NCLEX notes/ uworld LAPTOP

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The nurse cares for a client scheduled for a percutaneous left kidney biopsy as an outpatient. Which intervention should the nurse include in the client's post-procedure care plan? 1. Compare pre- and post-procedure BUN and creatinine levels 2. Insert and maintain the patency of an indwelling urinary catheter 3. Maintain prone position for at least 30 minutes 4. Monitor vital signs every 15 minutes for the first hour

A kidney biopsy involves obtaining a tissue sample for pathological evaluation to determine the cause of certain kidney diseases (eg, nephritis, transplant rejection). The kidney has extensive vasculature (similar to the liver); therefore, bleeding from the biopsy site is the major complicationfollowing a percutaneous kidney biopsy. Before the procedure, the client must give informed consent and discontinue all anticoagulants(eg, heparin, warfarin, rivaroxaban) and antiplatelet agents (eg, aspirin, clopidogrel, nonsteroidal anti-inflammatory drugs) for at least one week. The client should be typed and crossmatched for blood (although the need for a transfusion is rare). Blood pressure should be well-controlled. After the procedure, the nurse should monitor vital signs at least every 15 minutes for the first hour as tachycardia, tachypnea, and hypotension can indicate blood loss. The nurse should also assess the puncture site dressing for bleeding (Option 4). (Option 1) Blood urea nitrogen (BUN) and creatinine levels would not change significantly within 30-60 minutes. These are usually measured once every 24 hours and rarely every 12 hours. (Option 2) Insertion of an indwelling urinary catheter is not necessary to perform a kidney biopsy and is not part of the usual protocol. (Option 3) Post-procedure, the client should be positioned on the affected (left) side for 30-60 minutes to provide pressure and help prevent bleeding. The client is usually placed in the prone position during the procedure to facilitate access to the kidney.

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? 1. Aphasia [49%] 2. Apraxia [23%] 3. Dysarthria [22%] 4. Dysphagia [4%]

Aphasia refers to impaired communication due to a neurological condition (eg, stroke, traumatic brain injury). 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, ask 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 (Option 1). 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. (Option 2) Apraxia refers to loss of the ability to perform a learned movement (eg, whistling, clapping, dressing) due to neurological impairment. (Option 3) Dysarthria is weakness of the muscles used for speech. Pronunciation and articulation are affected. Comprehension and the meaning of words are intact, but speech is difficult to understand (eg, mumble, lisp). (Option 4) Dysphagia refers to difficulty swallowing. The term dysphagia is often confused with dysphasia. Clients with motor deficits after a stroke may have dysphagia, which requires swallowing precautions to prevent aspiration.

A client was prescribed phenytoin (100 mg PO 3 times a day) a month ago. Today, the client has a serum phenytoin level of 32 mcg/mL (127 mcmol/L). The nurse notifies the health care provider and expects which prescription? 1. Continue phenytoin as prescribed 2. Decrease phenytoin daily dose 3. Increase phenytoin daily dose 4. Repeat serum phenytoin level in 2 hours

Phenytoin (Dilantin) is an anticonvulsant drug used to treat generalized tonic-clonic seizures. The therapeutic serum phenytoin range is 10-20 mcg/mL (40-79 mcmol/L). In the presence of an elevated phenytoin level (32 mcg/mL [127 mcmol/L]), the nurse anticipates that the health care provider will prescribe a decreased daily dose (Option 2). The nurse should continue to monitor for signs of toxicity, typically presenting as neurological manifestations (eg, ataxia, nystagmus, slurred speech, decreased mentation). (Options 1 and 3) The serum phenytoin level is above the therapeutic level, so administering the prescribed dose or increasing the dose can further increase the risk for drug-induced toxicity. (Option 4) Repeating the serum phenytoin level in 2 hours will not result in a significant change because the average half-life of the drug is 22 hours.

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? 1. "Half of my vision looks like it's being blocked by a curtain." 2. "I have to use reading glasses to see small print." 3. "My vision seems cloudy and I notice a lot of glare." 4. "The colors don't seem as bright as they used to."

Chronic hyperglycemia can cause microvascular damage in the retina, leading to diabetic retinopathy, the most common cause of new blindness in adults. Option 1 indicates a retinal detachment requiring emergency management. A partial retinal detachment may be painless and cause symptoms such as a curtain blocking part of the visual field, floaters or lines, and sudden flashes of light. An unrepaired complete retinal detachment can cause blindness. (Option 2) The need for reading glasses is associated with presbyopia and is a common, nonemergency, age-related visual disorder. (Option 3) Cloudy vision with a glare is associated with a cataract, a nonemergency, age-related visual disorder. (Option 4) Although decreased vibrancy of colors is a sign of diabetic retinopathy and requires intervention, it is not indicative of a partial or complete retinal detachment; therefore, it is not an emergency. Educational objective:Chronic hyperglycemia can cause microvascular damage in the retina, leading to diabetic retinopathy, the most common cause of new blindness in adults.

An obese 85-year-old client, who is an avid gardener and eats only home-grown fruits, legumes, and vegetables, is admitted to the hospital with pneumonia after having an upper respiratory tract infection for a week. Which factor puts the client at greatest risk for developing pneumonia? 1. Advanced age 2. Environmental exposure 3. Nutritional deficit 4. Obesity

Pneumonia is an inflammatory process in the alveoli and interstitium of the lung usually caused by an infectious or noninfectious agent. Any condition, such as advanced age (>65), that compromises the respiratory system's protective mechanical or immune mechanisms to maintain the sterility of the lower airway can increase the risk for pneumonia. (Options 2, 3, and 4) Working in the garden and being exposed to environmental factors (eg, pollen), eating a vegetarian diet, and obesity do not pose the greatest risks for development of pneumonia.

The nurse accidentally sticks him/herself in the finger with a client's contaminated needle. The client has HIV infection. Place in order the steps the nurse should take. All options must be used.

Following a needlestick injury, the nurse's immediate actions should be to remove their gloves and thoroughly wash the affected area with soap and water. Exposure should be reported to the nurse's supervisor and the facility exposure hotline as soon as possible to facilitate the evaluation process. The nurse should then seek evaluation and treatment from the employee health clinic or emergency department. Blood should be drawn for baseline testing, and postexposure prophylaxis will be given based on the risk of exposure. Postexposure prophylaxis for HIV infection is most effective when given within two hours of an exposure incident.

LPN/LVN scope of practice

Monitoring RN findings Reinforcing education Routine procedures (eg, catheterization) Most medication administrations Ostomy care Tube patency & enteral feeding Specific assessments* (lung sounds, bowel sounds, neurovascular checks, stoma color) Collect and report data (VS, CBC, coagulation studies) Measurement and application of compression devices

A client with diabetes receiving peritoneal dialysis experiences chills and abdominal discomfort. The nurse assesses the client's abdomen by pressing one hand firmly into 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 (11.65 mmol/L). What is the priority action by the nurse? 1. Collect peritoneal fluid for culture and sensitivity [48%] 2. Heat the remaining dialysate fluid and increase the dwell time [8%] 3. Place the client in high Fowler's position [23%] 4. Prepare to administer regular insulin intravenously [19%]

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 effluent. 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 effluent from the drainage bag for culture and sensitivity (Option 1). Treatment of peritonitis is antibiotic therapy based on the culture results. Antibiotics may be added to dialysate, given orally, or administered intravenously. (Option 2) The client's chills and rebound tenderness are signs of infection that require further assessment. Dialysate is typically warmed to body temperature before instillation to prevent abdominal discomfort and increase urea clearance through vessel dilation. Dry heating with a heating cabinet or incubator rather than a microwave is recommended to reduce the danger of burning the peritoneum. The dwell time is based on the prescribed dialysis method and should not be extended without a prescription. (Option 3) High Fowler's position can help reduce shortness of breath if the client has volume overload, but it may worsen abdominal pain. (Option 4) Glucose (dextrose) is the osmotic agent in dialysate. Therefore, glucose levels must be monitored closely, particularly in clients with diabetes. However, a glucose level of 210 mg/dL (11.65 mmol/L) does not necessitate IV administration of regular insulin. Regular insulin can be added to the dialysate before the solution is instilled, or it can be administered subcutaneously to control glucose levels. Educational objective:Peritonitis is a common but serious complication of peritoneal dialysis. Manifestations include cloudy effluent, fever, abdominal pain, and rebound tenderness. Treatment is based on culture of the peritoneal fluid. Additional Information Reduction of Risk Potential NCSBN Client Need

A client with type I diabetes mellitus is brought to the emergency department by his wife. The client has fruity breath with rapid, deep respirations at 36 breaths per minute, reports abdominal pain, and appears weak. The nurse should anticipate implementation of which prescription(s)? Select all that apply. 1. Administer dextrose 50 mg intravenous (IV) push 2. Instruct client to breathe into a paper bag to treat hyperventilation 3. Perform a fingerstick and serum blood glucose test 4. Prepare to administer an IV infusion of regular insulin 5. Start an IV line and administer a bolus of normal saline

The client is exhibiting the cardinal signs and symptoms of diabetic ketoacidosis (DKA). DKA is an acute life-threatening complication, typically of type I diabetes, characterized by hyperglycemia, ketosis, and acidosis. It is caused by an intense deficit of insulin. Glucose cannot be used properly for energy when this deficit occurs and the body begins to break down fat stores, producing ketones, a byproduct of fat metabolism, resulting in metabolic acidosis. The lack of insulin also results in increased production of glucose in the liver, further exacerbating hyperglycemia. Because some of the symptoms of hypoglycemia and DKA overlap, a blood glucose level should be checked to ensure that hyperglycemia is present. Hyperglycemia can cause osmotic diuresis, leading to dehydration. In addition, ketones are excreted in the urine as the body tries to restore its pH balance. Vital electrolytes such as sodium, potassium, chloride, phosphate, and magnesium become depleted during the process. Cardinal signs of dehydration such as poor skin turgor, dry mucous membranes, tachycardia, orthostatic hypotension, weakness, and lethargy can occur. The nurse should start an IV and bolus the client with normal saline or 1/2 normal saline to reverse dehydration. This should occur prior to treating the hyperglycemia with regular insulin IV infusion. Because insulin promotes water, potassium, and glucose entrance into the cell, it can exacerbate vascular dehydration and imbalance of electrolytes, particularly potassium. A potassium level (along with other electrolytes) should also be assessed prior to beginning the prescribed insulin therapy. Other signs associated with DKA include Kussmaul respirations, deep, rapid respirations that have a fruity/acetone smell as the carbon dioxide is exhaled. This compensatory mechanism results in a lowered PaC02 in an attempt to restore the body's normal pH level and should not be reversed (Option 2). (Option 1) IV dextrose is administered during acute hypoglycemic episodes and would worsen DKA.

Occupational HIV postexposure prophylaxis: High-risk contact (prophylaxis recommended) Exposure of Mucous membrane, nonintact skin, or percutaneous exposure Exposure to Blood, semen, vaginal secretions, or any body fluid with visible blood (uncertain risk: cerebrospinal fluid, pleural/pericardial fluid, synovial fluid, peritoneal fluid, amniotic fluid), Low-risk contact (prophylaxis not recommended) Exposure to Urine, feces, nasal secretions, saliva, sweat, tears (with no visible blood)

Timing: Initiate urgently, preferably in the first few hours Continue for 28 days. Regimen ≥3-drug regimen recommended: Two nucleotide/nucleoside reverse transcriptase inhibitors (eg, tenofovir, emtricitabine) Plus Integrase strand transfer inhibitor (eg, raltegravir), protease inhibitor, or non-nucleoside reverse transcriptase inhibitor

The charge nurse on a telemetry unit is training a new registered nurse (RN). The charge nurse assists the new RN in prioritizing assessments of multiple clients. Which client should be assessed first? 1. A client in atrial fibrillation with an International Normalized Ratio of 4.0 who has a warfarin dose due 2. A client who had coronary artery bypass surgery 2 days ago, has a temperature of 99 F (37.2 C), and has a dose of vancomycin due 3. A client who is 48 hours post myocardial infarction, is experiencing ventricular bigeminy, and has a dose of amiodarone due 4. A client whose NPO status has just been discontinued after 8 hours and who is anxious to drink fluids

Ventricular bigeminy is a rhythm in which every other heartbeat is a premature ventricular contraction (PVC). PVCs in the presence of a myocardial infarction (MI) indicate ventricular irritability and increase the risk for a more serious dysrhythmia (eg, ventricular tachycardia, ventricular fibrillation). 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 health care provider (HCP). (Option 1) The client with atrial fibrillation (AF) should be seen after the MI client. Vital signs are stable, but the International Normalized Ratio (INR) should be lower (therapeutic range of 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. (Option 2) A temperature of 99 F (37.2 C) is not uncommon in the days immediately following surgery. The nurse should assess surgical incisions and respiratory status and give the scheduled antibiotic. (Option 4) After NPO status is discontinued, the client should be offered fluids. This task can be delegated to unlicensed assistive personnel and is not the priority.

Lumbar puncture position

lateral recumbent fetal position or sitting upright

Ginseng

promote mental alertness enhance immune system risk for bleeding

Tetracycline, Doxycycline, Demeclocycline, Minocycline

-stains/discoloration in teeth don't give to younger than 8, -nephrotoxic -hepatotoxic -phototoxic -avoid lasix

Give erythropoietin

hgb less than 10

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

The camp nurse protects the injured eye using an eye shield (eg, small Styrofoam or paper cup), 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. (Option 1) Flushing the eye with cool water is contraindicated as it may cause further damage by moving the splinter and/or introducing potential wound pathogens. (Option 2) Instilling optic antibiotic ointment would interfere with ophthalmologic medical examination. Optic antibiotic ointment may be prescribed by the health care provider to reduce the risk of infection once the object is removed from the eye. (Option 4) The nurse should not attempt to remove a foreign body embedded in the eye. An ophthalmologist, a health care provider who specializes in the surgical and nonsurgical evaluation and treatment of eye conditions, should remove the embedded object as soon as possible.

PTT (Heparin) or aPTT

25-35

Eryhtropoietin (EPO) hold

if Hgb greater than 11

The nurse is caring for the assigned clients on a pediatric inpatient unit. Which client is the priority? 1. 8-year-old with sickle cell crisis who has sudden-onset unilateral arm weakness [77%] 2. 11-year-old with viral meningitis requesting pain medication for headache [10%] 3. Male child scheduled for surgery for intussusception who has reddish mucoid stool [6%] 4. Male child with hemophilia who has hemarthrosis and is receiving desmopressin [5%]

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 ischemic stroke 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. (Option 2) Viral meningitis can cause fever, headache, and meningeal signs (neck stiffness). Headache is expected and not a priority over a client with stroke. (Option 3) Intussusception occurs when one portion of the intestine prolapses and then telescopes into another. It is a 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 address it. (Option 4) Hemophilia is seen primarily in males and is due to a lack of clotting factors. Symptoms include spontaneous bleeding (hemarthrosis) into the joints, especially the knee, ankle, or elbow. Treatment includes replacing the missing clotting factor. Desmopressin (DDAVP) stimulates the release of factor VIII. The child is receiving treatment already and joint rest has been prescribed. The sudden neurological change in the child with sickle cell crisis is a priority.

A nurse is teaching a client with a surgically repaired undescended testis about testicular self-examination (TSE). Which instructions should be included in the teaching? Select all that apply. 1. Perform the examination during a warm bath or shower 2. Perform the examination monthly on the same day 3. Report if one testis is slightly larger than the other 4. Report if there is a hard mass over the testis 5. Use both hands to feel each testis separately

Testicular cancer is the most common form of cancer in men age 15-35. When diagnosed early, it is highly curable. Clients at high risk for developing a tumor (eg, history of undescended testis) are encouraged to perform a monthly TSE. Client instructions for a TSE include: Perform TSE monthly on the same day (easy to remember) Perform TSE while taking a warm shower or bath as warm temperatures will relax the scrotal tissue and make the testis hang lower in the scrotum Use both hands to feel each testis separately Palpate each testicle gently, using the thumb and first 2 fingers Check that the testicle is normally egg-shaped and movable with a smooth surface The clinical findings that should be reported to the health care provider include: Painless, hardened lump on testes Scrotal swelling or heaviness Dull ache in pelvis or scrotum (Option 3) It is normal for one testicle to be slightly larger or hang lower than the other. Some people may also confuse epididymis (small coiled tube) as a small lump at the beginning. These do not need to be reported. Educational objective:Clients with a history of undescended testis or testicular tumor are encouraged to perform a monthly TSE. It is best done during a warm shower. The first indication of testicular cancer may be a painless, hardened lump on the testes or a feeling of scrotal heaviness.

The nurse reviews the most current laboratory results for assigned clients. Which finding is the highest priority for the nurse to report to the health care provider? 1. CD4+ cell count of 500/mm3 (0.5 × 109/L) in a client with oral candidiasis and HIV who is receiving fluconazole orally [16%] 2. Hemoglobin A1C of 7.3% in a client with community-acquired pneumonia and type 2 diabetes who is receiving IV levofloxacin [13%] 3. Platelet count of 148,000/mm3 (148 × 109/L) in a client with a venous thrombosis who is receiving a continuous heparin infusion [30%] 4. Serum glucose of 68 mg/dL (3.8 mmol/L) in a client with radiation enteritis who is receiving total parenteral nutrition [39%]

The American Society for Parenteral and Enteral Support (ASPEN) recommends 140-180 mg/dL (7.8-10.0 mmol/L) as the target range for glucose control in clients receiving nutritional support. Hypoglycemia (serum glucose <70 mg/dL [3.9 mmol/L]) can be due to slowing the rate of the infusion. Although it occurs less frequently in clients receiving total parenteral nutrition (TPN) than hyperglycemia (serum glucose >180 mg/dL [10.0 mmol/L]) does, hypoglycemia can lead to life-threatening complications (eg, seizures, nervous system dysfunction). Therefore, the serum glucose of 68 mg/dL (3.8 mmol/L) is the laboratory finding of highest priority for the nurse to report to the health care provider (HCP). (Option 1) A CD4+ cell count of 500/mm3 (0.5 × 109/L) in a client with HIV who is receiving oral fluconazole (Diflucan) to treat oral candidiasis is within normal limits (500-1,200/mm3 [0.5-1.2 × 109/L]) and does not need to be reported to the HCP. (Option 2) A hemoglobin A1C (HbA1c) of 7.3% in a client with type 2 diabetes who is receiving IV levofloxacin to treat pneumonia is not exceptionally high; the recommended goal is <7%. A bacterial infection causes physiologic stress and increased serum glucose. This increases insulin requirements but would not affect the current HbA1c level, as it reflects glucose control over a 2-3 month period. Therefore, this finding is not the highest priority for the nurse to report to the HCP. (Option 3) Heparin can lead to thrombocytopenia. However, a platelet count of 148,000/mm3 (148 × 109/L) is just below normal limits (150,000-400,000/mm3 [150-400 × 109/L]). Therefore, this finding does not need to be reported to the HCP.

exophthalmos teaching

-regular visits to ophthalmologist to measure eyeball protrusion and evaluate condition -anti-thyroid drugs should be taken to prevent further exacerbation - smoking cessation -restrict salt intake to decrease periorbital edema -use dark glasses to decrease glare and prevent external irritants and infection -perform intraocular muscle exercises (turning the eyes using complete ROM) to maintain flexibility

"Oh oh oh to touch and feel very good velvet ah" olfactory - smell optic - vision oculomotor - innervates eye muscle trochlear - innervates eye muscle trigeminal - sensory from face; motor to chewing muscles abducens - innervates eye muscle facial - innervates muscle of facial expresion; sensory taste vestibulocochlear - sense of hearing and equilibrium glossopharyngeal - moves tongue and pharynx muscles vagus - innervates visceral smooth muscle accessory - innervates neck muscles hypoglossal- moves tongue

1- sensory 2 - sensory 3 - motor 4 - motor 5 - mixed 6 - motor 7 - mixed 8 - sensory 9 - mixed 10 - mixed 11 - motor 12 - motor

An elderly client with osteoporosis falls onto an out-stretched hand and injures the wrist. The client has severe wrist edema, deformity, and pain rated a 10 on a pain scale of 0-10. What should be the nurse's firstaction? 1. Administer analgesia 2. Apply an ice pack to the wrist 3. Assess capillary refill and sensation 4. Elevate the wrist above heart level

A Colles' fracture is a type of wrist fracture (distal radius fracture) that causes a characteristic dinner fork deformity of the wrist. It usually occurs when the client tries to break a fall with an outstretched arm or hand, and lands on the heel of the hand. It is one of the most common fractures in women age >50 and is related to osteopenia or osteoporosis. While the client is undergoing evaluation by the health care provider (HCP) in the emergency department (ED), nursing interventions should include: Performing a neurovascular assessment (eg, pulse, temperature, color, capillary refill, sensation, movement). This is the priority nursing action as neurovascular insufficiency related to swelling (eg, compartment syndrome) or arterial/nerve damage by the bone fragments is associated with a Colles' fracture. If neurovascular status is compromised, urgent reduction of the fracture is indicated. Administering analgesia to promote comfort (Option 1). Applying an ice pack to the wrist to help reduce edema and inflammation (Option 2). Elevating the extremity on a pillow above heart level to reduce edema (Option 4). Instructing the client to move the fingers to reduce edema, increase venous return, and help improve range of motion.

The nurse is caring for a debilitated client with a percutaneous endoscopic gastrostomy (PEG) 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? 1. Insert a Foley catheter into the existing tract and inflate the balloon 2. Insert a small-bore nasointestinal tube to administer feedings and medications 3. Notify the health care provider who inserted the PEG tube 4. Reinsert the PEG tube into the existing tract immediately

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 close within hours of tube dislodgement. The nurse should notify the health care provider who placed the PEG tube as early dislodgement(ie, <7 days from placement) requires either surgical or endoscopic replacement (Option 3). (Options 1 and 4) The insertion of a Foley catheter or immediate reinsertion 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. (Option 2) 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. Educational objective:A PEG tube's tract begins to mature in 1-2 weeks and is fully established in 4-6 weeks. Tube dislodgement <7 days from placement requires surgical or endoscopic replacement. Attempting to reinsert a tube through an immature tract can result in improper placement into the peritoneal cavity, leading to peritonitis and sepsis.

The nurse is caring for a client with cellulitis of the leg. At 11:00 AM, the client reported itching and received a PRN dose of diphenhydramine. At 9:00 PM, the client reports trouble sleeping and requests another dose of diphenhydramine to help with sleep. Which action is most appropriate? Click on the exhibit button for additional information. 1. Administer a dose of diphenhydramine as it is within the specified time interval [23%] 2. Administer a dose of lorazepam to encourage relaxation [30%] 3. Inform the client that no medications can be administered for sleep at this time [6%] 4. Request a prescription for a sleep aid from the health care provider [39%] MedicationsTimeVancomycin: 1 g IVPB every 12 hours1000 and 2200Piperacillin-tazobactam: 3.375 g IVPB every 8 hours0600, 1400, and 2200Diphenhydramine: 25 mg orally as needed for itchingEvery 8 hours PRNLorazepam: 2 mg orally as needed for anxietyEvery 8 hours PRNOxycodone: 10 mg orally as needed for painEvery 4 hours PRN

A PRN (ie, as needed) medication prescription must state the name, dose, route, and purpose of the medication (eg, pain, nausea, sleep) and the time interval between doses. The nurse should administer a PRN medication for its prescribed purpose only. If the client requires medication for a different purpose, the nurse should contact the health care provider (HCP) to either clarify the current prescription or request a new prescription. If a client requests a sleep aid and does not have a prescription for sleep medication, the nurse should contact the HCP to request a prescription (Option 4). (Option 1) If diphenhydramine (Benadryl) is prescribed every 8 hours PRN and the previous dose was at 11:00 AM, it would be appropriate to administer a dose at 9:00 PM; however, diphenhydramine that is prescribed for itching may be administered only for itching. (Option 2) Lorazepam that is prescribed for anxiety may be administered only for anxiety. (Option 3) Informing a client that there is no prescribed medication that can be administered for sleep does not resolve a client's request for help with sleep. The nurse should implement actions to address the client's difficulty sleeping.

A PTT value >100 seconds would be considered critical and could result in life-threatening side effects.

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? 1. Contact the health care provider 2. Cut the tube with scissors 3. Increase gastric suction level 4. Place the client in high Fowler position

A balloon tamponade tube (eg, Sengstaken-Blakemore, 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 (Option 2). (Option 1) If airway obstruction occurs, the nurse should first clear the airway and then ensure that the client is stable before contacting the health care provider. (Option 3) Low intermittent suction to the gastric lumen of a balloon tamponade tube is used to drain stomach contents. Increasing the suction would not be indicated if the tube has become displaced. (Option 4) If the balloon tamponade tube is displaced and obstructing the airway, changing the client's position will not help until the client's airway is cleared by removing the tube.

Nurse should see the 6 yr old who just returned form bronchoscopy with a parent at the bedside

A bronchoscopy is an invasive procedure that allows visualization of the internal air passages via a flexible tube (bronchoscope) passed through either the nose or mouth to the internal airways. Following the procedure, the client will need to be monitored for complications such as bleeding, bronchial perforation, pneumothorax, and bronchial spasm. Potential for airway compromise requires that this client be seen first. (Option 1) A child with a potential hip dislocation will need to be evaluated, but this is not a priority. (Option 3) A CT scan can be done with or without the use of contrast (dye). Use of contrast would require monitoring for an allergic reaction to the dye. This client is young and has no parents present; the nurse will need to ascertain that basic needs are being met. (Option 4) This client is awaiting surgery. The nurse will need to assess that consent is signed and check for preoperative prescriptions. Although important, it is not a priority over the 6-year-old client's airway. Educational objective:When deciding which client to see first, the nurse should apply the "ABC" (airway, breathing, circulation) guideline to problems that clients may have or could develop.

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 healthcare provider immediately? 1. Diminished gag reflex after endotracheal tube removal [15%] 2. Increased agitation level and pulling at linens [28%] 3. Left arm drift during bilateral arm extension [53%] 4. Responds to verbal commands with eyes closed [2%]

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 postoperatively can be challenging, as the effects of anesthesia degrade the neurologic examination. Nurses should use the FAST acronym to assess for stroke: Facial drooping: Numbness or droopiness on one side of the face Arm weakness: Weakness or drifting of one arm when raised to shoulder level (Option 3) Speech difficulties: Slurring of words, incomprehensible speech, inability to understand others Time: Notation of the time of symptom onset, which is critical for guiding treatment (Option 1) Diminished gag reflex is common after anesthesia and endotracheal tube removal. The gag reflex should return as the client awakens. (Option 2) Individuals recovering from anesthesia may have alterations in mood or affect (eg, agitation, anxiety, tearfulness) that will resolve as anesthesia wears off. (Option 4) Drowsiness and somnolence during purposeful interactions (ie, following commands) are expected after anesthesia.

The charge nurse on a medical unit makes assignments for the nursing team composed of a registered nurse (RN), 2 licensed practical nurses (LPNs), and a student nurse (SN). Which assignment is the most appropriate? 1.LPN assigned to a client with a gastrointestinal bleed and hypotension who is receiving blood and requires vital sign monitoring every hour 2 LPN assigned to a newly admitted client with a bowel obstruction who is experiencing severe abdominal pain 3. RN assigned to a client with a change in mental status who is being transferred to the intensive care unit 4. SN assigned to a client with multiple sclerosis and dysphagia who requires multiple oral and IV medications

A client experiencing changes in mental status severe enough to require transfer to the intensive care unit (ICU) is considered critically ill and is the most appropriate assignment for the RN. This client is unstable and requires the RN's advanced skills to perform ongoing neurological assessments (eg, respiratory pattern, level of consciousness, mental status, motor and sensory activity) and vital sign checks, to document findings, and to report the client's condition to the ICU nurse until the transfer can be completed. (Option 1) This client is unstable and requires continuous assessment in a complex situation. Some states allow only RNs to administer blood transfusions. This assignment is not appropriate for an LPN. (Option 2) Accurate assessment of pain and bowel sounds (eg, presence, absence, pitch) is critical in a newly admitted client with a bowel obstruction and should be performed by the experienced RN; this assignment is not appropriate for an LPN. (Option 4) This client is at increased risk for aspiration; much of the RN's time will be spent observing and supervising the administration of oral and IV medications. This assignment is not appropriate for an SN.

A client newly returned to the unit after knee surgery asks the nurse for assistance to a chair. term-254What action should the nurse implement first? 1. Ask another nurse to help 2. Delegate the task to unlicensed assistive personnel 3. Premedicate the client for pain 4. 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 health care provider. Getting the client out of bed too early could cause injury to the surgical site or result in a fall. (Option 1) A client who had knee surgery will likely be unable to bear any weight on the affected limb. Depending on the client's size, it may be prudent for the nurse to get additional help. This could be requested after the activity prescription has been verified. (Option 2) Assistance with ambulation is often delegated to unlicensed assistive personnel (UAP); however, the nurse should verify the prescription first. It would also be prudent to have the UAP assist the nurse as this is the client's first time up after surgery. (Option 3) The nurse should assess the client's pain level before providing pain medication. Educational objective:The nurse should verify activity prescriptions before getting clients out of bed after surgery or a procedure. The nurse should be present when these clients begin ambulating and may need assistance from another nurse or unlicensed assistive personnel.

A client is hospitalized for a broken leg. The client has a history 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? Select all that apply. 1. Nurse floated from another medical-surgical floor 2. Nurse who is 24 weeks pregnant 3. Nurse with erythematous rash and honey-color crusts on the hand 4. Unlicensed assistive personnel who just received the yearly injectable flu vaccination 5. Unlicensed assistive personnel with a cold

A client who has recently received chemotherapy may be immunocompromised and should be protected from infectious contacts. Infectious contacts include staff members with a cold or impetigo, a common, highly contagious bacterial skin infection (Options 3 and 5). Impetigo vesicles rupture and form erosions, and the fluid creates a honey-colored crust. Common sites include the mouth and hands. The nurse should be referred to occupational health and must cover the site while working. (Option 1) The medical-surgical nurse has the training to care for a client with immunosuppression and a broken leg. If chemotherapy needs to be administered during the hospitalization, a chemotherapy certified nurse will administer the medication. (Option 2) The client is not radioactive or infectious, and the nurse will not be administering or handling the chemotherapeutic agents. Therefore, it is safe for the pregnant nurse to care for the client. (Option 4) The injectable influenza vaccination does not contain live influenza virus; therefore, the unlicensed assistive personnel is not infectious. The inactivated vaccine is safe and recommended for clients who are immunocompromised. Educational objective:Clients who are immunosuppressed from chemotherapy should not be cared for by a health care provider who is infectious. Additional Information Safety and Infection Control NCSBN Client Need

The registered nurse 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? 1. The client will contact the United Ostomy Association of America [1%] 2. The client will look at and touch the stoma [70%] 3. The client will read the materials provided on ostomy care [10%] 4. The client will verbalize methods to control gas and odor [18%]

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. It is not uncommon for a client to cope with this loss by refusing to look at or participate in the care of the stoma. Nursing interventions for this client will include: Supportive counseling and assistance in psychosocial adjustment Teaching and facilitating self-care Providing information about the reason for the surgery, prognosis, potential complications, and community resources The priority outcome of nursing care is that the client will look at and touch the stoma; this 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. (Option 1) This is an appropriate outcome; community organizations can offer support and educational materials to the client; however, it is not the priority. (Option 3) This is an appropriate outcome, but as a passive activity, it is not a strong indicator that the client is ready for self-care. (Option 4) This is an appropriate outcome as it indicates effective ostomy teaching; however, it is not the priority. Teaching will be more effective once the client has accepted the ostomy.

Several clients check into the emergency department at the same time. Which client should be seen first? 1. 8-month-old with persistent vomiting and diarrhea for several days 2. 5-year-old who has a foreign body in the right naris 3. 7-year-old who is restless after tonsillectomy surgery 3 days ago 4. 9-year-old with a second-degree burn to the arm who is crying inconsolably

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 and has signs of hemorrhage (eg, restlessness, frequent swallowing or clearing of the throat, vomiting of blood, pallor) should be seen first. The client may require surgery to cauterize the bleeding vessel(s). To decrease the risk of hemorrhage, the nurse should educate the client to limit coughing, gargling, and clearing of the throat. (Option 1) 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. (Option 2) A foreign body lodged in the nose does not compromise the airway and therefore is not life threatening. This client should be seen last. (Option 4) 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. Educational objective:A client who is status post tonsillectomy and adenoidectomy is at risk for hemorrhage and life-threatening airway compromise up to 14 days after surgery. Signs and symptoms of hemorrhage after tonsillectomy and adenoidectomy include restlessness, frequent swallowing or throat-clearing, vomiting of blood, and pallor.

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? Select all that apply. 1. Apply cool, moist washcloths to the affected areas 2. Keep the fingernails trimmed short to minimize skin scratching 3. Take a hot bath or shower to alleviate itching sensations 4. Use skin protectant or moisturizing cream over unbroken skin 5. Wear cotton gloves or long-sleeved clothing to avoid scratching

A client with cirrhosis may experience pruritus (itching) due to buildup of bile salts beneath the skin. Clients with cirrhosis are also at an increased risk for skin breakdown due to the development of edema, which increases skin fragility and impedes wound healing, and the loss of muscle and fat tissue from pressure points (eg, heels, sacrum). The nurse encourages the client to cut the nails short, wear cotton gloves, and wear long-sleeved shirts to avoid injury to the skin from scratching (Options 2 and 5). Other comfort measures include baking soda baths; calamine lotion; and cool, wet cloths, which cool and soothe irritated skin (Options 1 and 4). Cholestyramine (Questran) may be prescribed to increase the excretion of bile salts in feces, thereby decreasing pruritus. It is packaged in powdered form, must be mixed with food (applesauce) or juice (apple juice), and should be given 1 hour after all other medications. (Option 3) Temperature extremes (eg, hot baths/showers) may intensify pruritus. The nurse should instruct the client to bathe with tepid water until the pruritus has subsided.

The nurse is teaching the home health client how to perform colostomy irrigation. Which client action reveals that further teaching is required? 1. Attaches an enema set to the irrigation bag, lubricates it, gently inserts it into the stoma, and holds it in place 2. Fills irrigation container with 500-1000 mL of lukewarm tap water and flushes the irrigation tubing 3. Hangs the irrigation container on a hook at the level of the shoulder approximately 22 inches above the stoma 4. Slowly opens the roller clamp, allowing the irrigation solution to flow, but clamps the tubing when cramping occurs

A colostomy is a surgical procedure that creates an opening (stoma) 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. The procedure for bowel irrigation is as follows: Fill the irrigation container with 500-1000 mL of lukewarm water, flush irrigation tubing, and reclamp; hang the container on a hook or intravenous pole (Option 2) Instruct the client to sit on the toilet, place the irrigation sleeve over the stoma, extend the sleeve into the toilet, and place the irrigation container approximately 18-24 inches above the stoma (Option 3) Lubricate cone-tipped irrigator, insert cone and attached catheter gently into the stoma, and hold in place Slowly open the roller clamp, allowing irrigation solution to flow for 5-10 minutes Clamp the tubing if cramping occurs, until it subsides (Option 4) Once the desired amount of solution is instilled, the cone is removed and feces is allowed to drain through the sleeve into the toilet (Option 1) 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.

Which statement made by the client demonstrates a correct understanding of the home care of an ascending colostomy? 1. "I will avoid eating foods such as broccoli and cauliflower." [42%] 2. "I will empty the pouch when it is one-half full of stool." [36%] 3. "I will irrigate the colostomy to promote regular bowel movements." [16%] 4. "I will restrict my fluid intake to 2,000 milliliters of fluid a day." [4%]

A colostomy is a surgical procedure that creates an opening (stoma) 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 (ascending, transverse, descending, and sigmoid). 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 stoma and pouch appliance that should be taught to the client or caregiver includes the following: Ensure sufficient fluid intake (at least 3,000 mL/day unless contraindicated) to prevent dehydration; identify times to increase fluid requirements (hot weather, increased perspiration, diarrhea) (Option 4). Identify and eliminate foods that cause gas and odor (broccoli, cauliflower, dried beans, brussels sprouts) (Option 1). Empty the pouch when it becomes one-third full to prevent leaks due to increasing pouch weight (Option 2). (Option 3) Stool produced in the ascending and transverse colon is semiliquid, which eliminates the need for irrigation. Irrigation to promote a bowel regimen may be useful for descending or sigmoid colostomies as the stool is more formed.

During the immediate postoperative period after a colostomy, which stoma appearance requires the nurse to contact the health care provider (HCP) immediately? 1. Brick red with slight moisture noted [4%] 2. Dusky with moderate edema present [86%] 3. Pink with slight oozing of blood [4%] 4. Rosy with no stool produced [4%]

A colostomy is a surgical procedure that creates an opening (stoma) 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 (Option 1). Minor bleeding and oozing may occur (Option 3), 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 (Option 4). (Option 2) Inadequate blood supply can cause a change in the stoma color. Indications of poor vascularity include pale, dusky, or cyanotic color changes, any of which requires immediate notification of the HCP and surgical intervention to prevent ischemia and necrosis. Educational objective:A healthy stoma has the characteristics of mucosal tissue and should appear vascular and moist. Indications of decreased blood supply (pale, dusky, or cyanotic) should be reported to the HCP immediately. Additional Information Physiological Adaptation NCSBN Client Need

A client with a history of degenerative arthritis is being discharged home following an exacerbation of chronic obstructive pulmonary disease. After reviewing the discharge medications, the nurse should educate the client about which topics? Select all that apply. Click on the exhibit button for additional information. 1. Dryness of the mouth and throat may occur 2. Ringing in the ears is an expected, transient side effect 3. The albuterol canister should not be shaken before use 4. The health care provider should be notified if stools are black and tarry 5. Tiotropium capsules should not be swallowed Albuterol: 2 puffs q4-6hrs PRN Prednisone: 40mg PO daily Naproxen: 220mg PO twice daily Tiotropium: 1 capsule inhaled daily

A common side effect of tiotropium (Spiriva) and other anticholinergics (eg, ipratropium, benztropine) is xerostomia (dry mouth) due to the blockade of muscarinic receptors of the salivary glands, which inhibits salivation. Sugar-free candies or gum may be used to alleviate dry mouth and throat (Option 1). Tiotropium capsules should not be swallowed. These capsules are placed inside the inhaler device, and the capsule is pierced, allowing the client to inhale its contents (Option 5). Glucocorticoids (eg, prednisone), when taken in combination with aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) such as naproxen, can increase the risk of gastrointestinal ulceration and bleeding. The client should report black, tarry stools (ie, melena) to the health care provider as they could indicate gastrointestinal bleeding (Option 4). (Option 2) Tinnitus (ie, ringing in the ears) is an uncommon side effect of NSAID (eg, naproxen) use. Tinnitus is commonly associated with toxicity related to salicylate-containing NSAIDs (eg, aspirin) or aminoglycosides (eg, gentamicin, neomycin, tobramycin); its onset should be reported by a client taking these medications. The medication may need to be discontinued to prevent permanent hearing loss. (Option 3) The albuterol canister should be shaken prior to inhalation to ensure appropriate medication delivery. Educational objective:The nurse should teach the client taking glucocorticoids with aspirin or nonsteroidal anti-inflammatory drugs about the risk for gastrointestinal bleeding or ulceration. Xerostomia is a common side effect of anticholinergic drugs that can be alleviated with sugar-free candies or gum. Tiotropium capsules should not be swallowed.

A nurse is caring for a client at 37 weeks gestation who is undergoing a contraction stress test. Which fetal strip should the nurse associate with a negative contraction stress test?

A contraction stress test (CST) evaluates fetal well-being under stress by identifying uteroplacental insufficiency. Uterine blood flow is decreased during uterine contractions, which stresses the fetus during labor. Contractions are stimulated using either oxytocin administration or nipple stimulation. A fetal tracing is evaluated until 3 uterine contractions, each lasting 40-60 seconds, are captured within 10 minutes. A negative test has no late or variable decelerations and is associated with good fetal outcomes (Option 2). A positive test includes late decelerations with ≥50% contractions. A suspicious or equivocal test includes variable or prolonged decelerations or late decelerations with <50% contractions. A CST may be combined with a nonstress test to further evaluate fetal well-being. A negative CST with a reactive nonstress test provides strong reassurance of fetal well-being. (Options 1 and 4) These fetal tracings show late decelerations, indicating uteroplacental insufficiency. They indicate a positive test and an at-risk fetus. (Option 3) This fetal tracing has variable decelerations, indicating umbilical cord compression. This is a suspicious or equivocal test and follow-up testing is indicated.

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

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

The nurse provides post-procedure teaching for a female client who had a cystoscopy as an outpatient. Which client statement indicates the need for additional instruction? 1. "I can expect pink-tinged urine for at least 24 hours." [3%] 2. "I can take a warm bath and acetaminophen if I have discomfort or bladder spasms."[23%] 3. "I should expect frequency and burning when I urinate." [24%] 4. "I should expect to see blood clots in my urine for up to 24 hours." [48%]

A cystoscopy is a procedure that uses a flexible fiber-optic scope inserted through the urethra into the urinary bladder with the client in the lithotomy position. Complications associated with cystoscopy include urinary retention, hemorrhage, and infection. Therefore, clients are instructed to notify the health care provider (HCP) immediately if they have bright red blood when urinating, blood clots, inability to urinate, fever >100.4 F (38 C) and chills, or abdominal pain unrelieved by analgesia. These conditions necessitate evaluation by the HCP and may require antibiotic therapy or the insertion of a urinary catheter to irrigate the bladder, remove clots, or drain the bladder (Option 4). (Options 1 and 3) Pink-tinged urine, frequency, and dysuria are expected for up to 48 hours following a cystoscopy. Clients are instructed to increase fluids, drink 4-6 glasses of water daily to help dilute the urine, and avoid alcohol and caffeine for 24-48 hours as these can irritate the bladder. (Option 2) Abdominal discomfort and bladder spasms may occur for up to 48 hours following the procedure. Clients are taught to take a mild analgesic (eg, acetaminophen, ibuprofen) and a warm tub/sitz bath (except with recurrent urinary tract infections) for pain relief. Educational objective:Clients can expect pink-tinged urine, frequency, dysuria, and abdominal discomfort for up to 48 hours after cystoscopy. They are instructed to increase fluid intake, avoid alcohol and caffeine, take a mild analgesic and tub/sitz bath to relieve discomfort, and notify the HCP immediately of inability to void, gross hematuria, blood clots, fever, chills, or severe pain.

A nurse in the intensive care unit (ICU) is caring for a client with sepsis who is on a mechanical ventilator (MV). The client is exposed to the noise of the MV, monitoring equipment, and infusion pump alarms during the day and night. What should the nurse identify as the priority nursing diagnosis (ND)? 1. Anxiety 2. Disturbed sleep pattern 3. Powerlessness 4. Risk for acute confusion

A disturbance in sleep pattern refers to time-limited interruptions of the amount and quality of a client's sleep due to external factors (eg, noise, lighting, noxious odors, interruptions due to medical and nursing care). Evidence shows that excessive noise and sleep disturbances in critically ill clients can affect outcomes as they can lead to significant psychologic (eg, delirium, post-traumatic stress disorder, anxiety) and physiologic (eg, circadian rhythm disturbance, decreased REM sleep, increased heart rate, impaired immunity) consequences. 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 (circadian rhythm disturbance) is the priority ND.

A client is brought to the emergency department 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? 1. Determine onset of symptoms 2.Ensure that the client has 2 large-bore intravenous (IV) lines 3. Maintain patent airway 4. Prepare for head CT scan

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 (Option 3). 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 emergency department 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 (Option 4). This person will also ensure that the client has 2 large-bore IV lines for rapid infusion of fluids or medications as needed (Option 2). (Option 1) It is vital to determine the onset of symptoms as thrombolytic medications are used in a short time frame (typically within 4.5 hours of onset). Thrombolytic medications are used only in ischemic strokes, so the head CT must be completed to confirm the type of stroke (ischemic versus hemorrhagic). With all of these interventions, the priority nursing actions remain the same: ABC - airway, breathing, and circulation.

The nurse is caring for a client in the postanesthesia care unit following a gastroduodenostomy. Which of the following nursing interventions are appropriate? Select all that apply. 1. Applying bilateral sequential compression devices 2. Encouraging splinting of the incision with a pillow when coughing 3. Keeping the client NPO until bowel sounds return 4. Maintaining supine positioning at all times 5. Repositioning and irrigating a clogged nasogastric tube PRN

A gastroduodenostomy (Billroth I) involves removing the distal two-thirds of the stomach with anastomosis of the remaining stomach to the duodenum. Following partial gastrectomy, clients should remain NPO until bowel sounds return (Option 3). Once tolerated, consumption of small, frequent meals will help prevent the occurrence of dumping syndrome (ie, rapid emptying of stomach contents into the small intestine). Postoperative clients are at risk for developing venous thromboembolism (VTE) due to reduced mobility levels and require VTE prophylaxis (eg, sequential compression devices, compression hose) (Option 1). 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 (Option 2). (Option 4) 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. (Option 5) Clients may have a nasogastric tube postoperatively for gastric decompression. Clogged nasogastric tubes should be reported to the surgeon. Attempting to manipulate or flush the device may disrupt the surgical site, causing hemorrhage or gastric perforation.

The new graduate nurse provides care for a client with a halo external fixation device. Which actions by the new nurse are appropriate? Select all that apply. 1. Cleans around the pin sites using sterile water 2. Gently tightens the device screws if they become loose 3. Holds the frame of the device when logrolling the client 4. Places a small pillow under the head when client is supine 5. Uses a blow-dryer on the cool setting to dry the vest when wet

A halo external fixation device stabilizes a cervical or high thoracic fracture when there is insignificant damage to the ligaments or spinal cord. Sensory and muscle function should be monitored to determine any new deficits, and pin sites should be regularly assessed for loose pins or infection. Care for the client with a halo device includes: Cleaning pin sites with sterile solution (eg, chlorhexidine, water) to prevent infection (Option 1) Keeping the vest liner clean and dry (eg, changing weekly or when soiled, using a cool blow-dryer to dry) to protect the skin (Option 5) Placing foam inserts under pressure points to prevent pressure injury Placing a small pillow under the client's head when supine to reduce pressure on the device (Option 4) Keeping the correct-sized wrench available at all times in case of emergency (Option 2) Only the health care provider can adjust the pins. (Option 3) The nurse should avoid grabbing the device frame when moving or positioning the client, as this may cause the screws to loosen or alter device alignment

The day shift nurse provides handoff of care report to the oncoming night shift nurse. Which of the following statements by the nurse are appropriate to include in the report? Select all that apply. 1. "A continuous IV heparin infusion was initiated at 18 units/kg/hr at 0800, and the infusion bag will need to be replaced at 2100." 2. "I gave acetaminophen 500 mg PO to the client for a headache, with good relief." 3. "The client had morphine 2 mg IV 30 minutes ago for chest pain and now reports 3 on a pain scale of 0-10." 4. "The client's sisters visited today and were very rude, but they did bring the client's medication list." 5. "The radiology department called to say that an ultrasound will be performed at 2100."

A handoff of care report is the critical communication that occurs when transferring client care to another nurse (eg, shift change, department transfer). Transitions of care require thorough, precise communication to ensure client wellness and safety. Appropriate handoff communication allows for continuity of care and provides a synopsis of client needs and details of the client's care. To ensure appropriate and effective handoff communication, the nurse should: Provide identifying information (eg, client's name and room number). Note care priorities and upcoming or outstanding tasks (eg, time to replace a medication infusion bag, need to perform delayed wound care and cause of delay) (Option 1). Provide exact, pertinent information (eg, medication dose, time, measurable outcomes) (Option 3). Include multidisciplinary plans (eg, radiology examinations, family meetings, physical therapy) (Option 5). Relay significant client changes in a clear manner (ie, assessment, interventions, outcomes, evaluation). (Option 2) Report statements should include exact information (ie, time medication is administered, measurable outcome using a pain scale). "Good relief" is a vague term. (Option 4) Handoff should not include biased information or personal opinions (eg, "rude") and should include visitor information only if the visitor is involved in client care and/or teaching. It is appropriate to include information about a client's medication list. Educational objective:Nurse-to-nurse handoff of care reports should clearly communicate identifying information; care priorities and upcoming or outstanding tasks; exact, pertinent information; multidisciplinary plans; and significant client changes. Additional Information Management of Care NCSBN Client Need

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 persists and the client's oxygen saturation is dropping. What should the nurse do next? 1. Call the respiratory therapist to the bedside to troubleshoot [3%] 2. Elevate the head of the bed and apply a nonrebreather mask [18%] 3. Increase the oxygen delivery on the ventilator to 100% [8%] 4. Manually ventilate with a resuscitation bag device attached to the endotracheal tube [68%]

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 (eg, decreasing oxygen saturation), 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. (Option 1) Respiratory therapists have specialized training in mechanical ventilators. They should be called to the bedside but only after the nurse has begun to stabilize the client's condition using manual ventilation. (Option 2) Since the client is intubated, air cannot pass from the nares and oropharynx into the lungs, and ventilation can be achieved only via the endotracheal tube. (Option 3) The client would benefit from a higher oxygen level, but the ventilator is unable to deliver the programmed volume to the client, even with an increased oxygen level. The client's lungs must be manually ventilated with a resuscitation bag.

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? Select all that apply. 1. Avoid small, frequent meals 2. Can have a cup of coffee with each meal 3. Eat a low-residue, high-protein, high-calorie diet 4. Increase fluid intake to at least 2000 mL/day 5. Medication should be continued even after the resolution of symptoms 6. Take daily vitamin and mineral supplements

A low-residue, high-protein, high-calorie diet, along with daily vitamin and mineral supplements, is encouraged to meet the nutritional and metabolic needs of the client with 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. (Option 1) Small, frequent meals are encouraged to lessen the amount of fecal material present in the gastrointestinal tract and to decrease stimulation. (Option 2) Caffeine, alcohol, and tobacco are gastric irritants that stimulate the intestine and should be avoided. (Option 5) The prescribed sulfasalazine should be continued even when symptoms subside to prevent relapse. Because sulfasalazine hinders the absorption of folate, folic acid supplements are encouraged.

The nurse is caring for a client after a lumbar puncture (spinal tap). Which client assessment is mostconcerning and requires a nursing response? 1. Consumes 600 mL liquid over 4 hours [2%] 2. Insertion site dressing saturated with clear fluid [74%] 3. Observed lying in the right-sided Sim's position [9%] 4. Reports a headache rated 6/10 [13%]

A lumbar puncture involves removing a sample of cerebrospinal fluid through a needle inserted between vertebrae. Elevated intracranial pressure 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 (autologous blood into the epidural space) is required. (Option 1) Fluids are encouraged to help replace the cerebrospinal fluid. (Option 3) The client should lie flat for at least 4 hours. The prone or supine position is recommended to help prevent a headache. (Option 4) Up to 5%-30% of clients have the common complication of headache. 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 receives report on the assigned team of clients on the oncology unit. All are receiving chemotherapy. Which client should the nurse check on first? 1. Alopecia and oral mucositis noted on assessment 2. Morning hemoglobin result is 8 g/dL (80 g/L) 3. New-onset back pain and weakness in legs 4. Persistent vomiting and potassium result is 3.4 mEq/L (3.4 mmol/L)

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 (eg, numbness, paresthesia). 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. (Option 1) Cells with rapid turnover take up the chemotherapy and are most affected. Commonly expected findings are alopecia (loss of hair) and mucositis/ulcers in the mouth/gastrointestinal system. Comfort care and teaching will be given for these signs, but they are not a priority over a neurologic abnormality. (Option 2) Chemotherapy suppresses bone marrow, commonly resulting in neutropenia (low neutrophil count), anemia (low hemoglobin), and thrombocytopenia (low platelets). This would be monitored but is not an emergency at this current level. (Option 4) Nausea and vomiting are expected side effects of chemotherapy and/or radiation treatment. Potassium losses occur with vomiting or diarrhea. However, this potassium result is only slightly lowered. It should be monitored but is not the priority compared to the new neurologic assessment.

A client is admitted to the medical surgical floor with a hemoglobin level of 5.0 g/dL (50 g/L). The nurse should anticipate which findings? Select all that apply. 1. Coarse crackles 2. Dyspnea 3. Pallor 4. Respiratory depression 5. Tachycardia

A normal hemoglobin level for an adult male is 13.2-17.3 g/dL (132-173 g/L) and female is 11.7-15.5 g/dL (117-155 g/L). A client with severe anemia will have tachycardia, which will maintain cardiac output. The cardiovascular system must increase the heart rate and stroke volume to achieve adequate perfusion. Shortness of breath (dyspnea) 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 (pale complexion) occurs from reduced blood flow to the skin. (Option 1) Coarse crackles occur with fluid overload but not with anemia. (Option 4) Respiratory depression does not occur with anemia. Respiratory depression may occur post-administration of a narcotic or during oversedation.

A peak flow meter is a handheld device that measures the client's ability to push air out of the lungs. Measurements from a peak flow meter often guide the client's use of respiratory medications and the need to schedule an appointment with a health care provider. To obtain the most accurate readings to help guide, maintain, and evaluate treatment in clients with asthma, the procedure is performed in the following order: Before each use, slide the indicator on the numbered scale on the flow meter to 0 (or the lowest value), and stand or sit as upright as possible (Option 3). Inhale deeply, place the mouthpiece in the mouth, and close the lips tightly around the mouthpiece to form a seal (Option 2). Exhale as quickly and completely as possible and note the reading on the numbered scale (Option 1). Repeat the procedure 2 more times, with a 5- to 10-second rest period between exhalations (Option 5). Record the highest reading (ie, personal best) in the peak flow log (Option 4).

The nurse is performing a home visit for a child with cystic fibrosis who had a percutaneous endoscopic gastrostomy (PEG) tube placed 6 weeks ago. During inspection of the PEG tube, the nurse should correctly recognize which finding as expected? 1. External gastrostomy tube bumper is secured tightly to, and pressing against, the skin [40%] 2. Gastrostomy tube movement of 0.2 in (0.5 cm) is noted when the client coughs [33%] 3. Increased amounts of red, bumpy tissue are near the stoma compared to previous assessment [8%] 4. Resistance is felt when rotating the tube during cleaning [18%]

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

A graduate nurse is caring for a client with a triple-lumen peripherally inserted central catheter in the right arm. Which actions by the graduate nurse indicate that more education is needed? Select all that apply. 1. Flushing the line before and after each medication administration 2. Pausing the parenteral nutrition prior to drawing blood from a different port 3. Reinforcing a torn peripherally inserted central catheter line dressing with tape 4. Scrubbing the port with alcohol for 5 seconds before use 5. Taking the client's blood pressure in the left arm

A peripherally inserted central catheter (PICC) is a venous access device that is inserted via the cephalic or basilic vein and terminates in the superior vena cava. It is indicated for administration of noxious medications (eg, parenteral nutrition, chemotherapy), for long-term IV therapy, or in clients with poor venous access. Proper care and aseptic technique are important to maintain lumen patency and eliminate the risk of life-threatening central line-associated bloodstream infection (CLABSI). The nurse should inspect the insertion site for signs of infection (redness, drainage) and dressing integrity. Routine care includes sterile dressing changes every 48 hours with a gauze dressing or 7 days with a transparent semipermeable dressing (biopatch) as well as immediately if dressing is loose/torn, soiled, or damp. The line should be flushed before and after medication administration and per facility protocol (Option 1). Blood pressure and venipuncture should not be performed on the affected arm as compression of the vein can alter its integrity (Option 5). All infusing medications (except vasopressors) must be paused before drawing blood from the PICC to prevent false interpretation of the client's serum levels (Option 2). (Option 3) Dressings that no longer occlude the insertion site must be changed immediately. Loose corners may be temporarily reinforced with tape. (Option 4) The nurse should "scrub the hub" with alcohol or chlorhexidine/alcohol for 10-15 seconds. This should be done before flushing, drawing blood, or administering medication.

The nurse cares for a confused client who continues to pull at the intravenous (IV) catheter on the left forearm despite frequent instructions not to do so. What is the nurse's next action? 1. Apply a gauze wrap and elastic stockinette around the IV site 2. Apply a mitt on the right hand 3. Apply a soft wrist restraint on the right wrist 4. Apply an arm board to the left arm

A physical restraint that restricts body movement should be the last resort to keep a client from interfering with medical treatment. Restraints can cause bodily injury such as pressure ulcers, neurovascular and peripheral circulatory deficits, and psychological trauma. Therefore, less restrictive methods should always be tried first. Concealing the IV site and tubing by wrapping the forearm in gauze and an elastic stockinette can be effective in keeping a confused client from pulling at the IV line. (Options 2, 3, and 4) Applying a hand mitt, soft wrist restraint, or arm board may be necessary if less restrictive techniques, such as concealing the IV site or encouraging family member or sitter involvement, are ineffective in keeping the client from pulling at the IV line. However, applying one of these restraints should not be the nurse's next action.

A client is receiving chemotherapy for acute myeloid leukemia. The health care provider prescribes allopurinol to prevent tumor lysis syndrome (TLS). Which laboratory value indicates a therapeutic response to the medication? 1. Serum calcium 9.5 mg/dL (2.38 mmol/L) 2. Serum phosphate 4.0 mg/dL (1.29 mmol/L) 3. Serum potassium 4.5 mEq/L (4.5 mmol/L) 4. Serum uric acid level 6.0 mg/dL (357 µmol/L)

A potential complication of chemotherapy is acute tumor lysis syndrome (TLS), a rapid release of intracellular components into the bloodstream. Massive cell lysis releases intracellular ions (potassium and phosphorus) and nucleic acids into the bloodstream. Catabolism of the nucleic acids produces uric acid, resulting in severe hyperuricemia. Released phosphorus binds calcium, producing calcium phosphate mixture but lowering serum calcium levels. Both calcium phosphate and uric acid are deposited into the kidneys, causing renal injury. Allopurinol (Zyloprim) blocks the nucleic acid catabolism and prevents hyperuricemia but would not affect potassium, phosphate, and calcium levels. Chronic gout and uric acid calculi also require the administration of allopurinol to decrease uric acid accumulation. A normal blood uric acid level for an adult male is 4.4-7.6 mg/dL (262-452 µmol/L) and female is 2.3-6.6 mg/dL (137-393 µmol/L). (Option 1) The normal calcium level for adults is 8.6-10.2 mg/dL (2.15-2.55 mmol/L). The client with this complication would experience hypocalcemia. (Option 2) The normal phosphate level for adults is 2.4-4.4 mg/dL (0.78-1.42 mmol/L). In this condition, the phosphate level would show hyperphosphatemia. (Option 3) The normal potassium level for adults is 3.5-5.0 mEq/L (3.5-5.0 mmol/L). Hyperkalemia is usually present in a client with this chemotherapy-induced complication. Educational objective:The therapeutic effect of allopurinol (Zyloprim) is to decrease hyperuricemia caused by TLS. Laboratory values of significance in TLS include rising blood uric acid, potassium, and phosphate levels, with decreasing calcium levels. Additional Information Reduction of Risk Potential NCSBN Client Need

A client tells the nurse of wanting to lose 20 lb (9 kg) in time for the client's daughter's wedding, which is 16 weeks away. How many calories (kcal) will the client have to eliminate from the diet each day to meet this goal? 1. 450 kcal/day [27%] 2. 625 kcal/day [46%] 3. 860 kcal/day [17%] 4. 1,000 kcal/day [8%]

A reduction or energy expenditure of 3,500 calories (kcal) will result in a weight loss of 1 lb (0.45 kg). To lose 20 lb (9 kg), the client needs to reduce intake by a total of 70,000 kcal (3500 kcal x 20 lb [9 kg] = 70,000 kcal). Over a period of 16 weeks, this would require a daily reduction of: 625 kcal (70,000 kcal / [16 weeks x 7 days] = 625 kcal/day) Adding an exercise regimen to the client's daily routine would facilitate additional weight loss and/or reduce the need for severe caloric restriction. (Option 1) Reducing intake by 450 kcal/day over 16 weeks would result in a weight loss of 14.5 lb (6.5 kg). (Option 3) Reducing intake by 860 kcal/day over 16 weeks would result in a weight loss of 27.5 lb (12.4 kg). (Option 4) Reducing intake by 1000 kcal/day over 16 weeks would result in a weight loss of 32 lb (14.5 kg).

A reduction or energy expenditure of 3,500 calories (kcal) will result in a weight loss of 1 lb(0.45 kg). To lose 20 lb (9 kg), the client needs to reduce intake by a total of 70,000 kcal (3500 kcal x 20 lb [9 kg] = 70,000 kcal). Over a period of 16 weeks, this would require a daily reduction of: 625 kcal (70,000 kcal / [16 weeks x 7 days] = 625 kcal/day) Adding an exercise regimen to the client's daily routine would facilitate additional weight loss and/or reduce the need for severe caloric restriction. (Option 1) Reducing intake by 450 kcal/day over 16 weeks would result in a weight loss of 14.5 lb (6.5 kg). (Option 3) Reducing intake by 860 kcal/day over 16 weeks would result in a weight loss of 27.5 lb (12.4 kg). (Option 4) Reducing intake by 1000 kcal/day over 16 weeks would result in a weight loss of 32 lb (14.5 kg). Educational objective:A reduction or energy expenditure of 3500 calories (kcal) will result in a weight loss of 1 lb.

A client on a medical-surgical unit is receiving heparin therapy. Platelet levels decreased from 230,000/mm3 (230 × 109/L) 2 days ago to 80,000/mm3 (80 × 109/L) today. Which nursing actions are appropriate? Select all that apply. 1. Confirm validity of platelet result with new blood specimen 2. Hold the scheduled morning dose of heparin 3. Notify the health care provider of the platelet count 4. Obtain a full set of vital signs 5. Request change of prescription for heparin to enoxaparin

A significant reduction in platelets after initiation of heparin therapy can indicate heparin-induced thrombocytopenia (HIT), a severe, potentially lethal complication. HIT is an immune reaction to heparin that causes a drastic decrease of ≥50% in platelets and a paradoxical increase in arterial and venous thrombosis. The nurse should notify the health care provider immediately and anticipate stopping heparin therapy and initiating a non-heparin anticoagulant (eg, warfarin, rivaroxaban, argatroban) (Options 2 and 3). Clients with HIT have increased risk for deep venous thrombosis (DVT) and pulmonary embolism. The nurse should perform a neurovascular assessment and report evidence of vascular clots (eg, DVT) to the health care provider. The nurse should also measure a full set of vital signs to assess for pulmonary embolism (eg, tachycardia, tachypnea, decreased oxygen saturation) (Option 4). When large changes are noted in laboratory values, it is important to draw repeat samples to confirm those values, as errors in sampling or specimen handling could result in inappropriate intervention (Option 1). (Option 5) Clients who are suspected of having HIT or who have a history of HIT should never receive heparin or low-molecular-weight heparin (eg, enoxaparin). Only non-heparin anticoagulants may be given. Educational objective: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 health care provider.

After rolling the ankle outwards when jogging, a client develops ankle pain and swelling. The health care provider diagnoses a lateral ankle sprain. Which interventions does the nurse include in the discharge instructions? Select all that apply. 1. Apply heat to reduce swelling during the first 24 hours 2. Begin an exercise rehabilitation program when the pain subsides 3. Elevate the leg above the heart level on 2 pillows 4. Flex and dorsiflex the foot to prevent stiffness during the first 24 hours 5. Take ibuprofen every 6 hours as needed 6. Wrap the ankle with an elastic compression bandage

A sprain is a stretch and/or tear of a ligament. Treatment for a sprained ankle includes: Rest - Activity should be stopped and movement limited for 24-48 hours to promote healing. The health care provider may prescribe no weight-bearing on the joint for 48 hours, and crutches may be required. Ice (cold, cryotherapy) - Cold therapy or an ice pack should be applied for 10-15 minutes every hour for the first 24-48 hours. Vasoconstriction helps to reduce pain, inflammation, and swelling. Ice should not be applied directly to the skin. Compression (eg, ACE wrap, splint) - Pressure/compression can help prevent edema and promote fluid return (Option 6). Elevation - The extremity should be kept elevated above the heart on pillows for 24-48 hours to help reduce swelling by promoting fluid return (Option 3). Analgesia - Mild analgesia with a nonsteroidal anti-inflammatory drug (eg, ibuprofen) can be taken every 6 hours as needed to relieve pain and reduce swelling (Option 5). Exercise rehabilitation program - This should be initiated as soon as possible after the injury (ie, when pain subsides) to restore range of motion, flexibility, and strength and prevent reinjury (Option 2). (Option 1) Cold therapy or ice should be used initially; after the first 24-48 hours, moist heat can be applied for 20-30 minutes at a time to reduce swelling, with a cooldown between applications. (Option 4) Rest is indicated during the acute injury phase (24-48 hours). After this acute phase, the client is encouraged to use the extremity and move the joint to improve circulation and reduce swelling as long as the joint is protected with some type of immobilizer (eg, brace, tape, splint).

The nurse on the neurotrauma unit receives report on 4 clients. Which client should the nurse assess first? 1. Client in neurogenic shock from a spinal cord injury, with pulse of 56/min, blood pressure of 120/60 mm Hg, and warm and pink skin 2. Client with a concussion from closed-head injury due to a fall, Glasgow Coma Scale score of 15, headache, and memory loss 3. Client with a subdural hematoma, pulse of 48/min, blood pressure of 190/90 mm Hg, and a pupil that reacts slowly to light 4. Client with central diabetes insipidus from a head injury, hypernatremia, and urine output of 210 mL/hr

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(mid-line shift). Assessing for signs of increased intracranial pressure, including change in level of consciousness, Cushing triad (hypertension, bradycardia, and irregular respirations), ipsilateral pupil dilation, headache, and vomiting, is critical as surgery to evacuate the hematoma and relieve the pressure may be necessary. (Option 1) Manifestations of neurogenic shock include hypotension and bradycardia. Although the client has bradycardia and requires monitoring, the client is normotensive and has normal skin color and temperature, which indicate adequate perfusion. (Option 2) Headache, transient change in level of consciousness, and inability to remember the injury (retrograde amnesia) are expected manifestations of a concussion. The Glasgow Coma Scale score of 15 (range: 3-15) indicates complete orientation. (Option 4) 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 (>295 mOsmol/kg [295 mmol/kg]). Treatment is necessary, but polyuria (>200 mL/hr) and hypernatremia (sodium >145 mEq/L [145 mmol/L]) due to dehydration are expected manifestations. Educational objective:A subdural hematoma is caused by bleeding into the subdural space outside the brain. Surgical evacuation of the hematoma may be necessary to relieve the pressure on the brain, as increased intracranial pressure can lead to decreased cerebral perfusion, herniation (mid-line shift), and death.

The client with malignant left pleural effusion undergoes a thoracentesis and 900 mL of excess pleural fluid is removed. Which of these manifestations, if noted on the post-procedure assessment, should the nurse report to the health care provider immediately? 1. Asymmetrical chest expansion and decreased breath sounds on the left 2. Blood pressure 100/65 mm Hg (mean arterial pressure 77 mm Hg) 3. Client complains of 6/10 pain at the needle insertion site 4. Respiratory rate 24/min, pulse oximetry 94% on oxygen 2 L/min

A thoracentesis involves the insertion of a large-bore needle through an intercostal space to remove excess fluid. The procedure has the following advantages: Diagnostic - analysis of fluid to diagnose the underlying cause of the pleural effusion (eg, infection, malignancy, heart failure), including cytology, bacterial culture, and related testing Therapeutic - removal of excess fluid (>1 L) improves dyspnea and client comfort Complications from insertion of the needle and removal of large amounts of fluid include iatrogenic pneumothorax, hemothorax, pulmonary edema, and infection. After the procedure, the nurse assesses for pain and difficulty breathing; monitors vital signs and oxygen saturation; and observes for changes in respiratory rate and depth, symmetry of chest expansion, and breath sounds. If any abnormalities are noted, a post-procedure chest x-ray is obtained. Decreased chest expansion with inspiration and breath sounds on the affected side, tachypnea, tracheal deviation to the opposite side, and hyperresonance (air) on the affected side are manifestations of a pneumothorax. These should be reported immediately. (Option 2) Hypotension, pulmonary edema, and tachycardia can occur as the result of removal of large amounts of pleural fluid (>1.5 L). This client's blood pressure is adequate (mean arterial pressure 77 mm Hg), and the nurse should continue to monitor. However, this blood pressure does not need to be reported immediately. (Option 3) Mild to moderate pain is common after the procedure. It does not need to be reported immediately. (Option 4) Difficulty breathing, tachypnea, and hypoxemia are pulmonary complications that can occur after thoracentesis. Saturation (94%) and respiratory rate (24/min) are adequate and do not need to be reported immediately.

A client with a tracheostomy is alert and oriented and able to tolerate oral intake. Which action would be appropriate to reduce the client's risk of aspiration pneumonia? 1. Fully inflate the cuff before feeding [29%] 2. Have the client sit in an upright position with the neck hyperextended [24%] 3. Partially or fully deflate the cuff [21%] 4. Provide a modified diet of pureed foods [24%]

A tracheostomy tube with inflated cuff is used in clients who are at risk for aspiration (eg, who are unconscious or on mechanical ventilation). However, an inflated cuff is uncomfortable for clients who are awake because it is difficult to swallow or talk. The cuff is deflated when the client is improving, is determined not to be at risk of aspiration, and is awake. Before the cuff is deflated, the client is asked to cough (if possible) to expectorate the oropharyngeal secretions that have built up above the inflated cuff. In addition, suction is applied through the tracheostomy tube and then the mouth; the cuff is then deflated. Additional interventions to decrease the risk of aspiration include the following: Having the client sit upright with the chin flexed slightly toward the chest Monitoring for a wet or garbled-sounding voice Monitoring for signs of fever (Option 1) Inflating the cuff makes it difficult for a client who is awake to swallow and talk. In addition, more secretions can accumulate above the inflated cuff due to difficulty swallowing. The inflated cuff may not provide a 100% seal and the accumulated secretions can slide through it, causing aspiration. For these reasons, the deflated cuff is beneficial in awake clients with no risk of aspiration. (Option 2) Having the client sit upright will help reduce the risk of aspiration. However, the chin should be flexed toward the chest; hyperextension of the neck increases the risk of aspiration. (Option 4) There is no reason to give pureed foods just because the client has a tracheostomy. The client's diet should be determined by a swallowing evaluation.

The nurse is caring for a client receiving mechanical ventilation via tracheostomy 2 weeks following a tracheotomy. The nurse enters the client's room to address a ventilator alarm and notes the tracheostomy tube dislodged and lying on the client's chest. Which action by the nurse is appropriate? Click on the exhibit button for additional information. 1. Apply a nonrebreather face mask with 100% oxygen [35%] 2. Apply dry, sterile gauze over the stoma and secure with tape [8%] 3. Insert a new tracheostomy tube using the bedside obturator [46%] 4. Insert a sterile catheter into the stoma and suction the airway [9%]

A tracheostomy tube, an artificial airway inserted into the trachea through the neck, may be secured with sutures or tracheostomy ties. Accidental dislodgment of a tracheostomy tube is a medical emergency often resulting in respiratory distress from closure of the stoma and airway loss. If accidental dislodgment of mature tracheostomies (ie, >7 days after insertion) occurs where the tract is well formed, the nurse should attempt to open the airway by inserting a curved hemostat to maintain stoma patency and insert a new tracheostomy tube with an obturator (Option 3). (Option 1) Application of supplemental oxygen via nonrebreather face mask may not resolve respiratory distress because air can escape from the stoma. (Option 2) Covering the stoma with a sterile, occlusive dressing (eg, petroleum gauze, foam tape) and ventilating the lungs with a bag-valve mask over the nose/mouth may be necessary if the tube cannot be reinserted or the stoma is immature. Dry gauze is porous and does not adequately seal the stoma for ventilation. (Option 4) Tracheal suctioning may be necessary once the airway is resecured. However, suctioning prior to establishing an airway does not improve ventilation and may further reduce the oxygen supply.

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? 1. "Discontinue alternative birth control after at least 5 ejaculations." [14%] 2. "There is no need to use alternative birth control following today's procedure." [15%] 3. "Use alternative birth control for 6 months following today's procedure." [19%] 4. "Use alternative birth control until cleared by the health care provider." [50%]

A vasectomy is a surgical procedure performed for permanent male sterilization. During the procedure, the vasa deferentia (ie, ducts that carry sperm from the testicles to the urethra) 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 (eg, hormone production, erection, orgasm). Following a vasectomy, sperm continue to be produced but are absorbed by the body. Following the procedure, it can take several months for the remaining sperm to be ejaculated or absorbed. Alternative birth control should be used until the health care provider confirms that semen samples taken at a follow-up appointment are free of sperm; otherwise, pregnancy can occur (Option 4). (Options 1, 2, and 3) The length of time and number of ejaculations necessary to evacuate remaining sperm will vary. The only way to ascertain that the ejaculate no longer contains sperm is to test a client's semen samples. Educational objective:To prevent an unwanted pregnancy following a vasectomy, alternative methods of birth control should be used until semen samples are found to be free of sperm.

Diabetes insipidus (DI) is a condition that occurs due to insufficient production/suppression of antidiuretic hormone (ADH). Neurogenic DI is a type of DI that results from impaired ADH secretion, transport, or synthesis. It sometimes occurs after manipulation of the pituitary or other parts of the brain during surgery, brain tumors, head injury, or central nervous system infections. DI is characterized by polydipsia (increased thirst) and polyuria (increased urine output) with low urine specific gravity (dilute urine). As a result, fluids should be replaced orally/intravenously to prevent dehydration

ADH release is impaired in neurogenic DI. As a result, ADH replacement with vasopressin (Pitressin) can be used to treat DI. However, it also has vasoconstrictive properties. Therefore, desmopressin (DDAVP), an analog without vasopressor activity, is the preferred therapy. Clients on this treatment should be monitored for urine output, urine specific gravity, and serum sodium (to avoid hyponatremia due to excess DDAVP). (Option 2) DI is not associated with low/high blood glucose and should not be confused with diabetes mellitus (DM) as both DI and DM involve symptoms of excessive urination (polyuria). (Option 4) The Trendelenburg position (body laid flat and supine with feet higher than the head by at least 15-30 degrees) is contraindicated in most neurological conditions. Educational objective:DI occurs when there is insufficient production/suppression of ADH. It is characterized by polydipsia and polyuria with diluted urine. Oral and/or intravenous fluid replacement is imperative to prevent dehydration. DI is treated with ADH replacement drugs (eg, desmopressin acetate [DDAVP]). Clients should be monitored for urine output, urine specific gravity, and serum sodium. Additional Information Physiological Adaptation NCSBN Client Need

The nurse is caring for a client with right upper quadrant pain and jaundice. The client's alanine aminotransferase /aspartate aminotransferase (ALT/AST) levels are 7 times the normal values. What questions would be most helpful regarding the etiology for these findings? Select all that apply. 1. Do you have black tarry stool? 2. Do you use intravenous (IV) illicit drugs? 3. How much alcohol do you typically drink? 4. Were you recently immunized for pneumonia? 5. What over-the-counter 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 (Option 3), some over-the-counter medications (eg, acetaminophen), and certain herbal and dietary supplements (Option 5). IV illicit drug use increases the risk for hepatitis B and C infection (Option 2). (Option 1) Black tarry stool (melena) is an expected finding from a gastrointestinal bleed (from the digested blood). Melena can be seen in clients with gastric or esophageal varices, which are often complications of hepatic disease (eg, cirrhosis). However, melena is not an etiology of liver injury. (Option 4) Immunizations do not cause liver damage. It is possible to get a small elevation with an intramuscular injection, but not values this high.

ARF

ARF is defined as inadequate gas exchange that is intrapulmonary (pneumonia, pulmonary embolism) or extrapulmonary (head injury, opioid overdose) in origin. Respiratory failure associated with an alteration in O2 transfer or absorption is type I hypoxemic failure (eg, acute respiratory distress syndrome, pulmonary edema, shock). Respiratory failure associated with carbon dioxide (CO2) retention is type II hypercapnic, or ventilatory failure (eg, chronic obstructive pulmonary disease, myasthenia gravis, flail chest). ARF is a potential complication of major surgical procedures, especially those involving the thorax and abdomen, as in this client. ABG values that indicate the presence of ARF are PaO2 ≤60 mm Hg (8.0 kPa) or PaCO2 ≥50 mm Hg (6.67 kPa). ARF occurs quickly over time (minutes to hours), and so there is no physiologic compensation and pH is ≤7.30. Immediate intervention with high O2 concentrations is indicated, and noninvasive or invasive, positive-pressure mechanical ventilation may be necessary. (Option 2) PaO2 64 mm Hg (8.5 kPa) indicates hypoxemia, and PaCO2 45 mm Hg (6.0 kPa) is within the normal range, but results do not meet the criteria for ARF. (Option 3) PaO2 70 mm Hg (9.3 kPa) indicates hypoxemia, and PaCO2 30 mm Hg (4.0 kPa) indicates increased ventilation and an alkalotic state, but results do not meet the criteria for ARF. (Option 4) PaO2 86 mm Hg (11.5 kPa) is within normal range, and PaCO2 25 mm Hg (3.33 kPa) indicates increased ventilation and an alkalotic state, but results do not meet the criteria for ARF. Educational objective:Type I hypoxemic failure is associated with an alteration in O2 transfer (eg, acute respiratory distress syndrome, pulmonary edema, shock). Type II hypercapnic, or ventilatory, failure is associated with CO2 retention (eg, chronic obstructive pulmonary disease, myasthenia gravis, flail chest). ABG values that indicate the presence of ARF are PaO2 ≤60 mm Hg (8.0 kPa), PaCO2 ≥50 mm Hg (6.67 kPa), and pH ≤7.30. Additional Information Reduction of Risk Potential NCSBN Client Need

After receiving the hand-off nurse-to-nurse evening shift report, which client should the nurse assess first? 1. Client who is 3-days postoperative bowel resection, now reports shortness of breath and chest pain 2. Client who is 3-days postoperative right knee surgery, now reports fever, cough, and shortness of breath 3. Client who was transferred from the post-anesthesia care unit (PACU) 15 minutes ago 4. Client with a kidney stone who is requesting pain medication for severe flank pain

Abdominal surgery can cause engorgement of the large vessels in the pelvis leading to venous stasis and increased risk for a pulmonary embolism (PE). Therefore, this client's problem poses the greatest threat to survival and requires immediate attention. (Option 2) This client likely developed postoperative pneumonia. Though pneumonia needs to be assessed and treated as soon possible, it is not as life-threatening as acute PE. Pneumonia is fatal to clients within a period of days (rarely hours), but PE can lead to death in minutes to hours, depending on its severity. (Option 3) This client requires a thorough respiratory assessment. However, this client arrived 15 minutes ago, vital signs, including pulse oximetry, were already measured; and the day shift nurse who received the report from the PACU nurse assessed the client. (Option 4) Flank pain is expected in a client who is hospitalized for a kidney stone. Providing pain relief and comfort are priorities, but this client does not have the most urgent problem.

The nurse assesses a 40-year-old client with acromegaly in an outpatient health clinic. Which new finding is most important to report to the health care provider? 1. Complaints of knee pain when walking 2. Dark leathery skin 3. Fasting blood glucose 126 mg/dL (7.0 mmol/L) 4. Presence of S3 and S4 heart sound

Acromegaly is an uncommon condition caused by an overproduction of growth hormone(GH). It is usually due to pituitary adenoma, and onset in adult clients generally occurs at age 40-45. In an adult, increased GH results in overgrowth of soft tissues of the face, hands, feet, and organs. Additional heart sounds (S3, S4) require further assessment for cardiac conditions (eg, heart failure). (Options 1, 2, and 3) Although joint pain, skin changes, and hyperglycemia (normal fasting glucose 70-99 mg/dL [3.9-5.5 mmol/L]) are associated with acromegaly, these are not as life-threatening as acute heart failure (must be reported immediately to the health care provider).

The nurse develops a teaching plan for a client prescribed isoniazid, rifampin, ethambutol, and pyrazinamide to treat active tuberculosis (TB). Which of the following instructions associated with the adverse effects of rifampin is most important for the nurse to include? 1. Notify the health care provider if your urine is red 2. Take acetaminophen every 6 hours for drug-associated joint pain while taking this medication 3. Wear eyeglasses instead of soft contact lenses while taking this medication 4. You can stop taking the medications as soon as one sputum culture comes back normal

Active TB is treated with combination drug therapy. Isoniazid causes hepatotoxicity and peripheral neuropathy. Rifampin (Rifadin) also causes hepatotoxicity. Therefore, baseline liver function tests should be obtained. Clients should be advised to watch for signs and symptoms of hepatotoxicity (eg, jaundice, anorexia). Ethambutol causes ocular toxicity, and clients will need frequent eye examinations. A teaching plan for a client prescribed rifampin includes these additional instructions: Rifampin changes the color of body fluids (eg, urine, sweat) due to its body-wide distribution. Tears can turn red, making contact lenses appear discolored. Client should wear eyeglasses instead of soft contact lenses while taking this medication. Women should use nonhormonal birth control methods while taking this drug as it can decrease the effectiveness of oral contraceptives. (Option 1) Red urine is an expected finding with rifampin use; clients should not be concerned. (Option 2) Clients should be advised to not consume alcohol and drugs that can increase the risk for hepatotoxicity (eg, acetaminophen) during long-term use of this drug. (Option 4) The effectiveness of treatment for active TB is determined by 3 negative sputum cultures and chest x-ray. If the entire course of therapy (6-9 months) is not completed, reinfection, spread to others, and development of resistant strains of TB bacteria can result.

The nurse receives the handoff of care report on four clients. Which client should the nurse see first? 1. Client reporting incisional pain of 8 on a scale of 0-10 with a respiratory rate of 25/min who had a right pneumonectomy 12 hours ago [14%] 2. Client with a left pleural effusion who has crackles, absent breath sounds in the left base, and an SpO2 of 94% on room air [9%] 3. Client with a temperature of 100.4 F (38 C) and a respiratory rate of 12/min who had a small bowel resection 1 day ago [13%] 4. Client with pneumonia who has a temperature of 97.6 F (36.4 C), has an SpO2 of 93% on 4 L/min supplemental oxygen, and is becoming restless [62%]

Acute respiratory failure (ARF) is a life-threatening impairment of the lungs' ability to oxygenate blood and excrete carbon dioxide (CO2). ARF may occur from exacerbation of chronic (eg, chronic obstructive pulmonary disease, asthma) or acute (eg, pneumonia, pulmonary edema) illnesses. Nurses assessing for signs of ARF should consider both respiratory and neurological manifestations. Altered mental status (eg, confusion, agitation, somnolence) is a common and often overlooked symptom that may occur because of the brain's sensitivity to inadequate oxygenation and alterations in acid-base balance from retained CO2(Option 4). Additional signs and symptoms may include paresthesias, dyspnea, tachypnea, and hypoxemia. (Option 1) Clients recovering from recent pneumonectomy (ie, surgical removal of part or all of the lung) often experience considerable pain, which may cause respiratory distress if not adequately controlled. A client with tachypnea and severe pain should be seen promptly but only after addressing potential ARF. (Option 2) Crackles, absent or diminished breath sounds over the affected lobe, and slightly decreased oxygen saturation are expected findings in pleural effusion, in which fluid collects in the space surrounding the lung. (Option 3) Low-grade fever may occur following surgery (due to the release of inflammatory cytokines) or from postoperative atelectasis. The client should be encouraged to ambulate and deep-breathe.

When a client diagnosed with acute urinary retention is emergently catheterized, the nurse should initially assess for which priority manifestation that may occur as a result of the catheterization? 1. Dysuria 2. Hypotension 3. Infection 4. Tachycardia

Acute urinary retention is best treated with rapid, complete bladder decompression rather than the intermittent urine drainage that is limited to 500 to 1000 mL at a time. Rapid decompression can be associated with hematuria, hypotension, and postobstructive diuresis (Option 2). However, these are rarely clinically significant if appropriate supportive care is administered, whereas inability to relieve the obstruction can be associated with infection and kidney injury (Option 3). (Option 1) Dysuria from catheterization can be treated with analgesics or antispasmodic medications. Maintaining perfusion and adequate blood pressure is the priority concern. (Option 4) With sudden release of bladder obstruction, cardiovascular autonomic activity occurs and the blood pressure and heart rate are reduced due to the excitation of the parasympathetic system.

The nurse plans discharge teaching for a client with active herpes lesions who has a new prescription for oral acyclovir and topical lidocaine. What information will the nurse include in the teaching plan? 1. Adhesive bandaging should remain on the lesions to prevent virus shedding 2. Blood tests will be drawn to ensure the virus is eradicated 3. Condoms should be used during intercourse until the lesions are healed 4. Gloves should be used to apply the medication to the lesions

Acyclovir (Zovirax), famciclovir, and valacyclovir are commonly used to treat herpes infection as they shorten the duration and severity of active lesions. Genital herpes is a sexually transmitted infection caused by a herpes simplex virus and is highly contagious, especially when lesions are active. It remains dormant in the body even when active lesions are healed. There is no cure for genital herpes; treatment is aimed at relieving symptoms and preventing the spread of infection. Touching the lesions and then rubbing or scratching another part of the body can spread the infection. Therefore, gloves should be used when applying topical antiviral or analgesic (eg, lidocaine) medications. (Option 1) Herpetic lesions should be kept clean and dry. They can be cleansed with warm water and soap or other solutions. Bandages are not applied to the lesions. (Option 2) There is no cure for herpes infection. Genital herpes often leads to local recurrence. Some clients may need long-term suppressive therapy. (Option 3) During periods of active lesions, abstinence from sexual intercourse is indicated. Condoms should be used during periods of dormancy due to viral shedding.

The home health nurse reviews the laboratory results for 4 clients. Which laboratory value is most important for the nurse to report to the health care provider? 1. Client with Clostridium difficile infection receiving metronidazole has a white blood cell count of 15,000/mm3 (15.0 x 109/L) [7%] 2. Client with liver cirrhosis has an International Normalized Ratio of 1.5 [19%] 3. Client with mild asthma exacerbation receiving prednisone has a blood glucose of 250 mg/dL (13.9 mmol/L) [39%] 4. Client with rheumatoid arthritis taking adalimumab has a white blood cell count of 14,000/mm3 (14.0 x 109/L) [33%]

Adalimumab (Humira) is a tumor necrosis factor (TNF) inhibitor, a biologic disease-modifying antirheumatic drug (DMARD) classified as a monoclonal antibody. Its major adverse effects are similar to those of other TNF inhibitor drugs (eg, etanercept [Enbrel], infliximab [Remicade]) and include immunosuppression and infection (eg, current, reactivated). An elevated white blood cell count in this client can indicate underlying infection and should be reported immediately. (Option 1) This client with Clostridium difficile infection will have an elevated white blood cell count. The client is receiving appropriate therapy (eg, metronidazole, oral vancomycin). The nurse will need to monitor the white cell count and, if it keeps increasing, report it. (Option 2) The liver produces most blood clotting factors. Clients with liver cirrhosis will lose this ability and are at risk for bleeding. This client's International Normalized Ratio is mildly elevated (normal 0.75-1.25), which is expected with cirrhosis. (Option 3) Corticosteroids increase blood glucose. This is expected, and the client may need treatment if the glucose levels are markedly increased for a prolonged period. Most clients with asthma exacerbation are expected to take a 5- to 7-day course of steroids.

The nurse in the intensive care unit cares for a client with primary adrenocortical insufficiency (Addison's disease). The client reports nausea and abdominal pain. The blood pressure suddenly drops from 120/74 mm Hg to 88/48 mm Hg, heart rate increases from 80 to 100/min, and the client appears confused. Which action should the nurse take first? 1. Administer as-needed dose of hydrocortisone intravenous (IV) push 2. Complete a head-to-toe assessment to identify any sources of infection 3. Document the findings in the client's electronic medical record 4. Take blood pressure sitting and standing to assess for orthostatic hypotension

Addison's disease is adrenocortical insufficiency or hypofunction of the adrenal cortex. Addisonian crisis or acute adrenocortical insufficiency is a potentially life-threatening complication. Clients report nausea, vomiting, and abdominal pain. Signs of addisonian crisis include hypotension, tachycardia, dehydration, hyperkalemia, hyponatremia, hypoglycemia, fever, weakness, and confusion. Priority emergency management of addisonian crisis includes shock management, with fluid resuscitation using 0.9% normal saline and 5% dextrose; and administration of high-dose hydrocortisone replacement IV push. (Options 2, 3, and 4) Assessment and documentation are important components of the nursing process, but emergency treatment of an addisonian crisis is the priority action. Educational objective: Addisonian crisis is a potentially life-threatening complication of Addison's disease and commonly presents with abdominal pain, hypotension, and hypoglycemia. Emergency management includes shock management with fluid resuscitation using 0.9% normal saline and 5% dextrose, and administration of high-dose hydrocortisone replacement IV push.

The nurse is performing an initial assessment on a client diagnosed with Addison's disease. Which assessment findings should the nurse anticipate? Select all that apply. 1. Acanthosis nigricans 2. Hirsutism 3. Hyperpigmented skin 4. Truncal obesity 5. Weight loss

Addison's disease, or chronic adrenal insufficiency, occurs when the adrenal glands do not produce adequate amounts of steroid hormones (mineralocorticoids, glucocorticoids, androgens). Symptoms include weight loss, muscle weakness, low blood pressure, hypoglycemia, and hyperpigmented skin (skin folds, buccal area, palmar crease). Hyperpigmented skin is a characteristic universal finding; this results from increased adrenocorticotropic hormone which is due to a decrease in cortisol negative feedback. Treatment consists of replacement therapy with oral mineralocorticoids and corticosteroids (Options 3 and 5). (Option 1) Acanthosis nigricans is a skin condition that occurs with obesity and diabetes and appears as velvet-like patches of darkened, thick skin. These areas typically occur around the back of the neck and in the groin and armpits. (Option 2) Hirsutism is a condition in women that consists of male-pattern hair growth on the face, lower abdomen, chest, and back. Common causes are polycystic ovary syndrome and Cushing's syndrome. Loss of libido and decreased axillary and pubic hair are common in Addison's disease due to lower levels of androgens. (Option 4) Clients with Cushing's syndrome, an overproduction of steroid hormones, have truncal obesity or large deposits of abdominal fat.

Addisonian crisis

Addisonian crisis or acute adrenocortical insufficiency is a potentially life-threatening complication. Clients report nausea, vomiting, and abdominal pain. Signs of addisonian crisis include hypotension, tachycardia, dehydration, hyperkalemia, hyponatremia, hypoglycemia, fever, weakness, and confusion. Priority emergency management of addisonian crisis includes shock management, with fluid resuscitation using 0.9% normal saline and 5% dextrose; and administration of high-dose hydrocortisone replacement IV push.

Which situations would prompt the health care team to use the client's advance directive to make a decision regarding care? Select all that apply. 1. Client diagnosed with lumbar spinal cord compression has paraplegia 2. Client's Glasgow Coma Scale (GCS) score is 3 3. Client is refusing a life-saving treatment due to religious beliefs 4. Client with intracerebral hemorrhage has aphasia 5. Oriented client has cancer and is on a ventilator

Advance directives give people the chance to make decisions about their medical treatment ahead of time in case they are unable to personally make their wishes known. The 2 most common forms are living wills and durable power of attorney for health care (health care surrogate/proxy). A client who is alert and oriented can directly address a health care decision. Clients in a coma (GCS score ≤7) or with expressive aphasia would need an advance directive to make treatment decisions because they cannot directly express their wishes. Aphasia involves the inability to express thoughts and comprehend language due to brain dysfunction and includes both verbalizing and writing (Options 2 and 4). (Option 1) Mental capacity is not affected in spinal cord compression. The client is able to speak. (Option 3) An adult who is mentally capable of making decisions has the right to refuse treatment for any reason at any time whether the health care provider believes it is in the client's best interest or not. (Option 5) A client who is oriented can make and communicate decisions for him/herself although unable to verbalize. The client could nod or write out wishes.

Which client event would be considered an adverse event and would require completion of an incident/event/irregular occurrence/variance report? Select all that apply. 1. Administered 9:00 AM medication at 9:30 AM 2. Developed worsening cellulitis after missing antibiotics for 1 day 3. Has a seizure and a history of epilepsy 4. Slides off the edge of the bed and ends up sitting on the floor 5. Waits 4 hours to be transported for STAT diagnostic CT scan

Adverse event is an injury to a client caused by medical management rather than a client's underlying condition. It may or may not be preventable. The Institute of Medicine (2000) recognizes 4 types of errors. They are: Diagnostic (delay in diagnosis, failure to employ indicated tests, failure to act on results of monitoring) Treatment (error in performance of procedure, treatment, dose; avoidable delay) Preventive (failure to provide prophylactic treatment, inadequate follow-up/monitoring of treatment) Other (failure of communication, equipment failure, system failure) Option 4 is a fall, although the mechanism probably results in a lesser chance of serious injury. The risk fall assessment should be adjusted. Option 5 is an avoidable delay in application of a test, which will affect timely diagnosis. The nurse should advocate for a more timely completion of the test. Option 2 is a failure to provide appropriate treatment and has a direct correlation for worsening cellulitis. (Option 1) Failure to complete an ideal nursing care plan is not an adverse event. Hospitals have policies that allow medications to be given within a range (usually 30-60 minutes) of the due time. It could be an issue if the treatment was significantly out of the time range or omitted completely. (Option 3) The client's seizure is most likely related to an underlying condition rather than a medical management error.

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? 1. Heart rate 89/min, blood pressure 99/52 mm Hg 2. Potassium decrease from 5.7 mEq/L to 5.0 mEq/L (5.7 mmol/L to 5.0 mmol/L) 3. Urine output 31 mL/hr, respirations 20/min 4. Weight gain of 2.2 lbs (1 kg) in last 8 hours and palpable pulses

After a burn injury, increased capillary permeability leads to third spacing (fluid shifts to areas where normally minimal or absent), 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 (at least 30 mL/hr, or 0.5 mL/kg/hr) depends on adequate renal perfusion and is the greatest indicator that fluid resuscitation therapy has effectively restored tissue perfusion. (Option 1) Although stable vital signs (eg, systolic blood pressure ≥90 mm Hg, mean arterial pressure ≥65 mm Hg, heart rate <120/min) indicate client improvement, urine output is the greatest indicator of adequate fluid resuscitation. (Option 2) A decrease in serum potassium from 5.7 mEq/L to 5.0 mEq/L (5.7 mmol/L to 5.0 mmol/L) indicates that hyperkalemia is resolving but is not an indicator of tissue perfusion. (Option 4) Rapid increase in weight indicates that fluid shifts continue to occur and the kidneys are not eliminating properly. This could be a sign of fluid overload. Educational objective:Aggressive fluid resuscitation is essential to correct hypovolemia in a client with severe burns. Urine output ≥30 mL/hr or 0.5 mL/kg/hr, systolic blood pressure ≥90 mm Hg, and heart rate <120/min indicate adequate perfusion to vital organs. Additional Information Physiological Adaptation NCSBN Client Need

The nurse is caring for a client receiving IVPB azithromycin. Which client data obtained by the nurse should be reported to the health care provider (HCP) prior to administering any additional doses? 1. Currently nauseated and vomited once 2. Decreased white blood cell (WBC) count 3. Prolonged QT interval 4. Temperature of 101.4 F (38.6 C)

All macrolide antibiotics (eg, azithromycin, erythromycin, clarithromycin) can cause a prolonged QT interval, which may lead to sudden cardiac death due to torsades de pointes. Therefore, an electrocardiogram (ECG) should be monitored. Concurrent use of macrolide antibiotics with other drugs that prolong QT interval (eg, amiodarone, sotalol, haloperidol, ziprasidone, azole antifungals) will further increase this risk. Macrolides can also cause hepatotoxicity when taken in high doses or in combination with other hepatotoxic medications such as acetaminophen, phenothiazines, and sulfonamides. Elevation of aspartate transaminase and alanine transaminase levels (liver enzymes) may indicate that hepatotoxicity is occurring, and the nurse should report these results to the HCP. (Option 1) Nausea and vomiting can be side effects of azithromycin. They are not as concerning as the adverse reaction of prolonged QT interval. (Option 2) A decrease in the WBC count would be expected as infection is resolving. (Option 4) Fever may be present in a client with an infection. The nurse should use as-needed acetaminophen cautiously in a client also receiving azithromycin due to the risk of hepatotoxicity.

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? Select all that apply. 1. Chest compressions are performed at a rate of 70-80/min 2. Chest compressions are stopped for a 10-second pulse check every 2 minutes 3. Defibrillator pads are applied at the left and right sternal borders 4. Manual breaths are delivered at a rate of 2 breaths per 30 chest compressions 5. Resuscitation team is alerted to remain clear of client before defibrillation

All members of the health care team must follow basic life support guidelines to perform cardiopulmonary resuscitation (CPR) for clients experiencing cardiac arrest. Essential components of adult CPR include: Chest compressions are performed at a rate of 100-120/min and a depth of 2.0-2.4 inches (5-6 cm), allowing complete chest recoil between compressions (Option 1). Defibrillator 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 (Option 3). (Option 2) During CPR, compressions are paused every 2 minutes to assess the client's pulse. This pause should be no longer than 10 seconds to minimize delays between compression cycles. (Option 4) Manual breaths are administered at a rate of 2 breaths per 30 chest compressions in clients without advanced airways or once every 6 seconds without chest compression interruption with advanced airway placement. (Option 5) The team member managing the defibrillator should use firm verbal cues (eg, "stand clear!") to clear all team members from contact with the client, followed by visual confirmation before defibrillation. Educational objective:During cardiopulmonary resuscitation, chest compressions are performed at a rate of 100-120/min. Defibrillator pads are placed on the right upper chest and on the left lateral chest.

A client is scheduled for allergy skin testing to identify asthmatic triggers. Which medications should the nurse instruct the client to withhold before the test to ensure accurate results? Select all that apply. 1. Acetaminophen 2. Albuterol 3. Diphenhydramine 4. Enalapril 5. Loratadine

Allergy skin testing involves introducing common environmental and food allergens (ie, antigens) into the skin surface and then observing the site for an allergic reaction (eg, formation of a wheal, erythema). Several different antigens, as well as positive and negative controls, are usually tested at the same time for accuracy. To ensure an accurate result, the client should avoid antihistamines (eg, diphenhydramine [Benadryl], loratadine [Claritin], promethazine [Phenergan]) for up to 2 weeks prior to the test (Options 3 and 5). Antihistamines block mast cell release of histamines that are responsible for allergic symptoms. Systemic corticosteroids, used to treat the inflammatory component of asthma, may also affect the accuracy of allergy skin testing; therefore, the use of these medications is assessed by the health care provider. (Option 1) Acetaminophen does not have antihistamine properties and will not interfere with allergy skin testing. (Option 2) Albuterol, an inhaled short-acting beta adrenergic agonist, will not interfere with allergy skin testing results and should not be discontinued, as it is necessary to ensure client safety during acute asthma exacerbations. (Option 4) Enalapril, an ACE inhibitor, is used to treat high blood pressure and heart failure and will not impact the results of allergy skin testing. Educational objective:Allergy skin testing involves introducing common allergens (ie, antigens) into the skin surface and then observing the site for an allergic reaction (eg, formation of a wheal, erythema). Clients should avoid antihistamines as these drugs can prevent accurate results.

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? Select all that apply. 1. Human immunodeficiency virus (HIV) 2. Human papillomavirus (HPV) 3. Multiple sexual partners 4. Nulliparity 5. Sexual activity before age 18

Almost all cases of cervical cancer result from persistent infection due to human papillomavirus (HPV), a primary risk factor (Option 2). HPV is the most common sexually transmitted infection but is usually transient and resolves spontaneously. However, persistent HPV infection can cause abnormal changes in cervical epithelial tissue that slowly progress to invasive cancer if not treated. Most other risk factors for cervical cancer are related to behaviors that increase the client's risk of contracting HPV or an inability to clear the infection. Clients who have multiple sexual partners or initiate sexual activity at an early age (<18) increase their risk for exposure to HPV (Options 3 and 5). Clients with weakened immunity (eg, HIV, immunosuppressive therapy) may have an impaired ability to clear HPV, which increases the risk for cervical cancer due to persistent infection (Option 1). (Option 4) Nulliparity (ie, no previous pregnancies) is not a risk factor for cervical cancer; however, it is a risk factor for breast cancer.

Alpha-1-adrenergic antagonists (eg, terazosin, doxazosin, tamsulosin, alfuzosin) should be taken at ____

Alpha-1-adrenergic antagonists (eg, terazosin, doxazosin, tamsulosin, alfuzosin) should be taken at bedtime, not in the morning, to avoid orthostatic hypotension.

A housekeeping employee tells the staff nurse of having a headache and asks for acetaminophen. How should the nurse respond? 1. Ask about liver disease and give acetaminophen from the nurse's personal supply 2. Assess the employee's blood pressure 3. Check for allergies to drugs before giving acetaminophen from hospital stock 4. 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 (eg, allergies, liver disease), and a legal caregiving relationship will be established by administering the medication. If the employee does not want to go to the employee health provider, the nurse can suggest that the employee purchase acetaminophen in the gift shop. (Option 1) It is advisable for the nurse to ask about liver issues prior to administering acetaminophen, but this nurse has no prescription to administer it. Taking the medication from a personal supply, rather than hospital stock, does not change the fact that the nurse is functioning outside the job description while on duty. (Option 2) The nurse could technically perform the assessment, but it is not within the nurse's current role and job description. The employee health provider (or the emergency department) should be used for this assessment. (Option 3) The nurse should check for allergies before administering a drug, but this nurse has no prescription to administer acetaminophen. Acetaminophen being an over-the-counter medication does not change this fact. Educational objective:The nurse should not give medication to an employee without a prescription even if it is an over-the-counter drug. Additional Information Management of Care NCSBN Client Need

The nurse receives report on 4 clients. Which client should the nurse see first? 1. Client admitted 12 hours ago with acute asthma exacerbation who needs a dose of IV methylprednisolone 2. Client admitted 2 days ago with congestive heart failure who is reporting shortness of breath and had an extra dose of furosemide prescribed recently 3. Client admitted with intestinal obstruction who is reporting abdominal pain and distention and needs nasogastric tube placement 4. Client who had cardiac valve surgery 8 days ago but was readmitted with a sternal wound infection and needs antibiotics and a dressing change

Although it is not a STAT order, an extra dose of furosemide was prescribed for the client with congestive heart failure. The shortness of breath is most likely due to a change in fluid status, and this client is the priority. Furosemide works immediately and should be given urgently. (Option 1) Even though this client has asthma exacerbation, steroids (methylprednisolone [Solu-Medrol]) do not show their effect immediately. These drugs control underlying inflammation but take several hours/days to take effect. Bronchodilators such as albuterol or ipratropium work immediately. (Option 3) This client has intestinal obstruction and needs nasogastric tube placement. However, this is not a priority over a client with heart failure. (Option 4) This client with a sternal wound infection needs a dressing change and an antibiotic. Although this localized infection is important, it is not the priority.

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? Select all that apply. 1. "Grab bars should be installed in the shower and beside the toilet." 2. "I will place a safe return bracelet on the client's wrist." 3. "Keyed deadbolts should be placed on all exterior doors." 4. "Medications will be placed in a weekly pill dispenser." 5. "Throw rugs and clutter will be removed from the floors."

Alzheimer disease (AD) is a form of dementia that causes progressive decline of cognitive and physical abilities. The nurse should educate the client/caregiver to prepare for current and future safety needs. Interventions evolve to meet client needs at each stage of disease progression. Safety promotion for the client with moderate AD includes: Keyed deadbolts (with keys removed) and close supervision to provide a controlled environment for wandering (Option 3) Medical identification/location devices (eg, bracelets, shoe inserts) in case the client wanders outside the designated area (Option 2) Decreased water heater temperature and "hot" and "cold" labels on faucets to prevent burns Household hazards (eg, gas appliances, rugs, toxic chemicals) removed to prevent injury (Option 5) Grab bars installed in showers and tubs (Option 1) (Option 4) 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 health care provider prescribes amoxicillin/clavulanate (liquid) twice a day for a child with acute sinusitis. What instructions are most important for the parents? Select all that apply. 1. Administer it with food if nausea or diarrhea develops 2. Complete the medication course even if the child is better 3. Expect a rash, which is normal, as a side effect 4.Shake the medicine well before use 5. Use a household spoon to measure the dose

Amoxicillin/clavulanate belongs to aminopenicillin group and is often used to treat respiratory infections. Instructions for parents about amoxicillin include: The medication may be taken with or without food as food does not affect absorption The most common side effects of this medication are nausea, vomiting, and diarrhea. If nausea or diarrhea develops, the medicine may be administered with food to decrease the gastrointestinal side effects (Option 1). Shake the liquid well prior to administration. Administer at evenly spaced intervalsthroughout the day to maintain therapeutic blood levels (Option 4). Ensure that the child receives the full course of therapy; do not discontinue the medication if the child is feeling better or symptoms have resolved (Option 2). (Option 3) Rash, itching, dyspnea, or facial/laryngeal edema may indicate an allergic reaction, and the medication should be discontinued. (Option 5) Pediatric liquid medications are often dispensed with a measuring device designed to administer the exact dose prescribed. The following calibrated devices may be included: dropper, oral syringe, plastic measuring cup, or measuring spoon.

The charge registered nurse (RN) on a medical-surgical unit is responsible for making assignments. Which assignment made by the RN is most appropriate? 1. A licensed practical nurse (LPN) assigned to a client receiving blood transfusions [2%] 2. A student nurse assigned to a client who requires frequent intravenous pain medication [4%] 3. An LPN assigned to a client 2 days postoperative appendectomy scheduled to be discharged today [12%] 4. An RN assigned to a client 1 day postoperative repair of a compound fracture[79%]

An RN is appropriately assigned to the client who is most unstable. Following this client's orthopedic surgery, the nurse must perform frequent neurovascular, pain, drain, wound, and respiratory assessments; assess for potential risk factors (eg, pulmonary embolus); and provide emotional support as well. Good critical thinking skills are needed to develop, implement, and evaluate an appropriate plan of care for this client. (Option 1) Administration of blood is not within the scope of the LPN's practice. (Option 2) A student nurse may not be able to administer medications independently and/or would require close supervision by either nursing faculty or an RN preceptor. The student nurse may not be able to provide adequate pain relief in a timely manner. The nurse who assesses the pain should administer the medication and evaluate the response. (Option 3) A postoperative client requires thorough education and evaluation prior to discharge. This level of client education should be performed by an RN; an LPN may reinforce prior teaching completed by an RN but is not able to provide initial teaching or evaluate learning outcomes. Educational objective:An RN is appropriately assigned to the client who is most unstable. The LPN's scope of practice does not include new discharge teaching or the administration of blood.

The nurse is preparing a client who had a Roux-en-Y gastric bypass (RYGB) for discharge from the hospital. What information should the nurse plan to include related to the prevention of dumping syndrome? 1. Meals should be small and low in carbohydrate content 2. Fluids should be encouraged with each meal 3. Take a multivitamin with iron and calcium supplements daily 4. You will need to take your cobalamin injection monthly

An 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 nausea, vomiting, 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 (Option 1). (Option 2) Clients should be taught to consume food and fluids at least 30 minutes apart, and the health care provider may limit total daily fluid consumption. Limiting fluids decreases distension and feelings of fullness. (Option 3) Iron-deficiency anemia is a common side effect after an RYGB as iron is absorbed in the duodenum and proximal jejunum. Taking supplements of iron and calcium can help with this problem but does not prevent dumping syndrome. (Option 4) The smaller gastric pouch decreases the amount of intrinsic factor made by the parietal cells in the stomach, which may cause cobalamin deficiency. The client will need parenteral or intranasal cobalamin replacement; however, this will not prevent dumping syndrome.

The emergency nurse is triaging clients. Which report is most concerning and would be given priority for definitive diagnosis and care? 1. Abrupt, tearing, moving (upper to lower) back pain and epigastric pain 2. Severe lower back pain after lifting heavy boxes 3. Sharp calf ache with ambulation that improves with rest 4. Unilateral leg swelling with 2+ pitting edema after an airplane trip

An aortic dissection occurs when the arterial wall intimal layer tears and allows blood between the inner (intima) and middle (media) 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. (Option 2) 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. (Option 3) This is a description of intermittent claudication in the lower extremity due to peripheral artery disease. It is an ischemic muscle pain (due to the buildup of lactic acid from anaerobic metabolism) related to exercise that resolves with rest. (Option 4) This is a description of a deep venous thrombosis (DVT) resulting from immobility during a flight. The embolization of DVT can cause life-threatening pulmonary embolism; the client with aortic dissection already has a life-threatening condition. Educational objective: An aortic dissection, which classically includes moving, "ripping" back pain, is a medical emergency. Hypertension is the most important contributing factor.

The nurse assesses a client diagnosed with chronic kidney disease who had an internal arteriovenous fistula performed on the left arm yesterday. Which assessment finding would require immediate follow-up? 1. A bruit cannot be auscultated over the fistula site 2. Capillary refill of 2 seconds is assessed on the left hand 3. Client reports squeezing a rubber ball with the left hand several times daily 4. Incision is dry with no redness and has sterile skin closures in place

An arteriovenous fistula is a surgical connection of an artery to a vein created to provide vascular access for hemodialysis therapy in clients with kidney disease. Arterial blood flowing through this vein causes it to engorge and thicken (mature) over a period of several weeks, after which it can sustain frequent access by 2 large-bore needles required for dialysis. Maturing of the fistula is aided by having the client perform hand exercises, such as squeezing a rubber ball, that increase blood flow through the vein. Following fistula placement, it is important to monitor for patency. A palpable thrill (vibration) over the fistula or an auscultated bruit (blowing or swooshing sound caused by turbulent blood flow) indicates a patent fistula. Absence of the thrill or bruit can indicate potential clot formation in the fistula. Client reports of numbness or tingling as well as decreased capillary refill can also signal potential clotting. (Option 2) Capillary refill of <3 seconds is considered normal and indicates acceptable blood flow to the area. (Option 3) Daily hand exercises such as squeezing handgrips or a rubber ball are performed to help properly mature the fistula. (Option 4) A dry surgical incision without redness, warmth, and induration is an optimal finding. Sterile skin closures (eg, Steri-Strips) are used to help hold the incision together as it heals. Educational objective:Following placement of an arteriovenous fistula, it is imperative to monitor for signs of potential clotting of the fistula such as absence of a bruit, absence of a thrill, decreased capillary refill, and coolness of the extremity below the fistula.

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? 1. "I got short of breath this morning when I worked out." 2. "I have cut down on smoking to 1/2 pack per day." 3. "I haven't been feeling well, so I have been sleeping a lot." 4. "I took an acetaminophen in the waiting room for this bad headache."

An arteriovenous malformation (AVM) 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 can 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 (Option 4). (Option 1) 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 be discouraged from engaging in heavy exercise as it increases blood pressure. (Option 2) Clients with AVMs should avoid smoking to prevent hypertension. This client needs education on smoking cessation, but it is not the priority. (Option 3) Reports of not feeling well and sleeping a lot may be related to the headache and possible hemorrhage, but this alone would not prompt a call to the health care provider.

The nurse is caring for an assigned team of clients. Which client is the priority for the nurse at this time? 1. Client admitted with Guillain-Barré syndrome yesterday is paralyzed to the knees 2. Client admitted with multiple sclerosis exacerbation has scanning speech 3. Client with epilepsy puts on call light and reports having an aura 4. Client with fibromyalgia reports pain in the neck and shoulders

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 (ie, seizure precautions) are in place. (Option 1) Guillain-Barré syndrome is an ascending symmetrical paralysis. It can move upward rapidly or relatively slowly (over days/weeks). Respiratory compromise is the worst complication. A client with paralysis at the level of the knee after 24 hours would not take priority over a client who will have a seizure in few minutes. (Option 2) Scanning speech is a dysarthria in which there are noticeable pauses between syllables and/or emphasis on unusual syllables. It is an expected finding with multiple sclerosis. (Option 4) Fibromyalgia involves neuroendocrine/neurotransmitter dysregulation. Clients experience widespread pain with point tenderness at multiple sites, including the neck and shoulders. This client is not a priority.

A nurse is performing cardiopulmonary resuscitation (CPR) on an adult at a swimming pool. A bystander brings the automated external defibrillator (AED). The nurse notes that the victim is wet, lying in a small pool of water, and wearing a transdermal medication patch on the upper right chest. What is the most appropriate action at this time? 1. Do not use the AED and continue CPR until paramedics arrive [27%] 2. Move the client away from the pool of water before applying AED pads [26%] 3. Remove the transdermal patch and wipe the chest dry before using the AED [42%] 4. Wipe the chest dry and apply the AED pads over the transdermal patch [4%] Incorrect

An automated external defibrillator (AED) should be used as soon as it is available, as evidence shows early defibrillation is associated with improved cardiopulmonary resuscitation outcomes. For an AED to work appropriately, the pads must be placed correctly as incorrect placement interferes with appropriate conduction. The anterolateral position is the most common, with one pad below the right collarbone and the other pad a few inches below the left armpit. Additional steps are needed in special circumstances; these include: Moving the client out of large bodies of water Drying the chest area - Water conducts electricity; therefore, it is important to quickly wipe the chest dry before applying pads so that AED energy is appropriately transferred. Removing transdermal medication patches and wiping the chest of medication residue before applying AED pads (Option 1) The AED is used as soon as it is available; its use should not be delayed. (Option 2) The entire body does not need to be completely dry; the chest should be quickly wiped, as this is where the electrical current travels. The AED can still be used if the client is damp or lying in a small puddle of water. (Option 4) AED pads should not be placed over medication patches as this interferes with conduction and can burn the skin.

A 2-year-old at an outpatient clinic stops breathing and does not have a pulse. CPR is initiated. When the automated external defibrillator (AED) arrives, the nurse notes that it has only adult AED pads. What is the appropriate action at this time? 1. Continue CPR without using the automated external defibrillator (AED) until paramedics arrive 2. Place one AED pad on the chest and the other on the back 3. Place one AED pad on the upper right chest and the other on the lower left side 4. Place one AED pad on the upper right chest and dispose of the other

An automated external defibrillator (AED) should be used as soon as it is available. Pediatric AED pads or a pediatric dose 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 ("sandwiching the heart"). (Option 1) If an AED is available, it should be placed on the client as soon as possible. Research shows that survival rates increase when CPR and defibrillation occur within 3-5 minutes of arrest. (Option 3) Standard placement of adult AED pads on a 2-year-old would cause the pads to touch or overlap. Touching or overlapping of pads allows the shock to move directly from one pad to the other without traveling through the heart. (Option 4) Both AED pads are necessary for the defibrillator to work effectively. Educational objective: An automated external defibrillator (AED) should be used as soon as it is available. Adult AED pads can be used on a pediatric client if pediatric pads are unavailable. One pad is placed on the chest and the other is placed on the back ("sandwiching the heart").

A 64-year-old hospitalized client with chronic obstructive pulmonary disease exacerbation has increased lethargy and confusion. The client's pulse oximetry is 88% on 2 liters of oxygen. Arterial blood gas analysis shows a pH of 7.25, PO2 of 60 mm Hg (8.0 kPa), and PCO2 of 80 mm Hg (10.6 kPa). Which of the following should the nurse implement first? 1. Administer PRN nebulizer treatment 2. Administer scheduled dose of methylprednisolone IV 3. Increase client's oxygen to 4 liters 4. Place client on the bilevel positive airway pressure (BIPAP) machine

An elevated carbon dioxide (CO2) level (normal: 35-45 mm Hg [4.7-6.0 kPa]) is usually an indicator of hypercapneic respiratory failure. The bilevel positive airway pressure (BIPAP) machine will provide positive pressure oxygen and expel CO2 from the lungs. This client is already showing signs of lethargy and confusion, which is usually a late indicator of respiratory decline. Therefore, the nurse's priority should be to get the client on the BIPAP machine as soon as possible. (Option 1) Nebulizer treatments are commonly part of the treatment plan for a client with chronic obstructive pulmonary disease (COPD). However, these do not take priority when the client has CO2 retention and is deteriorating. If mental status worsens further (due to continued CO2 retention), the client will need intubation. Many BIPAP machines are able to deliver nebulizer treatment while providing positive pressurized oxygen. (Option 2) Steroid therapy is a common pharmaceutical intervention for COPD exacerbation, but it does not take priority over BIPAP in this deteriorating client. In addition, steroids take hours to days to have an effect. (Option 3) In a client with an elevated CO2 level and a history of COPD, the nurse should not increase the oxygen level as this could cause an increase in CO2retention, resulting in further respiratory failure. Educational objective:BIPAP therapy is an effective treatment to decrease CO2 levels in clients with hypercapnic respiratory failure.

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? Select all that apply. 1. Client should abstain from alcohol 2. Client should remain awake all night 3. Client should return if having difficulty walking 4. Responsible adult should be taught neurological examination 5. Responsible adult should stay with the client

An essential aspect of discharging a client with a head injury is ensuring that a responsible adult will check on the client as the level of consciousness can change (Option 5). Brain edema or increased intracranial pressure (IICP) may not be evident immediately. The client should return to the emergency department or notify the primary care provider if any of the following signs/symptoms are present in the next 2-3 days: Change in level of consciousness (eg, increased drowsiness, difficulty arousing, confusion) Worsening headache or stiff neck, especially if unrelieved by over-the-counter analgesics Visual changes (eg, blurring) Motor problems (eg, difficulty walking, slurred speech) (Option 3) Sensory disturbances Seizures Nausea/vomiting or bradycardia (indicates IICP) The client is also to abstain from alcohol, check before taking medications that can affect level of consciousness (eg, muscle relaxants, opioids), and avoid driving or operating heavy machinery (Option 1). (Option 2) It is not necessary to cause sleep deprivation by keeping the client awake. It is most important that the client can be easily aroused to an awake state. (Option 4) A neurological examination includes evaluation with the Glasgow Coma Scale, testing of pupils, and assessment of all 4 extremities for movement, strength, and sensation; this examination should be performed by a clinician. The responsible adult is taught the general indicative symptoms in the list above.

The nurse is caring for a client who has just returned from external fixation device placement for stabilization of a fractured femur. Which of the following interventions are appropriate to include in the client's plan of care? Select all that apply. 1. Assess for increasing drainage from pin sites 2. Check for loose pins and tighten them if loose 3. Maintain bed rest until the device is removed 4. Monitor pulses distal to the external fixation device 5. Perform pin care with a sterile cleaning solution

An external fixator is a device used to stabilize broken bones; metal pins are placed through the tissue into the bone and connect to a frame outside the skin. The nurse should monitor clients with external fixation closely for signs of neurovascular compromise and pin site infection, which can lead to osteomyelitis. When caring for clients with external fixation, the nurse can help prevent infection and maintain extremity and device integrity by: Assessing the pin sites regularly for new, increased, and/or purulent drainage and checking the skin surrounding the pins for erythema, warmth, pain, or breakdown (Option 1) Assessing for signs of compartment syndrome (eg, decreased pulses, coolness, pain, numbness) (Option 4) Performing pin site care with a sterile cleaning solution (eg, chlorhexidine, sterile normal saline) and gauze (Option 5) Monitoring pins and device for loosening and reporting to the health care provider (HCP) if they are loose (Option 2) The nurse should never manipulate loose pins but should instead notify the HCP immediately if loose pins are noted on assessment. (Option 3) The nurse should promote early mobilization for clients with external fixation devices. Some clients may begin walking with physical therapy the day after surgery.

The registered nurse (RN) is supervising a graduate nurse (GN) providing postoperative teaching for a male client after an inguinal hernia repair. Which statement by the GN would cause the RN to intervene? 1. "Elevate your scrotum and apply an ice bag to reduce swelling." [18%] 2. "Practice coughing to clear secretions and prevent pneumonia." [47%] 3. "Stand up to use the urinal if you have difficulty voiding." [27%] 4. "Turn in bed and perform deep breathing every 2 hours." [5%]

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 (eg, heavy lifting). 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, nausea, and vomiting. To prevent hernia reoccurrence after surgical repair, the client is taught to avoid activities that increase intraabdominal pressure (eg, coughing, heavy lifting) for 6-8 weeks (Option 2). If sneezing or coughing are unavoidable, the client should splint incisions and keep the mouth open while sneezing. (Option 1) Scrotal support garments and ice packs help decrease postoperative pain and scrotal swelling. The scrotum should be elevated with a pillow while the client is in bed. (Option 3) The nurse monitors urine output to assess for difficulty voiding after inguinal hernia repair. Male clients are encouraged to stand when voiding to improve bladder emptying. (Option 4) To prevent postoperative complications (eg, pneumonia, constipation) following inguinal hernia repair, the client should reposition frequently, ambulate as soon as possible, and practice deep breathing every 2 hours. .

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

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

The nurse is caring for a client with an acute ischemic stroke who has a blood pressure of 178/95 mm Hg. The health care provider prescribes as-needed antihypertensives to be given if the systolic pressure is >200 mm Hg. Which action by the nurse is most appropriate? 1. Give the antihypertensive medication [4%] 2. Monitor the blood pressure [61%] 3. Notify the health care provider [6%] 4. Question the prescription [27%]

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 blood 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 (eg, active ischemic coronary disease, heart failure, aortic dissection). A blood pressure of 178/95 mm Hg should be monitored, along with the client's other vital signs and status (Option 2). (Option 1) The elevated blood pressure may be a protective measure to ensure tissue perfusion; therefore, the antihypertensive drug should not be given unless indicated by the prescription parameters. (Options 3 and 4) The as-needed prescription is appropriate in this case, so there is no reason to question it and call the health care provider.

An unaccompanied 16-year-old girl comes to the emergency department with severe abdominal pain and vomiting. The client has a temperature of 102.2 F (39 C) 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? 1. Administer care until the parents or guardians can be reached [84%] 2. Admit the client but without giving care until the parents or guardians can be reached [2%] 3. Perform a pregnancy test to see if the client qualifies as an emancipated minor [10%] 4. Provide health care and follow-up advice but do not give any direct care [2%]

An unaccompanied minor should be treated if the medical condition is an emergency and should be assessed and stabilized. This client clearly has a medical need and could suffer consequences if not treated. In this scenario, care should be rendered and then explained later to the parent or guardian. This approach is supported by the ethical principles of beneficence and nonmaleficence. In addition, underage clients may consent in certain circumstances without parental consent. These circumstances usually include treatment for substance abuse problems, psychiatric disorders, or sexual transmitted diseases. (Option 2) This client has signs/symptoms of systemic infection and possible dehydration or sepsis, an emergent condition. It is unknown when the parents or guardians can be reached. It would be negligent to not further assess and treat a potentially worsening condition. It is assumed that the parents or guardians would want safe, quality care for the client. (Option 3) Qualifications for the status of emancipated minor are subject to state legislation but usually include individuals age <18 who are parents or pregnant, married, living as financially independent, or in the military. This client needs care that should be rendered regardless of status. (Option 4) Providing follow-up advice will not stabilize a potentially serious medical condition. Care must be provided.

A client comes to the emergency department following a bee sting. The client has a diffuse rash, hypotension, and throat tightness. One injection of IM epinephrine does not improve the client's condition. What action should the nurse take next? 1. Administer IV fluid bolus 2. Administer methylprednisolone 3. Prepare for emergency cricothyrotomy 4. Repeat IM epinephrine injection

Anaphylactic shock has an acute onset, and manifestations usually develop quickly (20-30 minutes). Circulatory failure and respiratory manifestations, including laryngeal edema (from inflammation) and bronchoconstriction (primarily from release of histamine), can lead to cardiac/respiratory arrest. The management of anaphylactic shock includes: Ensure patent airway, administer oxygen Remove insect stinger if present IM epinephrine is the drug of choice and should be given to this client. Epinephrine stimulates both alpha- and beta-adrenergic receptors and dilates bronchial smooth muscle (beta 2) and provides vasoconstriction (alpha 1). The IM route (mid anterior lateral thigh) is better than the subcutaneous route. Repeat dose every 5-15 minutes. Place in recumbent position and elevate legs Maintain blood pressure with IV fluids, volume expanders or vasopressors Bronchodilator (inhaled beta agonist) such as albuterol is administered to dilate the small airways and reverse bronchoconstriction Antihistamine (diphenhydramine) is administered to modify the hypersensitivity reaction and relieve pruritus Corticosteroids (methylprednisolone [Solu-Medrol]) are administered to decrease airway inflammation and swelling associated with the allergic reaction Anticipate cricothyrotomy or tracheostomy with severe laryngeal edema (Option 1, 2, and 3) These are appropriate responses that should come after a repeat dose of epinephrine has been given.

The nurse is educating a client recently diagnosed with anaphylactic allergy to latex. Which statement made by the client indicates that the client understood the condition correctly? 1. "I do not need to worry about my allergy when I am outside of a health care environment." [0%] 2. "I just need to check labels to ensure products do not contain latex and I will be fine." [18%] 3. "I should always carry my Epi-pen in case I have difficulty breathing." [78%] 4. "I should take better care of myself and eat healthy foods like bananas and chestnuts." [2%]

Anaphylactic shock is a medical emergency and the most severe form of an allergic reaction. Hives, itching, or a skin rash may or may not appear before rapid swelling of the mouth and throat (angioedema) makes breathing difficult or impossible within a span of minutes. Quick application of an epinephrine auto-injector (Epi-pen) into the thigh is the only acceptable option for treating anaphylactic shock. The intramuscular adrenaline injection immediately counteracts the life-threatening swelling, hypotension, and vasodilation that characterize anaphylaxis. Diphenhydramine (Benadryl) is also given to treat any associated rash or itching (hives, wheals, urticaria) but is not sufficient as a monotherapy. (Option 1) Latex products are everywhere. Clients and staff members should be educated and reminded about exposure to plastic products, condoms, and all other medical products containing latex. (Option 2) Numerous products may contain trace amounts of latex; this crucial information may be omitted on the labels. (Option 4) Bananas, avocados, chestnuts, and kiwifruit have been classified as having high-risk potential for cross-reaction allergy development. Clients should be advised to watch for potential allergic reactions due to a cross-allergen.

The nurse enters a client's room just as the unlicensed assistive personnel (UAP) is completing a bath and placing thigh-high anti-embolism stockings on the client. Which situation would cause the nurse to intervene? 1. UAP applies the anti-embolism stockings while maintaining the client in supine position [5%] 2. UAP carefully smoothes out any wrinkles over the length of the stockings [1%] 3. UAP checks that the toe opening of the stockings is located on the plantar side of the foot [10%] 4. UAP rolls down and folds over the excess material at the top of the stockings [82%]

Anti-embolism stockings are part of venous thromboembolism (VTE) prophylaxis in hospitalized clients. Anti-embolism stockings improve blood circulation in the leg veins by applying graduated compression. When fitted properly and worn consistently, the stockings decrease VTE risk. The 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. (Option 1) Anti-embolism stockings should be applied before ambulating while the client is in bed; this maximizes the compression effects of the stockings and promotes venous return. The UAP has performed this correctly. (Option 2) Wrinkles should be smoothed out to avoid impeding venous return. The UAP has performed this correctly. (Option 3) The toe opening should be located on the plantar side of the foot/under the toes. The UAP has performed this correctly. Educational objective:Anti-embolism stockings are worn by clients as part of VTE prophylaxis. It is important that the nurse verifies the stockings are correctly fitted and worn appropriately. Incorrect size and fit or alterations to the stockings can impede venous return.

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 ventilator change. In anticipation of this blood draw, what intervention should the nurse implement? 1. Avoid suctioning the client [36%] 2. Pre-oxygenate the client [21%] 3. Raise the head of the bed [31%] 4. Reduce the amount of sedation medication [11%]

Arterial blood gases (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. (Option 2) Pre-oxygenation should occur prior to suctioning and possibly before position changes. It will affect ABG results. (Option 3) The head of the bed should be maintained at 30 degrees or higher in an intubated client to prevent aspiration and allow for adequate chest expansion. This position will not affect ABG results. (Option 4) If a client is being weaned from the ventilator, sedation may be reduced. A client with reduced sedation may become anxious and have an increased activity level; these could affect the ABG results.

The nurse is performing a physical examination on a 10-year-old client with abdominal discomfort. Which actions would be appropriate during the examination? Select all that apply. 1. Ask the accompanying parent to rate and describe the client's pain 2 Ask the client to describe the chief symptom 3. Conduct a head-to-toe assessment in the same manner as an adult assessment 4. Explain the outcome of the examination to the parent without the child present 5. Honor the client's request to be examined without a parent present

Assessment based on the client's developmental age includes the following: Clients as young as 3 can tell and/or show the examiner where they hurt or how they feel in their own terms 10-year-olds are capable of understanding and assisting in their physical examination. In fact, school-age clients are usually quite interested in equipment and how it works. 10-year-olds are becoming modest and do not want a parent, especially of the opposite sex, in the room with them during a physical examination (Option 1) Pain is the fifth vital sign and is subjective data. A 10-year-old can describe and rate pain accurately. (Option 4) 10-year-olds will think there is something seriously wrong with them if the nurse and parent will not explain the results of the examination to them.

The nurse receives the assigned clients for today on a neurology unit. The nurse should check on which client first? 1. Client with history of head injury whose Glasgow Coma Scale (GCS) changes from 13 to 14 2. Client with history of myasthenia gravis who had ptosis in the evening 3. Client with history of T2 spinal injury who has diaphoresis, pulse 54/min, and hypertension 4. Client with history of transverse myelitis with 2+ bilateral lower extremity muscle strength

Autonomic dysreflexia (autonomic hyperreflexia) is a massive, uncompensated cardiovascular reaction by the sympathetic nervous system (SNS) 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 headache, marked diaphoresis above the level of injury, bradycardia, piloerection (goose bumps), and flushing. This is an emergency condition requiring immediate intervention. Management includes raising the head of the bed and then treating the cause. (Option 1) The Glasgow Coma Scale (GCS) is an objective scale used to monitor alertness/mental functioning in an acute head injury. The best score is 15, and the worst is 3. This client has an improving trend and is not a priority. (Option 2) Myasthenia gravis is an autoimmune disease manifesting mainly as muscle weakness and ptosis. The muscle weakness increases with activity, and by the end of the day, ptosis is present. These are expected findings for this condition, and so this client is not a priority. However, clients with myasthenic crisis can have respiratory failure, which, if it occurs, would be a priority. (Option 4) Transverse myelitis (spinal cord inflammation) usually results from a recent viral infection. Classic symptoms include paralysis, urinary retention, and bowel incontinence. Some clients recover, but many have permanent disability. Normal muscle strength is 5 on a scale of 0-5. Weakened muscle strength (2+ means only able to move laterally, not able to lift up against gravity) would be an expected finding. Educational objective:Autonomic dysreflexia in a client with a spinal cord injury is a priority and requires emergency intervention. Classic triggers are distended bladder or rectum. Management includes raising the head of the bed and then treating the cause (eg, Foley catheter kinks). Additional Information Management of Care NCSBN Client Need

A client with a C3 spinal cord injury has a headache and nausea. The client's blood pressure is 170/100 mm Hg. How should the nurse respond initially? 1. Administer PRN analgesic medication [2%] 2. Administer PRN antihypertensive medication [17%] 3. Lower the head of the bed [17%] 4. Palpate the client's bladder [62%]

Autonomic dysreflexia is an acute, life-threatening response to noxious stimuli, which clients with spinal cord injuries above T6 are unable to feel. Signs and symptoms include hypertension, bradycardia, a pounding headache, diaphoresis, and nausea. It is essential that the nurse assess for and remove noxious stimuli to prevent a stroke (Option 4). Noxious stimuli may include: Bladder distention (eg, obstructed urinary catheter, neurogenic bladder) Fecal impaction Tight clothing (eg, shoelaces, waistbands) (Options 1 and 2) Hypertension, headache, and nausea due to uncontrolled sympathetic activity will resolve once the cause is identified and removed. (Option 3) Lowering the head of the bed would increase blood pressure. The head of the bed should be raised to lower the blood pressure.

The client with suspected active pulmonary tuberculosis (TB) has a positive tuberculin skin test (TST). Which prescription from the health care provider does the nurse anticipate will confirm the diagnosis in this client? 1. Collect 2 blood cultures from different intravenous sites after cleansing with a chlorhexidine swab 2. Collect 2 early morning nose specimens (swabs) from each nare using sterile culturettes 3. Collect an early morning sterile sputum specimen on 3 consecutive days 4. Collect blood for the QuantiFERON-TB test after cleansing the site with a chlorhexidine swab

Bacteriologic testing is performed in clients with suspected TB disease to confirm the diagnosis. A stained sputum smear is examined microscopically for the presence of Mycobacterium tuberculosis (tubercle bacillus), and a culture identifies the growth of the microorganisms. Collect an early morning sputum sterile specimen on 3 consecutive days for an acid-fast bacilli (AFB) smear and culture. Fluids and expectorants can be given at bedtime to help liquefy secretions. It is usually easier for clients to produce a specimen upon awakening as secretions collect in the airways during the night. (Option 1) Blood cultures that identify microorganism in the blood are not usually obtained to confirm a diagnosis of TB. (Option 2) Nose cultures are routinely performed to determine the presence of methicillin-resistant Staphylococcus aureus but are not performed to confirm a diagnosis of TB. (Option 4) The QuantiFERON-TB blood test is performed to screen for TB and can be used as an alternate to the TST. The advantages it offers include the following: there are fewer false-positive results, only a single client visit is required, and results are available in 24 hours. However, it is more expensive.

A client comes to the clinic for a follow-up visit after a Billroth II surgery (gastrojejunostomy). The client reports occasional episodes of sweating, palpitations, and dizziness 30 minutes after eating. Which nursing action is most appropriate? 1. Check serum blood glucose for hypoglycemia 2. Ensure that the client consumes fluids with meals 3. Take the client's blood pressure while lying and standing 4. Teach the client to lie down after eating

Billroth II surgery (gastrojejunostomy) removes part of the stomach and shortens the upper gastrointestinal 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, nausea/vomiting, dizziness, generalized sweating, and tachycardia. To reduce the occurrence of symptoms, clients should avoid fluids with meals and lie down after eating to slow gastric emptying (Option 4). An upright or sitting position increases the force of gravity, which increases the rate of gastric emptying. (Option 1) Hypoglycemia can cause symptoms similar to those of dumping syndrome (eg, sweating, dizziness) but is unlikely to occur 30 minutes after eating. (Option 2) Clients should avoid consuming fluids with meals, which causes stomach contents to pass faster into the jejunum and worsens symptoms. Fluid intake should occur at least 30 minutes before/after meals. (Option 3) Reports of dizziness after standing may indicate orthostatic hypotension and warrant assessment of blood pressure while lying and standing; dizziness after eating is indicative of dumping syndrome. Educational objective:Clients are at risk of dumping syndrome after a gastrectomy and may experience abdominal cramping, nausea, vomiting, and diarrhea. To delay gastric emptying, clients should avoid fluids with meals and lie down after eating.

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. Select all that apply. 1. Discard the first 6-10 mL of blood drawn from the line 2. Flush the line with sterile normal saline before and after collection 3. Perform hand hygiene 4. Place the specimen in a biohazard bag 5. 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 (eg, biohazard bag) (Option 4). This alerts staff to take the necessary precautions to prevent infection transmission when handling the specimen. Other procedures to prevent transmission of infection include: Meticulous hand hygiene (Option 3) Use of disposable gloves during collection and handling of specimen Cleaning the specimen bag with a disinfecting wipe Proper and immediate transport of specimen to the lab Avoiding placing specimen in clean areas (eg, nursing station) An appropriate antiseptic (eg, 70% alcohol) scrub of the catheter hub prior to use inhibits microorganism entry and prevents transmission of infection to the client (Option 5). (Option 1) 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. (Option 2) 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.

A client underwent a transurethral resection of the prostate (TURP) today and has a 3-way Foley urinary catheter with continuous bladder irrigation (CBI). The client reports lower abdominal pain rated as an 8 on a scale of 0-10. What action should the nurse carry out first? 1. Administer prescribed belladonna-opium suppositories prn 2. Administer prescribed morphine intravenous push prn 3. Check amount and characteristics of urine output 4. Check when the client had the last flatus or bowel movement

Blood and mucus can obstruct the Foley catheter if the CBI is not infused at a sufficient rate. Bladder pain will result from distention if the flow is obstructed. The nurse should ensure that there is adequate urinary drainage and no blockage from blood clots before treating the pain. If the urinary flow is obstructed, manual irrigation with sterile normal saline should be performed until there are no clots or the urine is clear/pink. (Options 1 and 2) Belladonna-opium suppositories or antispasmodics (eg, oxybutynin) are used for bladder spasms, an expected complication of the TURP procedure. Clients should be instructed not to urinate around the catheter as this would increase bladder pressure and spasms. Narcotics can be used for postoperative pain. If the urinary flow is adequate, a description of the pain would help to determine whether to give the client a narcotic or an antispasmodic. Before treating the resulting pain, the possibility of a physiological etiology for procedure-related pain (eg, blockage of urinary flow from blood clots) should be ruled out first. (Option 4) Large intestine peristalsis does not usually return for at least 24 hours. Intestinal pain is usually related to the presence of flatus. It is too soon for this to be the primary cause. An etiology related to the procedure should be ruled out first. Educational objective:Causes of postoperative pain from TURP with a CBI include a kinked blocked catheter, bladder spasms, and general postoperative pain. The nurse should ensure first that urinary flow is intact prior to treating the pain with analgesics.

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? 1. Hairnet-like effect across vision 2. Loss of memory about the collision 3. Temporal headache 4. Tongue laceration oozing blood

Blunt-force trauma to the head is associated with potentially severe complications (eg, brain damage and herniation, retinal detachment, seizures). Prompt recognition of potential complications is essential to prevent irreversible changes to the client's neurological status and level of function. Retinal detachment is a separation of the retina from the posterior wall of the eye that may occur following head trauma. This is an ocular emergency as permanent blindness may result without intervention. Signs of retinal detachment include perception of lightning flashes or floaters and a curtain-like or gnats/hairnet/cobweb effect throughout the visual field (Option 1). (Option 2) Loss of memory about the accident, or retrograde amnesia, is commonly reported after mild head injuries. The client should be monitored for decreased level of consciousness or alterations in mental status, which may indicate intracranial bleeding. (Option 3) Headache is expected after mild head injury, and is not innately concerning except if the pain acutely worsens or is not relieved by over-the-counter analgesics (eg, acetaminophen, ibuprofen). (Option 4) A bleeding tongue laceration may occur when the force of the trauma causes the client to accidentally bite the tongue. Oozing blood, although disturbing to the client, does not pose an immediate threat.

The nurse caring for a group of clients on the gynecology unit recognizes that which are at increased risk for developing breast cancer? Select all that apply. 1.24-year-old whose sister had breast cancer at age 38 2. 32-year-old with genetic mutations in the BRCA1 and BRCA2 genes 3. 45-year-old whose menstrual period began at age 17 4.56-year-old who is postmenopausal and has gained 50 lb (22.6 kg) in the last 5 years 5. 65-year-old who took combined oral contraceptives for 15 years

Breast cancer is the unregulated growth of abnormal breast tissue cells and the second most common cause of cancer deaths among women. When palpated, the breast lump is usually described as hard, irregularly shaped, non-mobile, and nontender. Mammography usually detects breast cancer. Non-modifiable breast cancer risk factors include: Female sex and age ≥50 (Options 4 and 5) First-degree relative (mother or sister) with history of breast cancer (Option 1) BRCA1 and BRCA2 genetic mutations (Option 2) Personal history of endometrial or ovarian cancer Menarche before age 12 or menopause after age 55 Modifiable breast cancer risk factors include: Hormone therapy with estrogen and/or progesterone (increased risk if taken after menopause) (Option 5) Postmenopausal weight gain and obesity as fat cells store estrogen (Option 4) History of smoking and alcohol consumption Dietary fat intake Sedentary lifestyle (Option 3) A client whose menstrual period began at age 17 would not be at increased risk for breast cancer. Clients who began menarche early (before age 12) or had late menopause (after age 55) are at increased risk for breast cancer.

The nurse has received report on the following pediatric clients. Which action should the nurse perform first? 1. Administer water enema to the 2-year-old with intussusception who has severe abdominal pain 2. Call the health care provider about the 4-year-old with leukemia who has a low-grade fever 3. Measure head circumference of the 3-month-old with ventriculoperitoneal shunt placement 4. 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 irritabilitymay be exhibiting signs of hypoxia. The nurse should see this client first. (Option 1) Intussusception can be reduced with hydrostatic enema (nonoperative approach). This is important but is not a priority over a child with bronchiolitis and respiratory distress. (Option 2) 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. However, the client with bronchiolitis is the priority. (Option 3) Increased intracranial pressure will occur with shunt malfunction. The nurse should routinely measure the head circumference, but it is not a priority over a client with respiratory distress.

A client with a hip fracture is placed in Buck traction. Which activities are appropriate for the nurse to include in the client's plan of care? Select all that apply. 1. Assess for skin breakdown of the limb in traction 2. Ensure adequate pain relief 3. Keep the limb in a neutral position 4. Perform frequent neurovascular checks on the limb in traction 5. Reposition the client and use a wedge pillow

Buck traction is a type of skin traction used to immobilize hip fractures and reduce pain and spasm until the client can undergo surgical repair of the fracture. A traction boot is applied to the leg, below the fracture site. A weight gently and continuously pulls on the leg and hip, helping maintain alignment of the limb. The nurse should ensure that the traction boot is fitted properly and that the limb remains straight in a neutral position (Option 3). Skin traction exerts pressure on nerves, blood vessels, and soft tissue. The nurse should frequently assess neurovascular status (eg, pulse, capillary refill, color, temperature, sensation, movement) and skin integrity in the limb to which the boot is applied (Options 1 and 4). Overall pain level and efficacy of administered pain medications should be monitored closely, as increasing pain in the limb in traction may indicate neurovascular compromise (Option 2). (Option 5) Side-to-side repositioning of the client in Buck traction can cause injury. Side-to-side position changes cause the affected leg to be adducted or abducted, which, when paired with the force of traction, can increase spasm and pain and contribute to neurovascular and orthopedic compromise.

The registered nurse (RN) on an orthopedic unit is orienting a new graduate nurse (GN) assigned to a client with a fractured hip and in Buck's traction. The RN intervenes when the GN performs which action? 1. Elevates the head of the bed 45 degrees [29%] 2. Holds the weight while the client is repositioned up in bed [41%] 3. Loosens the Velcro straps when the client reports that the boot is too tight [27%] 4. Provides the client with a fracture pan for elimination needs [1%]

Buck's skin traction maintains proper alignment of an injured body part by using weights to apply a continuous pulling force. Appropriate actions for a client in Buck's skin traction include: The client should be supine or in semi-Fowler's position (maximum of 20-30 degrees). Elevating the head of the bed more than 30 degrees would promote sliding (Option 1). Regularly assess the neurovascular status and skin integrity of the limb in traction. Loosen Velcro straps if the boot is too tight as they can impair neurovascular status and skin integrity; tighten the straps if the boot is too loose as this can decrease effectiveness of the traction. When a change is made in the application of the boot or traction pulley system, the nurse should reassess neurovascular status in 30 minutes (Option 3). Provide a fracture pan, which is smaller than a bedpan, for elimination needs to minimize client movement and provide comfort (Option 4). Weights should be free-hanging at all times and should never be placed onto the bed or touch the floor. A staff member should support the weight while the client is repositioned up in bed to prevent excessive pull on the extremity (Option 2). Skeletal traction is applied directly to the bone with a metal wire or pin and is used to immobilize, position, or align a fracture when continuous traction is needed and skin traction is not possible. Removing the weights can cause injury to the client and should never be removed unless there is a life-threatening situation.

The registered nurse (RN) on an orthopedic unit is orienting a new graduate nurse (GN) assigned to a client with a fractured hip and in Buck's traction. The RN intervenes when the GN performs which action? 1. Elevates the head of the bed 45 degrees 2. Holds the weight while the client is repositioned up in bed 3. Loosens the Velcro straps when the client reports that the boot is too tight 4. Provides the client with a fracture pan for elimination needs

The nurse reviews the serum laboratory results and medication administration records for assigned clients. Which prescriptions should the nurse question and validate with the health care provider before administering? Select all that apply. 1. Bumetanide in the client with heart failure who has hypokalemia 2. Calcium acetate in the client with chronic kidney disease who has hyperphosphatemia 3. Carvedilol in the client with heart failure who has an elevated B-type natriuretic peptide level 4. Isoniazid in the client with latent tuberculosis who has elevated liver enzymes 5. Metronidazole in the client with Clostridium difficile infection who has leukocytosis

Bumetanide is a potent loop diuretic (eg, furosemide, torsemide) used to treat edema associated with heart failure and liver and renal disease. The diuretic inhibits reabsorption of sodium and water from the tubules and promotes renal excretion of water and potassium. The nurse should question the bumetanide prescription as the client with heart failure has hypokalemia (potassium <3.5 mEq/L [3.5 mmol/L]) and is already at increased risk for life-threatening cardiac dysrhythmias associated with this electrolyte imbalance (Option 1). Isoniazid is a first-line antitubercular drug used to treat latent or active tuberculosis. The nurse should question this prescription as increased liver function tests (eg, alanine aminotransferase, aspartate aminotransferase) can indicate development of drug-induced hepatitis (Option 4). (Option 2) Calcium acetate (PhosLo) is a phosphate binder used to treat hyperphosphatemia (normal phosphorous: 2.4-4.4 mg/dL [0.78-1.42 mmol/L]) in clients with chronic kidney disease. Calcium acetate lowers the serum phosphorous level by binding to dietary phosphate and excreting it in feces. (Option 3) Carvedilol (Coreg) is a beta blocker used to improve cardiac output and slow the progression of heart failure. B-type natriuretic peptide (BNP) (normal: <100 pg/mL [100 pmol/L]) is secreted from the ventricles in response to the increased ventricular stretch. Elevated BNP is expected in a client with heart failure; the nurse need not question this prescription. (Option 5) Metronidazole (Flagyl) is the first-line anti-infective drug used to treat infectious diarrhea caused by Clostridium difficile. Leukocytosis is expected with this bacterial infection. Educational objective:Loop diuretics (eg, bumetanide, furosemide, torsemide) can cause hypokalemia (potassium <3.5 mEq/L [3.5 mmol/L]). Elevated liver enzymes in clients receiving the antitubercular drug isoniazid can indicate development of drug-induced hepatitis. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

The nurse in an ambulatory care center is teaching a client with a diagnosis of persistent depressive disorder (dysthymia) about the appropriate use of bupropion hydrochloride SR. Which statement made by the client indicates a need for further teaching? 1. "If I have a sudden change in my mood, I should call my physician immediately." 2. "If I have trouble swallowing the tablet, I can cut it in half." 3. "If I miss a dose, I should not double the next dose to catch up." 4. "It may take several weeks before I get better."

Bupropion hydrochloride (Wellbutrin) is an atypical antidepressant used to treat depressive disorders, including major depressive disorder, seasonal affective disorder, and persistent depressive disorder (dysthymia). Preparations of bupropion hydrochloride include immediate-release, sustained release (SR), and extended-release (XL) tablets. Any medication marked SR or XL should not be chewed, cut, or crushed due to the risk of adverse effects from too rapid absorption of the drug. No form of bupropion hydrochloride should be altered; tablets should be swallowed whole, with or without food. Seizures are of particular concern if a client takes a high or toxic dose of bupropion hydrochloride. Clients on any kind of antidepressant need to be monitored closely for worsening depression, sudden or unusual behavior or mood changes, and the emergence of suicidal thoughts and behaviors. Clients with a diagnosis of depression and/or their family members need education and information on the increased risk of suicide (Option 1). Additional instructions to a client about the use of bupropion hydrochloride include the following: Limit alcohol; inform the health care provider if you are used to consuming large amounts of alcohol Do not double up on the medication if a scheduled dose is missed (Option 3) Take the medication at the same time each day It may take several weeks to feel the effects of bupropion hydrochloride (Option 4) Weight loss may occur when taking this medication Educational objective:No form of bupropion hydrochloride should be crushed, chewed, or cut due to the risk of seizures and other adverse effects caused by the more rapid absorption and resulting higher serum levels of the drug. No medications labeled SR or XL should be altered before they are administered. This type of medication preparation should be swallowed whole. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

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? 1. Administer 50-100 mcg fentanyl IV push q30min, PRN for pain [7%] 2.Apply topical bacitracin ointment to burn wounds, twice daily [1%] 3. Infuse 150 mL/hr lactated Ringer solution IV continuously [80%] 4. Obtain equipment and prepare client for escharotomy [10%]

Burn injuries are caused by direct tissue damage from exposure to caustic (eg, thermal, chemical, electrical) 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 (ie, airway, breathing, circulation). Circulatory compromise is common after sustaining a burn, as extensive tissue injury combined with the systemic inflammatory response causes 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 (Option 3). (Option 1) Although full-thickness burns destroy nerves and may be painless, clients with burns often have severe pain. However, pain is not life-threatening and may be treated after restoration of ABCs. (Option 2) Burn injuries impair immune system function and skin integrity, increasing the risk for infection. Prevention of infection with topical antimicrobials (eg, bacitracin, silver sulfadiazine) is important. However, restoration of ABCs is the priority. (Option 4) An escharotomy is a surgery involving incisions made through eschar (burned tissue) and is performed to prevent tissue ischemia and necrosis from impaired circulation. However, stabilizing circulatory status is the priority.

The nurse reinforces teaching for a client newly prescribed buspirone for generalized anxiety disorder. Which client statement indicates that teaching has been effective? 1. "Driving is not recommended until I stop taking this medication." 2. "If I experience a panic attack I should take an extra dose of medication." 3. "It will be 2-4 weeks before I feel the full effect of this medication." 4. "Withdrawal symptoms will occur if I abruptly stop taking this medication."

Buspirone (Buspar) is an anxiolytic medication that differs from other medications used to manage anxiety disorders (eg, benzodiazepines) because it typically lacks central nervous system depressant effects and has a low abuse potential. Therefore, buspirone has a favorable side-effect profile because it usually does not produce withdrawal symptoms, dependence, or psychomotor slowing (eg, slowing of thought, impaired movement). However, unlike other anxiolytic medications, buspirone does not work immediately. Onset of symptom relief occurs after 1 week of therapy, with full effects occurring between 2 and 4 weeks (Option 3). (Option 1) As with any medication, the nurse should advise clients to avoid driving until individual effects are known. However, it is unlikely that buspirone will cause psychomotor impairment and require cessation of driving or operating machinery for the duration of treatment. (Option 2) Buspirone should be taken as prescribed and is not indicated for relief of acute anxiety or panic attacks. The health care provider may prescribe an additional medication with a fast-acting effect for panic attacks. (Option 4) Buspirone does not cause physical dependence or tolerance, and withdrawal symptoms do not occur with discontinuation of use.

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? Select all that apply. 1. "For the past few years, I get a productive cough in the winter that goes away in spring." 2. "I occasionally have heartburn an hour after I eat fried foods and sausage." 3. "Last month when I was doing my breast self-examination, I noticed a marble-sized lump." 4. "My mole is itchy, and the borders have become uneven with a blackish to bluish color." 5. "Recently I have noticed that my bowel movements appear black."

Cancer is a growth of abnormal cells in an organ system that may impair the organ's function and spread throughout the body. Many cancers are invasive and life threatening if allowed to reach late stages of development. However, cancer is often difficult to identify early as the client may be asymptomatic or have only vague symptoms. Nurses should screen clients for and immediately report warning signs of cancer, which can be remembered with the mnemonic CAUTION: Change in bowel or bladder habits (Option 5) A sore that does not heal Unusual bleeding or discharge from a body orifice Thickening or a lump in the breast or elsewhere (Option 3) Indigestion or difficulty in swallowing that does not go away Obvious change in a wart or mole (Option 4) Nagging cough or hoarseness (Option 1) A productive cough that is annual and seasonal, particularly occurring in the winter, may indicate chronic bronchitis. The nagging cough found in clients with lung cancer is persistent, rather than seasonal. (Option 2) A client report of occasional indigestion after specific triggers (eg, high-fat or spicy food, caffeine) may indicate gastroesophageal reflux disease. However, indigestion that is persistent or chronic indigestion may indicate cancer. Educational objective:Warning signs of cancer for nurses to monitor include change in bowel or bladder habits, a sore that does not heal, unusual bleeding or discharge, thickening or a lump in the breast or elsewhere, indigestion or difficulty swallowing, any obvious change in a wart or mole, and nagging cough or hoarseness (mnemonic: CAUTION).

A client comes to the emergency department and reports headache, nausea, and shortness of breath after being stranded at home without electricity due to severe winter weather. While collecting a history, which question is most important for the nurse to ask? 1. "Are you up to date with your annual flu shot and other vaccinations?" 2. "Have you had difficulty eating or drinking in the last few days?" 3. "How have you been keeping your house warm during this weather?" 4. "Is there anything that you have found that relieves your symptoms?"

Carbon monoxide (CO) is a colorless, odorless gas produced by burning fuel (eg, oil, kerosene, coal, wood) in a poorly ventilated setting. CO toxicity (poisoning) is most often associated with smoke inhalation from structure fires, but is also generated by furnaces/hot water heaters fueled by natural gas or oil, coal or wood stoves, fireplaces, and engine exhaust. Clients with CO toxicity often have nonspecific symptoms, and the diagnosis can be missed. It is important to assess for possible CO exposure to initiate appropriate emergency care and prevent hypoxic neurologic impairment. To help identify elevated CO levels in the home, the nurse can ask about the following: Similar symptoms in other family members, or an illness in an indoor pet that developed at the same time Fuel-burning heating/cooking appliances; risk of CO toxicity increases in the fall and winter due to increased used of heat sources in an enclosed space (Option 3) (Options 1, 2, and 4) It is important to reconcile the client's vaccinations, obtain a nutritional history, and explore the nature of the client's symptoms, but it is essential to rule out the possibility of CO toxicity given the circumstances of this client's illness.

When assessing a client with cholelithiasis and acute cholecystitis, which findings might the nurse note during the health history and physical examination? Select all that apply. 1. Flank pain radiating to the groin 2. High-protein food ingestion before the onset of pain 3. Low-grade fever with chills 4. Pain at the umbilicus 5. Right upper-quadrant (RUQ) 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 (Option 5). Clients often report fatty food ingestion 1-3 hours before the initial onset of pain. Associated symptoms include low-grade fever, chills, nausea, vomiting, and anorexia (Option 3). During an acute attack, inflammation of the mucous lining and wall of the gallbladder occurs as a result of gallstone(s) 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. (Option 1) Flank pain radiating to the groin is seen with renal colic (ureteral stones). (Option 2) It is not dietary protein but food with significant fat content (cheese, avocado, fried foods, hamburger) 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 (choledocholithiasis). (Option 4) Initial onset of pain at the umbilicus is seen with acute appendicitis.

Carvedilol (Coreg)

Carvedilol (Coreg) is a beta blocker used to improve cardiac output and slow the progression of heart failure. B-type natriuretic peptide (BNP) (normal: <100 pg/mL [100 pmol/L]) is secreted from the ventricles in response to the increased ventricular stretch. Elevated BNP is expected in a client with heart failure; the nurse need not question this prescription.

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? Select all that apply. 1. Facilitating communication between health care providers (HCPs) 2. Obtaining health information from the client's nursing home 3. Reconciliation of home medications 4. Referral for home health after discharge 5. Visiting the client daily while hospitalized

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 fragmentation of care (Option 2), helps to coordinate care and communication between HCPs (Option 1), makes referrals, ensures quality standards are being met, and arranges for home health or placement after discharge (Option 4). (Option 3) Case managers typically do not provide direct client care. Medication reconciliation should be done between the primary nurse directly caring for the client and the HCP. (Option 5) Case managers often make daily rounds to the nursing department to review documentation in the client's chart but do not necessarily visit the client personally. Educational objective:The nurse providing direct client care should be familiar with the nurse case manager role as part of the interdisciplinary team. The goal of the nurse case manager is to facilitate provision of quality care across a continuum, decrease fragmentation of care across various settings, and contain costs.

A client arrives at the clinic for a follow-up after an emergency department visit the night before. The client sustained an ulnar fracture, and a fiberglass cast was applied. Which of the following teachings related to cast care should the nurse reinforce? Select all that apply. 1. Contact the clinic if any hot areas or foul odors develop in the cast 2. Cover the cast with a plastic bag for bathing, and avoid getting the cast wet 3. Elevate the affected extremity above heart level for the first 48 hours 4. Expect some numbness and tingling of the fingers during the first week 5. Use only soft, padded objects to scratch the skin under the cast

Casts (eg, fiberglass, plaster) are applied to immobilize fractured extremities during healing. Instructions for cast care include: Report foul odors or hot areas (hot spots) in the cast, which may indicate infection (Option 1). Avoid getting the cast wet, which may damage the cast and cause skin irritation/infection (Option 2). Elevate the affected extremity above heart level for the first 48 hours to reduce edema (Option 3). Regularly perform isometric and range of motion exercises to prevent muscle atrophy. (Option 4) The client should also be instructed to contact the health care provider about symptoms of impaired circulation in the affected extremity, including numbness or tingling, pallor, coolness, loss of pulse distal to the cast, or pain that is unrelieved by ice, elevation, and pain medication. Swelling within the cast may result in compartment syndrome, a condition that involves limb-threatening tissue ischemia due to compression of blood vessels and nerves within the extremity's internal compartments. (Option 5) The client should never insert objects inside the cast due to the risk of tissue injury and infection. Directing air inside the cast with a hair dryer on the cool setting may help relieve itching.

The nurse reviews a prescription to insert an indwelling urinary catheter in a hospitalized client. Which rationale for indwelling urinary catheter insertion is most appropriate? 1. The client has acute urinary retention 2. The client is confused and incontinent 3. The client is elderly and at risk for falls 4. The client is receiving intravenous diuretics

Catheter-associated urinary tract infections are prevalent in hospital settings. Only indwelling urinary catheters should be used when appropriate. Appropriate uses include the following: 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 incontinent clients Inappropriate uses include the following: Convenience or replacement for nursing care when the client is elderly, confused, incontinent, or voids frequently (Options 2, 3, and 4) 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

A client with uncontrolled hypertension is prescribed clonidine. What instruction is most important for the clinic nurse to give this client? 1. Avoid consuming high-sodium foods [4%] 2. Change positions slowly to prevent dizziness [47%] 3. Don't stop taking this medication abruptly [46%] 4. Use an oral moisturizer to relieve dry mouth [1%]

Central-acting alpha2 agonists (eg, clonidine, methyldopa) decrease the sympathetic response from the brainstem to the peripheral vessels, resulting in decreased peripheral vascular resistance and vasodilation. Clonidine is a highly potent antihypertensive. Abrupt discontinuation (including the patch) can result in serious rebound hypertension due to the rapid surge of catecholamine secretion that was suppressed during therapy. Clonidine should be tapered over 2-4 days. Abrupt withdrawal of beta blockers can also result in rebound hypertension and in precipitation of angina, myocardial infarction, or sudden death. (Option 1) Avoiding high-sodium foods is important for blood pressure control but is not the most important advice for this client as consumption of these is not immediately life-threatening. (Option 2) Dizziness is a side effect of clonidine. The nurse should teach the client to change positions slowly and sit for a few minutes before rising to prevent falls. Drowsiness is also quite common with clonidine. Clients should not use it with alcohol or central nervous system depressants. However, dizziness and drowsiness should diminish with continued use of the medication. (Option 4) Dry mouth is a side effect of clonidine. Use of over-the-counter mouth moisturizers, chewing gum, or hard candy may be helpful for clients with dry mouth.

Which medication prescriptions should the nurse question? Select all that apply. 1. Cephalexin for a client with severe allergy to penicillin 2. Fexofenadine for a client with hives 3. Ibuprofen for a client with asthma and nasal polyps 4. Lisinopril for a client with diabetes mellitus 5. Propranolol for a client with asthma

Cephalexin is a cephalosporin, which is chemically similar to penicillin. If a client has had a severe allergic reaction to penicillin, there is a 1%-4% chance of an allergic reaction (cross-sensitivity) to a cephalosporin (Option 1). Clients with nasal polyps often have sensitivity to nonsteroidal anti-inflammatory drugs (NSAIDS), including aspirin. In addition, NSAIDs can exacerbate asthma symptoms. Therefore, acetaminophen may be a better choice for these clients (Option 3). The selective beta blockers (eg, metoprolol, atenolol, bisoprolol) are generally given for heart failure and hypertension control due to their beta1-blocking effect. The nonselective beta blockers (eg, propranolol, nadolol), in addition, have a beta2-blocking effect that results in bronchial smooth muscle constriction. Therefore, nonselective beta blockers are generally contraindicated in clients with asthma (Option 5). (Option 2) H1 receptor antagonists (eg, fexofenadine, cetirizine, levocetirizine, loratadine) decrease the inflammatory response by blocking histamine receptors. Histamine is released from mast cells during a type I (immediate) hypersensitivity reaction (ie, allergic rhinitis, allergic conjunctivitis, and hives). (Option 4) Angiotensin-converting (ACE) inhibitors (ending in "pril") are the drugs of choice in diabetic clients with hypertension or proteinuria. This would be an appropriate administration.

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? 1. "I may feel a sharp pain that shoots to my leg, but it should pass soon." [13%] 2. "I will go to the bathroom and try to urinate before the procedure." [2%] 3. "I will need to lie on my stomach during the procedure." [81%] 4. "The physician will insert a needle between the bones in my lower spine." [1%]

Cerebrospinal fluid (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 H2O. 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 (Option 2) The procedure can be performed in the lateral recumbent position or sitting upright. These positions help widen the space between the vertebrae and allow easier insertion of the needle (Option 3). A sterile needle will be inserted between the L3/4 or L4/5 interspace (Option 4) Pain may be felt radiating down the leg, but it should be temporary (Option 1) After the procedure, instruct the client as follows: Lie flat with no pillow for at least 4 hours to reduce the chance of spinal fluid leak and resultant headache Increase fluid intake for at least 24 hours to prevent dehydration Educational objective:Lumbar puncture can be performed with clients in the sitting position or positioned on the left side with the knees drawn up (fetal position).

A client is brought to the emergency department 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? 1. An ecchymotic area on the forehead [2%] 2. Frontal headache rated as 10 on a 1-10 scale [8%] 3. Nasal drainage on gauze has a red spot surrounded by serous fluid [87%] 4. Small amount of bright red blood oozing from cheek laceration [1%]

Cerebrospinal fluid (CSF) rhinorrhea (or CSF otorrhea) 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 test 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. Identification of this pattern is very important as CSF leakage places the client at risk for infection. The client's nose should not be packed. No nasogastric or oral gastric tube should be inserted blindly when a basilar 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. (Option 1) A bruise is an expected finding after direct trauma. It would be a concern if the ecchymosis were around the eyes (periorbital, "raccoon eyes") or postauricular (Battle's sign) as this generally indicates a basilar skull fracture, a tear in the dura, and a potential CSF leak. (Option 2) A headache is an expected finding after trauma. It would be a concern if it were unrelieved by non-narcotic analgesics or accompanied by signs of increased intracranial pressure. (Option 4) The head is highly vascular and it is not unusual to have blood oozing after trauma. This is not as concerning as a potential CSF leak. However, it can become a problem if the nurse is unable to eventually stop the bleeding as substantial total blood loss is a concern.

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? Select all that apply. 1. "A long-term consequence of an untreated chlamydial infection is infertility." 2. "I can resume sexual intercourse tomorrow, as I already received the antibiotic." 3. "I can still spread the infection, even if I do not have any of the symptoms." 4. "I should have screening yearly for chlamydia even if I do not have symptoms." 5. "I will make sure my partner gets checked and treated to prevent reinfection."

Chlamydia is the most common sexually transmitted infection and is diagnosed frequently among women, adolescents, and those with multiple sexual partners. Many clients are asymptomatic or have minor symptoms (eg, spotting after sex, dysuria, abnormal vaginal discharge) but can still transmit the infection (Option 3). Therefore, all sexually active women age <25 and any client age ≥25 at high risk (eg, new or several sexual partners) are screened annually for chlamydia and gonorrhea (Option 4). The client's sexual partners should also receive treatment to prevent transmission and reinfection (Option 5). If not treated appropriately, chlamydia can ascend the female genital tract, producing serious complications such as pelvic inflammatory disease and infertility (Option 1). Clients should also be instructed in general safe sex practices (eg, using condoms, avoiding multiple partners) to help prevent transmission of sexually transmitted infections. Clients should be taught to abstain from sexual intercourse for 7 days after initiation of drug therapy (eg, single dose of azithromycin, 7 days of doxycycline). This client received treatment today and therefore must wait 7 days before resuming intercourse (Option 2). Educational objective:Clients with a chlamydial infection may be asymptomatic or experience minor symptoms (eg, spotting after sex, dysuria, abnormal vaginal discharge). Clients should abstain from sexual intercourse for 7 days after antibiotic treatment is initiated and until all sexual partners have completed treatment to prevent transmission and serious complications. Sexually active clients age <25 or those age ≥25 at high risk should be screened annually.

Four children are brought to the emergency department. Which child should be assessed first? 1. A 13-month-old who ingested an unknown quantity of children's multivitamins 2. A 15-month-old with a fever of 100.5 F (38.1 C) after being vaccinated 3. A 3-year-old with a forehead laceration and colorless nasal drainage 4. A 4-year-old with enlarged tonsillar lymph nodes who is crying in pain

Clear, colorless fluid draining from the nose or ears after head trauma is suspicious for cerebrospinal fluid (CSF) leakage (Option 3). 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 level of consciousness 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. (Option 1) Iron ingestion is the major concern with vitamin toxicity in children. However, children's formulations contain minimal or no iron. As a result, ingestion of an unknown quantity is unlikely to cause serious toxicity. This child should be seen second. (Option 2) A low-grade fever is common after immunizations; this child can be seen last. (Option 4) Although infection and pain are important, this child can be seen third. Educational objective:The child with head trauma who is leaking cerebrospinal fluid (CSF) is at risk for meningitis and intracerebral bleeding. If the drainage is clear, a dextrose test is used to determine if the drainage is CSF. The nurse should assess for signs of bleeding (eg, change in level of consciousness) and infection (eg, increased temperature) and anticipate a CT scan and prophylactic antibiotics.

The nurse is conducting an educational community outreach program on melanoma screening. Which statement by a resident would indicate the need for further education? 1. Abrupt changes in the size or color of a mole are warning signs. 2. All new growths and pigmentations must be biopsied to rule out cancer. 3. Melanoma can occur as any color. 4. Melanoma does not always occur as a new mole.

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. (Option 1) Rapid changes in a mole should be evaluated immediately. (Option 3) Amelanotic melanomas are pink growths similar to basal cell carcinomas of the skin. Blue, white, and red colorations can occur in melanoma. (Option 4) Malignant expansions of previous growths (moles, nevi) are common. Educational objective:Skin cancer screening should cover the basics - uneven, large, blotchy moles, or any sudden changes in mole size or color need to be checked out by a health care provider.

Which instructions should the nurse include when providing discharge teaching to a client with peptic ulcer disease due to Helicobacter pylori infection? Select all that apply. 1." Avoid foods that may cause epigastric distress such as spicy or acidic foods." 2. "It is best if you refrain from consuming alcohol products." 3. "Report black tarry stools to your health care provider immediately." 4. "Take your amoxicillin, clarithromycin, and omeprazole for the next 14 days." 5. "You may take over-the-counter drugs such as aspirin if you have mild epigastric pain."

Client teaching related to peptic ulcer disease (PUD) includes lifestyle changes (eg, dietary modifications, stress reduction), PUD complications, and medication administration. Helicobacter pylori infection and treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) are risk factors for complicated PUD. H pylori treatment includes antibiotics and proton-pump inhibitors for acid suppression. The recommended initial treatment is 7-14 days of triple-drug therapy with omeprazole (Prilosec), amoxicillin, and clarithromycin (Biaxin). (Option 5) Clients with PUD should avoid NSAIDs [eg, aspirin, ibuprofen (Motrin)] as they inhibit prostaglandin synthesis, increase gastric secretion, and reduce the integrity of the mucosal barrier. Educational objective:Clients with peptic ulcer disease should avoid NSAIDs, smoking, and excess use of alcohol or caffeine.

A registered nurse is precepting a new nurse in the intensive care unit. The client is sedated with propofol, 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? 1. Assesses gastric residual volumes every 4 hours 2. Measures the number of centimeters the feeding tube is secured at the nare every 4 hours 3. Requests that the physician change the client from continual to bolus feedings 4. Uses a sedation scale to titrate down the sedation (if possible)

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. (Option 1) Assessing gastric residual volumes according to institution policy (at least every 4 hours) is standard for clients receiving continual enteral feedings. Increased volumes may indicate poor absorption and increase the risk of regurgitation and aspiration. (Option 2) Measuring the number of centimeters at the nares every 4 hours can help determine if the tube has moved, but it can increase aspiration risk. X-ray confirmation may be necessary if the tube has moved. (Option 4) A sedation scale such as the Ramsay Scale is used to assess level of sedation. It is preferable to keep the client minimally sedated (asleep but arousable). This helps decrease the risk of aspiration. Educational objective:Assessing gastric residual volumes and level of sedation at regular intervals, checking enteral feeding tube placement, and administering continual rather than bolus tube feeding are interventions that help prevent aspiration in critically ill high-risk clients. Additional Information Reduction of Risk Potential NCSBN Client Need

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

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

A client with suspected foot osteomyelitis is scheduled for an MRI. Which findings should the nurse notify the health care provider about before the test? Select all that apply. 1. Aneurysm clip 2. Cardiac pacemaker 3. Colostomy 4. Retained metal foreign body in eye 5. Transdermal testosterone patcha

Clients must be screened for contraindications before exposure to a magnetic field (MRI) as it can damage implanted devices or metallic implants. Absolute contraindications can preclude testing, and relative contraindications can pose a hazard to the client's devices or implants, affect the quality of the images, or cause discomfort. Absolute contraindications: Cardiac pacemaker (Option 2) Implantable cardioverter defibrillator Cochlear implant Retained metallic foreign body, especially in organs such as the eye (Option 4) Relative contraindications: Prosthetic heart valve Metal plate, pin, brain aneurysm clip, or joint prosthesis (Option 1) - Some of these devices have nonferrous MRI-safe materials and should be verified. Implanted device (eg, insulin pump, medication port) 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 (eg, sedation can be prescribed, open MRI machine can be used). (Option 3) A colostomy is not a contraindication for MRI. (Option 5) Transdermal metal-containing medication patches (clonidine, nicotine, scopolamine, testosterone, or fentanyl) are not a contraindication for MRI. However, the nurse should remove the patch beforehand due to the risk of burns and replace after testing.

Which nursing interventions are appropriate for managing the care of a client receiving mechanical ventilation and continuous IV sedation? Select all that apply. 1. Maintain the head of the bed at 30-45 degrees 2. Mute ventilator alarms at night to allow the client to rest 3. Pause sedation daily to assess weaning readiness 4. Perform oral care with chlorhexidine solution 5. Place a manual resuscitation bag at the bedside

Clients requiring mechanical ventilation are at risk for a variety of ventilator-associated complications (eg, aspiration, pneumonia). When caring for a client receiving mechanical ventilation, the nurse should: Monitor respiratory status (eg, lung sounds, breathing pattern), airway patency, and ventilator functionality (eg, settings, alarm parameters). Maintain the head of the bed at 30-45 degrees to reduce aspiration risk (Option 1). Use the minimum amount of sedation necessary for client comfort (eg, compliant with ventilator, opens eyes to voice). Continuous IV sedation should be paused daily for evaluation of spontaneous respiratory effort and appropriateness for weaning off the ventilator (Option 3). Perform oral care with chlorhexidine oral solution every 2 hours, or per facility policy (Option 4). Perform tracheal suctioning as needed. Monitor correct endotracheal tube placement by noting insertion depth. Place emergency equipment at bedside (eg, manual resuscitation bag) (Option 5). (Option 2) Although the client should have a quiet environment at night, ventilator alarms should never be muted, as they may indicate life-threatening complications (eg, accidental extubation, tubing disconnection).

The nurse is caring for a mechanically ventilated client with a tracheostomy tube in the intensive care unit. What client care tasks can the nurse safely delegate to the unlicensed assistive personnel? Select all that apply. 1. Applying moisturizing solution to the oral mucosa and lips 2. Cleaning the area around tracheostomy stoma with normal saline 3. Educating the family to maintain the head of the bed at least 30 degrees 4. Obtaining and documenting respiratory rate and pulse oximetry readings 5. Performing passive and active range-of-motion exercises

Clients requiring mechanical ventilation receive care from many members of the health care team. Nurses must often delegate tasks to ensure that care is provided in a timely manner. When delegating, nurses must consider the stability of the clientand the experience level of unlicensed assistive personnel (UAP). In accordance with the five rights of delegation, nurses may delegate the following client care tasks to the UAP: Performing routine oral care, which will not affect medical stability in a client with a tracheostomy tube (Option 1) Measuring and obtaining vital signs (Option 4) Testing blood glucose (per hospital policy) Performing personal hygiene and skin care (eg, bathing) Performing passive and/or active range-of-motion exercises (Option 5) Measuring output (eg, urinary, drainage) (Option 2) The tracheostomy is a surgically created airway with a high risk of infection. Only licensed individuals (eg, registered nurse, licensed practical nurse) should perform tracheostomy care. (Option 3) Although an elevated head of bed (HOB) is necessary to prevent ventilator-acquired pneumonia and improve chest expansion, teaching is not within the scope of the UAP and should be performed only by nurses. However, after nurses provide teaching, the UAP may remind the family to keep the HOB elevated. Educational objective:When caring for a ventilated client, nurses may consider delegating the following tasks to unlicensed assistive personnel: vital sign measurement, oral care, personal hygiene, blood glucose testing, passive or active range-of-motion exercises, and measurement of urine and drainage output.

The nurse provides discharge instructions to a 67-year-old client with chronic bronchitis who was hospitalized for community-acquired pneumonia. Which instructions should be included in the discharge teaching plan? Select all that apply. 1. "Avoid the use of over-the-counter cough suppressant medicines." 2. "Oral antibiotics are not needed at home as you had intravenous (IV) therapy in the hospital." 3. "Pneumonia vaccination is not needed as you now have lifelong immunity." 4. "Schedule a follow-up with the health care provider (HCP) and chest x-ray." 5. "Use a cool mist humidifier in your bedroom at night." 6. "Use the incentive spirometer at home."

Clients should be taught to understand that symptoms of pneumonia (eg, cough, sputum production, shortness of breath, fatigue, and activity intolerance) remain after discharge even though the bacteria are no longer present and will dissipate over a 2-4 week period, depending on current health status and preexisting conditions. Discharge teaching includes the following instructions: Avoid the use of over-the-counter cough suppressant medicines. Unless prescribed by the HCP, cough suppressants are avoided as they impair secretion clearance, especially in clients with chronic bronchitis. Schedule a follow-up with the HCP and chest x-ray. Follow-up is needed at about 2 weeks after completion of antibiotic therapy. X-ray may be needed at a later time in certain high-risk clients to make sure the pneumonia is resolved with no underlying cancer. Use a cool mist humidifier in your bedroom at night. Humidifiers keep mucus membranes moist, maintain effectiveness of the mucociliary escalator, and facilitate expectoration of mucus. A warm bath also loosens the secretions. Continue using the incentive spirometer at home. Deep breathing and coughing promote lung expansion, ventilation, oxygenation, and airway clearance. Drink 1-2 liters of water a day, if not contraindicated, to help thin secretions and facilitate mobilization. Limit caffeine and alcohol as they can dry mucus membranes due to diuretic effects. Notify the HCP of any increase in symptoms (eg, shortness of breath, cough, sputum production, chest pain, fever, confusion). Avoid all tobacco products and second-hand smoke as these irritate the airways and impair mucociliary clearance and oxygenation. Eat a balanced diet, increase activity slowly over about 2 weeks, and take rest periods when needed to help maintain resistance to infection. (Option 2) After a client has IV antibiotic therapy, completing a full course of oral antibiotic therapy is necessary to prevent reoccurrence of disease and antibiotic resistance. (Option 3) Contracting pneumonia does not provide lifelong immunity to the disease. Yearly influenza vaccination and pneumonia vaccination as directed by the HCP are recommended.

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

Clients who follow a vegan diet eat only plant-based foods, omitting animal proteins (eg, meat, poultry, fish) and products (eg, dairy, eggs). Clients who are vegan are at risk for deficiency of vitamin B12 (cobalamin), which is primarily supplied by animal products. Chronic vitamin B12deficiency may precipitate megaloblastic anemia and neurological symptoms across the entire nervous system, from peripheral nerves to the spinal cord and brain. Manifestations of chronic deficiency include: Peripheral neuropathy (eg, tingling, numbness) (Option 4) Neuromuscular impairment (eg, gait problems, poor balance) Memory loss/dementia (in cases of severe/prolonged deficiencies) Clients who follow a vegan diet are encouraged to take supplemental vitamin B12 to prevent severe neurological complications. In addition, clients are taught to incorporate vitamin B12-fortified foods (eg, cereals, grain products, soy and nut milks, meat substitutes). (Options 1, 2, and 3) Visual disturbances, difficulty sleeping, and scaly patches of skin are likely not complications of a nutritional deficiency related to a vegan diet.

A student nurse assesses and obtains a urine specimen from a client with methicillin-resistant Staphylococcus aureus (MRSA) who is on contact precautions. The registered nurse intervenes when the student performs which action? 1. Cleans the disposable stethoscope with chlorhexidine solution before reuse with a different client 2. Removes the urine specimen cup from the room in a sealed biohazard bag 3. Scrubs the Foley catheter collection port with alcohol for 15 seconds before withdrawing a urine specimen 4. Uses an alcohol-based hand antiseptic solution after removing gloves

Clients with a health care-associated infection, such as methicillin-resistant Staphylococcus aureus, are placed on contact precautions to prevent transmission of microorganisms. Contact precautions include standard precaution measures in addition to use of a gown and gloves and single-client-use equipment (eg, stethoscopes, blood pressure cuffs, thermometers). Disposable or single-client-use equipment must not be shared between clients or transferred to other care areas. Dedicated equipment should be kept in the room for client care, and then disinfected or discarded when no longer needed (Option 1). (Option 2) The urine specimen should be placed in a leak-proof specimen cup and then sealed in a biohazard bag before transport to the laboratory. (Option 3) To prevent specimen contamination and the introduction of bacteria into the client's urinary tract, the nurse should scrub the Foley collection port with alcohol or chlorhexidine for 15 seconds before withdrawing a specimen. (Option 4) Hand hygiene with an alcohol-based hand rub is recommended, unless there is visible soiling of the hands with body fluids, or after contact with Clostridium difficile. In both situations, hand hygiene must be performed with soap and water to thoroughly remove contaminants left behind by alcohol-based rubs. Educational objective:

The nurse is caring for a client with acute pancreatitis admitted 2 days ago. Which assessment finding is most concerning? 1. Blood glucose levels for the past 24 hours are ≥250 mg/dL (13.9 mmol/L) [14%] 2. Client is lying with knees drawn up to the abdomen to alleviate pain [9%] 3. Five large, liquid stools that are yellow and foul-smelling [13%] 4. Temperature of 102.2 F (39 C) with increasing abdominal pain [62%]

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

The nurse is preparing to administer IV cefazolin to a client with cellulitis. The client's allergies are listed as amoxicillin, ciprofloxacin, and sulfa drugs. What should the nurse do first? 1. Administer the medication as prescribed [14%] 2. Clarify the prescription with the health care provider [49%] 3. Inquire about the type of allergic reaction [32%] 4. Notify the pharmacy that the drug is inappropriate [4%]

Clients with an allergy to penicillin antibiotics (eg, amoxicillin, ampicillin) can possibly experience a cross-sensitivity reaction to cephalosporin antibiotics (eg, cefazolin, cephalexin, ceftriaxone), because the drug molecules are structurally similar. The nurse should obtain more information about this client's reported allergies, as reactions range from mild to severe. In particular, the nurse must first assess the type of reaction the client had to amoxicillin (Option 3). The nurse should then clarify the prescription with the health care provider (HCP) prior to administration. If this client's reaction to amoxicillin was a rash or other mild reaction that was not life-threatening, the HCP may decide that cephalosporin can be safely administered. However, cephalosporins are contraindicatedfor a client with a history of anaphylactic reactions to penicillin, and a different antibiotic should be prescribed. (Option 1) The nurse should hold the medication until more is known about the client's reaction to amoxicillin. (Option 2) The nurse must first obtain more information about the reaction so the HCP can make an informed decision about whether the cephalosporin antibiotic can be administered or should be changed. (Option 4) The nurse must first obtain more information about the type of allergic reaction before notifying the pharmacy.

A nurse on an orthopedic unit is caring for four clients with a casted extremity. Which client does the nurse prioritize to see first? 1. Client reporting a tingling sensation 2. Client reporting itching under the cast 3. Client reporting pain of 5/10 on movement 4. Client reporting throbbing on dependent positioning

Clients with casted extremities after an acute injury are at risk for decreased peripheral perfusion due to increased edema and a cast that restricts the skin's ability to expand. Together, these create an impingement of the circulation, or acute compartment syndrome (ACS), which is a medical emergency. Nurses must prioritize clients demonstrating symptoms of ACS versus normal symptoms of a casted extremity. Expected responses include mild to moderate edema, warmth or throbbing secondary to edema, pain on movement or pain that improves with analgesics, itching (pruritus), and dry skin under the cast (Options 2, 3, and 4). High-priority symptoms that may indicate ACS include: Severe pain unresponsive to analgesics Immobility of digits Changes in sensation—tingling or numbness (indicating early nerve ischemia) (Option 1) Lack of pulses in distal extremity (not reliable for early ACS; absence of pulses indicates advanced/severe ACS) Cool and pale distal extremity

The nurse is performing discharge teaching on nutritional therapy for a client with chronic kidney disease. Which statement indicates that further teaching is needed? 1. "Because I have chronic kidney disease, I should avoid canned soups and cold-cut sandwiches." 2. "I can use a salt substitute because I am required to restrict both sodium and potassium in my daily diet." 3. "I must avoid eating raw carrots and tomatoes on my salads because I take hemodialysis treatments." 4. "The popsicles I eat should be counted in my daily fluid intake because they become liquid at room temperature."

Clients with chronic kidney disease (CKD) are at risk for fluid overload and hyperkalemia. Clients should avoid salt substitutes, which typically contain potassium chloride and may contribute to hyperkalemia (Option 2). To avoid further complications and prevent progressive kidney damage, clients with CKD are advised to follow certain dietary restrictions, including: Sodium restriction - Avoid high-sodium foods such as cured meats, pickled foods, canned soups, frankfurters, cold cuts, soy sauce, and salad dressings (Option 1). Potassium restriction - Avoid high-potassium foods such as raw carrots, tomatoes, and orange juice (Option 3). Fluid intake monitoring - Monitor fluid intake closely and accurately, being careful to include foods that are liquid-based (eg, popsicles, gelatin), because fluid is often restricted (Option 4). Low-protein diet - Eat 0.6-0.8 g/kg/day of protein to help prevent progression of kidney disease. If the client is already on hemodialysis, increased protein intake is recommended to prevent malnutrition. Low-phosphorus diet - Avoid foods high in phosphorus (eg, chicken, turkey, dairy).

The nurse evaluates morning laboratory results for several clients who were admitted 24 hours earlier. Which laboratory report requires priority follow-up? 1. Client with chronic obstructive pulmonary disease who has a PaCO2 of 52 mm Hg (6.9 kPa) [13%] 2. Client with heart failure who has a brain natriuretic peptide level of 800 pg/mL (800 ng/L) [15%] 3. Client with infected pressure ulcer who has a white blood cell count of 13,000/mm3 (13.0 x 109/L) [2%] 4. Client with pulmonary embolism who has a partial thromboplastin time of 127 seconds [68%]

Clients with pulmonary embolism or deep venous thrombosis are treated with anticoagulation. Unfractionated heparin is one such agent, and its efficacy is measured through partial thromboplastin time (PTT) levels. The goal during anticoagulation therapy is a PTT 1.5-2 times the normal reference range of 25-35 seconds. A PTT of 127 seconds is much too prolonged, and spontaneous bleeding could occur. (Option 1) Clients with chronic obstructive pulmonary disease typically have elevated PaCO2 levels secondary to air trapping. A PaCO2 of 52 mm Hg (6.9 kPa), although elevated from the normal range of 35-45 mm Hg (4.7-6.0 kPa), is not extreme for this client. (Option 2) Clients with heart failure are expected to have elevated brain natriuretic peptide (BNP) levels. The nurse should compare BNP levels with those from the previous day. The client is likely receiving therapy for heart failure and is therefore not a priority. (Option 3) A normal white blood cell (WBC) count is 4,000-11,000/mm3 (4.0-11.0 x 109/L). A WBC count of 13,000/mm3 (13.0 x 109/L) is elevated but would be expected in a client with an infection. Even if this is the client's first WBC result, it is not a priority over the client with elevated PTT.

A teenage client with sickle cell disease is admitted with a diagnosis of crisis. The client's current prescription is morphine 2 mg intravenous push every 4 hours prn. The client appears comfortable while watching television and tells the nurse "I have severe intolerable pain," and rates it a "10." What action should the nurse take? 1. Call the client's health care provider (HCP) to obtain a ibuprofen prescription for pain relief 2. Call the HCP for patient-control analgesia (PCA) at a higher dose of the same drug 3. Contact the HCP who issued the prescription to switch to meperidine 4. Realize the client is exhibiting signs of addictive behavior and needs an appropriate consult

Clients with sickle cell crisis often have excruciating pain related to the occlusion from the sickling and resulting ischemia. These individuals usually need large doses of narcotics as prior treatment has led to drug tolerance; they may also metabolize the drugs differently. Using only external cues to judge a client's pain is invalid as these clients have often learned how to distract themselves from focusing on the pain. Use of continuous PCA is recommended for relief rather than prn administration. (Option 1) Nonsteroidal anti-inflammatory drugs (eg, ibuprofen) are not very effective in treating the pain of sickle cell crisis. (Option 3) Meperidine (Demerol) is contraindicated for a sickle cell crisis as large frequent doses can result in normeperidine (toxic metabolite) accumulation. Symptoms start with tremors and can result in a seizure. (Option 4) Clients with sickle cell crisis are often undertreated due to the suspicion of drug abuse. However, studies have shown that the risk of abuse is small (0%-9%) and this range is similar to substance abuse risk in the general population. Therefore, the client's self-report is valid and appropriate treatment in the acute setting is warranted. Educational objective:Clients with sickle cell crisis often have excruciating pain and need large doses of narcotics. The most effective method is PCA of morphine or hydromorphone (Dilaudid). Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

Anabolic-androgenic steroids (AASs) are synthetic hormones used to treat hormonal disorders (eg, delayed puberty, male hypogonadism) and disease-associated (eg, cancer, AIDS) muscle loss but are commonly abused to enhance athletic performance by promoting increased muscle mass.

Clinical manifestations of AAS abuse in male clients include changes in mood (eg, aggressiveness, anxiety, depression), breast enlargement (ie, gynecomastia), rapid decrease in body fat and increase in muscle mass, development or worsening of acne, and development of male pattern baldness

The nurse reviews the medication administration records and laboratory results for assigned clients. Which medication requires that the health care provider be notified before administration? 1. Calcium acetate for a client with a phosphate level of 8.5 mg/dL (2.75 mmol/L) 2. Clopidogrel for a client with a platelet count of 70,000/mm3 (70 × 109/L) 3. Magnesium sulfate for a client with a magnesium level of 1.0 mEq/L (0.5 mmol/L) 4. Metformin for a client with a glycosylated hemoglobin level of 11%

Clopidogrel (Plavix) is a platelet aggregation inhibitor used to prevent blood clot formation in clients with recent myocardial infarction, acute coronary syndrome, cardiac stents, stroke, or peripheral vascular disease. Because it can cause thrombocytopenia and increase the risk for bleeding, the nurse should notify the health care provider(HCP) of the low platelet count (normal: 150,000-400,000/mm3 [150-400 × 109/L]) before administering clopidogrel. (Option 1) Calcium acetate (PhosLo) is used to control hyperphosphatemia in clients with end-stage kidney disease by binding to phosphate in the intestines and excreting it in the stool. Because the phosphate level is high (normal adult: 2.4-4.4 mg/dL [0.78-1.42 mmol/L]), it is not necessary to notify the HCP. (Option 3) Magnesium sulfate is used to correct hypomagnesemia and treat torsades de pointes and seizures associated with eclampsia. Because the magnesium level is low (normal adult: 1.5-2.5 mEq/L [0.75-1.25 mmol/L]), it is not necessary to notify the HCP. (Option 4) Metformin (Glucophage) is a first-line drug for the control of blood sugar in clients with type 2 diabetes mellitus. Glycosylated hemoglobin (A1C) measures the total hemoglobin that has glucose attached to it, expressed as a percentage. Glucose remains attached to the red blood cell for the life of the cell (about 120 days) and reflects glycemic control over an extended period. The recommended A1C level for a client with diabetes is <7%. Although the A1C level is elevated, the medication would be administered regardless of the result (unless the client is hypoglycemic), so it is not necessary to notify the HCP.

The nurse auscultates the lung sounds of a client with shortness of breath. Based on the sounds heard, which action would the nurse anticipate? Listen to the audio clip. (Headphones are required for best audio quality.) 1. Administer albuterol via nebulizer [20%] 2. Administer furosemide IV push [67%] 3. Instruct to use pursed-lip breathing [4%] 4. Prepare for chest tube insertion [7%]

Coarse crackles (loud, low-pitched bubbling) are heard primarily during inspiration and are not cleared by coughing. The sound is similar to that of Velcro being pulled apart. Coarse crackles may be confused with fine crackles (eg, atelectasis), which have a high-pitched popping sound. Coarse crackles are present when fluid or mucus collects in the lower respiratory tract (eg, pulmonary edema, pulmonary fibrosis). In heart failure, the left ventricle fails to eject enough blood, causing increased pressure in the pulmonary vasculature. As a result, fluid leaks into the alveoli (pulmonary edema). Diuretics (eg, furosemide) treat pulmonary edema by increasing fluid excretion by the kidneys (Option 2). (Option 1) Clients with asthma or chronic obstructive pulmonary disease (eg, emphysema) develop wheezing due to bronchospasm. Bronchodilators (eg, albuterol, ipratropium) are indicated for these clients. (Option 3) Emphysema is a chronic hyperinflation of the alveoli. Clients with emphysema are taught the pursed-lip breathing technique to prevent alveolar collapse during exhalation. Emphysema causes diminished lung sounds, prolonged expiration, and wheezing. (Option 4) Chest tubes are inserted into the pleural space to remove trapped air (eg, pneumothorax) or fluids (eg, hemothorax, pleural effusion). Lung sounds are diminished or absent when lung tissue is compressed by air or fluids in the pleural space.

Codeine

Codeine is an opioid drug prescribed as an analgesic to treat mild to moderate pain and as an antitussive to suppress the cough reflex. Although the antitussive dose (10-20 mg orally every 4-6 hours) is lower than the analgesic dose, clients can still experience the common adverse effects (eg, constipation, nausea, vomiting, orthostatic hypotension, dizziness) associated with the drug. Codeine decreases gastric motility, resulting in constipation. Increasing fluid intake and fiber in the diet and taking laxatives are effective measures to prevent constipation (Option 2). Changing position slowly is effective in preventing the orthostatic hypotension associated with codeine, especially in the elderly (Option 4). Taking the medication with food is effective in preventing the gastrointestinal irritation (eg, nausea, vomiting) associated with codeine (Option 5). (Options 1 and 3) These statements are inaccurate as photosensitivity, insomnia, palpitations, and anxiety are not adverse effects associated with codeine. Educational objective:The common adverse effects of codeine, an opioid drug, include constipation, nausea, vomiting, orthostatic hypotension, and dizziness. Interventions to help prevent them include increasing fluid intake and bulk in the diet, laxatives, taking the medication with food, and changing position slowly.

A healthy 50-year-old client asks the nurse, "What must I do in preparation for my screening colonoscopy?" Which statements by the nurse correctly answer the client's question? Select all that apply. 1. "No food or drink is allowed 8 hours prior to the test." 2. "Prophylactic antibiotics are taken as prescribed." 3. "Smoking must be avoided after midnight." 4. "The day prior to the procedure your diet will be clear liquids." 5. "You will drink polyethylene glycol as directed the day before."

Colonoscopy evaluates colonic mucosa. Therefore, clients should follow instructions to keep the colon clean with no stool left for better visualization during the procedure. These instructions include: Clear liquid diet the day before Nothing by mouth 8-12 hours prior to the examination The health care provider prescribes a bowel-cleansing agent such as a cathartic, enema, or polyethylene glycol (GoLYTELY) the day before the test. The type of prep depends on the health care provider's preference and client health status. (Option 2) Healthy clients screened for colon disease do not require antibiotics prior to the procedure. (Option 3) 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, but it is good for general health.

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

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

A 21-year-old client is being evaluated in the outpatient psychiatric clinic after starting isocarboxazid 2 weeks ago. Which of the client's statements needs to be addressed first? 1. "I am not sleeping well at night and would like a sleeping aid." 2. "I do not know how well I will do on this restricted diet." 3. "I have been having quite a bit of nausea and constipation." 4. "This medicine is not working; I am so tired of being depressed."

Commonly used monoamine oxidase inhibitors (MAOIs) include isocarboxazid, phenelzine, and tranylcypromine. These first-generation antidepressants are used only for resistant depression due to serious adverse affects. These medications inhibit the enzyme that breaks up norepinephrine, serotonin, and dopamine, thereby increasing their availability in the body. Clients taking MAOIs or other antidepressants are at increased risk for suicidal ideation, particularly children, adolescents, and young adults. The risk of suicidal thoughts can be more prevalent when starting the medication or with dose increases. Feelings of hopelessness or despair must be evaluated to assess if suicidal ideation or thoughts of self-harm are present (Option 4). (Option 1) MAOIs should be administered in the morning, as sleep dysfunction is common. This client statement should prompt a discussion of current medication habits, but is not the priority. (Option 2) Clients taking MAOIs need to avoid tyramine-containing foods (eg, cheese, overripe fruit, liquor, beef/chicken liver, fermented products) due to risk of hypertensive crisis. A medication change might be considered if a client is unable to adhere to the restrictions, but would not be priority. (Option 3) Nausea and constipation are adverse effects of MAOIs. Although strategies for management of adverse effects should be discussed, this is not priority. Educational objective:MAOIs and other antidepressants are associated with increased risk of suicidal ideation during the first few weeks of treatment. Clients taking MAOIs need to avoid tyramine-containing foods due to risk of hypertensive crisis. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

A client who underwent open reduction and internal fixation of a right tibial fracture 10 hours ago reports worsening leg pain that is unrelieved by PRN morphine. The nurse assesses that the client's right foot is cooler than the left. What is the nurse's priority action? 1. Administer the client's next dose of pain medication [0%] 2. Assess the client's vital signs [12%] 3. Maintain the extremity in a dependent position to promote blood flow [8%] 4. Report these findings to the health care provider immediately [79%]

Compartment syndrome (CS) results from compression of vascular structures by either external compression (restrictive dressings/casts) or increased pressure within a compartment (bleeding, inflammation, and edema). After an injury or trauma (eg, surgery), the vessels surrounding the injury site are compressed by swelling muscle and connective tissues. Muscle is encapsulated by a fibrous layer of fascia (ie, a compartment), which does not yield to swelling. Eventually, compression of tissues within the compartment restricts blood flow to the extremity. Signs of CS include the 6 Ps - pain (unrelieved by repositioning or analgesics), pallor, pulselessness, paresthesias, poikilothermia (coolness), and paralysis. The nurse should notify the health care providerimmediately as CS is a limb-threatening emergency and requires immediate surgery (fasciotomy) (Option 4). (Options 1 & 2) If the client is in pain, blood pressure and pulse may increase. However, assessing the client's vital signs and giving the client more analgesic medication do not address the signs of CS. These actions delay emergency intervention. This client has enough evidence for suspicion of CS. (Option 3) If CS is suspected, the nurse should place the extremity at heart level to promote venous return and limit swelling and loosen tight bandaging/casting material. If conservative measures fail, a fasciotomy(incision to open the fascia of the affected muscle compartment) may be required to relieve the compression.

A client in the postoperative period after an open reduction and internal fixation of a left wrist fracture reports constant, severe arm pain that is unrelieved by prescribed morphine administered 30 minutes ago. The client's nail beds appear dusky. What are the nurse's appropriate actions? Select all that apply. 1. Apply a heating pad and encourage range-of-motion exercises 2. Assess the temperature and movement of the fingers 3.Elevate the arm on pillows above the level of the heart 4. Notify the health care provider 5. Reassure the client, document findings, and reassess in 1 hour

Compartment syndrome, a serious postoperative complication, is caused by decreased blood flow to the tissue distal to the injury. It results from either decreased compartment size (restrictive dressings, splints, or casts) or increased pressure within the compartment (bleeding, inflammation, and edema). Earliest symptoms may include pain or numbness that is unrelieved by medication. Subsequent findings include diminished/absent pulses, pallor, coolness, swelling, decreased movement, and cyanosis. Failure to treat this condition can lead to loss of limb function, paralysis, and tissue necrosis. The nurse should assess neurovascular status and report to the health care provider immediately (Options 2 and 4). Removal of tight bandages/casts and fasciotomy (surgery) are required to relieve the pressure. (Option 1) Heat should not be applied to a client experiencing altered sensation, as it may burn the client. Active range of motion will not resolve compartment syndrome and delays needed care. (Option 3) Elevating the arm on pillows and providing additional analgesia may help reduce symptoms but may also reduce perfusion of the extremity. Instead, the extremity should be positioned at the level of the heart. (Option 5) Documenting findings is important. However, reassurance and reassessment 1 hour later without immediate intervention delays needed care.

The nurse will implement which nursing actions when caring for a client recently diagnosed with a hiatal hernia? Select all that apply. 1. Elevate the head of the hospital bed 2. Instruct the client to avoid tobacco and caffeine 3. Offer small, frequent, low-fat meals 4. Provide a girdle to reduce the hernia 5. Teach the client to avoid lifting or straining

Conditions that increase intraabdominal pressure (eg, pregnancy, obesity, ascites, tumors, heavy lifting) 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 (rolling hernia)occurs when the gastroesophageal junction remains in place but a portion of upper stomach folds up along the esophagus and forms a pocket. Paraesophageal hernias are a medical emergency. Although hiatal hernias may be asymptomatic, many clients experience signs and symptoms commonly associated with gastroesophageal reflux disease (GERD), including heartburn, dysphagia, and pain caused by increased intraabdominal pressure or supine positioning. Interventions to reduce herniation include the following: Diet modification—avoid high-fat foods and those that decrease lower esophageal sphincter pressure (eg, chocolate, peppermint, tomatoes, caffeine). Eat small, frequent meals, and decrease fluid intake during meals to prevent gastric distension. Avoid consumption of meals close to bedtime and nocturnal eating. Lifestyle changes—smoking cessation, weight loss. Avoid lifting or straining. Elevate the head of the bed to approximately 30 degrees—this can be done at home using pillows or 4 - 6 inch blocks under the bed. Wearing a girdle or tight clothes increases intraabdominal pressure and should be avoided.

A nurse is caring for a 1-month-old client who is being evaluated for congenital hypothyroidism. The nurse should recognize which of the following as clinical manifestations of hypothyroidism in infants? Select all that apply. 1. Difficult to awaken 2. Dry skin 3. Frequent, loose stools 4. Hoarse cry 5. Tachycardia

Congenital hypothyroidism occurs when abnormal development of the thyroid gland causes complete or decreased secretion of thyroid hormone (TH). Untreated hypothyroidism can cause severe intellectual disability in infants if undetected. Screening occurs after birth for all infants in the United States and Canada to prevent disability and encourage early treatment (ie, levothyroxine). TH plays an important role in growth, development, and regulation of many bodily functions (eg, heat production, muscle tone, skin function, cardiac function, metabolism). Clinical manifestations in affected infants reflect the pathophysiology of decreased TH and may include: Difficulty awakening, lethargy, or hyporeflexia due to alterations in central nervous system function (Option 1) Dry skin due to alterations in skin function (Option 2) Hoarse cry caused by swelling of the vocal cords due to fluid retention (Option 4) Constipation due to slowed metabolism Bradycardia due to the effect of TH on cardiac function (Options 3 and 5) Hyperthyroidism (Graves disease) is an autoimmune condition related to increased production of TH. Neonatal Graves disease is uncommon and usually occurs secondary to maternal hyperthyroidism. Tachycardia and increased bowel motility (frequent or loose stools) are features of hyperthyroidism and are related to an increase in metabolic processes.

A speeding driver sustained a closed-head injury in an acceleration/deceleration accident from striking a tree front end first. Based on the coup-contrecoup phenomenon, which assessments are most likely to be affected related to the involved areas of the brain? 1. Expressive speech, vision 2. Light touch, hearing 3. Sense of position, graphesthesia 4. Weber tuning fork test, cranial nerve I

Coup-contrecoup injury occurs when a body in motion stops suddenly (eg, head hits car windshield), causing contusions (bruising) 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 (Broca area), and voluntary movement are controlled by the frontal lobe. The contrecoup most likely injured the occipital lobe, where visionis processed. (Option 2) The temporal lobe (lateral aspect of the brain) controls hearing and integrates sensory data (eg, auditory, visual, somatic). The Wernicke speech area in the temporal lobe is responsible for language comprehension. Light touch is processed by the sensory cortex in the parietal lobe. (Option 3) An interruption of sensory function indicates injury to either the spinal column or the parietal lobe. These injuries affect proprioception (awareness of body positioning) and graphesthesia (ability to identify writing on the skin, by touch). (Option 4) The Weber test screens for conductive hearing loss by checking whether a tuning fork held along the midline of the head is heard evenly in both ears. Cranial nerve I is the olfactory nerve. Hearing and smell are both processed by the temporal lobe.

The evening shift nurse reviews the preoperative checklist and latest serum laboratory values for an elderly client with a ruptured diverticulum who is scheduled for surgery in the early morning. Which laboratory value is most important for the nurse to report to the health care provider? 1. Creatinine level 2.5 mg/dL (221 µmol/L) [55%] 2. Potassium level 3.5 mEq/L (3.5 mmol/L) [1%] 3. Sodium level 134 mEq/L (134 mmol/L) [2%] 4. White blood cell count 16,000/mm3 (16.0 × 109/L) [40%]

Creatinine level of 2.5 mg/dL (221 µmol/L) is the most important abnormal value (normal 0.6-1.3 mg/dL [53-115 µmol/L]) for the nurse to report to the health care provider. An elevated creatinine level increases the risk for intra- and postoperative complications. Nothing-by-mouth (NPO) status preoperatively, dehydration (ie, fluid shift from peritonitis), intraoperative fluid losses, antibiotic therapy, and advanced age affect renal function and increase the risk for postoperative exacerbation of kidney injury in this client. (Option 2) Potassium level 3.5 mEq/L (3.5 mmol/L) is within normal limits (3.5-5.0 mEq/L [3.5-5.0 mmol/L]). (Option 3) Sodium level 134 mEq/L (134 mmol/L) is decreased (normal 135-145 mEq/L [135-145 mmol/L]) but is most likely related to NPO status and fluid shift from peritonitis. (Option 4) Elevated White blood cell count (normal 4,000-11,000/mm3 [4.0-11.0 ×109/L]) is an expected finding related to ruptured diverticulum and peritonitis.

The nurse assesses a client with Cushing syndrome. Which clinical manifestations should the nurse expect? Select all that apply. 1. Hyperglycemia 2. Hypertension 3. Hyponatremia 4. Truncal obesity 5. Weight loss

Cushing syndrome is the result of prolonged exposure to excess corticosteroids, especially glucocorticoid steroids. The most common cause is the administration of corticosteroids, such as prednisone or hydrocortisone, for other conditions. However, pituitary adenomas can secrete adrenocorticotropic hormone (ACTH), which in turn causes the adrenal glands to produce too much cortisol. Clinical manifestations include: Androgen excess from adrenal gland stimulation can result in acne, hirsutism, and menstrual irregularities (eg, oligomenorrhea). Metabolic complications include truncal obesity (subsequently causing peripheral insulin resistance), hypertension, and hyperglycemia (ie, excess cortisol stimulating gluconeogenesis). Fat accumulation in the face (ie, moon face) and the back of neck (ie, buffalo hump) is common (Options 1, 2, and 4). Dermatological changes are possible and include easy bruising, purple striae, and skin atrophy; these result from loss of collagen. Proximal muscle weakness and bone loss (ie, osteoporosis) due to steroid catabolism on muscles and bone can develop in untreated clients. (Options 3 and 5) Hyponatremia and weight loss are associated with adrenocortical insufficiency, or Addison disease. Educational objective:Clinical manifestations of Cushing syndrome include weight gain, truncal obesity, moon face, skin atrophy, easy bruising, purple striae on the abdomen, muscle weakness, hypertension, and hyperglycemia. Associated androgen excess can result in acne, hirsutism, and menstrual irregularities. Additional Information Physiological Adaptation NCSBN Client Need

A highly intoxicated client was brought to the emergency department 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? 1. Administer atropine for bradycardia 2. Administer nifedipine for hypertension 3. Have CT scan performed to rule out an intracranial bleed 4. Perform hourly neurologic checks with Glasgow coma scale (GCS)

Cushing's triad is related to increased intracranial pressure (ICP). Early signs include change in level of consciousness. Later signs include bradycardia, increased systolic blood pressure with a widening pulse pressure (difference between systolic and diastolic), and slowed irregular (Cheyne-Stokes) 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 skull cannot expand after the fontanels close at age 18 months, so anything taking up more space inside the skull (eg, hematoma, tumor, swelling, etc.) is a concern for causing pressure on the brain tissue/brain stem and potential herniation. In this scenario, hidden head trauma causing an intracranial bleed must be ruled out with diagnostic testing. The client's intoxication could blunt an accurate history or presentation of a head injury. (Option 1) Atropine is used to stimulate the sinoatrial node in bradycardia with systemic symptoms. An electrocardiogram (ECG) should be obtained prior to administering atropine. In this client, there is no evidence of a cardiac etiology or systemic symptoms of poor perfusion/circulation from the bradycardia. (Option 2) Nifedipine (Procardia) is a calcium channel blocker that is a potent vasodilator. However, all components must be considered in this scenario as to the etiology of the hypertension rather than just treating that sign. Ruling out a cerebral cause of the hypertension is most important. (Option 4) The nurse would continue to perform neurologic assessments (including GCS). However, it is more important to obtain appropriate diagnostic tests and initiate treatment for the changing neurologic symptoms than to just monitor and document. In addition, the nurse should be performing these assessments more frequently than hourly in this rapidly changing client.

The nurse is reviewing new prescriptions from the health care provider. Which prescription would require further clarification? 1. Atorvastatin for hyperlipidemia in a client with angina pectoris [9%] 2. Bupropion for smoking cessation in a client with emphysema [15%] 3. Cyclobenzaprine for muscle spasms in a client with hepatitis [54%] 4. Metronidazole for trichomoniasis in a client with Crohn disease [20%]

Cyclobenzaprine (Flexeril) is a common, centrally acting skeletal muscle relaxant prescribed for muscle spasticity, muscle rigidity, and acute or chronic muscle pain/injury. Centrally acting muscle relaxants interfere with reflexes within the central nervous system (CNS) to decrease muscle spasm and rigidity. Like many medications, muscle relaxants are metabolized by the liver. The presence of liver disease (eg, hepatitis) decreases hepatic metabolism and can cause a buildup of medication, leading to medication toxicity and increased CNS depression (eg, weakness, confusion, drowsiness, lethargy). The prescription for a muscle relaxant would need to be clarified in a client with liver disease (Option 3). (Option 1) Atorvastatin (Lipitor) is a statin prescribed for hyperlipidemia. It is used for primary and secondary prevention of cardiovascular disease and would not warrant further clarification when used in a client with angina pectoris. (Option 2) Bupropion (Wellbutrin, Zyban) and varenicline (Chantix, Champix) are commonly prescribed for smoking cessation. Both bupropion and varenicline can cause serious neuropsychiatric effects (eg, depression, suicide); however, there is no contraindication for clients with emphysema. (Option 4) Metronidazole (Flagyl) is an antibiotic that can be used to treat a Trichomonasinfection. There is no contraindication for its use in clients with Crohn disease.

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

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

A client is diagnosed with diabetic ketoacidosis (DKA). The client reports frequent urination, thirst, and weakness. The nurse assesses a temperature of 102.4 F (39.1 C), fruity breath, deep labored respirations with a rate of 30/min, and dry mucous membranes. What is the priority nursing diagnosis (ND) at this time? 1. Deficient fluid volume related to osmotic diuresis 2. Imbalanced nutrition, less than body requirements related to inability to metabolize glucose 3. Ineffective breathing pattern related to the presence of metabolic acidosis 4. Ineffective health maintenance related to the inability to manage DM during illness

DKA is a life-threatening emergency caused by a relative or absolute insulin deficiency. The condition is characterized by hyperglycemia, ketosis, metabolic acidosis, and dehydration. The most likely contributing factors in this client include stress associated with illness and infection (elevated temperature) and inadequate insulin dosage and self-management. Deficient fluid volume related to osmotic diuresis secondary to hyperglycemia as evidenced by dry mucous membranes and client report of frequent urination, thirst, and weakness is the priority ND. Hyperglycemia leads to osmotic diuresis, dehydration, electrolyte imbalance, and possible hypovolemic shock and renal failure. Therefore, this condition requires rapid correction through the infusion of isotonic intravenous fluids and poses the greatest risk to the client's survival (Option 1). (Option 2) When the supply of insulin is insufficient and glucose cannot be metabolized for energy, the body breaks down fat stores leading to ketosis (fruity breath) and metabolic acidosis. However, it does not pose the greatest risk to survival and is not the priority ND. (Option 3) Tachypnea and deep labored respirations (ie, Kussmaul) are the body's attempt to eliminate excess acid (pCO2) through hyperventilation and normalize the pH. However, it does not pose the greatest risk to survival and is not the priority ND. (Option 4) Ineffective health maintenance related to inability to manage a condition during illness (evidenced by DKA development in this client) is an appropriate ND. However, it does not pose the greatest risk to survival at this time and is not the priority ND.

The nurse is reviewing client phone messages. Which client should the nurse call back first? 1. Client asking whether to take the morning dose of phenytoin before surgery the next day [29%] 2. Client taking dabigatran who reports heavier bleeding with her menstrual cycle [33%] 3. Client taking metronidazole who reports abdominal cramping and diarrhea [19%] 4. Client who has taken the last dose of insulin glargine and needs a refill [17%]

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

The nurse is preparing to defibrillate a client who suddenly went into ventricular fibrillation. Which steps are essential prior to delivering a shock? Select all that apply. 1. Apply defibrillator pads 2. Call out and look around to ensure that everyone is "all clear" 3. Continue chest compressions until ready to deliver shock 4. Ensure adequate IV sedation has been given 5. Ensure that the synchronization button is turned on

Defibrillation is indicated in clients with ventricular fibrillation (Vfib) and pulseless ventricular tachycardia. Cardiopulmonary resuscitation (CPR) should be initiated and compressions continued until the shock is ready to be delivered (Option 3). Certain pulseless rhythms (asystole and pulseless electrical activity) do not need defibrillation. Steps to perform defibrillation are as follows: Turn on the defibrillator Place defibrillator pads on the client's chest (Option 1) 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 (Option 2). Deliver the shock Immediately resume chest compressions (Option 4) IV sedation is not necessary for defibrillation as the client is already unconscious. It is often given prior to elective synchronized cardioversion to ease anxiety and decrease pain. (Option 5) Synchronized cardioversion delivers a shock on the R wave of the QRS complex and would not be appropriate for a client in Vfib (no identifiable QRS complexes). Rhythms that are ideal for synchronized cardioversion are supraventricular tachycardia, ventricular tachycardia with a pulse, and atrial fibrillation with rapid ventricular response. If the defibrillator is not synchronized with the R wave in a client with a pulse, the shock may be delivered on the T wave and can cause a lethal arrhythmia (eg, Vfib).

The school nurse is teaching a class of 10-year-old children about prevention of dental caries. Which recommendations would be part of the nurse's teaching plan? Select all that apply. 1. Chew sugar-free gum 2. Drink fruit drinks/juices instead of sugary, carbonated beverages 3. Include milk, yogurt, and cheese in dietary intake 4. Minimize consumption of sweet, sticky foods 5. Rinse mouth with water after meals when brushing is not possible

Dental caries (ie, cavities) form when bacteria (eg, Streptococcus mutans) digest carbohydrates in the mouth, producing acids that break down tooth enamel and cause mineral loss. Oral hygiene and dietary intake are significant factors contributing to the development of caries. Clients should increase intake of cariostatic foods, which have an inhibitory effect on the progression of dental caries (eg, dairy products, whole grains, fruits and vegetables, sugar-free gum containing xylitol) (Options 1 and 3). Cariogenic foods increase the risk for cavities and should be avoided. These include refined, simple sugars; sweet, sticky foods such as dried fruit (eg, raisins) and candy; and sugary beverages (eg, colas and other carbonated beverages, fruit drinks/juices) (Option 4). Additional practices to prevent dental caries include: Brushing after meals Flossing at least twice a day Rinsing the mouth with water after meals or snacks (Option 5) Drinking tap water rather than bottled water (most tap water sources add fluoride to promote dental health, whereas most bottled water does not contain fluoride) Finishing meals with a high-protein food (Option 2) Fruit drinks/juices contain high amounts of simple sugars; substituting these for other sugary beverages does not prevent dental caries. Whole fruits are better choices. Educational objective:Risk for dental caries can be reduced by avoiding highly cariogenic foods (eg, refined, simple sugars; sugary beverages; sweet, sticky foods), increasing intake of cariostatic foods (eg, dairy products, whole grains, fruits and vegetables), and maintaining oral hygiene (eg, brushing teeth, rinsing after meals). Additional Information Health Promotion and Maintenance NCSBN Client Need

A client with type 1 diabetes mellitus is on intensive insulin therapy. The client is of the Islamic faith and insists on fasting during Ramadan. What is the most important nursing action? 1. Advise the client of the risks of fasting when diabetic [22%] 2. Assess the client's clinical stability and glycemic control [47%] 3. Refer the client to the health care provider for adjustment of the insulin therapy [25%] 4. Refer the client to the registered dietitian for meal planning [5%]

Diabetic clients whose religious practices require them to change their current diet (eg, fasting) and glycemic management regimen should be assessed for clinical stability (eg, comorbidities) and glycemic control, including: History of hyperglycemia, hypoglycemia, and ketoacidosis Dosage and timing of medications Knowledge of meal planning Ability to perform blood glucose monitoring during the fast Fasting during Ramadan is one of the Five Pillars of Islam. Observance of Ramadan and daytime fasting occurs throughout the ninth month of the lunar calendar. During this time, Muslim clients are required to refrain from food and drink from dawn to sunset. Clients who are sick, children, pregnant women, and the elderly are exempt from fasting; however, some clients who fall into these categories may insist on fasting, creating challenges for their health care team. (Option 1) Clients with diabetes who are at lower risk for adverse events while fasting based on risk assessment need to receive instruction on adjusting their meal planning, physical exercise, and insulin therapy. Those at high risk for complications should be discouraged from fasting. (Options 3 and 4) These are appropriate nursing actions after the client has been assessed for risk of diabetic complications from fasting.

initiate K IV when serum K is 3.5-5

Diabetic ketoacidosis (DKA) is an acute, serious complication generally due to lack of insulin in clients with type 1 diabetes. DKA is characterized by hyperglycemia, ketosis, and acidosis. Hyperglycemia causes osmotic diuresis, resulting in profound dehydration. Clients with DKA may initially develop hyperkalemia as a compensatory response to acidosis despite having a total body potassium deficit from urinary loss. Management of DKA includes fluid resuscitation, IV insulin, and hourly blood glucose monitoring. When serum glucose is <250 mg/dL (13.9 mmol/L), D5W is administered to prevent hypoglycemia until ketoacidosis is resolved. Hypokalemia often occurs with resolution of acidosis and administration of IV insulin, which shifts potassium from the intravascular to the intracellular space. Therefore, potassium is administered even when the client is normokalemic (3.5-5.0 mEq/L [3.5-5.0 mmol/L]) to prevent hypokalemia and subsequent life-threatening arrhythmias (Option 4). (Option 1) Serum potassium, glucose, and anion gap or bicarbonate levels are regularly monitored in DKA to monitor treatment effectiveness. Although serum creatinine and BUN levels may be elevated due to dehydration and may be monitored, hourly monitoring is not indicated. (Option 2) IV insulin infusion may be discontinued on resolution of acidosis and ketosis, which generally occurs with a blood glucose level of <200 mg/dL (11.1 mmol/L). (Option 3) As blood glucose is reduced, the insulin infusion rate is decreased to prevent a hypoglycemic event. Educational objective:Hypokalemia often occurs with resolution of diabetic ketoacidosis and administration of IV insulin, which shifts potassium from the intravascular to the intracellular space. Potassium is administered even when the client is normokalemic (3.5-5.0 mEq/L [3.5-5.0 mmol/L]) to prevent life-threatening arrhythmias. Additional Information Physiological Adaptation NCSBN Client Need

A client returns to the unit after receiving hemodialysis for the first time. The client vomits once, reports headache, and appears restless and disoriented. What is the priority intervention? 1. Administer antihypertensives that were held prior to dialysis 2. Administer PRN ondansetron to relieve nausea 3. Contact the health care provider 4. Place client in Trendelenburg position

Dialysis disequilibrium syndrome (DDS) is a rare but potentially life - threatening complication that can occur in clients during the initial stages of hemodialysis (HD); it can be prevented by slowing the rate of dialysis. During HD, solutes (ie, urea) are removed more quickly from the blood than from the brain cells and cerebrospinal fluid, creating a concentration gradient that can lead to excess fluid in the brain cells and increased intracranial pressure. Characteristic neurologic manifestations include nausea and vomiting, headache, restlessness, change in mentation, and seizure activity. If DDS is suspected, the health care provider should be contacted immediately (Option 3). If severe, DDS can progress to coma and death. If DDS is identified during treatment, the rate of dialysis should be slowed or stopped. Treatment focuses on interventions to decrease cerebral edema and manage symptoms. (Option 1) Antihypertensives are withheld prior to HD to minimize the risk for hypotension. If the client is not hypotensive after HD, prescribed antihypertensives should be administered but are not the priority intervention for a client with DDS. (Option 2) Antiemetics should be administered to treat nausea associated with DDS, but they are not the priority intervention. (Option 4) Trendelenburg position may increase cerebral edema and would be inappropriate for a client with DDS. Educational objective:Dialysis disequilibrium syndrome (DDS) is a potentially life-threatening condition associated with cerebral edema. Characteristic neurologic manifestations include nausea and vomiting, headache, restlessness, change in mentation, and seizure activity. If DDS is suspected, the health care provider should be contacted immediately and dialysis should be slowed or stopped.

Which interventions would the nurse expect to be included in the care plan for a client with acute diverticulitis who has acute pain rated 8/10, nausea and vomiting, blood pressure 126/64 mm Hg, apical pulse 102/min, respirations 20/min, and temperature 101.2 F (38.4 C)? Select all that apply. 1. Administration of morphine sulfate 2 mg via intravenous (IV) push 2. Instructions to avoid straining 3. Maintenance of nothing-by-mouth (NPO) status 4. Placement of an IV line and infusion of normal saline 75 mL/hr 5. Protection of the skin from diarrhea by insertion of a rectal tube

Diverticular disease of the colon is a condition in which sac-like protrusions in the large intestine are caused by chronic increased intraabdominal pressure (eg, straining, lifting, tight clothing) and/or chronic constipation. When diverticula become infected and inflamed, the individual has diverticulitis. Acute care for diverticulitis focuses on allowing the colon to rest and the inflammation to resolve. This includes: NPO status - more acute cases require complete rest of the bowel. Less severe cases may be handled at home, and clients may tolerate a low-fiber or clear liquid diet (Option 3). IV fluids to prevent dehydration when NPO (Option 4) Pain relief via IV medications to maintain NPO status (Option 1) Preventing increased intraabdominal pressure to avoid perforation and rupture (Option 2) Preventing increased intestinal motility - avoid laxatives and enemas (Option 5) The most common area for diverticula to form is the sigmoid colon. Inserting a rectal tube/colonoscope/sigmoidoscope may cause further damage or perforation of the inflamed diverticula by increasing pressure and stimulating the rectum.

Which prescription should the nurse question when caring for a hospitalized client diagnosed with acute diverticulitis? 1. Metronidazole 500 mg IV every 8 hours [13%] 2. Nasogastric (NG) tube to suction [19%] 3. Nothing by mouth (NPO) [6%] 4. Prepare for barium enema in AM [59%]

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 the following: IV antibiotic therapy - to cover the gram-negative and anaerobic organisms that reside in the colon and contribute to diverticulitis; these commonly include metronidazole (Flagyl) plus trimethoprim/sulfamethoxazole (TMZ) (Bactrim or Bactrim DS; Septra) or ciprofloxacin (Cipro) (Option 1) NPO status - more acute cases require complete rest of the bowel (NPO status); less severe cases may be handled at home, and clients may tolerate a low-fiber or clear liquid diet (Option 3) NG suction - in severe cases of abdominal distention, nausea, or vomiting (Option 2) IV fluids - prevent dehydration Bed rest (Option 4) Any procedure or treatment that increases intraabdominal pressure (lifting, straining, coughing, bending), increases peristalsis (laxative, enema), or could lead to perforation or rupture of the inflamed diverticula should be avoided during the acute disease process. A barium enema may be used after treatment with antibiotics and the inflammation is resolved. Diagnostic examinations, such as abdominal x-rays or CT scans, may be used without risking rupture.

The clinic nurse supervises a graduate nurse who is teaching the parents of a 2-year-old with acute diarrhea about home management. The nurse would need to intervene when the graduate nurse provides which instruction? 1. "Do not administer antidiarrheal medications to your child." [26%] 2. "Follow the bananas, rice, applesauce, and toast diet for the next few days." [32%] 3. "Record the number of wet diapers and return to the clinic if you notice a decrease." [28%] 4. "Use a skin barrier cream such as zinc oxide in the diaper area until diarrhea subsides." [12%]

During bouts of acute diarrhea and dehydration, treatment focuses on maintaining adequate fluid and electrolyte balance. The first-line treatment is oral rehydration therapy, using oral rehydration solutions (ORSs) to increase reabsorption of water and sodium. Even if the diarrhea is accompanied by vomiting, ORS should still be offered in small amounts at frequent intervals. Continuing the child's normal diet (solid foods) is encouraged as it shortens the duration and severity of the diarrhea. The BRAT (bananas, rice, applesauce, and toast) diet is not recommended as it does not provide sufficient protein or energy. (Option 1) Use of antidiarrheal medications is discouraged as these have little effect in controlling diarrhea and may actually be harmful by prolonging some bacterial infections and causing fatal paralytic ileus in children. (Option 3) Parents should be taught to monitor their child for signs of dehydration by checking the amount of fluid intake, number of wet diapers, presence of sunken eyes, and the condition of the mucous membranes. (Option 4) Protecting the perineal skin from breakdown during bouts of diarrhea can be accomplished by using skin barrier creams (eg, petrolatum or zinc oxide).

The nurse assesses a client receiving peritoneal dialysis. Which assessment findings are most important for the nurse to report to the health care provider? Select all that apply. 1. Cloudy outflow 2. Low-grade fever 3. Oliguria 4. Pruritus 5. Tachycardia

During peritoneal dialysis (PD), a catheter is placed into the peritoneal cavity to infuse dialysate (dialysis fluid); the tubing is then clamped to allow the fluid to dwell for a specified period. After the dwell time, the catheter is unclamped and the fluid (effluent) drains out via gravity. Cloudy outflow (effluent), tachycardia, and low-grade fever are signs of peritonitis, an infection of the peritoneal cavity and a major concern with PD. Bloody fluid can indicate intestinal perforation or that the client may be menstruating. Brown effluent can indicate fecal contamination from perforation. All these findings need to be reported to the health care provider. (Option 3) Oliguria (very low urine output) is associated with acute or chronic kidney failure and is the reason the client is receiving peritoneal dialysis. It does not indicate a complication of PD. (Option 4) Pruritus (itching) is a common finding in clients with kidney failure, and may occur due to dry skin, neuropathy, or skin deposits of waste products (eg, urea, calcium-phosphate) that are normally removed via the kidney. PD can help relieve this symptom of kidney failure by filtering waste products.

A client with Ebola was just admitted to the unit. Which actions by the nurse would represent appropriate care of this client? Select all that apply. 1. Ensuring the client wears an N95 respirator at all times 2. Keeping the door of the client's room closed at all times 3. Maintaining a log of everyone in and out of the client's room 4. Removing both pairs of gloves before removing gown and mask 5. Restricting visitors from entering the client's room

Ebola (viral hemorrhagic fever) is an extremely contagious disease with a high mortality rate. Clients require standard, contact, droplet, and airborne precautions (eg, impermeable gown/coveralls, N95 respirator, full face shield, doubled gloves with extended cuffs, single-use boot covers, single-use apron). The client is placed in a single-client airborne isolation room with the door closed (Option 2). Visitors are prohibited unless absolutely necessary for the client's well-being (eg, parent visiting an infected child) (Option 5). For disease surveillance, a log is maintained of everyone entering or exiting the room, and all logged individuals are monitored for symptoms (Option 3). 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. (Option 1) In a private airborne isolation room, the client does not require a respirator mask. However, all other individuals entering the room must don appropriate personal protective equipment (PPE). (Option 4) The PPE removal process after caring for a client with Ebola requires strict monitoring by a trained observer. The outer gloves are first cleaned with disinfectant and removed. The inner gloves are wiped between removal of every subsequent piece of PPE (eg, respirator, gown) and removed last.

The nurse is providing care for a client with cancer of the left lung who will undergo video-assisted thoracic surgery in the morning. The client is nervous, jumpy, and short of breath. Pulse is 120/min, respirations are 30/min and shallow, and expiratory wheezing is auscultated in the left upper and lower lung posteriorly. Which of the following is the priority nursing action? 1. Administer prescribed intravenous morphine 2 mg to relieve anxiety 2. Page respiratory therapist to administer inhaled bronchodilator nebulizer treatment 3. Place head of the bed in Fowler's or high Fowler's position 4. Stay with client and encourage client to discuss feelings about the surgery

Elevating the head of the bed to Fowler's or high Fowler's position is the priority nursing action to help relieve shortness of breath, facilitate oxygenation (breathing), and promote lung expansion (airway). Alternate positions to high Fowler's include the following: Orthopneic position: Sitting in a chair, on the side, or in bed leaning over the bedside table, with one or more pillows under the arms or elbows for support Tripod position: Sitting in a chair leaning forward with hands or elbows resting on the knees. Sitting upright and leaning forward pulls the scapulae apart, promotes lung expansion, and decreases the diaphragmatic pressure produced by the viscera. (Option 1) Morphine is effective in relieving anxiety and decreasing the work of breathing by slowing respirations. It can cause hypoventilation and decrease gas exchange in the lungs and is not the priority action, especially as the client's respirations are shallow. (Option 2) The cause of the wheezing could be from lung tumor or true bronchoconstriction. Paging the respiratory therapist to administer a bronchodilator nebulizer treatment to relieve wheezing is an appropriate intervention, but it is not the priority action. (Option 4) Encouraging the client to talk about the diagnosis and upcoming surgery is an appropriate intervention to help alleviate anxiety and address self-actualization needs, but is not the priority action.

The nurse is providing teaching about contraception to a group of clients. Which statement by the nurse is appropriate to include? 1. "Backup contraception is required for the first 3 months after initiation of oral contraceptives." 2. "Diaphragm contraceptive devices, when used with spermicide, also provide protection from HIV infection." 3. "Over-the-counter emergency contraceptives should be taken within 3 days of unprotected intercourse." 4. "Use of an intrauterine device should be avoided in sexually active adolescent clients."

Emergency contraception (EC) prevents pregnancy after unprotected intercourse. Over-the-counter EC pills (eg, high-dose levonorgestrel [Plan B One-Step]) should be taken within 3 days (72 hr) of unprotected sexual intercourse (Option 3). If taken after 3 days, levonorgestrel will not harm an established pregnancy but may be less effective. Copper intrauterine device (IUD) insertion and oral ulipristal (eg, Ella) require a prescription and offer EC for up to 5 days (120 hr) after unprotected intercourse. (Option 1) 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. (Option 2) Diaphragms are flexible latex or silicone devices that cover the cervix and create a barrier against sperm. Spermicide (eg, nonoxynol 9) is applied to the rim of the device to increase effectiveness. Neither provides reliable protection against sexually transmitted infections (STIs), and spermicide may increase the risk of HIV transmission. (Option 4) Adolescents are appropriate candidates for IUD placement, which provides long-term contraception, and its effectiveness is not dependent on actions at the time of coitus. STI prevention (eg, condoms) and screening is important for all sexually active adolescents, especially those using IUDs. Educational objective:Over-the-counter emergency contraception pills (eg, high-dose levonorgestrel) are most effective within 3 days of unprotected sexual intercourse, whereas intrauterine devices (IUDs) offer emergency contraception for up to 5 days. Additional Information Health Promotion and Maintenance NCSBN Client Need

Lumbar puncture Pre-op and Post-op

Empty the bladder before the procedure The procedure can be performed in the lateral recumbent position or sitting upright. These positions help widen the space between the vertebrae and allow easier insertion of the needle A sterile needle will be inserted between the L3/4 or L4/5 interspace Pain may be felt radiating down the leg, but it should be temporary After the procedure, instruct the client as follows: Lie flat with no pillow for at least 4 hours to reduce the chance of spinal fluid leak and resultant headache Increase fluid intake for at least 24 hours to prevent dehydration

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? 1. 40-year-old client who has been taking hormonal birth control pills for the past 10 years 2. 45-year-old client who reports a history of an ectopic pregnancy with a ruptured ovary and two preterm births 3. 47-year-old client with polycystic ovary syndrome, obesity, and a history of unsuccessful infertility treatments 4. 60-year-old client who recently had a colposcopy after testing positive for a high-risk type of human papillomavirus

Endometrial cancer arises from the inner lining of the uterus and forms after the development of unregulated endometrial overgrowth (ie, hyperplasia). Although typically slow growing, it can metastasize to the myometrium (ie, uterine muscle tissue), cervix, and nearby lymph nodes and eventually beyond the pelvis. Many signs of endometrial cancer are nonspecific (eg, lower back or abdominal pain), but the hallmark symptom is abnormal uterine bleeding (eg, heavy, prolonged, intermenstrual, and/or postmenopausal bleeding). As with many cancers, the client's family and genetic history (eg, BRCA mutation carrier) are significant risk factors; however, prolonged estrogen exposure without adequate progesteroneis the greatest risk factor for developing endometrial cancer. Factors increasing estrogen exposure and endometrial cancer risk include: Conditions associated with infrequent or anovulatory menstrual cycles (eg, polycystic ovary syndrome, infertility, late menopause, early menarche) (Option 3) Obesity Tamoxifen (a medication given for breast cancer) (Option 1) Progestin-containing contraceptives (ie, birth control pills) are associated with a decreased endometrial cancer risk because progestins thin the uterine lining, therefore preventing endometrial hyperplasia. (Option 2) Ectopic pregnancy with a ruptured ovary or preterm birth is not associated with endometrial cancer, although never giving birth at term gestation may increase ovarian cancer risk. (Option 4) Infection with a high-risk type of human papillomavirus increases cervical (not endometrial) cancer risk.

The nurse on the medical-surgical unit receives report on assigned clients. Which client warrants immediate attention? 1. Client experiencing abdominal cramps 2 hours after colonoscopy 2. Client reporting white stools 8 hours after barium swallow study 3. Client with epigastric pain after endoscopic retrograde cholangiopancreatography 4. Client with small bowel obstruction with copious, greenish-brown drainage from the nasogastric tube

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. Signs and symptoms include acute epigastric or left upper quadrant pain, often radiating to the back, and a rapid rise in pancreatic enzymes (eg, amylase, lipase) (Option 3). (Option 1) Abdominal cramps can occur after a colonoscopy due to air inflation during the procedure. (Option 2) The barium contrast solution used during the procedure may make the client's stool white for up to 3 days. The nurse should encourage fluids, if appropriate, to assist in expulsion of the contrast medium. (Option 4) Copious, bile-colored (greenish-brown) drainage is expected in a client with a small bowel obstruction. The nurse should watch for signs and symptoms of electrolyte imbalances (hypokalemia), dehydration, and metabolic alkalosis.

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? Select all that apply. 1. "Avoid drinking alcoholic beverages." 2. "Do not abruptly stop taking your phenytoin." 3. "Go to the emergency department every time a seizure occurs." 4. "Wear an epilepsy medical identification bracelet." 5. "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 (Option 1). Practicing relaxation techniques (eg, biofeedback) may help reduce the number of episodes. The client should also be encouraged to wear an epilepsy medical identification bracelet in case of emergency (Option 4). Phenytoin (Dilantin), a hydantoin anticonvulsant, may decrease the effectiveness of some medications (eg, oral contraceptives, warfarin) due to stimulation of hepatic metabolism. An alternate, nonhormonal birth control method (eg, condoms, copper intrauterine device) should be used in addition to or instead of oral contraceptives (Option 5). Clients should discuss pregnancy plans with their health care provider, as phenytoin can cause fetal abnormalities (eg, cleft palate, heart malformations, bleeding disorders). Clients taking phenytoin should also receive education about practicing good oral hygiene as gingival hyperplasia is a potential complication. Anticonvulsants should not be stopped abruptly, as this increases the risk of seizure (Option 2). (Option 3) For a client with epilepsy, it is not necessary to go to an emergency department after a seizure, unless status epilepticus (ie, prolonged, repeated seizures) occurs or the client is injured.

The nurse is precepting a graduate nurse (GN) who is planning care for a newborn with suspected esophageal atresia and tracheoesophageal fistula. Which statement by the GN demonstrates a correct understanding? Select all that apply. 1. "I will closely monitor the client for respiratory distress." 2. "I will initiate contact isolation in expectation of projectile vomiting." 3. "I will insert and maintain a peripheral IV for the prescribed fluids." 4. "I will monitor oral and nasal secretions continuously and suction as needed." 5. "I will position the infant supine, with the head of the bed elevated."

Esophageal atresia (EA) and tracheoesophageal fistula (TEF) are congenital malformations in which, most commonly, the upper esophagus ends in a blind pouch (ie, atresia) and the lower esophagus connects to the primary bronchus or trachea. Priority nursing interventions include continuous monitoring for signs of complications related to aspiration (eg, respiratory distress); inserting and maintaining a peripheral IV for continuous fluids; frequent suctioning of the nasal and oropharyngeal secretions to maintain a patent airway; and supine positioning, with the head of the bed elevated to prevent aspiration of secretions (Options 1, 3, 4, and 5). The nurse should maintain the infant on NPO status until surgical repair is complete; projectile vomiting is a typical manifestation of pyloric stenosis, not EA/TEF (Option 2).

A newborn is being evaluated for possible esophageal atresia with tracheoesophageal fistula. Which finding is the nurse most likely to observe? 1. Choking and cyanosis during feeding 2. Concave (scaphoid) abdomen 3.Diminished lung sounds [2%] 4.Projectile vomiting after feeding

Esophageal atresia (EA) and tracheoesophageal fistula (TEF) consist of a variety of congenital malformations that occur when the esophagus and trachea do not properly separate or develop. In the most common form of EA/TEF, the upper esophagus ends in a blind pouch and the lower esophagus connects to the primary bronchus or the trachea through a small fistula. EA/TEF can usually be corrected with surgery. Clinical manifestations of EA/TEF include frothy saliva, coughing, choking, and drooling. Clients may also develop apnea and cyanosis during feeding (Option 1). Aspiration is the greatest risk for clients with EA/TEF, and newborns who demonstrate signs of the condition are immediately placed on nothing by mouth (NPO) status. (Option 2) A newborn with EA/TEF may have a distended abdomen due to the buildup of air in the stomach via the fistula from the trachea to the lower esophagus. A concave (ie, scaphoid) abdomen is associated with a congenital diaphragmatic hernia due to the migration of abdominal organs to the thoracic space. (Option 3) Diminished lung sounds are not an ordinary sign of EA/TEF unless aspiration pneumonia develops. These may be an indication of a diaphragmatic hernia or pneumothorax. (Option 4) A newborn with EA/TEF may experience apnea, choking, and cyanosis due to aspiration of fluid while eating. Projectile vomiting after feeding is a classic manifestation of hypertrophic pyloric stenosis. Educational objective:Clinical manifestations of EA/TEF include frothy saliva, coughing, choking, drooling, and a distended abdomen. Clients may also develop apnea and cyanosis while feeding. These findings must be reported to the health care provider for further evaluation.

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? Select all that apply. 1.m "A few years ago, I switched from smoking cigarettes to smoking cigars 1 or 2 times a week." 2. "I am proud that I was able to lose 10 lb, but I'm still considered obese for my height." 3. "I drink 3 or 4 beers nightly to relax, but I did switch to light beer recently." 4. "I have struggled with daily episodes of acid reflux for years, especially at nighttime." 5. "I snack on a lot of salted foods like popcorn and peanuts."

Esophageal cancer is a rare, rapidly growing 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 (eg, cigarettes, pipe, cigars) and excessive alcoholconsumption (ie, approximately >15 drinks/week for men, >8 drinks/week for women) (Options 1 and 3). 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 (which allows stomach acid to flow upward into the esophagus due to increased abdominal pressure) and uncontrolled gastroesophageal reflux disease contribute to the development of Barrett esophagus; they are both closely linked with esophageal cancer (Options 2 and 4). (Option 5) Consumption of salty foods is not associated with an increased risk of esophageal cancer but increases the risk of gastric cancer. Dietary factors that may increase a client's risk of esophageal cancer include high intake of nitrosamine-containing foods (eg, pickled foods, beer), frequent ingestion of extremely hot beverages (thermal injury), and deficient intake of fruits and vegetables. Educational objective:Esophageal cancer is a rapidly growing malignancy of the esophageal lining. Risk factors for esophageal cancer include smoking, excessive alcohol consumption, obesity, and gastroesophageal reflux disease. Additional Information Health Promotion and Maintenance NCSBN Client Need

A client with active pulmonary tuberculosis is prescribed 4-drug therapy with ethambutol. The community health nurse instructs the client to notify the health care provider immediately if which adverse effect associated with ethambutol occurs? 1. Blurred vision [46%] 2. Dark-colored urine [4%] 3. Difficulty hearing [25%] 4. Yellow skin [23%]

Ethambutol (Myambutol) is used in combination with other antitubercular drugs (eg, isoniazid, rifampin, pyrazinamide) to treat active tuberculosis. The client must have baseline and periodic eye examinations during therapy as optic neuritis is a potentially reversible adverse effect. The client is instructed to report signs of decreased visual acuity and loss of color (red-green) discrimination. (Options 2 and 4) Dark-colored urine and yellow skin can indicate the presence of hepatotoxicity, which is associated with many drugs used to treat tuberculosis (eg, isoniazid, pyrazinamide, rifampin). However, hepatotoxicity is not common with ethambutol. (Option 3) Difficulty hearing (tinnitus, subjective hearing loss) is an adverse reaction to streptomycin. Streptomycin, an aminoglycoside antibiotic, is a second-line drug sometimes used to treat multi-drug-resistant tuberculosis, with ototoxic and nephrotoxic adverse effects.

Which statements related to ethical nursing practices are correct? Select all that apply. 1. Accountability is documenting that the nurse administered the wrong medication 2. Autonomy is informing the client of the decision the family made for the client 3. Confidentiality is respecting a client's request to keep suicidal ideation a secret 4. Justice is providing the same cardiac care to a homeless person as a businessperson 5. Nonmaleficence is reporting abuse for a client with Alzheimer disease

Ethical principles guide decision making and appropriate behavior. Justice is treating every client equally regardless of gender, sexual orientation, religion, ethnicity, disease, or social standing (Option 4). Accountability refers to accepting responsibility for one's actions and admitting errors (Option 1). Nonmaleficence means doing no harm. It also relates to protecting clients who are unable to protect themselves due to their physical or mental condition. Examples include infants/children, clients under the effects of anesthesia, and clients with dementia (Option 5). (Option 2) Autonomy is freedom for a competent client to make decisions for oneself, even if the nurse or family does not agree (eg, informed consent, advanced directive). The nurse can provide information and should respect the client's decisions. (Option 3) Confidentiality means that information shared with the nurse is kept in confidence unless permission is given to share or it is required by law to be shared to protect the client and/or community (eg, reportable infectious diseases). If a client discusses suicidal ideation with the nurse, it must be appropriately reported to protect the client from self-harm.

The nurse is reinforcing education to a client with a venous thromboembolism who is prescribed rivaroxaban. Which statement by the client indicates the medication teaching has been effective? 1. "I need to continue to avoid eating spinach and kale." 2. "I probably will have some weakness in my legs when I take this medicine." 3. "I should avoid taking aspirin while receiving this medication." 4. "I will have to get blood drawn routinely to check my clotting levels."

Factor Xa inhibitors (eg, rivaroxaban [Xarelto], edoxaban, apixaban) are anticoagulants used to prevent and treat venous thromboembolism. Factor Xa inhibitors are being prescribed more frequently than other oral anticoagulants (eg, warfarin), as they have a lower risk of bleeding and require less ongoing monitoring (eg, PT/INR). Clients prescribed rivaroxaban should be educated to avoid taking over-the-counter medications or supplements that increase bleeding risk, such as NSAIDs (eg, aspirin), garlic, and ginger. The combined effects of rivaroxaban and other anticoagulants may greatly increase the risk of uncontrolled bleeding (eg, epidural, intracranial, gastrointestinal) and hemorrhage (Option 3). (Option 1) Unlike warfarin, factor Xa inhibitors are not affected by vitamin K, which is found in many green, leafy vegetables (eg, spinach, kale). (Option 2) Anticoagulants, particularly factor Xa inhibitors, increase the risk for spontaneous intracranial bleeding or formation of epidural hematomas. Clients taking factor Xa inhibitors should be instructed to immediately contact their health care provider for symptoms of neurological impairment (eg, extremity weakness, altered sensation, numbness). (Option 4) Routine monitoring of clotting times (eg, PT/INR, PTT) is unnecessary for clients prescribed factor Xa inhibitors. Educational objective:The nurse should instruct clients receiving factor Xa inhibitors (eg, rivaroxaban, edoxaban, apixaban), which are anticoagulants, to avoid taking additional medications or supplements with anticoagulant effects (eg, NSAIDs, garlic, ginger). The combined anticoagulant effects increase the risk for uncontrolled bleeding and hemorrhage.

The nurse is caring for an older adult client who is confused and has a high risk for falls. The client is incontinent of urine and frequently attempts to get out of bed unassisted to use the restroom. Which nursing interventions are appropriate when caring for this client? Select all that apply. 1. ensuring bed alarms remain activated 2. initiating an hourly rounding schedule 3. inserting an indwelling urinary catheter 4. moving client to a room close to the nurse's station 5. raising all side rails of the client's bed

Falls can occur with any client; however, advanced age, incontinence, confusion, and presence of lines, tubes, and drains increase the risk for falls and injury. Interventions to reduce falls in high-risk clients include: Hourly rounding (eg, assessing pain, offering toileting and nutrition) (Option 2) Moving the client to a room close to the nurses' station (Option 4) Activating bed alarms to alert staff if the client gets out of bed unassisted (Option 1) Asking family members or visitors to stay at the bedside with the client (Option 3) Lines, tubes, and drains (eg, indwelling urinary catheter, IV tubing) tether (ie, tie) the client to the bed or equipment and limit mobility, increasing fall risk. In addition, indwelling urinary catheters increase risk for infection and should be used only when clinically indicated (eg, strict hourly output, critical illness), not for the nurse's convenience (eg, clients requiring frequent toileting or incontinence care). The nurse can reduce urinary urgency and incontinence episodes by offering clients toileting with hourly rounding. (Option 5) Raising all side rails is considered a physical restraint and is associated with more severe fall injuries from clients attempting to climb over the side rails. Educational objective:Interventions to reduce falls in high-risk clients include hourly rounding, moving the client to a room close to the nurses' station, and using bed alarms. Lines, tubes, drains (eg, indwelling urinary catheters), and restraints (eg, all side rails raised) increase fall risk and should be used only when clinically indicated. Additional Information Safety and Infection Control NCSBN Client Need

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? 1. Fasting for 7 days is not likely to cause health problems 2. Fasting spares protein in favor of fat metabolism 3. Fasting will help control hunger pangs in the long term 4. Initial weight loss during fasting is primarily from fluid loss

Fasting for more than 1 or 2 days can cause a number of health problems: Increased stress - when fasting, the body goes into "starvation mode;" metabolism slows down and cortisol production increases Muscle damage - in starvation mode, the body breaks down muscle and converts amino acids to glucose Fluid loss - glycogen stores in the liver are also broken down as an energy source; this metabolic process releases water, resulting in fluid loss Increased hunger - appetite hormones are suppressed during a fast; however, when regular eating habits are resumed, appetite will be increased Depletion of essential nutrients Fatigue, headache, dehydration, dizziness, and muscle weakness (Option 1) Fasting for more than 1 or 2 days can lead to health problems. (Option 2) In starvation mode, the body will use protein, fat, and stored carbohydrates as energy sources. Protein is not spared. (Option 3) Appetite may be suppressed during a fast after the first few hours/days; however, when regular intake is resumed, hunger will return. Educational objective:Fasting can cause multiple health problems, including increased stress, slowing of the body's metabolism, muscle damage, fluid loss, increased hunger, depletion of nutrients, and physical symptoms such as headache, dizziness, fatigue, and muscle weakness.

The clinic nurse is taking vital signs on a client who reports being fatigued every day and gaining weight lately despite not eating much. The nurse should also ask about which symptoms? Select all that apply. 1. Cold intolerance 2. Constipation 3. Fever 4. Menstrual irregularity 5. Night sweats 6. Tachycardia

Fatigue and weight gain are classic manifestations of hypothyroidism. Features of hypothyroidism typically result from decreased metabolic rate and include cold intolerance, constipation, dry skin, irregular or prolonged menstrual periods, and mental slowing or difficulty concentrating. (Options 3, 5, and 6) Fever, tachycardia, and sweating are signs of hyperthyroidism, which is a hypermetabolic state, with signs and symptoms that are usually the opposite of those seen in hypothyroidism. The presenting symptoms of a hyperthyroid client would likely include weight loss despite an increased appetite and difficulty sleeping.

The registered nurse is teaching the parent of a 6-year-old about behavioral strategies for treating fecal incontinence due to functional constipation. Which statement by the parent indicates a need for further teaching? 1. "I will give my child a picture book to look at during toilet time." [29%] 2. "I will give my child a reward for each bowel movement while sitting on the toilet." [34%] 3. "I will keep a log of my child's bowel movements, laxative use, and episodes of soiling." [23%] 4. "I will schedule regular toilet sitting time for my child." [11%]

Fecal incontinence (ie, encopresis, soiling) refers to the repeated passage of stool in inappropriate places by children age ≥4 years. In more than 80% of cases, it is due to functional constipation (retentive type); in about 20% of cases, it may be caused by psychosocial triggers (nonretentive type). Management of fecal incontinence/constipation primarily includes 3 components: Disimpaction followed by prolonged laxative therapy, dietary changes (increased fiber and fluid intake), and behavior modification. Behavioral strategies are used to promote and restore regular toileting habits and to gain the child's cooperation and participation in the treatment program. Behavioral interventions include the following: Regularly schedule toilet sitting times 5-10 minutes after meals for 10-15 minutes (Option 4) Provide a quiet activity for the child during toilet sitting, which will help pass the time and make the experience more "enjoyable" (Option 1) Initiate a reward system to boost the child's participation in the treatment program; the reward would be given for effort, not for success of evacuation in the toilet (children with retentive encopresis have dysfunctional anal sphincters and little control over bowel movements; giving a reward for something the child has no control over would not be effective) (Option 2) Keep a diary or log of toilet sitting times, stooling, medications, and episodes of soiling to evaluate the success of the treatment (Option 3)

A student nurse is caring for a client with iron deficiency anemia who is newly prescribed ferrous sulfate. Which action by the student nurse requires the supervising nurse to intervene? 1. Encourages the client to drink extra fluids while taking ferrous sulfate 2. Offers the client orange juice for administration of ferrous sulfate 3. Plans to administer ferrous sulfate one hour before breakfast 4. Prepares to administer a prescribed calcium supplement with ferrous sulfate

Client prescribed ferrous sulfate for iron deficiency anemia, which action requires nursing intervention? * administering prescribed calcium supplement with ferrous sulfate

Ferrous sulfate is an oral iron supplement prescribed to prevent or treat iron deficiency anemia, which occurs when the body lacks sufficient iron, an essential mineral in the formation of new RBCs. Low iron levels may result from malabsorption, insufficient intake, increased requirements (eg, pregnancy), or blood loss. The nurse should avoid administering calcium supplements or antacids with or within 1 hour of ferrous sulfate because calcium decreases iron absorption (Option 4). (Option 1) Taking an iron supplement increases the client's risk for constipation. Instructing the client to increase fluid intake during therapy may help prevent hard stools. (Options 2 and 3) Taking an iron supplement with vitamin C (eg, orange juice) further enhances duodenal acidity and increases absorption. An acid-rich environment enhances iron absorption, so oral supplements should be taken 1 hour before or 2 hours after meals. Educational objective:Ferrous sulfate is an oral iron supplement prescribed to prevent or treat iron deficiency anemia. The nurse should administer the medication 1 hour before or 2 hours after meals because it is best absorbed in an acidic environment. Antacids or calcium supplements decrease absorption of iron if administered with or within 1 hour of ferrous sulfate. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

A client with fibromyalgia refuses to take the prescribed drug duloxetine. When the nurse asks, why, the client responds, "Because I'm not depressed!" What is the nurse's most appropriate response? 1. "Depression is common with fibromyalgia, but a low dose of this drug can prevent it." [12%] 2. "It can relieve your chronic pain and help you sleep better at night." [58%] 3. "It helps to relieve the adverse effects of your other prescribed drugs." [11%] 4. "You have the right to refuse. I will notify your health care provider (HCP)."[17%]

Fibromyalgia (FM) results from abnormal central nervous system pain transmission and processing. It is characterized by chronic, bilateral musculoskeletal axial pain (above and below the waist), multiple tender points, fatigue, and sleep/cognitive disturbances. Duloxetine (Cymbalta) is a serotonin-norepinephrine reuptake inhibitor that has both antidepressant and pain-relieving effects. It is used to relieve chronic pain that interferes with normal sleep patterns in clients with FM. With the restoration of normal sleep patterns, fatigue often improves as well (Option 2). Other effective drugs to treat the chronic pain associated with FM include pregabalin and amitriptyline (Elavil), an older tricyclic antidepressant drug. (Option 1) Although depression often accompanies chronic pain, duloxetine can be prescribed specifically to treat the chronic pain associated with FM. (Option 3) Duloxetine is prescribed for major depressive disorder and to relieve pain associated with diabetic neuropathy and FM. It is not given to relieve the adverse effects of other drugs. (Option 4) A client has the right to refuse any drug. However, the nurse should first explain the purpose of the drug to the client before notifying the HCP.

The nurse is providing teaching for parents of a child diagnosed with fifth disease. Which statement by a parent indicates a need for further teaching? 1. "Our child should be feeling much better in 7-10 days." 2. "Our child's condition is communicable until the rash disappears." 3. "We will ensure our child covers the mouth and nose when coughing or sneezing." 4. "We will give our child ibuprofen to treat the joint pain."

Fifth disease ("slapped face," or erythema infectiosum) is a viral illness caused by the human parvovirus and affects mainly school-age children. The virus spreads via respiratory secretions, and the period of communicability occurs before onset of symptoms. The child will have a distinctive red rash on the cheeks that gives the appearance of having been slapped. The rash spreads to the extremities and a maculopapular rash develops, which then progresses from the proximal to distal surfaces. The child may have general malaise and joint pain that are typically well controlled with nonsteroidal anti-inflammatory drugs such as ibuprofen. Affected children typically recover quickly, within 7-10 days. Once these children develop symptoms (eg, rash, joint pains), they are no longer infectious. Isolation is not usually required unless the child is hospitalized with aplastic crisis or immunocompromising condition. (Options 1, 3, and 4) These statements indicate that parent teaching regarding fifth disease was effective.

A client with asthma was recently prescribed fluticasone/salmeterol. After the client has received instructions about this medication, which statement would require further teaching by the nurse? 1. "After taking this medication, I will rinse my mouth with water." 2. "At the first sign of an asthma attack, I will take this medication." 3. "I have been smoking for 12 years, but I just quit a month ago." 4. "I received the pneumococcal vaccine about a month ago."

Fluticasone/salmeterol (Advair) is a combination drug containing a corticosteroid (fluticasone) and a bronchodilator (salmeterol). Salmeterol is a long-acting inhaled β2-adrenergic agonist that promotes relaxation of the bronchial smooth muscles over 12 hours. Fluticasone decreases inflammation. This medication is used as part of the treatment plan for prevention and long-term control of asthma. Client instructions include: After inhalation, rinse the mouth with water without swallowing to reduce the risk of oral/esophageal candidiasis Avoid smoking and using tobacco products Receive the pneumococcal and influenza vaccines if there is a risk for infection (Option 2) Fluticasone/salmeterol is not a rescue inhaler and does not treat acute exacerbations of asthma. The client should always have a rescue inhaler (eg, albuterol [short-acting β2-adrenergic agonist] or ipratropium [Atrovent]) for sudden changes in breathing and call 911 if the rescue inhaler does not relieve the breathing problem.

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? Select all that apply. 1. Add high-protein foods to diet 2. Consume high-carbohydrate meals 3. Eat small, frequent meals 4. Increase intake of fluids with meals 5. 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, nausea/vomiting, dizziness, generalized sweating, and tachycardia. The symptoms usually diminish over time. Recommendations to delay gastric emptying include: Consume meals high in fat, protein, and fiber, which take more time to digest and remain in the stomach longer than carbohydrates (Option 1). These foods also help meet the body's energy needs. Avoid consuming fluids with meals because this causes stomach contents to pass faster into the jejunum, which worsens symptoms. Fluid intake should occur up to 30 minutes before or after meals. Slowly consume small, frequent meals to reduce the amount of food in the stomach (Option 3). Avoid meals high in simple carbohydrates (eg, sugar, syrup) because these may trigger symptoms when the carbohydrates break down into simple sugars. Avoid sitting up after a meal because gravity increases gastric emptying. Instead, lying down after meals is encouraged (Option 5). (Option 2) Avoid meals high in simple carbohydrates because these may trigger dumping syndrome. (Option 4) Avoid consuming fluids with meals to reduce the risk of dumping syndrome. Educational objective:Dumping syndrome is a complication of gastrectomy. To delay gastric emptying and reduce the risk of dumping syndrome, clients should consume meals low in carbohydrates and high in fiber, proteins, and fats; avoid fluids during meals; eat small, frequent meals; and lie down after eating. Additional Information Reduction of Risk Potential NCSBN Client Need

A graduate nurse (GN) is caring for a postpartum client who is exclusively breastfeeding following a vaginal birth. Which action by the GN requires the nurse preceptor to intervene? 1. Allows the client's family and friends to visit as requested by the client within 1-2 hours of the birth 2. Delays administration of newborn antibiotic ophthalmic ointment until 2 hours following the birth 3. Encourages the client to send the newborn to the nursery each night to allow the client to rest 4. Promotes skin-to-skin contact with the newborn immediately following the birth and anytime the parents desire

Following birth, bonding and attachment between the client and newborn is supported by close contact (eg, rooming-in, skin-to-skin contact); rather than encouraging separation for long periods of time (eg, all night), the nurse should facilitate rooming-in to provide the client opportunities to learn and respond to the newborn's needs and to promote frequent breastfeeding (Option 3). Bonding is enhanced by encouraging skin-to-skin contact for both parents and by limiting visitors only if medically necessary (Options 1 and 4). The nurse can safely delay application of prophylactic antibiotic eye ointment for up to 2 hours after birth to encourage eye contact with the parents and avoid disruption in bonding (Option 2).

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 priorityintervention? 1. Blurry vision in the affected eye 2. Constipation 3. Itching in the affected eye 4. Sleeping on 2 pillows at night

Following cataract surgery, the client will be instructed that for several days (or until approved by the surgeon), activities that may increase intraocular pressure should be avoided to decrease the risk of damage to sutures or surgical site. These include bending (eg, vacuuming floors, playing golf), lifting more than 5 lb, sneezing, coughing, rubbing or placing pressure on the eye, or straining during a bowel movement. The nurse should encourage this client to increase fluids and fiber in the diet as well as consider an over-the-counter stool softener or laxative. (Option 1) It may take 1-2 weeks before visual acuity is improved. (Option 3) It is common for the client to experience itching ("sand" in the eye), photophobia, and mild pain for several days following surgery. Purulent drainage, increased redness, and severe pain should be reported. (Option 4) Sleeping on 2 pillows will elevate the head of the bed and decrease intraocular pressure.

The nurse is assessing a client an hour after a left lung lobectomy. The client is awake, alert, and oriented, and reports pain of 6 on a 0-10 scale. Pulse oximetry is 92% on 4 L oxygen via nasal cannula. The chest tube is set to continuous water seal suction at -20 cm H2O. The collection chamber has accumulated 320 mL of frank red drainage in the last hour. What is the priority nursing action? 1. Clamp the chest tube immediately 2. Increase oxygen to 6 L via nasal cannula 3. Medicate client for pain and document the findings 4. Notify the health care provider immediately

Following lung surgery, a chest tube is inserted into the pleural space to create a negative vacuum to re-inflate the lung and prevent air from re-entering the space. A client with a chest tube should be assessed for signs of air/fluid in the chest (eg, diminished breath sounds), excessive drainage (>100 mL/hr), pain, and infection at the drainage site. The collection chamber should be inspected every hour for the first 8 hours following surgery, then every 8 hours until it is removed. Excess drainage of frank red blood is indicative of hemorrhage and must be managed immediately. The priority action is to contact the health care provider for further management. (Option 1) Clamping the chest tube prevents air or fluid from leaving the pleural space, which may cause a reciprocal tension pneumothorax. The chest tube is clamped only a few hours prior to removal, momentarily to check for an air leak, or if the drainage apparatus needs to be changed. (Option 2) Although a pulse oximetry of 92% is low, this is an expected finding following lung surgery. (Option 3) Pain following surgery is a concern and the client will require medication; however, hemorrhage is the priority.

A client is being discharged home after an open radical prostatectomy. Which statement indicates a need for further teaching? 1. "I will try to drink lots of water." 2. "I will try to walk in my driveway twice a day." 3. "I will wash around my catheter twice a day." 4. "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 (Option 4). (Option 1) Fluid intake should be encouraged in this client. (Option 2) The client is at risk for postoperative deep vein thrombosis and pulmonary embolism. Ambulation is an important part of preventing these serious surgical complications. Ambulation will also help reduce constipation. (Option 3) The client who goes home with an indwelling catheter should learn how to clean around the catheter at the urinary meatus with warm water and soap to prevent infection. Educational objective:Clients who have had an open radical prostatectomy for prostate cancer should avoid anything that could cause strain on the rectal area. Straining, suppositories, and enemas are contraindicated in these clients, and interventions should be implemented to prevent constipation.

A nurse reviews the plan of care for a client who has increased intracranial pressure. Which nursing actions should be included? Select all that apply. 1. Administer a stool softener 2. Dim lights when not providing care 3. Elevate head on several pillows 4. Maintain body in midline position 5. Only perform oral suctioning when necessary

For clients with increased intracranial pressure (ICP), the goal is to reduce ICP while managing the client's basic needs; however, many nursing activities increase client ICP. Nursing interventions to decrease ICP include: Position head of bed to 30 degrees to promote venous return from the head, which will decrease cerebral edema. Elevating the head >30 degrees decreases blood pressure, which can decrease cerebral perfusion pressure (CPP); therefore, position the client to balance ICP and CPP. Keep head and body midline and avoid extreme hip or neck flexion as this impedes venous drainage (Option 4). Administer stool softeners to prevent straining to defecate (Option 1). Straining and coughing increase intrathoracic and intraabdominal pressure, which increase ICP. Keep the client in a calm environment with minimal noise and disturbances (eg, dim lights, limit visitors) (Option 2). Suction only when needed to maintain airway and for no longer than 10 seconds per suctioning pass (Option 5). Reduce metabolic demands (eg, pain, seizures, hypoxia, fever). Treat fever aggressively (eg, acetaminophen) but avoid shivering. (Option 3) For clients with increased ICP, elevating head of bed is preferred over utilizing pillows to elevate the head as pillows may flex the neck, decrease venous drainage, and increase ICP.

A nurse is teaching a parent of an infant about administration of an oral medication. What should be included in the teaching? Select all that apply. 1. Add the medication to the bottle of formula before feeding 2. Direct liquid medication toward the inside of the infant's cheek 3. Hold the infant in a semi-reclining position during administration 4. Measure and administer the medication using an oral syringe 5. Open the infant's mouth by gently pinching the nose shut

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 (Option 4). Oral medication should be administered with the infant in a semi-reclining position, which is similar to the feeding position (Option 3). 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 (Option 2). The medication should be dispensed slowly in small amounts, allowing the infant to swallow between squirts to prevent aspiration. (Option 1) 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. In addition, if the infant does not complete the full feed, underdosing will occur. (Option 5) 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 in the emergency department receives 4 clients. Which client should the nurse see first? 1. Child who is confused and irritable and whose parent claims 2 glyburide pills are missing [61%] 2. Child with an abscess on the buttock that is red, swollen, and warm to the touch[0%] 3. Child with immune thrombocytopenia who fell off a bike and reports shoulder pain [14%] 4. Child with low-grade fever, barking cough, and runny nose who has mild retractions [23%]

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 (irritability, confusion), hypoglycemia is likely. This client requires immediate intervention as severe hypoglycemia can result in coma and/or death. (Option 2) Buttock abscess, although painful, is not an emergency. Incision and drainage are needed. (Option 3) 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; therefore, this client is not the top priority. (Option 4) This child with brassy (barking) cough most likely has croup, which can be life-threatening and needs urgent assessment. However, because this client seems to be stable, the child with possible glyburide ingestion should be seen first. This child has mild retractions, a sign that the child is still moving air but work of breathing has increased. The presence of stridor or severe suprasternal, subcostal, and intercostal retractions would make this client a higher priority. Educational objective:Ingestion of antidiabetic drugs (eg, glyburide, glipizide, glimepiride) by a nondiabetic client (eg, child) is an emergency as severe hypoglycemia can result in coma and/or death. Additional Information Management of Care NCSBN Client Need

The nurse cares for a client following a percutaneous coronary intervention via the right groin. The client received an IV infusion of abciximab during the procedure. Which actions should the nurse implement? Select all that apply. 1. Assess invasive procedure sites for bleeding 2. Check hemoglobin and platelet count 3. Initiate a second large-bore IV line 4. Place the client on continuous cardiac monitoring 5. Report black tarry stools to the health care provider

Glycoprotein (GP) IIb/IIIa receptor inhibitors (eg, abciximab, eptifibatide, tirofiban) are used as platelet inhibitors to prevent the occlusion of treated coronary arteries during percutaneous coronary intervention procedures and prevent acute ischemic complications. GP IIb/IIIa receptor inhibitors can cause serious bleeding. The nurse should closely monitor the client for any bleeding at the groin puncture site after the percutaneous coronary intervention (Option 1). The nurse should check the client's baseline complete blood count (eg, hemoglobin, platelet count). Some clients may develop serious thrombocytopenia within a few hours, further increasing the bleeding risk (Option 2). Hypotension, tachycardia, changes in heart rhythm, blood in the urine, abdominal/back pain, mental status changes, and black tarry stools may also indicate internal bleeding and should be monitored carefully when GP IIb/IIIa receptor inhibitors are administered (Options 4 and 5). (Option 3) During and after the infusion of GP IIb/IIIa receptor inhibitors, no traumatic procedures(initiation of IV sites, intramuscular injections) should be performed unless absolutely necessary due to the risk of bleeding.

Glycoprotein (GP) IIb/IIIa receptor inhibitors are (eg, abciximab, eptifibatide, tirofiban) used as platelet inhibitors to prevent the occlusion of treated coronary arteries during percutaneous coronary intervention procedures and prevent acute ischemic complications. GP IIb/IIIa receptor inhibitors can cause serious bleeding. The nurse should closely monitor the client for any bleeding at the groin puncture site after the percutaneous coronary intervention (Option 1). The nurse should check the client's baseline complete blood count (eg, hemoglobin, platelet count). Some clients may develop serious thrombocytopenia within a few hours, further increasing the bleeding risk (Option 2). Hypotension, tachycardia, changes in heart rhythm, blood in the urine, abdominal/back pain, mental status changes, and black tarry stools may also indicate internal bleeding and should be monitored carefully when GP IIb/IIIa receptor inhibitors are administered (Options 4 and 5). (Option 3) During and after the infusion of GP IIb/IIIa receptor inhibitors, no traumatic procedures (initiation of IV sites, intramuscular injections) should be performed unless absolutely necessary due to the risk of bleeding.

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? Select all that apply. 1. The nurse accepts money from the victim 2. The nurse does not accompany the victim on the ambulance 3. The nurse does not apply direct pressure to the artery 4. The nurse knows the victim from college 5. The victim dies after reaching the hospital

Good Samaritan laws prevent civil action against nurses who stop of their own accord (eg, not part of their job duties) to help injured individuals after an accident. The nurse cannot receive payment for any care given (Option 1). 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 (Option 3). (Option 2) 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. (Option 4) Knowing the client does not affect the application of Good Samaritan laws. (Option 5) This nurse is not liable for the victim's outcome as long as the nurse performs in a competent manner.

A client with type 2 diabetes, coronary artery disease, and peripheral arterial disease developed hospital-acquired pneumonia (HAP) and has been receiving intravenous (IV) antibiotics for 4 days. Which parameter monitored by the nurse best indicates the effectiveness of treatment? 1. Color of sputum [7%] 2. Lung sounds [37%] 3. Saturation level [6%] 4. White blood cell count (WBC) [48%]

HAP is a bacterial infection acquired in a health care facility that was not present on admission. Almost all clients with bacterial pneumonia develop leukocytosis (WBC >11,000/mm3). Antibiotic therapy is the first-line treatment, but antibiotic resistance frequently occurs in HAP. If antibiotic therapy is effective, clinical improvement usually occurs within 3-4 days of initiation of IV antibiotics. The nurse monitors WBC as the best indicator of treatment effectiveness as antibiotics cause bacterial lysis or hinder bacterial DNA reproduction. The reduced number of bacteria and the resulting decrease in inflammation cause a decrease in the number of white blood cells needed to fight the infection. Other indicators of treatment effectiveness include improvement of infiltrates on chest x-ray, oxygenation, and signs and symptoms (cough, fever, sputum production). (Option 1) The color of sputum (eg, clear, yellow, green, grey, rusty, blood-tinged) can vary with different types of pneumonia; it is not the best indicator of treatment effectiveness. (Option 2) Adventitious/abnormal lung sounds (crackles, low-pitched wheeze, bronchial breath sounds) can be present as the pneumonia resolves or can be a sign of further complication (pleural effusion). However, these are not the best indicators of treatment effectiveness. (Option 3) Saturation is an indicator of oxygenation but can be affected by many other factors, such as coexisting disease, peripheral circulation, and drugs. It is not the best indicator of treatment effectiveness. Educational objective:Indicators of treatment effectiveness for HAP include decreased WBC on complete blood count with differential and improvement of infiltrates on chest-x-ray, oxygenation, and signs and symptoms (cough, fever, sputum production). Additional Information Physiological Adaptation NCSBN Client Need

A nurse is caring for a client who is intubated and has a subclavian central venous catheter. Which nursing intervention is most important to prevent the spread of infection to this client? 1. Frequent hand hygiene [86%] 2. No artificial nails [1%] 3. Use of chlorhexidine bath wipes [5%] 4. Wearing personal protective equipment [6%]

Hand hygiene is the most important factor in preventing infection transmission. The nurse should perform hand hygiene before and after client contact, before donning and after removing gloves, and after contact with bodily fluids (Option 1). Principles for proper hand hygiene include: Apply alcohol-based hand rubs liberally, covering the entire surface of the hands, and allow hands to dry completely. Do not use an alcohol-based hand rub if hands are visibly soiled. When using soap and water, wet the hands; apply soap; scrub all hand surfaces, wrists, and beneath the nails for at least 20 seconds; rinse; dry hands with a paper towel; and then use a new, dry paper towel to turn off the faucet. (Option 2) The nurse should not wear artificial nails, especially in high-risk areas (eg, intensive care unit), because artificial nails harbor microorganisms, even after hand washing. However, the priority intervention for infection prevention is hand hygiene. (Option 3) The nurse should use chlorhexidine to bathe clients who are critically ill, have central venous catheters, or are scheduled for surgery; and for indwelling catheter care. However, the risk for infection transmission would remain high if the nurse implements client care without performing hand hygiene. (Option 4) Personal protective equipment (eg, gloves) is appropriate but is not as important as (and does not replace) hand hygiene to prevent the spread of infection.

The nurse receives an obese client in the postanesthesia care unit who underwent a procedure under general anesthesia. The nurse notes an oxygen saturation of 88%. Which is the most appropriate initial intervention? 1. Assess pupillary response 2. Auscultate lung sounds 3. Inform anesthesia professional 4. Perform head tilt and chin lift

Head tilt and chin lift is a maneuver used to open the airway. The tongue may fall back and occlude the airway due to muscular flaccidity after general anesthesia. Manifestations associated with airway obstruction include snoring, use of accessory muscles, decreased oxygen saturations, and cyanosis. (Option 1) Constricted pupils can help identify opioid overdose. However, this should not be assessed before opening the airway. (Option 2) Auscultation of lung sounds should be done for every client as part of the postoperative assessment. However, the initial goal is to return the oxygen saturation level to normal (95%-100%). Hypoxia in an obese postoperative client who received general anesthesia is most likely due to airway obstruction. (Option 3) The anesthesia professional may need to be informed, but methods to restore the oxygen saturation level should be tried first. The anesthesia professional may then want to assess the sedation level of the client and prescribe a reversal agent.

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 (UTIs)? Select all that apply. 1. Cleanse periurethral area with antiseptics every shift 2. Ensure each client has a separate container to empty collection bag 3. Keep catheter bag below the level of the bladder 4. Routinely irrigate the catheter with antimicrobial solution 5. Use sterile technique when collecting a urine specimen

Health care catheter-associated UTIs are prevalent among hospitalized clients with indwelling urinary catheters. Steps to prevent infections in clients with urinary catheters include the following: 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 each client 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 bag 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 (tape or Velcro device) Inspect the catheter and tubing for integrity, secure connections, and possible kinks (Option 1) Perineal hygiene is performed using soap and water only every shift and as needed. Routine use of antiseptic cleansers is not shown to prevent infection and may lead to the development of drug-resistant bacteria. (Option 4) Routine irrigation with antimicrobial solution or systemic administration of antimicrobials is not recommended for routine catheter care and infection prevention.

Unlicensed assistive personnel report 4 situations to the registered nurse. Which situation warrants the nurse's intervention first? 1. Room 1: Client on a 24-hour urine collection had a specimen discarded by mistake 2. Room 2: Client and family request clergy to administer last rites 3. Room 3: Puncture-resistant sharps disposal container on the wall is full 4. Room 4: Client with diabetes mellitus has an 8 AM fingerstick glucose of 80 mg/dL (4.4 mmol/L)

Health care workers are required to abide by Occupational Safety and Health Administration standards and regulations to reduce work-related injuries (eg, sharps) and exposure to bloodborne pathogens (eg, HIV, hepatitis B and C). 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. (Option 1) 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 immediate intervention is not required. (Option 2) The nurse will arrange for a visit from clergy to administer the last rites (Sacrament of the Sick), a religious ceremony for Roman Catholic clients who are extremely or terminally ill. Although the situation requires prompt intervention, it does not involve a safety hazard. (Option 4) A fingerstick glucose of 80 mg/dL (4.4 mmol/L) is normal (70-110 mg/dL [3.9-6.1 mmol/L]) and requires no intervention unless the client received insulin and refuses or is unable to eat.

After morning report, the nurse must perform which action first when caring for assigned clients? 1. Administer IV bumetanide to a client with heart failure who has bilateral crackles and dyspnea 2. Hang the second unit of packed red blood cells for a client with a hemoglobin of 6 g/dL (60 g/L) 3. Replace the empty IV opioid medication syringe in a patient-controlled analgesia pump 4. Replace the heparin infusion bag that has 100 mL remaining and is infusing at 50 mL/hr

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 (Lasix) 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. (Option 2) The second unit of packed red blood cells is required to raise the hemoglobin to increase the blood's oxygen-carrying capacity, but this is not as urgent as improving gas exchange in the lungs. (Option 3) The patient-controlled analgesia tubing is connected to a running IV that is attached to an IV pump, so the IV line should remain patent even if the opioid syringe is empty. A short delay in receiving analgesia does not pose a threat to the client's survival, so this is not the priority action. (Option 4) An electronic IV pump is used to administer a heparin infusion. A new IV container is replaced when 50 mL is remaining to ensure the bag does not run dry. At the current rate of 50 mL/hr with 100 mL remaining, the new bag should be hung in about 1 hour, so this is not the priority action. Educational objective:Bumetanide (Bumex) is prescribed for clients with heart failure to promote diuresis and mobilize excess fluid in the systemic circulation and the lungs, which results in increased cardiac output and improved gas exchange. Additional Information Management of Care NCSBN Client Need

The nurse in the emergency department receives report on 4 clients. Which client should be seen first? 1. 5-year-old with an accidental epinephrine auto-injector stick and a heart rate of 124/min[13%] 2. 7-year-old who is crying, has vaginal lacerations and bruising, and has a heart rate of 118/min [16%] 3. 10-year-old with a large, draining abscess on the left buttock and a temperature of 101.2 F (38.4 C) [0%] 4. 14-year-old who is lethargic after playing a football game and has a temperature of 104.1 F (40.1 C) [68%]

Heatstroke occurs when excessive environmental heat exposure and/or overexertion (eg, athletics) cause hyperthermia and depletion of fluid and electrolytes (sweating, increased respirations), specifically sodium. Eventually, hypothalamic thermoregulation fails and sweat production stops, causing a rapid elevation of core temperature. Symptoms include: Temperature ≥104 F (40 C) Hot, dry skin Hemodynamic instability (tachycardia, hypotension) Altered mental status/neurological symptoms (confusion, lethargy, coma) 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 (eg, cool water immersion, cool IV fluid infusion). Antipyretics are ineffective as hyperthermia is unrelated to the inflammatory process (infection). (Option 1) Epinephrine auto-injectors (eg, EpiPen) for emergency treatment of allergic reactions can be accidentally injected, potentially causing adverse effects related to adrenergic activation (eg, tachycardia and hypertension). This client requires monitoring and supportive care (eg, antihypertensive medications). (Option 2) A child with vaginal lacerations requires evaluation for possible sexual abuse (ie, physical examination, evidence collection, mandatory reporting). This client needs treatment but is not the priority. (Option 3) An abscess requires treatment with antibiotics and, possibly, surgical intervention. However, this client is presently stable and not the priority. Educational objective:Heatstroke is a medical emergency characterized by a body temperature ≥104 F (40 C); hot, dry skin; tachycardia and hypotension; altered mental status; and neurological dysfunction. Clients require rapid cooling interventions to decrease the risk of permanent neurological injury or death.

The nurse cares for a client with type 2 diabetes mellitus and hemoglobin A1C results of 8% at an outpatient health clinic. Which statement by the nurse will best address these results? 1. "It is important for us to review the signs and symptoms of a hypoglycemic reaction." 2. "Let's review your diet, exercise, and medication regimen over the past 2-3 months." 3. "Please describe what you have eaten in the last 24-48 hours." 4. "You should fast for at least 8 hours prior to your morning blood work."

Hemoglobin A1C is a diagnostic test used to measure the percentage of glycosylated hemoglobin in the blood. A normal hemoglobin A1C is 4%-6% in clients without diabetes; the goal is to keep the level <7%in clients with diabetes. The A1C test measures blood glucose control over a period of 2-3 months; higher measurements indicate higher glycemic levels. High levels may indicate poor adherence to the recommended diet and exercise plan or ineffective antihyperglycemic medication regimen. It is important for the nurse to review the diet, exercise, and medication plan with the client who has a high hemoglobin A1C. (Option 1) Although it is important to review signs and symptoms of hypoglycemia with all clients with diabetes, this statement does not address the elevated hemoglobin A1C. (Option 3) A diet recall of the last 24-48 hours will not give the nurse adequate information on possible causes of an elevated hemoglobin A1C as this test measures glycemic control over 2-3 months. (Option 4) A hemoglobin A1C may be tested when the client is not fasting. Educational objective:Hemoglobin A1C is a diagnostic test used to measure the percentage of glycosylated hemoglobin in the blood over a period of 2-3 months. A normal hemoglobin A1C is 4%-6% in clients without diabetes; the goal is to keep the level <7% in clients with diabetes. Additional Information Reduction of Risk Potential NCSBN Client Need

The nurse planning teaching for the parents of a child newly diagnosed with hemophilia will include information about which long-term complication? 1. Heart valve injury 2. Intellectual disability 3. Joint destruction 4. Recurrent pneumonia

Hemophilia is a bleeding disorder caused by a deficiency in coagulation proteins. Clients with classic hemophilia, or hemophilia A, lack factor VIII. Clients with hemophilia B (Christmas disease) lack factor IX. When injured, clients with hemophilia should be monitored closely for external as well as internal bleeding. The most frequent sites of bleeding are the joints (80%), especially the knee. Hemarthrosis can occur with minimal or no trauma, with episodes beginning during toddlerhood when the child is active and ambulatory. Over time, chronic swelling and deformity can occur. (Option 1) Heart valve injury is common with rheumatic heart disease not hemophilia. (Option 2) Intellectual disability in children is commonly seen with fetal alcohol syndrome, Down syndrome, hypothyroidism, and lead poisoning. In rare cases, hemophilia can cause life-threatening intracranial bleeding. However, isolated intellectual disability is not seen. (Option 4) Recurrent pneumonia is commonly seen with cystic fibrosis not hemophilia.

The nurse receives 4 prescriptions for a child diagnosed with hemophilia A who was brought to the emergency department following an injury on the school playground. The child has vomited once and has a headache. Which prescription should the nurse carry out first? 1. Administer IV factor VIII 2. Administer IV ondansetron 3. Blood draw for hemoglobin 4. CT scan of the head

Hemophilia is a bleeding disorder caused by a deficiency in coagulation proteins. Treatment consists of replacing the missing clotting factor and teaching the client about injury prevention. Clients with hemophilia who are injured should be monitored closely for bleeding (eg, intracranial bleeds, bleeding into joints). Signs of an intracranial bleed include lethargy, headache, irritability, and vomiting. An intracranial bleed is lethal if unchecked, so administration of factor VIII to a client with hemophilia A is the first order of action, followed by a CT scan. (Option 2) Ondansetron (Zofran) can be given to treat nausea/vomiting, but administration of factor VIII is the priority. (Option 3) Laboratory studies, particularly hemoglobin and hematocrit levels, are necessary, but the priority is to administer factor VIII. (Option 4) A CT scan should be performed for diagnostic purposes, but the bleeding must be stopped emergently. Even if bleeding is evident on CT scan and the client is taken to the operating room, surgery cannot be performed without simultaneous factor VIII replacement.

The nurse is caring for a client 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? Select all that apply. 1. Administers coagulation factor replacement IV push 2. Administers ibuprofen PO PRN for pain 3. Applies ice packs to the affected joint hourly for 15 minutes 4.Elevates the affected leg in the extended position 5. Performs neurologic assessment every 30 minutes for 6 hours

Hemophilia is a group of disorders characterized by deficiencies in production or use of coagulation proteins (eg, factor VIII, factor IX), resulting in impaired clot formation and increased risk for uncontrolled bleeding. Hemophilia is typically identified by prolonged or excessive bleeding, severe bruising, or joint bleeding (ie, hemarthrosis) after injuries or procedures. Administration of supplemental IV clotting factors (eg, factor VIII, factor IX) is the primary treatment for acute bleeding in clients with hemophilia (Option 1). Clients with hemophilia have increased risk of hemarthrosis (ie, bleeding in joint). In addition to administration of IV clotting factors, hemarthrosis is managed with rest, ice, compression, and elevation (RICE). Application of ice or cold packs promotes local vasoconstriction and clot formation (Option 3). The affected joint should be maintained in the extended position to prevent flexion contracture (Option 4). Frequent neurologic assessments are required for clients with hemophilia who have suspected (facial laceration in this client) or confirmed head trauma, as neurologic alteration may indicate intracranial bleeding (Option 5). (Option 2) When caring for clients with hemophilia, the nurse should eliminate factors that increase bleeding risk or promote complications from bleeding. NSAIDs (eg, aspirin, ibuprofen) are avoided as they inhibit platelet aggregation, which increases bleeding risk Educational objective:For acute bleeding, clients with hemophilia are treated with supplemental IV clotting factors. Hemarthrosis is managed with rest, ice, compression, and elevation, and the affected joint should remain extended to prevent contractures. NSAIDs (eg, ibuprofen) increase bleeding risk and should be avoided for clients with hemophilia.

The nurse provides discharge teaching for the parents of a child newly diagnosed with hemophilia A. Which statements by the parents indicate that teaching has been effective? Select all that apply. 1. "A high-calorie, high-protein diet is best for our child." 2. "It is extremely important that we do not allow our child to become dehydrated." 3. "Our child should wear a medical alert bracelet at all times." 4. "We should avoid giving our child over-the-counter medicine containing aspirin." 5. "We should encourage a noncontact sport such as swimming."

Hemophilia is a hereditary bleeding disorder caused by a deficiency in coagulation proteins. Treatment consists of replacing the missing clotting factor and teaching the client about injury prevention, including: Avoid medications such as ibuprofen and aspirin that have platelet inhibition properties (Option 4). Avoid intramuscular injections; subcutaneous injections are preferred. Avoid contact sports and safety hazards; noncontact activities (eg, swimming, jogging, tennis) and use of protective equipment (eg, helmets, padding) are encouraged (Option 5). Dental hygiene is necessary to prevent gum bleeding, and soft toothbrushes should be used. MedicAlert bracelets should be worn at all times (Option 3). (Option 1) Malnutrition is not commonly associated with hemophilia; a regular diet is indicated. Clients with cystic fibrosis are at risk for malnutrition and need a high-calorie diet. (Option 2) Dehydration is not commonly associated with hemophilia. Avoiding dehydration is important for those with sickle cell anemia. Educational objective:Parents of a child with hemophilia should encourage noncontact sports, avoid giving medications that inhibit platelet aggregation, know how to control bleeding when it occurs, and ensure that the child wears a MedicAlert bracelet at all times. Additional Information Physiological Adaptation NCSBN Client Need

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? Select all that apply. 1. Ask if the client knows what day it is 2. Ask the client to extend the arms 3. Assess for telangiectasia (spider nevi) 4. Determine if the conjunctiva is jaundiced 5. Note amylase and lipase serum levels

Hepatic encephalopathy (HE) is a frequent complication of liver cirrhosis. Precipitating factors include hypokalemia, constipation, gastrointestinal hemorrhage, and infection. It results from accumulation of ammonia and other toxic substances in blood. Clinical manifestations of HE range from sleep disturbances (early) to lethargy and coma. Mental status is altered, and clients are not oriented to time, place, or person (Option 1). 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 (Option 2). Another sign is fetor hepaticus (musty, sweet odor of the breath) from accumulated digestive byproducts. (Option 3) Spider angiomas (eg, small, dilated blood vessels with bright red centers), gynecomastia, testicular atrophy, and palmar erythema are expected findings in cirrhosis due to altered metabolism of hormone in the liver. (Option 4) 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. (Option 5) Amylase and lipase are enzymes from pancreatic tissue. Alanine aminotransferase 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 administers lactulose to a client diagnosed with cirrhosis and hepatic encephalopathy. Which nursing action is inappropriate when administering this medication? 1. Assess mental status and orientation 2. Give on an empty stomach for rapid effect 3. Hold if 3 soft stools occur in a day 4. Mix with fruit juice to improve flavor

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 (Option 1). 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 (laxative). In this acidic environment, ammonia (NH3) is converted to ammonium (NH4+) and excreted rapidly. Lactulose can be given orally with water, juice, or milk (to improve flavor) or it can be administered via enema (Option 4). For faster results, it can be administered on an empty stomach (Option 2). The desired therapeutic effect of lactulose is the production of 2-3 soft bowel movements 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 (improved mental status, decreased ammonia levels) (Option 3). The client's electrolyte levels should be closely monitored during therapy as lactulose is a laxative that can cause dehydration, hypernatremia, and hypokalemia.

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? Select all that apply. 1. Assess the client's hand movements with the arms extended 2. Compare current mental status findings with those from previous shifts 3. Contact the health care provider to request a blood draw for ammonia level 4. Encourage the client to ambulate in the hallway 5. Hold the client's morning dose of lactulose

Hepatic encephalopathy is a serious complication of end-stage liver disease (ESLD) 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. (Option 4) The client with lethargy and confusion is at risk for falling. Ambulation is not an appropriate intervention at this point. (Option 5) 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 nurse is preparing an educational presentation on herbal supplements for the local community center. Saw palmetto is one herbal medicine being discussed. Which audience participants would find this information beneficial? 1. Clients diagnosed with heart failure 2. Clients experiencing major depressive disorder 3. Elderly clients with benign prostatic hyperplasia 4. Perimenopausal clients experiencing hot flashes

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

The nurse is teaching self-care management to a client experiencing an outbreak of genital herpes. Which statement by the client indicates a need for further teaching? 1. "I will be sure we use condoms during intercourse as long as I have lesions." [63%] 2. "I will not touch the lesions to prevent spreading the virus to other parts of my body."[6%] 3. "I will use a hair dryer on a cool setting to dry the lesions after taking a shower."[26%] 4. "I will use warm running water and mild soap without perfumes to wash the area."[4%]

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

The nurse is reinforcing teaching to a client with a hiatal hernia. Which statement by the client indicates that further teaching is needed? 1. "I need to raise the head of my bed on blocks by at least 6 inches." [11%] 2. "I will remain sitting up for several hours after I eat any food." [11%] 3. "If my reflux and abdominal pain don't improve, I might need surgery." [5%] 4. "Losing weight may reduce my reflux, so I plan to take a weight-lifting class."[71%]

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 asymptomatic, 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 (eg, short walks) because obesity increases abdominal pressure. However, nurses should teach clients to avoid activities that promote straining (eg, weight lifting), which increases abdominal pressure (Option 4). (Options 1 and 2) Sitting up for several hours after meals and sleeping with the head of the bed elevated at least 6 inches (15 cm) reduces upward movement of the hernia and decreases the risk of gastric reflux. (Option 3) If symptoms of hiatal hernias are uncontrolled with home management (eg, weight loss, diet modification, positioning after meals), surgical revision of the diaphragm may be required to prevent organ movement.

The nurse is caring for an infant diagnosed with Hirschsprung disease who is awaiting surgery. Which assessment finding requires the nurse's immediate action? 1. Abdominal distension with no change in girth for 8 hours [6%] 2. Did not pass meconium or stool within 48 hours after birth [26%] 3. Episode of foul-smelling diarrhea and fever [26%] 4. Excessive crying and greenish vomiting [39%]

Hirschsprung disease (HD) occurs when a child is born with some sections of the distal large intestine missing nerve cells, rendering the internal anal sphincter unable to relax. As a result, there is no peristalsis and stool is not passed. These newborns exhibit symptoms of distal intestinal obstruction. They have a distended abdomen and will not pass meconium within the expected 24-48 hours. They also have difficulty feeding and often vomit green bile. Surgical removal of the defective section of bowel is necessary and colostomy may be required. A potentially fatal complication is Hirschsprung enterocolitis, an inflammation of the colon, which can lead to sepsis and death. Enterocolitis will present with fever; lethargy; explosive, foul-smelling diarrhea; and rapidly worsening abdominal distension. (Option 1) Mild to moderate abdominal distension is an expected finding with a diagnosis of HD; however, increasing abdominal girth is a serious finding that must be reported. (Option 2) Failure to pass meconium or stool within 24-48 hours after birth is an expected finding of HD. (Option 4) Bilious vomiting and excessive crying are expected findings of HD. In enterocolitis, vomiting can occur more frequently and the client appears more ill.

The nurse is reinforcing education about home and lifestyle alterations to a client recently diagnosed with HIV. Which of the following statements by the client indicates a need for further education? Select all that apply. 1. "I don't have to use protection if my sexual partner is also HIV positive." 2. "I have to make sure my family knows not to borrow my razors." 3. "I need to avoid eating raw or undercooked meats and eggs." 4. "I started to use lambskin condoms during sex, as I have a latex allergy." 5. "I won't reuse or share any needles or syringes that I use to inject heroin."

Human immunodeficiency virus (HIV) is a viral infection of the CD4+ (helper T) cells, resulting in progressive immune system impairment. When educating clients with HIV, the nurse should discuss health promotion and infection transmission prevention strategies, particularly safe sex practices. Unprotected sex increases the risk of transmitting HIV and other sexually transmitted infections (STIs). Protected sex is important even with HIV-positive partners as HIV has multiple strains and coinfection results in HIV superinfection, which may hasten progression to AIDS (Option 1). Clients with HIV should use latex or synthetic condoms and/or dental dams during sexual activity involving mucous membrane exposure (ie, oral, vaginal, anal) to semen or vaginal secretions. Natural barriers (eg, lambskin) do not prevent transmission of STIs due to the presence of small pores (Option 4). (Option 2) Sharing personal hygiene devices that may have been exposed to blood (eg, toothbrushes, razors) increases HIV transmission risk and should be avoided. (Option 3) Immunosuppressed clients should be educated to avoid raw or undercooked foods (eg, eggs, meats, seafood) to avoid foodborne illnesses. (Option 5) To prevent transmission of HIV, hepatitis B virus, and other bloodborne diseases, IV drug users should be taught to avoid reusing or sharing needles or syringes. Educational objective:Clients with HIV are educated to use latex or synthetic barriers during all sexual encounters (ie, oral, vaginal, anal) in which nonintact skin or mucous membranes are exposed to semen or vaginal secretions. Unprotected sex increases the risk of transmitting HIV and other sexually transmitted infections, as well as HIV coinfection/superinfection.

HIV teaching

Human immunodeficiency virus (HIV) is a viral infection of the CD4+(helper T) cells, resulting in progressive immune system impairment. Clients with HIV are susceptible to opportunistic infections that typically occur during periods of low CD4+ counts. To reduce the risk of infection, nurses should educate clients with HIV to: · Obtain and remain up to date on vaccinations, including the annual influenza vaccination (Option 2). · Avoid eating undercooked meats (eg, steak that is pink) and having contact with cat feces (eg, cat litter box) because both are sources of Toxoplasma gondii, an opportunistic parasite that causes encephalitis (Options 1 and 3). · Avoid drinking water from poorly sanitized (eg, developing countries) or potentially contaminated (eg, rivers, wells) sources because it may contain infectious pathogens (eg, Cryptosporidium, Isospora, Giardia). Instead, use bottled or purified water when drinking and brushing teeth (Option 4). (Option 5) Educate clients with HIV to always use synthetic barriers (eg, condoms) during sex to reduce the risk of transmitting HIV and being infected with additional HIV strains or other sexually transmitted infections. Clients with an undetectable viral load have a lower risk of transmitting HIV to a sexual partner but should still use barrier contraception.

The nurse is providing education to a 32-year-old female client diagnosed with human papillomavirus (HPV). Which client statement indicates a need for further instruction? 1. "I can transmit the virus when I don't have symptoms." [5%] 2. "I know the virus can be spread through oral sex." [13%] 3. "I need to have a Papanicolaou test on an annual basis." [11%] 4. "My partner won't get HPV as long as we use a condom." [68%]

Human papillomavirus (HPV), one of the most common sexually transmitted infections, is associated with genital warts and cervical cancer. There are many different strains of HPV, with types 16 and 18 causing nearly all cases of cervical cancer. HPV infection is often asymptomatic, and genital warts due to HPV are typically painless. Prevention includes vaccination against HPV before sexual activity begins and safe sex practices/abstinence. The recommended age for vaccination in both boys and girls is age 11-12, but the vaccine can be given as early as age 9 and up to age 26. Clients with HPV and their partners should be educated that the virus can still be spread through skin-to-skin contact, even with the use of condoms (Option 4). Safe sex practices decrease the risk of disease transmission but do not prevent it entirely. (Option 1) HPV can be spread through sexual contact, even if symptoms are not present. (Option 2) HPV may be transmitted through vaginal, anal, or oral sex. (Option 3) Clients with HPV need to have annual Papanicolaou tests as the virus increases the risk of cervical cell changes (ie, dysplasia) and subsequent risk of cervical cancer. Educational objective:Human papillomavirus (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. Additional Information Health Promotion and Maintenance NCSBN Client Need

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? 1. "Genetic counseling is recommended. You will receive a referral before you leave." 2. "Huntington disease inheritance requires both biological parents to carry the gene." 3. "There are other ways to grow your family. You should consider adoption." 4. "This disease occurs spontaneously and is not likely to affect your children."

Huntington disease (HD) is an incurable autosomal dominant hereditary disease that causes progressive nerve degeneration, which results in impaired movement, swallowing, speech, and cognitive abilities. Chorea (involuntary, tic-like movement) is a hallmark sign. The onset of active disease is usually at age 30-50, and death from neuromuscular and respiratory complicationstypically 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 (Option 1). (Option 2) Autosomal dominant traits require only one copy of the affected gene (from one carrier parent) to manifest (eg, cause disease). (Option 3) Although adoption may be considered, the nurse's opinion is not appropriate or therapeutic for the client. After genetic testing and further education from a genetic counselor, the client can make an informed decision about starting a family. (Option 4) HD is hereditary, not spontaneous. The offspring of a client with the HD gene have at least a 50% chance of inheritance.

A 65-year-old client with end-stage renal disease comes to the emergency department after missing 5 hemodialysis sessions. Serum potassium level is 7.5 mEq/L (7.5 mmol/L) and ECG shows tall, peaked T waves. Which prescription will immediately protect the client from experiencing dysrhythmias associated with hyperkalemia? 1. Intravenous calcium gluconate 2. Intravenous regular insulin with dextrose 3. Oral sodium polystyrene sulfonate 4. Transport to hemodialysis unit

Hyperkalemia can be asymptomatic but may cause fatigue, generalized weakness, or in severe cases muscle paralysis and/or dysrhythmias. Management includes preventing life-threatening dysrhythmias and correcting serum potassium levels. Intravenous calcium gluconate is administered to hyperkalemic clients with ECG changes (eg, peaked T waves). Calcium gluconate itself does not decrease the serum potassium level but temporarily stabilizes the myocardium by raising the threshold for dysrhythmia occurrence. Once the nurse stabilizes the client by administering calcium gluconate, other prescriptions may then be implemented to decrease serum potassium level (eg, intravenous regular insulin with dextrose, sodium polystyrene sulfonate, hemodialysis) (Option 1). (Option 2) Intravenous regular insulin temporarily corrects hyperkalemia by shifting potassium into the cells. Dextrose is administered concurrently to prevent hypoglycemia. Although intravenous regular insulin will effectively decrease serum potassium levels, calcium gluconate will provide immediate protection from dysrhythmias. (Option 3) Sodium polystyrene sulfonate causes excretion of potassium from the body via the gastrointestinal tract. Although this will effectively decrease serum potassium levels, calcium gluconate will provide immediate protection from dysrhythmias. (Option 4) Although hemodialysis will effectively decrease serum potassium levels, calcium gluconate will provide immediate protection from dysrhythmias. Educational objective:The priority in treatment of hyperkalemia with ECG changes (eg, peaked T waves) is administration of intravenous calcium gluconate to prevent life-threatening dysrhythmias. Once calcium gluconate is administered, prescriptions to correct serum potassium (eg, intravenous regular insulin with dextrose, sodium polystyrene sulfonate, hemodialysis) may be implemented. Additional Information Physiological Adaptation NCSBN Client Need

The emergency department nurse cares for a client admitted with a diagnosis of hyperosmolar hyperglycemic state. The nurse understands which characteristics are commonly associated with this complication? Select all that apply. 1. Abdominal pain 2. Blood glucose level >600 mg/dL (33.3 mmol/L) 3. History of type 2 diabetes 4. Kussmaul respirations 5. Neurological manifestations

Hyperosmolar hyperglycemic state is a serious complication usually associated with type 2 diabetes. With this condition, clients are able to produce enough insulin to prevent diabetic ketoacidosis but not enough to prevent extreme hyperglycemia, osmotic diuresis, and extracellular fluid deficit. Because some insulin is produced, blood glucose rises slowly and symptoms may not be recognized until hyperglycemia is extreme, often >600 mg/dL (33.3 mmol/L). This eventually causes neurological manifestations such as blurry vision, lethargy, obtundation, and progression to coma. Because some insulin is present, symptoms associated with ketones and acidosis, such as Kussmaul respirations (hyperventilation) and abdominal pain, are typically absent (Options 1 and 4). Educational objective: Hyperosmolar hyperglycemic state differs from diabetic ketoacidosis in that it is typically associated with type 2 diabetes mellitus. Because these clients produce some insulin, severe hyperglycemia happens more slowly and is often not noted until neurological manifestations occur.

Hyperosmolar hyperglycemic state (type 2 diabetics usually) -Because these clients produce some insulin, severe hyperglycemia happens more slowly and is often not noted until neurological manifestations occur.

Hyperosmolar hyperglycemic state is a serious complication usually associated with type 2 diabetes. With this condition, clients are able to produce enough insulin to prevent diabetic ketoacidosis but not enough to prevent extreme hyperglycemia, osmotic diuresis, and extracellular fluid deficit. Because some insulin is produced, blood glucose rises slowly and symptoms may not be recognized until hyperglycemia is extreme, often >600 mg/dL (33.3 mmol/L). This eventually causes neurological manifestations such as blurry vision, lethargy, obtundation, and progression to coma. Because some insulin is present, symptoms associated with ketones and acidosis, such as Kussmaul respirations (hyperventilation) and abdominal pain, are typically absent (Options 1 and 4). Educational objective:Hyperosmolar hyperglycemic state differs from diabetic ketoacidosis in that it is typically associated with type 2 diabetes mellitus. Because these clients produce some insulin, severe hyperglycemia happens more slowly and is often not noted until neurological manifestations occur.

The nurse cares for a client with type 1 diabetes mellitus who is obtunded and responding to only painful stimuli. A STAT blood sample reveals a blood glucose level of 38 mg/dL (2.11 mmol/L). Which initial action by the nurse is best? 1. Administer 50% dextrose in water IV push [73%] 2. Assist the client to drink 4 oz (120 mL) of orange juice [21%] 3. Measure the client's heart rate and blood pressure [2%] 4. Observe for sweating, shakiness, and pallor [1%]

Hypoglycemia, a potentially life-threatening complication of diabetes mellitus, is identified by blood glucose <70 mg/dL (<3.9 mmol/L) and often occurs as a result of illness or inappropriate use of antidiabetic medications. When blood glucose levels (BGLs) are low, the body activates the autonomic nervous system, causing shakiness, palpitations, and sweating. Without intervention, hypoglycemia may cause altered mental status (eg, difficulty speaking, confusion), which may progress to seizures, coma, and death. Nurses caring for clients with hypoglycemia and altered mental status or dysphagia should immediately administer IV glucose replacement (eg, 50% dextrose in water) to quickly restore BGLs and prevent potentially lethal neurological changes (Option 1). Afterward, the nurse should retest the BGL every 15 minutes, repeating treatment if it remains low. (Option 2) Clients with altered mental status (eg, obtunded, responsive only to painful stimuli) are at high risk for aspiration and are not appropriate candidates for oral glucose replacement. (Options 3 and 4) Obtundation, a sign of severe hypoglycemia, and a confirmed BGL of 38 mg/dL (2.11 mmol/L) are sufficient indicators for implementing emergency intervention. Assessment of additional signs of hypoglycemia, heart rate, and blood pressure should not delay implementation of lifesaving treatment.

A nurse in the intensive care unit is caring for a client in the immediate postoperative period following abdominal surgery. The nurse receives several prescriptions. Which prescription should the nurse initiate first? Click on the exhibit button for additional information. 1. Acetaminophen 1000 mg IVPB every 8 hours 2. Cefazolin 2 g IVPB once, now 3. Norepinephrine 0.02-2.0 mcg/kg/min titrated IV 4. Normal saline 2 L via rapid IV bolus

Hypotension, tachycardia, and low central venous pressure (normal: 2-8 mm Hg) may indicate hypovolemic shock. Central venous pressure is a measurement of right ventricular preload (volume within the ventricle at the end of diastole) and reflects the client's fluid volume status. This client is recovering from major abdominal surgery and has a low-grade fever, placing the client at risk for fluid volume losses (eg, blood loss during surgery, insensible losses [sweating]). This client should be treated with isotonic fluids (eg, normal saline, lactated Ringer solution) to restore adequate fluid volume status. IV boluses of isotonic fluids (ie, fluid resuscitation) increase intravascular volume, which increases blood pressure and end-organ perfusion (Option 4). (Option 1) Acetaminophen is an analgesic and antipyretic that reduces fever and pain; however, the client's hemodynamic stability should be addressed first. (Option 2) Cefazolin, a cephalosporin antibiotic, may be prescribed prophylactically to prevent intra-abdominal infection after major abdominal surgery. Medications timed "now" should be administered within 90 minutes. This intervention should be performed after stabilizing the client's hemodynamic status. (Option 3) If the client remains hypotensive following a fluid bolus, vasopressor or inotropic medications (eg, norepinephrine, dopamine) should be initiated. However, vasopressor medications are not effective without first restoring circulatory fluid volume as there is insufficient volume to compress within the vascular space.

A client with hypothermia has just arrived in the emergency department 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? 1. Attaching the cardiac monitor [73%] 2. Covering the client's head [10%] 3. Drawing blood for electrolytes and glucose [7%] 4. Placing an additional large-bore IV catheter [7%]

Hypothermia occurs when the core temperature is below 95 F (35 C) 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. (Option 2) Covering the client's head is indicated to prevent heat loss; however, this can be done after the cardiac monitor has been attached. Depending on the severity of the hypothermia, the trunk should be warmed before the extremities to reduce the risk of afterdrop (core temperature drops further). This is due to cold peripheral blood returning to the central circulation. (Option 3) A blood draw for laboratory testing is important but should be performed after the cardiac monitor is attached. (Option 4) Two large-bore IV catheters are preferred; this can be accomplished after the cardiac monitor has been attached.

The nurse is caring for a client in the immediate postoperative period following an exploratory laparotomy after sustaining a gunshot wound to the abdomen. Which assessment finding is most important for the nurse to report to the health care provider? 1. Cold and clammy skin 2. Oxygen saturation of 92% 3. Sinus tachycardia of 108/min 4. Urine output of 0.6 mL/kg/hr

Hypovolemic (hemorrhagic) shock may occur after abdominal trauma or surgery as mesenteric edema resolves and previously compressed sites of bleeding reopen. The shock continuum is staged in severity from initial (I) to irreversible (IV). During the initial stage, there is inadequate oxygen to supply the demand at the cellular level and anaerobic metabolism develops. At this point, there may be no recognizable signs or symptoms. As shock progresses to the compensatory stage, sympathetic compensatory mechanisms are activated to maintain homeostasis (eg, oxygenation, cardiac output). Cold, clammy skin indicates failing compensatory mechanisms (ie, progressive stage), and immediate intervention is necessary to prevent irreversible shock and death (Option 1). (Option 2) Slightly low oxygen saturation may occur when there is inadequate oxygen supply and increased metabolic demand. It is not the most important finding to report. (Option 3) Sinus tachycardia is part of the compensatory response to maintain cardiac output and oxygen demand. It is not the most important finding to report. (Option 4) As shock continues, the kidneys decrease filtration and increase reabsorption to maintain blood pressure, eventually resulting in decreased urinary output. Normal urine output is 0.5-1 mL/kg/hr or >30 mL/hr.

A client with latent tuberculosis has been taking oral isoniazid (INH) 300 mg daily for 2 months. The client tells the nurse that for the past week she has had numbness, a burning sensation, and tingling in her hands and feet. Additional intake of which of the following would most likely have prevented this? 1. Folic acid 2. Vitamin B6 3. Vitamin B12 4. Vitamin D

INH interferes with the action of vitamin B6 (pyridoxine), resulting in peripheral neuropathy; it manifests as ataxia and paresthesia. Individuals who are most predisposed to becoming neurotoxic from taking INH include older adults, those who are malnourished, diabetic clients, pregnant or breastfeeding clients, alcoholics, children, those with liver or renal disease, and HIV-positive individuals. To prevent these complications, a vitamin B6 supplement at a dose of 25-50 mg/day is recommended for those at high risk. (Option 1) Folic acid deficiency does not cause peripheral neuropathy. It is associated with macrocytic anemia and neural tube defects in children. (Option 3) Vitamin B12 deficiency can cause peripheral neuropathy; however, it is not seen with INH therapy. (Option 4) Vitamin D deficiency causes osteomalacia but not peripheral neuropathy.

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 this situation? 1. Call security to escort the family member to the waiting room 2. Have the family member stand or sit in an area that is not in the staff's way 3. Inform the family member that relatives are not allowed in rooms during emergency situations 4. Let the family member stay and assign a staff person to explain what is happening

If family members are not causing a disruption in care of the client, they should be allowed to stay in the room with a staff member assigned to explain the interventions being implemented. The nurse should always try to be an advocate for the client and family. Witnessing the efforts of the resuscitation team can be reassuring even when the outcome is negative. The charge nurse should be prepared to escort family members from the room if they become disruptive. Educational objective:The nurse should support a family member who wants to be 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.

Impaired gas exchange in pneumonia patient

Impaired gas exchange is a deficit in oxygenation and/or elimination of carbon dioxide at the alveolar-capillary membrane. Impaired gas exchange related to a bacterial infectious process as evidenced by shortness of breath and tachypnea is an appropriate ND for a client with pneumococcal pneumonia. (Option 2) Impaired spontaneous ventilation is the inability to maintain independent ventilation to support life and requires mechanical ventilation. Based on this client's assessment data, it is not an appropriate ND. (Option 3) This client is demonstrating an ineffective breathing pattern; however, this problem is secondary to impaired gas exchange. An increased respiratory rate is the body's attempt to compensate for hypoxia caused by consolidations and secretions preventing adequate gas exchange in the lungs. Impaired gas exchange is the primary problem that is causing the ineffective respirations and is the more appropriate ND for this client. (Option 4) Risk for infection is the increased risk for invasion of microorganisms. However, this client has an actual, not potential infection, so this is not an appropriate ND. Educational objective:Impaired gas exchange related to a bacterial infectious process as evidenced by shortness of breath and tachypnea is an appropriate nursing diagnosis for a client with pneumonia.

The mother of a 6-year-old child with cystic fibrosis (CF) has received instruction on the use of pancreatic enzymes. Which statement made by the mother indicates a need for further teaching? 1. "I need to monitor the total amount of this medication that I give to my child every day." [6%] 2. "I should give this medication with or just before my child has a meal or snack." [10%] 3. "It is okay for my child to chew this medication." [61%] 4. "It is okay to open the capsule and sprinkle the medicine on a tablespoon of applesauce."[21%]

In CF, unusually thick mucus obstructs the pancreatic ducts, preventing pancreatic enzymes (amylase, trypsin, and lipase) from reaching the small intestine. The result is malabsorption of carbohydrates, fats, and proteins; the inability to absorb fat-soluble vitamins (A, D, E, and K) is of particular concern. Gastrointestinal signs and symptoms of CF include flatulence, abdominal cramping, ongoing diarrhea, and/or steatorrhea. Nutritional therapy includes the administration pancreatic enzyme supplements with or just before every meal or snack (Option 2). These enzymes are enteric-coated beads designed to dissolve only in an alkaline environment similar to that of the small intestine. They must not be mixed with a substance that would cause them to dissolve prior to reaching the jejunum. Capsule contents may be sprinkled on applesauce, yogurt, or acidic, soft, room-temperature foods with pH <4.5. Capsules should be swallowed whole and not crushed or chewed; chewing the capsules could cause irritation of the oral mucosa. Excessive intake of pancreatic enzymes can result in fibrosing colonopathy (Option 1). (Option 4) This is a true statement; some children have difficulty taking a whole capsule. Capsule contents can be sprinkled in acidic substances such as applesauce. Capsules should not be taken with milk as they can cause it to curdle.

Client with cirrhosis

In a client with cirrhosis and ascites, discomfort is often due to pressure of the fluid on the surrounding organs. Shortness of breath 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 (Option 2). In semi-Fowler position, the head of the bed is elevated 30-45 degrees; in Fowler position, elevation is 45-60 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 pruritus. It is important to use a specialty mattress and implement a turning schedule of every 2 hours (Option 4). 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 (Option 5). (Option 1) This client has ascites and peripheral edema; higher levels of fluid or sodium intake can worsen these conditions. (Option 3) 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 shortness of breath by causing the abdominal ascites to push upward on the diaphragm, restricting lung expansion. Educational objective:The client with discomfort and shortness of breath due to ascites should be positioned in the semi-Fowler or Fowler position to promote comfort and lung expansion. Music and other methods of distraction may also promote comfort. Meticulous skin interventions (eg, specialty mattress, turning schedule) are important to prevent tissue breakdown. Additional Information Basic Care and Comfort NCSBN Client Need

An elderly client has a 17-mm induration after a tuberculin skin test (TST). Based on this result, which statement is most accurate? 1. The client has a false-positive reaction due to advanced age 2. The client has a tuberculosis (TB) infection 3. The client has active TB disease 4. The client must be isolated immediately

In a heathy client, an induration >15 mm indicates a positive TST; this means that the client was exposed to TB, developed antibodies to the disease, and has a TB infection. Additional tests are needed to determine if the client has latent TB infection (LTBI) or active TB disease. Clients with LTBI are asymptomatic and cannot transmit the microorganism to others. Clients with active TB disease usually are symptomatic and can transmit the microorganisms through the air. (Option 1) The elderly have decreased immunity and may be unable to develop antibodies to react to the tuberculin; this can result in a false-negative TST reaction. (Option 3) A positive reaction to TST means that the client is infected with TB bacteria. The infectious bacteria are concealed by the body's defense and do not lead to active TB disease in most individuals. When the client has a decreased immunity (eg, immunosuppression), bacteria cause an active TB disease. Additional diagnostic tests (eg, chest x-rays, bacteriologic sputum smear for acid-fast bacilli and culture) are needed to determine if this client has active TB disease. (Option 4) A positive reaction indicates a TB infection only. Further evaluation and bacteriologic testing is necessary. If active TB is suspected before testing is completed, airborne transmission precautions will then be initiated.

A nurse is caring for a college athlete who was recently diagnosed with moderate persistent asthma. Which common asthma trigger should the nurse teach this client to avoid? 1. Latex-containing products 2. Penicillin antibiotics 3. Secondhand cigarette smoke 4. Strenuous physical activity

In clients with asthma, the airways are chronically inflamed with varying degrees of airway obstruction that can be exacerbated by exposure to triggering agents. Common asthma triggers include: Allergens: Dander (eg, cat, dog), dust mites, pollen Drugs: Beta blockers; nonsteroidal anti-inflammatory agents, including aspirin Environmental: Chemicals, sawdust, soaps/detergents Infectious: Upper respiratory infections Intrinsic: Emotional stress, gastrointestinal reflux disease Irritants: Aerosols/perfumes, cigarette smoke (including secondhand smoke), dry/polluted air (Option 3) Clients must be able to identify their individual triggers and avoid or learn to manage them. (Options 1 and 2) Penicillin antibiotics and latex-containing products may commonly trigger allergic reactions in many clients but do not commonly trigger asthma exacerbations in clients without these allergies. (Option 4) Although physical activity is an asthma trigger, athletes with asthma do not need to avoid activity altogether. Rather, they may take an inhaled bronchodilator 20 minutes before activity to help prevent exercise-induced asthma attacks. In addition, this client may be prone to minor musculoskeletal injuries (eg, sprains, strains) due to an active lifestyle; the nurse should teach about alternatives to common over-the-counter nonsteroidal anti-inflammatory medications that may be used for analgesia (eg, acetaminophen [Tylenol]). Educational objective:The nurse should teach an active young adult with asthma to identify and manage common triggers of asthma attacks, including cigarette smoke and nonsteroidal anti-inflammatory medications. Clients with asthma should take an inhaled bronchodilator 20 minutes before athletic activity to prevent exercise-induced asthma attacks.

The nurse teaching the parents of a child diagnosed with cystic fibrosis will advise the parents to choose foods that satisfy which recommended diet? 1. Gluten-free with added protein [7%] 2. High calorie, high protein, high fat [55%] 3. High protein, low fat, low phosphate [9%] 4. High protein, low fat, low sodium [27%]

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

The nurse prepares to instill dialysate for a client receiving peritoneal dialysis. Which nursing action is the priority? 1. Ensuring that the drainage collection bag is below the level of the abdomen 2. Placing the client in the semi-Fowler position 3. Recording the characteristics of output dialysate 4. Using sterile technique when spiking and attaching the bag of dialysate

In peritoneal dialysis (PD), the abdominal lining (peritoneum) is used as a semipermeable membrane to dialyze clients with decreased kidney function. A catheter is placed in the peritoneal cavity for infusing and draining dialysate (dialysis fluid). Dialysate is infused and dwells in the abdomen, which allows waste products and electrolytes to cross the peritoneum into the dialysate for removal. After the prescribed dwell time, the dialysate, electrolytes, and wastes are drained via gravity. When administering PD, it is essential to use sterile technique when spiking and attaching bags of dialysate to the client's PD catheter to prevent contamination and infection (Option 4). Bacterial peritonitis, an infection of the peritoneum, is a potential complication of PD that may lead to sepsis. Signs of peritonitis should be reported to the health care provider. (Options 1 and 2) Proper positioning of the catheter drainage bag (ie, below the abdomen) and the client (eg, Fowler or semi-Fowler position) promotes effluent outflow but is not a priority over infection prevention. (Option 3) Cloudy effluent may indicate infection, whereas bloody or brown effluent may indicate bowel perforation. Documenting effluent characteristics is important but not a priority over maintaining asepsis. Educational objective:Peritoneal dialysis (PD) uses the peritoneum as a semipermeable membrane to dialyze clients with decreased kidney function. Bacterial peritonitis is a potential complication of PD. Using sterile technique when spiking or changing bags of dialysate is a priority to avoid contamination and reduce the risk of peritonitis.

The parent of a 21-day-old male infant reports that the infant is "throwing up a lot." Which assessments should the nurse make to help determine if pyloric stenosis is an issue? Select all that apply. 1. Assess the parent's feeding technique 2. Check for family history of gluten enteropathy 3. Check for history of physiological hyperbilirubinemia 4. Check if the vomiting is projectile 5. Compare current weight to birth weight

In pyloric stenosis, there is gradual hypertrophy of the pylorus until symptom onset at age 3-5 weeks. It is common in first-born boys and the etiology is unclear. Pyloric stenosis presents with postprandial projectile vomiting (ejected up to 3 feet) followed by hunger (eg, "hungry vomiter"). This is clearly distinguished from the "wet burps" infants have due to a weak lower esophageal sphincter. The emesis is nonbilious as the obstruction is proximal to the bile duct. Infants have poor weight gain and are often dehydrated (eg, sunken fontanelle, decreased skin turgor, delayed capillary refill). The amount of milk consumed (particularly with bottle feedings) along with the mother's technique (mainly adequate burping) should be assessed to ensure there is no excessive air swallowing or overfeeding as an etiology. (Option 2) At times, formula intolerance or allergy is suspected initially when the infant first starts vomiting. However, celiac disease or gluten enteropathy is related to intolerance to gluten, a protein in barley, rye, oats, and wheat (BROW). Clients with celiac disease cannot eat these foods. A 3-week-old infant would only consume milk; this history would not be a factor at this time. (Option 3) Physiological hyperbilirubinemia occurs due to the newborn's immature liver that is unable to metabolize hemoglobin byproducts. This is a "normal" finding that is unrelated to pyloric stenosis. Educational objective:Pyloric stenosis is a hypertrophy of the pyloric sphincter that eventually causes complete obstruction. Classic signs include projectile nonbilious vomiting, an olive-shaped right upper quadrant mass, weight loss, dehydration, and/or electrolyte imbalance (metabolic alkalosis).

Four clients come to the emergency department simultaneously. Which client should the nurse see first for definitive care? 1. 6-month-old with a temperature of 101 F (38 C) who is rubbing the ears and being fussy 2. 10-day-old client with a red mark (stork bite) on the neck, the mother is concerned 3. A client who took a handful of amitriptyline pills, a tricyclic antidepressant drug 4. A client who tripped and hit the head but is alert with no loss of consciousness, currently takes warfarin

In this scenario, a client with a drug overdose (OD) is the highest priority as the actual amount taken and its effects are unknown. In addition, clients who deliberately OD often consume other substances (eg, alcohol) that can potentiate the effect of the drug. OD is especially concerning for a tricyclic antidepressant (TCA) due to the effect this can have on the cardiovascular and central nervous systems (eg, dysrhythmias, seizures). TCA use for depression is an uncommon second-line treatment, but the drug class is used for neuropathic pain and sometimes bed-wetting (enuresis). A client with head trauma (a vascular area of the body) who is currently on an anticoagulant could have potential intracranial bleeding and should be treated next. The 6-month-old client is exhibiting classic signs of otitis media (eg, fever, ear pulling/rubbing). This infection of the middle ear is a common childhood illness, often in conjunction with an upper respiratory infection. The child should be treated third and will need antibiotics, but this is nonurgent. Antipyretics can be given for comfort by protocol or direct order from the health care provider while the child is still in the triage/waiting area. The 10-day old client's mark is a salmon-colored patch (nevus simplex or angel kiss); this is a developmental vascular abnormality that will disappear within 1 year. It is at the nape of the neck but can also be seen on the eyelid, upper lip, or between the eyes. The mother needs reassurance and teaching.

The nurse teaches proper foot care to a client with diabetes mellitus. Which statement by the client indicates that further teaching is needed? 1. "I will apply lanolin to my feet to prevent dry skin." 2. "I will make sure my flip flops are made of leather." 3. "I will not apply a heating pad directly to my feet." 4. "I will test the water with a thermometer before bathing."

Individuals with type I or II diabetes mellitus are at increased risk for developing an infection or ulcer on their feet due to the chronic complication of peripheral neuropathy. Peripheral neuropathy results from damage to the nerves in the extremities. Clients may be unable to feel injuries if they occur and must take extra measures in caring for their feet. Clients should be taught to wear closed-toed, leather-based shoes to prevent injury. Careful, daily attention to foot care can prevent long-term complications. The following instructions can be used in teaching diabetic foot care: Proper footwear - Wear shoes that are comfortable, supportive, and well-fitting (preferably leather). Avoid high-heeled, open-heeled, and open-toed shoes. Wear clean, absorbent (eg, cotton) socks. Daily hygiene and inspection - Use a mild soap and warm water; dry feet thoroughly, especially between toes. Apply lanolin lotion to prevent drying (but not between toes) (Option 1). Inspect for any break in skin integrity using a mirror or a second person to visualize the bottom of the feet. Trim toenails straight across; file edges along contour of the toes. Injury avoidance - Do not walk barefoot, use hot water or heating pads, wear restrictive shoes or clothing, or cross the legs for extended periods (Options 3 and 4). Report problems - Do not self-treat corns, calluses, or ingrown toenails. Cleanse cuts or abrasions with mild soap and water; report non-healing or infected injuries to the health care provider immediately.

The nurse is teaching a group of clients diagnosed with diabetes mellitus. Which lesson regarding foot care should be included? Select all that apply. 1. Cut toenails straight across and file along the curves of the toes 2. Rub feet vigorously with a towel after bathing to ensure dryness 3. Use a mild foot powder on perspiring feet 4. Use cotton or lamb's wool to separate overlapping toes 5. Use an over-the-counter corn removal kit to remove corns or calluses

Individuals with type I or II diabetes mellitus are at increased risk for developing an infection or ulcer on their feet. This is due to the chronic complication of peripheral neuropathy, which results from nerve damage in the extremities. Instructions for diabetic foot care include: Wash feet daily with warm water and mild soap; test water temperature with thermometer beforehand. Gently pat feet dry, particularly between the toes (Option 2). Use lanolin to prevent dry and cracked skin, but do not apply between the toes. Inspect for abrasions, cuts, or sores. Have others inspect the feet if eyesight is poor. To prevent injury, use cotton or lamb's wool to separate overlapping toes. Cut toenails straight across and use a nail file to file along the curves of the toes. Avoid going barefoot and wear sturdy leather shoes. Use mild foot powder to absorb perspiration and wear clean, absorbent socks with seams aligned (Options 1, 3, and 4). Avoid using over-the-counter products (eg, iodine, alcohol, strong adhesives) on cuts or abrasions (Option 5). To improve circulation, do not sit with legs crossed or for extended periods, avoid tight-fitting garments, and perform daily exercise. Report other types of problems such as infections or athlete's foot immediately.

Four clients are seen by the emergency department nurse. Which client is a priority for treatment and definitive care? 1. 7-day-old fussy infant with a rectal temperature of 100.6 F (38.1 C) and 6 wet diapers today [41%] 2. Client receiving radiation therapy who has 6-in (15.2-cm) arm laceration that is not actively bleeding[26%] 3. Client with purulent drainage and crusting of the eyelid with vision unaffected [10%] 4. New parent who is crying and overwhelmed, and denies suicidal ideation [21%]

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 (eg, fever can be the only symptom), although some infants may have hypothermia, lethargy, poor feeding, or decreased urine output. Rectal temperature >100.4 F (38.0 C) or <96.8 F (36.0 C) is a "red flag" in a neonate. (Option 2) The client receiving radiation therapy is stable, and there is 6- to 8-hour window in which to safely close the wound. This is not a high-risk client. (Option 3) Bacterial conjunctivitis (pink eye) presents with conjunctival erythema; thick, purulent drainage; and "crusted" eyelids. The client will receive antibiotic drops or ointment, warm soaks/cool compresses, and infection control. Pink eye is highly contagious but not emergent. (Option 4) The parent has postpartum blues/depression and is not emergent. This client can be counseled or provided resources later after the infant with fever is seen.

The charge nurse is planning assignments for the day. Which clients will require the nursing staff to institute contact precautions? Select all that apply. 1. 38-year-old with methicillin-resistant Staphylococcus aureus 2. 42-year-old with Clostridium difficile diarrhea 3. 69-year-old with pertussis infection 4. 72-year-old with vancomycin-resistant Enterococcus 5. 80-year-old with influenza

Infections caused by methicillin-resistant Staphylococcus aureus (MRSA), C difficile, vancomycin-resistant Enterococcus (VRE), and scabies require contact precautions to be used. Contact precautions include: Placing client in private room (preferred) or cohorting clients with the same infection Using dedicated equipment (must be disinfected when removing from room) Wearing gloves when entering room Perform proper hand hygiene before exiting room (use soap and water or alcohol-based hand rubs for MRSA and VRE, but only soap and water for C difficile and scabies) Wearing gown with client contact and removing before leaving room Place door notice for visitors Having client leave room only for essential clinical reasons (ie, tests, procedures). If an x-ray is needed, try to arrange for a portable one. (Option 3) Clients with pertussis infection (whooping cough) need droplet precautions. (Option 5) Influenza requires droplet precautions. Educational objective:Clients with multidrug-resistant organisms (MRSA, VRE), C difficile diarrhea, and scabies require nursing staff to implement contact precautions.

The emergency department nurse receives report on 4 clients. Which client will the nurse prioritize for placement in an isolation room? 1. 4-year-old diagnosed with scabies who has red burrows and bumps along the neckline and inner elbows 2. 7-year-old diagnosed with measles who has a fever, conjunctivitis, cough, and maculopapular rash 3. 12-year-old with a positive rapid influenza test who has a fever, cough, and runny nose 4. 14-year-old with 4-inch wound on inner aspect of thigh with a positive culture for methicillin-resistant Staphylococcus aureus

Infectious agents that are spread by air currents are among the most contagious of pathogens. Therefore, clients with airborne infections (measles, tuberculosis, varicella, severe acute respiratory syndrome) should be isolated first using airborne precautions. These infections are spread via very small particles that circulate in the air. Clients with airborne infections are placed in an isolation room with negative pressure that provides air exchange or with a high-efficiency particulate air filtration system. (Option 1) Clients with scabies will be placed in contact isolation. The 4-year-old is contagious, but only if direct contact is made. Therefore, isolating the client with airborne precautions is the priority. (Option 3) Clients with influenza are placed on droplet precautions. The 12-year-old can spread pathogens via large droplets released into the air when coughing, sneezing, or talking. The client would be the second priority for isolation. (Option 4) Clients with methicillin-resistant Staphylococcus aureus infection are placed on contact precautions. The 14-year-old is contagious, but only if direct contact is made. The client requires isolation but is not a priority over the client whose pathogens are airborne.

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? Select all that apply. 1. BMI of 22 kg/m2 2. Endometriosis 3. Maternal age >35 4. Polycystic ovarian syndrome 5. Recurrent chlamydial infections

Infertility is the inability to conceive after unprotected intercourse (ie, no contraceptive use) for >12 months. Female fertility declines as women age, with the first significant decrease seen after age 35 (Option 3). Hormonal dysfunction (eg, polycystic ovarian syndrome) can cause ovarian cysts and anovulatory cycles (ie, lack of ovulation during a menstrual cycle), which impair fertility (Option 4). Some sexually transmitted infections (eg, chlamydia) may be asymptomatic in females, which can delay treatment (eg, antibiotics). Untreated or recurrent infections cause inflammation (eg, pelvic inflammatory disease), scarring, and damage to the reproductive tract, leading to infertility (Option 5). Endometriosis is characterized by endometrial tissue (ie, inner lining of the uterus) depositing outside the uterus. These endometrial lesions can result in chronic inflammation, pelvic pain, menstrual cycle abnormalities, and infertility (Option 2). (Option 1) Optimal female fertility is achieved at a BMI of 18.5-24.9 kg/m2; a BMI of 22 kg/m2 is within this normal range. Very low or very high BMI is associated with hormonal dysfunction and impaired fertility.

The nurse is caring for a client diagnosed with endometrial cancer who is receiving brachytherapy. Which interventions should the nurse implement while caring for this client? Select all that apply. 1. Cluster care to limit each staff member's time in the room to 30 minutes a shift 2. Instruct the client to be up and around in the room but not to leave the room 3. Keep the door to the room closed as radiation is emitting constantly from the client 4. Teach family members and visitors to stay at least 6 feet away from the client 5. Use a lead apron when providing direct client care to reduce exposure to radiation 6. Wear a radiation film-badge while in the client's room to monitor radiation exposure

Internal radiation (brachytherapy) involves direct application of a radioactive implant to the cancerous site or tumor for a short time, usually 24-72 hours. This technique is used to treat cervical and endometrial cancer and delivers a high dose of radiation to the cancerous tissues with a limited dose to adjacent normal tissues. Implementation of the following nursing measures is vital as the client receiving brachytherapy emits radiation. Following the principles of time, distance, and shielding provides staff and visitors protection from exposure to radiation. Time spent near the radiation source is restricted. The guideline is to limit staff time spent in the room to 30 minutes per shift.Cluster nursing care to minimize exposure to the radiation sourceRotate daily staff responsibilities to limit time spent in the client roomAll staff must wear a dosimeter film badge when assigned to care for a client receiving internal radiationNo individuals who are pregnant or under age 18 may be in the room All staff and visitors must keep the maximum distance possible from the radiation source. Maintaining a distance of at least 6 feet is an established standard.Assign the client to a private room with a private bathKeep the door to the room closedEnsure that a sign stating, "Caution, Radioactive Material" is affixed to the doorInstruct the client to remain on bedrest to prevent dislodgement of the implant Shielding with lead diminishes exposure to radiation. All staff providing nursing care that requires physical contact must wear a lead apron. (Option 2) The client receiving brachytherapy for endometrial cancer is instructed to remain on bedrest while the radiation implant is in place. If the implant dislodges from the vaginal cavity, the implant is never touched with the hands; instead, long-handled forceps are used to pick it up for placement in a lead container. Educational objective:Following the principles of time, distance, and shielding provides staff protection from exposure to internal radiation emissions. Staff should spend no more than 30 minutes in a client's room; should remain at least 6 feet away from the radiation source; and should wear lead aprons when providing direct client care. Additional Information Safety and Infection Control NCSBN Client Need

The nurse assesses a child with intussusception. Which assessment findings require priority intervention? 1. Abdominal rigidity with guarding 2. Absence of tears in crying child with IV start 3. Blood-streaked mucous stool in diaper 4. Sausage-shaped right-sided mass on palpation

Intussusception occurs when part of the intestine telescopes into another adjacent part and causes a blockage. This leads to swelling and decreased blood supply to the intestine. Tissue death as well as perforation to the bowel may result. If perforation occurs, the client could develop peritonitis in which the peritoneum in the abdomen becomes inflamed due to infection. This can quickly lead to sepsis and multiple organ failure. Peritonitis is characterized by fever, abdominal rigidity, guarding, and rebound tenderness. This condition can be fatal if it is not treated quickly. (Option 2) Absence of tears in a painful procedure during which the client is crying is a sign of dehydration. This is very common in clients with intussusception and should be treated. IV fluids should be started, and the client's hydration status (vital signs, mucus membranes, capillary refill) should be assessed frequently. (Option 3) A classic sign of intussusception is blood-streaked mucous stool, sometimes referred to as "currant jelly-like" stool. This is expected with intussusception. Treatment is an enema of either air or barium to unfold the intestine. (Option 4) A "sausage-shaped" right-sided mass is commonly felt on palpation in clients with intussusception. This is an expected finding for this condition. Educational objective:Intestinal perforation and peritonitis are common complications of intestinal obstruction (eg, intussusception). Peritonitis is characterized by fever, abdominal rigidity, guarding, and rebound tenderness and is a surgical emergency.

The clinic nurse is caring for several clients during well-child visits. The nurse should recognize which client as being the most at risk for anemia? 1. 1-month-old infant born at term gestation who exclusively breastfeeds 2. 2-month-old infant born at preterm gestation who exclusively receives iron-fortified formula 3. 3-month-old infant born at preterm gestation who is exclusively bottle-fed with breastmilk 4. 6-month-old infant born at term gestation who breastfeeds and eats iron-fortified infant cereal

Iron deficiency during infancy causes reduced hemoglobin production, resulting in anemia, decreased immune function, and delayed growth and development. During gestation, the fetus stores iron received from the mother; the amount of iron stored is dependent on the length of gestation. After birth, iron stores are progressively depleted and nutritional sources of iron are eventually required. Infants born at preterm gestation have less time in utero to accumulate iron. Preterm infants typically deplete iron stores by age 2-3 months and require additional iron supplementation (eg, oral iron drops, iron-fortified formula). Therefore, a 3-month-old infant born at preterm gestation who is exclusively receiving breastmilk is most at risk for anemia (Option 3). (Options 1 and 4) Infants born at term gestation have sufficient iron stores for the first 4-6 months of life. However, infants receiving exclusively breastmilk require iron supplementation (eg, oral iron drops) around age 4 months until food sources of iron (eg, iron-fortified infant cereal) are adequate around age 6 months. (Option 2) Although this client is at risk for anemia due to preterm gestation, the risk decreases due to intake of iron-fortified formula. The iron content of most infant formulas is adequate for the first 12 months of life. Educational objective:During gestation, the amount of iron a fetus stores is dependent on the length of gestation. Infants born at preterm gestation have lower iron stores at birth and are at an increased risk for iron-deficiency anemia. Iron supplementation (eg, oral iron drops, iron-fortified formula) is usually needed by preterm infants at an earlier age (2-3 months).

Several children seen at a local pediatric clinic are found to have a hemoglobin level of 10-11 g/dL (100-110 g/L). Which dietary modification would most likely help increase hemoglobin levels in these clients? 1. Ensuring adequate intake of meat, fish, and poultry [73%] 2. Increasing consumption of fruits and vegetables [13%] 3. Prioritizing intake of milk and other dairy products [3%] 4. Providing orange juice fortified with vitamin D at meals [9%]

Iron deficiency is the leading cause of anemia worldwide. Most cases of iron deficiency anemia (IDA) result from inadequate intake of foods high in iron. In IDA, red blood cells are small (microcytic) with reduced hemoglobin content, appearing paler (hypochromic) under a microscope. The richest dietary sources of iron include meat, fish, and poultry, which provide a form of iron that is easily absorbed by the body (Option 1). Plant-based foods (eg, dried fruits, nuts, legumes, green leafy vegetables, whole grains) are not as iron rich and contain a less bioavailable form of iron than animal-based foods. However, foods high in vitamin C(eg, tomatoes, potatoes, strawberries) may boost iron absorption when consumed with iron-rich foods. (Option 2) Fruits and vegetables are not the best sources of dietary iron. (Option 3) Milk and milk products are poor sources of dietary iron, and excessive calcium intake interferes with iron absorption. Overconsumption of milk, along with little or no consumption of other foods, is a leading cause of iron deficiency in young children. (Option 4) Although sources of vitamin C (eg, orange juice) may enhance iron absorption, increased intake of iron-rich foods is priority in treatment of IDA. Vitamin D has no direct effect on anemia.

The nurse teaches a client diagnosed with iron-deficiency anemia about iron-rich foods. Which meal does the client choose to indicate that teaching has been effective? 1. Chicken salad with lettuce on French bread, chocolate pudding, and milk 2. Fat-free yogurt, carrot sticks, apple slices, and diet soda 3. Ham, steamed carrots, green beans, gelatin dessert, and iced tea 4. Kale salad with boiled eggs and dried fruit, a brownie, and orange juice

Iron-deficiency anemia occurs when the body lacks sufficient iron to form red blood cells and synthesize hemoglobin. Iron-deficiency anemia can result from: Diets low in iron (eg, vegetarian and low-protein diets) Iron not being absorbed (eg, following many gastrointestinal [GI] surgeries, malabsorption syndrome) Increased iron requirement (eg, children's growth spurts, pregnancy, breastfeeding) Blood loss (eg, menstruation, bleeding in the GI tract [eg, ulcers, hemorrhoids]) Foods rich in iron include: Meats (eg, beef, lamb, liver, chicken, pork) Shellfish (eg, oysters, clams, shrimp) Eggs, green leafy vegetables, broccoli, dried fruits, dried beans, brown rice, and oatmeal Eating foods rich in vitamin C (eg, citrus fruits, potatoes, tomatoes, green vegetables) with iron-rich foods will enhance iron absorption but coffee and tea consumption interferes with this process. (Option 1) Chicken in a salad is a good source of iron. However, bread, pudding, and milk do not contain significant amounts of iron. (Option 2) Fat-free yogurt, carrot sticks, apple slices, and diet soda do not offer a significant source of iron. (Option 3) Ham is a good source of iron. However, carrots, green beans, and gelatin desserts are not significant sources. Furthermore, the tea will inhibit iron absorption.

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? 1. Beans, yogurt, and a fruit cup 2. Beef, broccoli, and a glass of wine 3. Eggs, a bagel, and black coffee 4. Steak, tomato basil soup, and cornbread

Irritable bowel syndrome (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 (eg, bananas, cabbage, onions); caffeine; alcohol; fermentable oligo-, di-, and monosaccharides and polyols (FODMAPs) (eg, honey, high-fructose corn syrup, wheat); and other gastrointestinal (GI) irritants (eg, spices, hot/cold food or drink, dairy products, fatty foods). Clients should gradually increase fiber intake (eg, whole grains, legumes, nuts, fruits, vegetables) as tolerated. Foods that are generally well tolerated include proteins, breads, and bland foods (Option 4). (Option 1) Although they are a great source of fiber, beans are gas-producing and should be avoided. Most dairy products are GI irritants; however, yogurt is often better tolerated and may be included in the diet. (Option 2) Gas-producing cruciferous vegetables (eg, broccoli, cabbage) should be avoided. Alcohol exacerbates IBS symptoms. (Option 3) Hot beverages and caffeine (eg, coffee) irritate the GI tract. Bagels are gas-producing.

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? Select all that apply. 1 Gown 2. Goggles or face shield 3. Hand washing 4. N95 particulate respirator 5. Surgical mask

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. (Options 1 and 2) 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 the tuberculosis is extrapulmonary with draining lesions (eg, cutaneous tuberculosis). (Option 5) 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.

The community health nurse prepares a teaching plan for a client with latent tuberculosis who is prescribed oral isoniazid (INH). Which instructions should the nurse include? Select all that apply. 1. Avoid drinking alcohol 2. Expect body fluids to change color to red 3. Report yellowing of skin or sclera 4. Report numbness and tingling of extremities 5. Take with aluminum hydroxide to prevent gastric irritation

Isoniazid (INH) is a first-line antitubercular drug prescribed as monotherapy to treat latent tuberculosis infection. Combined with other drugs, INH is also used for active tuberculosis treatment. Two serious adverse effects of INH use are hepatotoxicity and peripheral neuropathy. A teaching plan for a client prescribed INH includes the following: Avoid intake of alcohol and limit use of other hepatotoxic agents (eg, acetaminophen) to reduce risk of hepatotoxicity (Option 1) Take pyridoxine (vitamin B6) if prescribed to prevent neuropathy Avoid aluminum-containing antacids (eg, aluminum hydroxide (Maalox)) within 1 hour of taking INH Report changes in vision (eg, blurred vision, vision loss) Report signs/symptoms of severe adverse effects such as:Hepatoxicity (eg, scleral and skin jaundice, vomiting, dark urine, fatigue) (Option 3)Peripheral neuropathy (eg, numbness, tingling of extremities) (Options 4) (Option 2) Rifampin, another antitubercular drug, often causes a red-orange discoloration of body fluids (ie, urine, sweat, saliva, tears). However, this effect is not associated with INH use. (Option 5) Concurrent use of antacids containing aluminum decreases INH absorption. The medication may be taken with food if gastric irritation is a concern.

A client has a serum potassium level of 2.8 mEq/L, and the health care provider (HCP) prescribes intravenous (IV) potassium chloride (KCL). The nurse administers 10 mEq KCL/100 mL 5% dextrose in water at 100 mL/hr through the client's peripheral IV line using an infusion pump. Shortly after initiation of the infusion, the client reports feeling burning and discomfort at the IV site. What is the nurse's priority action? 1. Notify HCP to request a peripherally inserted central catheter (PICC) 2. Notify HCP to request an oral preparation of KCL 3. Slow the rate of the KCL infusion 4. Stop the infusion of KCL immediately

KCL, an electrolyte replacement to correct hypokalemia, is a high-alert drug that is never administered by the IV push, intramuscular, or subcutaneous routes. The recommended peripheral infusion rate is 5-10 mEq/hr. However, the nurse should always follow institution IV guidelines and policy and procedure for administering KCL. The nurse's priority action is to slow the infusion rate if the client feels a burning discomfort at the IV site shortly after initiation of the infusion. KCL irritates the vein, and irritation and discomfort at the site is expected. Slowing the infusion rate is effective in alleviating discomfort. (Option 1) KCL in concentrations 20-40 mEq/100 mL at a maximum rate of 40 mEq/hr should be administered through a central venous access device (CVAD) (eg, PICC, centrally inserted catheter) to prevent postinfusion phlebitis. A concentration of 10 mEq KCL/100 mL can be administered through a peripheral vein at the recommended infusion rate. (Option 2) The IV infusion is preferred over the oral preparation to decrease the risk for dysrhythmias when hypokalemia must be corrected quickly. Some clients may need both oral and IV forms if the serum potassium levels are markedly low. However, this action is not a priority. (Option 4) Rapid correction of this client's hypokalemia (2.8 mEq/L) is necessary due to risk for hypokalemia-associated dysrhythmias. Stopping the infusion when not necessary further increases risk. The nurse assesses the site at least every hour for adverse reactions (eg, redness, pain, swelling, phlebitis, thrombosis, extravasation or infiltration), and stops the infusion if any occur. Educational objective:Potassium chloride (KCL) administered by the IV route is prescribed for rapid correction of hypokalemia (<3.5 mEq/L). It is irritating to the vein but can be administered slowly through a peripheral vein at recommended infusion rates (5-10 mEq/hr). KCL concentrations 20-40 mEq/100 mL at a maximum rate of 40 mEq/hr should be administered through a CVAD to prevent postinfusion phlebitis or infiltration.

The nurse is reinforcing education to a client newly prescribed levetiracetam for seizures. Which statement made by the client indicates a need for further instruction? 1. "Drowsiness is a common side effect of this medication and will improve over time." 2. "I can begin driving again after I have been on this medication for a few weeks." 3. "I need to immediately report any new or increased anxiety when on this medication." 4. "I need to immediately report any new rash when on this medication."

Levetiracetam (Keppra) is an anticonvulsant prescribed for seizure disorders. As with other antiseizure medications, levetiracetam has a depressing effect on the central nervous system (CNS), which may cause drowsiness, somnolence, and fatigue as clients adjust to the medication. Clients should be assured that this is common and typically improves within 4-6 weeks (Option 1). However, the CNS-depressing effects of levetiracetam may be enhanced if taken with other CNS-depressing substances (eg, alcohol) or medications. New or increased agitation, anxiety, and/or depression or mood changes should be reported immediately as levetiracetam is associated with suicidal ideation (Option 3). Like other anticonvulsants, levetiracetam can trigger Stevens-Johnson syndrome, a rare but life-threatening blistering reaction of the skin. Rash, blistering, muscle/joint pain, or conjunctivitis should be reported and assessed immediately (Option 4). (Option 2) Clients with seizure disorders should avoid driving or operating heavy machinery until they have permission from their health care provider and have met the requirements of their department of transportation. Typically, the client must be free from seizures for an allotted time period. Educational objective: Levetiracetam is an anticonvulsant prescribed for seizure disorders. It may have depressing effects on the central nervous system (eg, drowsiness) as the body adjusts to therapy. Serious adverse effects include suicidal ideation and Stevens-Johnson syndrome. Clients with seizure disorders must meet the guidelines of their department of transportation and receive permission from their health care provider prior to legally operating a motor vehicle. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

A client is receiving lithium carbonate 900 mg/day for a schizoaffective disorder. The laboratory notifies the nurse that the client's lithium level is 1.0 mEq/L (1.0 mmol/L). Based on this result, which prescription does the nurse anticipate receiving from the health care provider? 1. Continue at the current dosage 2. Decrease the dosage 3. Discontinue the medication 4. Increase the dosage

Lithium carbonate is used as a mood stabilizer in clients with schizoaffective disorder (combination of schizophrenia and a mood disorder) and bipolar disorders. Lithium has a very narrow therapeutic index (0.6-1.2 mEq/L [0.6-1.2 mmol/L]); levels >1.5 mEq/L (1.5 mmol/L) are considered toxic. Lithium toxicity can be acute (eg, ingesting a bottle of lithium tablets in a suicide attempt) or chronic (eg, slow accumulation due to decreased renal function or drug-drug interactions). Acute or acute-on-chronic toxicity presents predominantly with gastrointestinal symptoms (eg, nausea, vomiting, diarrhea); neurologic manifestations occur later. However, neurologic manifestations occur early in chronic toxicity. Common neurologic manifestations include ataxia, confusion, or agitation, and neuromuscular excitability (eg, tremor, myoclonic jerks). Chronic toxicity also manifests as diabetes insipidus (eg, polyuria, polydipsia). (Options 2, 3, and 4) No dose adjustment is needed as this client's lithium level is therapeutic.

A client has been on lithium carbonate therapy for 7 days. Which of the following findings would be most important to report to the health care provider? 1. Diarrhea, vomiting, and mild tremor [52%] 2. Dry mouth and mild thirst [3%] 3. Hyperactivity and auditory hallucinations [25%] 4. Lithium level of 1.3 mEq/L (1.3 mmol/L) [18%]

Lithium carbonate is used for the initial and maintenance treatment of bipolar mania. Typical symptoms of mania include extreme hyperactivity, delusions and hallucinations, grandiosity, elation, poor judgment, aggressiveness, impulsivity, pressure of speech, insomnia, flight of ideas, and sometimes hostility. Acute lithium toxicity presents primarily with gastrointestinal side effects such as persistent nausea and vomiting and diarrhea. Neurologic symptoms typically manifest later and include tremor, confusion, ataxia, and sluggishness. Severe toxicity results in seizures and encephalopathy (Option 1). Serum lithium levels and clinical condition must be monitored before medication administration. Serum levels ≥1.5 mEq/L (1.5 mmol/L) and/or even the mildest symptomsof lithium toxicity must be reported to the health care provider. (Option 2) Dry mouth and thirst are common and expected side effects of lithium when treatment is initiated. They will resolve spontaneously and lithium need not be discontinued. (Option 3) Hyperactivity and auditory hallucinations are clinical findings associated with bipolar mania. Because lithium may take up to 3 weeks to become effective, it would not be unusual for a client to experience these symptoms after only 7 days of treatment. (Option 4) Lithium has a very narrow range of therapeutic serum levels; the usual ranges are 1.0-1.5 mEq/L (1.0-1.5 mmol/L) for treatment of acute mania and 0.6-1.2 mEq/L (0.6-1.2 mmol/L) for maintenance therapy. Educational objective:Acute lithium toxicity (>1.5 mEq/L [1.5 mmol/L]) presents primarily with gastrointestinal side effects such as persistent nausea and vomiting and diarrhea. Neurological symptoms typically manifest later and include tremor, confusion, ataxia, and sluggishness. The health care provider must be notified at the earliest indication of lithium toxicity.

A client with bipolar disorder is admitted to the psychiatric unit with acute mania and dehydration. Which prescription does the nurse question? 1. Administer zolpidem at bedtime as needed for insomnia 2. Continue prescribed home dose of 300 mg lithium PO every 8 hours 3. Give haloperidol and lorazepam IM together for aggressive behavior 4. Infuse 500 mL normal saline IV bolus over 1 hour

Lithium is a mood stabilizer commonly prescribed for mania (eg, bipolar disorder) as long-term maintenance therapy. Because lithium has a narrow therapeutic range (eg, 0.6-1.2 mEq/L [0.6-1.2 mmol/L]), serum levels should be monitored regularly (eg, following dose changes) to prevent toxicity (>1.5 mEq/L [1.5 mmol/L]). Lithium is excreted through the kidneys. To prevent toxicity the nurse should hold doses and clarify prescriptions for clients who have: Conditions/illnesses in which the kidneys try to conserve sodium (eg, hyponatremia, dehydration) as sodium and lithium are absorbed in proximal tubules simultaneously (Option 2) Decreased glomerular filtration rate (eg, severe renal dysfunction) as less of the drug is filtered into the urine Consistent amounts of fluid (2-3 L/day) and sodium prevent fluctuations in serum lithium. Clients should report signs (eg, weight changes, dizziness) and precipitating factors (eg, vomiting, diarrhea, increased sweating) of fluid and electrolyte imbalance. (Option 1) Zolpidem (Ambien) is a hypnotic medication that induces sleep for clients with sleep disturbances (eg, acute mania). (Option 3) Haloperidol (a first-generation antipsychotic) and lorazepam (a benzodiazepine) are commonly administered together to depress the central nervous system and decrease aggressive behaviors. (Option 4) Isotonic IV fluid boluses (eg, normal saline) are often required to reverse moderate to severe dehydration and prevent lithium toxicity.

A nurse is discharging a client who is receiving lithium for treatment of a bipolar disorder. It is most important for the nurse to provide which instruction to the client? 1. Avoid a high-potassium diet 2. Exercise regularly and maintain a high-fiber diet 3. Maintain oral hygiene 4. Report excessive urination and increased thirst

Lithium is a mood stabilizer most often used to treat bipolar affective disorders. It has a narrow therapeutic index (0.6-1.2 mEq/L [0.6-1.2 mmol/L]). Risk factors for lithium toxicity include dehydration, decreased renal function (in the elderly), diet low in sodium, and drug-drug interactions (eg, nonsteroidal anti-inflammatory drugs [NSAIDS] and thiazide diuretics). Chronic toxicity can result in: Neurologic manifestations - ataxia, confusion or agitation, and neuromuscular excitability(tremor, myoclonic jerks) Nephrogenic diabetes insipidus - polyuria and polydipsia (increased thirst) (Option 4) Clients should be educated about monitoring for these symptoms and obtaining serum lithium levels at regular intervals. (Option 1) Dietary potassium should be avoided when taking drugs such as potassium-sparing diuretics (eg, spironolactone, triamterene, amiloride) and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. (Option 2) Regular exercise and a high-fiber diet can prevent constipation, which is not a known side effect of lithium. Opioids, anticholinergics, and iron supplements are medications that cause constipation. (Option 3) Good oral hygiene is ideal for every client but is not specially indicated for those taking lithium. Clients taking phenytoin should maintain oral hygiene to prevent gingival hyperplasia.

The clinic nurse evaluates a client who was prescribed lithium therapy a month ago for bipolar disorder. Which client statement would cause the most concern? 1. "I've felt the need for an afternoon nap most days this week." 2. "I've gained 3 lb (1.36 kg) since I began taking this medication." 3. "I've had the stomach flu for the past couple of days." 4. "My mouth seems to be drier than usual lately."

Lithium is often used in the treatment of bipolar disorder. It has expected, mild side effects as well as potentially serious ones related to drug toxicity. Drowsiness, weight gain, dry mouth, and gastrointestinal upset are expected, mild side effects. Lithium toxicity occurs with dehydration, hyponatremia, decreased renal function, and drug-drug interactions (eg, nonsteroidal anti-inflammatory drugs, thiazide diuretics). Lithium and sodium are closely related in the body. Acute viral gastroenteritis (stomach flu) presents with abrupt onset of diarrhea, nausea, vomiting, and abdominal pain. Clients with vomiting and diarrhea are at risk of developing dehydration and/or low serum sodium, increasing the risk for lithium toxicity (Option 3). (Option 1) Drowsiness is an expected side effect. The nurse should advise the client to avoid hazardous activities and driving until the effects of lithium are known or this side effect subsides. (Option 2) Weight gain is an expected side effect. The nurse should provide client education about healthy food choices and proper exercise and/or provide for a dietary consult. (Option 4) Dry mouth is an expected side effect. The nurse should provide client teaching about measures to counteract this side effect (eg, ice chips, sugarless gum or candy, drinking plenty of water). However, excessive urination and polydipsia indicate nephrogenic diabetes insipidus from lithium toxicity. Educational objective:Dehydration and sodium loss from vomiting and diarrhea can lead to toxic lithium levels in clients receiving lithium therapy. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

A client with chronic heart failure is being discharged home on furosemide and sustained-release potassium chloride tablets. Which instructions related to the potassium supplement should the nurse give to the client? 1. "A diet rich in protein and vitamin D will help with absorption." [13%] 2. "If the tablet is too large to swallow, crush and mix it with applesauce or pudding." [8%] 3. "Potassium tablets should be taken on an empty stomach." [16%] 4. "Take it with a full glass of water and stay sitting upright afterward." [61%]

Loop diuretics (eg, furosemide [Lasix], bumetanide [Bumex]) are "potassium-wasting" diuretics, meaning that clients may experience potassium loss and hypokalemia. Hypokalemia in a client with heart failure creates a risk for life-threatening cardiac dysrhythmias. Therefore, clients taking loop diuretics usually require potassium supplementation. Potassium is an erosive substance that can cause pill-induced esophagitis. To prevent esophageal erosion, the client should take potassium tablets with plenty of water (at least 4 oz [120 mL]) and remain sitting upright for ≥30 minutes after ingestion. This prevents the tablet from becoming lodged in the esophagus or refluxing from the stomach (Option 4). Pill-induced esophagitis is also common with tetracyclines (eg, doxycycline) and bisphosphonates ("dronates": alendronate, ibandronate, pamidronate, risedronate), so clients taking these medications should be given similar instructions. (Option 1) A diet rich in protein and vitamin D helps with calcium-supplement, not potassium, absorption. (Option 2) Sustained-release medications should never be crushed as this would cause the client to absorb the medication too rapidly. (Option 3) Potassium should be taken during or immediately following meals to prevent gastric upset.

The nurse prepares a community education program about health promotion strategies for postmenopausal women. Which of the following teaching points are appropriate to include? Select all that apply. 1. Consider seeing a dietitian for help with healthy weight maintenance 2. Consult with a health care provider for cholesterol monitoring 3. Engage in a daily weight-bearing exercise regimen 4. Prioritize consumption of green, leafy vegetables and dairy products 5. Seek support to cope with any emotional symptoms

Loss of ovarian function during menopause causes a decrease in estrogen production, leading to reduced osteoblast activity and cardioprotective effect. Therefore, postmenopausal clients are at increased risk for osteoporosis and coronary artery disease (CAD). Other physiological changes after menopause may include weight gain, sleep disturbances, fat redistribution, and vaginal atrophy. Clients should utilize health promotion strategies to reduce the effects of decreased estrogen levels, including: Consuming optimal amounts of dietary calcium (green, leafy vegetables; dairy products) and engaging in weight-bearing exercise to promote bone health (Options 3 and 4) Closely monitoring cholesterol levels (eg, HDL, LDL, triglycerides), as increased LDL cholesterol increases risk for CAD (Option 2) Considering seeking the assistance of a dietitian, and maintaining a low-calorie diet rich in fruits and vegetables, as hormone changes may cause a predisposition to weight gain (Option 1) Seeking support to cope with any emotional symptoms (eg, depression, mood swings, sadness, difficulty concentrating) caused by changing hormone levels (Option 5) Educational objective:Postmenopausal women should consume plenty of calcium-rich foods (eg, dairy products; green, leafy vegetables), engage in weight-bearing exercise, monitor cholesterol levels, consider dietary counseling to maintain a healthy weight, eat a diet rich in fruits and vegetables, and seek support for any emotional symptoms.

Low CD4 count defined as

Low CD4 counts are defined as <750/mm3 for infants 12 months or younger, <500/mm3 for children between age 1-5 years <200/mm3 for children age >5 years and adults

The camp nurse conducts a class for incoming summer counselors on prevention of tick bites and Lyme disease. Which instructions should the nurse include? Select all that apply. 1. Apply a tick repellent spray before outdoor activities 2. Avoid hiking through areas of tall grass and thick underbrush 3. Cover ticks found on skin with petroleum jelly 4. Report bull's-eye rash or flulike symptoms to a health care provider 5. Wear a long-sleeved shirt tucked into pants and closed-toe shoes while hiking

Lyme disease develops after a bite from a deer tick infected with Borrelia burgdorferi. Clients initially develop flulike symptoms (eg, headache, fever, myalgia, fatigue). Many clients develop erythema migrans, a bull's-eye rash; however, it is not always present. Any of these symptoms should be reported immediately to a health care provider (Option 4). The client will likely be prescribed antibiotics (eg, doxycycline, amoxicillin) to treat Lyme disease and prevent it from causing complications (eg, carditis, chronic arthritis, meningitis, facial paralysis). To prevent tick bites during outdoor activities, clients should: Apply an insect repellent spray that contains tick-repelling ingredients (eg, DEET, picaridin) (Option 1) Avoid tall grass and thick underbrush, and hike only in the center of the trails (Option 2) Wear long-sleeved shirts tucked into pants, long pants tucked into socks or boots, and closed-toed shoes (Option 5) (Option 3) Covering attached ticks with petroleum jelly or nail polish is a folk remedy that actually increases the chance of infection by keeping the tick on the skin. Ticks should be promptly removed using tweezers, being careful to grasp the tick close to the attachment site and not crush it during removal.

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? Select all that apply. 1. Avoid massaging the area 2. Avoid receiving vaccinations in the affected arm 3. Elevate the arm above the heart 4. Perform isometric exercises 5. Use an intermittent pneumatic compression sleeve

Lymphedema is the accumulation of lymph fluid in the soft tissue. It can occur as a result of lymph node removal or radiation treatment. When the axillary nodes cannot return lymph fluid to central circulation, the fluid can accumulate in the arm, hand, or breast. The client's arm may feel heavy or painful, and motor function may be impaired. The presence of lymphedema increases the client's risk for infection or injury of the affected limb. Interventions to manage lymphedema include: Decongestive therapy (massage technique to mobilize fluid) Compression sleeves or intermittent pneumatic compression sleeve (Option 5)Compression sleeves are graduated with increased distal pressure and less proximal pressure.Clothing should also be less constrictive at the proximal arm and over the chest. Elevation of arm above the heart (Option 3) Isometric exercises (Option 4) Avoidance of venipunctures (eg, IV catheter insertion, blood draw), blood pressure measurements, and injections (eg, vaccinations) on the affected limb (Option 2) Injury prevention (limb less sensitive to temperature changes)Infection prevention (limb more prone to infection through skin breaks) (Option 1) Clients often learn massage techniques (ie, decongestive therapy) from physical therapists to increase lymphatic drainage and promote circulation of the extremity. Educational objective:Management for lymphedema includes decongestive massage therapy, compression bandages or sleeves, elevation of the arm above heart level, isometric exercises, and avoidance of venipuncture or blood pressure measurements on the affected limb.

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? Click the exhibit button for more information. 1. IM epinephrine 2. IV atropine 3. IV dantrolene 4. IV glucagon Temperature 105 F (40.6 C) Blood pressure 140/90 mm Hg Heart rate 150/min Respirations 28/min O2 saturation 98%

Malignant hyperthermia (MH) is a rare and life-threatening condition precipitated by certain medications used for anesthesia, including inhaled anesthetics (eg, desflurane, isoflurane, halothane) and succinylcholine (a paralytic used adjunctively for intubation and general anesthesia). 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, cardiac dysrhythmias, and myoglobinuria. MH requires emergent treatment with IV dantrolene to reverse the process by slowing metabolism. Succinylcholine should be discontinued. Other interventions include applying cooling blankets to reduce temperature and treating high potassium levels. (Option 1) IM epinephrine is administered for cardiac arrest, anaphylactic reactions, or severe asthma attacks; it is not appropriate for MH. (Option 2) IV atropine, an anticholinergic agent, is used to treat bradycardia. It would worsen tachycardia in this client. (Option 4) Naturally produced by the pancreas, glucagon is given intramuscularly, subcutaneously, or intravenously for severe hypoglycemia. IV glucose is preferred due to its immediate effect; however, if it is unavailable, glucagon can be given to stimulate glycogenolysis in the liver, thereby raising blood glucose. Educational objective:Malignant hyperthermia is a life-threatening hypermetabolic condition triggered by certain drugs used for general anesthesia. Prompt administration of IV dantrolene is critical. Other interventions include cooling the client and treating high potassium levels.

he nurse in the same-day surgery unit admits a client who will receive general anesthesia. The client has never had surgery before. Which question is most critical for the nurse to ask the client during the preoperative assessment and health history? 1. "Has any family member ever had a bad reaction to general anesthesia?" 2. "Have you ever experienced low back pain?" 3. "Have you ever had an anaphylactic reaction to a bee sting?" 4. "Have you ever received opioid pain medications?"

Malignant hyperthermia (MH) is a rare but life-threatening inherited muscle abnormality that is triggered by specific, inhaled anesthetic agents and the depolarizing muscle relaxant succinylcholine (Anectine) used to induce general anesthesia. In MH-susceptible clients, the triggering agent leads to excessive release of calcium from the muscles, leading to sustained muscle contraction and rigidity (usually of the jaw and upper body [early sign]), increased oxygen demand and metabolism, and dangerously high temperature (later sign). As MH is an inherited condition, proper screening and a thorough preoperative nursing assessment and health history can help minimize the client's risk (Option 1). (Option 2) Cervical spine problems should be assessed before the intubation. Low back pain history is not a priority for general anesthesia. (Option 3) It would be appropriate to ask about allergies (eg, drugs, latex). However, asking about an anaphylactic reaction to a bee sting is not the most critical question. (Option 4) History of prior opioid intake may be helpful, but the most important question is to ask about side effects and allergies.

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 health care provider immediately? 1. Difficult to arouse [14%] 2. Muscle stiffness [20%] 3. Pinpoint pupils [36%] 4. Temperature 94 F (34.4 C) [28%]

Malignant hyperthermia (MH) 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 (PACU). The most specific characteristic signs and symptoms of MH include hypercapnia (earliest sign), generalized muscle rigidity (eg, jaw, trunk, extremities), and hyperthermia. Hyperthermia is a later sign and can confirm a suspicion of MH. The nurse monitors the temperature as it can rise 1 degree Celsius every 5 minutes and can exceed 105 F (40.6 C). The nurse would notify the health care provider, indicating the need for immediate treatment (eg, dantrolene, cooling blanket, fluid resuscitation) (Option 2). (Options 1 and 3) A client who just arrived in the PACU after general anesthesia would be expected to be difficult to arouse; and to have small pupil size associated with drugs used to induce general anesthesia, sedating drugs, and opioid drugs to control pain. (Option 4) Hypothermia (<95 F [35 C]) is common in the immediate postoperative period due to anesthetic-induced vasodilation, decreased basal metabolic rate, and a cool environment. This can be managed by the nurse. Hyperthermia (fever) is also common due to the blood products and trauma from surgery. However, stiffness/rigidity in the presence of elevated temperature is more concerning.

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? 1. Client consuming 90% of each meal [18%] 2. Serum albumin of 3.6 g/dL (36 g/L) [43%] 3. Weight gain of 2 lb (0.9 kg) in 2 weeks [35%] 4. White blood cell count of 15,000/mm 3 (15.0 × 109/L) [2%]

Malnutrition occurs due to inadequate intake of major nutrients (eg, calories, carbohydrates, fat, protein) or micronutrients (eg, minerals, vitamins). As malnutrition worsens and protein intake is reduced, muscles become fatigued and weak. Clinical manifestations depend on the severity of the malnutrition, ranging from mild to extreme (eg, emaciation). Weight gain is the best indicator that the client is responding to medical nutritional therapy. (Option 1) 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. (Option 2) Although a serum albumin level of 3.6 g/dL (36 g/L) is within the normal range of 3.5-5.0 g/dL (35-50 g/L), visceral protein stores are poor indicators of nutritional status in acute and chronic disease. During an inflammatory response (eg, 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. (Option 4) A white blood cell count of 15,000/mm3 (15.0 × 109/L) is elevated (normal: 4,000-11,000/mm3 [4.0-10.0 × 119/L]), which indicates that the infection has not resolved. Educational objective:The best assessment finding for indicating improved nutritional status is a steady weight gain over a specified period. Serum prealbumin is a faster and more reliable indicator of current nutritional status than serum albumin.

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? 1. "Are you able to prepare your own meals?" 2. "Are you feeling lonely or depressed?" 3. "Have you lost any weight unintentionally?" 4. "How many meals do you eat each day?"

Malnutrition occurs when there is insufficient nutrient intake to meet body needs and relates to multiple factors (eg, poor diet, chronic illness, physical or cognitive impairments). Malnutrition may impair critical physiologic processes (eg, organ and immune system function, wound healing) and can have rapid and potentially lethal implications. Therefore, nurses should frequently assess clients for malnutrition, particularly those at increased risk (eg, advanced age, altered functional status). Assessing for malnutrition involves collecting dietary data (eg, 24-hour diet recall), laboratory values (eg, albumin or prealbumin), physical measurements (eg, BMI), and history of recent weight loss (Option 3). Reports of weight loss, especially unintentional, are critical findings often indicative of malnutrition. In addition, weight loss of ≥5% in 1 month or ≥10% in 6 months may indicate serious conditions (eg, cancer, tuberculosis, failure to thrive). (Option 1) Impaired functional status may contribute to a client's malnutrition. The nurse should prioritize assessing for the presence of malnutrition before assessment of contributing factors. (Option 2) Assessment of psychologic factors (eg, depression, loneliness) is important to determine possible reasons for malnutrition but should be performed only after determining the extent of malnutrition. (Option 4) Meal frequency, eating habits, and recent diet changes are possible contributing factors leading to malnutrition that should be assessed after determining malnutrition risk. Educational objective:Malnutrition occurs when nutrient intake is insufficient for body requirements. Nurses evaluating clients for malnutrition should first assess for unintentional weight loss, an important indicator of malnourishment. Afterwards, contributing factors of malnutrition (eg, functional status, mood alteration, diet) should be evaluated.

In DKA management, when serum glucose is <250mg/dL, D5W is administered to prevent hypoglycemia until ketoacidosis is resolved.

Management of DKA includes fluid resuscitation, IV insulin, and hourly blood glucose monitoring. When serum glucose is <250 mg/dL (13.9 mmol/L), D5W is administered to prevent hypoglycemia until ketoacidosis is resolved. Hypokalemia often occurs with resolution of acidosis and administration of IV insulin, which shifts potassium from the intravascular to the intracellular space. Therefore, potassium is administered even when the client is normokalemic (3.5-5.0 mEq/L [3.5-5.0 mmol/L]) to prevent hypokalemia and subsequent life-threatening arrhythmias

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? 1. Auscultate breath sounds to assess for crackles [49%] 2. Monitor for >50 mL/hr urine output [28%] 3.Monitor Glasgow Coma Scale increasing from 8/15 to 9/15 [13%] 4. Press over the tibia to assess for pitting edema [8%]

Mannitol (Osmitrol) is an osmotic diuretic used to treat cerebral edema (increased intracranial pressure) and acute glaucoma. When administered, mannitol causes an increase in plasma oncotic pressure (similar to excess glucose) that draws free water from the extravascular space into the intravascular 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 (as in kidney disease), 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. (Option 2) Urine output would be expected to increase from the diuretic effect of mannitol. This is not a complication. (Option 3) Glasgow Coma Scale scores range from 3-15. Improved mental status (orientation, alertness) is a desired effect of treatment. (Option 4) The presence of crackles is a more sensitive sign of fluid overload than pedal edema. Furthermore, in a bedridden client, the assessment should take place at a dependent part of the body, usually the sacral area. Educational objective:Mannitol is an osmotic diuretic used to treat cerebral edema and acute glaucoma. Normal kidney function and adequate urine output are crucial while administering this medication as mannitol accumulation can result in significant volume expansion, dilutional hyponatremia, and pulmonary edema.

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? 1. "Call the health care provider to stop your beta blocker if pregnancy occurs." 2. "If you plan to become pregnant, it is best to wait a few years and plan it at an older age." 3. "It is important to consistently use a reliable form of birth control." 4. "Your condition is not inheritable to your future children."

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 (Option 3). (Option 1) Beta blockers are commonly used to treat clients with Marfan syndrome to limit aortic root dilation. Such medications are generally safe to use during pregnancy, so the client should not discontinue therapy unless directed to do so by the health care provider. (Option 2) 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. (Option 4) Marfan syndrome is an autosomal dominant condition with a 50% chance of inheritance in offspring.

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? Select all that apply. 1. Elevating the head of the bed 30-45 degrees 2. Performing hourly in-line endotracheal suctioning 3. Practicing strict hand hygiene 4. Providing frequent oral care with chlorhexidine 5. Scheduling daily sedation vacations

Mechanically ventilated clients are at risk for developing ventilator-associated pneumonia (VAP) due to sedation and impairment of natural defenses (eg, coughing) by artificial airways. Interventions to reduce the risk of VAP include: Elevating the head of the bed 30-45 degrees (ie, semi-Fowler position) (Option 1) Providing oral care with antiseptic solutions (eg, chlorhexidine mouthwash) and suctioning subglottic secretions (Option 4) Performing scheduled daily sedation vacations and maintaining appropriate client sedation levels (Option 5) Practicing strict hand hygiene (Option 3) (Option 2) Endotracheal suctioning should be performed only when clinically indicated (eg, adventitious breath sounds, coughing, elevated peak airway pressure). Frequent suctioning increases the risk for tracheal and bronchial trauma, bleeding, and hypoxia.

The nurse is preparing to administer morning medications to a client with type 2 diabetes mellitus and end-stage renal disease who is scheduled for dialysis today. Which medication should the nurse hold for clarification prior to administration? Click the exhibit button for more information. 1. Atenolol [53%] 2. Calcium acetate [17%] 3. Insulin lispro [18%] 4. Vitamin E [10%] Medications Atenolol 50 mg by mouth daily 0900 Calcium acetate 667 mg by mouth With each meal Insulin lispro, high-dose sliding-scale subcutaneous injection with meals and before bedtime 0730 Vitamin E 400 IU by mouth daily0900

Medication administration may require modification on days that clients are scheduled to receive dialysis. The nurse should consider whether the medication will be dialyzed out of the client's system or may create adverse effects during dialysis. Fluid is removed during dialysis, which may cause hypotension. Typically, antihypertensives are held before dialysis to prevent hypotension. In addition, some medications are dialyzed out of the client's system and should therefore be held until after dialysis. Commonly held medications are water-soluble vitamins (eg, vitamins B and C), antibiotics, and digoxin. (Option 2) Clients with chronic kidney disease have high phosphorus levels as the kidney is unable to filter the phosphate from the body; dialysis also does not filter it. Therefore, the client should still take phosphate binders prior to dialysis. Phosphate binders (eg, calcium containing [calcium carbonate and calcium acetate]) and non-calcium containing [sevelamer and lanthanum]) block absorption of ingested phosphate from the intestine and excrete it through feces. (Option 3) Lispro is a fast-acting insulin that should be given 15-30 minutes before meals. It is appropriate to give scheduled lispro with breakfast prior to dialysis. (Option 4) Vitamin E is a fat-soluble vitamin that is not affected by dialysis. It is given to some clients to prevent leg cramps that can be experienced by dialysis clients.

Vegan megaloblastic anemia

Which of the following diets would place a client at the highest risk for macrocytic anemia? 1. Lacto-ovo-vegetarian [13%] 2. Lacto-vegetarian [8%] 3. Macrobiotic [15%] 4. Vegan [61%]

Megaloblastic anemia is caused by vitamin B12 or folic acid deficiency. Vitamin B12 deficiencycan 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 include meat, fish, poultry, eggs, and milk; some breads and cereals may be fortified with vitamin B12 as well as some nutritional yeasts. Vegans are strict vegetarians; they exclude all animal products, including eggs, milk, and milk products, from the diet. They also may avoid foods that are processed or not organically grown, thereby eliminating potentially fortified food sources of vitamin B12. Individuals who practice any form of vegetarianism are at risk for vitamin B12 deficiency. A vegan diet, with its elimination of all animal products, poses the highest risk. A vitamin B12supplement is recommended when dietary intake is inadequate. (Option 1) Lacto-ovo-vegetarian — eggs, milk, and milk products are included, but no meat is consumed. (Option 2) Lacto-vegetarian — milk and milk products are included in the diet; eggs and meats are excluded. (Option 3) Macrobiotic — whole grains, vegetables, fruits, and seaweeds are emphasized; fish and seafood may be included in the diet up to several times a week. Educational objective:Individuals who follow a plant-based diet, especially vegans, are at risk for vitamin B12deficiency and the resulting macrocytic anemia.

melatonin

Melatonin supplements are thought to help the body adjust quickly to new surroundings and time zones (jet lag). Most practitioners agree that the lowest possible dose should be used and should be taken only for a short time. There are no long-term studies on the safety of melatonin. Higher doses may cause side effects such as vivid dreams and nightmares. Research suggests that taking melatonin once a person has reached the travel destination is sufficient and that starting it prior to or during air travel may actually slow the recovery of jet lag, energy, and alertness. (Option 1) Evening primrose may be used for eczema or skin irritations. (Option 2) Ginseng is used to promote mental alertness and enhance the immune system. (Option 4) St. John's wort is used for treatment of depression. It has many interactions with other prescription medications. Educational objective:Short-term use of low-dose melatonin may be considered to treat jet lag and fatigue from traveling across time zones.

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? 1. Initiate fall precautions 2. Keep the emesis basin at bedside 3. Provide a quiet environment 4. Start intravenous fluids

Meniere disease (endolymphatic hydrops) results from excess fluid accumulation inside the inner ear. Clients have episodic attacks of vertigo, tinnitus, hearing loss, and aural fullness. The vertigo can be severe and associated with nausea and vomiting. Clients report feelings of being pulled to the ground (drop attacks). During an attack, the client is treated with vestibular suppressants, including sedatives (eg, benzodiazepines such as diazepam), antihistamines (eg, diphenhydramine, meclizine), anticholinergics (eg, scopolamine), and antiemetics. The nurse's priority is to plan for client safety with fall precautions given the severe vertigo and use of sedating medications. Fall precautions include adjusting the bed to a low position with side rails up and instructing the client to call for help before getting up. Vertigo may be minimized by staying in a quiet, dark room and avoiding sudden head movements. The client should reduce stimulation by not watching television or looking at flickering lights. The client's diet should be salt restricted to prevent fluid buildup in the ear. (Option 2) An emesis basin should be provided at the bedside, but fall precautions are the priority. (Option 3) A quiet environment can help minimize vertigo. However, it is a lower priority than the fall precautions. (Option 4) Most clients with Meniere disease require parenteral fluids given the nausea and vomiting. However, these are not the highest priority.

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? 1. Administer IV antibiotics 2. Infuse bolus of IV normal saline 3. Prepare to assist with lumbar puncture 4. Transport client for head CT scan

Meningitis is an inflammation of the meninges covering the brain and spinal cord. The key clinical manifestations of bacterial meningitis include fever, severe headache, nausea/vomiting, and nuchal rigidity. Other symptoms include photophobia, altered mental status, and other signs of increased intracranial pressure (ICP). In a hypotensive client with sepsis, the priority of care is fluid resuscitation to increase the client's blood pressure (Option 2). In addition to IV fluid administration, interventions and prescriptions for a client with sepsis and meningitis may include: Administer vasopressors. Obtain relevant labs and blood cultures prior to administering antibiotics. Administer empiric antibiotics, preferably within 30 minutes of admission (Option 1). This client will continue to decline without antibiotic therapy. Prior to a lumbar puncture (LP), obtain a head CT scan as increased ICP or mass lesions may contraindicate a LP due to the risk of brain herniation (Option 4). Assist with a LP for cerebrospinal fluid (CSF) examination and cultures (Option 3). CSF is usually purulent and turbid in clients with bacterial meningitis. CSF cultures will allow for targeted antibiotic therapy. Educational objective:For bacterial meningitis with sepsis, fluid resuscitation is the priority. Blood cultures should be drawn before starting antibiotics. After a head CT scan is performed to rule out increased intracranial pressure and mass lesions, cerebrospinal fluid cultures should be drawn via lumbar puncture.

The nurse is conducting a health-screening clinic at an industrial work site. The nurse should be most concerned about which client's risk for metabolic syndrome? 1. 27-year-old woman with triglycerides of 210 mg/dL (2.4 mmol/L), blood pressure of 128/82 mm Hg, and fasting blood glucose of 98 mg/dL (5.4 mmol/L) [6%] 2. 45-year-old man with waist circumference of 38 inches (96.5 cm), high-density lipoprotein of 49 mg/dL (1.3 mmol/L), and fasting blood glucose of 118 mg/dL (6.6 mmol/L) [12%] 3. 55-year-old woman with waist circumference of 37 inches (94 cm), triglycerides of 190 mg/dL (2.2 mmol/L), and fasting blood glucose of 120 mg/dL (6.7 mmol/L)[67%] 4. 82-year-old man with high-density lipoprotein of 45 mg/dL (1.2 mmol/L), blood pressure of 148/88 mm Hg, and fasting blood glucose of 104 mg/dL (5.8 mmol/L)[13%]

Metabolic syndrome is the presence of ≥3 metabolic health factors that increase a client's risk for stroke, diabetes mellitus, and cardiovascular disease. Criteria include: Abdominal obesity: Waist circumference (≥40 inches [102 cm] in men, ≥35 inches [89 cm] in women) High serum triglycerides >150 mg/dL (1.7 mmol/L) or hypertriglyceridemia drug treatment Low levels of high-density lipoprotein (HDL) cholesterol (<40 mg/dL [1.0 mmol/L] in men, <50 mg/dL [1.3 mmol] in women) Hypertension ≥130/85 mm Hg or hypertension drug treatment Fasting blood glucose ≥100 mg/dL (5.6 mmol/L) or hyperglycemia drug treatment The 55-year-old woman (waist circumference 37 inches [94 cm], triglycerides 190 mg/dL [2.2 mmol/L], fasting blood glucose 120 mg/dL [6.7 mmol/L]) is at highest risk for metabolic syndrome with 3 of 5 criteria (obesity, high triglycerides, hyperglycemia) (Option 3). (Option 1) The 27-year-old woman (triglycerides 210 mg/dL [2.4 mmol/L]) has only 1 metabolic syndrome-associated condition (hypertriglyceridemia). (Option 2) The 45-year-old man (fasting blood glucose 118 mg/dL [6.6 mmol/L]) has only 1 metabolic syndrome-associated condition (hyperglycemia). (Option 4) The 82-year-old man (blood pressure 148/88 mm Hg, fasting blood glucose 104 mg/dL [5.8 mmol/L]) has only 2 metabolic syndrome-associated conditions (hypertension, hyperglycemia). His HDL is within normal limits.

The nurse provides teaching about methotrexate to a 28-year-old client with rheumatoid arthritis. Which client statement indicates the need for further instruction regarding this drug? 1. "I know my resistance to germs will be lower, so I should get a flu shot this year." 2. "I should take precautions to prevent pregnancy while I take this medicine." 3. "I will have an eye examination every 6 months to check for damage caused by my medication." 4. "It will be a difficult change for me, but I will not have wine with dinner anymore."

Methotrexate (Rheumatrex) is classified as a folate antimetabolite, antineoplastic, immunosuppressant drug to treat various malignancies and as a nonbiologic disease-modifying antirheumatic drug (DMARD) to treat rheumatoid arthritis and psoriasis. The client's statement about getting an eye examination every 6 months indicates that further teaching is necessary as these examinations are not indicated for clients prescribed methotrexate (Option 3). However, frequent eye examinations are required for clients prescribed the nonbiologic antimalarial DMARD hydroxychloroquine (Plaquenil) as it can cause retinal damage. (Option 1) Methotrexate is an immunosuppressant and can cause bone marrow suppression. Clients are at risk for infection. They should avoid crowded places and individuals with known infection and should receive appropriate killed (inactivated) vaccines (eg, influenza, pneumococcal). Live vaccines (eg, herpes zoster) are contraindicated. (Option 2) Clients should not become pregnant while taking methotrexate or for at least 3 months after it is discontinued as the drug is teratogenic and can cause congenital abnormalities and fetal death. (Option 4) Clients taking methotrexate should avoid alcohol as the prescription drug is hepatotoxic and drinking alcohol increases the risk for hepatotoxicity.

The nurse assesses a client who is receiving methotrexate for rheumatoid arthritis. Which statement by the client is most concerning? 1. "I am nauseated and vomited three times today." [8%] 2. "I drink four large cups of coffee every day." [8%] 3. "I have small, purple spots all over my skin." [54%] 4. "I plan to stop taking birth control today." [28%]

Methotrexate is an antirheumatic drug prescribed to treat rheumatoid arthritis. It acts by interfering with folic acid metabolism, which inhibits DNA synthesis and cell reproduction. Adverse effects associated with methotrexate include bone marrow suppression, hepatotoxicity (ie, drug-induced liver injury), and gastrointestinal irritation (eg, nausea, vomiting, diarrhea). Bone marrow suppression is a serious adverse effect that leads to anemia, leukopenia, and thrombocytopenia. Thrombocytopenia (especially platelet count <100,000/mm3 [100 × 109/L]) is characterized by petechiae (ie, small, purple hemorrhagic spots), purpura, and/or other signs of bleeding (eg, melena, hematemesis, bleeding gums) (Option 3). Bone marrow suppression is managed by dose reduction or discontinuation of the medication. (Option 1) Nausea and vomiting are the most common side effects associated with methotrexate. The nurse should notify the health care provider and request a prescription for an antiemetic; however, vomiting is not the priority concern. (Option 2) Some substances decrease the effectiveness of methotrexate (eg, caffeine, folic acid) and should be avoided. (Option 4) Methotrexate is teratogenic, so pregnancy must be prevented. Effective contraceptives must be used throughout treatment and for one ovulatory cycle after completing treatment for women (three months after completion for men). This statement requires follow-up but is not priority as the client has not yet stopped taking birth control.

Metronidazole (Flagyl)

Metronidazole (Flagyl) is the first-line anti-infective drug used to treat infectious diarrhea caused by Clostridium difficile. Leukocytosis is expected with this bacterial infection.

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 the client? 1. Gloves and gown 2. Gloves and mask 3. Gown and N95 respirator 4. Gown, gloves, N95 respirator, and eye protection

Middle East respiratory syndrome (MERS) is a viral respiratory illness caused by the coronavirus (MERS-CoV). Symptoms include fever, cough, and shortness of breath that often worsen and cause death in many of those afflicted. 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 Centers for Disease Control and Prevention recommends the use of standard, contact, and airborne precautions with eye protection when caring for clients with MERS. (Options 1, 2, and 3) These options do not provide enough protection as each is missing a vital element that is recommended when caring for a client with MERS. Educational objective:Standard, contact, and airborne precautions with eye protection should be used when caring for a client with suspected or diagnosed Middle East respiratory syndrome. Additional Information Safety and Infection Control NCSBN Client Need

During shift report it was noted that the off-going nurse had given the client a PRN dose of morphine 2 mg every 2 hours for incisional pain. What current client assessment would most likely affect the oncoming nurse's decision to discontinue the administration every 2 hours? 1. Client reports burning during injection into the IV line 2. Client reports dizziness when getting up to use the bathroom 3. Client's blood pressure is 106/68 mm Hg 4. Client's respiratory rate is 11/min

Morphine is an opioid analgesic that can be given intravenously for moderate to severe pain. An adverse reaction to morphine administration is respiratory depression. A respiratory rate <12/min would be a reason to hold morphine administration. The nurse should perform a more in-depth assessment of the client's pain and causes. The morphine dose may need to be decreased or the time between administrations may need to be increased. The nurse should not administer additional doses until the respiratory rate increases. (Option 1) Morphine can cause burning during IV administration. This can be reduced by diluting the morphine with normal saline and administering it slowly over 4-5 minutes. (Option 2) The nurse should instruct the client to call for help before getting up to go to use the bathroom to avoid falls caused by dizziness from the morphine. (Option 3) Morphine can lower blood pressure, and clients receiving it should have blood pressure monitored. This blood pressure reading is not severely low and is not a priority over the respiratory depression.

The nurse is caring for a 2-year-old who is receiving a saline enema for treatment of intussusception. Reporting which client finding to the health care provider (HCP) is most important? 1. Passed a normal brown stool 2. Passed a stool mixed with blood 3. Stopped crying 4. Vomited a third time

Most cases of intussusception are successfully treated without surgery using hydrostatic (saline) or pneumatic (air) enema. The nurse will monitor for passage of normal brown stool, indicating reduction of intussusception. If this occurs, the HCP should be notified immediately to modify the plan of care and stop all plans for surgery. (Option 2) In intussusception, the stools are mixed with blood and mucus, giving a characteristic "currant jelly" appearance. This is an expected finding. (Option 3) Pain in intussusception is typically intermittent. It occurs every 15-20 minutes, along with screaming and drawing up of the knees. Therefore, if a child stops crying, it may not be due to reduction of intussusception. (Option 4) Intense pain causes spasms of the pyloric muscle that lead to vomiting after each episode. Vomiting tends to resolve once the intussusception is reduced. Educational objective:Reduction of intussusception is often performed with a saline or air enema. The HCP should be notified if there is passage of a normal stool as this indicates reduction of the intussusception. All plans for surgery should be stopped and the plan of care should be modified.

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? 1. "Avoid excess stretching of your lower extremities." 2. "Build strength by increasing the duration of daily exercise." 3. "Let me speak with your health care provider about getting a wheelchair." 4. "You should keep your feet apart and use a cane when walking."

Multiple sclerosis (MS) 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. (Option 1) Range-of-motion, strengthening, and stretching exercises help limit spasticity and contractures in clients with MS. (Option 2) 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. (Option 3) Wheelchairs are advised only if exercise and gait training are not successful as clients should maintain mobility and independence as long as possible.

At 8 AM, medications are prescribed for assigned clients. Which medication should the nurse administer first? 1. Acetylsalicylic acid for a client with a history of coronary artery disease and ischemic stroke. 2. Metformin for a client with serum glucose of 285 mg/dL (15.8 mmol/L) who is scheduled for a CT scan with contrast. 3. Morphine sulfate for a client with terminal lung cancer who has chronic bone pain. 4. Pyridostigmine for a client with myasthenia gravis exacerbation who reports difficulty swallowing.

Myasthenia gravis (MG) is a chronic, neurologic autoimmune disorder that involves damage to acetylcholine receptors at the neuromuscular junctions, which results in skeletal muscle weakness. The ocular (ptosis) and facial muscles, along with those responsible for chewing and swallowing, are affected initially; however, weakness can progress to the respiratory muscles(eg, intercostal, diaphragm). Pyridostigmine (Mestinon) 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. (Option 1) Acetylsalicylic acid (Aspirin) is prescribed daily to prevent ischemic attacks and myocardial infarction in clients with coronary artery disease and ischemic stroke; it is not the priority medication. (Option 2) Metformin (Glucophage) is an anti-hyperglycemic drug that can cause lactic acidosis in clients with kidney disease. Contrast used for CT scan can cause kidney injury. It is recommended that the drug be held before and resumed 48 hours after the CT scan (if renal function [creatinine] is normal). (Option 3) Analgesia with opioids is appropriate to treat chronic pain associated with terminal cancer. However, decreasing the aspiration risk is more urgent than providing pain relief. Educational objective:Pyridostigmine (Mestinon) inhibits acetylcholine breakdown and is prescribed to temporarily increase muscle strength in clients with myasthenia gravis. The ocular and facial muscles, along with those responsible for chewing and swallowing, are affected initially; this can increase the client's aspiration risk.

A client is admitted to the hospital with an exacerbation of myasthenia gravis. What are the appropriate nursing actions? Select all that apply. 1. Administer an anticholinesterase drug AC 2. Anticipate a need for an anticholinergic drug 3. Develop a bladder training schedule 4.Encourage semi-solid food consumption 5. Teach the necessity for annual flu vaccination

Myasthenia gravis is an autoimmune disease involving a decreased number of acetylcholine receptors at the neuromuscular junction. As a result, there is fluctuating weakness of skeletal muscles, most often presented as ptosis/diplopia, bulbar signs(difficulty speaking or swallowing), and difficulty breathing. Muscles are stronger in the morning and become weaker with the day's activity as the supply of available acetylcholine is depleted. Treatment includes anticholinesterase drugs (pyridostigmine [Mestinon]) that are administered before meals so that the client's ability to swallow is strongest during the meal (Option 1). Semi-solid foods (easily-chewed foods) are preferred over solid foods (to avoid stressing muscles involved in chewing and swallowing) or liquids (aspiration risk) (Option 4). All clients with a serious chronic co-morbidity should receive the annual flu vaccine(also the pneumonia vaccine if appropriate) as they are more likely to have a negative outcome if the illness is contracted. It is especially important in clients with myasthenia gravis as the flu (or pneumonia) would tax the already compromised respiratory muscles (Option 5). (Option 2) An anticholinergic drug, such as atropine, is used for treatment in a cholinergic crisis (eg, the medication is too high or there is excess acetylcholine). The need would not be anticipated during a myasthenic crisis (eg, exacerbation of myasthenia gravis), which is usually a result of too little medication related to noncompliance, illness, or surgery. (Option 3) The skeletal muscles are involved in myasthenia gravis; dysfunction of the reflexes or central nervous system affects bowel and bladder control. This issue is classic with multiple sclerosis.

A client is admitted to the hospital for evaluation of suspected pulmonary tuberculosis (TB). The nurse assesses for which characteristic presenting signs and symptoms associated with TB disease? Select all that apply. 1 Dysuria 2. Jaundice 3. Low back pain 4. Night sweats 5. Purulent or blood-tinged sputum 6. Weight loss

Mycobacterium tuberculosis is a gram-positive, acid-fast bacillus that is transmitted through the airborne route. TB is usually (85%) pulmonary but can also be extrapulmonary (eg, meninges, genitourinary, bone and joints, gastrointestinal). TB, regardless of location, commonly presents with constitutional symptoms, including: Low-grade fever Night sweats Anorexia and weight loss Fatigue Additional symptoms depend on the location of the infection. Pulmonary tuberculosis typically includes: Cough Purulent or blood-tinged sputum Shortness of breath Dyspnea and hemoptysis are typically seen in the late stages. The classic manifestations of TB can be absent in immunocompromised clients and the elderly. (Option 1) Dysuria is a symptom of extrapulmonary genitourinary TB. (Option 2) Jaundice can be present in disseminated TB with liver involvement. It can also be a side effect associated with drugs used to treat pulmonary TB (eg, isoniazid). (Option 3) Back pain indicates spinal TB.

The nurse is caring for a 72-year-old client with hypothyroidism admitted to the emergency department for altered mental status. The client lives alone but has not taken medications or seen a health care provider for several months. Which action is the priority? Click on the exhibit button for additional information. 1. Administer IV levothyroxine [20%] 2. Check serum TSH, triiodothyronine, and thyroxine [10%] 3. Place a warming blanket on the client [19%] 4. Prepare for endotracheal intubation [48%]

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

Spinal immobilization: NSAIDS

N - Neurological examination. Focal deficits include numbness and decreased strength.S - Significant traumatic mechanism of injuryA - Alertness. The client may be disoriented or have an altered level of consciousness .I - Intoxication. The client could have impaired decision-making ability or lack awareness of pain (Option 1).D - Distracting injury. Another significant injury could distract the client from spinal pain.S - Spinal examination. Point tenderness over the spine or neck pain on movement (if there is no midline tenderness) may be present

A client with type 1 diabetes is prescribed NPH insulin before breakfast and dinner. Although the client reports feeling well, the 6 AM blood glucose level has averaged 60 mg/dL (3.3 mmol/L) over the past week. Which action is appropriate for the nurse to recommend to the client? 1. Collect urine sample to check for urine ketones 2. Consume a snack of milk and cereal at bedtime 3. Increase carbohydrate intake at each meal 4. Take only the prebreakfast dose of NPH

NPH insulin is intermediate-acting with an onset of 1-2 hours, peak of 4-12 hours, and duration of 12-18 hours. Due to its long peak, hypoglycemia (blood glucose <70 mg/dL [<3.9 mmol/L]) can result from use of NPH, especially because the overnight hours (during sleep) typically represent the longest interval between meals. To prevent hypoglycemia related to an evening dose of NPH, the client should eat a bedtime snack consisting of protein and complex carbohydrates (eg, cereal with milk, crackers with peanut butter) (Option 2). Complex carbohydrates paired with protein provide sustained, slow release of glucose, thereby preventing hypoglycemia. (Option 1) Testing for urine ketones should be done as part of a sick-day plan or when evaluating for diabetic ketoacidosis. Ketosis occurs in hyperglycemia, especially when blood glucose is >180 mg/dL (>10 mmol/L). (Option 3) Increasing the client's carbohydrate intake at each meal may disrupt glycemic control and lead to a persistent elevation of blood glucose. Elevated blood glucose can cause complications, such as diabetic ketoacidosis. (Option 4) The client may require an adjustment to the prescribed insulin regimen; however, it is dangerous for the client to drastically alter the prescribed dose. In addition, it is outside the nurse's scope of practice to recommend a change in the prescribed dose.

The nurse reviews the laboratory results of several clients. Which finding should the nurse report to the health care provider immediately? 1. Client who is receiving tube feedings and has a phenytoin level of 8 mcg/mL (32 mcmol/L) 2. Client with a heart rate of 62/min who has a digoxin level of 1.3 ng/mL (1.7 nmol/L) 3. Client with a new prosthetic aortic valve who has an INR of 3.0 4. Client with a poor appetite and a lithium level of 0.8 mEq/L (0.8 mmol/L)

Narrow therapeutic index medications have a higher chance of producing adverse effects due to a very small difference between therapeutic and toxic levels. These medications require close monitoring of serum drug levels for adequate, but not toxic, dosing. Clients should also be monitored for signs of toxicity, which are specific to each medication. Phenytoin (Dilantin) is an antiseizure medication with a therapeutic index of 10-20 mcg/mL (40-79 mcmol/L) (Option 1). Tube feedings decrease phenytoin absorption, which reduces serum drug concentrations and may precipitate seizures. The nurse should pause tube feedings for 1-2 hours before and after phenytoin administration to ensure adequate absorption. Phenytoin toxicity produces nystagmus, dysarthria, ataxia, and encephalopathy. (Option 2) A heart rate of 62/min is expected in a client taking digoxin (therapeutic index 0.5-2.0 ng/mL [0.6-2.6 nmol/L]). Digoxin toxicity produces gastrointestinal symptoms (nausea, vomiting, diarrhea), bradycardia, and visual disturbances (blurred vision, yellow-green halos). (Option 3) The therapeutic INR for a client with a mechanical heart valve is 2.5-3.5. (Option 4) Anorexia is a common side effect of lithium (therapeutic index 0.6-1.2 mEq/L [0.6-1.2 mmol/L]). Lithium toxicity produces nausea, vomiting, ataxia, and tremors.

Client 8 days post-op ileostomy who reports nausea, vomiting, and abdominal bloating should be called back first

Nausea, vomiting, 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 (eg, peritonitis), and/or tissue necrosis. It is urgent and potentially life-threatening. The client must be evaluated by the health care provider in a timely manner. (Option 1) Constipation is common after abdominal surgery due to opioid usage and decreased peristalsis from bowel manipulation. Increasing food or fluids might help the client have a bowel movement. (Option 3) Phantom limb pain is a sensation of pain or tingling in the amputated body part. Wrapping the extremity or applying ice or heat might help until the client can be evaluated by the health care provider. (Option 4) Active infection is a relative contraindication for elective surgical procedures. The client should be called back for assessment and likely rescheduling of surgery but would not take priority over a client with bowel obstruction. Educational objective:A bowel or stoma obstruction is urgent and requires immediate medical attention. Signs of obstruction may include nausea, vomiting, abdominal pain, bloating, and decreased stool output. If left untreated, bowel obstruction can lead to electrolyte disturbances, dehydration, bowel perforation and infection (eg, peritonitis), and/or tissue necrosis.

The nurse is reviewing phone messages from clients in a surgery clinic. Which client would be the priority to call back first? 1.Client 1 week postoperative appendectomy who has not had a bowel movement in 4 days 2. Client 8 days postoperative ileostomy placement who reports nausea, vomiting, and abdominal bloating 3. Client postoperative right below-the-knee amputation who is concerned about a new tingling sensation in the right foot 4. Client with a temperature of 101.2 F (38.4 C) who is scheduled for a shoulder arthroplasty the next morning

The nurse is caring for a baby born at 30 weeks gestation and diagnosed with necrotizing enterocolitis. Which nursing action should be implemented? 1. Encourage parents to increase skin-to-skin care [10%] 2. Measure abdominal girth daily [62%] 3. Measure rectal temperature every 3-4 hours [7%] 4. Position client on side and check diaper for stool [18%]

Necrotizing enterocolitis occurs predominantly in preterm infants secondary to gastrointestinal and immunologic immaturity. On initiation of enteral feeding, bacteria can be introduced into the bowel, where they can proliferate excessively due to compromised immune clearance. This results in inflammation and ischemic necrosis of the intestine. As the disease progresses, the bowel becomes congested and gangrenous with gas collections forming inside the bowel wall. Measuring the client's abdominal girth daily is an important nursing intervention to note any worsening intestinal gas-associated swelling. Clients are made NPO and receive nasogastric suction to decompress the stomach and intestines. Parenteral hydration and nutrition and IV antibiotics are given. (Option 1) Skin-to-skin care (kangaroo care) promotes bonding with a healthy newborn. It is allowed in some instances for premature infants depending on the condition and week of gestation. Skin-to-skin care should be avoided in infants who are not stable as it may cause additional stress. (Option 3) Taking a client's temperature every 3-4 hours is important; however, rectal temperatures should be avoided due to the risk of perforation of the gangrenous, friable colon. (Option 4) To avoid pressure on the abdomen and facilitate observation for a distended abdomen, clients are placed supine and undiapered.

A client with massive trauma and possible spinal cord injury is admitted to the emergency department following a dirt bike accident. Which clinical manifestation does the nurse assess to help best confirm a diagnosis of neurogenic shock? 1. Apical heart rate 48/min [36%] 2. Blood pressure 186/92 mm Hg [19%] 3. Cool, clammy skin [40%] 4. Temperature 100 F (37.7 C) tympanic [2%]

Neurogenic shock belongs to the group of distributive (vasodilatory) shock. It affects the vasomotor center in the medulla and causes a disruption in the sympathetic nervous system (SNS); the parasympathetic nervous system (PNS) remains intact. The imbalance of activity between the SNS and PNS results in massive vasodilation and pooling of blood in the venous circulation, causing hypotensionand bradycardia, the characteristic manifestations of neurogenic shock. (Option 2) Hypotension, not hypertension, is characteristic of neurogenic shock. (Option 3) Warm, dry skin is more likely to be present in neurogenic shock; cool, clammy skin is not a characteristic manifestation. (Option 4) Although thermoregulation may be impaired (poikilothermia) in neurogenic shock, a low-grade temperature of 100 F (37.7 C) is not a characteristic manifestation.

The nurse is caring for a client who was just resuscitated following an out-of-hospital cardiac arrest. The client does not follow commands and remains comatose. What intervention does the nurse anticipate being added to the client's plan of care? 1. Assisting the health care provider in discussing a do-not-resuscitate order with the family [14%] 2. Obtaining equipment and cold fluids for induction of therapeutic hypothermia [21%] 3. Placing a small-bore nasogastric feeding tube for enteral nutrition [42%] 4. Planning for passive range-of-motion exercises to prevent contractures [21%]

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. The client is cooled to 89.6-93.2 F (32-34 C) for 24 hours before rewarming. Cooling is accomplished by cooling blankets; ice placed in the groin, axillae, and sides of the neck; and cold IV fluids. The nurse must closely assess the cardiac monitor (bradycardia is common), core body temperature, blood pressure (mean arterial pressure to be kept >80 mm Hg), and skin for thermal injury. The nurse must also apply neuroprotective strategies such as keeping the head of the bed elevated to 30 degrees. After 24 hours, the client is slowly rewarmed. (Option 1) It is too early to consider a do-not-resuscitate order. If the client does not respond to therapeutic hypothermia or there is evidence of neurologic impairment, it may be discussed at some point. (Option 3) Clients are generally kept NPO during therapeutic hypothermia and rewarming. The feeding tube may be needed after that time. (Option 4) Passive range-of-motion exercises would be indicated for this client but are not the immediate priority.

Normal CSF pressure

Normal CSF pressure is 60-150 mm H2O.

A nurse is reviewing the laboratory results of a client admitted for an asthma exacerbation. Elevation of which of these cells indicates that the client's asthma may have been triggered by an allergic response? 1. Eosinophils 2. Lymphocytes 3. Neutrophils 4. Reticulocytes

Normal eosinophil count is 1%-2%. Elevated eosinophils are seen in allergy. In a client with an asthma exacerbation, a high eosinophil count would indicate an allergic trigger for the asthmatic response. The nurse should explore the client's allergy history and ways to reduce the allergic exposure that may be contributing to the exacerbation. (Option 2) Lymphocytes form the major part of immune system. Elevated levels are seen with viral infections and hematologic malignancies. (Option 3) Normal neutrophils are 55%-70%. Elevated neutrophils indicate infection. (Option 4) Reticulocytes are immature red blood cells. Normal reticulocyte count is 0.5%-2.0%. Levels are elevated in hemolytic anemia or hemorrhage when the marrow is attempting to compensate for lost blood.

Postoperative leukocytosis (leukocytes >11,000 mm3 [>11X109/L]) is common in the first 48 hours after orthopedic surgery from normal inflammatory immune responses.

Normal leukocyte count 4,500 - 11,000/mm^3 (4.5 - 11 x10^9)

The nurse assesses a client with hyperparathyroidism who had a parathyroidectomy 4 hours ago. Which assessment technique should the nurse use to check for complications in this client? 1. Ask client to place backs of the hands against each other to provide hyperflexion of the wrist while the elbows remain flexed [17%] 2. Instruct client to lie down and run the heel of one foot down the shin of the other leg [7%] 3. Perform Romberg test by asking the client to stand with eyes closed and feet together[8%] 4. Place blood pressure (BP) cuff on arm, inflate to pressure > than systolic BP, and hold in place for 3 minutes [66%]

Normal serum calcium is 8.6-10.2 mg /dL (2.15-2.55 mmol/L). Hypocalcemia (serum calcium <8.6 mg/dL [2.15 mmol/L]) is a potential complication of parathyroidectomy because the parathyroids regulate calcium levels in the blood. When one or more parathyroids are removed, it may take some time for others that have been dormant during hyperparathyroidism (which causes an increase in serum calcium) to begin regulating serum calcium. Trousseau's sign may indicate hypocalcemia before other signs and symptoms of hypocalcemia, such as tetany, occur. Trousseau's sign can be elicited by placing the BP cuff on the arm, inflating to a pressure > than systolic BP, and holding in place for 3 minutes. This will occlude the brachial artery and induce a spasm of the muscles of the hand and forearm when hypocalcemia is present. Chevostek's sign another early indicator of hypocalcemia, should also be assessed. It may be elicited by tapping the face at the angle of the jaw and observing for contraction on the same side of the face. (Option 1) Phalen's maneuver is used to diagnose carpal tunnel syndrome. (Option 2) The heel-to-shin test is another means of assessing cerebellar function. An abnormal examination is evident when the client is unable to keep the foot on the shin. (Option 3) The Romberg test is a component of a neurological examination to assess vestibular function (perception of head position in space), proprioception (perception of the body in space), and vision.

The nurse cares for a client who has oral candidiasis. The health care provider has prescribed nystatin oral suspension. Which of the following nursing actions are appropriate? Select all that apply. 1. Assist the client in removing dentures and soaking them in nystatin 2. Inspect the oral mucous membranes thoroughly before administering nystatin 3. Instruct the client to discontinue the medication as soon as symptoms subside 4. Instruct the client to swish the suspension in the mouth for several minutes 5. Shake the bottle of suspension thoroughly before measuring the dose

Nystatin is an antifungal medication commonly used to treat mucocutaneous candidal infections(ie, oral, intestinal, vaginal, skin). When caring for a client prescribed nystatin, the nurse should: Assist clients with oral candida who wear dentures in removing them and soaking them in nystatin suspension because dentures often become a reservoir for reinfection (Option 1). Assess the appearance of the affected area (eg, oral cavity, skin lesions) frequently throughout nystatin therapy (eg, before administration, during routine assessments) to monitor treatment efficacy and identify potential side effects (eg, mucous membrane irritation) (Option 2). Instruct clients prescribed nystatin liquid suspension for oral thrush to swish the suspension in the mouth for several minutes and then swallow the medication to allow treatment of any esophageal candida (Option 4). Ensure that liquid suspension forms of nystatin are shaken well before being measured for dosing because medication precipitates and causes unequal concentrations within the liquid (Option 5). (Option 3) Clients receiving nystatin should be educated to take the medication as prescribed each day and avoid missing doses; nystatin therapy is continued for at least 48 hours after symptoms subside to prevent recurrence of the infection. Educational objective:Oral nystatin suspension is an antifungal medication used to treat oral thrush caused by candidal infections. Nurses administering nystatin should assist the client in removing and soaking dentures, if present; assess the affected area frequently; educate the client to swish the medication in the mouth before swallowing; and ensure that the suspension is well shaken before dosing. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

A hospitalized client with a history of obstructive sleep apnea sleeps while wearing a full face mask with continuous positive airway pressure (CPAP). Oxygen saturation drops to 85% during the night. What is the nurse's first action? 1. Assess level of consciousness and lung sounds 2. Check the tightness of the straps and mask 3. Notify the health care provider immediately 4. Remove the mask and administer supplemental oxygen

Obstructive sleep apnea (OSA) is a chronic condition that involves the relaxation of pharyngeal muscles during sleep. The resulting upper airway obstruction with multiple events of apnea and shallow breathing(hypopnea) leads to hypoxemia and hypercapnia. CPAP is an effective treatment for OSA; it involves using a nasal or full face mask that delivers positive pressure to the upper airway to keep it open during sleep. In this case, the nurse's first action should be to check the tightness of the straps that hold the mask in place. The full face mask must fit snugly over the client's nose and mouth without air leakage to maintain the positive airway pressure and prevent obstruction of upper airway airflow. Readjustment of the head straps may be necessary (Option 2). (Option 1) Underlying OSA is the most likely reason for this client's drop in oxygen saturation during sleep. If CPAP is not effective, then the characteristic OSA signs (eg, hypoxia, hypercapnia) will occur. In addition, decreased level of consciousness and lung sounds are expected when there is no airflow to the lungs. Although the nurse should assess these parameters, this should not be the first action. (Option 3) If the attempt to readjust the straps and mask seal does not reverse the client's hypoxemia quickly, the nurse should notify the health care provider and respiratory therapist (per institution policy). However, this should not be the nurse's first action. (Option 4) Supplemental oxygen may be indicated if readjustment of the straps and mask seal does not reverse the client's hypoxemia quickly. This should not be the nurse's first action.

The nurse is teaching an overweight 54-year-old client about ways to decrease symptoms of obstructive sleep apnea. Which interventions would be most effective? Select all that apply. 1. Eating a high-protein snack at bedtime 2. Limiting alcohol intake 3. Losing weight 4. Taking a mild sedative at bedtime 5. Taking modafinil at bedtime 6. Taking a nap during the day

Obstructive sleep apnea (OSA) is characterized by partial or complete airway obstructionduring sleep that occurs from relaxation of the pharyngeal muscles. The result is repeated episodes of apnea (≥10 seconds) and hypopnea (≤50% normal ventilation), which cause hypoxemia and hypercarbia. Common symptoms include frequent periods of sleep disturbance, snoring, morning headache, daytime sleepiness, difficulty concentrating, forgetfulness, mood changes, and depression. Interventions include: Continuous positive airway pressure device at night to keep the structures of the pharynx and tongue from collapsing backward Limiting alcohol intake at bedtime as it can cause muscles of the oral airway to relax and lead to airway obstruction (Option 2) Weight loss and exercise can reduce snoring and sleep apnea-associated airway obstruction. Obesity contributes to the development of OSA (Option 3). Avoiding sedating medications (eg, benzodiazepines, sedating antidepressants, antihistamines, opiates) as they may exacerbate OSA and worsen daytime sleepiness (Option 1) Eating before bedtime can interfere with sleep and contribute to excess weight. (Option 4) Sedatives at bedtime can relax the muscles of the oral airway and lead to airway obstruction. (Option 5) Stimulants such as modafinil may be prescribed for daytime sleepiness but should be avoided at bedtime as they can cause insomnia. (Option 6) Napping during the day can make it more difficult to sleep through the night.

The nurse is gathering data on a client with obstructive sleep apnea. Which findings are consistent with this client's diagnosis? Select all that apply. 1. Difficulty arousing from sleep 2. Excessive daytime sleepiness 3. Morning headaches 4. Postural collapse and falling 5. Snoring during sleep 6. Witnessed episodes of apnea

Obstructive sleep apnea (OSA) is the most common type of breathing disorder during sleep and is characterized by repeated periods of apnea (>10 seconds) and diminished airflow (hypopnea). A partial or complete obstruction occurs due to upper airway narrowing that results from relaxation of the pharyngeal muscles or from the tongue falling back on the posterior pharynx due to gravity. During periods of apnea, desaturation (hypoxemia) and hypercapnia occur; these stimulate the client to arouse and breathe momentarily to restore airflow. These cycles of apnea and restored airflow can occur several hundred times per night, resulting in restless and fragmented sleep. Partners of clients with OSA witness loud snoring, apnea episodes, and waking with gasping or a choking sensation (Options 5 and 6). During the day, clients experience morning headaches, irritability, and excessive sleepiness. Excessive daytime sleepiness can lead to poor work performance, motor vehicle crashes, and increased mortality (Options 2 and 3). (Option 1) Frequent (not difficult) arousal from sleep is associated with OSA. (Option 4) Cataplexy is a brief loss of skeletal muscle tone or weakness that can result in a client falling down. It is associated with narcolepsy, a chronic neurologic sleep disorder.

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? 1. Administer PO analgesic medication 2. Cover the affected eye with an eye patch 3. Initiate continuous eye irrigation 4. Perform a Snellen vision test

Ocular chemical burns require emergency care to prevent permanent vision loss. Alkali burns (eg, ammonia, cement, lye-containing drain cleanser) are particularly dangerous as they will quickly penetrate deep into the eye, causing severe, irreversible damage. For 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 (Option 3). Before transport to an emergency care facility, tap water can be used for eye irrigation. If transported by ambulance, emergency care personnel continue irrigation during transport with IV tubing or a Morgan lens. Irrigation is continued until the pH of the eye returns to normal (pH 6.5-7.5), which typically requires 30-60 minutes depending on the type of chemical. (Option 1) Depending on the severity of the burn, anesthetic eye drops may be instilled prior to irrigation because ocular burns are very painful, but systemic analgesia is not a priority. (Option 2) Care of ocular burns may include covering the eye with an eye patch and use of eye drops to prevent eye muscle spasms; however, eye irrigation should be performed first. (Option 4) The Snellen eye chart is commonly used to assess visual acuity. However, eye irrigation is essential and should not be delayed.

Which statement is most important to emphasize when teaching a 40-year-old female client newly diagnosed with fibrocystic breast changes? 1. "Breast changes that are not related to your cycle should be reported to your provider." 2. "If your breasts become sore during the month, you may take ibuprofen as needed." 3. "Schedule yearly clinical breast examinations with your health care provider." 4. "These cysts are benign, and research shows that they do not increase the risk of cancer."

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 (ie, not related to the menstrual cycle) may indicate malignancy (ie, cancer) and should be immediately reported to the health care provider (HCP) (Option 1). (Option 2) Clients should be instructed that cyclic pain and swelling may be reduced by decreasing caffeine and sodium intake; taking vitamins E, A, and B complex; wearing a support bra; utilizing cold compresses; and taking nonsteroidal anti-inflammatory drugs (eg, ibuprofen). (Option 3) Clients age >40 should receive yearly clinical breast examinations by an HCP and practice breast self-awareness. Emphasis is placed on the importance of reporting any suspicious breast changes. (Option 4) The client should be taught that fibrocystic breast changes are benign and do not increase the risk of breast cancer; however, reporting noncyclic changes is a higher priority

A client taking morphine sulfate for acute pain has not voided in 6 hours. The nurse suspects the client has developed urinary retention. What is the priority nursing intervention? 1. Ask if the client needs to use the bedpan [13%] 2. Assess the client's fluid intake [23%] 3. Assess the client's skin turgor [4%] 4. Palpate the client's suprapubic area [58%]

Opioids (eg, morphine sulfate), anticholinergic medications, and tricyclic antidepressants can cause urinary retention; they increase bladder sphincter tone and/or relax bladder muscle. The nurse should assess the client's suprapubic area to determine if the client has urinary retention. If the area is distended and dull to percussion, the nurse should proceed with interventions. (Option 1) While asking if a bedpan is needed is an important nursing intervention, it does not aid in the assessment of urinary retention. (Option 2) Gathering assessment data indicating the presence of urinary retention is necessary prior to other interventions. The nurse should assess for fluid intake after assessing bladder distension. (Option 3) The client's skin turgor is assessed after the nurse checks for urinary retention and fluid intake. There is no need to assess skin turgor until other indicators of adequate fluid intake are reviewed.

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? Select all that apply. 1. Apply a water-soluble lubricating agent to moisturize mouth tissues 2. Brush teeth with a soft-bristle toothbrush 3. Cleanse the mouth with normal saline after meals and at bedtime 4. Do not drink hot liquids or eat foods that are spicy or acidic 5. Rinse with alcohol-based antiseptic mouthwash to decrease mouth odor 6. Use palifermin as prescribed to alleviate oral pain

Oral mucositis, inflammation or ulceration of the oral mucosa, results from chemotherapy or radiation therapy. Oral hygiene practices that minimize oral mucositis and promote comfort include the following: Cleansing the mouth with normal saline after meals and at bedtime to promote oral health Use of a soft-bristle toothbrush to decrease gum irritation Application of prescribed viscous lidocaine HCl (Xylocaine) to alleviate oral pain Use of water-soluble lubricating agents to moisten mouth tissues that may become dry due to therapy Avoidance of hot liquids and spicy/acidic foods, which can cause oral discomfort (Option 5) Clients with mucositis should avoid antiseptic mouthwashes with alcohol as they are irritating to mucous membranes. (Option 6) Administration of palifermin (Kepivance), a recombinant human keratinocyte growth factor, prevents oral mucositis in clients diagnosed with hematologic malignancies. However, it does not help with pain. Viscous lidocaine HCl (Xylocaine) alleviates the oral pain caused by mucositis. Educational objective: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 viscous lidocaine.

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? 1. Anticipate the scheduling of a biopsy [66%] 2. Apply ice to the node [3%] 3. Reassure the client that it is an expected finding 4. Request an antibiotic [2%]

Ordinarily, lymph nodes are not palpable in adults. However, a lymph node that is palpable, superficial, small (0.5-1 cm), mobile, firm, and nontender is considered a normal finding. It could easily be explained by the relatively recent mastectomy (trauma) with resulting inflammation and lymph flow interference. A tender, hard, fixed, or enlarged node is an abnormal finding. Tender nodes are usually due to inflammation but hard or fixed nodes could indicate malignancy. (Option 1) A biopsy is performed for an abnormal lymph node finding that could suggest malignancy. (Option 2) The swelling is caused by inadequate lymph drainage or inflammation, not localized edema. Ice is not recommended for this normal finding. (Option 4) There is no indication of lymphangiitis requiring antibiotics. This may produce a red streak with induration following the course of the lymphatic collecting duct. Infected skin lesions may also be present. Educational objective: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.

The nurse is caring for an infant with osteogenesis imperfecta admitted with a new fracture. The client also has old fractures in multiple stages of healing but no bruising, abrasions, or redness of the skin. Which nursing intervention should be included in the plan of care? 1. During diaper changes, carefully lift the infant by the ankles [8%] 2. Lift from under the arms when picking up the infant [22%] 3. Obtain blood pressure manually to avoid cuff over-tightening [45%] 4. Request a social work consultation to assess for child abuse [23%]

Osteogenesis imperfecta (OI) (brittle bone disease) is a rare genetic condition resulting in impaired synthesis of collagen by osteoblasts. Collagen allows bone to be somewhat flexible while still maintaining strength. Impaired collagen causes bones to be frail and easily fractured. Clinical manifestations can range from mild defects to lethal disease in utero. OI is usually transmitted by autosomal dominant inheritance. The nurse's priority for a client with OI is careful handling to minimize additional fractures. Care of the infant with OI includes: Checking blood pressure manually to avoid cuff over-tightening, which may occur with automatic blood pressure cuffs (Option 3) Lifting the infant by slipping a hand under the broadest areas of the body (eg, back, buttocks) so the pressure is distributed Repositioning the infant frequently using supportive devices and gel padding to avoid molding of the soft bones of the skull (Options 1 and 2) Lifting by the ankles or under the arms puts too much pressure on the delicate bones (eg, legs, ribcage). (Option 4) Nonaccidental traumas with fractures (eg, child abuse) are usually associated with soft-tissue injury (eg, bruising, abrasions, redness) from the force of an external source.

A client newly diagnosed with osteomalacia is reviewing home care instructions with the nurse. Which statements indicate the need for further instruction? Select all that apply. 1. "I will avoid foods high in calcium and phosphorus." 2. "I will avoid going outside on sunny days." 3. "I will decrease activity to prevent bone injury." 4. "I will eat foods that are fortified with vitamin D." 5. "I will use a cane to help me get around better."

Osteomalacia is a reversible bone disorder caused by vitamin D deficiency and is characterized by weak, soft, and painful bones that can easily fracture or become deformed. In vitamin D deficiency, calcium and phosphorus cannot be absorbed from the gastrointestinal tract and are unavailable for calcification of bone tissue. Vitamin D deficiency is also associated with increased risk of falls, especially in elderly clients, due to muscle weakness. Nursing management focuses on: Implementing safety measures such as canes or walkers to prevent falls and injury (Option 5) Encouraging light to moderate activity, which can help promote bone strength and health (Option 3) Increasing dietary intake of:Calcium (eg, leafy green vegetables, dairy) (Option 1)Phosphorus (eg, milk, organ meats, nuts, fish, poultry, whole grains)Vitamin D (eg, vitamin D-fortified milk and cereal, egg yolks, saltwater fish, liver); exposure to sunlight is also recommended as it synthesizes vitamin D (Options 2 and 4) Taking over-the-counter or prescription supplemental vitamin D

The nurse teaches a client with osteopenia, who is lactose intolerant, how to increase dietary calcium and vitamin D intake. Which lunch food is the best choice? 1. Broiled chicken breast [14%] 2. Canned sardines [42%] 3. Egg white omelet [29%] 4. Peanut butter [14%]

Osteopenia is more than normal bone loss for the client's age and sex. Adequate dietary intake of calcium and vitamin D is necessary to promote bone growth, prevent resorption (bone loss), and prevent progression to osteoporosis. Milk and milk products are the best sources of calcium. However, other food sources are available for individuals who are lactose intolerant. They include some fish (eg, sardines, salmon, trout), tofu, some green vegetables (eg, spinach, kale, broccoli), and almonds. Good food sources of vitamin D include egg yolks and oily fish (eg, salmon, sardines, tuna). Canned sardines are the best choice as sardines are an excellent source of calcium and vitamin D (Option 2). (Options 1, 3, and 4) These foods have only small amounts of calcium per serving and no vitamin D.

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? 1. Instills ear drops at room temperature [1%] 2. Instills ear drops with dropper by occluding the ear canal [69%] 3. Places a cotton ball loosely in outermost auditory canal after the instillation [14%] 4. Pulls pinna up and back and instills drops [14%]

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 general procedure for instilling ear drops includes the following steps: Perform hand hygiene and don clean gloves. The ear canal is not sterile, but aseptic technique is used Position the client side-lying with the affected ear up (if not contraindicated). This facilitates administration and prevents drops from leaking out of the ear Warm ear drops to room temperature (ie, use hand or warm water) to help avoid vertigo, dizziness, or nausea as the internal ear is sensitive to temperature extremes (Option 1) Pull the pinna up and back to straighten the ear canal in clients >4 years old and adults. Pull the pinna down and back in clients <3 years old (Option 4) Support hand on the client's head and instill the prescribed number of drops by holding the dropper 1 cm (1/2 in) above the ear canal. This avoids damaging the ear canal with the dropper (Option 2) Apply gentle pressure to the tragus (fleshy part of external ear canal) if it does not cause pain, which facilitates the flow of medication into the ear canal Instruct the client to remain side-lying for at least 2-3 minutes to facilitate medication distribution and prevent leakage Place a cotton ball loosely in the client's outermost ear canal for 15 minutes, only if needed, to absorb excess medication. Perform this with caution and avoid in infants or very young clients as it is a choking hazard (Option 3)

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? Select all that apply. 1. "Always ask the health care provider or pharmacist before taking OTC medications." 2. "Ingredients in some OTC medications may interact with prescription medications." 3. "It is best to avoid OTC medications, but herbal and supplement products are usually safe." 4. "Remember to discuss all medications, herbs, and supplements you take with your health care providers." 5. "Taking OTC medications can sometimes hide symptoms of a serious disease or illness."

Over-the-counter (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 the supervision of a health care provider (HCP). Prior to taking OTC medications, the client should talk with an HCP or pharmacist, particularly if already taking prescribed medications (Option 1). Even when taken as directed by the OTC medication label, interactions and adverse effects may occur when used in combination with prescription medications (Option 2). 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 (Option 4). When OTC medications are used to manage symptoms (eg, ibuprofen for back pain), the diagnosis and treatment of serious underlying medical conditions (eg, malignancy) may be delayed (Option 5). (Option 3) Herbal products and supplements, although they are prepared from plants or "all-natural" substances, may contain compounds that interact with prescription medications. These interactions may cause increased or decreased prescription medication effect, serious adverse effects, and medication toxicities. Educational objective:Nurses should instruct clients to talk with a health care provider (HCP) or pharmacist before taking over-the-counter medications as they may interact with prescription medications or hide symptoms of a serious condition. All medications, herbal products, and supplements taken should be discussed with HCPs. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

The nurse is caring for a client with overflow urinary incontinence related to diabetic neuropathy. Which of the following interventions are appropriate? Select all that apply. 1. Decrease fluid intake to 1 glass with each meal and at bedtime 2. Encourage the client to bear down while attempting to void 3. Inspect the perineal area for evidence of skin breakdown 4. Measure postvoid residual volumes as prescribed 5. Tell the client to wait 30 seconds after voiding and then attempt to void again

Overflow urinary incontinence occurs due to compression of the urethra (eg, uterine prolapse, prostate enlargement) or impairment of the bladder muscle (eg, spinal cord injury, diabetic neuropathy, anticholinergic medications). Both types involve incomplete bladder emptying and urinary retention, which lead to overdistension and overfilling of the bladder and frequent involuntary dribbling of urine. When caring for clients with overflow incontinence, the nurse should: Implement a fixed voiding schedule (eg, every 2 hours) to prevent bladder overfilling. Instruct the client to use the Valsalva maneuver (ie, "bearing down") and Credé maneuver (ie, gently applying pressure to the lower abdomen) to help facilitate bladder emptying (Option 2). Assess the perineal area for skin breakdown related to incontinence (Option 3). Measure postvoid residual volumes as prescribed to ensure that the client is not retaining large amounts of urine (Option 4). Instruct the client to wait 20-30 seconds after voiding and then attempt to void a second time (ie, double voiding) to help empty residual urine (Option 5). (Option 1) Fluid restriction can lead to dehydration with concentrated urine, which irritates the bladder and increases the risk for urinary tract infection. Dehydration also contributes to constipation, which worsens incontinence by compressing the bladder. Educational objective:When caring for clients with overflow incontinence, the nurse should implement a fixed voiding schedule, teach the client techniques that assist with bladder emptying (eg, Valsalva maneuver, Credé maneuver, double voiding), monitor for perineal skin breakdown, and measure postvoid residual volumes as prescribed.

A client is 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? 1. Decreased albumin [2%] 2. Elevated troponin [1%] 3. Hyperkalemia [10%] 4. Hypocalcemia [85%]

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 (capillary leak → third spacing), latent hypoxia or acute respiratory distress syndrome (ARDS), 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 (tetany) and decreased cardiac contractility (cardiac arrhythmia) are concerns related to hypocalcemia. (Option 1) Decreased albumin levels are seen with malnutrition; clients who are alcoholics can have low serum albumin but that alone is not responsible for the client's symptom. (Option 2) Troponin elevation is specific to myocardial infarction and is unrelated to pancreatitis. (Option 3) Potassium abnormalities are not usually present in acute pancreatitis. They are more likely to occur with hemolysis, when the intracellular potassium enters the serum. The ecchymoses in pancreatitis (Grey Turner's sign, Cullen's sign) are due to the blood-stained exudates from autodigestion and are usually only seen in severe cases.

A client with ascites due to cirrhosis has increasing shortness of breath and abdominal pain. The health care provider requests that the nurse prepare the client for a paracentesis. Which nursing actions would the nurse implement prior to the procedure? Select all that apply. 1. Educate client about the procedure and obtain informed consent 2. Initiate NPO status 6 hours prior to the procedure 3. Obtain baseline vital signs, abdominal circumference, and weight 4. Place client in high Fowler position or as upright as possible 5. 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: Verify that the client received necessary information to give consent and witness informed consent Instruct the client to void to prevent puncturing the bladder (Option 5) Assess the client's abdominal girth, weight, and vital signs (Option 3) Place the client in the high Fowler position or as upright as possible (Option 4) (Option 1) Paracentesis is an invasive procedure requiring delivery of informed consent by the health care provider (HCP). The HCP explains the benefits and risks of the procedure. The nurse's role is to witness informed consent and verify that it has occurred. (Option 2) NPO status is not required for paracentesis, which is often performed at the bedside or in an HCP's office using only a local anesthetic.

A nurse is caring for a client who developed paralytic ileus after a stroke. The client reports nausea, abdominal discomfort, and distension; bowel sounds are absent. Which prescription does the nurse question? 1. Hydrocodone 5/325 mg 1 tab every 4 hours PRN for moderate pain 2. Increase continuous IV normal saline rate from 75 to 100 mL/hr 3. Insert nasogastric tube and attach to wall suction 4. Ondansetron 4 mg IVP every 4 hours PRN for nausea

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

A client with Parkinson disease is prescribed carbidopa-levodopa. Which of the following instructions should the nurse include with the client's discharge teaching? Select all that apply. 1. "Change positions slowly, and sit on the side of the bed before standing." 2. "This medication takes several weeks to reach maximum benefit." 3. "You may experience some facial and eye twitching, but this is not harmful." 4. "Your tremors should disappear completely while on this medication." 5. "Your urine and saliva may turn reddish-brown, but this is not harmful."

Parkinson disease (PD) is characterized by decreased dopamine levels, uncontrolled acetylcholine, and formation of abnormal protein clusters (Lewy bodies) in the brain. PD causes both physical and neurological (eg, mood alterations, dementia) symptoms. Carbidopa-levodopa is a combination antiparkinsonian medication used to reduce physical symptoms of PD by increasing dopamine levels in the brain. Levodopa is converted to dopamine in the brain but is largely metabolized before reaching the brain. Carbidopa does not have a therapeutic effect on PD but prevents breakdown of levodopa before reaching the brain, which makes levodopa more effective. Client teaching for carbidopa-levodopa includes: Implementing fall precautions (eg, changing positions slowly, removing rugs), as orthostatic hypotension is a common side effect (Option 1) Knowing that carbidopa-levodopa takes several weeks to reach its maximum effectiveness (Option 2) Understanding that harmless discoloration (eg, red, brown, black) of secretions (eg, urine, perspiration, saliva) may occur while taking carbidopa-levodopa (Option 5) Avoiding high-protein meals, which interfere with the absorption of carbidopa-levodopa (Option 3) Dyskinesia (eg, facial or eyelid twitching, tongue protrusion, facial grimacing) may indicate overdose or toxicity of carbidopa-levodopa and should be reported immediately to the health care provider. (Option 4) Carbidopa-levodopa often decreases, but does not eliminate, tremor and rigidity.

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? 1. "It can't be Parkinson's disease because you aren't old enough." 2. "Make sure you tell the physician about your concerns." 3. "Parkinson's disease does not cause that kind of hand shaking." 4. "Tell me more about your symptoms. When did they start?"

Parkinson's disease (PD) 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 (Option 4). (Option 1) It is incorrect to say that the client is too young to have PD although it is usually seen after age 60; about 15% of PD cases are diagnosed before age 50. (Option 2) Although the nurse should encourage the client and family to discuss concerns with the health care provider, this is not the most helpful response. (Option 3) Although the typical parkinsonian tremor occurs at rest and not during purposeful movement, it is not helpful to dismiss a concern without probing for more information. Educational objective:Therapeutic communication includes acknowledging concerns and probing for additional information as part of an assessment.

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? Select all that apply. 1. "I need to avoid taking medicines like ibuprofen without a prescription." 2. "I should avoid drinking excess coffee or cola." 3. "I should enroll in a smoking cessation program." 4. "I should reduce or eliminate my intake of alcoholic beverages." 5. "I will eliminate whole wheat foods, like breads and cereals, from my diet."

Peptic ulcer disease (PUD) is characterized by ulceration of the protective layers (ie, mucosa) of the esophagus, stomach, and/or 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 gastrointestinal Helicobacter pylori infections, genetic predisposition, chronic NSAID (eg, aspirin, ibuprofen, naproxen) use, stress, and diet and lifestyle choices. Nurses educating clients with PUD about ulcer prevention should focus on modifiable risk factors: NSAIDs: Chronic use of NSAIDs can damage the gastric mucosa and delay ulcer healing (Option 1). Caffeine: Cola, tea, and coffee should be avoided as they stimulate stomach acid secretion (Option 2). Smoking: Tobacco increases secretion of stomach acid and delays ulcer healing (Option 3). Alcohol: Alcohol should be avoided as it stimulates stomach acid secretion and impairs ulcer healing (Option 4). Meal timing: Eating multiple small meals throughout the day or eating shortly before sleeping may actually worsen PUD by increasing stomach acid secretion. (Option 5) Evidence does not support the standard elimination of specific foods from the diet in clients with PUD. However, clients should avoid foods that exacerbate their symptoms. Educational objective:Peptic ulcer disease (PUD) is a gastrointestinal illness caused by breaks in the gastrointestinal mucosa, leading to ulcer formation. To reduce ulcer formation risk, clients with PUD should be instructed to stop smoking; avoid chronic NSAID use; avoid meals or snacks before sleeping; and limit alcohol and caffeine consumption.

A nurse in the cardiac intensive care unit assesses a client with diabetes who had a percutaneous coronary intervention with stent placement via the left femoral artery 3 hours ago. Which assessment finding requires priority notification of the health care provider? 1. 1+ palpable pedal pulses bilaterally [18%] 2. 2-cm area of ecchymosis in the left groin [32%] 3. Angina rated as 4 on pain scale of 0-10 [38%] 4. Blood glucose of 220 mg/dL (12.2 mmol/L) [10%]

Percutaneous coronary intervention (PCI) with stent placement is performed to improve coronary artery patency and increase cardiac perfusion. After the use of contrast media to identify the occlusion, a balloon and stent are inserted via a catheter through a large artery (eg, femoral artery) and threaded up to the blocked coronary artery. The balloon expands the stent against the arterial wall, compressing plaque and improving patency. The stent remains in the client after the balloon and catheter are removed. Potential complications of PCI include thrombosis, stent occlusion, bleeding/hematoma, and limb ischemia. The nurse should immediately notify the health care provider of postprocedure angina, which indicates possible thrombosis or stent occlusion; necessary prescriptions (eg, nitroglycerin, second PCI) should be obtained and promptly initiated (Option 3). (Option 1) Neurovascular assessments (eg, circulation, sensation) of the affected extremity should be compared with those of the unaffected extremity and the client's baseline; this client's 1+ pulses are not a concern as they are bilateral, not unilateral. Most clients with diabetes and coronary artery disease may also have baseline peripheral artery disease. (Option 2) A small amount of bleeding/ecchymosis is expected at the access site due to anticoagulation therapy, which is initiated prior to PCI. The nurse should assess for signs of hematoma formation and retroperitoneal hemorrhage (eg, ecchymosis, flank/back pain). (Option 4) Increased blood glucose needs to be treated but is not a priority over stent occlusion.

The nurse is caring for a client whose peritoneal dialysis is beginning to exhibit insufficient outflow. What actions should the nurse perform initially? Select all that apply. 1. Assess for abdominal distention and constipation 2. Contact the client's health care provider 3. Examine the catheter for kinks and obstructions 4. Flush the tubing with 100 mL of dialysate 5. Place the client in a side-lying position

Peritoneal dialysis uses the abdominal lining (ie, peritoneum) as a semipermeable membrane to dialyze a client with insufficient renal function. A catheter is placed into the peritoneal cavity, and dialysate (ie, dialysis fluid) is infused. The tubing is clamped to allow the fluid to remain in the cavity, usually for 20-30 minutes (dwell phase). The catheter is then unclamped to allow dialysate to drain via gravity. Insufficient outflow results most often from constipation when distended intestines block the catheter's holes. If outflow becomes sluggish, the nurse should assess the client's bowel patterns and administer appropriate prescribed medications (eg, stool softeners) (Option 1). The nurse should also check the tubing for kinks and reposition the client to a side-lying position or assist with ambulation (Options 3 and 5). The drainage bag should be maintained below the abdomen to promote gravity flow. The nurse should assess for fibrin clots and milk the tubing to dislodge or administer fibrinolytics (eg, alteplase) as prescribed. If these measures are ineffective, an x-ray may be needed to check the catheter location. (Options 2 and 4) The nurse should identify the problem before instilling additional fluids and perform routine assistive measures before contacting the health care provider.

A nurse in an urgent care center triages multiple clients. Which client should the nurse assess first? 1. Client who reports nosebleed that has not resolved after holding pressure for 1 hour [28%] 2. Client who reports sinus congestion with thick nasal drainage and severe facial pain [3%] 3. Client with a sore throat who reports difficulty in opening mouth and swallowing[64%] 4. Client with seasonal allergies who reports new onset of unilateral ear pain and pressure [3%]

Peritonsillar, or retropharyngeal, abscess is a serious complication that can result from tonsillitis or pharyngitis. The presenting features of peritonsillar abscess, in addition to fever, include a "hot potato" (muffled) voice, trismus (inability to open the mouth), pooling of saliva (drooling), and deviation of the uvula to one side. The abscess can progress to life-threatening airway obstruction (eg, dysphagia, stridor, restlessness). The nurse should immediately assess the client with symptoms of peritonsillar abscess and monitor for signs of airway obstruction (Option 3). (Option 1) A client with epistaxis (ie, nosebleed) that does not resolve with external pressure will require further hemostatic interventions, such as cauterization or nasal packing (eg, gauze, nasal tampon, balloon catheter). This client should be assessed after the client with signs of impending airway obstruction. (Option 2) Symptoms of acute sinusitis include severe facial pain, nasal congestion with purulent nasal drainage, and fever. In most cases, the etiology is viral but can be complicated by secondary bacterial infection. This client likely requires antibiotics and supportive care but is not the priority. (Option 4) Acute otitis media (ie, infection of the middle ear) may develop secondary to rhinitis (eg, common cold, seasonal allergies) due to inflammation of the Eustachian tube. This client with otitis media will likely require antibiotics and pain management but is not the priority.

Common applications of droplet precautions Neisseria meningitidis Haemophilus influenzae type B Diphtheria Mumps Rubella Pertussis Group A Streptococcus (strep throat) Viral influenza

Personal protective equipment: Surgical mask Private room As needed for procedures with risk of splash or body fluid contact: gloves, gown, goggles/face shield

The nurse plans care for a 3-year-old who was admitted with suspected pertussis infection. Which instructions will the nurse include in the plan of care? Select all that apply. 1. Institute droplet precautions 2. Monitor for signs of airway obstruction 3. Offer small amounts of fluids frequently 4. Place the child in a negative-pressure isolation room 5. Request an order for cough suppressant

Pertussis (whooping cough) is a very contagious communicable disease caused by the Bordetella pertussis bacteria. These organisms attach to the small hairs in the airway and release a toxin that causes swelling and irritation. Pertussis is spread from person to person by coughing, sneezing, and close contact. As a result, an affected client should be placed in standard (universal) and droplet isolation precautions when hospitalized. At first, symptoms similar to the common cold and a mild fever occur, but eventually these clients develop a characteristic violent, spasmodic cough. Coughing is so severe that the person is forced to inhale afterward, resulting in a distinctive, high-pitched "whooping" sound. Coughing episodes may continue until a thick mucus plug is expectorated and are sometimes followed by vomiting (posttussive emesis). Treatment consists of antibiotics and supportive measures. Humidified oxygen and adequate fluids will help loosen the thick mucus. Suction as needed is important in infants. Respiratory status should be monitored for obstruction. The client should be positioned on the left side to prevent aspiration if vomiting occurs. Vaccination against whooping cough is available, but some individuals will still develop the disease, although in a milder form. (Option 4) An airborne precaution such as placing the client in a negative pressure isolation room is needed for individuals with measles, tuberculosis, and varicella zoster (chicken pox) infections (airing MTV). (Option 5) Cough suppressants are not used as they are not very effective for pertussis. In addition, the child needs to cough up any mucus plugs that might develop to keep the airway clear.

During a routine assessment of a developmentally normal 18-month-old, the parent expresses concern about the small amount of food the child consumes. What is the nurse's priority intervention? 1. Check the child for parasitic infections 2. Consult a pediatric nutritionist for suspected eating disorder 3. Educate the parent about physiologic anorexia 4. Notify the primary health care provider

Physiologic anorexia occurs when the very high metabolic demands of infancy slow down to keep pace with the moderate growth of toddlerhood. During this phase, toddlers are increasingly picky about their food choices and schedules. Although to the parents it may appear that the child is not consuming enough calories, intake over several days actually meets nutritional and energy needs. Parents should be educated concerning what constitutes a healthy diet for toddlers and which foods they are more likely to consume. Some strategies for dealing with a toddler during a stage of physiologic anorexia and pickiness include: Set and enforce a schedule for all meals and snacks Offer the child 2 or 3 choices of food items Do not force the child to eat Keep food portions small Expose the child repeatedly to new foods on several separate occasions Avoid TV and games during meals or snacks (Options 1 and 2) Parasitic infection can cause malnutrition (eg, failure to thrive). There is no indication that the child is suffering from any malnutrition. Therefore, an evaluation for parasites or referral to a nutritionist is not necessary. (Option 4) Evaluation of a toddler's nutritional status is a routine assessment and within the nurse's scope of practice. Educational objective:Physiologic anorexia is a normal period of decreased appetite that occurs in toddlers around age 18 months as a result of decreased metabolic needs. Parents should be taught to provide multiple food options, set a schedule for meals/snacks, and avoid watching TV or playing games during meal time; toddlers should not be forced to eat. Additional Information Health Promotion and Maintenance NCSBN Client Need

The home health nurses visits a 72-year-old client with pneumonia who was discharged from the hospital 3 days ago. The client has less of a productive cough at night but now reports sharp chest pain with inspiration. Which finding is most important for the nurse to report to the health care provider? 1. Bronchial breath sounds 2. Increased tactile fremitus 3.Low-pitched wheezing (rhonchi) 4. Pleural friction rub

Pleurisy is characterized by stabbing chest pain that usually increases on inspiration or with cough. It is caused by inflammation of the visceral pleura (over the lung) and the parietal pleura (over the chest cavity). The pleural space (between the 2 layers) normally contains about 10 mL of fluid to help the layers glide easily with respiration. When inflamed, they rub together, causing pleuritic pain. A pleural friction rub is auscultated in the lateral lung fields over the area of inflammation. The sound is produced by the 2 layers rubbing together and can indicate pleurisy, a complication of pneumonia. It is characterized by squeaking, crackling, or the sound heard when the palm is placed over the ear and the back of the hand is rubbed with the fingers. Complications of pneumonia are more prevalent in elderly clients with underlying chronic disease. (Option 1) Clients with consolidative lung processes (pneumonia) may also have bronchial breath sounds due to over-transmission of sound over the chest wall. Breath sounds are diminished or absent over a pleural effusion or pneumothorax. (Option 2) Palpable vibration felt on the chest wall is known as fremitus. Sound travels faster in solids (consolidation) than in an aerated lung, resulting in increased fremitus in pneumonia. It is an expected finding in clients with pneumonia. It is concerning if decreased because the client may be developing pleural effusion. (Option 3) Low-pitched wheezing (rhonchi) is a continuous adventitious breath sound heard over the large airways, usually during expiration. It indicates the presence of secretions in the larger airways and is an expected finding as pneumonia resolves. Educational objective:Pleurisy is characterized by stabbing pleuritic chest pain that increases on inspiration. It is a complication of pneumonia caused by inflamed parietal and visceral pleurae rubbing together. Additional Information Physiological Adaptation NCSBN Client Need

The nurse assesses a client with left-sided pneumonia who has an intermittent, productive cough with copious amounts of thick, yellow sputum. Which of the following interventions help to facilitate secretion removal? Select all that apply. 1. Chest physiotherapy 2. Cough suppressant 3. Huff coughing technique 4. Pursed-lip breathing 5. Right side-lying position

Pneumonia is an inflammatory reaction in the lungs, often due to infection, that causes alveoli to fill with cellular debris and thick, purulent exudate (ie, consolidation), which may cause impaired ventilation and oxygenation. Interventions to facilitate secretion removal in clients with pneumonia include: Performing chest physiotherapy (percussion, vibration, postural drainage) to loosen and break up thickened secretions (Option 1) Assisting the client to perform huff coughing, which raises secretions from the lower to the upper airway for expectoration (Option 3) Ensuring adequate hydration through increased oral fluid intake (≥2-3 L/day) and administration of prescribed IV fluids, which thins pulmonary secretions to promote improved secretion clearance Positioning the head of the bed to 45-60 degrees (ie, Fowler position) to promote effective coughing and optimal lung expansion (Option 2) Cough suppressants reduce the urge to cough triggered by airway irritants (eg, purulent secretions) and ultimately impair secretion removal. (Option 4) Pursed-lip breathing prolongs exhalation and prevents airway collapse, which alleviates dyspnea relating to air trapping (eg, chronic obstructive pulmonary disease). However, it does not facilitate secretion removal. (Option 5) Side-lying positioning is utilized in hypoxic clients with unilateral pneumonia to increase perfusion to the healthy lung by gravity and improve oxygenation by positioning the client with the unaffected (good) side down. However, side-lying position alone does not improve secretion clearance

Poison ivy

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. (Applying cool, wet compresses; applying topical cortisone; and discouraging the child from scratching the area are all appropriate after the rash has developed. Washing the area has the highest priority and is most important immediately after exposure.

The nurse plans discharge teaching for a client newly diagnosed with polycythemia vera. Which actions will the nurse include in the teaching plan? Select all that apply. 1. Elevate the legs and feet when sitting 2. Increase dietary intake of foods rich in iron 3. Increase fluid intake during exercise and hot weather 4. Increase water temperature to reduce post-bath itching 5. Report swelling or tenderness in the legs

Polycythemia vera (PV) is a chronic disorder of the bone marrow in which too many red blood cells, white cells, and platelets are produced. Clients with PV are at risk of developing blood clots due to increased blood volume and viscosity. Clients are instructed to elevate the legs and feet when sitting, wear support stockings, and report signs of thrombosis (eg, swelling and tenderness in the legs). Adequate fluid intake during exercise and hot weather is important to reduce fluid loss and decrease viscosity (Options 1, 3, and 5). (Option 2) 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. (Option 4) Itching is a common and frustrating symptom of PV. Reducing water temperature, using starch baths, and patting the skin dry rather than rubbing vigorously are beneficial.

A client with polycythemia vera comes to the clinic for a monthly treatment. The nurse knows that treatment for this condition will consist of which of the following? 1. Blood transfusion 2. Fluid bolus 3. Phlebotomy 4. Steroid injection

Polycythemia vera (PV) is a chronic myeloproliferative disorder in which the bone marrow produces an abnormally high number of RBCs. Although PV is an abnormality of the bone marrow, secondary polycythemia can occur in an individual with chronic hypoxemia, such as chronic obstructive pulmonary disease or chronic lung disease. The danger of PV is seen when the client develops blood clots—due to the increased viscosity of the blood, which makes the circulation sluggish—and decreased tissue perfusion. 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 the goal hematocrit is reached. Hematocrit is then monitored monthly, and additional blood draws are performed as necessary. (Option 1) A blood transfusion is contraindicated in a client with PV because this would have the opposite of the desired effect, further increasing the RBC count and clotting. (Option 2) Although an IV fluid bolus may be helpful in the short term to reduce blood viscosity, it is not a maintenance treatment for PV. Instead, the client should be encouraged to drink >3 L of fluid daily and avoid dehydration. (Option 4) Steroid injections are not typically used to treat PV.

The nurse provides care for a client diagnosed with polycythemia vera. Which statement by the client would require immediate follow-up? 1. "I am trying to find makeup to cover my unattractive, ruddy facial complexion."[1%] 2. "I must have injured my leg in some way. It is sore, swollen, and red." [64%] 3. "I take a baby aspirin to relieve my occasional headaches." [29%] 4. "My skin itches so severely, and no lotion or cream seems to help." [5%]

Polycythemia vera (PV) is a hematological disorder in which too many RBCs (and often WBCs and platelets) are produced, causing increased blood viscosity, venous stasis, and increased risk for thrombus formation. The nurse should teach clients with PV measures to prevent thrombus (eg, wearing graduated compression stockings, elevating legs when sitting, maintaining adequate hydration). Clients should also learn to monitor for and report signs and symptoms of thrombus (eg, redness, tenderness, or swelling in one leg). Reports of possible thrombus require immediate intervention to avoid serious injury (stroke, PE) (Option 2). (Option 1) Venous stasis causes the skin on the face, hands, and feet to become ruddy (red). This is an expected finding. (Option 3) Occasional headaches or blurred vision can result from sluggish, viscous blood flow in the brain. Aspirin therapy is used for its antiplatelet and analgesic action. The nurse should assess the client's headaches; however, they are not the priority. (Option 4) Pruritis is a common occurrence in clients with PV, often after bathing. Clients should bathe with cool water and pat (not rub) themselves dry with a towel to avoid histamine release and use antihistamine creams for relief. Venous stasis can also cause itching, and aspirin can help.

An older adult client takes multiple prescription medications plus several over-the-counter medications. Which intervention by the clinic nurse is most important in reducing the risk for drug interactions? 1. Assist client with making a list of all medications, doses, and times to be taken [34%] 2. Encourage client to obtain all prescription medications from the same pharmacy [14%] 3. Have client bring all medications taken regularly or occasionally to each appointment [39%] 4. Instruct client to use a pill organizer to separate pills by day and time [11%]

Polypharmacy and the physiologic changes associated with aging place older adults at an increased risk of adverse drug events. Decreased renal and hepatic function causes increased drug half-life and impaired drug clearance, potentially resulting in toxicity and adverse events. Clients may see different health care providers and receive multiple prescriptions for different health problems (polypharmacy). Clients should be encouraged to bring all medications (ie, prescription, over-the-counter [OTC], herbal supplements) they take regularly and occasionally to each appointment so that potential drug interactions can be evaluated (Option 3). (Option 1) Keeping a list of all medications and their dosages is a good idea to help organize the client's medications. However, the client may not remember all the medications and may not regularly update the list. (Option 2) Getting all medications from the same pharmacy is preferable. The pharmacist can monitor for possible interactions from prescription drugs, but many clients do not report the use of OTC medications or herbal supplements to the pharmacist. (Option 4) A pill organizer helps the client remember to take medications at the appropriate times. By ensuring drugs are taken at prescribed intervals, some interactions can be avoided. However, this may not take into account herbal supplements and OTC drugs taken as needed.

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 (PPV)? 1. Dehydration 2. Hypokalemia 3. Hypotension 4.Increased cardiac output

Positive pressure ventilation (PPV) delivers positive pressure to the lungs using a mechanical ventilator (MV), either invasively through a tracheostomy or endotracheal tube or noninvasively through a nasal mask/facemask, nasal prongs, or a mouthpiece. 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 preset volume and concentration of oxygen (eg, 21%-100%) 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 (eg, hemorrhage, hypovolemic shock) and decreased venous tone (eg, septic shock, neurogenic shock). (Option 1) Fluid and/or sodium retention usually occurs about 48-72 hours after initiation of PPV due to: (1) increased intrathoracic pressure and decreased cardiac output that stimulate the kidneys to release renin; (2) physiologic stress that leads to the release of antidiuretic hormone and cortisol; and (3) breathing through the ventilator's closed circuitry, which decreases insensible loss associated with respiration. (Option 2) Hypokalemia is not associated with PPV. (Option 4) PPV increases intrathoracic pressure and reduces venous return to the right side of the heart, reducing preload and cardiac output as well. Educational objective: Positive pressure ventilation causes increased intrathoracic pressure and reduced venous return and cardiac output, which can result in hypotension. Additional Information Physiological Adaptation NCSBN Client Need

After performing a physical assessment and obtaining vital signs for a client immediately after a laparoscopic cholecystectomy, which nursing intervention is the priority? 1. Apply anti-embolism stockings 2. Assist with early ambulation 3. Offer stool softeners 4. Provide low-fat foods

Postoperative nursing care after a laparoscopic cholecystectomy focuses on prevention of complications. Carbon dioxide (CO2) 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 irritate 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 (Option 2). Early ambulation not only improves breathing but also decreases the risk of thromboembolismand stimulates peristalsis. (Option 1) Anti-embolism stockings help prevent the development of deep vein thrombosis, but early ambulation is more effective at thromboembolism prevention and is therefore the priority intervention. (Option 3) Stool softeners may prevent postoperative constipation caused by surgical anesthetics and opioids, which contribute to decreased peristalsis. However, early ambulation promotes bowel motility and reduces constipation. (Option 4) After laparoscopic cholecystectomy, the client should maintain a clear liquid diet until bowel sounds return. After obtaining an order from the health care provider, the nurse should advance to a low-fat diet and educate the client on weight reduction and maintaining a low-fat diet.

Primary open-angle glaucoma (POAG)

Primary open-angle glaucoma (POAG) is an eye condition characterized by an increase in intraocular pressure and gradual loss of peripheral vision (ie, tunnel vision). The signs/symptoms of POAG develop slowly and include painless impairment of peripheral vision with normal central vision, difficulty with vision in dim lighting, increased sensitivity to glare, and halos observed around bright lights. POAG can lead to blindness if left untreated. (Option 1) Retinal detachment is separation of the retina from the underlying epithelium that allows fluid to collect in the space. The signs/symptoms include sudden onset of light flashes, floaters, cloudy vision, or a curtain appearing in the vision. (Option 2) Age-related macular degeneration is a degenerative eye disease that brings about the gradual loss of central vision, leaving peripheral vision intact. (Option 4) A cataract is cloudiness (ie, opacity) of the lens that may occur at birth or more commonly in older adults. The signs/symptoms of a cataract include painless, gradual loss of visual acuity with blurry vision; scattered light on the lens producing glare and halos, which are worse at night; and decreased color perception.

A client diagnosed with end-stage renal disease comes to the dialysis clinic for treatment. Which actions should the nurse take to prepare the client for hemodialysis? Select all that apply. 1. Administer subcutaneous heparin to decrease clotting during dialysis 2. Administer the client's morning doses of carvedilol and lisinopril 3. Check the client's medical records to determine the last post-dialysis weight 4. Obtain a set of client vital signs and the client's current weight 5. Palpate the fistula in the client's arm for a thrill and auscultate for a bruit

Prior to dialysis treatment, the nurse should assess the client's fluid status (weight, blood pressure, peripheral edema, lung and heart sounds), vascular access (arteriovenous fistula, arteriovenous grafts), and vital signs (Option 4). The amount of fluid removed (ultrafiltration) is determined by calculating the difference between the last post-dialysis weight and the client's current pre-dialysis weight (Option 3). After the client is connected to the dialysis machine, IV heparin is added to the blood from the client to prevent clotting that can occur when blood contacts a foreign substance. Giving subcutaneous heparin prior to initiation is not necessary (Option 1). (Option 2) During dialysis, excess fluid is removed, making the client prone to hypotension. In addition, medications are removed from the blood during hemodialysis, making them ineffective. Many medications that are taken once daily can be held until after the dialysis treatment to prevent their removal. If blood pressure medications are given prior to dialysis, the client can develop hypotension during the dialysis and then uncontrolled hypertension (decreased drug concentrations). (Option 5) Arteriovenous fistulas are created by anastomosing an artery to a vein; a thrill can be felt when palpating the fistula, and a bruit can be heard during auscultation when the fistula is functioning properly.

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? 1. "If you begin vomiting any time within 24 hours of taking the pill, take an additional pill." 2. "If you take your pill 3 or more hours after your usual time, use a backup contraceptive." 3. "In your pill pack, there are 21 days of progestin pills and 7 days of inactive iron pills." 4. "The use of POPs increases your risk of developing deep venous thrombosis."

Progestin-only pills (POPs), a form of oral contraception, work by thickening cervical mucus (ie, hinders sperm motility), thinning the endometrium (ie, hinders implantation), 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(eg, condom) is advised until the pill is taken correctly for 2 days (Option 2). (Option 1) An additional POP should be taken if diarrhea or vomiting occurs within 3 hours of the last dose. (Option 3) In a POP pack, there are no inactive pills. The client does not take a break from the hormone to menstruate; subsequently, breakthrough bleeding is commonly reported. (Option 4) Signs of deep venous thrombosis (eg, calf pain, warmth, swelling) are especially concerning for clients taking estrogen-containing contraceptives, as estrogen increases the risk for blood clots. In contrast, POPs have a low cardiovascular risk profile (eg, hypertension, venous thromboembolism).

A client with rheumatoid arthritis (RA) tells the home health nurse, "My fatigue and stiffness are getting worse and I'm having trouble moving around, especially in the morning. What can I do?" Which intervention would be best for the client to perform first? 1. Eat a high-calorie carbohydrate breakfast immediately after awakening 2. Perform range of motion exercises before getting out of bed 3. Take a warm shower or bath immediately after getting out of bed 4. Take prescribed nonsteroidal anti-inflammatory medication on awakening

Prolonged morning stiffness of the affected joints is a major complication of rheumatoid arthritis (RA). Taking a warm shower or bath first on awakening would be the best intervention as heat decreases stiffness and promotes muscle relaxation and mobility. With increased flexibility and decreased stiffness, the client's usual morning activities (eg, dressing, making breakfast) would be easier and less painful and tiring to perform. (Option 1) A balanced diet and weight control are important. Diet and exercise should be proportional, especially during periods of disease exacerbation and decreased physical activity as excess weight exerts additional stress on weight-bearing joints. (Option 2) Range of motion exercises are more effective after a warm bath or shower as stiffness is decreased, thereby improving flexibility. (Option 4) Nonsteroidal anti-inflammatory drugs (NSAIDS) (eg, naproxen [Naprosyn], ibuprofen [Motrin]) should not be taken on an empty stomach as these can cause gastrointestinal upset. If prescribed once daily, these are probably best taken in the evening after dinner as RA symptoms slowly increase during the night and worsen in the morning. A higher serum drug level in the morning can help to reduce inflammation and stiffness. Therefore, if NSAIDS are prescribed twice daily, taking them in the morning with breakfast and in the evening with dinner is recommended.

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? 1. "Having sex will make the infection worse." 2. "I enjoy iced tea, so I will drink more to stay hydrated." 3. "I should take ciprofloxacin until I feel better." 4. "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 (eg, ibuprofen). Alpha-adrenergic blockers (eg, tamsulosin, alfuzosin) help relax 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. Clients should be instructed to: Hydrate with clear liquids (eg, water, fruit juices). Avoid coffee, tea, and other caffeinated beverages due to diuretic and stimulant properties, which may worsen symptoms (Option 2). Complete the full course of antibiotics regardless of symptom improvement to ensure infection resolution (Option 3). Engage in sexual intercourse or masturbation to reduce discomfort related to retained prostatic fluid. Clients should use a barrier prophylactic method (eg, condoms) when engaging in sexual activity with a partner to prevent transmission of the causative organism (Option 1). Take stool softeners as prescribed to reduce straining during defecation; tension of the pubic muscles presses against the prostate, causing pain (Option 4). Take sitz baths, in which the hips and buttocks are immersed in warm water, to help relieve symptoms.

The nurse cares for a client with a pulmonary embolism. Which of the following clinical manifestations would the nurse anticipate? Select all that apply. 1. Bradycardia 2. Chest pain 3. Dyspnea 4. Hypoxemia 5. Tachypnea 6. Tracheal deviation

Pulmonary embolism (PE) is a potentially life-threatening medical emergency occurring when a blood clot, fat or air embolus, or tissue (eg, tumor) travels via the venous system into the pulmonary circulation and obstructs blood flow into the lung. This prevents deoxygenated blood from reaching the alveoli, which leads to hypoxemia due to impaired gas exchange and cardiac strain due to congested blood flow in the pulmonary arteries. Clinical manifestations of PE range from mild (eg, anxiety, cough) to severe (eg, heart failure, sudden death). However, many clients initially have mild, nonspecific symptom sthat are often misdiagnosed and inadequately managed, greatly increasing the likelihood of progression to shock and/or cardiac arrest. Clinical manifestations of PE include: Pleuritic chest pain (ie, sharp lung pain while inhaling) (Option 2) Dyspnea and hypoxemia (Options 3 and 4) Tachypnea and cough (eg, dry or productive cough with bloody sputum) (Option 5) Tachycardia Unilateral leg swelling, erythema, or tenderness related to deep vein thrombosis (Option 1) Tachycardia, rather than bradycardia, is expected with PE because the heart attempts to compensate for hypoxemia, right ventricular overfilling, and decreased left ventricular cardiac output. (Option 6) Tracheal deviation is a sign of tension pneumothorax (not PE), which occurs when pressure on the side of the collapsed lung pushes organs toward the unaffected lung. Educational objective: Pulmonary embolism is a potentially life-threatening medical emergency occurring when a pulmonary artery is obstructed. Common clinical manifestations include pleuritic chest pain, dyspnea, hypoxemia, tachypnea, cough, tachycardia, and unilateral leg swelling.

A client is admitted with a pulmonary embolus. The nurse assesses restlessness, one-word dyspnea and shortness of breath with activity, tachycardia, pleuritic chest pain, and severe anxiety. Arterial blood gases indicate respiratory alkalosis and hypoxemia. When initiating the care plan, the nurse should choose which nursing diagnosis as the highest priority? 1. Activity intolerance related to imbalance between oxygen supply and demand 2. Acute pain related to inspiration and inflammation of pleura 3. Anxiety related to fear of the unknown, chest pain, and dyspnea A client is admitted with a pulmonary embolus. The nurse assesses restlessness, one-word dyspnea and shortness of breath with activity, tachycardia, pleuritic chest pain, and severe anxiety. Arterial blood gases indicate respiratory alkalosis and hypoxemia. When initiating the care plan, the nurse should choose which nursing diagnosis as the highest priority? 1. Activity intolerance related to imbalance between oxygen supply and demand 2. Acute pain related to inspiration and inflammation of pleura 3. Anxiety related to fear of the unknown, chest pain, and dyspnea 4. Impaired gas exchange related to ventilation-perfusion imbalance

Pulmonary embolism (PE) is usually caused by a dislodged thrombus that travels through the pulmonary circulation, becomes lodged in a pulmonary vessel, and causes an obstruction to blood flow in the lung. The nursing diagnosis of impaired gas exchange involves an alteration in the normal exchange of oxygen and carbon dioxide at the alveolar-capillary membrane, resulting in inadequate oxygenation and hypoxemia (respiratory alkalosis, pO2 <80 mm Hg, restlessness, dyspnea, and tachycardia). Impaired gas exchange related to a ventilation-perfusion (V/Q) imbalance is the highest priority nursing diagnosis. It addresses the most basic physiologic need—oxygen. Clients will not survive without adequate oxygenation. (Options 1, 2, and 3) Activity intolerance, acute pain, and anxiety elicit autonomic responses (exertional discomfort, dyspnea, tachycardia) and are all appropriate nursing diagnoses. However, none are the highest priority or pose the greatest threat to survival.

The nurse is discussing feeding and eating practices with the mother of a 1-year-old. Which statement made by the mother indicates a need for further instruction? 1. "I give my child chopped fruit rather than juice." 2. "I make sure my child drinks plenty of water between meals." 3. "My child is fussy at bedtime so I put him to sleep with a bottle of milk." 4. "When I give my child a new food, I wait a week before trying a second new food."

Putting a child to bed with a bottle of milk or other beverage containing sugar leads to extensive and rapid dental caries in the developing teeth, a condition known as baby bottle tooth decay. The carbohydrate-rich fluid pools around the teeth and nourishes decay, producing bacteria (Streptococcus mutans). Sucking on a bottle for extended periods can also push the jawline out of shape. Bottles containing milk or sugary beverages should not be used as bedtime pacifiers. (Option 1) Whole fruit chopped in small pieces is a better choice than juice. Fruit juice is higher in sugar, has no fiber, promotes tooth decay, and can affect the child's appetite for other non-sugary foods. (Option 2) Providing water to a child between meals has several benefits: It accustoms the child to the taste of water, and the child will be more likely drink water than a sugary beverage when thirsty It helps reduce the risk of constipation and urinary tract infections It helps the child maintain a healthy weight (Option 4) Spacing the introduction of new foods by several days to a week allows for detection of a food intolerance or allergic reaction.

The nurse is planning care for a client being admitted with newly diagnosed quadriplegia (tetraplegia). Which intervention will the nurse prioritize? 1. Assess vital capacity and tidal volume once per shift and PRN [23%] 2. Perform passive range of motion exercises on affected joints every 4 hours [8%] 3. Provide time during each shift for the client to express feelings [8%] 4. Turn the client every 2 hours throughout the day and night [60%]

Quadriplegia (tetraplegia) 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 (if prescribed). (Options 2, 3, and 4) This client will need passive range of motion exercises on affected joints to prevent contractures. Turning the client will be necessary to prevent skin breakdown over bony prominences. The client will need to express feelings and work through the grief process related to loss of function. Bladder and bowel training programs will be necessary. All of these interventions are important for this client but are not the priority over maintenance of adequate oxygenation.

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

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

Glargine (Lantus) is a long-acting (basal) insulin given to prevent hyperglycemia for 24 hours. The drug has no peak, and so timing of administration is not dependent on food intake. However, if the client is NPO for more than 12 hours, the provider may hold it. Lispro (Humalog) is a rapid-acting insulin with a peak of 30 minutes to 3 hours and should be given only if it is certain the client will eat within 15 minutes. Lispro is prescribed in two ways: Scheduled prandial (ie, fixed dosage) given to prevent hyperglycemia with consumption of food. Typically, this would not be held unless the blood sugar is below normal (70 mg/dL [3.9 mmol/L]) or according to facility guidelines. Correctional (ie, sliding-scale dosage) given to correct hyperglycemia. Typically, this would be held when blood glucose is below 150 mg/dL (8.3 mmol/L).

Rapid-acting insulin (eg, scheduled prandial fixed dosing, correctional sliding-scale dosing) is given if a client plans to eat within 15 minutes. Scheduled prandial insulin prevents hyperglycemia after meals and is held when blood glucose is below normal (70 mg/dL [3.9 mmol/L]). Correctional insulin corrects existing hyperglycemia. Additional Information Physiological Adaptation NCSBN Client Need

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 (ADL)? Select all that apply. 1. Ask simple questions that require "yes" or "no" answers 2. If the client becomes frustrated, seek a different care provider to complete ADL 3. Remain calm and allow the client time to understand each instruction 4. Show the client pictures of ADL (eg, shower, toilet, and toothbrush) or use gestures 5. Speak slowly but loudly while looking directly at the client

Receptive aphasia refers to impairment or loss of language comprehension (ie, speech, reading) that is caused by a neurological condition (eg, stroke, traumatic brain injury). 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. Appropriate interventions to aid communication include: Ask short, simple, "yes" or "no" questions (Option 1). Use gestures or pictures (eg, communication board) to demonstrate activities (Option 4). Remain patient and calm, allowing the client time to understand each instruction (Option 3). (Option 2) Clients with aphasia often become frustrated due to inability to communicate effectively. Frustration does not result from the nurse's care, so reassigning the client to a different care provider is not an effective solution. (Option 5) Eye contact is important in all communication, but raising the voice will not help. Speaking loudly will not improve comprehension and may increase anxiety and confusion. Educational objective:

A client just diagnosed with methicillin-resistant Staphylococcus aureus septic arthritis is receiving the first dose of IV vancomycin. Which finding is most concerning to the nurse? 1. Diffuse muscle pain [3%] 2. Flushing and pruritus [12%] 3. Low blood pressure [4%] 4. Wheezing and hives [79%]

Red man syndrome (RMS) is a condition that can occur with rapid IV vancomycin administration. It is characterized by flushing, erythema, and pruritus, typically on the face, neck, and chest. Muscle pain, spasms, dyspnea, and hypotension may also occur. RMS is usually a rate-related infusion reaction and not an allergic reaction. It can be reduced by infusing vancomycin over a minimum of 60 minutes. It can be difficult to differentiate severe RMS from anaphylaxis as flushing and hypotension can occur in both conditions. However, hives, angioedema (lip swelling), wheezing, and respiratory distress are more suggestive of anaphylaxis. The client exhibiting signs and symptoms suggestive of anaphylaxis should have the vancomycin infusion stopped immediately and be treated with intramuscular (IM) epinephrine. The infusion must not be restarted if anaphylaxis is suspected. A slowed infusion rate or pre-medications will not prevent a future anaphylactic response. (Option 1) Muscle pain and spasms may be symptoms of RMS. The nurse should also assess for other medications the client may be taking that could cause these symptoms (ie, statins). (Option 2) Flushing and pruritus may also be symptoms of RMS. The nurse should further assess the client's airway for possible anaphylaxis. (Option 3) Low blood pressure (BP) can have many causes, RMS being one of them. If low BP is due to RMS, stopping or reducing the rate of vancomycin (depending on severity) would solve this. If low BP is due to anaphylaxis, IM epinephrine must be given in addition to stopping the vancomycin infusion.

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? 1. Serum albumin level and body weight 2. Serum potassium and phosphate 3. Symptoms of dumping syndrome 4. White blood cell count and neutrophils

Refeeding syndrome is a potentially fatal complication of nutritional rehabilitation in chronically malnourished clients (eg, anorexia nervosa, chronic alcoholism). 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 (adenosine triphosphate). Hypophosphatemia causes muscle weakness and respiratory failure. Deficiencies in potassium and magnesium potentiate cardiac arrhythmias. Therefore, aggressive initiation of nutrition without adequate electrolyte repletion can quickly precipitate cardiopulmonary failure. (Option 1) Daily weights and periodic serum albumin level are indicated to evaluate the efficacy of nutritional replenishment but are not the most important assessment as failure to monitor these does not result in death. (Option 3) Dumping syndrome is seen after surgery for stomach cancer or bariatric surgery, which results in decreased storage area in the stomach. Eating concentrated carbohydrates or excess fluids causes the food to be "dumped"/emptied rapidly into the small intestine. Symptoms include diaphoresis, cramping, weakness, and diarrhea within 30 minutes of eating. Dumping syndrome is not seen with anorexia nervosa. (Option 4) The central lines carry a risk of infection. The signs of infection include leukocytosis and left shift. However, risk of infection is not greatest in the first few days of parenteral nutrition.

A homeless man known to have chronic alcoholism and who has not eaten for 8 days is undergoing nutritional rehabilitation via oral and enteral feedings. Which of the following findings would indicate that the client is developing refeeding syndrome? 1. Phosphorus 2.0 mg/dL (0.65 mmol/L), potassium 2.9 mEq/L (2.9 mmol/L), magnesium 1.0 mEq/L (0.5 mmol/L) [43%] 2. Phosphorus 4.0 mg/dL (1.29 mmol/L), potassium 3.5 mEq/L (3.5 mmol/L), magnesium 2.0 mEq/L (1.0 mmol/L) [11%] 3. Random blood glucose 60 mg/dL (3.3 mmol/L), sodium 120 mEq/dL (120 mmol/L), calcium 7.0 mg/dL (1.75 mmol/L) [28%] 4. Random blood glucose 100 mg/dL (5.6 mmol/L), sodium 140 mEq/dL (140 mmol/L), calcium 10.0 mg/dL (2.50 mmol/L) [17%]

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 (glucose) 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 phosphorous, potassium, and/or magnesium (mnemonic PPM). Other findings may include fluid overload, sodium retention, hyperglycemia, and thiamine deficiency. Actions to prevent refeeding syndrome include the following: Obtaining baseline electrolytes Initiating nutrition support cautiously with hypocaloric feedings Closely monitoring electrolytes Increasing caloric intake gradually (Option 2) These values are within normal ranges for phosphorus (2.4-4.4 mg/dL [0.78-1.42 mmol/L]), potassium (3.5-5.0 mEq/L [3.5-5.0 mmol/L]), and magnesium (1.5-2.5 mEq/L [0.75-1.25 mmol/L]). In refeeding syndrome, the values for one or more of these electrolytes are decreased. (Option 3) These laboratory values are below normal ranges but are not associated with refeeding syndrome. (Option 4) These are normal laboratory values and are not associated with refeeding syndrome.

The charge nurse in the medical-surgical unit is evaluating client safety. Which actions by unlicensed assistive personnel (UAP) would require the nurse to intervene? Select all that apply. 1. 1 UAP repositioning a client who is 8 hours postoperative total hip replacement 2. 1 UAP using a gait belt to transfer a partial weight-bearing client from the bed to a chair 3. 2 UAPs repositioning a client who is sedated and has been on the left side for 2 hours 4. 2 UAPs using the log-rolling technique to move a client with a cervical collar 5. 3 UAPs using a draw sheet to move a client who weighs 220 lb (100 kg) up in bed

Repositioning and transferring clients can be delegated to unlicensed assistive personnel (UAP) when it is deemed safe and appropriate. The nurse must provide UAPs with detailed instructions, including when to move the client, which techniques to use, and when to use assistive persons or devices. The nurse must also notify UAPs of any client mobility restrictions. Unstable clients and spinal cord stabilization require the presence of a nurse for repositioning or moving (Option 4). 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 (Option 1). 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 (Option 2). Use 2 or more caregivers to reposition clients who are uncooperative or unable to assist (eg, comatose, medicated) (Option 3). Use a full-body sling lift to move/transfer nonparticipating clients. Use 2-3 caregivers to move cooperative clients weighing less than 200 lb (91 kg). Use 3 or more caregivers to move cooperative clients weighing more than 200 lb (91 kg)

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

Respiratory syncytial virus (RSV) is a common cause of respiratory tract infection and bronchiolitis in infants and children, occurring primarily during the winter. It affects the ciliated cells of the respiratory tract, causing bronchiolar swelling and excessive mucus production. RSV in infants causes rhinorrhea, fever, cough, lethargy, irritability, and poor feeding. Severe RSV infection also causes tachypnea, dyspnea, and poor air exchange. Interventions are supportive, including: Providing supplemental oxygen and suctioning to support oxygen exchange and clear the airway (Option 5) Elevating the head of the bed to improve diaphragmatic expansion and promote secretion clearance (Option 3) Administering antipyretics to reduce fever and provide comfort (Option 1) Initiating IV fluids to correct dehydration due to fever, tachypnea, or poor oral intake (Option 2) RSV is transmitted via direct contact with respiratory secretions. Contact isolation is required, and droplet precautions are added if within 3 ft (0.91 m) of the client, depending on facility policy (Option 4). Palivizumab (Synagis), a monoclonal antibody, is administered intramuscularly once monthly during the winter and spring to prevent RSV in children at high risk for contracting the infection (eg, prematurity, chronic lung disease).

A 2-year-old is suspected of having retinoblastoma. The nurse recognizes which sign as being most characteristic of this disease? 1. Absence of red reflex 2. Fixed and mid-dilated pupil 3. Ptosis of the eye 4. Purulent eye discharge

Retinoblastoma, a unilateral or bilateral retinal tumor, is the most common childhood intraocular malignancy. It is typically diagnosed in children under age 2 and is usually first recognized when parents report a white "glow" of the pupil (leukocoria). Light reflecting off the tumor will cause the pupil to appear white instead of displaying the usual red reflex (Option 1). Parents may even accidentally visualize leukocoria when taking a photograph of the child using a flash. Strabismus(misalignment of the eyes) is the second most common sign; visual impairment is a late sign indicative of advanced disease. Treatment depends on severity and may include radiation therapy or enucleation (removal of the eye) and fitting for prosthesis. Siblings should undergo regular ocular screening, as some forms of retinoblastoma are hereditary. (Option 2) A fixed and mid-dilated pupil is seen in acute glaucoma. (Option 3) Ptosis is drooping of the upper eyelid often associated with injury of the oculomotor nerve (cranial nerve III). Ptosis is also characteristic for myasthenia gravis. (Option 4) Bacterial conjunctivitis causes eyelid swelling, a red conjunctiva, eye discomfort, and purulent eye discharge.

The graduate nurse (GN) receives report on a postpartum client with an Rh-negative blood type. Which statement by the GN regarding the Rh immune globulin injection requires the preceptor to provide further teaching? 1. "Additional doses of Rh immune globulin may be required if excessive fetomaternal hemorrhage is suspected." 2. "I should administer Rh immune globulin to the client within 72 hours after birth." 3. "If the maternal antibody screen is negative, I will hold Rh immune globulin and contact the health care provider." 4. "Rh immune globulin is not required if the newborn's blood type is Rh negative."

Rh alloimmunization (ie, isoimmunization) occurs when a pregnant client with an Rh-negative blood type is exposed to Rh-positive fetal RBCs during pregnancy and birth. After exposure, the maternal immune system produces antibodies to the Rh antigen that can cause serious complications for an Rh-positive fetus during future pregnancies (eg, hemolytic anemia). Rh immune globulin (RhoGAM) prevents antibody formation by suppressing the maternal immune response and is effective only if the client has never developed antibodies to the Rh antigen (ie, Rh sensitization). The nurse should verify that the client is not Rh sensitized by checking for a negative antibody screen (eg, indirect Coombs test) and then proceeding with administration of Rh immune globulin (Option 3). A positive maternal antibody screen would require further clarification from the health care provider (HCP). (Option 1) If the HCP suspects excessive fetomaternal hemorrhage, a Kleihauer-Betke stain is performed to quantify the fetal RBCs in maternal circulation. Depending on the quantity of fetal RBCs, >1 dose of Rh immune globulin may be required. (Option 2) Rh immune globulin should be administered within 72 hours of birth to ensure effectiveness. (Option 4) If the newborn is Rh negative, Rh immune globulin is not necessary postpartum. Educational objective:Rh alloimmunization occurs when a pregnant client with an Rh-negative blood type is exposed to Rh-positive fetal RBCs. Postpartum, the nurse should verify that the client is not Rh sensitized by checking for a negative antibody screen and then proceeding with administration of Rh immune globulin if the newborn is Rh positive. Additional Information Health Promotion and Maintenance NCSBN Client Need

A 25-year-old marathon runner is admitted for suspected rhabdomyolysis. The client has oliguria, dark amber urine, and muscle pain. The nurse should implement which prescription first? 1. ECG 2. IV morphine 2 mg 3. Normal saline bolus 4. Urine sample

Rhabdomyolysis occurs when muscle fibers are released into the blood, usually after an intense muscle injury from exercise, heat stroke, or physical trauma. Acute renal failure can occur when elevated myoglobin (protein found in muscle tissue) levels overwhelm the kidneys' filtration ability. The nurse's priority is to prevent kidney damage using rapid IV fluid resuscitation to flush the damaging myoglobin pigment from the body. Common signs of rhabdomyolysis are dark, oftentimes bloody urine, oliguria, and fatigue. (Option 1) With muscle injury, intracellular potassium is released into the circulation, potentially causing dangerous arrythmias. Therefore, ECG and cardiac monitoring are needed. However, with IV fluid administration, potassium levels decrease rapidly. In addition, clients with rhabdomyolysis have extensive third spacing of the fluids into the injured muscles. Therefore, aggressive fluid resucitation is a high priority. The general rule is that treatment/prevention of an underlying expected problem is a priority over testing to identify the problem. (Option 2) Pain and symptom management should be a high priority but should not take precedence over preserving the client's kidney function. (Option 4) Although obtaining a urine specimen to assess the characteristics is important, laboratory testing would not take priority over treatment to preserve kidney function. Educational objective:Rhabdomyolysis is a medical emergency caused by muscle injury that releases myoglobin into the bloodstream. The nurse's priority when treating the client is to preserve kidney function by administering large volumes of IV fluid.

Client admitted for cocaine OD with creatinine kinase of 30,00 U/L priority to report to HCP

Rhabdomyolysis occurs when muscle tissue is damaged and myoglobin (protein found in muscle tissue) is released into the blood, usually after an injury from overexertion, dehydration, severe vasoconstriction (eg, cocaine use), 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 (>250 µkat/L), are observed with severe muscle damage and can be a precursor to kidney injury (Option 2). Forced saline diuresis with intravenous fluids (to prevent blockage of the renal tubules with myoglobin) is necessary to prevent permanent kidney damage. (Option 1) Postoperative leukocytosis (leukocytes >11,000 mm3 [>11X109/L]) is common in the first 48 hours after orthopedic surgery from normal inflammatory immune responses. (Option 3) Clients with end-stage renal disease commonly have elevated creatinine and blood urea nitrogen levels. These are expected findings. (Option 4) Increased brain natriuretic peptide levels can indicate stretching of the chambers of the heart in heart failure. Levels >100 pg/mL (>100 pmol/L) can indicate heart failure and would be expected in this client. Educational objective:Rhabdomyolysis occurs when large amounts of muscle tissue break down and is associated with elevated creatine kinase levels, myoglobinemia, and myoglobinuria. Acute kidney injury, a complication of rhabdomyolysis, can be prevented by prompt administration of intravenous fluids.

The nurse is educating a client recently diagnosed with rheumatoid arthritis about home care and symptom management. Which of the following client statements indicates a need for further teaching? 1. "Daily range-of-motion exercises are important to keep my joints flexible." 2. "I can use a moist heat pack to help with joint stiffness." 3. "I should elevate my knees with pillows when I'm sleeping." 4. "I will make sure to rest in between activities throughout the day."

Rheumatoid arthritis (RA) is a chronic, autoimmune disorder characterized by inflammation and damage to synovial joints; progressive fibrosis of joint membranes results in pain, deformity, and stiffness. Over time, remodeling of joint capsules and associated pain reduce the ability to perform activities of daily living(eg, toileting, bathing, dressing) and engage in routine tasks (eg, walking, opening doors). To maximize functional ability and quality of life, the nurse should educate clients with RA about home-care and symptom-management strategies: Perform gentle range-of-motion exercises daily to maintain joint flexibility (Option 1). Apply moist heat packs to stiff joints and ice packs to painful joints (Option 2). Plan frequent rest periods to reduce fatigue and inflammation of affected joints during activities (Option 4). (Option 3) Clients with RA should be instructed to sleep and rest in a flat, neutral position. Body aligners or immobilizers may be used to keep joints straight, but prolonged flexion of joints (eg, elevating knees on pillows) increases the risk of contracture and may hasten decline of joint function. Educational objective:Rheumatoid arthritis, a chronic autoimmune disorder, causes inflammation and remodeling of synovial joints, with progressive loss of functional capacity. Clients should be educated to protect the joints with range-of-motion exercises, allow for periods of rest during activities, use moist heat for stiffness and cold packs for pain, and sleep in a flat, neutral position.

A nurse is caring for a client diagnosed with rheumatoid arthritis (RA). Which assessment finding does the nurse expect to assess? 1. Asymmetrical pain in the large weight bearing joints [11%] 2. Low back pain and stiffness that is worse in the morning [18%] 3. Pain, swelling, and redness of the great toe [3%] 4. Symmetrical pain and swelling in the small joints of the hands [67%]

Rheumatoid arthritis (RA) is a chronic, systemic, inflammatory, autoimmune condition of unknown origin that has periods of exacerbation and remission. The body's immune system attacks the lining of the joints, leading to bone erosion and joint deformity. Although there is no cure for the disease, early diagnosis and appropriate treatment can help limit localized joint destruction and systemic organ damage. Characteristic features of RA include the following: Symmetrical pain and swelling that initially affects the small joints of the hands and feet Morning joint stiffness that lasts from 60 minutes to several hours Elevated ESR and rheumatoid factor levels (Option 1) Asymmetrical pain in the weight bearing joints is characteristic of osteoarthritis. Crepitus, especially over the knee joints, is also present in osteoarthritis. (Option 2) Low back pain and stiffness, worse in the morning and improving as the day progresses, is characteristic of ankylosing spondylitis. RA typically does not involve the spine, except the cervical spine. (Option 3) Pain, swelling, and redness of one or more extremity joints (typically the great toe) are characteristic of acute gout attack. Educational objective:RA is a chronic, systemic, inflammatory, autoimmune disease of unknown origin. Early localized articular symptoms include bilateral, symmetrical pain and swelling that initially affects the small joints of the wrists, hands, and feet and morning joint stiffness that lasts at least an hour.

The nurse is assessing a client diagnosed with tuberculosis who started taking rifapentine a week ago. Which statement by the client warrants further assessment and interventionby the nurse? 1. "I do not want to get pregnant, so I restarted my oral contraceptive last month." 2. "I have been taking my medications with breakfast every morning." 3. "I should alert my health care provider if I notice yellowing of my skin." 4. "Since I started this medicine, my saliva has become a red-orange color."

Rifapentine (Priftin), a derivative of rifampin, is an antitubercular agent used with other drugs (eg, isoniazid) as a combination therapy in active and latent tuberculosis infections. Both rifampin and rifapentine reduce the efficacy of oral contraceptives by increasing their metabolism; therefore, this client will need an alternate birth control plan (non-hormonal) to prevent pregnancy during treatment (Option 1). (Option 2) Rifapentine should be taken with meals for best absorption and to prevent stomach upset. (Option 3) Hepatotoxicity may occur; therefore, liver function tests are required at least every month. Signs and symptoms of hepatitis include jaundice of the eyes and skin, fatigue, weakness, nausea, and anorexia. (Option 4) Rifapentine may cause red-orange-colored body secretions, which is an expected finding. Dentures and contact lenses may be permanently stained. Educational objective:Clients taking rifampin or rifapentine (Priftin) as part of antitubercular combination therapy should be taught to prevent pregnancy with non-hormonal contraceptives, notify the health care provider of any signs or symptoms of hepatotoxicity (eg, jaundice, fatigue, weakness, nausea, anorexia), and expect red-orange-colored body secretions.

The nurse is reinforcing teaching to the parent of a child diagnosed with ringworm. Which statement by the parent indicates a need for further teaching? 1. "Antifungal cream must be applied to all affected areas to eradicate ringworm from the body." 2. "Hand washing is very important as ringworm can be spread among humans and pets." 3. "My child has been infected by a worm and must be treated to rid it from the body." 4. "My child will be uncomfortable due to itching, but this is not a dangerous condition."

Ringworm, or tinea corporis, is a fungal infection on the superficial keratin layers of the skin, hair, and/or nails. Ringworm is a misleading name as the condition is not caused by a worm infestation. However, it is highly contagious and spreads via contact. Management includes teaching appropriate hygiene (eg, washing hands after touching infected areas), limited contact with personal items (eg, hair brush), and treatment with the prescribed shampoos as well as topical and/or oral medications (eg, terbinafine [Lamisil], miconazole). (Option 1) Antifungal cream (terbinafine [Lamisil]) is the preferred treatment and is applied to infected areas twice a day. It may take 1-4 weeks to complete treatment depending on infection severity. (Option 2) Ringworm is spread via contact with shared surfaces (eg, bathroom floors, gymnasium mats, car seats), personal items, or pets. Important preventive measures include cleaning surfaces frequently, not sharing personal items, and practicing hand hygiene. (Option 4) This is not a dangerous condition; however, the client will be uncomfortable due to itching. Efforts should be made to discourage scratching as this facilitates spread of infection.

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)? 1. Consume a low-fat, low-salt diet 2.Do not smoke cigarettes 3. Exercise and lose weight 4. Take prescribed antihypertensive medications

Risk factors for stroke include diabetes, high cholesterol, hypertension, smoking, obesity (particularly in the abdomen), 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 don't feel bad with untreated hypertension, they may not realize that it is essential to continue the medications. The nurse should therefore emphasize this point. (Option 1) A low-fat, low-salt diet is beneficial to the client, but managing hypertension with medications is most important. (Option 2) Smoking is also a major risk factor for stroke, and smoking cessation should be emphasized. However, hypertension is the single most important risk factor. (Option 3) Normal BMI is 18.5-24.9 kg/m2. Obesity increases the risk of ischemic stroke, but hypertension control is most important. In addition, it is not indicated if the client is slightly overweight or morbidly obese to make this the highest risk factor. Educational objective:The single most important factor in preventing strokes is controlling hypertension.

The charge nurse evaluates the care provided by a new registered nurse (RN) for a client receiving mechanical ventilation (MV). Which action by the new RN indicates the need for further education? 1. Administers morphine to relieve anxiety and restlessness 2. Applies suction when inserting the catheter into the airway 3. Increases the oxygen concentration on the MV before suctioning 4. Suctions when MV high-pressure alarm continues to sound and rhonchi are present

Risks associated with suctioning include hypoxemia, microatelectasis, and cardiac dysrhythmias. Suctioning removes secretions and oxygen. To minimize both the amount of oxygen removed and mucosal trauma, suctioning is applied when removing not inserting, the catheter into the artificial airway. If secretions are thick and difficult to remove, increasing hydration, not suctioning time, is indicated. Aerosols of sterile normal salineor mucolytics such as acetylcysteine (Mucomyst) administered by nebulizer can also be used to thin the thick secretions, but water should not be used. Aerosol therapy may induce bronchospasm in certain individuals and can be relieved by use of a bronchodilator (albuterol). (Option 1) Morphine is administered to promote breathing synchrony with the mechanical ventilator, reduce anxiety, and promote comfort in clients receiving MV. (Option 3) Preoxygenation with 100% oxygen for 30 seconds before suctioning, unless otherwise specified, is the recommended practice to reduce suctioning-associated risks for hypoxemia, microatelectasis, and cardiac dysrhythmias. (Option 4) It is appropriate to suction the client when the high-pressure alarm on the MV sounds, saturations drop, rhonchi are auscultated, and secretions are audible or visible. These manifestations can indicate excessive secretions impairing airway patency.

The most recent laboratory results for a 12-month-old who is HIV-positive show a CD4 lymphocyte count of 500/mm3 and a CD4 lymphocyte percentage of 10%. The nurse anticipates administering which immunizations? Select all that apply. 1. Haemophilus influenza type b (Hib) 2. Hepatitis A 3. Measles, mumps, rubella 4. Pneumococcal conjugate vaccine 5. varicella

Routine immunization is particularly beneficial to children who are HIV-positive as they are more susceptible to preventable diseases due to a compromised immune system. The standard vaccine schedule for a 12-month-old includes Hib, PCV (PVC13), MMR, varicella, and Hep A. HIV-positive children who are asymptomatic and not extremely immunocompromised can receive the appropriate age-specific immunizations as recommended. However, live vaccine preparations (eg, MMR, varicella) are contraindicated in the presence of marked immunosuppression, as determined by CD4 lymphocyte percentages and/or counts (Options 3 and 5). An individual with a CD4 lymphocyte percentage <15% is considered to be severely immunocompromised. Low CD4 lymphocyte counts vary slightly by age due to the normal occurrence of elevated CD4 counts during infancy and early childhood. Low CD4 counts are defined as <750/mm3 for infants 12 months or younger, <500/mm3 for children between age 1-5 years, and <200/mm3 for children age >5 years and adults. Educational objective:Children who are HIV-positive and not severely immunocompromised can receive routine childhood immunizations. Children with severe immunosuppression as indicated by CD4 lymphocyte counts and/or percentages should not receive any live vaccines, including MMR and varicella.

Which client with an endocrine problem is most appropriate for the charge nurse to delegate to the licensed practical nurse (LPN)? 1. A client experiencing Addisonian crisis with a prescription for hydrocortisone IV 2. A client with Cushing syndrome who needs intermittent urinary catheterization 3. A client with diabetic ketoacidosis on insulin intravenous (IV) infusion 4. A client with thyrotoxicosis and new-onset atrial fibrillation

Routine procedures such as urinary catheterization fall well within the LPN scope of practice, the other clients are in crisis, requiring acute care. (Options 1, 3) LPNs are trained in many nursing skills; these include but are not limited to nasotracheal suctioning, Foley catheter and nasogastric tube insertion, dressing changes, and subcutaneous, intramuscular, and oral medication administration. However, IV medication administration is typically reserved for the RN. (Option 4) Frequent assessment of unstable clients or clients with changes in condition is an exclusive RN task. Other key components of RN practice that should not be delegated or assigned include planning, implementation of complex care, evaluation, and teaching.

The parent of a 7-month-old reports that the child has been crying and vomiting with a distended belly for the past 4 hours. The infant is now lying quietly in the parent's arms with a pulse of 200/min and respirations of 60/min. Which of the following components of SBAR (situation, background, assessment, recommendation/read-back) communication is most important for the nurse to report to the health care provider? 1. Client has been ill for approximately 4 hours 2. Client has improved from apparent earlier distress 3. Client is now lethargic with abnormal vital signs 4. Does the health care provider want to order a laxative?

SBAR (situation, background, assessment, recommendation/read-back) is an established reporting format used to communicate with the health care provider (HCP). Use of SBAR ensures that the HCP receives the necessary information to make a clinical judgment regarding treatment or need for immediate assessment. In this situation, the client's presentation indicates worsening symptoms that require immediate intervention. The client's lethargy represents a declining level of consciousness. The client also has significantly abnormal vital signs (normal infant pulse rate is 110-160/min, respirations generally around 40/min). These are ominous signs that should be reported immediately (Option 3). Educational objective:SBAR (situation, background, assessment, recommendation/read-back) is used to transmit complete essential information to the health care provider. Any abnormal vital signs or current deterioration should be communicated immediately. Additional Information Management of Care NCSBN Client Need

The nurse cares for a client admitted to the hospital due to confusion. The client has a nonmetastatic lung mass and a diagnosis of syndrome of inappropriate antidiuretic hormone (SIADH). Which action(s) should the nurse expect to implement? Select all that apply. 1. Fluid bolus (normal saline) 2. Fluid restriction 3. Salt restriction in the diet 4. Seizure precautions 5. Strict record of fluid intake and output

SIADH is an endocrine condition in which antidiuretic hormone overproduction leads to water retention, increased total body water, and dilutional hyponatremia (low serum sodium). Hyponatremia can cause confusion, seizures, or other neurologic complications. It is important for the nurse to anticipate these problems and institute seizure precautions. SIADH treatment includes: Fluid restriction to <1000 mL/day Oral salt tablets to increase serum sodium (Option 3) Hypertonic saline (3%) during the first few hours for clients with markedly decreased serum sodium and severe neurologic manifestations Vasopressin receptor antagonists (eg, conivaptan) The nurse should also maintain a strict fluid intake and output chart and daily weights and carefully monitor neurologic status to evaluate for improvement or deterioration. (Option 1) Normal saline fluid bolus would worsen the hyponatremia as the client already has excess fluid volume. Symptoms are caused by a low sodium level. If the sodium level must be raised, the client will need hypertonic (3%) saline or salt tablets as these contain mainly sodium and little free fluid.

The clinic nurse provides teaching for the parent of a child diagnosed with scabies. Which instructions should the nurse include in the teaching plan? Select all that apply. 1. All persons in close contact with the child need treatment 2. Apply the permethrin cream to all skin surfaces 3. Discard the child's stuffed animals 4. Fumigate all living areas in the home 5. Wash the child's clothing and bedding in hot water

Scabies is a highly contagious skin infestation of the Sarcoptes scabiei mite. Scabies spreads easily via direct person-to-person contact (eg, skilled nursing facility, day care, prison). The pregnant female mite burrows into the outer skin layer to lay eggs and feces, leaving a superficial burrow track. Intense itching, especially at night, occurs due to the body's inflammatory response to the mite's eggs and feces. Treatment for scabies typically involves 1 or 2 applications of a scabicide cream(eg, 5% permethrin). For infants and children, permethrin should be massaged into all skin surfaces from the head to the feet, avoiding contact with the eyes (Option 2). Even after effective treatment, itching often continues for several weeks. All persons in close contact with the client during the lengthy 30- to 60-day incubation period (time from infestation to symptom onset) should also seek treatment (Option 1). To prevent reinfection, clothing and linens should be washed and dried on the hottest settings (Option 5). (Options 3 and 4) Discarding stuffed animals is not required. Nonwashable belongings can be sealed in plastic bags for ≥3 days because scabies mites can survive away from skin for only 2-3 days. Fumigation of living areas is not necessary. Educational objective:Scabies spreads easily through skin-to-skin contact. Clients with scabies and all persons in close contact should receive treatment with a scabicide cream applied to all skin surfaces. Potentially infested belongings should be washed and dried on the hottest settings or sealed in plastic bags for ≥3 days. Additional Information Physiological Adaptation NCSBN Client Need

The clinic nurse assesses an 8-year-old client who reports a sore throat and has a bright red, pruritic rash on the chest that feels like fine bumps and looks like a sunburn. Which diagnostic tool does the nurse anticipate the health care provider will prescribe? 1. Allergy skin testing [20%] 2. Complete blood count [10%] 3. Rapid streptococcal antigen test 4. Skin biopsy [2%]

Scarlet fever (ie, scarlatina), a complication of group A streptococcal infection (eg, streptococcal pharyngitis), is common in early childhood and is characterized by a distinctive red rash. The rash begins on the neck and chest and spreads to the extremities, resembles a bad sunburn, blanches with pressure, and has fine bumps like sandpaper. Additional manifestations of streptococcal pharyngitis (eg, exudative pharyngitis, fever, swollen anterior cervical lymph nodes) are typically present. Because the clinical presentation (ie, rash plus sore throat) is characteristic, but not diagnostic, of scarlet fever, the health care provider will prescribe a rapid streptococcal antigen test to confirm symptom etiology (Option 3). Swabbing the posterior pharynx and tonsils provides test results within minutes. Throat culture may be necessary to verify results. (Option 1) Dermatologic manifestations of an allergic reaction (eg, contact dermatitis) may necessitate allergy testing (eg, scratch or patch testing). However, the client's symptoms are characteristic of scarlet fever, not an allergic reaction. (Option 2) A complete blood count may reveal elevated WBCs in the presence of any infection, but this is not diagnostic for streptococcal pharyngitis. (Option 4) A skin biopsy involves removing skin and examining it under a microscope to detect certain dermatologic conditions (eg, infection, lupus) but is not anticipated because the client's symptoms are characteristic of scarlet fever.

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? 1. First degree 2. Second degree 3. Third degree 4. Fourth degree

Second-degree (partial-thickness) burns appear as moist or weeping wounds with blisters and shiny, fluid-filled vesicles, and clients have moderate to severe pain. Both the epidermis and dermis are damaged. Immediate care of minor burn injuries involves removal of clothing and debris from the affected area, cooling and cleansing of the wound, and pain management. Minor burn injuries can be treated on an outpatient basis with wound care and dressing changes. Major burn injuries require hospitalization and emergency interventions (eg, airway management, fluid resuscitation). (Option 1) First-degree (superficial) burns are dry with blanchable redness. They usually damage the epidermis only. (Options 3 and 4) Third-degree (full-thickness) burns are dry and inelastic with waxy white, leathery, or charred black color. They destroy the dermis and may involve subcutaneous tissue. Fourth-degree (full-thickness) burns have the same appearance as third-degree burns, with additional involvement of fascia, muscle, and/or bone tissue. Due to nerve damage, pain is not the major feature, unlike with second-degree burns. Educational objective: Second-degree (partial-thickness) burns damage both the epidermis and the dermis, and appear as moist or weeping wounds with redness, blisters, shiny fluid-filled vesicles, and moderate to severe pain.

A client with generalized anxiety disorder has received a new prescription for sertraline. The nurse should teach this client about which possible side effect? 1. Constipation 2. Sedation 3. Sexual dysfunction 4. Weight loss

Selective serotonin reuptake inhibitors (SSRIs) are commonly used to treat major depression and anxiety disorders. SSRIs (eg, fluoxetine, paroxetine, citalopram, escitalopram, sertraline) are generally well tolerated except for sexual dysfunction. Clients often underreport this side effect. However, when asked specifically, over 50% of clients taking SSRIs may be experiencing some type of sexual dysfunction. This can be a decrease in sexual desire, arousal, or orgasm and may vary by gender. The nurse should discuss this with the client. The side effect may decrease or cease after a 2- to 4-week waiting period for the therapeutic effect, or the client may be able to switch to a different antidepressant medication (eg, bupropion). (Option 1) Constipation is uncommon with SSRIs. Drugs with anticholinergic activity (eg, tricyclic antidepressants such as amitriptyline) may result in constipation or urinary retention. (Option 2) Sedation is a common side effect of benzodiazepines (eg, alprazolam, lorazepam, diazepam, and chlordiazepoxide), first generation antihistamines, and narcotic medications. SSRIs may cause insomnia. (Option 4) Weight gain is a common side effect of most SSRIs, especially with long-term therapy. Educational objective:

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? 1. Assess the client's feelings about placement at a skilled nursing facility for care 2. Educate the client on the risks of tissue death if not properly cared for at home 3. Explore the client's abilities and motivation to perform care at home 4. Provide the client with the supplies needed to change dressings as recommended

Self care is a critical component of health. However, barriers to self care are multifactorial, and 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 must assess for adequate knowledge and ability to perform self-care activities and the desire to complete such activities (Option 3). Once the barriers have been identified, the nurse can work with the client to create an individualized plan to meet health care needs. (Option 1) Without understanding the barriers to self care, the nurse cannot identify proper resources to assist the client in meeting needs. Placement for skilled nursing may be excessive for a client who lives independently. (Option 2) Education on tissue death may be perceived as threatening and not therapeutic. (Option 4) Financial resources or supplies may not be the barrier; therefore, this intervention may not effectively assist the client in performing self care successfully.

The nurse is performing beginning of shift assessments on 4 clients. Which client's assessment findings should the nurse immediately report to the health care provider? 1. 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 2. 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 3. 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 (442 µmol/L), and reports nausea and itching 4. 82-year-old client with a pressure injury who has a change in mental status, temperature of 96.4 F (35.8 C), 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 (eg, 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 (ie, immunosenescence). Because of altered immune function, older adults often do not develop typical signs of infection (eg, fever, leukocytosis). Instead, nurses must observe for and immediately report atypical indicatorsof infection (eg, altered mental status, hypothermia, leukopenia) because early identification and intervention reduce mortality (Option 4). (Option 1) Chronic use of central nervous system depressants (eg, alcohol) causes a reflexive increase in catecholamine production (eg, epinephrine). During alcohol withdrawal, hypertension, agitation, and anxiety occur because catecholamine production is no longer inhibited. (Option 2) Clients with stable angina (ie, chest and jaw pain relieved with sublingual nitroglycerin) often experience orthostatic hypotension, an adverse effect of nitrate drugs. (Option 3) Clients with chronic kidney disease (CKD) commonly experience nausea and pruritus due to buildup of nitrogenous wastes in the blood (ie, azotemia). Elevated creatinine is an expected finding in CKD. Hypertension does require intervention by the nurse after management of infection and sepsis. Educational objective:Immunosenescence is an age-related decrease in the immune and inflammatory responses that increases older adult clients' risk of infection and sepsis and causes atypical signs of infection (eg, hypothermia, altered mental status, leukopenia). Atypical signs of infection should be immediately reported to increase the client's chance of survival. Additional Information Management of Care NCSBN Client Need

An adult client with bacterial pneumonia becomes increasingly disoriented and somnolent. Which assessment findings indicate that the client may be in septic shock? Select all that apply. 1. Blood pressure of 80/50 mm Hg 2. Capillary refill of 5 seconds 3. Temperature of 96.4 F (35.8 C) 4. Urine output of 125 mL/hr 5. WBC count of 26,000/mm3 (26 x 109/L)

Sepsis is an overwhelming response to infection that causes impaired organ function. Septic shock occurs when sepsis causes cardiovascular collapse and/or impairs the body's ability to maintain normal metabolic and cellular processes. Manifestations of septic shock include: Fever or hypothermia (>100.4 F [38 C]; <96.8 F [36 C]) - Either fever or low body temperature is found in sepsis and septic shock. Fever occurs in response to infection, whereas low body temperature can occur as shock worsens due to metabolic alterations and inadequate tissue perfusion (Option 3). Hypotension - Systolic blood pressure <90 mm Hg or mean arterial pressure <65 mm Hg in a client with infection may indicate septic shock. Altered perfusion from hypotension may cause lactic acid accumulation and metabolic acidosis (Option 1). Prolonged capillary refill - A refill time >3-4 seconds in adults indicates inadequate tissue perfusion as a result of altered peripheral circulation and hypotension (Option 2). Tachycardia - A resting heart rate >90/min is common in septic shock to compensate for decreased systemic vascular tone and hypotension. WBC count >12,000/mm3 (12 x 109/L) or immature neutrophils (bands) of >10% - An increased WBC count, especially with bands, indicates severe infection (Option 5). (Option 4) Clients with septic shock typically develop decreased urine output (ie, <0.5 mL/kg/hr) due to inadequate organ perfusion.

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? 1. Arouse the client and ask what the current month is 2. Document "relief apparently obtained" and recheck at 03:00 AM 3. Let the client sleep but verify respiratory rate 4. Wake the client up and check for paresthesia

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. A neurologic assessment includes: Glasgow Coma Scale (GCS)—best eye, verbal, and motor responses. Best verbal response assesses orientation to person, place, and time (time is the most sensitive). Pupils—equal, round, response to light, and accommodate (PERRLA) Motor—strength and movement in all four extremities. Vital signs—especially any signs of Cushing's triad of bradycardia, bradypnea/abnormal breathing pattern and widening pulse pressure (the difference between systolic and diastolic blood pressure readings). The nurse is assessing for signs of increased intracranial pressure (ICP). This client is not admitted in the hospital to get a good night sleep. The client is admitted due to the need for serial neurologic assessments by a professional nurse, and that is the priority. (Option 2) Although pain relief has probably been achieved, this option does not reflect any neurologic assessment. One of the early signs of increased ICP is change in level of consciousness. This option does not assess the client's arousability. (Option 3) Checking the respiratory rate and characteristics is part of the neurologic assessment. However, this alone is insufficient for assessing a neurologic status after a blunt head injury. (Option 4) It is good to awaken the client, but paresthesia is part of a neurovascular assessment. Neurovascular assessment, commonly known as the 5 Ps, consists of paresthesia, pain, pallor, paralysis, and pulselessness. A neurovascular assessment is used when circulation is a primary concern. It is not the primary neurologic assessment needed in a closed head injury.

The nurse is caring for a client admitted with serotonin syndrome after taking citalopram and tramadol. Which assessment findings does the nurse expect to find? Select all that apply. 1. Absent deep tendon reflexes 2. Cold, clammy skin 3. Muscle rigidity 4. Restlessness and agitation 5. Sinus tachycardia

Serotonin syndrome, a potentially life-threatening condition, develops when drugs affecting the body's serotonin levels are administered simultaneously or in overdose. Drugs, which may trigger this reaction, include selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors (MAOIs), dextromethorphan, ondansetron, St. John's wort, and tramadol. The diagnosis is primarily clinical and based on medication history and clinical findings. Symptoms may include mental status changes (eg, anxiety, agitation, disorientation), autonomic dysregulation (eg, hyperthermia, diaphoresis, tachycardia/hypertension), and neuromuscular hyperactivity (eg, tremor, muscle rigidity, clonus, hyperreflexia). (Option 1) The client experiencing serotonin syndrome would exhibit hyperreflexia. (Option 2) The client experiencing serotonin syndrome would exhibit warm moist skin and a fever.

Serotonin syndrome, a potentially life-threatening condition, develops when drugs affecting the body's serotonin levels are administered simultaneously or in overdose. Drugs, which may trigger this reaction, include selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors (MAOIs), dextromethorphan, ondansetron, St. John's wort, and tramadol. The diagnosis is primarily clinical and based on medication history and clinical findings. Symptoms may include mental status changes (eg, anxiety, agitation, disorientation), autonomic dysregulation (eg, hyperthermia, diaphoresis, tachycardia/hypertension), and neuromuscular hyperactivity(eg, tremor, muscle rigidity, clonus, hyperreflexia). (Option 1) The client experiencing serotonin syndrome would exhibit hyperreflexia. (Option 2) The client experiencing serotonin syndrome would exhibit warm moist skin and a fever.

A client with advanced kidney disease has serum potassium of 7.1 mEq/L (7.1 mmol/L) and creatinine of 4.5 mg/dL (398 µmol/L). What is the priority prescribed intervention? 1. Administer IV 50% dextrose and regular insulin 2. Administer IV furosemide 3. Administer oral sodium polystyrene sulfonate 4. Prepare the client for hemodialysis catheter placement

Severe hyperkalemia (potassium >7.0 mEq/L [7.0 mmol/L]) requires urgent treatment because cardiac muscle cannot tolerate very high potassium levels. Severe hyperkalemia increases the risk for life-threatening ventricular dysrhythmias (eg, ventricular tachycardia and fibrillation, asystole). IV administration of 50 mL 50% dextrose with 10 units of regular insulin is the priority intervention as it is most effective in reducing the potassium level quickly. The insulin temporarily shifts the potassium from the extracellular fluid back into the intracellular fluid. The dextrose prevents hypoglycemia associated with the increase of insulin in the body and can be eliminated if the client has hyperglycemia (Option 1). If the client has ECG changes (eg, tall peaked T waves), calcium gluconate should be given before insulin/dextrose. This will stabilize the cardiac muscle until the potassium level can be reduced with insulin/dextrose. (Option 2) Furosemide (Lasix) increases the renal excretion of potassium and is usually prescribed for clients with fluid overload. However, administration of furosemide would take time to be effective and is not the priority. (Option 3) Sodium polystyrene sulfonate (Kayexalate) is administered by mouth or enema to remove potassium from the body by exchanging sodium for potassium ions in the intestines; these are then excreted in feces. This is not the priority due to the delayed onset of potassium removal. (Option 4) Hemodialysis is an invasive procedure that can be initiated if more conservative, noninvasive therapies are ineffective in reducing the potassium level. Placement of the catheter will delay treatment. Educational objective:Administration of IV 50% dextrose and regular insulin rapidly corrects an elevated serum potassium level by shifting potassium intracellularly. If the client has ECG changes from hyperkalemia, calcium gluconate should be given first to stabilize cardiac muscle. Additional Information Physiological Adaptation NCSBN Client Need

Elevated creatinine kinase typically >15,000 U/L

Severely elevated creatine kinase levels, typically >15,000 U/L (>250 µkat/L), are observed with severe muscle damage and can be a precursor to kidney injury. Forced saline diuresis with intravenous fluids (to prevent blockage of the renal tubules with myoglobin) is necessary to prevent permanent kidney damage.

The emergency nurse plans care for a female victim of sexual assault. Which of the following interventions should the nurse include in the care plan? Select all that apply. 1. Determine if the victim has douched or had a bath or shower since the incident 2. Educate the victim regarding the need for a pelvic examination 3. Obtain the date of the last menstrual period and current method of birth control 4. Perform head-to-toe assessment of injuries and document injury locations 5. Provide prescribed prophylactic antibiotic medications for sexually transmitted infection

Sexual assault, or the coercing or forcing of sexual encounters (eg, groping, rape, incest, human trafficking), may happen to any individual regardless of age, gender, ethnicity, or relationship to the perpetrator. Nurses providing emergency care should support victims' complex physical and psychosocial needs, initiate preventive and therapeutic treatments, and collect and preserve forensic evidence. Priority nursing actions include: Determining whether the client has bathed, showered, or douched, as these actions may compromise evidence (Option 1) Educating the victim that a pelvic examination is recommended to identify injuries and collect evidence (Option 2) Obtaining the date of the client's last menstrual period and current method of birth control to identify risk for pregnancy (Option 3) Performing a head-to-toe assessment to identify physical injuries requiring treatment and thoroughly documenting all injuries on a body map (Option 4) Providing prophylactic therapies for sexually transmitted infections and pregnancy (Option 5)

A client with myocardial infarction (MI) underwent successful revascularization with stent placement, is now chest pain free, and will be attending cardiac rehabilitation as an outpatient. The client is embarrassed to talk to the health care provider (HCP) about resuming sexual relations after an MI. What teaching should the nurse initiate with this client? 1. If the client is able to climb 2 flights of stairs without symptoms, the client may be ready for sexual activity if approved by the HCP [88%] 2. Inform the client that medications such as sildenafil or tadalafil are available as prescriptions from the HCP [1%] 3. It will be 6 months before the heart is healthy enough for sexual activity [2%] 4. The client will be ready for sexual activity after completion of cardiac rehabilitation [8%]

Sexual counseling is important for cardiac clients, yet can be difficult for clients and HCPs to discuss and is often neglected. Clients' concern about resumption of sexual activity can prove to be more stressful than would be the activity itself. The nurse should encourage clients to discuss concerns with the HCP; in general, if a client can walk 1 block or climb 2 flights of stairs without symptoms, the client can resume sexual activity safely. (Option 2) The use of erectile agents is contraindicated if the client is consuming any form of nitrates. (Option 3) Resumption of sexual activity depends on the emotional readiness of the client and the client's partner and on the HCP's assessment of recovery. In general, it is safe to resume sexual activity 7-10 days after an uncomplicated MI. (Option 4) The client may participate in cardiac rehabilitation, but this should not impact the ability to engage in sexual activity, especially if the client remains asymptomatic.

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? 1. A private room with contact and droplet precautions 2. A private room with negative airflow and contact and airborne precautions 3. A private room with positive airflow and airborne precautions 4. A semi-private 2-bed room with standard precautions

Shingles (herpes zoster) is a reactivation of the varicella-zoster (chicken pox) virus. It is more likely to occur when a client's immune system is compromised by disease (eg, HIV infection) or treatments (eg, chemotherapy). 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 recirculating to the rest of the hospital. Localized shingles require only standard precautions for clients with intact immune systems and contained/covered lesions. (Option 1) Negative airflow and airborne precautions are also required in addition to contact precautions. Droplet precautions are not necessary. (Option 3) Positive airflow would pull fresh air from outside into the hospital room, and then the air from the room would circulate throughout the rest of the hospital. It is not appropriate for this type of infection. Instead, positive airflow would be used for protective isolation in a client who is immunocompromised. (Option 4) A semi-private room is not appropriate for this client with a communicable illness. Standard precautions are used for localized shingles in clients with intact immune systems and contained/covered lesions.

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 to the medical unit? 1. Client newly admitted for an evolving ischemic stroke 2. Client newly diagnosed with diabetes mellitus who needs insulin administration teaching 3. Client with exacerbation of chronic obstructive pulmonary disease (COPD) with a new tracheostomy 4. Client with sickle cell crisis who requires frequent intravenous (IV) opioid medication for pain

Sickle cell crisis is managed with IV hydration, frequent IV pain medication, and as-needed blood transfusion. Many orthopedic clients require medication with opioids to control pain, IV fluids, and blood transfusion (blood loss with surgery/trauma). 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. (Option 1) The client newly admitted for an evolving ischemic stroke is best assigned to an experienced nurse who regularly works on the unit. The nurse will perform baseline and frequent follow-up neurologic assessments to determine if the client's condition is worsening. (Option 2) The client newly diagnosed with diabetes mellitus who needs insulin administration teaching is best assigned to a nurse who regularly works on the unit. The nurse would be familiar with the location of diabetic teaching materials, documentation procedure, and referral resources, and would be better able to evaluate the client's understanding and performance of insulin administration the next day. (Option 3) The client with exacerbation of COPD with a new tracheostomy is best assigned to an experienced nurse who regularly works on the unit. Care of a new tracheostomy requires the nurse to be familiar with assessment (eg, appearance, bleeding) and care (eg, suctioning). Educational objective:A stable client with the least complex problems and the most clearly defined outcomes is the most appropriate assignment for a float nurse.

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 off the transfusion and disconnects the tubing at the catheter hub. What action should the nurse take next? 1. Check vital signs 2. Maintain IV access with normal saline 3. Notify the health care provider 4. Recheck identification labels and numbers

Signs of a transfusion reaction include chills, fever, low back pain, flushing, and itching. Nursing interventions include: Stop transfusion immediately and disconnect tubing at the catheter hub. Maintain IV access with normal saline, using new tubing to prevent hypotension and vascular collapse (Option 2). Notify health care provider (HCP) and blood bank. Monitor vital signs. Recheck labels, numbers, and the client's blood type. Treat client's symptoms according to the HCP's prescription. Collect blood and urine specimens to evaluate for hemolysis. Return blood and tubing set to the blood bank for additional testing. Complete necessary facility paperwork to document the reaction. (Option 1) Monitoring vital signs would be the step after ensuring IV access, administering normal saline, and notifying the HCP. (Option 3) The nurse should ensure continued IV access before notifying the HCP. The HCP will likely prescribe IV medications (eg, vasopressors, antihistamines, corticosteroids) to treat the transfusion reaction, so a patent IV is critical. (Option 4) Mislabeling blood and administering the wrong blood type are the most common causes of a transfusion reaction. However, maintaining IV access takes priority over investigating a potential clinical error. Educational objective: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. Additional Information Physiological Adaptation NCSBN Client Need

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? Select all that apply. 1. Family history of skin cancer 2. High number of moles 3. History of severe adolescent acne 4. Immunosuppressant medication use 5. Outdoor occupation

Skin cancers are most often linked to damage of skin cells' DNA by overexposure to ultraviolet radiation (eg, sunlight, tanning beds). The three most common types of skin cancer are squamous cell carcinoma, basal cell carcinoma, and melanoma. Melanomas 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. Risk factors for skin cancer include: Family or personal history of skin cancer (Option 1) Celtic ancestry traits (eg, light skin, red or blond hair, blue or green eyes, many freckles) Aging Atypical or high number of moles because some skin cancers develop from pre-existing moles (Option 2) Immunosuppression (eg, immunosuppressant medications, HIV), which lowers the body's ability to defend against cancerous mutations (Option 4) Ultraviolet light exposure (eg, chronic sun exposure, outdoor occupation, tanning bed use, history of severe sunburns) (Option 5) 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 health care provider. Early detection and treatment significantly improve outcomes. (Option 3) Acne is not a known risk factor for skin cancer. Educational objective:Risk factors for skin cancer include family or personal history of skin cancer, Celtic ancestry traits (eg, light skin, blue eyes), aging, atypical or high number of moles, immunosuppression, and ultraviolet light exposure (eg, chronic sun exposure, outdoor occupation).

During the admission assessment of a client with a small-bowel obstruction, the nurse anticipates which clinical manifestations? Select all that apply. 1. Abdominal distension 2. Absolute constipation 3. Colicky abdominal pain 4. Frequent vomiting 5. Pain during defecation

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, intussusception, 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 nausea and vomiting (Option 4), colicky intermittent abdominal pain (Option 3), and abdominal distension (Option 1). 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 nasogastric tube, administering prescribed IV fluids, and instituting pain control measures. (Option 2) Symptoms of a large-bowel obstruction differ slightly from small-bowel obstruction and include gradual onset of symptoms, cramping abdominal pain, abdominal distension, absolute constipation, and lack of flatus. Constipation and decreased flatus resulting from small-bowel obstruction would occur later, as the stool and gas in the large colon would be expelled for a few days. (Option 5) Pain during defecation usually indicates a rectal problem such as inflammation, anal fissure, or thrombosed hemorrhoids. Educational objective:Common symptoms of small-bowel obstruction include rapid onset of nausea and vomiting, colicky intermittent abdominal pain, and abdominal distension. Absolute constipation and lack of flatus are usually seen with large-bowel obstruction. Initial treatment of an obstruction includes placing the client on NPO status, inserting a nasogastric tube, administering IV fluids, and instituting pain control measures.

The nurse prepares to administer a prescribed dose of sodium polystyrene sulfonate to a client with hyperkalemia. Which action by the nurse is most important prior to administering the dose? 1. Assessing the client's abdomen and reviewing the medical record for frequency of stools 2. Assisting the client onto a bedside commode 3. Teaching the client the importance of frequent assessment of potassium and sodium levels 4. Verifying that the client had a daily weight assessment

Sodium polystyrene sulfonate (Kayexalate) is used to treat mild to moderate hyperkalemia. Potassium is exchanged for sodium in the intestines and excreted in the stool, thereby lowering the serum potassium. In clients without normal bowel function (eg, post surgery, constipation, fecal impaction), there is a risk for intestinal necrosis. During sodium polystyrene sulfonate therapy, severe hypokalemia (palpitations, lethargy, cramping) can develop. Frequent monitoring of electrolyte status is required. Because potassium exchanges with sodium content of the resin, excess sodium absorption could put clients at risk of developing volume overload(water follows sodium). The client should be monitored for signs of fluid overload (eg, crackles, jugular venous distension, edema) and have daily weights and intake and output assessment. (Option 2) The client will experience frequent, loose stools at the beginning of therapy. Some clients may be more comfortable with a bedside commode. Assisting the client onto the commode is important, but assuring normal bowel function is the priority. (Option 3) Client teaching about necessary laboratory testing is important, but assuring normal bowel function is the priority. (Option 4) Daily weights are important in the evaluation of potential edema from the medication's sodium content, but assuring normal bowel function is the priority. Educational objective:Clients receiving sodium polystyrene sulfonate must have normal bowel function to avoid the risk of intestinal necrosis. The nurse must assess for constipation, signs of impaction, and recent bowel patterns.

The nurse is preparing to administer a sodium polystyrene sulfonate retention enema. Which explanation by the nurse best describes the purpose of this type of enema? 1. "A contrast medium is administered rectally to visualize the colon via x-ray." 2. "Bedridden clients receive this enema to stimulate defecation and relieve constipation." 3. "This enema assists the large intestines in removing excess potassium from the body." 4. "This enema is administered before bowel surgery to decrease bacteria in the colon."

Sodium polystyrene sulfonate (Kayexalate) retention enema is a medicated enema administered to clients with high serum potassium levels. The resin in Kayexalate replaces sodium ions for potassium ions in the large intestine and promotes evacuation of potassium-rich waste from the body, thereby lowering the serum potassium level. Kayexalate can also be given orally and is much more effective. Kayexalate can rarely be associated with intestinal necrosis. (Option 1) A barium enema uses contrast medium (barium) administered rectally to visualize the colon using fluoroscopic x-ray. (Option 2) A fleet enema relieves constipation by infusing a hypertonic solution into the bowel, pulling fluid into the colon and causing distension and then defecation. (Option 4) A neomycin enema is a medicated enema that reduces the number of bacteria in the intestine in preparation for colon surgery.

Which components are used in determining the standards of professional nursing practice? Select all that apply. 1. Care given with good intention to the best of one's ability 2. Clinical practice statements of professional organizations 3. Health care institution's policies and procedures 4. Nurse Practice Act of the state or province/territory 5. Nurse's usual custom and practice

Standards of nursing practice and care are universal criteria that are used when determining if appropriate, professional care has been delivered. The definition of this minimum acceptable level of care reflects what reasonable, prudent, and careful nurses would do in specific circumstances. The state or province/territory boards of nursing help to regulate these standards. Sources used to define standard of care include statements from professional organizations, agency policies and procedures, textbooks, current literature, expert consensus, the Nurse Practice Act, and statutes from regulatory organizations (Options 2, 3, and 4). (Option 1) The standard of care includes objective criteria and does not consider intention. Guidelines are used in determining if duties were performed in an appropriate manner. A nurse can have good intentions but still fail to meet the standards of professional nursing practice. (Option 5) Standard of care is determined by objective, third-party authoritative/reasonably reliable sources. Nurses who are suspected of negligence, yet cannot provide documentation of the event in question, can testify about their interpretation of usual custom and practice as it relates to the incident. However, an individual's typical actions are not authoritative in determining the universal standard of nursing care and cannot replace the use of objective, authoritative, and predetermined standards of care. .

The registered nurse is counseling the parent of a child who was diagnosed with attention-deficit hyperactivity disorder and received a prescription for methylphenidate immediate-release tablet. Which statement by the parent demonstrates that teaching has been effective? 1. "An additive-free, low-sugar diet will reduce my child's symptoms." 2. "I can now manage my child's condition on my own." 3. "My child should not take the last daily dose after 6 PM." 4. "Once medication is started, I will not have to monitor my child anymore."

Stimulant medications (eg, methylphenidate, dextroamphetamine, lisdexamfetamine) are first-line agents in the treatment of attention-deficit hyperactivity disorder (ADHD). Methylphenidate (Ritalin) is administered in divided doses 2 or 3 times daily, usually 30-45 minutes before meals. As a stimulant, methylphenidate may interfere with sleep and should be given no later than around 6 PM (Option 3). The sustained-release preparation should be given in the morning. The dosage in children is usually started low and titrated to the desired response. (Option 1) Contrary to popular myth, sugar does not increase hyperactivity; although an additive-free diet may be a healthy approach for children, eliminating additives or food colorings does not decrease the symptoms of ADHD. (Option 2) A team approach (parents, teachers, health care providers) is the most effective way to help a child with ADHD. School-based interventions may include specific classroom modifications or accommodations to be incorporated into the treatment plan. (Option 4) Children should be monitored closely during initial treatment for development of tics and continuously for adherence and response to therapy. Educational objective:Methylphenidate is a stimulant drug with the potential to cause insomnia. Parents are instructed to administer the last dose no later than 6 PM to prevent sleep disruption.

The nurse provides discharge teaching for the parent of a child newly prescribed methylphenidate for attention-deficit hyperactivity disorder (ADHD). The nurse advises the parent that the child might experience which side effects? 1. Decreased blood pressure and growth delays 2. Heart palpitations and weight gain 3. Loss of appetite and restlessness 4. Trouble sleeping and a dry cough

Stimulant medications are commonly used to treat ADHD in children and adults. Methylphenidate (Ritalin) and amphetamines (eg, dextroamphetamine, lisdexamfetamine) are the most commonly used stimulants. The major problems with stimulant medications include: Decreased appetite and weight loss - can lead to growth delays Cardiovascular effects - hypertension and tachycardia (particularly in adults) Appearance of new or exacerbation of vocal/motor tics Excess brain stimulation - restlessness, insomnia Abuse potential - misuse, diversion, addiction (Option 1) Growth delays are a common side effect. The medications may cause hypertension, not hypotension. (Option 2) Heart palpitations are a common side effect; weight loss, not weight gain, can be a problem. (Option 4) Trouble sleeping is a common side effect, but the medications do not cause a dry cough. Educational objective:Methylphenidate (Ritalin) is a central nervous system stimulant with the following potential side effects: anorexia and weight loss/growth delays, restlessness and insomnia, hypertension and tachycardia, vocal or motor tics, and abuse potential.

The nurse provides education for caregivers of a client with Alzheimer disease. Which instructions should the nurse include? Select all that apply. 1. Complete activities such as bathing and dressing as quickly as possible 2. Decrease the client's anxiety by limiting the number of choices offered 3. Redirect the client if agitated by asking for help with a task or going for a walk 4. Remember to interact with the client as an adult, regardless of childlike affect 5. Use open-ended questions when communicating with the client

Strategies for caring for clients with Alzheimer disease address progressive memory loss and declining ability to communicate, think clearly, and perform activities of daily living. Caregivers should also learn to manage clients' problematic behavior and mood swings. Therapeutic guidelines include: Use distraction and redirection (eg, going for a walk) to manage agitation (Option 3). Speak slowly and use simple words and yes-or-no questions. Do not try to rationalize with the client. Use visual cues when giving directions. Interact with the client as an adult, even as the client regresses to childlike affect and behavior; respect client dignity by avoiding use of pet names (eg, "honey," "sweetie," "darling") (Option 4). Break down complex activities into steps with simple instructions. Decrease the client's anxiety by limiting the number of choices (Option 2). (Option 1) Allow plenty of time for task completion. The client cannot process information rapidly, and hurrying or rushing can cause agitation or anxiety. (Option 5) Ask questions that can be answered with yes, no, or very few words. Do not ask open-ended questions, which can overwhelm the client and cause increased stress and frustration.

A client is transferred from the post-anesthesia recovery unit to the surgical unit following an open cholecystectomy. Which interventions are most important for the nurse to perform to prevent postoperative pneumonia? Select all that apply. 1. Administer morphine only if the pain is >8 on a 1-10 pain scale 2. Ambulate within 8 hours after surgery, if possible 3. Have client cough with splinting every hour 4. Have client deep breathe and use the incentive spirometer every hour 5. Maintain pneumatic compression devices when client is in bed 6. Place client in Fowler's position

Strategies to prevent postoperative pneumonia include the following: Adequate pain control is a priority so that the client can move, deep breathe, and cough more effectively and comfortably. Opioids are effective for relieving postoperative pain, but because they depress respirations and the cough reflex, assessing the client's response to the medication and level of sedation is important. Ambulate within 8 hours after surgery, if possible. Mobilization/early ambulation decreases atelectasis and hypoventilation, and promotes coughing, deep breathing, and lung expansion. Usually, it can be initiated within 4-8 hours after surgery. Coughing with splinting every hour. Splinting of the incision and adequate pain management are useful for promoting an effective cough (huff, cascade) that clears the airway of secretions. Deep breathing and use of the incentive spirometer every hour. Deep breathing in conjunction with the use of the incentive spirometer promotes ventilation and oxygenation. It opens the pores of Kohn that permit air from well-ventilated alveoli to move into collapsed alveoli, and it helps to prevent/decrease atelectasis and hypoventilation caused by the effects of anesthesia, analgesia, and pain. Place in Fowler's position. Elevating the head of the bed 45-60 degrees helps to promote oxygenation and prevent aspiration. Turn and reposition the client at least every 2 hours. Swab mouth with chlorhexidine swabs every 12 hours. Mouth care prevents ventilator-associated and postoperative pneumonia. Use hand hygiene (all personnel) to decrease transmission of microorganisms. (Option 1) Adequate pain control is a priority. The decision to hold opioids is usually based on sedation level. Giving pain medicine only for severe pain is not appropriate. If the client is awake and complains of pain, adequate analgesia should be provided (oral or IV). (Option 5) Use of pneumatic compression devices promotes venous return and helps to prevent venous thrombosis, not pneumonia.

A client diagnosed with septic shock has an upward-trending glucose level (180-225 mg/dL [10.0-12.5 mmol/L]) requiring control with insulin. The client's spouse asks why insulin is needed as the client is not a diabetic. What is the most appropriate response by the nurse? 1. "It is common for critically ill clients to develop type II diabetes. We give insulin to keep the glucose level under control (<140 mg/dL [7.8 mmol/L])." [3%] 2. "The client was diabetic before, but you just didn't know it. We give insulin to keep the glucose level in the normal range (70-110 mg/dL [3.9-6.1 mmol/L])." [1%] 3. "The increase in glucose is a normal response to stress by the body. We give insulin to keep the level at 140-180 mg/dL (7.8-10.0 mmol/L)." [40%] 4. "This increase is common in critically ill clients and affects their ability to fight off infection. We give insulin to keep the glucose level in the normal range (70-110 mg/dL [3.9-6.1 mmol/L])."[55%]

Stress-induced hyperglycemia (gluconeogenesis) can occur in hospitalized clients in relation to surgery, trauma, acute illness, and infection. Hyperglycemia (glucose level >140 mg/dL [7.8 mmol/L]) affects both diabetic and non-diabetic hospitalized clients, especially those who are critically ill. Approximately 80% of clients in the intensive care unit who develop hyperglycemia have no history of diabetes before admission. Hyperglycemia is associated with increased risk of complications (eg, health care-associated infection, increased length of stay, acute kidney injury). To minimize complications and avoid hypoglycemia, the recommended glucose target range for critically ill clients is 140-180 mg/dL [7.8-10.0 mmol/L]. For non-critically ill clients, <140 mg/dL [7.8 mmol/L] fasting and <180 mg/dL [10.0 mmol/L] random blood glucose are recommended.

The graduate nurse cares for several poststroke clients. Which of the following nursing interventions are appropriate? Select all that apply. 1. Implement fall precautions for the client with cerebellar stroke 2. Increase lighting for the client with cranial nerve VII affected 3. Initiate swallow precautions for the client with cranial nerves IX and X affected 4. Place spoon within field of vision for the client with homonymous hemianopsia 5. Speak louder in front of the client who has receptive aphasia

Strokes cause 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 (Option 1). Cranial nerves IX(glossopharyngeal) and X (vagus) control the gag and swallowing mechanisms, making swallow precautions necessary (Option 3). Blindness in the same half of each visual field, homonymous hemianopsia, is suspected when clients ignore objects on one side. Initially, the nurse assists (eg, places utensil in unaffected visual field), but the client must learn to turn the head to scan the environment (Option 4). (Option 2) 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. (Option 5) Clients experiencing receptive aphasia, impaired comprehension of speech and writing, typically have injury to the Wernicke area of the brain, located in the left temporal lobe. The nurse would not speak louder as this does not aid comprehension. The nurse should speak clearly, ask "yes" or "no" questions, and use gestures and pictures to increase understanding.

The nurse is planning care for a client with suspected stroke who has just arrived at the emergency department 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? Select all that apply. 1. Arrange for a speech pathologist consult 2. Discuss community resources with family 3. Obtain a STAT CT scan of the head 4. Perform a baseline neurologic assessment 5. 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 (Option 3). Determining exactly when symptoms began is essential for diagnosis and planning treatment. Thrombolytic therapy (eg, alteplase, tissue plasminogen activator [tPA]) is used to dissolve blood clots and restore perfusion to brain tissue in clients with an ischemic stroke unless contraindicated (eg, active bleeding, uncontrolled hypertension, aneurysm). It must be administered within 4.5 hours from onset of symptoms (Option 5). A baseline neurologic assessment is essential for tracking ongoing neurologic symptoms that indicate improvement or complications which guide later treatments (Option 4). (Options 1 and 2) Consultation with a speech pathologist and providing the family with information about community resources are important later but not during the initial (acute) phase of stroke management.

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? Select all that apply. 1. Administer hydromorphone IV PRN for pain 2. Administer intravenous fluids 3. Insert a nasogastric tube for nasogastric suction 4. Maintain client in a supine position, with head of bed flat 5. Provide small, frequent, high-carbohydrate, high-calorie meals

Supportive care for symptom relief and prevention of complications are the major goals in clients with acute pancreatitis. These strategies include: NPO status - The client is maintained on NPO status as any ingestion of food will stimulate the excretion of pancreatic enzymes. A nasogastric tube is used to suction out gastric secretions; this will reduce nausea and lessen stimulation of the pancreas as these juices will move to the duodenum. Pain management - Intravenous opioids (eg, hydromorphone, fentanyl) are frequently utilized for pain management. Morphine can also be used; worsening pancreatitis due to increase in sphincter of Oddi pressure has not been proven in studies. IV fluids - Aggressive fluid replacement to prevent hypovolemic shock is critical. Inflammation of the pancreas releases chemical mediators that increase capillary permeability and cause third spacing (fluid going into empty spaces). (Option 4) The client should maintain positions that flex the trunk and draw the knees up to the abdomen (semi-Fowler's) to decrease tension on the abdomen. A side-lying position with the head elevated to 45 degrees will help relieve the pain even better. (Option 5) NPO status is maintained to inhibit stimulation of pancreatic enzymes. Educational objective:The major goals in acute pancreatitis are symptom management (eg, opioids, NPO status, nasogastric suction) and monitoring and prevention of complications (eg, IV fluids), giving the pancreas time to heal.

The emergency nurse is admitting a 12-year-old client who reports palpitations. Which action should the nurse anticipate? Click the exhibit button for additional information. 1. Administering epinephrine by rapid IV push [6%] 2. Assisting the client to a tripod position [13%] 3. Instructing the client to hold their breath and bear down [66%] 4. Sedating the client for immediate asynchronous defibrillation [13%] Temperature97.1 F (36.2 C)Blood pressure114/74 mm HgHeart rate234/minRespirations24/minSpO297% Physical assessmentNeurologicAlert and oriented to person, place, and time. Follows commands.CardiovascularTachycardia noted. +1 radial pulses. +1 carotid pulses. Jugular veins 1 cm at 45-degree angle.RespiratoryClear to auscultation. No adventitious sounds. Even and unlabored breathing.SkinColor appropriate for ethnicity. No cyanosis or mottling. ExtremitiesNo edema in upper or lower extremities.

Supraventricular tachycardia (SVT) is the most common tachyarrhythmia of childhood and refers to a rapid heart rate of 200-300/min with no variation in rate during activity. It can lead to life-threatening congestive heart failure if left untreated. Symptoms in children may include palpitations, dizziness, or chest pain. Once an ECG confirms SVT, the nurse should anticipate nonpharmacological interventions (ie, vagal maneuvers) to convert SVT to sinus rhythm if the client is stable. Placing an ice bag to the client's face and instructing the client to hold their breath while bearing down (Valsalva) are vagal maneuvers that can slow electrical conduction through the heart's atrioventricular node (Option 3). If these maneuvers are ineffective, or if the client becomes unstable, administration of adenosine or synchronized cardioversionis indicated. (Option 1) IV epinephrine is not an appropriate treatment for a stable client with tachycardia and would further increase the client's heart rate. Epinephrine is typically used for clients with pulseless arrhythmias (eg, asystole). (Option 2) The tripod position opens the airway and promotes airflow, particularly for clients with significant airway obstruction (eg, epiglottitis). The child with palpitations may assume any position of comfort. (Option 4) Asynchronous defibrillation is indicated for the treatment of lethal cardiac arrhythmias (eg, ventricular fibrillation, pulseless ventricular tachycardia).

The clinic nurse evaluates a parent's understanding of home care management for a child diagnosed with attention deficit hyperactivity disorder. Which parent statement indicates a need for the nurse to provide additional instruction? 1. "I met with my child's babysitter and teacher to discuss how behavior should be handled." 2. "I placed a desk with new school supplies in my child's bedroom to encourage completion of homework." 3. "I posted a sign showing the steps of our morning routine in my child's bedroom and bathroom." 4. "I use a sticker chart with a reward system to encourage my child to complete chores and tasks on time."

Symptoms of attention deficit hyperactivity disorder (ADHD) include hyperactivity, impulsiveness, and inattention. Clients with ADHD are easily distracted and have difficulty staying focused on tasks. Potential distractions in the bedroom (eg, TV, toys, music) may be too enticing during homework time; therefore, providing a quiet area with minimal distractions and optimal supervision (eg, kitchen table) is best for a child with ADHD who is trying to complete homework (Option 2). Caregivers should provide the client with consistency in rules and discipline, simple to-do lists, task-completion charts, and rewards for desired behavior to facilitate a therapeutic environment (Options 1, 3, and 4).

The nurse receives handoff of care report on four clients. Which client should the nurse assess first? 1. Client who had an appendectomy today and reports severe nausea and 8 out of 10 pain [28%] 2. Client with a diabetic foot ulcer who has current blood glucose level of 301 mg/dL (16.7 mmol/L) [13%] 3. Client with a fever of unknown origin whose arterial blood gas reveals PaCO2 30 mm Hg (4.0 kPa) [56%] 4.Client with persistent diarrhea who has continuous lactated Ringer solution IV infusing at 125 mL/hr [2%]

Systemic inflammatory response syndrome (SIRS) is a pathophysiologic response mediated by the release of large quantities 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 (ie, sepsis), 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 (often associated with a low PaCO2 value). Clients who develop multiple symptoms of SIRS require aggressive fluid resuscitation and treatment to address possible causes (eg, antibiotics for infection) as SIRS may be life-threatening (Option 3). (Options 1 and 2) Addressing a client's postoperative pain and nausea and further assessing a client with hyperglycemia and diabetes are important but are lower priorities than initiating care for SIRS. (Option 4) 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.

The public health nurse provides care for a client on a directly observed therapy (DOT) program to treat tuberculosis (TB). Which option best describes the care the nurse provides on this program? 1. Follows the client until 3 sputum cultures are normal [34%] 2. Gives the client bus tokens or cab fare vouchers to attend scheduled clinic visits [2%] 3. Provides and watches the client swallow every prescribed medication [56%] 4. Screens all of the client's close contacts [6%]

TB is curable if the client completes the prescribed medication regimen. Noncompliance with the treatment plan is a major problem in treating TB due to the length of time drug therapy is required (usually about 6 months) and the associated unpleasant side effects. DOT is an effective patient-centered treatment strategy developed by the World Health Organization that increases compliance with drug therapy, prevents reinfection and the development of multi-drug resistant TB strains, and controls the spread of TB disease worldwide. The public health nurse provides and watches the client swallow every prescribed medication for at least the first 2 months of antitubercular medication therapy, preferably longer. Any designated person (ie, caregiver) can provide the medications and observe the client swallow them. This can take place in any designated area (eg, clinic, home, school, workplace). (Option 1) The public health nurse follows the client throughout the treatment period until all sputum smears and cultures are normal, but not in the DOT program. (Option 2) The public health nurse gives the client bus tokens or cab fare vouchers to attend scheduled clinic visits as incentives, but not in the DOT program. (Option 4) The public health nurse screens all of the client's close contacts for possible infection and prophylactic treatment, but not in the DOT program.

The nurse receives a new prescription for tamoxifen for a client with breast cancer. Which information found in the client's medical record would require follow-up with the health care provider? 1. Documentation of an allergy to shellfish and peanuts [19%] 2. History of quitting cigarette smoking 5 years ago [1%] 3. Hospitalization with deep venous thrombosis 1 year ago [60%] 4. Previous treatment for depression following the death of a parent [18%]

Tamoxifen is a selective estrogen receptor modulator that is prescribed to treat certain types of breast cancer and to prevent breast cancer recurrence. Tamoxifen works by blocking estrogen receptors in certain estrogen-sensitive tissues (eg, breast, vagina), but it also increases affinity for estrogen in some tissues, such as the uterus. In the treatment of breast cancer, tamoxifen inhibits growth of estrogen receptor-positive tumors. Clients typically take tamoxifen for several (eg, 5-10) years after treatment to prevent breast cancer recurrence. Common side effects of tamoxifen therapy, like the effects typically seen in menopause (eg, hot flashes, vaginal dryness, menstrual irregularities), are related to decreased estrogen. Follow-up would be required for clients with symptoms or a history of tamoxifen's most serious side effects, including: Thromboembolic events (eg, deep venous thrombosis, pulmonary embolism, stroke) (Option 3) Endometrial cancer (eg, abnormal vaginal bleeding) (Options 1, 2, and 4) Shellfish and peanut allergies, previous smoking history, and history of depression are not contraindications for treatment with tamoxifen.

The health care provider is starting an elderly client on terazosin to treat benign prostatic hyperplasia (BPH). Which information should be included when teaching this client about the new medication? 1. Change positions slowly when going from lying to standing [44%] 2. Do not drink grapefruit juice when taking this drug [44%] 3. Take this medication first thing in the morning, before breakfast [7%] 4. Your stool may become darker and that's normal [3%]

Terazosin is an alpha-adrenergic blocker that can relieve urinary retention in clients with BPH. It relaxes the smooth muscle in the bladder neck and prostate gland; however, it also relaxes smooth muscle in the peripheral vasculature, which can cause orthostatic hypotension, syncope (blacking out), and falls. This is particularly common when the drug is started (first-dose hypotension) or when the dosage is increased. The serious effects can be avoided by instructing the client to take the medication at bedtime, change positions slowly when going from lying to standing, and avoid any medications that also increase smooth muscle relaxation (eg, phosphodiesterase-5 inhibitors [sildenafil or vardenafil] used to treat erectile dysfunction). Some clients may also experience ejaculatory dysfunction (decreased or absent ejaculation). (Option 2) Grapefruit juice can cause significant interactions with drugs such as calcium channel blockers and sildenafil. However, it does not appear to interact with alpha blockers such as terazosin. (Option 3) Alpha-1-adrenergic antagonists (eg, terazosin, doxazosin, tamsulosin, alfuzosin) should be taken at bedtime, not in the morning, to avoid orthostatic hypotension. (Option 4) Oral iron tablets and bismuth salts (Pepto-Bismol) can turn stools dark, an expected side effect. This can be confused with upper gastrointestinal bleeding, which can also cause melena. Educational objective:Alpha blockers are commonly used to treat symptoms of urinary retention in clients with BPH. Orthostatic hypotension is a common side effect that can be avoided by teaching the client to take the medication at bedtime, avoid abrupt position changes, and avoid medications for erectile dysfunction, which can worsen hypotension.

The nurse plans teaching for an adolescent client being discharged home with a Boston brace for treatment of scoliosis. Which instruction will the nurse include in the discharge teaching plan? 1. Apply body lotion or powder under the brace to prevent skin irritation 2. Avoid any exercises that require the use of spinal muscles 3. Keep the brace on for all activities, including showering 4. Wear a cotton t-shirt under the brace at all times

The Boston brace, Wilmington brace, thoracolumbosacral orthosis (TLSO) brace, and Milwaukee brace are used to diminish the progression of deformed spinal curves in scoliosis. Braces do not cure the existing spinal deformities but do prevent further worsening. These braces are also sometimes used for clients who undergo spinal fusion. The braces are molded plastic shells worn around the trunk of the body under the client's outer clothing. Due to the risk for skin breakdown, clients should wear a cotton t-shirt under the brace to decrease skin irritation and absorb sweat. Compliance is a major problem in most adolescents as they are preoccupied with body image and appearance. Psychosocial issues (eg, body image, sense of control, socialization) are very important to discuss. Many clients may find it helpful to meet other individuals their age who also wear the braces. (Option 1) The use of lotion or powder can cause skin irritation due to heat buildup beneath the brace. (Option 2) It is important to build and maintain strength in the spinal muscles to promote stabilization throughout treatment. Most prescribed bracing courses allow brace removal for such exercises. (Option 3) The exact course of bracing treatment varies based on the type of brace and severity of spinal curvature. Most braces are worn for 18-23 hours per day and removed for bathing and exercise. Clients should never shower while wearing a hard brace as padding will absorb moisture and promote skin breakdown.

The parent of an 11-month-old child calls the pediatric outpatient clinic and tells the nurse that the child was exposed to measles 2 days ago during a family trip to a theme park. What is the best response by the nurse? 1. Bring the baby into the clinic for the measles, mumps, rubella (MMR) vaccine 2. Check the baby's temperature twice a day 3. Do not allow the child to have contact with other children 4. Does your child have a fever or rash?

The Centers for Disease Control and Prevention (CDC) recommends that the first dose of MMR vaccine be given to children between age 12-15 months to ensure optimal vaccine response. However, the vaccine is safe for children age <12 months; it could provide some protection or modify the clinical course of the disease if administered within 72 hours of the child's initial measles exposure. Immunoglobulin, if administered within 6 days of exposure, is also utilized as post-exposure prophylaxis. A child who receives the MMR vaccine prior to the first birthday will need to be revaccinated at age 12-15 months and again between age 4-6 years. (Option 2) Because a fever is one of the first emerging signs of a measles infection, it would be appropriate to advise the parent to check the child's temperature. However, this is not the most important action. (Option 3) This is not the most important instruction to give to the parent. After receiving the MMR vaccine, the child can be around other children. If the child does not receive the MMR vaccine, exposure to other children would not be advised. (Option 4) Although fever and rash are 2 of the clinical signs of measles, the measles incubation period is 7-21 days. The clinical indicators of measles would not be seen only 2 days after exposure. Educational objective:As advised by the CDC, a child age <12 months can and should receive the MMR vaccine when there is an outbreak of measles and the child risks contracting the illness due to an exposure. The child will need to be revaccinated between age 12-15 months and between age 4-6 years.

The registered nurse (RN) delegates to the unlicensed assistive personnel (UAP) the ambulation of a client. The RN observes the UAP placing 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? 1. Discuss the need for UAP inservice education with the nurse manager [0%] 2. Give praise to the UAP for encouraging the client to walk the entire hall [0%] 3. Immediately lower the bag and speak privately to the UAP [97%] 4. Let the UAP complete assigned tasks and speak to the UAP at the end of the shift [1%]

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. (Option 1) Future inservice education is not a timely solution to this immediate need. It is appropriate to carry out teaching first rather than initiate disciplinary actions. According to the Federal Drug Administration's (FDA's) mandate, as no serious harm was caused, the incident does not need to be reported. (Option 2) The most important issue needing intervention is the improper positioning (too high) of the Foley catheter bag. Positive reinforcement for appropriate actions can also be included (and is beneficial), but the error should first be corrected to prevent harm. (Option 4) It is important to attend to the error right away to help ensure that the UAP does not repeat it. Letting this UAP complete assigned tasks first does not immediately deal with the incorrect position of the Foley bag and may not effectively teach (aid retention of) the correct positioning to the UAP. Educational objective:When observing a provider making an error, correct it immediately to stop any potential harm to the client. Correct the provider privately and as soon as possible. Additional Information Management of Care NCSBN Client Need

The nurse assesses several clients using the Glasgow Coma Scale. Which scenario best demonstrates a correct application of this scale? 1. The nurse applies pressure to the nail bed, and the client tries to push the nurse's hand away. The nurse scores motor response as "localization of pain." [30%] 2. The nurse asks the client what day it is and the client says "banana." The nurse scores verbal response as "confused." [21%] 3. The nurse speaks with client and then the client's eyes open. The nurse scores eye opening as "spontaneous." [43%] 4. The nurse walks in the room and the client states "Hi honey. How are you?" The nurse scores verbal response as "oriented." [5%]

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

While caring for a client in skeletal traction, which tasks can the registered nurse (RN) delegate to experienced unlicensed assistive personnel (UAP) to help prevent immobility hazards? Select all that apply. 1. Assist with active and passive range of motion (ROM) exercises 2. Change bed linens while logrolling the client from side to side 3. Check the color and temperature of the affected extremity 4. Remind the client to use the incentive spirometer 5. Reapply pneumatic compression device after bathing the client

The UAP has the skills and knowledge to perform standard procedures to prevent immobility hazards for a client in traction (eg, pneumonia, pressure ulcers, foot drop, thromboembolism). When providing care for a stable client, the RN can safely delegate these tasks to the UAP: Assist with active and passive ROM exercises after the client has been taught how to perform them by the RN or physical therapist (Option 1) Notify the RN of client reports of pain, tingling, or decreased sensation in the affected extremity Remind the client to use the incentive spirometer after the client has been taught proper use by the RN or respiratory therapist (Option 4) Maintain proper use of pneumatic compression devices (Option 5) Remind the client to move frequently using the overhead trapeze (Option 2) The UAP changes the linens from the top to the bottom of the bed with assistance; clients are instructed to lift themselves using the overhead trapeze. This approach maintains immobilization of the injured extremity. Logrolling the client will require multiple staff members, including one person to stabilize weights. (Option 3) The RN is responsible for peripheral circulation, neurovascular, and skin assessments.

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? Select all that apply. 1. 22-year-old man with a head injury sustained during a college football game 2. 30-year-old woman recently hospitalized for reconstructive augmentation mammoplasty 3. 56-year-old man 2 weeks post myocardial infarction 4. 68-year-old woman recently diagnosed with pancreatic cancer 5. 74-year-old man with portal hypertension related to alcohol-induced cirrhosis 6. 82-year-old woman 1 week post cataract surgery

The Valsalva maneuver (straining during defecation) involves holding the breath while bearing down on 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 (Option 1). 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 (Option 3). 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 (Option 5). The maneuver increases intraocular pressure and is contraindicated in clients with glaucoma and recent eye surgery (Option 6). (Option 2) The otherwise healthy client recovering from reconstructive augmentation mammoplasty is not at risk for complications related to the Valsalva maneuver. (Option 4) The client recently diagnosed with pancreatic cancer is not at risk for complications related to the Valsalva maneuver.

A home health nurse is supervising a home health aide who is changing the dressing for a client with a chronic heel wound. Which actions by the aide indicate adherence to appropriate infection control procedures? Select all that apply. 1. Open a sterile container of 4 x 4's using the outermost corner to peel back the cover 2. Pull glove off over the soiled dressing to encase it before disposal 3. Save unused sterile 4 x 4's by taping original package shut for the next dressing change 4. Wash hands prior to putting on gloves and after removing them 5. Wrap soiled dressing in paper towels before disposing of it in the trash can

The aide should wash the hands prior to gloving and after glove removal (Option 4). Sterile dressing supplies opened prior to the dressing change; this should be done by carefully peeling from the outermost corner of the package to expose the contents without contaminating the sterile product (Option 1). A contaminated used dressing should be placed in impervious plastic or a paper bag before disposal in the household trash (Option 2). (Option 3) Unused sterile supplies should not be saved as it is not possible to ensure their sterility. (Option 5) Paper towels are not impervious and infectious waste from the dressing can seep through and into other items in the trash can.

A nursing unit implements a quality improvement process of written reminders to ameliorate incentive spirometer (IS) use in postoperative clients. What is the best indicator that the client goal for this process has been met? 1. Chart audits indicate that client incidence of nosocomial pneumonia decreased by 20% [79%] 2. Documentation shows that 100% of nurses attended an inservice seminar on the topic [2%] 3. Nurses report an increased number of written reminders given to appropriate clients [7%] 4. Surgeons who admit to the unit report increased satisfaction with current client IS use [9%]

The best indicators of a successful intervention (desired effect achieved) are objective criteria. This is an objective measurable result that can be correlated with the intervention. (Option 2) Attending an inservice seminar for staff education is an important and necessary step for intervention implementation. However, the intervention will be successful only if the information is applied and the desired outcome achieved. (Option 3) Reporting the number of written reminders given to respective clients is necessary. However, this reporting of intervention achievement is subjective as recall can be inaccurate. Even if it were an accurate recounting, it does not prove that the intervention succeeded. The appropriate focus should be on client outcomes, not nursing staff behaviors. (Option 4) Although approval from surgeons provides helpful support for the intervention, an objective evaluation beyond personal opinions is required. Educational objective: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 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? 1. "I should apply spermicide to the cervical cap before inserting it." 2. "I should not use the cervical cap while I am on my period." 3. "I will remove and clean the cervical cap as soon as possible after intercourse." 4. "It is okay for me to insert the cervical cap several hours before I have sex."

The cervical cap is a barrier method of contraception used with spermicide (eg, nonoxynol-9). 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 (Option 3). 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. (Option 1) Prior to insertion, spermicide is applied to the cervical cap to maximize contraceptive effectiveness. Spermicide should be applied inside the cap, along the rim of the cap, and in the groove on the underside of the cap. (Option 2) Use of cervical caps during menses (or during the postpartum period in clients with lochia discharge) increases the risk of toxic shock syndrome; an alternate contraceptive method should be used during this time. (Option 4) Inserting the cervical cap several hours before intercourse is acceptable and may improve correct use. Before each use, the client should inspect the cap for holes, cracks, or tears to ensure its effectiveness for blocking sperm. Educational objective:The cervical cap is a barrier method of contraception used with spermicide. It can be inserted several hours before intercourse and should be left in place for at least 6 hours after. Its use during menses increases the risk of toxic shock syndrome. Additional Information Health Promotion and Maintenance NCSBN Client Need

The charge nurse on the telemetry unit is making client assignments. Which client is appropriate to assign to the licensed practical nurse (LPN)? 1. Client 2 days after aortic valve surgery who needs a urinary catheter reinserted due to inability to void 2. Client being discharged after deep vein thrombosis who needs teaching on how to self-administer enoxaparin injections 3. Client who has just been admitted to the telemetry unit from the emergency department with a rule-out myocardial infarction 4. Client with a nitroglycerin infusion with prescription to titrate to keep systolic blood pressure <150 mm Hg; currently is 110/62 mm Hg

The charge nurse should assign the most stable and predictable client to the LPN. The client who needs to have a urinary catheter reinserted is within the scope of practice for the LPN. The other clients need nursing interventions that require independent nursing knowledge, skill, and judgment such as assessment, client teaching, and evaluation of care. (Option 2) The registered nurse (RN) is responsible for initial client teaching. Teaching self-administration of enoxaparin can be complex and should be done by the RN. The LPN can reinforce the teaching done by the RN. (Option 3) The client being admitted from the emergency department requires clinical assessment and clinical judgment, which should be handled by the RN. (Option 4) The client on nitroglycerin is complex and requires titration of an intravenous medication; this client should be assigned to an RN. Educational objective: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 cares for a client with impairment of cranial nerve VIII. What instructions will the nurse provide the unlicensed assistive personnel prior to delegating interventions related to the client's activities of daily living? 1. "Be aware of the client's shoulder weakness and provide support as needed." 2. "Ensure that the client sits upright and tucks the chin when swallowing food." 3. "Explain all procedures in step-by-step detail before performing them." 4. "Make sure the items needed by the client are within reach."

The client has an impairment of cranial nerve (CN) VIII, the vestibulocochlear (or auditory) 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 unlicensed assistive personnel (UAP) about helping the client with activities of daily living, the nurse emphasizes the need to keep items at the bedside within the client's reach (Option 4). (Option 1) Weakness of the shoulder muscle occurs with impairment of CN XI, the spinal accessory nerve. Impairment of CN VIII does not affect shoulder strength. (Option 2) Dysphagia may occur with impairment of CN IX (glossopharyngeal) and CN X (vagus), not CN VIII. Instructing the client to tuck the chin while eating is a technique for those who have difficulty swallowing. (Option 3) Impairment of visual acuity occurs with disorders affecting CN II (optic). Because impairment of CN VIII does not affect visual acuity, providing a detailed, step-by-step explanation of procedures may be helpful but is not the most appropriate instruction to give the UAP. Educational objective:Impairment of cranial nerve (CN) VIII, the vestibulocochlear or auditory nerve, may cause dizziness, vertigo, loss of hearing, and motion sickness. To assist the client with impairment of CN VIII, needed items should be placed nearby to decrease the risk of the client getting out of bed and falling.

The nurse assesses a client with suspected acute pancreatitis and anticipates the client reporting pain in which anatomical area? 1. Left flank radiating to the left groin area 2. Left upper quadrant radiating to the back 3. Periumbilical area shifting to the right lower quadrant 4. Right upper quadrant radiating to the right shoulder

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. Nausea and vomiting 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). (Option 1) Kidney stones cause sudden, excruciating pain in the flank, back, or lower abdomen due to stretching of the ureter. The pain radiates to the groin area. (Option 3) 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. (Option 4) Cholecystitis (inflammation of the gallbladder) causes pain in the right upper quadrant that often radiates to the right shoulder area.

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 fired twice. What action should the nurse take? 1. Administer epinephrine 1 mg IV push [18%] 2. Deactivate the ICD with a magnet [5%] 3. Initiate chest compressions [66%] 4. Take no action and let the ICD work [9%]

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 cardiopulmonary resuscitation (CPR) to provide circulation of blood to the vital organs. The nurse should implement the pulseless arrest algorithm, allowing 30-60 seconds for the ICD to complete its therapy cycle before applying external defibrillation pads/paddles. (Option 1) Epinephrine should be administered after CPR and defibrillation. (Option 2) The ICD is firing as it was programmed to do. It should not be deactivated. (Option 4) The nurse should let the ICD work but needs to implement CPR in addition.

The nurse reviews the laboratory results for 4 assigned clients. Which result is most important for the nurse to report to the primary health care provider? 1. Client with atrial fibrillation receiving warfarin for 7 days with an International Normalized Ratio (INR) of 1.3 2. Client with chronic bronchitis who has a hematocrit of 56% [0.56] and hemoglobin of 19 g/dL (190 g/L) 3. Client with Clostridium difficile infection who has a white blood cell count of 15,000/mm3 (15 × 109/L) 4. Client with sepsis receiving gentamycin who has a creatinine of 0.6 mg/dL (53 µmol/L)

The client with atrial fibrillation 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 (normal 0.75-1.25) is a measurement used to assess and monitor coagulation status in clients receiving anticoagulation therapy. The therapeutic INR level for a client receiving warfarin (Coumadin) to treat atrial fibrillation is 2-3. The subtherapeutic INR of 1.3 is the most important result to report to the health care provider (HCP) as the client is at increased risk for a stroke and dose adjustment is needed. (Option 2) A client with chronic obstructive pulmonary disease and chronic bronchitis has chronic alveolar hypoxia, which stimulates erythropoiesis (red blood cell production) and leads to polycythemia (hematocrit >53% [0.53] in males, >46% [0.46] in females; hemoglobin >17.5 g/dL [175 g/L] in males, >16 g/dL [160 g/L] in females). Increased hematocrit and hemoglobin are expected in this client and are not the most important results to report to the HCP. (Option 3) Leukocytosis (white blood cells >11,000/mm3 [11 × 109/L]) is expected in a client with C difficile infection and is not the most important result to report to the HCP. (Option 4) A client receiving gentamycin, a nephrotoxic drug, has a normal creatinine level (0.6-1.3 mg/dL [53-115 µmol/L), which is not the most important result to report to the HCP. Educational objective:The therapeutic INR range is 2-3 for a client receiving warfarin to treat atrial fibrillation. Subtherapeutic INR increases the risk for atrial thrombus formation, with subsequent embolization and stroke. Excess anticoagulation (INR >3-4) increases the risk for bleeding. Additional Information Management of Care NCSBN Client Need

Which client is most appropriate for the charge nurse in the postpartum unit to assign to the float nurse from the intensive care unit? 1. Client experiencing fever and pain with mastitis [36%] 2. Client preparing for discharge after cesarean birth [9%] 3. Client showing disinterest in caring for the newborn [5%] 4. Client with hysterectomy after postpartum hemorrhage [48%]

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 the intensive care unit would have the assessment skills needed to recognize any changes. (Option 1) Mastitis is a very painful infection. A postpartum nurse would be most familiar with the comfort measures associated with mastitis. (Option 2) A client preparing for discharge after cesarean birth would require an experienced postpartum nurse as discharge instructions would involve teaching related to both the newborn and the client. (Option 3) Psychosocial adjustment after giving birth can be complex. An experienced postpartum nurse would be trained to assess for signs of adjustment issues.

When the nurse assesses an erratic plethysmograph waveform, the first action is to assess the client's oxygenation/perfusion status and assess for a motion artifact

The erratic pulse oximeter tracing is representative of an artifact plethysmograph waveform caused by motion. When an electronic assessment reading is questionable, the nurse should always assess the client first for possible etiology. The assessment includes the client's oxygenation and perfusion status (skin temperature, color), the level of consciousness (in sedated clients), and restlessness or agitation. This assessment data guides the nurse in the correct analysis of the tracing. (Option 2) The artifact is most likely from movement or loose contact between the sensor and the area of the body to which it is attached. It is not an electrical artifact and does not require the device to be disconnected from this client. (Option 3) The pulse oximeter reading is 95%. Unless there are audible or visual secretions, increased ventilator peak pressure readings, coughing, or rhonchi, this client does not require immediate endotracheal suctioning. (Option 4) The reading on the device is 95% and the low alarm is set to 90%. Therefore, alarm parameters do not need to be reset. Educational objective:When the nurse assesses an erratic plethysmograph waveform, the first action is to assess the client's oxygenation/perfusion status and assess for a motion artifact. This assessment data guides the nurse in the correct analysis of the tracing. Additional Information Reduction of Risk Potential NCSBN Client Need

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? 1. "Close your eyes and identify this smell." 2. "Follow my finger with your eyes without moving your head." 3. "Look straight ahead and let me know when you can see my finger." 4. "Raise your eyebrows, smile, and frown."

The facial nerve, cranial nerve VII, 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 health care provider is notified. (Option 1) Cranial nerve I is the olfactory sensory nerve. This nerve is tested by having the client identify a readily recognized odor. (Option 2) Cranial nerve III is a motor nerve of the eye, which is tested by having the client track an object, such as a finger, through the fields of vision. (Option 3) Cranial nerve II is the optic nerve and is a sensory nerve. It is assessed by testing the fields of vision for the client's ability to see objects in the field.

The spouse of a client calls the nurse at the clinic and reports that the client is not feeling well and is concerned that something is seriously wrong. How should the nurse respond initially? 1. Ask the spouse to further describe the client's symptoms 2. Indicate that privacy rules prevent discussion of concerns with the spouse 3. Offer a same-day appointment to the client 4. Tell the spouse to have the client call the nurse

The first step in the nursing process is assessment. In this situation, additional information is needed before the nurse can determine the next course of action (Option 1). (Option 2) The United States' Health Insurance Portability and Accountability Act (HIPAA) and Canada's Personal Information Protection and Electronic Documents Act (PIPEDA) prevent release of private, privileged health care information to people who do not need to know it for a client's care. In this case, the nurse is not releasing any information and is obtaining further information to assess the client's condition. In addition, there is no privacy violation in obtaining information that the spouse would know. (Option 3) Additional information is required before knowing whether the client needs to be seen in the clinic. The client may need instruction to instead call 911 and go to the emergency department. (Option 4) The nurse can ask the client to call, but the client may be unable (eg, seizure, unconscious) or unwilling to do so. In addition, the client may not be aware of signs (eg, acute-onset confusion) that are concerning to the spouse. The situation is unclear (eg, the client may have trouble speaking [ie, stroke symptom]) but may be clarified after the nurse receives additional information from the spouse.

The nurse cares for a client who returns from the operating room after a tracheostomy tube placement procedure. Which of the following is the nurse's priority when caring for a client with a new tracheostomy? 1. Changing the inner cannula within the first 8 hours to help prevent mucus plugs 2. Checking the tightness of ties and adjusting if necessary, allowing 1 finger to fit under these ties 3. Deflating and re-inflating the cuff every 4 hours to prevent mucosal tissue damage 4. Performing frequent mouth care every 2 hours to help prevent infection

The immediate postoperative priority goal for a client with a new tracheostomy is to prevent accidental dislodgement of the tube and loss of the airway. If dislodgement occurs during the first postoperative week, reinsertion of the tube is difficult as it takes the tract about 1 week to heal. For this reason, dislodgement is a medical emergency. The priority nursing action is to ensure the tube is placed securely by checking the tightness of ties and allowing for 1 finger to fit under these ties. (Option 1) Changing of the inner cannula and tracheostomy ties is not usually performed until 24 hours after insertion; this is due to the risk of dislodgement with an immature tract. However, the dressing can be changed if it becomes wet or soiled. Suctioning can be performed to remove mucus and maintain the airway. (Option 3) The cuff is kept inflated to prevent aspiration from secretions and postoperative bleeding. Cuffs are not regularly deflated and re-inflated. The respiratory therapist should monitor the amount of air in the cuff several times a day to prevent excessive pressure and mucosal tissue damage. (Option 4) Frequent mouth care to help prevent stomal and pulmonary infection is important in a client with an artificial airway, but it is not the priority action immediately following tracheostomy.

The spouse of an immunocompromised client is diagnosed with influenza virus infection. The spouse asks the office nurse how long contact with the client should be avoided to prevent the infection from spreading. What is the nurse's most appropriate response? 1. "Avoid close contact for about a week." 2. "It's impossible to avoid contact with the client. Just wash your hands often." 3. "You are sick already, and so you are not contagious anymore." 4. "You don't have to worry as long as the client has received the influenza vaccination."

The influenza virus has an incubation period of 1-4 days, with peak transmission starting at about 1 day before symptoms appear and lasting up to 5-7 days after the illness stage begins (Option 1). (Option 2) Influenza is transmitted by inhaling droplets that an infected individual exhales into the air when sneezing, coughing, or speaking. If contact with others is unavoidable, wearing a mask can offer some protection against virus transmission. (Option 3) Individuals with the influenza virus can transmit the virus during the incubation period and illness stage of the infection. It is not appropriate to assume that the spouse can no longer transmit the infection. (Option 4) Although vaccination provides immunity against influenza in about 2 weeks after inoculation, it does not offer complete protection against all virus strains. Therefore, close contact with others should be avoided during the illness stage, especially those with an impaired immune system.

A nurse in the neonatal intensive care unit discovers a cyanotic newborn with excessive frothy mucus in the mouth. What should be the nurse's first action? 1. Administer 100% oxygen 2. Auscultate the lungs 3. Place infant in knee-chest position 4. Suction the infant's mouth

The initial nursing action for a client experiencing cyanosis and excess oral secretions is suctioning the mouth (ie, oropharynx) to clear the airway (Option 4). Excessive frothy mucus and cyanosis in a newborn could be due to esophageal atresia (EA) and tracheoesophageal fistula (TEF). If EA/TEF is suspected, the infant should be kept supine with the head elevated at least 30 degrees to prevent aspiration. A nasogastric tube should be inserted and connected to continuous or intermittent suction until surgical repair. (Option 1) Oxygen cannot be delivered to the lungs if secretions obstruct the airway. Therefore, suctioning is a priority. (Option 2) This infant is aspirating and in immediate distress, which should be addressed without delay. After suctioning the excess saliva and ensuring a clear airway, the nurse may perform further assessments. (Option 3) This infant's cyanosis is a result of aspirating secretions and does not indicate a circulatory problem. The knee-chest position is appropriate to increase pulmonary blood flow in infants with a cyanotic heart defect (eg, tetralogy of Fallot). Educational objective:The initial nursing action for a client experiencing cyanosis and excess oral secretions is oropharyngeal suctioning to ensure airway patency.

A clinic nurse receives messages on 4 clients. Which client should the nurse call back first? 1. Client with celiac disease reporting diarrhea and foul-smelling stools [5%] 2. Client with chronic kidney disease reporting nausea, vomiting, and headache [61%] 3. Client with nausea and diarrhea after taking amoxicillin-clavulanate [16%] 4. Client with nausea, vomiting, and diarrhea after eating egg salad [16%]

The kidneys regulate fluid volume and blood pressure. Because renal damage often results in elevated blood pressure, clients with chronic kidney disease are at risk for uncontrolled hypertension and hypertensive emergencies. Hypertensive encephalopathy is a type of hypertensive crisis characterized by nausea, vomiting, and headache (Option 2). Treatment is urgent (ie, within 1 hour) to prevent damage to the heart, kidney, and brain. The client should check blood pressure at home, if possible, and then proceed to the emergency department for further assessment and treatment (eg, titration of antihypertensive medication). (Option 1) Celiac disease is an autoimmune disorder that interferes with the digestion of gluten. Diarrhea and foul-smelling stools are expected findings for this client, especially if noncompliant with a gluten-free diet. (Option 3) Nausea and diarrhea are possible side effects of many antibiotics. The nurse should inquire about fever and frequency of diarrhea, as antibiotic use could also cause Clostridium difficile infection. However, this does not take priority over a client with a potentially life-threatening hypertensive crisis. (Option 4) Nausea, vomiting, and diarrhea are signs of acute gastroenteritis (ie, food poisoning). Most symptoms of food poisoning resolve spontaneously in several hours to days and are usually not life-threatening. Encouraging adequate oral hydration is important.

The nurse is caring for a client with a history of headaches. 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 health care provider (HCP)? 1. Blood pressure 136/88 mm Hg 2. Flat affect and drowsiness 3. Poor appetite 4. Respiratory rate 12/min

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. (Option 1) The blood pressure is slightly elevated but does not warrant immediate action or signify an emergency situation. (Option 3) A poor appetite is not an emergency finding or situation. (Option 4) The respiratory rate is slightly low, but if it is not irregular it is not an emergency as a single observation. This finding would warrant further assessment and continued monitoring, but it is not as significant as the change in level of consciousness.

The community health nurse is hosting an influenza vaccine clinic. Which client can safely receive the intranasal live attenuated influenza vaccine? 1. 6-year-old client receiving aspirin therapy for Kawasaki disease [0%] 2. 12-year-old client who has a mild egg allergy [100%] 3. 18-year-old client who is pregnant at 8 weeks gestation [0%] 4. 25-year-old client who is neutropenic after chemotherapy [0%]

The live attenuated influenza (flu) vaccine (LAIV), an intranasal spray containing a weakened form of the live flu virus, is safe and effective for most individuals age 2-49, including those with a history of an egg allergy (Option 2). Because the LAIV contains the live virus, it can precipitate the influenza infection; therefore, the LAIV is contraindicated for individuals who are at a greater risk for complications from the flu. Children receiving aspirin therapy (due to the risk of Reye syndrome), pregnant women, immunocompromised individuals (eg, neutropenic after chemotherapy), and those who live with or work closely with immunocompromised individuals should not receive the LAIV but can, in many cases, receive the inactivated vaccine (Options 1, 3, and 4).

The nurse is administering influenza vaccinations to clients at a community health fair. For which client would it be appropriate to administer the intranasal live attenuated influenza vaccine? 1. 23-year-old client who is at 25 weeks gestation [7%] 2. 32-year-old client with a kidney transplant [7%] 3. 48-year-old client with a total knee replacement [44%] 4. 80-year-old client with Alzheimer disease [40%]

The live attenuated influenza vaccine (LAIV), administered via intranasal spray, contains a weakened form of the live virus and is approved for healthy, nonpregnant clients age 2-49 (Option 3). The LAIV is contraindicated in pregnant or immunocompromised clients (eg, client taking immunosuppressants [history of organ transplant], HIV infection) and those with chronic health conditions (eg, chronic obstructive pulmonary disease, severe asthma) that increase the chance of life-threatening illness if influenza infection occurs (Options 1 and 2). The LAIV is not indicated for clients age ≥50 in the United States or age ≥60 in Canada (Option 4).

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

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

A client diagnosed with acute glomerulonephritis has pitting edema in both lower extremities, blood pressure of 170/80 mm Hg, and proteinuria. When developing a plan of care for this client, the nurse should include which most accurate indicator of fluid loss or gain? 1. Blood pressure measurements 2. Daily weight measurements 3. Intake and output measurements 4. Severity of pitting edema

The most accurate indicator of fluid loss or gain in an acutely ill client is weight, as accurate intake and output and assessment of insensible losses may be difficult (Option 3). A 2.2-lb (1-kg) weight gain is equal to 1,000 mL of retained fluid. (Option 1) Blood pressure measures the amount of pressure exerted on the arterial walls due to factors such as peripheral artery constriction or dilation, not just fluid volume status. (Option 4) Pitting edema is not an accurate indicator as the fluid may shift from intravascular to interstitial spaces without an overall change in fluid gain or loss throughout the body.

Which client is most appropriate for the 7:00 AM-7:00 PM charge nurse on a cardiac step-down unit to assign to a float registered nurse from a medical-surgical unit? 1. Client who just returned to the unit after coronary angioplasty and placement of a stent 2. Client with atrial fibrillation scheduled for electrical cardioversion this afternoon 3. Client with heart block scheduled for pacemaker placement this afternoon 4. Client with heart failure and deep vein thrombosis receiving an IV infusion of heparin

The most appropriate assignment for the float nurse is the client with heart failure and IV heparin. The nurse from a general medical-surgical unit should be familiar with the assessment, nursing care, nursing diagnoses, and medications administered to clients with heart failure and with the facility's protocol for administration of a continual IV heparin infusion. (Option 1) This client should be assigned to an experienced nurse who regularly works on the unit. The nurse would be familiar with monitoring for bleeding at the femoral access site, post-procedure angina (eg, coronary vasospasm, acute thrombosis), and alterations in peripheral pulses. The experienced nurse would be better able to provide education as most clients are discharged 24 hours after stent placement. (Option 2) This client's nurse should be familiar with cardioversion. The nurse could explain the procedure to the client, assist if the procedure is done on the unit, and monitor the client for post-procedure complications (eg, cardiac dysrhythmias). (Option 3) This client's nurse should be familiar with monitoring for heart block until a pacemaker is placed, pacemaker placement, and postprocedure complications.

The emergency department nurse assesses an elderly client who was just admitted with a fractured hip after a fall. Which assessment findings would the nurse most likely expect? Select all that apply. 1. Ecchymosis over the thigh and hip 2. Groin and hip pain with weight bearing 3. Internal rotation of the affected extremity 4. Muscle spasm around the affected area 5. Shortening of the affected extremity

The most common clinical manifestations of hip fractures include: Ecchymosis and tenderness over the thigh and hip - occur from bleeding into the surrounding tissue as the femur is very vascular and a fracture can result in significant blood loss (>1000 mL) (Option 1) Groin and hip pain with weight bearing (Option 2) Muscle spasm in the injured area - occurs as the muscles surrounding the fracture contract to try to protect and stabilize the injured area (Option 4) Shortening of the affected extremity - occurs because the fracture can reduce the length of the bone and the muscles above the fracture line pull the extremity upward (Option 5) Abduction or adduction of the affected extremity depending on location and mechanism of injury.

The clinic nurse cares for a 4-year-old who has been diagnosed with a pinworm infection. Which client symptom supports this diagnosis? 1. Anal itching that is worse at night [78%] 2. Intestinal bleeding with anemia [1%] 3. Poor appetite with weight loss [7%] 4. Red, scaly, blistered rings on skin [12%]

The most common worm infection in the United States is pinworm, which is easily spread by inhaling or swallowing microscopic pinworm eggs, which can be found on contaminated food, drink, toys, and linens. Once eggs are ingested, they hatch in the intestines. During the night, the female pinworm lays thousands of microscopic eggs in the skinfolds around the anus, resulting in anal itching and troubled sleep. When the infected person scratches, eggs are transferred from the fingers and fingernails to other surfaces. Pinworm infection is treated with anti-parasitic medications. (Option 2) Hookworms (eg, Ancylostoma) are parasitic bloodsucking roundworms that are contracted from larvae in contaminated soil. They can infect the intestines, causing intestinal bleeding and anemia. (Option 3) Poor appetite, inadequate absorption of nutrients from food, and weight loss are symptoms associated with tapeworm infection (eg, Taenia solium). Tapeworm larvae are ingested when a person eats food that is contaminated with feces or undercooked meat from an infected animal. (Option 4) Ringworm is a skin infection caused by a fungus. It leads to red, scaly, blistered rings on the skin or scalp that grow outward as infection spreads. The fungus is easily spread by sharing hair care instruments and hats or via towels, linens, clothing, and sports equipment. Educational objective:The most common worm infection is pinworm, which is spread by inhaling or swallowing microscopic pinworm eggs, which travel to and hatch in the intestines. During the night, the female pinworm lays eggs in the skinfolds around the anus, resulting in anal itching and disturbed sleep.

The school nurse is speaking with the parent of a fourth grade student about a bed bug 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? 1. Instruct the parent to launder the child's clothing and store it in tightly sealed plastic bags [55%] 2. Instruct the teacher of the child's classroom to use an insecticide spray [3%] 3. Send letters home to all of the children's parents informing them about the finding [27%] 4. Send the child home and prohibit school attendance until the infestation has been resolved [13%]

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 (Option 1). (Option 2) A professional pest control company should be brought in to evaluate the classroom/school for bed bugs; treatment with an insecticide may or may not be necessary. (Option 3) Sending letters home to parents is premature at this point. After professional pest control personnel evaluate the classroom/school, letters can be sent to inform parents of the findings and any precautions that should be taken. (Option 4) Sending the child home is unnecessary and may be perceived as punitive and stigmatizing. Bed bugs do not inhabit humans; this child is not "infested" (seen in children with head lice).

The charge nurse on a medical-surgical 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? 1. 65-year-old client 1 day postoperative left femoral-popliteal bypass graft surgery with a diminished pedal pulse 2. 66-year-old client admitted for hypertensive crisis 2 days ago; blood pressure currently 180/102 mm Hg; reports headache and blurred vision 3. 75-year-old client with an ischemic stroke transferred from the intensive care unit 1 hour ago; unresponsive with right-sided paralysis 4. 78-year-old client with diabetes and cellulitis of the left foot; requires frequent dressing changes due to excessive drainage

The new nurse has the basic skills to provide insulin coverage if necessary, perform wound care (eg, assessment, sterile dressing changes, documentation), and provide diabetic teaching for this client. (Option 1) A more experienced nurse should care for this client as frequent assessments are needed to determine artery patency and changes in circulatory status distal to the graft, especially in the presence of a diminished pedal pulse. (Option 2) A more experienced nurse should care for this client due to frequent assessments and neurologic checks to determine the possible development of target organ disease (eg, brain, heart, lungs, kidneys), especially in the presence of headache and visual disturbances. (Option 3) A more experienced nurse should care for this client due to airway management, aspiration precautions, blood pressure control, and frequent assessments to determine changes in neurologic status.

A hospitalized client is receiving chemotherapy. Based on today's blood laboratory results, what action should the nurse take? Click on the exhibit button for additional information. 1. Assess for hematuria [7%] 2. Check for peaked T waves [16%] 3. Obtain prescription for epoetin alfa [15%] 4. Place a mask on the client [60%]

The normal range for a WBC count is 4,000-11,000/mm3 (4.0-11.0×109/L). Clients with neutropenia (a reduction in WBCs) are predisposed to infection. The absolute neutrophil count (ANC) is determined by multiplying the total WBC count by the percentage of neutrophils. Neutropenia is an ANC below 1,000/mm3 (1.0×109/L). An ANC below 500/mm3 (0.5×109/L) is defined as severe neutropenia and is a critical emergency. This client's neutropenia is probably a result of bone marrow suppression from the chemotherapy. The client needs reverse or protective isolation from organisms that people or objects may have that the client lacks resistance to. A hospitalized client needs to be in a private room, and the room may need to be equipped with HEPA (high-efficiency particulate air) filtration (or positive pressure air flow). Until the room can be readied, the client should be protected with a mask and separated from infectious clients. Additional neutropenic precautions include avoiding raw fruits/vegetables, standing water, and undercooked meat. In addition, no infectious health care providers (eg, with colds) should care for the client. (Option 1) Thrombocytopenia (low platelets) can result from bone marrow suppression caused by chemotherapy. This client's platelets are at the low end of the normal range (150,000-400,000/mm3 [150-400× 109/L]). Spontaneous or surgical bleeding from thrombocytopenia rarely occurs with a platelet count of >50,000/mm3 (50 × 109/L). (Option 2) This client's potassium level is slightly low (normal 3.5-5.0 mEq/L [3.5-5.0 mmol/L]). Low potassium, if it affects the cardiac tracing, causes flattened T waves. Peaked or tented T waves on a cardiac tracing are related to hyperkalemia. (Option 3) Epoetin alfa (human recombinant erythropoietin) is a hematopoietic growth factor. The erythropoietin is produced in the kidney and stimulates bone marrow production of red blood cells (RBCs), a process called erythropoiesis. Epoetin alfa is used to stimulate RBC production but is not typically prescribed unless the client has symptomatic anemia with hemoglobin of <10 g/dL (100 g/L).

The labor and delivery nurse is performing a vaginal examination to assess for cervical dilation and effacement. While palpating the presenting fetal part, the nurse feels a diamond-shaped structure that feels soft in the middle. What is the nurse's best action? 1. Document fetal presentation as breech [10%] 2. Document fetal presentation as cephalic [64%] 3. Elevate the fetal presenting part away from the prolapsed cord [11%] 4. Request that the health care provider confirm fetal presentation [12%]

The nurse is most likely palpating the diamond-shaped anterior fontanelle of the fetal head, which is in cephalic (ie, head down) presentation. Therefore, the nurse should document the fetal presentation as cephalic. The posterior fontanelle is triangular and separated from the anterior fontanelle by the sagittal suture. By identifying the location of these fetal skull landmarks, an experienced examiner can determine the fetal head position, or the direction the occiput is facing. (Option 1) With breech presentation, the fetal buttocks, legs, or feet may be palpated. Fetal buttocks do not feel as round, smooth, or firm as the head during vaginal examination. Although the anus could be mistaken for a fontanelle, the anal sphincter feels firmer to palpation than a fontanelle and is circular, rather than triangular or diamond shaped. (Option 3) A prolapsed cord would feel soft and rubbery on palpation and may be pulsating. If the cord is prolapsed, an emergency cesarean delivery is usually required. (Option 4) Palpating the anterior fontanelle should reassure the nurse that the fetus is in a cephalic presentation, so there is no indication for informing the health care provider.

The health care 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? 1. Administer the medication and monitor client frequently [1%] 2. Ask a nursing colleague if this drug amount is used [0%] 3. Check hydromorphone dose that the client had previously [14%] 4. Question the prescription with the prescriber [82%]

The nurse needs to have appropriate knowledge about a medication prior to administering it. Hydromorphone (Dilaudid) is a potent narcotic that has 5-10 times the strength of morphine. This client was prescribed a hydromorphone dose that is too high given that the typical maximum dose is 2 mg. As the drug prescription is outside a safe range, it must be questioned and cannot be administered automatically. (Option 1) A prescription that greatly exceeds the safety range should not be given without questioning/clarification. However, anytime the outer limit of drug dosing of a potent narcotic is administered, the client should be monitored frequently for adverse effects. This includes the sedation scale and arousability as sedation precedes respiratory depression for narcotics. (Option 2) When there is a medication dosing question, authoritative resources (eg, the pharmacist, current drug literature) should be consulted rather than relying on a nursing colleague who could be mistaken. (Option 3) Even if the client is opiate-tolerant, the dosage is significantly outside the safety range and the prescription should be questioned or clarified.

The nurse assesses a newly admitted adult client on a neurological inpatient unit. Which assessment findings require immediate follow-up by the nurse? Select all that apply. 1. Cannot flex the chin toward the chest 2. Eyes move in opposite direction of head when head is turned to side 3. New onset of right arm drift 4. Pupils 8 mm in diameter bilaterally 5. Toes point downward when sole of foot is stimulated

The nurse performs a neurological assessment to evaluate for changes in motor and sensory functions by assessing pupils, cranial nerves, and neuromuscular functioning. 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 (eg, meningitis) (Option 1). A new-onset unilateral drift of a limb could indicate a stroke. The nurse assesses for other strokelike symptoms (eg, changing level of consciousness, asymmetrical smile, garbled speech), activates the facility stroke protocol, and notifies the health care provider accordingly (Option 3). Normal pupils are 3-5 mm in diameter. Pupil dilation can be the result of medication use or neurological causes (eg, increased intracranial pressure, brain herniation) (Option 4). (Option 2) Oculocephalic reflex (doll's eyes) 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. The test is not performed if spinal trauma is suspected. (Option 5) The normal finding in adults is an absent Babinski reflex (ie, toes point downward with stimulus to the sole). The presence of Babinski reflex (ie, toes fan outward and upward with stimuli) is expected in infants up to age 1, but in an adult may indicate a brain or spinal cord lesion. Educational objective:Abnormal neurological assessments include nuchal rigidity; new-onset unilateral drift of a limb; pupils <3 mm or >5 mm in diameter; absent oculocephalic reflex; and presence of Babinski reflex in an adult client.

Why is voiding prior to RBC infusion necessary?

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 for 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 incompatibility. 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. Starting the transfusion with an empty bladder will help ensure that any urine specimen collected after a reaction is reflective of the body's physiological processes after the blood transfusion has started (Option 4). (Options 1 and 2) Hypotension is a sign of a transfusion reaction and is not expected. Bedrest is not required, but the client should be assisted if out of bed during a transfusion to prevent falls. Educational objective:An acute hemolytic transfusion reaction is a life-threatening reaction caused primarily by blood incompatibility. If it occurs, the transfusion should be stopped and a fresh urine specimen should be collected and sent to the laboratory to analyze for hemolyzed RBCs. Asking the client to void prior to starting the transfusion helps ensure that any urine specimen collected after a reaction is reflective of the body's physiological processes after the blood transfusion. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

The office nurse for an orthopedic health care provider receives 4 telephone messages. Which client does the nurse call back first? 1. Client who had a left total knee replacement 7 days ago and reports cramping pain in the left calf 2. Client with a fractured wrist who reports severe itching under a cast that was applied 3 days ago 3. Client with an ankle sprain who is using crutches and reports tingling in the forearm and fingers 4. Client with an intact anterior cruciate ligament injury who reports tightness in the knee unrelieved with ice

The nurse should call the client with the knee replacement first. Cramping calf pain can indicate the presence of a deep vein thrombosis (DVT), which can occur following joint replacement surgery despite prophylactic anticoagulation. This symptom needs immediate intervention with diagnostic testing (eg, venous Doppler study) as a venous embolus can lead to a pulmonary embolus, which is potentially life-threatening. (Option 2) Itching is to be expected due to drying of the skin under the cast. The nurse can suggest directing the air from a hair dryer on a cool setting under the cast to help relieve itching. This is not a potentially life-threatening event. (Option 3) This client is most likely using the crutches incorrectly or they are not fitted correctly. Pressure on the ulna or radial nerves can lead to numbness and tingling of the fingers and hand weakness. This symptom needs intervention, but it is not potentially life-threatening. (Option 4) Pain and swelling are to be expected with an anterior cruciate ligament injury and are treated with RICE (rest, ice, compression, elevation) for 24-48 hours. Pain and a feeling of tightness can indicate an effusion that may require aspiration, but the condition is not potentially life-threatening.

A sexually active female client has had 3 urinary tract infections (UTIs) in 12 months. Which instructions should the nurse include in teaching the client how to prevent UTI recurrence? Select all that apply. 1. Douche with a water and vinegar solution after intercourse 2. Increase daily intake of fluids 3. Use a spermicidal contraceptive jelly 4. Use fragrance-free perineal deodorant products 5. Void immediately after intercourse 6. Wear underwear with a cotton crotch

The nurse should encourage a sexually active female client to implement the following interventions to help prevent recurrent UTIs: Take all antibiotics as prescribed even if symptoms have improved as bacteria may still be present Increase fluid intake; this dilutes the urine (minimizing bladder irritation), promotes frequent urination, and prevents urinary stasis. The client should void at least every 2-4 hours. Some health care providers recommend drinking cranberry juice as it inhibits bacterial attachment to the bladder wall, but there is no clinical evidence to support its effectiveness in preventing UTIs (Option 2). Wipe from front to back to prevent introducing bacteria from the vagina and anus into the urethra Avoid synthetic fabrics as these materials (eg, nylon, spandex) seal in moisture and create an environment conducive to bacterial proliferation; cotton underwear is recommended instead (Option 6). Void after sexual intercourse to flush out bacteria that may have entered the urethra (Option 5). (Options 1 and 4) Avoid douching and using feminine perineal products (eg, deodorants, powders, sprays), as they can alter the vaginal pH and normal flora, increasing the risk for infection. Take showers instead of baths as bath products (eg, bubble bath, oils) and bacteria in bath water can irritate the urethra and increase the risk of infection. (Option 3) Avoid spermicidal contraceptive jelly as it can suppress the production of protective vaginal flora. Discontinue diaphragm use temporarily (until symptoms subside and antibiotic course is completed); a diaphragm increases pressure on the urethra and bladder neck, which may inhibit complete bladder emptying.

The nurse receives report on 4 assigned clients. Which client should the nurse assess first? 1. Client 1 hour post laparoscopic cholecystectomy for gallstones who reports right shoulder pain 2. Client 4 hours post tracheostomy who has a small amount of pink drainage on the tracheotomy dressing 3. Client 48 hours post abdominal hysterectomy who is ambulatory and reports aching in the right leg 4. Client 3 days post open gastric bypass who reports fever and foul-smelling discharge at the surgical site

The nurse should first assess the client showing symptoms of a deep venous thrombosis (DVT) (eg, unilateral edema, warmth, redness, tenderness on palpation). DVT is a postoperative complication related to venous stasis and subsequent thrombosis. If a DVT is suspected, early diagnostic testing (eg, venous ultrasound) and treatment with anticoagulant therapy (eg, heparin, enoxaparin) are critical to prevent clots from traveling to the pulmonary circulation and causing pulmonary embolism. (Option 1) The client is experiencing a common post laparoscopic cholecystectomy problem of referred pain to the right shoulder. Carbon dioxide, used to inflate the abdominal cavity during surgery, causes irritation to the phrenic nerve and diaphragm, which may cause difficulty breathing. Interventions for alleviation include the Sims position, deep breathing, ambulation, and analgesics. (Option 2) A small amount of pink serosanguineous drainage at the new tracheostomy site is expected postoperatively. The nurse should notify the health care provider if bleeding becomes excessive. (Option 4) Conditions that increase the likelihood of surgical site infection include obesity, immunosuppression, malnutrition, diabetes, and advanced age. The nurse should notify the health care provider of signs and symptoms of infection (eg, fever, purulent drainage), but the client with a DVT is priority due to the risk of pulmonary embolism.

A 6-year-old client was diagnosed with type 1 diabetes mellitus 2 years ago. The nurse would like to encourage the client to participate in disease management. Which of the following diabetes care tasks are appropriate for the child to perform? Select all that apply. 1. Choose insulin injection site with parental oversight of rotation schedule 2. Push plunger of insulin syringe after a parent inserts and stabilizes the needle 3. Select and clean the site for finger-stick blood glucose testing 4. Use a chart to determine insulin dose based on glucometer reading 5. Verbalize two or three signs and symptoms of hypoglycemia

The nurse should offer school-aged children (age 6-12) as much opportunity as possible to participate in care to promote psychosocial development (industry versus inferiority) and provide a sense of control. Parents should transfer management of care to the child in small steps based on the child's skill level and cognitive ability. School-aged children are in the concrete operational stage of development and are most successful performing simple, concrete tasks with a limited number of steps. Appropriate diabetes management tasks for school-aged children include: Choosing and cleaning a finger for blood glucose testing before a parent or caregiver performs the puncture (Option 3) Selecting the site for insulin injection, with a parent or caregiver verifying appropriate site rotation (Option 1) Pushing the syringe plunger to administer insulin after a parent or caregiver inserts the needle (Option 2) Identifying signs and symptoms of hypoglycemia and hyperglycemia (Option 5) (Option 4) Adjusting insulin doses based on glucose readings is too complicated for school-aged children, and mistakes can be life-threatening. Children develop the cognitive ability to analyze test results and adjust insulin doses at approximately age 14.

What nursing care related to peripherally inserted IV catheters can reduce the incidence of catheter-related infections? Select all that apply. 1. After insertion, secure the catheter with a sterile, semipermeable dressing 2. Clean ports with an alcohol swab prior to accessing the catheter system 3. Prior to insertion, apply chlorhexidine, using friction, to the venipuncture site 4. Prior to insertion, shave excess hair over the selected venipuncture site 5. Replace or remove the venous catheter every 48 hours

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 (preferably chlorhexidine, using a back-and-forth motion) and then allowed to air-dry completely (Option 3). Chlorhexidine is preferred as it achieves an antimicrobial effect within 30 seconds, whereas povidone-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 (eg, Tegaderm) should be used to secure the catheter hub to reduce infection risk and allow visualization of the site (Option 1). When the catheter is accessed, the needleless port should be cleansed with an alcohol swab to kill externally colonized microorganisms (Option 2). (Option 4) Excessive hair may be clipped but never shaved as shaving may cause microabrasions and potential portals of entry for microorganisms. (Option 5) Peripheral IV catheters should not be removed or replaced more frequently than every 72-96 hours unless signs of complications (eg, infiltration, infection, phlebitis) occur.

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? 1. Autonomy [4%] 2. Nonmaleficence [80%] 3. Paternalism [6%] 4. Veracity [8%]

The nurse violated the ethical principle "nonmaleficence" (ie, do no harm). It is rare to see a nurse inflict intentional harm. However, problems do occur due to unintentional harm, which is usually a result of poor clinical judgment. Beneficence is a nurse's duty to promote good and do what is best for the client. (Option 1) Autonomy is allowing the clients to choose the direction of their care. This is accomplished with advanced directives along with informed consent and choices regarding proposed treatments. (Option 3) Paternalism is a type of beneficence whereby clients are treated as children. The nurse claims to know what is best for the client and coerces the client to act as the nurse wishes without considering the client's autonomy. (Option 4) Veracity refers to the duty to tell the truth. This principle should always be applied to client care and documentation. Educational objective:Nonmaleficence is the ethical principle of doing no harm. All nurses must exercise sound clinical judgment to prevent harm, even if it is unintentional, to their clients.

The nurse is caring for a client involved in a motor vehicle collision who had a chest tube inserted to evacuate a pneumothorax caused by fractured ribs. Where would the nurse observe an air leak?

The presence of an air leak is indicated by continuous bubbling of fluid at the base of the water seal chamber. If the client has a known pneumothorax, intermittent bubbling would be expected. Once the lung has re-expanded and the air leak is sealed, the bubbling will cease. The nurse is expected to assess for the presence or absence of an air leak and to determine whether it originates from the client or the chest tube system. (Option 1) Section A is the suction control chamber. Gentle, continuous bubbling indicates that suction is present. (Option 2) Section B is part of the water seal chamber, but an air leak will not be evident in this upper portion. Tidaling of fluid is expected in this portion of the chamber and indicates patency of the tube. (Option 4) Section D is the collection chamber, where drainage from the client will accumulate. The nurse will assess amount and color of the fluid and record these as output.

A nurse cares for a frail, elderly client with osteoporosis in a nursing home. Which interventions are appropriate to include in the client's care plan to help prevent a hip fracture? Select all that apply. 1. Calcium supplements 2. Encourage bed rest 3. Use of full bed rails during the night 4. Vitamin D supplements 5. Weight-bearing exercises

The primary treatment goal for elderly clients with osteoporosis is to prevent bone fracture, especially hip fracture. Teaching to increase bone mineral density and prevent bone loss (resorption) includes: Bisphosphonate medication (eg, alendronate [Fosamax], risedronate [Actonel], zoledronic [Reclast]) Calcium and Vitamin D supplementation (Options 1 & 4) Smoking cessation and alcohol avoidance, as these increase bone resorption and contribute to falls Weight-bearing exercise (eg, walking, dancing) and resistance training (eg, weights) ≥3 times a week for 30 minutes, as increasing mechanical stress on bone increases bone density (Option 5) Interventions to prevent falls and resulting hip fracture include: Maintain bed in low and locked position Ensure that call light and personal belongings are within reach Orient client and ensure use of non-skid footwear, eyeglasses and hearing aids, and assist devices if needed Keep environment well-lit and free of clutter (Option 2) A client should not be placed on bed rest solely for the prevention of falls. Immobilization actually increases fracture risk due to bone resorption, a condition called disuse osteoporosis. The nurse should encourage and assist with mobility and weight-bearing exercises to prevent muscle atrophy and bone resorption. (Option 3) The client may actually incur more injury from a fall if trying to climb over side rails to get out of bed. The nurse should utilize bed alarms if the client is prone to getting out of bed without assistance.

The nurse is caring for a client with surgical complications who requires continuous total parenteral nutrition (TPN). The nurse assists the health care 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? 1.A ttach a filter to the IV tubing 2. Check baseline fingerstick glucose levels 3. Check the results of the portable chest x-ray 4. Program the electronic infusion pump

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. (Option 1) Filters are used during TPN infusion to remove particulate matter, precipitates, or microorganisms. Because TPN uses a hypertonic solution (eg, dextrose concentration >10%), it increases the risk for infection. Therefore, the use of a 0.22-micron filter is recommended to remove microorganisms when administering a lipid-free formula. The use of a 1.2-micron filter is recommended when administering TPN with lipids. Although this action is appropriate, it is not the priority. (Option 2) The nurse should monitor the baseline blood glucose (BG) level and fingerstick BG every 6 hours while the client is receiving TPN; it should be maintained in the range of 140-180 mg/dL (7.8-10.0 mmol/L) for a hospitalized adult client. This action is appropriate, but it is not the priority. (Option 4) TPN is always administered using an electronic infusion pump to ensure an accurate and consistent hourly infusion rate to help avoid fluctuations in BG levels. This action is appropriate, but it is not the priority. Educational objective:Incorrect placement of a subclavian central venous catheter can result in an iatrogenic pneumothorax or hemothorax. The priority is to check the results of the chest x-ray to verify that the catheter tip has been placed correctly in the superior vena cava. Other appropriate actions include attaching a filter to the IV tubing, monitoring baseline and fingerstick BG levels every 6 hours, and programming the electronic infusion device to ensure an accurate and consistent hourly infusion rate.

An experienced registered nurse (RN) is mentoring a new nurse in the telemetry unit. Which assessment technique by the new nurse requires intervention by the RN? 1. Nurse carefully auscultates for heart murmurs at Erb's point 2. Nurse palpates bilateral carotid arteries simultaneously to assess for symmetry 3. Nurse places client in semi-Fowler's position to assess for jugular venous distension 4. Nurse positions client supine to assess the point of maximal impulse

The pulses in the neck should be palpated for information on arterial blood flow. The carotid arteries should be palpated separately to avoid vagal stimulation causing dysrhythmias such as bradycardia or a syncopal episode. Pulse symmetry for other key arteries (eg, temporal, brachial, radial, posterior tibial) is assessed by bilaterally palpating each pair simultaneously. (Option 1) Erb's point is located at the third left intercostal space (ICS) near the sternum and is an appropriate location to auscultate heart sounds for murmurs. (Option 3) Jugular venous distension should be assessed with the client in semi-Fowler's position (ie, head of the bed elevated at a 30- to 45-degree angle). (Option 4) To assess the point of maximal impulse (PMI) the client is positioned supine or with the head of the bed elevated to 45 degrees; the nurse should palpate for a short tap at the midclavicular line of the fourth or fifth ICS (pulsation may or may not be visible). A displaced PMI (eg, below the fifth ICS) may be an indication of an enlarged heart.

The student nurse observes the respiratory therapist (RT) 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 before the blood sample is drawn. Which statement made by the RT is most accurate? 1. "The Allen's test is done to determine if capillary refill is adequate." 2. "The Allen's test is done to determine if the radial pulse is palpable." 3. "The Allen's test is done to determine the patency of the ulnar artery." 4. "The Allen's test is done to determine the presence of a neurologic deficit."

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. The modified Allen's test includes the following steps: Instruct the client to make a tight fist (if possible) Occlude the radial and ulnar arteries using firm pressure Instruct the client to open the fist; the palm will be white if both arteries are sufficiently occluded Release the pressure on the ulnar artery; the palm should turn pink within 15 seconds as circulation is restored to the hand, indicating patency of the ulnar artery (positive 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 (eg, brachial artery, femoral artery) must be used. (Option 1) Capillary refill is tested by applying pressure to the fingernail bed to cause blanching. If refill is adequate, the nail bed should become pink in less than 3 seconds after pressure is released. (Option 2) The radial artery is palpated with the fingertips to determine the presence of the radial pulse. (Option 4) A neurologic deficit is assessed by monitoring color, sensation, and movement of the hand. Educational objective:The radial artery site at the wrist is preferred for collecting an arterial blood gas sample because it is near the surface, easy to palpate and stabilize, and has good collateral supply from the ulnar artery. The patency of the ulnar artery must be confirmed by performing a modified Allen's test to assure adequate circulation to the hand before proceeding with the arterial blood gas collection. Additional Information Reduction of Risk Potential NCSBN Client Need

The medical surgical nurse cares for a client who had a mediastinal tumor removed 2 days ago and reports difficulty breathing. The client becomes confused and restless, and respirations are 30/min. What is the nurse's next action? 1.Administer a dose of prescribed prn anti-anxiety medication 2. Call the health care provider who performed the surgery 3. Call the rapid response team 4. Place the client in the left lateral recovery position

The rapid response team (RRT) consists of a group of health care providers who bring critical care expertise to the bedside of clients demonstrating early signs of deterioration such as dyspnea, confusion, and restlessness. This team differs from the "Code" team that is called when a client stops breathing or goes into cardiac arrest. Any health care worker can call the RRT. (Option 1) The client's restlessness and confusion are likely secondary to low oxygenation. Anxiety will cause hyperventilation, which will only exacerbate the situation. However, administering anti-anxiety medication is not the priority over obtaining help quickly. In addition, the client's oxygenation could deteriorate depending on the prescribed anti-anxiety medication, which could depress respirations. (Option 2) The health care provider who performed the surgery must be notified of the client's deteriorating condition; however, this should be done after calling the RRT. Stabilizing the client is the priority. (Option 4) The recovery position is used as a first aid measure for an unconscious client who is still breathing. The client is placed on the left or right side in a three-fourths prone position with the top leg flexed. This position maintains the airway and ensures that the client does not choke on vomit.

The health care provider suspects a rotator cuff injury in a client who is an avid tennis player. The nurse would most likely assess which of the following? 1. Complete stiffness of the shoulder joint 2. Paresthesia over the first 3½ fingers 3. Shoulder pain with arm abduction 4. Tenderness over the lateral epicondyle

The rotator cuff is a group of 4 shoulder muscles and tendons that attach to the humeral head. It allows for rotation of the arm. A partial or full thickness rotator cuff tear can occur gradually over time as a result of aging, repetitive use, or an injury to the shoulder. It can also occur as a result of a sports injury involving repetitive overhead arm motion (eg, swimming, tennis, baseball, weight lifting). Characteristic symptoms of rotator cuff injury usually include shoulder pain and weakness. Severe pain when the arm is abducted between 60 and 120 degrees (painful arc) is characteristic (Option 3). (Option 1) Restriction of active and passive ranges of motion of the shoulder (complete stiffness) is seen with frozen shoulder. (Option 2) Pain and paresthesia over the first 3½ fingers suggest carpal tunnel syndrome. (Option 4) Tenderness over the lateral epicondyle is seen with tennis elbow.

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? Record the answer using a whole number.

The rule of nines is used to estimate quickly the percentage of total body surface area (TBSA) affected by partial- and full-thickness burns in an adult client. Superficial (first-degree) burns are not included in the calculation of affected TBSA. For a client who has sustained partial-thickness burns to the back and to the anterior and posterior surfaces of the right arm and leg, TBSA is calculated as follows: TBSA = [back] + [anterior and posterior of right arm] + [anterior and posterior of right leg]TBSA = [18] + [4.5 + 4.5] + [9 + 9]TBSA = 18 + 9 + 18 = 45% Once the affected TBSA has been estimated, the volume of necessary fluid resuscitation can be calculated (ie, Parkland formula [4 mL x kg of body weight x TBSA]). TBSA also determines the required level of care. In general, clients require transfer to a burn center for specialty care for: Full-thickness burns Partial-thickness burns >10% TBSA Electrical or chemical burns Inhalation injuries

The nurse is planning education for clients in group prenatal care who are entering the second trimester of pregnancy. Which of the following are appropriate for the nurse to include in second-trimester teaching? Select all that apply. 1. Anticipate light fetal movements around 16-20 weeks gestation 2. Expect to have an abdominal ultrasound for fetal anatomy evaluation 3. Gain about 1 lb (0.5 kg) per week if pre-pregnancy BMI was normal 4. Increase consumption of iron-rich foods like meat and dried fruit 5. Plan for gestational diabetes screening near the end of the second trimester

The second trimester (14 wk 0 d to 27 wk 6 d) is a time of positive changes for many pregnant clients (eg, improved nausea) and when physical evidence of the pregnancy is noted (eg, increased fundal height). The nurse should prepare clients for expected physical changes and discuss prevention of potential complications. Quickening, or a client's first perception of light fetal movement, is expected around 16-20 weeks gestation, depending on parity (Option 1). Weight gain increases by approximately 1 lb (0.5 kg) per week if pre-pregnancy BMI has been normal (Option 3). Increasing intake of iron-rich foods (eg, meat, dried fruit) and continuing prenatal vitamins both help to prevent anemia caused by increased fetal iron requirements after 20 weeks gestation (Option 4). Preterm labor warnings and signs of preeclampsia should be reviewed beginning at 20 weeks gestation. The nurse should also discuss routine screening/diagnostic tests performed during the second trimester. An ultrasound is performed around 18-20 weeks gestation to evaluate fetal anatomy and the placenta (Option 2). Screening for gestational diabetes mellitus (GDM) occurs between 24-28 weeks gestation (ie, 1-hour glucose challenge test) (Option 5). GDM is a complication of pregnancy caused by hormonally related maternal insulin resistance.

The nurse assesses 4 clients. Which assessment finding requires the nurse's priority action? 1. 26-year-old with splenectomy reports a headache and chills [52%] 2. 40-year-old with immune thrombocytopenic purpura has petechiae on the arms [19%] 3. 60-year-old with marked anemia reports shortness of breath when ambulating [12%] 4. 68-year-old with polycythemia vera has a hematocrit of 66% (0.66) [16%]

The spleen is part of the immune system and functions as a filter to purify the blood and remove specific microorganisms that cause infections (eg, pneumococcal pneumonia, meningococcal meningitis). 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 headache needs immediate intervention (eg, cultures, imaging, antibiotic therapy). Therefore, the client with the splenectomy who is reporting headache and chills requires immediate action. (Option 2) Immune thrombocytopenic purpura (ITP) is an autoimmune condition in which clients have abnormal platelet destruction with a count <150,000/mm3 (150 x 109/L). 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 red blood cells. Petechiae are an expected finding. (Option 3) A client with marked anemia can develop exertional dyspnea due to the body's inability to meet the metabolic demands (oxygen supply) associated with activity. This is an expected finding. (Option 4) Polycythemia vera (true primary polycythemia) is a chronic myeloproliferative disease characterized by bone marrow overproduction of red blood cells, white blood cells, and platelets. This leads to increased hematocrit (>53% [0.53]) and blood volume, enhanced blood viscosity, and abnormal clotting. A hematocrit of 66% (0.66) is an expected finding. Educational objective:Overwhelming postsplenectomy bacterial infection is a major lifelong complication in clients without a functioning spleen. A minor infection can quickly become life-threatening and septic; therefore, any indicator of infection requires immediate attention and treatment intervention. Additional Information Reduction of Risk Potential NCSBN Client Need

Which health history information would be most important for the nurse to obtain when assessing a client with suspected bladder cancer who reports painless hematuria? 1. Family risk factors [31%] 2. Industrial chemical exposure [16%] 3. Tobacco use [45%] 4. Usual diet [6%]

The tell-tale symptom of bladder cancer, seen in >75% of cases, is painless hematuria; the client will report seeing blood in the urine with no associated pain. As with many other types of cancer, the primary cause of bladder cancer is cigarette smoking or other tobacco use (Option 3). Poorer outcomes are seen with increased length of time as a smoker and higher number of packs per day. (Option 1) Clients who have family members with bladder cancer have an increased risk of developing bladder cancer themselves; however, the primary risk factor is tobacco use. (Option 2) Occupational carcinogen exposure is the second most common risk factor. Occupational exposures include printing, iron and aluminum processing, industrial painting, metal work, machining, and mining. Clients are exposed to carcinogens through direct skin contact and inhalation (aerosols and vapors). (Option 4) Consuming a high-fat diet and using artificial sweeteners are risk factors for developing bladder cancer, but they are not the primary cause. Educational objective:Painless hematuria is the most common presenting symptom of bladder cancer. Cigarette smokingor other tobacco use is the primary risk factor.

The transducer should be leveled to the client's phlebostatic axis to measure arterial pressure correctly

The transducer should be leveled to the client's phlebostatic axis to measure arterial pressure correctly. However, this should be done after the client has been checked for a physiological cause of the alarm.

An elderly client with a history of stable chronic obstructive pulmonary disease, alcohol abuse, and cirrhosis has a serum theophylline level of 25.8 mcg/mL (143 µmol/L). Which clinical manifestation associated with theophylline toxicity should worry the nurse most? 1. Alterations in color vision 2. Gum (gingival) hypertrophy 3. Hyperthermia 4. Seizure activity

Theophylline has narrow therapeutic index and plasma concentrations >20 mcg/mL (111 µmol/L) are associated with theophylline drug toxicity. Conditions associated with chronic toxicity include advanced age (>60), drug interactions (eg, alcohol, macrolide and quinolone antibiotics), and liver disease. Acute toxicity is associated with intentional or accidental overdose. Symptoms of toxicity usually manifest as central nervous system stimulation (eg, headache, insomnia, seizures), gastrointestinal disturbances (eg, nausea, vomiting), and cardiac toxicity (eg, arrhythmia). (Option 1) Alteration in color perception and visual changes are commonly seen with digoxin toxicity. (Option 2) Gum hypertrophy is seen with phenytoin toxicity. (Option 3) Hyperthermia and tinnitus are often seen with aspirin overdose.

A nurse is assessing a client with type 2 diabetes mellitus who was recently started on pioglitazone. Which client data obtained by the nurse is most important to bring to the attention of the health care provider? 1. Bilateral pitting edema in ankles 2. Blood pressure is 140/88 mm Hg 3. Most recent HbA1c is 6.7% 4. Retinal photocoagulation in right eye

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

Aspiration pneumonia develops when aspirated material (eg, food, emesis, gastric reflux) causes an inflammatory response and provides a medium for bacterial growth. At-risk conditions include cognitive changes (eg, dementia, head injury, stroke, sedation), difficulty swallowing, compromised gag reflex, and tube feeding.

Thicken liquids (eg, to nectar or honey consistency) for clients with dysphagia; thin liquids are more difficult to control when swallowing (Option 1). Ensure that the client is fully awake before eating. The nurse should time the administration of sedating medications (eg, opioids, benzodiazepines) to avoid sedation during meals (Option 2). Elevate the head of the bed to 90 degrees during and for 30 minutes after meals, and never place the head of the bed lower than 30 degrees (Option 3). Encourage clients to facilitate swallowing by flexing the neck (chin to chest) (Option 5). Administer prescribed antiemetics (eg, ondansetron) as needed to prevent vomiting. Monitor for coughing, gagging, and pocketing food.

Ribbon like stool

Thin, ribbon-like stool is characteristic of Hirschsprung disease (congenital aganglionic megacolon). Bowel obstruction is caused by failure of the internal sphincter to relax.

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% (0.36), and the hemoglobin is 12 g/dL (120 g/L). Which action should the nurse carry out first? 1. Assess vital signs 2. Increase the IV rate to 125 mL/hr 3. Notify the health care provider 4. Perform a bladder scan

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 (ie, injured site, peritoneal cavity). This fluid serves no physiologic purpose, cannot be measured, and leads to decreased circulating volume (hypovolemia) and cardiac output. The priority intervention is to assess vital signs as the manifestations associated with third-spacing include weight gain, decreased urinary output, and signs of hypovolemia, such as tachycardia and hypotension. If third-spacing is not recognized and corrected early on, postoperative hypotension can lead to decreased renal perfusion, prerenal failure, and hypovolemic shock (Option 1). (Option 2) Increasing the IV flow rate of the isotonic solution may be an appropriate intervention once the nurse has assessed the client, including taking a full set of vital signs. The nurse should intervene only after assessing to rule out other problems for which an increase in IV fluid intake would not be an appropriate solution (eg, Foley catheter obstruction). (Option 3) The nurse will notify the health care provider to report oliguria (<0.5 mL/kg/hr) after collecting all of the data necessary (ie, vital signs). This is not the nurse's first action. (Option 4) Urinary retention is possible following surgery due to the adverse effects of anesthesia, opioids, anticholinergic drugs, and immobility. However, a bladder scan is not an appropriate action in this situation as the client has a Foley catheter. Irrigating the catheter is the appropriate intervention if the nurse questions its patency.

The nurse is caring for an adolescent client diagnosed with type 1 diabetes. The client exhibits hot, dry skin and a glucose level of 350 mg/dL (19.4 mmol/L). Arterial blood gases show a pH of 7.27. STAT serum chemistry labs have been drawn. Cardiac monitoring shows a sinus rhythm with peaked T waves, and the client has minimal urine output. What is the nurse's next priority action? 1. Administer IV regular insulin 2. Administer normal saline infusion 3. Obtain urine for urinalysis 4. Request prescription for potassium infusion

This client has diabetic ketoacidosis (DKA). All clients with DKA experience dehydration due to osmotic diuresis. Prompt and adequate fluid therapy restores tissue perfusion and suppresses the elevated levels of stress hormones. The initial hydrating solution is 0.9% saline infusion. (Option 1) Insulin therapy should be started after the initial rehydration bolus as serum glucose levels fall rapidly after volume expansion. (Option 3) Urinalysis is important but not a priority. (Option 4) Potassium should never be given until the serum potassium level is known to be normal or low and urinary voiding is observed. Peaked T waves indicate hyperkalemia in this client. Clients with insulin deficiency frequently have increased serum potassium levels due to the extracellular shift despite having total body potassium deficit from urinary losses. Once insulin is given, serum potassium levels drop rapidly, often requiring potassium replacement. Potassium is never given as a rapid IV bolus, as cardiac arrest may result.

The nurse working on the inpatient psychiatric unit is preparing to administer 9:00 AM medications to a client. The medication administration record is shown in the exhibit. On assessment, the client is tremulous, exhibits muscle rigidity, and has a temperature of 101.1 F (38.4 C). Which action should the nurse take? Click on the exhibit button for additional information. 1. Give all medications, including acetaminophen, and reassess in 30 minutes 2. Hold the haloperidol, give acetaminophen, and reassess in 30 minutes 3.Hold the haloperidol and notify the health care provider (HCP) immediately 4. Hold the hydrochlorothiazide and notify the HCP immediately Medications: Haloperidol: 5 mg orally, twice a day 0900, 2100 Hydrochlorothiazide: 25 mg orally, daily0900Omeprazole: 20 mg orally, daily 0900 Acetaminophen: 650 mg orally, PRN Every 4 hours

This client is exhibiting signs and symptoms of neuroleptic malignant syndrome (NMS), a rare but potentially life-threatening reaction. NMS is most often seen with the "typical" antipsychotics (eg, haloperidol, fluphenazine). However, even the newer "atypical" antipsychotic drugs (eg, clozapine, risperidone, olanzapine) can cause the syndrome. NMS is characterized by fever, muscular rigidity, altered mental status, and autonomic dysfunction (eg, sweating, hypertension, tachycardia). Treatment is supportive and is directed at reducing fever and muscle rigidity and preventing complications. Treatment in an intensive care unit (ICU) may be required. The most important intervention is to immediately discontinue the antipsychotic medication and notify the HCP for further assessment. (Option 1) Administering acetaminophen may be appropriate, but it is more important to discontinue the haloperidol and notify the HCP immediately. (Option 2) Due to the life-threatening nature of NMS, the HCP should be informed immediately. The HCP may order muscle enzymes, administer IV fluids/medications, and move the client for close monitoring (eg, to the ICU). (Option 4) Hydrochlorothiazide is a diuretic commonly used for hypertension. It does not cause NMS symptoms. Educational objective:NMS is characterized by fever, muscle rigidity, altered mental status, and autonomic dysfunction. The most important intervention is to discontinue the antipsychotic medication.

The nurse is triaging a 7-year-old with sickle cell crisis. The client is short of breath and vomiting and has severe generalized body and joint pains. Which assessment finding requires the most immediate intervention? 1. Blood work showing anemia [5%] 2. Enlarged spleen on palpation [55%] 3. Right arm weakness [25%] 4. Swelling of hands and feet [13%]

This client is exhibiting signs and symptoms of sickle cell crisis, which occurs when the client's sickle-shaped cells block blood flow through the vessels. These clients tend to have a small spleen due to repeated small splenic infarctions (autosplenectomy). Splenic sequestration crisis occurs when a large number of "sickled" cells get trapped in the spleen, causing splenomegaly. This is a life-threatening emergency as it can lead to severe hypovolemic (hypotensive) shock. The classic assessment finding is a rapidly enlarging spleen. (Option 1) Normal red blood cells live about 120 days. Sickle cells break apart and die within less than 20 days; therefore, the client always has a shortage of red blood cells (anemia). Due to anemia, clients often report feeling fatigued. (Option 3) Right arm weakness could indicate new-onset stroke, a common complication of sickle cell disease that needs to be assessed. However, splenic sequestration is immediately life-threatening and a priority. (Option 4) Swelling of hands and feet (dactylitis) is another symptom of this disease due to the sickled red blood cells blocking blood flow to the hands and feet. This is often detected in babies as the first sign of the disease.

The nurse receives report on 4 clients. Which client should the nurse assess first? 1. Client with end-stage renal disease receiving hemodialysis who reports fever with chills and nausea [18%] 2. Client taking ibuprofen for ankylosing spondylitis who reports black-colored stools [11%] 3. Client with altered mental status who is not following commands starts vomiting[61%] 4. Client with acute diverticulitis receiving antibiotics who reports increasing abdominal pain [8%]

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. (Option 1) Clients receiving hemodialysis are at risk for bloodstream infections. Blood cultures need to be obtained from a client with a bloodstream infection, and antibiotics would then be administered. This is not a priority over airway compromise. (Option 2) Clients with ankylosing spondylitis often take nonsteroidal anti-inflammatory drugs to control back pain and are at risk of developing gastric ulcers. They can cause melena (black stools). The client needs further assessment of orthostatic vital signs and hemoglobin level. This is not a priority over airway compromise. (Option 4) Clients with acute diverticulitis (inflammation of the diverticula) are at risk for perforation, which can be manifested by increasing abdominal pain, rigidity, guarding, and rebound tenderness (peritoneal signs). This client needs further assessment, but this is not a priority over airway compromise. Educational objective:A client with altered mental status and not following commands is at risk for aspiration and airway compromise from vomiting.

The nurse assesses diminished lung sounds and high-pitched wheezing in a client with acute asthma exacerbation. Arterial blood gas (ABG) findings are shown in the exhibit. Which acid-base imbalance does the nurse correctly identify? Click the exhibit button for more information. 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis pH 7.49 PaCO2 30mmHg PaO2 79 mmHg HCO3 25mEq/L

This client's ABG analysis shows respiratory alkalosis. This is likely due to increased loss of acidic carbon dioxide from hyperventilation (rapid respirations). Hyperventilation due to other causes (eg, anxiety, pain) may also induce respiratory alkalosis. This client's ABG has a high pH (alkalosis), low carbon dioxide, and low oxygen level. Carbon dioxide is acidic; therefore, decreased carbon dioxide indicates a more basic (alkalotic) state due to a respiratory cause. (Option 1) In metabolic acidosis, pH is decreased (<7.35) and HCO3- is decreased (<22 mEq/L [22 mmol/L]). (Option 2) In metabolic alkalosis, pH is increased (>7.45) and HCO3- is increased (>26 mEq/L [26 mmol/L]). (Option 3) In respiratory acidosis, pH is decreased (pH <7.35) and PaCO2 is increased (>45 mm Hg [5.98 kPa]). Educational objective:Loss of acidic carbon dioxide from hyperventilation causes an increase in pH, creating a state of respiratory alkalosis.

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? 1. Administer IV normal saline [50%] 2. Determine if urinary occult blood is present [1%] 3. Perform a neurological assessment [41%] 4. Verify that there is no stool impaction [6%]

This presentation is classic for neurogenic shock, a distributive shock. Vascular dilation with decreased venous return to the heart is present due to loss of innervation from the 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 (T6 or higher). Systolic blood pressure should remain at 80 mm Hg or above to adequately perfuse the kidneys. Administration of fluids is a priority to ensure adequate kidney and other organ perfusion. (Option 2) Testing for the presence of blood in the urine is important in determining if kidney damage has occurred, but circulation stability is a priority. (Option 3) A neurological assessment is essential, but circulation stability is a priority ("C before D" [disability]). (Option 4) Bladder and stool impaction are etiologies for autonomic dysreflexia and generally occur in a client with a high-level fracture at T6 or above with a stimulation below the fracture. Autonomic dysreflexia is a medical emergency that presents with severe headache, hypertension, piloerection, and diaphoresis. It is seen weeks to years after the injury.

For which client is it most important for the nurse to provide teaching on ways to prevent the spread of the condition? 1. Client with eczema on upper torso [6%] 2. Client with oral candidiasis [20%] 3. Client with psoriasis on hands [9%] 4. Client with tinea corporis [63%]

Tinea corporis (ringworm) is a fungal infection of the skin often transmitted from one person to another or from an infected animal to a 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. This condition is treated with topical antifungals (eg, tolnaftate, haloprogin, miconazole, clotrimazole). (Option 1) Eczema is a skin rash caused by an immune disorder that is often triggered by an allergy. Itching is common, but the rash is not contagious. (Option 2) Oral candidiasis, or thrush, often occurs after a course of antibiotics or corticosteroids or can occur in infants with immature immune systems. An infant who is breastfed can transfer candidiasis to the mother's breast. There is also a small risk of transmission when infants place pacifiers or toys in their mouths and subsequently transfer these items to another child's mouth. However, oral candidiasis is significantly less contagious than tinea corporis. (Option 3) Psoriasis is a chronic autoimmune disease that most often affects the skin by causing dry, scaly, red rashes. Psoriasis is not contagious.

To 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? 1. Angle of Louis at 2nd intercostal space (ICS) to left of sternal border 2. Aortic area at 2nd ICS to right of sternal border 3. Level of atria at 4th ICS, ½ anterior-posterior (AP) diameter 4. 5th ICS at mid clavicular line (MCL)

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 (½ AP)of the chest wall. If the transducer is placed too low, the reading will be falsely high; if placed too high, the reading will be falsely low. This concept is similar to the positioning of the arm in relation to the level of the heart when measuring blood pressure indirectly using a sphygmomanometer or noninvasive blood pressure-monitoring device. The upper arm should be at the level of the phlebostatic axis. (Option 1) The angle of Louis is the palpable raised notch where the manubrium and sternum are joined. This anatomical location is useful in counting the ICSs and in finding auscultatory areas. (Option 2) The aortic area is an auscultatory area located at the 2nd ICS to the right of the sternal border. (Option 4) The mitral area (apex), an auscultatory area, and the point of maximal impulse are located at the 5th ICS at the MCL.

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 correct technique when walking down the stairs? 1. Descends with the cane on the step first, followed by the left leg, and then the right leg [44%] 2. Descends with the cane on the step first, followed by the right leg, and then the left leg [32%] 3. Descends with the left leg on the step first, followed by the cane, and then the right leg [15%] 4. Descends with the right leg on the step first, followed by the left leg, and then the cane [8%]

To prevent falls after a total knee replacement, clients should use a cane to provide maximum support when climbing up and down any stairs. Clients should hold the cane on the stronger side and move the cane before moving the weaker leg, regardless of the direction. Clients must also keep 2 points of support on the floor at all times (ie, both feet, foot and cane). When descending stairs, the client should: Lead with the cane Bring the weaker leg down next (in this client, it is the left leg) Finally, step down with the stronger leg (Option 1) When ascending stairs, the client should: Step up with the stronger leg first Move the cane next, while bearing weight on the stronger leg Finally, move the weaker leg To remember the order, use the mnemonic "up with the good and down with the bad." The cane always moves before the weaker leg. (Options 2, 3, and 4) These options do not provide enough support to the weaker leg when descending.

The nurse provides discharge teaching to a client who had total hip replacement 4 days ago. Which client statement indicates that additional teaching is necessary? 1. "I will concentrate on leaning forward as I carefully sit down in a chair." [55%] 2. "I will do my leg raises and quadriceps and buttock isometric exercises 2-3 times a day." [23%] 3. "I will use the sock puller that the therapist gave me when I get dressed." [2%] 4. "My child got me a riser for the toilet seat at home. I hope my feet reach the floor!" [18%]

To prevent hip prosthesis dislocation following hip arthroplasty, a client must not force the hip into >90 degrees of flexion. Clients should use a chair with armrests and a high firm seat and proceed to place the hands on the armrests for support while lowering themselves onto the seat and when rising from it. Bending forward when getting into a chair creates excessive hip flexion (>90 degrees) and must be avoided. (Option 2) The client performs leg exercises 2-3 times a day to help strengthen the muscles surrounding the hip and continues them for several months after discharge. These include isometric quadriceps and gluteal setting, leg raises, and abduction exercises from the supine and standing positions. (Option 3) The client must not twist from the waist, reach across the affected extremity, or bend forward >90 degrees when dressing or putting on slippers, shoes, and socks. The client is instructed to use assistive equipment when getting dressed, such as a reacher/grabber, sock puller, or a long-handled shoehorn. (Option 4) The client should use a toilet riser or a bedside commode chair with arms to prevent excessive hip flexion when getting on and off the toilet seat.

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? 1. Step behind client with arms around waist, squat using the quadriceps, and lower client to the floor [26%] 2. Step in front of client, brace knees and feet against the client's, and assist to the floor gently [7%] 3. Step slightly behind client with feet apart, extend one leg, and let client slide against it to the floor [57%] 4. Step 12 inches behind the client, support under axillae, tighten back, and lower client to the floor [8%]

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 actions include: Step slightly behind the client and place the arms under the axillae or around the client's waist Place feet wide apart with knees bent - creates a broad base of support, provides stability, and reduces the risk for back injury to the nurse Place one foot behind the other and extend the front leg - allows the nurse to bring the client backward by using the leg muscles to rock backward while supporting the client's weight Let the client slide down the extended leg to the floor - lowers the client gently to the floor while keeping the client's head protected from injury (Options 1 and 4) These actions do not provide close proximity to the client, a broad base of support, or a lower center of gravity to increase the nurse's stability and help prevent back injury. (Option 2) These actions are appropriate for helping a client rise from the bed or chair but not for assisting a falling client to the floor.

The health care provider has explained the risks and benefits of a planned surgical procedure and asks the nurse to witness the client's signature on the consent form. Which situation would affect the legitimacy of the signature? 1. Client asks whether a blood transfusion will be required during surgery [35%] 2. Client expresses a fear of postoperative pain [3%] 3. Client received a dose of hydrocodone for pain 12 hours ago [39%] 4. Client wishes to wait to sign the consent until the spouse is present [20%]

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

The client has just returned from having a cast placed on the right forearm and is found putting a lead pencil in the cast to "reach the itch." What is the nurse's priority action? 1. Offer the client a straw to reach the itch instead of a lead pencil 2. Perform a peripheral neurovascular check of the casted extremity 3. Pour a generous amount of baby powder or corn starch in the cast to reach the itch 4. Review appropriate itch relief technique using the cool setting of a hair dryer

To relieve itching underneath a casted area, clients should use the cool setting of a hair dryer to direct air under the cast. Clients should never place any object, lotions, or powders in or around the casted area as skin irritation, injury, or infection may occur. Signs and symptoms of infection (eg, sores, purulent drainage, foul odors) and persistent itching should be reported to the health care provider. (Options 1 and 3) Nothing should be placed inside a cast due to the risk for injury and infection. (Option 2) The skin of the casted extremity should be assessed as the client could have damaged it by inserting a pointed object. Regular neurovascular checks should be performed on a client with a new cast as the client is at risk for compartment syndrome. However, there is no indication of peripheral vascular impairment (eg, changes in extremity color, temperature, or pulse) or peripheral neurologic impairment (eg, loss of sensory or motor function) of the casted extremity; therefore, this is not the priority at this time.

A client has a follow-up checkup in the urology clinic. Six months ago, the client started taking tolterodine. What data collected from the client should the nurse report to the health care provider? 1. Client excitedly reports being able to go an entire work day without having to urinate [71%] 2. Client is using an over-the-counter artificial saliva product for dry mouth[10%] 3. Client reports occasional dizziness in the morning and when changing positions [14%] 4. Client reports symptoms of constipation [4%]

Tolterodine (Detrol LA), oxybutynin (Ditropan), and solifenacin (Vesicare) are antimuscarinic/anticholinergic medications used for overactive bladder and urge urinary incontinence. They decrease urinary urgency and frequency. The most common side effects are anticholinergic (eg, dry mouth, constipation, cognitive dysfunction). The client's report of not urinating the entire day while at work may indicate that the dosage is too high and is causing urinary retention. Urinary retention can lead to bladder infections and distension. This information should be reported to the health care provider (HCP). (Option 2) Artificial saliva products and sugar-free hard candy and gum are acceptable ways to manage dry mouth caused by anticholinergic medications. (Option 3) Occasional dizziness is a side effect of tolterodine. The client should rise and change positions slowly. However, if this client is receiving too high a dose, reduction of the dose may alleviate the dizziness. Severe dizziness should be reported to the HCP. (Option 4) Constipation can be managed with increased fiber in the diet, fluids, stool softeners, or laxatives. Educational objective:Anticholinergic medications (eg, tolterodine, oxybutynin, solifenacin) are commonly used for overactive bladder. The client should experience a reduction in the number of times needed to urinate, but the number should not decrease below typical urination frequency. The nurse should also teach the client how to manage the common side effects of dry mouth, constipation, and mild dizziness. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

A nurse is completing discharge teaching to the parent of a child who is postoperative following a tonsillectomy. Which finding should be reported as a priority? 1. Ear pain [3%] 2. Frequent swallowing [89%] 3. Low-grade fever [2%] 4. Objectionable mouth odor [3%]

Tonsillectomy is usually performed as an outpatient procedure. Postoperative bleeding is an uncommon but important complication and it can last up to 2 weeks. It manifests with frequent or continuous swallowing and/or cough from the trickling blood; some clients may also develop restlessness. Discharge teaching includes: Avoid coughing, clearing the throat, or blowing of the nose Limit physical activity Milk products are discouraged due to their coating effect, which can prompt clearing of the throat Oral mouth rinses, gargling, and vigorous tooth brushing should be avoided to prevent irritation (Options 1, 3, and 4) The presence of slight ear pain, a low-grade fever, and objectionable mouth odor are common findings during the first 5-10 days after the procedure. Persistent moderate-to-severe earache, fever, or cough requires further evaluation. Educational objective:Postoperative bleeding after a tonsillectomy is uncommon but can last up to 14 days after surgery. Continuous swallowing, restlessness, and frequent coughing are early indicators of bleeding. To prevent hemorrhage, the client should avoid clearing the throat, blowing the nose, and coughing. Additional Information Reduction of Risk Potential NCSBN Client Need

The nurse is assisting with cardiopulmonary resuscitation of a client in cardiac arrest. The rhythm in the exhibit is displayed on the cardiac monitor. Which medication administration should the nurse anticipate? Click the exhibit button for additional information. 1. Adenosine IV 2.Dopamine IV 3. Magnesium IV 4. Metoprolol IV

Torsades de pointes (ie, "twisting of the points") is a polymorphic ventricular tachycardia characterized by QRS complexes that change size and shape in a characteristic twisting pattern. Torsades de pointes is usually due to a prolonged QT interval (more than half the RR interval), which is the result of electrolyte imbalances, especially hypomagnesemia, or some medications. The first-line treatment is IV magnesium (Option 3). Treatment may also include defibrillation and discontinuation of any QT-prolonging medications. (Option 1) Adenosine is an antiarrhythmic used to treat supraventricular tachycardia. (Option 2) Dopamine is a vasopressor used to treat symptomatic hypotension. (Option 4) Metoprolol is a beta blocker used for heart rate control in tachyarrhythmias. Educational objective: Torsades de pointes is usually due to a prolonged QT interval, which is the result of electrolyte imbalances, especially hypomagnesemia, or some medications. First-line treatment is magnesium IV. Treatment may also include defibrillation and discontinuation of QT-prolonging medications.

A graduate nurse (GN) is caring for a client who underwent a total knee replacement 1 day earlier. Which intervention by the GN would cause the supervising nurse to intervene? 1. Applies a cold pack over the operative knee 2. Initiates a continual passive motion device 3. Obtains a leg-immobilizing device for ambulation 4. Places a support pillow under the operative knee

Total knee replacement (knee arthroplasty) is a surgery that replaces the knee joint with an artificial implant. Knee arthroplasties are primarily performed for clients with severe pain or mobility impairment from arthritis. Following a knee arthroplasty, the nurse must plan care to reduce the client's risk of complications while promoting comfort and recovery. Contracture of the operative joint is a serious complication of knee arthroplasty that impairs the client's mobility. To prevent contracture formation, the nurse should maintain the operative knee in an extended position with a knee immobilizer or pillow placed under the lower leg or heel. Placing a pillow behind the knee causes joint flexion, which increases the risk of contracture (Option 4). (Option 1) Cold packs may be applied intermittently over the operative joint to reduce postoperative swelling and pain. (Option 2) Using a continual passive motion device, if prescribed, may improve range of motion through knee flexion and extension and prevent contractures. (Option 3) Applying a leg immobilizer during ambulation provides support, maintains alignment, and prevents dislocation of unstable operative joints.

A client is receiving an infusion of total parenteral nutrition (TPN) 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? 1. Hang 0.9% normal saline until new bag arrives, then increase TPN to 150 mL/hr for 1 hour 2. Hang 10% dextrose in water until the new bag arrives, then resume TPN at 75 mL/hr 3. Hang dextran in saline until the new bag arrives, then resume TPN at 75 mL/hr 4. Hang lactated Ringer's until the new bag arrives, then resume TPN at 75 mL/hr

Total parenteral nutrition (TPN) is administered via a central venous catheter to meet the nutritional needs (eg, glucose, amino acids, vitamins, minerals) of clients who cannot digest nutrients via the gastrointestinal 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 (eg, normal saline, lactated Ringer's [LR]), the pancreas will continue to produce insulin in response to the residual glucose, which may cause hypoglycemia (Option 2). (Option 1) The infusion of 0.9% saline solution without dextrose can lead to hypoglycemia. Rapid infusion (150 mL/hr) of the hypertonic TPN solution can increase the risk for fluid overload and hyperglycemia. The nurse should never increase the rate of central TPN to make up for volume lost during previous hours. (Option 3) Dextran in saline solution is a colloid used to expand intravascular volume in clients with hypovolemia. It can cause fluid overload and so is not an appropriate action. (Option 4) LR contains electrolytes but no glucose; hypoglycemia may result. Educational objective:Abrupt cessation of central total parenteral nutrition (TPN), which usually contains 20%-50% dextrose, increases the risk for hypoglycemia, as the pancreas will continue to produce insulin in response to the residual glucose. When TPN is discontinued, the infusion rate is gradually reduced and then replaced with a solution containing dextrose.

A client undergoes transurethral resection of the prostate for benign prostatic hyperplasia. The client has a 3-way Foley catheter with continuous bladder irrigation. Which assessment is the best indication that the bladder irrigation flow rate is productive? 1. Blood pressure 120/80 mm Hg, pulse 80/min 2. Client has no bladder spasms 3. Irrigation input 3,000 mL, Foley output 3,000 mL 4. Output urine is light pink in color

Transurethral resection of the prostate (TURP) involves the insertion of a scope to remove obstructing prostate tissue. Continuous bladder irrigation (CBI) with a 3-way Foley catheter is initiated after the procedure. The catheter balloon applies direct pressure to the bleeding tissue while the tubing allows the urine to drain. During the first 24 hours, the urine color changes from reddish-pink to pink. Small clots are also expected for up to 36 hours after surgery. However, the nurse should adjust the irrigation rate with these normal findings so that the urine remains light pink without clots (Option 4). (Option 1) Vital signs within normal limits indicate hemodynamic stability but will not reflect the patency of the draining catheter. (Option 2) Painful bladder spasms are expected after TURP and catheter placement. Spasms are typically treated with antispasmodics (eg, belladonna-opium suppositories, oxybutynin [Ditropan]). (Option 3) The total Foley output should be more than the CBI input, as the Foley output includes CBI fluid (not processed through the kidneys) plus the normal renal output of urine. An obstruction is indicated if the CBI input is equal to or greater than the Foley output. Educational objective:A 3-way Foley catheter with continuous bladder irrigation allows urine to drain after a transurethral resection of the prostate. During the first 24 hours, the urine color changes from reddish-pink to pink. Small clots may occur for up to 36 hours. However, the nurse adjusts the irrigation flow to keep the urine light pink without clots.

A client diagnosed with trigeminal neuralgia is given a prescription of carbamazepine by the health care provider. Which intervention does the nurse add to this client's care plan? 1. Encourage client to drink cold beverages 2. Encourage client to eat a high-fiber diet 3. Encourage client to perform facial massage 4. Encourage client to report any fever or sore throat

Trigeminal neuralgia is sudden, sharp pain along the distribution of the trigeminal nerve. The symptoms are usually unilateral and primarily in the maxillary and mandibular branches. Clients may experience chronic pain with periods of less severe pain, or "cluster attacks" of pain between long periods without pain. Triggers can include washing the face, chewing food, brushing teeth, yawning, or talking. Pain is severe, intense, burning, or electric shock-like. The primary intervention for trigeminal neuralgia is consistent pain control with medications and lifestyle changes. The drug of choice is carbamazepine. It is a seizure medication but is highly effective for neuropathic pain. Carbamazepine is associated with agranulocytosis (leukopenia) and infection risk. Clients should be advised to report any fever or sore throat. Behavioral interventions include the following: Oral care - use a small, soft-bristled toothbrush or a warm mouth wash Use lukewarm water; avoid beverages or food that are too hot or cold (Option 1) Room should be kept at an even and moderate temperature Avoid rubbing or facial massage. Use cotton pads to wash the face if necessary. Have a soft diet with high calorie content; avoid foods that are difficult to chew. Chew on the unaffected side of the mouth. (Option 2) A high-fiber diet is not required for a client with trigeminal neuralgia, and the additional chewing with higher-fiber foods may serve as a pain trigger. (Option 3) Clients with trigeminal neuralgia are encouraged not to massage the face as this can trigger pain

A client with bronchial asthma and sinusitis has increased wheezing and decreased peak flow readings. During the admission interview, the nurse reconciles the medications and notes that which of the following over-the-counter medications taken by the client could be contributing to increased asthma symptoms? 1. Guaifenesin 600 mg orally twice a day as needed 2. Ibuprofen 400 mg orally every 6 hours for pain as needed 3. Loratadine 1 tablet orally every day as needed 4. Vitamin D 2,000 units orally every day

Two groups of commonly used drugs, nonsteroidal anti-inflammatory drugs and beta-adrenergic antagonists (beta blockers), have the potential to cause problems for clients with asthma. Ibuprofen (Motrin) and aspirin are common over-the-counter anti-inflammatory drugs that are effective in relieving pain, discomfort, and fever. About 10%-20% of asthmatics are sensitive to these medications and can experience severe bronchospasm after ingestion. This is prevalent in clients with nasal polyposis. (Option 1) Guaifenesin (Mucinex) is an expectorant used to facilitate mobilization of mucus and should not have the potential to exacerbate asthma or cause an attack. (Option 3) Loratadine (Claritin) is an antihistamine and should not have the potential to exacerbate asthma or cause an attack. (Option 4) Vitamin D is used to help maintain bone density and should not have the potential to exacerbate asthma or cause an attack. Educational objective:Ibuprofen and aspirin are common over-the-counter anti-inflammatory drugs that can cause bronchospasm in some clients with asthma. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

A nurse is teaching the parent of a 6-year-old with a urinary tract infection (UTI) how to avoid repeat infections. Which statements by the parent indicate that the teaching has been effective? Select all that apply. 1. "I just bought my child new nylon panties." 2. "I will make sure my child does not hold urine." 3. "I will not give my child any more bubble baths." 4. "I will teach my child to wipe from the front to the back." 5. "I will use antibacterial soap for bathing my child."

UTIs are one of the most common conditions in children, with a higher occurrence in girls (due to the short urethra and its close proximity to the vagina and anus). Girls should be taught to wipe from front to back; this will help minimize the chances of bacteria entering the urethra from the perianal area (Option 4). Urinary stasis (incomplete emptying of the bladder) is the most common contributing factor to UTIs; sedentary urine provides an ideal environment for bacterial growth. Constipation and straining increase the pressure on the bladder neck and may prevent the bladder from emptying completely. The child should be encouraged to drink plenty of fluids and use the restroom as soon as the urge to go is felt, which will decrease the risk of constipation and promote frequent urination. Avoiding "holding in" urine and voiding regularly help to prevent urinary retention and flush bacteria out of the urinary tract (Option 2). Scented soaps or commercially prepared bubble bath products should be avoided as they cause irritation to the urethra. Antibacterial soap should not be used for bathing a child as it may reduce the presence of normal flora. The bathtub should be filled with water only, and the hair should be washed last (Options 3 and 5). (Option 1) Tight clothing and synthetic fabrics (eg, nylon, spandex, Lycra) should be avoided as they seal in moisture and promote bacterial growth. Cotton underwear is recommended as it absorbs moisture.

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

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

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? Select all that apply. 1. The 60-year-old client was just diagnosed with benign prostatic hyperplasia (BPH) 2. The client reports a mobile, golf ball-sized lesion under the skin over the right thigh that feels doughy 3. The client reports a nagging cough with hoarseness for the past 3 months 4. The female client who weighed 150 lb (68.0 kg) has lost 15 lb (6.8 kg) in 3 months without dieting 5. The male client reports a skin change on the breast that looks like an orange peel

Unintentional weight loss of >10% of usual weight (in non-obese clients) requires evaluation and could indicate underlying cancer. Nausea, anorexia, and dysgeusia (altered taste sensation) are also clinical features of cancer and contribute to weight loss (Option 4). The warning signs of cancer can be remembered with the 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 (Option 3) Although 99% of breast cancers are found in women, men can also develop breast cancer, especially if risk factors, such as past chest radiation, are present. Later signs of breast cancer include a newly retracted nipple or an orange-peel appearance of the breast tissue (peau d'orange) caused by the plugging of dermal lymph drainage (Option 5). (Option 1) BPH is caused by hormonal changes related to aging. Growth is not related to cancer. (Option 2) Lipomas are benign, fatty masses and rarely become malignant. They are subcutaneous, have a soft doughy feel, and are mobile and asymptomatic. Masses that are hard and fixed, not soft and mobile, usually indicate malignancy.

The nurse reinforces teaching about self-management strategies for a client with urge incontinence. Which of the following statements indicate that teaching has been effective? Select all that apply. 1. "I am going to join a walking program to lose excess weight." 2. "I may have dry mouth as a side effect from the oxybutynin." 3. "I really need caffeine to get myself going in the morning." 4. "I should perform Kegel exercises several times daily." 5. "I will void every 2 hours until I am having fewer accidents."

Urge incontinence (UI), also known as overactive bladder, occurs when the bladder contracts randomly, causing a strong, sudden urge to urinate that is followed by urine leakage. UI may occur without cause or may result from spinal cord injury and impairment of the bladder (eg, interstitial cystitis) or neurological system (eg, Parkinson disease, stroke). Interventions for clients with UI include: Loss of excess weight to reduce pressure on the pelvic floor (Option 1). Anticholinergic medications (eg, oxybutynin, tolterodine) to decrease bladder spasms. Dry mouth (xerostomia) is a frequent adverse effect (Option 2). Avoidance of bladder irritants (eg, artificial sweeteners, caffeine, citrus juices, alcohol, carbonated drinks, nicotine) (Option 3). Pelvic floor exercises (eg, Kegel) to strengthen the muscles and help prevent urinary leakage (Option 4). Bladder training (eg, voiding every 2 hours while awake) and gradually lengthening intervals between voiding (Option 5).

A female client comes to the clinic with a suspected lower urinary tract infection; urinalysis confirms a diagnosis of cystitis. Which symptoms reported by the client would be most consistent with this condition? Select all that apply. 1. Chills and vomiting 2. Flank pain 3. Painful urination 4. Urinary frequency 5. Urinary urgency

Urinary tract infections (UTIs) are usually bacterial in origin and are most often caused by Escherichia coli. The microorganisms from the perineal area enter the urethra, causing inflammation and infection (urethritis). They ascend to the bladder, where they multiply, causing inflammation and infection (cystitis). The bacteria may continue to ascend the urinary tract to the ureters and kidneys, causing inflammation and infection in the kidneys (pyelonephritis). A UTI is classified as upper or lower according to its location within the urinary tract. Cystitis is the most common community-acquired UTI. It is an infection of the lower urinary tract and involves inflammation of the bladder mucosa, leading to hyperemia, tissue hemorrhage, and pus formation. This inflammatory process leads to burning with urination (dysuria), urinary frequency and urgency, hematuria, and suprapubic discomfort (Options 3, 4, and 5). (Options 1 and 2) When the infection ascends to the kidneys (pyelonephritis), clients become very ill. They develop nausea, vomiting, fever with chills, and flank pain. Assessment shows costovertebral angle tenderness. If the infection is not recognized and treated, clients can become septic.

A client with methicillin-resistant Staphylococcus aureus (MRSA) bacteremia has been receiving IV vancomycin for the last 3 days. Which blood test trend is most important for the nurse to review when preparing to administer this medication? 1. Blood cultures [18%] 2. Creatinine levels [63%] 3. Magnesium levels [1%] 4. White blood cell (WBC) count [16%]

Vancomycin can cause nephrotoxicity, which occurs most often in clients who already have some degree of renal impairment. Serum creatinine levels should be monitored daily during IV vancomycin treatment to look for an increase in level over a few days. If an increasing trend is identified, the nurse should consult with the health care provider (HCP) and/or pharmacist before administering the dose. (Option 1) Blood cultures may be checked periodically during vancomycin therapy, but they are not likely to change this quickly. (Option 3) Magnesium levels are typically not affected by vancomycin therapy. (Option 4) The WBC count may be helpful in determining the effectiveness of vancomycin therapy in treating infection. However, this laboratory result is unlikely to influence the nurse's decision on whether to administer the dose. Therefore, it is not the highest priority.

The nurse prepares to administer IV vancomycin to an 80-year-old client with a methicillin-resistant Staphylococcus aureus infection. The nurse should notify the health care provider about which serum laboratory results before administering the drug? Select all that apply. 1. Blood urea nitrogen is 60 mg/dL (21.4 mmol/L) 2. Creatinine is 2.1 mg/dL (185.6 µmol/L) 3. Glucose is 140 mg/dL (7.7 mmol/L) 4. Hemoglobin is 15 g/dL (150 g/L) 5. Magnesium is 1.5 mEq/L (0.75 mmol/L) 6. White blood cell count is 14,000/mm3 (14.0 × 109/L)

Vancomycin is a glycopeptide antibiotic that is excreted by the kidneys. It is used to treat serious infections with gram-positive microorganisms (Staphylococcus aureus [methicillin-resistant Staphylococcus aureus]) and diarrhea associated with Clostridium difficile. Serum vancomycin trough level is monitored before the 4th dose (15-20 mg/L [10.4-13.8 µmol/L] is optimal). Blood urea nitrogen (BUN) and creatinine levels are monitored regularly (usually 2-3 times/week) in clients receiving the drug due to increased risk of nephrotoxicity, especially in those with impaired renal function, receiving aminoglycosides, and who are >60 years old. The health care provider (HCP) can lower the dose, decrease the drug administration frequency, or discontinue vancomycin. It is important to know the baseline values of BUN and creatinine to monitor trending and identify if there is an increase. Before administering this drug, the nurse should notify the HCP that the client's BUN (60 mg/dL [21.4 mmol/L]) and creatinine (2.1 mg/dL [185.6 µmol/L]) are both increased. The normal range for BUN is 6-20 mg/dL (2.1-7.1 mmol/L) and creatinine is 0.6-1.3 mg/dL (53-115 µmol/L). (Option 3) An elevated glucose level (>110 mg/dL [6.1 mmol/L]) is expected in a client with an infection due to physiological stress and gluconeogenesis; this does not need to be reported to the HCP. (Option 4) A hemoglobin level of 15 g/dL (150 g/L) is normal (13.2-17.3 g/dL [132-173 g/L] in adult men; 11.7-15.5 g/dL [117-155 g/L] in adult women) and does not need to be reported to the HCP. (Option 5) A magnesium level of 1.5 mEq/L (0.75 mmol/L) is normal (1.5-2.5 mEq/L [0.75-1.25 mmol/L]) and does not need to be reported to the HCP. (Option 6) A white blood cell count of 14,000/mm3 (14.0 × 109/L) is elevated and expected in a client with a serious infection; this does not need to be reported to the HCP. Educational objective:As nephrotoxicity can occur, monitoring of vancomycin trough level to maintain optimal drug level and renal function is indicated in clients receiving vancomycin, especially in those with impaired renal function and who are >60 years old.

The nurse is contributing to the plan of care for a client who has active varicella with open, moist lesions. Which of the following actions are appropriate to include in the plan of care? Select all that apply. 1. Don gown, gloves, and N95 respirator when entering the client's room 2. Ensure that pregnant staff members are not assigned to care for this client 3. Place single-use, disposable thermometer and stethoscope in the room 4. Place the client in a private room with negative air pressure 5. Request discontinuation of isolation precautions once all lesions are dry and crusted

Varicella (chickenpox) is a highly contagious infection characterized by a generalized rash of itchy, vesicular lesions. Both chickenpox and shingles are caused by the varicella-zoster virus (VZV), which is transmitted through airborne particles or contact with open vesicles. For chickenpox and disseminated (widespread) shingles, the nurse should use precautions for both airborne isolation (ie, N95 respirator mask), negative air pressure room) and contact isolation (eg, gown, gloves, disposable equipment) (Options 1 and 3). Once the vesicles have crusted, the client is no longer contagious, and isolation precautions may be discontinued (Option 5). Rooms with negative air pressure are equipped with specialized air equipment that continuously filters air out of the room and creates a negative pressure gradient that prevents infectious airborne particles from escaping through the doorway (Option 4). Pregnant health care workers should not be exposed to clients with TORCH infections (Toxoplasmosis, Other [VZV/parvovirus B19], Rubella, Cytomegalovirus, Herpes simplex virus), as these infections can cause fetal abnormalities

The nurse is reviewing discharge teaching with the parent of a child with acute myelogenous leukemia who was admitted with varicella-zoster virus. The client has multiple lesions that have not crusted. Which of the following instructions should the nurse include? Select all that apply. 1. "Apply diphenhydramine cream sparingly to lesions after bathing your child." 2. "Keep giving your child the acyclovir at home as prescribed to fight the virus." 3. "You can give your child acetaminophen for pain and fever." 4. "Your child should receive the varicella virus vaccine in 30 days." 5. "Your child will no longer be infectious after all the lesions have crusted over."

Varicella-zoster virus (VZV) infection (chickenpox) is characterized by lesions that begin as a maculopapular rash, progress to weeping vesicular lesions, and typically crust over within approximately 1 week. The lesions are often pruritic and/or painful, and clients frequently have an accompanying fever. In most cases, treatment is supportive in nature and includes: Cool oatmeal baths and topical antihistamines (eg, diphenhydramine) applied to lesions for itching (Option 1) Acetaminophen as needed for fever or pain (Option 3) Immunocompromised clients (eg, clients with acute myelogenous leukemia [AML]) are at risk for severe varicella (eg, disseminated, pneumonia) and require aggressive therapy, including an antiviral agent (eg, acyclovir). Antiviral therapy should be continued until all the lesions have crusted over (Option 2). VZV is spread via airborne and contact transmission. Clients are most infectious in the days leading up to the rash and continue to be infectious until the entire rash reaches the crusting stage (Option 5). (Option 4) Immunocompromised clients should not receive live attenuated vaccines (eg, varicella virus vaccine). In addition, the vaccine is not indicated for a client who has already developed immunity after recovering from VZV infection.

clt at risk for wound dehisence and evisceration

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 (Option 3). (Option 1) This client trying to leave against medical advice is the second priority. The nurse needs to assess this client for pain and determine when pain medication was administered last. If this situation cannot be resolved quickly, the nurse should notify the client's health care provider immediately to determine level of competency and inform the client of the risks of refusing treatment. (Option 2) The nurse must follow-up 30 minutes after the morphine is administered, not immediately, to assess the effectiveness of the pain medication. (Option 4) Providing discharge instructions to this client can wait without consequence. Educational objective:Postoperative nausea, vomiting, and dry heaving should be treated with antiemetic medication as soon as possible as it increases a client's risk for wound dehiscence and evisceration (medical emergency).

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? Select all that apply. 1. "I can use a humidifier to help prevent nosebleeds." 2. "I need to avoid contact sports such as soccer or hockey." 3. "I should use a soft-bristled toothbrush and floss carefully." 4. "I will call my health care provider if I soak a menstrual pad every hour." 5. "I will take naproxen to decrease inflammation if I am injured."

Von Willebrand disease is a genetic bleeding disorder caused by a deficiency of von Willebrand factor (vWF), which plays an important role in coagulation. Intranasal desmopressin or topical therapies (eg, thrombin) 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. Client teaching includes: Notify the health care provider of signs of bleeding (eg, severe joint pain or swelling, headache [especially after injury], blood in urine/stool, uncontrollable nosebleed). Use a humidifier or nasal spray to keep the mucosa moist, reducing the risk of nosebleeds (Option 1). Avoid aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs). Avoid activities with a higher risk for injury (eg, contact sports) (Option 2). Maintain gum integrity (eg, soft-bristled toothbrush, gentle flossing) to minimize bleeding potential (Option 3). Report heavy menstrual bleeding (eg, soaking a pad in <3 hours), which can be managed with hormonal therapies and intranasal desmopressin (Option 4). (Option 5) Clients should avoid medications that can exacerbate bleeding, including aspirin and NSAIDs (eg, ibuprofen, naproxen, ketorolac). Clients should instead use the mnemonic RICE (rest, ice, compression, elevation) to help with pain and inflammation. Educational objective:In von Willebrand disease, a genetic bleeding disorder, deficient von Willebrand factor prevents effective coagulation. Clients can decrease bleeding risk by avoiding high-risk activities (eg, contact sports) and nonsteroidal anti-inflammatory drugs, keeping nasal mucosa moist, and maintaining gum integrity (eg, soft-bristled toothbrush). Additional Information Reduction of Risk Potential NCSBN Client Need

The nurse is caring for a client who had an acute myocardial infarction 8 hours ago. The client states, "I am worried about how this is going to affect my job and family." Which of the following responses by the nurse is therapeutic? 1. "As long as you make some healthy lifestyle changes, you should be able to continue working." 2. "I will have the social worker visit you to review the available community resources." 3. "It is too soon to worry about those things; focus on the health of your heart right now." 4. "These are common concerns. It must be frightening to feel unsure about meeting your family's needs."

When a client expresses concern about something, the nurse should use active listening (eg, restating what is implied) to validate the client's emotions and encourage discussion (Option 4). Providing uncertain reassurance, advising the client to not worry, and immediately deferring to other members of the health care team devalue the client's concerns and discourage further expression of feelings (Options 1, 2, and 3). The nurse should contact the social worker about providing resources after using therapeutic communication.

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? 1. Administer the correct medication and obtain current vital signs 2. Alert the graduate nurse and complete an incident report 3. Assess the client and notify the health care provider 4. Discontinue the dopamine and inform the nursing supervisor

When a medication error occurs, client safety is the nurse's first priority. The nurse should assess the client immediately for any adverse effects and inform the healthcare provider (HCP) (Option 3). 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 (eg, supervisor, manager), and an incident or occurrence report should be filed within 24 hours. (Option 1) Prior to administering the correct medication, the HCP should be informed to ensure that the original medication is appropriate in light of the medication error. Additional medications or therapies may be necessary to reverse the effects of the medication given in error. (Option 2) Although it is important that the graduate nurse has a chance to learn from the mistake, ensuring client safety is the first priority. An incident report can be filed after the client is stable. (Option 4) Discontinuing dopamine without providing another medication for hemodynamic stabilization may harm the client. The nursing supervisor should be informed after client stabilization.

The nurse administers IV vancomycin to a client with a methicillin-resistant Staphylococcus aureus infection. Which nursing actions are most appropriate? Select all that apply. 1. Assess client for lethargy and decreased deep tendon reflexes 2. Assess skin for flushing and red rash on face and torso 3. Infuse medication over at least 60 minutes 4. Monitor blood pressure during infusion 5. Observe IV site every 30 minutes for pain, redness, and swelling

When administering IV vancomycin, the nurse should assess for and work to prevent possible complications by performing the following: Draw the prescribed trough level prior to administration. Therapeutic vancomycin levels range from 10-20 mg/L (6.9-13.8 µmol/L) for hemodynamically stable clients. Adverse effects of vancomycin toxicity include nephrotoxicity (eg, elevated creatinine levels) and ototoxicity (eg, hearing loss, vertigo, tinnitus). Infuse medication over at least 60 minutes (≤10 mg/min). Faster rates increase the likelihood of complications (Option 3). Monitor blood pressure during the infusion. Hypotension is a possible adverse effect (Option 4) Assess for hypersensitivity. Red man syndrome is a nonallergic histamine reaction characterized by sudden onset of severe hypotension, flushing, and/or maculopapular rash of the face, neck, chest, and upper extremities (Option 2). Monitor for anaphylaxis (eg, rash, pruritus, laryngeal edema, wheezing). Observe IV site every 30 minutes for pain, redness, or swelling. Vancomycin is a vesicant and may cause thrombophlebitis or, if extravasation occurs, tissue necrosis. Administration using a central venous catheter is preferred; however, a peripheral IV may be used for short-term therapy (Option 5). (Option 1) Assessment of deep tendon reflexes is appropriate with magnesium sulfate administration. Manifestations of hypermagnesemia include lethargy, nausea, vomiting, and decreased deep tendon reflexes. Educational objective:Nursing care of clients receiving IV vancomycin includes drawing prescribed trough levels before drug administration, infusing the drug over at least 60 minutes, monitoring the client during administration (eg, blood pressure, respiratory status, signs of hypersensitivity/anaphylaxis), and assessing the IV site during and after administration.

The nurse is caring for a client with a chest tube to evacuate a hemopneumothorax after a motor vehicle accident. The drainage has been consistently 25-50 mL/hr for the majority of the shift. However, over the past 2 hours there has been no drainage. Which actions should the nurse take? Select all that apply. 1. Auscultate breath sounds 2. Increase amount of suction 3. Instruct client to cough and deep breathe 4. Milk the chest tube 5. Reposition the client

When chest drainage stops abruptly, the nurse must perform assessments and interventions to ascertain if this is an expected finding. Auscultating breath sounds (Option 1) helps the nurse detect whether breath sounds are audible in all lung fields, potentially indicating that the lung has re-expanded and there is no more drainage. Other interventions to facilitate drainage include having the client cough and deep breathe (Option 3) and repositioning the client (Option 5). If a client has been in one position for a prolonged period, drainage may accumulate and a position change may facilitate improved drainage. (Option 2) A change in suction level should be performed only after obtaining a health care provider (HCP) prescription. The nurse should perform the assessment of breath sounds, coughing and deep breathing, and client repositioning before notifying the HCP about a change in suction level. In general, suction above 20 cm H2O is not indicated. (Option 4) Milking chest tubes to maintain patency is performed only if prescribed. It is generally contraindicated due to potential tissue damage from highly increased pressure changes in the pleural space.

The nurse is teaching a class on nutrition and feeding practices for young children. What should the nurse recommend as the best snack for a toddler? 1. ½ cup orange juice [7%] 2. Dry, sweetened cereal [19%] 3. Raw carrot sticks [27%] 4. Slices of cheese [45%]

When choosing foods for a toddler (age 1-3 years), parents should consider the following factors: Safety: Small, hard, sticky, or slippery foods (eg, hot dogs, whole grapes, nuts, raw carrot sticks, popcorn, peanut butter, hard candy, fruit snacks) pose a choking risk and should not be offered. Nutrient density: Foods should contain valuable nutrients (eg, protein, vitamins) rather than just "empty calories" (eg, sugars). Potential for foodborne illness: Children are at a higher risk for developing food-related infections, especially if given raw, unpasteurized foods (eg, partially cooked eggs, raw fish, raw bean sprouts). Healthy snacks for a toddler include pieces of cheese, whole-wheat crackers, banana slices, yogurt, cooked vegetables, and cottage cheese with thinly sliced fruit (Option 4). (Option 1) Although orange juice is a source of vitamin C, it contains a large amount of sugar and lacks fiber. Toddlers should have no more than 4-6 oz of 100% fruit juice per day. (Option 2) Sweetened cereals, especially those marketed toward children, can be high in sugar and low in nutrients. (Option 3) Raw carrot sticks are hard and pose a choking risk. Parents should serve carrots and other hard vegetables grated or cooked. Educational objective:Food for young children should contain valuable nutrients and pose little risk of choking or foodborne infection. An example of a healthy snack for a toddler is a slice of cheese.

The nurse is forming a plan of care for an 82-year-old client with a history of anxiety, hypertension, urinary incontinence, and arthritic back pain. Which nursing diagnosis should be addressed first? Click on the exhibit button for additional information. 1. Anxiety 2. Chronic pain 3. Risk for acute confusion 4. Risk for falls Furosemide: 40 mg by mouth daily Metoprolol XL: 100 mg by mouth daily Oxybutynin XL: 5 mg by mouth daily Potassium chloride: 10 mEq by mouth twice a day Hydrocodone/acetaminophen: 5/325 mg by mouth every 6 hours PRN for pain Lorazepam: 1 mg by mouth 3 times daily PRN for anxiety

When determining which nursing diagnosis to address first, the nurse should consider factors that affect client safety. Risk for falls is an immediate safety concern (Option 4). Nursing diagnoses that relate to chronic conditions (eg, anxiety, chronic pain) are addressed after risk for falls. The nurse should immediately implement fall risk precautions by placing the bed in the lowest position, ensuring that the call light is within reach, and turning on the bed alarm. Interventions for addressing other client needs may be carried out after measures to ensure client safety. Advanced age is associated with decreased visual acuity, muscle mass, strength, and reaction time. Medications that cause dizziness or drowsiness increase the risk for falls. Diuretics (eg, furosemide) increase urinary frequency and may cause hypotension. Antihypertensive medications (eg, lisinopril, metoprolol) may cause bradycardia and dizziness. (Option 1) Safety needs are addressed before love and belonging needs (eg, anxiety). Anxiety interventions (eg, therapeutic touch, medication) may be implemented after safety interventions. (Option 2) Safety is the immediate concern for a client with a high fall risk. Arthritic joint changes are a source of chronic pain. Pain interventions (eg, medication, repositioning) may be implemented after safety interventions. (Option 3) A client with advanced age in an unfamiliar environment may develop acute confusion during the hospital course, but a high fall risk is a more immediate concern on admission. Educational objective:The nursing diagnosis of risk for falls should be addressed first for a client who has multiple risk factors for falls. Advanced age, incontinence, certain medications, and limited mobility increase fall risk.

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? 1. Did the study have institutional review board approval? 2. Do the characteristics of the sample population match those of the nurse's unit? 3. What are the credentials of the study's researcher? 4. What was the financial support provided for the study?

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. (Option 1) An institutional review board (IRB) is a committee that reviews research before it is conducted to ensure that is it ethical. Legally, any study of human subjects needs IRB approval to provide protection from unnecessary risk. Peer-reviewed journals usually require a statement of IRB approval before accepting an article for publication. However, the IRB process does not determine whether the findings are relevant for a particular setting. (Option 3) The educational credentials of a researcher may be relevant, especially if a non-health care professional has conducted a health care study. However, the integrity of the research process and findings is more important than the holding of any particular degree. (Option 4) Financial support can be considered, particularly when research finds favorably for a drug or product that is manufactured or supported by a sponsor of the study. Although it is essential for a financial relationship to be disclosed, that alone does not negate the usefulness of the study.

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? 1. Bend at the waist [2%] 2. Keep the feet close together [2%] 3. Pivot on the foot proximal to the chair [29%] 4. Use a transfer belt [64%]

When transferring a client from bed to chair the following are recommended for client safety: Clients should wear nonskid shoes (first step) Make sure the bed and chair (wheelchair) brakes are locked 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. Transfer the client toward the stronger (not the weaker) side. If the client is weak on the left side, ask the client to pivot on the right side. (Option 1) Bending at the waist often requires the nurse to use the back for lifting, making for poor body mechanics. (Option 2) The nurse should provide a wide body stance for more stability. Keeping the feet close together would not be good body mechanics and could cause injury. (Option 3) The nurse using proper body mechanics would pivot on the foot distal to the chair.

The nurse is reinforcing education with the parents of a 2-year-old child about diet choices to promote growth. The family observes a strict vegan diet. Which of the following statements by the nurse are appropriate? Select all that apply. 1. "Diets consisting of legumes as the only protein source are sufficient for growth." 2. "It is important to feed your child fortified breads and cereals to help with iron intake." 3. "Preparing meals with vegetables and fruits will ensure sufficient vitamin B12 intake." 4. "Try to pair foods high in iron with foods high in vitamin C to aid iron absorption." 5. "Your child may require calcium and vitamin D supplementation due to lack of dairy intake."

With careful monitoring of nutritional intake, a vegan diet (ie, excluding all animal-derived products [eg, meat, dairy, eggs]) can be appropriate for clients in all age groups. Pediatric clients consuming a vegan diet are at increased risk for nutritional deficiencies (eg, protein, calories, calcium, vitamin D, iron, vitamin B12) due to rapid growth and development. Nurses educating clients about preventing nutritional deficiencies in vegan diets should include information about: Iron: Plant sources of iron, which are in smaller quantities and difficult to absorb, should be supplemented with fortified cereals and breads to decrease risk of iron-deficient anemia (Option 2) Vitamin C: Iron absorption is improved when dietary sources of iron and vitamin C are taken together (Option 4) Calcium: Without animal sources of calcium (eg, dairy, eggs, fish), vegan diets require supplementation of calcium and vitamin D for bone health (Option 5) (Option 1) Many plant-based proteins (eg, legumes, grains) do not individually contain all the essential amino acids to support growth and tissue repair; therefore, vegan clients will require further teaching on combinations of protein sources. (Option 3) Fruits and vegetables do not provide vitamin B12. The nurse should educate the parents on the need for multivitamins or fortified grains as quality vitamin B12 sources.

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? 1. Blood urea nitrogen (BUN) of 60 mg/dL (21.4 mmol/L) [6%] 2. Creatinine of 4.0 mg/dL (354 µmol/L) [2%] 3. Potassium of 7.0 mEq/L (7.0 mmol/L) [87%] 4. Sodium of 155 mEq/L (155 mmol/L) [2%]

With the exception of clients in end-stage renal disease, a serum potassium value >6.5 mEq/L (6.5 mmol/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 (7.0 mmol/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 health care provider (HCP). In this case, it is likely that a repeat blood draw would be prescribed. Pseudohyperkalemia can be avoided on the repeat blood draw by using heparin-impregnated hematology vials to prevent clotting, minimal use of a tourniquet and fist clenching, and use of a larger gauge needle for the sample. (Option 1) This blood urea nitrogen (BUN) value is elevated (normal 6-20 mg/dL [2.1-7.1 mmol/L]) and could be related to kidney damage or dehydration. Therefore, it is not the most likely erroneous result. (Option 2) Similar to the BUN level, this creatinine value is significantly elevated (normal 0.6-1.3 mg/dL [53-115 µmol/L]). Further nursing assessment is indicated, with documentation and involvement of the HCP in evaluating the impact of this kidney damage on the client's health. (Option 4) This sodium value is high (normal 135-145 mEq/L [135-145 mmol/L]) and requires further exploration. The nursing assessment should be documented and reported to the HCP.

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? 1. Blood urea nitrogen (BUN) of 60 mg/dL (21.4 mmol/L) 2. Creatinine of 4.0 mg/dL (354 µmol/L) 3. Potassium of 7.0 mEq/L (7.0 mmol/L) 4. Sodium of 155 mEq/L (155 mmol/L)

Med-surge LPN delegation

Wound care and routine medication administration are the most appropriate tasks to assign to the LPN. The LPN can perform sterile procedures and cleanse and dress wounds for which there is an established prescription plan (Option 4). Pain rated at 8/10 is an expected finding in a client with chronic back pain, and the oral analgesic may be administered as scheduled by the LPN (Option 1). If this client were experiencing new-onset, unexplained pain requiring intravenous analgesic administration, the client would need assessment by the RN. (Option 2) The LPN may perform specific assessments, but evaluating the fluid volume status of a heart failure client is a comprehensive assessment involving multiple body systems (eg, heart and lung sounds, peripheral edema, adequacy of urine output). This client will also require discharge education on home management of heart failure, which is the responsibility of the RN. (Options 3 and 5) UAP have the appropriate skills and knowledge to meet clients' elimination, hygiene, and comfort needs. Although these tasks could be safely carried out by an LPN, underutilizing UAP would be an ineffective use of resources. Educational objective:LPNs may safely perform sterile procedures and routine medication administration. The RN is responsible for discharge planning and performing comprehensive clinical assessments. The nurse should also consider appropriate use of resources when making assignments or delegating tasks. Additional Information Management of Care NCSBN Client Need

The client is brought to the emergency department in handcuffs by the police. Witnesses said that the client became violent and confused after consuming large amounts of alcohol at a party. The client is placed in 4-point restraints, and ziprasidone hydrochloride is administered. The client is sleeping 30 minutes later. What is a priority action for the nurse at this time? 1. Check for a history of bipolar disease 2. Determine if restraints can now be removed 3. Monitor for widened QT intervals and hypotension 4. Obtain blood for the current blood alcohol level

Ziprasidone hydrochloride (Geodon) is an atypical antipsychotic drug that is used for acute bipolar mania, acute psychosis, and agitation. Its use carries a risk for QT prolongation leading to torsade de pointes. A baseline electrocardiogram and potassium are usually checked. At a minimum, the client should be placed on a cardiac monitor. The client should also be monitored for hypotension and seizures, especially if the previous medical history is not known or obtainable. The risk for adverse effects is increased with the interaction of alcohol. (Option 1) Although knowing past psychiatric history will assist in determining the cause of this episode, this knowledge is not essential when caring for this client's current needs. Any physical reasons for the behavior should be ruled out before focusing on psychiatric history. Risk for suicide also needs to be assessed after the client is alert and sober. (Option 2) This should be reassessed after the drug is wearing off, not before the medication is peaking. The client could suddenly wake up and become violent again. Also, it is a priority to perform restraint monitoring per protocol, including checks on circulation and hydration/elimination needs. The client's physiological response is priority. (Option 4) It would be beneficial to know the current alcohol (ethanol) level in order to estimate the client's level of intoxication and when the client will be sober. The body normally clears alcohol at a rate of 25-50 mg/dL per hour. However, there is a reliable history that the client had been drinking, and the presence of alcohol in the blood carries a risk for drug interaction. Therefore, it is more important to monitor the client for any negative effects (adverse physiological responses) from the drug than to quantify the current alcohol level.

frontal lobe

controls higher-order processing, such as executive function and personality. Injury to the frontal lobe often results in behavioral changes.

The nurse taught the caregiver of a child with a ventriculoperitoneal (VP) shunt about when to contact the health care provider (HCP). The caregiver shows understanding of the instructions by contacting the HCP about which symptom? 1. A temperature of 99 F (37 C) that occurs during the evening [3%] 2. The child cannot recall items eaten for lunch the previous day [10%] 3. The child vomits after awakening from a nap and 1 hour later [78%] 4. The VP shunt is palpated along the posterior-lateral portion of the skull [7%]

e caregiver of a child with a VP shunt must understand symptoms of increased intracranial pressure (ICP), which indicate shunt malfunction. Vomiting may be a sign of increased ICP and would require that the HCP be contacted. (Option 1) Fever may indicate shunt infection, but a temperature of 99 F (37 C) remains within acceptable parameters. Contacting the HCP is not indicated. (Option 2) Memory lapse or changes in mental status may indicate increased ICP. The inability to remember one meal would not indicate a change of mental status. (Option 4) A VP shunt is tunneled under the scalp and can be palpated.

The parent of a child treated for injuries consistent with suspected child abuse has been told that a report will be made to Child Protective Services (CPS). The parent says angrily to the nurse, "I don't know why this is being reported. I told the health care provider (HCP) that it was an accident." What is the best response by the nurse? 1. "A case worker from CPS will be visiting you in a few days. The case worker can explain it to you then." 2. "Did you ask the HCP why it is being reported?" 3. "Reporting your child's injuries is required by law. It is for your child's safety and protection." 4. "Your explanation of your child's injuries does not seem plausible."

in discussing the reporting aspect of suspected child abuse with a caregiver, the nurse needs to convey an attitude that is not judgmental, punitive, or threatening. Whether or not the parent has actually harmed or abused the child, the parent needs to know that a report will be made, why it is being filed, and an investigation will be conducted by a CPS worker and/or by the police. The nurse should emphasize that the primary concerns are for the safety and well-being of the child and that reporting is mandatory for the types of injuries sustained by the child. It is not unusual for a parent to react to this information with denial and/or anger. The nurse needs to anticipate that such a reaction may occur and maintain a supportive, empathetic, and nonaccusatory approach. (Option 1) This response also diverts the need for the nurse to provide a response or explanation to the parent. The child's caregiver should be told why the report is being filed. (Option 2) This response is nontherapeutic. It diverts the need for the nurse to respond to the parent's question, and it does not provide information or education. (Option 4) This response is confrontational and could give the parent the impression that the nurse and health care team do not believe the story of how the child sustained the injuries. The parent could react with a heightened sense of anger.

Nausea and vomiting in which client is of greatest concern to the nurse? 1. Client postoperative ophthalmic surgery 2. Client receiving chemotherapy 3. Client with Ménière disease 4. Client with severe gastroenteritis

increased intraocular pressure can cause damage to the blood vessels and retina and cause potential permanent vision loss. Coughing, vomiting, straining to lift objects (>5 lb), and bending at the waist temporarily increase intraocular pressure and must be avoided after eye surgery. Antiemetic medication is administered as needed following ophthalmic surgery to prevent vomiting. (Options 2 and 4) Nausea and vomiting are expected side effects of chemotherapy and severe gastroenteritis. (Option 3) Ménière disease affects the inner ear. Vertigo, nausea, and vomiting are expected manifestations of this disease.

Parieral lobe

integrates somatic and sensory input. Injury to the parietal lobe could result in a deficit with sensation. The nurse would verify the client's injuries and documented imaging studies to confirm that this was an expected deficit and document it accordingly. If it is a new or unexpected deficit, the nurse should inform the health care provider immediately.

DKA plasma glucose> 250 mg/dL pH <7.30 Serum HCO3 < 18 Serum ketones +

is a life-threatening complication of type 1 diabetes characterized by hyperglycemia (>250 mg/dL [13.9 mmol/L]) resulting in ketosis, a metabolic acidosis. Glucose cannot be taken out of the bloodstream and used for energy without insulin, which individuals with type 1 diabetes cannot produce. Similar to a state of starvation, the body begins to break down fat stores into ketones, causing a metabolic acidosis (low pH and low HCO3). As a compensatory mechanism, this client has deep and rapid respirations with fruity/acetone smell (Kussmaul respirations) in an attempt to reduce carbon dioxide levels by inducing a respiratory alkalosis to partially compensate for the ketoacidosis, which has nearly normalized the pH.

Bumetanide

is a potent loop diuretic (eg, furosemide, torsemide) used to treat edema associated with heart failure and liver and renal disease. The diuretic inhibits reabsorption of sodium and water from the tubules and promotes renal excretion of water and potassium. The nurse should question the bumetanide prescription as the client with heart failure has hypokalemia (potassium <3.5 mEq/L [3.5 mmol/L]) and is already at increased risk for life-threatening cardiac dysrhythmias associated with this electrolyte imbalance

Intusussception

is an intestinal obstruction that occurs when a segment of the bowel folds (ie, telescopes) into another segment. Pressure gradually increases within the bowel, causing ischemia and leakage of blood and mucus into the lumen, which produces the characteristic stool mixed with blood and mucus (ie, red, "currant jelly"). Initially, some infants may have only general symptoms (eg, irritability, diarrhea, lethargy). Subsequently, episodes of sudden abdominal pain (cramping), drawing the knees up to the chest, and inconsolable crying are seen. After an episode, the infant may vomit and then appear otherwise normal. Assessment may show a sausage-shaped abdominal mass.

St. John's Wort

may be used for tx of depression, has many interactions with other prescription meds

Aortic dissection

occurs when the arterial wall intimal layer tears and allows blood between the inner (intima) and middle (media) 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.

erythropoietin administered not IM

IV , SUBQ

In DKA management, BG of <200mg/dL IV insulin infusion may be discontinued

IV insulin infusion may be discontinued on resolution of acidosis and ketosis, which generally occurs with a blood glucose level of <200 mg/dL (11.1 mmol/L).

INR should be 1-2

if taking anticoag (WARFARIN) it wil be 2- 3

The risk management nurse is reviewing client records. Which nursing intervention could have contributed to a sentinel event? 1. Administered flumazenil to a client who overdosed on lorazepam [9%] 2. Administered insulin/dextrose to a client with potassium level of 7.2 mEq/L (7.2 mmol/L) [16%] 3. Administered warfarin to a client with International Normalized Ratio of 6 [64%] 4. Initiated nitroprusside infusion in a client with blood pressure of 210/112 mm Hg [8%]

A sentinel event is any unanticipated event in a health care setting that results in death or serious physical or psychological injury. Warfarin is an anticoagulant often used in clients with the following: Atrial fibrillation (to prevent clot formation and reduce the risk for stroke) Deep venous thrombosis and pulmonary embolism (to prevent additional clots) Mechanical heart valves (to prevent clot formation on valves) The International Normalized Ratio (INR) is a blood test used to monitor the effectiveness of warfarin therapy. The typical target INR is 2-3. In some instances (eg, mechanical heart valves), the therapeutic INR target is as high as 3.5. The higher the INR, the higher the bleeding risk. The nurse should not administer warfarin if the INR is over 4. (Option 1) Flumazenil is the appropriate antidote for a benzodiazepine overdose. (Option 2) Insulin quickly lowers serum potassium by pushing it intracellularly. Dextrose is given to prevent hypoglycemia. This is an appropriate action. (Option 4) Nitroprusside is a potent vasodilator often used for hypertensive urgencies.

The nurse is preparing medication for 4 clients on a respiratory medical-surgical unit. Which situation would prompt the nurse to clarify the prescribed treatment with the health care provider? 1. Client with bronchospasm who is due to receive nebulized acetylcysteine [53%] 2. Client with chronic obstructive pulmonary disease due to receive PO prednisone [18%] 3. Client with cystic fibrosis who is due to receive PO pancrelipase with breakfast [18%] 4. Client with suspected bacterial pneumonia due to receive IV levofloxacin [10%]

Acetylcysteine (Mucomyst) may be given via nebulizer to help loosen and liquefy respiratory secretions to more easily clear them from the airway. Inhaled acetylcysteine may be used for clients with cystic fibrosis or other respiratory conditions with thick bronchial mucus. Acetylcysteine has no therapeutic effect on airway smooth muscle as it works primarily on secretions and has been shown to cause and/or worsen bronchospasm. Nurses caring for clients with reactive airway diseases (eg, asthma) prescribed acetylcysteine should clarify the prescription with the health care provider (Option 1). (Option 2) Chronic obstructive pulmonary disease (COPD) is a respiratory illness in which excess mucus, inflamed bronchioles, and easily collapsible airways trap air within the alveoli. Oral corticosteroids (eg, prednisone) may be used to reduce airway inflammation and improve ventilation in clients with acute COPD exacerbation. (Option 3) Cystic fibrosis is a genetic condition that causes dehydration and thickening of mucus in the respiratory, gastrointestinal, and genitourinary systems. Thick mucus within the pancreas impairs the release of digestive enzymes (eg, lipase), requiring supplementation to improve digestion and prevent malnutrition in clients with CF. (Option 4) Levofloxacin (Levaquin) is a broad-spectrum antibiotic that may be used to treat respiratory tract infections, such as bacterial pneumonia.

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

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

The charge nurse is educating a new nurse on IV start technique for a 6-year-old with autism spectrum disorder. Which statement by the new nurse indicates that further teaching is required? 1. "I will explain the procedure with the use of pictures." [30%] 2. "I will have the child's caregiver at the bedside to provide comfort." [3%] 3. "I will hold the child's hand as a soothing measure." [60%] 4. "I will limit the number of hospital staff in the room to ease anxiety." [5%]

Autism spectrum disorders (ASDs) are neurodevelopmental disorders characterized by impairedv social interaction and behavior. Each child with ASD has unique communication needs, which the nurse should incorporate into an individualized plan of care. When performing a procedure on a child with ASD, the nurse should engage the following communication techniques to ease the child's anxiety and increase cooperation: Provide brief, concrete, and developmentally appropriate communication or demonstrations, explaining each step during the procedure. Children with ASD may respond to pictures, as they tend to be visually oriented (Option 1). Encourage caregivers to remain near the child to provide comfort and reassurance (Option 2). Reduce stimulation by limiting the number of staff members in the room (Option 4). Introduce staff or equipment slowly, preferably with caregivers nearby. (Option 3) Children with ASD may experience stress in response to touching and eye contact. Limit physical contact until conferring with the child's caregiver to assess which actions are soothing and which may trigger behavioral outbursts.

The nurse is caring for a client with a central venous catheter (CVC) who reports feeling nauseated and chilled. The nurse notes that the CVC insertion site is red and inflamed and that the client has a temperature of 102 F (38.8 C). Which new prescription from the health care provider should the nurse implement first? 1. Administer ondansetron 4 mg IV push PRN for nausea or vomiting [3%] 2. Document the occurrence and notify the hospital's epidemiology team [1%] 3. Initiate the first dose of IV piperacillin/tazobactam via a new peripheral IV [13%] 4. Obtain blood cultures and discontinue the central venous catheter [81%]

Central venous catheters (CVCs) are used in the treatment of clients who require long-term IV access or are prescribed hypertonic solutions (eg, total parenteral nutrition) or vesicant medications. CVCs can serve as a portal of entry for bacteria, which increases the risk of developing serious bloodstream infections. Nurses caring for clients with CVCs should report any new or worsening signs of infection (eg, fever, chills, erythema at the CVC site) to the health care provider because central line-related bloodstream infections (CRBSIs) require prompt treatment to prevent possible sepsis. In response to a possible CRBSI, the CVC should be removed as soon as possible to prevent continued exposure to the infection source. Blood cultures should be obtained before initiating antibiotic therapy, as antibiotics may contaminate the sample and prevent identification of the infectious organism (Option 4). (Options 1 and 2) Administering medications for comfort, completion of documentation, and facility-based report protocols should be done as soon as possible. However, to prevent progression to sepsis, treatment of a suspected CRBSI should not be delayed. (Option 3) Initiation of antibiotics is essential in treating infection and preventing its progression. However, the nurse should first draw blood cultures and remove the CVC, if possible.

The nurse is caring for a 7-month-old client during a well-child visit. Which of the following gross motor skills should the nurse expect to identify at this age? Select all that apply. 1. Bears full weight on feet with support 2. Moves from lying down to a sitting position 3. Pulls up into a standing position from sitting 4. Sits using hands for extra support 5. Walks while holding on to furniture

Childhood development usually occurs in an orderly and predictable manner, with more complex skills being acquired as age increases. Fine (eg, grasp) and gross (eg, posture, balance, movement) motor skills are assessed during routine well-child visits to identify normal development and detect delays. During infancy, gross motor development begins with head and neck control and progresses to skills such as turning over, bearing weight on the arms in a prone position, sitting with the head erect, standing, crawling (ie, abdomen touching floor), creeping (ie, abdomen lifted off floor), and walking. By age 7 months, infants should be able to bear their full weight while standing with caregiver support and sit with minimal support from their hands (ie, tripod sitting) (Options 1 and 4). (Option 2) By age 7 months, infants can roll over, but the ability to move from a prone to a sitting position is not expected until age 10 months. (Option 3) Some infants learn to pull themselves up into a standing position early, but this is not expected until age 9-10 months. (Option 5) Walking while holding on to furniture is not expected until age 11 months.

The nurse reviews discharge instructions with a client who has advanced chronic obstructive pulmonary disease. Which client statement indicates appropriate understanding? Select all that apply. 1. "I need to take iron supplements to prevent anemia." 2. "I should report an increase in sputum." 3. "I will eat a low-calorie diet." 4. "I will get a pneumococcal vaccine." 5. "I will use albuterol if I am short of breath."

Clients with chronic obstructive pulmonary disease (COPD) suffer from progressive inflammatory tissue damage, which eventually leads to lung scarring and airway remodeling. Through these mechanisms, COPD leads to chronic air trapping and reduced gas exchange by decreasing ventilation. Clients with COPD are at increased risk for respiratory infections, which can trigger an acute exacerbation of COPD. Therefore, it is vital that clients receive both routine influenza and pneumococcal vaccinations (Option 4). It is also important that clients seek medical help for increased sputum (Option 2), worsening shortness of breath, or lack of relief from prescribed emergency medications (eg, albuterol, ipratropium) (Option 5). (Option 1) COPD may lead to polycythemia (increased red blood cells), in which the body attempts to compensate for chronic hypoxia by increased proliferation of erythrocytes. This occurs when erythropoietin is released from the kidneys in response to hypoxemia and leads to erythropoiesis. This ultimately has the opposite effect of anemia, making supplementation with iron not necessary and possibly even harmful. (Option 3) Clients with COPD have increased work of breathing and are often winded by simple activities (eg, eating). Clients should eat frequent, small, high-calorie meals to conserve energy and meet nutritional requirements.

The nurse is reinforcing discharge teaching for a client who is hearing impaired. Which of the following actions should the nurse implement? Select all that apply. 1. Encourage the client to repeat back teaching 2. Ensure adequate lighting in the client's room 3. Provide teaching to the family instead of the client 4. Sit directly in front of the client while speaking 5. Use printed materials with pictures and illustrations

Clients with hearing impairment require accommodations to promote engagement in care and ensure understanding of teaching. Nursing interventions should focus on facilitating effective and inclusive communication with hearing-impaired clients to maintain their safety. Always communicate with hearing-impaired clients by sitting directly in front of them in a well-lit room so all visual cues, such as facial expressions and hand gestures, can be seen (Options 2 and 4). Some hearing-impaired clients can also lip-read, which requires adequate visibility. Avoid lighting that can create shadows or glares that could distort what the client sees. The nurse can evaluate the clients' level of understanding by encouraging them to repeat back instructions (Option 1). If the client is unable to repeat them back, provide further clarification with an alternative approach. Consider incorporating printed materials with visuals, such as pictures and illustrations, or acting out demonstrations to supplement the verbal instructions (Option 5). (Option 3) The client should always remain the focus of teaching. With the client's consent, including the family in teaching can be helpful; however, the client should not be excluded.

The nurse on the antepartum unit is performing shift assessments of several pregnant clients. Which client assessment is the priority to report to the health care provider? 1. Client with gestational diabetes mellitus reporting dysuria [2%] 2. Client with hyperemesis gravidarum with a blood pressure of 90/48 mm Hg [42%] 3. Client with oligohydramnios and a reactive fetal nonstress test [7%] 4. Client with preeclampsia with 3+ reflexes and 2 beats of clonus [47%]

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

The emergency department 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? 1. Head-tilt chin-lift in the supine position on a backboard 2. Head-tilt chin-lift in the Trendelenburg position 3. Jaw-thrust maneuver in semi-Fowler's position 4. Jaw-thrust maneuver in the supine position on a backboard

Clinical situations involving trauma should follow ABC: Airway, Breathing, and Circulation. 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 Advanced Trauma Life Support-qualified health care provider. Until the spine 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. (Option 1) 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. If the cervical vertebrae are fractured, the spinal cord could be badly damaged. (Option 2) 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. (Option 3) The jaw-thrust maneuver is appropriate, but stabilization of the spine is best performed in the supine position, such as on the flat, hard surface of a backboard.

The nurse cares for a child newly diagnosed with cystic fibrosis. What should be included in the client's multidisciplinary plan of care to be discussed with the parents? Select all that apply. 1. Aerobic exercise 2. Chest physiotherapy 3. Financial needs 4. Low-calorie diet 5. Oral fluid restriction

Cystic fibrosis (CF) is a genetic disorder involving the cells lining the respiratory, gastrointestinal (GI), and reproductive tracts. A defective protein responsible for transporting sodium and chloride causes secretionsin these areas to be thicker and stickier than normal. These abnormal secretions plug smaller airway passages and ducts in the GI tract, which can impair digestive enzymes and result in ineffective absorption of essential nutrients. These sticky respiratory secretions lead to a chronic cough and inability to clear the airway, eventually causing chronic lung disease (bronchiectasis). As a result of these changes, the client's life span is shortened; most affected individuals live only into their 30s. Chest physiotherapy helps remove sticky secretions that cause ineffective airway clearance (Option 2). Aerobic exercise is beneficial to promote removal of airway secretions, improve muscle strength, and increase lung capacity (Option 1). Financial needs must be discussed, as clients with CF have a large financial burden due to health care costs, medications, and special equipment (Option 3). (Option 4) A diet high in fat and calories is recommended due to defective digestive enzymes and impaired nutrient absorption. (Option 5) Fluids are not restricted; liberal intake is recommended to assist in thinning respiratory secretions.

A client with a history of a seizure disorder has a seizure while sitting in a chair. Which nursing interventions are appropriate during the seizure activity? Select all that apply. 1. Administer oxygen as needed if client becomes cyanotic 2. Insert a flexible nasopharyngeal airway for airway protection 3. Move the client from the chair to the floor to prevent a fall 4. Record the duration of seizure activity for documentation 5. Restrain the client's arms and legs to prevent injury

During seizure activity, the priority is client safety. Nursing interventions include: Assist seated or standing clients to lie down, while protecting the head, and position on the side to maintain a patent airway and prevent aspiration (Option 3). Loosen restrictive clothing and clear the area near the client (eg, furniture corners, sharp or hard objects) to prevent injury. Administer oxygen as needed in response to signs of hypoxia (eg, cyanosis, pallor) (Option 1). Record and document the time and duration of the seizure (Option 4). (Option 2) Although clients may require oxygen if they are symptomatic (decreased oxygen saturation level), artificial airways or other objects are never inserted into the mouth or nose during a seizure due to risk of trauma. A nasopharyngeal airway would not prevent the tongue from obstructing the airway during a seizure. When seizure activity has stopped, suctioning and/or insertion of an oral airway may be necessary if the client's airway is obstructed. (Option 5) The client should never be restrained during a seizure. Strong muscle contractions occur during seizures; therefore, if the client is restrained, injury could occur.

The nurse is teaching the mother of a newborn about gastroesophageal reflux. What does the nurse suggest to help prevent reflux? Select all that apply. 1. Burp during and after feeds 2. Engage baby in active play after the feeding 3. Feed baby in side-lying position 4. Hold baby upright 20-30 minutes after each feeding 5. Offer smaller but more frequent feeds 6. Place baby on tummy after feeding

Gastroesophageal reflux (GER) is attributed to an immature lower esophageal sphincter. It is common in infants age ≤3 months and results in spitting up after feeds. If an infant is gaining weight and meeting developmental milestones, treatment is aimed at controlling the symptoms. Because infants with GER are at risk for aspiration and apnea, caregivers should be instructed in cardiopulmonary resuscitation. Burping the baby frequently helps expel trapped air before milk builds up over it. If there is milk over an air pocket, the milk will come up with the burp (Option 1). Holding the baby upright for 20-30 minutes after feedings allows gravity to assist in keeping the food in the stomach while the stomach settles (Option 4). Feeding the baby smaller but more frequent feeds prevents the stomach from becoming too full and expelling extra milk and allows for more complete emptying before the next feed. It also ensures that the child is getting the required ounces daily (Option 5). (Options 2, 3, and 6) These infants should not be rocked or agitated by active play for at least 30 minutes after feeding and should be kept calm and upright. Placing them on the stomach creates abdominal pressure, which can aggravate the reflux. Infants should not be placed in a car seat after feedings as this can increase intra-abdominal pressure and cause reflux.

The nurse receives handoff of care report on four clients. Which client should the nurse assess first? 1. Client who had an emergency appendectomy 48 hours ago and is reporting hearing waves and seeing fish swimming through the walls [73%] 2. Client who had an exploratory laparoscopy 2 hours ago and has absent bowel sounds and is reporting nausea [9%] 3. Client with diabetes mellitus who has a foot ulcer and is reporting feeling pins and needles in the lower legs [9%] 4. Client with Parkinson disease who has tremors while resting and developed black-colored urine after taking carbidopa/levodopa [7%]

Hallucinations represent a serious safety risk to the client and others because these may compel clients to engage in behaviors or activities that trigger self-injury or violence toward others (eg, command hallucinations). Hallucinations experienced by clients without a psychiatric illness may indicate withdrawal from alcohol or narcotics, which can be life-threatening without prompt intervention. Nurses should promptly assess clients with new or worsening hallucinations (Option 1). (Option 2) Clients undergoing abdominal surgery (eg, exploratory laparoscopy) often have nausea and absent bowel sounds for the first few hours postoperatively due to side effects of anesthetics and decreased peristalsis after bowel manipulation. (Option 3) Clients with diabetes mellitus may develop diabetic neuropathy as a complication of neurovascular damage from inadequate long-term blood glucose management. Feeling "pins and needles" is an uncomfortable but harmless symptom of diabetic neuropathy. (Option 4) Resting tremors are an expected finding with Parkinson disease. Carbidopa/levodopa, a common medication used to manage symptoms of Parkinson disease, can cause a harmless darkening of urine color (eg, brown, black).

The nurse is caring for a client who had an anterior wall myocardial infarction 2 days ago. The telemetry technician notifies the nurse at 8:30 AM that the client is in ventricular trigeminy. What is the nurse's priority intervention? Click the exhibit button for additional information. 1. Administer potassium replacement [74%] 2. Administer the dose of amiodarone [10%] 3. Attach cardiac defibrillator pads [5%] 4. Notify the health care provider [10%] Sodium140 mEq/L (140 mmol/L)Potassium3.0 mEq/L (3.0 mmol/L)Magnesium1.8 mg/dL (0.9 mmol/L)Creatinine1.1 mg/dL (97 µmol/L) Aspirin 81 mg PO daily0900Amiodarone 200 mg PO daily0900 Potassium replacement protocol If serum potassium is:≤3.2 mEq/L (3.2 mmol/L)Administer potassium chloride 40 mEq PO every 2 hours x 2 doses 3.3-3.8 mEq/L (3.3-3.8 mmol/L)Administer potassium chloride 40 mEq PO x 1 dose ≥3.9 mEq/L (3.9 mmol/L)No treatment Repeat serum potassium levels 2 hours after completion of potassium replacement. If creatinine >1.5 mg/dL (133 �mol/L), do not initiate protocol. Call health care provider for specific orders.

In ventricular trigeminy, premature ventricular contractions (PVCs) occur every third heartbeat. Myocardial injury (eg, myocardial infarction) predisposes the client to ectopy (eg, PVCs), which increases the client's risk for lethal dysrhythmias (eg, ventricular tachycardia). PVCs are caused and/or exacerbated by hypoxia, electrolyte imbalances, emotional stress, stimulants, fever, and exercise. This client's morning laboratory results show hypokalemia (potassium <3.5 mEq/L [3.5 mmol/L]); therefore, the priority is treatment of the underlying cause of the ectopy by administering the prescribed potassium replacement (Option 1). Health care providers (HCPs) often prescribe electrolyte replacement algorithms to clients at risk for electrolyte imbalances (eg, myocardial injury, receiving diuretics) unless a contraindication exists (eg, serum creatinine >1.5 mg/dL [133 µmol/L], anuric, weight <99.2 lb [45 kg]). (Option 2) Amiodarone is an antiarrhythmic medication with a long duration of action (ie, 13-107 days). An acute drop in the drug level is not likely the cause of the ectopy. The nurse should administer amiodarone as prescribed after initiating the potassium replacement. (Option 3) Correcting the electrolyte imbalance should resolve the client's ectopy, preventing the need for defibrillation. (Option 4) The HCP should be notified; however, the nurse should first assess the client and initiate potassium replacement.

The nurse is walking through a mall parking lot and witnesses the collapse of a child. The child is not breathing and has a pulse of 50/min. After the nurse calls emergency services and delivers rescue breaths for 2 minutes, the child is still not breathing and is now pale with a pulse of 49/min. What is the nurse's next action? 1. Assess the child's airway [57%] 2. Begin chest compressions [30%] 3. Continue rescue breathing [9%] 4. Perform abdominal thrusts [2%]

Infants and children (age 1 year to puberty) often develop respiratory distress and bradycardia prior to cardiac arrest. After witnessing the collapse of a child who is not breathing but has a pulse, the nurse should contact emergency services and initiate rescue breathing. After two minutes of rescue breathing, if the pulse remains ≤60/min and there are signs of poor perfusion (eg, skin pallor), the nurse should initiate compressions because the heart isn't circulating blood and oxygen effectively (Option 2). Initiating compressions prior to cardiac arrest improves outcomes. (Option 1) Assessing the airway interrupts valuable time that could be spent providing high-quality compressions. In addition, the nurse can determine airway patency while delivering rescue breaths by watching for the rise and fall of the chest. (Option 3) If the heart rate increases to >60/min with signs of adequate perfusion, the nurse should continue with rescue breathing only (1 breath every 3-5 seconds or 12-20 breaths/min for children). (Option 4) Abdominal thrusts (ie, Heimlich maneuver) are powerful, upward squeezes to the diaphragm to expel an object from the trachea of a choking victim. There is no indication that this child is choking.

The nurse plans care for a child admitted with measles. Which of the following interventions will the nurse include in the plan of care? Select all that apply. 1. Advise measles vaccination for susceptible family members 2. Apply calamine lotion to reduce itching 3. Place a tracheostomy tray at the bedside 4. Place the client in a negative-pressure isolation room 5. Use a N95 respirator mask during client contact

Measles (ie, rubeola) is a highly contagious viral illness that affects people of all ages. Measles spreads when infected individuals cough or sneeze, sending the virus through the air, where it remains suspended for up to 2 hours. Widespread vaccination with the measles, mumps, and rubella (MMR) vaccine, such as in the United States, has reduced measles incidence by 99%. However, an increase in international travel and unvaccinated children have caused a resurgence of the disease. For hospitalized clients with measles, the plan of care should include the following: Recommendation of postexposure prophylaxis (ie, MMR vaccine) for eligible, susceptible (eg, unvaccinated) family members within 72 hours of exposure to decrease the severity and duration of symptoms in case they contract the disease (Option 1) Implementation of airborne precautions, including a negative-pressure isolation room and use of an N95 respirator mask, during contact with the client by health care staff (Options 4 and 5) Administration of vitamin A supplements to prevent severe, measles-induced vitamin A deficiency, which can cause blindness, particularly in clients in low-resource areas (Option 2) An erythematous, maculopapular, morbilliform rash is characteristic of measles, but it is not typically pruritic. Calamine lotion is effective for soothing pruritic rashes (eg, varicella [chickenpox]). (Option 3) A tracheostomy tray is not required for this client with measles because respiratory paralysis or emergency intubation is not expected.

A nurse manager on a pediatric oncology unit is leading a discussion about personal coping strategies that nurses can use to remain effective when caring for dying children. What should be included in the discussion? 1. Attending a child's memorial service can be helpful 2. Avoid expressing personal feelings of grief or loss directly with the family 3. Personal contact with the family of the deceased should end after they leave the hospital 4. The length of daily exercise routines should be increased

Nurses who care for dying children experience many of the same feelings that the child's family does, resulting in stress that may lead to compassion fatigue. To remain positive in the caring role, nurses must implement appropriate coping strategies to enhance self-care and grief resolution. Attending a memorial service can demonstrate care for the grieving family while also providing closure for the nurse. Other helpful strategies for coping include: taking time off from work if distancing is needed, utilizing personal and professional support systems (eg, spouse, employee assistance programs, experienced mentors), and maintaining good health through adequate rest, regular exercise, and proper nutrition. (Option 2) The nurse should maintain a level of objectivity to make effective care decisions, but it is sometimes appropriate to share personal emotions of loss or sadness with the family of a dying child. Honesty and personal connection support the coping process for the nurse and the family. (Option 3) Personal contact with the family of the deceased child for an extended period after their loss is helpful for the nurse and the family during the grieving process, particularly if a close relationship was established during hospitalization. (Option 4) Although exercise is an important part of maintaining overall health, there is no evidence that increasing the length of daily exercise routines is an effective coping strategy

The nurse is assessing the abdomen of a client experiencing gastrointestinal distress. Place the answer choices in the correct order of assessment. All options must be used.

Nursing assessments are generally performed in order of least to most invasive. To perform an abdominal assessment, the nurse places the client in the supine position to promote relaxation of the abdominal muscles. Standing on the right side of the client, the nurse makes a visual inspection of the abdomen before touching the client. After inspection, the nurse auscultates the abdomen. Auscultation is performed next because percussion and palpation may increase peristalsis, potentially leading the nurse to make an erroneous interpretation of bowel sounds. The nurse should lightly place the diaphragm of the stethoscope in the right lower quadrant because high-pitched bowel sounds are normally present in this region. After auscultation, the nurse proceeds to percussion. Palpation is performed last because it may induce pain, resulting in abdominal rigidity, guarding, and a change in respirations. This rigidity may affect the tone heard on percussion. Percussion is also intended to identify borders of organs that move with respiration (eg, liver, spleen). A client in pain from abdominal tenderness will likely take quick, shallow breaths, which will change how far organs are displaced and make it more difficult for the examiner to identify true borders of organs.

The nurse prepares to administer intravenous albumin to a client with severe liver disease who has a low serum albumin level of 1.5 g/dL (15 g/L). Which characteristic finding associated with hypoalbuminemia should the nurse anticipate assessing? 1. Altered mental status [29%] 2. Easy bruising [14%] 3. Loss of body hair [8%] 4. Pitting edema [47%]

Oncotic pressure (or colloid osmotic pressure) is a form of osmotic pressure exerted by plasma proteins (albumin) in the blood that pulls water into the circulatory system. Albumin (normal: 3.5-5.0 g/dL [35-50 g/L]) 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 (Option 4). (Options 1, 2, and 3) Altered mental status, easy bruising, and loss of body hair are manifestations of liver disease, not hypoalbuminemia. Altered mental status (hepatic encephalopathy) 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 prepares to administer potassium chloride to a client through a peripherally inserted IV line. What are the appropriate nursing interventions related to administration of this medication? Select all that apply. 1. Administer as IV bolus 2. Assess IV site frequently 3. Assess renal function laboratory results and urine output 4. Place client on cardiac monitor 5. Verify that IV pump infusion is not >10 mEq/hr (10 mmol/hr)

Potassium chloride (KCl) is commonly prescribed to correct or prevent hypokalemia. The normal range for serum potassium is 3.5-5.0 mEq/L (3.5-5.0 mmol/L). Potassium is commonly lost through diarrhea, vomiting, and diuretic use. Clients receiving KCl IV should have periodic cardiac monitoring during therapy, as changes in potassium levels can cause cardiac rhythm disturbances and rapid infusion can cause cardiac arrest (Option 4). Potassium is a vesicant; therefore, the IV insertion site should be monitored frequently for extravasation to prevent tissue necrosis (Option 2). The maximum infusion rate of KCl through a peripheral line is 10 mEq/hr (10 mmol/hr) and the maximum concentration is 40 mEq/L (40 mmol/L) (Option 5). Higher rates and concentrations require a central venous catheter. Renal function should be assessed as clients with impaired renal function are unable to excrete potassium and other electrolytes effectively, potentially leading to toxicity. To assess renal function, the nurse should monitor renal function laboratory results (eg, blood urea nitrogen, creatinine) and urine output (Option 3). (Option 1) KCl is never administered by IV push or as a fluid bolus. KCl is always diluted and given via infusion pump.

The nurse conducts a developmental assessment of a 4-year-old child. Which of the following tasks does the nurse anticipate that the child will perform successfully? Select all that apply. 1. Draw a circle 2. Jump rope with both feet 3. Sit quietly for 30 minutes 4. Use a spoon and fork 5. Walk up and down stairs

Preschool-age children begin to master more gross motor activities while rapidly increasing their fine motor abilities. The preschooler age 4 should have the fine motor skills to manipulate small tools (eg, scissors, pencil) and therefore be able to draw simple shapes (eg, circle, square) and perform more self-care activities (eg, eating with a spoon and fork) (Options 1 and 4). The gross motor skills and balance of a child age 4 improve, allowing for more independent, complex movements (eg, walking up and down stairs) (Option 5). (Option 2) A preschool-age child typically gains the ability to jump rope around age 5. A child age 4 would not yet be expected to jump rope successfully. (Option 3) It is normal for preschool-age children to be unable to sit quietly for longer than 15 minutes at a time.

A child's arm is burned from accidentally spilling boiling water on it, and the parent calls the clinic. The nearest emergency department is an hour away. Which instructions would be appropriate to give the parent? Select all that apply. 1. "Apply antibiotic ointment to any open skin." 2. "Briefly soak the arm with cool water." 3. "Cover the area with a clean, dry cloth." 4. "Place ice on the arm to relieve pain." 5. "Remove clothing, if not stuck to skin, around the burn."

Proper emergency care immediately following a burn can prevent infection, hypothermia, and further tissue damage. Once the source of the burn is contained, the nurse teaches the client home care that can be given prior to arrival to the emergency department. Client teaching includes: Soak area briefly in cool water to stop the burning process (Option 2). Remove any clothing or jewelry around the burn to avoid constriction as edema develops. This also allows for quick assessment of the burn by clinicians. Only a health care provider may remove clothing that is stuck to the burned area (Option 5). Cover with a clean, dry cloth to prevent contamination, further trauma, and hypothermia (Option 3). (Option 1) Medications should not be applied to a burn until prescribed by a health care provider as they may interfere with assessment of the burned area. (Option 4) Placing ice on a burn or wrapping the area in ice can increase tissue damage and may cause hypothermia with large burns. No ice, ointments, creams, or butter should be placed on the open skin.

A student nurse is accompanying the charge nurse when conducting daily rounds. Which personal protective measure by the charge nurse does the student nurse question? 1. Dons a mask with eye shield before irrigating a draining wound for a client on standard precautions [7%] 2. Places a "soap and water only" sign on the door of a client with Clostridium difficile [12%] 3. Wears 2 pairs of gloves when emptying the urinary catheter collection bag of a client with HIV [55%] 4. Wears an N95 respirator before entering the room of a client with active varicella-zoster [23%]

The best way for health care workers to protect themselves against possible HIV infection is to consistently follow standard (universal) precautions with all clients, regardless of HIV status. HIV is spread when nonintact skin comes into contact with infected blood, breast milk, semen, and vaginal secretions. No extra precautions are needed for routine care of clients with HIV as the virus is not spread through casual contact, droplets, or aerosolized particles. Some experienced nurses hold to the common misconception that "double-gloving" reduces the risk of contracting HIV. Appropriate use of a single pair of clean gloves provides a barrier between the nurse's hands and the client's blood and body fluids (Option 3). (Option 1) In compliance with standard precautions, situations in which blood or body fluids may splash or be sprayed (eg, suctioning, irrigation) require additional personal protective equipment (eg, face shield, gown) as necessary. (Option 2) Washing hands with soap and water is required to remove Clostridium difficile spores; hand hygiene with foam or gel alone is ineffective. (Option 4) An N95 respirator is worn when the client has an illness that can be aerosolized and spread through the air (eg, tuberculosis, varicella-zoster).

The nurse on the cardiac unit reviews a current rhythm strip from a client who experienced an inferior wall myocardial infarction. What action should the nurse take first? Click on the exhibit button for additional information. 1. Document the rhythm as an expected finding [30%] 2. Obtain the transcutaneous pacemaker [20%] 3. Prepare to administer adenosine IV [13%] 4. Review medications the client is receiving [35%]

The client is experiencing a second-degree type 2 atrioventricular (AV) block (Mobitz II), which is characterized by more P waves than QRS complexes. The PR intervals are consistent or constant, reflecting regular conduction of electrical impulses through the AV node, but dropped QRS beats randomly occur as ventricular conduction is blocked. A second-degree type 2 AV block can rapidly deteriorate to complete heart block (third-degree AV block), which is life-threatening. The nurse should quickly obtain a transcutaneous pacemaker, assess the client for symptoms (eg, bradycardia, hypotension, syncope), and be prepared to pace the client if symptoms occur (Option 2). If the client is asymptomatic, the pacemaker is kept nearby in case the rhythm deteriorates, and the health care provider is alerted. (Option 1) A common complication following myocardial infarction is the development of new arrhythmias. Although a second-degree type 2 AV block is not completely unexpected in this client, it indicates a concerning situation that requires assessment and monitoring. (Option 3) Adenosine is used to treat supraventricular tachycardia. Adenosine creates a transient heart block, which then allows the heart to resume normal sinus rhythm. It is never given for bradyarrhythmias. (Option 4) Medications should be reviewed as drug toxicity (eg, beta blockers, digoxin) can cause this type of block. However, this can be done after other interventions. Educational objective:

The student nurse is performing an assessment of a 10-year-old diagnosed with attention-deficit hyperactivity disorder (ADHD). In addition to the 3 core symptoms of ADHD (hyperactivity, impulsiveness, and inattention), which of the following would the student nurse expect to find during the assessment? 1. Confusion and a learning disability [24%] 2. Delayed physical and emotional development [12%] 3. Disorientation and cognitive impairment [14%] 4. Low self-esteem and impaired social skills [49%]

The core symptoms of ADHD include hyperactivity, impulsiveness, and inattention. Hyperactive children are restless; have difficulty remaining seated when required; and exhibit excessive talking, blurting out answers prematurely, and interrupting others. Inattention is characterized by reduced ability to focus and attention to detail, easy distractibility, and failure to follow through (eg, homework, chores). The primary symptoms of ADHD have a negative impact and can make life difficult for children in school, at work, and in social situations. Symptoms interfere with opportunities to acquire social skills and may also result in rejection and critical judgment by peers. The negative consequences of ADHD include: Poor self-esteem Increased risk for depression and anxiety Increased risk for substance abuse Academic or work failure Trouble interacting with peers and adults (Option 1) Children with ADHD are more likely to have a learning disability. Confusion is not a typical clinical finding. (Option 2) Although children with ADHD may appear to be emotionally immature for their age, ADHD is not associated with delayed physical growth. (Option 3) Children with ADHD are not disoriented. ADHD is associated with a range of cognitive impairments, but no single cognitive dysfunction typifies all children with the disorder. Some children have no impairment at all.

An emergency department 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? Select all that apply. 1. Apply a hard cervical collar 2. Assess neck range of motion 3. Inspect client's respiratory pattern 4. Position client flat on firm surface 5. Use logrolling technique if moving client

The initial priorities for a client with a suspected cervical spine 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 (eg, a backboard), and moving the client as a unit (logrolling) if required (Options 1, 4, and 5). 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 (eg, hypotension, bradycardia, poikilothermia [ie, inability to regulate body temperature]), 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 (Option 3). (Option 2) 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 assesses the site where a client received an intradermal purified protein derivative (ie, Mantoux) test 48 hours ago and notices a 16-mm area of induration. The client has no symptoms. Which action will the nurse take next? 1. Document the negative response in the client's medical record [5%] 2. Have the client return in a week to receive a second injection [4%] 3. Obtain a prescription for the client to have a chest x-ray [77%] 4. Place the client in an airborne-infection isolation room [12%]

The intradermal purified protein derivative (PPD) test, or Mantoux test, is administered to screen for tuberculosis (TB). The forearm is injected with 0.1 mL of the PPD, and the client returns in 48-72 hours to have the site assessed for induration (a raised area). Redness alone is not read as a positive response. An area of induration >15 mm is considered a positive response in any client (Option 1). However, a positive PPD test does not mean that the client has active TB infection but rather that the client has been exposed to TB and has developed an immune response. Positive sputum cultures, chest x-rays, and the presence of symptoms confirm that the client has active disease(Option 3). (Option 2) A second injection is not needed when the client has a positive PPD. (Option 4) Placing the client in airborne precautions before confirming the presence of active TB is premature. Only clients with active TB (eg, symptoms, positive chest x-ray or sputum stain/culture) require isolation.

Which prescriptions for these clients does the nurse question? Select all that apply. 1. Client with Clostridium difficile colitis, prescribed vancomycin 125 mg PO 2. Client with diabetes and elevated mealtime glucose, prescribed lispro insulin scale 6 units subcutaneously 3. Client with gastrointestinal bleed and nasogastric tube, prescribed pantoprazole 40 mg intravenous 4. Client with hypertension and blood pressure (BP) 94/40 mm Hg, prescribed metoprolol succinate SR 50 mg PO 5. Client with otitis media and penicillin allergy, prescribed ampicillin 500 mg PO

The nurse would question the prescriptions for the following clients: Client with hypertension and BP 94/40 mm Hg, prescribed metoprolol succinate SR (Toprol-XL) 50 mg PO: This client's mean arterial pressure (MAP) is only 58 mm Hg ({[2x diastolic] + systolic} ÷ 3). A MAP >60-65 mm Hg is necessary to perfuse the vital organs (eg, brain, coronary arteries, kidneys). Toprol-XL is a long-acting beta blocker and will continue to drop the client's BP over a 24-hour period. Client with otitis media and penicillin allergy prescribed ampicillin 500 mg PO: Ampicillin is classified as a penicillin antibiotic and is contraindicated in clients with a penicillin allergy. (Option 1) C difficile colitis is treated with metronidazole or vancomycin, depending on severity and number of relapses. Vancomycin is typically given orally in this situation, unlike other nonintestinal infections in which IV is the standard route. There is no reason to question this prescription. (Option 2) A sliding insulin (correction) scale is used to prescribe rapid-acting lispro (Humalog) to control postprandial hyperglycemia. The nurse would not question this prescription. (Option 3) Proton pump inhibitors (eg, pantoprazole, omeprazole) are prescribed for gastroesophageal reflux disease, and ulcer treatment and prophylaxis. The IV preparation is administered when the oral route is contraindicated. The nurse would not question this prescription.

Which nursing instruction is the highest priority when teaching a 38-year-old female client newly diagnosed with stress incontinence? 1. Coaching related to Kegel exercises [45%] 2. Importance of voiding every 2 hours [30%] 3. Minimizing caffeine and alcohol [19%] 4. Use of incontinence pads and pessary [4%]

The nursing care plan for a client experiencing stress incontinence includes pelvic floor exercises, bladder training, incontinence products, and lifestyle modifications. The highest priority for a client newly diagnosed with stress incontinence is preventing skin breakdown and urinary tract infections through bladder training. Teaching the client to empty the bladder every 2 hours when awake and every 4 hours at night reduces these risks (Option 2). Pelvic floor exercises (eg, Kegel exercises), which strengthen the sphincter and structural supports of the bladder, are an essential part of the teaching plan but are not the priority for this client (Option 1). It will take approximately 6 weeks for pelvic floor muscle strength to improve. Natural bladder irritants (eg, smoking, caffeine, alcohol) increase incontinence and should be eliminated but are not the priority in this client (Option 3). Pessaries relieve minor pelvic organ prolapse and may be used in some clients when initial conservative measures fail. This client should receive initial instruction on the importance of emptying the bladder often (Option 4)

A 3-month-old 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 prioritynursing action? 1. Document a description of the injury 2. Question the mother about where the infant sleeps 3. Report the injury per facility protocol 4. Separate the mother from the infant

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 (torsion), which is an unlikely accidental injury in a nonambulatory child. Fractures in young children, especially nonambulatory 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 in the United States and Canada (Option 3). However, the nurse should also be aware of cultural health practices (eg, cupping, coining) and physiologic conditions (eg, hemophilia, Mongolian spots) mimicking maltreatment. After reporting suspected maltreatment, the nurse should: Facilitate a complete physical evaluation (eg, skeletal survey, growth/development comparisons, radiographic studies, neurologic examination) Document facts and observations objectively, using medical terms when possible (Option 1). Include the history provided by the parent or caregiver and the time period from injury occurrence to evaluation. Perform a review of child-care practices with the caregiver (Option 2). (Option 4) A child and caregiver should only be separated when the child is in immediate physical danger or if authorities must interview a verbal child without the parent present.

The public health nurse conducts a teaching program for parents of infants. Which statement by a participant indicates that teaching has been successful? 1. "After age 6 months, it is safe to use honey to sweeten my infant's formula." [2%] 2. "I should wait until my infant is 1 year old to introduce egg products." [29%] 3. "I will switch my 1-year-old to low-fat milk instead of commercial formula." [12%] 4. "My infant should be able to pick up small finger foods by age 10 months." [56%]

The pincer grasp, a thumb to forefinger movement, develops at age 8-10 months. This is the time to start offering small finger foods, such as crackers or cut-up pieces of nutritious foods. Caregivers should inform their health care provider if the infant does not achieve this significant milestone in fine motor development (Option 4). (Option 1) Formula should never be sweetened. Honey (especially raw or wild) should not be offered to children age <12 months because their immature gut systems are susceptible to Clostridium botulinum(botulism) infection. (Option 2) Common allergenic foods (eg, eggs, fish, peanut products) may be introduced along with other foods starting at age 4-6 months. Previous guidelines recommended delaying introduction of these foods until age 12 months. However, recent evidence suggests that delaying introduction of these foods may actually increase the risk for food allergy. (Option 3) Infants should be transitioned to whole milk, not low-fat milk, at age 12 months. Due to rapid growth, a child's brain requires the nutrition from the fat found in whole milk.

A child received the varicella immunization. The day after the injection, the parent calls the nurse to say that the child has discomfort, slight redness, and 2 vesicles at the injection site. What instruction would be appropriate for the nurse to provide to this parent? 1. Administer aspirin to decrease discomfort [7%] 2. Cover the vesicles with a small bandage until they are dry [41%] 3. Isolate the child from other children for 21 days to avoid exposure [8%] 4. Make an appointment with the health care provider (HCP) as soon as possible [43%]

The varicella immunization is administered to prevent infection of varicella zoster, commonly known as chickenpox. Side effects of the immunization include discomfort, redness, and a few vesicles at the injection site. Covering the vesicles with clothing or a small bandage will reduce the risk of transmission from any exudate. Once the vesicles have dried, or crusted, a dressing is no longer necessary. (Option 1) Acetaminophen is the appropriate medication to reduce the discomfort of the injection. Aspirin should be avoided in children due to the risk of Reye syndrome. (Option 3) Unless the rash becomes widespread, isolation of the child is unnecessary. It is unlikely that the infection will be transmitted by the 2 vesicles, but covering them with clothing or a small bandage will decrease the risk of transmission. (Option 4) Discomfort, redness, and a few vesicles at the injection site are common side effects of the varicella immunization and do not require the attention of an HCP.

The nurse is caring for a client who is having a thoracentesis. Following the procedure, the nurse monitors for complications. The initial postprocedure monitoring plan should include what? Select all that apply. 1. Level of alertness 2. Lung sounds 3. Oxygen saturation 4. Respiratory pattern 5. Temperature 6. Urine output

Thoracentesis is commonly used to treat pleural effusion. The health care provider (HCP) will prepare the skin, inject a local anesthetic, and then insert a needle between the ribs into the pleural space where the fluid is located. A complication of thoracentesis is pneumothorax, which occurs when the needle goes into the lung and causes the lung to slowly deflate, like a balloon with a small hole in it. Bleeding is another, yet less common, complication of the procedure. Signs of pneumothorax include increased respiratory rate, increased respiratory effort, respiratory distress, low oxygen saturation, and absent breath sounds on the side where the procedure was done (where the lung is collapsed) (Options 2, 3, and 4). Tension pneumothorax may also develop, with tracheal shift to the unaffected side, severe respiratory distress, and cardiovascular compromise. Altered level of consciousness may occur due to decreased oxygenation and blood flow to the brain (Option 1). A tension pneumothorax may be prevented by early detection of pneumothorax through appropriate monitoring. (Option 5) Infection would be a later complication (occurring a few days after the procedure), so monitoring temperature is not required during the initial postprocedure period. (Option 6) Urine output should not be affected by thoracentesis or the drugs administered for this procedure.

The nurse is providing education to a client diagnosed with a trichomoniasis vaginal infection who has been prescribed a onetime dose of oral metronidazole. Which of the following statements by the nurse are appropriate? Select all that apply. 1. "Abstain from sexual intercourse until the symptoms are cleared." 2. "Avoid drinking alcohol for at least 3 days after taking the last dose." 3. "Inform your sexual partners that they need to be treated." 4. "Metronidazole may temporarily turn your urine a dark, brownish color." 5. "Vaginal douching after intercourse may prevent recurrence of infection."

Trichomoniasis is a sexually transmitted infection caused by Trichomonas vaginalis. Infected clients may be asymptomatic but usually seek care when a profuse, frothy, yellow-green, malodorous vaginal discharge is noted. Pruritus, dysuria, and dyspareunia (ie, pain during sex) may also occur. Oral metronidazole (Flagyl) is the most common drug used to treat trichomoniasis. Client education includes: Abstain from sexual intercourse until the infection is cleared (ie, about 1 week after treatment) (Option 1). Avoid drinking alcohol while taking metronidazole and for 3 days after completion of therapy because the combination can cause flushing, nausea/vomiting, and severe abdominal pain (Option 2). Have partner(s) treated simultaneously to avoid reinfection. Use condoms to prevent the infection in the future (Option 3). Know that potential side effects of metronidazole may include a metallic taste, gastrointestinal upset, or dark-colored urine (Option 4). (Option 5) Vaginal douching is not recommended as it gets rid of good bacteria and alters the pH of the vagina, increasing the risk for infection (eg, bacterial vaginosis). Teach the client to cleanse the exterior vulva using only unscented products, wear breathable undergarments, and report persisting odors/discharge to the health care provider.

The health care provider (HCP) has prescribed amitriptyline 25 mg orally every morning for an elderly client with recent herpes zoster infection (shingles) and severe postherpetic neuralgia. What is the priority nursing action? 1. Encourage increased fluid intake [19%] 2. Provide frequent rest periods [10%] 3. Teach the client to get up slowly from the bed or a sitting position [55%] 4. Tell the client to wear sunglasses when outdoors [14%]

Tricyclic antidepressants (eg, amitriptyline, nortriptyline, desipramine, imipramine) are commonly used for neuropathic pain. Side effects are especially common in elderly clients. The most common side effects experienced by clients taking tricyclic antidepressants include dizziness, drowsiness, dry mouth, constipation, photosensitivity, urinary retention, and blurred vision. The priority nursing action is to teach caution in changing positions due to the increased risk for falls from dizziness and orthostatic hypotension, especially in elderly clients.

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

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

During the discharge process, the nurse observes a new parent placing a newborn into a car seat in the vehicle. Which action by the parent requires the nurse to intervene? 1. Anchors the car seat in the center of the vehicle's back seat [34%] 2. Dresses the newborn in a sleep sack before securing the harness [47%] 3. Keeps the car seat at a 45-degree angle [9%] 4. Uses a car seat that faces the rear of the vehicle [7%]

Vehicle safety for newborns and small children is important for reducing preventable injuries and deaths. Newborns and children age <2 years must be placed in a rear-facing car seat in the vehicle's back seat. The car seat's harness is secured snugly at or below the shoulders, at the hips, and between the legs; the connectors clip together at the center of the chest. The harness fits securely when the newborn is dressed in lightweight clothing. Tucking blankets between the newborn and the harness or dressing the newborn in bulky coats or a sleep sack reduces the car seat's effectiveness (Option 2). (Option 1) The car seat should be placed in the back seat and in the center (away from the doors), if possible. This protects the child from airbag deployment as well as collisions to the vehicle's sides. (Option 3) When the car seat tilts back at a 45-degree angle, there is less danger of the newborn's head and neck falling forward and obstructing the newborn's airway. (Option 4) A rear-facing car seat protects the newborn's head and neck from whiplash in a collision.

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

Venous thromboembolism (VTE) occurs when a thrombus (eg, deep vein thrombosis) forms and embolizes into the bloodstream (eg, pulmonary embolism). Hospitalized clients tend to have multiple risk factors for VTE, including venous stasis from prolonged immobility and endothelial damage from surgeries or IV catheter placement. VTE prophylaxis should be implemented in all hospitalized clients. Measures include: Administration of anticoagulants (eg, enoxaparin), usually prescribed in clients with a moderate or high risk of VTE (eg, postsurgical) unless contraindicated (eg, active bleeding) (Option 1) Application of compression devices or antiembolism stockings to limit venous stasis (Option 2) Frequent ambulation, 4-6 times daily as tolerated, to improve circulation and promote venous return (Option 4) Foot and leg exercises (eg, extend and flex the feet and knees) to promote venous return by activating calf muscles (Option 5) (Option 3) Elevating the legs while in bed promotes venous return by gravity. However, the nurse should ensure that any pillows used to elevate the legs do not place pressure directly behind the knees, as pressure on the posterior knees compresses leg veins. Clients should also avoid crossing the legs to prevent pressure on the back of the knees.

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? 1. Low Fowler's position with knees bent [64%] 2. Prone to prevent further evisceration [2%] 3. Side-lying lateral position [3%] 4. Supine with head of the bed flat [29%]

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 health care provider 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. (Option 2) Prone positioning would put undue pressure on an open incision and protruding bowel and could contaminate the open wound. (Option 3) A side-lying lateral position (recovery position) is often used following emergency situations such as cardiac arrest or seizure, but it will not lessen the tension placed on this open wound. (Option 4) Supine with the head of the bed flat may actually increase tension placed on the open wound.

A normal prothrombin time is 11-16 seconds

, and so a level of 11 seconds would not be concerning.

Terazosin and grapefruit : NO INTERACTION

Grapefruit juice can cause significant interactions with drugs such as calcium channel blockers and sildenafil. However, it does not appear to interact with alpha blockers such as terazosin.

12 months vaccine

Hep B #3 Haemophilus influenza type b (Hib) #4 Pneumococcal conjugate (PVC) 4 Inactivated Poliovirus (PV) 3 MMR 1 (live vaccine) VZV 1 (live vaccine)

temporal lobe

integrates visual and auditory input and past experiences. Temporal lobe injury clients cannot understand verbal or written language.

occipital lobe

of the brain registers visual images. Injury to the occipital lobe could result in a deficit with vision.

The emergency department nurse is triaging clients. Which neurologic presentation is most concerning for a serious etiology and should be given priority for definitive treatment? 1. History of Bell's palsy with unilateral facial droop and drooling 2. History of multiple sclerosis and reporting recent blurred vision 3. Reports unilateral facial pain when consuming hot foods 4. Temple region hit by ball, loss of consciousness, but Glasgow Coma Scale score 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 artery. 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. (Option 1) Bell's palsy (peripheral facial paralysis) is an inflammation of the facial nerve (CN VII) in the absence of other disease etiologies, such as stroke. There is flaccidity of the affected side with drooling. This differs from the concerning drooling with epiglottis in which the client's throat is too sore and/or swollen to swallow saliva. Treatment includes steroids, measures to relieve symptoms, and protection of the eye (which may not close tightly), but the condition is not emergent. (Option 2) Multiple sclerosis is a chronic, relapsing, and remitting degenerative disorder involving the brain, optic nerve, and spinal cord. Optic neuritis is a common presentation but is not life-threatening. (Option 3) Trigeminal neuralgia (tic douloureux) presents with paroxysms of unilateral excruciating facial pain along the distribution of the trigeminal nerve (CN V) that are often triggered by touch, talking, or hot/cold air or intake. Carbamazepine (Tegretol) is the drug of choice; the condition is not life-threatening

Isoniazid

is a first-line antitubercular drug used to treat latent or active tuberculosis. The nurse should question this prescription as increased liver function tests (eg, alanine aminotransferase, aspartate aminotransferase) can indicate development of drug-induced hepatitis Normal ALT: 8-40 AST: 8-40

The nurse is caring for an elderly client after hip 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? 1. Administer the prescribed as-needed milk of magnesia [16%] 2. Ask dietary services to add more fruits and vegetables to the client's tray [5%] 3. Notify the health care provider (HCP) [4%] 4. Perform a focused abdominal assessment [73%]

Constipation may develop as a side effect of anesthesia, pain medication, physiological stress, and/or immobility. The nurse's first priority is to assess the client. The nurse can administer the as-needed laxative once it has been determined to be safe. The HCP is contacted if the focused abdominal assessment indicates a potential complication, such as postoperative ileus. (Option 1) The nurse's first priority is assessment. A laxative would not help if this client had intestinal obstruction (from adhesions). (Option 2) The client is taught to eat a high-fiber diet and increase fluid intake to promote normal bowel function. The nurse would not change the diet until further assessment of the client is accomplished and the HCP has prescribed a new diet. (Option 3) The nurse should further assess the client before contacting the HCP.

melena

(dark red or black, sticky stool) is an indication of an upper gastrointestinal (UGI) bleed. Gastritis is a common cause of UGI bleeding in infants and toddlers

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

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

A client with AIDS treated for intractable seizures is transferred from the intensive care unit 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? 1. Room 1—client with Clostridium difficile [2%] 2. Room 2—client with fever of unknown origin [4%] 3. Room 3—client with bacterial pneumonia [3%] 4. Room 4—client with upper gastrointestinal bleed [90%]

The best option is room 4 as the client with the upper gastrointestinal bleed does not put the immunocompromised client with AIDS at increased risk for infection. (Options 1, 2, and 3) These room options put the client with AIDS at increased risk for infection because: Room 1 - C difficile is a highly contagious bacterial infection transmitted through stool and requires contact precautions Room 2 - fever of unknown origin is often a symptom of an undiagnosed viral or bacterial infection Room 3 - pneumonia is an infectious respiratory disease

The nurse is caring for a client with severe chronic obstructive pulmonary disease (COPD). The nurse anticipates which laboratory results for this client? 1. Anemia 2. Neutropenia 3. Polycythemia 4. Thrombocytopenia

The client with severe COPD will have a chronically low oxygen level, hypoxemia. To compensate, the body produces more red blood cells (RBCs) to carry needed oxygen to the cells. A high RBC count is called polycythemia. (Option 1) Anemia is not expected and will worsen symptoms of COPD. (Option 2) Neutropenia (low white blood cell count) is not expected in COPD. Chemotherapy and many medications (clozapine [antipsychotic], methimazole [antithyroid]) can cause neutropenia which increases the risk of infection. (Option 4) Thrombocytopenia (low platelet count) is not anticipated in COPD. Alcohol use, HIV infection, and many medications (heparin) can cause thrombocytopenia.

To determine the most appropriate method to transfer a client safely for the first time, the nurse should assess 2 factors:

Whether the client can bear weight: Neurological deficits (eg, paralysis, paresis [weakness])Decreased muscle strength (eg, prolonged immobility, multiple sclerosis, muscular dystrophy)Trauma (eg, amputee, hip fracture) Whether the client is cooperative and able to follow instructions:Altered mental status (eg, delirium, drug intoxication)Decreased cognitive ability (eg, dementia, head injury)

LPN skills

Increased brain natriuretic peptide levels can indicate stretching of the chambers of the heart in heart failure. Levels >100 pg/mL (>100 pmol/L) can indicate heart failure and would be expected in this client.

normal BNP : less than 100

Exophthalmos (hyperthyroidism)

*protrusion of eyeballs caused by increased orbital tissue expansion and can be IRREVERSIBLE. *risk for cornea dryness, injury and infection

A home health nurse visits a client with chronic obstructive pulmonary disease. The nurse teaches the client to use abdominal breathing to perform the "huff" cough technique to facilitate secretion removal. Place the steps in the correct order. All options must be used.

1. Sit upright in a chair with feet spread shoulder-width apart and lean forward. 2. Perform a slow, deep inhalation with your mouth using your diaphragm. 3. Hold your breath for 2-3 seconds and then forcefully exhale quickly. 4. Repeat the huff once or twice more, while refraining from performing a normal cough. 5. Rest for 5-10 normal breaths and repeat as necessary until mucus is cleared.

Fast flush of the arterial line system (square wave test)

A fast flush of the arterial line system (square wave test) should be performed after the nurse has ruled out a physiological cause of the low pressure alarm. This test helps to verify if the arterial line is functioning correctly.

The nurse completes the preoperative assessment for a client scheduled for a total knee replacement today. Which information should the nurse report to the health care provider (HCP) as soon as possible before the surgery? 1. Has allergy to strawberries 2. Is experiencing burning on urination starting yesterday 3. Rates knee pain as a 9 on a 0-10 scale 4. Stopped taking celecoxib 7 days ago

A recent/current infection is a contraindication to total joint replacement surgery as a wound infection is more likely to occur in a client with a preexisting infection. The nurse should report the new onset of burning on urination to the HCP. Burning could indicate the presence of a urinary tract infection. (Option 1) Allergy to strawberries is not a contraindication to the scheduled surgery. However, a latex allergy should be documented. (Option 3) Severe knee pain is expected in a client undergoing a total knee replacement. (Option 4) Clients are directed to stop taking nonsteroidal anti-inflammatory drugs, including selective COX-2 inhibitors (eg, celecoxib [Celebrex]), 7 days before surgery to decrease the risk of intra- and postoperative bleeding.

CSF

A nurse in the emergency department assesses 4 clients. Based on the laboratory results, which client is the highest priority for treatment? 1. Client with abdominal pain, respirations 28/min, and blood alcohol level 80 mg/dL (0.08 mg% [17.4 mmol/L]) 2. Client with chronic obstructive pulmonary disease, pH 7.34, pO2 86 mm Hg (11.5 kPa), pCO2 48 mm Hg (6.4 kPa), and HCO3 30 mEq/L (30 mmol/L) 3. Client with dull headache, pulse oximeter reading 95%, and serum carboxyhemoglobin level 20% 4. Client with emesis of 100 mL coffee-ground gastric contents and serum hemoglobin 15 g/dL (150 g/L)

Carbon monoxide (CO) 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 emergency department because symptoms are nonspecific (eg, headache, dizziness, fatigue, nausea, dyspnea) and the pulse oximeter reading often appears within normal limits. A serum carboxyhemoglobin test is needed to confirm the diagnosis. Normal values are <5% in nonsmokers and slightly higher (<10%) 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 (Option 3). (Option 1) Normal blood alcohol content is 0 mg/dL (0 mmol/L), and the legal level for driving under the influence is 80 mg/dL (0.08 mg% [17.4 mmol/L]). The client's abdominal pain and increased respiratory rate require adequate assessment but are not the highest priority. (Option 2) The arterial blood gases indicate compensated respiratory acidosis, which is characteristic for a client with chronic obstructive pulmonary disease; this is not the highest priority. (Option 4) Emesis of 100 mL coffee-ground gastric contents would indicate an older, not fresh, gastrointestinal bleed; the hemoglobin level is normal (13.2-17.3 g/dL [132-173 g/L] for males, 11.7-15.5 g/dL [117-155 g/L] for females). The cause of the gastrointestinal bleed must be determined, but this is not the highest priority. Educational objective:Clients with carbon monoxide (CO) poisoning have elevated serum carboxyhemoglobin levels (normal <5% in nonsmokers) and false-normal pulse oximeter readings. They require immediate administration of 100% oxygen to correct hypoxemia and eliminate toxic CO from the blood. Additional Information Management of Care NCSBN Client Need

Clients with end-stage renal disease commonly have elevated creatinine and blood urea nitrogen levels. These are expected findings.

Normal creatinine 0.6 -1.2 mg/dL Normal BUN: 8- 20 mg/dL or 2.9 -7.1 mmol/L

PT/INR (prothrombin time/international normalized ratio) warfarin

Prothrombin time: 11-14 sec International normalized ratio (INR): 0.9-1.2

A nurse is evaluating an acutely ill client with suspected meningitis. The nurse should take what action first? 1. Check for Kernig's and Brudzinski's signs 2. Establish IV access 3. Place the client on droplet precautions 4. Prepare the client for lumbar puncture

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 (ie, other than meningococcal meningitis) usually do not require droplet precautions. (Option 1) Although assessment is a priority and meningeal signs should be checked, the nurse can only safely perform these assessments once droplet precautions are in place. (Options 2 and 4) A peripheral IV catheter should be inserted to provide fluids. Subsequently, preparation for lumbar puncture is needed. However, placing the client on isolation is a priority to protect the nurse and other clients and care providers. Educational objective: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.

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? Select all that apply. 1. Blanches with manual pressure 2. Half of the lesion is raised and half is flat 3. History of purulent drainage 4. Lesion is the size of a nickel 5. Various color shades are present

The examination for skin cancer follows the ABCDE rule: Asymmetry (eg, one half unlike the other) (Option 2) Border irregularity (eg, edges are notched or irregular) Color changes and variation (eg, different brown or black pigmentation) (Option 5) Diameter of 6 mm or larger (about the size of a pencil eraser) (Option 4) Evolving (eg, appearance is changing in shape, size, color) (Option 1) Normal variations in skin will blanch with manual pressure. Failure to blanch is typically an indication that there is blood beneath the skin, as in petechiae and/or purpura. (Option 3) Pus or purulent drainage is usually indicative of an infectious process, not cancer.

The nurse is reinforcing education to the caregivers of a 9-year-old client diagnosed with scarlet fever. The client has a history of type 1 diabetes mellitus. Which statement by the caregivers indicates that further teaching is needed? 1. "We will encourage extra fluid intake while our child is sick." 2. "We will increase the frequency of blood glucose checks." 3. "We will monitor our child's urine for ketones with each void." 4. "We will not administer insulin if our child is unable to eat."

An acute illness (eg, scarlet fever) in clients with type 1 diabetes may trigger the release of stress hormones, which leads to higher blood glucose and ketone levels (sometimes leading to ketoacidosis). Clients with type 1 diabetes do not produce any insulin (unlike those with type 2 diabetes), so clients should not skip administration of external insulin even if not eating. Insulin therapy should be continued as prescribed during an acute illness (Option 4). Additional sick-day management includes: Increasing frequency of blood glucose level checks (every 1-4 hours) Increasing or decreasing the dose of insulin as needed based on blood glucose levels Maintaining adequate hydration Testing for urinary ketones frequently (Options 1 and 3) Stress hormones released during illness cause increased insulin resistance and lead the body to break down fat for energy. Ketones are produced when fat is broken down, which can lead to diabetic ketoacidosis (DKA). The client's urine should be monitored frequently for ketones while the client is sick. Fluids are encouraged to clear ketones from the system and prevent dehydration. (Option 2) Blood glucose should be assessed frequently while the client is ill due to the potentially unpredictable and rapidly changing levels caused by illness and/or fasting.

Based on the nursing assessment progress notes, what is the correct staging of the client's pressure injury? Click on the exhibit button for additional information. 1. Stage 1 [10%] 2. Stage 2 [75%] 3. Stage 3 [12%] 4. Stage 4 [1%] Shallow, open area with clean, dark pink wound bed about 1 cm in diameter noted on coccyx. Surrounding area is slightly hard and warm to touch with erythema. Foam dressing clean, dry, and intact. No drainage noted. Enterostomal consult made.________________, RN

Pressure injuries are staged from 1 to 4 to classify the degree of tissue damage and determine the most appropriate and effective wound treatments. Stage 1: Intact skin with nonblanchable redness Stage 2: Partial-thickness skin loss (abrasion, blister, or shallow crater) involving the dermis or epidermis; the wound bed is red or pink and may be shiny or dry Stage 3: Full-thickness skin loss; subcutaneous fat is visible but not tendon, muscle, or bone; tunneling may be present Stage 4: Full-thickness skin loss with visible tendon, muscle, or bone; slough or eschar (scabbing, dead tissue) may be present; undermining and tunneling may be present Pressure injuries are described as "unstageable" if the base is covered by necrotic tissue or eschar

The clinic nurse evaluates the treatment plan of a client with long-standing rheumatoid arthritis. Which question is most important for the nurse to ask? 1. "Have the assistive devices helped with dressing and grooming?" 2. "How do you feel about the changes in your appearance?" 3. "How is your pain control with the current medication regimen?" 4. "Is your level of energy adequate for completing your daily activities?"

Rheumatoid arthritis is an autoimmune disorder that affects joints and other body systems. Chronic inflammation of the synovial joints causes increasing pain and swelling in the joints and eventual joint deformities with decreased or absent range of motion and loss of function. Clients become easily fatigued and must learn to pace themselves and use assistive devices to accomplish activities of daily living. Goals of treatment are to manage pain, minimize loss of joint mobility, maximize self-care, and maintain self-esteem and a positive body image. Assessing for adequate pain control is the priority, as inadequate pain control will cause disuse of joints, leading to stiffness and decreased joint mobility (Option 3). (Options 1, 2, and 4) If pain is not adequately controlled, the client will be unlikely to use assistive devices and be too fatigued to perform activities of daily living. This can lead to being dependent on others, causing frustration and poor self-esteem and body image.

DKA (type 1 usually, younger age) -less pronounced altered mentation - more rapid onset of hyperglycemic symptoms -hyperventilation and abdominal pain common

-Glucose 250-500 - HCO3 <18 -elevated anion gap -positive serum ketones -serum osmolality < 320

Hyperosmolar hyperglycemic state (type 2 diabetics usually) - more pronounced altered mentation -gradual onset of hyperglycemic symptoms -hyperventilation and abdominal pain less common

-Glucose >600 - HCO3 > 18 -normal anion gap -negative or small serum ketones -serum osmolality > 320

Exophthalmos Nursing care

-maintain HOBin a raised position to facilitate drainage from periorbital area -artificial tears or other similar products to moisten the eyes to prevent corneal drying (causing abrasions/ulcers) -taping the clt's eyelids shut during sleep if they do not close on their own

The nurse receives a report on 4 clients. Which client should the nurse assess first? 1. A 29-year-old heroin user admitted for arm cellulitis 24 hours ago has abdominal cramps and is restless 2. A 34-year-old admitted with femur fracture 24 hours ago is confused and has SpO2 of 91% 3. A 65-year-old admitted with serum sodium of 125 mEq/L (125 mmol/L) 8 hours ago is confused 4. A 78-year-old admitted for urinary tract infection 6 hours ago is disoriented to time and place

A fat embolism is life-threatening; therefore, the client with the femur fracture is the priority. There is a risk for the formation of fat emboli following certain fractures, typically those of the long bones and pelvis. Globules of fat leave the bone and travel through the bloodstream to the lungs, skin, and brain where they cause damage by occluding small vessels. Altered mental status will result from blocked blood vessels in the brain. An embolism to the lung would result in respiratory distress. A hallmark sign of fat emboli is the presence of petechiae (pin-sized red/purple spots) that result from small-vessel clotting and appear across the chest, in the axillae, and in the soft palate. (Option 1) This hospitalized heroin user is likely experiencing heroin withdrawal, which manifests with vomiting, abdominal cramping, and diarrhea; restlessness and diaphoresis; frequent yawning; rhinorrhea and lacrimation; and myalgias and arthralgias. This client needs treatment, but this condition is not life-threatening. (Option 3) Moderate hyponatremia (normal sodium 135-145 mEq/L [135-145 mmol/L]) can cause altered mental status and can lead to seizures if it becomes severe. This client needs treatment and should be the second priority after the client with fat embolism. (Option 4) Infections can cause altered mental status, especially in elderly clients. As the infection resolves, mental status improves. Educational objective: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 (on chest, axillae, and soft palate) are the classic manifestations.

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? 1. Insert a large-bore IV line and infuse normal saline 2. Obtain blood for type and crossmatch and hemoglobin 3. Remove constrictive clothing to enhance circulation 4. 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 (embedded) objects include bullets or blast fragments from firearms as well as sharp objects such as scissors, nails, or knives. The embedded object creates a puncture wound and then controls potential bleeding by putting pressure on the wound. First responders 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 (Option 4) and later during transport to a health care facility where skilled trauma care is available. Exception to the rule: First responders (EMS providers) may remove the impaled object if it obstructs the airway and prevents effective cardiopulmonary resuscitation. (Option 1) An IV line may be inserted and fluids begun on scene after stabilization of the object and initial assessment. (Option 2) Blood may be drawn after stabilization of the object and initial assessment. (Option 3) Clothing may be removed on scene after stabilization of the object and initial assessment.

The nurse is assessing a client who had an esophagogastroduodenoscopy (EGD) 2 hours ago. Which finding requires an immediate report to the health care provider? 1. Blood pressure drop from 122/88 mm Hg to 106/72 mm Hg [30%] 2. Gag reflex has not returned [31%] 3. Sore throat when swallowing [3%] 4. Temperature spike to 101.2 F (38.4 C) [34%]

A sudden temperature spike 1-2 hours after an esophagogastroduodenoscopy (EGD) could be a sign of perforation or a developing infection. The nurse should notify the health care provider immediately. (Option 1) This blood pressure drop could be due to several things (sedation, blood loss, sepsis), but without any other symptoms indicating an emergency condition, it is still within the normal range. (Option 2) The gag reflex may take a few hours to return as the EGD involves applying a topical anesthetic to the throat. Absent gag reflex after a prolonged period (6 hours) would require reporting to the health care provider. (Option 3) A sore throat is expected after certain procedures (EGD, intubation) due to local irritation. Warm saline gargles could provide some relief.

The nurse reviews the analgesia prescriptions for assigned clients. The nurse should question the health care provider about which prescription? 1. Lidocaine 5% patch over intact skin for a client with chronic postherpetic neuralgia who reports intolerable, persistent, burning pain [22%] 2. Hydromorphone IV for a client who has a fractured femur, is a known IV heroin abuser, and rates pain as 9 on a 0-10 scale [34%] 3. Tramadol for a client who is being prepared for discharge following a laparoscopic cholecystectomy and rates abdominal pain as 6 on a 0-10 scale [16%] 4. Transdermal fentanyl patch for a client who is 1 day postoperative above-the-knee amputation and reports intermittent, throbbing stump pain [26%]

A transdermal fentanyl patch is prescribed for clients suffering from moderate to severe chronic pain. The patch provides continuous analgesia for up to 72 hours. However, the drug is absorbed slowly through the skin into the systemic circulation and can take up to 17 hours to reach its full analgesic effect. Therefore, it is not recommended for treating acute postoperative, temporary, or intermittent pain as it does not provide immediate analgesia when applied. (Option 1) A lidocaine 5% transdermal patch provides a localized, topical anesthetic to intact skin. It is commonly prescribed for clients with chronic postherpetic neuralgia, a painful, debilitating condition that can develop following a herpes zoster (shingles) infection. (Option 2) The client with opioid abuse history would be experiencing the same type and degree of pain as other clients with a fractured femur. However, a higher dose or a stronger opioid analgesic (eg, hydromorphone) is needed for pain relief due to the client's increased opioid tolerance. (Option 3) Tramadol is a synthetic opioid analgesic prescribed to treat moderate to severe postoperative pain. It is appropriate to prescribe at discharge as it has fewer complications related to respiratory depression compared with other opioids.

During a screening clinic, the nurse performs a health assessment on several adult clients. Which finding by the nurse is most important to report to the primary health care provider? 1. Body mass index (BMI) of 23 kg/m2 2. Brownish skin thickening on the neck 3. Fasting total cholesterol of 180 mg/dL (4.7 mmol/L) 4. Round 3x3 mm pale pink mole

Acanthosis nigricans is a skin disorder characterized by the presence of symmetric, hyperpigmented velvety plaques located in flexural and intertriginous regions of skin (axilla, neck). Skin tags (acrochordons) are commonly present on regions affected by acanthosis nigricans. Both indicate insulin resistance (diabetic dermopathy). The client should be referred to the primary health care provider for evaluation of undiagnosed diabetes mellitus and/or metabolic syndrome. (Option 1) A BMI of 18.5 to 24.9 kg/m2 indicates a normal weight. (Option 3) A fasting total cholesterol <200 mg/dL (5.2 mmol/L) is normal. (Option 4) Although any change or growth of a mole should be reported, a pale or brown round mole <5 mm is typically a normal finding.

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? 1. "I bought a new nightlight for the hallway to the bathroom." 2. "I feel so much more secure wearing my electronic fall alert device." 3. "I walk in my stockings at home because it helps to relieve my bunion pain." 4. "My daughter helped me secure the small, thin rug in my kitchen with strong tape."

According to the Centers for Disease Control and Prevention, 1 out of 3 adults aged >65 experience a fall every year. 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. There are multiple simple strategies that can help reduce falls in the home environment and these include: Exercising regularly for 30 minutes 3 times/week increases strength, balance, coordination, and flexibility; therefore, decreasing fall risk. Maintaining a well-lit, clutter-free environment (eg, adding nightlights and removing or securing area rugs to the floor with double-sided tape) (Options 1 and 4). Using grab bars and non-skid bath mats in the bathroom. Wearing shoes or slippers with non-skid soles, both inside and outside of the home. Periodically reviewing medications and side effects (eg, orthostatic hypotension) with a pharmacist and/or health care provider (HCP). Getting regular vision exams. Wearing an electronic fall alert device. The fear of falling increases fall risk and these devices provide the security of knowing help is available immediately if a fall occurs

After a needlestick injury, the nurse should remove gloves, wash the area, report the incident to the facility exposure office, and proceed to employee health for baseline blood draw and possible postexposure prophylaxis.

The nurse is caring for a client with asthma exacerbation. Blood pressure is 146/86 mm Hg, pulse is 110/min, and respirations are 32/min. The respiratory therapist administers nebulized albuterol as prescribed. One hour after the treatment, the nurse assesses which finding that indicates the drug is producing the therapeutic effect? 1. Constricted pupils 2. Heart rate of 120/min 3. Respirations of 24/min 4. Tremor

Albuterol (Proventil) is a short-acting inhaled beta-2 agonist used to control airway obstruction caused by chronic obstructive pulmonary disease, asthma, or bronchitis. It also is used to prevent exercise-induced asthma. The therapeutic effect is relaxation of the smooth muscles of the airways, which results in immediate bronchodilation. Bronchodilation decreases airway resistance, facilitates mucus drainage (expectorates mucus plugs), decreases the work of breathing, and increases oxygenation. As a result of these actions, the respiratory rate will decrease and peak flow will be increased (if tested). However, short-acting beta-2 agonists are associated with the following side effects (not therapeutic effects): tremor (most frequent), tachycardia and palpitations, restlessness, and hypokalemia. These side effects are due to the oral deposition of medication (subsequent systemic absorption) and can be reduced with the use of a spacer or chamber device. (Option 1) The presence of constricted pupils is neither a side effect nor therapeutic effect of the drug. Constricted pupils are often seen with opioid medications (eg, morphine, oxycodone).

A home health nurse is giving an infection control presentation on pulmonary tuberculosis (TB) disease to a group of home health aides. Which statement made by a home health aide indicates an understanding about the mode of transmission of pulmonary TB? 1. "It is spread by contact with the client's blood or urine." 2. "It is spread by contact with the client's soiled clothing and bed linens." 3. "It is spread by contact with the client's soiled eating utensils." 4. "It is spread by small droplets that the client coughs or sneezes into the air."

All health care workers caring for clients with TB disease must follow standard and airborne transmission precautions and wear high-efficiency particulate or N95 respirator masks. (Options 1, 2, and 3) Pulmonary TB is not spread via contact with the client's blood, urine, or soiled clothing, bed linens, or eating utensils. Educational objective:Mycobacterium tuberculosis microorganisms from a client with active pulmonary TB disease are transmitted to another person via airborne droplets.

A client with Alzheimer disease is found slumped over the lunch tray on the bedside table, coughing violently with emesis visible in the back of the throat. The client has a pulse of 135/min, respirations 32/min, and oxygen saturation 84%. The client also has circumoral cyanosis and decreased level of consciousness. Place the nurse's actions while awaiting the arrival of the rapid response team in priority order. All options must be used. 1. Place client in High Fowler 2. Perform oropharyngeal suctioning 3. administer 1000% oxygen by nonrebreather mask 4. assess lung sounds 5. Notify HCP

Alzheimer disease is a neurological condition that increases the risk for aspiration and aspiration pneumonia, a common cause of death in clients with swallowing dysfunction. The nurse activates a rapid response because the client is in acute respiratory distress. While waiting for the team, the nurse should implement the following actions in order: Place in high Fowler's position - quickly maximizes ability to expand lungs, promotes oxygenation, and helps to decrease risk of further aspiration Perform oropharyngeal suctioning - the priority is clearing the airway after the client has been placed in a position that prevents further aspiration Administer 100% oxygen by nonrebreather mask - corrects hypoxemia/hypoxia once the airway has been cleared to allow passage of oxygen. The nurse has already gathered focused assessment data and determined the need for emergent oxygen delivery (eg, tachycardia, tachypnea, hypoxia, cyanosis, decreased level of consciousness). Assess lung sounds - determines air movement and presence of adventitious sounds (eg, crackles, wheezing, stridor) that can indicate obstruction, secretions, atelectasis, or fluid. This assessment is performed once emergency measures are in place (eg, oxygen) and the client has been stabilized. Notify the primary HCP - to report the situation and assessment data To provide more efficient care, any of these tasks can be delegated to a second RN. Educational objective:While waiting for the rapid response team to respond to an adult client with acute respiratory distress, the nurse implements the following actions: positioning; suctioning to clear the airway, administering high-concentration oxygen; assessing lung sounds; and notifying the HCP.

The nurse is caring for a client who is taking riluzole for amyotrophic lateral sclerosis (ALS). The client asks, "There's no cure for ALS, so why should I keep taking this expensive drug?" What is the nurse's best response? 1. "It may be able to slow the progression of ALS." [78%] 2. "It reduces the amount of glutamate in your brain." [14%] 3. "The case manager may be able to find a program to assist with cost." [4%] 4. "You have the right to refuse the medication." [2%]

Amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig disease, is a debilitating, progressive neurodegenerative disease with no cure. Clients develop fatigue and muscle weakness that progresses to paralysis, dysphagia, difficulty speaking, and respiratory failure. Most clients diagnosed with ALS survive only 3-5 years. Riluzole (Rilutek) is the only medication approved for ALS treatment. Riluzole, a glutamate antagonist, is thought to slow neuron degeneration by decreasing the production and activity of the neurotransmitter glutamate in the brain and spinal cord. In some clients, riluzole may slow disease progression and prolong survival by 3-6 months. The nurse should provide teaching about the purpose of the medication so that the client can make an informed decision about taking it (Option 1).

A client suffering from chronic kidney disease is scheduled to receive recombinant human erythropoietin and iron sucrose. The client's hemoglobin is 9.7 g/dL (97 g/L) and hematocrit is 29% (0.29). What is the appropriate nursing action? 1. Administer the erythropoietin in the client's ventrogluteal muscle[42%] 2. Check blood pressure prior to administering the erythropoietin[39%] 3. Hold the client's next scheduled iron sucrose dose[3%] 4. Hold the erythropoietin and inform the health care provider[15%]

Anemia associated with chronic kidney disease is treated with recombinant human erythropoietin (Epogen/Procrit, epoetin). Therapy is initiated when hemoglobin is <10 g/dL (100 g/L) to alleviate the symptoms of anemia (eg, fatigue) and the need for blood transfusions. Therapy should be discontinued or the dose reduced for hemoglobin >11 g/dL (110 g/L) to prevent venous thromboembolism and adverse cardiovascular outcomes from blood thickened by high concentrations of RBCs. Hypertension is a major adverse effect of erythropoietin administration. Therefore, uncontrolled hypertension is a contraindication to recombinant erythropoietin therapy. Blood pressure should be well controlled prior to administering erythropoietin (Option 2). (Option 1) Erythropoietin is administered intravenously or in any subcutaneous area (not intramuscularly). (Option 3) Iron in the form of iron sucrose (Venofer) or ferric gluconate (Ferrlecit) may be prescribed to promote an adequate response to erythropoietin. Adequate stores of iron, vitamin B12, and folic acid are required for the erythropoietin to work. (Option 4) The dose should be held if the client has a hemoglobin level >11 g/dL (110 g/L) or uncontrolled hypertension. Educational objective: Anemia of chronic kidney disease is treated with recombinant human erythropoietin for hemoglobin <10 g/dL (100 g/L). Hemoglobin levels >11 g/dL (110 g/L) are associated with thromboembolic and cardiovascular events. Uncontrolled hypertension is a contraindication to recombinant human erythropoietin therapy.

A nurse in the surgical admitting unit is preparing a client for elective coronary artery bypass surgery. Which statement by the client should the nurse report immediately to the health care provider (HCP)? 1. "I haven't had anything to eat or drink since 8 PM yesterday." [0%] 2. "I took my prasugrel this morning with just a tiny sip of water." [88%] 3. "I'm really nervous about this surgery." [7%] 4. "It always takes several attempts to start my IV." [3%]

Antiplatelet medication (eg, prasugrel [Effient], clopidogrel [Plavix], ticagrelor [Brilinta]) are often prescribed to a client after a percutaneous coronary intervention such as angioplasty or stent placement. These agents should be stopped at least 5-7 days prior to the surgery to reduce the chance of intraoperative and postoperative bleeding. The nurse should immediately report to the HCP that the client is still taking prasugrel and took it the morning of the surgery. Unless the surgery is emergent, it will most likely be postponed at least a week. (Option 1) Nothing by mouth for at least 6-8 hours prior to surgery is typical. (Option 3) The nurse can assist the client in discussing reasons for the anxiety. Anxiety is common prior to surgery; unless the client refuses to go through with the surgery or requests to speak with the HCP, the nurse can usually deal with this issue. (Option 4) Difficult IV sticks can be handled by the nurse. Educational objective:Medications that cause increased risk for bleeding include anticoagulants (eg, warfarin, heparin) and antiplatelets (eg, aspirin, clopidogrel, prasugrel, ticagrelor, dipyridamole).

The nurse receives new prescriptions for a client with right lower quadrant pain and suspected acute appendicitis. Which prescription should the nurse implement first? 1. Administer 0.25 mg hydromorphone IV push for pain 2. Draw blood for complete blood count and electrolyte levels 3. Initiate IV access and infuse normal saline 100 mL/hr 4. Obtain urine specimen for urinalysis

Appendicitis is inflammation of the appendix and often results 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 the client with appendicitis, the nurse should utilize the ABCs (ie, airway, breathing, circulation). Fluid resuscitation with IV crystalloids (eg, normal saline, lactated Ringer solution) is an important intervention aimed at preventing circulatory collapse resulting from fluid losses (eg, vomiting, diarrhea) and NPO status (Option 3). (Option 1) Pain medications may be administered to promote comfort, but should be administered via IV route to maintain NPO status in case of emergency surgery. However, circulation takes priority over pain medication. (Options 2 and 4) Blood and urine samples often are prescribed to assist with treatment and care decisions. However, the nurse should prioritize circulatory status over obtaining laboratory specimens. Educational objective:Nurses caring for clients with appendicitis should prioritize client care according to the ABCs (ie, airway, breathing, circulation). Initiating IV crystalloids (eg, normal saline) is a priority action that prevents circulatory collapse resulting from fluid losses (eg, vomiting, diarrhea) and NPO status. Additional Information Physiological Adaptation NCSBN Client Need

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

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

The night nurse receives the hand-off report on assigned clients. Which client should the nurse assess first? 1. Client with acute kidney injury scheduled for hemodialysis in the morning has a urine output of 200 mL for the past 8 hours 2. Client with an indwelling urinary catheter who is 1-day postoperative prostatectomy reports severe bladder spasms 3. Client with an ureteral stent placed this morning after laser lithotripsy reports burning on urination and hematuria 4. Client with spinal cord injury (above T6) requiring intermittent catheterization reports a throbbing headache and nausea

Autonomic dysreflexia (hyperreflexia) 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 headache, nausea, and blurred vision; hypertension and bradycardia; and diaphoresis and skin flushing above the level of the injury. It is a medical emergency that requires immediate intervention (eg, bladder catheterization) to remove the precipitating trigger. (Option 1) Oliguria (<0.5 mL/kg/hr or <280 mL in 8 hours for an adult of average weight [154 lb or 70 kg]) is an expected finding in a client with kidney injury scheduled for hemodialysis; this client assessment is not the priority. (Option 2) Bladder spasms are an expected finding in a client with an indwelling urinary catheter following a prostatectomy. The nurse can administer prescribed analgesic and antispasmodic drugs (eg, Belladonna-opium suppositories, oxybutynin) to alleviate discomfort. However, this client assessment is not the priority. (Option 3) Laser lithotripsy breaks down a large stone into small fragments to ease stone elimination. The ureteral stent maintains ureter patency by preventing obstruction caused by edema or stone fragments. Burning on urination and hematuria are common expected side effects associated with this procedure. This client assessment is not the priority.

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? Select all that apply. 1. Disposable gown 2. Face shield 3. Gloves 4. N95 respirator 5. Surgical mask

Bacterial meningitis (eg, Neisseria meningitidis) and many respiratory illnesses (eg, influenza) are 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 (1.8 meters) away from the client. Droplet precautions for routine care (eg, medication administration) require the use of a surgical mask, as the highest risk of transmission is through inhalation of droplets (Option 5). 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 (eg, suctioning, wound care) (Options 1, 2, and 3). Dedicated medical equipment (eg, stethoscope, blood pressure cuff) should remain in the room to limit spread of infection. (Option 4) 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. Educational objective:When caring for clients on droplet precautions, a surgical mask is needed for routine care, such as assessment or medication administration. If there is risk of contact with body fluids during procedures (eg, wound care, suctioning), gloves, gown, and face shield are used.

The nurse assesses a client with benign prostatic hyperplasia. Which client statement requires further assessment? 1. "I have a burning sensation when I urinate." 2. "I have been having some dribbling after I finish urinating." 3. "I missed 3 days of finasteride while on a trip last week." 4. "I was awakened 3 times last night by the need to urinate."

Benign prostatic hyperplasia (BPH) is an abnormal prostate enlargement that most commonly affects male clients age >50. The prostate gradually enlarges and compresses the urethra, causing voiding problems. Symptoms include urinary urgency, frequency, and hesitancy, dribbling urine after voiding, nighttime frequency (nocturia), and urinary retention. Treatment includes lifestyle changes and medications that shrink or slow growth of the prostate, and symptom management interventions (eg, voiding schedule, avoidance of caffeine and antihistamines). Surgical prostate resection may be required. Clients with BPH have increased risk for urinary tract infection (UTI) because of incomplete bladder emptying and urine retention. Symptoms of UTI are often similar to those of BPH; however, burning sensation with urination and cloudy/foul-smelling urine are specific UTI symptoms that require further assessment and treatment (Option 1). (Options 2 and 4) Dribbling after urination and nocturia are expected findings with BPH. (Option 3) Finasteride (Proscar) is a medication that inhibits further growth of the prostate. Appreciable differences in prostate size are noticed only after several months of therapy. Missing three doses would not cause immediate or long-term adverse effects. Educational objective:Clients with benign prostatic hyperplasia (BPH) have increased risk for urinary tract infections (UTI) due to incomplete bladder emptying and urine retention. Symptoms of UTI that differ from those of BPH include burning sensation with urination and cloudy/foul-smelling urine. Additional Information Reduction of Risk Potential NCSBN Client Need

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? Select all that apply. 1. Client coughs and gasps when swallowing food and liquids 2. Client is easily frustrated while attempting to speak 3. Client is unable to understand speech and is completely nonverbal 4. Client misunderstands and inappropriately responds to verbal instruction 5. Client's speech is limited to short phrases that require effort

Broca (expressive) 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 (eg, "and," "is," "the") (Option 5). Clients with Broca aphasia are aware of their deficits and can become frustrated easily (Option 2). In comparison, clients with Wernicke (receptive) aphasia are unaware of their speech impairment. (Option 1) Trouble swallowing, often identified by coughing and gasping when eating and drinking, is dysphagia, which is not related to Broca aphasia. (Option 3) Clients with damage to multiple language areas of the brain may develop global aphasia, resulting in the inability to read, write, or understand speech. This is the most severe form of aphasia. (Option 4) Clients with damage to the temporal portion of the brain may develop Wernicke (fluent) aphasia (ie, the inability to comprehend the spoken and/or written word) and exhibit a long, but meaningless, speech pattern.

Calcium acetate (PhosLo)

Calcium acetate (PhosLo) is a phosphate binder used to treat hyperphosphatemia (normal phosphorous: 2.4-4.4 mg/dL [0.78-1.42 mmol/L]) in clients with chronic kidney disease. Calcium acetate lowers the serum phosphorous level by binding to dietary phosphate and excreting it in feces

The school nurse creates a cafeteria menu for a newly enrolled child with celiac disease. Which lunches would be appropriate for this child? Select all that apply. 1. Beef barley soup with mixed vegetables and French bread 2. Grilled chicken, baked potato, and strawberry yogurt 3. Mexican corn tacos with ground beef and cheese 4. Peanut butter and jelly on rice cakes with an oatmeal cookie 5. Rice noodles with chicken and broccoli

Celiac disease (celiac sprue) is an autoimmune disorder in which the body is unable to process gluten, a protein found in most grains. Gluten consumption will damage the villi of the small intestine; this results in malabsorption of fats (steatorrhea, foul-smelling stools) and other nutrients, which can lead to malnutrition and failure to thrive. The child will need to adhere to a gluten-free diet for life. Rice, corn, and potatoes are gluten free and are allowed in the diet (Options 2, 3, and 5). A child with celiac disease cannot eat barley, rye, oats, or wheat (mnemonic - BROW). (Option 1) A child with celiac disease cannot consume barley or French bread as both contain gluten. (Option 4) Peanut butter and jelly on rice cakes are permitted but not the oatmeal cookie. Educational objective:Celiac disease is an autoimmune disorder in which an individual cannot tolerate gluten, a protein found in barley, rye, oats, and wheat (BROW). Rice, corn, and potatoes are allowed in the diet and can be used as grain substitutes. Affected individuals must adhere to a gluten-free diet for life.

A nurse on a pediatric unit is admitting a school-aged child with suspected Reye syndrome. Which information obtained during the history taking is most consistent with this condition? 1. No history of varicella vaccine administration 2. Recent exposure to bats 3. Recent influenza infection 4. Recent use of acetaminophen for fever

Children who develop Reye syndrome often have had a recent viral infection, especially varicella (chicken pox) or influenza. Clinical manifestations include fever, lethargy, acute encephalopathy, and altered hepatic function. Elevated serum ammonia levels are an expected laboratory finding. Acute encephalopathy manifests with vomiting and a severely altered level of consciousness; it can rapidly progress to seizures and/or coma. The risk of developing Reye syndrome increases if aspirin therapy is used to treat the fever associated with varicella or influenza. As a result of this awareness, there has been a significant increase in the use of acetaminophen or ibuprofen for fever management in children. (Option 1) Although a child who has not received the varicella vaccine may have an increased risk of developing chicken pox, this evidence alone is not enough to substantiate suspected Reye syndrome. (Option 2) Recent exposure to bats would place the child at risk for rabies, a severe infection affecting the nervous system. This finding would not be indicative of Reye syndrome. (Option 4) The use of aspirin to treat fever, especially in clients with Kawasaki disease, can be associated with Reye syndrome. Acetaminophen is an appropriate antipyretic choice to reduce the risk of Reye syndrome. Educational objective:Reye syndrome is characterized by fever, acute encephalopathy, and altered hepatic function. It often develops following a viral infection, especially varicella or influenza. The risk of developing Reye syndrome increases if aspirin therapy is used to treat fever.

The school nurse evaluates a 9-year-old who is sweating, trembling, and pale. The client has type 1 diabetes managed with insulin glargine and NPH. What is the mostappropriate action by the nurse? 1. Administer scheduled dose of NPH insulin 2. Give emergency glucagon IM injection 3. Give peanut butter and crackers 4. Provide 4 oz (120 mL) of a regular soft drink

Clients experiencing hypoglycemia may develop shakiness, palpitations, sweating, pallor, and altered mental status (eg, difficulty speaking, confusion). If manifestations of hypoglycemia are present, the nurse should check the client's blood glucose (BG) level immediately. A BG of <70 mg/dL (3.9 mmol/L) requires treatment; however, if glucose testing is not readily available, the client should be treated based on symptoms. Hypoglycemia treatment in a conscious client is administration of 15 g of a quick-acting carbohydrate (Option 4). After treatment, the nurse should recheck BG every 15 minutes, repeating treatment if it remains low. Quick-acting carbohydrate options include: 4 oz (120 mL) of a regular soft drink or fruit juice 8 oz (240 mL) of low-fat milk 1 tablespoon (15 mL) of honey or syrup 6 hard candies Commercial dextrose products (Option 1) The nurse should hold the client's scheduled insulin until the client's BG is normal and symptoms resolve. (Option 2) An emergency glucagon IM injection is indicated if the client is somnolent, unconscious, seizing, or unable to swallow. (Option 3) After the client's BG improves, the client should eat a meal. However, if the next meal is more than an hour away, the nurse should give the client a serving of carbohydrate plus protein or fat (eg, peanut butter, cheese) to maintain glucose levels.

A client with palpitations is admitted with supraventricular tachycardia. The client's heart rate is 210/min. Which is the most appropriate initial intervention? 1. Ask the client to bear down as if having a bowel movement 2. Grab the crash cart and apply hands-free defibrillation pads 3. Place ECG leads on client to further assess electrical activity 4. Place IV line distally from the heart for adenosine administration

Clients with paroxysmal supraventricular tachycardia (SVT) (regular, narrow QRS complex tachycardia) are initially treated with vagal maneuvers. The act of "bearing down" as if having a bowel movement (Valsalva) 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 atrioventricular node. (Option 2) Cardioversion (not defibrillation) is used with this type of arrhythmia when it is refractory to medication. Cardioversion delivers a synchronized electrical current to the heart. This works by stopping the electrical activity to the heart and briefly allowing a normal heartbeat to return. (Option 3) An ECG is used to diagnose SVT and can be obtained while or after the client is asked to perform the vagal maneuvers as it is not therapeutic. (Option 4) Adenosine is the drug of choice to treat SVT and has a 5- to 6-second half-life (the time it takes for the drug to be reduced to half of its original concentration). Placing the IV line as close as possible, not distal, to the heart is essential for the drug to have full effect. Adenosine is given rapidly over 1-2 seconds and then followed by a rapid 20-mL normal saline flush. Transient asystole is common, and clients often experience flushing and dizziness. Educational objective:Supraventricular tachycardia is a regular, narrow QRS complex tachycardia with a rate of around 150-220/min. The best treatment is vagal maneuvers and adenosine IV push. Additional Information Physiological Adaptation NCSBN Client Need

The nurse reinforces the physical therapist's teaching regarding the use of a cane when caring for a client with osteoarthritis of the left knee. Which client statement indicates the need for further teaching? 1. "I will hold the cane in my right hand." [17%] 2. "I will move my left leg forward after moving the cane." [34%] 3. "I will place the cane several inches in front of and to the side of my right foot."[25%] 4. "My cane should equal the distance from my waist to the floor." [23%]

Clients with one-sided weakness or injury, increased joint pressure, or poor balance can use a cane to provide support and stability when walking. Cane length should equal the distance from the client's greater trochanter to the floor as incorrect cane length can cause back injury. A cane measured from the waist would be too long to provide optimal support (Option 4). Teaching points to assist a client in appropriate use of a cane include: Hold the cane on the stronger side to provide maximum support and body alignment, keeping the elbow slightly flexed (20-30 degrees) (Option 1). Place the cane 6"-10" (15-25 cm) in front of and to the side of the foot to keep the body weight on both legs to provide balance (Option 3). For maximum stability, move the weaker leg forward to the level of the cane, so that body weight is divided between the cane and the stronger leg (Option 2). If minimal support is needed, the cane and weaker leg are advanced forward at the same time. Move the stronger leg forward past the cane and the weaker leg, so the weight is divided between the cane and the weaker leg. Always keep at least 2 points of support on the floor at all times.

A client at 9 weeks gestation arrives at the clinic for an initial obstetric appointment. The nurse reviews the client's medical history and obtains a list of current medications. The nurse recognizes that which of the following medications should be clarified with the health care provider immediately? Select all that apply. 1. Albuterol 2. Doxycycline 3. Insulin aspart 4. Isotretinoin 5. Levothyroxine 6. Lisinopril

Clients with preexisting conditions (eg, asthma, hypertension, diabetes) may require changes to medication therapy if they become pregnant. In particular, teratogenic or unnecessary medications should be discontinued (before conception, when possible). The nurse should refer a client taking contraindicated medications to a health care provider immediately. For example: Doxycycline, a tetracycline antibiotic, is avoided in pregnancy because it can impair bone mineralization and discolor permanent teeth in the fetus (Option 2). Isotretinoin (Accutane) has a black box warning for severe birth defects. Retinoids may not be prescribed to women of childbearing age without a formal agreement to participate in iPLEDGE (a prescription tracking program) and a commitment to use two forms of contraception (Option 4). ACE inhibitors such as lisinopril (Prinivil) have a black box warning for use in pregnancy because they can affect fetal renal function and lung development or cause fetal death (Option 6). (Option 1) Albuterol, an inhaled beta agonist, has not been conclusively proved to be safe during pregnancy but should be continued when medically indicated (eg, severe asthma) to prevent the risks of asthma during pregnancy (eg, preterm birth, growth restriction). (Option 3) Insulin is safe for use during pregnancy and is commonly used to treat pregestational or gestational diabetes. (Option 5) Levothyroxine (Synthroid) for treatment of hypothyroidism is safe but should be monitored carefully to ensure an appropriate dose due to physiological changes in pregnancy. Educational objective:Commonly used medications that are absolutely contraindicated in pregnancy include doxycycline, isotretinoin, and ACE inhibitors. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

A client is having a severe asthma attack lasting over 4 hours after exposure to animal dander. On arrival, the pulse is 128/min, respirations are 36/min, pulse oximetry is 86% on room air, and the client is using accessory muscles to breathe. Lung sounds are diminished and high-pitched wheezes are present on expiration. Based on this assessment, the nurse anticipates the administration of which of the following medications? Select all that apply. 1. Inhaled albuterol nebulizer every 20 minutes 2. Inhaled ipratropium nebulizer every 20 minutes 3. Intravenous methylprednisolone 4. Montelukast 10 mg by mouth STAT 5. Salmeterol metered-dose inhaler every 20 minutes

Clinical manifestations characteristic of moderate to severe asthma exacerbations include tachycardia (>120/min), tachypnea (>30/min), saturation <90% on room air, use of accessory muscles to breathe, and peak expiratory flow (PEF) <40% of predicted or best (<150 L/min). Pharmacologic treatment modalities recommended by the Global initiative for Asthma (2014) to correct hypoxemia, improve ventilation, and promote bronchodilation include the following: Oxygen to maintain saturation >90% High-dose inhaled short-acting beta agonist (SABA) (albuterol) and anticholinergic agent (ipratropium) nebulizer treatments every 20 minutes Systemic corticosteroids (Solu-Medrol) (Option 4) Montelukast (Singulair) is a leukotriene receptor blocker with both bronchodilator and anti-inflammatory effects; it is used to prevent asthma attacks but is not recommended as an emergency rescue drug in asthma. (Option 5) A long-acting beta agonist (Salmeterol) is administered with an inhaled corticosteroid for long-term control of moderate to severe asthma; it is not used as an emergency rescue drug in asthma.

The nurse is caring for a 78-year-old client with a urinary tract infection (UTI). Which assessment finding would be most concerning and require immediate follow-up by the nurse? 1. Confusion 2. Presbyopia 3. Temperature 100.2 F (37.8 C) 4. White blood cell (WBC) count 12,000/mm3

Confusion is a common clinical manifestation of urinary tract infections in the elderly but still should be cause for concern and requires follow-up to rule out other possible causes. Confusion is not a normal finding in the elderly adult client. Some causes of confusion in the elderly include dehydration, lack of blood flow to the brain (stroke), decreased ability to metabolize medications, and concurrent infections. (Option 2) Presbyopia is the decrease in ability to see objects close up. This is common in clients over age 40. (Option 3) The elderly tend to have a lower body temperature, so 100.2 F (37.8 C) is considered febrile. This elevation is probably a result of the UTI and the nurse should follow up after further assessing the confusion. (Option 4) An elevated WBC count would be expected in the presence of a current infection. Educational objective:Confusion is a common clinical manifestation of UTI in the elderly; however, it is still a cause for concern and should be evaluated further by the nurse.

A client has been given instructions about collecting a urine specimen to test creatinine clearance. The client indicates correct understanding of the specimen collection procedure by making which statement? 1. "A catheter is placed temporarily then removed after I void." 2. "I must provide a midstream sample in a sterile container." 3. "I will need to collect all my urine in a container for 24 hours." 4. "The first AM specimen is best as it is more concentrated."

Creatinine clearance is a measure of glomerular function and is a sensitive indicator of renal disease progression. A 24-hour urine collection is needed for the test. When the test begins, the first urine specimen is discarded and the time is noted. All other voided urine for the next 24 hours is collected in a container and kept cool. At the end of the 24 hours, the client should void one last time and add the specimen to the container. Blood is drawn to measure serum creatinine level in addition to urine creatinine. (Option 1) An in-and-out catheter (straight catheter) is used for any test requiring a urine specimen when the client is unable to urinate or unable to follow the specimen collection procedure. A catheter is also used for a cystourethrogram or a residual urine test. (Option 2) Clean catch or midstream urine samples are collected for urinalysis or urine culture and sensitivity testing. For a creatinine clearance test, all urine for the 24-hour period must be collected or the test must be started again. (Option 4) The first AM void is preferable for a urinalysis or urine culture and sensitivity as an overnight specimen is more concentrated.

The registered nurse 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 unlicensed assistive personnel? 1. Apply a collagenase dressing to a client's pressure ulcer for wound debridement 2. Assist a client 1 day postoperative hip fracture repair to the bathroom 3. Feed a client through a gastrostomy tube after elevating the head of the bed 4. Offer orange juice to a client if the blood glucose level is <70 mg/dL (<3.9 mmol/L)

Delegation is the process of transferring responsibility of performing a task while maintaining the ultimate responsibility for the action and its outcome. The registered nurse (RN) should take into account the five rights of delegation (right task, right person, right circumstances, right communication/direction, and right supervision/evaluation) and the scope of practice when deciding which tasks to delegate. The unlicensed assistive personnel (UAP) can assist clients out of bed or to the bathroom, assist with activities of daily living, and position clients. The RN is responsible for assessing the client and adhering to the nursing process. (Option 1) Debridement of a wound involves removing debris or dead tissue to convert contaminated wounds into clean wounds so that normal healing can take place. Dressing (eg, collagenase) changes for debridement require sterile technique; UAP can change dressings only for chronic wounds using clean technique. (Option 3) The UAP can elevate the head of the bed when a client receives enteral nutrition to prevent aspiration. However, feeding through a gastrostomy tube cannot be delegated to the UAP as it requires assessment of tube placement and aspiration of gastric residual volume. (Option 4) Offering orange juice is an intervention for treating hypoglycemia that is outside the UAP's scope of practice. The UAP should report the blood glucose level to the RN so that the RN can first reassess the client for accompanying symptoms of hypoglycemia; these would require RN assessment and interpretation before intervention.

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? 1. Client with charred, leathery skin over entire back, chest, and legs 2. Client with cool skin, shivering from sitting in water until rescued 3. Client with diabetes who was unable to take prescribed insulin today 4. Client with high-pitched, crowing inspiratory respirations

Disaster triage is based on the principle of providing the greatest good for the greatest number of people. Clients are triaged rapidly using a color-coded system to categorize them from highest medical priority (emergent) to lowest (expectant). The client with stridor (eg, high-pitched, crowing inspiratory respirations), which typically occurs from constricted or blocked upper airways, is at risk for impending respiratory failure due to a compromised airway. This client should be classified as emergent, requiring immediate treatment and possibly prophylactic intubation (Option 4). (Option 1) Using the rule of nines, clients with full-thickness burns to the chest, back, and legs are suspected to have at least 72% total body surface area burns and should be classified as expectant (black tag). (Option 2) Clients with wet clothing or cold water immersion are at risk for hypothermia but can be easily self-managed by provision of warm, dry blankets; this client should be classified as nonurgent (green tag). Untreated hypothermia may lead to decreased cerebral metabolism, dysrhythmias, and coagulopathies. (Option 3) Clients with diabetes mellitus who are unable to receive insulin may develop hyperglycemia, which is unlikely to cause rapid deterioration. This client can perform self-care and should be classified as nonurgent (green tag). Educational objective:During mass casualty events, the goal is the greatest good for the greatest number of people. Clients are triaged rapidly using a color-coded system that categorizes them from highest medical priority to lowest: red (emergent), yellow (urgent), green (nonurgent), and black (expectant). Additional Information Safety and Infection Control NCSBN Client Need

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? 1. Central venous pressure is 6 mm Hg [15%] 2. Heart rate is 120/min [56%] 3. Mean arterial pressure is 78 mm Hg [14%] 4. Systemic vascular resistance is 900 dynes/sec/cm-5 [13%]

Dopamine (Intropin) 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. The lowest effective dose of dopamine should be used as dopamine administration leads to an increased cardiac workload. Significant adverse effects include tachycardia, dysrhythmias, and myocardial ischemia. A heart rate of 120/min may indicate that the dopamine infusion needs to be reduced (Option 2). (Options 1, 3, and 4) These measurements fall within the respective reference ranges and do not indicate a need to adjust dopamine administration. Normal central venous pressure is 2-8 mm Hg; normal mean arterial pressure ([systolic blood pressure + (2 x diastolic blood pressure)]/3) is 70-105 mm Hg; and normal systemic vascular resistance is 800-1200 dynes/sec/cm-5.

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

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

A client has an allergy skin test that is positive for dust mites. The nurse provides instruction on environmental interventions the client can use to control symptoms by reducing exposure to this allergen. Which intervention would be described in this teaching? 1. Allergy shots or sublingual immunotherapy 2. Antihistamine use 3. Vacuum carpeting once a week 4. Wash bed linens in hot water once a week

Environmental interventions can be very effective in controlling dust mite allergy symptoms. The bed is a common site of allergen exposure. Dust mite allergen exposure can be greatly reduced by washing bed linens every 1-2 weeks with hot water. High temperature (>140 F [60 C]) is needed to kill the dust mites; warm or cold water washing should not be recommended. Other environmental interventions that can help control symptoms include the use of special allergy-proof mattress and pillow covers and vacuuming the mattress on a regular basis. (Option 1) Allergy shots and sublingual immunotherapy can reduce allergy symptoms by exposing the immune system to the allergen over time, reducing the immune response with subsequent exposure. However, this is not an environmental intervention. (Option 2) Antihistamines can be effective in controlling allergy symptoms. However, they are not an environmental intervention. (Option 3) If possible, clients with allergy or asthma should avoid having carpeting in the home. If carpeting is used, vacuuming should be done almost daily (not weekly) to remove the dust mites.

The nurse is caring for a client who received extracorporeal shock wave lithotripsy with ureteral stent placement for treatment of a kidney stone. Which discharge instructions provided by the nurse are appropriate? Select all that apply. 1. "Contact your health care provider if you develop a fever or chills." 2. "Except for using the bathroom, you should stay on bed rest for the next 48 hours." 3. "Increase your fluid intake to help flush out the kidney stone fragments." 4. "It is common to have some blood in the urine up to 24 hours after this procedure." 5. "You may develop some bruising on your back or on the side of your abdomen."

Extracorporeal shock wave lithotripsy (ESWL) is a noninvasive procedure that uses high-energy acoustic shock waves to break up kidney stones into small fragments that can be excreted in the urine. The procedure is typically performed in an outpatient setting under general anesthesia. Temporary ureteral stents are often placed during the procedure to facilitate the passage of the stone fragments and prevent occlusion of the ureter. Stents are typically removed in 1-2 weeks. After an ESWL procedure, the client should be instructed to: Increase fluid intake to help flush out the kidney stone fragments (Option 3). Expect some bruising and pain of the back and/or flank of the affected side. Analgesics may be required (Option 5). Expect to see blood in the urine (hematuria). Urine color should progress from bright red to pink-tinged during the first several hours. Hematuria is concerning if the urine remains bright red for a prolonged period (eg, >24 hours) (Option 4). Report any symptoms of infection (eg, fever, chills) to the health care provider (Option 1). (Option 2) Ambulation is encouraged after ESWL to facilitate passage of the stone fragments. Educational objective:Following extracorporeal shock wave lithotripsy, the client should increase fluid intake and ambulate frequently to facilitate passage of the stone fragments. Expected side effects include hematuria as well as bruising and pain of the back and/or flank. Urine color should progress from bright red to pink-tinged during the first several hours. Additional Information Reduction of Risk Potential NCSBN Client Need

Evening Primrose

For eczema or skin irritations

The nurse is caring for a client diagnosed with Guillain-Barré syndrome (GBS) after a recent gastrointestinal (GI) illness. Monitoring for which of the following is a nursing care priority for this client? 1. Diaphoresis with facial flushing 2. Hypoactive or absent bowel sounds 3. Inability to cough or lift the head 4. Warm, tender, and swollen leg

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 history 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 include: Inability to cough Shallow respirations Dyspnea and hypoxia 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 (FVC) is the gold standard for assessing ventilation; a decline in FVC indicates impending respiratory arrest requiring endotracheal intubation. (Option 1) Severe autonomic dysfunction can present as diaphoresis and facial flushing. (Option 2) The client with GBS is also at risk for paralytic ileus, which is related to either immobility or nerve damage. As a result, the nurse should monitor for the presence hypoactive/absent bowel sounds. (Option 4) Clients with GBS are at risk of developing deep venous thrombosis due to lack of ambulation and should receive pharmacologic prophylaxis (heparin) and support stockings. Although symptoms in options 1, 2, and 4 represent a progressive illness and are important to communicate to the health care provider promptly, they are not the highest priority compared to impending respiratory failure.

A client is prescribed long-term pharmacologic therapy with hydroxychloroquine to treat systemic lupus erythematosus. Which intervention related to the drug's adverse effects should the nurse include in the teaching plan? 1. Have an ophthalmologic examination every 6 months 2. Take the medication on an empty stomach 3. Take vitamin D and calcium supplements 4. Wear a MedicAlert bracelet

Hydroxychloroquine (Plaquenil) is an antimalarial drug, but it is more commonly prescribed to reduce fatigue and treat the skin and arthritic (eg, joint inflammation, pain) manifestations of systemic lupus erythematosus (SLE). Hydroxychloroquine can also help to reduce lupus exacerbations in clients with inactive to mild disease, but several months can pass before its therapeutic effects become apparent. Although rare, serious adverse drug reactions such as retinal toxicity and visual disturbances can occur with hydroxychloroquine. Therefore, clients are instructed to undergo regular ophthalmologic examination every 6-12 months (Option 1). (Option 2) Hydroxychloroquine should be taken with food to decrease gastrointestinal upset (common side effect). (Option 3) Some clients with severe SLE are prescribed long-term corticosteroid (prednisone) therapy to prevent organ damage and are at risk for adverse reactions, such as accelerated osteoporosis. Osteoporosis is not an adverse reaction of hydroxychloroquine, and vitamin D and calcium supplementation is not required. (Option 4) There are no effects of hydroxychloroquine that would require wearing a MedicAlert bracelet.

The nurse in the endocrinology clinic is reviewing phone messages from clients. Which client would be the priority to call first? 1. Client with a history of thyroidectomy who needs a refill for levothyroxine 2. Client with Addison disease who is taking corticosteroids and reports new mood swings 3. Client with diabetes who reports blood sugars of 250-300 mg/dL (13.9-16.7 mmol/L) in the past week 4.Client with hyperthyroidism who has a new temperature reading of 101.5 F (38.6 C)

Hyperthyroidism results from excessive secretion of thyroid hormones. Affected clients are at risk for developing thyroid storm, a life-threatening form of hyperthyroidism. Symptoms of thyroid storm include fever, tachycardia, cardiac dysrhythmias (eg, atrial fibrillation), nausea, vomiting, diarrhea, and altered mental status. Client management includes reducing fever, maintaining hydration, and preventing cardiac compromise (eg, heart failure). (Option 1) The post-thyroidectomy client who needs a refill of the thyroid replacement medication should be contacted third. Without thyroid replacement therapy, this client would experience signs and symptoms of hypothyroidism (eg, extreme fatigue, bradycardia). (Option 2) Clients on corticosteroids may report moods swings and irritability; these are common side effects. (Option 3) The client with diabetes who is asymptomatic but has elevated blood sugars should be contacted second as prolonged hyperglycemia may lead to dehydration and acidosis. Educational objective:Clients with hyperthyroidism are at risk for developing thyroid storm, a life-threatening condition. Symptoms include fever, tachycardia, cardiac dysrhythmias, nausea, vomiting, diarrhea, and altered mental status. Client management includes reducing fever, maintaining hydration, and preventing cardiac compromise.

The nurse is caring for a client diagnosed with influenza who has had high fever, muscle aches, headache, and sore throat for 36 hours. The health care provider prescribes ibuprofen and oseltamivir. Which of the following actions by the nurse are appropriate? Select all that apply. 1. Clarify the prescription for oseltamivir with the health care provider 2. Instruct the client to cover the mouth and nose while coughing or sneezing 3. Place a mask on the client when transporting the client through the halls 4. Plan discharge teaching about the importance of annual influenza vaccination 5. Use contact precautions when providing care for the client

Influenza (flu) is a contagious viral infection that affects the respiratory tract. Symptoms include fever, chills, severe muscle aches, headache, cough, sore throat, nasal congestion, and malaise. Influenza treatment includes rest, hydration, humidified air, and antipyretics/analgesics. Antiviral medications (eg, zanamivir [Relenza], oseltamivir[Tamiflu]) are given to clients with symptom onset within the last 48-72 hours. These medications inhibit viral reproduction and can shorten the duration of the illness. Annual vaccination is recommended to prevent influenza (Option 4). To prevent spreading influenza, infected clients should be on droplet precautions (eg, surgical mask, private room), wear a mask when being transported out of the room, and be taught to cover the mouth and nose while coughing or sneezing (Options 2 and 3). Hand hygiene should also be emphasized as the influenza virus can persist on unwashed hands and surfaces. (Option 1) Oseltamivir is an appropriate antiviral medication for this client who reports onset of influenza symptoms 36 hours ago. (Option 5) The influenza virus is spread via droplet transmission when infected persons cough or sneeze. Hospital personnel caring for clients with influenza should adhere to droplet precautions in addition to standard (universal) precautions.

A client had a thoracotomy 2 days ago to remove a lung mass and has a right chest tube attached to negative suction. Immediately after turning the client to the left side to assess the lungs, the nurse observes a rush of approximately 125 mL of dark bloody drainage into the drainage tubing and collection chamber. What is the appropriate nursing action? Click on the exhibit button for additional information. 1. Document and continue to monitor chest drainage 2. Immediately clamp the chest tube 3. Notify the health care provider 4. Request repeat hematocrit and hemoglobin levels

Immediately following a thoracotomy, chest tube drainage (50-500 mL for the first 24 hours) is expected to be sanguineous (bright red) for several hours and then change to serosanguineous (pink) followed by serous (yellow) over a period of a few days. A rush of dark bloody drainage from the chest tube when the client was turned following a period of minimal drainage is most likely related to retained blood due to a partial blockage in the tube. Bright red drainage indicates active bleeding and would be of immediate concern. (Option 2) The chest tube should not be clamped because it is placed to drain the fluid leaking after surgery. (Option 3) The nurse would notify the health care provider immediately of bright red drainage or continued increased drainage (>100 mL/hr) and of changes in the client's vital signs and cardiovascular status that could indicate bleeding (eg, hypotension, tachycardia, tachypnea, decreased capillary refill, cool and pale skin). This is not the appropriate action. (Option 4) It would be appropriate to request repeat serum hematocrit and hemoglobin levels if active bleeding is suspected, but the postoperative levels are stable at this time. This is not the appropriate action.

The nurse in the postanesthesia care unit (PACU) is caring for an unresponsive client who just came from the operating room following surgery under general anesthetic for colorectal cancer. The nurse chooses what as the highest priority nursing diagnosis (ND)? 1. Acute pain 2. Impaired physical mobility 3. Ineffective airway clearance 4. Risk for fluid volume deficit

Ineffective airway clearance, which is the inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway, is the priority ND as it poses the greatest threat to survival. The most common causes of respiratory complications in the immediate postoperative period include the following: Airway obstruction, which can be due to retained secretions or the tongue falling backward against the soft palate in sedated clients. Suctioning and an artificial oral airway can be used to prevent obstruction until the client becomes more responsive. Hypoxemia, which can be due to atelectasis from increased retained secretions or hypoventilation, aspiration, or bronchospasm. Pulse oximetry and supplemental oxygen are used to maintain pulse oximeter readings >92%; placing the client in side-lying position and administrating antiemetic medications help to decrease aspiration. Hypoventilation, which can be due to depression of the respiratory drive as a result of anesthesia, pain, and opioid analgesia. (Option 1) Most clients receive continual or bolus epidural or patient-controlled opioid analgesia to control postoperative pain. Pain assessment after surgery is a priority, and acute pain is an appropriate ND. However, it does not pose the greatest threat to survival and is not the priority diagnosis at this time. (Option 2) Ambulation and ability to reposition are important interventions to prevent multiple postoperative complications. However, impaired physical mobility is not the priority ND at this time. (Option 4) Risk for fluid volume deficit related to fluid losses during surgery is an appropriate diagnosis, but it does not pose the greatest threat to survival and is not the priority ND at this time.

After six months of unprotected intercourse and failing to conceive, a 37-year-old female client reports feeling anxious and depressed because of her situation. Which response by the nurse is most appropriate? 1. "It is recommended to try to conceive for one year before undergoing a fertility evaluation." 2. "Let's review how you are timing intercourse, as optimal timing will increase your chances." 3. "Reflecting on positive things in your life may help alleviate your anxiety and depression." 4. "Tell me more about how this has affected you and your family in the last six months."

Infertility is diagnosed when a couple fails to conceive after 12 months (women age <35) or 6 months (women age ≥35) of frequent, unprotected intercourse. Difficulty achieving pregnancy may affect a couple's social, financial, and intimate relationships. Therefore, clients may benefit from a holistic approach to care. The nurse should be alert for signs of psychosocial distress such as expressions of guilt, denial, anger, or isolation. Anxiety and depression are common among couples with infertility concerns and require further evaluation of the client's emotions. Active listening and open-ended questions may help clients speak more openly and honestly about their feelings (Option 4). (Option 1) Women age ≥35 and couples with certain medical indications (eg, endometriosis, history of male subfertility) should generally seek fertility evaluation after 6 months of regular, unprotected intercourse. (Option 2) Assessing intercourse timing helps the nurse discuss awareness of fertility and natural conception methods. However, the nurse should prioritize the client's psychosocial needs before providing this type of education. (Option 3) Encouraging the client to focus on the positive aspects of life does not address the client's emotional concerns, places the client's feelings on hold, and invalidates the client's feelings. Educational objective:When caring for clients with infertility concerns, the nurse should be alert for signs of psychosocial distress and expressions of guilt, denial, anger, isolation, anxiety, or depression. Evaluation of the client's emotions using active listening and open-ended questions is the primary intervention.

A parent brings a 6-month-old child to the primary health care provider after the child abruptly started crying and grabbing intermittently at the abdomen. The client's stool has a red, currant jelly appearance. What intervention does the nurse anticipate? 1. Administer epoetin alfa (erythropoietin) 2. Give air (pneumatic) enema 3. Have the parent give 2 ounces of extra juice a day for constipation 4. Perform hemoccult test on stool

Intussusception is a process in which one part of the intestine prolapses and then telescopes into another part. It is one of the most frequent causes of intestinal obstruction during infancy. Initially, the telescoping is intermittent, resulting in periodic pain in association with the legs drawn up toward the abdomen. Pain is severe, progressive, and associated with inconsolable crying. Ongoing obstruction can compromise circulation, causing mucosal ischemia, occult bleeding, and, if untreated, grossly bloody "currant jelly" stools (mixture of blood and mucus). A contrast enema is used for diagnostic purposes and often reduces the intussusceptions. An air enema is considered safer than a barium enema. (Option 1) Human recombinant erythropoietin (epoetin alfa [Epogen, Procrit]) stimulates bone marrow to form red blood cells and is used to combat the effects of chemotherapy (due to bone marrow suppression) and/or kidney disease (erythropoietin is secreted by the kidneys). Human recombinant erythropoietin is not indicated in this client. (Option 3) Constipation during infancy usually can be corrected by increasing fluids or adding 2 ounces of pear or apple juice to the daily diet. In addition, eliminating constipating foods and increasing high-fiber foods can help. In this client, it is more important to treat the intussusception as there is no evidence of constipation. (Option 4) A hemoccult test is performed typically when occult (hidden) blood is suspected due to a dark and tarry stool. Blood is evident in intussusception, and so the priority in this client is to treat the cause of the bloody mucus stool. Educational objective:Intussusception (the intestine telescoping into itself) causes intermittent cramping and progressive abdominal pain, inconsolable crying, and currant jelly stool (from blood or mucus). It is often treated successfully with an air enema.

A 2-year-old in the emergency department is suspected of having intussusception. Which assessment finding should the nurse expect? 1. Black, sticky stools 2. Greasy, foul-smelling stools 3. Stools mixed with blood and mucus 4. Thin, "ribbon-like" stools

Intussusception is an intestinal obstruction that occurs when a segment of the bowel folds (ie, telescopes) into another segment. Pressure gradually increases within the bowel, causing ischemia and leakage of blood and mucus into the lumen, which produces the characteristic stool mixed with blood and mucus (ie, red, "currant jelly"). Initially, some infants may have only general symptoms (eg, irritability, diarrhea, lethargy). Subsequently, episodes of sudden abdominal pain (cramping), drawing the knees up to the chest, and inconsolable crying are seen. After an episode, the infant may vomit and then appear otherwise normal. Assessment may show a sausage-shaped abdominal mass. (Option 1) Melena (dark red or black, sticky stool) is an indication of an upper gastrointestinal (UGI) bleed. Gastritis is a common cause of UGI bleeding in infants and toddlers. (Option 2) Oily or bulky, foul-smelling stool is an indication of excess fat in the stool (steatorrhea) from malabsorption. This is characteristic of pancreatic insufficiency, cystic fibrosis, or celiac disease. (Option 4) Thin, ribbon-like stool is characteristic of Hirschsprung disease (congenital aganglionic megacolon). Bowel obstruction is caused by failure of the internal sphincter to relax. Educational objective: The classic symptom triad of intussusception is abdominal pain, "currant jelly" stools, and a sausage-shaped abdominal mass. However, it is more common for clients to have episodes of sudden abdominal pain, inconsolable crying, and vomiting followed by periods of normal behavior.

Which actions are appropriate for the registered nurse to delegate to an experienced licensed practical nurse? Select all that apply. 1. Administer heparin continuous infusion to a client with a venous thromboembolism 2. Auscultate bowel sounds 2 days after repair of an inguinal hernia 3. Discuss concerns about last shift's care with an irate family member 4. Monitor flow rate and drainage in a client receiving bladder irrigation 5. Teach Kegel exercises after a client has a catheter removed

Licensed practical nurses (LPNs) can execute higher-level skills under the direction of a registered nurse (RN). These include administering routine medications for expected needs and performing focused assessments such as breath sounds, bowel sounds, and neurovascular checks (eg, pulse, capillary refill, numbness) (Option 2). LPNs can also monitor findings such as flow rate and drainage in a client receiving continuous bladder irrigation (Option 4). Initial admission or postoperative assessments must be completed by the RN. (Option 1) Continuous IV drug infusions are managed by the RN. This is especially true with drug categories such as anticoagulants, which will require titration depending on client response. (Option 3) In this situation, the LPN is not explaining the LPN's own care to the family, but rather that provided by others on a different shift. Issues related to unit management should be handled by the charge RN. (Option 5) Initial teaching should be performed by the RN. The LPN can reinforce the RN's initial teaching.

The charge nurse in an intensive care unit is rounding and reviewing hemodynamic data for clients in the unit. Which client requires immediate intervention? 1. Client who is septic due to pneumonia with central venous pressure of 6 mm Hg 2. Client who recently underwent a coronary artery bypass graft with cardiac output of 5 L/min 3. Client with a gastrointestinal bleed and mean arterial pressure of 58 mm Hg 4. Client with an adrenal gland tumor and blood pressure of 168/95 mm Hg

Mean arterial pressure (MAP) is the average pressure within the arteries. Compared to blood pressure alone, MAP is a more precise measurement of the body's ability to perfuse organs and tissues. MAP of at least 60 mm Hg is required to adequately perfuse vital organs, but MAP ≥70 mm Hg is optimal. Without intervention, MAP <60 mm Hg may progress to ischemia, organ damage, and death (Option 3). Common causes of low MAP include hypovolemia (eg, hemorrhage, severe dehydration), sepsis, and heart failure. Typical interventions include replacing intravascular volume (eg, IV fluids, albumin, blood products) and administering IV medications such as vasopressors (eg, norepinephrine, vasopressin) to induce peripheral vasoconstriction and inotropes (eg, dobutamine) to increase cardiac contractility. MAP is calculated automatically by intra-arterial blood pressure monitors and some noninvasive blood pressure machines. MAP can also be calculated manually using the systolic blood pressure (SBP) and diastolic blood pressure (DBP) readings and the following formula: MAP = (SBP + [2 × DBP])/3. (Options 1 and 2) Central venous pressure of 6 mm Hg and cardiac output of 5 L/min are within normal limits. (Option 4) Blood pressure of 168/95 mm Hg is an elevated reading requiring further assessment. However, low MAP is the highest priority due to risk for tissue ischemia. Educational objective:Mean arterial pressure (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.

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? 1. Encourage client to eat bulk-forming foods such as whole grain bread 2. Encourage rest, fluids, and acetaminophen for the fever 3. Make an appointment for the client with the health care provider today 4. Take 2 tablets of loperamide followed by 1 tablet after each loose stool

Most bouts of diarrhea are self-limiting and last ≤48 hours. Clients experiencing diarrhea that lasts >48 hours or accompanied by fever or bloody stools should be evaluated by a health care provider (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 (eg, Clostridium difficile). (Option 1) Instructions on eating bulk-forming foods may be helpful with diarrhea; however, this option does not seek to address the underlying problem causing the 4 days of diarrhea and fever. The client should see the HCP. (Option 2) 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. (Option 4) Loperamide (Imodium) is a synthetic opioid used as an antidiarrheal. It slows peristalsis and subsequently increases fluid absorption. It should not be used more than 2 days or if fever is present as retention of bacteria or toxins inside the colon can make the process worse and cause toxic megacolon.

The nurse is caring for a 6-year-old who is postoperative open right tibial fracture reduction with cast placement. Which finding requires priority action? 1. Blood-tinged stain on the inner aspect of the cast 2. Capillary refill of 2 seconds on the affected extremity 3. Mild swelling of toes on the right foot 4. Pain of 9/10 an hour after a dose of morphine

Neurovascular integrity should always be tested first after cast application by performing circulation, motor, and sensory checks. The client should have no numbness or tingling. If pain is not relieved (especially with passive range of motion) by prescribed pain medication or is out of proportion to the injury, the nurse should notify the health care provider (HCP). Permanent damage to the circulatory and nervous systems (compartment syndrome) can occur if this is not addressed immediately (Option 4). Pallor, pulselessness, and paralysis are late signs of compartment syndrome. (Option 1) Blood stains on a cast after an open orthopedic surgical procedure are not unusual. The nurse should circle the stains and mark the date and time on the cast so further bleeding can be easily visualized. However, rapid enlargement of a stain needs to be reported to the HCP. (Option 2) The skin on the affected extremity should be pink and warm. When blanched, it should return to normal color in <3 seconds. (Option 3) Mild swelling/edema of the toes can occur from cast pressure and can be reduced with leg elevation using pillows. Increasing swelling should be reported to the HCP. Most clients report severe pain when the cause is compartment syndrome, which is a priority. Educational objective:Compartment syndrome is a limb-threatening emergency that can occur after fracture reduction. Neurovascular checks should always be performed first. The client should not have numbness or tingling. If pain is not relieved (especially with passive range of motion) by prescribed pain medication or is out of proportion to the injury, the nurse should notify the health care provider.

Normal pupils are 3-5mm in diameter

Normal pupils are 3-5 mm in diameter. Pupil dilation can be the result of medication use or neurological causes (eg, increased intracranial pressure, brain herniation)

The nurse evaluates the results of laboratory tests completed on a client admitted for a non-healing wound. Which of the following values would be a priority for the nurse? 1. Blood urea nitrogen 15 mg/dL (5.4 mmol/L) 2. Serum albumin 3.7 g/dL (37 g/L) 3. Serum potassium 4.5 mEq/L (4.5 mmol/L) 4. Serum sodium 153 mEq/L (153 mmol/L)

Nutritional deficiencies (eg, zinc, protein, vitamin C) and dehydration can impair wound healing. Dehydration (loss of free water) can increase serum sodium levels. The normal value for serum sodium is 135-145 mEq/L (135-145 mmol/L). The value listed, 153 mEq/L (153 mmol/L), is high. Increased serum sodium level (hypernatremia) has an osmotic action that causes water to be pulled from the interstitial spaces into the vascular system. Remember that "water goes where salt is." This action decreases wound healing at a cellular level, reducing the nutrients cells need for repair. (Option 1) Normal blood urea nitrogen (BUN) values are 6-20 mg/dL (2.1-7.1 mmol/L). Elevated BUN may indicate dehydration and could impair wound healing. (Option 2) Malnutrition can impair wound healing. Serum albumin and prealbumin levels are obtained to assess nutritional status. The normal value for albumin is 3.5-5.0 g/dL (35-50 g/L). (Option 3) The normal value for serum potassium is 3.5-5.0 mEq/L (3.5-5.0 mmol/L).

steatorrhea

Oily or bulky, foul-smelling stool is an indication of excess fat in the stool (steatorrhea) from malabsorption. This is characteristic of pancreatic insufficiency, cystic fibrosis, or celiac disease.

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? 1. "I have a leftover prescription at home I can use if I have pain." [95%] 2. "I will cancel the wine tasting I have planned for this weekend." [1%] 3. "I will have someone drive me home and will take a couple of days off work." [1%] 4. "I will have someone stay with me and make sure I am okay." [0%]

Opioid pain medications should be avoided following a head injury; therefore, the nurse should clarify what medication the client has at home (Option 1). Any change in level of consciousness, 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. A client with a head injury should be taught the following: Notify the health care provider if you experience increased drowsiness, nausea or vomiting, worsening headache, seizures, vision changes, behavioral changes, weakness or numbness, or difficulty with balance or walking Avoid alcohol and other central nervous system (CNS) depressants (eg, benzodiazepines) (Option 2) Have someone stay with you (Option 4) Avoid driving, using heavy machinery, playing contact sports, or taking hot baths for 1-2 days (Option 3) Educational objective:Clients should avoid opioid pain medications and CNS depressants (eg, alcohol) when recovering from a head injury. They should also avoid driving, using heavy machinery, playing contact sports, or taking hot baths for 1-2 days.

A client is receiving scheduled doses of carbidopa-levodopa. The nurse evaluates the medication as having the intended effect if which finding is noted? 1. Improvement in short-term memory [15%] 2. Improvement in spontaneous activity [65%] 3. Reduction in number of visual hallucinations [10%] 4. Reduction of dizziness with standing [8%]

Parkinson disease is caused by low levels of dopamine in the brain. Levodopa is converted to dopamine in the brain, but much of this drug is metabolized before reaching the brain. Carbidopa helps prevent the breakdown of levodopa before it can reach the brain and take effect. This combination medication is particularly effective in treating bradykinesia (generalized slowing of movement). Tremor and rigidity may also improve to some extent. Carbidopa-levodopa (Sinemet) once started should never be stopped suddenly as this can lead to akinetic crisis (complete loss of movement). However, prolonged use can also result in dyskinesias (spontaneous involuntary movements) and on/off periods when the medication will start or stop working unpredictably. (Option 1) Carbidopa-levodopa does not improve memory. Medications for the treatment of Alzheimer disease, such as donepezil and rivastigmine, are used to improve cognition and memory. (Options 3 and 4) Orthostatic hypotension and neuropsychiatric disturbances (eg, confusion, hallucinations, delusions, agitation, psychosis) are serious and important adverse effects of carbidopa-levodopa. Health care providers usually start the medications at low doses and gradually increase them to prevent these effects.

The health care provider prescribes phenazopyridine hydrochloride for a client with a urinary tract infection. What would the office nurse teach the client to expect while taking this medication? 1.Constipation 2. Difficulty sleeping 3. Discoloration of urine 4. Dry mouth

Phenazopyridine hydrochloride (Pyridium) is a urinary analgesic prescribed to relieve the pain and burning associated with a urinary tract infection. The urine will turn bright red-orange while on this medication; other body fluids can be discolored as well. Because staining of underwear, clothing, bedding, and contact lenses can occur, the nurse should suggest that the client use sanitary napkins and wear eyeglasses while taking the medication. Phenazopyridine hydrochloride provides symptomatic relief but no antibiotic action, and so it is important that the client take a full course of antibiotics. (Options 1, 2, and 4) Constipation, difficulty sleeping, and dry mouth are not common adverse effects of phenazopyridine hydrochloride.

A client is admitted to the intensive care unit with suspected pheochromocytoma. The client's vital signs are temperature of 99.6 F (37.5 C), blood pressure (BP) of 200/110 mm Hg, heart rate of 110/min, and respirations of 20/min. The client is sweating profusely and reports a severe headache. Which prescription should the nurse implement first? 1. Draw labs to assess electrolyte panel 2. Give acetaminophen 650 mg by mouth as needed for headache 3. Place a fan in the client's room 4. Start nitroprusside infusion at 0.5 mcg/kg/min

Pheochromocytoma is a condition caused by a tumor in the adrenal medulla. This results in excess release of catecholamines such as epinephrine and norepinephrine, leading to paroxysmal hypertensive crisis. Important points to note when caring for these clients include the following: Hypertension is difficult to treat and is often resistant to multiple drugs. The client should avoid activities that can precipitate a hypertensive crisis (eg, bending, lifting, Valsalva maneuver). Abdominal palpation should be avoided as manipulation of the adrenal gland and release of catecholamines can precipitate a hypertensive crisis. Hypertensive crisis puts the client at risk for stroke and so has the highest priority for treatment. Nitroprusside (Nitropress, Nipride) is a vasodilator given via infusion and can be titrated to keep the BP within a desired parameter. (Options 1, 2, and 3) Administration of acetaminophen and use of a fan may help relieve symptoms. Drawing an electrolyte panel is appropriate. However, these are not life-saving interventions and so are not the highest priority.

Positive pressure ventilation (PPV) delivers positive pressure to the lungs using a mechanical ventilator (MV), either invasively through a tracheostomy or endotracheal tube or noninvasively through a nasal mask/facemask, nasal prongs, or a mouthpiece. 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 preset volume and concentration of oxygen (eg, 21%-100%) 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 (eg, hemorrhage, hypovolemic shock) and decreased venous tone (eg, septic shock, neurogenic shock). (Option 1) Fluid and/or sodium retention usually occurs about 48-72 hours after initiation of PPV due to: (1) increased intrathoracic pressure and decreased cardiac output that stimulate the kidneys to release renin; (2) physiologic stress that leads to the release of antidiuretic hormone and cortisol; and (3) breathing through the ventilator's closed circuitry, which decreases insensible loss associated with respiration. (Option 2) Hypokalemia is not associated with PPV. (Option 4) PPV increases intrathoracic pressure and reduces venous return to the right side of the heart, reducing preload and cardiac output as well. Educational objective:Positive pressure ventilation causes increased intrathoracic pressure and reduced venous return and cardiac output, which can result in hypotension.

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 health care provider? 1. Bluish discoloration of the erect penis [66%] 2. Drank a 6-pack of beer 8 hours ago [4%] 3. Extreme penile pain rated as 9 on 0-10 scale [9%] 4. Has not voided for at least 6 hours [19%]

Priapism is a sustained, painful erection often associated with sickle cell anemia, as the sickling (crescent shaping) of red blood cells can lead to penile vascular occlusion, erectile tissue hypoxia, and tissue necrosis. Bluish discoloration is of most concern as it can be a sign of ischemia to the penis. (Option 2) Some factors, such as alcohol intake; spinal cord injury; and phosphodiesterase-5 enzyme inhibitor (ie, sildenafil), psychotropic (ie, trazodone), and illegal (ie, cocaine) drugs can contribute to the development of priapism. Possible penile ischemia is a more urgent concern than alcohol intake. (Option 3) Extreme pain related to tissue hypoxia is an expected, characteristic manifestation of priapism and requires analgesia, but it is not as urgent a concern as possible penile ischemia. (Option 4) Difficulty voiding and urinary retention are complications associated with priapism. It is important to monitor urine output as catheterization may be necessary, but this is not as urgent a concern as possible penile ischemia.-

A nurse is teaching home management to a client newly diagnosed with severe psoriasis. Which client statement indicates that further teaching is needed? 1. "Exposure to sunlight will worsen my psoriasis." [31%] 2. "I should avoid drinking alcohol." [8%] 3. "I should use moisturizing creams frequently." [51%] 4. "Stress can worsen psoriasis." [8%]

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 (eg, stress, trauma, infection), topical therapy (eg, corticosteroids, moisturizers), phototherapy (eg, ultraviolet light), and systemic medications, including cytotoxic (eg, methotrexate) and biologic (eg, infliximab) agents (Options 3 and 4). The client should avoid alcohol as it can worsen psoriasis (Option 2). In addition, the liver, kidneys, and bone marrow are specifically affected by the systemic medications commonly used to control psoriasis. (Option 1) Exposure to ultraviolet light (eg, phototherapy, sunlight) can help slow epidermal turnover and decrease exacerbations; however, there is a greater long-term risk of skin cancer. Therefore, frequent skin examinations by a health care provider are important.

The emergency department 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? Select all that apply. 1. Breath smells of alcohol 2. Client disoriented to place 3. Client reports eyes burning 4. History of multiple sclerosis 5. Point tenderness over spine

Spinal immobilization is not a benign procedure. An acronym to help determine the need for spinal immobilization is NSAIDs: N - Neurological examination. Focal deficits include numbness and decreased strength.S - Significant traumatic mechanism of injuryA - Alertness. The client may be disoriented or have an altered level of consciousness (Option 2).I - Intoxication. The client could have impaired decision-making ability or lack awareness of pain (Option 1).D - Distracting injury. Another significant injury could distract the client from spinal pain.S - Spinal examination. Point tenderness over the spine or neck pain on movement (if there is no midline tenderness) may be present (Option 5). (Option 3) The sensation of burning eyes could be related to many issues and does not necessarily have a direct correlation to spinal trauma. (Option 4) There is no direct correlation of multiple sclerosis (autoimmune progressive nerve demyelinization) with the need for spinal immobilization. Educational objective:Indications for spinal immobilization include abnormal neurological findings, significant mechanism of injury, change in orientation or level of consciousness, intoxication, distracting injury, and point tenderness over the spine. Additional Information Reduction of Risk Potential NCSBN Client Need

The hospice nurse is caring for an actively dying client who is unresponsive and has developed a loud rattling sound with breathing ("death rattle") that distresses family members. Which prescription would be most appropriate to treat this symptom? 1. Atropine sublingual drops [33%] 2. Lorazepam sublingual tablet [13%] 3. Morphine sublingual liquid [48%] 4. Ondansetron sublingual tablet [4%]

The "death rattle" is a loud rattling sound with breathing that occurs in a client who is actively dying. When the client cannot manage airway secretions, the movement of these secretions during breathing causes a noisy rattling sound. This can distress family and friends at the bedside of the dying client. The "death rattle" can be treated using anticholinergic medications to dry the client's secretions. Medications include atropine drops administered sublingually or a transdermal scopolamine patch. (Option 2) Lorazepam is a benzodiazepine that is used to treat anxiety and restlessness in terminally ill clients. It can be effective for alleviating dyspnea exacerbated by anxiety, but it is ineffective for controlling secretions (the cause of the "death rattle"). (Option 3) Morphine is an opioid analgesic that is effective for pain treatment as well as terminal dyspnea. The client is not exhibiting these symptoms, so morphine would be inappropriate. (Option 4) Ondansetron will help the nausea and vomiting but is not very effective for treating the "death rattle."

The nurse is caring for a pediatric client with end-stage leukemia who is on comfort care and is unresponsive. The child's parent asks, "How can you tell if my child is in pain?" Which of these would the nurse describe as signs of discomfort? Select all that apply. 1. Blank facial expression 2. Facial grimacing 3. Groaning 4. Knees bent up near chest 5. Lying still

The FLACC scale (face, legs, activity, cry, and consolability) can be used to assess pain in the child who is nonverbal. This includes assessment for: Facial grimacing Leg movement, tension, or bending up toward the chest Activity, including squirming, arching, jerking Crying or moaning Difficulty consoling or comforting the child The nurse will provide teaching on signs that should prompt the parent to administer as-needed pain medication to the child. (Option 1) A child who is comfortable will usually have a neutral facial expression. A child in pain is likely to exhibit grimacing, frowning, or clenching of the jaw, based on the FLACC face assessment. (Option 5) A child who is comfortable will be lying quietly. A child who is squirming and moving is more likely to be in pain, based on the FLACC activity assessment. Educational objective:It is difficult to assess for pain in the nonverbal client, particularly if the person is unresponsive at the end of life. The FLACC scale is an accurate method of assessing pain in the nonverbal child. This tool should be used to teach parents how to promote comfort for their nonverbal child. Additional Information Basic Care and Comfort NCSBN Client Need

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? Select all that apply. 1. Identify the number "8" traced on the palm 2. Shrug the shoulders against resistance 3. Swallow water 4. Touch each finger of one hand to the hand's thumb 5. 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 (tandem), on toes, and on heels (Option 5). Coordination testing involves the following: Finger tapping - ability to touch each finger of one hand to the hand's thumb (Option 4). Rapid alternating movements - rapid supination and pronation Finger-to-nose testing - clients touch the clinician's finger and then their own nose as the clinician's finger varies in location Heel-to-shin testing - client runs each heel down each shin while in a supine position (Option 1) This is a test of sensory function, specifically fine touch (graphesthesia). Other tests for this include identifying an object in the hand (stereognosis) and two-point discrimination. (Option 2) Shrugging the shoulders against resistance (as well as turning the head against resistance) is a test for cranial nerve (CN) XI (spinal accessory). (Option 3) In a client who has an intact gag reflex, the ability to swallow water helps to assess CN IX (glossopharyngeal) and CN X (vagus). The nurse can also observe for a symmetrical rise of the soft palate and uvula by asking the client to say "ah."

A category 4 hurricane has disrupted a rural local health care system, creating a significant increase in emergency department admissions. Which client would the nurse assess first? 1. 55-year-old with type 2 diabetes mellitus complaining of a headache after being involved in a minor motor vehicle accident 2. 45-year-old with type 1 diabetes mellitus with a blood glucose of 690 mg/dL (38.3 mmol/L) complaining of abdominal pain and fatigue 3. 7-year-old with status asthmaticus and an oxygen saturation of 89% 4. 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

The child with status asthmaticus is at risk for rapid deterioration of respiratory status and respiratory failure. The clinical finding of decreased oxygen saturation (normal reference is ≥95%) indicates mild-to-moderate status asthmaticus. This client needs to be treated immediately. (Option 1) This client needs assessment and monitoring of neurological functioning following head trauma. The client is currently stable and has the least priority at this time. Development of altered mental status, spinal pain, nausea, vomiting, or loss of consciousness would shift the status to a higher priority. (Option 2) The clinical findings of fatigue, abdominal pain, and blood glucose level of 690 mg/dL (38.3 mmol/L) indicate developing diabetic ketoacidosis. This client is at risk of life-threatening hemodynamic instability and needs immediate treatment. However, the client can be seen after the child with status asthmaticus and impending respiratory deterioration. (Severe respiratory instability takes precedence over hemodynamic instability.) (Option 4) This client's history is indicative of dehydration. She needs restoration of normal fluid balance, but she is not at risk of impending severe respiratory or hemodynamic instability, as are clients 3 and 2.

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

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

A client's arterial blood gases (ABGs) are shown in the exhibit. The nurse would expect which finding to demonstrate that the client is compensating for the ABGs? Click on the exhibit button for additional information. 1. Decrease in bicarbonate reabsorption [26%] 2. Decrease in respiratory rate [14%] 3. Increase in bicarbonate reabsorption [21%] 4. Increase in respiratory rate [37%] PH: 7. 25 PO2: 79 PaCO2: 35 HCO3: 12

The client's ABGs have low pH consistent with acidosis. If it is a primary respiratory acidosis, pCO2 would be higher. If it is metabolic acidosis, bicarbonate would be lower. Because this client has low pH coupled with low bicarbonate, the most likely diagnosis is primary metabolic acidosis. Respiratory alkalosis is the body's natural compensation for metabolic acidosis. Respiratory alkalosis is achieved by blowing more CO2 off from the system through rapid breathing. (Option 1) Decreased bicarbonate reabsorption would produce metabolic acidosis; this would occur as a compensation for primary respiratory alkalosis (decreased pCO2 and high pH). (Option 2) When the respiratory rate is decreased, pCO2 would increase, creating a respiratory acidosis; this would occur in response to a primary metabolic alkalosis. (Option 3) Increased bicarbonate reabsorption would produce metabolic alkalosis; this would occur as a compensation for primary respiratory acidosis (increased pCO2 and low pH). Educational objective:Respiratory alkalosis is the body's natural compensation for metabolic acidosis. It is achieved by blowing more CO2 off from the system through rapid breathing.

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

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

The nurse is caring for a client with multiple renal calculi. Which nursing interventions should be included in the plan of care? Select all that apply. 1. Administer analgesics at regularly scheduled intervals 2. Encourage fluid intake of up to 3 L/day 3. Instruct client to stay on bed rest 4. Provide massage to the client's flank 5. Strain all urine for the presence of stones

The formation of renal calculi (ie, kidney stones) can be due to various factors (eg, family history, dietary imbalances, immobilization, dehydration). Manifestations include sudden, severe abdominal or flank pain and nausea/vomiting. Client management focuses on analgesics administered at regularly scheduled intervals, rehydration of up to 3 L/day unless contraindicated by other comorbidities, and ambulation to facilitate the passage of calculi (Options 1 and 2). To retrieve stones that the client may pass, the nurse should strain all urine obtained (Option 5). The collected stones are analyzed to determine their composition (eg, calcium oxalate, calcium phosphate, struvite, uric acid, cystine), which can then direct preventive measures, such as dietary and lifestyle changes, after discharge. (Option 3) Immobilization is a contributing cause of renal calculi formation and should be avoided. Ambulation and frequent mobilization are encouraged as tolerated to help facilitate the passage of calculi. (Option 4) Massage therapy to the flank should not be performed to prevent further instigation of renal colic. Other interventions, such as monitored heat therapy, would be acceptable.

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? Select all that apply. 1. Covering client with warm blankets 2. Logrolling the client from side to side frequently 3. Mechanical ventilation 4. Warmed blood administration 5. Warmed IV fluids

The initial management of a near-drowning victim focuses on airway management due to potential aspiration (leading to acute respiratory distress syndrome), pulmonary edema, or bronchospasm (leading to airway obstruction). Hypoxia is managed and prevented by ensuring a patent airway via intubation and mechanical ventilation as necessary (Option 3). 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 (Option 2). There are passive, active external, and active internal rewarming methods. Passive rewarming methods include removing the client's wet clothing, providing dry clothing, and applying warm blankets. Active external rewarming involves using heating devices or a warm water immersion. Active internal rewarming is used for moderate to severe hypothermia and involves administering warmed IV fluids and warm humidified oxygen (Options 1 and 5). (Option 4) Unless blood loss has occurred from trauma during the near-drowning incident, administration of blood products is not indicated.

The nurse cares for a client with type 1 diabetes mellitus. Which laboratory result is most important to report to the primary health care provider? 1. Fasting blood glucose 99 mg/dL (5.5 mmol/L) 2. Serum creatinine 2.0 mg/dL (177 µmol/L) 3. Serum potassium 3.9 mEq/L (3.9 mmol/L) 4. Serum sodium 140 mEq/L (140 mmol/L)

The normal serum creatinine for an adult is 0.6-1.3 mg/dL (53-115 µmol/L). It provides an estimation of the glomerular filtration rate and is an indicator of kidney function. A level of 2 mg/dL (177 µmol/L) is clearly abnormal. The client with diabetes mellitus is at risk for diabetic nephropathy, a complication associated with microvascular blood vessel damage in the kidney. Early treatment and tight control of blood glucose levels are indicated to prevent progressive renal injury in a client with diabetic nephropathy. (Option 1) Normal serum fasting blood glucose is 70-99 mg/dL (3.9-5.5 mmol/L). (Option 3) Normal serum potassium is 3.5-5.0 mEq/L (3.5-5.0 mmol/L). (Option 4) Normal serum sodium is 135-145 mEq/L (135-145 mmol/L).

The nurse employed in a woman's health care clinic would be most concerned about which client statement? 1. "I recently noticed a small, round, painless, mobile lump in my left breast while showering." 2. "Last night while breastfeeding, my nipples were cracked and my breasts were painful." 3. "My right breast is red and warm with little tiny indented areas on the surface of the skin." 4. "Sometimes during my cycle, I notice breast nodules that are movable and feel soft to the touch."

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 (peau d'orange), pitting appearance on the skin surface. The nurse would be most concerned about this client and make an immediate referral to the health care provider for examination and evaluation. (Option 1) Clients usually describe lumps related to fibroadenoma, a benign breast disorder, as small, round, painless, mobile lumps with no breast tissue retraction or discharge. (Option 2) Further assessment is needed to determine if the client is at risk for developing mastitis. Mastitis may develop in lactating women when the nipples become dry and crack. The cracked nipples may provide a portal of entry for microorganisms, especially Staphylococcus. The client should be taught appropriate care of the breast during lactation. The client diagnosed with mastitis will experience warm, red, painful, and edematous breasts. (Option 4) Clients usually describe fibrocystic breast nodules as soft, movable nodules that change size at various times during the menstrual cycle. Fibrocystic breast changes are a common benign breast disorder.

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? Select all that apply. 1. II 2. III 3. IV 4. V 5. VI

The oculomotor (cranial nerve III), trochlear (cranial nerve IV), and abducens (cranial nerve VI) are motor nerves of the eye that are tested by having the client track an object, such as a finger, through the fields of vision. The oculomotor nerve is also tested by checking for pupillary constriction and accommodation (constriction with near vision). Deficits in cranial nerves III, IV, and VI can include disconjugate gaze (eyes do not move together), nystagmus (fine, rapid jerking eye movements), or ptosis (drooping of the eyelid).

A 3-month-old 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? 1. Document a description of the injury [15%] 2. Question the mother about where the infant sleeps [26%] 3. Report the injury per facility protocol [52%] 4. Separate the mother from the infant [4%]

The office nurse instructs a client newly diagnosed with asthma about the use of the peak flow meter to evaluate airflow. Which statement made by the client indicates an understanding of the nurse's teaching? 1. "I will exhale as quickly and forcibly as possible through the mouthpiece of the device to obtain a peak flow reading." [42%] 2. "I will move the indicator to the desired reading on the numbered scale before using the device." [11%] 3. "I will record my personal best reading, which is the average of 3 consecutive peak flow readings." [38%] 4. "I will remember to use the device after taking my fluticasone metered-dose inhaler (MDI)." [7%]

The peak flow meter is a hand-held device used to measure peak expiratory flow rate (PEFR) and is most helpful for clients with moderate to severe asthma. Exhaling as quickly and forcibly as possible through the mouthpiece of the device evaluates the degree of airway narrowing by measuring the volume of air that can be exhaled in one breath. Use of the device permits self-management and provides information to guide and evaluate treatment. (Option 2) The client moves the indicator on the numbered scale to 0 or to the lowest number on the scale before using the device. (Option 3) The personal best reading is the highest peak flow reading the client can attain, usually over a 2-week period, when asthma is in good control. (Option 4) The peak flow meter is used after a short-acting bronchodilator rescue MDI to evaluate response, not after a corticosteroid MDI.

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? 1. Compressing the chest to a depth of at least 2 in (5 cm) [62%] 2. Pausing after each set of 15 compressions to allow for 2 rescue breaths [8%] 3. Placing the heel of the hand on the upper half of the client's sternum [10%] 4. Providing compressions at a rate of at least 80-100/min [18%]

The primary goal of cardiopulmonary resuscitation (CPR) is adequate perfusion to the brain and vital organs. High-quality chest compressions for adults are at least 2 in (5 cm) deep to adequately pump blood but no more than 2.4 in (6 cm) deep to prevent unnecessary client injury (Option 1). The chest should recoil completely after each compression to allow complete refilling of the heart chambers, which promotes effective perfusion. (Option 2) Interruption of compressions should be minimized; at least 60% (preferably more) of the total resuscitation time should be made up of compressions. For adults (and in single-rescuer CPR for any age), a cycle of 30 compressions followed by 2 rescue breaths provides the best outcome. If the client has an advanced airway, continuous compressions and 10 breaths/min should be provided. (Option 3) Correct hand placement is in the center of the chest, on the lower half of the sternum(breastbone). Hand placement on the upper half of the sternum does not provide adequate perfusion. (Option 4) Studies have shown better client outcomes due to improved perfusion with a compression rate of 100-120/min.

Place the nursing actions for performing a renal system physical assessment in the correct order. All options must be used. Correct order: 1. advise client to empty bladder completely 2. observe skin and contour of abdomen and lower back 3. auscultate renal arteries in right and left upper quadrant 4. percuss and palpate both the right and left kidneys 5. document the assessment of renal system function

The steps for a renal system assessment are: Empty the bladder to avoid discomfort during percussion and palpation and to provide a clean-catch sample (if prescribed) (Option 1) Inspect the abdomen and lower back for color, contour, symmetry, distension, and movements (eg, visible peristalsis). Inspection is always done first during physical examination (Option 4). The nurse should auscultate immediately after inspection as percussion or palpation may increase bowel motility and interfere with sound transmission during auscultation. Listen for renal artery bruits in the right and left upper abdominal quadrants (Option 2). Percuss for kidney borders, costovertebral angle tenderness, and bladder distension. A dull percussion sound indicates solid structures or fluid-filled cavities (eg, distended bladder). Palpate for bladder distension, masses, and tenderness. A distended bladder may be palpated at any point from the symphysis pubis to the umbilicus and is felt as a firm, rounded organ. A normal kidney is not usually palpable; a palpable kidney may indicate hydronephrosis or polycystic kidney disease (Option 5). Document all renal assessment findings immediately after the examination (Option 3). Educational objective:Physical assessment of the renal system includes the techniques of inspection, auscultation, percussion, and palpation, in that order. Allow the client to empty the bladder before beginning the assessment and auscultate immediately after inspection as percussion or palpation may increase bowel motility and interfere with sound transmission during auscultation. Always document the findings. Additional Information Reduction of Risk Potential NCSBN Client Need

The nurse teaches a group of homeless community clients preventive measures related to transmission of hepatitis A. Which of these measures would the nurse teach as the priority precaution to prevent transmission? 1. Do not share needles when injecting drugs [5%] 2. Practice safe sex by using condoms [1%] 3. Receive the hepatitis A vaccine [5%] 4. Wash hands after bowel movements and before eating [88%]

The transmission of hepatitis A occurs most commonly through the fecal-oral route through poor hand hygiene and improper food handling by infected persons. It is seen primarily in developing countries. After infection, the hepatitis A virus reproduces in the liver and is secreted in bile. Therefore, hand hygiene (especially after toileting and before meals) is the most important intervention to reduce the occurrence of hepatitis A infection (Option 4). Vaccination against hepatitis A is recommended for all children at age 1 and for adults at risk of contracting the virus (health care workers, men who have sex with men, drug users, those who travel to areas with a high prevalence, those with clotting disorders, and those with liver disease). (Options 1 and 2) Hepatitis A is secreted in bile and is more often transmitted via the fecal-oral route. However, the virus can also be spread through needle sharing between intravenous drug users and unsafe sexual practices. These practices should be discouraged and hand hygiene encouraged as the most important intervention for prevention. (Option 3) Vaccination is an important means of preventing infection. However, hygienic measures (eg, hand washing, sanitation, cleanliness, avoiding sharing personal items) are readily implemented by all clients regardless of means.

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? Select all that apply. 1. Locate and remove any medication patches 2. Locate possible medical alert band or necklace 3. Remove rings and jewelry and lock in a secure location 4. Remove tampon and replace with menstrual pad 5. 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. This includes checking for: Medical alert bracelets/necklaces: Indicating allergy status, emergency contact, or code status (Option 2) Contact lenses: Remove to prevent corneal injury (Option 5) Medication patches: To prevent drug interactions and determine conditions currently being treated Tampons (in female clients): Remove to prevent toxic shock syndrome or infection (Option 4) Rings and jewelry: Remove to prevent constrictive injury or vascular damage if edema develops (Option 3) (Option 1) Medication patches should not be removed without first consulting the health care provider. Clients are often prescribed transdermal patches for chronic conditions (eg, clonidine for hypertension, nitroglycerin for angina). Removing and discarding a medication patch without additional information may harm the client.

Which client should the nurse assess first? 1. Client with atrial fibrillation with a new prescription for warfarin [5%] 2. Client with chronic obstructive pulmonary disease with an oxygen saturation of 91% [1%] 3. Client with postoperative pain rated 8 out of 10 [5%] 4. Client with third-degree heart block with a pulse of 42/min [86%]

Third-degree atrioventricular (AV) block, or complete heart block, occurs when electrical conduction from the atria to the ventricles is blocked, causing decreased cardiac output (eg, dizziness, syncope, mental status changes, heart failure, hypotension, bradycardia). The client with third-degree AV block is a high priority, as the client may decompensate to cardiogenic shock and even periods of asystole (Option 4). Treatment includes administration of atropine and temporary pacing (eg, transcutaneous) until a permanent pacemaker can be placed. (Option 1) Atrial fibrillation puts clients at risk for development of atrial thrombi, which can embolize and cause a stroke. Administration of warfarin (a long-term anticoagulant) is important to prevent thrombus formation; however, symptomatic third-degree AV block is a higher priority. (Option 2) Clients with chronic obstructive pulmonary disease often have pulse oximetry readings that are lower than normal (eg, 91%). The goal in this client population is to keep the oxygen saturation 88-92%. (Option 3) The client experiencing severe postoperative pain should be assessed for surgical complications (eg, infection), and the pain should be treated (eg, with hydrocodone). However, severe pain does not take priority over third-degree AV block. The nurse can see the client as soon as possible or ask another nurse for help.

The unlicensed assistive personnel on the cardiac floor reports to the registered nurse that during the first vital sign measurement on the shift, a client's blood pressure measured 198/102 mm Hg on the automated blood pressure machine. What action should the nurse take first? 1. Have the unlicensed assistive personnel recheck the client's blood pressure 2. Immediately notify the health care provider 3. Obtain the client's PRN labetalol from the medication dispensing machine 4. Recheck the client's blood pressure with a manual cuff

This client's abnormally high blood pressure increases the risk for complications such as stroke. The nurse should assess this client and recheck the blood pressure with a manual cuff to verify the accuracy of the previous measurement taken by the unlicensed assistive personnel (UAP). The nurse will need to assess the client further before making additional nursing judgments and taking action. (Option 1) The nurse should not instruct the UAP to perform additional blood pressure measurements as this client could have severe hypertension; delegation of such a task is inappropriate (does not fit the "right circumstances" for delegation). If the client's reading is not as high as previously thought after blood pressure measurement with a manual cuff, the nurse can then instruct the UAP to take subsequent measurements with a different automatic blood pressure machine. (Option 2) The nurse may need to notify the health care provider but only after the client has been assessed further by the nurse. (Option 3) The client's blood pressure must be verified for accuracy before administering a PRN antihypertensive. Educational objective:When the unlicensed assistive personnel (UAP) reports an abnormal vital sign to the nurse, the nurse should assess the client further. It is inappropriate delegation to have the UAP recheck the client.

The nurse is reviewing teaching with the parents of a child who has tinea capitis (ringworm of the scalp) and is newly prescribed griseofulvin oral suspension and 1% selenium sulfide shampoo. Which statement by the child's parent requires the nurse to intervene? 1. "I will discontinue the griseofulvin once the ringworm stops itching and the scales go away." 2. "I will give the griseofulvin suspension to my child after consumption of high-fat food, like ice cream." 3. "I will monitor my child for increased sensitivity to sunlight while taking griseofulvin." 4. "I will wash my child's scalp a few times per week with the medicated shampoo."

Tinea capitis (ringworm of the scalp) is a contagious fungal infection that lives on the surface of the scalp, resulting in scaly, pruritic, erythematous, circular patches with hair loss. The infection is transmitted via direct contact with infected persons, pets, or objects (eg, hairbrushes, bedding, towels, hats). Treatment may include 1% selenium sulfide shampoo applied several times each week in combination with an antifungal medication (eg, griseofulvin oral suspension) that the client must take for several weeks to months. Keratin-producing cells absorb griseofulvin, causing resistance to the fungus; because the fungus requires keratin (protein in hair and skin cells) to live and grow, it is not able to reproduce. To ensure that infected keratin is shed completely, treatment with griseofulvin should not be discontinued early, even if symptoms (eg, itching, scaling) decrease (Option 1). (Option 2) The client will best absorb griseofulvin (ie, suspension, microsized tablets) when taken after/with high-fat foods (eg, ice cream). (Option 3) Photosensitivity is a common side effect of griseofulvin treatment, and the client should avoid prolonged exposure to the sun and use sunscreen. (Option 4) The client should apply medicated shampoo (eg, 1% selenium sulfide) to the scalp a few times each week.

The nurse is planning care for a client immediately following a thyroidectomy. Which of the following nursing actions are appropriate to include in the plan of care? Select all that apply. 1. Assessing frequently for facial or extremity numbness or tingling 2. Encouraging the client to perform neck flexion and extension frequently 3. Ensuring that a tracheostomy insertion kit is at the bedside at all times 4. Maintaining the head of the bed at 30-45 degrees 5. Monitoring the client's voice strength and quality

Thyroidectomy is a surgery involving partial or complete removal of the thyroid, often to treat hyperthyroidism or thyroid cancer. Clients undergoing a thyroidectomy require close monitoring as they are at increased risk for airway compromise due to potential neck swelling, hypocalcemia, and nerve damage. Nurses planning care following a thyroidectomy promote client recovery and monitor for and prevent complications by: Assessing for and immediately reporting signs of hypocalcemia (eg, facial or extremity numbness or tingling, stridor, Trousseau and Chvostek signs), which may occur from parathyroid gland trauma during surgery (Option 1) Assessing for stridor and new or worsening changes in voice strength and quality(eg, hoarseness, whispering), which may indicate laryngeal nerve damage that can result in respiratory arrest (Option 5) Keeping emergency airway equipment (eg, tracheostomy kit, suction, oxygen) at the bedside in case respiratory distress develops (Option 3) Maintaining the client in semi-Fowler position, which promotes drainage of surgical site edema around the neck and reduces the risk of respiratory distress (Option 4) (Option 2) Postoperatively, the client should avoid excessive neck flexion and extension, which may strain and cause disruption of the incision site, leading to hemorrhage. Encourage the client to maintain neutral head and neck alignment.

A client is able to partially bear weight and follow the nurse's instructions. Which would be the most appropriate method for the nurse to use to safely transfer this client? 1. 1-person stand and pivot with gait belt and walker 2. 1-person standby assist with walker 3. 2-person motorized stand-assist lift 4. 2-person stand and pivot with gait belt and walker

To determine the most appropriate method to safely transfer a client for the first time, the nurse should assess: Whether the client can bear weight Whether the client is cooperative If the client is cooperative and able to partially bear weight, a safe transfer requires a 1-person stand and pivot technique with a gait belt or powered stand-assist lift (Option 1). If the client can fully bear weight and is cooperative, the client will not require an assisted transfer. However, a caregiver should stand by during the first transfer for safety or for assistance (Option 2). (Option 3) This method would be appropriate for a client who has no weight-bearing ability but can follow instructions and has enough upper body strength to use a motorized stand-assist lift. (Option 4) If the nurse determines that the client cannot be safely transferred with assistance from 1 caregiver, a 2-person stand and pivot transfer may be performed. However, the nurse should first encourage the client to use as much own strength as possible.

Which of the following drug administrations should be reported as a practice error? Select all that apply. 1. Cephalexin administered; client has history of anaphylaxis from penicillin 2. Hydromorphone 2 mg administered; client reports pruritus 3. Immunization for 3-month-old administered in ventrogluteal site 4. Oral niacin (nicotinic acid) administered; client has facial flushing 5. Warfarin administered; client at 12 weeks gestation

Warfarin (Coumadin) is generally contraindicated in pregnancy. Warfarin is a teratogen and exposure during early pregnancy can result in fetal malformations (warfarin embryopathy). It crosses the placenta, resulting in fetal anticoagulation; dangerous fetal bleeding, including intracranial hemorrhage, can occur. As a result, a client on warfarin is taught to use effective contraception (Option 5). For children age <7 months, the site for immunizations is the anterolateral thigh (vastus lateralis). The gluteus medius muscle (muscle injected with a ventrogluteal injection) is developed through crawling and walking. The muscles are not developed enough at this age to be used as an acceptable site (Option 3). History of penicillin hypersensitivity should be determined prior to administration. Clients who are truly allergic to penicillins (eg, anaphylaxis) have an increased risk of allergy to other beta-lactam antibiotics. The incidence of cross-reactivity is 1%-4% (Option 1). (Option 2) Pruritus (itching) is a known side effect of narcotic administration, particularly if the client is opioid naïve. It does not represent true allergy and is often treated with an antihistamine. Nausea is also quite common when opioid therapy is initiated, but clients quickly develop tolerance. (Option 4) Niacin (nicotinic acid or B3) is used in large doses for lipid-lowering properties. In large doses, it may produce cutaneous vessel vasodilation. The resulting warm sensation within the first 2 hours after oral ingestion is uncomfortable but harmless. It may last for several hours. Effects usually subside as therapy continues.

The oncology nurse is caring for a client with tumor lysis syndrome. Which prescription should the nurse question? 1. Allopurinol 200 mg PO every 24 hours [22%] 2. Normal saline IV at 150 mL/hr continuous [10%] 3. Sevelamer 800 mg PO 3 times daily with meals [25%] 4. Spironolactone 25 mg PO every 12 hours [41%]

Tumor lysis syndrome (TLS), an oncologic emergency, occurs when cancer treatment successfully kills cancer cells, resulting in the release of intracellular components (eg, potassium, phosphate, nucleic acids). Clients with TLS develop significant imbalances of serum electrolytes and metabolites. TLS may result in the following life-threatening conditions: Hyperkalemia (>5.0 mEq/L [5.0 mmol/L]) that can cause lethal dysrhythmias Large amounts of nucleic acids (normally converted to uric acid and excreted by the kidneys) that can overwhelm the kidneys and cause hyperuricemia and acute kidney injury (AKI) from uric acid crystal formation Hyperphosphatemia (>4.4 mg/dL [1.42 mmol/L]) that can cause AKI and dysrhythmias Hypocalcemia (<8.6 mg/dL [2.15 mmol/L]) that can cause tetany and cardiac dysrhythmias Potassium-sparing medications (eg, spironolactone) can worsen hyperkalemia (Option 4). Loop or osmotic diuretics may be prescribed to increase urine output and lower serum potassium. Sodium polystyrene sulfonate (Kayexalate) also helps to reduce potassium. (Options 1 and 2) Hypouricemic agents (eg, allopurinol) prevent the formation of uric acid, and aggressive fluid hydration (eg, IV normal saline) flushes out the kidneys to avoid the accumulation of toxins. Hydration therapy also dilutes serum potassium, lowering the risk for lethal dysrhythmias. (Option 3) Health care providers often prescribe mealtime phosphate binders (eg, sevelamer, lanthanum carbonate, calcium acetate) to prevent absorption of additional nutritional phosphorus. Educational objective:Tumor lysis syndrome is an oncologic emergency that results in hyperkalemia, hyperuricemia, hyperphosphatemia, and hypocalcemia. Treatment includes aggressive hydration, correction of electrolyte abnormalities (eg, loop diuretics, phosphate binders), and hypouricemic agents (eg, allopurinol). Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

The nurse is caring for a client who has been receiving mechanical ventilation (MV) for 4 days. During multidisciplinary morning rounds, the health care provider questions the development of a ventilator-associated pneumonia (VAP). Which of the following manifestations does the nurse assess as the best indicator of VAP? 1. Blood-tinged sputum [4%] 2. Positive blood cultures [11%] 3. Positive, purulent sputum culture [53%] 4. Rhonchi and crackles [30%]

VAP is the second most common health care-associated infection (HAI) in the United States and is associated with increased mortality, hospital cost, and length of stay. Because it is a nosocomial infection, signs and symptoms associated with VAP usually present within ≥2-3 days after initiation of mechanical ventilation (MV). Characteristic clinical manifestations of VAP include purulent sputum, positive sputum culture, leukocytosis (12,000 mm3), elevated temperature (>100.4 F [38 C]), and new or progressive pulmonary infiltrates suggestive of pneumonia on chest x-ray. (Option 1) Blood-tinged sputum may occur but is not the best indicator of VAP. (Option 2) Positive blood cultures may identify the microorganism causing the infection but are not the best indicator of VAP. Positive blood cultures could be from another source of infection. (Option 4) Rhonchi and crackles are adventitious lung sounds associated with pneumonia but can be present in pulmonary edema or just from increased mucous secretions. They are not the best indicator of VAP.

The nurse is preparing to administer the fourth dose of vancomycin IVPB to a client with infective endocarditis. Which intervention does the nurse anticipate? 1. Administering PRN antiemetic prior to the infusion 2. Administering via an infusion pump over at least 30 minutes 3. Drawing a trough level just prior to administration of the vancomycin 4. Starting a new IV line before administration

Vancomycin is a very potent antibiotic that can cause nephrotoxicity and ototoxicity. Measuring for serum concentrations is a way to monitor for risk of nephrotoxicity as well as for therapeutic response. Trough serum vancomycin concentrations are the most accurate and practical method for monitoring efficacy. A trough should be obtained just prior (about 15-30 minutes) to administration of the next dose. (Option 1) Unlike some chemotherapy medications, vancomycin does not commonly cause nausea or vomiting. Premedication with antiemetics is not required. However, premedication with antihistamines (diphenhydramine) is recommended if the client had developed red man syndrome, also known as red neck syndrome, with prior vancomycin infusion. This syndrome is characterized by red blotching of the face, neck, and chest due to too rapid administration. (Option 2) Vancomycin should be administered over a minimum of 60 minutes. Too rapid administration can cause red man syndrome, considered a toxic effect rather than an allergic reaction. (Option 4) The nurse would want to verify patency of the IV line prior to administration as thrombophlebitis is a possibility with vancomycin; however, a new IV line is not necessarily required.

The nurse develops a teaching care plan for the client with a prescription to change antidepressant medications from imipramine to phenelzine. Which instruction is appropriate to include in the teaching? 1. Continue avoiding foods high in tyramine until the imipramine withdrawal period is over 2. Skip the nighttime dose of imipramine and start the phenelzine the next morning 3. Taper down the imipramine, then discontinue for 2 weeks before starting phenelzine 4. Taper down the imipramine while gradually increasing the phenelzine

When a client switches from a tricyclic antidepressant (TCA) (eg, imipramine, amitriptyline, nortriptyline) to a monoamine oxidase inhibitor (MAOI) (eg, phenelzine, isocarboxazid, tranylcypromine), a drug-free period of at least 2 weeks should elapse between the tapered discontinuation of the TCA and the initiation of the MAOI. This timing is based on the half-life value and allows for the first medication to leave the system. Without a washout period, the client could experience hypertensive crisis (eg, blurred vision, dizziness, severe headache, shortness of breath). If the TCA is withdrawn abruptly, the client may experience a discontinuation syndrome. (Option 1) A tyramine-restricted diet is indicated for clients on an antidepressant regimen containing an MAOI to decrease the risk of hypertensive crisis. Because this client is starting an MAOI, the diet should be initiated 2 weeks prior to starting the medication. If the switch was from an MAOI inhibitor to another antidepressant, the client would need to continue to follow the dietary restrictions for 2 weeks after discontinuing the MAOI. (Option 2) An overnight washout period is inadequate to clear the imipramine from the client's system before starting the phenelzine. (Option 4) TCAs and MAOIs cannot be taken at the same time due to the risk of a hypertensive crisis. Educational objective:Caution must be taken when a client switches from a tricyclic antidepressant to a monoamine oxidase inhibitor to avoid adverse reactions (eg, hypertensive crisis, discontinuation syndrome). Usually, antidepressants are withdrawn gradually with a drug-free period before the new antidepressant is initiated. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

The nurse responds to the bed alarm of a client with a severe urinary tract infection and finds the client lying on the floor and soiled with urine. Which of the following entries by the nurse are appropriate to include when documenting the event in the client's electronic medical record? Select all that apply. 1. Blood pressure 102/60 mm Hg, pulse 97/min, and SpO2 98% on room air 2. Client found at 2310 soiled with urine, lying on the floor near foot of bed 3. Client has continuously refused to use the call bell as instructed 4. Client states, "My bottom hurts and I feel a little bit dizzy" 5. Jones, MD, notified at 2322. Will continue to monitor for indications of injury.

When documenting client care, nurses should use accurate, detailed, and objective statements (eg, what the nurse sees or hears) that are free from biased language and personal judgments. Examples of appropriate documentation include: Data gathered by direct measurement (eg, vital signs, wound measurements) (Option 1) Observations (eg, client actions [eg, crying] or observable assessments [eg, soiled with urine]) (Option 2) Client statements, documented as direct quotes (Option 4) Detailed descriptions of nursing actions and interventions (eg, which health care provider was notified) (Option 5) (Option 3) Documenting "client has continuously refused" is negatively biased and may be interpreted as anger or frustration from the nurse. The nurse should document that the call bell was within the client's reach and that the client was frequently reminded to use it for assistance. It would also be appropriate to document any client statements about refusing to use the call bell.

elective serotonin reuptake inhibitors (SSRIs) are commonly used to treat major depression and anxiety disorders. SSRIs (eg, fluoxetine, paroxetine, citalopram, escitalopram, sertraline) are generally well tolerated except for sexual dysfunction. Clients often underreport this side effect. However, when asked specifically, over 50% of clients taking SSRIs may be experiencing some type of sexual dysfunction. This can be a decrease in sexual desire, arousal, or orgasm and may vary by gender. The nurse should discuss this with the client. The side effect may decrease or cease after a 2- to 4-week waiting period for the therapeutic effect, or the client may be able to switch to a different antidepressant medication (eg, bupropion). (Option 1) Constipation is uncommon with SSRIs. Drugs with anticholinergic activity (eg, tricyclic antidepressants such as amitriptyline) may result in constipation or urinary retention. (Option 2) Sedation is a common side effect of benzodiazepines (eg, alprazolam, lorazepam, diazepam, and chlordiazepoxide), first generation antihistamines, and narcotic medications. SSRIs may cause insomnia. (Option 4) Weight gain is a common side effect of most SSRIs, especially with long-term therapy. Educational objective:SSRIs (eg, fluoxetine, paroxetine, citalopram, escitalopram, sertraline) can cause sexual dysfunction. The client should be encouraged to report this to the health care provider if they are still present 2-4 weeks after treatment initiation. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

RN delegates what to LPN in a client with established colostomy ?

he RN may delegate care of stable clients with established ostomies to the licensed practical nurse (LPN). The following actions related to ostomy care are generally within the LPN scope of practice: Provide ostomy care and observe for skin breakdown (Option 2) Perform specific assessments (eg, bowel sounds, stoma color) (Option 3) Monitor drainage characteristics (eg, color, amount) (Option 5) Reinforce education Irrigate an established ostomy Document observations and interventions (Option 1) The RN may delegate specific assessments to the LPN. The LPN focuses on data collection and determining normal versus abnormal findings. For example, the LPN may determine that a client's colostomy stoma is an abnormal color whereas the RN synthesizes assessment findings (eg, color, temperature, capillary refill) to determine the quality of tissue perfusion. (Option 4) Developing the plan of care is the responsibility of the RN and cannot be delegated. Educational objective:Tasks requiring initial assessment, initial or discharge education, care planning, or care of an unstable client require the clinical judgment of the registered nurse (RN) and may not be delegated. The licensed practical nurse may perform basic care activities of the client with an established ostomy, perform specific assessments, monitor RN findings, and reinforce education. Additional Information Management of Care NCSBN Client Need

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

Aortic root repair with mechanical heart valve replacement is a procedure often performed for clients with Marfan syndrome, a connective tissue disorder that increases the risk for aortic rupture. Clients with mechanical valve replacement via sternotomy require education on lifestyle changes and prevention of complications, including: The client should avoid lifting heavy objects to prevent disruption of the sternotomy sutures/wires (Option 2). Anticoagulant therapy (eg, warfarin) will be needed for life after a mechanical valve replacement to prevent thromboembolic events (eg, stroke) and valve thrombosis (Option 3). Signs and symptoms of heart failure (eg, weight gain ≥3 lb [1.36 kg] in a week) should be reported immediately because they may indicate valve failure (Option 4). Bleeding precautions (eg, using an electric shaver) should be initiated because anticoagulant therapy increases the risk of uncontrolled bleeding (Option 5). (Option 1) Clients with mechanical heart valves are at high risk for infective endocarditis because bacteria can adhere to and proliferate on components of the valve. The client should receive prophylactic antibiotics before invasive respiratory and dental procedures, including routine dental cleanings.

The nurse is reviewing new arterial blood gas results for a client with an exacerbation of chronic obstructive pulmonary disease. The client's serum pH is 7.45. Which result noted by the nurse is a priority to report to the health care provider? 1. HCO3− of 35 mEq/L (35 mmol/L) [12%] 2. Hemoglobin of 19 g/dL (190 g/L) [3%] 3. PaCO2 of 67 mm Hg (8.91 kPa) [33%] 4. PaO2 of 52 mm Hg (6.92 kPa) [50%]

Chronic obstructive pulmonary disease (COPD), a progressive inflammatory lung disease, causes hypersecretion of mucus and changes in airway structure that reduce expiratory airflow (ie, air trapping) and impair oxygen and carbon dioxide (CO2) exchange. Impaired gas exchange in COPD may be identified by abnormal arterial blood gas results, including elevated partial pressure of CO2 (PaCO2) and decreased partial pressure of oxygen (PaO2). PaO2 <60 mm Hg (7.98 kPa) in a client with COPD indicates significant hypoxemia, which requires the nurse to contact the health care provider for additional interventions (eg, oxygen, positive-pressure ventilation) (Option 4). (Options 1 and 3) Clients with COPD chronically retain CO2, resulting in respiratory acidosis. This client's results are consistent with compensated respiratory acidosis in which renal resorption of HCO3− increases to normalize serum pH. (Option 2) Clients with COPD often experience chronic hypoxia and may demonstrate a compensatory increase in hemoglobin (ie, polycythemia) to promote maximal oxygen transport.

Cephalosporin HAIRY

Hyperglycemic Anaphylactic shock if allergic Insufficient platelet (thrombocytopenia) Renal problem if they are allergic Yellow poop (diarrhea)

The nurse cares for a group of clients on a medical surgical floor. The client with which condition is at highest risk for developing syndrome of inappropriate antidiuretic hormone (SIADH)? 1. Carpal tunnel syndrome [3%] 2. Diabetes mellitus [45%] 3. Sciatica [8%] 4. Small cell lung cancer [42%]

SIADH is an endocrine condition in which too much ADH is produced, causing water retention, increased total body water, and dilutional hyponatremia (low serum sodium). Some cancer cells, particularly those of small cell lung cancer, have the ability to produce and secrete ADH, leading to SIADH. Other causes include central nervous system disorders (eg, stroke, trauma, neurosurgery) and some commonly used medications (eg, desmopressin, carbamazepine). (Options 1 and 3) Carpal tunnel syndrome is a result of aggravated tendons in the wrists causing narrow, pinched nerves. Sciatica is numbness, tingling, or pain caused by an irritation of the sciatic nerve. Both are examples of peripheral nerve disorders. SIADH is more common among clients with central nerve disorders (eg, stroke, neurosurgery). (Option 2) Diabetes mellitus is an endocrine disorder characterized by hyperglycemia and is not commonly associated with SIADH.

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? 1. "Adoption or surrogacy are options for those who are unable to conceive." [0%] 2. "Consider talking to your health care provider about fertility-enhancing medications that can help you conceive more quickly." [28%] 3. "There is no cause for concern unless you haven't been able to conceive for 1 year." [37%] 4. "Using an over-the-counter urine ovulation detector kit to time sexual intercourse may improve your chances of conceiving." [34%]

Teaching about menstrual cycle physiology increases fertility awareness and helps couples optimize their chances of becoming pregnant sooner. Timing of sexual intercourse near ovulation (ie, "fertile window") is essential to conception because the ovum and sperm have limited viability in the reproductive tract. Instructing the client about how to track menstrual cycles (eg, length and regularity of menses) and recognize signs of ovulation (eg, cyclic changes in cervical mucus) may improve fertility awareness. Urine ovulation predictor kits may also be used to detect the surge of luteinizing hormone (LH) that precedes ovulation by 12-24 hours. These predictor kits are easily accessed, over-the-counter tests that can help the client time intercourse during the "fertile window" to improve chances of conceiving (Option 4). (Option 1) It is best to provide teaching and encouragement rather than alternatives to pregnancy (eg, adoption, surrogacy). (Option 2) Teaching about fertility-enhancing medications (eg, clomiphene) may be indicated for clients unable to conceive naturally but is not the best reply to this client at this time. (Option 3) Infertility is the inability to conceive after 12 months of frequent, unprotected intercourse for clients without medical complications (eg, advanced maternal age). However, this is not the best response because this teaching does not assist the client.

The nurse is assisting a client who has a bedside needle liver biopsy scheduled. Which are the essentialactions? Select all that apply. 1. Assess for rising pulse and respirations afterward 2. Check PT/INR and PTT values before the procedure 3. Ensure that the client's blood is typed and crossmatched 4. Have the client void to ensure an empty bladder 5. Position the client flat or on the left side after the procedure

The client's coagulation status is checked before the liver biopsy using PT/INR and PTT. The liver ordinarily produces many coagulation factors and is a highly vascular organ. Therefore, bleeding risks hould be assessed and corrected prior to the biopsy (Option 2). Blood should be typed and crossmatched in case hemorrhage occurs (Option 3).After the procedure, frequent vital sign monitoring is indicated as the early signs of hemorrhage are rising pulse and respirations, with hypotension occurring later (Option 1). (Option 4) The needle is inserted between ribs 6 and 7 or 8 and 9 while the client lies supine with the right arm over the head and holding the breath. A full bladder is a concern with paracentesis when a trocar needle is inserted into the abdomen to drain ascites. An empty bladder may aid comfort, but it is not essential for safety. (Option 5) The client must lie on the right side for a minimum of 2-4 hours to splint the incision site. The liver is a "heavy" organ and can "fall on itself" to tamponade any bleeding. The client stays on bed rest for 12-14 hours.

A client arrives in the emergency department with right-sided paralysis and slurred speech. The nurse understands that the client cannot receive thrombolytic therapy due to which reason? 1. Client had gallbladder surgery 2 months ago [11%] 2. Client has experienced loss of the gag reflex [2%] 3. Client has platelet count of 130,000/mm3 [130 × 109/L] [27%] 4. Client has symptoms that started 12 hours earlier [58%]

Thrombolytic therapy (tissue plasminogen activator [tPA]) is used to dissolve blood clots and restore perfusion in clients with ischemic stroke. The nurse assesses for contraindications to tPA due to the risk of hemorrhage. tPA must be administered within a 3- to 4.5-hour window from onset of symptoms for full effectiveness (Option 4). (Option 1) Recent major surgery (within the past 14 days) is a contraindication as tPA dissolves all clots in the body and may therefore disrupt the surgical site. Gallbladder surgery 2 months prior is outside the window of contraindication. (Option 2) Loss of the gag reflex and other major functions would most likely make the client a candidate for thrombolytics due to proof of deficits from stroke. (Option 3) Clients with thrombocytopenia (platelet count <100,000/mm3 [100 × 109/L]) and/or coagulation disorders should not receive tPA as these conditions further increase the risk for bleeding. Other contraindications include hemorrhagic stroke, uncontrolled hypertension, and stroke or head trauma within the past 3 months.

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

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

The nurse assessing a client with an upper gastrointestinal bleed would expect the client's stool to have which appearance? 1. Black tarry 2. Bright red bloody 3. Light gray "clay-colored" 4. Small, dry, rocky-hard masses

The nurse would expect a client experiencing an upper gastrointestinal (GI) bleed to have black tarry stools (melena). As blood passes through the GI tract, digestion of the blood ensues, producing the black tarry appearance. (Option 2) Bright red bloody stool (hematochezia) would indicate a lower GI hemorrhage. (Option 3) Decreased bile flow into the intestine due to biliary obstruction would produce a light gray "clay-colored" stool. (Option 4) 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 (eg, anticholinergics) may contribute to constipation.

Which client incident would be classified as an adverse event that requires an incident/event/irregular occurrence/variance report? Select all that apply. 1. Client admitted with white blood cell count of 28,000 mm3 (28.0 × 109/L) and dies from sepsis 2. Client receives 1 mg morphine instead of prescribed 0.5 mg morphine 3. Client refuses pneumonia vaccination and contracts pneumonia 4. Nurse did not report client's new hemoglobin result of 6 g/dL (60 g/L) to oncoming nurse 5. Provider was not notified of client's positive blood culture results

An adverse event is an injury to a client caused by medical management rather than a client's underlying condition. It may or may not be preventable. The Institute of Medicine (2000) recognizes 4 types of errors. They are: Diagnostic (delay in diagnosis, failure to employ indicated tests, failure to act on results of monitoring) Treatment (error in performance of procedure, treatment, dose; avoidable delay) Preventive (failure to provide prophylactic treatment, inadequate follow-up/monitoring of treatment) Other (failure of communication, equipment failure, system failure) Option 2 is a treatment error. Option 4 is a communication error as well as inadequate follow-up. Option 5 is a communication error and a failure to respond to an abnormal test. Timely reporting of critical results of tests and diagnostic procedures is part of the Joint Commission Hospital National Patient Safety Goals. (Option 1) The client was admitted with signs of a severe infection and the death is likely a result of that process rather than a medical error. (Option 3) Under the ethical principle of autonomy, the client has the right to refuse anything even if it is not to the client's ultimate best interest. The pneumonia could be due to lack of vaccination, but there is no direct relationship.

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? Select all that apply. 1. Aim the nozzle at the base of the fire 2. Pull out the pin on the handle 3. Shake the canister prior to use 4. Squeeze the handle to spray 5. 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 (eg, fire extinguisher) is involved. The mnemonic PASS is often used to help people remember the steps used in operating a fire extinguisher: P - Pull the pin on the handle to release the extinguisher's locking mechanismA - Aim the spray at the base of the fireS - Squeeze the handle to release the contents/extinguishing agentS - Sweep the spray from side to side until the fire is extinguished (Option 3) The extinguisher does not need to be shaken before use, and doing so would delay extinguishing the fire.

The nurse is reviewing laboratory data of a client who is receiving warfarin therapy for atrial fibrillation. Today's INR is 5.0. What action should the nurse take? 1. Administer the next scheduled dose of warfarin [13%] 2. Anticipate infusing fresh, frozen plasma [3%] 3. Call the pharmacy to see if protamine is available [6%] 4. Request a prescription from the health care provider (HCP) for vitamin K [76%]

A therapeutic INR level is dependent on the reason the client is receiving the warfarin (an anticoagulant). Typically the therapeutic INR range should be 1.5-2 times the normal "control" value (INR of 2-3) for medical reasons such as deep vein thrombosis, atrial fibrillation, or stroke. An INR of 3 to 3.5 is desired for the client with a mechanical heart valve. An INR of 5.0 or higher places the client at risk for bleeding and requires a dosage adjustment of the warfarin or the administration of vitamin K as an antidote. (Option 1) The warfarin should not be administered with an INR of 5. The nurse should hold the dose until further instructions have been received by the HCP. (Option 2) Fresh, frozen plasma is considered when major bleeding is occurring related to warfarin overdose, but this is typically after the vitamin K has been administered. (Option 3) Protamine is the reversal agent for heparin overdoses.

A registered nurse (RN), a licensed practical nurse (LPN), and unlicensed assistive personnel 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? Select all that apply. 1. Administering oral pain medication 2. Assessing characteristics of pain 3. Measuring vital signs before and after analgesic administration 4. Monitoring pain level using a numeric scale 5. Providing discharge teaching about pain management

Everyone on the health care team contributes to the client's pain management. The registered nurse (RN) is responsible for developing the pain management care plan, which includes assessing subjective characteristics of pain (ie, P - provocation/palliation, Q - quality, R - region/radiation, S - severity, T - timing); performing initial client and caregiver teaching, including discharge instructions; and evaluating the effectiveness of the care plan (Options 2 and 5). The nurse should always consider the 5 rights of delegation prior to delegating a task. In this case, the RN may delegate the following tasks to the licensed practical nurse (LPN): Administering oral pain medication; individual practice region and facility policy will determine which of the various routes of medication the LPN is permitted to use (Option 1) Monitoring current objective pain level (numeric scale) (Option 4) (Option 3) The RN should delegate vital sign measurement to the unlicensed assistive personnel (UAP). Although vital sign measurement is within the LPN's scope of practice, delegating this task to UAP is a more efficient use of resources. The RN should provide instructions regarding timing of vital sign measurement and is responsible for evaluating the client's vital signs.

A nurse is caring for a client with unstable angina. After 5 minutes on a nitroglycerin IV infusion, the client reports relief of chest pain but a new dull, throbbing headache. What is the appropriate nursing action? 1. Decrease the infusion rate and reassess the client's report of pain [23%] 2. Document the finding and administer prescribed acetaminophen [57%] 3. Notify the health care provider and request a CT scan of the head [3%] 4. Stop the infusion immediately and notify the health care provider [15%]

Nitroglycerin is an antianginal medication that causes potent vasodilation (coronary and systemic) and is used in the treatment of acute coronary syndrome (eg, unstable angina, myocardial infarction). IV nitroglycerin administration requires continuous cardiac monitoring and frequent blood pressure assessment (eg, every 15 minutes for the first hour). Headache is an expected side effect from vasodilation of cranial vessels and should decrease with continuing nitroglycerin therapy. As long as the client does not have severe hypotension (eg, systemic blood pressure <90 mm Hg), the finding can be documented and the headache can be treated with aspirin or acetaminophen. (Options 1 and 4) If the headache becomes severe or persistent despite acetaminophen, the health care provider (HCP) may temporarily decrease the dose. The nurse should not arbitrarily stop the infusion or decrease the rate. (Option 3) Nitroglycerin therapy can precipitate increased intracranial pressure (ICP). Additional signs of increased ICP (eg, decreased level of consciousness, vomiting, Cushing triad) should be reported to the HCP. A CT scan of the head is not indicated at this time.

The nurse is teaching a postpartum client about breastfeeding. Which statement by the client indicates a correct understanding of teaching? 1. "I will feed my baby for 5-10 minutes on each breast." [13%] 2. "I will hold my baby on their back with the head turned toward my breast." [16%] 3. "If I need to reposition my baby's latch, I will use my finger to break the suction first." [64%] 4. "The baby's mouth should grasp only the nipple without the areola." [4%]

Sore nipples and painful breastfeeding are common reasons clients discontinue breastfeeding. Teaching proper technique helps clients continue breastfeeding, promotes comfort for the mother, and ensures adequate newborn nutrition. Key principles of proper breastfeeding and latch technique include: Breastfeed every 2-3 hours on average (8-12 times/day) Breastfeed "on demand" whenever the newborn exhibits hunger cues (eg, sucking, rooting reflex) Position the newborn "tummy to tummy" with mouth in front of nipple and head in alignment with body Ensure a proper latch (ie, grasps both nipple and part of areola) Feed for at least 15-20 minutes per breast or until the newborn appears satisfied Insert a clean finger beside the newborn's gums to break suction before unlatching (Option 3) Alternate which breast is offered first at each feeding (Option 1) Five to ten minutes per breast may be insufficient to feed and may lead to inadequate breast emptying and insufficient nutritional intake. (Option 2) Awkward manipulation of the head while breastfeeding makes it difficult for the newborn to latch and feed comfortably. The mother should support the newborn's head and keep it in alignment with the body in all breastfeeding positions. (Option 4) If the newborn grasps the nipple only, breastfeeding will be painful due to pinching.

A nurse in the cardiac intensive care unit receives report on 4 clients. Which client should the nurse assess first? 1. Client 2 months post heart transplant with sustained sinus tachycardia of 110/min at rest [8%] 2. Client 3 hours post coronary artery stent placement via femoral approach and reporting severe back pain [73%] 3. Client receiving IV antibiotics for infective endocarditis with a temperature of 101.5 F (38.6 C) [3%] 4. Client who had coronary bypass graft surgery 3 days ago and has swelling in the leg used for the donor graft [14%]

A client who undergoes percutaneous coronary intervention (PCI) and intracoronary stent placement using the femoral approach is at increased risk for retroperitoneal hemorrhage. Administration of antithrombotic drugs before, during, and after PCI can exacerbate potentially life-threatening bleeding from the femoral artery. Hypotension, back pain, flank ecchymosis (Grey-Turner sign), hematoma formation, and diminished distal pulses can be early signs of bleeding into the retroperitoneal space and require immediate intervention/evaluation (eg, notify health care provider, serial CBCs, abdominal CT). (Option 1) During a heart transplant, the donor heart is cut off from the autonomic nervous system (denervated), which alters the heart rate during rest and exercise after the transplant. The transplanted heart is expected to be tachycardic (eg, 90-110/min). (Option 3) Infective endocarditis is often associated with cardiac valve disease and requires long-term antibiotic therapy (4-6 weeks). Characteristic manifestations include fever, myalgia, chills, joint pain, anorexia, and petechiae. (Option 4) Some clients notice swelling in the leg used for donor venous graft (interruption of blood flow). Elevating the leg and wearing compression stockings can help decrease symptoms.

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? Select all that apply. 1. Administer PRN stool softeners daily 2. Administer scheduled enoxaparin injection 3. Implement seizure precautions 4. Keep client NPO until swallow screen is performed 5. 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 (ICP) (Option 3). During the acute phase, a client may develop dysphagia. To prevent aspiration, the client must remain NPO until a swallow function screen reveals no deficits (Option 4). The nurse should perform neurological assessments (eg, level of consciousness, pupillary response) at regular intervals and report any acute changes (Option 5). Preventing activities that increase ICP or blood pressure will minimize further bleeding. The nurse should: Reduce stimulation, maintain a quiet and dimly lit environment, limit visitors Administer stool softeners to reduce strain during bowel movements (Option 1) Reduce exertion, maintain strict bed rest, assist with activities of daily living Maintain head in midline position to improve jugular venous return to the heart (Option 2) Enoxaparin is an anticoagulant used to prevent venous thromboembolism (VTE). 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 (eg, compression stockings) to prevent VTE.

The nurse in the emergency department is assessing telemetry strips for assigned clients. Which client tracing is a priority for the nurse to assess? 1. [16%] 2. [2%] 3. [55%] 4. [25%]

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

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

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

The clinic nurse is assessing a client who is being treated for depression and suicidal ideation. Which client statement best indicates that the client is not currently at risk for suicide? 1. "I lost my imipramine prescription. Could I have a refill?" [2%] 2. "I plan to attend my granddaughter's graduation next month." [78%] 3. "I seem to have a lot more energy since I started therapy." [3%] 4. "I will sign a 'no-suicide' contract at today's appointment." [14%]

Clients receiving treatment for depression and suicidal ideation must be carefully monitored for indications of increasing suicidal intent. During a client interview, the nurse should assess: Access to psychiatric medications Availability of help during a crisis (eg, counselor, family) Future goals and plans Home and work environment risks Overall affect and level of energy Possible access to weapons Clients who articulate long-term personal goals and family milestones are less likely to commit suicide (Option 2). (Option 1) Imipramine (Tofranil) is a tricyclic antidepressant, an overdose of which is extremely dangerous and likely fatal. Although the nurse may interpret the client's report of having lost the prescription as an attempt to be compliant, the nurse must also be aware that the client may be stockpiling medication for a suicide attempt. (Option 3) Clients often feel more energetic after beginning treatment, yet thoughts of suicide may not have fully resolved and the client may now have the energy to follow through with suicide plans. (Option 4) "No-harm/no-suicide" contracts are widely used in clinical practice to support a client's ability to avoid acting on suicidal thoughts. These agreements do not guarantee safety and are not the best indicator of decreased suicide risk.

A client is started on lisinopril therapy. Which assessment finding requires immediate action? 1. Blood pressure 129/80 mm Hg [2%] 2. Heart rate 100/min [7%] 3. Serum creatinine 2.5 mg/dL (221 µmol/L) [85%] 4. Serum potassium 3.5 mEq/L (3.5 mmol/L) [4%]

The dosage of angiotensin-converting enzyme (ACE) inhibitors (eg, lisinopril, enalapril, ramipril) should be adjusted for clients with renal impairment. A serum creatinine of 2.5 mg/dL (221 µmol/L ) indicates renal impairment (normal 0.6-1.3 mg/dL [53-115 µmol/L]). The nurse should notify the health care provider so that the dosage can be decreased or held. (Options 1, 2, and 4) The client's blood pressure, heart rate, and serum potassium (normal 3.5-5.0 mEq/L [3.5-5.0 mmol/L]) are within normal limits. They do not require immediate action. Hyperkalemia and hypotension are contraindications for giving ACE inhibitors.

A female client with liver cirrhosis and chronic anemia is hospitalized for a deep venous thrombosis. The client is receiving a heparin infusion and suddenly develops epistaxis. Which laboratory value would indicate that the heparin infusion needs to be turned off? 1. Hematocrit of 30% (0.30) [2%] 2. Partial thromboplastin time of 110 seconds [65%] 3. Platelet count of 80,000/mm3 (80 x 109/L) [23%] 4. Prothrombin time of 11 seconds [8%]

Heparin is an anticoagulant that helps prevent further clot formation. It is titrated based on a partial thromboplastin time (PTT). The therapeutic PTT target is 1.5-2.0 times the normal reference range of 25-35 seconds. A PTT value >100 seconds would be considered critical and could result in life-threatening side effects. Common sentinel events that result from heparin drips include epistaxis, hematuria, and gastrointestinal bleeds. (Option 1) A normal hematocrit for a female is 35%-47% (0.35-0.47). In a client with a history of chronic anemia, a hematocrit of 30% (0.30) may be an expected finding. (Option 3) A normal platelet count is 150,000-400,000/mm3 (150-400 x 109/L). In a client with a history of liver cirrhosis, a platelet count of 80,000/mm3 (80 x 109/L) would be anticipated. An episode of bleeding rarely occurs with a platelet count >50,000 mm3 (50 x 109/L). (Option 4) A normal prothrombin time is 11-16 seconds, and so a level of 11 seconds would not be concerning.

The pediatric nurse is preparing to administer an acetaminophen suppository to an 11-month-old with pyrexia. Which actions are appropriate? Select all that apply. 1. Advance past the external sphincter only 2. Guide suppository along the rectal wall 3. Hold buttocks together firmly after insertion 4. Position client supine with knees and feet raised 5. 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. Basic steps for suppository administration include the following: Apply clean gloves and position the client appropriately based on age and size (eg, infant supine with knees and feet raised, older child side-lying with knees bent) (Option 4). Lubricate the tip of the suppository with water-soluble jelly. Petroleum-based products can reduce absorption. Insert the suppository past the internal sphincter using the fifth finger if the child is under 3 years (Option 5). Use of the index finger may cause injury to the colon or sphincters in children younger than age 3 years. Angle suppository and guide it along the rectal wall. The suppository should remain in contact with the rectal mucosa (and not be buried inside stool) to ensure systemic absorption (Option 2). Hold the buttocks together for several minutes, or until the urge to defecate has passed, to prevent immediate expulsion (Option 3). If a bowel movement occurs within 10-30 minutes, observe for the presence of the suppository. (Option 1) The suppository must be inserted past both the external and internal sphincters for proper placement. If not inserted far enough, it may be expelled before achieving a therapeutic effect.

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? 1. 0.45% normal saline 2. 5% dextrose in 0.9% normal saline (D5NS) 3. 5% dextrose in water (D5W) 4. 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 (LR), also known as Ringer's lactate, is the solution of choice for fluid resuscitation of a burned client due to its similarity in chemical composition to human plasma (Option 4). LR remains in the intravascular space longer than other solutions, which helps to stabilize blood pressure and avert shock. (Option 1) Hypotonic solutions (eg, 0.45% normal saline) quickly leave the intravascular space and are not useful in replacing intravascular volume. They may also contribute to peripheral and interstitial edema, which can lead to pulmonary complications. (Option 2) Hypertonic solutions (eg, 5% dextrose in 0.9% normal saline [D5NS], 3% saline) can cause further electrolyte imbalances in a client with severe burns, resulting in hypernatremia, hyperchloremia, and arrhythmias. (Option 3) Although technically an isotonic solution, 5% dextrose in water (D5W) behaves as a hypotonic solution when dextrose is metabolized by the body and free water is released to the tissues rather than remaining in the intravascular space.

A client with a bowel obstruction has been treated with gastric suctioning for 4 days. The nurse notices an increase in nasogastric drainage. Which acid-base imbalance does the nurse correctly identify? Click the exhibit button for more information. 1. Metabolic alkalosis, compensated [31%] 2. Metabolic alkalosis, uncompensated [58%] 3. Respiratory alkalosis, compensated [5%] 4. Respiratory alkalosis, uncompensated [4%] pH 7.50 PaCO245 mm Hg (5.98 kPa) PaO290 mm Hg (12 kPa) HCO332 mEq/L (32 mmol/L)

This client's ABG analysis shows uncompensated metabolic alkalosis. The most likely cause of this alkalosis is the loss of acidic gastric contents from prolonged gastric suctioning. Metabolic imbalances affect the bicarbonate level. This client's ABG is high in pH (alkalosis) and bicarbonate. Bicarbonate (HCO3-) is basic; therefore, an elevated bicarbonate level indicates a more basic (alkalotic) state due to a metabolic cause. The nurse recognizes that this is uncompensated alkalosis. The lungs compensate for metabolic imbalance by either blowing off acidic carbon dioxide (hyperventilating) or retaining it (hypoventilating). Hypoventilation raises the carbon dioxide level, making the blood more acidic. Compensation is complete once the pH returns to normal limits (Option 1). (Options 3 and 4) Respiratory alkalosis (pH >7.45) results from a decreased PaCO2 (<35 mm Hg [4.66 kPa]). The kidneys compensate for respiratory alkalosis by excreting HCO3-. Therefore, a decrease in HCO3- (<22 mEq/L [22 mmol/L]) and normalized pH (7.35-7.45) would indicate compensated respiratory alkalosis.

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? 1. Do your other children have this condition? [18%] 2. How long did your infant have diarrhea? [19%] 3. How often are you feeding the infant? [23%] 4. What do you think caused your infant's illness? [37%]

All clients have cultural influences that can affect their beliefs and concerns about causes of medical conditions and expectations for treatment. The nurse should have clients express what caused their medical illnesses or problems to gain knowledge of their beliefs and understandings about the conditions; this is fundamental to developing a culturally sensitive and appropriate teaching and care plan. Culturally competent care requires the nurse to recognize that the client's interpretation of an illness is more significant than the nurse's knowledge of the illness. Clients' beliefs about health and disease may be complex and tightly rooted in centuries-old traditions. Some clients welcome scientific explanations about their conditions, whereas others ignore a nurse's teaching that does not align with their personal perspectives. The nurse must never assume that a client knows (or does not know) about a subject; accurate assessment about knowledge and beliefs is necessary. (Option 1) The nurse may ask about other family members; however, this does not address cultural beliefs and concerns. (Option 2) Knowing the duration of diarrhea will help determine the infant's nutritional status and fluid balance but does not address cultural beliefs and concerns. (Option 3) Although it is important to determine that nutritional intake is adequate for normal growth and development, this does not address cultural beliefs and concerns.

The nurse plans to administer 9:00 AM medications via the nasogastric (NG) route to a client with an NG tube. The nurse contacts the primary health care provider (PHCP) to clarify which prescriptions that are contraindicated using this route? Select all that apply. 1. Enteric-coated ibuprofen 200-mg tablet 2. Extra-strength acetaminophen 500-mg tablet 3. Metoprolol extended-release 50-mg tablet 4. Sulfamethoxazole double-strength 800-mg tablet 5. Tamsulosin 0.4-mg slow-release capsule

Enteric-coated drugs have a barrier coating that dissolves at a slower rate (usually in the small intestine) to protect the stomach from irritant effects. Crushing enteric-coated medications (eg, ibuprofen) 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. (Options 2 and 4) Double- and extra-strength drugs such as sulfamethoxazole and acetaminophen may be crushed and administered separately through an NG tube as long as they are not enteric-coated. The nurse should flush the tube with water before and after each drug administration.

The parent of a 15-month-old calls the nurse and says that the child developed a rash and mild fever after receiving a routine measles, mumps, rubella, and varicella (MMRV) vaccine in the pediatric clinic 5 days ago. What is the best response by the nurse? 1. "Apply over-the-counter hydrocortisone cream to the rash." 2. "Bring your child to the clinic this afternoon." 3. "This is a common reaction to the MMRV vaccine." 4. "What is your child's temperature right now?"

Some children have a mild reaction to the MMRV vaccine within 5-12 days after the first dose. Problems include low-grade fever, mild rash, swelling and erythema at the injection site, irritability, and restlessness. Although rare, fever after MMRV vaccination can lead to febrile seizures. Therefore, it is important for the nurse to determine the child's temperature to evaluate the risk for a febrile convulsion. It would also be important for the nurse to instruct the parent to monitor the child's temperature and administer acetaminophen for a fever above 102 F (38.9 C). Children with a history of seizures should be vaccinated with separate MMR and varicella vaccines instead of the combination MMRV vaccine. (Option 1) This is not an appropriate intervention. The rash should disappear in 2-3 days. (Option 2) The child seems to be experiencing a normal reaction to the vaccine; a clinic visit is not necessary. (Option 3) Although this is an appropriate response, it is most important for the nurse to first determine the child's temperature and the extent of the fever.

The long-term care nurse is caring for a client diagnosed with macular degeneration. Which client statement supports this diagnosis? 1. "I have been seeing small flashes of light." [7%] 2. "I have trouble threading my sewing needle. I have to hold it far away to see it." [9%] 3. "I notice that my peripheral vision is becoming worse." [19%] 4. "I see a blurry spot in the middle of the page when I read." [63%]

Macular degeneration is a progressive, incurable disease of the eye in which the central portion of the retina, the macula, begins to deteriorate. This deterioration causes distortion (blurred or wavy visual disturbances) or loss of the central field of vision, whereas the peripheral vision remains intact (Option 4). 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 supplements (eg, carotenoids, vitamins C and E), 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. (Option 1) Seeing small flashes of light is associated with retinal detachment. (Option 2) Inability to see things close up, known as presbyopia, occurs when the lens of the eye becomes less elastic with age and therefore unable to adjust to near and far vision. (Option 3) Poor peripheral vision, also called tunnel vision, can result from optic nerve damage seen in glaucoma.

The cardiac care unit has standing instructions that the health care provider (HCP) should be notified of an abnormal mean arterial pressure (MAP). The nurse will need to notify the HCP about which client? 1. A client from the cardiac catheterization lab with a blood pressure (BP) of 102/58 mm Hg [8%] 2. A client just admitted from the emergency department with a BP of 150/72 mm Hg [20%] 3. A client with a BP of 92/60 mm Hg who just received a dose of nitroglycerin [35%] 4. A client with heart failure on metoprolol with a BP of 106/42 mm Hg [35%]

The MAP refers to the average pressure within the arterial system felt by the vital organs. A normal MAP is between 70-105 mm Hg. If the MAP falls below <60 mm Hg, vital organs may be underperfused and can become ischemic. A normal MAP is 70-105 mm Hg. The client with the BP of 106/42 mm Hg has a MAP of 63 mm Hg, in the abnormal range. The nurse should report this to the HCP and monitor the client closely. (Options 1, 2, and 3) These MAPs are within the 70-105 mm Hg normal range.

The client comes to the emergency department status post fall. The client is squinting both eyes and reports sudden blurry vision. The nurse is aware that this deficit reflects injury to which area of the brain? Left-clicking the mouse will put an X to show the answer before submitting the question.

The occipital lobe of the brain registers visual images. Injury to the occipital lobe could result in a deficit with vision. The nurse should notify the health care provider immediately and document the finding. The frontal lobe controls higher-order processing, such as executive function and personality. Injury to the frontal lobe often results in behavioral changes. The temporal lobe integrates visual and auditory input and past experiences. The parietal lobe integrates somatic and sensory input.

A client has just returned to the room after having a mammogram. The client is teary and in a shaky voice says to the nurse, "The radiology technician told me that it looks really bad - the tumor in my breast is very large." Which is the best response by the nurse? 1. "I can see that you are very upset. Let's talk about what happened." [93%] 2. "I'll report the technician to the head of the radiology department." [0%] 3. "The technician never should have said that to you." [1%] 4. "Your health care provider will discuss treatment options with you." [4%]

Acknowledging that the client is upset conveys concern and understanding on the part of the nurse and helps establish a therapeutic dialogue. The client can vent feelings and discuss fears because the nurse provides the opportunity to talk about what happened (focusing and listening). This action also establishes interpersonal sensitivity and helps the nurse relate therapeutically to the client. Clients who feel threatened or injured by their medical condition(s) need to feel safe and supported. The nurse is in a unique position to provide the nurturing and caring that clients need as they cope with medical diagnoses and difficult situations. (Option 2) This is not an appropriate response; the proper chain of command would have the nurse report the event to a supervisor. (Option 3) This statement may be true, but it does not facilitate a dialogue about the client's feelings and fears. (Option 4) This response does not address the client's feelings or what happened during the mammogram. Educational objective:

The nurse is triaging victims at the site of a mass casualty incident. Which victim should be seen first? 1. Client with a head injury and fixed, dilated pupils [23%] 2. Client with an open right femur fracture and palpable pedal pulses [27%] 3. Client with full-thickness burns covering 85% total body surface area [45%] 4. Client with shallow lacerations over legs and arms [2%]

During a mass casualty event, the goal of the nurse is to triage rapidly and provide the greatest good for the greatest number of people. Clients are commonly triaged using a color-coded system and placed into four categories. When prioritizing clients for treatment, emergent needs should be managed first followed by urgent and nonurgent needs. If no clients are identified as having emergent needs, clients with urgent needs (eg, open fractures with palpable pulses) should be treated first (Option 2). (Options 1 and 3) Clients who are expectant due to the severity of their injuries (eg, severe neurological trauma, full-thickness burns >60% total body surface area) are the lowest priority for treatment. However, the nurse should provide palliative care, if possible, while addressing the needs of others. (Option 4) Clients with nonurgent needs (eg, minor lacerations) should receive treatment after emergent and urgent clients.

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? Select all that apply. 1. Arrange furniture to allow for free movement 2. Keep frequently used items within easy reach 3. Lock doors leading to stairwells and outside areas 4. Place an identifying symbol on the bathroom door 5. Provide a dark room free of shadows for sleeping

hen 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. Injury-prevention modifications include: Arrange furniture to allow for free movement to prevent falls (Option 1). Place frequently used items within easy, visible reach of the client (Option 2). Place locks on stairwells and outside doors to decrease the client's risk of falls and becoming lost during periods of wandering (Option 3). Label the doors to the bathroom and other commonly used rooms to assist with environment interpretation and promote independent functioning (Option 4). (Option 5) Providing a night light in the sleeping area can prevent falls, aid in orientation, and decrease illusions.

There has been a major disaster involving a manufacturing plant explosion. The emergency department nurse is sent to triage victims. Which client should the nurse send to the hospital first? 1. Client who has partial-thickness burns on both hands [4%] 2. Client who is screaming and has a left lower arm laceration [3%] 3. Client with a broken, protruding right tibia and gray, pulseless foot [73%] 4. Client with a gaping head wound and Glasgow Coma Scale score of 3 [19%]

During a mass casualty event, the goal of the nurse is to triage rapidly and provide the greatest good for the greatest number of people. Clients are commonly triaged using a color-coded system and placed into 4 categories. When prioritizing clients for treatment, emergent needs should be managed first, followed by urgent and then nonurgent. The client with an open fracture and impaired distal perfusion (eg, absent distal pulses, capillary refill >3 seconds) has an emergent need for care as limb loss may occur without rapid intervention (Option 3). (Option 1) Nonurgent treatment is appropriate for the client with partial-thickness burns to a small portion of the body (eg, hands). (Option 2) Depending on the size and depth of the laceration, this client would most likely be categorized as nonurgent or urgent. (Option 4) A large, open head wound and a Glasgow Coma Scale score of 3 is indicative of severe neurological trauma. This client has a poor prognosis regardless of treatment (expectant) and would be the lowest priority.

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

Gastroesophageal reflux disease (GERD) occurs when chronic reflux of stomach contents causes inflammation of the esophageal mucosa. The lower esophageal sphincter normally prevents stomach contents from entering the esophagus. Factors that decrease the tone of the lower esophageal sphincter (eg, caffeine, alcohol), delay gastric emptying (eg, fatty foods), or increase gastric pressure (eg, large meals) can precipitate GERD. Lifestyle and dietary measures that may help prevent GERD and associated symptoms include: Weight loss because excessive abdominal fat may increase gastric pressure Avoiding GERD triggers such as caffeine, alcohol, nicotine, high-fat foods, chocolate, spicy foods, peppermint, and carbonated beverages (Options 1 and 5) Chewing gum to promote salivation, which may help neutralize and clear acid from the esophagus Sleeping with the head of the bed elevated (Option 4) Discontinuing the use of tobacco products (Option 2) Refraining from eating at bedtime and/or lying down immediately after eating (Option 3) Clients with GERD should eat small, frequent meals with sips of water or fluids to help facilitate the passage of stomach contents into the small intestine and help prevent reflux from an overly full stomach during and after meals.

The nurse receives report on 4 clients. Which client should the nurse see first? 1. Client with a history of chronic hypertension exhibiting epistaxis and blurred vision [56%] 2. Client with a unilateral, pulsating headache reporting sensitivity to light [18%] 3. Client with episodes of vomiting and abdominal cramps following a outdoor party [7%] 4. Client with multiple sclerosis reporting blurred vision and right arm weakness [17%]

Hypertensive encephalopathy (HE) is a medical emergency caused by a sudden elevation in blood pressure (eg, hypertensive crisis) creating cerebral edema and increased intracranial pressure (ICP). Triggers of HE include an acute exacerbation of pre-existing hypertension, drug use, MAOI-tyramine interaction, head injury, and pheochromocytoma. The client may report severe headache, 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 history of chronic hypertension and active signs of increased ICP (eg, anxiety, epistaxis) requires immediate assessment and treatment (Option 1). (Option 2) The client with a unilateral, pulsating headache has symptoms consistent with migraine. Supportive care for this client includes pain and environmental management but is not a priority over a client with HE. (Option 3) The client with abdominal cramping and vomiting may likely have food poisoning and require nonemergency supportive care, along with additional assessment. (Option 4) The client with multiple sclerosis (MS) may have recurrent exacerbations, including symptoms of blurred vision (due to optic neuritis), focal weakness, and/or sensory abnormalities (eg, numbness, tingling). MS exacerbations are treated with corticosteroids but are not immediately life-threatening.

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

Older adults experience expected, age-related physiologic changes, several of which increase their risk for respiratory illnesses and infection. With aging, mucus becomes thicker and more difficult to clear because the mucous membranes produce and secrete less mucus. Costal cartilage becomes calcified, reducing lung compliance and expansion (Option 2). The respiratory muscles become weaker and the cough is less forceful (Option 1). The number of respiratory cilia is decreased, and they become less effective in their brushing motion (Option 5). All these changes reduce the body's ability to clear mucus and pathogens. The immune system of older adults is also diminished as the function and quality of lymphocytes (ie, T cells, B cells) are altered and respiratory defenses (eg, mucus clearance) are impaired (Option 3). The older adult's dry mucous membranes are also more vulnerable to respiratory pathogens and infection (Option 4).

Which situations would require the nurse to obtain a prescription for physical restraints? Select all that apply. 1. Belt restraint used for a confused client who keeps trying to get out of bed but is on bed rest 2. Elbow restraints used temporarily for a toddler while drawing blood 3. Full padded side rails in the raised position for a client during a seizure 4. Long leg immobilizer used for a client with a fractured tibia 5. Soft ankle restraint to prevent bleeding at the femoral site following cardiac catheterization

A physical restraint 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 health care 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 usinterm-754g a quick-release knot. It is used to protect a confused or disoriented client who is on bed rest. Although the client can turn, it is considered a restraint because it restricts physical mobility and confines the client to the bed involuntarily (Option 1). Soft limb restraints (eg, wrist, ankle) immobilize one or more extremities and are used for the prevention of falls or attempted removal of devices. Following a procedure 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 (Option 5). 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. (Option 2) Elbow restraints used as a protective device to temporarily immobilize a child (<30 minutes) to perform a medical, diagnostic (eg, drawing blood), or surgical procedure are not considered a physical restraint. (Option 3) 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. (Option 4) 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.

A client is being discharged after having a coronary artery bypass grafting (CABG) x 5. The client asks questions about the care of chest and leg incisions. Which instructions should the registered nurse include? Select all that apply. 1. Report any itching, tingling, or numbness around your incisions 2. Report any redness, swelling, warmth, or drainage from your incisions 3. Soak incisions in the tub once a week then clean with hydrogen peroxide and apply lotion 4. Wash incisions daily with soap and water in the shower and gently pat them dry 5. Wear an elastic compression hose on your legs and elevate them while sitting

Incisions may take 4-6 weeks to heal. The nurse should instruct clients on how to care for their incisions; these instructions are as follows: Wash incisions daily with soap and water in the shower. Gently pat dry (Option 4). Itching, tingling, and numbness around the incisions may be present for several weeks due to damage to the local nerves (Option 1). Tub baths should be avoided due to risk of introducing infection (Option 3). Do not apply powders or lotions on incisions as these trap the bacteria at the incision (Option 3). Report any redness, swelling, and increase in drainage or if the incision has opened (Option 2). Wear a supportive elastic hose on the legs. Elevate legs when sitting to decrease swelling (Option 5).

The nurse is performing open endotracheal suctioning for a client with a tracheostomy tube. Which of the following actions by the nurse are appropriate? Select all that apply. 1. Administers 100% oxygen prior to suctioning the client 2. Applies suction while withdrawing the catheter from the airway 3. Instills sterile normal saline into the tracheostomy prior to suctioning 4. Limits suctioning to 20 seconds during each suction pass 5. Uses sterile gloves and technique throughout the procedure

Open endotracheal (ET) suctioning is a skill performed to remove pulmonary secretions and maintain airway patency in clients who are unable to clear secretions independently. ET suctioning is important to promote gas exchange and prevent alveolar collapse, but inappropriate technique increases the client's risk for complications (eg, pneumonia, hypoxemia) or tracheal injury (eg, trauma, bleeding). To reduce the risk of complications and injury during ET suctioning, the nurse should: Preoxygenate with 100% oxygen and allow for reoxygenation periods between suction passes (Option 1) Suction only while withdrawing the catheter from the airway (Option 2) Use strict sterile technique throughout suctioning (Option 5) Limit suctioning to ≤10 seconds on each suction pass (Option 3) Instilling sterile normal saline solution or sterile water (ie, lavaging) in the client's airway, a practice no longer supported by evidence, greatly increases the risk for infection by potentially transporting bacteria from the upper airway into the lower airways. (Option 4) Suctioning longer than 10 seconds increases risk for collapse of airway structures (eg, alveoli, bronchioles) and hypoxemia (ie, oxygen saturation <90%).

A nurse is caring for a 3-month-old infant who has bacterial meningitis. Which clinical findings support this diagnosis? Select all that apply. 1. Depressed anterior fontanelle 2. Frequent seizures 3. High-pitched cry 4. Poor feeding 5. Presence of the Babinski sign 6. Vomiting

Bacterial meningitis is an inflammation of the meninges in the brain and spinal cord that is caused by specific types of bacteria, including group B streptococcal, meningococcal, or pneumococcal pathogens. Clinical manifestations of bacterial meningitis in infants age <2 include: Fever or possible hypothermia Irritability, frequent seizures High-pitched cry Poor feeding and vomiting Nuchal rigidity Bulging fontanelle possible but not always present One of the most common acute complications of bacterial meningitis in children is hydrocephalus. Long-term complications include hearing loss, learning disabilities, and brain damage. Due to the severity of potential complications, prompt identification and immediate treatment are vital for any client with suspected bacterial meningitis. (Option 1) Infants with bacterial meningitis may have bulging fontanelles due to an increase in intracranial pressure. Depressed fontanelles indicate severe dehydration. (Option 5) The Babinski reflex can be present up to 1-2 years and is a normal expected finding; it does not indicate meningitis.

The charge nurse is preparing for the admission of an elderly client with delirium and agitation associated with urinary tract infection. To promote client safety, which intervention is most important for the charge nurse to implement? 1. A bed near the nursing station 2. Four-point leather restraints 3. Minimizing environmental stimuli 4. One-on-one supervision from a sitter

Client and staff safety is an ongoing concern when working with clients who are confused and agitated. The least restrictive restraint should be used. One-on-one supervision provided by a trained staff member who stays with the client at all times can promote safety while reducing or eliminating the use of restraints on a client who is confused and agitated. Frequent reassurance, touch, and verbal orientation (regarding name, location, time, and the client's situation) can lessen disruptive behaviors. Placing a large clock and calendar within the client's visibility would also help. (Option 1) Ideally, the client will be placed in a room near the nursing station. However, the client with delirium and agitation will also require ongoing supervision to minimize harm to self or others. (Option 2) Four-point leather restraints are one of the most restrictive restraint options. These are not appropriate as a first-line option for promoting safety. (Option 3) Reducing environmental stimuli is important for an agitated client, but these alone are not most helpful.

The charge nurse is making client assignments for the oncoming shift. Which client assignment is most appropriate for a nurse who is 10 weeks pregnant? 1. Client receiving brachytherapy for endometrial cancer [28%] 2. Client with an infected surgical wound positive for methicillin-resistant Staphylococcus aureus [44%] 3. Client with a herpes zoster rash on the face and scalp [18%] 4. Client with pneumonia who recently traveled to a region with the Zika virus [7%]

A pregnant nurse does not have a high risk for contracting methicillin-resistant Staphylococcus aureus (MRSA) if appropriate infection precautions are used (Option 2). The nurse should carefully follow contact precautions, including wearing gloves and gown and performing strict hand hygiene. Even if the pregnant nurse were to contract MRSA, there are few known harmful effects to the fetus. TORCH infections (Toxoplasmosis, Other [parvovirus B19/varicella-zoster virus], Rubella, Cytomegalovirus, Herpes simplex virus) can cause fetal abnormalities, and clients with these infections should not be assigned to pregnant health care workers. (Option 1) Clients receiving brachytherapy have radioactive implants placed in a body cavity. To safely care for these clients, nurses limit/cluster client time and keep a distance of at least 6 ft (1.8 m) unless wearing lead shielding for direct care. Pregnant health care workers should not care for these clients if possible as fetal radiation exposure is teratogenic. (Option 3) Herpes zoster (ie, shingles, varicella-zoster virus infection) is a TORCH infection, and pregnant health care workers should avoid caring for these clients. (Option 4) Zika virus may be transmitted through mosquito bites, infected body fluids, and sexual contact. Using standard precautions should provide protection; however, because Zika is known to cause birth defects, pregnant health care workers should not care for a client exposed to it if at all possible.

Which of the following are examples of medical battery? Select all that apply. 1. A child is placed in a papoose restraint for suturing of a facial laceration with the parent present 2. Application of soft wrist restraints to the arms of a confused, adult client with a nasogastric tube 3. The nurse administers 2 mg of morphine PRN to a difficult, alert client but tells the client it is saline 4. The nurse inserts a needed urinary catheter even though a competent client refuses it 5. The nurse threatens to put a client in restraints if the client does not stay in bed

Battery is the intentional touching of a person that is legally defined as unacceptable or occurs without the person's consent. Many routine actions that are permissible when proper consent is obtained would otherwise be considered medical battery. Furthermore, actions can be considered battery even if no physical injury results. Any health care provider (HCP) who performs a medical or surgical procedure without receiving the required informed consent from a competent client (or parent/legal guardian in the case of a child) is committing battery and could be legally charged (Option 3). A competent client has the right to refuse any treatment, even if it is for the client's benefit. The nurse should help the client understand the need (eg, informed refusal), but the client's decision should be upheld. Proceeding to administer treatment to a competent client who has refused that treatment is medical battery (Option 4). (Option 1) The temporary restraint for this minor child is needed for a therapeutic intervention, and it is implied that the parent consents to its use. (Option 2) Using a restraint to prevent a client from inadvertently removing essential medical interventions is an acceptable medical precaution. A prescription from the HCP is required, and the nurse is responsible for performing appropriate, timely assessments related to the restraint. This is not an example of battery as there is a medical reason for the restraint and a prescription/order was obtained. (Option 5) This is an example of assault. Assault is a deliberate threat with the power to carry out the threat.

A pregnant client comes in for a routine first prenatal examination. According to the last menstrual period, the estimated gestational age is 12 weeks. Where would the nurse expect to palpate the uterine fundus in this client? 1. 12 cm above the umbilicus [9%] 2. At the level of the umbilicus [7%] 3. Halfway between the symphysis pubis and the umbilicus [41%] 4. Just above the symphysis pubis [41%]

The enlarging pregnant uterus should be just above the symphysis pubis at approximately 12 weeks gestation (Option 4). At 16 weeks gestation, the fundus is roughly halfway between the symphysis pubis and the umbilicus. It reaches the umbilicus at 20-22 weeks gestation and approaches the xiphoid process around 36 weeks gestation. At 38-40 weeks, the fetus engages into the maternal pelvis and the fundal height drops. After 20 weeks gestation, the fundal height, measured in centimeters from the symphysis pubis to the top of the fundus, correlates closely to the weeks of gestation. (Options 1, 2, and 3) At 12 weeks gestation, the uterine fundus should be just above the symphysis pubis.

An elderly client with chronic kidney disease is admitted with urosepsis. Based on the admitting diagnosis and laboratory results, which prescriptions would the nurse question? Select all that apply. Click on the exhibit button for additional information. 1. Administer IV antibiotic medications 2. Continue home dose of valsartan 3. Initiate continuous cardiac telemetry 4. Obtain blood and urine cultures 5. Obtain CT scan of abdomen with contrast

Urosepsis is a type of bloodstream infection that originates from the urinary tract. The initial treatment of sepsis focuses on the management or prevention of septic shock, mainly by administering boluses of isotonic IV fluids (fluid resuscitation) and IV broad-spectrum antibiotics (Option 1). Blood and urine cultures are obtained, ideally before the first dose of antibiotics (Option 4). Continuous vital sign and cardiac telemetry monitoring are initiated as hyperkalemia and sepsis cause cardiovascular disturbances (eg, dysrhythmias and hypotension, respectively) (Option 3). (Option 2) Chronic kidney disease impairs the excretion of excess potassium and can potentiate hyperkalemia, which can lead to life-threatening arrhythmias (eg, ventricular fibrillation). ACE inhibitors (eg, lisinopril, ramipril) or angiotensin II receptor blockers (eg, valsartan, losartan, irbesartan) can be used to manage hypertension secondary to renal disease; however, these drugs can worsen hyperkalemia. (Option 5) Clients with chronic kidney disease and elevated creatinine are unable to excrete the iodinated contrast administered for CT scans. Toxic effects from the contrast can occur; therefore, this prescription should be clarified before the scan.

The nurse notes muffled heart tones in a client with a pericardial effusion. How would the nurse assess for a pulsus paradoxus? 1. Check for variation in amplitude of QRS complexes on the electrocardiogram strip [7%] 2. Compare apical and radial pulses for any deficit [48%] 3. Measure the difference between Korotkoff sounds auscultated during expiration and throughout the respiratory cycle [26%] 4. Multiply diastolic blood pressure (DBP) by 2, add systolic blood pressure (SBP), and divide the result by 3; [(DBP x 2) + (SBP)]/3 [17%]

Muffled heart tones in a client with pericardial effusion can indicate 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 tachypnea, tachycardia, jugular venous distension, 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. The procedure for measurement of pulsus paradoxus is as follows: Place client in semirecumbent position Have client breathe normally Determine the SBP using a manual BP cuff Inflate the 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 slowly deflate the cuff until you hear sounds throughout inspiration and expiration; also note the pressure Determine the difference between the 2 measurements in steps 5 and 6; this equals the amount of paradox The difference is normally <10 mm Hg, but a difference >10 mm Hg may indicate the presence of cardiac tamponade. (Option 1) Variation in QRS amplitude is termed electrical alternans. It could be present in cardiac tamponade, but it is not how pulsus paradoxus is determined. Electrical alternans is due to the swinging motion of the heart in a fluid-filled pericardial sac. (Option 2) An apical/radial pulse deficit may be present during certain dysrhythmias, but this is not the procedure for measuring pulsus paradoxus. (Option 4) This is the formula for calculating mean arterial pressure.

The nurse dons personal protective equipment (PPE) before providing care for a client in airborne transmission-based precautions. Place the steps for donning PPE in the appropriate sequence. All options must be used. The CDC suggests the following sequence for donning PPE: hand hygiene, gown, mask or respirator, goggles or face shield, and gloves.

PPE for the health care worker protects the mucous membranes, airways, skin, and clothing from contact with potentially infectious agents. The category of transmission-based precautions (eg, contact, droplet, airborne) required determines the type of PPE that the health care worker will wear. The exact procedure for donning and removing PPE varies with the level of precautions required. Guidelines are provided by the Centers for Disease Control and Prevention (CDC) and by institution policy and procedure. The sequence for donning PPE includes: Hand hygiene Gown - fully cover torso from neck to knees, arms to end of wrists, and wrap around back; fasten in back of neck and waist Mask or respirator - secure ties or elastic bands at middle of head and neck; fit flexible band to nose bridge; fit snugly to face and below chin; fit-check respirator Goggles or face shield - place over face and eyes and adjust fit; may be combined with mask (visor) Gloves - don and extend to cover wrist of isolation gown

While the nurse and unlicensed assistive personnel are turning an intubated and heavily sedated client during a bath, the client coughs and expels the endotracheal tube. What is the priority nursing action? 1. Assess respiratory rate and breath sounds to ensure ventilation is occurring [26%] 2. Deliver rescue breathing with a bag-valve-mask attached to 100% oxygen [58%] 3. Immediately alert the health care provider and prepare for reintubation [10%] 4. Initiate a code blue to prepare for potential cardiac arrest due to hypoxemia [3%]

Accidental extubation is a medical emergency. A sedated client is unable to protect the airway and requires immediate reintubation. If a client is accidentally extubated, the nurse should remain with the client, protect the airway using the head-tilt chin-lift or the jaw-thrust maneuver if spinal injury is suspected, and deliver breaths using a bag-valve-mask with 100% oxygen until reintubation is achieved (Option 2). (Option 1) Assessing the respiratory system is important but isAccidental extubation is a medical emergency. A sedated client is unable to protect the airway and requires immediate reintubation. If a client is accidentally extubated, the nurse should remain with the client, protect the airway using the head-tilt chin-lift or the jaw-thrust maneuver if spinal injury is suspected, and deliver breaths using a bag-valve-mask with 100% oxygen until reintubation is achieved (Option 2). (Option 1) Assessing the respiratory system is important but is not the priority action. Rescue breathing should not be delayed, as sedation significantly depresses respiration. Assessment is important for a new problem but not for an existing one, especially if delayed care can lead to life-threatening complications. (Option 3) Another nurse can notify the health care provider. Oxygenation is the priority action. (Option 4) While there is a risk for cardiac arrest, the nurse should support the client's airway and breathing to prevent arrest. A code blue should be initiated if cardiac arrest occurs. Rescue breathing should not be delayed, as sedation significantly depresses respiration.

A client is receiving packed red blood cells intravenously through a double-lumen peripherally inserted central catheter (PICC) line. During the transfusion, the nurse receives a new prescription to begin amphotericin B IVPB. What is the nurse's best action? 1. Administer amphotericin B through the unused lumen of the PICC line [18%] 2. Insert a peripheral IV line to begin infusion of amphotericin B [19%] 3. Interrupt the blood transfusion to infuse amphotericin B, then resume after infusion [0%] 4. Wait 1 hour after transfusion finishes before administering amphotericin B [60%]

Amphotericin B is an antifungal medication used to treat systemic fungal infections. It is commonly associated with severe adverse effects, including hypotension, fever, chills, and nephrotoxicity. Due to the similarity between the adverse effects of amphotericin B and the symptoms of a blood transfusion reaction, the nurse's best action is to complete the blood transfusion and allow one hour of observation before initiating amphotericin B (Option 4). This allows the nurse to distinguish between transfusion-related reactions and adverse effects from amphotericin B. (Options 1 and 2) Although starting a peripheral IV line or using the unused lumen of the peripherally inserted central catheter line would prevent mixing the drug with the blood products, it would not help distinguish the onset of potentially fatal sequela from either component. (Option 3) Transfusions should not be interrupted after initiation except in cases of transfusion-related reactions or fluid overload. In addition, interrupting and restarting transfusions increases the risk for infection. Blood products should be transfused within 4 hours of removal from refrigeration.

The nurse cares for a client with ulcerative colitis who is having abdominal pain and ≥10 bloody stools per day. Which of the following interventions should be included in the client's plan of care? Select all that apply. 1. Administer prescribed analgesic medications as needed 2. Encourage the client to discuss feelings about illness 3. Initiate strict, hourly intake and output monitoring 4. Investigate the client's compliance with the medication regimen 5. Offer the client high-protein foods during meals and snacks

Ulcerative colitis (UC) is a chronic inflammatory bowel disease characterized by inflammation and ulceration of the large intestine (colon) that results in abdominal pain, frequent bouts of bloody diarrhea, anorexia, and anemia. The nurse planning care for a client with UC should: Manage pain: Intestinal inflammation often produces severe abdominal pain that limits treatment compliance. Provide prescribed analgesics to promote comfort and treatment adherence (Option 1). Address psychosocial needs: Chronic illness may increase the risk of hopelessness and/or depression due to prolonged treatment and frustration over lack of improvement or symptom control. Encourage clients to discuss emotions and feelings (Option 2). Assess fluid balance: Diarrhea, blood loss, and poor oral intake contribute to dehydration. Strict intake and output monitoring helps ensure adequate fluid intake and prevent dehydration (Option 3). Evaluate treatment adherence: UC exacerbations may be spontaneous or may be precipitated by certain foods or lack of adherence to prescribed treatments (eg, medications). Assess compliance with prescribed treatments and provide education as needed to promote adherence (Option 4). Promote nutrition: Pain after eating may lead to anorexia, and intestinal inflammation decreases nutrient absorption; both result in nutritional deficiency. Help clients select nutrient-dense, high-protein foods to promote recovery and meet nutritional needs (Option 5).

The nurse is preparing to give a heparin injection to a client who is malnourished and cachectic. Which method of injection would be appropriate for this client? 1.27 g, 1/4 in 2.25, 1/2 in 3.25 g , 1/2 4. 15 , 1 and 1/2 in

When administering subcutaneous anticoagulant injections (eg, heparin, enoxaparin), the nurse must select the appropriate needle length and angle to avoid accidental intramuscular injection, especially in clients with insufficient adipose tissue (eg, cachexia). Intramuscular injection of heparin would cause rapid absorption, resulting in a hematoma and painful muscle irritation. The nurse should administer subcutaneous injections at 90 degrees if 2 in (5 cm) of subcutaneous tissue can be grasped, or at 45 degrees if only 1 in (2.5 cm) can be grasped (Option 2). Anticoagulants are best absorbed if administered in the abdomen at least 2 in (5 cm) away from the umbilicus. (Option 1) A 15-degree angle is used for intradermal injections and would not deliver medication into the subcutaneous tissue. (Option 3) A 90-degree injection angle is appropriate for clients with sufficient adipose tissue (ie, at least 2 in [5 cm] can be grasped). (Option 4) Needles longer than 5⁄8 in (1.6 cm) are used to administer intramuscular injections.

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