Skills

The nurse assesses the breath sounds of a 2-day postoperative total laryngectomy client and determines that suctioning is needed to clear secretions. The client is off the mechanical ventilator and is receiving humidified oxygen via a tracheostomy mask. Place the steps for suctioning the tracheostomy tube in the correct order. All options must be used. Unordered Options Ordered Response

*Evidence shows there is no difference between intermittent or continuous suction in preventing tracheal damage. QUWorld hen performing the suctioning procedure, the nurse follows institution policy and observes principles of infection control and client safety. Strict aseptic technique is naintained because suctioning can introduce bacteria into the lower airway and lungs. 1. Place the client in semi-Fowler's position, if not contraindicated, to promote lung expansion and oxygenation. 2. Preoxygenate with 100% oxygen (hyper-oxygenate) to prevent hypoxemia and microatelectasis. Alternately, if the client is breathing room air independently, ask the client to take 3-4 deep breaths. 3. Insert the catheter gently the length of the airway without applying suction to prevent mucosal tissue damage. The distance can be premeasured (0.4-0.8 in [1-2 cm] past the distal end of the tube). 4. Withdraw the catheter slightly (0.4-0.8 in [1-2 cm]) if resistance is felt at the carina (bifurcation of the left and right mainstem) to prevent mucosal tissue damage. 5. Apply intermittent suction while rotating the suction catheter during withdrawal to prevent mucosal tissue damage. Limit suction time to 5-10 seconds with each suction pass to prevent mucosal tissue damage and limit hypoxia. Educational objective: Suctioning removes secretions from the airway. The nurse should minimize risks associated with suctioning by using correct aspiration technique and client positioning Semi-Fowler's position promotes lung expansion. Preoxygenation and limit of suction time to 5-10 seconds reduces hypoxia and trauma

The nurse is inserting an indwelling (Foley) urinary catheter into a male client. After inserting the catheter about 6 in (15.2 cm), the nurse notes drops of urine in the tubing. What action should the nurse take next? O 1. Further insert the catheter 1-2 in (2.5-5.1 cm) O 2. Have the client hold his breath O 3. Immediately inflate the 5 mL balloon O 4. Secure the tubing to the client's leg

1 OUWorld Urine could be in the urethra and evident in the tubing even though the tip with the balloon is not in the bladder. It is necessary to further insert the catheter before inflatin the balloon to make sure the tip is in the bladder and not the urethra (causing urethral trauma). In the male client, it is recommended that the catheter be inserted 7-9 in (17-22.5 cm) o until urine flows out, due to the longer urethra. The catheter should then be inserted at least an additional 1 in (2.5 cm) or to catheter bifurcation. (Option 2) The client should be told to take slow, deep breaths to help relax the externe sphincter and provide a distraction. (Option 3) The catheter needs to be inserted further before inflating the balloon to prevent urethral trauma. (Option 4) Securing the catheter to the leg occurs after the balloon is inflated and placement is assured. Educational objective: Insert the Foley urinary catheter further if drops appear in the tubing to ensure that the tir with the balloon is in the bladder. Inflating the balloon before advancing the catheter could result in urethral trauma

The nurse is preparing to flush a client's central venous catheter. Which size syringe is best for the nurse to choose? O 1.1 mL (1%) O 2.3 mL (10%) 0 3.10 mL (80%) © 4.30 mL (8%)

10 ml 30 ml OUWorld Flushing the lumen of a central venous access device (central venous catheter [CVCI) with normal saline is recommended to assess patency before medication infusion, prevent medication incompatibilities after infusion, and prevent occlusion after blood sampling. A 10-mL syringe is generally preferred for flushing the lumen of a CVC (Option 3). The smaller the syringe, the greater the amount of pressure per square inch exerted during injection, increasing the risk for damage to the CVC. The "push-pause" method involves slowly injecting normal saline into the CVC catheter and stopping for any resistance. Injecting against resistance can damage the CVC, which may result in complications, including embolism and malfunction. The nurse should always consult the specific manufacturer guidelines and facility policy when caring for a CVC (Options 1 and 2) A smaller syringe (eg, 1 mL, 3 mL) creates more pressure, which increases the risk for damage to the CVC (Option 4) A 30-mL syringe is unnecessarily large to flush a CVC. Educational objective: When flushing the lumen of a central venous catheter, the nurse should use the safest syringe possible and the "push-pause" method to avoid exerting too much pressure, which may damage the catheter. The smaller the syringe, the greater the amount of pressure exerted during the flush. A 10-mL syringe is generally recommended; however, it is also important to consult the manufacturer's guidelines.

NCLEX-RN TEST - Kristina McMillan E Notes @ Calculator 4 Feedback The nurse is assisting a client who has a bedside needle liver biopsy scheduled. Which are the essential actions? Select all that apply. | 1.Assess for rising pulse and respirations afterward 2. Check PT/INR and PTT values before the procedure 3. Ensure that the client's blood is typed and crossmatched 4. Have the client void to ensure an empty bladder 5. Position the client flat or on the left side after the procedure

1234 OUWorld The client's coagulation status is checked before the liver biopsy using PT/INR and PTT. The liver ordinarily produces many coagulation factors and is a highly vascular organ. Therefore, bleeding risk should be assessed and corrected prior to the biopsy (Option 2). Blood should be typed and crossmatched in case hemorrhage occurs (Option 3).After the procedure, frequent vital sign monitoring is indicated as the early signs of hemorrhage are rising pulse and respirations, with hypotension occurring later (Option 1). (Option 4) The needle is inserted between ribs 6 and 7 or 8 and 9 while the client lies supine with the right arm over the head and holding the breath. A full bladder is a concern with paracentesis when a trocar needle is inserted into the abdomen to drain ascites. An empty bladder may aid comfort, but it is not essential for safety. (Option 5) The client must lie on the right side for a minimum of 2-4 hours to splint the incision site. The liver is a "heavy" organ and can "fall on itself" to tamponade any bleeding. The client stays on bed rest for 12-14 hours Educational objective: Essential nursing actions related to a needle liver biopsy include checking coagulation, blood type, and crossmatch beforehand, positioning the client on the right side for hours afterward, and monitoring vital signs and for potential signs of shock.

The nurse prepares to administer a cleansing enema to a client with constipation. Which interventions are appropriate? Select all that apply. 1. Assist the client into left lateral position with right knee flexed 2. Encourage the client to retain the enema for as long as possible 3. Insert tubing into the rectum with the tip directed toward the umbilicus 4. Keep the enema solution refrigerated until ready to administer 5. Slow administration rate if the client reports abdominal cramping

1235 Cleansing enemas (eg, normal saline, soapsuds, tap water) relieve constipation by stimulating intestinal peristalsis. When administering an enema, appropriate interventions include: • Place the client in a left lateral position with the right knee flexed (ie, Sims position) to promote flow of the enema into the colon (Option 1). • Hang the enema bag no more than 12 in (30 cm) above the rectum to avoid overly rapid administration. • Lubricate the enema tubing tip and gently insert 3-4 in (7.6-10 cm) into the rectum. • Direct the tubing tip toward the umbilicus (ie, anteriorly) during insertion to prevent intestinal perforation (Option 3). • Encourage the client to retain the enema for as long as possible (eg, 5-10 minutes) (Option 2). • Open the roller clamp on the tubing to allow the solution to flow in by gravity. If the client reports abdominal cramping, use the roller clamp to slow the rate of administration (Option 5). (Option 4) Enemas are administered at room temperature or warmed, as cold enema solutions cause intestinal spasms and painful cramping. Enemas may be warmed by placing the container of solution in a basin of hot water. Educational objective: When administering an enema, the nurse should place the client in the left lateral position with the right knee flexed, insert the tubing into the rectum with the tip directed toward the umbilicus, and slow the rate of administration if the client reports abdominal cramping. Enemas should be administered at room temperature or warmed.

The student nurse verbalizes the procedure for obtaining a wound culture to the nurse preceptor. Which of the following statements by the student indicate a correct understanding? Select all that apply. 1. "I will apply the prescribed bacitracin ointment after collecting the wound culture L 2. "I will cleanse the wound by gently flushing it with normal saline." O 3."I will obtain a sample of the drainage accumulated since the last dressing change." 4. "I will perform hand hygiene and apply new gloves before obtaining the wound culture." L5. "I will swab the wound from the outermost margin toward the center."

124 OuWorld Wound cultures identify microorganisms to aid in prescribing appropriate antibiotics and are obtained as follows: 1. Perform hand hygiene, and apply clean gloves. Remove the old dressing. Remove and discard gloves. 2. Perform hand hygiene, and apply sterile gloves. Assess the wound bed. Cleanse the wound bed and surrounding skin with normal saline (eg, flushing, swabbing with gauze) to remove drainage and debris (Option 2). Remove and discard gloves. 3. Perform hand hygiene, and apply clean gloves. Gently swab the wound bed with a sterile swab, from the wound center toward the outer margin (Options 4 and 5). Avoid contact with skin at the wound edge as it can contaminate the specimen with skin flora. 4. Place the swab in a sterile specimen container; avoid touching the swab to the outside of the container. 5. Apply prescribed topical medication (eg, bacitracin) after obtaining cultures to prevent interference with microorganism identification (Option 1). Apply new dressing. 6. Remove and discard gloves, and perform hand hygiene. Label the specimen, and document the procedure (Option 3) Pooled purulent exudate likely contains skin flora different from the pathogen(s) responsible for the infection. Microorganisms responsible for infection are most likely found in viable tissue. Educational objective: Wound cultures are used to identify microorganisms and select appropriate antibiotics The nurse should assess and clean the wound, swab from the wound center toward the outer margin, and avoid contamination (eg, hand hygiene, not touching intact skin with swab) to prevent misidentification of microorganisms.

A client with hypokalemia is prescribed IV potassium chloride (KCI) to infuse at 10 mEq/hr. The pharmacy sends 20 mEq of KCl in 250 mL of D,W. To deliver the prescribed dose, the nurse sets the infusion pump at how many milliliters per hour (mL/hr)? Record your answer using a whole number. Answer (mL/hr)

125 ml/he

A nurse is caring for a 3-month-old client with a new tracheostomy. Which findings woL indicate a need for suctioning? Select all that apply. 1. Audible gurgling _ 2. Heart rate 105/min 3. Increased irritability 4. Oxygen saturation 88% L5.Respiratory rate 30/min

134 vo mechanism and ciliary function, causing an increase in thick secretions that may occlude the airway. Focused respiratory assessments are critical to determine the need for suctioning and to maintain a patent airway. To decrease the risks associated with the procedure (eg, atelectasis, hypoxemia, trauma, infection), suctioning should be performed only when necessary. Assessment findings that indicate a need for suctioning include: • Decreased oxygen saturation (Option 4) • Altered mental status (eg, irritability, lethargy) (Option 3) • Increased heart rate (normal infant range: 90-160) • Increased respiratory rate (normal infant range: 30-60) • Increased work of breathing (eg, flared nostrils, use of accessory muscles) • Adventitious breath sounds (eg, crackles, wheezes, rhonchi) (Option 1) • Pallor, mottled, or cyanotic skin coloring (Options 2 and 5) Respiratory rate of 30/min and heart rate of 105/min are within normal limits for an infant and would not indicate distress or a need for suctioning. Educational objective: Assessment findings that indicate the need to suction a client's tracheostomy or endotracheal tube include decreased oxygen saturation, altered mental status (eg, irritability), increased heart rate or respirations, increased work of breathing, and adventitious breath sounds.

NCLEX-RN TEST - Kristina McMillan E Notes @ Calculator C Feedback The nurse is suctioning the artificial airway of a conscious client. Which actions demonstrate correct technique? Select all that apply. 1.Apply suction for no longer than 5-10 seconds L 2. Insert catheter with low, intermittent suction applied 3. Set suction higher than 130 mm Hg for thick, copious secretions 4. Wait at least 1 minute between suction passes 5. Withdraw catheter immediately if client begins coughing

145 *Evidence shows there is no difference between intermittent or continuous suction in preventing tracheal damage. OuWorld The process of suctioning a client's airway removes oxygen in addition to the secretion therefore, the client should be preoxygenated with 100% 02, and suction should be applied for no more than 10 seconds during each pass to prevent hypoxia (Option 1 The nurse must wait 1-2 minutes between passes for the client to ventilate to prevent hypoxia (Option 4). In addition, deep rebreathing should be encouraged. (Option 2) The suction catheter should be no more than half the width of the artificia airway and inserted without suction. (Option 3) The nurse should don sterile gloves if the client does not have a closed suction system in place. Suction should be set at medium pressure (100-120 mm H for adults, 50-75 mm Hg for children) as excess pressure will traumatize the mucosa can cause hypoxia. (Option 5) Clients usually cough as the catheter enters the trachea, and this helps loosen secretions. The catheter should be advanced until resistance is felt and then. prevent mucosal damage, retracted 1 cm before applying suction. Educational objective: Proper airway suctioning technique includes preoxygenation, limiting a suction pass ti seconds, and allowing 1-2 minutes between passes to prevent hypoxia. Medium sucl pressure should be set at 100-120 mm Hg for adults, with the catheter inserted withou suction

Which of these are correct nursing actions related to client positioning? Select all that apply. 0 1. Position client in high Fowler's for a paracentesis related to end-stage cirrhosis 0 2. Position client on left side after liver biopsy - 3. Position client on side with head, back, and knees flexed after lumbar puncture 4. Position client Trendelenburg on left side if air embolism is suspected 5. Position client with arm raised above head for chest tube placement

145 Abdominal paracentesis is used to remove ascitic fluid from the peritoneal cavity in end-stage liver disease (cirrhosis). The client should be positioned in high Fowler's or sat upright to facilitate the flow of fluid to the bottom of the peritoneal cavity, where the needle will be inserted. The client should void prior to the procedure to decrease the risk of bladder puncture (Option 1). In the event of an air embolus, the head of the bed should be lowered (Trendelenburg) and the client positioned on the left side; this will cause the air to rise to the right atrium. The health care provider should be notified immediately and the nurse should remain with the client (Option 4). Chest tube insertion should be performed with the client's arm raised above the head on the affected side. If possible, the head of the bed should be raised 30-60 degrees to reduce risk of injury to the diaphragm (Option 5). (Option 2) After a liver biopsy, the client should lie on the right side for a minimum of 2 hours (to apply pressure and splint the puncture site) and then supine for an additional 12-14 hours. The risk for bleeding is increased due to the high vascularity of the liver, but correct positioning reduces this risk. (Option 3) During a lumbar puncture, the client is positioned side-lying, with the head, back, and knees flexed. A small pillow may be placed between the legs and under the head for comfort and to maintain the spine in a horizontal position. Following the procedure, the client will be positioned according to the health care provider's prescription (usually supine or with head of the bed elevated 30 degrees). Educational objective: For medical procedures, the nurse should ensure that the client: • Has an empty bladder and is in high Fowler's or a sitting position for paracentesis • Is Trendelenburg on the left side for suspected air embolism • Has the arm raised above the head on the affected side for chest tube insertion • Lies on the right side (for 2 hours) and then supine (12-14 hours) after liver biopsy • Is side-lying with the head, back, and knees flexed for lumbar puncture

An elderly client is brought to the emergency department with lethargy, chills, and sharp chest pain with deep breathing. Pulse oximeter shows 93% on room air and respirations are 24/min. What is the nurse's initial action? O 1. Administer intravenous (IV) morphine O 2. Auscultate the client's lung sounds 3. Initiate an IV infusion of normal saline O 4. Initiate nasal oxygen at 3 L/min

2 Assessment is the first step in the nursing process that is used to gather information. Lung auscultation is the nurse's initial action with this client. Before intervening, the nurse should assess respiratory status and vital signs to obtain the baseline data that will be compared to subsequent changes (Option 1) Morphine is administered to provide comfort and pain relief. This is an appropriate intervention to facilitate breathing and oxygenation, but it is not the best initial action. Assessment of respiratory status and vital signs should be performed before intervening. (Option 3) Initiation of an IV infusion of saline is done to provide hydration and IV access. This is an appropriate intervention, but it is not the best initial action. (Option 4) Although the saturation is decreased (93%) and the respiratory rate is increased (24/min), both are adequate to support oxygenation at this time. Nasal oxygen at 3 L/min should be initiated to improve oxygenation. Even though this is an appropriate intervention, it is not the best initial action. Educational objective: The nurse should first assess the client's condition before intervening. This is important as the ability to plan effective nursing care, set priorities, identify appropriate interventions, and make sound clinical decisions is based on the information obtained from the assessment.

The 70-year-old client with type 2 diabetes and hypertension is scheduled for ureteral stent removal in 2 hours. The preoperative protocol ECG is done in the inpatient unit, and results indicate a "possibly acute" ST segment elevation. What action is most important for the nurse to take? O 1. Document the test results on the preoperative checklist O 2. Notify the health care provider about the test results O 3. Place the printed ECG in the front of the chart O 4. Report the results to the surgical nurse to tell the surgeon

2 This is a high-risk client (eg, older age, hypertension, diabetes), and the acute, new, significant finding needs further evaluation and possible intervention before undergoing the stress of surgery. In addition, clients with a long history of diabetes often have associated neuropathy and may not experience the chest pain typical of myocardial infarction (MI), known as silent MI. As a result, the nurse must ensure that the health care provider (HCP) is made aware of this client's new findings in a timely manner. (Options 1, 3, and 4) All of these actions should also be performed. However, the most important action is for the nurse to personally notify the client's HCP in a timely manner so that appropriate treatment can be provided. Educational objective: When significant abnormal results are obtained on a presurgical client, it is the nurse's responsibility to ensure that the health care provider is notified in a timely manner.

A client started a 24-hour urine collection test at 6:00 AM. The unlicensed assistive personnel (UAP) reports discarding a urine specimen of 250 mL at 10:00 AM by mistake but adding all specimens to the collection container before and after that time. What action should the nurse take? O 1. Add 250 mL to the total output after the 24-hour urine collection is complete tomorrow morning O 2. Discard urine and container, and restart the 24-hour urine collection tomorrow morning O 3. Discard urine and container, have client void, add urine to new container, and then restart test O 4. Relabel the same collection container, and change the start time from 6:00 AM to 10:00 AM

2 Timed urine collection tests are usually done to assess kidney function and measure substances excreted in the urine (eg, creatinine, protein, uric acid, hormones). These tests require the collection of all urine produced in a specified time period (a crucial step) to ensure accurate test results. The proper container (with or without preservative) for any specific test is obtained from the laboratory. The collection container must be kept cool (eg, on ice, refrigerated) to prevent bacterial decomposition of the urine. Not all of the client's urine was saved during the collection period. Therefore, the nurse or UP must discard the urine and container and restart the specimen collection procedure. Although a 24-hour urine collection can begin at any time of the day after the client empties the bladder, it is common practice to start the collection in the morning after the client's first morning voiding and to end it at the same hour the next morning after the morning voiding (Option 2). (Option 1) Adding 250 mL to the total output when the test is completed is not an appropriate action as the actual urine output from the 24-hour period is needed for accurate results. (Option 3) To start the collection period, the nurse asks the client to void and discards this specimen (it is not added to the collection container). The 24-hour period starts at the time of the client's first voiding. (Option 4) Relabeling the same container and changing the start time from 6:00 AM to 10:00 AM is not an appropriate action. The container would include part of the urine produced in a 28-hour period, and the test results would be inaccurate. Educational objective: It is common practice to start a 24-hour urine collection test at the time of the client's first voiding in the morning. If any urine is discarded by accident during the test period, the procedure must be restarted. All produced urine should be placed in the same container and kept cool (on ice).

The health care provider prescribes 2 mEq (2 mmol)/kg of 8.4% sodium bicarbonate IV to be administered over the next 4 hours. The client weighs 150 lb, and the pharmacy supplies the following IV solution: 8.4% sodium bicarbonate in 1000 mL of D.W with 150 mEq (150 mmol) of sodium bicarbonate. At what rate in milliliters per hour (mL/hr) should the nurse set the infusion pump? Record your answer using a whole number. Answer (mL/hr)

227ml/hr

A 7-year-old client receives a scalp laceration to the back of the head while on a playground, and the new nurse prepares to irrigate the wound. Which actions by the nurse would require the experienced nurse to intervene? Select all that apply. 1. Administers the prescribed analgesic 30 minutes before irrigating the wound 2. Cleanses the wound from the most to the least contaminated area E 3. Obtains a 10-mL syringe and a 27-gauge needle 4. Reviews the child's most recent immunization record L 5. Uses continuous pressure to irrigate and repeats until drainage is clear

23 OUWord Before an open wound is closed, irrigation is performed to wash out debris and bacteria to ensure appropriate wound healing. This is important for wounds obtained in an outdoor environment (eg, playground) as contamination with soil or dirt greatly increases the risk of infection. To perform wound irrigation: • Administer the analgesic 30-60 minutes before the procedure to allow medication to reach therapeutic effect (Option 1). • Don a gown and mask with face shield to protect from splashing fluid and sterile gloves to maintain surgical asepsis and prevent infection. • Fill a 30- to 60-mL sterile irrigation syringe with the prescribed irrigation solution. • Attach an 18- or 19-gauge needle or angiocatheter to the syringe and hold 1 in (2.5 cm above the area. • Use continuous pressure to flush the wound, repeating until drainage is clear (Option 5). • Dry the surrounding wound area to prevent skin breakdown and irritation. Immunization history is reviewed to determine tetanus vaccination status (Option 4). Typically, a tetanus vaccination is administered if the client has not had one within the last 5-10 years, depending on the contamination level of the wound. (Option 2) Wounds should be cleaned from the least to the most contaminated area to prevent recontamination. (Option 3) A 10-mL syringe would require frequent refilling; a larger syringe is more appropriate. The narrow lumen of a 27-gauge needle would provide excessive irrigation pressure. Educational objective: Open wounds must be free of dirt and bacteria prior to closure to reduce the risk of infection. Wound irrigation requires surgical asepsis. Physiological Adaptation NCSBN Client Need

The nurse is preparing to administer several medications through a client's feeding tube. None of the medications are extended release. Which of the following actions should the nurse implement? Select all that apply. 1. Combine all medications and administer together L 2. Crush each medication separately before administration 3. Determine if the medications are available in liquid form 4. Flush the tube before and after medication administration 5. Mix medications with enteral feeding formula before administration

234 Failure to correctly administer medications through feeding tubes (eg, nasogastric, gastrostomy) can result in obstruction of the tube, reduced medication absorption or efficacy, and medication toxicity. Before administering medications through a feeding tube, the nurse should determine if any of the medications are available in a liquid form because liquid medications are less likely to clog the tube (Option 3). Medications should be crushed, dissolved, and administered separately to prevent interactions (eg, chemical reactions) between medications or interference with absorption (Option 2). In addition, a feeding tube should be flushed before and after each medication is given to avoid potential drug interactions and ensure tube patency (Option 4). (Option 1) When using a feeding tube, each medication should be administered individually to prevent interactions between medications. (Option 5) Medications mixed with enteral feedings may form a thick consistency and clog the tube. Educational objective: When using a feeding tube, medications should be crushed, dissolved, and administered separately to prevent interactions. Feeding tubes should be flushed before and after each medication is given. Liquid medications should be used if possible Pharmacological and Parenteral Therapies NCSBN Client Need

The nurse notes muffled heart tones in a client with a pericardial effusion. How would the nurse assess for a pulsus paradoxus? O 1. Check for variation in amplitude of QRS complexes on the electrocardiogram strip O 2. Compare apical and radial pulses for any deficit © 3. Measure the difference between Korotkoff sounds auscultated during expiration and throughout the respiratory cycle 4. Multiply diastolic blood pressure (DBP) by 2, add systolic blood pressure (SBP), and divide the result by 3; [(DBP x 2) + (SBP)1/3

3 Muffled heart tones in a client with pericardial effusion can indicate the development of cardiac tamponade. This results in the build-up of fluid in the pericardial sac, which leads to compression of the heart. Cardiac output begins to fall as cardiac compression increases, resulting in hypotension. Additional signs and symptoms of tamponade include tachypnea, tachycardia, jugular venous distension, narrowed pulse pressure, and the presence of a pulsus paradoxus. Pulsus paradoxus is defined as an exaggerated fall in systemic BP >10 mm Hg during inspiration. The procedure for measurement of pulsus paradoxus is as follows: 1. Place client in semirecumbent position 2. Have client breathe normally 3. Determine the SBP using a manual BP cuff 4. Inflate the BP cuff to at least 20 mm Hg above the previously measured SBP 5. Deflate the cuff slowly, noting the first Korotkoff sound during expiration along with the pressure 6. Continue to slowly deflate the cuff until you hear sounds throughout inspiration and expiration; also note the pressure 7. Determine the difference between the 2 measurements in steps 5 and 6; this equals the amount of paradox 8. The difference is normally <10 mm Hg, but a difference >10 mm Hg may indicate the presence of cardiac tamponade (Option 1) Variation in QRS amplitude is termed electrical alternans. It could be present in cardiac tamponade, but it is not how pulsus paradoxus is determined. Electrical alternans is due to the swinging motion of the heart in a fluid-filled pericardial sac. tion 2) An apical/radial pulse deficit may be present during certain dysrhythmias, bu is not the procedure for measuring pulsus paradoxus. ton 4) This is the formula for calculating mean arterial pressure. cational objective: nurse should assess the client for pulsus paradoxus when cardiac tamponade is pected. The amount of paradox is the difference between the pressure heard at the † Korotkoff sound during expiration and the Korotkoff sounds heard throughout piration and expiration. A difference of <10 mm Hg is normal, but if it is >10 mm Hg. may indicate cardiac tamponade.

The nurse plans to start an IV line on a female client hospitalized with pneumonia. The nurse reviews the electronic medical record for relevant information and learns that the client is right-handed and has a history of a left-sided mastectomy with lymph node removal. Which site is best for the nurse to select for the client's IV line? O 1. Basilic vein of the left forearm (4%) O 2. Cephalic vein in the right antecubital space (28%) © 3. Median vein of the right forearm (63%) 4. Radial vein of the left wrist (4%)

3 OUWorld The client's medical history should be reviewed prior to starting an IV line so that the nurse can identify any contraindications to specific anatomical sites. Lymph node removal during a mastectomy may affect lymphatic fluid drainage on the affected side and cause lymphedema or other complications such as infection, venous thromboembolism, or trauma to the affected arm. The nurse must avoid any needlesticks, IV insertions, or blood pressure measurements in the affected arm (Options 1 and 4). The nondominant side is preferred when no medical contraindications exist. However, in this case, the right forearm is best because the client had a left-sided mastectomy (Option 3). Other considerations when selecting IV sites include avoidance of areas that have obstructed blood flow, dialysis sites, areas distal to old puncture sites, bruised areas, painful areas, or areas with skin conditions or signs of infection. (Option 2) The antecubital space should be avoided when possible (except for emergency insertion) as it inhibits mobility and may be positional. Educational objective: The nurse should review the client's medical record and assess for contraindications to IV sites, including impaired lymphatic drainage (prior mastectomy), arteriovenous fistula or graft (used for hemodialysis), and areas distal to old puncture sites. Pharmacological and Parenteral Therapies NCSBN Client Need

The nurse prepares equipment for insertion of a large-bore nasogastric (NG) tube for a hospitalized client. Which actions should the nurse take to measure and mark the tube? Select all that apply. 1. Fold tube in half and mark at the halfway point L 2. Extend tape measure from naris to stomach D 3. Measure from tip of nose to earlobe to xiphoid process 4. Place a small piece of tape at the point of measurement E 5. Use rubber clamp after measuring to mark the point of measurement

34 OuWorld Because distance from the nares to the stomach varies with each client, it is important to measure and mark the NG tube prior to insertion to ensure its correct placement in the stomach. The Traditional Method is most commonly used for large-bore NG tube placement. Traditional Method: Using the end of the tube that will eventually rest in the stomach, measure from the tip of the nose, extend the tube to the earlobe and then down to the xiphoid process (Options 1, 2, and 3). Mark the distance with a small piece of tape that can be easily removed (Options 4 and 5). Educational objective: Ensure proper measurement prior to inserting a large-bore NG tube by measuring from the tip of the nose, extending the tube to the earlobe, and then down to the xiphoid process. Mark the distance with a small piece of tape that can be easily removed

A student nurse is preparing to administer the hepatitis B vaccine to a newborn. Which statement by the student nurse requires the preceptor to provide further teaching? O 1. "A ⅝-inch, 25-gauge needle is appropriate for intramuscular injection in newborns." © 2. "I will clean the injection site with an antiseptic swab before administration." O 3. "I will draw the medication into a 1-mL syringe." O 4. "The medication should be administered into the deltoid muscle."

4 OUWorld Intramuscular (IM) injections (eg, hepatitis B vaccine, vitamin K) are commonly administered to newborns shortly after birth or before discharge. The vasts lateralis muscle in the anterolateral middle portion of the thigh is the preferred site for IM injections in newborns (age <1 month) and infants (age 1-12 months). The deltoid muscle is an inappropriate injection site for newborns due to inadequate muscle mass (Option 4). (Option 1) For IM injections, the needle length should be % inch for newbras and % to 1 inch for infants; these lengths are adequate for reaching the muscle mass while avoiding underlying tissues (eg, nerves, bone). A 22- to 25-gauge needle is appropriate for clients age <12 months (Option 2) The medication should be administered using aseptic technique; cleaning the site with an antiseptic solution (eg, alcohol) is appropriate. (Option 3) A 1-mL syringe (eg, tuberculin) should be used to measure very small doses in 0.01-mL increments for newborns, infants, and small children. Pediatric medication dosages can be very small and should be measured to two decimal places. Educational objective: The preferred site for intramuscular (IM) injection in newborns is the vasts lateralis muscle in the anterolateral portion of the middle thigh. A 1-mL syringe should be used, and medication dosages should be calculated to two decimal places. A ⅝-inch, 22- to 25- gauge needle is appropriate for IM injection in a newborn. Pharmacological and Parenteral Therapies NCSBN Client Need

The nurse is drawing a blood specimen from the client's right basilic vein. The client cries out, retracts the arm, and reports feeling "pins and needles" in the right arm. Which action by the nurse is appropriate? O 1. Obtain a smaller-gauge needle and reattempt at the same site (0%) × O 2. Partially withdraw and then reinsert the needle at a different angle (8%) 3. Provide reassurance and firmly stabilize the arm to complete the collection (9%) O 4. Withdraw the needle and reattempt in a different site with new equipment (81%)

4 OUWorld The preferred site for venipuncture when collecting blood specimens is the antecubital fossa's median cubital vein. The basilic vein lies close to the brachial nerve and artery. When severe, shooting pain radiates down a client's arm during venipuncture, nerve injury may be occurring. The client may also report feelings of "pins and needles" or numbness at and/or near the venipuncture site. If this occurs, the nurse should promptly withdraw the needle, obtain new equipment, and choose a different site for specimen collection (Option 4). (Options 1 and 2) Because the pain and numbness during venipuncture indicate a nerve injury, the nurse should reattempt the specimen collection using a different site. Reattempting at the same site with a smaller-gauge needle or from a different angle could cause nerve damage. (Option 3) Reassurance may help calm an anxious client, and stabilization may help prevent injury if a client attempts to withdraw the arm during routine venipuncture. However, this client has nerve pain, which indicates that the attempt should be stopped immediately to prevent nerve damage. Educational objective: The presence of pain and feelings of "pins and needles" during venipuncture may indicate nerve pain and require prompt cessation of the attempt. The nurse should withdraw the needle, obtain new equipment, and choose a different site for the specimen collection. Reduction of Risk Potential NCSBN Client Need

A client postoperative from a transurethral prostatectomy has a triple-lumen, indwelling urinary catheter and is receiving continuous bladder irrigation of sterile normal saline solution at 175 mL/hr. The nurse empties the urine drainage bag for a total of 2300 mL the end of the 8-hour shift. How many milliliters (mL) should the nurse document as thr net urine output for the shift? Record your answer using a whole number. Answer 900 (mL)

Explanation A transurethral prostatectomy (TURP) is a surgical prostate-removal procedure commonly performed for male clients with prostate cancer. Following a TURP, clients typically receive continuous bladder irrigation (CBI) with a sterile, isotonic solution (eg, normal saline) via indwelling urinary catheter. CB prevents bladder obstruction by large blood clots in the bladder or urethra. Monitoring urine output in clients receiving CBI can be challenging because there is continuous output from the irrigation. To calculate net urine output, the nurse should subtract the irrigation input from the total catheter output. Use the following steps to calculate the net urinary output: 1. Calculate the total volume of irrigation solution infused into the bladder Irrigation infusion rate x hours infused = total irrigation volume OR 175 mL 8 = 1400 mL irrigation volume hr 2. Calculate the net urine output Catheter output - irrigation volume = net urine output OR 2300 mL catheter output - 1400 mL irrigation volume = 900 mL net urine output Educational objective: Continuous bladder irrigation is a therapy commonly used to prevent bladder obstruction by blood clots after a prostatectomy. To calculate the net urine output in a client with continuous bladder irrigation, the nurse should subtract the total amount of irrigating solution infused from the total amount of catheter output.

The nurse is preparing to administer a continuous enteral feeding for a client with a nasogastric tube. Place the steps in the correct order. All options must be used. Unordered Options Your Response / Correct Response

Explanation The steps for administering a continuous enteral feeding include: • Identify the client using 2 identifiers (eg, first and last name, medical record number, date of birth) (Option 4) and explain the procedure to the client. Perform hand hygiene and apply clean gloves. • Elevate the head of the bed ≥30 degrees and keep it elevated for at least 30 minutes after feeding to minimize the risk of aspiration (Option 2). • Validate tube placement by checking the gastric pH as well as assessing the external tube length and comparing it with the measurement at the time of insertion. The tube should be marked at the nostril with a permanent marker during the initial x- ray validation (Option 5). • Check gastric residual volume. • Flush the tube with 30 mL of water after checking residual volume, every 4-6 hours during feeding, and before and after medication administration (Option 3). • Administer the prescribed enteral feeding solution by connecting the tubing and setting the rate on the infusion pump (Option 1). Educational objective: The general steps for administering a continuous enteral feeding include identifying the client, elevating the head of bed at least 30 degrees, validating tube placement, flushing the tube with 30 mL of water, and administering the prescribed enteral feeding solution. Basic Care and Comfort NCSBN Client Need

The nurse is assessing the abdomen of a client experiencing gastrointestinal disti Place the answer choices in the correct order of assessment. All options must I used.

Placement in supine position Inspection Auscultation Percussion Palpation Nursing assessments are generally performed in order of least to most invasive. To perform an abdominal assessment, the nurse places the client in the supine posi to promote relaxation of the abdominal muscles. Standing on the right side of the clie the nurse makes a visual inspection of the abdomen before touching the client. After inspection, the nurse auscultates the abdomen. Auscultation is performed next because percussion and palpation may increase peristalsis, potentially leading the nur to make an erroneous interpretation of bowel sounds. The nurse should lightly place diaphragm of the stethoscope in the right lower quadrant because high-pitched bow sounds are normally present in this region. After auscultation, the nurse proceeds to percussion. Palpation is performed last because it may induce pain, resulting in abdominal rigidity, guarding, and a change in respirations. This rigidity may affect the tone heard on percussion. Percussion is also intended to identify borders of organs that move with respiration (eg, liver, spleen). A client in pain from abdominal tenderness will likely take quick, shallow breaths, which w change how far organs are displaced and make it more difficult for the examiner to identify true borders of organs. Educational objective: Abdominal examination is performed with the client in the supine position using the following sequence: inspection, auscultation, percussion, and palpation.