*NCLEX PREP PREDICTOR*

The nurse delivers a change-of-shift report. Which information is important for the nurse to include in the report? (Select all that apply.) 1. Client's admitting diagnosis and relevant history. 2. Client's emotional response to condition. 3. Current intravenous (IV) solution and flow rate. 4. Description of routine morning care provided. 5. Use of and response to as needed medications.

1, 2, 3, 5

The nurse conducts a well visit assessment on an infant client the parent states we've decided not to do any more immunizations so baby doesn't get autism which responses by the nurse is best? 1. I will let the health care provider know so you can discuss your concerns 2. immunizations don't cause autism 3. its your decision 4. I don't blame you; autism is scary

1. I will let the health care provider know so you can discuss your concerns

A client admitted to the hospital receives a diagnosis of hepatitis B on which factors will the nurse base the plan of care. 1. blood and body fluids of an infected individual can be contagious 2. Client should not receive any blood or blood products during hospitalization. 3. Client should not have blood drawn during hospitalization. 4. Client has increased susceptibility to other viruses because of the hepatitis B

1. blood and body fluids of an infected individual can be contagious

A nurse is monitoring for a stoma prolapse in a client with a colostomy. The nurse should observe which of the following appearances in the stoma if prolapse occurred? 1. protruding 2. narrowed & flattened 3. sunken & inverted 4. dark, bluish colored

1. protruding 2. stenosed 3. retracted 4. ischemia

The nurse plans care for a client diagnosed with Clostridium difficile. Which transmission-based precautions should the nurse implement? 1. Standard precautions .2. Airborne precautions. 3. Droplet precautions. 4. Contact precautions.

4. Contact precautions.

Which statement will the nurse include when teaching a patient about loop diuretics? a. Take the medication at bedtime. b. Take the medication on an empty stomach. c. Rise slowly from a lying or sitting to standing position to prevent dizziness. d. Avoid fruit and vegetables in the diet.

c. Rise slowly from a lying or sitting to standing position to prevent dizziness.

Which finding alerts the nurse to consider alcohol use disorder in a client hospitalized for a physical illness? a. depression, difficulty falling asleep, decreased concentration b. elevated vitamin B1 (thiamine) level, leukocytosis, thrombocytopenia c. tremors, elevated temperature, nocturnal leg cramps, reports of pain d. flu-like symptoms, night sweats, elevated temperature, decreased deep tendon reflexes

c. tremors, elevated temperature, nocturnal leg cramps, reports of pain

what does the nurse know to be correct concerning the use of mannitol in patients? a. decreases intracranial pressure b. increases intraocular pressure c. causes sodium and potassium retention d. causes diuresis in several days

A

what is the classification of furosemide? a. loop diuretic b. osmotic c. potassium sparing d. thiazide

A

A patient is taking furosemide 40 mg daily for heart failure and hypertension. It is most important for the nurse to assess the patient for the development of a. low serum potassium, sodium, and magnesium, and elevated calcium. b. low serum potassium and sodium, and elevated magnesium and calcium. c. low serum potassium, sodium, magnesium, and calcium. d. low serum potassium and sodium, with magnesium and calcium remaining normal.

c. low serum potassium, sodium, magnesium, and calcium.

The community health nurse provides care to a newborn client who is prescribed enteral feedings through a gastrostomy tube. which statement by the client's mother indicated a need for immediate follow-up by the nurse? a. it takes about 25 minutes to give one feeding b. I use a bottle warmer to warm the formula c. I wash the syringe with soap after each time I use it d. it is easy to give liquid medicine though the feeding tube

d. it is easy to give liquid medicine though the feeding tube

The nurse provides care for a client diagnosed with heart failure. Which client statements indicate to the nurse that medication therapy is effective? (Select all that apply.) 1. "Since I've been taking captopril, my feet are not as puffy." 2. "Taking spironolactone has kept my pulse less than 60." 3. "Lisinopril seems to help me not be as short of breath." 4. "Now that I'm taking carvedilol, I don't have palpitations." 5. "Before taking valsartan, I had to stop and rest while cooking." 6. "I seem to urinate more when I take digoxin."

1) CORRECT - ACE inhibitors, such as captopril, reduce peripheral edema. This statement indicates the medication therapy is effective. 2) INCORRECT - A pulse rate below 60 beats/min is not desirable. Potassium-sparing diuretics, such as spironolactone, reduce blood volume, which may decrease heart rate. This statement does not indicate the medication therapy is effective. 3) CORRECT - ACE inhibitors, such as lisinopril, reduce pulmonary congestion, which will decrease dyspnea. This statement indicates the medication therapy is effective. 4) INCORRECT - Beta-blockers primarily slow heart rate and reduce blood pressure, although some will also reduce palpitations. Carvedilol is known to cause palpitations. However, the absence of this side effect does not indicate a therapeutic effect. 5) CORRECT - Angiotensin II receptor blockers (ARBs), such as valsartan, decrease pulmonary congestion and improve cardiac output, which should reduce client's fatigue and dyspnea. This statement indicates the medication therapy is effective. 6) CORRECT - Cardiac glycosides, such as digoxin, improve cardiac output, which increases urine output. This statement indicates the medication therapy is effective. *Think Like a Nurse: Clinical Decision-Making* In evaluating effectiveness of medications used to treat heart failure, the nurse should look for manifestations indicating an improvement of cardiac output, renal function, tissue perfusion, and activities of daily living. The client is informed to report to the provider sudden or steady gain in daily weight, such as 2 to 3 lbs (0.91 to 1.4 kg) in 24 hours or 5 lbs (2.3 kg) or more in 1 week. If taking digoxin, the client should be taught how to take their pulse rate for a full minute and be aware not to take digoxin if rate is less than 60 beats/minute. *Content Refresher* The treatment of heart failure involves improving contractility, optimizing preload, and reducing afterload. Treatment includes administration of inotropic drugs, diuretics, vasodilators, angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blocking drugs (ARBs), and aldosterone-blocking agents. The treatment is effective if the client maintains adequate systemic perfusion and oxygenation without signs of cardiovascular complications or organ system damage (e.g. kidney failure).

The nursing staff at the pediatric hospital discuss instituting a community education program regarding intellectual disabilities, particularly prevention. It is most beneficial for the nurses to emphasize which area? 1. Alcoholism treatment. 2. Phenylketonuria (PKU) screening. 3. Nutritional supplementation. 4. Prenatal classes.

1) CORRECT - Alcohol is recognized as the leading cause of preventable intellectual disability. This is included in the fetal alcohol syndrome (FAS) complex of symptoms. 2) INCORRECT - Screening for PKU occurs in newborns as a routine part of their care. 3) INCORRECT - Nutrition supplementation is important, especially considering the absence of folic acid is a teratogen causing spina bifida. However, many foods are now supplemented to offset this risk. Therefore, preventing or reducing alcohol-related birth defects is a priority that is best addressed in a community program. 4) INCORRECT - Prenatal classes tend to focus on the parents in the last trimester of pregnancy, when any issues with the fetus may be already developed and no longer preventable or reversible. *Think Like a Nurse: Clinical Decision-Making* In many cases of intellectual disability, the exact cause is unknown. Prenatal exposure to alcohol or other drugs can be a cause. Prenatal errors in central nervous system development also may be responsible. Public health efforts to prevent intellectual disability should be geared toward adequate prenatal care that emphasizes abstinence from alcohol and other teratogens. In assessing clients with intellectual disability, the nurse should keep in mind that the most sensitive early indicator is delayed language development due to the extent of cognition required to understand and produce speech. *Content Refresher* Fetal alcohol syndrome (FAS) is a group of birth defects that occur when a pregnant woman drinks moderate amounts of alcohol. Assess the infant or child for unusual facial features (a smooth philtrum, thin upper lip, upturned nose, flat nasal bridge and midface, epicanthal folds, smallpalpebral fissures, and small head circumference), lower-than-average height and/or weight, problems with attention and hyperactivity, and poor coordination. Identify health and community resources to assist with cognitive and developmental delays. Refer the mother to an alcohol treatment program.

a patient has heart failure and a high dose of furosemide is ordered. what suggests a favorable response to furosemide? a. decrease in level of consciousness occurs, and the patient sleeps more b. respiratory rate decreases form 28 to 20/min and depth increases c. increased congestion is heard in breath sounds, and the patient complains of shortness of breath d. urine output is 50 ml/4h and intake is 200 mL

B

a patient is taking HCTZ 50 mg/day and digoxin 0.25 mg/day. the nurse plans to monitor the patient for which potential electrolyte imbalance? a. hypocalcemia b. hypokalemia c. hyperkalemia d. hypermagnesemia

B

the patient has been prescribed HCTZ for her hypertension. when she comes to the office for a follow up appointment, the nurse observes her drinking an energy drink. which herb, commonly found in some energy drinks, can increase blood pressure when taken with thiazide diuretics? a. ginger b. ginkgo c. licorice d. st. johns wort

B

the patient has been receiving spironolactone 50 mg/day for heart failure. the nurse should closely monitor for which condition? a. hypokalemia b. hyperkalemia c. hypoglycemia d. hypermagnesemia

B

The nurse provides care to clients in the postanesthesia care unit (PACU). Which client requires immediate attention by the nurse? 1. Client with a new tracheotomy with a small amount of serosanguineous drainage on the dressing. 2. Client who is responsive with a moderate amount of clear fluid draining from the nasogastric tube. 3. Client with a chest tube and dark red drainage in the collection chamber. 4. Client who is unresponsive to verbal stimuli with the oral airway out of place.

4) CORRECT - The client who is unresponsive and missing an oral airway needs to have the airway reinserted to maintain a patent airway.

The nurse performs discharge teaching for a client who had coronary artery bypass graft (CABG). Which statement made by the client assures the nurse that teaching was successful? 1. "I may have a moderate amount of bloody drainage from the incision after I go home." 2. "I will have an elevated temperature and excessive fatigue for about 1 month." 3. "I will have moderate pain and tenderness of the incision sites for 2 to 4 weeks after the surgery." 4. "After I go home, I may see some swelling in the leg used for the donor graft."

4 1) INCORRECT— A small amount of serosanguineous drainage may occur, but a moderate amount of sanguinous drainage must be reported to the health care provider (HCP) immediately. 2) INCORRECT— An elevated temperature and excessive fatigue suggest the complication of post-pericardiotomy syndrome. The syndrome includes pleural pain, an elevated white count, and dysrhythmias. These symptoms must be reported to the HCP immediately. 3) INCORRECT— Minimal incisional pain and tenderness may occur for up to 6-12 weeks after surgery. This must be clarified to the client. 4) CORRECT— Edema of the graft site usually increases at home because a client is more active. When sitting, the client should elevate the legs to help relieve the edema. *Think Like A Nurse: Clinical Decision Making* A leg vein is often used for coronary artery bypass grafting. The site of the donor vein may become edematous once the client returns home, primarily because of the increase in activity. Leg elevation helps reduce the edema. Incision pain can last up to 6 to 12 weeks. *Content Refresher* A coronary artery bypass graft (CABG) is a surgical intervention performed when cardiac muscle ischemia occurs due to coronary artery blockage. The clinical presentation may vary depending on the location and degree of narrowing of the arteries involved. When coronary arteries are involved, the client may present with chest pain, shortness of breath, fatigue, and arrhythmias. Prior to surgery, the nurse should provide pre-operative and post-operative teaching to the client. The teaching should include post-operative expectations, signs and symptoms of complications, and instructions for uneventful healing and recovery.

the 70 year old patient has heart failure and has been prescribed HCTZ. what statement by the patient indicates understanding of the dosing regimen? a. I need to take it on an empty stomach for it to work b. I really only need to take my medicine when I am having a hard time breathing c. it may take several weeks before it starts to work d. I should take it in the morning so I don't have to go to the bathroom at night

D

the nurse has received an order to administer 40 mg of furosemide IV to the patient. what does the nurse know about how this drug should be administered? a. must be mixed in 50 mL of normal saline b. can only be give in a central line c. patient must be on a cardiac monitor d. should be given over 1-2 minutes

D

the patient has been diagnosed with hypertension and diabetes and has been started on HCTZ. what statement by the patient indicates understanding of the drug teaching the nurse has provided? a. it will start working within minutes b. I don't need to monitor my blood sugar c. I should take my drug on an empty stomach d. I need to to keep track of my weight and blood pressure at home

D

when compared to thiazides, how do loop diuretics differ? a. they are more effective as antihypertensives b. they promote potassium absorption c. they cause calcium reabsorption d. they are more potent as diuretics

D

The nurse prepares to collect a 24-hour urine specimen for creatinine clearance. Which action does the nurse take? 1. Ask the laboratory if there is a preservative in the collection container. 2. Discard the last voided specimen prior to ending the collection. 3. Obtain a prescription from the health care provider for a urinary catheter. 4. Determine the client's weight prior to beginning the urine collection.

1) CORRECT - All urine should be saved in a container that is refrigerated or kept on ice. Some collections will require preservatives in the container, and the nurse must be certain the correct container is obtained. Instruct the client to void into a separate collection container and add it to the specimen container. 2) INCORRECT - All urine must be collected during the specified collection period. The urine voided at the beginning of the 24-hour period is discarded, signaling the beginning of the test. 3) INCORRECT - There is no need for an indwelling urinary catheter unless the client is incontinent. 4) INCORRECT - It is not necessary to obtain the client's weight. *Think Like A Nurse: Clinical Decision Making* One role of the nurse is to ensure the health care provider's prescriptions are implemented as expected. This role requires that the nurse be familiar with procedures relative to prescribed tests. The nurse is aware the 24-hour specimen for urine is prescribed primarily for assessment and diagnosis renal function. The container used for the specimen is impermeable to light and most often needs to be kept refrigerated until the collection period ends. Depending upon the reason for the specimen, an additive may need to be in the container; the nurse should validate if an additive is required. The nurse should discard the urinary output prior to initiating the test; the urine the bladder is outside the time parameter of the test. *Content Refresher* A 24-hour urine specimen is obtained to determine creatinine clearance, which is the most accurate indicator of renal function. Creatinine is a waste product of protein breakdown. The creatinine clearance result closely approximates the client's glomerular filtration rate. The creatinine clearance is determined by multiplying the urine creatinine by the urine volume and dividing by the serum creatinine. The normal creatinine clearance level ranges from 70 to 135 mL/min, with a 1 mL/min/year decrease after the age of 40.

The nurse provides postpartum care to a client who is bottle-feeding her newborn. Which client statement requires follow up by the nurse? 1. "It feels so good to stand in a warm shower. " 2. "I 'll wear a tight-fitting bra. " 3. "I 'll take the pain medication prescribed by the doctor. " 4. "Ice packs will help my breasts feel better. "

1) CORRECT - Application of warm or hot water to the breasts may stimulate milk production and cause breast engorgement. To help suppress lactation, the client should be instructed to avoid running warm water over the breasts, especially the nipples. 2) INCORRECT - To help suppress lactation, the client should wear a well-fitted bra (even while sleeping) until softening of the breasts occurs. This statement is reflective of an appropriate action and requires no follow up by the nurse. 3) INCORRECT - Mild analgesics may be prescribed to help reduce pain related to breast engorgement. The client's statement indicates correct understanding of the plan of care and requires no follow up. 4) INCORRECT - Application of ice packs to the breasts will help relieve engorgement. This statement indicates an appropriate action and requires no follow up by the nurse. *Think Like a Nurse: Clinical Decision-Making* A warm or hot shower during the postpartum period feels relaxing and comforting. However, if the the client intends to dry up her breast milk stores, the warm water is counterproductive, stimulating milk production. At the very least, the client must turn her breasts away from the stream of warm water to reduce the stimulation. This is temporary, as the breast milk will dry up within days of delivery. *Content Refresher* Nursing interventions when caring for the postpartum client include: Assess lochia. Monitor vital signs (VS). Massage a soft (boggy) uterus and report an unresponsive uterus to the health care provider. Encourage the mother to wear a supportive bra. Teach about breastfeeding or methods to manage breast engorgement for the non-breastfeeding mother. Assist with ambulation and assess for orthostatic hypotension. Assess for bladder distension and implement strategies to enhance voiding. Teach procedure for perineal care. Encourage increasing fluid intake and high fiber diet. Administer prescribed stool softeners and analgesics. Provide ice packs and sitz baths as prescribed. Encourage expression of feelings about maternal role.

The nurse provides care to a client newly diagnosed with schizophrenia who is prescribed chlorpromazine 25 mg PO tid. Which client statement indicates to the nurse a correct understanding of the medication administration instructions? (Select all that apply.) 1. "It is important that I brush my teeth three times a day." 2. "It may take 6 weeks for my medication to work." 3. "I can have a glass of wine with dinner each night" 4. "I am driving myself home today and to work tomorrow." 5. "I need to have blood drawn regularly for a few months." 6. "I should not be concerned if my urine turns pink."

1) CORRECT — Dry mouth is an adverse effect of chlorpromazine, so it is important to maintain good oral hygiene. 2) CORRECT — It can take at least 6 weeks before the client notices improvement in symptoms. 3) INCORRECT— Alcohol should not be mixed with this class of medication. 4) INCORRECT — The client should avoid driving until dosing is stabilized due to potential side effects such as sleepiness. 5) CORRECT — There is a risk of leukopenia in the first 3 months, and this necessitates lab work. 6) CORRECT — Pink urine is an expected side effect of chlorpromazine. *Think Like a Nurse: Clinical Decision-Making* Client education is an expected competency for every nurse. An essential first step is to assess the client's teaching and learning needs, including literacy issues. Health literacy has been shown to be a stronger predictor of health status than age and educational level. Comprehension and compliance are increased when client education materials are written at a sixth-grade or lower reading level and contain pictures and illustrations. The nurse should always use the teach-back method. The client should be encouraged to ask questions. The nurse should keep in mind that chlorpromazine is also used to control nausea and vomiting and to relieve prolonged hiccups. *Content Refresher* Chlorpromazine is a conventional (typical) antipsychotic medication, a phenothiazine, that is used to treat psychotic disturbances. This medication is contraindicated in clients experiencing alcohol withdrawal, bone marrow suppression, closed angle glaucoma, and severe liver and cardiovascular disease. Complete blood counts, fasting blood glucose levels, cholesterol, and liver function studies should be monitored periodically. Common adverse effects include sedation, blurred vision, dry mouth, constipation, urinary retention, photosensitivity, and orthostatic hypotension.

The oncology nurse is reassigned to the medical-surgical unit. The charge nurse for the medical-surgical unit assigns which clients to the oncology nurse? (Select all that apply.) 1. Client who is receiving total parenteral nutrition (TPN) following gastrectomy 48 hours ago. 2. Client who will be discharged to home today following total hip replacement 72 hours ago. 3. Client who requires administration of pain medication after undergoing bariatric surgery 6 hours ago. 4. Client admitted yesterday who is newly diagnosed with atrial fibrillation. 5. Client who requires QID dressing changes for treatment of a MRSA-positive stage 4 pressure injury. 6. Client admitted 3 days ago who is prescribed IV antibiotics for treatment of pneumonia.

1) CORRECT - Based on the available client data, no unexpected assessment findings are present and there is no apparent deterioration of the client's condition. The TPN administration requires application of the nurse's fundamental knowledge and skills. 2) INCORRECT - The client being discharged will require specialized teaching related to postoperative care, hip precautions, equipment, and referrals. The client's care is best assigned to a nurse who is familiar with the specialized plan of care. 3) INCORRECT - The client underwent a surgical procedure within the past 24 hours and, as such, is at high risk for complications. The client's care is best assigned to a nurse who is familiar with postoperative complications relevant to the procedure. 4) INCORRECT - The client with a newly-diagnosed cardiac abnormality is at high risk for instability and will require close monitoring for complications. The client's care is best assigned to a nurse who is familiar with the specialized plan of care. 5) CORRECT - Based on the available client data, no unexpected assessment findings are present and there is no apparent deterioration of the client's condition. Dressing changes and implementation of MRSA precautions require application of the nurse's fundamental knowledge and skills. 6) CORRECT - Based on the available client data, no unexpected assessment findings are present and there is no apparent deterioration of the client's condition. Administration of IV antibiotics requires application of the nurses's fundamental knowledge and skills. *Think Like A Nurse: Clinical Decision Making* When assigning clients to a reassigned nurse, the charge nurse should identify clients who require basic nursing care and whose condition is stable. Providing TPN is a basic nursing skill, and the client is likely to be stable 48 hours after surgery. Dressing changes, standard precautions, and providing IV antibiotics are all basic nursing skills. *Content Refresher* Unit to unit assignment is the process of reassigning nurses from their regular unit assignment to short-staffed areas. When determining client assignments, look for similarities of skills and knowledge between the care delivered in the home unit and the care given in the host unit. Assign clients who are stable and do not require specialized nursing knowledge.

The nurse performs a nutrition assessment on an adolescent female client. Which dietary recommendation does the nurse give to the client and parents? 1. High calcium. 2. Low iron. 3. High protein. 4. Low sodium.

1) CORRECT - During puberty, adolescents experience rapid growth spurts. The adolescent female needs a diet high in calcium to support growth, as well as to help prevent osteoporosis in later years. Adequate iron should be also consumed. Dietary recommendations for adolescent females who have begun menstruating include high iron to prevent iron-deficiency anemia. As opposed to large amounts of protein, adequate protein should be consumed. Sodium restriction is not indicated for healthy adolescents.

The nurse monitors a client newly diagnosed with diabetes mellitus (DM) for signs of complications. Which findings alert the nurse to a hyperglycemic event? (Select all that apply.) 1. Polydipsia. 2. Diaphoresis. 3. Polyuria. 4. Bradycardia. 5. Polyphagia.

1) CORRECT - Excessive thirst and fluid intake results gradually as blood glucose levels increase. The body attempts to rid itself of excess glucose through renal excretion. Urine levels increase, which cause dehydration. The client is thirsty and drinks more to replace lost fluids. 2) INCORRECT - Diaphoresis is not a sign of hyperglycemia. Sweating is the body's attempt to cool itself. 3) CORRECT - Increased urine output results gradually as blood glucose levels increase. The body attempts to rid itself of excess glucose through renal excretion. 4) INCORRECT - Bradycardia is not a sign of hyperglycemia. 5) CORRECT - In hyperglycemia, blood glucose is increased as the body lacks the insulin necessary to facilitate transfer of glucose into body cells. Body cells therefore experience a lack of fuel. Increased appetite and food intake occurs as the body attempts to feed its cells. *Think Like A Nurse: Clinical Decision Making* The nurse understands that hyperglycemia causes a client to produce a high volume of glucose-rich urine, removing glucose from the bloodstream. Glucose is a solute that attracts water via osmosis. High glucose levels in the blood attract a high volume of water, which is then excreted. This results in increased thirst because the client becomes dehydrated from so much fluid leaving with the sugar. Hyperglycemia means that the glucose is not inside the cells, where it is needed to provide energy. As long as the glucose is in the blood stream and not being pushed into the cells by insulin, the client will be excessively hungry. *Content Refresher* Hyperglycemia occurs in a client with diabetes mellitus who lack adequate glycemic control. Normal blood glucose is 70 to 110 mg/dL (3.9 to 6.1 mmol/L). Assess for signs of hyperglycemia, including polyuria, polydipsia, polyphagia, lethargy, malaise, headache, and blurred vision. Assess urine for glucose and ketones. Assess arterial blood gases, electrolytes, and blood glucose levels. Assess vital signs and monitor for signs of orthostatic hypotension due to dehydration. Administer insulin or oral antidiabetic agents. Discuss the need for regular exercise and dietary management of hyperglycemia. Monitor intake and output and notify the health care provider of changes suggestive of fluid overload or deficit.

The nurse teaches a class on contraception. Which client statement would require follow up teaching by the nurse? 1. "I should not use an oral contraceptive since I have a very heavy menstrual flow." 2. "I will need to quit smoking if I want to use birth control pills." 3. "I will need to use a contraceptive for several weeks after my spouse has a vasectomy." 4. "I know a condom needs to have a space left at the tip after it is put on an erect penis."

1) CORRECT - Oral contraceptives, including combination and progestin-only pills, reduce menstrual cramps and reduce menstrual flow. 2) INCORRECT- Smoking increases the risk of clot formation while taking oral contraceptives. Clients should stop smoking prior to taking oral contraceptives to reduce the risk of stroke, thromboembolic disease, or myocardial infarction. 3) INCORRECT- A vasectomy is not immediately effective. It may take up to 3 months post-vasectomy for seminal fluid to test negative for sperm. Other methods of contraception are required until a negative seminal fluid analysis is obtained. 4) INCORRECT- A client should allow for some space at the end of the condom by the head of the penis to collect semen in order to avoid breakage or spillage. *Think Like a Nurse: Clinical Decision-Making* It is essential that the nurse evaluate the client's understanding of use of the contraceptive of choice. Incorrect use of contraceptive devices can lead to pregnancy, infections, or complications. The nurse must also ensure clients know the risks and benefits of each method. For the client with heavy menses, hormonal contraceptives such as birth control pills, injections, patches, and implants significantly reduce menstrual flow and associated cramping, improving the client's quality of life. *Content Refresher* Hormonal contraceptives are used to prevent ovulation and to thicken cervical mucus to prevent pregnancy. Adolescent girls and young women are often prescribed hormonal contraceptives, specifically birth control pills, for irregular or absent menstrual periods, menstrual cramps, acne, premenstrual syndrome (PMS), endometriosis, primary ovarian insufficiency (POI), and polycystic ovary syndrome (PCOS). Risk factors associated with hormonal contraceptives include an increased risk of cervical and breast cancers, increased risk of heart attack and stroke, migraines, high blood pressure, gallbladder disease, infertility, and benign liver tumors.

The nurse screens clients at a health fair for vitamin B 12 deficiency. Which clients will the nurse determine as needing vitamin B 12 supplementation? (Select all that apply.) 1. Recently diagnosed with pernicious anemia. 2. Treated for acute lymphocytic leukemia. 3. Follows a strict vegan diet. 4. Takes medication for gastroesophageal reflux disease. 5. Takes metformin (Glumetza) for type 2 diabetes mellitus. 6. Had a gastrectomy 2 years ago.

1) CORRECT - Pernicious anemia is a risk factor for vitamin B 12 deficiency because the stomach does not secrete intrinsic factor with this health problem. 2) INCORRECT - Acute lymphocytic anemia is not a risk factor for vitamin B 12 deficiency. 3) CORRECT - A vegan diet is a risk factor for vitamin B 12 deficiency because this vitamin is found in animal muscle meats. 4) INCORRECT - Gastroesophageal reflux disease is not a risk factor for vitamin B 12 deficiency. 5) CORRECT - Metformin is a risk factor for vitamin B 12 deficiency because it interferes with the absorption of the vitamin. 6) CORRECT- A gastrectomy is a risk factor for vitamin B 12 deficiency because there is no stomach to secrete intrinsic factor. *Think Like a Nurse: Clinical Decision-Making* The nurse should be aware that clients with health problems or who experience situations that affect the function of the stomach, or the stomach lining, are at risk for developing a vitamin B 12 deficiency. Client situations that may necessitate the need for supplementation of this vitamin include those with pernicious anemia, those who have had a gastrectomy, individuals who are prescribed metformin, and anyone who consumes a diet low in animal meat. The nurse should recognize that clients with these conditions are likely candidates to receive vitamin B 12. *Content Refresher* Individuals at risk for experiencing a vitamin B 12 deficiency include those with a history of gastric bypass surgery or pernicious anemia. Individuals who consume foods that are deficient in vitamin B 12 and folic acid, such as vegetarians, are also at risk of having a B 12 deficiency. If a client is diagnosed with a vitamin B 12 deficiency, the nurse needs to provide education about dietary sources of vitamin B 12 and folic acid.

A client refuses to allow a student nurse to provide care stating, "They are going to hurt me." Which responses by the nursing student cause the nurse intervene? (Select all that apply.) 1. "Don't worry. We've never killed anyone." 2. "What specifically are you worried about?" 3. "We often look pretty scary." 4. "That sounds frightening." 5. "The nurse will assist you with your bath instead."

1) CORRECT - Telling the client not to worry and that students have not killed anyone supports the client's belief. It also provides false reassurance, which is not a therapeutic response. 2) INCORRECT- Asking the client explain specific worries clarifies the client statement, which is an appropriate statement to make. 3) CORRECT - Stating that students look scary supports the client's belief and is not a therapeutic response. 4) INCORRECT- Saying that the client's statement sounds frightening reflects the client's feelings. 5) CORRECT - Saying that the nurse will help the client with the bath instead of the nursing student minimizes the client's concern. However, the tasks were delegated to the nursing student. This response supports the client's fears and beliefs. *Think Like a Nurse: Clinical Decision-Making* The client has a belief that nursing students are not qualified or safe to provide care. The student needs to dispel the client's misperceptions of care provided by student nurses. The best approaches for the student to take include asking the client to explain specific issues that are causing fear or concern and reflecting the client's feelings. *Content Refresher* Therapeutic communication includes the following skills: 1) being silent, 2) showing acceptance, 3) providing recognition, 4) offering self, 5) using broad openings, 6) providing leads and encouragement, 7) timing events, 8) focusing, 9) asking about thoughts/feelings, 10) encouraging comparisons, 11) restating and reframing, 12) reflecting, 13) presenting reality, 14) sharing observations, 15) clarifying meaning, 16) expressing doubt, 17) interpreting feelings, and 18) formulating a plan for care. Non-therapeutic communication techniques include reassuring, rejecting, approving/disapproving, agreeing/disagreeing, giving advice, belittling, stereotyping, probing, or using denial.

The nurse provides care for clients on the medical and surgical unit. Which situation requires immediate intervention by the nurse? 1. A client who had a liver biopsy is resting quietly on his back after the procedure. 2. A visitor is sitting without a mask just inside the doorway of a client on droplet precautions. 3. A client who had a cholecystectomy 2 days ago is draining purulent fluid through the T-tube. 4. A client scheduled for a cardiac catheterization is expressing anxiety and reservations about undergoing the procedure.

1) CORRECT - The client should be lying on his right side for several hours after the procedure in order to promote hemostasis and thereby prevent hemorrhage and bile leakage. 2) INCORRECT - The doorway is likely to be 3 feet away from the client, and that is the safe distance for not wearing a mask. 3) INCORRECT - The client has an infection that may have been present prior to surgery and is being drained or it may be currently infected. This client is not the priority, though. 4) INCORRECT - Assessment of the client's concerns is essential, with possible patient teaching. If the client has signed a consent and decides to rescind it, the client can do so and the HCP should be notified. *Think Like A Nurse: Clinical Decision Making* A liver biopsy is a relatively safe procedure. Serious complications, such as bleeding, infection, and injury to nearby organs, are very rare. Although complications are rare, the nurse must ensure the client maintains a position that decreases the risk of complications; therefore, the nurse has the client lie on the right side to prevent hemorrhage and bile leakage. Other interventions appropriate for this client include monitoring vital signs frequently and initiating care that promotes comfort. *Content Refresher* A liver biopsy may be performed to diagnose liver cancer. Monitor for bleeding post liver biopsy. Liver cancer assessment includes assessing client for weight loss, nausea, vomiting, general weakness, fever, hepatosplenomegaly, ascites, jaundice, decrease in appetite, feeling of fullness, fatigue, pain, and abdominal swelling. Assess respiratory status and monitor abdominal girth. Restrict sodium and fluids, as prescribed. Serve small, frequent meals with foods that are attractive and palatable. Encourage deep breathing exercises. Provide supplemental oxygen, as indicated.

The nurse provides care for a newborn diagnosed with a myelomeningocele. Which actions will the nurse identify as most important when providing care to this client? 1. Monitor for elevated temperature, irritability, and lethargy. 2. Perform range-of-motion exercises to feet, ankles, and knee joints. 3. Apply lotion to healthy skin and gently massage skin. 4. Measure occipito-frontal circumference daily.

1) CORRECT - The newborn is at risk to develop an infection called meningitis because of the myelomeningocele sac. Change the dressing every 2 to 4 hours using aseptic technique. Monitor the temperature and the infant for signs of increased irritability and lethargy. 2) INCORRECT - Range-of-motion exercises prevent contractures, but need to be done to all joints. The risk for infection takes priority. 3) INCORRECT - Lotion and a gentle massage does prevent skin irritation. Keep the perineal area clean and dry. Place the newborn on a pressure-reducing surface. These actions are necessary, but risk for infection takes priority. 4) INCORRECT - The newborn is at risk for impaired circulation of cerebrospinal fluid, and measuring the head is necessary. The risk for infection takes priority. *Think Like A Nurse: Clinical Decision Making* Prior to implementing any action for this client, the nurse asks, "What is the greatest risk to a client with a myelomeningocele?" Using knowledge of anatomy and pathophysiology, the nurse will recall that a myelomeningocele occurs during the development of the neurologic system in utero. Upon birth, the area of the myelomeningocele requires special care to prevent the development of an infection. In a newborn, symptoms of an infection may include an elevated temperature, the inability to be consoled, and slow responses to stimulation. *Content Refresher* Myelomeningocele, or spinal bifida, is a malformation of the neural tube in which a pouch protrudes through the vertebrae. The pouch contains a section of the spinal cord along with cerebrospinal fluid (CSF). This malformation can occur anywhere along the spinal column, but is commonly seen at the lumbar or sacral regions of the spine. Clinical manifestations depend on the location of the malformation and range from paralysis to weakness of legs and/or trunk along with bowel, bladder, and cognitive dysfunction. In addition, neonates may have trouble feeding due to impaired swallowing and/or respiratory difficulties. Surgical intervention is needed 24 to 48 hours after birth to repair this malformation. After delivery, cover the pouch on the newborn's back with sterile dressing and place the neonate on the stomach to protect the pouch.

A severe storm has blown out the windows on a 30-bed medical/surgical unit. The nurse determines that clients have to be evacuated to other rooms throughout the hospital. Which client does the nurse transfer first? 1. An adult client admitted with exacerbation of asthma who is receiving nebulizer treatments. 2. An adult client with type 1 diabetes mellitus and a recent blood glucose of 124 mg/dL (6.88 mmol/L). 3. An adult client transferred from cardiac intensive care earlier in the day post-myocardial infarction. 4. An adult client with a peptic ulcer who is receiving a blood transfusion.

1) CORRECT - This client is unstable and is currently experiencing breathing concerns. The client is at risk of ineffective airway clearance due to particles in the air from storm debris and damage to the windows. 2) INCORRECT - The client's blood sugar is slightly elevated above normal limits. This client is stable and does not require immediate transfer. 3) INCORRECT - The client has a potential circulation concern. However, there is no indication that the client is currently unstable. There is another client who is a higher priority. 4) INCORRECT - This is the second most unstable client, as the client is experiencing a current circulatory concern and requires frequent monitoring due to the blood transfusion. However, the client with a current breathing concern will take higher priority. *Think Like a Nurse: Clinical Decision-Making* Before evacuating the clients, the nurse should think, "Which client requires care that cannot be delayed?" Actual client problems take priority of potential problems. A client with an acute exacerbation of asthma presents with an actual problem that requires a nebulizer treatment. A delay in this client's treatment could cause harm. A client receiving a blood transfusion requires close monitoring for potential complications of the transfusion, but does not require immediate intervention. A blood glucose level of 124 mg/dL (6.88 mmol/L) in a client with type 1 diabetes requires glucose monitoring, but no immediate intervention. A client transferred to the medical-surgical unit 1 day ago remains in stable condition and requires no immediate attention. *Content Refresher* The nurse, when acting as case manager, must use various sources of information such as interdisciplinary observations and discipline specific plans of care and documentation to identify client and family needs. These issues and concerns address the immediate needs based on the current health status of the client and anticipated needs based on the client 's anticipated optimal level of function. Case management is critical during disaster planning.

A client returns to the care area after a myelogram. Which intervention does the nurse include in this client's care plan? 1. Encourage oral fluid intake. 2. Maintain the prone position for 12 hours. 3. Encourage to ambulate after the procedure. 4. Evaluate distal pulses on the affected side.

1) CORRECT- After a myelogram, fluids should be encouraged to facilitate dye excretion, to replace cerebrospinal fluid, and to prevent the development of a spinal headache. 2) INCORRECT - The prone position is not appropriate for the client recovering from a myelogram. The client is on bed rest for several hours after the procedure to prevent the development of a spinal headache. 3) INCORRECT - After a myelogram, bed rest is maintained for several hours afterward to prevent the development of a spinal headache. 4) INCORRECT - An extremity is not used when having a myelogram. The dye is injected into the spinal canal. *Think Like A Nurse: Clinical Decision Making* A myelogram is used to assess the spinal cord, the canal, and associated structures. A lumbar puncture is performed and dye is injected into the spinal canal to assess cerebrospinal fluid flow. After the procedure, the client should increase the intake of oral fluids to facilitate the removal of the dye from the body and replace cerebrospinal fluid that was lost during the procedure. Bedrest in the supine, and not the prone, position is prescribed after the procedure to help reduce the development of a spinal headache. *Content Refresher* A myelogram is a diagnostic procedure in which a contrast medium is injected into the subarachnoid space of the vertebrae and X-rays or computed tomography (CT) is used to visualize the spinal canal and surrounding structures. Prepare the client for the procedure, providing client/family with information about what to expect. Instruct the client to increase fluids until 4 hours before test, then to take nothing by mouth. Increase fluids and maintain bedrest for 2 to 4 hours post-procedure. Provide the client/family with teaching about the avoidance of strenuous activity posttest and signs/symptoms to report.

The nurse assesses a client who is diagnosed with hypoparathyroidism. Which data, if found in the client's medical history, are associated with the diagnosis of hypoparathyroidism? (Select all that apply.) 1. Carpal spasms. 2. History of convulsions. 3. Renal calculi. 4. Pathologic fractures. 5. Muscle irritability.

1) CORRECT- Carpal spasms are associated with hypoparathyroidism. A positive Trousseau sign, a positive Chvostek sign, muscle irritability, and tetany occur as a result of hypocalcemia. 2) CORRECT- Convulsions may occur in the client diagnosed with hypoparathyroidism because of neuromuscular irritability secondary to hypocalcemia. 3) INCORRECT - Hyperparathyroidism, not hypoparathyroidism, is associated with the formation of renal calculi, which occur as a result of the increased urinary excretion of calcium and phosphorus. 4) INCORRECT - Bone demineralization leading to pathologic fractures is associated with hyperparathyroidism, not hypoparathyroidism. 5) CORRECT- Muscle irritability (including cramps and spasms) is seen with hypoparathyroidism. *Think Like a Nurse: Clinical Decision-Making* The parathormone (PTH) regulates serum calcium. Normally, in the bone, PTH stimulates bone resorption and inhibits bone formation, resulting in release of calcium and phosphate into the blood. When there is not enough PTH, hypocalcemia results. The client might report tingling of the lips and fingertips and increased muscle tension and stiffness. In extreme cases, laryngospasms may be observed. The nurse needs to monitor the client for airway obstruction. When giving IV calcium replacement, the nurse should infuse the medication slowly because rapid infusion may cause serious hypotension and cardiac arrest. Ideally, the client should be attached to a bedside cardiac monitor. *Content Refresher* Hypoparathyroidism is associated with inadequate circulating parathyroid hormone (PTH). Consequently, hypocalcemia occurs due to a lack of PTH that is needed to maintain serum calcium levels. The most common cause of hypoparathyroidism is iatrogenic and may occur during neck surgery (e.g. thyroidectomy). The clinical features of hypoparathyroidism are due to hypocalcemia. Additional features of hypoparathyroidism include lip tingling, extremity stiffness, lethargy, anxiety, and personality changes. Dysphagia, laryngospasms, and compromised breathing may occur due to tonic spasms of smooth and skeletal muscles.

The nurse provides care for a client at risk for coronary artery disease (CAD). The nurse identifies that which risk factors can be modified to help prevent CAD? (Select all that apply.) 1. Hypertension. 2. Obesity. 3. Gender. 4. Family history. 5. Diabetes mellitus.

1) CORRECT- Hypertension is a modifiable risk factor for CAD. 2) CORRECT - Obesity is a modifiable risk factor for CAD. 3) INCORRECT - Gender is a nonmodifiable risk factor for CAD. 4) INCORRECT - Family history is a nonmodifiable risk factor for CAD. 5) CORRECT - Diabetes mellitus is a modifiable risk factor for CAD. *Think Like a Nurse: Clinical Decision-Making* The nurse is aware that lifestyle changes are essential to prevent, halt, or reverse coronary artery disease. Smoking and extended sitting should be avoided. Heart-healthy eating includes consuming more fish than red meat, increasing fresh vegetables, and avoiding canned foods and frozen dinners, which often contain an entire day 's allowance of sodium. Weight management is a critical factor. Extra body fat, especially around the abdominal area, increases the risk of heart disease. Regular physical exercise is a great way to promote cardiovascular health and decrease stress. Chronic, vessel-damaging conditions like diabetes mellitus, high cholesterol, and hypertension must be controlled. *Content Refresher* Coronary artery disease (CAD) is characterized by the buildup of atherosclerotic plaque inside the coronary arteries, which are the vessels that supply blood to the heart muscle (myocardium). Assess for factors that contribute to development of CAD, including dyslipidemia (abnormal fat levels in the blood), smoking, diabetes mellitus, sedentary lifestyle, obesity, metabolic syndrome, increased serum homocysteine level (elevated mostly due to meat consumption), and family history of CAD. Assess dietary intake of sodium, as well as saturated fat and trans fat consumption.

A client receiving an IV fluid infusion of dextrose 5% and 0.45% normal saline at 125 mL/hr develops restlessness; rapid, shallow respirations; crackles in both lung fields; and distended neck veins. Which action is appropriate for the nurse to implement? 1. Contact the health care provider. 2. Clamp the intravenous catheter. 3. Administer diphenhydramine, as prescribed. 4. Place in the Trendelenburg position.

1) CORRECT- The client exhibits signs of fluid overload (rapid, shallow respirations; distended neck veins; crackles on auscultation; and restlessness). The nurse should immediately contact the health care provider to prevent a delay in treatment. 2) INCORRECT - The IV catheter should be clamped immediately for a suspected air embolism. This client exhibits signs of fluid overload, and not an air embolism. 3) INCORRECT - Diphenhydramine is indicated for treatment of allergic reactions. This client exhibits signs of fluid overload, and not an allergic reaction. 4) INCORRECT - The client exhibits signs of fluid overload. The client should be placed in a high-Fowler position to ease respiration, and not the Trendelenburg position. Placing on the left side in Trendelenburg is indicated for an air embolism. *Think Like A Nurse: Clinical Decision Making* The nurse is aware that IV infusion of supplemental fluids are prescribed to support normal physiologic functioning. At times and with a disease process, the extra fluid is not being appropriately utilized by the body. Extra IV fluid gravitates to areas such as the lungs and peripheral tissues. The nurse know symptoms of extra fluid in these areas include shortness of breath, new onset of a productive cough, altered lung sounds, full and bounding pulses, and peripheral edema. These symptoms indicate fluid overload, which should be immediately reported to the health care provider for evaluation and treatment. *Content Refresher* When caring for a client at risk for fluid volume overload, assess the client's intake and output, lab values for hemoglobin, hematocrit, electrolyte levels, urine specific gravity, vital signs, lung sounds, and changes in the client's weight. Fluid volume overload is a potential complication of IV fluid infusion; signs include weight gain, increased abdominal girth, neck vein distention, elevated blood pressure, rapid respirations, and edema. Symptoms include confusion, weakness, fatigue, and difficulty breathing. The nurse should alert the health care provider immediately as untreated fluid overload can result in heart failure.

A client develops post-concussion syndrome caused by a head injury sustained from a fall. For which client statements will the nurse intervene? (Select all that apply.) 1. "The concussion showed up on the head computed tomography scan." 2. "I may have a persistent headache for 2 weeks or longer." 3. "I should notify the health care provider if I have repeated episodes of vomiting." 4. "I can immediately resume contact sports at school." 5. "I may have trouble remembering details from one day to the next." 6. "I have no recollection of the events surrounding the incident."

1) CORRECT— A concussion does not appear on a head computed tomography scan. Concussion is a clinical diagnosis based upon symptoms. 2) INCORRECT - The client recovering from a concussion may have a persistent headache that lasts for 2 weeks or longer. 3) INCORRECT - Repeated and continuous bouts of vomiting after a concussion may indicate that the condition is worsening or intracranial pressure is increasing, and should be reported to the health care provider. 4) CORRECT— After a head injury, the client should refrain from contact sports due to the risk of reinjury and worsening of the condition until it has cleared. 5) INCORRECT - Inability to remember daily details is a common finding in post-concussion syndrome. 6) INCORRECT - Amnesia about the event that caused the head injury is a common finding in post-concussion syndrome. *Think Like a Nurse: Clinical Decision-Making* Before responding to the client, the nurse needs to stop and recall the mechanism of action that causes a concussion. A concussion is a common brain injury that is diagnosed according to the client's symptoms; a test that definitively diagnoses a concussion is not available. The development of a concussion occurs after the head has been injured through an accident or sports activity. The contents of the head is jostled around the cranium, temporarily affecting brain tissue functioning. The client recovering from this type of injury must abstain from engaging in the activity that caused the head injury until full healing occurs. *Content Refresher* A concussion results from a blow to the head or movement of the brain within the skull that jars the brain, resulting in a temporary loss of neurologic function. Concussions may result from playing contact sports, being involved in an auto accident, or falling. The symptoms of a concussion are usually self-limiting. Mild analgesics may be given for a headache. Repetitive concussions can lead to chronic traumatic encephalopathy, a form of neurodegeneration. A concussion that results in increased intracranial pressure can lead to permanent brain damage, brain herniation, and death.

The nurse is preparing the client for a C3 to C4 laminectomy. Which client statement indicates to the nurse the client requires further instruction? (Select all that apply.) 1. "My pain will be completely gone when I wake up. " 2. "I should not twist my back right after surgery. " 3. "I will probably be incontinent after the surgery. " 4. "I do not smoke so there will not be complications. " 5. "It does not matter if I take herbal supplements. "

1) CORRECT— Postoperative pain is common. This client requires further instruction regarding this common phenomenon. 2) INCORRECT— Correct body alignment (neutral positions of extension) may protect from further damage at surgical site. 3) CORRECT— Bowel or bladder incontinence would be an unexpected complication that might indicate spinal cord injury. This statement indicates the need for further instruction. 4) CORRECT— The client may still have complications, although the risks for many complications are reduced. This statement indicates the need for further instruction. 5) CORRECT— The use of herbal supplements should be shared with the health care team as some herbs interfere with other treatments and medications. This statement indicates the need for further instruction. *Think Like a Nurse: Clinical Decision-Making* Although the client may be experiencing severe nerve pain generating from the C3-C4 site, the surgery, in time, will eliminate or decrease that pain. However, post-operative pain will still occur. The spine will need to be kept in proper anatomical alignment after a laminectomy until healing is complete. *Content Refresher* Also known as a ruptured or slipped disk, a herniated disk occurs when the nucleus pulposus (inner part of disk) protrudes or ruptures through the annulus fibrosus (outer ring of disk). Herniated disks are treated either medically or through surgical interventions. The following surgical procedures may be performed: laminectomy, discectomy (microdiscectomy), spinal fusion, foraminotomy, and intradiscal electrothermal therapy. Since the herniated disk likely occurred due to injury, the client will need to learn proper body mechanics, such as proper lifting techniques, to prevent re-injury.

The nurse provides care for a client prescribed negative-pressure wound therapy for a wound on the left lower extremity. Which is the most important action for the nurse to take prior to initiation of the therapy? 1. Check serum protein levels. 2. Check serum calcium level. 3. Assess capillary refill of the upper extremities. 4. Check white blood cell count.

1) CORRECT— Protein is essential for wound healing. If the client's protein level is low, wound healing will be impaired and the negative-pressure wound therapy may not be helpful. 2) INCORRECT - This is not a priority assessment. Because calcium is protein-bound, calcium may be low in the context of low protein. But assessing the actual protein level will provide a better indicator of the client's nutritional status relevant to wound healing. 3) INCORRECT - While blood perfusion to the lower extremities is relevant to wound healing for this client, the perfusion to the upper extremities is not helpful for the nurse to determine the client's ability to benefit from the therapy. 4) INCORRECT - While a white blood cell count may signal infection, it is not specific to the wound and does not affect the nurse's decision-making around the client's ability to benefit from the therapy. *Think Like A Nurse: Clinical Decision Making* Wound healing is largely dependent on the body's internal environment. The client needs adequate dietary protein or a nutrient-rich infusion to promote healing. If the client is anemic, this condition must be corrected. An adequate red blood cell (RBC) count is needed to ensure sufficient oxygen delivery to the traumatized tissue. If the client demonstrates impaired systemic oxygenation, then supplemental oxygen should be administered as prescribed. Nursing assessment includes identifying potential barriers to wound healing, including inadequate client hygiene, and educating the client about infection control. *Content Refresher* Wound healing involves preventing infection, promoting blood flow, and increasing nutritional stores to promote tissue growth. Dressings are applied to protect the wound, manage drainage, and maintain adequate moisture in the wound bed. Goals include maintenance of pink, moist tissue in the wound bed, which is reflective of granulation tissue, without evidence of necrosis, tunneling, or undermining. Risk factors that delay wound healing include advanced age, arterial or venous insufficiency, obesity, anemia, neuropathy, infection, diabetes, smoking, malnutrition, and medications (such as corticosteroids). Monitor the serum protein and albumin levels. Educate the client about maintaining adequate intake of protein, vitamin C, and zinc to promote tissue healing.

The nurse provides care for four clients who require teaching about their medical conditions. The nurse assesses that which client is the most ready to learn? 1. A client who woke up from a nap recently, just ate a snack, and is sitting up in bed. 2. A client who was just informed of a cancer diagnosis by the health care provider. 3. A client recovering from a stroke who has returned from physical therapy. 4. A client who received pain medication 5 minutes ago for relief of discomfort.

1) CORRECT— This client should be rested and less distracted and is most likely not tired or hungry. 2) INCORRECT - This client will be preoccupied by the new cancer diagnosis. 3) INCORRECT - This client is most likely tired after therapy and will display cognitive deficits not conducive to learning. 4) INCORRECT - This client's pain is most likely not yet relieved so discomfort may be a distractor. *Think Like A Nurse: Clinical Decision Making* Before providing education to a client, the nurse must assess the client's state of readiness for the teaching/learning process. The assessment will need to involve the client's physical and psychosocial status. The nurse should recognize situations that interfere with remembering instructional material, which includes anxiety, pain, and fatigue. When deciding which client should be the first to have a teaching session, the nurse should mentally ask, "Which client is the best prepared to receive information?" Of the clients needing teaching in this scenario, the one who is most likely to be receptive is the client who is rested, had something to eat, and appears alert. *Content Refresher* When preparing to educate a client, the nurse should assess readiness to learn. A client who is anxious, fatigued, or in pain may not be ready for a teaching/learning session. Ensure a comfortable environment with adequate lighting. Prepare for the teaching activity. Question learners regarding their expectations. Allow time for discussion and questions. Stop for a break when the learner indicates that one is needed. Determine which factors help or hinder the learning process. Evaluate the effectiveness of the teaching/learning session.

The nurse instructs a client diagnosed with diverticulosis. Which client statement indicates that further teaching is needed? 1. "I will eat fruits and vegetables with every meal. " 2. "I will select meats that are low in fat. " 3. "I will start weight lifting for strength. " 4. "I will work on losing some weight. "

1) INCORRECT - Adding fiber to the diet will increase bulk in the stool, which is helpful for clients with diverticulosis. However, the client should avoid fiber if diverticulitis develops. 2) INCORRECT - It is helpful for clients to get no more than 30% of their daily calories from fat. 3) CORRECT— Clients with diverticulosis should avoid weight lifting or excessive bending due to the stress placed on the abdomen. 4) INCORRECT - Losing weight will benefit a client by placing less pressure on the abdominal area. *Think Like A Nurse: Clinical Decision Making* When evaluating the effectiveness of client teaching, the nurse listens carefully to each client statement in order to identify risks for harm and validate understanding. A client with diverticulosis is at risk for rupturing a diverticuli if undo stress or strain is placed on the abdominal region. The client should be counseled to avoid lifting weights, but can engage in other physical activity that places less stress on the abdominal region. *Content Refresher* When providing health education, the nurse should: Determine the learner's knowledge level and previous experiences. Create a positive learning environment. Minimize distractions and use clear, brief instructions. Clearly communicate the objectives and expectations. Demonstrate ideal performance of a skill. Emphasize the information or skill in a context relevant to the learner. Allow for repeat performance of skills with sufficient amount of time, type, and variability for learners to become proficient. Teaching about diverticulosis should include information about physical activities and diet habits to reduce exacerbation of disease.

The nursing assistive personnel (NAP) reports that a client scheduled for surgery has a temperature of 102.5 °F (39.1 °C). Which action will the nurse take first? 1. Document the finding in the medical record. 2. Notify the health care provider immediately. 3. Administer acetaminophen per rectum, as prescribed. 4. Verify the temperature measurement.

1) INCORRECT - After verifying the client's temperature, the nurse should document the finding in the client's medical record. 2) INCORRECT - The nurse should notify the health care provider of the finding after validating the accuracy of the temperature. If the temperature remains unexpectedly elevated, surgery may be delayed. 3) INCORRECT - After verifying the temperature and reporting it to the health care provider, the nurse may administer acetaminophen per rectum, as prescribed. 4) CORRECT- The nurse should first verify the client's temperature to ensure accuracy before intervening. By doing so, the nurse prevents unnecessary intervention should the reported finding be in error. *Think Like A Nurse: Clinical Decision Making* The nurse recognizes that an elevated temperature in a client being prepared for surgery can be an issue. The client could have an infection, which would need to be managed before the surgery. Prior to contacting the health care provider about the elevated temperature and plans for the surgery, the nurse should validate the measurement. Should the measurement be valid, the surgery will most likely be postponed, and the client will undergo testing to determine the source of the infection and receive treatment. *Content Refresher* Temperature is the degree of internal heat or cold expressed on a scale, either Fahrenheit or Celsius. Temperature is assessed as part of a diagnostic evaluation for infection. Activity level, environmental temperature, and time of day can affect readings. Temperature can affect other vital signs, so assessment of all vital signs should be done if temperature is abnormal. Obtaining vital signs to include temperature can be delegated to the nursing assistive personnel (NAP). When the delegated task has been completed, the nurse must follow through with post task assessment and outcome findings. Since the temperature is elevated, the nurse needs to assess if the client recently consumed a hot drink or smoked. The nurse needs to re-assess the client's temperature.

The client is admitted to the emergency department after a motor vehicle accident. The client does not recall the accident, is oriented to person, but does not know what city the hospital is in and is confused regarding the day. Pupils are equal in size and reactive to light. The client reports a severe headache and is restless. Which action does the nurse take first? 1. Continue to orient the client to the situation. 2. Apply soft wrist restraints or a vest restraint. 3. Perform a bedside neurological assessment. 4. Administer pain medications as prescribed.

1) INCORRECT - Assess the client before implementing interventions. The overall neurological status takes precedence over orienting the client. 2) INCORRECT - The nurse must use the least restrictive method to keep the client safe. Restraints are avoided whenever possible, particularly in the client with possible increased intracranial pressure (ICP). 3) CORRECT— Neurological checks are done initially and every 15 minutes thereafter for this symptomatic client. The client may be developing increased ICP. Confusion, restlessness, pupillary changes, and altered level of consciousness are the earliest signs of increased ICP. 4) INCORRECT - Pain medication may be administered if prescribed, after assessment. The nurse avoids narcotic administration when possible because it may mask signs of altered ICP. *Think Like A Nurse: Clinical Decision Making* Restlessness is often an indicator of a serious pathophysiological issue. Restlessness is easily dismissed or overlooked, but is associated with many urgent conditions such as shock, infection, pain, hypoxia, dehydration, hypotension, hemorrhage, opioid withdrawal, anaphylaxis, pulmonary embolism, tachydysrhythmias, anastomic leak after bariatric surgery, aneurysm, hyperthyroidism, or increased ICP. The client exhibiting restlessness always needs a complete nursing assessment and prompt intervention when abnormalities are noted. *Content Refresher* Increased intracranial pressure (ICP) occurs when there is an increase in cerebrospinal fluid (CSF) pressure or an increase in the pressure within the brain itself. Implement neurological checks. Keep HOB elevated 30 degrees. Maintain neutral, midline positioning of the client's head and neck. Ensure airway patency and continuously monitor for changes in level of consciousness. Initiate seizure precautions if necessary. Prescribed medications may include osmotic diuretics, anticonvulsants, antiemetics, and medications to decrease gastric irritation, such as a histamine receptor antagonist or a proton pump inhibitor (PPI). Monitor vital signs closely for Cushing triad . Teach the client to avoid activities that increase ICP (normal ICP: 5-15 mm Hg), such as bearing down during a bowel movement.

The unlicensed assistive personnel (UAP) calls the nurse and states, "The client in room 218 is reporting shortness of breath." Which response by the nurse is appropriate? 1. "Call the respiratory therapist and request an arterial blood gas be performed." 2. "Ask the client when the shortness of breath started." 3. "Ensure the nasal cannula is in the client's nares." 4. "Listen to the client's lung sounds and notify me if you hear wheezing or crackles."

1) INCORRECT - Assessment is needed by the nurse before requesting an arterial blood gas. 2) INCORRECT - While it is important to establish when the shortness of breath began, this is not the nurse's priority statement. The nurse needs to deal with the "here and now" and address the client's symptom. 3) CORRECT— Ensuring the nasal cannula is in the client's nares can immediately improve oxygenation. The skill of applying (not setting or adjusting oxygen flow) and adjusting a nasal cannula can be delegated to the UAP. 4) INCORRECT - The nurse cannot delegate nursing assessment or any part of the nursing process to the UAP. *Think Like A Nurse: Clinical Decision Making* The nurse is aware the unlicensed assistive personnel (UAP) are able to complete routine tasks for stable clients within the identified scope of practice. Assisting with the application of nasal cannula is within the scope of practice for this level of care provider. The nurse always need to understand In delegation, the nurse retains the accountability and responsibility for assessing and evaluating the effectiveness of treatment (the nursing process). In this scenario, the UAP is performing correctly by informing the nurse of a client issue or a change in the client's status. Shortness of breath is noted without the process of assessment. *Content Refresher* The nurse cannot delegate any task that requires a nursing assessment. In deciding whether or not to delegate a nursing task, the nurse needs to assess the following factors: the client's present health status, safety of the situation, and the intended client outcome. In addition, the the nurse must assess the individual's knowledge, skill, training, and scope of practice before delegating a task. After delegating a task, the nurse needs to assess understanding of the particular instructions by the person receiving the delegation. In this scenario, the nurse knows the client requires oxygen delivery and may have displaced the nasal cannula.

The nurse reviews the medical records for clients arriving at the community clinic for care. Which client does the nurse identify as requiring immediate intervention? 1. A client whose fourth and fifth fingers are contracted onto the palm. 2. A client reporting numbness, tingling, and pain when the inside of the wrist is lightly tapped. 3. A client whose fingers hurt and turn from white to blue to red in cold weather. 4. A client in an arm cast with contracted fingers and wrist.

1) INCORRECT - Contraction of the fourth and fifth fingers is a characteristic of a Dupuytren contracture. This is a slow, progressive contracture of the palmar fascia and does not cause immediate concern. 2) INCORRECT - Numbness, tingling, and pain when the inside of the wrist is lightly tapped is considered a positive response to the Tinel sign and indicates carpal tunnel syndrome. This response is not of immediate concern. 3) INCORRECT - Finger pain and turning in color from white to blue to red indicates Raynaud disease. The color change is a normal sequence and is accompanied by tingling, numbness, and burning pain. This is not of immediate concern. 4) CORRECT— Contracted fingers and wrist in the client with an arm cast describes a Volkmann contracture. This is a type of compartment syndrome caused by obstruction of arterial blood flow to the forearm and hand. The fingers cannot be straightened. There is severe pain and there may be signs of diminished circulation. This client is the priority. *Think Like A Nurse: Clinical Decision Making* The nurse is presented with a group of clients who are all experiencing musculoskeletal or neurological issues. When deciding which client to see first, the nurse considers the long-term consequences of delaying assessment and treatment. The nurse will utilize integrated processes, including the ABCs, Maslow, and the nursing process. The client who is in a cast demonstrating contraction of the fingers and wrist is experiencing a , which is Volkmann contracture. The condition can result in severe pain and is an emergency. *Content Refresher* Casts are either plaster or fiberglass that becomes rigid when applied and provides support to either upper or lower extremity fractures. With a cast, the goal is to maintain tissue perfusion to the affected extremity. However, a client with a cast is at risk for compartment syndrome. The nurse needs to monitor a casted extremity for signs and symptoms of compartment syndrome. Signs and symptoms include increased pain, decreased pulses in extremity, paresthesia, paralysis, and pale or discolored skin. If the client is experiencing symptoms of compartment syndrome, the nurse needs to contact the health care provider immediately.

A client diagnosed with a spinal cord injury is being treated for a neurogenic bladder. Which medication does the nurse expect to be prescribed as part of this client's bladder retraining program? 1. Diphenhydramine. 2. Diazepam. 3. Dicyclomine. 4. Bethanechol.

1) INCORRECT - Diphenhydramine is an antihistamine that promotes urinary retention. 2) INCORRECT - Diazepam is an anti-anxiety medication that may cause nausea, but it will not affect the urinary system. 3) INCORRECT - Dicyclomine is an anti-cholinergic medication that promotes urinary retention. 4) CORRECT - Bethanechol is a cholinergic or parasympathomimetic medication used to treat functional urinary retention. It mimics the action of acetylcholine. *Think Like A Nurse: Clinical Decision Making* The pathway between the bladder, spinal cord, and cerebral cortex must be intact for bladder sensation and urethral sphincter action to be intact. A neurogenic bladder, which lacks this pathway, can be the result of multiple sclerosis, Parkinson disease, stroke, or spinal cord injury. Incorrectly managed neurogenic bladder can lead to autonomic dysreflexia or urinary tract infections secondary to hydronephrosis. The nurse anticipates that a medication such as bethanechol will be prescribed because it is a cholinergic or parasympathomimetic medication used to treat functional urinary retention. *Content Refresher* Neurogenic bladder, a disorder of the bladder caused by disruption of nervous system innervation, may lead to urinary retention, infection, and overflow incontinence. Neurogenic bladder usually requires continuous or intermittent self-catheterization, so it is important to teach the client and family how to perform the necessary procedure. Monitoring fluid intake and consuming a low-calcium diet to prevent the development of urinary/kidney stones should be included in the teaching plan. Bladder retraining and scheduled toileting should also be taught for clients with urinary retention. Medications may decrease retention and assist urine flow. Surgical procedures, such as urinary diversion, may also be considered.

The nurse notes that an adolescent client without any previous health problems is prescribed intravenous and oral fluids to treat meningitis. For which serious complication does the nurse monitor this client? 1. Heart failure. 2. Hypovolemic shock. 3. Cerebral edema. 4. Pulmonary edema.

1) INCORRECT - Heart failure is unlikely to occur in a healthy adolescent. 2) INCORRECT - Hypovolemia occurs as the result of fluid deficit, not fluid overload. 3) CORRECT - Since the client has inflammation of the meninges, the client is vulnerable to developing cerebral edema and increased intracranial pressure. 4) INCORRECT - Pulmonary edema is unlikely in a healthy adolescent. *Think Like A Nurse: Clinical Decision Making* The nurse should recall the pathophysiologic and infectious disease processes of meningitis. In this illness, the meninges are irritated with either a bacteria or virus. This irritation causes nuchal rigidity and photophobia as two major symptoms of the disorder. It is essential to keep in mind the location of the infection and the impact interventions will have on the client's status. The nurse should be aware of actions that contribute to increased intracranial pressure (IICP). One major cause of IICP is fluid overload. Since the client is prescribed both oral and intravenous fluids, the risk for IICP is high. The client needs close monitoring. *Content Refresher* Meningitis is the inflammation of the meninges, which are protective coverings of the brain and spinal cord in response to an infectious organism (bacterial, viral, or fungal). An inflammatory response is initiated with an increase in production of cerebrospinal fluid, which causes an increase in the intracranial pressure. Signs and symptoms of meningitis include fever, headache, a change in mental status, sensitivity to light, nausea and vomiting, a stiff neck, and opisthotonos . Treatment includes antibiotic therapy along with medications to manage the head and neck pain and to reduce fever. If the etiology is determined to be viral in nature, the antibiotic medications will be cancelled. Continuous assessment for seizure activity and for signs of increased intracranial pressure are essential components of treatment plan.

The nurse provides care to a client who requires wound care. When collecting a wound drainage specimen for culture, the nurse implements which step? 1. Administer a single dose of antibiotic medication 30 minutes before obtaining the specimen. 2. Remove the crusts or scabs with sterile forceps and then culture the site beneath. 3. Swab the area in which the largest collection of drainage is present. 4. Irrigate the wound with sterile water prior to obtaining the specimen.

1) INCORRECT - Ideally, antibiotic medication should not be administered until after the specimen has been collected, as antimicrobial medications may interfere with bacterial growth and cause challenges when identifying organisms. 2) INCORRECT - An appropriate specimen can be obtained without causing the client the discomfort of debriding (removing crusts and scabs with sterile forceps). The nurse does not generally debride a wound to obtain a specimen. 3) INCORRECT - Wound culture specimens should be obtained from a cleaned area of the wound. 4) CORRECT- Irrigating the wound with sterile water or normal saline prior to collecting a drainage specimen is appropriate. Microbes responsible for the infection are more likely to be found in viable tissue. Collected drainage contains old and mixed organisms. *Think Like A Nurse: Clinical Decision Making* Prior to collecting a specimen from an infected wound, the nurse needs to think about the physiology of the wound and the circumstances causing the infection. Signs of an infected wound include warmth, redness, and exudate. One might think that the exudate is what should be analyzed; however, this is incorrect. The exudate has microorganisms from the wound and the environment and would not provide an adequate analysis of the organism causing the infection. To ensure that the wound is properly cultured, the exudate should be flushed from the wound prior to taking a swab of the wound bed. *Content Refresher* Wound care includes assessment and cleaning of a wound using sterile or clean technique with application of a dressing. Assessment of the wound is critical to evaluate drainage and healing. Cleaning may include irrigation and/or mechanical debridement. Dressings keep the wound bed moist, help to absorb exudates, decrease bacterial count, and support wound healing. Consult a wound nurse, if needed. Don gloves to remove old dressings. Perform wound irrigation and obtain wound cultures as prescribed by the health care provider. Apply new dressings using sterile or clean technique. Document the wound appearance including size, location, amount of exudate, condition of skin surrounding the wound, and client tolerance of the dressing change.

The nurse provides care for a client with a head injury who is placed on a volume-cycled ventilator. Which action by the nurse best indicates an understanding of proper management of a client on a mechanical ventilator? 1. Water is added to the tubing to provide for humidification of inspired air. 2. The sigh setting on the ventilator is adjusted to occur every hour. 3. Ventilator settings are adjusted according to the client 's serum electrolytes. 4. A high concentration of oxygen is delivered to prevent tissue ischemia and necrosis.

1) INCORRECT - No water should be in the tubing. The tubing is assessed for the presence of water, which is removed. A humidifier of the oxygen is used. 2) CORRECT— The setting on the ventilator should be set for 1.5 times the tidal volume and adjustment should occur every 1 to 3 hours. 3) INCORRECT - The settings on the ventilator are based on findings of arterial blood gas results and are changed by the prescription of the health care provider. 4) INCORRECT - The ventilator is adjusted to deliver the lowest concentration of oxygen to maintain normal arterial blood gasses for a client. *Think Like A Nurse: Clinical Decision Making* The typical person will involuntarily sigh during periods of relief or anxiety, after digesting a heavy meal, or during exercise. This action fully expands the lungs. The typical tidal volume delivered during mechanical ventilation will leave areas of microatelectasis in the lungs (i.e., tiny areas of the alveoli that remain collapsed and trap mucous for bacterial growth). A sigh is delivered occasionally to the intubated client. The sigh volume is greater volume than the preset tidal volume. This allows the normal tidal volume setting to be low enough to avoid trauma to the alveoli while also preventing atelectasis and pneumonia. *Content Refresher* Mechanical ventilation is the process by which the fraction of inspired oxygen (FiO2) (21% [room air] or more) is moved in and out of the lungs by a mechanical ventilator. While there are multiple different ventilatory modes, (1) assist-control (A/C) and (2) synchronized intermittent mandatory ventilation (SIMV) are the two commonly used upon initiation of mechanical ventilation. To reduce volutrauma, lower tidal volume targets are recommended (5 to 8 mL/kg/ideal body weight). To reduce barotrauma, clients with stiff lungs (e.g., acute respiratory distress syndrome [ARDS]) should not receive levels of positive end-expiration pressure (PEEP) greater than 5 cm H 2O. Additionally, clients with compliant lungs (e.g., chronic obstructive pulmonary disease [COPD]) are also at risk for barotrauma. Sighs on the ventilator aid in improving gas exchange.

The nurse prepares to complete an initial assessment for a client who has an indwelling urinary catheter. Which observation indicates to the nurse a need for intervention? 1. The client's urinary drainage bag contains amber-colored urine. 2. The client's urinary drainage tubing does not contain a dependent loop. 3. The client's urinary drainage system is positioned below the level of the bladder. 4. The client's urinary drainage bag is secured to the client's sheet.

1) INCORRECT - Normal findings include urine that ranges in color from pale yellow to dark amber. However, dark amber urine may be an indication of dehydration or liver disease. While this data requires further assessment, there is another finding that requires immediate intervention by the nurse. 2) INCORRECT - The urinary drainage tubing should not contain dependent loops, which prevent adequate urinary drainage, thus increasing the risk for catheter-associated urinary tract infections. 3) INCORRECT - The client's urinary drainage bag should be positioned below the level of the bladder to prevent backflow of urine into the bladder. 4) CORRECT- The client's urinary drainage bag should be properly secured to the client's thigh (not the bed linen) to prevent catheter movement, which increases the risk for catheter-associated urinary tract infections. *Think Like a Nurse: Clinical Decision-Making* An indwelling urinary catheter may be placed for a variety of reasons. Prior to inserting this device, the nurse should review the physiology of the urinary system and the purpose for the catheter. Because the device is inserted into the body, there is a high risk for urinary tract infection, so the nurse is careful to perform the procedure using sterile technique. Once inserted, the catheter should be secured to the client's leg to prevent accidental dislodging and injury. And to ensure that urine flows unobstructed, the collection device needs to be placed lower than the level of the bladder. Clients with an indwelling urinary catheter are always placed on input and output measurements. *Content Refresher* Urine output provides information about kidney function. The kidneys' ability to make and concentrate urine is a reflection of fluid overload/fluid deficit in the body. Urine can be obtained by voiding or catheterization. When obtaining urine through catheterization, the client is at an increased risk for a urinary tract infection (UTI). Because of this, the nurse needs to implement interventions to prevent UTIs. This includes routine assessment of urine color, amount, and consistency. Urine should be clear, and amber or yellow in color. The minimum amount of urine produced should be 30 mL/hr or 720 mL/day. If the urine becomes cloudy, dark, bloody, or foul-smelling, the nurse needs to alert the health care provider of a possible UTI.

When teaching a client diagnosed with chronic renal disease and heart failure about dietary management, the nurse recommends which action? 1. Increase intake of chicken and fish. 2. Drink 2 to 3 L of water each day. 3. Use salt substitutes rather than salt. 4. Increase intake of whole-grain pasta and breads.

1) INCORRECT - The body is unable to store excess proteins. Proteins break down into wastes like urea, which breaks down into nitrogen that cannot be excreted by the compromised kidneys. The client with chronic renal disease should maintain normal protein intake. 2) INCORRECT - One to two liters of fluid intake is recommended to maintain fluid balance and avoid retention of excess fluid that cannot be excreted by the compromised kidneys or managed by the compromised heart. Three liters is too much. 3) INCORRECT - Many salt substitutes are high in potassium, which may not be adequately excreted by the compromised kidneys. The client can use a variety of spices instead. 4) CORRECT - Increasing whole-grain carbohydrate intake helps the client to maintain energy requirements. *Think Like A Nurse: Clinical Decision Making* Chronic kidney disease comes with many dietary restrictions and has the potential to significantly decrease clients' quality of life or causes them to decide to eat whatever they desire, ignoring the new, stricter renal needs. The nurse makes general recommendations, such as increasing intake of whole-grain carbohydrates, but then offers specific examples for the client's use and understanding, such as whole-grain bread and pasta. *Content Refresher* Chronic kidney disease is an irreversible loss of kidney function with a decrease in glomerular filtration rate to 10 mL per minute, resulting in pH and electrolyte imbalances and waste product accumulation. Almost all body systems are affected by kidney disease. The client will exhibit multiple symptoms, including fluid overload, hypertension, malaise, electrolyte imbalance, uremia, metabolic acidosis, anemia, muscle cramping, confusion, an inability to focus, and bone disorders from lack of vitamin D. Dialysis and transplant are options clients must consider to maintain life.

The nurse provides care to a client with a cast on the left leg. Which exercise will the nurse recommend to this client? 1. Passive exercise of the affected limb. 2. Quadriceps setting of the affected limb. 3. Active range of motion exercises of the unaffected limb. 4. Passive exercise of the upper extremities.

1) INCORRECT - Passive range of motion exercises are performed by the nurse. They serve to maintain joint mobility. However, they cannot be done on an extremity with a cast. 2) CORRECT— Quadriceps setting is an isometric exercise. It is performed by contracting the muscle without moving the joint. This exercise maintains muscle strength while the limb is in a cast. 3) INCORRECT - Active range of motion exercises of the unaffected limbs are not the best suggestion. It is more important to maintain the muscle strength of the limb with the cast. 4) INCORRECT - If the client is going to ambulate with crutches, strengthening and not passive exercises are needed. *Think Like A Nurse: Clinical Decision Making* Quadriceps setting, also known as "quad sets," is an isometric exercise that helps promote muscle maintenance in a casted extremity. Desired outcomes associated with performance of quad sets include preventing disuse syndrome, which is characterized by muscle wasting, weakness, and disability. To perform quad sets, the client sits on a flat, level surface and extends the casted leg in front of the body. The client then contracts the thigh muscles while pressing the knee toward the surface beneath the leg. The client maintains the muscle contraction for a few seconds before relaxing. The exercise is repeated for approximately 10 sets. Ideally, quad sets should be performed hourly to maintain muscle mass while the limb is immobilized. *Content Refresher* Monitor the casted extremity for signs and symptoms of compartment syndrome, which include increased pain, decreased pulses in the affected extremity, paresthesia, paralysis, and pale or discolored skin. Monitor the client for signs and symptoms of fat embolism (commonly seen with long bone fractures), deep vein thrombosis, pneumonia and urinary tract infection, and skin breakdown. Administer prescribed prophylactic anticoagulant medication. Assess for pain and administer analgesics or non-steroidal anti-inflammatory drugs (NSAIDs) as prescribed. Prescribed interventions may include elevation of the affected extremity and application of cold packs.

The nurse determines which client is at highest risk of developing colorectal cancer? 1. An adult client who teaches high school and has a history of endometrial cancer. 2. An adult client who owns a restaurant and has a history of alcoholism. 3. An older adult client who is a cattle farmer diagnosed with Crohn disease. 4. An older adult client who is a bus driver and has a hiatal hernia and obesity.

1) INCORRECT - Stress is a general risk factor for cancer. A history of endometrial cancer also increases the risk of colorectal cancer. 2) INCORRECT - Stress is a general risk factor for cancer. Alcoholism is a risk factor that is specific to colorectal cancer. 3) CORRECT— Age is a general risk factor for cancer. A history of inflammatory bowel disease is a significant risk factor that is specific to colorectal cancer. This is enough information to place this client at higher risk. However, the nurse might also assess that the cattle farmer enjoys a high quantity of red meat, further increasing the risk of developing colorectal cancer. 4) INCORRECT - Age and obesity are general risk factors for all cancers. *Think Like A Nurse: Clinical Decision Making* Awareness of factors that increase the risk for developing health alterations allows the nurse to develop client-specific strategies aimed at health promotion and disease prevention. Because each client demonstrates risk factors for cancer, education about disease prevention is helpful for all the clients. Age is a non-modifiable risk factor. The clients who experience chronic stress may benefit from learning stress reduction techniques. The client with obesity may be taught general activity and diet alterations and referred to a dietitian. *Content Refresher* Cancer is the term used for a group of diseases that result from unregulated growth of malignant cells. The nurse should review the following information with the client: family history of cancer, modifiable risk factors, immunization profile for those cancers that respond to immune proliferation, and presence of 7 CAUTION warning symptoms of cancer (change in bowel or bladder habits, a sore that does not heal, unusual bleeding or discharge, thickening or lump in the breast or elsewhere, indigestion or difficulty in swallowing, obvious change in a wart or mole, nagging cough or hoarseness).

The nurse receives hand-off communication from the previous shift. Which client will the nurse see first? 1. Client with chronic renal failure reporting swollen fingers and ankle edema. 2. Client 1 day postoperative after abdominal surgery with dried blood on the abdominal dressing. 3. Client with type 1 diabetes mellitus who states, "I have this quivering feeling in my abdomen." 4. Client on high doses of antibiotics for a resistant infection reporting diarrhea.

1) INCORRECT - Swollen fingers and ankle edema indicates peripheral edema, which occurs in the client with chronic renal failure. Treatment includes fluid and sodium restrictions. 2) INCORRECT - Dried blood on a postoperative wound dressing is not life-threatening. This is a stable client. 3) CORRECT - A quivering feeling indicates hypoglycemia. Additional symptoms include tachycardia, cold and clammy skin, weakness, and pallor. The client's capillary blood glucose level should be assessed, and a carbohydrate source provided. 4) INCORRECT - Diarrhea commonly occurs with antibiotic therapy. The nurse should monitor fluid and electrolytes, and check for skin breakdown. *Think Like A Nurse: Clinical Decision Making* The client with diabetes experiencing a "quivering" feeling in the abdomen could be developing a hypoglycemic reaction. This client needs to have a capillary blood glucose level assessed and receive appropriate interventions. *Content Refresher* Type 1 diabetes mellitus (DM) is a condition that results from a deficiency of insulin. Complications include hypoglycemia and hyperglycemia, ketoacidosis, coronary heart disease, hypertension, stroke, peripheral vascular disease, nephropathy, retinopathy, and neuropathy.

The nurse teaches a group of nursing students about secondary health promotion. Which activity does the nurse include in the teaching? 1. Support group referral. 2. Cancer screening. 3. Influenza vaccine administration. 4. Falls prevention.

1) INCORRECT - Tertiary health promotion begins after diagnosis and treatment of an illness. An example includes referring a client to support group after breast cancer treatment. 2) CORRECT - Cancer screening, a form of secondary prevention, focuses on early detection and prompt treatment of the illness. 3) INCORRECT - Vaccine administration is an example of primary health promotion, which focuses on preventing disease or injury. 4) INCORRECT - Falls prevention is an example of primary health promotion, which focuses on preventing disease or injury. *Think Like A Nurse: Clinical Decision Making* Primary prevention reduces the likelihood of developing a health alteration. For cancer prevention, general health promotion strategies include eliminating the use of tobacco and alcohol, adding antioxidant-rich foods, reducing nitrate-rich foods, increasing activity levels throughout the day, maintaining a healthy weight, and managing stress. There are also cancer-specific prevention techniques the nurse teaches if a client is at risk for a specific type of cancer. For many types of cancer, there still is no good secondary prevention, or screening, available. *Content Refresher* Health promotion refers to the process of equipping people to increase control over their health and to improve their health status. Risk factors for health alterations include sedentary lifestyle, poor nutrition, family history, obesity, smoking, secondhand smoke, high levels of stress, high total cholesterol, and hypertension. Primary prevention refers to measures such as diet, proper exercise, and immunizations to prevent the occurrence of a specific disease. Secondary prevention refers to early detection of disease that can lead to interventions to prevent disease progression (e.g., biometric screening, physical examination, eye examinations, and mammography). Tertiary prevention refers to activities that limit disease progression, such as rehabilitation.

The cardiac monitor of a client who is awake and alert and has a peripheral pulse shows ventricular tachycardia with a rate of 160 beats/min. Which actions are appropriate for the nurse to implement? (Select all that apply.) 1. Defibrillate using 200 joules. 2. Monitor blood pressure. 3. Alert the rapid response team. 4. Prepare to administer adenosine by slow IV push. 5. Obtain a 12-lead electrocardiogram as prescribed.

1) INCORRECT - The client is awake and alert, so synchronized cardioversion using 100 joules is recommended if medication fails to convert the rhythm. 2) CORRECT— The nurse should monitor the client's blood pressure to determine whether the client is tolerating the rhythm. 3) CORRECT— The nurse should alert the rapid response team to assist with the client's care. Evidence shows that rapid response teams help improve client outcomes when changes in condition occur. 4) INCORRECT - The health care provider may prescribe IV adenosine for the client with paroxysmal superventricular tachycardia (not ventricular tachycardia) with a pulse. The medication should be administered by rapid IV push followed by a flush of preservative-free normal saline solution. The drug is not effective when administered slowly. 5) CORRECT— The nurse should obtain a 12-lead ECG, as prescribed, to evaluate the client's cardiac conduction. *Think Like a Nurse: Clinical Decision-Making* Treatment of ventricular tachycardia with a pulse requires treatment of reversible causes. The nurse prepares for possible synchronized cardioversion. The client might require sedation prior to the procedure. The client's hemodynamic status should be monitored closely while promoting airway patency. The nurse is expected to draw a serum metabolic profile to verify if electrolyte imbalances caused the ventricular tachycardia. If the client becomes pulseless, the cardiac arrest team should be summoned (e.g., "call a code"). *Content Refresher* Ventricular tachycardia (VT) is characterized by a run of three or more consecutive premature ventricular complexes (PVCs). During an episode of VT, the ventricles take control as the pacemaker of the heart maintaining a ventricular rate of 150 to 250 beats/min. P waves are usually not visible, and the rhythm may be regular or irregular. If the client has a pulse, IV drugs (e.g., procainamide, sotalol, or amiodarone) are prescribed. If drugs are ineffective, synchronized cardioversion is prescribed. If the client does not have a pulse, administer cardiopulmonary resuscitation (CPR) and prepare for rapid defibrillation.

The nurse evaluates the progress of a client recently diagnosed with type 1 diabetes mellitus. As part of the treatment plan, the client receives insulin (human recombinant) 32 units and insulin (regular) 8 units each morning. Which action performed by the client requires an intervention by the nurse? 1. The client adds the long acting insulin to the syringe, for a total of 40 units after drawing up 8 units of the regular insulin. 2. The client draws up 32 units of the clear insulin, followed by 8 units of cloudy insulin for a total of 40 units. 3. The client initially injects air into the long-acting vial without drawing up any insulin. 4. The client injects air into each vial of insulin equal to the amount of insulin to be withdrawn.

1) INCORRECT - The client needs to initially draw up 8 units of the regular insulin (clear) before drawing up the long-acting insulin (cloudy). This is a correct action by the client. 2) CORRECT — Regular insulin is clear and drawn up first for 8 units as prescribed. The long-acting insulin is cloudy, and the client needs to draw up 32 units for a total of 40 units of insulin. This action requires an intervention by the nurse. 3) INCORRECT - Injecting air into the regular insulin without drawing up the medication is an appropriate action by the client. The client needs to place air into the long-acting insulin vial first followed by the regular insulin vital. 4) INCORRECT - Placing air into each vial allows the client to withdraw the prescribed insulin. *Think Like A Nurse: Clinical Decision Making* Regular insulin is clear in color and the long-acting insulin is cloudy. The client reversed the prescribed amounts of insulin and should draw up 32 units of the long-acting insulin and 8 units of the regular insulin. When teaching a client about mixing insulin, the nurse will present methods of assuring that the process is followed correctly. In this scenario, the nurse should instruct the client to label each vial as either #1 or #2. In addition, the client should be taught to carefully check the dose each time the medication is to be given. *Content Refresher* The nurse should educate the client on the preparation and administration of insulin, including the mixture of two insulins. Using aseptic technique, the nurse injects the prescribed units of air of the isophane insulin (NPH insulin) into its vial without drawing up or touching the needle to the insulin and withdraws the needle. The nurse then injects the prescribed units of air of the regular insulin into the regular insulin vial and withdraws the prescribed units of regular insulin. The nurse then reinserts the needle into the NPH vial and withdraws the prescribed units. The nurse will teach the procedure and have the client demonstrate the skill.

The nurse in the emergency department provides care for a client admitted with a possible cervical spinal cord injury (SCI). Which action does the nurse perform first? 1. Ask how the accident occurred. 2. Assess neurological functioning. 3. Auscultate respirations. 4. Ask about previous medical conditions.

1) INCORRECT - The history of the incident is the least important assessment. Airway assessment is the priority. 2) INCORRECT - The neurological assessment is important, but the airway and circulation are the priorities for assessment. Remember the ABCs. 3) CORRECT— Assessing respiratory and breathing function is the priority assessment, especially for the client with a suspected cervical injury. 4) INCORRECT - Assess the client 's current condition, and then get past medical history from the client, if able, or family. *Think Like A Nurse: Clinical Decision Making* The nurse is aware that a cervical spinal cord injury is devastating to the body. Using knowledge about anatomy and physiology gives the nurse understanding that the nerves that control respiratory function arise from the cervical spinal cord region. If an injury to this area occurs, there is a risk of the client losing the ability to independently maintain respiratory functioning. The nurse will apply the concepts of airway-breathing-circulation (ABCs) and Maslow basic needs to identify the first actions for client assessment and care. The nurse's priority should be to assess the client for respiratory function including rate and quality of breath sounds. *Content Refresher* When caring for a client with a suspected spinal cord injury (SCI), the nurse should determine type of injury and time since injury. Assess response to interventions during emergency, acute, and rehabilitative stages. Assess vital signs, pain level, sensation, motor strength, movement, and reflexes. Determine level of consciousness. The priority is to assess the client's airway, breathing, and circulation. Treatment consists of immobilization, stabilization, prevention of complications, and surgery as needed. Spinal cord stimulation and stem cell transplantation are recent and innovative treatments. Depending upon the level of injury, treatment is directed at maximizing function and independence. An interdisciplinary team approach is necessary to maximize functioning and decrease complications.

The nurse provides care for a toddler diagnosed with pneumonia who is in an oxygen tent. The mother indicates that the toddler's birthday is tomorrow and she would like to have a party. Which statement by the mother is important for the nurse to address? 1. "I plan to bring paper streamers to put on the wall." 2. "My child loves to look at Mylar balloons." 3. "I found the neatest candles to put on the cake." 4. "My child's grandparents are planning to come."

1) INCORRECT - The mother can decorate the room with paper streamers because this posses no risk to the toddler. This statement does not require any intervention from the nurse. 2) INCORRECT - Mylar balloons are appropriate to have in the clinical setting. There is no reason for the nurse to address this statement. 3) CORRECT - Oxygen is combustible and can cause a fire if it comes in contact with an open flame or electrical equipment. The nurse needs to inform the mother that the candles cannot be lighted. 4) INCORRECT - The toddler's grandparents should be encouraged to attend the party. This statement does not require follow-up from the nurse. *Think Like a Nurse: Clinical Decision-Making* Oxygen supports combustion. Open flames are to be avoided at all times in the presence of oxygen treatment. Other safety measures that the nurse should inform the client's mother include never smoking or allowing anyone else to smoke around oxygen. Post NO SMOKING signs in every room of the home where oxygen is in use. Keep oxygen canisters at least 5 to 10 feet away from any heat source. Avoid using lotions, creams, or other home care products containing petroleum. Turn the oxygen supply valve to the off position when oxygen is not in use. Avoid using anything that may cause a spark around home oxygen, and install and maintain smoke detectors at home. *Content Refresher* Oxygen delivery is the volume of oxygen delivered to the tissues per minute. It is affected by the arterial oxygen or oxygen saturation and cardiac output. Cardiac output is affected by preload, afterload, and contractility. Oxygen saturation is also adversely affected by respiratory function, which is directly related to respiratory infections and inhibited respiratory development.

The nurse provides care for the client with a radium implant. Which action is most important for the nurse to take? 1. Evaluate the position of the applicator every 2 hours. 2. Place the client on a low-residue diet to decrease bowel movements. 3. Encourage the use of the bedside commode every 1 to 2 hours. 4. Decrease fluid intake to decrease radiation in the bladder.

1) INCORRECT - The position of the applicator should be checked every 8 hours, not every 2 hours. 2) CORRECT — Bowel movements can dislodge the radium implant. This diet will decrease the amount of stool and number of bowel movements. 3) INCORRECT - A client is on strict bedrest to prevent dislodging the radium implant. 4) INCORRECT - Decreasing fluids will not alter exposure to radiation. A client should have a high fluid intake. *Think Like A Nurse: Clinical Decision Making* A radiation source is sometimes placed inside or next to an area of the body requiring cancer treatment. Intracavitary radiation, such as that used for cervical cancer, requires many special precautions to maintain an adequate dose for the client and to limit radiation exposure to others. The client is on bed rest, may be given medication to induce constipation, will either have an indwelling urinary catheter or be required to use a bedpan, and will have additional restrictions to avoid dislodging the implant from the vagina or uterus. This requires about three days of hospitalization before the source is removed from the client's body. *Content Refresher* Internal radiation is energy emitted from a radiation source that is absorbed into tissue to damage and kill cancer cells. Assess for side effects from radiation, such as fatigue, anorexia, nausea, and vomiting. A film badge should be worn by staff while delivering direct care to these clients. Organize care activities to minimize time in direct contact with the client. Tell the client the reason for time and distance limitations when providing care. Only the care that must be delivered near the source is delivered in close proximity.

The nurse on the surgical unit provides care for a client after an ileostomy. Which action is most important for the nurse to perform? 1. Empty the ileostomy bag from the bottom. 2. Apply lotion to the skin around the stoma. 3. Cover the ileostomy with gauze. 4. Measure the output from the ileostomy.

1) INCORRECT - The pouch should be emptied when it is one-third to one-half full. This action is not the most important. 2) INCORRECT - Do not use moisturizers, as they can prevent a good seal around the stoma. 3) INCORRECT - The drainage from an ileostomy is constant and is very irritating to the skin. A client must wear the pouch at all times. 4) CORRECT— The output from an ileostomy is liquid and usually copious in amount. Include the amount in a client's intake and output to help keep the client balanced. *Think Like A Nurse: Clinical Decision Making* Clients are taught early how to care for their stomas and appliances. Keeping the site clean, avoiding alcohol on the skin, and avoiding oils on the skin are important to site care. The nurse measures output to ensure the intestinal out-pouching is working effectively. This also has the effect of gradually teaching the client how to empty the appliance and care for the site. Many clients need this mental adjustment time prior to being discharged to provide self-care. *Content Refresher* Nursing interventions when caring for the client with an ileostomy include: Assess stoma viability, appearance, bleeding, and functionality postoperatively. Monitor intake and output, including fecal material as output. Provide impeccable skin care, ensuring a skin barrier between stoma and pouch to protect the skin from exposure to drainage. Encourage increased fluid intake, increased salt and potassium-rich foods, avoidance of foods that could cause blockage, and a low-residue diet until ileostomy is completely functional. Weigh daily and assess for signs of fluid deficit. Provide client/family education about stoma and skin care, dietary recommendations, and signs/symptoms to report. Refer to support group and social services if needed.

The school nurse is observing a high school basketball game. Two cheerleaders are tumbling and hit each other in midair. One of the cheerleaders begins to cry and says, "I think my arm is broken." Which action should the school nurse take first? 1. Call 911. 2. Immobilize the arm. 3. Notify parents of incident. 4. Inspect the affected arm.

1) INCORRECT - The school nurse needs to assess the arm first before implementing a 911 call. 2) INCORRECT - The school nurse needs to assess the arm first to determine if the arm needs to be immobilized. 3) INCORRECT - Although it is important to notify parents, assessing the arm for potential injury is the priority. 4) CORRECT— Inspection is the first step of physical assessment. The school nurse needs to remove clothing to inspect the arm for bleeding, swelling, or deformities. *Think Like A Nurse: Clinical Decision Making* If the injury was unobserved, a thorough history should be elicited for the mechanism of injury and for any accompanying or associated events surrounding the injury. If the injury involved a fall, the circumstances surrounding the fall should be explored. The nurse should first assess the site of injury and the client. If it is determined that the client is unstable, the nurse should then call 911. While waiting for the paramedic, the affected arm should be immobilized, supported, and protected from further injury. *Content Refresher* Assessment in general includes questioning the client regarding the chief complaint, history of the present illness, past medical history, family health history, health practices, health beliefs, and functional, psychosocial, and cultural status. The nurse will also conduct a physical assessment and assess for the possibility of fracture.

The nurse provides care for a client who had an above the knee amputation. Which intervention reduces phantom limb sensation? 1. A low dose of an opioid. 2. Mirror therapy. 3. Psychotherapy. 4. A low dose of a sedative.

1) INCORRECT - There is no evidence that a low dose of an opioid reduces phantom limb sensation. 2) CORRECT— The mirror is thought to provide visual information to the brain, replacing sensory feedback expected from the missing limb. 3) INCORRECT - There is no evidence that psychotherapy reduces phantom limb sensation. 4) INCORRECT - There is no evidence that a low dose of a sedative reduces phantom limb sensation. *Think Like A Nurse: Clinical Decision Making* The nurse understands a client recovering from an amputation is at risk for the development of phantom limb pain. This pain is believed to be caused by either pinched nerve endings that occurred during the amputation, or because of neural pathways in the brain, which causes the client to feel sensations in the amputated limb. One action to help reduce phantom limb pain is the mirror therapy suggested in this scenario. The nurse places a mirror at the incision site, and encourages the client is to look into the mirror and see that the limb is no longer present. The visual reminder is believed to help reroute the neural pathways and eliminate the sensations of phantom limb pain. *Content Refresher* The most common amputations are of the lower extremities due to tissue damage from peripheral vascular disease associated with diabetes, hypertension, hyperlipidemia, and smoking. Traumatic amputations, especially among those in the military, are also common. Men are at greater risk for amputations than women. Amputation may also be necessary to treat certain cancers. Complications include delayed healing, infection, chronic pain, phantom limb pain, and contractures. A multidisciplinary approach is needed to assist the client to manage pain, reduce infection, cope with the traumatic event, and learn to live without the missing body part.

The nurse provides care for a client admitted with a diagnosis of acute myocardial infarction. The client's spouse tells the nurse about an anxiety disorder that the client has been self-medicating with alcohol. It is most important for the nurse to assess for which symptoms? 1. Heart palpitations, shortness of breath, and nausea. 2. Fatigue, decreased appetite, and generalized pruritis. 3. Tachycardia, generalized tremors, and hypertension. 4. Dry mouth, diaphoresis, and upper extremity tingling.

1) INCORRECT - These are physiological symptoms related to anxiety. This is important, but not the most important. 2) INCORRECT - Although alcohol may cause cirrhosis, a long-term diagnosis, it is more important to assess for withdrawal. 3) CORRECT - Alcohol withdrawal begins a few hours after reduction of alcohol intake and peaks in 24 to 48 hours. Alcohol withdrawal can be dangerous and must be managed carefully. 4) INCORRECT - These are physiological symptoms related to anxiety. This is important, but not the most important. Diaphoresis occurs in alcohol withdrawal and anxiety. *Think Like A Nurse: Clinical Decision Making* The client is at risk for alcohol withdrawal symptoms, which include seizures, tremors, elevated blood pressure, and rapid heart rate. Assessing for alcohol withdrawal should be the nurse's priority, as it poses a physical risk to the client. Heart palpitations, shortness of breath, nausea, dry mouth, and diaphoresis are manifestations of anxiety. *Content Refresher* Alcoholism is a disease that is progressive and fatal and associated with impaired control over alcohol ingestion and preoccupation with alcohol. Signs of addiction include regular binge or excessive drinking, inability to control drinking, drinking more to achieve the same effect, withdrawal symptoms if alcohol withheld (tremors), and giving up other activities for drinking.

A client in the psychiatric unit continually states to the nurse, "My stomach is missing." Which response by the nurse is appropriate? 1. "Well then, you should not have any trouble losing weight." 2. "Where did your stomach go?" 3. "It sounds like you feel very empty and alone." 4. "I am here to help you, okay?"

1) INCORRECT - This is a nontherapeutic response that does not address the client's emotional state or offer reorientation to reality. 2) INCORRECT - The nurse should not explore a delusion and should not argue with the client having a delusion. The client will try to convince the nurse about the truth of the delusion. The nurse should instead respond to the client's emotional state. 3) CORRECT— Delusions often reflect the client's underlying emotion. The nurse should first respond to the client's emotional state, as in this response, and then reorient the client. 4) INCORRECT - This places the focus on the nurse and does not address the client's statement. *Think Like A Nurse: Clinical Decision Making* The statement, "my stomach is missing" can be symbolic of feelings of emptiness. The nurse should attempt to respond in a manner that acknowledges the client's feelings. The therapeutic benefit of the nurse's statement that the client must feel empty and alone, is that the client may validate feelings or contribute more information related the client's statement. Further intervention can be provided based on the client's response about feelings. The nurse must remember that therapeutic communication is an important assessment tool. ^Content Refresher^ When caring for a client with delusions, the nurse should: Ensure a safe environment. Reduce external stimulation. Monitor the client's thinking and associated behavior. Report increased anxiety and/or increasing risk for violence. Provide prescribed medications, as indicated. Acknowledge the client's concern about false belief(s), but do not agree with them. Do not argue about delusions, but reorient the client. Focus on feelings such as fear or anxiety and offer alternative thoughts and behaviors to reduce negative feelings. Make brief, frequent contact and offer orienting information. Assist to socialize with others. Provide care with unconditional positive regard.

The nurse provides care for a pregnant client. The client reports heartburn. Which client statement requires the nurse to intervene? 1. "I sit upright for 2 hours after eating." 2. "I sleep with an extra pillow." 3. "I will stop smoking." 4. "I eat every 6 hours."

1) INCORRECT - This is an appropriate action. Sitting upright after eating reduces reflux. 2) INCORRECT - Elevating the head while sleeping decreases reflux. 3) INCORRECT - Tobacco increases reflux, as does carbonated beverages, fatty foods, acidic foods, and spicy foods. 4) CORRECT—The nurse should intervene. The client should eat small, frequent meals. *Think Like a Nurse: Clinical Decision-Making* A pregnant client may experience a variety of nuisance health problems that did not exist prior to becoming pregnant. One of these health situations is heartburn. Heartburn can be caused by changes in the client's hormone levels affecting the rate of digestion and tolerance of different foods, or heartburn may be caused by the enlarging uterus putting pressure on the stomach. One action for the mother to take to lessen the effects of heartburn is to eat small meals more frequently and to choose foods that are not spicy or irritating to the gastric lining. *Content Refresher* When providing care for the pregnant client, the nurse should assess pre-pregnancy weight, comorbid medical conditions, and the client's current nutritional intake. Assess whether pregnancy is single fetus or multiple fetuses. Pregnant women need to eat at least three servings of protein per day, six or more servings of whole grains per day, five or more servings of fruits and vegetables per day, and three or more servings of dairy products per day. The diet should also consist of foods with essential fats, daily prenatal vitamins, and drinking at least 8 glasses of water. Pregnant women should be counseled to avoid alcohol, excessive caffeine, raw meats and seafood, high-mercury fish, uncooked or processed meats, and unpasteurized dairy products.

The nurse provides teaching for a client newly diagnosed with diabetes. How does the nurse best assess the client's style of learning? 1. Ask family members to describe the client's style. 2. Employ a variety of teaching strategies. 3. Ask the client how personal learning best occurs. 4. Observe the client's interactions with others.

1) INCORRECT - This is not the best source of information because they may not know how the client learns best. 2) INCORRECT - This is not effective or efficient and may increase stress for the client. 3) CORRECT— This is the best source for discovering which teaching strategies to use. 4) INCORRECT - These interactions may not include learning activities. *Think Like A Nurse: Clinical Decision Making* Planning and preparing for teaching is more than just identifying a topic that needs to be addressed. The nurse needs to apply the principles of teaching and learning in order to assess the client for readiness to learn, as well as the best way to provide the information. Some clients learn better when watching a video, while others prefer to read teaching material. In order to support the client's learning needs, the first action is to find out how the client prefers to receive new information. From this, the nurse can then identify strategies to not only provide the necessary information, but to ensure the information is received in order to support the client's health needs. *Content Refresher* When providing health education, the nurse should: Determine the learner's knowledge level, preferred learning style, and previous experiences. Create a positive learning environment. Minimize distractions and use clear, brief instructions. Clearly communicate the objectives and expectations. Demonstrate ideal performance of a skill. Emphasize the information or skill in a context relevant to the learner. Allow for repeat performance of skills with sufficient amount of time, type, and variability for learners to become proficient.

The nurse provides care for a client admitted for elective surgery. The nurse assesses the client's vital signs. How does the nurse position the client for this part of the admission assessment? 1. Lying flat on back with knees flexed. 2. Side-lying with knees flexed. 3. Lying flat with extremities fully extended. 4. Sitting upright.

1) INCORRECT - This is not the preferred position. Evidence indicates that blood pressure is 8 mm Hg higher when lying down than when seated upright. 2) INCORRECT - This position may make the client feel more vulnerable and is not the best position for measuring the blood pressure. 3) INCORRECT - Lying on the back may increase blood pressure reading. It is not the preferred position. 4) CORRECT - This position allows the nurse to easily access the anterior and posterior chest for auscultation of breath sounds and is the preferred position for measuring blood pressure. It allows for eye contact and helps client feel less vulnerable. *Think Like A Nurse: Clinical Decision Making* When assessing blood pressure (BP), measurements will vary depending on whether the nurse is using an automated device or the traditional manual approach. BP readings also vary based on the client's comfort level and sense of anxiety or frustration. Client positioning also affects the BP reading. The client should sit comfortably with feet and back supported. The effort required to sit up without resting the feet and back can raise BP. The arm should rest at heart level for the best reading. BP readings of hospitalized clients often are taken while the client is supine. This is acceptable as long as the nurse accounts for the difference, noting to change body position and recheck if results are questionable. *Content Refresher* Ensure the client avoids consumption of caffeinated products, smoking, or exercise for at least 30 minutes prior to obtaining blood pressure (BP) measurement. Position the client seated with feet flat on the floor and arm supported comfortably at the level of the heart. Avoid obtaining a BP in the same arm in which there is an arteriovenous fistula, where lymphedema exists, or after lymph node dissection for treatment of breast cancer. The BP cuff is placed above the elbow, with the stethoscope placed lightly over the brachial artery. The cuff is inflated to a pressure of 30 mm Hg above the level at which the radial pulse is no longer palpable. Slowly deflate the cuff, listen for the Korotkoff phase, watch the sphygmomanometer, and listen until the sounds disappear completely.

The nurse provides care for a client 2 hours after placement of a cuffed tracheostomy tube. When the nurse enters the client's room, the tracheostomy tube is displaced out of the stoma. Which action does the nurse take first? 1. Place oxygen at 6 L per minute over the stoma opening. 2. Auscultate bilateral breath sounds. 3. Check the client's pulse oxygenation reading. 4. Use a hemostat to dilate the opening of the stoma.

1) INCORRECT - Unless the airway is opened, the client will not be able to access the oxygen. With a newly placed tracheostomy, the stoma will not stay open. The nurse should first dilate the opening of the stoma, and then place oxygen. 2) INCORRECT - This assessment is not relevant at this time, as the client cannot breathe with a closed stoma. 3) INCORRECT - This assessment is not relevant at this time, as the issue is that the client does not have a patent airway. The nurse should first establish an airway. 4) CORRECT— The client's issue is the loss of an airway. The first action is to open the airway. A newly placed tracheostomy will not stay open without the tube. Some stoma swelling is expected due to the recent surgical procedure as well. The nurse should utilize hemostats to open the airway. *Think Like A Nurse: Clinical Decision Making* The nurse needs to ensure that the client has an adequate airway. This is especially true for clients who have artificial airways, necessitating the need for certain items to be at the bedside at all times. For the client with a dislodged tracheostomy tube, a hemostat is inserted into the stoma and gently opened to create an opening for adequate ventilation. Because the tracheostomy is so new, there is an increased risk that the opening will close or collapse. It is for this very reason that a hemostat should be at the bedside of every client with a tracheostomy. *Content Refresher* When ventilatory effort is diminished (loss of airway), adequate oxygen is not taken into the lungs and limits the amount that is available for gas exchange at the alveolar level. If the airway is reduced, an inadequate amount of oxygen is taken in and available for alveolar gas exchange. These factors create the condition for hypoxemia and resulting hypoxia. When caring for a client who is unable to maintain a patent airway, the nurse must take measures to establish a patent airway and to maintain or improve ventilation and oxygenation.

The nurse sees four clients for an annual health assessment. To which of these clients does the nurse offer the meningococcal immunization? 1. A 60-year-old who works as an Licensed Practical Nurse in a skilled nursing facility. 2. A first-year college student who lives in a residence hall. 3. A 30-year-old who is sexually active, but human immunodeficiency virus (HIV) negative. 4. A retired military veteran who served combat duty.

1) INCORRECT - Working in a skilled nursing facility is not a risk factor for bacterial meningitis. 2) CORRECT- Due to past outbreaks of bacterial meningitis in dormitories, first-year college students living in a residence hall should be immunized against bacterial meningitis. 3) INCORRECT - Being sexually active is not a risk factor for bacterial meningitis. However, being HIV positive is a risk factor. 4) INCORRECT - Active military personnel often live in crowded situations so they are at risk for bacterial meningitis. However, retired military veterans are not at risk. *Think Like A Nurse: Clinical Decision Making* Nurses are asked to make decisions using the nursing processes of critical thinking and clinical judgement. In this scenario, the nurse is in a unique situation in which the ages of clients are not within a specific group, and the day-to-day environment and life experiences are varied. When considering the purpose of the meningococcal vaccination, the nurse should mentally ask, "Which client is most at risk for contracting this health problem?" Research would indicate that outbreaks of meningitis have been linked with those who are in close living quarters. Of the clients to be seen, the one that is most likely to live closely with others is the college student. The nurse should strongly recommend this client receive the meningococcal vaccination. *Content Refresher* Age is a factor that influences the risk of developing meningitis. Infants and older, debilitated persons are most at risk. People who live in environmentally close settings are also more susceptible. Persons who have not been immunized for mumps, Haemophilus influenza, and Streptococcus pneumoniae are also at a greater risk. College students who live in a dormitory are advised to get immunized against bacterial meningitis due to living in close proximity to each other.Clients will present with acute pain due to headaches related to increased intracranial pressure, disturbed sensory perception related to irritation of the meninges, and risk for impaired cerebral tissue perfusion related to cerebral edema.Some complications may persist for an extended period of time and these include headaches, mild mental impairment, and incoordination. An increase in intracranial pressure, which could result in brainstem herniation, is a very serious complication of the acute phase of the disease and is most likely to occur with bacterial meningitis. There is additional risk for seizure activity, diabetes insipidus, syndrome of inappropriate antidiuretic hormone, hydrocephalus, and dysfunction of cranial nerves.

A neonate is treated in the newborn nursery for hyperbilirubinemia using phototherapy lights. Which situation requires immediate intervention by the nurse? 1. The parent turns off the phototherapy lights and removes the newborn 's eye patches in preparation for feeding. 2. The parent is worried because the newborn experiences frequent loose, greenish stools and increased urine output. 3. A laboratory technician turns off the phototherapy lights to draw the newborn's blood. 4. The jaundice observed around the newborn 's eyes and nose has begun to disappear.

1) INCORRECT — No intervention is required in this situation. Turning off the light and removing the eye patches before oral feeding is appropriate. 2) INCORRECT — This is an expected finding. Loose, greenish stools and increased urine output reflect increased excretion of bilirubin, which indicates that the phototherapy is working. 3) INCORRECT — This is an appropriate action. Phototherapy lights must be turned off when blood is drawn to ensure accurate bilirubin measurements. 4) CORRECT — This indicates that the eye patches are not adequately placed or are not adequately opaque and are allowing light to enter. With phototherapy, eyes must be completely shielded with patches or an opaque mask in order to prevent exposure to the light, which could result in eye damage, especially to the retina. *Think Like A Nurse: Clinical Decision Making* The nurse has a responsibility to understand the parameters and guidelines for administering therapy. The eyes of a newborn must be completely covered when using phototherapy to treat jaundice from hyperbilirubinemia. Since the yellow color is diminished around the eyes and nose, this indicates that the eye covering is not appropriately applied. The eye coverings need to be immediately adjusted so that the newborn is not being exposed to a situation that increases risk for retinal damage. *Content Refresher* When caring for a newborn with physiological jaundice, the nurse should: Encourage the mother to breastfeed frequently. Monitor the neonate for six wet diapers and three stools per day as an indication of elimination of bilirubin. Observe for jaundice (sclera and skin) and monitor diagnostic bilirubin tests. Initiate phototherapy and exchange transfusion as prescribed if levels of bilirubin are severe. Teach parents about physiological jaundice, signs of hyperbilirubinemia, and actions to take.

The nurse provides care to a client with suspected cholelithiasis. Which information in the client's health history indicates a risk for this disease process? (Select all that apply.) 1. African American ethnicity. 2. Body mass index of 21. 3. Given birth to 3 children. 4. Being 50 years of age. 5. Fasting for religious reasons.

1) INCORRECT- A Native American or U.S. Southwestern Hispanic ethnicity places a client at risk for cholelithiasis, not African American ethnicity. 2) INCORRECT- Obesity increases the risk for cholelithiasis, but a BMI of 21 is within normal range. 3) CORRECT- Multiparous clients at higher risk of developing cholelithiasis. 4) CORRECT- Risk increases with age, with the highest incidence occurring after age 40. 5) CORRECT- Fasting decreases gallbladder movement, and bile can become overly concentrated with cholesterol, causing stones to form. *Think Like a Nurse: Clinical Decision-Making* When providing care to any client, it is essential that the nurse review the medical history to determine risk factors for the development of certain disease processes or health problems. This client has several risk factors for the formation of gall stones, including multiparity, being over the age of 40 years, fasting, and obesity. When planning care for this client, it is essential for the nurse to provide education about these risk factors along with methods to decrease these risks so that future instances of gall stone formation can be avoided. *Content Refresher* Cholecystitis is inflammation of the wall of the gallbladder. This condition is usually associated with obstruction related to the presence of cholelithiasis or biliary sludge. Additional risk factors associated with cholelithiasis include the use of oral contraceptives and a sedentary lifestyle. Once gallstones become symptomatic, definitive surgical intervention with cholecystectomy is usually indicated.

The nurse teaches a client about methods of birth control. Which client statement about the use of a male condom requires follow-up teaching by the nurse? 1. "Condoms are the only methods of birth control that also help prevent the spread of sexually transmitted infections." 2. "I will put the condom on before I have an erection to collect all sperm." 3. "I will leave a space at the tip of the condom to collect the ejaculate." 4. "I will hold the condom firmly at the base of the penis and withdraw the penis before the erection ends."

1) INCORRECT- Condoms are the only method of birth control that also help prevent the spread of sexually transmitted infections. 2) CORRECT - The condom should be applied when the penis is erect and before it touches a partner's mouth or genital area. 3) INCORRECT- The client should pinch the tip of the condom and place it on the head of the penis, leaving a small space at the top to collect the semen to avoid breakage. 4) INCORRECT- The client should hold onto the rim of the condom and withdraw the penis prior to the loss of an erection to avoid spillage of seminal fluid. *Think Like a Nurse: Clinical Decision-Making* Each pregnancy management option has benefits and drawbacks. According to Planned Parenthood, condoms are 85% effective at preventing pregnancy and are considered an effective strategy for preventing the transmission of sexually transmitted infections. Other options tend to be based on controlling the woman's hormones or vaginal entry of sperm. The nurse helps clients determine their goals and which option best fits their lifestyle, as well as facilitates discussion about sexuality and pregnancy issues. *Content Refresher* Instruct the client to apply the condom to the erect penis, leaving space at the tip of the condom. A condom should be applied before every instance of vaginal or anal penetration. Instruct the client to use water-based lubricant and never petroleum-based lubricant, which increases risk of condom breakage. If the condom breaks, the partner should immediately instill contraceptive foam or cream. Instruct the client to check the condom's expiration date, to never reuse a condom, and to never store the condom in hot places (e.g. wallet or car).

The nurse reviews the importance of receiving an annual influenza vaccination with a client. Which statement indicates to the nurse that the client requires further instruction? 1. "I will get the shot since I am 69 years old." 2. "I had bronchitis twice last year, so I will get the shot." 3. "I volunteer at a preschool, so I will get the shot." 4. "I live with two large dogs, so I will get the shot."

1) INCORRECT- The annual influenza vaccination is recommended for people over 65 years of age. 2) INCORRECT- The annual influenza vaccination is recommended for people with chronic respiratory or cardiovascular disease. 3) INCORRECT- The annual influenza vaccination is recommended for people who come in contact with young children. 4) CORRECT- The client is not at risk for getting influenza from a dog. Therefore, this client statement indicates the need for further education. *Think Like A Nurse: Clinical Decision Making* The annual influenza vaccination is recommended for most, if not all, people. It is particularly important for older adult clients to receive this vaccination because of a change in immunity that occurs naturally with aging. Older adults are also more likely to have chronic respiratory and cardiovascular illnesses, which would be exacerbated by an episode of the flu. Younger children are prone to contracting and transmitting bacteria and viruses, but the influenza virus is not transmitted from animals. *Content Refresher* Primary prevention includes activities that promote health and prevent illness, such as giving immunizations. It is important to teach the client about illness prevention specific to the identified individual/family/community health risks.

The nurse teaches a client about the correct use of the transdermal nicotine patch. The client states, "Using the patch will help me cut down on smoking." Which response does the nurse provide to this client? 1. "If you use the nicotine patch, then you will no longer have any desire to smoke cigarettes." 2. "If you use the nicotine patch, then you should try not to smoke as many cigarettes each day." 3. "If you smoke while you are using the nicotine patch, then you are at risk of having a heart attack." 4. "If you plan on continuing to smoke cigarettes, then you will not be given a prescription for the nicotine patch."

1) INCORRECT- The nicotine patch may decrease cravings, but the client may or may not continue to have the desire to smoke. 2) INCORRECT- Clients who use the nicotine patch should be advised not to smoke while wearing the nicotine patch. Smoking while wearing the nicotine patch can cause serious complications, including myocardial infarction. 3) CORRECT- The nurse has an obligation to instruct the client that smoking while wearing the nicotine patch increases the risk of myocardial infarction. 4) INCORRECT- Advising the client that compliance is mandatory is non-therapeutic and may be perceived by the client as confrontational. Instead, the nurse should educate the client about contraindications related to nicotine replacement therapy (NRT) and explore the client's motivation to stop smoking. *Think Like A Nurse: Clinical Decision Making* The nurse has the responsibility to understand that the nicotine patch reduces nicotine cravings associated with smoking cessation by providing the client with nicotine. Clients with hypertension, heart disease, or a history of myocardial infarction should consult with a health care provider before using a nicotine patch. It is important for the nurse to inform the client that smoking while wearing the patch causes nicotine overdose. The nurse should also inform the client of the signs and symptoms of nicotine overdose such as, nausea, vomiting, dizziness, weakness, and rapid heartbeat. An allergy to adhesive tape might cause rashes from the nicotine patch. *Content Refresher* Nicotine causes vasoconstriction, so the use of multiple forms of nicotine can dangerously increase the client's blood pressure and lead to a myocardial infarction. However, cigarette smoking causes lung cancer, as well as cancers of the skin, mouth, nose, throat, larynx, esophagus, liver, bladder, kidney, pancreas, colon, rectum, cervix, stomach, and blood, as well as acute myeloid leukemia. Smoke from other people's cigarettes, pipes, or cigars (i.e. secondhand smoke) also causes lung cancer. A nicotine patch assists the client with smoking cessation, because the patch provides a steady level of nicotine. The patch can be used up to 8 weeks. Teach the client common side effects of the nicotine patch (e.g. transient itching, burning, redness at patch site, insomnia, nausea, and headache). Instruct the client to rotate sites to reduce skin irritation.

The mother of a newborn decides not to breastfeed. Which is the most appropriate response from the nurse to this client? 1. "Breastfeeding will encourage a close bond between you and your baby. " 2. "Breastfeeding may help prevent your baby from becoming ill. " 3. "Tell me about your thoughts and concerns about breastfeeding. " 4. "Formula is more costly and less convenient than breastfeeding. "

1) INCORRECT— Although breastfeeding will encourage a close bond between the mother and baby, the nurse needs to address the client's reasons for not wanting to breastfeed. 2) INCORRECT— The statement that breastfeeding may help prevent the baby from becoming ill is too vague. The nurse needs to find out why the client does not want to breastfeed before persuading the mother to do so. 3) CORRECT— Asking the client to talk about thoughts and concerns about breastfeeding allows the client to voice specific reasons for not doing so. Having this information may allow the nurse to better assist the client to determine what is the best feeding method for the client and new baby. 4) INCORRECT— Formula may be more costly and less convenient that breastfeeding. However, the client's specific concerns need to be addressed. *Think Like A Nurse: Clinical Decision Making* The decision to breastfeed a newborn is a personal decision that is made by the mother. At times, breastfeeding may be viewed as undesirable. However, in order to support the client and the nutritional status of the newborn, the nurse needs to find out why the client does not want to use this feeding approach. It is appropriate to ask the client to explain why breastfeeding is not desired. Once the client has an opportunity to share thoughts and feelings, the nurse can then help the client identify the feeding approach that supports the mother's needs while ensuring adequate nutrition for the newborn's growth and development. *Content Refresher* The nurse needs to use therapeutic communication when caring for this client. Therapeutic communication includes the following communication skills: 1) being silent, 2) showing acceptance, 3) providing recognition, 4) offering self, 5) using broad open statements, 6) asking about thoughts/feelings, 7) restating and reframing, 8) reflecting, 9) presenting reality, 10) sharing observations, and 11) clarifying meaning. The nurse needs to avoid non-therapeutic communication techniques such as reassuring, rejecting, approving/disapproving, agreeing/disagreeing, giving advice, belittling, stereotyping, probing, or using denial.

The nurse assesses a client during the client's first prenatal visit. The nurse determines that the client is at 6 weeks' gestation. The nurse identifies which finding as a probable sign of pregnancy? 1. Amenorrhea. 2. Uterine enlargement. 3. Urinary frequency. 4. Fetal heart tone auscultated by Doppler.

1) INCORRECT— Amenorrhea is a presumptive sign of pregnancy. Presumptive signs are felt by the woman, such as nausea/vomiting, breast sensitivity, fatigue, and quickening. 2) CORRECT— Probable signs are findings observed by the health care provider. Uterine enlargement, souffle and contractions, positive urine pregnancy test, Hegar's sign, and Chadwick's sign are all probable signs of pregnancy. 3) INCORRECT - Urinary frequency is a presumptive sign of pregnancy. Presumptive signs are felt by the client. 4) INCORRECT - Fetal heart tones auscultated by Doppler is a positive sign of pregnancy along with palpation of fetal movement and a sonogram of the fetus. *Think Like A Nurse: Clinical Decision Making* The client's first prenatal visit is an ideal time for the client to get a comprehensive assessment (physical, psychosocial, laboratory tests) and screen for factors (e.g. diabetes, hypertension, obesity) that might place the mother and fetus at risk for any health problems. The nurse should follow a standardized protocol. For first-time parents, the prenatal visit is both exciting and challenging. The nurse should provide time for parents to ask questions and give directions on where to find information and what to expect throughout the pregnancy. *Content Refresher* Fundal height is generally defined as the distance from the pubic bone to the top of the uterus measured in centimeters. The height of the uterus matches the gestational age of the fetus. Failure of the uterus to enlarge could indicate abnormalities in fetal growth.

The nurse teaches a client diagnosed with breast cancer about radiation therapy. Which client statement indicates additional teaching is required? 1. "I have to wait until my breast tissue heals to begin radiation therapy." 2. "Radiation therapy should help prevent my cancer from returning." 3. "I'm glad I won't feel tired as a result of my radiation treatments." 4. "I'll need to watch my skin for changes."

1) INCORRECT— Clients diagnosed with breast cancer receive external radiation therapy after the tissues heal, which could be a month or longer after surgery. 2) INCORRECT— Clients with breast cancer commonly undergo external radiation therapy after breast cancer surgery to help lower the risk that the cancer will return in the breast or nearby lymph nodes. 3) CORRECT— Clients commonly experience fatigue with external radiation therapy. This statement indicates the need for further teaching. 4) INCORRECT— Skin changes ranging from mild redness to blistering and peeling may occur with external radiation therapy. The client should avoid exposing the treated area to the sun because it may worsen skin changes. *Think Like A Nurse: Clinical Decision Making* Clients diagnosed with cancer are given a large amount of information about their diagnosis and prognosis, as well as treatments such as radiation, chemotherapy, and surgery. The information often is delivered at a time when the client is emotionally overwhelmed and unable to process it. The nurse continually reassesses the client's understanding and reinforces teaching as needed. Radiation treatments are typically administered daily for a month or more. The client not only will be tired from the radiation but likely also from the daily trips to the radiation or cancer center to have the treatments administered. *Content Refresher* External beam radiation therapy is a form of cancer treatment that uses highly charged electrons to penetrate malignant tumors with pinpoint accuracy. During radiation therapy, the client may experience radiation dermatitis . Radiation therapy can also cause an impaired immune response, making the client susceptible to infection. Therefore, monitor the client's white blood cell (WBC) count. Wash the radiation site with water only. Avoid hot or cold applications to the radiation site. Do not apply lotions, creams, or powders to the site. Do not remove treatment area marks. Adhere to infection control protocols.

The nurse provides care to an older adult client with partial and full thickness burns over 75% of the body. Which assessment indicates to the nurse the client is developing shock? 1. Epigastric pain and seizures. 2. Widening pulse pressure and bradycardia. 3. Cool, clammy skin and tachypnea. 4. Kussmaul respirations and lethargy.

1) INCORRECT— Epigastric pain is a warning sign of seizures in a client with preeclampsia. 2) INCORRECT— Widening pulse pressure and bradycardia occurs in cardiac disorders. 3) CORRECT— The body responds to early hypovolemic shock by adrenergic stimulation. Vasoconstriction compensates for the loss of fluid and causes cool, clammy skin and a rapid rate of breathing. 4) INCORRECT— Kussmaul respirations and lethargy are associated with diabetic ketoacidosis. Think Like A Nurse: Clinical Decision Making The older adult clients are predisposed to shock due to co-existing co-morbidities, repeated and prolonged hospitalizations, reduced immunity, functional limitations, and above all due to the effects of aging itself. One of the major age-associated changes in the cardiovascular response to physical or emotional stress is a decrease in cardiac output due to decreased heart muscle contractility and heart rate response to increased stress. The nurse should monitor the older adult client with shock more closely when providing fluid boluses due to increased risk for heart failure. The nurse should be attentive in looking for atypical signs of shock such as alteration in mental status. Content Refresher The nurse should assess the client at risk for shock, identifying baseline vital signs, strength of peripheral pulses, color of skin, warmth, and other indicators of perfusion. Assess urinary output. Assess cardiac rhythm. Assess hemodynamic parameters. Assess breathing and oxygenation status. Signs and symptoms of shock include hypotension, cool, pale skin, decreasing urinary output, tachycardia, restlessness, hypoxia, tachypnea, dyspnea, and respiratory and metabolic acidosis.

The nurse provides care to a client diagnosed with diabetes mellitus. As the nurse prepares to administer the client's prescribed lispro insulin, the client's son states, "Another nurse already gave my mom her insulin." Which nursing action is most appropriate? 1. Return the unused insulin to the client's medication supply drawer. 2. Document insulin administration on behalf of the client's previous nurse. 3. Contact the nurse from the previous shift. 4. Recheck the client's serum glucose level.

1) INCORRECT— If the medication is prepared in a sealed, unit-dose package, returning the insulin to the client's drawer may be acceptable. However, additional information is needed to confirm that the client has already received the prescribed insulin. 2) INCORRECT— Documenting on behalf of another nurse is illegal and unethical. Additional information is needed to confirm that the client has already received the prescribed insulin. In the event that the client already received the insulin dose, the nurse who administered the insulin is required to document the medication administration. 3) CORRECT— Contacting the client's previous nurse is the safest action, as this action will allow for confirmation that the prescribed insulin dose was already administered. 4) INCORRECT— In the event that the client's previous nurse already administered the prescribed insulin, the medication may not yet have taken effect. Contacting the nurse from the previous shift is the safest action. *Think Like A Nurse: Clinical Decision Making* The Joint Commission requires all health care providers to implement a standardized approach to handoff communications including an opportunity to ask and respond to questions. In the scenario described, it is best to verify with the previous nurse if the insulin was already given. One way to improve handoff is to create an action list, to-do items to be completed by the nurse receiving the sign-out. *Content Refresher* Communication between health care team members facilitates effective teamwork and collaboration which leads to safe client care. The nurse needs to practice assertive communication strategies while determining communication challenges and/or barriers that may impede effective communication among team members.

The spouse of a combat veteran asks the nurse how to respond when the client yells and wants to be left alone. Which response by the nurse to the client's spouse is best? 1. "You have not done anything wrong. Your spouse is probably experiencing war memories." 2. "Do what is asked. Make the environment quiet and keep your distance until your spouse is less upset." 3. "Approach your spouse calmly and slowly, saying your name and current location." 4. "Touch your spouse's arm gently and ask what is causing the anger."

1) INCORRECT— Saying the client has done nothing wrong is not the best response, as this provides false reassurance. The client may have post-traumatic stress disorder (PTSD) and may be having flashbacks. The client's spouse may unknowingly trigger a PTSD experience. 2) CORRECT— The client is probably having PTSD flashbacks. When a combat veteran has a flashback, the veteran is psychologically in a war zone, reliving a trauma as if it were occurring now, and may misidentify people as a threat. The client's spouse should be directed to maintain a safe distance and limit stimuli. 3) INCORRECT— A calm, slow approach is useful when a client is diagnosed with PTSD, but approaching the client and talking slowly and calmly should not be done during a flashback. 4) INCORRECT— The client is giving clear directions to stay away. Approaching the client may cause further agitation and possible injury. The client should not be asked questions during this time. *Think Like A Nurse: Clinical Decision Making* The nurse recognizes the client is experiencing a psychiatric condition as a result of being in combat. This frequently occurs, but can be difficult for the family to handle and accept. The nurse explains the psychiatric issue to the spouse and then emphasizes the need to maintain personal safety. The client is psychologically reliving a traumatic event, which could cause the client to act out. The environment should be kept as calm and quiet as possible to reduce environmental stressors and reduce stimuli once the episode passes. The nurse provides information about assistance and support programs for the client and family. *Content Refresher* Post-traumatic stress disorder (PTSD) is an anxiety disorder that occurs following a traumatic event usually involving death or injury. Risk factors include previous physical or sexual abuse, psychiatric history, poor social support, being in the military, or the victim of a violent crime. Symptoms include persistent anxiety, irritability, exaggerated startle responses, hypervigilance, flashbacks to the traumatic event, difficulty concentrating, sleep disturbances, and disturbances in social or occupational functioning. Early diagnosis and management are associated with good outcomes. Referral to a mental health specialist or psychiatrist should be done. Treatment with anti-depressants can be helpful. Cognitive-behavioral approaches and family counseling should be instituted with appropriate follow up until symptoms improve. Post-traumatic stress disorder increases the risk of suicide, so assessment for suicidal thoughts is imperative.

The nurse provides care for a client at 28 weeks' gestation. The nurse teaches the client how to perform fetal kick counts. Which client statement indicates to the nurse that the client understands the teaching? 1. "I should count my baby's movements at different times of the day." 2. "I should lie down flat when I count my baby's movements." 3. "I should feel my baby move more than five times in one hour." 4. "I should call my doctor if I notice my baby moving more than usual."

1) INCORRECT— The client should try to count fetal movements at the same time each day, preferably about an hour after a meal. 2) INCORRECT— Lying quietly in the left side-lying position when performing fetal kick counts can promote fetal movement. The supine position is more likely to cause decreased fetal movement, maternal back pain, shortness of breath, and possibly supine hypotension. 3) CORRECT— More than five fetal kicks in a one hour time frame is indicative of fetal well-being. 4) INCORRECT— The client should notify the health care provider if the client notices the fetus moving less frequently, if it takes longer to note 10 movements, if the fetus does not move in the morning, or if there are less than three movements in 8 hours. These can indicate the fetus is at risk for a poor birth outcome. *Think Like a Nurse: Clinical Decision-Making* Pregnancy is an exciting time for many clients, and the health of the developing fetus is a primary interest. One activity that a pregnant client can perform to help "keep an eye" on the developing fetus is to count the number of times the fetus kicks during a specific time frame. When teaching the client about this activity, the nurse should decide what is essential for this client to know about the frequency of the kicks and the counting process. It is important for the client to understand expected outcomes in order to prevent unwarranted worry or concern. The fetus will usually kick 10 times over 3 hours. The client should be informed when to report unexpected results to the health care provider. *Content Refresher* During prenatal care visits, the nurse will observe for the physiological changes as predicted throughout the pregnancy and question the client about noted observations, while explaining the purpose of the change in bodily function. During the third trimester, the client should demonstrate an understanding of the signs of premature labor; symptoms to report that could indicate infection, gestational diabetes, or pregnancy-induced hypertension; and signs of potential fetal distress. The nurse can teach the client how to perform kick-counts as a way of assessing fetal wellbeing.

The nurse on the medical surgical unit receives the shift report. Which client will the nurse see first? 1. A client 1 day postoperative after an appendectomy. 2. A client who had a detached retina surgically repaired 4 hours ago. 3. A client with an esophagogastric tube inserted. 4. A client 2 days postoperative after a laminectomy with spinal fusion.

1) INCORRECT— This is a stable client with expected outcomes. This client is not a priority. 2) INCORRECT — This client will require assessment and teaching, but there is another client who is a higher priority. 3) CORRECT — Esophagogastric tubes are used to treat bleeding esophageal varices. This client is at high risk for bleeding and hypotensive shock. The nurse should assess vital signs for decreased blood pressure and elevated pulse, and should ensure that balloon pressure and volume are maintained. This client represents a circulatory risk and is the highest priority. 4) INCORRECT — This client will require assessment and teaching, but there is another client who is a higher priority. *Think Like A Nurse: Clinical Decision Making* In determining which client to see first, the nurse considers which client is most unstable. While there are no indicators that any of these four clients are currently unstable, the client at highest risk for complications is the client with an esophagogastric tube. An esophagogastric tube is used to compress bleeding esophageal varices. Because this client has a history of bleeding, the priority is to assess this client's blood pressure and heart rate. The other clients are not experiencing any changes with airway, breathing, or circulation and can be seen afterwards. *Content Refresher* Complications associated with cirrhosis include portal hypertension, esophageal varices, ascites, hepatic encephalopathy, and death. Balloon tamponade through an esophagogastric tube is the treatment method used to manage bleeding esophageal varices. Bleeding from esophageal varices can lead to a compromised airway and a decrease in cardiac output. With a decrease in cardiac output, there is a potential for inadequate tissue perfusion and oxygenation.

The nurse coordinates care for clients in the emergency department (ED). Which activity can the nurse properly delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) 1. Determine appropriate room placement of clients. 2. Transport a client to the radiology department for a diagnostic procedure. 3. Discontinue a client's peripheral intravenous access. 4. Chaperone the health care provider during a client's pelvic examination. 5. Determine the size of equipment needed for a client's care. 6. Explain to a client the reasons to return to the ED for treatment.

2, 4 1) INCORRECT - This activity requires assessment and nursing judgment as room assignments are decided with respect to client acuity, diagnosis, and the primary nurse's current client load. 2) CORRECT - The UAP can transport stable clients, so this activity can be delegated to the UAP. 3) INCORRECT - This activity requires assessment by the nurse to ensure the catheter tip is intact. 4) CORRECT - The UAP can chaperone the health care provider for examinations as chaperoning merely requires the presence of another person in the room. Therefore, this activity can be delegated to the UAP. 5) INCORRECT - This activity requires nursing judgment. Once the nurse determines the appropriate size of needed equipment, the UAP can then gather equipment. 6) INCORRECT - This activity describes client teaching, which is the nurse's responsibility. It cannot be delegated to the UAP. *Think Like a Nurse: Clinical Decision-Making* The nurse may delegate components of client care but may not delegate the nursing process itself. The five rights of delegation include right task, right circumstances, right person, right communication, and right supervision. Core nursing functions of assessment, planning, evaluation, and formulation of nursing judgments cannot be delegated. Each state designates which tasks may be safely delegated to nursing team members. The nurse is required to be familiar with the nursing assistive personnel's scope of practice and job description. *Content Refresher* During delegation of client care, the nurse transfers responsibility and authority to another health care team member. However, the nurse maintains accountability for task completion. Delegation of nursing tasks to the UAP requires consideration of factors, including the UAP's scope of practice, the client's health status, potential safety risks, and the desired client outcome. The nurse must assess the UAP's knowledge, training, and competency level relevant to the task. During delegation, the nurse must provide clear instructions to the UAP and evaluate the UAP's comprehension of the instructions prior to initiating the task. The nurse completes post-task assessment and outcomes evaluation.

The nurse overhears two nursing assistive personnel (NAP) discuss a client's protected health information (PHI) in a public elevator. Which action does the nurse take next? 1. Assess the elevator for visitors and nonstaff passengers. 2. Contact the supervisor on the floor where the NAPs work. 3. Instruct the NAPs to stop the conversation immediately. 4. Notify the hospital risk manager and ethics committee.

3 1) INCORRECT - PHI should never be discussed in public spaces as this violates the client's right to confidentiality. It is difficult, if not impossible, to safeguard client PHI in public spaces. 2) INCORRECT - The nurse's supervisor should be notified. Then, that nursing supervisor can notify the supervisor on the floor where the NAPs work. However, immediate action is required by the nurse to halt the conversation before any additional client PHI is divulged. 3) CORRECT—The nurse's priority action is to stop the conversation before additional, confidential information about the client is shared. PHI should not be discussed in public spaces where information can be heard by those who do not have a "need to know." 4) INCORRECT - The nurse's supervisor should be notified. Then, that nursing supervisor can notify the supervisor on the floor where the NAPs work. Immediate action, however, is required by the nurse to halt the conversation before any additional client PHI is divulged. *Think Like A Nurse: Clinical Decision Making* All health care providers have the responsibility to ensure that all clients are treated with respect and receive the privacy that they deserve. The inappropriate discussion of a client's personal health information is a violation of the trust that the client has in the health care system and those who provide the care. The nurse knows that discussing a client's private information hinders this trusting relationship and it must be stopped. The only appropriate action in this scenario is to direct the care providers to immediately stop discussing the client's information. *Content Refresher* Client privacy is an ethical principle that guides nursing practice; the client has the right to privacy with regard to health and other personal information.Provide client/family written and verbal information about the protection of privacy and personal health information in the clinical setting. Maintain confidentiality and establish professional boundaries with colleagues that support the privacy of health information. Advocate for clients who cannot communicate their desires. If obtaining collateral information or sharing information necessary to deliver the highest quality care in an emergency situation, obtain consent as soon as possible from client, if possible, or client representative.

A client reports difficulty falling asleep at night. Which activities will the nurse recommend to this client? (Select all that apply.) 1. Eat a heavy meal within 2 hours of bedtime. 2. Have a glass of wine 30 minutes before bedtime. 3. Arise at a specific hour every morning. 4. Exercise 1 hour before bedtime. 5. Drink warm milk before bedtime. 6. Take a warm bath before bedtime.

3, 5, 6 1) INCORRECT - Eating a heavy meal within 2 hours of bedtime prevents sleep for most people. 2) INCORRECT - Ingesting alcohol 30 minutes before bedtime prevents sleep for most people. 3) CORRECT — Arising at a specific hour every morning promotes sleep by following a set schedule. 4) INCORRECT - Exercise before bedtime prevents sleep by stimulating the body and increasing the metabolism. 5) CORRECT — Warm milk promotes sleep because milk may encourage the release of serotonin, which has a calming effect. 6) CORRECT — A warm bath promotes sleep by helping with relaxation. *Think Like a Nurse: Clinical Decision-Making* When providing care to a client who is experiencing sleep difficulties, the nurse recommends following sleep rituals and routines that help promote adequate sleep. The nurse can also suggest specific interventions known to promote sleep. These interventions may include waking up the same time every day (which supports a set schedule for sleep), drinking warm milk (which facilitates the release of serotonin which promotes sleep), or taking a warm bath (which relaxes muscles and prepares the body for rest and sleep). *Content Refresher* The nurse needs to determine the client's sleep and activity pattern. Encourage the client to establish a bedtime routine to facilitate transition to sleep. Other topics of discussion with client may include comfort measures, sleep promoting techniques, and lifestyle changes that can contribute to optimal sleep. The nurse would also review the client's physical and psychosocial health status, and prescribed medications to determine a possible cause for the client's insomnia.

The nurse plans care for a client diagnosed with Clostridium difficile. Which transmission-based precautions should the nurse implement? 1. Standard precautions. 2. Airborne precautions. 3. Droplet precautions. 4. Contact precautions.

4) CORRECT— A client diagnosed with Clostridium difficile must be placed under contact precautions . Initiating contact precautions is essential when the organism can be transmitted by direct contact.

a patient who has had an acute myocardial infarction has been started on spironolactone 50 mg/day. when evaluating routine lab work, the nurse discovers the patient has a potassium level of 5.8 mEq/L. what is the priority nursing intervention? a. dose should be held and intake of foods rich in potassium should be restricted b. dose should be continued and the patient should be encouraged to eat fruits and vegetables c. dose should be increased and the patient instructed to decrease foods rich in potassium d. instruct the patient to continue with the current dose and report any signs or symptoms of hypokalemia

A

in which patient are loop diuretics contraindicated? a. the patient with anuria b. patient with asthma c. patient with allergy to ceftriaxone d. patient with gastric ulcers

A

the nurse assesses the patient who is taking HCTZ for hypertension. what might the nurse expect to see if the patient is experiencing undesired side effects? (select all that apply) a. diarrhea b. dizziness c. headache d. hypocalcemia e. vomiting

A, B

the 65 year old patient had an acute myocardial infarction 6 months ago and has been prescribed spironolactone 100 mg/day to treat an irregular heart rate. what statement by the patient indicates that he understands the medication teaching the nurse has provided? a. I need sodium so my heart beats regularly b. this drug is dangerous if you have had a heart attack c. it helps keep potassium so my heart does not get irregular d. I need to take it with lots of bananas to keep my potassium up

C

A patient is admitted to the intensive care unit with increased intracranial pressure. The nurse would anticipate administering a. furosemide. b. mannitol. c. triamterene. d. spironolactone.

B

A patient is receiving furosemide. It is most important for the nurse to monitor the patient for the development of a. hyperkalemia. b. hypokalemia. c. hyponatremia. d. hypernatremia.

B

Before administering triamterene, it is most important for the nurse to determine if the patient is also receiving a. digoxin. b. potassium chloride. c. acetaminophen. d. doxazosin.

B

what is the optimal time to administer diuretics? a. at bedtime b. after arising for the day c. on an empty stomach d. with meals

B

what is the pharmacological action of spironolactone? a. increase potassium and sodium excretion b. promote potassium retention c. promote potassium and calcium retention d. promote potassium excretion and sodium retention

B

what should the nurse do when a patient is taking furosemide? a. instruct the patient to change positions quickly when getting out of bed b. assess blood pressure before administration c. administer the drug at bedtime for maximum effectiveness d. teach the patients to avoid fruits to prevent hyperkalemia

B

the nurse knows that which statement is correct regarding nursing care of a patient receiving HCTZ? (select all that apply) a. monitor patients for signs of hypoglycemia b. administer ordered potassium supplements c. monitor serum potassium and uric acid levels d. assess blood pressure before administration e. notify the health care provider is a patient has had oliguria for 24 hours

B, C, D, E

which type of diuretics are frequently prescribed to treat hypertension and congestive heart failure? (select all that apply) a. carbonic anhydrase inhibitors b. loop diuretics c. osmotic diuretics d. potassium sparing diuretics e. thiazide diuretics

B, D, E

A patient is taking furosemide 40 mg daily for heart failure and hypertension. It is most important for the nurse to assess the patient for the development of a. low serum potassium, sodium, and magnesium, and elevated calcium. b. low serum potassium and sodium, and elevated magnesium and calcium. c. low serum potassium, sodium, magnesium, and calcium. d. low serum potassium and sodium, with magnesium and calcium remaining normal.

C

A patient with congestive heart failure gains 5 pounds in 1 week. This most likely indicates a fluid weight gain of a. ½ L. b. 1 L. c. 2 L. d. 3 L.

C

Which statement will the nurse include when teaching a patient about loop diuretics? a. Take the medication at bedtime. b. Take the medication on an empty stomach. c. Rise slowly from a lying or sitting to standing position to prevent dizziness. d. Avoid fruit and vegetables in the diet.

C