RN- Nursing Concept- Clinical Decision Making / Clinical Judgment

The nurse is caring for a client with an order for an intravenous infusion of dextrose with 5% normal saline at 1500 mL over 8 hrs. The drip administration is set at 10 drops/mL. How fast will the IV infuse (drops/minute)? Record your answer using a whole number.

31 Explanation: 1500 × 10 gtts = 15,000 gtts/8 hr = 1875 gtts/60 min = 31.25 gtts/min=31 gtts/min.

A client has suffered a deep partial-thickness burn to the right arm from a high-voltage source of energy that was not turned off while working on it. What is the priority nursing intervention in the acute phase of care?

A cardiac monitor should be used for at least 24 hours to anticipate the potential for cardiac dysrhythmias. Explanation: A client with electrical burns based on energy and potential damage to the heart needs cardiac monitoring. Dextrose is not useful for fluid volume expansion and infection would occur much later. Urine output needs hourly monitoring based on myoglobin release.

A client is admitted with a 6.5-cm thoracic aneurysm. The nurse records findings from the initial assessment in the client's chart, as shown. At 1030, the client has sharp midchest pain after having a bowel movement. What should the nurse do first?

Assess the client's vital signs. Explanation: The size of the thoracic aneurysm is rather large, so the nurse should anticipate rupture. A sudden incidence of pain may indicate leakage or rupture. The blood pressure and heart rate will provide useful information in assessing for hypovolemic shock. The nurse needs more data before initiating other interventions. After assessment of vital signs, neurologic status, and pain, the nurse can then contact the HCP. (less) Remediation: Aneurysm, thoracic aortic Question 44: (see full question) A client with acute pancreatitis has a blood pressure of 88/40 mm Hg, heart rate of 128 bpm, respirations of 28/min, and Grey Turner's sign. What prescription should the nurse implement first? You selected: Position on the left side. Incorrect Correct response: Place an intravenous line. Explanation: Grey Turner's sign is a bluish discoloration in the flank area caused by retroperitoneal bleeding. The vital signs are showing hemodynamic instability. IV access should be obtained to provide immediate volume replacement. The urine output will provide information on the fluid status. A nasogastric tube is indicated for clients with uncontrolled nausea and vomiting or gastric distension. Repositioning the client may be considered for pain management once the client's vital signs are stable. (less) Remediation: Pancreatitis IV catheter insertion Question 45: (see full question) The client is receiving an IV infusion of 5% dextrose in normal saline running at 125 ml/h. When hanging a new bag of fluid, the nurse notes swelling and hardness at the infusion site. The nurse should first: You selected: discontinue the infusion. Correct Explanation: Signs of infiltration include slowing of the infusion and swelling, pain, hardness, pallor, and coolness of the skin at the site. If these signs occur, the IV line should be discontinued and restarted at another infusion site. The new anatomic site, time, and type of cannula used should be documented. The nurse may apply a warm soak to the site, but only after the IV line is discontinued. Parenteral administration of fluids should not be stopped intermittently. Stopping the flow does not treat the problem, nor does it address the client's needs for fluid replacement. Infiltrated IV sites should not be irrigated; doing so will only cause more swelling and pain. (less) Remediation: IV catheter insertion Intravenous Therapy: Monitoring an IV Site and Infusion Question 46: (see full question) A client who was prescribed clozapine 2 months ago arrives in the clinic and informs the nurse that he has been feeling extremely fatigued and feverish and has a sore throat. The nurse observes that the client has two small ulcerations of the oropharynx. Which of the following does the nurse suspect may be occurring with this client? You selected: Agranulocytosis Correct Explanation: Clozapine has a potential side effect of agranulocytosis, which can develop suddenly or over a period of time. It is characterized by fever, malaise, a sore throat with ulcerations, and leukopenia. The drug must be immediately discontinued. It is important for the client to have weekly blood counts for 6 months of therapy and then every 2 weeks. Thiamine deficiency is exhibited by shortness of breath and other symptoms of congestive heart failure. Tardive dyskinesia is a side effect of antipsychotic medications and is characterized by lip smacking, tongue protrusion, chewing, blinking, grimacing, and choreiform movements of the limbs and feet. Dystonic reactions are an extrapyramidal side effect characterized by spasms in several muscle groups. (less) Remediation: clozapine Question 47: (see full question) A charge nurse is completing day-shift client care assignments on the genitourinary floor. A new graduate is present for the first day on the unit. An agency nurse and an experienced nurse are also present. The charge nurse should assign the new graduate nurse to the care of which of the following clients? You selected: Middle-aged stable client with bladder cancer awaiting surgery Correct Explanation: The charge nurse should assign the new nurse to the middle-aged client newly diagnosed with bladder cancer awaiting surgery, as this client has a condition common to the genitourinary floor and is of low acuity and stable. The charge nurse should assign the agency nurse to the client who had an ileo conduit. Their conditions have lesser acuity. The charge nurse should assign the experienced nurse to the most acute clients: the middle-age kidney-transplant recipient (less) Remediation: Kidney cancer Question 48: (see full question) After receiving the shift report, a registered nurse in the cardiac step-down unit must prioritize her client care assignment. The nurse has an ancillary staff member available to help her care for her clients. Which of these clients should the registered nurse assess first? You selected: The client with heart failure who is having some difficulty breathing. Correct Explanation: The registered nurse should care for the client with heart failure who is experiencing difficulty breathing. Breathing takes precedence over the other client needs. Although anxiety can be detrimental to a client with myocardial infarction, anxiety does not take precedence over another client's breathing difficulty. The ancillary staff member can answer the call light of the client admitted with controlled atrial fibrillation. The coronary bypass client in pain needs her analgesic, but that does not take priority over a client with difficulty breathing. (less) Remediation: Dyspnea Question 49: (see full question) The nurse is caring for a child receiving a blood transfusion. The child becomes flushed and is wheezing. What should the nurse do first? You selected: Switch the transfusion to normal saline solution. Correct Explanation: The child is having a reaction to the blood transfusion. The priority is to stop the blood transfusion but maintain an open venous access for medication or high fluid volume delivery. Thus, switching the transfusion to normal saline solution would be done first. Since the child is having difficulty breathing, applying oxygen would be the next action. Additionally, vital signs are taken to determine the extent of circulatory involvement. Then the HCP would be notified and, if necessary, the crash cart would be obtained. (less) Remediation: Blood transfusion reaction Blood transfusion: Indications, administration and adverse reactions Blood and blood product transfusion reaction management, pediatric Question 50: (see full question) A school nurse is examining a student at an elementary school and notes vesicular lesions that ooze, forming crusts on the face and extremities. Which of the following actions by the nurse is most appropriate? You selected: Sending the child home and encourage evaluation by physician Correct Explanation: The nurse should send the child home due to possible impetigo and encourage the parents to have the child evaluated by the physician. Impetigo is contagious until the child has been on antibiotics for 24-48 hours, which is why the child should be sent home to be seen by the physician. Impetigo starts as papulovesicular lesions surrounded by redness. The lesions become purulent and begin to ooze, forming crusts. Impetigo occurs most commonly on the face and extremities. Small red lesions on the trunk and in the skin folds are characteristic of scarlet fever. A discrete pink-red maculopapular rash that starts on the face and progresses down to the trunk and extremities is characteristic of rubella (German measles). Cleansing the lesions with Dakin's solution is not appropriate

A nurse is caring for a client with mild active bleeding from placenta previa. Which assessment factor indicates that an emergency cesarean birth may be necessary?

Fetal heart rate of 80 beats/minute Explanation: A drop in fetal heart rate signals fetal distress and may indicate the need for a cesarean birth to prevent neonatal death. Maternal blood pressure, pulse rate, respiratory rate, intake and output, and description of vaginal bleeding are all important assessment factors; however, changes in these factors don't always necessitate the delivery of the neonate.

A nurse practitioner (NP) orders an antibiotic for a client to which the client is allergic. The nurse preparing the medication notices the allergy alert and contacts the NP by phone. The NP does not return the call and the first dose is due to be given. Which of the following actions by the nurse is the best solution to this situation?

Hold the medication until speaking with the NP. Explanation: The nurse must speak to the NP and review the order. The other answers are incorrect because the nurse is aware of a stated allergy and must not give a medication that can cause an allergic reaction. The pharmacist cannot prescribe a new medication.

A mother reports that her school-age child has suddenly begun wetting the bed. Which action should the nurse take?

Obtain a urine sample for urinalysis. Explanation: In this situation, the nurse needs more information before proceeding. Physical causes of the enuresis need to be ruled out before psychosocial problems are addressed. Enuresis is not a normal finding in a school age child.

The physician orders 20 mEq of potassium chloride to be added to the IV solution of a client in diabetic ketoacidosis. The nurse is aware that the reason for this is which of the following?

Replacement of electrolyte deficit Explanation: After treatment with insulin for diabetic ketoacidosis is begun, potassium ions reenter the cells, causing hypokalemia. Therefore, potassium, along with the replacement fluids, is generally supplied. Potassium will not correct hypercapnea or flaccid paralysis. Cardiac dysrhythmias are a result of excess or deficit of potassium.

A nurse is teaching the parents of a young child how to handle suspected poisoning. If the child ingests poison, the parents should first:

call the poison control center. Explanation: Before intervening in any way, the parents should first call the poison control center for specific instructions. Ipecac syrup is no longer recommended for the ingestion of poisons. The parents may have to call an ambulance after calling the poison control center. Punishment for being bad isn't appropriate because the parents are responsible for making the environment safe.

Which client requires immediate nursing intervention? The client who:

presents with a rigid, boardlike abdomen. Explanation: A rigid, boardlike abdomen is a sign of peritonitis, a possibly life-threatening condition. Epigastric pain occurring 90 minutes to 3 hours after eating may indicate a duodenal ulcer. Anorexia and periumbilical pain are characteristic of appendicitis. A client with a large-bowel obstruction may have ribbonlike stools.

A nurse is checking the laboratory results of an adult client with colon cancer admitted for further chemotherapy. The client has lost 30 lb (13.6 kg) since initiation of the treatment. Which laboratory result should be reported to the health care provider (HCP)?

albumin level of 2.8 g/dL (28 g/L) Explanation: The nurse must recognize that an albumin level of 2.8 g/dL (28 g/L) indicates catabolism and potential for malnutrition. Normal albumin is 3.5 to 5.0 g/dL (35 to 50 g/L); less than 3.5 (35 g/L) indicates malnutrition. The other laboratory results are normal. (less)

What is a priority for the nurse developing a plan with a client admitted to the hospital with an acute exacerbation of rheumatoid arthritis?

Achieving a controlled level of pain and fatigue throughout the day. Explanation: Symptoms of rheumatoid arthritis include localized pain, stiffness, and decreased joint mobility after a period of rest, such as after sleeping. This can be more localized, which causes symptoms such as pain or stiffness. Lack of mobility over a period of time can increase the symptoms. Other answers are incorrect because they do not reflect management of care. Working on a positive self image is about self esteem. Always performing activities of daily living does not reflect promoting management; clients do not need to be independent. Accepting and working toward understanding is not about management.

The daily white blood cell (WBC) count in a client with aplastic anemia drops overnight from 3,900 to 2,900/µl (3.9 to 2.9 X 109/L). Which is the appropriate nursing intervention?

Call the primary care provider, and request that the client be placed in reverse isolation. Explanation: The client will need a prescription from the health care provider (HCP) to be placed in reverse (protective) isolation because the normal defenses are ineffective and place the client at risk for infection (leukopenia, less than 5,000 cells/?L [5 × 109/L]). The faster the decrease in WBCs, the greater the bone marrow suppression, and the more susceptible the client is to infection from not only pathogenic but nonpathogenic organisms. The client will continue to be monitored, the laboratory may be called, and the report will be placed on the chart, but protection of the client must be instituted immediately.

The nurse is caring for a client with a subdural hematoma. Which of the following is the priority outcome?

Ensure airway patency and optimal oxygen levels and protect from injury. Explanation: Because there is rapid progression of the subdural hematoma, with changes in consciousness, the priority is to maintain airway patency. Relaxation of the tongue and jaw may result in airway obstruction, and because the client is experiencing changes in consciousness, protection from injury is very important. When the cause and damage of subdural hematoma has been corrected, blood pressure hopefully will be corrected. Nutrition, hydration, elimination, and skin integrity are secondary in importance. (less)

The nurse is working in a community mental health clinic. A client who is diagnosed with schizophrenia is taking clozapine and reports of a sore throat. What is the most appropriate action for the nurse to take? You selected: Encourage the use of saline mouth rinses until the sore throat is gone.

Obtain an order for the client to have a white blood cell count drawn. Explanation: The report of a sore throat may indicate an infection caused by agranulocytosis, a depletion in white blood cells. The way to determine this is by obtaining a white blood cell count. The other options do not get to the cause of the client's concern.

Which client should the nurse assess first?

A client newly diagnosed with hypertension, with a blood pressure of 164/92 mm Hg who is having chest pain. Explanation: The client with chest pain may be experiencing acute myocardial infarction and is unpredictable. A rapid assessment and intervention are needed. The remaining clients are all stable and have expected symptoms associated with their diagnosis.

The client with glaucoma is scheduled for a hip replacement. Which prescription would require clarification before the nurse carries it out?

Administer atropine sulfate. Explanation: Atropine sulfate causes pupil dilation. This action is contraindicated for the client with glaucoma because it increases intraocular pressure. The drug does not have this effect on intraocular pressure in people who do not have glaucoma. Morphine causes pupil constriction. Deep-breathing exercises will not affect glaucoma. The client should resume taking all medications for glaucoma immediately after surgery.

A 10-year-old child has blood glucose readings during a 24-hour period. Which reading requires the most immediate intervention?

50 mg/dL (2.8 mmol/L) Explanation: A normal blood is 70 to 110 mg/dL. Hypoglycemia is an immediate concern. When the brain does not have enough glucose, the client will become rapidly unconscious and, if uncorrected, seizures and death can result. A reading of 100 mg/dL is normal, and no intervention is necessary. Readings of 150 and 200 mg/dL are elevated and could cause complications, but complications from the elevation would not occur as rapidly.

A nurse on the telemetry unit is faced with various monitor rhythms. Which rhythm takes priority?

A client's cardiac rhythm suddenly changes from normal sinus rhythm to uncontrolled atrial fibrillation. Explanation: The client whose cardiac rhythm suddenly changes from normal sinus rhythm to uncontrolled atrial fibrillation takes priority. This cardiac rhythm change may cause clots to shower from the atria, placing the client at risk for a stroke. The client whose cardiac monitor reveals sinus tachycardia with isolated premature ventricular contractions is not experiencing a life-threatening situation; therefore, he does not take priority. Frequent paced beats with capture is a normal finding for a client with a pacemaker. Sinus tachycardia with premature atrial contractions is not a priority situation. Atrial fibrillation

A client had a colon resection yesterday. The client's hemoglobin was 14.1 g/dL yesterday and today it is 7.2 g/dl. The client's oxygen saturation is 87%. After reviewing the chart (see chart) and notifying the health care provider (HCP), the nurse should first:

Administer oxygen at 2 liters per minute. Explanation: This client has decreased oxygen saturation and also decreased hemoglobin, which puts the client at great risk for cardiac ischemia. The nurse should start the oxygen as prescribed. The nurse can take the vital signs more frequently once the oxygen flow has been started. It is not appropriate to increase the rate of the intravenous infusion, and it would be necessary to request a prescription to do so. After starting the oxygen, the nurse can ask the client about the current pain level.

A nurse preceptor is reviewing documentation by a new nurse. Which of the following chart entries would require the preceptor to provide instruction about appropriate notation?

Angrily stated, "My doctor is rude." Offered the name of another personal healthcare provider. Explanation: Documentation should contain data describing information the nurse obtains through the special senses of hearing, touch, vision, or smell. The documentation should be specific, precise, and accurate. It should not contain judgmental information but may contain descriptions of actions and quotes of what a client said. The nurse should support clients' decisions but should not interfere with the doctor-client relationship.

A nurse is preparing a client for an intravenous pyelography. Which of the following is the priority action?

Assess allergies to iodine. Explanation: The nurse should assess this client for allergies to iodine because the dye used in an intravenous pyelography is iodine based, and the client could potentially have a life-threatening reaction to the dye. The nurse should obtain vital signs before the client receives the procedure and assess the client's last bowel movement, but these actions are not the priority. Urine output should be monitored and documented.

What are important nursing priorities on the first postoperative day for a client who has had an open reduction and internal fixation (ORIF) after a right hip fracture?

Assessing the neurovascular status in the right leg, providing pain control, encouraging position changes, and early ambulation Explanation: Assessing the neurovascular status, including circulation and innervation, is very important postoperatively. Control of pain is also a priority. Maintaining the integrity of the skin through frequent turns and ambulation will prevent pressure ulcers. Correct postoperative positioning involves maintaining the leg in a neutral position and preventing adduction. Bed rest can result in immobility consequences. Assessing skin integrity and nutritional status is positive, but maintaining bedrest is incorrect. Reorienting frequently will not prevent disorientation, and the nurse would not restrict pain measures.

A client with an intravenous (IV) site is experiencing pain. The nurse understands that pain with infusion is a sign of which of the following?

Catheter position at the insertion site due to movement Explanation: The catheter pressing against the vein causes the pain. This would be a common result due to normal movement of the client throughout the day. The other choices should not cause pain at insertion.

A client in an acute care mental health program refuses his morning dose of an oral antipsychotic medication and believes he's being poisoned. The nurse should respond by taking which action?

Consulting with the physician about a care plan. Explanation: To determine a care plan for clients who are noncompliant with medications, the nurse should consult with the physician. Unless the client presents a danger to himself or others, he can't be forced to take medications. Crushing the medication and putting it in food might make the client suspicious. The nurse shouldn't omit the dose and try again the next day. The nurse should instead make another attempt to administer the drug to avoid decreased drug levels.

The most important responsibility of the nurse is to prioritize and ensure that routine nursing measures on non-critical clients are assigned. The nurse is performing which of the following functions?

Delegation Explanation: The professional nurse is responsible for delegating routine nursing measures to non-licensed personnel. The nurse needs to make the decision as to which aspects can be delegated and which clients need to be assessed and cared for by professional nurses. The definitions of the other terms do not pertain to this situation.

On the second day following an abdominal perineal resection, the nurse notes that the wound edges aren't approximated and one half of the incision has torn apart. What should the nurse do first?

Cover the wound with a sterile dressing moistened with normal saline. Explanation: When dehiscence occurs, the nurse should immediately cover the wound with a sterile dressing moistened with normal saline. If the dehiscence is extensive, the incision must be resutured in surgery. Later, after the sutures are removed, additional support may be provided to the incision by applying strips of tape as directed by institutional policy or by the surgeon. An abdominal binder may also be utilized for additional support.

Thirty minutes after a Sengstaken-Blakemore tube is inserted, the nurse observes that the client appears to be having difficulty breathing. What should the nurse do first?

Determine whether the tube is obstructing the airway. Explanation: If the gastric balloon should rupture or deflate, the esophageal balloon can move and partially or totally obstruct the airway, causing respiratory distress. The client must be observed closely. No direct action should be taken until the condition is accurately diagnosed.

The nurse is assessing a client admitted with a myocardial infarction with the following assessment: dyspnea, heart rate of 140 bpm, and crackles in the posterior chest. The nurse would interpret these findings as which of the following?

Development of congestive heart failure Explanation: Crackles probably signify pulmonary edema, which occurs when there is left-sided congestive heart failure. The client is very dyspneic, and the heart appears to be compensating (increased rate because of respiratory congestion). Initiation of measures to help strengthen the heartbeat is a very important priority. Signs and symptoms do not indicate hypoglycemic reaction or renal failure. Heart block would be indicated by bradycardia.

A nurse is assessing a client in the recovery room who has had a vaginal hysterectomy. Which assessment finding should the nurse bring to the healthcare provider's immediate attention?

Foley catheter draining urine at 10 mL/hour Explanation: A complication of vaginal hysterectomy would be injury to the ureters resulting in decreased urinary output. The other findings are normal and expected after a vaginal hysterectomy.

A young adult is admitted to the emergency department after an automobile accident. The client has severe pain in the right chest from contact with the steering wheel. What should the nurse do first?

Maintain adequate oxygenation. Explanation: Blunt chest trauma may lead to respiratory failure, and maintenance of adequate oxygenation is the priority for the client. Decreasing the client's anxiety is related to maintaining effective respirations and oxygenation. Although pain is distressing to the client and can increase anxiety and decrease respiratory effectiveness, pain control is secondary to maintaining oxygenation. Maintaining adequate circulatory volume is also secondary to maintaining adequate oxygenation.

Which nursing intervention is most important postoperatively for an infant who has received a ventriculoperitoneal shunt?

Monitor intake and output. Explanation: In the postoperative period, intake and output are carefully monitored to prevent fluid overload that could lead to increased intracranial pressure. Feedings should start when the infant is fully awake. The infant will need to be disturbed to check vital signs and be repositioned. Age-appropriate activities are important but not until the infant is awake and less fussy.

The nurse is performing an assessment on an infant with intravenous fluids infusing in the right hand. Which of the following assessment findings would the nurse recognize as acceptable in the infant?

No blood return Explanation: Infants and children have small, fragile veins, making a lack of blood return a normal finding. Erythema, pain, edema, and streaking are signs of infiltration. The nurse may document this finding as a patent IV site. An IV infusion should be discontinued immediately if any of these signs are observed.

Doxorubicin is prescribed for a female client with breast cancer. The client is distressed about hair loss. What should the nurse do?

Provide resources for a wig selection before hair loss begins. Explanation: Resources should be provided for acquiring a wig since it is easier to match hair style and color before hair loss begins. The client has expressed negative feelings of self-image with hair loss. Excessive shampooing and manipulation of hair will increase hair loss. Hair usually grows back in 3 to 4 weeks after the chemotherapy is finished; however, new hair may have a new color or texture. A wig, hairpiece, hat, scarf, or turban can be used to conceal hair loss. Social isolation should be avoided, and the client should be encouraged to socialize with others.

The nurse is caring for a client with a nasogastric tube who is receiving intermittent tube feedings by gravity every 4 hours. The nurse aspirates 75 mL of residual prior to the next feeding. What action should the nurse take next?

Return the residual and begin the feeding. Explanation: The amount of residual is within normal limits, and the client should have the feeding started. The residual should be returned to help prevent electrolyte imbalances. The other options do not ensure adequate nutritional management for the client.

The nurse administers a tap water enema to a client. While the solution is being infused, the client has abdominal cramping. What should the nurse do first?

Temporarily stop the infusion, and have the client take deep breaths. Explanation: If the client begins to experience abdominal cramping during administration of the enema fluid, the nurse's first action is to temporarily stop the infusion and have the client take a few deep breaths. After the cramping subsides, the nurse can continue with the enema solution. If the cramping does not subside, the nurse should clamp the tubing and remove it. Raising the height of the container will increase the flow of fluid and cause the cramping to increase. Rubbing the abdomen while infusing the enema fluid will not stop the cramping

Twenty-four hours after a bone marrow aspiration, the nurse evaluates which client outcome as an appropriate one?

There is no bleeding at the aspiration site. Explanation: After a bone marrow aspiration, the puncture site should be checked every 10 to 15 minutes for bleeding. For a short period after the procedure, bed rest may be prescribed. Signs of infection, such as redness and swelling, are not anticipated at the aspiration site. A mild analgesic may be prescribed for pain, but if the client has pain longer than 24 hours, the nurse should assess the client for internal bleeding or increased pressure at the puncture site which may be the cause of the pain and should consult the health care provider (HCP).

The nurse is reviewing laboratory values of a client receiving clozapine. Which of the following laboratory values does the nurse immediately report to the health care provider (HCP)?

WBC of 3,500 Explanation: A side effect of clozapine is leukopenia. A WBC count is drawn every week and if it starts to drop, the HCP is notified. Slightly low hemoglobin levels or a normal sodium level are not significant. Hyaline casts occur because of protein in the urine, and a small amount is normally found in the urine, especially after exercise.

A client received burns to his entire back and left arm. Using the Rule of Nines, the nurse can calculate that he has sustained burns on what percentage of his body?

You selected: 27% Explanation: According to the Rule of Nines, the posterior trunk, anterior trunk, and legs each make up 18% of the total body surface. The head, neck, and arms each make up 9% of total body surface, and the perineum makes up 1%. In this case, the client received burns to his back (18%) and one arm (9%), totaling 27% of his body.

The nurse has received a change of shift report on clients. Which client should the nurse assess first?

a client with asthma with respirations of 36 breaths/min whose wheezing has diminished Explanation: Respirations of 36 breaths/min and diminished wheezing are indicative of respiratory distress. This finding takes precedence over a client scheduled for an angiogram, a client with a heart rate if 90 bpm needing a scheduled beta blocker, or a client with a PaO2 of 56 mm hg, which is indicated for a client being discharged home on oxygen.

A nurse is caring for an adolescent involved in a motor vehicle crash. The adolescent has a chest tube in place. If the chest tube is accidentally removed, the nurse should immediately:

cover the opening with petroleum gauze. If a chest tube is accidentally removed, the nurse should cover the insertion site with sterile petroleum gauze. The nurse should then observe the client for respiratory distress because tension pneumothorax may develop. If tension pneumothorax does develop, the nurse should remove the gauze to allow air to escape. The nurse shouldn't reintroduce the tube. Rather, the nurse should have another staff member call a physician so another tube can be introduced by the physician under sterile conditions.

A client is receiving total parenteral nutrition (TPN). The nurse notices that the bag of TPN solution has been infusing for 24 hours but has 300 mL of solution left. The nurse should:

discontinue the current solution, change the tubing, and hang a new bag of TPN solution. Explanation: IV fluids should not be infused for longer than 24 hours because of the risk of bacterial growth in the solution. The appropriate action for the nurse to take is to discontinue the current TPN solution, change the tubing, and hang a new bag of solution. Changing the filter does not decrease the risk of contamination. Notifying the HCP for a change in flow rate is not an acceptable solution.

A health care provider prescribes gentamicin for a client with peritonitis. The client has preexisting impaired vision and hearing. The nurse should:

question the prescription because gentamicin could cause further hearing impairment. Explanation: Aminoglycoside antibiotics can cause damage to the eighth cranial nerve and result in ototoxicity. If the client is already hearing impaired, the nurse should question the prescription with the health care provider, who may determine that prescribing another antibiotic would be safer. Gentamicin is an appropriate antibiotic for gram-negative infections such as peritonitis. Gentamicin does not cause visual impairment.

A client is suspected of having a slow gastrointestinal bleed. The nurse should evaluate the client for which sign?

tarry stools Explanation: Black, tarry stools indicate the presence of a slow upper gastrointestinal bleed. The longer the blood is in the system, the darker it becomes as the hemoglobin is broken down and iron is released. Vital sign changes, such as an increased pulse, are not evident with slow gastrointestinal bleeds. Nausea and abdominal cramps can occur but are not definitive signs of gastrointestinal bleeding.

A client with a history of heart failure has just been admitted with dyspnea and pulmonary edema. What is the appropriate action of the nurse? Select all that apply.

• Raise the head of the bed • Administer morphine 2-4mg IV push • Administer furosemide 60 mg IV push • Administer hi flow oxygen Explanation: This client is experiencing acute decompensated heart failure. Treatment for heart failure exacerbation and pulmonary edema include oxygenation (raise head of the bed and administer oxygen); remove fluids with furosemide and decrease the workload of the heart; improve alveolar gas exchange; and increase cardiac output using morphine also with administration of additional cardiac medications. Carvedilol is not used for worsening heart failure.

A client with bipolar 1 disorder has been prescribed olanzapine 5 mg two times a day and lamotrigine 25 mg two times a day. Which adverse effects should the nurse report to the health care provider (HCP) immediately? Select all that apply.

• rash • hyperthermia • muscle rigidity Explanation: Lamotrigine, an antiepileptic, is used as a mood stabilizer for clients with bipolar disorder and has been found to be effective for the depressive phase of bipolar disorder. Common adverse effects are dizziness, headache, sedation, tremors, nausea, vomiting, and ataxia. The development of a rash needs to be reported and evaluated by the heath care provider because it could indicate the start of a severe systemic rash known as Stevens-Johnson syndrome, a toxic epidermal necrolysis, which would necessitate the discontinuation of lamotrigine. Hyperthermia in conjunction with muscle rigidity suggests the development of neuroleptic malignant syndrome, a life-threatening complication associated with olanzapine.

A nurse is caring for a client diagnosed with a deep vein thrombosis (DVT). The client begins to experience symptoms of chest pain, dyspnea, and restlessness. Physical assessment reveals a heart rate of 140 beats per minute, blood pressure of 100/60 mm Hg, and respirations of 40 breaths per minute. What is the priority action of the nurse?

Assess the client's oxygen saturation (SaO2) level Explanation: The client has symptoms consistent with a pulmonary embolism (PE). Assessment of airway and breathing and oxygenation status is the priority. Many clients begin treatment for PE on the basis of clinical history, symptoms and clinical examination before definitive diagnostic testing has been completed. A 12 lead EKG and/or neurological examination will not determine the oxygenation status of the client. Immediate action and nursing interventions are required to stabilize this client and prevent further deterioration.

A parent brings a 3-month-old infant to the clinic, reporting that the infant has a cold, is having trouble breathing, and "just does not seem to be acting right." Which action should the nurse take first?

Assess the infant's oxygen saturation. Explanation: In an infant with these symptoms, the first action by the nurse would be to obtain an oxygen saturation reading to determine how well the infant is oxygenating. Because the parent probably can provide no other information, checking the heart rate would be the second action done by the nurse. Then the nurse would obtain the infant's weight.

A nurse formulates a nursing diagnosis of Impaired physical mobility for a client with full-thickness burns on the lower portions of both legs. To complete the nursing diagnosis statement, the nurse should add which "related-to" phrase?

Related to circumferential eschar Explanation: As edema develops on circumferential burns, eschar forms a tight, constricting band, compromising circulation to the extremity distal to the circumferential site and impairing physical mobility. This client isn't likely to develop fat emboli unless long bone or pelvic fractures are present. Infection doesn't alter physical mobility. A client with burns on the lower portions of both legs isn't likely to have femoral artery occlusion.

A nurse, driving on a highway, is the first on the scene after a multivehicle collision. Which assessment data found in the accident victims would require immediate care?

Severe head injuries Explanation: Clients with severe head injuries are the highest priority because of potential brain damage and spinal cord injury. The other options identified are not life threatening. All are important, but based on ABCs, head injury is first.

A nurse is performing an admission assessment on a client entering a long-term care facility. She notices a broken area of skin that extends into the dermis on the client's coccyx. How should the nurse document this wound?

Stage II pressure ulcer Explanation: A stage II pressure ulcer is a break in the skin that extends into the epidermis or the dermis. A stage I pressure ulcer is area of nonblanchable redness that may become cyanotic. A stage III pressure ulcer extends into the subcutaneous tissue. A stage IV pressure ulcer extends into the muscle or bone; most of the true tissue damage isn't easily seen.

In the early postoperative period, the nurse notes a bright red, 3" × 5" (7.6 cm x 12.7 cm) area of drainage on the client's abdominal laparotomy dressing. What should be the nurse's first action in response to this observation?

Take the client's vital signs. Explanation: The sudden onset of bright red drainage of this magnitude needs to be further assessed. Assessing vital signs is an important nursing action to determine whether there have been any changes in the client's status. Additional steps would include reinforcing the dressing and notifying the health care provider (HCP). Increasing the IV flow rate does not address the bleeding. Changing the dressing would be done only if the HCP prescribed it.

Which action should the nurse do first when noting clear drainage on the child's dressing and bed linen after a craniotomy for a brain tumor?

Test the fluid for glucose. Explanation: Glucose in this clear, colorless fluid indicates the presence of cerebrospinal fluid. Excessive fluid leakage should be reported to the HCP. The nurse should not change the dressing of a postoperative craniotomy client unless instructed to do so by the surgeon. Ordinarily, the head of the bed would not be elevated because this would put pressure on the sutures. The nurse should notify the HCP after testing the fluid for glucose.

Which of the following clients should the nurse assess first?

The child with stridor and nasal flaring Explanation: Although all the clients need to be assessed, the highest priority is to evaluate the child with stridor, which indicates impending airway obstruction. Nasal flaring indicates the child is struggling to breathe, a further indication of the critical nature of the situation. The client with wheezing throughout the lung fields would be the second client that needs to be seen. The client in a tripod position could be having increased difficulty breathing or be fatigued and would need to be assessed next. The client with rhonchi would be the lowest priority.

An adolescent is brought to the emergency department (ED) after accidentally taking an overdose of heroin. The adolescent is semiconscious, unable to respond appropriately to questions, slurs his words, and has constricted pupils; his vital signs are blood pressure 60/50 mm Hg, pulse 50 beats/minute, and respirations 8 breaths/minute. Naloxone is administered to temporarily reverse the effects of the heroin. Which finding would first indicate that the naloxone administration has been effective?

The client's respirations improve to 12/min. Explanation: Decreased respirations and coma are the two most dangerous effects of heroin overdose, so an increase in respirations after administration of the naloxone demonstrates initial effectiveness of the medication. Changes in cognition and psychomotor activity will take more time to become apparent. The client's blood opioid level may not drop to a nontoxic level for a few days.

A client, age 75, is admitted to the hospital. Because of the client's age, the nurse should modify the assessment by:

You selected: allowing extra time for the assessment. Explanation: When assessing an elderly client, the nurse should allow extra time to compensate for aging-related physiologic changes, address the client respectfully rather than by his first name, and give simple instructions. Speaking in a loud voice is demeaning and assumes that the client has difficulty hearing, which may not be the case.

When a client has an acute attack of diverticulitis, the nurse should first:

assess the client for signs of peritonitis. Explanation: The nurse should first assess the client for signs of peritonitis. Complications of diverticulitis include perforation with peritonitis, abscess, and fistula formation, bowel obstruction, ureteral obstruction, and bleeding. A computed tomography (CT) scan with oral contrast is the test of choice for diverticulitis. A client with acute diverticulitis does not receive a barium enema or colonoscopy because of the possibility of peritonitis and perforation. With acute diverticulitis, the goal of treatment is to allow the colon to rest and inflammation to subside. The client is kept on NPO status; parenteral fluid therapy is provided.

Immediately after receiving an injection of bupivacaine, the client becomes restless and nervous and reports a feeling of impending doom. The nurse should:

assess the client's vital signs. Explanation: The nurse should assess the client's vital signs because there is a likelihood of having a reaction to the bupivacaine. If the client's vital signs are abnormal, immediate intervention may be necessary. Although the nurse may ask the client to continue to describe feelings, this is not likely to be a psychosocial reaction. Simple reassurance is inappropriate in most clinical situations and can be dangerous if physiologic causes of restlessness are overlooked. The nurse should not administer epinephrine until vital signs have been assessed.

The client has returned to the surgery unit from the postanesthesia care unit (PACU). The client's respirations are rapid and shallow, the pulse is 120 bpm, and the blood pressure is 88/52 mm Hg. The client's level of consciousness is declining. The nurse should first:

call the rapid response team (RRT)/medical emergency team. Explanation: The nurse should first call the rapid response team (RRT) or medical emergency team that provides a team approach to evaluate and treat immediately clients with alterations in vital signs or neurological deterioration. The client's vital signs have changed since the client was in the PACU, and immediate action is required to manage the changes; the staff in PACU are not responsible for managing care once the client is transferred to the surgical unit. The respiratory therapist may be a part of the RRT but should not be called first.

The nurse is preparing to start an IV infusion. Before inserting the needle into a vein, the nurse should apply a tourniquet to the client's arm to:

distend the veins. Explanation: Applying a tourniquet obstructs venous blood flow and, as a result, distends the veins. A tourniquet does not stabilize veins or immobilize the arm, nor is it applied to occlude arterial circulation.

At 0800, the nurse reviews the amount of t-tube drainage for a client who underwent an open cholecystectomy yesterday. After reviewing the output record (see chart), the nurse should:

evaluate the tube for patency. Explanation: The t-tube should drain approximately 300 to 500 mL in the first 24 hours, and after 3 to 4 days the amount should decrease to less than 200 mL in 24 hours. With the sudden decrease in drainage at 0800, the nurse should immediately assess the tube for obstruction of flow that can be caused by kinks in the tube or the client lying on the tube. Drainage color must also be assessed for signs of bleeding. The tube should not be irrigated or clamped without a prescription.

A neonate is experiencing respiratory distress and is using a neonatal oxygen mask. An unlicensed assistive personnel has positioned the oxygen mask as shown. The nurse is assessing the neonate and determines that the mask:

is appropriate for the neonate. Explanation: The correct size covers the nose but not the eyes. The mask is too large if it covers the neonate's eyes. Masks that are too small may pinch the nose. Masks should fit snugly against the cheeks and chin. It is not necessary to cover the mask with a soft cloth. If the mask fits snugly, it will not be as likely to rub the skin.

A client who is experiencing alcohol withdrawal exhibits tremors, diaphoresis, and hyperactivity. Blood pressure is 190/87 mm Hg, and pulse is 92 bpm. Which medication should the nurse expect to administer?

lorazepam Explanation: The nurse would most likely administer a benzodiazepine, such as lorazepam, to the client who is experiencing symptoms of alcohol withdrawal. The benzodiazepine substitutes for the alcohol to suppress withdrawal symptoms. The client experiences symptoms of withdrawal because of the "rebound phenomenon" when sedation of the central nervous system (CNS) from alcohol begins to decrease. Haloperidol is an antipsychotic and is not indicated for alcohol withdrawal symptoms. Benztropine is used to treat extrapyramidal symptoms associated with antipsychotic therapy. Naloxone is used in opioid overdose to reverse the CNS depression caused by the opioid.

A nurse is assessing a client with nephrotic syndrome. The nurse should assess the client for which condition?

massive proteinuria Explanation: Nephrotic syndrome is characterized by massive proteinuria caused by increased glomerular membrane permeability. Other symptoms include peripheral edema, hyperlipidemia, and hypoalbuminemia. Because of the edema, clients retain fluid and may gain weight. Hematuria is not a symptom related to nephrotic syndrome.

The nurse is caring for a client with end-stage kidney disease. What arterial blood gas results are most closely associated with this disorder?

pH 7.20, PaCO2 36, HCO3 14- Explanation: Metabolic acidosis occurs in ESKD because the kidneys are unable to excrete increased loads of acid. Decreased acid secretion results from the inability of the kidney tubules to excrete ammonia (NH3-) and to reabsorb sodium bicarbonate (HCO3-). There is also decreased excretion of phosphates and other organic acids.

Which medication should the nurse anticipate administering in the event of a heparin overdose?

protamine sulfate Explanation: Protamine sulfate is a heparin antagonist. It is administered intravenously very slowly (over at least 10 minutes). Warfarin sodium has anticoagulant properties and would be contraindicated. Vitamin K works in opposition to warfarin, not heparin. Atropine sulfate is an anticholinergic drug and would not be effective in treating a heparin overdose.

A 4-year-old child is having a sickle cell crisis. The initial nursing intervention should be to:

provide oral and I.V. fluids. Explanation: Initial nursing interventions for the child in a sickle cell crisis include providing hydration and oxygenation to prevent more sickling. Pain relief is also a concern. However, painful joints are treated with analgesics and warm packs because cold packs may increase sickling. Antibiotics will be given to treat a sickle cell crisis if it's thought to be bacterial but only after hydration and oxygenation have been addressed. Daily supplements of folic acid will help counteract anemia but they aren't a priority during sickle cell crisis.

The nurse is caring for a client in labor and notes late decelerations on the external fetal monitoring strip. Which of the following actions will the nurse include in the client's plan of care? Select all that apply.

• Change the client's position • Administer oxygen to the client • Contact the healthcare provider Explanation: Late decelerations are caused by placental insufficiency and need to have an active response. Increasing the pitocin would cause the fetus to have further placental insufficiency. Discontinuing the external fetal heart monitor would be inappropriate as the fetus needs intervention. Calling the healthcare provider would be necessary for a change in the plan of care. Application of oxygen to the client would help facilitate further oxygenation of the fetus. Changing the client's position may help alleviate the decelerations if they are caused by hypotension and will help determine if the decelerations are truly late.

A nurse has been caring for an adolescent client in a residential facility. The child has been through a series of foster placements since infancy with no success in any placement until the age of 7 when placed with a middle-aged single woman. The client thrived there until the woman was killed in a car accident. The client attempted suicide after her foster mother died in response to the loss and the child was placed in the residential facility. The nurse has become close to this client and wants to help her address her issues and move on with her life. Which comment to the manager demonstrates that the nurse understands the client's issues and is able to respond appropriately to the client's needs?

"It is difficult for her to love and trust again after her losses. In this facility, she can learn to deal with her loss in a less emotionally charged environment than a foster home." Explanation: The severe emotional trauma the girl has experienced will likely make it difficult for her to be successful in an adoptive placement at the present time, whether that placement is with someone she knows (the nurse) or another adoptive family. Additionally, adoption by the nurse is inappropriate because it blurs the lines between her professional and personal life and is likely to confuse the client. It is clear that the client has many issues and that love alone is not likely to solve all her problems. Treatment at the residential facility will allow her to work through emotional issues in a more therapeutic environment. Though not currently ready for adoption, she may be ready for adoption in the future after sufficient treatment.

The nurse is caring for a client who is 30 years of age with a fracture of the right femur and left tibia. Both legs have casts. The nurse assesses the following: respirations are 30 per minute and are rapid and shallow; presence of faint expiratory wheeze; and coughing produces thin pink sputum. The client is yelling at the nurse and wants to be released from the hospital; this is behavior unlike that previously reported. The last pain medication was administered 3 hours ago. The nurse should first:

notify the health care provider (HCP). Explanation: The nurse's first action is to notify the HCP because the client is likely experiencing a fat embolus. Fat emboli are associated with embolization of marrow or tissue fat or platelets and free fatty acids to the pulmonary capillaries, producing rapid onset of symptoms. Multiple fractures and fractures of the long bones or pelvis increase a client's risk for developing a fat embolus; in addition, young adults between 20 and 30 years of age are at a higher risk for fat emboli with fractures. When fat emboli do occur, hypoxia results; therefore, it is most important the nurse assess changes in level of consciousness and observe changes in behavior such as restlessness and irritability. The nurse does not cut the cast; there is no indication that the casts are obstructing circulation. ABGs are used to confirm the diagnosis, not a chest x-ray. The client's behavior is a result of hypoxemia, not pain.

A client receiving 5-fluorouracil is experiencing nausea and vomiting. Which is the nurse's best course of action?

Administer odansetron prior to administering the 5-fluorouracil Explanation: Fluorouracil, an antimetabolite antineoplastic medication, may cause nausea, vomiting, diarrhea, bone marrow suppression, and stomatitis. Premedication with an antiemetic medication such as odansetron will prevent nausea and vomiting during treatment.

Assessment of a nulligravid client in active labor reveals the following: moderate discomfort; cervix dilated 3 cm, 0 station and completely effaced; and fetal heart rate of 136 bpm. Which should the nurse plan to do next?

Assist the client with comfort measures and breathing techniques. Explanation: The client's assessment findings indicate that the client is in the latent phase of the first stage of labor. Therefore, the nurse should plan to assist the client with comfort measures and breathing techniques to relieve discomfort. The client can move around, walk, or ambulate at this phase of labor. If the client chooses to remain in bed, a left side-lying position provides the greatest perfusion. It is too early for the client to have an epidural anesthetic. Epidural anesthesia is usually administered when the cervix is dilated 4 to 5 cm. The fetal heart rate is normal, so internal fetal monitoring is not warranted at this time.

A physician orders a tricyclic antidepressant for a client who has suffered an acute myocardial infarction (MI) within the previous 6 months. Which action should the nurse take?

Question the physician about the order. Explanation: Cardiovascular toxicity is a problem with tricyclic antidepressants, and the nurse should question the use of these drugs in a client with cardiac disease. Administering the medication would be an act of negligence. A nurse can't discontinue a medication without a physician's order. It's the nurse's responsibility, not the client's, to discuss questions of care with the physician.

A client is to start on enteral tube feedings. What should a nurse do to make this as comfortable as possible for the client?

Start the tube feeding slowly. Explanation: Administering the tube feeding too fast could upset the client's stomach causing diarrhea and putting the client at risk for aspiration. Elevation of the client's head prevents the risk of aspiration. Room temperature feeding is recommended when giving an enteric feeding. Enteric tubing and pumps should be used when giving an enteric feeding.

A client is sitting in a chair and begins having a tonic-clonic seizure. The most appropriate nursing response is to:

carefully move the client to a flat surface and turn him on his side. Explanation: When caring for a client experiencing a tonic-clonic seizure, the nurse should help the client to a flat nonelevated surface and then position him on his side to ensure that he doesn't aspirate and to protect him from injury. These steps help reduce the risk of injury from falling or hitting surrounding objects and help establish an open airway. The client shouldn't be restrained during the seizure. Also, nothing should be placed in his mouth; anything in the mouth could impair ventilation and damage the inside of the mouth.

A client has been taking aluminum hydroxide 30 ml six times per day at home to treat his peptic ulcer. He tells the nurse that he has been unable to have a bowel movement for 3 days. Based on this information, the nurse would determine that the most likely cause of the client's constipation is because the client:

is experiencing an adverse effect of the aluminum hydroxide. Explanation: It is most likely that the client is experiencing an adverse effect of the antacid. Antacids with aluminum salt products, such as aluminum hydroxide, form insoluble salts in the body. These precipitate and accumulate in the intestines, causing constipation. Increasing dietary fiber intake or daily exercise may be a beneficial lifestyle change for the client but is not likely to relieve the constipation caused by the aluminum hydroxide. Constipation, in isolation from other symptoms, is not a sign of a bowel obstruction.

Which of the following nursing actions addresses the primary concern for a client with Guillain-Barré syndrome?

Preparing for mechanical ventilation Explanation: As this disease progresses, the nurse can expect the client to have weakness and possible paralysis of the diaphragm. This may lead to respiratory failure and require mechanical ventilation. This is the primary concern for the client. The other issues are not as high a priority as maintaining a patent airway.

A client receiving a blood transfusion experiences an acute hemolytic reaction. Which nursing intervention is the most important?

Stop the transfusion, infuse normal saline solution, and call the physician. Explanation: When a transfusion reaction occurs, the transfusion should be immediately stopped, normal saline solution should be infused to maintain venous access, and the physician and blood bank should be notified immediately. Other nursing actions include saving the blood bag and tubing, rechecking the blood type and identification numbers on the blood tags, monitoring vital signs, obtaining necessary laboratory blood and urine samples, providing proper documentation, and monitoring and treating for shock. Because they can cause red blood cell hemolysis, dextrose solutions should not be infused with blood products. Antihistamines are administered for a mild allergic reaction, not a hemolytic reaction.

When preparing to admit an infant diagnosed with diarrhea to the pediatric unit, the nurse should assign the infant to which room?

a private room Explanation: To reduce the risk of infection transmission, an infant with diarrhea of undetermined origin should be placed in a private room until a causative organism can be identified. However a negative pressure room is not needed because airborne precautions are not required with diarrheal disease.

When collaborating with the health care provider (HCP) to develop a the plan of care for a child diagnosed with attention deficit hyperactivity disorder (ADHD), the treatment plan will likely include which treatments?

psychostimulant medications, such as methylphenidate, and behavior modification Explanation: ADHD is typically managed by psychostimulant medications, such as methylphenidate and pemoline, along with behavior modification. Antianxiety medications, such as buspirone, are not appropriate for treating ADHD. Homeschooling commonly is not a possibility because both parents work outside the home. Antidepressants, such as imipramine, are indicated for major depressive disorders and must be used with extreme caution in children because they carry the risk of suicidal thinking. Family therapy may be a part of the treatment. Anticonvulsant medications, such as carbamazepine, are not appropriate for ADHD. Also, carbamazepine levels are obtained weekly early during therapy to avoid toxicity and ascertain therapeutic levels.

The nurse is reviewing the chart information for a client with increased ascites. The data include the following: temperature 98.9° F (37.2° C), heart rate 118 bpm, shallow respirations 26/min, blood pressure 128/76 mm Hg, and SpO2 89% on room air. The nurse should first:

raise the head of the bed. Explanation: Elevating the head of the bed will allow for increased lung expansion by decreasing the ascites pressing on the diaphragm. The client requires reassessment. A paracentesis is reserved for symptomatic clients with ascites with impaired respiration or abdominal pain not responding to other measures such as sodium restriction and diuretics. There is no indication for blood cultures. Heart sounds are assessed with the routine physical assessment.

An older client with diabetes who has been maintained on metformin has been scheduled for a cardiac catheterization. The nurse should verify that the health care provider (HCP) has written a prescription to:

withhold the metformin prior to the cardiac catheterization. Explanation: The nurse should verify that the HCP has requested to withhold the metformin prior to any procedure requiring dye such as a cardiac catheterization due to the increased risk of lactic acidosis. Additionally, the drug will usually be withheld for up to 48 hours following a procedure involving dye while it clears the client's system. The HCP may prescribe sliding scale insulin during this time if needed. Regardless of how or when the medication is administered, the medication should be withheld. The amount of protein in the client's diet prior to the cardiac catheterization has no correlation with the medication or the test.

A client with stage II ovarian cancer undergoes a total abdominal hysterectomy and bilateral salpingo-oophorectomy with tumor resection, omentectomy, appendectomy, and lymphadenectomy. During the second postoperative day, which assessment finding requires immediate intervention?

Shallow breathing and increasing lethargy Explanation: Shallow breathing and a change in the level of consciousness, such as increasing lethargy requires immediate intervention because they may indicate a respiratory complication — for example, atelectasis or carbon dioxide retention. To avoid respiratory complications, the nurse should encourage turning, coughing, deep breathing, and ambulation during the early postoperative period. Abdominal pain, hypoactive bowel sounds, and serous drainage from the incision are expected findings during the first few days after this type of surgery.

At 8 a.m.(0800), a nurse assesses a client who's scheduled for surgery at 10 a.m.(1000). During the assessment, the nurse detects dyspnea, a nonproductive cough, and back pain. What should the nurse do next?

You selected: Immediately notify the physician of these findings. Explanation: The nurse should notify the physician immediately because dyspnea, a nonproductive cough, and back pain may signal a change in the client's respiratory status. The nurse should then check the results of any ordered tests (such as a chest X-ray, serum electrolyte levels, and CBC) because this information may help explain the change in the client's condition. The nurse should sign the preoperative checklist after notifying the physician of the client's condition and learning whether the physician will proceed with the scheduled surgery.

A 31-year-old client, G3, T0, P2, Ab0, L0 at 32 weeks' gestation, is being admitted to the hospital with contractions of moderate intensity occurring every 3 to 4 minutes per the client report. The client is crying on admission; the history reveals that the client has previously had two nonviable fetuses at 30 weeks' gestation. What nursing action would be the highest priority for this client?

Assess maternal contraction and fetal heart rate pattern. Explanation: The physical aspects of care have a higher priority than the psychosocial aspects. The client report is part of the electronic medical record, but the maternal contraction pattern and the fetal heart rate pattern must be completed immediately upon admission to establish a baseline. The need for a tocolytic agent cannot be determined until the maternal fetal unit has been assessed. Assessment of the circumstances and etiologies of the prior fetal demises are important but are not of the highest importance. The psychosocial aspects are very important in the care of this client and can briefly be discussed as the physical aspects of assessment are being completed, but in-depth psychosocial care will need to wait until the physical aspects have been completed.

A client in labor is receiving oxytocin. The electronic fetal monitoring strip shows contractions occurring every 30 seconds to 2 minutes, with an intensity of 90 mm Hg and increasing resting tone. How should the nurse respond to these findings?

Discontinue the oxytocin infusion. Explanation: Oxytocin should be discontinued when contractions occur less than 2 minutes apart or last longer than 90 seconds. The nurse can stop oxytocin infusion independently without seeking permission from the physician — an action that would waste valuable time. This client isn't oxygen deprived and, therefore, doesn't need supplemental oxygen. Checking the FHR isn't appropriate in this situation because the decelerations occur and resolve with each contraction, independent of oxytocin administration.

A client diagnosed with major depression spends most of the day lying in bed with the sheet pulled over his head. Which approach by the nurse is most therapeutic?

Initiate contact with the client frequently. Explanation: The nurse should initiate brief, frequent contacts throughout the day to let the client know that he is important to the nurse. This will positively affect the client's self-esteem. The nurse's action conveys acceptance of the client as a worthwhile person and provides some structure to the seemingly monotonous day. Waiting for the client to begin the conversation with the nurse is not helpful because the depressed client resists interaction and involvement with others. Sitting outside of the client's room is not productive and not necessary in this situation. If the client were actively suicidal, then a one-on-one client-to-staff assignment would be necessary. Questioning the client until he responds would overwhelm him because he could not meet the nurse's expectations to interact.

A client with bipolar disorder is taking lithium carbonate 300 mg t.i.d. His lithium level is 2.7 mEq/L. In assessing the client at his clinic visit, the nurse finds no evidence of lithium toxicity. The first assessment question the nurse should ask before ordering another blood test is:

when the client took his last dose of lithium. Explanation: Normal lithium levels range from 0.6 to 1.2 mEq/L. This client's lithium level is extremely high. The nurse needs to determine when the client took a dose of lithium in relation to having his blood drawn because the test results may have been affected if the client had his blood drawn too soon after his last dose. Blood work should be done at least 12 hours after a client's last dose of lithium. Questioning the client about whether he's embarrassed to report medication problems or if he's experiencing depression or suicidal ideation wouldn't elicit information that would help the nurse understand why the client's lithium level is elevated. Although it's appropriate for the nurse to review the medication with the client, the main concern at this time is ensuring that the blood work is done at the proper time in relation to his last dose of lithium.

When planning care for a group of clients, the nurse notes that which client is most susceptible to infection?

an 86-year-old with burns from using a heating pad Explanation: The very young and the elderly are more susceptible to infection. An elderly client with a break in skin integrity, such as the 86-year-old with a burn, is at an increased risk for infection. The 6-year-old does not have a compound fracture (protruding through the skin) and is not at high risk for infection. A client with an appendectomy is at risk for infection of the surgical site but not as high a risk as the client with burns. While a client with diabetes is at risk for infection, this adolescent is not at high risk at this time.

A client has a history of heart failure and has been prescribed furosemide, digoxin, and potassium chloride. The client has nausea, blurred vision, headache, and weakness. The nurse notes that the client is confused. The telemetry strip shows first-degree atrioventricular block. The nurse should assess the client for signs of:

digoxin toxicity. Explanation: Early symptoms of digoxin toxicity include anorexia, nausea, and vomiting. Visual disturbances can also occur, including double or blurred vision and visual halos. Hypokalemia is a common cause of digoxin toxicity associated with arrhythmias because low serum potassium can enhance ectopic pacemaker activity. Although vomiting can lead to fluid deficit, given the client's history, the vomiting is likely due to the adverse effects of digoxin toxicity. Pulmonary edema is manifested by dyspnea and coughing.

Three weeks after an infant receives a spica cast, the mother calls the nurse because the infant's toes are swollen and cool to the touch. What should the nurse instruct the mother to do?

Have the child fitted for a larger cast. Explanation: Infants grow rapidly and may require application of a larger cast. A cast adequate for an infant after surgery may be outgrown in less than 1 month. The cast becomes too tight, impairing circulation evidenced by toe swelling and coolness to touch. The mother should keep the child's feet in a recumbent position. When feet are dependent in a cast, decreased venous return may occur. Reduced venous return along with decreased feet and leg movement subsequently leads to edema, which resolves when the feet are returned to a recumbent position. The cotton wadding used to line the cast does not shrink over time. If the child had surgery, the chances of infection are minimal after a 3- to 4-week period. In addition, other symptoms of infection, such as fever and possibly a hot spot on the cast, would be present.

A client, diagnosed with acute pancreatitis 5 days ago, is experiencing respiratory distress. Which finding should the nurse report to the health care provider (HCP)?

arterial oxygen level of 46 mm Hg (6.1 kPa) Explanation: Manifestations of adult respiratory distress syndrome (ARDS) secondary to acute pancreatitis include respiratory distress, tachypnea, dyspnea, fever, dry cough, fine crackles heard throughout lung fields, possible confusion and agitation, and hypoxemia with arterial oxygen level below 50 mm Hg. The nurse should report the arterial oxygen level of 46 mm Hg (6.1 kPa) to the HCP. A respiratory rate of 12 is normal and not considered a sign of respiratory distress. Adventitious lung sounds, such as crackles, are typically found in clients with ARDS. Oxygen saturation of 96% is satisfactory and does not represent hypoxemia or low arterial oxygen saturation.