Unit 3- Clinical decision making

A nurse caring for a client in labor notes that her blood pressure (BP) rises during contractions. Which should be the nurse's next action?

Continue to monitor BP. During contractions, blood flow to the intervillous spaces changes, compromising fetal blood supply. Increased BP is expected during pain and contractions but it should return to precontraction levels, ensuring adequate blood flow to the fetus.

A nurse is assessing a client when she returns from same-day surgery for a dilatation and curettage. The nurse checks preoperative vital signs at 0830 to compare them with the current vital signs at 2230 (see chart). What should the nurse do first?

Cover the client with warmed blankets. The client's body temperature dropped 2.5° F (1.4° C) from the preoperative to postoperative phase. The client lost heat during the preoperative period. The client has not had time to regain the heat she has lost and should not be discharged postoperatively until her postoperative vital signs, which include body temperature, are closer to her preoperative vital signs. The client's pulse rate, respiratory rate, and blood pressure have compensated according to the client's hypothermic state and will reflect changes as the client warms up. There are no indications that the client needs more pain medication, oxygen, or IV fluids.

The nurse on a medical-surgical unit has interventions to complete in the morning. Which tasks are most appropriate to delegate to an unlicensed assistive personnel (UAP)? Select all that apply.

assisting a client with ambulation opening breakfast foods on the breakfast tray The nurse is able to delegate assisting with ambulation and opening breakfast foods to the UAP. Monitoring and evaluating clients are not in the scope of practice of the unlicensed personnel. Applying a hydrogel is also not in the unlicensed personnel's scope of practice.

On initial assessment of a 7-year-old child with rheumatic fever, which finding would require contacting the primary care provider immediately?

heart rate of 150 bpm A heart rate of 150 bpm is very high for a 7-year-old child and may indicate carditis. For this age group, the normal heart rate while awake is 70 to 110 bpm.Swollen and painful joints (e.g., the knee), twitching in the extremities (chorea), and a red rash on the trunk are characteristic findings in the child with rheumatic fever and do not require immediate primary care provider notification.

To promote early and efficient ambulation for a client after an above-the-knee amputation, the nurse is aware that the leg will need to be positioned in which way?

in functional alignment Muscles that originate at the vertebrae or pelvic girdle and insert on the femur act to abduct, adduct, flex, extend, and rotate the femur. Normal body alignment should be maintained because it facilitates the safe and efficient use of muscle groups for balance and stability. Functional alignment is essential for all bone repair.

A 10-month-old child is found choking and becomes unconscious. What is the nurse's priorityintervention after opening the child's airway?

look inside the child's mouth for a foreign object As soon as the infant is found choking, the nurse should give five back blows and five chest thrusts in an attempt to dislodge the object and open the airway. After the airway is open, the nurse should check for a foreign object and remove it with a finger sweep if it can be seen. After the object is removed, 30 quick compressions should be given before rescue breathing is attempted. Blind finger sweeps should never be performed because this may push the object further into the airway.

A 14-year-old brought to the emergency department with right lower quadrant pain is tentatively diagnosed with acute appendicitis. The nurse should further assess the client for which sign or symptom?

low-grade fever The most common manifestations of appendicitis include right lower quadrant pain, localized tenderness, and a low-grade fever. Other signs of inflammation, including increased pulse and respiratory rates, may be present. Costovertebral angle tenderness and gross hematuria are associated with urologic problems. Widening pulse pressure is seen in increased intracranial pressure.

A client reports having difficulty voiding to the nurse. What question(s) will the nurse ask the client? Select all that apply.

"Are you waking up in the middle of the night to void?" "How much fluids are you drinking in the late evenings?" "What are your usual voiding patterns?" The nurse will focus on the genitourinary system with voiding during the night, drinking fluids in the evening, and patterns of voiding. The history of hemorrhoids and the colonoscopy are related to the gastrointestinal system.

A client who has had AIDS for years is being treated for a serious episode of pneumonia. A psychiatric nurse consult was arranged after the client stated, "I'm tired of being in and out of the hospital. I'm not coming in here anymore. I have other options." The nurse would evaluate the psychiatric nurse consult as helpful if the client makes which statements?

"I realize that I really do have more time to enjoy my friends and family." Focusing on enjoying time with family and friends conveys a renewal of hope for the future and a decreased risk of suicide. Simply saying that no one wants the client to commit suicide does not say the client does not want to do it. Avoiding a transfer to a psychiatric unit does not mean the client is no longer suicidal. Fear of not being successful with suicide usually is not a deterrent.

The nurse is explaining hemodialysis to a student nurse. What statement leads the nurse to determine that additional teaching is needed?

"It will extract the client's red blood cells." The nurse recognizes that additional teaching is needed when the student nurse states that hemodialysis will extract the client's red blood cells. The semi-permeable membrane in hemodialysis does not permit diffusion of blood cells across the membrane. Hemodialysis will remove extra fluid, cellular waste, and will lower blood urea levels.

A nurse is caring for a client receiving thioridazine 300 mg TID. It would be most important for the nurse to follow up with which client statement?

"My eye doctor said I have a new pigmented layer on my retina." Retinal pigmentation may occur if thioridazine dosage exceeds 600 mg per day; this can lead to vision loss, so the nurse should follow up on this statement. Drinking ten glasses of water a day is encouraged. Weight gain is an adverse reaction to thioridazine and should be followed up; however, the immediate priority is preventing vision loss. Administration of thioridazine can be given without regard to food. Therefore, taking the first dose immediately in the morning is appropriate.

A client with bipolar disorder is taking lithium carbonate 300 mg t.i.d. The client's lithium level is 2.7 mEq/L. In assessing the client, the nurse finds no evidence of lithium toxicity. The first assessment question the nurse should ask before ordering another blood test is:

"When did you take your last dose of lithium?" 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 blood drawn because the test results may have been affected if the client had blood drawn too soon after the last dose. Blood work should be done at least 12 hours after a client's last dose of lithium. Questioning the client about reporting medication problems or 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 the last dose of lithium.

The client is ordered oxycodone/acetaminophen 20mg tablets, one or two prn for pain. The client rates the pain as a 7 on the numeric scale of 0/10. The nurse should administer how many oxycodone/acetaminophen?

2 The nurse should administer 1 tablets for pain less than 5 on a numeric scale of 0/10, and administer 2 tablets for pain greater than 5 on a numeric scale of 0/10.

A triage nurse in a large urban hospital has received five clients in the emergency department at the same time. Place the clients in the order in which the nurse should attend them. All options must be used.

45-year-old client with chest pain who collapses and is pulseless 80-year-old client with a respiratory rate of 8 breaths/min, blood pressure 80/50 mm Hg, and cyanosis 50-year-old client with history of type 2 diabetes and an open fracture of the left lower leg 60-year-old client with chest discomfort who was not wearing a seat belt in motor vehicle collision 35-year-old client with a dry, hacking cough and fever for the past 3 days The 45-year-old client who collapsed after chest pain and is pulseless is the immediate priority because the client is in cardiac arrest and requires cardiopulmonary resuscitation (CPR). The next priority is the 80-year-old client with a respiratory rate of 8 breaths/min, hypotension, and cyanosis; this client is breathing at a rate that will impair oxygenation, and the blood pressure indicates impaired perfusion. The client with the open fracture is the next priority, because stabilization of the fracture is important. The client with chest discomfort from the motor vehicle collision should be prioritized fourth; the accident could have resulted in a cardiac contusion, so careful monitoring is needed. The client with the cough and fever would be the lowest priority at this time.

A psychiatric nurse in the emergency department is assigned to care for a group of clients. Which client should the nurse see first?

A client who states she was sexually assaulted an hour ago. A rape or assault of any kind is a crisis situation and the primary nursing focus should be safety for the client. In addition to the psychological crisis, the client could have physiologic injuries that need immediate medical attention. The client with a panic disorder does have acute symptoms of anxiety, but is not in crisis. The client off their medication and worsening depressive symptoms is a concern but is not in immediate danger.

A client scheduled for hemodialysis is prescribed an oral antihypertensive daily. What is the correct action by the nurse regarding the medication?

Administer it after the hemodialysis treatment. The nurse should administer the medication after the hemodialysis treatment to prevent a hypotensive episode. The medication should not be held on the days the client has dialysis unless the client's blood pressure contraindicates giving the medication. Administering the medication prior to the treatment may lead to the client becoming hypotensive during dialysis or having the medication filtered out of the bloodstream during the hemodialysis treatment.

A client admitted to the emergency department with atrial fibrillation has a heart rate of 160 bpm. The nurse should implement which prescription first?

Administer oxygen via nasal cannula. The nurse should first administer oxygen; in atrial fibrillation the workload of the heart is increased, and as a result myocardial oxygen demands are also increased. A heparin bolus may be prescribed; it is not clear how long the client has been in atrial fibrillation, and it is critical to determine this before treatment is initiated. Beta blockers and cardioversion are not primary interventions, and it is important first to determine if the client is hemodynamically stable and the length of time the client has had atrial fibrillation.

The client is admitted to the medical/surgical unit for treatment of acute thrombophlebitis of the right calf. The client is administered 5000 units of heparin IV, followed by 1000 units of IV heparin per hour. Which action by the nurse is most appropriate if the client receives too much heparin?

Administer protamine sulfate. Protamine sulfate is the antidote for heparin. Vitamin K is the antidote for warfarin sodium and calcium gluconate is the antidote for magnesium sulfate toxicity. The client is already receiving warfarin sodium.

A client who had abdominal surgery 4 days ago reports that "something gave way" during a sneeze. The nurse observes a wound evisceration. What should the nurse do next?

Apply a sterile, moist dressing. Evisceration involves separation of all layers of the abdominal wall, resulting in protrusion of abdominal contents. The nurse's first priority should be to protect the client's abdominal contents. She should apply warm, sterile saline dressings over the protruding viscera. Next, the nurse should institute NPO status because the client will ultimately need surgery. The client is at risk for shock, so the nurse should monitor vital signs frequently after applying the sterile, moist dressing. The extensiveness of the protrusion is not important, it will need surgical repair regardless.

A 12-year-old client who has had type 1 diabetes since infancy tests his glucose level before lunch and has a reading of 245 mg/dL (13.6 mmol/L). What will the nurse do next? Select all that apply.

Ask client to take the prescribed bolus dose plus additional aspart insulin per the sliding scale. Ensure the client's lunch tray is present on the unit prior to giving insulin. Aspart insulin is rapid-acting and has an onset of about 10 minutes. It is given on a set scedule as a bolus dose prior to meals to offset the effect of carbohydrates. When the blood glucose level is above a desired range (usually 180 mg/dL [10 mmol/L]), additional "correction" dosing of the aspart is added to the bolus dose. Because the onset is rapid, the nurse should ensure the lunch tray is present before the dose is given. It is not necessary for the nurse to recheck the blood glucose level if the client has successfully performed testing independently. This client has lived with diabetes for 12 years, and questioning the ability to check the level could negatively affect the nurse-client relationship. Milk, graham crackers, and peanut butter can be given for a low blood glucose level, not an elevated level. There is no need to assess for symptoms, because there is already an objective assessment finding (i.e., the blood glucose reading) on which to base the treatment plan.

A client in the emergency department has symptoms of anxiety, a "racing heart," and dyspnea. The cardiac monitor shows sinus tachycardia with a heart rate of 122. What is the appropriate action of the nurse?

Assess the client's vital signs and oxygen saturation. Sinus tachycardia has multiple causes; further assessment is needed before determining the treatment. Administration of beta blockers or diazepam may not be indicated depending on the cause of the sinus tachycardia. A 12-lead EKG and tropin level might be appropriate following assessment of the client.

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. 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.

A client receiving an intravenous infusion states that, "My arm is feeling cool." Which priority action should be taken?

Assess the intravenous site. The statment that the client's arm is "feeling cool" could be an indication of infiltration; therefore, assessment of the I.V. site is indicated and should be completed first, as this poses a potential risk to the client. The other actions should be acted on but are not the highest priority.

A client with a recent diagnosis of deep vein thrombosis (DVT) has sudden onset of shortness of breath and chest pain that increases with a deep breath. What should the nurse do first?

Assess the oxygen saturation. A client with DVT is at high risk for a pulmonary embolism from an embolus traveling to the lung. Sudden onset of symptoms and worsening of chest pain with a deep breath suggest a pulmonary embolism. The nurse assesses the client and obtains oxygen saturation levels prior to calling the HCP and administering morphine. Range of motion is a preventive measure for DVT and is not appropriate that this time.

The child is admitted to the hospital with congestive heart failure (CHF). Which nursing actions are performed prior to administration of digoxin? Select all that apply.

Auscultate apical pulse for 1 full minute. Hold if pulse is less than 90, then recheck in 1 hour. Necessary interventions in administering digoxin to a child include auscultating the apical pulse for 1 full minute and holding the medication if the pulse is less than 90 bpm, then rechecking the apical pulse in 1 hour. If the pulse is still less than 90 bpm, the healthcare provider must be notified. The nurse should follow the above interventions and not call the health care provider immediately, and the nurse does not need to auscultate respiration for 1 full minute. Nausea, vomiting, diarrhea, appetite loss, and visual disturbances (yellow/green or blue halos around visual images) can also be signs of toxicity. Promoting good dental hygiene is a good intervention, but is not related to the administration of digoxin.

The nurse is reviewing the client's medication administration record (MAR) and notes that the healthcare provider ordered a medication. The nurse notes that the dosage ordered is outside the usual dosage range for that drug. Which action(s) by the nurse would be most appropriate? Select all that apply.

Call and clarify the healthcare providers order. Hold the medication. the nurse should hold the medication until the healthcare provider is notified and the order clarified. Only the healthcare provider can justify or discontinue what the dosage of the drug is to be. The nurse should not call anyone but the healthcare provider who ordered the medication to clarify.

A physical therapist has instructed the nursing staff on how to perform range-of-motion (ROM) exercises for an infant with torticollis. The nurse is uncomfortable when the infant cries and grimaces during the exercises. What is the most important action for the nurse to take?

Call the physical therapist. The only cure for the torticollis is exercise or surgery. The physical therapist is the expert in exercise and should be called for assistance in this situation. The primary health care provider should only be called if there is concern over the orders written, or an abnormal development in the child.

A client's caretaker calls the home care nurse and states accidentally puncturing the central venous catheter after discontinuing the total parenteral nutrition. What instructions should the nurse provide to the caretaker?

Clamp the catheter. The nurse should instruct the caretaker to clamp the catheter to prevent the client from experiencing an air embolism. The client should be positioned on the left side with head lower than the feet, not higher. The catheter should not be removed by the caretaker; it will need to be removed in an acute care or outpatient setting by a healthcare provider. As the client is not experiencing signs or symptoms of an air embolism or other complication, there is no need to contact 911 at this time.

The nurse is reviewing this worksheet with the unlicensed assistive personnel (UAP) when prioritizing afternoon nursing care. What is the priority order for the nurse's administration of client care at 1300 hours?

Client 4, Client 3, Client 2, Client 1 It is important for the nurse to prioritize care in an efficient manner. The highest priority for the afternoon is administering requested pain medication for a postoperative client. Next, the intravenous piggyback would be initiated; the wound dressing could be changed while the IV is infusing. A client on a toileting schedule would be taken to the restroom as the last priority; this task that could also be delegated.

The nurse is caring for a client who is 24 hours after gastric bypass surgery. The client has experienced four episodes of vomiting in the past 12 hours, each producing between 500 and 800 ml of bright yellow-green liquid emesis. What action should the nurse take?

Contact health are provider for a STAT abdominal x-ray prescription. The client is producing bilious emesis (bright yellow-green liquid emesis that resembles bile), which is a warning sign of gastrointestinal obstruction. Obstruction is a rare but serious complication of gastric bypass procedures. The nurse should request the prescription for an x-ray to investiage this possibility. The nurse should also keep the client NPO (not on clear fluids) and may increase fluids, but this is dependent on the client's hydration status and current blood pressure and urine output: information that is not provided. While antiemetic medication may be requested, the diagnosis of the bowel obstruction is most important. If an obstruction is present, the client's vomiting will not be well controlled with medication.

A client is admitted to the local psychiatric facility with bipolar disorder in the manic phase. The physician decides to start the client on lithium carbonate therapy. One week after this therapy starts, the nurse notes that the client's serum lithium level is 1 mEq/L. What should the nurse do?

Continue to administer the medication as ordered. The serum lithium level should be maintained between 1 and 1.4 mEq/L during the acute manic phase; therefore, the nurse should continue to administer the medication as ordered. Unless the client has signs or symptoms of lithium toxicity, the nurse has no need to call the physician, withhold the medication, or repeat the laboratory test. Nonetheless, the nurse should continue to monitor the client's serum lithium level and watch for indications of toxicity if the level begins to rise. Note that it's possible for a client with a normal lithium level to experience lithium toxicity.

A preschool-age child has just been admitted to the pediatric unit with a diagnosis of bacterial meningitis. What is the nurse's priority intervention?

Decrease environmental stimulation. A child with the diagnosis of meningitis is more comfortable in an environment with decreased stimuli. Noise and bright lights would stimulate this child and cause the child to cry, in turn, increasing intracranial pressure. Vital signs should be assessed initially every hour and temperature monitored every 2 hours. Neurosigns should be assessed according to the child's condition, but more frequently that every 12 hours. Children are usually much more comfortable if allowed to lie flat because this position reduces meningeal irritation.

The nurse is caring for a client with a double lumen tunneled central catheter with ordered bloodwork and intermittent I.V. medications. What is the correct action by the nurse?

Dedicate the largest lumen for blood draws. The nurse should dedicate the largest lumen for blood draws and the other for medication administration. There is no need to insert a peripheral line for I.V. medication administration or to obtain bloodwork via peripheral blood draws.

A nurse is monitoring a client on the telemetry unit. The electrocardiogram tracing shows a PR interval of 0.22 seconds. What is the appropriate action of the nurse?

Document the findings and continue to monitor the client. The PR interval normally ranges from 0.12 to 0.20 seconds. A reading of 0.22 seconds is first-degree heart block. The nurse should monitor the client and document the findings. The other interventions are not necessary at this time.

The nurse is a assessing a newborn and notes the presence of strabismus. Which is the nurse's bestaction?

Document the findings in the newborn's chart. Strabismus is a normal finding during the newborn stage and the finding should be documented. There is no association with bilirubin levels and hearing screenings with strabismus.

Which of the responsibilities related to the care of a client with a Foley catheter are appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? Select all that apply.

Empty drainage bag, and record output at specified times. Apply catheter-securing device to the client's leg. Provide Foley catheter and perineal care each shift. Ensure the urine drainage bag is below the level of the bladder at all times. While the scope of practice for a UAP may vary by state, province, or territory, as well as by place of employment, general duties include recording input and output, including emptying and recording urine output from a Foley catheter. A UAP with proper training may apply a securing device to maintain safety, provide regular Foley catheter and perineal care and ambulate a client with a catheter, continually monitoring that the collection bag remains below the level of the bladder to help prevent infection. Activities such as irrigating or flushing a catheter should not be assigned to a UAP as these activities involve nursing assessment skills.

A nurse should perform which intervention for a client with Cushing's syndrome?

Explain that the client's physical changes are a result of excessive corticosteroids. The nurse should explain to the client that Cushing's syndrome causes physical changes related to excessive corticosteroids. Clients with hyperthyroidism, not Cushing's syndrome, are heat intolerant and must have cool clothing and bedding. Clients with Cushing's syndrome should have a high-protein, not low-protein, diet. Clients with Addison's disease must increase sodium intake and fluid intake in times of stress of prevent hypotension.

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 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.

Which position would be appropriate for a client with severe ascites?

Fowler's Ascites can compromise the action of the diaphragm and increase the client's risk of respiratory problems. Ascites also greatly increases the risk of skin breakdown. Frequent position changes are important, but the preferred position is Fowler's. Placing the client in Fowler's position helps facilitate the client's breathing by relieving pressure on the diaphragm. The other positions do not relieve pressure on the diaphragm.

A 62-year-old client reports being tired all the time, having trouble sleeping, and having trouble thinking. What should the nurse do?

Further assess the client's mental status and health history. Fatigue, difficulty thinking, and sleep disturbances can signal depression or other medical problems. The nurse should explore the client's medical and psychosocial history and conduct a mental status examination to gather additional data before making recommendations. These signs and symptoms are not associated with the normal aging process. Referral to a senior citizens' support group may be appropriate later, depending on the client's needs and interests. At this time, the nurse does not have enough information about the client's daily schedule to suggest that napping is a problem. It is more important to first determine the source of the client's symptoms so that the client can be treated appropriately.

During the immediate postpartum period after giving birth to twins, the client experiences uterine atony. What should the nurse do first?

Gently massage the fundus. Uterine atony means that the uterus is not firm because it is not contracting. First, the nurse should gently massage the uterus in an effort to help contract the uterus and make it firm. Clients with multiple gestation, polyhydramnios, prolonged labor, or large-for-gestational-age fetus are more prone to uterine atony.Assessing for infection is inappropriate because puerperal infection is not associated with uterine atony.Determining if the uterus has ruptured is inappropriate because uterine atony is not a sign of uterine rupture.Increasing the intravenous fluid rate may be prescribed if the client develops symptoms of shock.

The health care provider (HCP) prescribes mirtazapine 30 mg PO at bedtime for a client diagnosed with depression. Which nursing action is indicated?

Give the medication as prescribed. The nurse should give the medication as prescribed. Mirtazapine is given once daily, preferably at bedtime to minimize the risk of injury resulting from postural hypotension and sedative effects. The usual dosage ranges from 15 to 45 mg. There is no reason to question the HCP's prescriptions. The nurse should administer the medication as prescribed. Requesting to give the medication in three divided doses is inappropriate and demonstrates the nurse's lack of knowledge about the drug.

A client is receiving fluid replacement with lactated Ringer's after 40% of the body was burned 10 hours ago. The assessment reveals temperature 97.1°F (36.2°C), heart rate 122 bpm, blood pressure 84/42 mm Hg, central venous pressure (CVP) 2 mm Hg, and urine output 25 mL for the last 2 hours. The IV rate is currently at 375 mL/h. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, what prescription should the nurse request from the health care provider?

IV rate increase The decreased urine output, low blood pressure, low CVP, and high heart rate indicate hypovolemia and the need to increase fluid volume replacement. Furosemide is a diuretic that should not be given due to the existing fluid volume deficit. Fresh frozen plasma is not indicated. It is given for clients with deficient clotting factors who are bleeding. Fluid replacement used for burns is Lactated Ringer's solution, normal saline, or albumin.

A client is to start chemotherapy to treat lung cancer. A venous access device has been placed to permit administration of chemotherapeutic medications. Three days later at the scheduled appointment to receive chemotherapy, the nurse assesses that the client is dyspneic and the skin is warm and pale. The vital signs are blood pressure 80/30 mm Hg, pulse 132 bpm, respirations 28 breaths/min, temperature 103°F (39.4°C), and oxygen saturation 84%. The central line insertion site is inflamed. After the nurse calls the rapid response team, what should the nurse do next?

Insert a peripheral intravenous fluid line and infuse normal saline. The client is experiencing severe sepsis, and it is essential to increase circulating fluid volume to restore the blood pressure and cardiac output. The wet compress, administering the antipyretic, and monitoring the client's cardiac status may be beneficial for this client, but they are not the highest priority action at this time. These three interventions may require the nurse to leave the client, which is not advisable at this time.

The nurse is caring for a client 12 hours post radical prostatectomy. The nurse collects the following data from the unlicensed assistive personnel (UAP): Blood pressure 110/64 mm Hg, heart rate 100 beats per minute, respiratory rate 14 breaths/min, temperature 99.9°F (37.8°C), intake 1420 ml, output 330 ml via a urinary catheter. What is the next action by the nurse?

Irrigate the urinary catheter as prescribed. The client has produced less than 30 ml of urine per hour in the past 12 hours and has an intake/output imbalance. The nurse recognizes that for this client, blood clots may be preventing the flow of urine from the urinary catheter and would irrigate the urinary catheter as prescribed before contacting the health care provider with findings. There is no indication for a recheck of vital signs. The nurse may administer the prescribed acetaminophen 650 mg for the mildly elevated temperature, but recognizes that this may be due to atelectasis and would encourage the client to cough and deep breathe prior to administering the medication.

The mental health unit provides a unit landline for clients to use for telephone calls. A client with bipolar disorder is monopolizing the use of the telephone by making several calls each day, interfering with the ability of other clients to use the telephone. What should the nurse do?

Limit the amount of calls the client can make each day. The nurse should limit the amount of telephone calls the client can make. Setting limits for a client with bipolar disorder, mania, helps to control the hyperactive client who has excessive goal-directed activity, especially when it interferes with the rights of other clients. Giving the client access to his cell phone rewards the behavior. Reminding the client that others need to use the telephone will probably be futile because the client with mania is experiencing cognitive impairment and needs to be active. Taking away the client's telephone privileges is not the best action because the client has a right to use the telephone. The nurse is responsible for helping the client manage behavior by setting constructive limits.

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

Monitor intake and output. 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.

When assessing a neonate, the nurse observes a vaguely outlined area of scalp edema that is most likely caput succedaneum. What is the most appropriate nursing action based on this finding?

Note the finding on the assessment record. Caput succedaneum refers to a vaguely outlined area of scalp edema that crosses the suture line and typically clears within a few days after birth. The nurse should note this finding on the assessment record, but no other action is needed. Caput succedaneum isn't found on neonates who were in the breech position.

A client with hydrocephalus reports having had a headache in the morning on arising for the last 3 days, but it disappears later in the day. What should the nurse do next?

Notify the health care provider (HCP). ICP is highest in the early morning, and the client with hydrocephalus may be experiencing signs of increased ICP that need to be treated. The increased ICP is not related to fluid levels, and the nurse should not advise the client to increase fluid intake. While ICP does fluctuate during the day, it is highest in the morning, and the nurse should notify the HCP. Pain medication will not treat the potentially increasing ICP and may mask important signs of increasing ICP.

A client with a well-managed ileostomy has sudden onset of abdominal cramps, vomiting, and watery discharge from the ileostomy. What should the nurse tell the client to do?

Notify the health care provider (HCP). Sudden onset of abdominal cramps, vomiting, and watery discharge with no stool from an ileostomy are likely indications of an obstruction. It is imperative that the health care provider (HCP) examine the client immediately. Although the client is vomiting, the client should not take an antiemetic until the HCP has examined the client. If an obstruction is present, ingesting fluids or taking milk of magnesia will increase the severity of symptoms. Oral intake is avoided when a bowel obstruction is suspected.

A term primigravida was involved in a car accident 3 hours ago. She is having labor contractions every 4 minutes, and her cervical exam is dilated 3 cm, 100% effaced, and station −1. She is crying uncontrollably and states her pain is constant and severe, rating it at 10/10. What is the nurse's the priority action?

Notify the provider of the pain and request an assessment for potential abruption. The woman is at risk for placental abruption due to her recent car accident. Symptoms of a placental abruption include unrelenting pain and a rigid boardlike abdomen. She may or may not have vaginal bleeding. In contrast, labor contractions are intermittent. The priority action by the nurse should be to ensure that this client is further evaluated by her HCP. Subsequent actions could include assisting with pain control measures, assessing contractions, and checking cervical dilation.

A client presents to the emergency room with abdominal pain and upper gastrointestinal bleeding. The client is sweating and appears to be in moderate distress. Which nursing action would be a priority at this time?

Obtain vital signs. The priority nursing action is vital signs. Vital signs provide valuable information on the internal body system. Symptoms of shock, such as low blood pressure, a rapid weak pulse, cold clammy skin, and restlessness, can be monitored. Assessing bowel sounds and abdominal tenderness can provide useful data but is not a priority. Documentation is a lower priority and a health care provider's order is needed for a nasogastric tube placement.

A client with a peritonsillar abscess has been hospitalized. Upon assessment, the nurse determines the following: a temperature of 103°F (39.4°C), body chills, and leukocytosis. The client begins to have difficulty breathing. In what order from first to last should the nurse perform the actions? All options must be used.

Open the airway. Start an IV access site. Call the health care provider (HCP). Explain the situation to the family. An open airway is essential to survival. The nurse should first ensure an open airway. Next, the nurse should start an IV and then notify the HCP. Finally, the nurse should inform the family of the situation and, if appropriate, allow them to remain with the client.

A nurse is caring for a client in the intensive care unit. While the client is being turned and repositioned in bed, the gastrostomy tube (G-tube) is accidentally dislodged. What is the priorityintervention?

Place a new, sterile foley catheter into the stoma to keep it from closing

A client with a history of asthma is brought to the emergency department in respiratory distress. Which is the priority action by the nurse?

Position in Fowler's position, initiate oxygen, and administer bronchodilators as ordered. Priority actions are important to maximize effective ventilation because of the narrowing and spasms of the bronchioles and excessive secretions. It is important to position the client in the high Fowler's position and to oxygenate. The use of bronchodilators help counteract the bronchospasms. Other positions, such as supine and recovery, are not as effective as Fowler's. Ambulation increases the demand for oxygen, so is incorrect.

Which of the following actions would the nurse perform if the nurse suspects the complication of thrombophlebitis in the leg in a postpartum woman? Select all that apply.

Prepare the client for venous Doppler ultrasound. Assess vital signs. Place client on bed rest. Tenderness, elevated temperature of limb, consistent pain, and edema are indicators of thrombophlebitis. Changes in limb color of either blueness or redness can also occur with thrombophlebitis. With symptoms of thrombophlebitis, the client should be placed on bed rest, and the nurse should assess vital signs frequently. The client will need a diagnostic ultrasound of the vein for confirmation. The client will require anticoagulation, not TPA therapy. TPA in a postpartum woman would cause uncontrollable hemorrhage. Although the nurse wants to prevent dehydration, suppression of lactation would not be indicated. Giving the estrogens needed to stop breast milk production would also further increase the client's risk of clotting.

The nurse is assessing for blood return from a client's implanted port. Which nursing intervention is appropriate to assure that the needle will be flushed with pure saline?

Prevent blood from entering the saline flush syringe. To assure that the needle will be flushed with pure saline, the nurse does not allow blood to enter the saline flush syringe when assessing for blood return from an implanted port. Washing hands prevents contamination, drawing the least amount of blood prevents overwasting, and flushing with heparin prevents clots.

When administering an I.V. medication through a central line, the nurse notes that a client's central line gauze dressing was last changed 24 hours previously. What is the appropriate action by the nurse?

Proceed to administer the I.V. medication. Gauze dressings should be changed every 2 days so the nurse should proceed to administer the medication. There is no need for an incident report or to contact the healthcare provider.

A client commonly jumps when spoken to and reports feeling uneasy. The client says, "It's as though something bad is going to happen." In which order, from first to last, should the nursing actions be done? All options must be used.

Reduce environmental stimuli. Ask the client to deep breathe for 2 minutes. Discuss the client's feelings in more depth. Teach problem-solving strategies. Immediate anxiety-reducing strategies are decrease stimuli and perform deep breathing. Once the anxiety is lessened, the client's feelings can be explored for triggers and underlying issues. Then problem-solving strategies can be discussed to handle the triggers and issues appropriately.

The client is taking 50 mg of lamotrigine daily for bipolar depression. The client shows the nurse a rash on his arm. What should the nurse do?

Report the rash to the health care provider (HCP) The nurse should immediately report the rash to the HCP because lamotrigine can cause Stevens-Johnson syndrome, a toxic epidermal necrolysis. The rash is not a temporary adverse effect. Giving the client an ice pack and questioning the client about recent sun exposure are irresponsible nursing actions because of the possible seriousness of the rash.

A client attends a follow-up visit to a clinic after being diagnosed with atypical depression. The practitioner prescribed tranylcypromine sulfate, 10 mg by mouth twice a day during the last visit 14 days ago. Which would be the priority action by the nurse for this client?

Screen the client for new, worsened, or increased depression. Clients taking this medication could have increased suicidal thoughts and actions and should be screened for new, worsened, or increased depression. Although it is important to ask about over-the-counter medications, which could interact with tranylcypromine sulfate, this would not be the priority assessment. Clients on tranylcypromine sulfate do have an increased sunburn risk, but this would not be a priority to teach. The client's blood pressure should be closely monitored but not the heart rate.

The nurse just started an infusion of blood on a client. A few minutes pass and the client develops a sudden fever. What are the priority interventions by the nurse? Select all that apply.

Start the normal saline infusion. Continue to monitor vital signs. Stop the blood infusion. Notify the healthcae provider. Development of fever during blood transfusion can indicate a transfusion reaction. The appropriate nursing action is to discontinue the blood transfusion, infuse normal saline to prevent a more severe reaction, continue to monitor vital signs, and call the healthcare provider. Other interventions include serum analysis of BUN and creatinine, and returning the blood and tubing to the laboratory to be analyzed. Forcing oral fluids is not part of transfusion reaction care.

During the intravenous administration of a chemotherapeutic vesicant drug, the nurse observes that there is a lack of blood return from the intravenous catheter. What should the nurse do first?

Stop the administration of the drug. An intravenous catheter with no blood return is most likely occluded and not patent. A chemotherapeutic vesicant drug extravasates into the surrounding skin tissue and causes tissue necrosis. The nurse stops administration of the drug immediately. Repositioning the arm does not improve patency. Irrigating the catheter may cause the medication to enter tissue. It is inappropriate to wait and see if the arm becomes edematous because of the vesicant action of the drug.

A client has been receiving oxytocin to augment her labor. The nurse notes that contractions are lasting 100 seconds. Which immediate action should the nurse take?

Stop the oxytocin infusion. Oxytocin should be withheld immediately, as it stimulates contractions. A contraction that continues for more than 90 seconds signals tetany and could lead to decreased placental perfusion and possibly uterine rupture. The nurse should monitor the fetal heart tones, stop the oxytocin, and notify the provider. The client should be turned on her left side to increase blood flow to the fetus, which can be decreased with tetany. This decreased blood flow can potentially compromise the fetus.

A group of people arrives at the emergency department reporting extreme periorbital swelling, cough, shortness of breath, and tightness in the throat. They report that someone threw a bomb that exploded at their feet. What is the best action by the nurse?

Take them to the decontamination area. The best action by the nurse is to take the clients to the decontamination area to be decontaminated. That way the agent is no longer infiltrating the clients nor are the other individuals in the emergency room exposed to the decontaminating agent. Once decontamination is completed, then other actions can be administered such as administering oxygen and/or NAAK. But the first priority is to stop the decontaminating agent from continuing to impact the victims by completing decontamination.

The nurse provides care to a client with chemical dependency. What are the primary nursing considerations for this client? Select all that apply.

Teach the client to deal with life stressors through coping skills. Support the client's decision to stop substance use. Promote family interaction and involvement in the rehabilitation process. Nursing consideration for clients undergoing treatment for chemical dependency would include helping the client gain new ways to cope with stressors. Nurses should give positive reinforcement for the client's decision to stop using. Making restitution may be a requirement for a 12-step program, but not all clients will choose to enter such programs. Clients must take responsibility for themselves; that need should not be assigned to family members. However, family should be encouraged to be active in the rehabilitation process.

A client who has recently had a fractured hip repaired must be transferred from the bed to a wheelchair. Which information should the nurse consider while assisting the client?

The appropriate proximity and visual relationship of the wheelchair to the bed must be maintained. The wheelchair should be angled close to the bed so the client can pivot on the stronger leg. When the wheelchair is within the client's visual field, the client will be aware of the distance and direction the body must navigate to transfer safely and avoid falling. During a transfer, the knees need to be extended to support the weight, the bed needs to be in low position, and pivoting needs to be accomplished on the unaffected leg.

A client in the intensive care unit (ICU) is on a dobutamine drip. During an assessment the client states, "I was feeling better but now my chest is tight and I feel like my heart is skipping." Physical assessment reveals a heart rate of 110 beats per minute and blood pressure of 160/98 mm Hg. What is the nurse's immediate concern for this client?

The dobutamine may need to be decreased. Dobutamine is a vasoactive adrenergic that works by increasing myocardial contractility and stroke volume in order to increase the cardiac output in heart failure clients. A serious side effect of adrenergic drugs is the worsening of a preexisting cardiac disorder. Increasing the dosage of the drug will worsen the problem. The client does not show symptoms of allergic reaction or heart failure.

The nurse is irrigating a client's ear due to impacted cerumen. Which nursing action is correct for this procedure?

The nurse should instill mineral oil 30 minutes before irrigation to soften the cerumen. The nurse can use mineral oil to soften the cerumen before irrigation of the ear. Using warm water, not cool water, is best for irrigation for client comfort and loosening of the cerumen. The client would need gentle, not forceful, irrigation in order to prevent perforation of the tympanic membrane. Irrigation would be completed before attempting to mechanically remove the cerumen.

The nurse is observing a student nurse perform an irrigation of a client's nasogastric (NG) tube. Which action by the student nurse would cause the nurse to stop the procedure?

The student nurse irrigates the NG tube through the blue air vent port. The student nurse would not want to instill fluid through the blue air vent port - this is reserved for air only and is a way to decrease pressure that can build up into the stomach when suction is used. The student nurse should wear clean not sterile gloves because it is not a sterile procedure. The student nurse would disconnect the suction tubing in order to attach the syringe and can use gravity versus pushing the fluid in to instill it.

The nurse working with a group of nursing students. What breaches in client care require the nurse to intervene to protect client privacy? Select all that apply.

Transporting a client to radiology on the public elevator Discussing clients in the cafeteria with other hospital staff Transporting a client to radiology on the public elevator and discussing clients in the cafeteria are examples of breaches in client privacy. Asking a client's name and date of birth prior to medication administration, attaching client's hospital labels to a laboratory specimen, and keeping the client's door closed during bathing will allow the nurse to provide client privacy.

A client with a partial thickness burn injury has had Biobrane applied 2 weeks ago. The Biobrane is now separating from the wound. What nursing intervention is appropriate?

Trim away the Biobrane that has separated from the wound. It is normal for the Biobrane to separate as the wound heals. It should be trimmed away as it separates. There is no need to apply a new dressing to the healing skin. The Biobrane should not be forcibly removed. It will slowly release as healing occurs.

A nurse is caring for clients on a medical/surgical unit. Which client should the nurse see first?

a 60-year-old client admitted with partial-thickness (second-degree) burns covering the arms, chest, neck, and face The client with parital-thickness (second-degree) burns covering the upper body is the most at risk for airway complications and should be assessed first. The postoperative client with low-grade temperature should be assessed next. Although temperature elevations are common postoperatively, the fact that this client is only 48 hours post-CABG makes this assessment the next highest priority. Third, the nurse should assess the client awaiting cholecystectomy. Chills are common when cholecystitis is present, but because the client has a procedure pending the next day, the nurse needs to ensure the client has no acute changes that need to be addressed. Finally, the client with hypertension and dizziness would be assessed. An elevated blood pressure in this range is not urgent.

The client will have an electroencephalogram (EEG) in the morning. The nurse should instruct the client to have which foods/fluids for breakfast?

a full breakfast as desired without coffee, tea, or energy drinks Beverages containing caffeine, such as coffee, tea, cola, and energy drinks, are withheld before an EEG because of the stimulating effects of the caffeine on the brain waves. A meal should not be omitted before an EEG because low blood sugar could alter brain wave patterns; the client can have the entire meal except for the coffee. The client does not need to be on a liquid diet or NPO.

There has been a car accident involving four vehicles on a remote highway. The nearest emergency department is 15 minutes away. Which victim should be transported by helicopter rather than an ambulance to the nearest hospital?

a middle-aged female with cold, clammy skin; heart rate of 120 bpm; and is unconscious The middle-aged female is likely in shock; she is classified as a triage level I, requiring immediate care. The child with moderate trauma is classified as triage level III, urgent, and can be treated within 30 min. The man with asthma and the man with the severe headache are classified as emergent, triage level II, and can be transported by ambulance and reach the hospital within 15 min.

The parents report that their 1-day-old is drooling and having choking episodes with excessive amounts of mucus and color changes, especially during feedings. The nurse should contact the health care provider (HCP) to further assess the baby and request which prescription?

an x-ray for gastric tube placement The drooling and excessive mucus production is highly suggestive of a tracheoesophageal fistula (TEF). The initial diagnosis is made when a gastric tube cannot be passed to the stomach. A lactation consult would be warranted only after determining feedings were safe to continue. While cyanosis can be a sign of sepsis and hypoglycemia, the cyanosis is most likely related to the excessive secretions and airway patency. A blood gas may be needed, but only after ruling out a TEF.

During the first 24 hours after a client is diagnosed with addisonian crisis, which intervention should the nurse perform frequently?

assess vital signs. Because the client in addisonian crisis is unstable, vital signs and fluid and electrolyte balance should be assessed every 30 minutes until the client is stable. Daily weights are sufficient when assessing the client's condition. The client shouldn't have ketones in their urine, so there is no need to assess the urine for their presence. Oral hydrocortisone isn't administered during the first 24 hours in severe adrenal insufficiency.

One hour after receiving pyridostigmine bromide for myasthenia gravis, a client reports difficulty swallowing and excessive respiratory secretions. What medication would the nurse anticipate to reverse the effects of pyridostigmine bromide?

atropine These symptoms suggest cholinergic crisis or excessive acetylcholinesterase medication, typically appearing 45 to 60 minutes after the last dose of acetylcholinesterase inhibitor. Atropine, an anticholinergic drug, is used to antagonize acetylcholinesterase inhibitors. The other drugs are acetylcholinesterase inhibitors. Edrophonium is used for diagnosis, and pyridostigmine bromide is used to treat myasthenia gravis and would worsen these symptoms. Acyclovir is an antiviral and would not be used to treat these symptoms.

The nurse is caring for a 9-month-old infant with severe diarrhea that has lasted 3 days and who displays evidence of severe dehydration with increased heart rate and decreased blood pressure. What nursing assessment is a priority?

capillary refill time Increased heart rate and low blood pressure are indicators of possible hypovolemic shock, which makes assessing capillary refill time the priority. If it is greater than 3 seconds, this is evidence of shunting of blood and decreased peripheral perfusion and the need for emergent IV therapy. All other assessments are relevant but not as important as gathering evidence about hypodynamic stability. A 9-month-old infant who is dehydrated would have poor skin turgor, a sunken fontanel, dry mucous membranes, and lack of wet diapers for several hours. Increased thirst usually occurs in the beginning stages of dehydration and is more likely with older children. An infant generally has poor feedings.

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 them on their side. When caring for a client experiencing a tonic-clonic seizure, the nurse should help the client to a flat nonelevated surface and then position them on their side to ensure that the client doesn't aspirate and to protect them 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 their mouth; anything in the mouth could impair ventilation and damage the inside of the mouth.

A nurse notices that a client admitted for exacerbation of chronic obstructive pulmonary disease is short of breath. The client has signed an advance directive indicating that they don't want to be resuscitated. The nurse should

check the client's oxygen saturation. The nurse should check the client's oxygen saturation before calling the physician. The fact that the client has signed an advance directive doesn't mean that the nurse shouldn't provide any care. There's no reason for the nurse to get the crash cart at this point.

A nurse is caring for several clients on an oncology unit. Which client should the nurse see first?

client with a white blood cell count of 2000 µL A white blood cell count of 2000 µL puts the client at risk for infection. The nurse would want to see this client first in order to reduce the transmission of bacteria and other organisms from working with other clients. The client on bed rest can wait and the other clients are stable.

A client is receiving chemotherapy that has the potential to cause pulmonary toxicity. Which signs or symptoms indicates a toxic response to the chemotherapy?

cough and shortness of breath Cough and shortness of breath are significant symptoms because they may indicate decreasing pulmonary function secondary to drug toxicity. Decrease in appetite, difficulty in thinking clearly, and spasms of the diaphragm may occur as a result of chemotherapy; however, they are not indicative of pulmonary toxicity.

The nurse working in a skilled nursing home is evaluating a client that has completed a 10-day course of antibiotics three days ago for pneumonia. What assessments will the nurse need to notify the healthcare provider about? Select all that apply.

cough with phlegm change in level of consciousness A change in the level of consciousness and a cough with phlegm are abnormal assessments related to pneumonia. Clear breath sounds, pulse oximetry reading of 96%, and tympanic temperature 98.2°F (36.8°) are normal assessments indicating that the antibiotic may have helped manage the pneumonia symptoms.

A client presents with a congenital heart defect and increased pulmonary blood flow. Which signs or symptoms will alert the nurse that congestive heart failure is occurring? Select all that apply.

coughing tachypnea with feeding course breath sounds Congestive heart failure is caused by increased pulmonary blood flow or obstruction to the systemic blood outflow tract. Signs of this occurring would be an increase in weight, coughing, difficulty or fast breathing (tachypnea) with feeding, oliguria, and course breath sounds.

The nurse provides a neonate with an initial feeding. The nurse would suspect a tracheoesophageal fistula if the neonate demonstrated which behavior?

coughing, choking, and cyanosis that occur after several swallows of formula The newborn with tracheoesophageal fistula swallows normally, but the fluids quickly fill the blind pouch. The infant then coughs, chokes, and becomes cyanotic while the fluid returns through the nose and mouth.Poor rooting reflexes and sucking attempts are typical of infants with neurologic dysfunction or related to reflex depression secondary to medication given to the mother during labor.Projectile vomiting is typical of infants with neurologic dysfunctions.This reflex may also be depressed by medication given to the mother during labor. Falling asleep after taking little formula is characteristic of an infant who becomes exhausted with the exertion of feeding, commonly caused by a cardiac anomaly.

A client is admitted to the neurologic intensive care unit for an intracranial hemorrhage. Which medication prescription should the nurse question for this client?

enoxaparin The nurse should question the precription for enoxaparin for this client. noxaparin is a low-molecular weight heparin, and is an anticoagulant, which causes increased bleeding and impaired clotting, and would cause further complications in the client with bleeding in the brain. Famotidine is a common peptic ulcer prevention agent, and is often given to intensive care unit clients to help prevent gastric ulcers due to the stress of hospital admission. Ondansetron is a common antiemetic, and would be appropriate for this client to treat or prevent nausea and vomiting, because vomiting increases intracranial pressure. Morphine is a narcotic pain reliever, and would be an appropriate analgesic medication for the client with an intracranial hemorrhage.

A nurse who is teaching a group of caregivers about Reye's syndrome presents the following scenario: A 6-year-old client with a history of varicella and aspirin intake is brought to the emergency department. The nurse suspects Reye's syndrome. For which assessment findings should the nurse instruct the caregivers to seek immediate medical attention?

fever, lethargy, and vomiting Reye's syndrome occurs in children with a history of a viral infection, varicella, or influenza. It is commonly associated with the administration of aspirin. The client presents with fever, vomiting, and decreased level of consciousness, which can lead to coma and death. As the disease progresses, the client also develops impaired liver function. A client with joint pain, a red macular rash with a clear center, and a low-grade fever probably has rheumatic fever. A client presenting with peripheral edema, fever for more than 5 days, and a "strawberry tongue" probably has Kawasaki disease. A client with a red, raised "bull's eye" rash, malaise, and joint pain should be tested for Lyme disease.

The client is six hours post-open hysterectomy. Intravenous fluids are infusing at 125 mL/hr, urinary catheter has drained 170 mL since surgery, and the client reports pain as a 3 out of 10. What is the nurse's priority concern?

fluid balance All abdominal surgery clients have a potential for fluid volume deficit. Post-op urine output should be at least 30 mL/hr; the output of 170 mL in six hours is slightly under this minimally accepted amount. Pain is sufficiently treated. Although the nurse does need to determine if the catheter is functioning properly, this investigation is related to the priority concern of decreased urine ouput. Incisional healing is an ongoing concern but not a priority at this time.

A client has her first prenatal visit at 15 weeks' gestation. The client weighs 144 lb (65.5kg) and states this is a 4-pound weight gain. Which assessment finding requires further investigation?

fundal height of 18 cm Fundal height (in centimeters) should roughly equal the number of weeks' gestation. This client should have a fundal height of 15 to 16 cm. A height of 18 cm could be indicative of many things, including multiples or polyhydramnios. The blood pressure, urine, and weight findings are within normal limits for this client. During the first trimester, weight gain should average between 1 and 4.5 pounds (0.5-2 kg).

A multigravid client gave birth vaginally 2 hours ago. A family member notifies the nurse that the client is pale and shaky. Which are the priority assessments for the nurse to make?

fundus and lochia A client who is pale and shaking could be experiencing hypovolemic shock likely caused by blood loss. A primary cause of blood loss after the birth of an infant is uterine atony. Therefore, the priority assessments should be the fundus of the uterus for firmness and location. In addition, the amount of vaginal bleeding (lochia) should also be assessed. An immediate intervention for uterine atony is fundal massage that will help the uterus to contract and therefore stop additional bleeding. Assessing the client's level of consciousness does not require additional time and can be done by the nurse while the fundus and lochia are assessed. Obtaining vital signs, blood glucose, and temperature are important but should be done either after the fundus has been assessed and massaged or should be obtained by a second responder. Assessing for uterine infection and pain should be done after treatment for hypovolemic shock has been initiated.

The health care provider has prescribed salicylates for a client with osteoarthritis. The nurse assesses the client and determines that intervention is necessary when the client exhibits:

hearing loss. Many elderly people already have diminished hearing, and salicylate use can lead to further or total hearing loss. Salicylates do not increase pain in joints, decrease calcium absorption, or increase bone demineralization.

Which lab values should the nurse report to the health care provider (HCP) when the client has anemia?

intrinsic factor, absent The defining characteristic of pernicious anemia, a megaloblastic anemia, is lack of the intrinsic factor which results from atrophy of the stomach wall. Without the intrinsic factor, vitamin B cannot be absorbed in the small intestine and folic acid needs vitamin B for deoxyribonucleic acid synthesis of RBCs. The gastric analysis is done to determine the primary cause of the anemia. An elevated excretion of the injected radioactive vitamin B, which is protocol for the first and second stage of the Schilling test, indicates that the client has the intrinsic factor and can absorb vitamin B in the intestinal tract. A sedimentation rate of 16 mm/hour is normal for both men and women and is a nonspecific test to detect the presence of inflammation; it is not specific to anemias. An RBC value within the normal range does not indicate an anemia.

A client has been diagnosed with bacterial pneumonia. After 1 day of IV antibiotic therapy, the client's white blood cell count is still 14,000/mm3 (14 X 109/L). The nurse should:

notify the health care provider. If the white blood cell count does not begin decreasing, it may indicate that the antibiotic is not effective against the organism causing the pneumonia. The health care provider should be notified as he or she may want to consider changing antibiotics.While rechecking the client's white blood cell count may be appropriate, it is the health care provider's responsibility to make this decision.Reverse isolation is used for clients with a very low white blood cell count.The antibiotic dosing schedule should be strictly maintained.

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- 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.

A nurse is using Dorothea Orem's general theory of nursing while caring for a client. Which intervention is appropriate?

providing discharge teaching about new medication Dorothea Orem's general theory of nursing addresses self-care deficits as the basis for nursing care. This theory posits that the nurse intervenes to reestablish the client's self-care capacity. Discharge teaching addresses the client's knowledge deficit, increasing the ability for self-care. Dorothy Johnson's behavioral systems theory views nursing as a means to reestablish balance in the client's social and behavioral subsystems, which have been disrupted by stress. According to Virginia Henderson's theory of nursing, the nurse focuses on the client's basic needs. In Martha Rogers' unitary human beings theory, the nurse helps restore the clients' energy and balance and the changes that occur as they constantly evolve.

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. 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 nurse is reviewing arterial blood gas results on an assigned client. The pH is 7.32 with PCO2 of 49 mm Hg and a HCO3−of 28 mEq/L. The nurse reports to the physician which finding?

respiratory acidosis Respiratory acidosis would be reported to the physician citing the lab values. Analysis of the blood gases reveals that the client is acidotic with a pH under 7.35. Also noted is the PCO2above the normal range of 30 to 40 mm Hg. The HCO3− is slightly elevated because the normal level is 22 to 26 mEq/L.

An infant, age 8 months, has a tentative diagnosis of congenital heart disease. During physical assessment, the nurse measures a heart rate of 170 beats/minute and a respiratory rate of 70 breaths/minute. How should the nurse position the infant?

sitting in an infant seat Because the infant's assessment findings suggest that respiratory distress is developing, the nurse should position the infant with the head elevated at a 45-degree angle to promote maximum chest expansion; an infant seat maintains this position. Placing an infant flat on the back or abdomen or in high Fowler's position could increase respiratory distress by preventing maximal chest expansion.

A nurse is changing a client's surgical incision dressing on post-op day three. For which observation would the nurse take immediate action?

small amount of creamy yellow drainage Yellow, creamy drainage describes purulent dischage and suggests infection; the nurse must report this finding to the healthcare provider immediately and obtain a culture as ordered. Clear pink to red watery discharge describes serosanguinous dischage, which is evidence of some edema at the site; it does not warrant immediate intervention. Reddended wound edges are expected as healing occurs, and epithelizing tissue represent normal findings for a wound.

A nurse is conducting a detailed skin assessment on an 80-year-old client. Which finding requires further investigation?

small, waxy nodule with pearly borders A small waxy nodule with pearly borders may indicate a basal cell carcinoma. This finding requires further investigation and treatment. Yellow, waxy deposits on the lower eyelids, bright red moles on the hands, and areas of dry, scaly skin are normal age-related changes to skin

A primigravid client at 30 weeks' gestation has been admitted to the hospital with premature rupture of the membranes without contractions. Her cervix is 2 cm dilated and 50% effaced. Which factor is most important for the nurse to assess next?

temperature. Premature rupture of the membranes is commonly associated with chorioamnionitis, or an infection. A priority assessment for the nurse to make is to document the client's temperature every 2 to 4 hours. Temperature elevation may indicate an infection. Lethargy and an elevated white blood cell count also indicate an infection. The red blood cell count would provide information related to anemia, not infection. The client is not in labor. Therefore, assessing the degree of discomfort is not a priority at this time. Urinary output is not a reliable indicator of an infection such as chorioamnionitis.

An infant is to have moderate sedation for an outpatient procedure. The nurse knows that

the infant should respond to gentle tactile or verbal stimulation. An infant under moderate sedation should respond to verbal or tactile stimuli. Infants under general anesthesia have decreased or absent reflexes. Infants who undergo general or moderate sedation rarely remember the procedure. PCA pumps aren't used during sedation.

A client has an International normalized ratio (INR) of 1.6, creatine kinase-MB (CK-MB) of 90 μ/L, troponin 2.1 ng/L, and myoglobin 90 μg/L. Which result requires the nurse to take action?

troponin of 2.1 ng/L Troponins I and T are cardiac enzymes that are only released when the cardiac muscle is damaged. Elevation of these values above the respective reference ranges of 0-0.1 ng/L or 0-0.2 ng/L indicates a myocardial infarction. Myoglobin is released when muscle cells are damaged. Myoglobin may rise above the normal level of 0-90 μg/L with a myocardial infarction (MI) but is not a clear indicator of MI because it can also rise during strenuous exercise, traumatic injury, and intramuscular injections. CK-MB will rise following MI, but may be elevated by events that also raise myoglobin. A normal range for CK-MB is between 30 and 170 μ/L. The INR test is a measure of blood clotting. An INR value of 1.6 is within the normal range.

A client with a major burn injury is receiving fluid resuscitation. Which assessment finding indicates that this treatment has been effective?

urine output at 0.5 mL/kg/hour Hourly urine output is often used as an indicator of effective fluid resuscitation, with about 0.5 mL/kg/hr for an adult considered adequate. Blood pressure changes are less reliable because significant hypotension does not develop until volume losses exceed 30%. Degree of orientation is not used as an indicator of adequate fluid resuscitation. If fluid resuscitation is adequate, the heart rate should be lower than 120 beats/minute or in the upper limits of normal for the client's age. However, the fear, anxiety, and pain that accompany burn injuries often increase the heart rate.

The nurse is assessing a client with heart failure whose blood pressure and weight are being monitored remotely. The nurse reviews data obtained within the last 3 days. The nurse calls the client to follow up. What should the nurse ask the client first?

"Are you having shortness of breath?" The client has gained 5 lb (2.3 kg) in 3 days with a steady increase in blood pressure. The client is exhibiting signs of heart failure, and if the client is short of breath, this will be another sign. Asking how the client is feeling is too general, and a more focused question will quickly determine the client's current health status. The scales should be calibrated periodically, but a 5-lb (2.3-kg) weight gain, along with increased blood pressure, is not likely due to problems with the scale. The weight gain is likely due to fluid retention, not drinking too much fluid.is short of breath, this will be another sign. Asking how the client is feeling is too general and a more focused question will quickly determine the client's current health status. The scales should be calibrated periodically, but a 5-lb (2.3-kg) weight gain, along with increased blood pressure, is not likely due to problems with the scale. The weight gain is likely due to fluid retention, not drinking too much fluid.

The nurse assigned to telephone triage returns a call from a parent whose teenager experienced a hard tackle last night. The parent reports, "He seemed dazed after it happened and the coach had him sit out the rest of the game, but he's fine now." What is the most appropriate instruction for the nurse to give?

"He can't return to play until he has been evaluated by a health care provider." Appearing dazed or stunned after a head injury is a symptom of a concussion. Concussion care includes removing the athlete from play and having the injury evaluated. Athletes should not return to play until they have been cleared by a health care provider (HCP). Concussions require ongoing monitoring. Since the client has no signs of deterioration in neurologic function, it may best be provided by a HCP, who will follow him over time, rather than through an emergency department.

A client is admitted with an eating disorder. Which client response should the nurse address first?

"I feel dizzy and light-headed when I get up." The priority intervention, by the nurse, would be to assess the client's vital signs to note any alterations. A client stating "My life is over if I gain weight" is an example of catastrophizing. Dental erosion and caries are commonly found in a client with an eating disorder. Muscle weakness is also commonly found in a client with an eating disorder.

A client has been informed of a diagnosis of cancer. Which client statement should the nurse address first?

"I need to end this before the cancer kills me." By making a statement such as "I need to end this," the client could be indicating a plan to commit suicide. The nurse should address this first. The other statements should be addressed second.

A nurse is assessing the family of a 10-year-old child brought into the emergency department with severe injuries. Which statement made by the parents could indicate child abuse?

"The injury happened a few days ago but I didn't think it was bad." A delay in seeking treatment for a child's serious injuries is a sign of abuse. Anxiety is expected and is a normal response. The parent's specific description of the origin of the injury is not congruent with child abuse. In abuse cases, vague descriptions of the injuries are more common than detailed ones, and abusers often prevent a child from explaining the nature of their injuries rather than encouraging it.

The client was recently diagnosed with a hiatal hernia. The healthcare provider orders an antacid that has reduced adverse effects. What should the nurse include in the client's teaching about the side effects of antacids?

"The major side effect of an antacid is diarrhea." Major side effects of antacids include diarrhea, constipation, dry mouth, gas, nausea, and stomach pain. These should be explained to the client. Side effects do not include profuse sweating, decreased urge to urinate, or fast breathing. Some antacids, depending on the type, can cause dry mouth, increased urge to urinate, and slow breathing.

A client asks the nurse why epoetin alfa is administered during dialysis sessions. Which response by the nurse is accurate?

"The medication is a form of erythropoietin that stimulates red blood cell production." Epoetin alfa stimulates red blood cell production essential for clients with chronic renal failure. It is not used to eliminate the rise of creatinine, to assist activity levels, or to increase renal output.

The nurse is to administer ceftriaxone. The order reads: give 50 mg/kg now. The client weighs 75 kg. How many grams of ceftriaxone will the nurse give? Record your answer using one decimal place.

3.8 75 × 50 = 3750 mg (1 g)/(1000 mg) × 3750 mg/L = 3.8 g

A labor and birth nurse is assessing the fetal heart rate of a client who is at term. Which rate would cause the nurse to intervene?

60-79 beats per minute This fetal heart rate (FHR) could indicate fetal distress and should be evaluated first. In a full-term fetus, the baseline FHR normally ranges from 121-160 beats per minute. The greatest concern would be the lowest fetal heart rate range.

The nurse monitors a client following the insertion of a chest tube for a hemopneumothorax. Which observation should the nurse report to the healthcare provider?

600 mL of blood in the collection chamber in 1 hour A blood loss of 600 mL may place the client in danger of developing hypovolemic shock. All of the other choices are normally expected with a chest tube.

A nurse is assigned to four clients. Which client should the nurse see first?

A client who is being prepared for a major surgery receiving clopidogrel Clopidrogel is an anti-platelet drug that should be stopped seven days prior to surgery because it can increase the risk of bleeding. All the other options are correct. Fondaparinux can be given to a client who had ORIF to prevent blood clot formation. Pegfilgastrim is given to a client with low white blood cell (WBC). Emtricitabine is a nucleoside-nucleotide reverse transcriptase inhibitor (NNRTI) drug used for clients with HIV/AIDS.

Following surgery for removal of a brain tumor, a client is coughing, short of breath, and has a "bad" feeling. The nurse obtains the following vital signs: blood pressure of 80/60 mm Hg; pulse rate of 120 bpm; and respiratory rate of 30 shallow breaths/min. What should the nurse do first?

Activate the Rapid Response Team (RRT). RRTs, or medical emergency teams, provide a team approach to evaluate and treat immediately clients with alterations in vital signs or neurological deterioration. Calling the neurosurgeon or consulting the CNS may not result in a rapid response. The Trendelenburg position is usually used in treating shock, but because the client has had brain surgery, the head should not be lower than the trunk.

A client is experiencing severe anaphylactic shock. What actions should the nurse take first? Select all that apply.

Administer diphenhydramine. Ask the client if they are lightheaded. Give intravenous fluids. Prepare for insertion of an endotracheal tube. Diphenhydramine would be administered because it reverses the effect of histamine. Lightheadedness is a symptom of anaphylactic shock. Intravenous fluids will be given to treat hypotension. Metoprolol is used to treat hypertension or chest pain. An endotracheal tube would be inserted if a respiratory arrest is imminent. Hematuria would be seen in urinary problems, such as bladder or kidney stones, enlarged prostate, kidney infection or urinary tract infection.

The nurse assesses a school-age child in the emergency department and finds a respiratory rate of 52 breaths/min, accessory muscle use, wheezing, and an oxygen saturation of 87% on room air. What action will the nurse take first?

Apply supplemental oxygen. A client in respiratory distress with a saturation lower than 90% needs to have supplemental oxygen placed immediately, followed by initiation of cardiac monitoring. The other interventions follow these actions.

A nurse is caring for a client with a prescription for hydromorphone 2 mg I.V. as needed for pain. The client is reporting pain at a 10/10 and is requesting to be medicated. When trying to retrieve the prescribed hydromorphone, the nurse is unable to access the computerized automated dispensing cabinet (ADC) because of an expired password. What is the most appropriate action by the nurse?

Ask another nurse to administer the medication to the client while contacting information services to reset password. Managing pain in a client with a pain rating 10/10 is a priority and care should not be delayed. The nurse should ask another nurse to medicate the client while contacting information services to reset the password as soon as possible to prevent delay in care for other clients. Hydromorphone is a Schedule II controlled substance and by federal law a record must be kept of the name of the nurse who obtained and administered the substance. The nurse who obtains the medication from the computerized ADC is the nurse who is required to administer it. A nurse's user name and password is a secure identification code equivalent to a nurse's signature and should never be given to another staff member.

The nurse used a secure access code to obtain a morphine 2 mg/ml vial from the computerized automated dispensing cabinet (ADC). Before exiting the system, the nurse is prompted to count the remaining vials. The nurse counts 10 remaining vials, but the system reads 9 remaining vials. What is the next action by the nurse?

Ask another nurse to assist with following the procedure to resolve the discrepancy. Morphine is a controlled substance. Federal law requires an accurate record for each controlled substance administered to prevent diversion and misuse. Accurate counts of vials are an important part of maintaining this accurate record. In the event of a discrepancy, the nurse should ask another nurse to act as a witness and follow the facility procedure for resolving a discrepancy. Resolving the discrepancy is a priority and should happen before medicating the client. The nurse should not change the number or waste the extra vial because this will not maintain an accurate record of the controlled substance administration as required by law.

The nurse was unsuccessful starting a peripheral intravenous line in the right forearm of a client with a history of a left axillary lymph node removal. What should the nurse do next?

Ask another nurse to attempt to start a peripheral intravenous line. Another nurse needs to attempt to start an intravenous line. That nurse may be successful with starting the intravenous line. The nurse should not begin by notifying the health care provider. This action should only be performed if multiple attempts have been made to insert an intravenous line without success. The nurse will not set up for placement of a triple-lumen central venous catheter without notifying the health care provider and getting an order. The client should not have an intravenous line started in the left forearm because of the lymph node removal. The removal of lymph nodes increases the risk of lymphedema, which can lead to an infection.

The nurse is preparing the prescribed hydromorphone 1 mg I.V. After drawing up the prescribed dose from a 2 mg/ml vial, what is the next action by the nurse?

Ask another nurse to witness the waste of 0.5 ml of medication into the sink. Hydromorphone is a controlled substance. Federal law requires the careful recording of all controlled substances to prevent diversion or misuse. All controlled substances require two nurses to witness and document the waste of a partial dose. After preparing the medication, the nurse should ask another nurse to act as a witness to the waste of the partial dose in the sink. The sharps container and the client's drawer are not secure and therefore will not prevent the diversion of the controlled substance. The partial dose in a single-dose vial will not be returned to the automated dispensing cabinet.

Just prior to administering lorazepam 2 mg I.V. to an agitated client, the client knocks the medication to the floor. After retrieving the medication, what is the best action by the nurse?

Ask another nurse to witness the waste of the medication. Lorazepam is a Schedule IV controlled substance. Federal law requires two nurses to witness and document the waste of all controlled substances in order to prevent diversion and misuse of the substance. The nurse should ask another nurse to witness the waste of the medication either into the sink or an approved pharmaceutical waste container as per the facility policy. Controlled substances should never be placed into a sharps container as these are not secure and may lead to diversion of the substance. A nurse would not administer a medication that had been knocked to the floor as this would result in contamination of the syringe.

A nurse records a client's fingerstick blood glucose level and gives 2 units of regular insulin as ordered. At the next scheduled blood glucose assessment, the nurse realizes that the wrong client was tested and given insulin. What is the nurse's priority action related to this incident?

Assess both clients, and call the appropriate healthcare providers to notify them of the errors. The nurse must acknowledge the mistake and take all necessary actions to prevent or minimize harm arising from the incidents. This includes assessing the clients for complications of the error and notifying the healthcare providers to receive further direction in correcting the error. After performing these steps, the nurse should document the actions taken. The other options are incorrect because they are either incomplete or do not demonstrate that the nurse has taken responsibility for the mistakes.

What should the nurse do first when admitting a toddler with croup?

Assess respiratory status. For the child with croup, assessing the child's respiratory status is the priority. It is especially important to assess airway patency because laryngeal spasms can occur suddenly. After the nurse has assessed the toddler's respiratory status, having a tracheostomy set at the bedside would be the next priority. Monitoring vital signs is important, as is ensuring adequate fluid intake to keep secretions loose, but assessing respiratory status is key.

The nurse is assessing a client with somatic symptom disorder who reports a fall. The nurse finds the client rubbing the left knee. How should the nurse best intervene?

Assess the client's injury, notify the healthcare provider, and document the incident. The nurse should assess the injury, notify the healthcare provider, and thoroughly document the incident in accordance with facility protocol. Even though a patient with somatic symptom disorder is likely to have many physical complaints, the nurse should thoroughly investigate each complaint to avoid overlooking a serious problem. The nurse should always notify the healthcare provider of the findings in accordance with facility protocol.

The client with a cervical spinal cord injury is admitted to the rehabilitation unit with skeletal traction (Gardner-Wells Traction). What nursing actions are a priority when caring for the client? Select all that apply

Assess the client's skin integrity. Maintain proper body alignment. Assess client's neurological function. The nurse will assess the client's skin integrity, maintain proper body alignment, and assess client's neurological function. The Gardner Wells traction does not have weights and clients are limited with active range of motion.

After transurethral resection of the prostate, the nurse notices that the urine draining from the catheter is bright red, has numerous clots, and is viscous. Which nursing action is most appropriate?

Assess vital signs and notify the surgeon. Blood clots are normal after transurethral resection of the prostate, but bright red urine can indicate a hemorrhage. The nurse should assess the client's vital signs and notify the surgeon. Irrigation of the catheter may help remove clots, but it does not decrease bleeding. Milking a urinary catheter or increasing fluid intake is not effective for controlling bleeding or decreasing clots.

When performing a heelstick on a newborn, the nurse is unable to obtain an adequate sample. What should the nurse do?

Attempt the heelstick in a new location. If unable to obtain an adequate sample from a heelstick, using a different site, placing foot in a dependent position, and warming the heel are recommended. If none of this works, then venipuncture can be done. There is no need to call the health care provider and a cold compress decreases blood flow to the area instead of increasing blood flow.

The nurse is to administer an antibiotic to a client with burns, but there is no medication in the client's medication box. What should the nurse do first?

Call the pharmacy department. By contacting the pharmacy to report the absence of the medication, the pharmacy can bring the medication to the client's medication box. From there on, the pharmacy can make sure the correct medications are present. Contacting the shift coordinator or the client's HCP will not correct the original cause of the variance. It is never appropriate to "borrow" a medication from another client.

Two months after an adolescent's thoracic spinal cord injury, he has a pounding headache. The nurse notes that the client's arms and face are flushed and he is diaphoretic. What should the nurse do next?

Check the patency of the urinary catheter. The adolescent is exhibiting signs of autonomic dysreflexia, a generalized sympathetic response usually caused by bladder or bowel distention. Immediate treatment involves eliminating the cause. Because bladder distention is a common cause of this problem, the nurse should immediately determine the patency of the indwelling (Foley) catheter. Lowering the head below the knees would increase the blood pressure and is contraindicated because of the spinal cord injury. Lying flat will not decrease blood pressure. Epinephrine is contraindicated because it elevates blood pressure and therefore can exacerbate the problem.

If a client's central venous catheter accidentally becomes disconnected, what should a nurse do first?

Clamp the catheter. If a central venous catheter becomes disconnected, the nurse should immediately apply a catheter clamp. If a clamp isn't available, the nurse may place a sterile syringe or catheter plug in the catheter hub. After cleaning the hub with alcohol or povidone-iodine solution, the nurse must replace the I.V. extension set and restart the infusion. Calling the physician, applying a dry sterile dressing to the site, and telling the client to take a deep breath aren't appropriate interventions at this time.

The nurse is reviewing the physician's order written for a postmenopausal client: "calcitonin salmon nasal spray 200 IU, one spray every day." What is the appropriate action to be taken by the nurse regarding this order?

Clarify with the physician that the spray should be given in only one nostril per day. Calcitonin salmon nasal spray should be administered in only one nostril per day. Many preprinted order sheets automatically print "administer in both nostrils" when a nasal spray is ordered. Nurses must be familiar with the directions for each medication they give before administering medications. The other options are incorrect because calcitonin salmon nasal spray is prescribed to postmenopausal clients for the treatment of osteoporosis and requires a physician's order.

The nurse is caring for a multigravid client in active labor with continuous electronic fetal heart rate monitoring. As the client begins to push, the nurse observes that the fetal heart rate shows a deceleration pattern that mirrors the contractions. What should the nurse do?

Continue to monitor the client and fetus. Early decelerations are decelerations that mirror the contraction pattern. They are caused by pressure on the fetal skull and are not considered an ominous sign. The nurse should continue to monitor the client and fetus. Early decelerations are common during the second stage of labor.Turning the client to the left side is not warranted.Pushing in the squatting position should not alter the early deceleration pattern.Administering oxygen is not warranted.

The parents of a preschooler suspect that the child has recently ingested a large amount of acetaminophen. The child does not appear in immediate distress. The nurse should anticipate doing which intervention in order of priority, from first to last? All options must be used.

Determine the time and amount of drug ingested. Administer activated charcoal. Draw acetaminophen serum levels. Administer acetylcysteine IV. The nurse should first attempt to determine exactly when and how much acetaminophen the parents think the child has taken. Determining the time of ingestion helps establish the immediate care and when lab values should be drawn. Gastric decontamination with activated charcoal is used within 4 hours of ingestion to bind the drug and help prevent toxic serum levels. Serum blood levels should be done after the gastric decontamination, but preferably not too soon after ingestion since levels drawn before 4 hours may not reflect maximum serum concentrations and will need to be repeated. The decision to administer acetylcysteine and prevent liver damage is based on serum levels.

A local chemical plant has had an environmental leak requiring the mass evacuation of its employees and neighbors in the surrounding area. The emergency room nurse is in the triage area when the first client is brought to the hospital. What should the nurse do first?

Determine what decontamination measures took place in the field before approaching the client. During a disaster the nurse's priority is personal safety. Determining what decontamination measures have already taken place will inform the nurse of necessary precautions. The nurse should not cut off the clothing or place the client in the shower until an assessment of the hazardous material has been completed. Containing the exposed clients in one area, free from other clients, is important, but the safety of the healthcare workers is the priority.

A client receiving total parenteral nutrition (TPN) is ordered to undergo a 24-hour urine test for creatinine clearance. Which actions should the client take to initiate this collection?

Discard the first morning void, then continue the collection for exactly 24 hours. Evidence-based practice (EBP) dictates that the nurse should start the test after the first morning void, but this first void should be discarded. The other choices are not correct.

A nurse is caring for a woman G1 P0 at 40 weeks gestation in active labor. Assessments include: cervix 5 cm dilated; 90% effaced; station 0; cephalic presentation; FHR baseline is 135 bpm and decreases to 125 bpm shortly after onset of 5 uterine contractions and returns to baseline before the uterine contraction ends.Based on this assessment, what action should the nurse take first?

Document findings on the client's chart, and continue to monitor labor progress. The nurse would document these findings as "early" decelerations. Early decelerations are thought to be the result of vagal nerve stimulation caused by compression of the fetal head during labor. They are considered normal physiologic response to labor and do not require any intervention. Early decelerations do not require position change or O2 as they are not a sign of fetal distress. Variable decelerations are thought to be due to umbilical cord compression. Early decelerations are not emergent and do not require immediate reporting to the health care provider (HCP) or preparing for caesarean birth.

When assessing a client prescribed hemodialysis, the nurse notes the client's blood pressure is 140/82 mm Hg, heart rate is 82 beats/min, and respirations are 12 breaths/min. The nurse also notes a continuous vibration over the client's fistula. What is the appropriate action by the nurse?

Document presence of a thrill. The continuous vibration noted when palpating a hemodialysis fistula is known as a thrill. This is an expected finding so the nurse should document the presence of the thrill. There is no need to contact the healthcare provider or to hold the hemodialysis. The nurse should not administer oxygen as there is no indication that the client is in need of oxygen at this time.

During the assessment of a client's mouth, the nurse notes the absence of saliva. The client reports having pain behind the ear. The client has been nothing-by-mouth (NPO) for several days but now can have liquids. What should the nurse do next?

Encourage the client to suck on hard candy. The lack of saliva, pain near the area of the ear, and the prolonged NPO status of the client are indications that the client may be developing parotitis, or inflammation of the parotid gland. Parotitis usually develops with dehydration combined with poor oral hygiene or when clients have been NPO for an extended period. Preventive measures include the use of sugarless hard candy or gum to stimulate saliva production, adequate hydration, and frequent mouth care. The client does not have indications of stomatitis (inflammation of the mouth), which produces excessive salivation and a sore mouth. The client does not have indications of oral candidiasis (thrush), which causes bluish white mouth lesions, and the nurse does not need to request a prescription for an antifungal mouthwash. There are no indications that the client has gingivitis, which can be recognized by the inflamed gingiva and bleeding that occur during toothbrushing, and while the client should brush the teeth and gums, increasing salivation to prevent parotitis is the priority at this time.

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. 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.

The nurse attempts to obtain a blood specimen from an implanted port. The port does not have blood return. What should the nurse do next?

Have the client change positions. If an implanted port does not have blood return, having the client change position, performing the valsalva maneuver, and raising or lowering the head of the bed can promote blood return. The port should not be removed; the access needle may need to be removed and reinserted depending on the facility policy. A chest x-ray may be required but is not what the nurse should do first. Changing the dressing may not help with blood return.

A young adult client comes to the clinic in an agitated state. The client's friends report that the client has been consuming beverages combining energy drinks and alcohol all day. What is the priorityaction by the nurse in caring for this client's immediate needs?

Hydrate the client, and monitor laboratory results and vital signs. The nurse should recognize that the client is most likely in an alcohol- and caffeine-intoxicated state. It is important to determine baseline laboratory results, monitor vital signs, and begin hydration to aid in dilution of the intoxicating agents. Verifying consumption of drinks and alcohol and an illicit drug screening panel are important but not the priorities for care. Contacting the client's next of kin is important in care but not a priority if the client needs treatment.

The nurse notes what appears to be a ventricullar fibrillation rhythm on a client's telemetry monitor. What should the nurse do first?

Immediately assess the client's level of consciousness. Before taking any action, the nurse needs to confirm the accuracy of the telemetry reading. The nurse first assesses the client. If in ventricular fibrillation, the cardiac output drops rapidly and the client will lose consciousness. If the client is conscious and asymptomatic, the nurse needs to assess for reasons for artifact and adjust the client's telemetry leads. The other actions may be taken once the nurse confirms accuracy of the reading, beginning with calling the emergency response team (i.e., calling a code blue). The nurse will initiate cardiopulmonary resuscitation after calling the code. Once the team arrives, interventions such as defibrillation and medications will be administered.

A client with type 1 diabetes is admitted to an acute care facility with diabetic ketoacidosis. To correct this acute diabetic emergency, which measure should the healthcare team take first?

Initiate fluid replacement therapy. The healthcare team first initiates fluid replacement therapy to prevent or treat circulatory collapse caused by severe dehydration. Although diabetic ketoacidosis results from insulin deficiency, the client must have an adequate fluid volume before insulin can be administered; otherwise, the drug won't circulate throughout the body effectively. Therefore, insulin administration follows fluid replacement therapy. Determining and correcting the cause of diabetic ketoacidosis are important steps, but the client's condition must first be stabilized to prevent life-threatening complications.

A child is admitted to the hospital with a febrile seizure. What action should the nurse take?

Keep the room temperature low and bedclothes to a minimum. One nursing goal for a child with febrile seizures is to maintain the child's temperature at a level low enough to prevent recurrence of seizures. Decreasing the environmental temperature and removing excess clothing and blankets will help decrease the child's temperature.There is no reason to keep the child supine; a side-lying position would be acceptable and help decrease intracranial pressure. A febrile seizure, though, results from abnormal electrical activity in the brain due to elevated body temperature.Isolation precautions are not necessary unless the child has a condition that warrants such an isolation.Using a tongue blade to separate the teeth in the upper jaw from the lower jaw in an attempt to prevent the child from biting the tongue has proven to be ineffective and may result in broken teeth.

The nurse assesses the postpartum client and notes blood gushing from the vagina, pallor, and a rapid, thready pulse. What is the nurse's priority intervention?

Massage the fundus. Uterine atony can contribute to postpartum hemorrhage, which results in excessive vaginal bleeding and signs of shock, such as pallor and a rapid, thready pulse. The priority measure to correct postpartum hemorrhage is to massage the fundus. Emptying the bladder via indwelling catheter and checking vital signs are not priorities. Massaging the fundus will increase uterine tone and decrease vaginal bleeding. The healthcare provider will have to be called, but the nurse must first intervene. Cervical lacerations produce a steady flow of bright red blood in a client with a firmly contracted uterus.

A client is admitted to the labor and delivery unit in labor with blood flowing down her legs. What would be the priority nursing intervention?

Monitor fetal heart tones. Monitoring fetal heart tones would be the priority, due to a possible placenta previa or abruptio placentae. Although an indwelling catheter may be placed, it is not a priority intervention. Performing a cervical examination would be contraindicated because any agitation of the cervix with a previa can result in hemorrhage and death for the mother or fetus. Preparing the client for a cesarean birth may not be indicated. A sonogram will need to be performed to determine the cause of bleeding. If the diagnosis is a partial placenta previa, the client may still be able to deliver vaginally.

A 4-month-old infant has been carried into the emergency department after falling off the parents' bed and hitting the head on the floor. What should the nurse do first?

Move the family to an area where an assessment can be completed and call for a physician. A head injury in an infant can be extremely serious. The nurse's priority should be to move the infant and family to an area where assessment and treatment can occur. Triaging the infant and having the parents wait for evaluation by a physician is inappropriate because of the potential seriousness of the injury. Although increased intracranial pressure can result from head trauma, it's unlikely that inserting a VP shunt would be the first treatment. The fact that the child was left unattended in an unsafe location is a significant safety issue, but notifying child protective services isn't a priority at this time.

The nurse discovers that a client's TPN solution was running at an incorrect rate and is now 2 hours behind schedule. Which action is most appropriate for the nurse to take to correct the problem?

Notify the health care provider (HCP) When TPN fluids are infused too rapidly or too slowly, the HCP should be notified. TPN solutions must be carefully and accurately infused. Rate adjustments should not be made without a written prescription from the HCP. Significant alterations in rate (10% increase or decrease) can result in fluctuations of blood glucose levels. Speeding up the solution can result in too much glucose entering the system.

The nurse reviews the medical record of an adolescent with a history of losing weight and fatigue is admitted to the hospital with a diagnosis of stage I chronic renal failure (see exhibit).

Notify the health care provider (HCP). The nurse would expect a person with a normal glomerular filtration rate (GFR) to have approximately equal inputs and outputs. Chronic renal failure has five stages. In stage I, the GFR is approximately ?90 mL/min/1.73 m2. In stage II, the GFR decreases to approximately 60 to 89 mL/min/1.73 m2. The decreased urine output may indicate worsening disease and should be reported. Assessing the client's intake and output is still important, but notifying the provider is the priority. Fluids are restricted based on decreased sodium. Clients are encouraged to drink to thirst. Therefore, there is not enough information to suggest increasing or restricting fluids.

A client is scheduled for an intravenous pyelogram. Before the procedure, the nurse learns that the client has a sensitivity to shellfish. What should the nurse do next?

Notify the health care provider. Sensitivity to shellfish or iodine may cause an anaphylactic reaction to the contrast material, which contains iodine. Administering a cathartic or antiflatulent will not prevent an anaphylactic reaction to the contrast material. Keeping a client on NPO status for 8 hours before the procedure is part of the usual preparation for such a procedure to prevent aspiration of food or fluids if the client vomits when lying on the x-ray table.

An adult client is admitted to the hospital after vomiting bright red blood and is diagnosed with a bleeding duodenal ulcer. The client develops a sudden, sharp pain in the midepigastric region along with a rigid, board-like abdomen. After obtaining the client's vital signs, what should the nurse do next?

Notify the health care provider. The client is likely experiencing a perforation of the ulcer, and the nurse should notify the health care provider immediately. The body reacts to perforation of an ulcer by immobilizing the area as much as possible. This results in board-like abdominal rigidity, usually with extreme pain. Perforation is a medical emergency requiring immediate surgical intervention because peritonitis develops quickly after perforation.Administering pain medication is not the first action, although the nurse later should institute measures to relieve pain.Elevating the head of the bed will not minimize the perforation.A nasogastric tube may be used following surgery.

A client receiving digoxin has a serum magnesium level of 0.9 mg/dL (0.57 mmol/L). What is the nurse's best action?

Notify the healthcare provider. The decreased magnesium level can potentiate digoxin toxicity, and the healthcare provider should be notified. The digoxin should not be administered until the nurse receives clarification from the healthcare provider. Increasing fluids is not appropriate. Calcium gluconate is administered for hypermagnesemia.

A client is receiving peritoneal dialysis. What should the nurse assess while the dialysis solution is dwelling in the client's abdomen?

Observe respiratory status. During dwell time, the dialysis solution is allowed to remain in the peritoneal cavity for the time prescribed by the health care provider (HCP) (usually 20 to 45 minutes). During this time, the nurse should monitor the client's respiratory status because the pressure of the dialysis solution on the diaphragm can create respiratory distress. The dialysis solution would not cause urticaria or affect circulation to the fingers. The client's laboratory values are obtained before beginning treatment and are monitored every 4 to 8 hours during the treatment, not just during the dwell time.

A nurse is developing a care plan for a client with disseminated intravascular coagulation (DIC). Which nursing intervention should the nurse include?

Place a pressure-reducing mattress on the client's bed. A client with DIC is at risk for Impaired skin integrity related to bleeding or ischemia. The nurse should place the client on a pressure-reducing mattress and perform skin care every 2 hours. The nurse should avoid administering any medication that decreases platelet function, such as aspirin. The nurse should perform mouth care using sponge swabs and baking soda solution, not lemon-glycerin swabs, because lemon-glycerin swabs can dry the oral mucosa, which may lead to bleeding. I.M. injections should be avoided in clients with DIC because of the potential for bleeding.

A client with acute pancreatitis has a blood pressure of 88/40 mm Hg, heart rate of 128 bpm, respirations of 28 breaths/min, and Grey Turner's sign. What prescription should the nurse implement first?

Place an intravenous line. 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.

The nurse obtains a blood specimen via venipuncture in a preschool child. What is the nurse's next action?

Place in a biohazard bag for transport to the laboratory. After drawing blood via venipuncture, tubes should be inverted 8 to 10 times but not shaken due to risk of damage to erythrocytes. The specimen should be labeled with client's name, time and date of collection, initials of person collecting, and medical record number. Allergies are not required. The specimen should be placed in a biohazard bag for transport. The nurse should not tell the child that there are no more procedures. This is false reassurance because there may be a need to draw more specimens.

The nurse is caring for a primigravida client who has been admitted to the labor and birth unit. Assessment reveals fetal malpresentation, green amniotic fluid, and a fetal heart rate (FHR) of 98 beats/minute. What is the nurse's priority intervention?

Prepare for an emergency cesarean birth. Because the abnormal FHR and amniotic fluid color suggest fetal distress, the nurse should prepare for an emergency cesarean birth. Giving oxytocin may increase fetal distress. Applying a fetal scalp electrode and having the client push would not address this emergency situation.

A school-age child is admitted to the hospital with the diagnosis of probable infratentorial brain tumor. During the child's admission to the pediatric unit, which action should the nurse anticipate taking first?

Prepare the child and parents for diagnostic procedures. When a brain tumor is suspected, the child and parents are likely to be very apprehensive and anxious. It is unrealistic to expect to eliminate their fears; rather, the nurse's goal is to decrease them. Preparing both the child and family during hospitalization can help them cope with some of their fears. Although the nurse may be able to decrease some of the child's anxiety, it would be impossible to eliminate it. Children with infratentorial tumors seldom have seizures, so seizure precautions are not indicated. Although introducing the child to other children is a positive action, this action would be more appropriate once the nurse has decreased some of the child's and parents' anxiety by preparing them.

A client with active genital herpes is admitted to the labor and birth unit during the first stage of labor. Which plan of care does the nurse anticipate for this client?

Prepare the client and partner for a cesarean birth as soon as possible. For a client with active genital herpes lesions, cesarean birth helps avoid infection transmission to the neonate, which would occur during a vaginal birth. Penicillin G is given for a bacterial colonization of group B streptococcus. Tocolytics are given to stop labor; they are not appropriate treatment. Valacyclovir is a treatment for an active herpes infection, but would not work in time for the client to deliver vaginally.

Immediately after birth, a nurse assesses the neonate's respiratory effort as slow. The neonate is actively moving but grimaces in response to stimulation. The neonate's fingers and toes are bluish and the heart rate is 130 bpm. Which step should the nurse take next?

Provide oxygen and stimulate the baby to cry. The nurse should stimulate the baby to cry, provide oxygen, and call the provider to evaluate reflex irritability. It would be inappropriate to tell the provider that the neonate appears abnormal. The neonate's Apgar score is 7. Of a maximum possible Apgar score of 10, the nurse deducts one point for acrocyanosis, one point for slow respiratory effort, and one point for the grimace. Although keeping the infant warm is important, the infant clearly needs more aggressive interventions such as oxygen and stimulation

A client is admitted to the emergency department with sudden onset of chest pain. Which prescriptions should the nurse implement immediately? Select all that apply.

Provide oxygen. Administer nitroglycerin. Administer aspirin. Administer morphine. When emergently managing chest pain, the nurse can use the memory mnemonic MONA to plan care: morphine, oxygen, nitroglycerin, and aspirin. A Foley catheter is not included in the emergent management of chest pain and can be inserted when the pain has been relieved and the client is stable. Acetaminophen is not used to manage chest pain.

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 breaths/min, blood pressure 128/76 mm Hg, and SpO2 89% on room air. What should the nurse do first?

Raise the head of the bed. 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.

A client with depression is exhibiting a brighter affect, ability to attend to hygiene and grooming tasks, and is beginning participation in group activities. The nurse asks the client to identify three of her strengths. After much hesitation and thinking, the client can state she is usually a nice person, a good cook, and a hard worker. What should the nurse do next?

Reinforce the client for identifying and sharing her strengths. After the client identifies and shares her strengths, the nurse reinforces the client for her ability to evaluate herself in a positive manner. Doing so promotes self-esteem and offers hope for improvement. Asking the client to identify three additional strengths or volunteering the client to lead the cooking group could be too overwhelming for the client at this time and may increase her anxiety and feelings of worthlessness. Although educating the client about the importance of medication is important, doing so at another time would be more appropriate.

The client was found not breathing and was transported to the hospital. A family member states the client may have taken too much pain medication because the client frequently forgets if the medication was taken. Which observation(s) by the nurse indicates therapeutic effect of naloxone hydrochloride in the client? Select all that apply.

Reverses decreased respiratory rate of 10. Reverses decreased level of consciousness. Reverses blood pressure of 90/58. Therapeutic effect includes reversal of respiratory depression, sedation, and hypotension. Therapeutic effect does not include increasing nerve pain or increasing inflammation.

A new diabetic client meets all the criteria to be discharged, but expresses anxiety about being able to manage treatment. What is the best action for the nurse to take? Select all that apply.

Review diabetic teaching with the client. Remind the client of self-care in the hospital. Reinforce the client's follow-up appointments. The nurse's best actions are to review diabetic teaching, reinforce the successes the client had in managing care while in the hospital, and remind the client of the follow-up care appointments in place for support. Since the client is anxious, it is important that the nurse recognize reinforcing the knowledge and skills the client has mastered while in the hospital as this will boost client confidence at the time of discharge. Focusing on either the imminent discharge or the presenting anxiety will be counterproductive and nontherapeutic for the client. It is inappropriate to request a prescription for anxiety or to consider postponing the client's scheduled discharge.

A client with type I diabetes is learning how to inject themselves with insulin. Place the steps for self-injection of insulin in order. All options must be used.

Stabilize the skin with one hand. Pick up the syringe with the other hand. Insert the needle straight into the skin. Push the plunger all the way into the skin. Pull the needle out of the skin. Press cotton ball over injection site for several seconds. The first step is to stabilize the skin with one hand to keep it from moving when inserting the needle and to make sure the insulin is injected into the subcutaneous fat. The second step is to pick up the syringe with the other hand to administer the injection into the subcutaneous fat. The third step is to insert the needle straight into the skin to administer the insulin. The fourth step is to push the plunger all the way in to deliver the insulin into the subcutaneous fat. The fifth step is to pull the needle out of the skin after the insulin has been administered, and the sixth step is to press a cotton ball over injection site for several seconds to prevent insulin from coming out of the insertion site.

An older adult is admitted to the hospital with sudden onset of severe pain in the back, flank, and abdomen. The client reports feeling weak; the blood pressure is 68/31 mm Hg. There has been no urine output. Bilateral leg pulses are weak, although bruit and pulsation are noted at the umbilicus. What should the nurse do first?

Start an IV infusion. The symptoms noted are classic symptoms of leaking abdominal aneurysm and shock; the client needs immediate fluid volume replacement. Assessing the pulses with a Doppler will be of no additional diagnostic value. Palpating the abdomen on a client with a suspected abdominal aneurysm is contraindicated and could lead to rupture. After emergency fluid resuscitation, consent for surgery is needed.

After abdominal surgery 3 days ago the client continues to have pain every 4 to 6 hours ranging from 3 to 7 on a 10-point scale. The client has prescriptions for morphine 10 mg IM every 3 to 4 hours and acetaminophen with codeine 30 mg every 3 to 4 hours as needed for pain. The client has been taking the morphine every 4 hours for the past 3 days but tells the nurse that the morphine is no longer lasting 4 hours and wants to receive pain medication every 3 hours. The nurse reviews the progress notes that indicate the client has obtained pain relief for 5 to 6 hours after receiving the morphine. What should the nurse do to help the client manage the pain?

Suggest that the client take the acetaminophen with codeine every 3 hours. Evidence indicates that acetaminophen with codeine provides pain relief for most clients with moderate pain. Because the progress notes indicate that the client is obtaining relief from the morphine for more than 4 hours and has moderate pain, the nurse can suggest that the client try taking the acetaminophen with codeine every 3 hours. The goal for this client is to gradually use less pain medication. The client can be encouraged to ambulate, but that will not be sufficient to manage the postoperative pain at this point.

The nurse prepares the client for a lumbar puncture (LP) (see client chart below) to rule out a subarachnoid hemorrhage. Which assessment finding would require intervention before the procedure?2/10/2017190056-year-old, right-handed client presents with severe onset of headache and projectile vomiting that started 45 minutes prior to admission. Physical examination findings include nuchal rigidity.

Suspected increased intracranial pressure (ICP) Sudden removal of CSF result in a lowered pressure in the lumbar area than in the brain which can cause brain herniation, especially in the presence of increased ICP. Therefore a LP is contraindicated when increased ICP is suspected. Vomiting may be caused by reasons other than increased ICP; therefore, LP isn't strictly contraindicated. A LP may be performed on clients requiring mechanical ventilation. Blood in the CSF is diagnostic for subarachnoid hemorrhage.

The nurse notices that a client's heart rate decreases from 63 to 50 bpm on the monitor. What should the nurse do first?

Take the client's blood pressure. The nurse should first assess the client's tolerance to the drop in heart rate by checking the blood pressure and level of consciousness and determine if atropine is needed. If the client is symptomatic, atropine and transcutaneous pacing are interventions for symptomatic bradycardia. Once the client is stable, further physical assessments can be done.

A client is experiencing an acute hemolytic reaction while receiving 1 unit of packed red blood cells. What actions should the nurse take first? Select all that apply.

Take the client's temperature. Assess for anxiety and mental status changes. Maintain the intravenous line with normal saline using new intravenous tubing. A fever is a symptom of acute hemolytic reaction. The blood container and tubing should not be disposed of. They need to be sent back to the blood bank for repeat typing and culture. Anxiety and mental status changes are symptoms of acute hemolytic reaction. Maintaining the intravenous line with normal saline needs to be done to give medications quickly. New tubing needs to be used because the blood being infused in the tubing is causing the reaction.

A client who is neatly dressed and clutching a leather briefcase tightly in his arms scans the adult inpatient unit on his arrival at the hospital and backs away from the window. The client requests that the nurse move away from the window. The nurse recognizes that doing as the client requested is contraindicated for which reason?

The action indicates nonverbal agreement with the client's false ideas. The nurse's nonverbal behavior, moving away from the window as the client requests, indicates agreement with the client's false ideas. The client's behavior is likely to be reinforced if the nurse takes steps to agree with the false ideas the client holds.

A medication order reads, "Meperidine 1 ml I.M. stat." A nurse responsible for administering the drug should base the next action on which understanding?

The nurse should clarify the order with the physician. The nurse must clarify this order with the physician because meperidine is available in several dosage strengths, and 1 ml may contain varying amounts of the drug. A stat order need not specify a precise administration time. Meperidine is commonly given I.M. Because the order specifies the drug volume but not the dosage, the nurse shouldn't consider this order correct and valid.

The nurse assesses the client's stoma during the initial postoperative period. What observation should the nurse report to the health care provider (HCP) immediately?

The stoma is dark red to purple. A dark red to purple stoma indicates inadequate blood supply. Mild edema and slight oozing of blood are normal in the early postoperative period. The colostomy would typically not begin functioning until 2 to 4 days after surgery.

The nurse is caring for an adult with iron deficiency anemia. The healthcare provider has ordered iron dextran for the client. Which routes or techniques can be used with this medication? Select all that apply.

Z-track IV IV and Z-track are the preferred routes or techniques to give iron dextran. Although z-track is an (technique) IM injection, it should be given z-track because iron can cause staining of the skin.

The nurse has just received change-of-shift report for four clients. Based on this report, the nurse should assess which client first?

a 35-year-old admitted after motor vehicle accident whose urine output has totaled 30 mL over the last 2 hours Urine output should be at least 500 mL in 24 hours (20 mL/h); this client's output has been just 15 mL/h for the past 2 hours requiring further assessment by the nurse. The nurse should first assess all clients and address physiological needs including pain control and safety measures; the nurse should then take time with the client having difficulty coping in order to listen and further determine her needs.

The nurse is examining charts to identify clients at risk for developing multiple myeloma. Which client is most at risk?

a 60-year-old Black man Multiple myeloma is more common in middle-aged and older adult clients. The median age at diagnosis is 60 years. It is twice as common in Black clients as it is in White clients, and it occurs most often in Black men.

The nurse on the postpartum unit is caring for four couplets. There will be a new admission in 30 minutes. The new client is a G4 P4, Spanish-speaking only client with an infant who is in the special care nursery (SCN) for respiratory distress. The nurse should place the new client in a room with which client?

a G4 P4 who is 2 days postpartum with infant, Spanish speaking only The ability to communicate with a person of the same language would be an advantage, an opportunity for socialization and support for the new mother who speaks Spanish. If a Spanish-speaking mother were placed with the client who also had a baby in SCN, she would have no communication opportunity, and the same would apply for rooming with the mother who has had a cesarean section. The client who is non-English speaking does not identify the language spoken, and the nurse cannot assume that it is Spanish.

Which client admitted to the emergency department should the nurse see first?

a client experiencing a "ripping" sensation in the chest A client experiencing a "ripping" sensation in the chest is indicative of a ruptured thoracic aneurysm and warrants an immediate intervention. While a blood pressure of 170/95 mm Hg is high, there is not enough information that suggests that this client is a higher priority than the others. A urine output of 240 mL in 12 hours is less than 30 ml/hour; however, this is this client's only problem now, and the nurse can investigate the cause next. A client experiencing bloody stools will need to be seen; however, no other information is present that would warrant this client being seen first.

The nurse is concerned about poor nutritional status of several clients on the unit. The nurse recommends placement of a gastrostomy tube for feeding as most appropriate for which client?

a client with dysphagia from a stroke 1 month ago and awaiting extended care A gastrostomy tube (G-tube) is placed through a stoma and remains in situ for long-term enteral feeding. This invasive procedure is not without risk so it is only appropriate for clients who are not able to swallow for a long period of time. The client who has had dysphagia for 1 month is the most appropriate candidate for a G-tube. The client who had a stroke 48 hours ago may still recover the ability to swallow so if enteral feeding is required, a nasogastric or small bowel feeding tube is more appropriate. The client with ulcerative colitis exacerbation should have bowel rest, and it is not indicated that the client cannot swallow. Although enteral feeding can be part of comfort care, the placement of a G-tube is not appropriate in a client with terminal cancer who is on comfort care.

In a disaster situation in the emergency department, the nurse is assessing a client who is critically ill, with a high likelihood of mortality. Which triage level would be appropriate?

a low priority In a situation when disaster triage is needed, the clients with the highest mortality rate are not given life-saving treatments. Care for the most clients where supplies can be used and staff can be used. The other choices are not correct.

A pregnant client is diagnosed with partial placenta previa. The nurse should prepare the client for which intervention?

activity limited to bed rest Treatment of partial placenta previa includes bed rest, hydration, and careful monitoring of the client's bleeding.Placenta previa involves an abnormal implantation of the placenta. Platelets are not affected. Therefore, a platelet infusion is not necessary.Vaginal birth is the preferred method of birth. An immediate cesarean section is not warranted unless fetal distress occurs or the client begins to hemorrhage.Induction of labor should be initiated with caution and only if birth is indicated because of the risk for possible hemorrhage or fetal distress.

The nurse is caring for a client postoperatively after having a low anterior resection of the colon 6 hours prior. The client rates incisional pain 6/10. The prescribed orders include morphine 1 to 2 mg IV every hour as needed for pain. The client is alert with vital signs within normal limits. How will the nurse best manage the client's pain?

administer morphine 1 mg IV and reassess pain level in 20 minutes Morphine is an opioid analgesic. Prevention of respiratory depression and increased sedation begins with the administration of the lowest effective dose. To best manage the client's pain with dose range orders, the nurse would begin with the lowest prescribed dose and titrate as needed to achieve effective analgesia while minimizing side effects. After administering the lowest prescribed dose, the nurse would assess the client's pain level and response to the therapy in 20 minutes (morphine peaks in 20 minutes). Based on the client's response, the nurse would then administer additional morphine as necessary.

Which nursing intervention has the highest priority during the first hour after the admission of a client with cholecystitis who is experiencing pain, nausea, and vomiting?

administering pain medication. Administering pain medication would have the highest priority during the first hour after the client's admission.Completing the admission history can be done after the client's pain is controlled.Maintaining hydration is important but will be accomplished over time. In the first hour after admission, the highest priority is pain relief.It is not appropriate to try to teach while a client is in pain. Teaching about planned diagnostic tests can occur after the client is comfortable.

The nurse is caring for a 12-year-old admitted for vaso-occlusion related to sickle cell disease. What intervention(s) will the nurse expect to implement? Select all that apply.

administration of hydromorphone for pain administration of oxygen administration of toradol intravenously Vaso-occulsion due to sickle cell disease is when the red blood cells (RBCs) morph into sickle cell shape and plug up the blood vessels causing extreme pain. The treatment of sickle cell includes administration of pain medication, administration of an anti-inflammatory, and administration of oxygen to prevent further sickling of other RBCs. Bed rest is encouraged and heat is applied to help vasodilation the venous system.

The client visits the health care provider reporting a red, swollen, and painful right great toe and is subsequently diagnosed with gouty arthritis. Which drug does the nurse anticipate the healthcare provider to order?

allopurinol Allopurinol is used to manage and prevent gout attacks and is also used for the treatment of calcium oxalate kidney stones. Phenytoin is used to treat and prevent seizures. Zaroxolyn is used to treat blood pressure and edema. Furosemide treats fluid retention and swelling caused by congestive heart failure, liver disease, and kidney disease.

The nurse assesses a 6-month-old for vaccination readiness. Which finding would most likely indicate the need to delay administering the diphtheria, tetanus, and acellular pertussis (DTaP) vaccine?

an acute bilateral ear infection Vaccination in the presence of a moderate-to-severe infection, with or without fever, increases the risk of injury and decreases the chance of mounting good immunity. An acute bilateral ear infection would constitute a moderate infection/illness. There is currently no evidence to suggest vaccines raise the risk of SIDS. A mild temperature may be expected with the DTaP. A fever of >40.5°C (105°F) within 48 hours of vaccination would warrant caution. The DTaP is not a live vaccine. No special precautions are needed regarding immunosuppressed family members.

A nurse and an unlicensed assistive personnel (UAP) are caring for four clients together on the telemetry unit. Which nursing action can be delegated safely to the UAP?

applying electrodes in the correct position for ECG monitoring Unlicensed assistive personnel (UAP) can be educated in correct lead placement for ECG monitoring. Assessment of clients and monitoring of unstable clients is not within the scope of practice for a UAP and should be done by the registered nurse. Client teaching must be completed by an RN, not a UAP.

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 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 bed rest is incorrect. Reorienting frequently will not prevent disorientation, and the nurse would not restrict pain measures.

The nurse is caring for a client prescribed a tocolytic agent. The nurse takes immediate action based on what assessment finding?

bilateral crackles on lung auscultation Tocolytics are used to stop labor contractions. The most common adverse effect associated with the use of these drugs is pulmonary edema. Bilateral crackles on lung auscultation is a sign of pulmonary edema, and prompt action would be required. A serum glucose level of 170 mg/dL (9.4 mmol/L) is elevated and should be reported, but it is not life-threatening. Tocolytics may cause tachycardia and increased cardiac output with bounding arterial pulsations. A peripheral pulse strength of +2 indicates a slightly lower than normal level that is not an immediate cause for concern.

An elderly client who is receiving steroids has secondary diabetes and chronic kidney disease (CKD) and takes insulin. The client has had episodes of hypoglycemia. The nurse should:

continue to monitor the client's blood glucose values. The nurse should continue to monitor glucose in the blood to prevent the client from continuing to experience hypoglycemia. One of the risk factors for hypoglycemia is decreased insulin clearance as with impaired kidney function and/or renal failure. Another risk factor for hypoglycemia is increased glucose utilization when there is too much activity or exercise without enough food.Protein is digested slower than carbohydrate, but with chronic kidney disease (CKD) it is more difficult for the kidneys to rid the body of metabolic waste products.

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 condition?

development of congestive heart failure 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.

When receiving a client from the postanesthesia care unit after a splenectomy, which should the nurse assess next after obtaining vital signs?

dressing After a splenectomy, the client is at high risk for hypovolemia and hemorrhage. The dressing should be checked often; if drainage is present, a circle should be drawn around the drainage and the time noted to help determine how fast bleeding is occurring. The nasogastric tube should be connected, but this can wait until the dressing has been checked. A urinary catheter is not needed. The last pain medication administration and the client's current pain level should be communicated in the exchange report. Checking for hemorrhage is a greater priority than assessing pain level.

A nurse regularly inspects a client's I.V. site to ensure patency and prevent extravasation during dopamine therapy. What is the treatment for dopamine extravasation?

elevating the affected limb, applying warm compresses, and administering phentolamine as ordered If extravasation occurs with dopamine administration, the nurse should elevate the affected limb, apply warm compresses, and administer phentolamine as ordered. The nurse shouldn't massage the limb or apply cold compresses. Physicians don't generally order hyaluronidase for dopamine extravasation. An incision isn't required or appropriate to drain the affected area.

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

fetal heart rate of 80 beats/minute 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.

The nurse is assessing a client with chronic obstructive pulmonary disease. Which finding requires immediate intervention?

inability to speak Inability to speak could indicate respiratory distress. Pulsed lip breathing, while it is an abnormal finding is not indicative of respiratory distress. Distant heart sounds could indicate heart failure but are not indicative of any distress.

A nurse is completing a health assessment with an adult client in a healthcare provider's office. What assessment findings will the nurse report to the healthcare provider as inidcations of fluid volume deficit? Select all that apply.

increased heart rate dry mucous membranes muscle hyperreflexia The nurse will identify increased heart rate, dry mucous membranes, and hyperactive muscle responses as indications of fluid volume deficit. Hyperglycemia and hyperactive bowel sounds are not common findings of fluid volume deficit.

The nurse is assessing a 4-month-old client. For what finding will the nurse take immediate action?

intercostal retractions on inspiration The presence of intercostal retractions is a sign of respiratory distress from an obstruction or a disease such as pneumonia, which causes the infant to have to work to breathe. Infants and children up to age 7 are abdominal breathers. After that age, they change to an adult pattern of breathing, which uses the diaphragmatic and thoracic muscles. A normal respiratory rate for an infant up to age 1 is 20 to 40 breaths/minute. A fever for an infant and child is defined as 100.4 oF (38 oC) or above.

A client has been diagnosed with an acute episode of angle-closure glaucoma. The client asks the nurse what will be done. What should the nurse tell the client about this health problem? Acute angle-closure glaucoma:

is a medical emergency that can rapidly lead to blindness. Acute angle-closure glaucoma is a medical emergency that rapidly leads to blindness if left untreated. Treatment typically involves miotic drugs and surgery, usually iridectomy or laser therapy. Both procedures create a hole in the periphery of the iris, which allows the aqueous humor to flow into the anterior chamber. Bed rest does not affect the progression of acute angle-closure glaucoma. Steroids are not a treatment for acute angle-closure glaucoma; in fact, they are associated with the development of glaucoma.

A laboring client in the latent stage of labor begins reporting pain in the epigastric area, blurred vision, and a headache. Which medication would the nurse anticipate for these symptoms?

magnesium sulfate Magnesium sulfate is the drug of choice to treat hypertension of pregnancy because it reduces edema by causing a shift from the extracellular spaces into the intestines. It also depresses the central nervous system, which decreases the incidence of seizures. Terbutaline is a smooth muscle relaxant used to relax the uterus. Oxytocin is the synthetic form of the pituitary hormone used to stimulate uterine contractions. Calcium gluconate is the antagonist for magnesium toxicity

What is the most important goal for a child with ineffective airway clearance?

suctioning the child's secretions The most important goal is to maintain a patent airway. The child with ineffective airway clearance has secretions which can obstruct the airway. Reducing anxiety and administering medications are necessary after the airway is secure. The child should not be allowed to eat or drink anything to prevent the risk of aspiration.

A nurse is performing an assessment of a postpartum client 2 hours after birth, and notes heavy bleeding with large clots. What should be the nurse's initial action?

massaging the fundus firmly Initial management of excessive postpartum bleeding is firm massage of the fundus along with a rapid infusion of oxytocin or lactated Ringer's solution. Bi-manual compression is performed by a health care provider. Ergonovine should be used only if the bleeding doesn't respond to massage and oxytocin. The health care provider should be notified if the client doesn't respond to fundal massage, but other measures should be taken in the meantime.

The client has second- and third-degree burns. The family asks if there is anything that can be given to the client for pain. Which analgesic would the nurse anticipate to manage the client's pain?

morphine administered by IV The best and most effective medication for second- and third-degree burns would be IV morphine. IM medications may not be absorbed, and codeine may not provide sufficient analgesia.

A client with nausea, vomiting, and abdominal cramps and distention is admitted to the healthcare facility. Which test result is most significant?

serum potassium level of [3 mEq/L (3.0 mmol/L)] A serum potassium level of 3 mEq/L is below normal, indicating hypokalemia. Because hypokalemia may cause cardiac arrhythmias and asystole, it's the most significant finding. In a client with a potential fluid volume imbalance, such as from vomiting, the other options are expected but none are as life-threatening as hypokalemia. A BUN level of 29 mg/dl indicates slight dehydration. A serum sodium level of 132 mEq/L is slightly below normal but not life-threatening. A urine specific gravity of 1.025 is normal.

Which nursing assessment data would be given priority for a child with clinical findings related to tubercular meningitis?

signs of increased intracranial pressure (ICP) Assessment of fever and evaluation of nuchal rigidity are important aspects of care, but assessing for signs of increasing ICP should be the highest priority due to the life-threatening implications. Urinary and fecal incontinence can occur in a child who is ill from nearly any cause. This doesn't pose a great danger to life.

As the nurse administers a tap water enema, the client begins to have abdominal cramping. The nurse should first:

temporarily stop the infusion until the cramping subsides. When the client initially begins to have abdominal cramping during an enema, the nurse should temporarily stop the infusion until the cramping subsides. If, on resuming the flow of enema fluid, the client continues to have cramping or inability to retain further fluid, the nurse should discontinue the enema. Having the client take slow, deep breaths can help decrease the amount of cramping. Telling the client to hold the breath will not relieve cramping and is inappropriate. The client should be placed in a left Sims' position, not a supine position, to facilitate flow of the fluid into the colon.

A client with suspected myasthenia gravis is scheduled for a edrophonium test. The nurse identifies which test finding that most likely indicates a positive test result?

temporary muscle improvement Administration of the edrophonium test will have no effect with a normal client but will cause a temporary improvement of muscle weakness in a client with myasthenia gravis.

A nurse just received a shift report for a group of clients on the telemetry unit. Which client should the nurse assess first?

the client admitted with first-degree atrioventricular (AV) block whose cardiac monitor now reveals type II second-degree AV block The client whose cardiac rhythm now shows type II second-degree AV block should be assessed first. The client's rhythm has deteriorated from first-degree heart block to type II second-degree AV block and may continue to deteriorate into a lethal form of AV block (known as complete heart block). The client who underwent cardioversion 2 days ago has likely had the underlying reason for the sustained ventricular tachycardia corrected. The client with a history of heart failure may have chronic bibasilar crackles and pitting edema of both feet. Therefore, assessing this client first is not necessary. The client who underwent PCI with stenting was at risk for reperfusion arrhythmias and/or bleeding from the arterial puncture site but could be considered to be stable 24 hours post-procedure.

The nurse is assessing a client recovering from a hemorrhagic cerebral vascular accident (CVA) that occurred 7 days ago. Which assessment finding should be reported to the healthcare provider?

worsening headache A worsening headache is a clinical manifestation associated with a vasospasm. The development of cerebral vasospasm is a serious complication of subarachnoid hemorrhage and is a leading cause of morbidity and mortality in those who survive the initial hemorrhage. Frequent coughing, tachycardia, and diminished pedal pulses are not as concerning as a worsening headache.

The nurse is prioritizing care for several clients. Which client should the nurse assess first?

the client with stridor who just received the first dose of an antibiotic The highest priority client is the client with stridor who started an antibiotic. Stridor is an assessment finding indicating an extremely narrowed airway. This may indicate an anaphylactic reaction to the antibiotic. The nurse must intervene to prevent anaphylactic shock. The airway is the top priority. Next, the nurse should assess the client with wheezing. Finally, the clients with improving chest pain and elevated blood pressure should be assessed.

In which parts of the body should the nurse administer an intramuscular injection to a 6-month-old infant?

the lateral middle third of the thigh between the greater trochanter and the knee The appropriate site to give an injection to an infant is the vastus lateralis. The dorsogluteal, ventrogluteal, and deltoid muscles are areas for older children and adults.

The single parent of a young teenager is being treated for complicated bronchitis at a small rural hospital. The parent does not live in the area and has a poor command of English. The facility is experiencing delays in accessing a translator. In considering whether to allow the teenager to translate medical information for his parent, the nurse should consider that:

these circumstances may allow the child to translate. The nurse must recognize that care of a non-urgent nature requires informed consent, necessitating education and understanding of the client or responsible person, who is of legal age. If the circumstances are of an urgent but not sensitive nature, the child may be allowed to provide basic translation on this occasion. The nurse should assess the emotional and intellectual capacity of the child in this instance and document this as well. The language in question and the duration of the delay in accessing a translator do not impact the decision to allow the child to translate. While desirable, this option can also be anticipated to involve delays in arriving at the rural area in a timely manner.

A primigravid client is admitted to the labor and delivery area, where the nurse evaluates her. Which assessment finding may indicate the need for cesarean birth?

umbilical cord prolapse Indications for cesarean birth include umbilical cord prolapse, breech presentation, fetal distress, dystocia, previous cesarean birth, herpes simplex infection, condyloma acuminatum, placenta previa, abruptio placentae, and unsuccessful labor induction. Insufficient perineal stretching; rapid, progressive labor; and fetal prematurity aren't indications for cesarean birth.