Other

The office nurse, while reviewing a client's health information, notices that the client has recently started taking St. John's wort for symptoms of depression. What additional information is most important for the nurse to obtain?

St. John's wort is an herbal product commonly used by many clients to treat depression. However, it may interact with medications used to treat depression or other mood disorders, including tricyclic antidepressants, selective serotonin and/or norepinephrine receptor inhibitors (SSRIs/SNRIs), and monoamine oxidase inhibitors (MAOIs). Taking St. John's wort with these medications tends to increase side effects and could potentially lead to a dangerous condition called serotonin syndrome. Serotonin is a chemical produced by the body that is needed for the nerve cells and brain to function. Excessive serotonin causes symptoms that can range from mild (shivering and diarrhea) to severe (muscle rigidity, fever, and seizures). Severe serotonin syndrome can be fatal if it is not treated. (Option 2) The nurse can ask the client if a diagnosis of depression has been made by an HCP, but inquiring about possible medications that can interact with St. John's wort is more important at this time. (Option 3) St. John's wort may interfere with the absorption of iron and other minerals. This is a teaching point, but it is not the highest priority question to ask the client. (Option 4) St. John's wort can cause photosensitivity which could be exacerbated by use of tanning beds. However, this is not the highest priority question to ask the client. Educational objective:St. John's wort interferes with many prescription medications. It is a priority for the nurse to assess for concomitant use of St. John's wort with prescription SSRIs, MAOIs, or tricyclic antidepressants as such combinations can cause serotonin syndrome.

A client arrives at the clinic for a follow-up after an emergency department visit the night before. The client sustained an ulnar fracture, and a fiberglass cast was applied. Which of the following teachings related to cast care should the nurse reinforce?

Casts (eg, fiberglass, plaster) are applied to immobilize fractured extremities during healing. Instructions for cast care include: Report foul odors or hot areas (hot spots) in the cast, which may indicate infection (Option 1). Avoid getting the cast wet, which may damage the cast and cause skin irritation/infection (Option 2). Elevate the affected extremity above heart level for the first 48 hours to reduce edema (Option 3). Regularly perform isometric and range of motion exercises to prevent muscle atrophy.

A client admitted with acute myocardial infarction suddenly displays air hunger, dyspnea, and coughing with frothy, pink-tinged sputum. What would the nurse anticipate when auscultating the breath sounds of this client?

Acute-onset dyspnea and cough productive of pink, frothy sputum indicate severe pulmonary edema, likely a complication from myocardial infarction. Pink sputum results from ruptured bronchial veins due to high back pressure. The mix of blood and airway fluids creates the pink tinge. On assessment, crackles can be heard at the lung bases. (Option 1) Bronchial breath sounds are normally heard over the trachea. These are harsh and high-pitched; inspiration and expiration are of similar duration. The presence of these on lung periphery indicates pneumonia (consolidation). (Option 2) Clear vesicular breath sounds (normal breath sounds) are not expected in pulmonary edema. (Option 4) Stridor is consistent with a laryngospasm or edema of the upper airway. Educational objective: Acute-onset dyspnea and cough with frothy, pink-tinged sputum indicate pulmonary edema. Auscultation reveals crackles at the lung bases

Which clinical finding would the nurse anticipate in a client with chronic venous insufficiency?

Chronic venous insufficiency (CVI) occurs when the valves in the veins of the lower extremities consistently fail to keep venous blood moving forward, which causes chronic increased venous pressure. The increased pressure pushes fluid out of the vascular space and into the surrounding tissues, where tissue enzymes break down red blood cells. The destruction of red blood cells releases hemosiderin (a reddish-brown protein that stores iron), which causes a brownish skin discoloration; chronic edema and inflammation cause the tissue to harden and appear leathery (Option 1). Affected skin is highly prone to breakdown and ulcerations (eg, venous leg ulcers), commonly on the inside of the ankle. (Options 2, 3, and 4) Diminished pulses, nonhealing ulcers on a toe, and shiny, hairless extremities are usually associated with peripheral arterial disease due to hardening of the arterial walls, which constricts blood flow and impairs transportation of nutrients to tissues. Educational objective:Chronic venous insufficiency occurs when the valves in the veins of the lower extremities fail to keep blood moving forward. Chronic edema and inflammatory changes lead to brownish, thickened skin on the extremities and venous leg ulcers (commonly on the inside of the ankle).

The nurse is assessing a 70-year-old client with a long history of type 2 diabetes mellitus for sudden, severe nausea, diaphoresis, dizziness, and fatigue in the emergency department. Which hospital protocol would be the most appropriate to follow initially?

Early recognition and treatment of heart attack are critical. Women, the elderly, and clients with a history of diabetes may not have the classic heart attack symptoms of dull chest pain with radiation down the left arm. Instead, they can present with "atypical" symptoms such as nausea, vomiting, belching, indigestion, diaphoresis, dizziness, and fatigue. (Option 1) Taking a careful history and evaluating for any sick contacts would be helpful in identifying food poisoning, but a more important initial step is to assess for a heart attack. (Option 2) A viral infection is a possibility, but fever and myalgia are usually present during an episode of influenza. (Option 4) Early intervention in stroke is also critical, and a neurologic assessment would take place after the acute coronary syndrome algorithm, especially with negative electrocardiography and serum heart enzyme levels. Educational objective:Myocardial infarctions in women, the elderly, and diabetics may have gastrointestinal distress as the main symptom; this needs to be evaluated with the institutional protocol for acute coronary syndrome.

The home health nurse is visiting an infant who recently had surgery to repair tetralogy of Fallot. Which of the following signs of heart failure should the nurse teach the parents to report to the health care provider?

Following repair of tetralogy of Fallot, clients often develop chronic pulmonary regurgitation. Insufficient flow into the pulmonary vasculature causes the right ventricle to work harder, leading to right ventricular hypertrophy and a subsequent reduction in right ventricular function and cardiac output. The decrease in forward blood flow causes blood to back up into venous circulation, resulting in heart failure. Clinical manifestations of heart failure include: Pale, cool extremities due to reduced perfusion to the systemic circulation (Option 1) Periorbital edema (puffiness around the eyes) and rapid weight gain due to systemic venous congestion and fluid retention (Options 3 and 5) Reduction in the number of wet diapers due to reduced perfusion to the kidneys (Option 4) (Option 2) Infants with heart failure generally have decreased appetite and feeding due to dyspnea and fatigue.

A client is 1-day postoperative abdominoplasty and is discharged to go home with a Jackson-Pratt (JP) closed-wound system drain in place. The nurse teaches the client how to care for the drain and empty the collection bulb. Which statement indicates that the client needs further instruction?

It is common for clients to be discharged with a JP closed-wound surgical drain in place after abdominal and breast reconstruction surgery. The purpose of the drain is to prevent fluid buildup in a closed space, which can put tension on the suture line and compromise the integrity of the incision, increase the risk for infection, and decrease wound healing. The general procedure for emptying the drainage device includes the following steps in order: Perform hand hygiene as asepsis must be maintained to prevent the transmission of microorganisms even though there is less chance of bacteria entering the wound using a closed-wound drainage device (eg, JP, Hemovac) than an open-drain device (eg, Penrose) Pull the plug on the bulb to open the device and pour the drainage into a small, calibrated container (eg, plastic water cup, urine specimen container) as this facilitates recording accurate drainage output (Option 2) Empty the device every 4-12 hours unless it is 1/2 to 2/3 full before then because as the small capacity bulb (100 mL) fills, the amount of negative pressure in the bulb decreases (Option 1) Compress the empty bulb by squeezing it from side-to-side with 1 or 2 hands until it is totally collapsed. Although the reservoir can be collapsed by pressing the bottom towards the top, compressing the sides of the reservoir (bulb) is recommended as it is more effective in establishing negative pressure (Option 3) Clean the spout on the bulb with alcohol and replace the plug when it is totally collapsed to restore negative pressure (Option 4)

The nurse is reinforcing teaching about ulcer prevention with a client newly diagnosed with peptic ulcer disease. Which of the following client statements indicate appropriate understanding of teaching?

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

The nurse cares for a client who had an abdominal aortic aneurysm repair 6 hours ago. Which assessment findings would indicate possible graft leakage and require a report to the primary care provider?

Repair of abdominal aortic aneurysms can be done via femoral percutaneous placement of a stent graft (endovascular aneurysm repair) or via an open surgical incision of the aneurysm and placement of a synthetic graft. With either procedure, postoperative monitoring for graft leakage or separation is a priority. Manifestations of graft leakage include ecchymosis of the groin, penis, scrotum, or perineum; increased abdominal girth; tachycardia; weak or absent peripheral pulses; decreasing hematocrit and hemoglobin; increased pain in the pelvis, back, or groin; and decreased urinary output (Options 1, 2, and 4). (Option 3) Urinary output would be decreased due to inadequate perfusion to the kidney if a newly placed graft were leaking, causing hypotension. (Option 5) Increased thirst and appetite loss are not signs of graft leakage.

The clinic nurse provides teaching for a client scheduled for a barium enema the next day. Which statement by the client shows a need for further instruction?

A barium enema, or lower gastrointestinal series, uses fluoroscopy to visualize the colon outlined by contrast to detect polyps, ulcers, tumors, and diverticula. This procedure is contraindicated for clients with acute diverticulitis as it may rupture inflamed diverticula and cause subsequent peritonitis. Preprocedure instructions include: Take a cathartic (eg, magnesium citrate, polyethylene glycol) to empty stool from the colon. Follow a clear liquid diet the day before the procedure to aid in bowel preparation and to prevent dehydration; avoid red and purple liquids. Do not eat or drink anything 8 hours before the test (Option 2). Expect to be placed in various positions during the procedure. You may experience abdominal cramping and an urge to defecate (Option 3). Postprocedure instructions include: Expect the passage of chalky, white stool until all barium contrast has been expelled (Option 1). Take a laxative (eg, magnesium hydroxide [Milk of Magnesia]) to assist in expelling the barium. Retained barium can lead to fecal impaction (Option 4). Drink plenty of fluids to promote hydration and eat a high-fiber diet to prevent constipation. Educational objective:A barium enema uses fluoroscopy with contrast to evaluate for colon abnormalities. Before the procedure, clients undergo bowel preparation using cathartics and a clear liquid diet. Laxatives after the procedure assist in expelling the contrast

Which interventions should the nurse perform when assisting the health care provider with removal of a client's chest tube?

A chest tube is removed when drainage is minimal (<200 mL/24 hr) or absent, an air leak (if present) is resolved, and the lung has reexpanded. The general steps for chest tube removal include: Premedicate the client with analgesic (eg, IV opioid, nonsteroidal anti-inflammatory drug [ketorolac]) 30-60 minutes before the procedure to promote comfort as evidence indicates that most clients report significant pain during removal (Option 1). Provide the health care provider (HCP) with sterile suture removal equipment (Option 5). Instruct the client to breathe in, hold it, and bear down (Valsalva maneuver) while the tube is removed to decrease the risk for a pneumothorax. Most HCPs use this technique to increase intrathoracic pressure and prevent air from entering the pleural space (Option 2). Apply a sterile airtight occlusive dressing to the chest tube site immediately; this will prevent air from entering the pleural space (Option 4). Perform a chest x-ray within 2-24 hours after chest tube removal as a post-procedure pneumothorax or fluid accumulation usually develops within this time frame. (Option 3) The client should be placed in semi-Fowler's position or on the unaffected side to promote comfort and facilitate access for tube removal. Educational objective:Before chest tube removal, the client is given an analgesic and then asked to perform Valsalva during the procedure. The nurse should also bring sterile suture removal equipment and a sterile airtight occlusive dressing. Post-procedure chest x-ray is necessary within 2-24 hours

The nurse is caring for a client after a motor vehicle accident. The client's injuries include 2 fractured ribs and a concussion. The nurse notes which of the following as expected neurological changes for the client with a concussion?

A concussion is considered a minor traumatic brain injury and results from blunt force or an acceleration/deceleration head injury. Typical signs of concussion include: A brief disruption in level of consciousness Amnesia regarding the event (retrograde amnesia) Headache These clients should be observed closely by family members and not participate in strenuous or athletic activities for 1-2 days. Rest and a light diet are encouraged during this time. (Options 1 and 4) The following manifestations indicate more serious brain injury and are not expected with simple concussion: Worsening headaches and vomiting (indicate high intracranial pressure) Sleepiness and/or confusion (indicate high intracranial pressure) Visual changes Weakness or numbness of part of the body Educational objective:Expected neurological changes with a concussion include brief loss of consciousness, retrograde amnesia, and headache. These clients should be observed closely by family members and not participate in strenuous or athletic activities for 1-2 days

A client is scheduled for a coronary arteriogram procedure. Which information should the nurse provide to the client prior to the procedure?

A coronary arteriogram (angiogram) is an invasive diagnostic study of the coronary arteries, heart chambers, and function of the heart. It requires that the client have an intravenous (IV) line started for sedating medications; the femoral or radial artery will be accessed during the procedure. The client should be instructed: Not to eat or drink anything for 6-12 hours prior to the procedure (depending on the particular health care provider performing the procedure) (Option 4) The client may feel warm or flushed while the contrast dye is being injected (Option 2) Hemostasis must be obtained in the artery that was cannulated for the procedure. Most commonly, this is the femoral artery. Compression is applied to the puncture site and the client may have to lie flat for several hours to ensure hemostasis (Option 1)

The telemetry nurse reports the cardiac monitor rhythms of 4 clients to the medical unit nurse assigned to care for them. The nurse should assess the client with which rhythm first?

A demand ventricular electronic pacemaker set at 70/min delivers an impulse (fires) when it senses an intrinsic rate below the predetermined rate of 70/min. Failure to capture occurs when the pacemaker sends an impulse to the ventricle, but the myocardium does not depolarize (pacer spike with no QRS complex; no palpable pulse beat); this is usually associated with pacer lead (wire) displacement or battery failure. The malfunction can result in bradycardia (pulse <60/min) or asystole and decreased cardiac output; the nurse should perform an assessment and notify the health care provider immediately. (Option 1) Clients with atrial fibrillation are usually prescribed an anticoagulant, such as rivaroxaban (Xarelto), due to increased risk for blood clots that can lead to stroke. This client's ventricular rate is controlled, so there is no urgency. (Option 3) First-degree atrioventricular (AV) block can be associated with beta-adrenergic blocker drugs, such as atenolol (Tenormin), as they delay conduction at the AV node. This is reflected as prolonged PR interval on ECG. Although first-degree AV block should be monitored for progression, it is an expected adverse drug effect. Only second- or third-degree heart block should be the priority. (Option 4) Dehydration can cause hypotension. Tachycardia is a normal compensatory mechanism to increase the cardiac output associated with hypotension. Educational objective:A demand electronic pacemaker should deliver an impulse when it senses an intrinsic pacemaker drop below a predetermined rate. Bradycardia with failure to capture (pacer spike with no QRS complex) indicates malfunction and requires immediate notification of the health care provider

While preparing to insert a peripheral IV line, the nurse notices scarring near the client's left axilla. The client confirms a history of left breast cancer and modified radical mastectomy. Which actions should the nurse take? Select all that apply.

A modified radical mastectomy includes removal of axillary lymph nodes that are involved in lymphatic drainage of the arm. Any trauma (eg, IV extravasation) to the arm on the operative side can result in lymphedema, characterized by painful and lengthy swelling, as normal lymphatic circulation is impaired by scarring. Therefore, starting an IV line in this arm is contraindicated. The nurse should insert the IV line into the most distal site of the unaffected side (Option 2). For client safety, it is also important to ensure documentation of the mastectomy history, place a restricted extremity armband on the affected arm, and place a sign above the client's bed notifying hospital staff of necessary mastectomy precautions (eg, no blood pressure measurements, venipuncture, or IV lines) (Options 3 and 4). In general, venipuncture is contraindicated in upper extremities affected by: Weakness Paralysis Infection Arteriovenous fistula or graft (used for hemodialysis) Impaired lymphatic drainage (prior mastectomy) (Option 1) The stylet should be advanced until blood return is seen (approximately ¼ inch). If advanced fully, the stylet may penetrate the posterior wall of the vein and cause a hematoma. (Option 5) Keeping the affected arm in a dependent position for a long time can increase lymphedema. The client should be reminded that raising the limb helps drainage. Educational objective:IV line insertion is contraindicated on the operative side of clients with a prior mastectomy. Additional contraindications for IV line insertion include weakness, paralysis, or infection of the arm; or presence of an arteriovenous fistula

A postoperative client who is receiving continuous enteral feedings via a nasoenteric tube becomes dyspneic with a productive cough, and the nurse auscultates crackles and diminished breath sounds in lung bases. Which action is appropriate at this time?

A nasoenteric tube is passed through the nares into the duodenum or jejunum when it is necessary to bypass the esophagus and stomach. Nasoenteric tubes have a decreased risk of aspiration compared with nasogastric tubes; however, a nasoenteric tube can become dislodged to the lungs, causing aspiration of enteral feedings. If a client with a feeding tube develops signs of aspiration pneumonia (diminished or adventitious lung sounds [eg, crackles, wheezing], dyspnea, productive cough), the feeding should be stopped immediately and tube placement checked (eg, measure insertion depth, obtain x-ray, assess aspirate pH) (Option 2). Some facilities use capnography to determine placement; if a sensor detects exhaled CO2 from the tube, it is in the client's airway and must be removed immediately. (Option 1) An inhaled bronchodilator may be prescribed to treat aspiration pneumonia, but the priority is to stop the feeding and check tube placement to prevent additional aspiration. (Option 3) Crackles may be heard with fluid overload, aspiration, or pneumonia. A diuretic would be appropriate if a client is experiencing pulmonary edema from fluid overload. If a client receiving enteral feedings develops signs of aspiration, the nurse should initially hold feedings and assess tube placement. (Option 4) Incentive spirometry promotes expansion of the lungs and resolves atelectasis; however, the priority for this client is assessing for and preventing aspiration. Educational objective:Nasoenteric tubes can become dislodged, causing the tube to enter the stomach or lungs. Feedings should be stopped immediately and tube placement checked if the client develops signs of aspiration.

The nurse is drawing blood from a client's peripheral vein for laboratory specimens. Which of the following are correct nursing actions?

A tourniquet is applied 3-5 inches above the desired puncture site for no longer than 1 minute when looking for a vein. If longer time is needed, release the tourniquet for at least 3 minutes before reapplying. Prolonged obstruction of blood flow by the tourniquet can change some test results. Pulsating bright red blood indicates that an artery was accessed. If this happens, the needle should be removed immediately and pressure should be applied for at least 5 minutes, followed by a pressure dressing to prevent a hematoma. (Option 2) Skin preparation involves cleaning using an antiseptic solution and friction and allowing the skin to air dry. Remaining solution may hemolyze and/or dilute the blood sample. Traditionally, alcohol (alone or with povidone iodine) is applied in a circular motion, from insertion site outward (clean to dirty). Current research suggests that the most effective method is applying chlorhexidine (2%) in a back and forth motion, followed by adequate drying time. (Option 4) The veins on the ventral aspect of the wrist are located near nerves, resulting in painful venipuncture and a higher risk of nerve injury. There is also an increased risk of arterial access on the ventral aspect of the wrist, and so this site should be avoided. (Option 5) The filled tube should be gently inverted 5-10 times to mix anticoagulant solution with the blood. Vigorously shaking the tube can cause hemolysis and false results. Educational objective: When performing phlebotomy for a laboratory specimen, allow the cleansed area to air dry, do not use the veins on the ventral side of wrist, position the tourniquet for no more than 1 minute at a time, and invert the tube gently 5-10 times to mix the solution with blood. Insertion in an artery will cause pulsation; if this happens, immediately remove the needle and apply pressure for 5 minutes.

The nurse is caring for a client receiving mechanical ventilation via tracheostomy 2 weeks following a tracheotomy. The nurse enters the client's room to address a ventilator alarm and notes the tracheostomy tube dislodged and lying on the client's chest. Which action by the nurse is appropriate?

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

A client has just returned from the cardiac catheterization laboratory for a permanent pacemaker placement. How should the nurse document the rhythm on the client's cardiac monitor?

An atrioventricular pacemaker (also known as a sequential or dual chamber pacemaker) paces the right atrium and right ventricle in sequence. The ECG will have 2 pacer spikes, one before the P wave and one before the QRS complex. The P wave following the atrial pacer spike may be normal or abnormal appearing. The QRS complex following the ventricular pacer spike is typically wide and distorted. An atrioventricular pacemaker can improve synchrony between the atria and ventricles. It may be implanted in the client with bradycardia, heart block, or cardiomyopathy.

The caregiver of a toddler calls the clinic because the child has accidentally ingested one capsule of amitriptyline found in the medicine cabinet. The caregiver states that the child appears to be acting normally. Which response by the nurse is appropriate?

Amitriptyline is a tricyclic antidepressant (TCA) that can produce cardiac toxicity and neurological disturbances by altering cholinergic pathways, sodium channels, and calcium channels, causing symptoms such as atrioventricular block, hypotension, cardiac arrest, and seizure. TCAs have a narrow therapeutic index and rapid onset of action, so ingestion of even a small amount may be life-threatening for a toddler. Symptoms of toxicity are usually evident within hours of ingestion, but cardiac failure can develop days after. Neurological and hemodynamic assessments, as well as ECG monitoring in an emergency department setting, are recommended (Option 2). (Option 1) Syrup of ipecac is no longer routinely recommended for oral poisonings. The uncontrolled vomiting and vagal response induced can be harmful after ingestion of toxic substances. Treatments such as oral activated charcoal may be used in the inpatient setting to remove the ingested toxin if the client presents immediately after the ingestion. (Option 3) The caregiver should not be instructed to stay home to monitor for symptoms due to the rapid onset of toxicity. (Option 4) An outpatient clinic is not sufficiently staffed or equipped for acute management of amitriptyline toxicity. The nurse should refer the client to the nearest emergency department, which is the safest environment for monitoring and treatment. Educational objective:Amitriptyline is a tricyclic antidepressant (TCA) that can cause toxic cardiac and neurological effects in children, even in small doses. Children who have accidentally ingested TCAs should be evaluated immediately in an emergency department

The nurse is reinforcing education to the caregivers of a 9-year-old client diagnosed with scarlet fever. The client has a history of type 1 diabetes mellitus. Which statement by the caregivers indicates that further teaching is needed?

An acute illness (eg, scarlet fever) in clients with type 1 diabetes may trigger the release of stress hormones, which leads to higher blood glucose and ketone levels (sometimes leading to ketoacidosis). Clients with type 1 diabetes do not produce any insulin (unlike those with type 2 diabetes), so clients should not skip administration of external insulin even if not eating. Insulin therapy should be continued as prescribed during an acute illness (Option 4). Additional sick-day management includes: Increasing frequency of blood glucose level checks (every 1-4 hours) Increasing or decreasing the dose of insulin as needed based on blood glucose levels Maintaining adequate hydration Testing for urinary ketones frequently (Options 1 and 3) Stress hormones released during illness cause increased insulin resistance and lead the body to break down fat for energy. Ketones are produced when fat is broken down, which can lead to diabetic ketoacidosis (DKA). The client's urine should be monitored frequently for ketones while the client is sick. Fluids are encouraged to clear ketones from the system and prevent dehydration. (Option 2) Blood glucose should be assessed frequently while the client is ill due to the potentially unpredictable and rapidly changing levels caused by illness and/or fasting. Educational objective:Clients with type 1 diabetes should not discontinue insulin usage during an illness. Encouraging fluids and monitoring glucose and ketone levels are priorities for this client

A client is being discharged after receiving an implantable cardioverter defibrillator. Which statement by the client indicates that teaching has been effective?

An implantable cardioverter defibrillator (ICD) can sense and defibrillate life-threatening dysrhythmias. It also includes pacemaker capabilities such as overdrive pacing for rapid heart rhythms or back-up pacing for bradycardias that may occur after defibrillation. The ICD consists of a lead system placed into the endocardium via the subclavian vein. The pulse generator is implanted subcutaneously over the pectoral muscle. Postoperative care and teaching are similar to those for pacemaker implantation. Clients are instructed to refrain from lifting the affected arm above the shoulder (until approved by the health care provider) to prevent dislodgement of the lead wire on the endocardium (Option 2). (Option 1) Firing of the ICD may be painful. Clients have described the feeling as a blow to the chest. (Option 3) Driving may be approved by the health care provider after healing has occurred. Long-term decisions are based on the ongoing presence of dysrhythmias, frequency of ICD firings, and state laws regarding drivers with ICDs. (Option 4) Travel is not restricted. The ICD may set off the metal detector in security areas. A hand-held wand may be used but should not be held directly over the ICD. The client should carry the ICD identification card and a list of medications while traveling. Educational objective:After placement of an implantable cardioverter defibrillator, clients are instructed to avoid lifting the arm on the side of the ICD above the shoulder (until cleared by the health care provider) to avoid dislodging the lead wire system.

While turning a client, the nurse observes that the client's radiation implant has dislodged and is now lying on the linens. Which action by the nurse is appropriate?

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

The nurse has just administered a dose of 0.5 mg atropine to a client with a heart rate of 48/min and blood pressure of 90/62 mmHg. Which rhythm strip would indicate that the medication achieved the desired outcome?

Atropine is given to the client experiencing symptomatic bradycardia. In symptomatic bradycardia, the heart rate is <60/min and is inadequate for the client's condition, causing symptoms such as hypotension, chest pain, or syncope. Atropine acts to increase the heart rate by inhibiting the action of the vagus nerve (parasympatholytic effect). A normal sinus rhythm and reversal of clinical symptoms indicate that the medication has had the desired effect. (Option 1) A continuation of sinus bradycardia would not indicate that the atropine had been effective. (Option 3) Sinus tachycardia would be an undesirable effect of atropine as the heart rate would be >100/min. (Option 4) The client with first-degree atrioventricular block may have a normal heart rate, but the atrioventricular conduction time is prolonged. Educational objective:Atropine is given to the client with symptomatic bradycardia. The desired outcome would be an increase in heart rate, evidence of normal sinus rhythm on the cardiac monitor, and reversal of any clinical symptoms associated with the bradycardia

A cardiac catheterization was performed on a client 2 hours ago. The catheter was inserted into the left femoral artery. What signs of potential complications should the nurse report immediately to the health care provider (HCP)? Select all that apply. ​​​​​​​ (Option 5) Urine output in this client is above 30 mL/hr and considered to be within the normal range.

Bleeding at the puncture site indicates that a clot has not formed at the insertion site. This is an arterial bleed as catheterization was done via the femoral artery. Arterial bleeds can lead to hypovolemic shock and death if not treated immediately. Reduced warmth in the lower extremity of the insertion site is a sign of decreased perfusion (lack of oxygenated blood flow) to the extremity and can result in tissue necrosis of the affected area. (Option 2) The client may lie flat for several hours and is encouraged to engage in quiet activities for 24 hours after the procedure to prevent dislodging the clot at the insertion site. (Option 3) Although clients are encouraged to drink fluids to flush dyes out of their system and prevent dehydration, decreased fluid intake would not warrant notifying the HCP. (Option 5) Urine output in this client is above 30 mL/hr and considered to be within the normal range. Educational objective:If not treated immediately, arterial bleeds can lead to hypovolemic shock and death. Reduced warmth in the lower extremity of the catheter insertion site is a sign of decreased perfusion (lack of oxygenated blood flow)

The nurse admits an adult client with partial-thickness burns to the anterior surface of the right leg and the anterior and posterior torso. The client weighs 198 lb. The total body surface area burned is calculated using the rule of nines. How many mL of IV fluid will the client require in the first 24 hours?

Burn injuries are caused by direct tissue damage from exposure to caustic sources (eg, thermal, chemical, electric). This initial tissue injury, combined with the systemic inflammatory response, causes increased capillary permeability, fluid and electrolyte shifts, and decreased intravascular volume. These intravascular losses often lead to hypovolemic shock in clients with extensive burns and require emergency fluid resuscitation for client survival. The Parkland formula is an IV fluid resuscitation protocol used to calculate the fluid replacement needed in the first 24 hours after a burn injury. Half of the calculated fluid volume is administered during the first 8 hours after the injury, when many clients have the greatest amount of intravascular volume loss. Use the following steps to calculate the volume needed for infusion: Calculate the total body surface area (TBSA) burned using the rule of nines (anterior torso)+(posterior torso)+(anterior leg)=TBSA burnedanterior torso+posterior torso+anterior leg=TBSA burned OR 18%+18%+9%=45% TBSA burned18%+18%+9%=45% TBSA burned Convert pounds to kilograms to determine body weight (1 kg2.2 lb)(198 lb )=90 kg1 kg2.2 lb198 lb =90 kg Calculate the volume needed for infusion 4 mL × body weight (kg)×TBSA burned (%)=infusion volume (mL)4 mL × body weight kg×TBSA burned %=infusion volume mL OR 4 mL × 90 kg × 45% TBSA = 16200 mL4 mL × 90 kg × 45% TBSA = 16200 mL Educational objective:The Parkland formula (4 mL × body weight [kg] × total body surface area burned [%]) is used to calculate the amount of IV fluid required for a client during the initial 24 hours after a burn injury. Half of the calculated volume is administered within the first 8 hours

The nurse is caring for a client after percutaneous placement of a coronary stent for a myocardial infarction. The client rates lower back pain as 5 on a scale of 0-10 and has blood pressure of 140/92 mm Hg. The cardiac monitor shows normal sinus rhythm with occasional premature ventricular contractions. Which prescription should the nurse administer first? Normally, your blood potassium level is 3.6 to 5.2 millimoles per liter (mmol/L)

Clients with myocardial infarction (MI) are at risk for life-threatening dysrhythmias (eg, heart block, ventricular tachycardia, ventricular fibrillation) both during the MI and following reperfusion therapy (eg, coronary artery stenting). Myocardial ischemia damages cardiac muscle cells, causing electrical irritability (eg, premature ventricular contractions) that can be exacerbated by electrolyte imbalances (eg, hypokalemia). Hypokalemia hyperpolarizes cardiac electrical conduction pathways, increasing the risk for dysrhythmias. Therefore, prompt potassium replacement is the priority in these clients (Option 3). (Option 1) ACE inhibitors (eg, captopril, enalapril, lisinopril) help reduce the risk of future MIs by reducing blood pressure and cardiac workload and inhibiting ventricular remodeling. ACE inhibitors should be administered after MI; however, life-threatening dysrhythmias pose a higher risk to the client. (Option 2) Administering morphine is an appropriate intervention to address the client's back pain, but it is not the priority. (Option 4) Strict glycemic control in the resolution phase of an acute MI is associated with better long-term outcomes (eg, reduced morbidity/mortality), but it does not take priority. Educational objective:Prompt potassium replacement is the priority action for hypokalemic clients with myocardial infarction because they are at increased risk for life-threatening dysrhythmias (eg, heart block, ventricular tachycardia, ventricular fibrillation) and cardiac arrest.

A client is brought to the emergency department with multiple trauma injuries. The nurse sees the client's Jehovah's Witness identification card. As part of providing culturally competent care, the nurse would anticipate the client accepting which of the following?

Culturally competent nursing care involves recognizing certain cultural and religious beliefs. A health-related belief of Jehovah's Witnesses is that transfusions containing blood in any form are not acceptable. Witnesses do not accept transfusions of whole blood or any of its 4 major components (ie, red cells, white cells, platelets, and plasma) (Options 2, 3, and 5). Shock prevention is a major concern in the setting of blood loss and can be accomplished with the use of non-blood volume expanders such as saline, lactated Ringer's, dextran, and hetastarch. These can be administered safely to clients who refuse blood products (Option 4). Recombinant human erythropoietin (eg, epoetin alfa) and IV iron are accepted by most Jehovah's Witnesses. These medications stimulate the bone marrow to produce more red blood cells, resulting in increased hematocrit and hemoglobin levels (Option 1). Educational objective:Jehovah's Witnesses believe that transfusion of blood and blood products is not acceptable. Acceptable blood product alternatives include non-blood volume expanders (eg, saline, lactated Ringer's, dextran, hetastarch) and albumin-free erythropoietin. Unacceptable treatments are transfusions of whole blood, red cells, white cells, platelets, and plasma.

A client is receiving a continuous heparin infusion and the most recent aPTT is 140 seconds. The nurse notices blood oozing at the surgical incision and IV insertion sites. What interventions should the nurse implement?

Depending on the institution and HCP, a therapeutic aPTT level for a client being heparinized is somewhere between 46-70 seconds (1.5-2.0 times the baseline value). An aPTT of 140 seconds is too long and this client is showing signs of bleeding. The nurse should stop the heparin infusion, notify the HCP, and review administration guidelines for possible administration of protamine (reversal agent for heparin). (Option 1) Continuing the heparin infusion will put the client at risk for a severe bleeding episode. (Option 2) Vitamin K is the reversal agent for warfarin. (Option 3) There is no reason to redraw blood for laboratory workup at this time as the abnormal aPTT result is consistent with the client's bleeding. Laboratory studies may need to be redone within 1 hour of stopping the infusion or giving a reversal agent. Educational objective:The nurse should stop the infusion of heparin when there is evidence of bleeding. The HCP should be notified immediately and the nurse should be prepared to give protamine if ordered.

A client with a blood pressure (BP) of 250/145 mm Hg is admitted for hypertensive crisis. The health care provider prescribes a continuous IV infusion of nitroprusside sodium. Which of these is the priority goal in initial management of hypertensive crisis?

Hypertensive crisis is a life-threatening emergency due to the possibility of severe organ damage. If not treated promptly, complications such as intracranial hemorrhage, heart failure, myocardial infarction (MI), renal failure, aortic dissection, or retinopathy may occur. Emergency treatment includes IV vasodilators such as nitroprusside sodium. It is important to lower the blood pressure slowly, as too rapid a drop may cause decreased perfusion to the brain, heart, and kidneys. This may result in stroke, renal failure, or MI. The initial goal is usually to decrease the MAP by no more than 25% or to maintain MAP at 110-115 mm Hg. The pressure can then be lowered further over a period of 24 hours. MAP is calculated by adding the systolic blood pressure (SBP) and double the diastolic blood pressure (DBP), and then dividing the resulting value by 3. MAP = (2 x DBP + SBP) / 3 (Option 2) A blood pressure of 120/80 mm Hg (MAP 93 mm Hg) is too low for an initial goal. This rapid drop from the client's initial pressure of 250/145 mm Hg (MAP 180 mm Hg) is a decrease of greater than 25% and could cause organ damage. However, it may be necessary to lower the SBP below 120 mm Hg if the client is experiencing an aortic dissection, as a higher BP can cause rupture. (Option 3) The nurse should monitor HR and rhythm for signs of MI or heart failure. However, the priority goal for this client is to achieve a therapeutic blood pressure, not HR. (Option 4) The nurse should carefully monitor urine output as an indicator of renal function. Output should be greater than 30 mL/hr, but this is not the priority goal in management of hypertensive crisis.

The client has a chest tube for a pneumothorax. While repositioning the client for an x-ray, the technician steps on the tubing and accidently pulls the chest tube out. The client's oxygen saturation drops and the pulse is 132/min; the nurse hears air leaking from the insertion site. What is the nurse's immediate action?

If the chest tube is dislodged from the client and the nurse hears air leaking from the site, the nurse's immediate action should be to apply a sterile occlusive dressing (eg, petroleum jelly dressing) taped on 3 sides. This action permits air to escape on exhalation and inhibits air intake on inspiration. The nurse would then notify the HCP and arrange for the reinsertion of another chest tube (Option 1). (Option 2) A tension pneumothorax develops when air enters the pleural space but cannot escape. Increased intrapleural pressure and excessive accumulation of air can apply pressure to the heart and great vessels and drastically decrease cardiac output. An occlusive dressing taped on 4 sides would prevent the air in the pleural space from escaping on exhalation and would increase the risk for a tension pneumothorax. (Option 3) The nurse would stay with the client, assess lung sounds, and monitor vital signs frequently; however, this is not the immediate action. (Option 4) The nurse would notify the HCP and prepare for reinsertion of a chest tube, but it is not the immediate action. Educational objective:If a chest tube is dislodged from the client and the nurse hears air leaking from the site, the immediate action should be to apply an occlusive sterile dressing taped on 3 sides. This action decreases the risk for a tension pneumothorax by inhibiting air intake on inspiration and allowing air to escape on expiration.

The nurse is caring for a client with chronic, stable angina. The client takes the long-acting nitrate isosorbide mononitrate. Which client outcome indicates that the drug is effective?

Long-acting nitrates are used to reduce the incidence of anginal attacks. Nitrates are effective if the client is able to do activities without the incidence of chest pain. The client should be taught to report any increase in chest pain and how to manage headaches, a common side effect of nitrates. (Options 2 and 3) A reduction in stress level and anxiety, and being able to sleep through the night are positive outcomes for any client with cardiovascular disease. However, these outcomes are not directly related to long-acting nitrate use. (Option 4) Nitrates are vasodilators and may decrease the client's blood pressure, which is a positive outcome but not the primary reason for taking the medication. This client is taking the medication for angina. Educational objective:The ability to perform activities without chest pain is a desirable client outcome of long-acting nitrate use. The nurse would want to assess for this outcome in clients taking these medications

The nurse is preparing to administer 40 mg of IV furosemide. Prior to administering the medication, the nurse should assess which parameters?

Loop diuretics (furosemide, torsemide, bumetanide) are used to treat fluid retention, such as that found in clients with heart failure or cirrhosis. When administering loop diuretics, the nurse can expect the client's kidneys to excrete a significant amount of water and potassium. When potassium is excreted at a fast rate, the client could develop hypokalemia, a medical emergency that can result in other life-threatening complications such as heart arrythmias, as well as muscle cramps and weakness (Option 4). Blood pressure should also be assessed prior to administration of loop diuretics as excess diuresis may cause intravascular volume depletion that results in low blood pressure. A client with baseline hypotension may develop a critically low blood pressure. Excess diuresis can also affect kidneys, and the blood urea nitrogen and creatinine levels can become elevated as well. Therefore, these levels should be assessed (Options 1 and 2). (Options 3 and 5) Loop diuretics typically do not cause abnormalities in white blood cell counts or liver function tests, so these do not need to be assessed routinely. Educational objective:When administering furosemide, it is important to closely monitor the client's vital signs, serum electrolytes (potassium), and kidney function tests (blood urea nitrogen, creatinine) prior to administration to prevent side effects such as hypokalemia, hypotension, and kidney injury.

During assessment of a client who underwent a coronary artery bypass graft 10 hours ago, the nurse notes that the amount of drainage from the mediastinal chest tube has decreased from 100 mL to 20 mL over the last hour. Which of the following nursing actions is appropriate?

Mediastinal chest tubes are used to drain air or fluid from the mediastinal space and/or pericardial cavity (ie, after cardiac surgery). Obstruction (eg, clot) of the chest tube will result in excess fluid buildup in the pericardium, leading to inhibited cardiac contractility and eventual diagnosis of cardiac tamponade. Cardiac tamponade is a life-threatening form of obstructive shock marked by decreased cardiac output and eventually obstructive cardiac arrest if untreated. If chest tube drainage is markedly decreased, the nurse should quickly assess for signs of cardiac tamponade (Option 1) and if no such signs are present should troubleshoot other possible causes of chest tube occlusion. (Option 2) The health care provider should be notified after relevant assessment data has been gathered and troubleshooting has been performed. (Option 3) The chest tube should be kept free of dependent loops and kinks. This assists with proper drainage and prevents fluid from accumulating and backflowing into the mediastinum. (Option 4) Stripping (or milking) a chest tube should not be performed, unless specifically prescribed, as it can exert excessively high negative pressure and traumatize tissues within the mediastinum. Educational objective:A marked decrease in mediastinal chest tube drainage warrants immediate assessment for signs of cardiac tamponade (eg, muffled heart tones, pulsus paradoxus, hypotension). If there are no signs of tamponade, the nurse should troubleshoot other possible causes of chest tube occlusion and contact the health care provider

The nurse has unlicensed assistive personnel (UAP) caring for a client with an acute attack of Meniere disease. Which action by the UAP will require follow-up by the nurse?

Meniere disease (endolymphatic hydrops) results from excess fluid accumulation in the inner ear. Clients have episodic attacks of vertigo, tinnitus, hearing loss, and aural fullness. The vertigo can be severe and is associated with nausea and vomiting. Clients report feeling being pulled to the ground (drop attacks). Fall precautions that should be instituted include assisting the client when arising and ambulating (Option 1), placing the bed in low position, and raising side rails. However, raising all side rails is considered a restraint and would be inappropriate. The nurse would need to intervene and instruct the UAP that 2 or 3 side rails lifted up would be sufficient (Option 3). (Options 2 and 4) Vertigo may be minimized by staying in a quiet, dark room and avoiding sudden head movements. The client should reduce stimulation by not watching television and not looking at flickering lights. Educational objective:Safety is a priority for the client experiencing an acute attack of Meniere disease. Fall precautions include placing the bed in low position, raising 2 or 3 side rails, and assisting the client with arising and ambulating. Vertigo can be minimized by staying in a quiet, dark room without a television or flickering lights.

The nurse in the outpatient clinic is reviewing phone messages. Which client should the nurse call back first?

Mitral valve regurgitation is the result of a disrupted papillary muscle(s) or ruptured chordae tendineae, allowing a backflow of blood from the left ventricle through the mitral valve into the left atrium. This backflow can lead to dilation of the left atrium, reduced cardiac output, and pulmonary edema. Clients are often asymptomatic but are instructed to report any new symptoms indicative of heart failure (eg, dyspnea, orthopnea, weight gain, cough, fatigue). This client should be assessed first due to possible heart failure, which would require immediate intervention. (Option 1) Kidney transplant recipients are on an immunosuppressant regimen to prevent rejection of the transplanted organ, which can leave them susceptible to infections such as candidiasis (thrush) of the oral cavity. (Option 3) The client with a spider bite is displaying signs and symptoms of infection, and further assessment is required to evaluate for conditions such as cellulitis. This client should be called second. (Option 4) Clients with hypertension who develop sinus or nasal congestion have limited options for symptom relief. Decongestants containing a vasoconstrictor (eg, pseudoephedrine) can exacerbate hypertension.

The home care nurse visits the house of an elderly client. Which assessment finding requires immediate intervention?

New onset of dependent edema of the feet could represent congestive heart failure. This is an urgent medical condition that needs prompt evaluation for characteristic signs (eg, weight gain, lung crackles) and treatment. (Option 1) Loss of short-term memory could be an early sign of dementia. It is important to assess clients' mental status to ensure safety in their homes. Further intervention is required, but this condition is not life-threatening. (Option 2) A painful red area on the buttocks represents the beginning stages of a pressure injury. Although not emergent, this does require further intervention. It is important to recognize pressure injuries early and start treatment promptly before they progress to advanced stages. Advanced pressure injuries are more difficult to treat and heal slower in the elderly. (Option 4) Strong, foul smelling urine is likely due to a urinary tract infection. This does require treatment to prevent further complications but is not a priority over suspected heart failure. Urinary tract infections can cause fever with confusion in the elderly. Educational objective: New onset of dependent edema in an elderly client could be due to heart failure; the client needs further assessment for characteristic signs such as lung crackles and increased body weight (fluid retention).

The nurse is preparing to administer a unit of packed red blood cells to a 16-year-old with blood loss anemia. The client currently has D5W infusing through a 20-gauge IV catheter. What action should the nurse take?

Normal saline (NS) is the only fluid that can be given with a blood transfusion. Dextrose solutions may lyse the red blood cells. All other IV solutions and medications may cause precipitation and are incompatible with blood. Blood transfusions should be infused through a dedicated IV line. If a transfusion must be started in an IV catheter currently in use, the nurse should discontinue the infusion(s) and tubing, and then flush the catheter with NS prior to connecting the blood administration tubing. After transfusion, the catheter should be cleared with NS before any other IV fluids are administered. (Option 1) Packed red blood cells are not compatible with D5W. The nurse must discontinue the D5W and flush the catheter with NS before administering blood. (Option 2) Although an 18-gauge IV catheter is preferred for blood administration, a 20-gauge catheter is acceptable. The nurse can start a second IV catheter if required, but there is no need to discontinue the original one. (Option 4) Blood should not be run with any other fluid except NS. Blood can be infused with an IV pump if the fluid in the tubing is compatible. Educational objective:Blood transfusions cannot be run with any other IV fluid except normal saline (NS). Dextrose can lyse the red blood cells, and other fluids can cause precipitation. If another fluid has been infused through an IV catheter, the nurse should discontinue the infusion(s) and tubing and flush with NS before administering blood.

The nurse reviews the serum laboratory results of assigned clients. Which results are most important to report to the health care provider?

Potassium-sparing diuretics (eg, spironolactone, triamterene, eplerenone), ACE inhibitors (eg, lisinopril, ramipril), and angiotensin II receptor blockers (eg, losartan, valsartan, candesartan) cause hyperkalemia. Therefore, these should be held in clients with underlying hyperkalemia (Option 4). Aminoglycosides (eg, gentamicin, tobramycin, amikacin) are used to treat serious infections. The nurse should monitor renal function and peak and trough levels, and report an elevated creatinine level (>1.3 mg/dL [115 µmol/L]) to the health care provider as it is a major adverse effect that can indicate reversible nephrotoxicity. An adjustment in the dose and dosing interval may be required (Option 5). (Option 1) Neutropenia (decreased neutrophil count) increases a client's susceptibility to infection. Filgrastim (Neupogen) is used to increase the neutrophil count in clients with certain malignancies and in those undergoing chemotherapy. Neutropenia is expected in this client and is not the most important result to report. (Option 2) Acute osteomyelitis, an infection of the bone, is characterized by local and systemic manifestations of infection (eg, leukocytosis - white blood cell count >11,000/mm3 [11.0 x 109/L], increased erythrocyte sedimentation rate, fever) and involves long-term antibiotic therapy. This is expected and is not the most important result to report. (Option 3) Acute pancreatitis is an acute inflammation of the pancreas, characterized by abdominal pain and elevated levels of amylase and lipase, which are digestive enzymes produced by the pancreas. The pain is treated with opioids (eg, hydromorphone, fentanyl). Morphine can also be used; worsening pancreatitis due to an increase in sphincter of Oddi pressure has not been proven in studies. Elevated lipase level is expected and is not the most important result to report. Educational objective:ACE inhibitors (eg, lisinopril, ramipril) and angiotensin II receptor blockers ("sartans") can cause hyperkalemia (potassium >5.0 mEq/L [5.0 mmol/L]). Aminoglycosides (eg, tobramycin, gentamicin, amikacin) can cause nephrotoxicity.

The nurse teaches a client about the use of regular and neutral protamine Hagedorn (NPH) insulin. Which statement by the client indicates that further teaching is needed?

The Institute for Safe Medication Practices has labeled insulin a high-alert medication. These types of medication can be safe and effective when administered or taken according to recommendations. However, errors in administration may cause death or serious illness. NPH is an intermediate-acting insulin with a duration of 12-18 hours; it is generally prescribed 2 times daily (morning and evening). Regular insulin and other rapid-acting insulins (lispro, aspart, glulisine) are typically used with a sliding scale for tighter control of blood glucose throughout the day. These are generally taken before meals and at bedtime. (Options 1, 2, and 3) These are correct statements and indicate the teaching objective was completed successfully. Educational objective:NPH is an intermediate-acting insulin with a duration of 12-18 hours and typically prescribed twice a day

The cardiac care unit has standing instructions that the health care provider (HCP) should be notified of an abnormal mean arterial pressure (MAP). The nurse will need to notify the HCP about which client?

The MAP refers to the average pressure within the arterial system felt by the vital organs. A normal MAP is between 70-105 mm Hg. If the MAP falls below <60 mm Hg, vital organs may be underperfused and can become ischemic. MAP can be calculated using the formula below: Mean Arterial Pressure =Systolic Blood Pressure + (Diastolic Blood Pressure × 2)3 A normal MAP is 70-105 mm Hg. The client with the BP of 106/42 mm Hg has a MAP of 63 mm Hg, in the abnormal range. The nurse should report this to the HCP and monitor the client closely. (Options 1, 2, and 3) These MAPs are within the 70-105 mm Hg normal range. Educational objective: Mean Arterial Pressure =Systolic Blood Pressure + (Diastolic Blood Pressure × 2)3 A normal MAP is 70-105 mm Hg. A MAP <60 mm Hg will not allow for adequate perfusion of vital organs.

The registered nurse (RN) is providing discharge instructions to a client who has had coronary artery bypass grafting (CABG). Which teaching is correct?

The RN providing discharge instructions for a client recovering from a CABG should include the following guidelines: Explain the need for modification of cardiac risk factors, including smoking cessation, weight reduction, maintaining a healthy diet, and increasing activity levels through exercise. Encourage a daily shower (Option 4) as a bath could introduce microorganisms into the surgical incision sites. Surgical incisions are washed gently with mild soap and water and patted dry. The incisions should not be soaked or have lotions or creams applied as this could introduce pathogens (Option 5). Explain that light house work may begin in 2 weeks, but there is to be no lifting of any object weighing >5 lb (2.26 kg) without approval of the HCP (Option 3). Lifting, carrying, and pushing heavy objects are isometric activities. Heart rate and blood pressure increase rapidly during isometric activities, which should be limited until approved by the HCP, generally about 6 weeks after discharge. Guide the client to gradually resume activity and possibly participate in a cardiac rehabilitation program. Clarify no driving for 4-6 weeks or until the HCP approves. If the client is able to walk 1 block or climb 2 flights of stairs without symptoms (eg, chest pain, shortness of breath, fatigue), it is usually safe to resume sexual activity (Option 1). Notify the HCP if the following symptoms occur: Chest pain or shortness of breath that does not subside with rest Fever >101 F (38.3 C) Redness, drainage, or swelling at the incision sites (Option 2). Educational objective: Discharge teaching for a client recovering from a CABG should include instructions related to medications, activity level, driving, sexual activity, and symptoms to report to the HCP

A client with renal failure recently started dialysis and is unable to work due to ongoing health problems. The client's spouse has started working for a cleaning service to replace the lost income. The dialysis nurse notices that the client has become withdrawn and increasingly frustrated by small inconveniences when coming to dialysis. Which is the most appropriate first response by the nurse?

The client with chronic illness who is unable to work may experience depression, grief, loss, a feeling of inadequacy, or a loss of meaning and purpose in life. It can take time to adjust and accept the new roles, and this stress can increase a person's vulnerability to ongoing health problems. This client has gone from being the main source of income, or "breadwinner," to being someone who is unable to support the family. The client is now dependent on the spouse for financial stability and this is causing a strain. This type of role change can be particularly difficult for men who are used to providing for their families and for anyone who is well-established in a career. The nurse has noticed a change in the client's behavior but has not assessed the client to determine the factors contributing to this change. Assessment is needed before interventions can be planned. An open-ended reflective statement and nonverbal communication expressing acceptance and willingness to listen in the setting of a trusting relationship are appropriate to begin this assessment. (Option 1) This response ignores the client's feelings and closes off an opportunity to assess the client's emotional state and the role change brought on by illness and the spouse's new job. (Option 3) The source of the client's behavior change is not apparent at this point, so further assessment is needed. It is premature to intervene by recommending a support group. (Option 4) The nurse is assuming that the client is angry about inability to work, but the client has not said this. Further assessment is needed to understand the client's emotions and their source. Educational objective:Chronic illness can result in role changes that influence the client's self-concept. The nurse can positively influence self-concept by empathizing, communicating acceptance, and assessing the client's feelings and perceptions on the issue

During a home visit, the community health nurse observes bruises in various stages of healing on the extremities and torso of an elderly client. The client explains that the bruises are from bumping into furniture and the wall in the wheelchair. What is the priority nursing action?

The client's injuries are inconsistent with the explanation given in that bumping into furniture could explain bruising on the extremities but does not account for the bruises on the torso (trunk). In addition, the bruises are in various stages of healing, which suggests that the injuries occurred over multiple occasions. The nurse's findings are suggestive of elder abuse but not conclusive. Further assessment is needed to confirm the nurse's suspicions and to determine the extent of the abuse. The nurse will assess the client for general hygiene, clothing, nutritional and hydration status, presence of other injuries, inappropriate medication administration, signs of depression, and other statements by the client suggesting neglect. During the assessment and client interview, the nurse will need to maintain a neutral, nonjudgmental attitude to facilitate a trusting nurse-client relationship. (Option 1) Asking the client to explain the bruises on the torso is a "why" type of question, places the client on the defensive, and does not facilitate a trusting nurse-client relationship. (Option 3) Reporting the bruises to the HCP is an appropriate nursing action but is not the priority. The nurse needs additional information about the client's status and situation. (Option 4) Talking to the client's child and/or other family members may be an appropriate nursing action. However, the nurse needs more information about the client's status to determine needed interventions. Further assessment for indications of elder abuse is the priority. Educational objective:When elder abuse is suspected, the nurse needs to perform further assessment to validate and confirm any initial findings and to determine the extent of the abuse and/or neglect. Areas of assessment for elder abuse include the client's general hygiene, clothing, nutritional and hydration status, presence of other injuries, inappropriate medication administration, signs of depression, and other statements suggesting neglect.

A client comes to the emergency department in acute decompensated heart failure. The client is very anxious, with a respiratory rate of 30/min and pink, frothy sputum. After placing the client on oxygen via nasal cannula, which of these actions is the next priority?

This client is exhibiting signs of pulmonary edema, a life-threatening condition. In the presence of acute left ventricular failure, pulmonary vasculature overload causes increased pulmonary venous pressure that forces fluid out of the vascular space into the pulmonary interstitium and, if untreated, into the alveoli. Clinical manifestations of pulmonary edema include: A history of orthopnea and/or paroxysmal nocturnal dyspnea Anxiety and restlessness Tachypnea (often >30/min), dyspnea, and use of accessory muscles Frothy, blood-tinged sputum Crackles on auscultation The priority of care is to improve oxygenation by reducing pulmonary pressure and congestion. Diuretics (eg, furosemide) are prescribed to remove excess fluid in pulmonary edema (Option 2).

The nurse observes a client who is postoperative left total knee replacement use a cane. Which action by the client indicates an understanding of the correct technique when walking down the stairs?

To prevent falls after a total knee replacement, clients should use a cane to provide maximum support when climbing up and down any stairs. Clients should hold the cane on the stronger side and move the cane before moving the weaker leg, regardless of the direction. Clients must also keep 2 points of support on the floor at all times (ie, both feet, foot and cane). When descending stairs, the client should: Lead with the cane Bring the weaker leg down next (in this client, it is the left leg) Finally, step down with the stronger leg (Option 1) When ascending stairs, the client should: Step up with the stronger leg first Move the cane next, while bearing weight on the stronger leg Finally, move the weaker leg To remember the order, use the mnemonic "up with the good and down with the bad." The cane always moves before the weaker leg. (Options 2, 3, and 4) These options do not provide enough support to the weaker leg when descending. Educational objective:To prevent falls when descending the stairs using a cane, the client should lead with the cane, follow with the weaker leg, and then step down with the stronger leg

The health care provider prescribes a continuous IV infusion of regular insulin at 5 units/hr. The infusion bag contains 50 units of regular insulin in 100 mL of normal saline solution. At what rate in milliliters per hour (mL/hr) does the nurse set the IV pump?

Using dimensional analysis, use the following steps to calculate the infusion rate of regular insulin: Identify the prescribed, available, and required medication information Prescribed: 5 units regular insulinhr Available: 50 units regular insulin100 mL normal saline Required: mLhrPrescribed: 5 units regular insulinhr Available: 50 units regular insulin100 mL normal saline Required: mLhr Convert prescription to infusion rate needed for administration Prescription×available medication=mLhrPrescription×available medication=mLhr OR (units regular insulinhr)(mLunits regular insulin)=mLhrunits regular insulinhrmLunits regular insulin=mLhr OR ⎛⎝5 units regular insulinhr⎞⎠⎛⎝100 mL50 units regular insulin⎞⎠=10 mL regular insulinhr5 units regular insulinhr100 mL50 units regular insulin=10 mL regular insulinhr Educational objective:To calculate the infusion rate of IV regular insulin, the nurse should first identify the prescribed dose (eg, 5 units/hr) and available dose (eg, 50 units/100 mL) and then convert to milliliters per hour (eg, 10 mL/hr).

A hospitalized client has been treated for the past 48 hours with a continuous heparin infusion for a deep vein thrombosis (DVT). When the nurse prepares to administer the evening dose of warfarin, the client's spouse says "Wait! My spouse can't have that! My spouse is already getting heparin for DVT." How should the nurse respond?

Warfarin begins to take effect in 48-72 hours and then takes several more days to achieve a maximum effect. Therefore, an overlap of a parenteral anticoagulant like heparin with warfarin is required. The typical overlap is 5 days or until the INR reaches the therapeutic level. The nurse will need to explain this overlap of the 2 medications to the client and the spouse. (Option 2) The nurse should not discontinue the heparin infusion until the INR is at the therapeutic level. (Option 3) Anticoagulants like heparin and warfarin will not break down or dissolve clots. However, they inhibit any further clot formation and keep the current clot from getting larger. Thrombolytics, such as tissue plasminogen activator, do break down clots. (Option 4) Clarification from the HCP is not needed. The warfarin should be administered to the client after explaining the reasons for its use to the client and the spouse. Educational objective:Warfarin requires an overlap of therapy with unfractionated heparin infusion or low-molecular-weight heparin (eg, enoxaparin, dalteparin) for several days until the INR is in the therapeutic range for the client's condition.

Which procedures are appropriate for the nurse to use when obtaining an adult client's blood for a laboratory test?

When performing phlebotomy, clean the site, "fix" or hold the vein taut, and then insert the needle bevel up at a 15-degree angle (no steeper than 30 degree). Some recommend bevel down for children. This will help prevent going through the vein completely. The Infusion Nurses Society (INS) identifies the standard of care as no more than 2 attempts by any 1 individual. If the nurse is unable to successfully draw blood after 2 attempts, a phlebotomist or a different nurse should be asked to complete the blood draw. The affected side of a client who has had a mastectomy (especially with lymph node removal) should not be used. It places the client at risk for infection and lymphedema. (Option 3) An arm without IV infusion is preferred. If it is necessary to use the arm with the IV infusion, the specimen should be collected from a vein several centimeters below (distal to) the point of IV infusion, with the tourniquet placed in between. (Option 5) The finger specimen should be obtained from the third or fourth finger on the side of the fingertip, midway between the edge and midpoint. The puncture should be made perpendicular to the fingerprint ridges. Puncture parallel to the ridges tends to make the blood run down the ridges and will hamper collection. A heel stick collection on an infant should be done on the plantar surface. Educational objective: When obtaining blood from a client, insert the needle at 15-degree angle, limit attempts to 2, and avoid the side of a mastectomy. A capillary specimen should be obtained at the side of the finger pad. Never draw a specimen above an IV infusion

The nurse is caring for a client with left-sided weakness from a stroke. When assisting the client to a chair, what should the nurse do?

When transferring a client from bed to chair the following are recommended for client safety: Clients should wear nonskid shoes (first step) Make sure the bed and chair (wheelchair) brakes are locked Use a transfer belt. A transfer belt worn around the client's waist allows the nurse to assist the client while maintaining proper body mechanics and safety. Transfer the client toward the stronger (not the weaker) side. If the client is weak on the left side, ask the client to pivot on the right side. (Option 1) Bending at the waist often requires the nurse to use the back for lifting, making for poor body mechanics. (Option 2) The nurse should provide a wide body stance for more stability. Keeping the feet close together would not be good body mechanics and could cause injury. (Option 3) The nurse using proper body mechanics would pivot on the foot distal to the chair. Educational objective:A transfer belt worn around the client's waist allows the nurse to assist the client while maintaining proper body mechanics and safety

A blood transfusion is prescribed for a client experiencing complications of sickle cell anemia with a hemoglobin level of 6 g/dL (60 g/L). Which of the following actions by the registered nurse are appropriate?

lood transfusions are commonly administered to clients experiencing anemia or acute blood loss. To ensure client safety during blood administration, the nurse should: Verify two client identifiers (eg, name, medical record number, date of birth), the prescription, and the blood products with another licensed health care provider (Option 1). Ensure that blood type and Rh type are compatible (Option 3). An Rh-positive client can safely receive Rh-positive or Rh-negative blood. Administer the blood via filtered tubing with normal saline to prevent clumping in the tube and hemolysis of red blood cells (Option 5). Monitor vital signs during transfusion per facility-specific protocol (eg, before transfusion, 15 minutes after transfusion begins, periodically). Transfuse blood products within 4 hours due to the risk for bacterial growth. (Option 2) The nurse remains with the client for the first 15 minutes (ie, approximately 50 mL) of the transfusion and obtains vital signs directly to monitor for adverse reactions (eg, fever, chest pain). Delegating vital signs to unlicensed assistive personnel after the initial 15-30 minutes may be appropriate for stable clients. (Option 4) Infusing blood over 6 hours increases the risk of bacterial contamination and hemolysis of the blood product. Educational objective:The nurse facilitates safe blood administration by verifying the prescription, blood type, and at least two client identifiers with another licensed health care provider; administering blood with normal saline; obtaining vital signs directly for the first 15 minutes (ie, approximately 50 mL of the transfusion); and transfusing blood within 4 hours.