy and immediate surgical management may be required. --Clients with acute pancreatitis are expected to have an elevated blood glucose. --Clients with acute pancreatitis often report severe, burning midepigastric abdominal pain that radiates to the back. Clients may seek relief from pain by positioning themselves in the knee-chest position, which decreases intra-abdominal pressure. --The client with pancreatitis may develop steatorrhea due to decrease in lipase production.

The ED nurse is triaging clients. Which neurologic presentation is most concerning for a serious etiology and should be given priority for definitive treatment? -history of Bell's palsy with unilateral facial droop and drooling -history of multiple sclerosis and reporting recent blurred vision -reports unilateral facial pain when consuming hot foods -temple region hit by ball, loss of consciousness, but GCS is now 14

-temple region hit by ball, loss of consciousness, but GCS is now 14 --Epidural hematoma is an accumulation of blood between the skull bone and dura mater. The majority of epidural hematomas are associated with fracture of the temporal bone and subsequent rupture or tear of the middle meningeal arterty. The bleed is arterial in origin, and so hematoma develops quickly. The clinical presentation of epidural hematoma is characteristic. The client may lose consciousness at the time of impact. The client then regains consciousness quickly and feels well for some time after the injury. This transient period of well-being is called a lucid interval. It is followed by a quick decline in mental function that can progress into coma and death.

The nurse is caring for a client newly prescribed crutches. Which finding indicates the need for further teaching? -the axillary pads are torn and show signs of wear -the client has a 30 degree bend at the elbow when walking -the crutches and injured foot are moved simultaneously in a 3-point gait -there is a 3 finger-width space noted between the axilla and axillary pads

-the axillary pads are torn and show signs of wear --Proper crutch fit includes a 3-4 finger-width space between the axillary pad and axilla and a handgrip location that allows 20-30 degrees of elbow flexion. Clients should support their body weight on the hands and arms, not the axillae. Wear and tear on the crutch pads many indicate improper use or fit. Clients progress from 3-point gait to 2-point gait and then 4-point gait as rehabilitation continues.

The nurse at the radiological imaging center is admitting a client for an MRI of the right knee. Which information obtained by the nurse should be reported immediately to the prescribing healthcare provider? -the client ate a full breakfast that morning -the client has an implantable cardioverter defibrillator -the client is allergic to povidone-iodine -the client took all prescribed cardiac medications before arriving.

-the client has an implantable cardioverter defibrillator --Radio waves and a magnetic field are used to view soft tissue during MRI. This test is especially useful in diagnosing tumors, disc disease, asvascular necrosis, ligament tears, cartilage tears, and osteomyeltis. MRIs can have open or closed chambers. The client should be advised that the procedure is painless but the machine will make loud tapping noises and may cause claustrophobia in some clients inside a closed chamber. MRI is contraindicated in clients with aneurysm clips, metallic implants such as ICDs, pacemakers, electronic devices, hearing aids, and shrapnel. The large magnet of the MRI can damage the ICD or interfere with its function. MRI is a noninvasive test that does not require anesthesia. The client is not required to have nothing by mouth and can take medications as normally indicated. The client is not required to have nothing by mouth and can take medications as normally indicated. No betadine is used during an MRI; gadolinium contrast is used

The family practice clinic nurse is conducting client intake histories. Which client findings or histories indicate a need for heightened concern that the client may have cancer? SATA -the 60-year-old client was just diagnosed with benign prostatic hyperplasia -the client reports a mobile, golf ball-sized lesion under the skin over the right thigh that feels doughy -the client reports a nagging cough with hoarseness for the past 3 months -the female client who weight 150 lb has lost 15 b in 3 months without dieting -the male client reports a skin change on the breast that looks like an orange peel

-the client reports a nagging cough with hoarseness for the past 3 months -the female client who weight 150 lb has lost 15 b in 3 months without dieting -the male client reports a skin change on the breast that looks like an orange peel --Signs of potential cancer include unplanned weight loss, nagging cough/hoarseness, and dimpled skin on the breast. Hard, fixed masses, non-healing ulcers, and changing moles may also indicate malignancy and require further workup. Lymphomas are benign, fatty masses and rarely become malignant. They are subcutaneous, ave a soft doughy feel, and are mobile and asymptomatic.

The elderly client with end-stage renal disease who has refused dialysis is admitted to a long-term care facility for rehabilitation following hospitalization. The next day, the client becomes agitated and says to the nurse, "I've got to get back home to my things. I have so much to do." Which is the most likely interpretation of this client's behavior? -the client has been admitted to the facility without the client's consent -the client is becoming delirious and should be assessed for infection -the client is concerned that someone might steal possessions -the client wants to take care of business before imminent death

-the client wants to take care of business before imminent death --This client with advanced renal failure who decides not to start dialysis treatments may have only a few weeks to live. Toxins will build up in the body and soon lead to increased weakness and cognitive decline. This client knows there is a limited time left to live and wants to ensure that possessions will be taken care of appropriately after the client's death.

A nurse is providing anticipatory guidance to a client with early Alzheimer disease and osteoarthritis. Current symptoms include mild forgetfulness and cognition changes. Which is the best example of an educational goal for anticipatory guidance? -the client will demonstrate proper organization of medications in a weekly pill box by the end of the teaching session -the client will identify and attend a support group meeting for clients with dementia by the end of the month -the client will verbalize 2 home safety changes that can prevent falls during disease progression by the end of the session -the client will verbalize 3 examples of easy, nutritious meals that can be prepared independently by the end of the clinic visit

-the client will verbalize 2 home safety changes that can prevent falls during disease progression by the end of the session --anticipatory guidance prepares the client and caregivers for future health needs and is useful throughout life, from pediatric growth and development to anticipated changes related to diseases processes/ This type of education promotes health and helps to reduce client/caregiver stress and anxiety, which heighten with unexpected cognitive, physical, and emotional changes. Anticipatory guidance educational goals should be client-oriented, realistic, objective, measurable, and focused on preparing for future needs specific to this client. The client with Alzheimer disease and osteoarthritis is at high risk for falls with disease progression. In the early stage, the client can make changes in the home to promote safety in the future.

The nurse has just received report on the telemetry unit. Which client should be seen first? -the client 2 days post coronary artery bypass; the night shift nurse reports diminished lung sounds in the bases -the client 4 hours post permanent pacemaker insertion that is 100% paced -the client with DVT who has a dose of enoxaparin due -the client with coronary artery disease and atrial fibrillation who has a dose of warfarin due

-the client with DVT who has a dose of enoxaparin due --This client has a current clot and is at risk for development of PE if the clot mobilizes. Enoxaparin is a low-molecular-weight heparin given as an anticoagulant and should not be delayed. The nurse should monitor the client for S/S of bleeding and clinical manifestations of a PE (dyspnea, chest pain, or hypoxemia) --atelectasis is a common complication after heart surgery and the nurse should assess the client and encourage coughing, deep breathing, and use of the incentive spirometer. The client with a-fib is at risk of forming left atrial clots, which can embolize and cause stroke. Warfarin and other anticoagulants are given for prevention of clot formation, which is important but not a critical as DVT.

A client with a dislocated shoulder is prescribed a shoulder sling. The nurse applies the sling and evaluates the fit before discharge from the emergency room. Which assessment finding indicates an incorrect fit? -the elbow is flexed at 90 degrees -the hand is held slightly below elbow level -the sling ends in the middle of the palm with fingers visible -the sling supports the wrist

-the hand is held slightly below elbow level --To ensure proper shoulder sling fit, the nurse should assess for the following: elbow flexion at 90 degrees; hand is held slightly above the level of the elbow; bottom of the sling ends in the middle of the palm with the fingers visible; and the sling supports the wrist joint.

The nurse observes a client self-administering nasal fluticasone. Which observation would require the nurse to intervene and provide further teaching? -a sitting position is assumed as the head is bowed slightly forward -the client points the spray tip toward the nasal septum during instillation -the nasal spray tip is inserted into the nostril as the other nostril is occluded -while administering the medication, the client inhales deeply through the nose

-the nasal spray tip is inserted into the nostril as the other nostril is occluded --the proper positioning and administration of nasal sprays allow the medication to reach the nasal passages. When educating a client on how to self-administer nasal sprays, the nurse includes pointing the nasal spray tip toward the side and away from the center of the nose

Following a motor vehicle crash, the nurse stops to help a victim who has a laceration with spurting blood. The nurse giving reasonable assistance could be held liable despite Good Samaritan laws in which situations? SATA -the nurse accepts money from the victim -the nurse does not accompany the victim on the ambulance -the nurse does not apply direct pressure to the artery -the nurse knows the victim from college -the victim dies after reaching the hospital

-the nurse accepts money from the victim -the nurse does not apply direct pressure to the artery --Good Samaritan laws prevent civil action against nurses who stop of their own accord to help injured individuals after an accident. The nurse cannot receive payment for any care given. It is essential for the nurse to perform in the same manner as any reasonable and prudent medical professional would in the same or similar circumstances. A reasonable, prudent nurse would apply pressure to help control an arterial bleed. --although this nurse is not legally obligated to offer assistance, it can be argued that there is an ethical responsibility. Once the nurse starts to render care, the nurse is responsible to continue until the care can be handed off to an appropriate caregiver, such as a paramedic. The nurse is not obligated to accompany the client to the hospital.

Which of the following are examples of medical battery? SATA -a child is placed in a papoose restraint for suturing of a facial laceration with the parent present -application of soft wrist restraints to the arms of a confused, adult client with a NG tube -the nurse administers 3 mg of morphine PRN to a difficult, alert client but tells the client it is saline -the nurse inserts a needed urinary catheter even though a competent client refuses -the nurse threatens to put a client in restraints if the client does not stay in bed

-the nurse administers 3 mg of morphine PRN to a difficult, alert client but tells the client it is saline -the nurse inserts a needed urinary catheter even though a competent client refuses

The nurse assesses several clients using the Glasgow Coma Scale. Which scenario best demonstrates a correct application of this scale? -the nurse applies pressure to the nail bed, and the client tries to push the nurse's hand away. The nurse scores motor response as "localization of pain" -The nurse asks the client what day it is and the client says "banana". The nurse scores verbal response as "Confused" -the nurse speaks with client and then the client's eyes open. The nurse scores eye opening as "spontaneous" -the nurse walks in the room and the client states "Hi honey, how are you?" The nurse scores verbal response as "oriented"

-the nurse applies pressure to the nail bed, and the client tries to push the nurse's hand away. The nurse scores motor response as "localization of pain" --The GCS is used to determine LOC. The nurse follows a standardized assessment to determine the score of the client's eye opening response, verbal response, and ability to obey a command. If there is no response, the nurse next uses noxious stimuli and records the physical response. If the client tries to remove the painful stimulus, it is recorded as "localized" or moving toward the pain; whereas if the client retracts from the stimulus, it is recorded as "withdrawal".

The nurse is caring for a 5 year old client who is dehydrated and malnourished, and suspects that the client may be neglected. Which information most strongly supports the nurse's suspicion of child neglect? -the parent cannot stay the hospital due to potential job loss from absence -the parent is in the process of a divorce and will soon be a single parent -the parent is witnessed stealing food and drinks from the cafeteria -the parent leaves the client's younger sibling to care for the client's newborn sibling

-the parent leaves the client's younger sibling to care for the client's newborn sibling --supervisory neglect is a type of child neglect and represents an immediate risk to the safety of younger children. The nurse should ensure that the children are safe and report the child neglect incident to social services.

The charge nurse on the orthopedic unit has 4 semiprivate room beds available. Which room should the nurse assign to a client being transferred from the post anesthesia recovery unit following a total knee replacement? -room where client is in skeletal traction following a fracture of the femur, who has erythema at the pin sites -the room with a client with cellulitis and osteomyelitis following blunt trauma of the tibia -the room with a client with compartment syndrome following a crush injury, who is 1 day post fasciotomy -the room with a client with a long leg cast following open reduction of a fractured tibia

-the room with a client with a long leg cast following open reduction of a fractured tibia --This client has the lowest potential risk for infection. --erythema can be a sign of infection. The client with the fasciotomy wound is also a potential source of infection due to usually keeping the wound open for several days to relieve the pressure in the myofascial compartment.

The HCP prescribes a multivitamin regimen that includes thiamine for a client with a hx of chronic alcohol abuse. The nurse is aware that thiamine is given to this client population for which purpose? -to lower the blood alcohol level -to prevent gross tremors -to prevent Wernicke encephalopathy -to treat seizures related to acute alcohol withdrawal

-to prevent Wernicke encephalopathy --Clients with chronic alcohol abuse suffer from poor nutrition related to improper diet and altered nutrient absorption. Poor thiamine intake and/or absorption can lead to Wernicke encephalopathy, a serious complication that manifests as altered mental status, oculomotor dysfunction, and ataxia. Clients are prescribed thiamine to prevent this condition.

The emergency department nurse is obligated to make a report for which symptoms? SATA -to a client's employer that the client had a car crash while intoxicated -to the authorities that an elderly client has suspicious bruising but denies caregiver abuse -to the medical examiner of a death following trauma, even if the family refuses autopsy -to the spouse of a client that the client has a reportable STI -to the supervisor that an oncoming healthcare provider has the smell of alcohol on the breath

-to the authorities that an elderly client has suspicious bruising but denies caregiver abuse -to the medical examiner of a death following trauma, even if the family refuses autopsy -to the supervisor that an oncoming healthcare provider has the smell of alcohol on the breath

The emergency department nurse is triaging clients. Which client is a priority for diagnostic workup and definitive care? -fell, twisting the right knee; heard a "pop" -history of glomerulonephritis; has "iced-tea" colored urine -pain 10/10 in reddened eye; wears contact lens -took a handful of amitriptlyine tablets after a fight with spouse

-took a handful of amitriptyline tablets after a fight with spouse --Overdoses are generally a priority due to the unpredictability of dosing and client response. Specifically, the tricyclic antidepressant amitriptyline is lethal if taken in overdose, especially if consumed with alcohol. Death typically results due to serious cardiac arrhythmias.

A client is being admitted for a potential cerebellar pathology. Which tasks should the nurse ask the client to perform to assess if cerebellar function is within the defined limits? SATA -identify the number "8" traced on the palm -shrug the shoulders against resistance -swallow water -touch each finger of one hand to the hand's thumb -walk heel-to-toe

-touch each finger of one hand to the hand's thumb -walk heel-to-toe --The cerebellum is involved in 2 major functions: coordination of voluntary movements and maintenance of balance and posture. Maintenance of balance is assessed with gait testing and includes watching the client's normal gait first and then the gait on heel-to-toe, on toes, and on heels. Coordination testing involves the following: Finger tapping, rapid alternating movements, finger-to-nose testing, and heel-to-skin testing. --identifying a tracing on the palm is an example of testing sensory function, specifically fine touch. -shrugging the shoulders against resistant is an example of testing cranial nerve XI (spinal accessory). --swallowing water is an example of assessing CN IX (glossophrayngeal) and CN X (vagus)

Appropriate toys for preschoolers

-toys that encourage imitation of adults --dolls, puppets, imaginative toys, dress-up clothes, medical kits, cars, planes. preschoolers have imaginations and enjoy make-believe

An unconscious client is brought to the emergency department by the paramedics after being hit by a car. An emergency craniotomy is required. The client has no identification. What action should be taken next? -contact the national database to see if the client has a healthcare proxy -contact the police to help identify the client and locate family members -obtain a court order for the client's surgical procedure -transport the client to the operating room under implied consent

-transport the client to the operating room under implied consent --Implied consent in emergency situations includes the following criteria (there is an emergency; treatment is required to protect the client's health; it is impractical to obtain consent; it is believed that the client would want treatment if able to consent) In this case, it would be assumed that the client would want life-saving surgery; the healthcare provider should proceed.

The nurse prepares to assess a newly admitted client diagnosed with chronic alcohol abuse whose laboratory report shows a magnesium level of 1.0 mEq/L. Which assessment finding does the nurse anticipate? -constipation and polyuria -increased thirst and dry mucous membranes -leg weakness and soft, flabby muscles -tremors and brisk deep-tendon reflexes

-tremors and brisk deep-tendon reflexes --Hypomagnesemia, a low blood magnesium level, is associated with alcohol abuse due to poor absorption, inadequate nutritional intake, and increased losses via the GI and renal systems. It is associated with ventricular arrhythmias (most serious concern) and neuromuscular excitability. --constipation and polyuria indicate hypercalcemia.

4 clients come to the ED. Which client should the triage RN assign as highest priority for definitive diagnosis and treatment? -client with COPD with yellow expectoration and oxygen saturation of 91% -healthy child with new-onset fiery-red rash on cheeks and the "flu" -middle-aged client with vaginal itching and white, curdlike discharge -unconscious elderly client who smells of alcohol and has fresh vomit on the face

-unconscious elderly client who smells of alcohol and has fresh vomit on the face --Vomit and decreased LOC places this client at risk for airway obstruction.

Beliefs about death for children ages 10-12

-understands that death is final and eventually affects everyone -thinks about how death will affect them personally

The nurse helps the healthcare provider perform a thoracentesis at the bedside. In which position does the nurse place the client to facilitate needle insertion and promote comfort? -fetal position, lying on unaffected side with knees drawn to the abdomen and hands clasped around them -lying on the affected side with head of the bed elevated to 30-45 degrees -prone with head turned to the affected side and arms over the head, supported by a pillow -upright leaning forward over the bedside table, with arms supported on pillows

-upright leaning forward over the bedside table, with arms supported on pillows --During a thoracentesis, a needle is inserted into the pleural space to remove fluid for diagnostic or therapeutic purposes. Before the procedure, the nurse places the client in an upright sitting position on the side of the bed, leaning forward over the bedside table, with arms supported on pillows. This position ensures that the diaphragm is dependent, facilitates access to the pleural space through the intercostal spaces, and promotes client comfort. --if unable to sit, the client can be positioned lying on the UNaffected side, not the affected side.

What are contraindications of anticholinergics?

-urinary retention greater than normal (300mL) -narrow-angle glaucoma -bowel ileus/obstruction --there is no need to further relax smooth muscles

The nurse cares for a client admitted with severe burns who is now on fluid resuscitation therapy. Which assessment findings would best indicate that fluid resuscitation has been successful? -heart rate 89/min, blood pressure 99/52 mm Hg -potassium decrease from 5.7 mEq/L to 5.0 mEq/L -urine output 31 mL/hr, respirations 20/min -weight gain of 2.2 lbs in last 8 hours and palpable pulses

-urine output 31 mL/hr, respirations 20/min --After a burn injury, increased capillary permeability leads to third spacing, allowing proteins, plasma, and electrolytes to leave the vascular space and occupy other spaces and tissues. This creates a state of hypovolemic shock, which poses the highest risk of mortality in the initial phase of the burn process. Therefore, aggressive fluid resuscitation to correct hypovolemia is a priority. Adequate urine output depends on adequate renal perfusion and is the greatest indicator that fluid resuscitation therapy has effectively restored tissue perfusion.

A client is seen following a motor vehicle collision. An IV infusion of 1 L 0.9% normal saline solution was administered before arrival at the hospital. The IV line is now infusing at 200 mL/hr. Which assessment finding alerts the nurse to the development of hypovolemic shock? -jugular venous distension -mean arterial blood pressure 65 mm Hg -urine output <0.5 mL/kg/hr -warm, flushed skin

-urine output <0.5 mL/kg/hr --Hypovolemic shock most commonly occurs from blood loss but can occur in any condition that reduces intravascular volume. Hypovolemia is classified as either an absolute or a relative fluid loss. Reduced intravascular volume results in decreased venous return, decreased stroke volume and cardiac output, inadequate tissue perfusion, and impaired cellular metabolism. Decreased urine output despite fluid replacement indicates inadequate tissue perfusion to the kidneys and is a manifestation of hypovolemic shock in a client with normal renal function.

To reduce the risk of client and staff injury, safe transfers and repositioning are achieved using the following guidelines:

-use a gait/transfer belt to transfer a partially weight-bearing client to a chair -use 2 or more caregivers to reposition clients who are uncooperative or unable to assist - use a full-body sling lift to move/transfer clients weighing less than 200 lb -use 3 or more caregivers to move cooperative clients weighing more than 200 lbs

The nurse is caring for a client with left-sided weakness from a stroke. When assisting the client to a chair, what should the nurse do? -bend at the waist -keep the feet close together -pivot on the foot proximal to the chair -use a transfer belt

-use a transfer belt --A transfer belt worn around the client's waist allows the nurse to assist the client while maintaining proper body mechanics and safety. --the nurse using proper body mechanics would pivot on the foot distal to the chair.

While turning a client, the nurse observes that the client's radiation implant has dislodged and is now lying on the linens. Which action by the nurse is appropriate? -get the client out of bed and away from the radiation source -manually reinsert the implant and notify the healthcare provider -use long-handled forceps to secure the implant in a lead container -wrap the implant in the linens and place it in a biohazard bag

-use long-handled forceps to secure the implant in a lead container --An internal radiation implant emits radiation in or near a tumor to treat certain malignancies. When caring for clients undergoing brachytherapy, the nurse should monitor closely for evidence of implant dislodgment. The dislodged implant emits radiation that can be dangerous to healthcare workers at the bedside. Long-handled forceps and a lead-lined container should be kept in the room of the client who has a radioactive implant in case of dislodgment. If dislodgment occurs, the nurse should first use long-handled forceps to place the implant in a lead-lined container to contain radiation exposure. The nurse should also notify the healthcare provider.

The nurse in the ICU is giving UAP directions for bathing a client who has a surgical incision infected with methicillin-resistant Staph aureus (MRSA). Which instructions would be most effective for reducing infection? -assist the client to the shower and provide directions to use antibacterial soap -delay the bath until the client has receives antibiotic therapy for 24 hours -use a bath basin with warm water and a new washcloth for each body area -use packaged pre-moistened cloths containing chlorhexidine to bathe the client

-use packaged pre-moistened cloths containing chlorhexidine to bathe the client --Current evidence supports the recommendation for clients with MRSA or other drug-resistant organisms to be bathed with pre-moistened cloths or warm water containing chlorhexidine solution. bathing clients in this way can significantly reduce MRSA infection.

The best way to communicate and obtain information from a client with Alzheimer is to:

-use simple statements and questions -face the client, allowing the client to visualize the speaker's face and help reduce distraction -provide a quiet environment to remove distracting stimuli.

Key teaching to reduce the client's risk of bleeding with immune thrombocytopenic purpura.

-use soft-bristle toothbrushes, gentle flossing, and nonalcoholic mouthwashes to prevent periodontal disease and gingival bleeding -avoid activities that may cause trauma. -wear footwear -take prescribed stool softeners and laxatives as needed to prevent hard stools and straining -use electric razors to reduce the risk of nicking the skin -avoid nonsteroidal anti-inflammatory drugs.

The nurse teaches a parent how to administer an oral liquid medication to a 2-month-old client. The nurse knows that the parent understands the teaching when the parent does which of the following? -allows the client to sip the medication from a cup -expels the medication from a dropper onto the back of the tongue -mixes the medication in the infants bottle of formula -using a syringe, administers the medication in small amounts into the back of the cheek

-using a syringe, administers the medication in small amounts into the back of the cheek --using a syringe to measure the medication is the most accurate technique to ensure that the proper amount of medication is being administered. The correct procedure for administering oral medication to an infant is to place small amounts of the medication at the back of the cheek, allowing time for the infant to swallow each amount. This technique decreases the risk for choking and ensures that all the medication is consumed.

Use for methotrexate

-various malignancies -rheumatoid arthritis -psoriasis

Which of the following diets would place aclient at the highest risk for macrocytic anemia? -lacto-ovo-vegetarian -lacto-vegetarian -macrobiotic -vegan

-vegan --megaloblastic anemia is caused by vitamin B12 or folic acid deficiency. Vitamin B12 deficiency can also result in peripheral neuropathy and cognitive impairment. Vitamin B12 is formed by microorganisms and found only in animal foods; some plant foods may contain minimal amounts of vitamin B12 only if they accidentally contain animal particles. Natural sources of vitamin B12 includes meat, fish, poultry, egg, and milk. Vegans are strict vegetarians; they exclude all animal products, including eggs, milk, and milk products from their diet. They also may avoid foods that are processed or not organically grown, thereby eliminating potentially fortified food sources of vitamin B12

Steps performed by a nurse when assisting a lumbar puncture.

-verify informed consent -gather the lumbar puncture tray and needed supplies -explain the procedure to older child and adult -have client empty bladder -place client in the appropriate position (side-lying with knees drawn up and head flexed or sitting up and bent forward over a bedside table) -assist the client in maintaining the proper position -provide a distraction and reassure the client throughout the procedure -label specimen containers as they are collected -apply a bandage to the insertion site -deliver specimens to the laboratory

A client newly returned to the unit after knee surgery asks the nurse for assistance to a chair. What action should the nurse implement first? -ask another nurse for help -delegate the task to unlicensed assistive personnel -premedicate the client for pain -verify the client's activity prescription

-verify the client's activity prescription --A client newly admitted from a surgical procedure may have activity restrictions or bed rest prescribed for a certain period. Before assisting the client to the chair, the nurse needs to verify the activity level prescribed by the healthcare provider. Getting the client out of bed too early could cause injury to the surgical site or result in a fall.

The nurse inserts a small-bore nasogastric tube and prepares to initiate enteral feedings for a hospitalized client with laryngeal cancer. Which action should the nurse take first? -crush and administer medications -dilute enteral formula as prescribed -flush the tube with 30 mL of water -verify tube placement with an X-ray

-verify tube placement with an X-ray --enteral feedings are given to provide nutrition to clients who are unable to take in nutrients by mouth. Placement verification is imperative prior to initiating enteral feedings to prevent complications such as aspiration. Lung aspiration can lead to pneumonia, acute respiratory distress syndrome, and abscess formation. After placement is verified, the nurse may flush the tube with water, administer prescribed medications, flush the tube again, and then prepare and deliver the enteral feeding

Clonidine

-very potent antihypertensive medication --abrupt discontinuation can result in serious rebound hypertensive crisis ---other side effects include dizziness, drowsiness, and dry mouth

Beliefs about death for adolescent

-views death on an adult level -understands that their own death is inevitable, but it is a difficult concept for them to perceive -able to think about the spiritual and religious aspects of death

What is Fifth disease?

-viral illness that affects school-aged children --caused by human parvovirus and spreads through respiratory secretions

The nurse is evaluating a client with liver cirrhosis who received IV albumin after a paracentesis to drain ascites. Which assessment finding indicates that the albumin has been effective? -abdominal circumference reduced from admission recording -flapping tremor no longer visible with arm extension -shortness of breath no longer experienced in supine position -vital signs remain within the client's normal parameters

-vital signs remain within the client's normal parameters --Ascites is the accumulation of fluid in the peritoneal space that often occurs in clients with liver cirrhosis. Ascitic fluid increases abdominal pressure, resulting in weight gain, abdominal distension and discomfort, and shortness of breath. Paracentesis is often performed to reduce symptoms of ascites. However, clients undergoing paracentesis must be monitored closely for hypotension as changes in abdominal pressure often result in systemic vasodilation. Clients may receive IV albumin after paracentesis, which increases intravascular oncotic pressure resulting in increased intravascular fluid volume. Albumin administration prevents hypotension and tachycardia by irrigating hemodynamic changes associated with paracentesis. --Asterixis occurs due to elevated blood ammonia levels. Lactulose is commonly used to treat asterixis as it promotes ammonia excretion. Albumin does not affect ammonia excretion.

A nurse discontinues patient-controlled analgesia per the health care provider's prescription, and notes that there is 10 mL of morphine sulfate left in the cartridge. All other nurses on the unit appear busy. What is the most appropriate action by the nurse? -ask UAP to witness the wasting of the medication -document that another nurse was not available to waste the medication -wait until another nurse is available and then witness the waste together -waste the morphine alone and then show the empty cartridge to the charge nurse

-wait until another nurse is available and then witness the waste together --waste of controlled substances must be witnessed by two licensed nurses to comply with facility policy and government regulations.

Gross motor skills of an 18 month old

-walk up/down stairs with help -throws ball overhead -jumps in place

15 month old growth and development

-walks alone -crawls up stairs -builds 2-block tower -throws objects -grasps spoon -names commonplace objects

Gross motor skills for a 10-12 month old infant

-walks first step independently -crawls up stairs

Steps to prevent infections in clients with urinary catheters include:

-wash hands thoroughly and regularly -perform routine perineal hygiene with soap and water each shift and after bowel movements -keep drainage system off the floor or contaminated surfaces -keep the catheter bag below the level of the bladder -ensure eachclient has a separate, clean container to empty collection bag and measure urine -use sterile technique when collecting a urine specimen -facilitate drainage of urine from tube to bad to prevent pooling of urine in the tube or backflow into the bladder -avoid prolonged kinking, clamping, or obstruction of the catheter tubing -encourage oral fluid intake in clients who are awake and if not contraindicated -secure the catheter in accordance with hospital policy -inspect the catheter and tubing for integrity, secure connections, and possible kinks

A parent calls the nursing triage line during the evening. The parent says that a 7-year-old was found playing in an area with poison ivy and asks what to do. Which is the most important instruction to give the parent? -apply cool, wet compresses for itching -apply topical cortisone ointment to the area -discourage the child from scratching the area -wash the skin where the contact occurred.

-wash the skin where the contact occurred. --Poison ivy can cause a contact dermatitis rash in those who are sensitive to the oily resin found on the leaves, stems, and roots of the plant. About 50% of people who come in contact with the plant develop a rash. It is often linear in appearance where the plant brushed against the skin. The rash develops 12-48 hours after exposure and can last for several weeks. The severity of the rash depends on the amount of resin on the skin. It is most important to first thoroughly wash the area to remove the resin and prevent its spread to other areas of the body.

An 80-year-old client has been hospitalized with pneumonia and malnutrition. Physical assessment findings include weakness and decreased muscle mass. Which finding best indicates that the client is responding to treatment? -client consuming 90% of each meal -serum albumin of 3.6 g/dL -weight gain of 2 lbs in 2 weeks -white blood cell count of 15,000/mm3

-weight gain of 2 lbs in 2 weeks --Malnutrition occurs due to inadequate intake of major nutrients or micronutrients. As malnutrition worsens and protein intake is reduce, muscles become fatigued and weak. Clinical manifestations depend on the severity of the malnutrition, ranging from mild to extreme. Weight gain is the best indicator that the client is responding to medical nutritional therapy. --consuming 90% of meals indicates that the client's appetite is good or improving, but does not provide conclusive evidence of an improved nutritional status. -although a serum albumin level of 3.6 g/dL is within the normal range of 3.5-5.0 g/dL, visceral protein stores are poor indicators of nutritional status in acute and chronic disease. During an inflammatory response (pneumonia), protein synthesis by the liver is decreased. Serum albumin has a long half-life, so laboratory levels may not reflect the change in nutritional status for over 2 weeks. Prealbumin has a half-life of only 2 days and is quicker and more reliable than serum albumin as an indicator of acute change in nutritional status -a while blood cell count of 15,000/mm3 is elevated, which indicates that the infection has not resolved.

Lifestyle and dietary measures that may prevent GERD and associated symptoms

-weight loss (excessive abdominal fat may increase gastric pressure) -small, frequent meals with sips of water or fluids (helps facilitate the passage of stomach contents into the small intestine and prevent reflux from becoming overly full during meals) - Avoiding GERD triggers (caffeine, alcohol, nicotine, high-fat foods, chocolate, spicy foods, peppermint, and carbonated beverages) -chewing gum (promotes salivation, which may help neutralize and clear acid from the esophagus) -sleeping with the head of the bed elevated -refraining from eating at bedtime and/or lying down immediately after eating

Basic supportive care for toxic epidermal necrolysis

-wound care: sterile, moist dressings are applied to open areas of skin -infection prevention: strict sterile technique and reverse isolation decrease infection risk -fluids and nutrition: vital signs and urine output are monitored for signs of hypovolemia. oral feedings should be initiated early to promote wound healing; NG tube may be needed -hypothermia prevention: maintain room temperature 85 and higher -pain management: analgesics are administered around the clock and before painful procedures -eye care: sterile, cool compresses are applied to relieve discomfort. Lubricants may relieve dryness and prevent corneal abrasion

What is the type gauge size and needle length for an intramuscular injection?

18-25 gauge -1-1.5 inches

Should you raise your voice when communicating/talking with a hearing impaired client?

NO raising the voice to speak loudly creates a higher pith that is harder to understand

Can a small-barrel syringe be used for enteral feeding tubes?

NO they create too much pressure and rupture the tube

Can you place leftover formula into the fridge for the next feeding?

NO!! --should be discarded after feeding due to the infant's saliva being mixed with the formula, allowing for faster bacterial growth

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

administer IV normal saline --This presentation is classic for neurologic shock, a distributive shock. Vascular dilation with decreased venous return to the heart is present due to loss of innervation from spine. Classic signs/symptoms are hypotension, bradycardia, and pink and dry skin from the vasodilation. Neurogenic shock usually occurs in cervical or high thoracic injuries. Administration of fluids is a priority to ensure adequate kidney and other organ perfusion.

Terazosin drug classification -function

alpha-adrenergic blocker --relieves urinary retention in clients with BPH. It relaxes smooth muscles (including in peripheral vasculature)

What medications are contraindicated in a client with acute angle-closure glaucoma?

antihistamines and anticholinergics. --increases intraocular pressure

What should clients receiving allergy skin tests avoid?

antihistamines for 2 or more weeks prior to the test. --these include diphenhydramine (benadryl) loratadine (claritin), and promethazine (phenergan)

A client with palpitations is admitted with supraventricular tachycardia. The client's heart rate is 210/min. Which is the most appropriate initial intervention? --ask the client to bear down as if having a bowel movement --grab the crash cart and apply hands free defibrillation pads --place ECG leads on client to further assess electrical activity --place IV line distally from the heart fro adenosine administration

ask the client to bear down as if having a bowel movement --clients with paroxysmal SVT are initially treated with vagal maneuvers. The act of "bearing down" as if having a bowel movement is an example of these maneuvers and may need to be attempted more than once. Vagal maneuvers work by increasing intra-thoracic pressure and stimulating the vagus nerve, which supplies parasympathetic nerve fibers to the heart, resulting in slowed electrical conduction through the arterioventricular node. Cardioversion (not defibrillation) is used with this type of arrhythmia when it is refractory to medication. Adenosine is the drug of choice to treat SVT and has a 5-6 second half-life. Placing the IV line as close as possible, not distal, to the heart is essential for the drug to have full effect.

The nurse is caring for a client who is 1 day postoperative extensive abdominal surgery for ovarian cancer. The client is receiving IV Ringer's lactate at 100 mL/hr and continual epidural morphine for pain control. The Foley catheter urine output has decreased to <20 mL/hr over the past 2 hours. The postoperative hematocrit is 36% and the hemoglobin is 12 g/dL Which action should the nurse carry out first? --assess vital signs --increase the IV rate to 125 mL/hr --notify the healthcare provider --perform a bladder scan

assess vital signs --Third-spacing of fluids can occur 24-72 hours after extensive abdominal surgery as a result of increased capillary permeability due to tissue trauma. It occurs when too much fluid moves from the intravascular into the interstitial or third space, a place between cells where fluid does not normally collect. This fluid serves no physiologic purpose, cannot be measured, and leads to decreased circulating volume and cardiac output. The priority intervention is to assess vital signs as the manifestations associated with third-spacing (weight gain, decreased urinary output, and signs of hypovolemia--tachycardia/hypotension). If third-spacing is not recognized and corrected early on, postoperative hypotension can lead to decreased renal perfusion, prerenal failure, and hypovolemic shock. the nurse will notify the healthcare provider to report oliguria after collecting all the data required. A bladder scan is not an appropriate action in this situation as the client has a Foley catheter.

The nurse is caring for an intubated client whose oxygen saturation begins to drop. What action should the nurse take first? --auscultate lung sounds bilaterally --hyper-oxygenate with 100% oxygen --manually ventilate with bag valve mask --suction the endotracheal tube

auscultate lung sounds bilaterally --A drop in oxygen saturation signifies a problem with ventilation. When an artificial airway is present, the nurse should assess the client to determine the cause of hypoventilation. Auscultating lung sounds is the first step and quickest intervention to confirm proper tube placement. It is not uncommon for the tube to become displaced in the hypopharynx, which would not allow proper ventilation. Another important complication is pneumothorax, which can cause hypotension and a drop in oxygen saturation. Lung auscultation would help diagnose this as well.

Define systemic lupus erythematosus

autoimmune disorder in which an abnormal immune response leads to chronic inflammation of different parts of the body

define Marfan Syndrome

autosomal dominant disorder that affects the connective tissues of the body --major cause of death in this disease is aortic root disease (aneurysm or dissection)

Clients with SLE should be advised to..

avoid harsh sunlight and ultraviolet light exposure, as well as harsh soaps and chemicals. --receive annual influenza vaccinations due to susceptibility to infections

What is common in toddlers as they learn to walk and when should it resolve by?

bowlegs --18 to 24 months

age appropriate toys for 4-6 months

brightly colored toys (small enough to grasp, large enough for safety)

Common S/E of beta blockers

bronchoconstriction or bronchospasm. --a client taking a BB and exhibiting wheezing should be of concern. --check for hx of asthma before administration

breath sounds of a normal lung

bronchovesicular and vesicular

How is the facial nerve assessed?

by observing for symmetrical movements during facial expressions, such as a smile, frown, or closing the eyes.

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

check for bleeding at tube connection sites --The low pressure alarm could signal hypotension. The nurse's first action should be to check the client for evidence of hypotension and the cause. Arterial lines carry the risk of hemorrhage and are most likely to occur at connection sites of the tubing and catheter. A client can lose a large amount of arterial blood in a short period of time. The nurse should verify that these connections are tight on admission of the client in the ICU. A fast flush of the arterial line system (square wave test) should be performed after the nurse has ruled out a physiological cause of the low pressure alarm. The transducer should be leveled to client's phlebostatic axis to measure arterial pressure correctly AFTER the client has been checked for a physiological cause of the alarm.

What is a risk for teeth misalignment and malocclusion?

child using a pacifier or sucks the thumb after the eruption of the permanent teeth

What is Kawasaki disease?

childhood condition that causes inflammation of arterial walls (vasculitis) --etiology is unknown --no diagnostic tests --not contagious

Who commonly gets otitis media?

children two years of age or less

Describe myasthenia gravis

chronic neurological autoimmune disease --acetylcholine receptors are blocked, causing muscle weakness. --infection, undermedication, and stress result in myasthenia crisis

Why does the death rattle occur?

client cannot manage airway secretions. movement of these secretions during breathing results in rattling noise

What is the most reliable indicator for client's pain level?

client's self-report of symptoms

Who is the best client for a nasal cannula?

clients with adequate Tidal volume and normal vital signs. --it is not the best choice for unstable COPD clients with varying tidal volumes.

What clients should avoid NSAIDs?

clients with kidney failure due to NSAIDs being nephrotoxic.

For which types of clients are non-rebreathing reservoir masks used?

clients with low saturations resulting from asthma, pneumonia, trauma, and severe sepsis --it can deliver 60-95% oxygen concentrations

The nurse is caring for a client in the immediate postoperative period following an exploratory lapraotomy after sustaining a gunshot wound to the abdomen. Which assessment finding is most important for the nurse to report to the healthcare provider? --cold and clammy skin --oxygen saturation of 92% --sinus tachycardia of 108/min --urine output of 0.6 mL/kg/hr

cold and clammy skin --hypovolemic shock may occur after abdominal trauma or surgery as mesenteric edema resolves and previously compressed sites of bleeding reopen. Cold, clammy skin indicates compensatory mechanisms and immediate intervention is necessary to prevent irreversible shock and death.

If an immature trach is accidentally dislodged, what should the nurse do?

cover the stoma with a sterile, occlusive dressing and ventilate the lungs with a bag-valve mask over the nose/mouth,

A client with blunt trauma undergoes an exploratory laparotomy to repair the intraabdominal injury. After 24 hours, the client has a nasogastric tube attached to continual low suction, 2 hemovac closed-wound suction abdominal drains, and is receiving IV Ringer's lactate and continual epidural morphine. The client now develops hypotension, tachycardia, oliguria, and severe nausea. What is the client's priority nursing diagnosis at this time? --deficient fluid volume --impaired urinary elimination --nausea --risk for infection

deficient fluid volume --This client is exhibiting symptoms of hypovolemia, which include hypotension, tachycardia, and decreased urinary output. Therefore, the priority nursing diagnosis is deficient fluid volume related to active intravascular loss that is secondary to hemorrhage, gastric suction, wound drainage, and possible third spacing as evidenced by decreased urine output, hypotension, and tachycardia. The adverse effects of the epidural anesthesia can contribute to hypotension as well. This nursing diagnosis poses the greatest threat to survival because if not corrected, it can lead to decreased cardiac output, acute renal failure, and hypovolemic shock.

define invasion of privacy

disclosing medical information to others without client consent. Under HIPPA, a client's information regarding medical treatment is private and cannot be released without the client's permission

A nurse in the ICU is caring for a client with sepsis who is on a mechanical ventilator. The client is exposed to the noise of the mechanical ventilator., monitoring equipment, and infusion pump alarms during the day and night. What should the nurse identify as the priority nursing diagnosis? --anxiety --disturbed sleep pattern --powerlessness --risk for acute confusion

disturbed sleep pattern --Sleep disturbance pattern can lead to anxiety, powerlessness, and acute confusion. Therefore, disturbed sleep pattern related to environmental factors such as excessive noise and changes in daylight-darkness exposure is the primary nursing diagnosis. A disturbance in sleep pattern refers to time-limited interruptions of the amount and quality of a client's sleep due to external factors (noise, light). Evidence shows that excessive noise and sleep disturbances in critically ill clients can affect outcomes as they can lead to significant psychologic and physiologic consequences. All other options were appropriate nursing diagnoses, but not the priority.

At what age is it appropriate to receive the influenza vaccine?

greater than 6 months of age

another name for pediculosis capitits

head lice

Acoustic nerve assessment

hearing and Romberg test

The nurse is caring for a client with sepsis and acute respiratory failure who was intubated and prescribed mechanical ventilation 3 days ago. The nurse assesses for which adverse effect associated with the administration of positive pressure ventilation? --dehydration --hypokalemia --hypotension --increased cardiac output

hypotension ---Positive pressure ventilation delivers positive pressure to the lungs using a mechanical ventilator, either invasively through a tracheostomy or endotracheal tube or noninvasively through a nasal mask, etc. The most common type used in the acute care setting for clients with acute respiratory failure is the volume cycled positive pressure MV, which delivers a present volume and concentration of oxygen with varying pressure. Positive pressure applied to the lungs compresses the thoracic vessels and increases intrathoracic pressure during inspiration. This leads to reduced venous return, ventricular preload, and cardiac output, which results in hypotension. The hypotensive effect of PPV is even greater in the presence of hypovolemia (hemorrhge, hypovolemic shock) and decreased venous tone (septic shock, neurogenic shock). Fluid and/or sodium retention usually occurs about 48-72 hours after initiation of PPV due to increased intrathoracic pressure and decreased cardiac output that stimulate the kidneys to release renin, physiologic stress that leads to the release of antidiuretic hormone and cortisol, and breathing through the ventilator's closed circuitry, which decreases insensible loss associated with respiration. Hypokalemia is not associated with PPV.

Define Battery

involves making physical contact with the client without permission. This includes harmful acts or acts that the client refuses.

The ED nurse receives a client with extensive injuries to the head and upper back. The nurse will perform what action to allow the best visualization of the airway? --head-tilt-lift in the supine position on a backboard --head-tilt-chin-lift in the Tendelenburg position --Jaw-thrust maneuver in semi-Fowler's position --jaw-thrust maneuver in the supine position on a backboard.

jaw-thrust maneuver in the supine position on a backboard. --Clinical situations involving trauma should follow ABC. Airway assessment is particularly critical in clients with injuries to the head, neck, and upper back. Injury to the upper back should be treated as spinal trauma until the client has been cleared by an Advance Trauma Life Support-qualified healthcare provider. Until thespine is appropriately assessed, the client should be placed on a backboard and stabilized. The nurse should use the jaw-thrust maneuver to avoid movement of an unstable spine. One provider should stabilize the cervical vertebra allowing the second provider to articulate the jaw independently of the spinal column. Although use of the backboard is appropriate, the head-tilt-chin-lift should not be used as it involves manipulation of the neck without proper stabilization. The head-tilt chin-lift does not stabilize the alignment of the head and neck and can cause spinal cord damage. In addition, the Trendelenburg position causes the abdominal organs to shift toward the diaphragm, which increases the work of breathing. Stabilization of the spine is best performed in the supine position, such as on a flat, hard surface of a backboard.

When caring for a client with a left radial artery catheter, which assessment data obtained by the nurse indicates the need to take immediate action? --capillary refill of less than 3 seconds --left hand cooler than right --mean arterial pressure of 65 mm Hg --pressure bag at 300 mm Hg

left hand cooler than right --Although the Allen's test is performed before cannulating the radial artery and determines the adequacy of ulnar artery blood flow, circulation to the extremity is monitored frequently. The nurse must assess color, capillary refill, sensation, temperature, and movement per institution policy. Impairment in any of these parameters must be reported immediately because it may indicate impaired circulation to the extremity, and removal of the catheter may be necessary. To maintain patency of the arterial blood pressure monitoring system, an intravenous bag of normal saline solution is placed in a pressure infuser device. The device is set to maintain continual pressure at 300 mm Hg. The pressure drops as the volume of solution in the bag decreases and can be pumped back up. This does not pose an immediate threat to the client.

The obtain accurate continuous blood pressure readings via a radial arterial catheter, the nurse places the air-filled interface of the stopcock at the phlebostatic axis. Where is it located? --angle of Louis at 2nd intercostal space to left of sternal border --aortic area at 2nd ICS to right of sternal border --level of atria at 4th ICS, 1/2 anterior-posterior diameter --5th intercostal space at midclavicular line

level of atria at 4th ICS, 1/2 anterior-posterior diameter --to measure pressures accurately using continual arterial and/or pulmonary artery pressure monitoring, the zeroing stopcock of the transducer system must be placed at the phlebostatic axis. This anatomical location, with the client in the supine position, is at the 4th ICS, at the midway point of the AP diameter of the chest wall

Clients at greatest risk for pressure injuries include those with:

limited movement long bone or hip fractures quadriplegia critically ill --clients with deficits in mobility and activity, incontinence, inadequate nutrition, chronic illness, renal failure, anemia, problems with oxygenation, edema, or infection

Describe the diet for a client with hepatitis

low fat, small, frequent meals (decreases nausea and promote intake with anorexia) --promote water consumption and diets adequate in carbs and calories

Language developmental milestone for 2-3 month old

makes cooing sounds

Treatment of mononucleosis

managing symptoms -hydration, rest, control of pain, reducing fever -antibiotics are NOT used d/t the disease being viral

A nurse is caring for a client on a mechanical ventilator. The ventilator is sounding an alarm and displaying an alert about low tidal volumes. The nurse has checked all connections and the endotracheal tube, but the alarm perisists and the client's oxygen saturation is dropping. What should the nurse do next? --call the respiratory therapist to the bedside to troubleshoot --elevate the head of the bed and apply a nonrebreather mask --increase the oxygen delivery on the ventilator to 100% --manually ventilate with a resuscitation bag device attached to the endotracheal tube

manually ventilate with a resuscitation bag device attached to the endotracheal tube --A low tidal volume alarm indicates that the volume of air the ventilator is delivering is lower than the set volume. This is most often due to a disconnection, loose connection, or leak in the circuit. The nurse should troubleshoot the most common causes of the alarm, but if the client's condition is deteriorating clinically, then the nurse should disconnect the ventilator and manually ventilate the client's lungs with a resuscitation bag device at 10-15 L/min oxygen until the ventilator alarm state can be resolved.

Define Strabismus

misalignment of the eyes caused by defect in eye muscle --treated with patching the stronger eye or surgery

Rehabiliation phase of burn treatment is aimed at improving...

mobility and independence

When are OTC emergency contraception pills most effective?

most effective within 3 days of unprotected sexual intercourse

Initial management of heat exhaustion includes...

moving the client from the heat to a cooler area and providing a cool, electrolyte-containing sports drink or water.

The client is brought to the ED after his face slammed into a brick wall during a gang fight. Which client assessment finding is most important for the nurse to consider before inserting a nasogastric tube? --an ecchymotic area on the forehead --frontal headache rated as 10 on a 1-10 scale --nasal drainage on gauze has a red spot surrounded by serous fluid --small amount of bright red blood oozing from cheek lacerations

nasal drainage on gauze has a red spot surrounded by serous fluid --CF rhinorrhea can confirm that a skull fracture has occurred and transversed the dura. If the drainage is clear, dextrose testing can determine if it is CSF. However, the presence of blood would make this test unreliable as blood also contains glucose. In this case, the halo/ring rest should be performed by adding a few drops of the blood-tinged fluid to gauze and assessing for the characteristic pattern of coagulated blood surrounded by cSF. No nasogastric or oral gastric tube should be inserted blindly when a basiliar skull fracture is suspected as there is a risk of penetrating the skull through the fracture site and having the tube ascend into the brain. These tubes are placed under fluoroscopic guidance in clients with such fractures. A bruise is expected after direct trauma. It would be a concern if the ecchymosis were around the eyes or postauricular as this generally indicates basiliar skull fractures. A headache is a common finding after trauma. It would be more concerning if it were unrelieved by non-narcotic analgesics or accompanied by signs of increased intracranial pressure.

What is the danger with heparin-induced thrombocytopenia?

organ damage from local thrombi and/or embolization, leading to stroke and/or pulmonary embolism

Mannitol drug class

osmotic diuretic

S/E of high dose furosemide

ototoxicity --administer slowly

define gingival hyperplasia

overgrowth of gum tissues or reddened gums that bleed easily

A client at 3 weeks gestation goes into cardiac arrest. What is the nurse's best action while performing cardiopulmonary resuscitation for this client? --compress chest at second intercostal space, right sternal border --perform chest compressions slightly higher on the sternum --place hands just below the diaphragm to perform chest compressions --position client in the supine position for optimal compressions

perform chest compressions slightly higher on the sternum --Common causes of sudden cardiac arrest in pregnant clients include embolism, eclampsia, magnesium overdoses, and uterine rupture. If CPR is required, several modifications must be made to ensure efficacy of the rescue efforts. During pregnancy, the heart is displaced toward the left because the growing uterus pushes upward on the diaphragm, particularly in the third trimester. To accommodate this displacement, the hands should be placed on the sternum slightly higher than usual for chest compressions during CPR. In addition, a gravid uterus can significantly compress the client's vena cava and aorta, thereby hindering effective blood flow during CPR. The uterus should be manually displaced to the client's left to reduce this pressure. The nurse can also place a rolled blanket or wedge under the right hip to displace the uterus. If ROSC does not occur after 4 minutes of CPR, emergency cesarean section is usually initiated.

Describe the prodromal phase of a seizure

period with warning signs that precede the seizure. This phase occurs before the aural phase

A 2 year-old at an outpatient clinic stops breathing and does not have a pulse. CPR is initiated. When the automated external defibrillator arrives, the nurse notes that it has only adult AED pads. What is the appropriate action at this time? --continue CPR without using the automated external defibrillator until paramedics arrive --place one AED pad on the chest and the other on the back --place one AED pad on the upper right chest and the other on the lower left side -place one AED pad on the upper right chest and dispose of the other

place one AED pad on the chest and the other on the back --An AED should be used as soon as it is available. Pediatric AED pads or a pediatric attenuator should be used for children age birth to 8 years if available. Standard adult pads can be used as long as they do not overlap or touch. If adult AED pads are used, one should be placed on the chest and the other on the back

The charge nurse is evaluating the skills of a new RN assigned to care for a client with shock. Which action taken by the new RN indicates a need for further education? --administers furosemide to a client with pulmonary artery wedge pressure of 24 mm Hg with cardiogenic shock --increases norephinephrine infusion rate to maintain mean arterial pressure >65 mm Hg in a client with anaphylactic shock --moves pulse oximeter sensor from the finger to the forehead of a client with septic shock --places the head of bed for a client with hypovolemic shock in high Fowler's position

places the head of bed for a client with hypovolemic shock in high Fowler's position --The nurse manager would intervene when the new RN places the HOB of a client with hypovolemic shock in high Fowler's position. Raising the HOB causes blood pressure to decrease, especially in a client with hypovolemic shock and inadequate circulating vascular system. Furosemide is an appropriate drug for the nurse to administer to decrease left ventricular preload in a client in cardiogenic shock with PAWP of 24 mm Hg. Norepinephrine is a vasopressor used to increase stroke volume, cardiac output, and MAP. Titrating a norepinephrine infusion upward to maintain the MAP within normal limits is an appropriate nursing action for a client in anaphylactic shock

Define Hirschsprung's disease

portion of the colon having no innervation and requires removal

bumetanide drug class --function

potent loop diuretic --treats edema associated with heart failure and live/renal disease --POTASSIUM WASTING

The emergency department nurse is caring for a client who requires gastric lavage for a drug overdose. Which action would be appropriate? --lavage through a small-bored nasogastric tube --place client in Trendelenburg Position during lavage --prepare intubation and suction supplies at the bedside --wait an hour after gastric decompression to initiate lavage

prepare intubation and suction supplies at the bedside --Gastric lavage is performed through an orogastric tube to remove ingested toxins and irrigate the stomach. Gastric lavage is rarely performed as it is associated with a high risk of complications (aspirations, esophageal or gastric perforation, dysrhythmias). Gastric lavage is only indicated if the overdose is potentially lethal or if gastric lavage can be initiated within one hour of the overdose. Activated charcoal is the standard treatment for overdose, but it is ineffective for some drugs (lithium, iron, alcohol). Intubation and suction supplies should always be available at the bedside during gastric lavage in case the client develops aspiration or respiratory distress. Gastric lavage is usually performed through a large-bore orogastric tube so that a large volume of water or saline can be instilled in and out of the tube. During gastric lavage, clients should be placed on their side or with the head of bed elevated to minimize aspiration risk.

The nurse is admitting a client with a possible diagnosis of Guillain-Barre syndrome. When collecting data to develop a plan of care for the client, the nurse should give priority to which of the following items? --orthostatic blood pressure changes --presence or absence of knee reflexes --pupil size and reaction to light --rate and depth of respirations

rate and depth of respirations --Guillain-Barre syndrome is an acute, immune-mediate polyneuropathy that is most often accompanied by ascending muscle paralysis and absence of reflexes/ Lower-extremity weakness progresses over hours to days to involve the thorax, arms, and cranial nerves. Neuromuscular respiratory failure is the most life-threatening complication. The rate and depth of the respirations should be monitored. Measurement of serial bedside forced vital capacity is the gold standard for assessing early ventilation failure.

A RN is precepting a new nurse in the ICU. The client is sedated with propfol, on a mechanical ventilator, and is receiving enteral feeding via nasogastric tube. The new nurse performs interventions to prevent aspiration. The preceptor should intervene if the new nurse performs which of the following actions? --assesses gastric residual volumes every 4 hours --measures the number of centimeters the feeding tube is secured at the nare every 4 hours --requests that the physician change the client from continual to bolus feedings --uses a sedation scale to titrate down the sedation (if possible)

requests that the physician change the client from continual to bolus feedings --Critcially ill clients are at increased risk for aspiration of oropharyngeal secretions and gastric content. It is common in clients who are intubated, sedated, on a mechanical ventilator, and receiving enteral feedings. The nurse must provide nursing interventions to prevent aspiration and monitor for its signs and symptoms. Clients are at increased risk when receiving bolus rather than continual enteral feedings. Bolus feedings should be avoided in critically ill clients, who are already at increased risk for aspiration. Assessing gastric residual volumes is standard for clients receiving continual enteral feedings. Increased volumes may indicate poor absorption and increase the risk of regurgitation and aspiration. Measuring the number of centimeters at the nare ever 4 hours can determine if the tube has moved, but it can increase aspiration risk. X-ray confirmation may be necessary if the tube has moved. A sedation scale is use to assess level of sedation.

What are the most commonly affected glands with Sjogren's syndrome?

salivary and lacrimal glands

Vagus nerve assessment

say "ah" and assess uvular and palate movement

Define pulmonary fibrosis

scarring of lung tissues, causing reduced function, dry cough, and dyspnea. --a progressive complication of scleroderma

When are peer relationships important

school-age (6-12 years)

What should be done with items that cannot be washed/dry cleaned in order to kill head lice?

sealed in a plastic bag for 14 days

drug classification of tamoxifen

selective estrogen receptor modulator --prescribed for treatment/prevention of estrogen-positive breast cancers

Sumatriptan drug class

selective serotonin agonist

The flight nurse assesses an alert and oriented client at an industrial accident scene who was impaled in the abdomen by a pair of scissors. Which nursing action is the immediate priority on arrival at the scene? --insert a large bore IV line and infuse normal saline --obtain blood for type and crossmatch and hemoglobin --remove constrictive clothing to enhance circulation --stabilize the scissors with sterile bulky dressings.

stabilize the scissors with sterile bulky dressings. --A sharp object that pierces the skin and lodges in the body may result in penetrating trauma to nearby tissue and organs. Common types of impaled objects include bullets or blast fragments from firearms as well as sharp objects. The embedded object creates a puncture wound and then controls potential bleeding by putting pressure on the wound. First responded should not manipulate or remove the impaled object. Manipulation or removal may cause further trauma and bleeding; therefore, stabilization of the object is the first priority to prevent it from moving during initial client assessment and later during transport to a healthcare facility where skilled trauma care is available. An IV line may be inserted and fluids begun on scene after stabilization of the object and initial assessment. Blood may be drawn after stabilization of the object and initial assessment. Clothing may be removed on scene after stabilization of the object and initial assessment.

What is required for a client to be able to leave against medical advice?

the client must be legally competent to make an educated decision to stop treatment. --disqualifications for legal competency include altered consciousness, mental illness, and being under chemical influence.

Define paternalism

type of beneficence whereby clients are treated as children.

Describe preschoolers play

unorganized play with no specific goal/rules --associative play

define hypospadias

urethral opening on the underside of the penis --corrected at age 6-12 months of age through surgery --requires monitoring of urinary output to ensure urethra patency

What is the best indicator of adequate rehydration?

urine output

When is growth hormone replacement therapy stopped?

usually when growth is less than 1 inch per year and bone age is 14 for girls and 16 for boys

Define electrical alternans

variation in QRS amplitude --could be present in cardiac tamponade.

Describe phentolamine (Regitine)

vasodilator injected subcutaneously to counteract the effects of some adrenergic agonists (norepinephrine or dopamine)

Raynaud phenomenon is characterized by...

vasospasm-induced color changes in the fingers, toes, ears, and nose. --can develop secondary to scleroderma

What is used to treat hydrocephalus?

ventriculoperitoneal shunt

What can infants with bacterial meningitis develop?

hydrocephalus

describe percussion associated with pneumo

hyperresonance

Describe percussion associated with emphysema

hyperresonant

when can an infant respond to their own name? (what month)

7 months

Examples of Aminoglycosides

-"mycin" -gentamicin -tobramycin -amikacin

Classic signs/symptoms of neurogenic shock?

--hypotension --bradycardia --pink/dry skin from the vasodilation

Describe the subacute phase of Kawasaki disease?

--skin peels from hands/feet; child is irritable

Growth and Development 4 year old

-1,500 vocab -throws overhead -may have imaginary friends

S/S of retinoblastoma

-lack of red reflex (white glow of pupil-- known as leukocoria)

What are complications of intussusception?

-intestinal perforation -peritonitis

Characteristics of nephrotic syndrome

-massive proteinura -edema -hypoalbuminemia

Proper position for lumbar puncture

-side-lying with knees drawn up and head flexed -sitting up and bent forward over a bedside table

Most common contributing factor to UTIs in infants

-urinary stasis -constipation -infrequent vomiting

Examples of live vaccines

-varicella -MMR

when does the posterior fontanelle close?

2 months of age

What is required for a client with trach to have with them at all times?

2 spare trach tubes, one of the same size and one a size smaller --this ensures that the tube can be replaced quickly and effectively

How long do symptoms of pneumonia last?

2-4 weeks after discharge. --during this time, the client should avoid OTC cough suppressant medications as they impair secretion clearance, especially in clients with chronic bronchitis.

At what age can a child undress without help?

3 years of age

Rule of nines head percentage

4.5%

What PaCO2 level indicates hypercapnia and hypoventilation?

>45 mm Hg

CN VIII

Acoustic

midazolam drug class

Benzodiazepine

What is the most common STI?

Chlamydia

Another name for Broca's aphasia?

Expressive aphasia

CN XII

Hypoglossal

Treatment of syphilis while pregnant

IM penicillin G benzathine

Can someone take 2 NSAIDs at once?

NEVER

What is the most common form of childhood cancer?

leukemia

Olfactory assessment involves

smell test

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? --"I will auscultate the neck to assess for endotracheal cuff leaks" --"I will perform endotracheal suctioning routinely after oral care" --"I will provide oral care and oral suctioning every 2 hours" --"I will reposition the client from side to side at least every 2 hours"

"I will perform endotracheal suctioning routinely after oral care" --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. Auscultating the neck to monitor for an ET tube cuff leak is a standard component of respiratory assessment in mechanically ventilated clients.

MAP calculation

(systolic + 2x diastolic)/3

When does separation anxiety start? when does it peak? when does it potentially stop?

- 6 months of age -10-18 months of age -up to 3 years

Misoprostol drug use

- a cervical ripening agent -administer orally or vaginally

What are the steps for administering ophthalmic ointment?

- perform hand hygiene -tilt the head back, pull the lower lid down, and look upward - squeeze a thin strip of ointment onto the lower eyeliid, from the inner to the outer edge -close the eyes gently for 2-3 minutes after applying the ointment

What are the 6 rights to medication administration?

- the right client -the right medication -the right dose -the right time -the right route -the right documentation

Nursing Management for the post-hemorrhoidectomy client includes:

--pain relief: pain is originally managed with pain medications, including nonsteroidal anti-inflammatory drugs and/or acetaminophen. opioids can be prescribed but may worsen constipation. Beginning 1-2 days postop, warm sitz baths are used as a means to relieve pain. --preventing constipation: encourage a high-fiber diet and adequate fluid intake. Administer docusate as prescribed.

Clinical features of peritonsillar/retropharyngeal abscess

-"hot potato" (muffled voice) -trismus (inability to open mouth) -pooling of saliva -deviation of uvula to one side --lack of treatment results in tonsillitis or pharyngitis

Examples of ACE inhibitors

-"pril" -lisinopril -ramipril

What does Hawthorn extract treat?

heart failure

Treatment of nephrotic syndrome

-corticosteroids -other immunosuppressants

Characteristics of Reye Syndrome

-fever -acute encephalopathy -altered hepatic function

Final stage of Erickson's developmental tasks --task

-late adulthood --integrity vs despair

extremely elevated blood lead levels causes

-permanent cognitive impairment -seizures -blindness -even death

COPD symptoms @ night

-repeated periods of apnea -loud snoring -interrupted sleep

The nurse reviews a prescription to insert an indwelling urinary catheter in a hospitalized client. Which rationale for indwelling urinary catheter insertion is most important? -the client has acute urinary retention -the client is confused and incontinent -the client is elderly and at risk for falls -the client is receiving intravenous diuretics

-the client has acute urinary retention --The use of indwelling urinary catheters should be minimized during hospitalization. Appropriate use includes urinary obstruction or retention, some perioperative circumstances, required prolonged immobilization, end-of-life comfort, and facilitating healing of an open perineal or sacral wound. Indwelling urinary catheters should not be used for convenience or as a substitute for nursing care

Indications for airborne precautions

-tuberculosis -varicella zoster -herpes zoster -rubeola (measles)

A nurse is performing a dressing change for a hospitalized client with an infected surgical incision. Which actions should the nurse take? -have the client remove the existing dressing while the nurse prepares sterile supplies -wear clean gloves for removal and application of a new dressing -wear clean gloves to remove the existing dressing, changing to sterile gloves to apply the new dressing -wear sterile gloves, gown, and goggles to remove the soiled existing dressing

-wear clean gloves to remove the existing dressing, changing to sterile gloves to apply the new dressing --The existing dressing is already contaminated so clean gloves can be worn to remove and discard it. Surgical wounds should be re-dressed using aseptic technique, which would require sterile gloves and sterile dressing supplies. The nurse should carefully remove the soiled dressing to avoid shedding an microorganisms into the air and expose the wound for minimal time to avoid additional contamination.

Ways to prevent thrombus

-wearing graduated compression stockings -elevating legs when sitting -maintaining adequate hydration

6th stage of Erickson's developmental task --task

-young adult --intimacy vs isolation

midazolam initial dose

1 mg and titrate slowly. max dose of 3.5

When do kids partake in playing with adult tools?

1-7 years of age --enjoy imitation

Phenytoin therapeutic range

10-20 mcg/mL

when does an infant vocalize one-two words?

10 months

What is a normal pulse for a 1 year old?

100-160 beats/minute

What is a normal heart rate for an infant (1-12months)?

100-160/min

When do infants begin eating with fingers?

12 months

When is birth weight tripled?

12 months

@ what age is it appropriate to provide an infant with whole milk?

12 months of age due to rapid growth

when can an infant build 2-block towers?

15 months

when do infants begin crawling up stairs?

15 months

normal platelets

150,000-400,000/m3

What is the recommended size of urinary catheter and balloon for an adult male?

16 F

At what age is oral vocab 10 or more words?

18 months

when can an infant build a 3-block tower?

18 months

when does the anterior fontanelle usually close?

18 months

Anterior and posterior leg rule of nines percentage

18%

Rule of nines abdomen percentage

18%

When does voluntary control of the anal and urethral sphincters occur?

18-24 months

As the nurse begins to assist with ambulation of a 9-year-old who is one day post appendectomy, the child cries out, "It hurts too much. I can't do it." What is the first action by the nurse? 1. Administer an analgesic 2. Assess the child's level of pain using a numeric rating scale 3. Come back later in the day 4. Tell the child, "Get up and walk if you want to go home soon."

2. Assess the child's level of pain using a numeric rating scale --When a client is in pain, assessment is the first necessary nursing action. The pain assessment helps to determine the appropriate relief measure and serves as a baseline for evaluating the effectiveness of the chosen pharmacological or non-pharmacological measure. A numeric pain scale can be used with most children who can count and understand the concept of numbers, generally at around age 5. The scale uses a straight line with divisions marked in units from 0-10.

What is malignant hyperthermia (MH)?

rare, life-threatening inherited muscular abnormality that is triggered by specific drugs used to induce general anesthesia. --screen for MH susceptibility by asking if any of the client's blood relatives have ever experienced an adverse reaction to general anesthesia

A client started a 24-hour urine collection test at 6:00 AM. The unlicensed assistive personnel (UAP) reports discarding a urine specimen of 250 mL at 10:00 AM by mistake but adding all specimens to the collection container before and after that time. What action should the nurse take? 1. Add 250 mL to the total output after the 24-hour urine collection is complete tomorrow morning 2. Discard urine and container, and restart the 24-hour urine collection tomorrow morning 3. Discard urine and container, have client void, add urine to new container, and then restart test 4. Relabel the same collection container, and change the start time from 6:00 AM to 10:00 AM

2. Discard urine and container, and restart the 24-hour urine collection tomorrow morning --Timed urine collection tests are usually done to assess kidney function and measure substances excreted in the urine. These tests require the collection of all urine produced in a specified time period to ensure accurate test results. The proper container for any specific test is obtained from the lab. The collection container must be kept cool to prevent bacterial decomposition of the urine. Not all of the client's urine was saved during the collection period. Therefore, the nurse or UAP must discard the urine and container and restart the specimen collection procedure. Although a 24-hour urine collection can begin at any time of the day after the client empties the bladder, it is common practice to start the collection in the morning after the client's first morning voiding and to end it at the same hour the next morning after the morning void.

CN XI

Spinal accessory

What insulins can be mixed with intermediate-acting insulins?

short-acting or rapid-acting.

What position is best for decreasing aspiration risk?

side-lying --it uses gravity to drain oropharygneal and gastric secretions

How should a client be placed during lumbar puncture?

side-lying, with head, back, and knees flexed. A small pillow might be placed between the legs and under the head for comfort and maintain spine in horizontal position.

Describe the play used by infants?

solidary play (plays by themselves)

At what age can an infant turn the book pages 1 at a time?

24 months

At what age does an infant have a 300-word vocab?

24 months

What is the type gauge size and needle length for a subcutaneous injection?

25-27 --3/8-5/8 inch

At what rate does the body clear alcohol?

25-50 mg/dL per hour

When can a child copy a circle?

3 years of age

When does moro reflex disappear? (what month)

3-4 months

Define hemoptysis

spitting of blood that originated in lungs

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

3. Patch both eyes with eye shields ---The camp nurse protects the injured eye using an eye shield, ensuring the shield does not touch the foreign body. The eyes work in synchrony with each other; therefore, the non-injured eye is patched to prevent further eye movement. The nurse also facilitates transport to the nearest emergency care center for assessment and treatment by an ophthalmologist. Flushing the eye with cool water is contraindicated as it may cause further damage by moving the splinter or introducing potential wound pathogens. Instilling optic antibiotic ointment would interfere wit h ophthalomologic medical examination.

At what age do infants begin eating solid foods?

4-6 months

What is a normal blood glucose range for an infant within the first 24 hours after delivery?

40-60 mg/dL

Therapeutic PTT

46-70 seconds

When may teething begin?

5 months

when is birth weight usually doubled? (what month)

5 months

At what age can a child tie their shoes?

5 years

At what age does gender-specific behavior occur?

5 years

at what age does cooperative play occur?

5 years

Incubation period for MERS

5-6 days --can range from 2-14 days

Where is the tricuspid valve auscultated?

5th ICS to the lower left sternal border

When can an infant hold their own bottle?

6 months

when can an infant turn from back to stomach?

6 months

In what ages do febrile seizures most commonly occur?

6 months to 6 years

Normal BUN

6-20 mg/dL

Normal MAP

70-105 mm Hg --<60 mm Hg can result in underprofused organs

when does the pincer grasp start to develop? what month

8 months

normal infant heart rate

90-160

What are the five rights of delegation?

A. Right task B. Right circumstance C. Right person D. Right direction or communication E. Right supervision

Is head lag at 6 months of age normal?

NO!! Abnormal --often associated with cerebral palsy or autism

Should women greater than 60 years of age take iron supplements?

NO; they are at risk for excess iron levels

What drug classification and use is metronidazole

AKA flagyl --antimicrobial --used to treat IBD

Can insulin glargine be mixed with other drugs?

NOOOO it can be administered separately from regular insulin

What is the priority assessment for a client newly diagnosed with quadriplegia?

airway management and oxygenation

Treatment of Sjogren's syndrome

alleviating symptoms due to no cure being present

Can a child with a viral infection receive aspirin or medications containing salicylates?

NOOOO --increases risk for Reye Syndrome ---this includes pepto-bismol (bismuth subsalicylate)

Function of heparin

NOT dissolving clots --it slows the time it takes for blood to clot, thus preventing current clots from getting bigger and new clots from forming

Treatment for Fifth disease

NSAIDs for joint pain --client should recover within 7-10 days

CN VI

Abducens

Define autonomy

allowing clients to choose the direction of their care --accomplished with advanced directives along with informed consent and choices regarding proposed treatments

define assault

an act that threatens the client and causes the client to fear harm, but without the client being touched

What is intussusception?

an intestinal obstruction that results when a part of the intestine folds into a section next to it. --it is a medical emergency and can be fatal if left untreated

Early-morning low back stiffness is seen with...

ankylosing spondylitis

The warning signs of cancer can be remembered with what acronym?

CAUTION -change in bowel or bladder habits -a sore that does not heal -unusual bleeding or discharge from a body orifice -thickening or a lump in the breast or elsewhere -indigestion or difficulty in swallowing -obvious change in a wart or mole -nagging cough or hoarseness

Methylphenidate drug classification -function

CNS stimulant - used for ADHD and narcolepsy.

What causes mononucleosis?

Eptein-Barr virus --common in adolescents d/t sharing drinks, kissing, or exposure to saliva

CN IX

Glossopharyngeal

What is hydrochlorothiazide commonly used for?

HTN

What is the single most important medication to be given in anaphylatic shock?

IM ephinephrine --repeat dose Q5-15 minutes if symptoms are still present --other drugs: bronchodilators; antihistamines; corticosteroids

Treatment for infective endocarditis

IV antibiotics for 4-6 weeks

age appropriate toys for 6-9 months

Large toys with bright colors, movable parts, and noisemakers

What must you monitor when administering levofloxacin?

Levofloxacin (antibiotic) must be administered 2 or more hours before ingestion of aluminum/magnesium antacids, iron supplements, multivitamins containing zinc, or sucralfate.

What is used for control of asthma long-term?

Montelukast (leukotriene inhibitor) --given in combination with beta agonists and corticosteroid inhalers

Should a nurse strip a chest tube?

NEVER unless specifically prescribed.

Can someone with a penicillin allergy have cephalexin?

NO -it is chemically similar to penicillin

When should deep suctioning of a trach occur?

ONLY for respiratory distress d/t the risk for injury

CN III

Oculomotor

Which is cranial nerve I?

Olfactory

CN II

Optic

T/F syphilis can cross the placenta

TRUE

T/F preschool children have imaginary friends

TRUE! this is normal --they also believe in monsters under the bed; parents should acknowledge the fears

how is pleural effusion treated?

thoracentesis

Lead-based paints can be found in what houses?

those built before 1978

Best activities for a client with juvenile idiopathic arthritis (JIA)

those with low impact --swimming --riding a stationary bike --throwing/kicking a ball --yoga

TORCH

Toxoplasmosis Other (VZV/parovirus B19) Rubella Cytomegalovirus Herpes Simplex Virus

CN X

Vagus

Which ethnicity has the higher incidence of osteoporosis?

White and Asian Women

Which ethnicity has the higher incidence of melanoma?

White women those over the age of 60

Is levothyroxine safe for administration during pregnancy?

YES!!

Can a child less than 12 months of age receive the MMR vaccine?

YES-if there is an outbreak of measles and the child risks contracting the illness --the child will need to be revaccinated at 12-15 months and 4-6 years

What is Sjogren's syndrome?

a chronic autoimmune disorder in which moisture-producing exocrine glands of the body are attacked by white blood cells.

define ventricular septal defect

a septal opening between the ventricles allows left-to-right shunting, resulting in excess blood flow to the lungs.

How is a stable client with ventricular tachycardia treated?

antiarrhythmic medications (amiodarone, procainamide, sotalol)

how is the death rattle treated?

anticholinergic medications --transdermal scopolamine or atropine sublingual drops (dries up excess secretions)

Phenytoin drug class

anticonvulsant

drug class ofmetoclopramide

antiemetic

What medication might be administered with morphine sulfate?

antiemetics --tolerance develops quickly and persistent N/V is rare

What legal term is this an example of? "Threatening to adminsiter a benzodiazepine if the client does not comply" --assault; battery; false imprisonment; informed consent; invasion of privacy

assault

What is the priority nursing action when caring for a hospitalized client wearing an insulin pump?

assess client's mental capacity to determine the ability to self-manage the pump safely

Which clients should the nurse clarify if prescribed acetylcysteine?

those with reactive airway diseases (asthma) --it can cause or worsen bronchospasm

How is the severity of asthma symptoms determined?

assessing client's peak expiratory flow

When are likes and dislikes established?

at school-age (6-12 years)

How is the dosage of levothyroxine determined?

based on TSH level

How is pleural effusion diagnosed?

chest x-ray or CT

how is lithium excreted from the body?

kidneys

Nephrotic syndrome is characterized by

massive proteinuria and hypoalbuminemia, resulting in edema (commonly seen in abdomen, face, perineum)

Social/cognitive developmental milestones for 6-9 month old

may have stranger anxiety

Sumatriptan treats

migraines --constricts dilated cranial blood vessels

When does Reye syndrome develop?

often following a viral infection, most commonly varicella or influenza

What is a normal finding when performing the Babinski sign on an adult?

toes to point downward

Define neutropenia

low white blood cell count

Common causes of dementia is older adults

infection, medication, and hypoxia

What must be performed before starting "-statin" medications?

liver function tests --these drugs are metabolized by the hepatic enzyme system

Tricuspid heart auscultation

located @ 5th IC, left sternal border

Mitral heart auscultation

located @ apex, PMI, and 5th ICS @ MCL

Describe cystic fibrosis genetic pattern

--disorder with an autosomal recessive inheritance pattern --requires offspring to inherit 2 abnormal genes to be affected

Language skills of 3 year old

-3-4 word sentence -asking "why" questions -can state her own age

What are some screening tests used to evaluate children?

-Denver II -Stanford-Binet

Risk factors for macular degeneration include

-advanced age -family history -hypertension -smoking -long-term poor intake of carotenoid-containing fruits and veggies

What is the typical site of injection for subcutaneous injections?

-abdomen -posterior upper arm -thigh

Aortic heart auscultation

located at 2nd intercostal spaced, right sternal border

Erb heart auscultation

located at 3rd ICS, left sternal border

Pulmonic heart auscultation

located at second intercostal space, left sternal border

What do clients with a mechanical heart valve require long-term?

long-term anticoagulation d/t the increased risk for thromboembolism.

Bumetanide drug classification

loop diuretic

What type of dressing is used for burn injuries?

loose, nonadherent, sterile dressings

Misoprostol medication administration

-do not take with antacids -take with food -pregnancy category X

S/S of rotavirus

-foul-smelling, water diarrhea for 5-7 days --fever often present -vomiting --vaccination must be given before 8 months of age

Manifestations of chronic open-angle glaucoma

-gradual loss of peripheral vision -difficulty adjusting to different lighting

s/s of extravasation

-pain -blanching -swelling -redness

describe "death rattle"

loud rattling sound with breathing that occurs in a client who is actively dying.

Gross motor developmental milestone for 4-5 month old

-rolls back and forth -sits with support

Social/cognitive skills of 18 month old

-temper tantrums -understands ownership -imitates others

fine motor skills of a 10-12 month old child

-uses 2-finger pincer -hits 2 objects together

DVT risk factors

-venous statis -blood hypercoagulability -endothelial damage

What is a normal respiratory rate for an infant?

30-60/min

What CPR ratio is used in single rescue CPR for an infant?

30:2 chest-to-breath ratio

When might a child have an imaginary friend?

4 years

anterior and posterior arm rule of nines percentage

9%

Describe exhalation with pursed lips

double the time of inhalation

Hypoglossal nerve assessment

stick out tongue

Define dental avusion

tooth separating from the mouth --dental emergency

Function of allopurinol

treat gout by inhibiting uric acid production and improve solubility

What are the three stages of Kawasaki disease?

-acute -subacute -convalescent

examples of -Statins

-atorvastatin -simvastatin -rosuvastatin

Signs of phlebitis

-erythema -edema -warmth -pain -palpable venous cord

Therapeutic digoxin level

0.5-2.0 mg/dl

At what age should the pincer grasp be present?

10 months of age --introduction of finger foods at this age is appropriate

when can an infant elevate self to the sitting position? (what month)

9 months

What PaCO2 level indicates hypoxemia?

< 60 mm Hg

What is a normal carboxyhemoglobin for nonsmokers?

<5%

What is a high gastric residual volume?

> 500 m:

Aortic stenosis is...

characterized by narrowing of the aortic valve opening, limiting the left ventricles ability to eject blood into the aorta

What should be used to assess distance visual acuity in children greater than 6 years of age?

Snellen chart

CN V

Trigeminal

Describe toddlers play

play next to each other, but not with one another --parallel play

Thickening of the skin is seen with...

scleroderma

Decerebrate posturing is a sign of...

severe brain damage

Describe Stage 2 pressure ulcers

shallow, open wounds with partial-thickness skin loss of the dermis. --wound bed is red/pink

Broca aphasia is characterized by?

short, limited sentences with retained ability to comprehend speech

Who should not receive isoniazid?

someone with increased liver enzyme d/t the risk of drug-induced hepatitis

What are the most common causes of pelvic inflammatory disease?

gonorrhea and chlamydia

A client with massive trauma and possible spinal cord injury is admitted to the ED following a dirt bike accident. Which clinical manifestation does the nurse assess to help best confirm a diagnosis of neurogenic shock? --apical heart rate 48/min --blood pressure 186/92 mm Hg --cool, clammy skin --temperature 100 degrees F tympanic

apical heart rate 48/min --Neurogenic shock belongs to the group of distributive shock. It affects the vasomotor center in the medulla and causes a disruption in the sympathetic nervous system; the parasympathetic nervous system remains intact. The imbalance of activity between the SNS and PNS results in massive vasodilation and pooling of blood in the venous circulation, causing hypotension and bradycardia, the characteristics manifestations of neurogenic shock.

What vitamin supplement might pre-term infants need?

iron supplements at 2-3 months of age d/t lower iron storage at birth

Describe Gullian-Barre syndrome

-acute, immune-mediated polyneuropathy that is most often accompanied by ascending muscle weakness and absent deep tendon reflexes.

Coordination testing involves

-finger tapping (finger to thumb) -rapid alternating movements (rapid supination and pronation) -finger-to-nose testing (touch clinician finger and then client's nose) -heel-to-shin testing (run heel down each shin while supine)

Clinical manifestations of tardive dyskinesia

-lip/tongue movement -grimace -brow furrow or twitch -excess blinking -foot tap -hand wringing -tremor/shake -rocking torticollis (persistent neck flexion or extension)

Orlistat drug class and use

-lipase inhibitor -used for clients with obesity who struggle to lose weight --functions by preventing absorption of fat from the GI tract.

For medical procedures, the nurse should ensure that the client....

-has empty bladder and is in high Fowler's or sitting position for paracentesis -trandelenburg on left side for suspected air embolism -has arm raised above the head on the affected side for chest tube insertion -lies on right side (2+ hrs) and supine (12-14 hrs) after liver biopsy -side-lying with head, back, and knees flexed for lumbar puncture.

Language of a 10-12 month old

- 3 to 5 words - nonverbal gestures

The office nurse receives 4 telephone messages. Which client should the nurse call back first? -28 year old female client who fell on ice yesterday and has low back pain and spasm -42 year old male client who developed sharp, burning leg pain radiating from buttock to knee after lifting heavy weights -65 year old female client 10 days post spinal fusion who has increased persistent back pain and fever of 101.2 F - 70 year old male client with peripheral vascular disease who has acute-onset abdominal pain radiating to the low back

- 70 year old male client with peripheral vascular disease who has acute-onset abdominal pain radiating to the low back --an abdominal aortic aneurysm is a blood-filled bulge in the abdominal aorta caused by weakening in the vessel wall due to increased pressure. Risk factors include male sex, age > 65, coronary artery and peripheral vascular diseases, hypertension, and family and smoking hx. AAA dissection or rupture may manifest as acute-onset abdominal pain radiating to the back and is typically associated with symptoms of hemorrhagic shock. This client's symptoms could indicate impending rupture, which can lead to life-threatening vascular hemorrhage. --Client 3's fever and pain can be associated with a postoperative infection within the bone and surrounding tissue. Although diagnosis and treatment with prescribed antibiotics are crucial to prevent sepsis, it is not as critical as a potential massive hemorrhage.

The charge nurse is making assignments for the oncoming shift. Which client assignments should be avoided by the nurse who is pregnant? -2 year old client who is combative on postoperative day 2 for tonsillectomy and adenoidectomy -5 year old client admitted for dehydration secondary to severe throat pain associated with group A Streptococcus - 9 year old client with parvovirus B-19 infection admitted for observation after a febrile seizure -14 year old client with acute lymphocytic leukemia who received intrathecal chemotherapy 4 days ago and was admitted for a blood transfusion

- 9 year old client with parvovirus B-19 infection admitted for observation after a febrile seizure --Parvovirus B-19 is a common childhood infection known as "fifth disease". Infected clients display a characteristic "slapped cheek" rah on the face. Symptoms range in severity; however, most children do no require intervention. Transmission of the infection is usually through person-to-person contact, especially with respiratory secretions. Although rare, infection with parvovirus B-19 during pregnancy can cause fetal anomalies. It is recognized as a TORCH infection,a group of infections that cause fetal abnormalities. Delegation of this client to a pregnant nurse is inappropriate due to potential harm to the fetus. Extreme caution should be taken while handling cytotoxic medication; however, intrathecal administration days prior to contact should not pose a risk to the pregnant nurse,

What are some atypical presentations of MI in women, older adults, or clients with diabetes?

-indigestion -jaw/shoulder pain -dyspnea -diaphoresis -N/V

How much should an infant weight by 6 months? By one year?

--double in birth weight by 6 months --triple in birth weight by 12 months with chest and head circumference being equal

Rhythms that are ideal for synchronized cardioversion includes...

--supraventricular tachycardia --ventricular tachycardia with a pulse --atrial fibrillation with rapid ventricular response

examples of tricyclic antidepressants

-Amitriptyline -nortriptyline -imipramine -desipramine -clomipramine -doxepin -amoxapine.

The charge RN on a medical-surgical unit is responsible for making assignments. Which assignment made by the RN is most appropriate? -a LPN assigned to a client receiving blood transfusions -a student nurse assigned to a client who requires frequent IV pain medication -an LPN assigned to a client 2 days postoperative appendectomy scheduled to be discharged today -An RN assigned to a client 1 day postoperative repair of a compound fracture

-An RN assigned to a client 1 day postoperative repair of a compound fracture --An RN is appropriately assigned to the client who is the most unstable. The postoperative client requires thorough education and evaluation prior to discharge, which requires the skill of an RN due to being out of LPN scope of practice.

Examination of a skin lesion involves

-Asymmetry -Border irregularity -Color change and variation -Diameter of 6 mm or larger -Evolving (changing appearance in shape, size, and color)

A hospitalized client is scheduled for a percutaneous kidney biopsy at 10 AM. At 8 AM, the nurse reviews the client's vital signs and most current serum laboratory results. Which finding is most important to report to the HCP? -Blood pressure of 180/100 mm Hg -creatinine of 2 mg/dl -hemoglobin of 9.8 g/dL -platelet count of 120,000/mm3

-Blood pressure of 180/100 mm Hg ---The kidney is a highly vascular organ; therefore, uncontrolled hypertension is a contraindication to kidney biopsy as increased renal arterial pressure places the client at risk for post-procedure bleeding. Blood pressure must be lowered and well-controlled using antihypertensive medications before performing a kidney biopsy. An elevated serum creatinine level can be expected in a client with probable real disease.

The nurse is teaching a client of American Indian heritage how to self-administer insulin. As the nurse describes the necessary steps in the injection process, the client continuously avoids eye contact and occasionally turns away from the nurse. Which action is most appropriate for the nurse to take in this situation? -Continue teaching the client and verify understanding by return demonstration -discuss how important it is for the client to pay attention during the teaching -maintain eye contact during the teaching by following the client's movements -provide written instructions and a private place for the client to learn independently

-Continue teaching the client and verify understanding by return demonstration --Communication with individuals of various cultures may be difficult for the nurse at times due to cultural language differences. The mainstream American and European cultures value direct eye contact, believing that it is a sign of attention and trustworthiness. People of American Indian and Asian cultures view direct eye contact as rude and disrespectful and will likely move the eyes away, not allowing the nurse to maintain eye contact. If the client avoids eye contact during a teaching episode, the most appropriate action is to continue with the instruction and verify understanding by return demonstration.

S/E of autonomic dysreflexia

-HTN -bradycardia -pounding HA -diaphoresis -nausea

A client is brought to the emergency department after sustaining third-degree burns over 50% of the body. Which solution is the best choice for fluid resuscitation in this client? -0.45% normal saline -5% dextrose in 0.9% normal saline -5% dextrose in water -Lactated Ringer's Solution

-Lactated Ringer's Solution --The greatest immediate threat to a client with severe and extensive burn injuries is hypovolemic shock and electrolyte imbalance. This is due to cellular damage and increased capillary permeability caused by direct thermal trauma, which result in fluid loss. In the emergent phase of burn management, it is critical to establish an airway and replenish lost intravascular fluid, proteins, and electrolytes. Lactated Ringer's is the solution of choice for fluid resuscitation of a burned client due to its similarity in chemical composition to human plasma. Lactated Ringer's remains the in intravascular space longer than other solutions, which helps to stabilize blood pressure and avert shock.

what does metoclorpramide treat?

-N/V -gastroparesis by increased GI motility and prompting stomach emptying

S/S of methadone toxicity

-N/V -lethargy --monitor RR, pulse oximetry, ECG tracings (QT interval prolongation leading to life-threatening complications, such as torsades)

Components for airborne precautions

-N95 respirator or powered air-purifying respirator -negative-pressure isolation room with high-efficiency particuate air filter -as needed if contact with body fluid is anticipated: clean gloves, disposable gown, goggles/face shield

Components of airborne precautions

-N95 respiratory or powered air-purifying respirator -negative-pressure isolation room with high-efficiency particulate air filter -clean gloves, disposable gown,goggles/face shield as needed

Common applications of droplet precautions

-Neisseria meningitidis -Haemophilus influenzae type B -diphtheria -mumps -rubella -pertussis -Group A Strep -viral influenza

PASS

-Pull the pin on the handle to release the extinguisher's locking mechanism -Aim the spray at the base of the fire -Squeeze the handle to release the contents/extinguishing agent -Sweep the spray from side to side until the fire is extinguished

The charge nurse on a medical unit makes assignments for the nursing team composed of a RN, 2 LPNs, and a SN. Which assignment is most appropriate? -LPN assigned to a client with a GI bleed and hypotension who is receiving blood and requires VS monitoring every hour -LPN assigned to a newly admitted client with a bowel obstruction who is experiencing severe abdominal pain -RN assigned to a client with change in mental status who is being transferred to ICU -SN assigned to a client with MS and dysphagia who requires multiple oral and IV meds

-RN assigned to a client with change in mental status who is being transferred to ICU

What information is included in SBAR?

-Situation (what prompted the communication) -Background (pertinent information, admission time frame, when change of condition occurred, current diagnosis, relevant history, vital signs) -Assessment (the nurse's assessment of the situation) -Recommendation (request for prescription or action from the HCP)

The oncology nurse is caring for a client with tumor lysis syndrome. Which prescription should the nurse question? -allopurinol 200 mg PO every 24 hours -normal saline IV at 150 m/hr continuous -Sevelamer 800 mg PO3 times daily with meals -Spironolactone 25 mg PO every 12 hours

-Spironolactone 25 mg PO every 12 hours --Tumor lysis syndrome is an oncologic emergency that occurs when cancer treatment successfully kills cancer cells, resulting in the release of intracellular components. Clients with TLS develop significant imbalances of serum electrolytes and metabolites. Potassium-sparing medications can worsen hyperkalemia.

Indications for airborne precautions?

-TB -vericella zoster -herpes zoster -rubeola

The nurse is caring for a client in the intensive care unit who suffered partial-thickness burns to 36% of the body. During the first 24 hours, the nurse would anticipate which of the following assessments? -hemoglobin 10.2 g/dL -hyperactive bowel sounds -serum sodium 152 mEq/L -Tall, peaked T waves on ECG

-Tall, peaked T waves on ECG --Burn injuries cause tissue damage that leads in increased vascular permeability and fluid shifts. In the emergent phase after a burn (first 24-72 hours)fluid, proteins, and intravascular components leak into the surrounding interstitium,causing decreased intravascular oncotic pressure and decreased intravascular volume, and resulting in fluid shifts and hypovolemia. Potassium, the predominant intracellular cation, is released when cellular damage occurs, resulting in hyperkalemia. Clients with hyperkalemia experience muscle weakness, ECG changes, and cardiac arrhythmias. Hematocrit and hemoglobin values will be elevated due to hypovolemia. The sympathetic nervous system is activated in response to a burn,causing decreased peristalsis. N/V, gastric distension, and paralytic ileus may occur. Sodium is the most abundant extracellular cation. Hyponatremia occurs as sodium is lost via fluid shifts and insensible losses.

A home health nurse is visiting a client who underwent right-sided mastectomy with lymph node removal. The client is concerned about swelling in her arm on the affected side. Which instructions should the nurse discuss with the client? SATA -avoid massaging the area -avoid receiving vaccinations in the affected arm -elevate the arm above the heart -perform isometric exercises -use an intermittent pneumatic compression sleeve

-avoid receiving vaccinations in the affected arm -elevate the arm above the heart -perform isometric exercises -use an intermittent pneumatic compression sleeve

The nurse enters a client's room just as the UAP is completing a bath and placing thigh-high anti-embolism stockings on the client. Which situation would cause the nurse to intervene? -UAP applies the anti-embolism stockings while maintaining the client in supine position -UAP carefully smooths out any wrinkles over the length of the stockings -UAP checks that the toe opening of the stockings is located on the plantar side of the foot -UAP rolls down and folds over the excess material at the top of the stockings

-UAP rolls down and folds over the excess material at the top of the stockings --Stockings should not be rolled down, folded down, cut, or altered in any way. If stockings are not fitted and worn correctly, venous return can actually be impeded.

The home health nurse is following up with the parent of a Native American infant recently diagnosed with lactose intolerance. In accordance with principles of culturally competent care, what is the most important question for the nurse to ask the parent? -do your other children have this condition? -How long did your infant have diarrhea? -How often are you feeding the infant? -What do you think caused your infant's illness?

-What do you think caused your infant's illness? --When providing culturally competent care, it is most important for the nurse to assess the client's beliefs regarding the cause of current illness. This will facilitate development of a culturally sensitive and appropriate teaching and care plan.

The public health nurse identifies which of the following clients as being at high risk for developing colorectal cancer? -a 28-year-old female client with a body mass index of 38 kg/m3 -a 38-year-old male client with a 15-year history of ulcerative colitis -a 48-year-old male client whose father has a history of colorectal cancer -a 58-year-old male client who consumes a diet high in fruits and vegetables -a 68-year-old female client with a 40-year history of cigarette smoking

-a 28-year-old female client with a body mass index of 38 kg/m3 -a 38-year-old male client with a 15-year history of ulcerative colitis -a 48-year-old male client whose father has a history of colorectal cancer -a 68-year-old female client with a 40-year history of cigarette smoking

S/S of cardiac tamponade

-muffled heart tones -pulsus paradoxus -hypotension

Fine motor skills of 3 year old

-draws circle -feeds self with no help -grips crayon with fingers, not in a fist

Characteristics of peritonitis

-fever -abdominal rigidity -guarding -rebound tenderness --peritonitis is a medical emergency and requires surgery

DASH diet includes

-fresh fruits/veggies in diet -whole wheat in diet -choose low-fat or fat-free dairy products -choose meats low in cholesterol (fish) -limit red meats -limit sweets and foods high in sodium

complications of acute otitis media (AOM)

-hearing loss -spread of infection

Fine motor development milestones for 4-5 month old

-holds objects with palmar grasps -puts things in mouth

Modifiable breast cancer risk factors

-hormone therapy with estrogen and/or progesterone -postmenopausal weight gain and obesity (fat cells store estrogen) -hx of smoking/alcohol consumption -dietary fat intake -sedentary lifestyle

Common SE of tamoxifen?

-hot flashes -vaginal dryness -menstrual irregularities --symptoms are similar to menopause d/t decreased estrogen

examples of tricyclic antidepressants

-imipramine -amitriptyline -desipramine

Clinical manifestations of fetal alcohol syndrome

-intellectual disability -developmental delay -distinct facial characteristics (indistinct philtrum, thin upper lip, epicanthal folds, flat midface, short palpebral fissures)

describe toddler assessment (place in order of what to perform first)

-interact with parents -play with the child -measure weight and height -auscultate lungs/heart -obtain vitals --create rapport with child; start with least invasive first

Treatment/Management of Tetralogy of Fallot

-knee-to-chest to improve oxygenation by reducing the volume of blood that is shunted through the overriding aorta and ventricular septal defect

Beliefs of death for children birth-2 years of age

-no understanding -sensitive to loss and separation -may be distressed by environmental changes

social/cognitive skills of a 2 year old

-parallel play -begins independence from parents

normal ICP level

0-15 mm Hg

The nurse is caring for an 83-year-old bedridden client experiencing fecal incontinence. Which nursing interventions is the highest priority for this client? -consult with the wound care nurse specialist -insert a rectal tube to contain the feces -provide perianal skin care with barrier cream -use incontinence briefs to protect the skin

-provide perianal skin care with barrier cream --Disruptions of motor function and/or sensory function can result in fecal incontinence. The presence of stool can lead to skin breakdown, urinary tract infections, spread of infections, and contamination of wounds. Therefore, maintenance of perineal and perianal skin integrity is the highest priority. Stool should be removed promptly from the skin by gently cleansing the perineum and perianal area with mild soap. Dry the soiled area and apply a thick moisture barrier product to the skin. Clean, dry linens and clothing should be provided.

lithium therapeutic range

0.6-1.2 mEq/L

What are clients receiving desmopressin at risk for?

-water intoxication -hyponatremia --report S/S of hyponatremia to HCP (HA, mental status changes, muscle weakness)

Venipuncture is contraindicated in upper extremities affected by:

-weakness -paralysis -infection -arteriovenous fistula or graft -impaired lymphatic drainage (prior mastectomy)

Foods that are protein and/or calorie dense

-whole milk and dairy products -granola, muffins, biscuits -potatoes with sour cream and butter -meat, fish, eggs, dried beans, almond butter -pasta/rice dishes with cream sauce

The nurse is preparing to flush a client's central venous catheter. Which size syringe is best for the nurse to choose? -1 mL -3 mL -10 mL -30 mL

10 mL --Flushing the lumen of a central venous access device with normal saline is recommended to assess patency before medication infusion, prevent medication incompatibilities after infusion, and prevent occlusion after blood sampling. A 10-mL syringe is generally preferred for flushing the lumen of a CVC. The smaller the syringe, the greater the amount of pressure per square inch exerted during injection, increasing the risk for damage to the CVC. The "push-pause" method involves slowly injecting normal saline into the CVC catheter and stopping for any resistance. Injecting against resistance can damage the CVC, which may result in complications, including embolism and malfunction. The nurse should always consult the specific manufacturer guidelines and facility policy when caring for a CVC.

What is the type gauge size and needle length for a intradermal injection?

25-27 gauge --1/4-5/8 inch

Where is the pulmonic valve ausculated?

2nd ICS to the left sternal border

Where is aortic valve ausculated?

2nd ICS to the right sternal border

Normal adult urinary output

30 mL/hr

At what age does an infant have sphincter control for toilet training?

30 months

normal infant respiratory rate

30-60

What is a normal respiration rate for an infant (1-12 months)?

30-60/min

normal female hematocrit

35-47%

An adult client was severely burned in a warehouse accident. The client has sustained partial-thickness burns to the back and to the anterior and posterior surfaces of the right arm and leg. Using the rule of nines, what percentage of the client's body surface area is burned?

36%

Where is the Erb's point ausculated?

3rd ICS to the left sternal border

When does a trach become mature?

> 7 days after insertion

A client with appendicitis has pain relieved momentarily. Is this good or bad?

BAD --the appendix has now ruptured.. pain will return soon after

Is it good or bad for no wheezing to be present with asthma exacerbation?

BAD -sign that the airways are COMPLETELY blocked

T/F: sulfonylureas (glyburide) are safe to administer to elderly population

FALSE --avoid them in the elderly population d/t the potential delayed elimination, causing risk for prolonged hypoglycemia

T/F: metformin increases insulin secretion

FALSE --metformin does not increase insulin secretion, so the risk of hypoglycemia is minimal even when meals are skipped

CN VII

Facial

What do clients with hemophilia A lack?

Factor VIII

A client undergoing endotracheal intubation received IV sedation and succinylcholine. Shortly after respiratory status has been stabilized, the client becomes flushed and profusely diaphoretic and has a rigid jaw. Which medication should the nurse prepare to administer? --IM epinephrine --IV atropine --IV dantrolene --IV glucagon

IV dantrolene --malignant hyperthermia is a rare and life-threatening condition precipitated by certain medications used for anesthesia, including inhaled anesthetics (desflurane, isoflurane, halothane) and succinylcholine. Skeletal muscles become unable to control calcium levels, leading to a hypermetabolic state manifested by contracture and increased temperature. Early signs of MH include tachypnea, tachycardia, and a rigid jaw or generalized rigidity. As the condition progresses, the client develops a high fever. Muscle tissue is broken down, leading to hyperkalemia, cardia dysrhythmias, and myoglobinuria. MH requires emergent treatment with IV dantrolene to reverse the process by slowing metabolism. Succinylcholine should be discontinued. IM epinephrine is administered for cardiac arrest, anaphylatic reactions, or severe asthma attacks. IV atropine is used to treat bradycardia. Glucagon is given for severe hypoglycemia

What happens when isotonic solutions are infused into the extracellular vascular compartment?

the isotonic solution remains in the extracellular vascular compartment because no concentration gradient is present

What is the second stage of Erickson's developmental Tasks? --the task?

toddler --Autonomy vs shame and doubt

Most effective method for pain management in sickle cell crisis

PCA of morphine or hydromorphone (Dilaudid)

What is administered to a client with measles?

vitamin A supplements --prevents severe measles induced vitamin A-deficiency, which can cause blindness

What must a patient with TB (or other airborne transmission diseases) required to wear when leaving their negative-pressure isolation room?

a surgical mask (this contains exhaled respiratory secretions)

Which drugs are best for pain management in a client with immune thrombocytopenic purpura?

acetaminophen opiates

What is ethambutol used to treat?

active TB -client MUST have baseline and periodic eye exams while taking this medication (can cause optic neuritis) --report S/S of decreased visual acuity and lose of color (red-green) discrimination

Aortic dissection is characterized by...

acute onset of excruciating, sharp, or "ripping" chest pain that radiates to the back

What is priority in treatment of a child with hemophilia A when bleeding is suspected?

administration of factor VIII --aids in clot formation --CT scan is performed after administration

When do kids partake in exploratory play?

age 0-1 years of age

When do kids partake in playing games and hobbies?

ages 8-12 years

Client presents with ventricular tachycardia. Which action should the nurse take first? --assess client for a pulse --assess oxygen saturation --initiate cardiopulmonary resuscitation --prepare to defibrillate the client

assess the client for a pulse --Clients in ventricular tachycardia can be pulseless or have a pulse. Treatment is based on this assessment. VT with a pulse should be further assessed for clinical stability or instability. Signs of instability include hypotension, altered mental status, signs of shock, chest pain, and acute heart failure

How are descending aortic dissections typically described?

associated with back pain and abdominal pain --abrupt in onset --described as "worst ever", "tearing", or "ripping" pain

A client with hypothermia has just arrived in the ED via ambulance. The client is being rewarmed with blankets, and the IV fluids are being changed over to warmed fluids. What additional intervention is a priority? --attaching the cardiac monitor --covering the client's head --drawing blood for electrolytes ad glucose --placing an additional large-bore IV catheter

attaching the cardiac monitor --Hypothermia occurs when the core temperature is below 95 degrees F and the body is unable to compensate for heat loss. As the core temperature decreases, the cold myocardium becomes extremely irritable and prone to dysrhythmias. The client should be handled gently as spontaneous ventricular fibrillation could develop when moved or touched. Therefore, placing the client on a cardiac monitor is a high priority; the nurse should anticipate defibrillation in these clients.

The nurse is caring for a client on a mechanical ventilator. The settings on the ventilator have just been changed and the standing prescription is to draw arterial blood gases 30 minutes after a ventilatory change. In anticipation of this blood draw, what intervention should the nurse implement? --avoid suctioning the client --pre-oxygenate the client --raise the HOB --reduce the amount of sedation medication

avoid suctioning the client --ABGs indicate the acid-base balance in the body and how well oxygen is being carried to the tissues. It is common to measure ABGs after a ventilator change to assess how well the client has tolerated it. Factors such as changes in the client's activity level or oxygen settings, or suctioning within 20 minutes prior to the blood draw can cause inaccurate results. Unless the client's condition dictates otherwise, the nurse should avoid suctioning as it will deplete the client's oxygen level and cause inaccurate test results.

What diet modifications are recommended to reduce herniation?

avoiding high-fat foods and foods that decrease lower esophageal sphincter pressure, such as chocolate, peppermint, tomatoes, and caffeine --eat small, frequent meals --decrease fluid intake during meals to prevent gastric distension. --avoid consumption of meals close to bedtime and nocturnal eating.

A client with acute respiratory distress syndrome is receiving positive pressure mechanical ventilation with 15 cm H2O positive end-expiratory pressure. The nurse should assess for which complication associated with PEEP? --barotrauma --decreased oxygen saturation --hypertension --oxygen toxicity

barotrauma --High levels of PEEP can cause overdistension and rupture of the alveoli, resulting in barotrauma to the lung. Air from ruptured alveoli can escape into the pulmonary interstitial space or pleural space, resulting in a pneumothorax and/or subcutaneous emphysema. PEEP applies a given pressure at the end of expiration during mechanical ventilation. It counteracts small airway collapse and keeps alveoli open so that they can participate in gas exchange. PEEP is usually kept at 5 cm H2). However, a higher level of PEEP is an effective treatment strategy for acute respiratory distress syndrome (ARDS), a type of progressive respiratory failure that causes damage to the type II surfactant-producing pneumocytes that the leads to atelectasis, noncompliant luns, poor gas exchange, and refractory hypoxia.

The home health nurse is providing care for a 6-year-old client who has a tracheostomy and is being mechanically ventilated when the ventilator's apnea alarm sounds. The nurse finds the client to be unresponsive and pulseless, and that there are no other caregivers present. Which action should the nurse take first? --begin chest compressions --deliver 2 breaths using a bag valve device connected to the tracheostomy --locate and apply an automated external defibrillator --use a phone to call 911

begin chest compressions --Cardiac arrest is the sudden cessation of cardiac output that is usually caused by an arrhythmia. Arrest ca be precipitated by a variety of factors and is a medical emergency. In children, cardiac arrest is commonly caused by hypoxia and respiratory failure. If the nurse is a single rescuer in a witnessed cardiac arrest of a pediatric client, the first action is to promptly initiate CPR, starting with chest compressions. For the pediatric client, initiating CPR before other interventions helps minimize risk for end organ damage and brain injury. The nurse should provide 30 chest compressions and 2 rescue breaths in each cycle of CPR.

What is saw palmetto used to treat?

benign prostatic hyperplasia

What is a classic sign of cyanide poisoning?

bitter almond smell on client's breath

define hemianopsia

blindness in half the visual field from eacheye

Complications of ventriculoperitoneal shunt?

blockage --will have S/S of increased ICP

Function of clomiphene

blocks estrogen receptors in the hypothalamus and pituitary. --taken orally for 5 days early in the menstrual period. Necessary to engage in frequent sexual intercourse 5 days after complete the medication regimen

What is the advantage of continuous subcutaneous insulin infusion (CSII) therapy?

blood sugars will not go up and way down

What happens when hypertonic solutions are infused into the vascular compartment?

body fluids shift from intracellular compartment into extracellular vascular compartment

What happens when hypotonic solutions are infused into the extracellular vascular compartment?

body fluids shift out of intravascular compartments into interstitial tissue and cells

age appropriate toys for 9-12 months

books with large pictures, large push-pull toys, teddy bears

Define Tetralogy of Fallot

complex heart defect that results in decreased pulmonary blood flow, mixing of oxygenated and unoxygenated blood, and inadequate blood flow into the left side of the heart

Cloudy vision with a glare is associated with what visual disorder?

cataract, a non-emergency, age-related visual disorder.

Cephalexin drug class

cephalosporin --it is chemically similar to penicillin and should not be administered to someone with a penicillin allergy

What triggers malignant hyperthermia?

certain drugs used to induce general anesthesia in susceptible clients --the triggering agent leads to excessive release of calcium from the muscles, leading to sustained muscle contraction and rigidity.

The nurse is caring for a client with surgical complications who requires continuous total parenteral nutrition. The nurse assists the healthcare provider with the insertion of a subclavian triple lumen central venous access device. What is the nurse's priority action before initiating the TPN infusion? --attach a filter to the IV tubing --check baseline fingerstick glucose check --check the results of the portable chest x-ray --program the electronic infusion pump

check the results of the portable chest x-ray --The priority action after placing a subclavian central venous catheter is to check the results of the chest x-ray to ensure that the catheter tip is placed correctly in the superior vena cava. Obtain verification before using the catheter as perforation of the visceral pleura can occur during insertion and lead to an iatrogenic pneumothorax or hemothorax. Although these complications are rare, due to the use of ultrasound to guide insertion, if present, the TPN would infuse into the pleural space.

Trigeminal nerve assessment

clench teeth and light touch

The nurse observes a nursing student performing chest compressions on an adult client. Which technique indicates that the student understands how to provide high-quality chest compressions during cardiopulmonary resuscitation? --compressing the chest to a depth of at least 2 in --pausing after each set of 15 compressions to allows for 2 rescue breaths --placing the heel of the hand on the upper half of the client's sternum --providing compressions at a rate of at least 80-100/min

compressing the chest to a depth of at least 2 in --the primary goal of CPR is adequate perfusion to the brain and vital organs. High-quality chest compressions for adults are at least 2 in deep to adequately pump blood but no more than 2.4 in deep to prevent unnecessary client injury. The chest should recoil completely after each compression to allow complete refilling of the heart chambers, which promotes effective perfusion

define false imprisonment

confinement of a client against the client's will or without legal justification

What is the absolute priority when treating a client with asystole or PEA?

continuous, high-quality CPR

Function of cerebellum

coordination of voluntary movements and maintenance of balance and posture

What is often the earliest sign of asthma exacerbation?

cough

Language developmental milestones for 1 month old

cries when upset

What causes electrical alternans?

due to swinging motion of the heart in a fluid-filled pericardial sac

Describe percussion associated with atelectasis

dullness

Describe percussion associated with pleural effusion

dullness

What types of foods are included in a low residue diet?

easily digested foods such as enriched breads, rice, pasta, cooked vegetables, canned fruits, and tender meats.

What is the most accurate indicator of fluid loss or gain in an acutely ill client?

daily weights

therapeutic effect of allopurinol

decrease hyperuricemia from tumor lysis syndrome

Describe breath sound associated with emphysema

decreased

Describe tactile fremitus associated with atelectasis

decreased

Describe tactile fremitus associated with emphysema

decreased

Describe tactile fremitus associated with pneumo

decreased

Describe tactile fremitus with pleural effusion

decreased

Describe breath sounds associated with pneumo

decreased or absent

describe breath sounds associated with atelectasis

decreased or absent

describe breath sounds associated with pleural effusion

decreased or absent

The nurse precepts a new nurse caring for a client showing signs of improvement from hypovolemic shock. Which action by the new nurse would cause the preceptor to immediately intervene? --change the oxygen mask to a nasal mask --delays requesting a new norepinephrine IV bag when the first is almost finished --postpones giving IV antibiotics due to inadequate IV access --questions prescription to change IV fluids from 0.9% to 0.45% normal saline

delays requesting a new norepinephrine IV bag when the first is almost finished --hypovolemic shock, the most common type of shock, occurs when blood volume decreases through hemorrhage or movement of fluid from the intravascular compartment into the interstitial space (third-spacing). Treatment involves preventing additional fluid loss, restoring volume through IV fluids, and improving hemodynamic stability through vasoactive medications (norepinephrine, dopamine). Norepinephrine causes vasoconstricton and improves heart contractility/output, but the effects end quickly. It should be tapered slowly and cautiously to avoid the progression or relapse of shock. Postponing antibiotics would be a greater concern if the client were in septic shock 0.45% normal saline is a hypotonic fluid that decreases circulatory volume. Clients in hypovolemic shock require isotonic solutions to increase circulatory volume.

Define Dysphagia

difficulty swallowing

How often should women have PAP smears?

every 3 years after age 21, regardless of sexual activity

Meniere disease results from...

excess fluid accumulation in the inner ear

Trocheal nerve assessment

extraocular movements- inferior adduction

Abducens nerve assessment

extraocular movements- lateral abduction

Define FLACC scale

face, legs, activity, cry, and consolability

Facial nerve assessment

facial movements (close eyes, smile)

Risk factors for skin cancer includes:

family or personal history of skin cancer -celtic ancestry traits (light skin, red/blonde hair, blue/green eyes, freckles) -aging -atypical or high number of moles -immunosuppression (lowers body's ability to defend against cancerous mutations) -ultraviolet light exposure

How is rotavirus spread?

fecal-oral route --can be transmitted through contact with food, toys, diapers, and hands.

What position is appropriate for a lumbar puncture?

fetal position

Multiple tender points is characteristic of...

fibromyalgia

S/S of infant increased work of breathing

flared nostrils and use of accessory muscles

Describe Sim's Position

flat and side-lying

Define infant botulism

food poisoning that occurs after consuming Clostridium botulinum (bacteria found in soil and animal products, such as raw honey/milk)

Broca aphasia involves damage to what area of the brain?

frontal lobe

Describe Stage 3 pressure ulcers

full thickness skin loss

Glossopharyngeal nerve assessment

gag reflex

Gross motor developmental milestones for 2-3 month old

gains head control when held

Social/cognitive developmental milestones for 1 month old

gazes at parents when they speak

In the intensive care unit, the nurse cares for a client who is being treated for hypotension with a continuous infusion of dopamine. Which assessment finding indicates that the infusion rate may need to be adjusted? --central venous pressure is 6 mm Hg --heart rate is 120/min --mean arterial pressure is 78 mm Hg --systemic vascular resistance is 900 dynes/sec/cm^-5

heart rate is 120/min --dopamine is a sympathomimetic inotropic medication used therapeutically to improve hemodynamic status in clients with shock and heart failure. It enhances cardiac output by increasing myocardial contractility, increasing heart rate, and elevating blood pressure through vasoconstriction. Renal perfusion is also improved, resulting in increased urine output. All other options were within respective reference ranges and do not indicate a need to adjust dopamine administration.

What heart rate might indicate a decrease in dopamine infusion?

heart rate of 120/min

What indicates hemorrhage after a bronchoscope?

hemoptysis of bright red blood

Describe the Venturi Mask

high-flow device that delivers a guaranteed oxygen concentration, regardless of the client's respiratory rate, depth, or tidal volume. --it is the most appropriate oxygen delivery device for a client with rapid changes in inspired oxygen concentration (COPD).

Fine motor developmental milestones in 2-3 month old

holds rattle when it is placed in hand

What type of fluid is 5% dextrose in 0.9% normal saline?

hypertonic solution

Major side effects of sulfonylureas

hypoglycemia --do NOT combine with alcohol

What can repeatedly discarding gastric content cause in a patient?

hypokalemia and metabolic alkalosis

What type of fluid (hyper,hypo,or iso) is 0.45% normal saline?

hypotonic solution

Narrowing pulse pressure is a sign of...

hypovolemic shock

What is the underlying cause of failure to thrive?

inadequate dietary intake --observation of the child while being fed may provide information related to the cause.

What are the hemodynamic effect of PEEP?

increased intrathoracic pressure, which leads to reduced venous return, decreased preload and cardiac output, and hypotension.

How does ACE-I impact potassium levels in the body?

increases serum potassium by decreasing urinary potassium excretion

what is midazolam commonly used for?

induce conscious sedation

What is the first stage of Erickson's developmental tasks?

infancy

Clomiphene

infertility treatment for women. --stimulates ovulation

The nurse is caring for a client with an implantable cardioverter defibrillator (ICD). The client goes into ventricular tachycardia and is pulseless. The ICD has first twice. What action should the nurse take? --administer epinephrine 1 mg IV push --deactivate the ICD with a magnet --initiate chest compressions --take no action and let the ICD work

initiate chest compressions --The client with an ICD that is firing is receiving electrical shocks from the internal defibrillator to interrupt the dysrhythmia. It is still imperative that the client receive chest compressions in the form of CPR to provide circulation of blood to the vital organs. The nurse should implement the pulseless arrest algorithm.

What is the usual site location for intradermal injections?

inner forearm

What can help alleviate anxiety in teenagers due to recent health diagnosis?

interaction with peers who are experiencing similar health issues

characterization of trigeminal neuralgia

intermittent, severe, unilateral facial pain precipitated by light touch, hot/cold foods, chewing, and swallowing

pregnancy effects of syphilis

intrauterine fetal demise and preterm labor

What is the third stage of Erickson's developmental tasks? --task?

preschool -initiative vs guilt

What vitamins should a client being administered orlistat take?

vitamins A, D, E, K > 2 hours after orlistat

Physiologic anorexia in toddlers

is normal. --decreased appetite around 18 months is a result of decreased metabolic needs. --parents should be taught to provide multiple food options, set schedule for meals/snacks, avoid watching TV or playing games during meal times. --toddlers should not be forced to eat

What type of fluid is 5% dextrose in water?

isotonic solution HOWEVER, it behaves as a hypotonic solution due to dextrose metabolizing in the body and water being released into the tissues.

How does bi-pap effectively treat increased CO2?

it provides positive pressure oxygen and expels CO2 from the lungs in clients with hypercapnic respiratory failure

What are the most frequent sites for bleeding in clients with hemophilia A?

joints, specifically the knee

When descending stairs with a cane, the client should

lead with the cane, bring the weaker leg down second, and finally step down with the stronger leg.

Where is the most common area for diverticula to develop?

left (descending, sigmoid) colon

Define hemolytic uremic syndrome

life-threatening complication of E. coli diarrhea

What is evident of DDH in clients greater than 3 months of age?

limited hip abduction and limb shortening on affected side

Describe a rash caused from poison ivy

linear in appearance

Define Thrombocytopenia

low platelet count

Upon arrival in the post-anesthesia care unit, the nurse performs the initial assessment of a client who had surgery under general anesthesia. Which assessment finding prompts the nurse to notify the healthcare provider immediately? --difficult to arouse --muscle stiffness --pinpoint pupils --temperature of 94 degrees F

muscle stiffness --Malignant hyperthermia is a rare, life-threatening inherited muscle abnormality that is triggered by certain drugs used to induce general anesthesia in susceptible clients. The triggering agent leads to excessive release of calcium from the muscles, leading to sustained muscle contraction and rigidity. It can occur in the operating room or in the post-anesthesia care unit. A client who just arrived in the PACU after general anesthesia would be expected to be difficult to arouse and to have small pupil sizes. Hypothermia is common in the immediate postoperative period due to anesthetic-induced vasodilation, decreased basal metabolic rate, and a cool environment.

Which feeding tube has a higher risk for aspiration-- Nasoenteric or nasogastric?

nasoenteric

What can hypertonic formulas sometimes cause?

nausea vomiting diarrhea

what is another name for myopia?

nearsightedness

What is a common way for pediatric "silent" asthma to appear?

night coughing until the child vomits

isosorbide drug class

nitrate

Describe associative play. At what age is it present?

no group goal, but often follows a leader --preschool age

tactile fremitus of a normal lung

normal

What must be monitored when administering mannitol?

normal kidney function and adequate urine output.

Define Dystrophin

protein for muscle stabilization

The nurse is caring for a client who was just resuscitated following an out-of-hospital cardiac arrest. The client does not allow commands and remains comatose. What intervention does the nurse anticipate being added to client's plan of care? --assisting the healthcare provider in discussing a do no resuscitate order with the family --obtaining equipment and cold fluids for induction of therapeutic hypothermia --planning for passive range-of-motion exercises to prevent contractures

obtaining equipment and cold fluids for induction of therapeutic hypothermia --Neurologic injury is the most common cause of mortality in clients who have had cardiac arrest, particularly ventricular fibrillation or pulseless ventricular tachycardia. Inducing therapeutic hypothermia in these clients within 6 hours of arrest and maintaining it for 24 hours has been shown to decrease mortality rates and improve neurologic outcomes It is indicated in all clients who are comatose or do not follow commands after resuscitation. It is too early to consider a do-not-resuscitate order. If the client does not respond to therapeutic hypothermia or these is evidence of neurologic impairment, it may be discussed at some point. Clients are generally kept NPO during therapeutic hypothermia and rewarming. The feeding tube may be needed after the rewarming process. Passive range-of-motion exercises would be indicated for this client, but are not the immediate priority.

What position should a client be placed after a liver biopsy?

on the right side for a minimum of 2 hours. this is to apply pressure and splint the puncture site. after that- supine for 12-14 hours.

How should a client be placed during gastric lavage?

on their side or with the head of the bed elevated to minimize aspiration risk

Define clubfoot

one or more feet turned inward --treat with early manipulation of foot through the use of long-leg cast. The cast is weekly replaced for 5-8 weeks (known as Ponseti method)

what is midazolam commonly administered with?

opioid analgesic (morphine or fentanyl)

Who commonly uses Black cohosh?

perimenopausal women experiencing hot flashes

Describe the ictal phase of a seizure

period of active seizure activity

Methadone drug class

potent narcotic with a long half-life

The nurse is supervising a graduate nurse on a telemetry unit. An assigned client develops asystole with no pulse, and emergency care interventions are initiated. Which action by the graduate nurse would cause the supervising nurse to interevene? --administers IV epinephrine --applies oxygen with bag-mask --initiates chest compressions --provides defibrillator shock

provides defibrillator shock --The client in asystole has a total absence of ventricular electrical activity and is pulseless, apneic, and unresponsive. The nurse should first verify the monitor reading by assessing the client and palpating for a pulse, and then call for help and initiate emergency care. Defibrillation is not indicated when there is no electrical activity present or when the heart muscle is not contracting despite an organized rhythm.

Oculomotor assessment

pupil constriction and extraocular movements

What is palpable epigastric, olive-shaped mass a symptom of?

pyloric stenosis

treatment of retinoblastoma

radiation therapy or enucleation (removal of eye)

What is malignant hyperthermia (MH)?

rare, life-threatening inherited muscle abnormality.

age appropriate toys for 2-4 months

rattles, cradle gym

What types of foods are avoided in clients with ulcerative colitis?

raw fruits and vegetables, whole grains, highly seasoned foods, fried foods, and alcohol

define apraxia

refers to loss of the ability to perform a learned movement (whistling, clapping, dressing) due to neurological impairment

What is the only insulin that can be administered IV push?

regular insulin

describe breathing using pursed lip method?

relaxing the shoulder and neck, inhaling through the nose for 2 seconds with mouth closed, and exhaled through pursed lips for 4 seconds

What should the nurse monitor for in clients taking aminoglycosides?

renal function and any changes in hearing/balance -- aminoglycosides are ototoxic and nephrotoxic.

describe percussion of normal lung

resonance

What can infant botulism progress rapidly into?

respiratory failure/arrest

define retinoblastoma

retinal tumor typically diagnosed in children less than 2 years of age

Flumazenil function

reverse the sedative effects of benzos (specifically midazolam)

Bronchitis often results in what breath sound?

rhonchi (continuous low-pitched adventitious breath sounds)

another name for tinea corporis

ringworm

What position should infants be placed to sleep?

supine NEVER prone

What position should the client be placed in when removing a triple-lumen subclavian central venous catheter?

supine position --increases central venous pressure and decreases possibility of air getting into the vessel

What position should a client who received a cast placement be in?

supine with the extremity elevated for the first 48 hours

How is esophageal atresia and tracheoesophageal fistula commonly treated?

surgery

Describe convalescent phase of Kawasaki disease?

symptoms disappear slowly

Major side effects of Thyroid replacement (levothyroxine)

symptoms of hyperthyroidism -diarrhea -weight loss -palpitations -tachycardia -sweating -heat intolerance

How is an unstable client with ventricular tachycardia treated?

synchronized cardioversion

Clinical manifestations of ventricular septal defect

systolic murmur auscultated at sternal border @ 3rd intercostal space

The nurse in the ICU is caring for a client who is postoperative from a cardiac surgery. The client has a mediastinal chest tube. During assessment, the nurse notes bubbling in the suction control chamber. Which nursing action is appropriate? --assess the insertion site for presence of subcutaneous emphysema --notify the surgeon of a large air leak --take no action as the chest tube is functioning appropriately --turn down the wall suction until the bubbling disappears

take no action as the chest tube is functioning appropriately --Gentle, continuous bubbling in the suction control chamber of a chest tube drainage unit indicates that suction is present and the unit is functioning appropriately. The nurse should document the finding and continue to monitor

What can extended use of a high dose of metoclopramide cause?

tardive dyskinesia (a movement disorder that is characterized by uncontrollable motions like sucking/smacking lips)

Priority nursing actions for clients taking tricyclic antidepressants

teach caution in changing positions d/t increased risk for falls from dizziness and orthostatic hypotension

Which triple lumen CVC is the largest lumen?

the distal port.

What does veracity refer to?

the duty to tell the truth

What should be performed if mature trachestomies are accidentally dislodged?

the nurse should attempt to open the airway by inserting a curved hemostat to maintain stoma patency and insert new trach tube with an obturator

Should phenytoin be administered with other drugs or enteral feedings?

these can affect absorption of phenytoin and should not be administered together

What are the beliefs of a preschooler pertaining to getting hospitalized?

they believe they cause it d/t their egocentric and magical thinking

Defibrillation is indicated in which clients?

those with ventricular fibrillation and pulseless ventricular tachycardia

How should you assess pain in a nonverbal child?

through utilization of the FLACC scale

What is the function of PEEP?

to provide pressure at the end of expiration during mechanical ventilation. This keeps alveoli open to participate in gas exchange.

What is the purpose of the square wave test?

to verify if the arterial line is functioning correctly.

The nurse is caring for a client who has a near-drowning accident in cold weather. Which assessment finding indicates the most severe injury? --decreased body temperature --toes pointed straight down --weak and thready pulses --wheezing on auscultation

toes pointed straight down --near-drowning occurs when a client is under water and unable to breathe for an extended period. In a matter of seconds, major body organs begin to shut down from lack of oxygen and permanent damage results. Decerebrate posturing is a sign of severe brain damage. During assessment, the nurse would observe arms and legs straight out, toes pointed down, and the head/neck arched back. These assessment findings indicate that severe injury has occurred. Hypothermia is generally seen in near-drowning victims. One of the first goals of treatment is to warm the client. Sustained hypothermia will eventually lead to organ failure, making this an urgent findings, but not initially life-threatening. A weak and thready pulse is generally detected in near-drowning victims due to hypothermia. Once the client is properly warmed, the pulse generally returns to normal. The wheezing may indicate that the client has bronchospam, but the client is still moving air and providing oxygen to the body, so this is not an immediate concern.

What should be thrown away after a child starts antibiotics for pharyngitis?

toothbrush 24 hours after antibiotics. --this is to prevent reinfection from pharyngitis

Age appropriate toys of preschooler

toys imitative of adult patterns and roles -playground materials -housekeeping toys -coloring books -tricycles with helmet

What is the priority of action of a client experiencing a failure to capture on the EKG?

transcutaneous pacemaker --call doctor after that

Function of thiazolidinediones and piolitazone

treat type 2 diabetes mellitus by improving insulin sensitivity --carries a low risk for hypoglycemia

What drug classification is amitriptyline?

tricyclic antidepressant --AKA Elavil

Which type of precautions are all patients placed on?

universal

Define dysarthria

weakness of the muscles used for speech. Pronunciation and articulation are affected. Comprehension and the meaning of words are intact, but speech is difficulty to understand.

Define failure to thrive

weight is less than 80% of ideal for age

When does infertility get diagnosed?

when a couple fails to conceive after 12 months (for females age <35) or 6 months (for females age >35)

define leukocoria

white glow of the pupil rather than a red glow

When should -statins be taken?

with evening meals --most of the cholesterol in the body is synthesized by the liver at midnight--thus -statins function better in the evening