6. Leadership and management (305)

The nurse is caring for the following assigned clients. The nurse should follow up on which client first? A client who has A. mechanical ventilation and the low-pressure alarm sounds. B. a new colostomy and refuses to participate in care. C. acute glomerulonephritis and has periorbital edema. D. atrial fibrillation and an irregular pulse.

Choice A is correct. A client receiving mechanical ventilation requires multiple assessments. The low-pressure alarm is concerning for ventilator disconnection or low cuff pressure. The high-pressure alarm is concerning for obstruction such as secretions. This client should be assessed first under the priority model of "ABCs" = airway, breathing, circulation. Additional Info The client receiving mechanical ventilation should always be assessed over the alarm. The nurse needs to ensure these alarms are functional, but the client's assessment is the priority if the alarm sound goes off. The low pressure alarm may sound for a cuff leak or disconnection. The high pressure alarm may be triggered for obstruction (client biting on the tube, secretions in the airway). Choices B, C, and D are incorrect. A client with a new colostomy may be indifferent when caring for themselves as they adjust to the change in body image. Further, a client with acute glomerulonephritis will exhibit periorbital edema and high blood pressure. Finally, an irregular pulse is consistent with atrial fibrillation.

After administering an insulin injection to a patient on a sliding scale, the nurse realizes that a high dose was erroneously given. Which of the following would be the best response by the charge nurse to prevent future errors? A. Discuss events preceding the error with the nurse B. Complete an incident report and place it in the patient's chart C. Inform the patient, family, and physician of error D. Monitor the patient for adverse effects

Choice A is correct. Events preceding the error should be discussed with the nurse. This is the only response that focuses on preventing future errors. It would be most important to determine factors that contributed to the error, such as rushing, lack of knowledge/education, improper staffing caseload/patient acuity, or communication issues. Choice B is incorrect. Incident reports are legal, confidential documents and are not placed in the chart. They should be reported based on facility policy. Choice C is incorrect. It would be appropriate for the nurse to notify the patient, family, and physician per facility policy, but this action does not prevent future errors. Choice D is incorrect. The nurse should closely monitor for any adverse effects of the patient receiving the wrong dose, but this action does not prevent future errors.

The nurse is triaging phone calls at the mental health clinic. Which client situation requires immediate follow-up? A client prescribed A. olanzapine reporting muscle stiffness and feeling hot. B. haloperidol reporting blurred vision and constipation. C. clozapine reporting occasional twitches of the mouth. D. aripiprazole reporting feeling very restless.

Choice A is correct. Olanzapine is an atypical antipsychotic medication and, like all antipsychotics, causes the client to be at risk of developing neuroleptic malignant syndrome (NMS). This condition can be fatal if not treated promptly, as it causes the client hyperpyrexia, metabolic acidosis, dehydration, and cardiac dysrhythmias. Additional Info ✓ Second-generation antipsychotics (risperidone, olanzapine, quetiapine, clozapine, lurasidone, ziprasidone, aripiprazole, brexpiprazole) are preferred because of the decreased risk of movement disorders. ✓ The concern with SGAs is that they may adversely impact the client metabolically by raising glucose and weight (especially clozapine and olanzapine). ✓ For a client receiving any generation antipsychotic, the nurse must always monitor for neuroleptic malignant syndrome (NMS) manifested by fever, muscle rigidity, delirium, and tachycardia. ✓ Tardive dyskinesia is a delayed adverse effect causing abnormal, involuntary, irregular choreoathetoid movements of the head, limbs, and trunk muscles. It commonly occurs after six months of treatment. Choice B is incorrect. Haloperidol is a typical antipsychotic and has anticholinergic side effects such as blurred vision, memory impairments, and constipation. Choice C is incorrect. Clozapine is an atypical antipsychotic medication and, like all antipsychotic medication, raises the risk of the client developing tardive dyskinesia. Although this is a serious adverse reaction, it is not life-threatening, unlike NMS. Choice D is incorrect. Aripiprazole is an atypical antipsychotic medication and may cause the client to develop akathisia. Akathisia is not life-threatening, unlike NMS. Treatment of akathisia is by having the provider lower the prescribed dose or prescribe propranolol.

The nurse is caring for the following assigned clients. It would be a priority for the nurse to assess the client A. being evaluated for chest pain and requesting an antacid for indigestion. B. reporting nervousness following the administration of albuterol. C. requesting pain medication for their chronic knee and back pain. D. awaiting discharge teaching on their insulin pump and glucometer.

Choice A is correct. Reports of indigestion could be a symptom associated with myocardial infarction. This atypical sign is concerning because the client is already being evaluated for chest pain. Thus, the nurse needs to follow up with this client. Additional Info When prioritizing client care, the nurse should always see clients who report acute changes, appear unstable, or have imminent safety concerns. Unstable patients will have abnormal vital signs or exhibit signs such as restlessness which is a non-reassuring finding in any client as it could be hypoxia, increased intracranial pressure, etc. Choices A, B, and D are incorrect. Nervousness following the administration of albuterol is an expected finding because albuterol stimulates beta-adrenergic receptors. Pain medication for chronic pain is a priority but not the initial priority because the nurse should always prioritize acute needs over chronic needs. Discharge teaching is a low-priority task for the nurse.

The nurse is caring for assigned clients. The nurse should immediately follow-up on the client who A. is being treated for pneumonia and develops restlessness. B. is receiving intravenous fluids for influenza and dehydration and reports a headache. C. has a chest drainage system in place for a hemothorax and tidaling is present in the water seal chamber. D. is being treated for pleurisy and is experiencing inspiratory chest pressure.

Choice A is correct. Restlessness is a concerning finding as it may indicate the client is experiencing shock or hypoxia. The nurse needs to act and perform vital signs to determine the etiology of restlessness. If the restlessness is due to hypoxia, supplemental oxygen should be provided. The most significant complication with pneumonia is the client developing acute respiratory distress syndrome, which may require mechanical ventilation. Choices B, C, and D are incorrect. Headache is a common finding for both dehydration and influenza. Considering this is an expected finding, the nurse should not prioritize this client over the client experiencing restlessness. Tidaling and intermittent bubbling in the water seal chamber of the chest drainage system are expected. It is continuous bubbling in this chamber, which indicates an air leak. Pleurisy is a condition that causes inflammation of the pleural cavity, and a classic sign is coughing, which induces chest pain and chest pain with inspiration. Treatment may be prescribed antibiotics and anti-inflammatories.

The nurse is caring for assigned clients. The nurse should initially assess the client who A. is recovering from a femoral angioplasty and reports their foot is falling asleep. B. has diabetes mellitus and refused their prescribed glargine insulin. C. received alteplase three hours ago for a stroke and has a Glasgow Coma Scale of 14. D. had a T6 spinal cord injury and has not had a bowel movement since yesterday.

Choice A is correct. Following a femoral angioplasty, the affected extremity should be assessed for a pulse, and the client should be instructed to report any decreased sensation. A common complication following this procedure is arterial occlusion which causes a decreased pulse and the client to experience a reduced sensation (or paresthesias). Additional Info The neurovascular assessment is a priority following a femoral angioplasty. This includes assessing the affected extremities' distal pulse and temperature. Additionally, the client should report any signs of decreased sensation or paresthesia. Antiplatelets are commonly prescribed following this procedure to prevent occlusion. Choices B, C, and D are incorrect. Any client who refuses a medication should receive follow-up as the nurse is instrumental in explaining the purpose of the medication. However, this is not the priority because the client would adversely face hyperglycemia which is not immediately life-threatening. A GCS of 14 (with the highest score of 15) is optimal and does not require immediate follow-up. Finally, bowel and bladder function disturbances are commonly seen with a thoracic spinal cord injury. However, this is not of immediate concern, considering the last bowel movement was one day ago.

The nurse in the emergency department (ED) has a client with suspected septic shock. The priority intervention for this client is to A. establish a peripheral vascular access device. B. obtain the prescribed consult with infectious disease. C. provide frequent updates regarding the client's care. D. perform a physical assessment for the potential source of infection.

Choice A is correct. Shock is a medical emergency and indicates a significant loss in bodily perfusion. In clients with septic shock, a common feature is severe hypovolemia, necessitating rapid fluid resuscitation. Additionally, intravenous broad-spectrum antibiotic therapy should start within one hour of presentation. The nurse must act quickly to establish peripheral vascular access, which will be vital to obtaining the necessary laboratory specimens (blood cultures, lactic acid) and delivering fluid resuscitation along with broad-spectrum antibiotics. Two large bore IV access should be established within five minutes of presentation, one for fluid resuscitation and the other for antibiotic delivery. If peripheral intravenous access can not be obtained, the nurse should attempt to get intraosseous access. Additional Info Treatment goals for a client with septic shock include the following: ✓ Optimal perfusion as demonstrated by a MAP ≥ 65 mmHg. ✓ Normal respiratory rate, pulse, temperature, pulse oximetry, mentation, and urine output. ✓ Clearance of lactic acid. A falling lactic acid indicates a favorable response to fluids and oxygenation. ✓ Lactic acid is produced when tissue is not being perfused. ✓ A serum lactic acid level of 2 mmol/L or greater may indicate the severity of sepsis. Choice B is incorrect. Obtaining a consult with infectious disease is a crucial intervention so that this specialist may determine the appropriate medical management. However, staying with the client and restoring circulating volume is vital when a client is in shock. Choice C is incorrect. Frequent updates regarding the client's care would be a psychosocial need. This does not prioritize the client's physical instability. Choice D is incorrect. The source of the infection is essential, but performing a physical assessment would tak

The nurse is caring for a client receiving a prescribed diltiazem infusion. The client has the following tracing on the electrocardiogram shown in the exhibit. The nurse should perform which priority action? See the exhibit. View Exhibit A. discontinue the diltiazem infusion. B. notify the primary healthcare physician (PHCP). C. assess the client's oxygen saturation and respiratory rate (RR). D. prepare a prescription of intravenous (IV) atropine.

Choice A is correct. The tracing shows sinus bradycardia. The priority action would be discontinuing the diltiazem infusion as this medication is a calcium channel blocker that lowers heart rate and blood pressure. If the infusion continued, it would lower the heart rate to dangerous levels compromising cardiac output. Additional Info ✓ Diltiazem is a calcium channel blocker for treating hypertension and atrial fibrillation. ✓ When given continuously in an infusion, the nurse must closely monitor the client's blood pressure and heart rate. ✓ Diltiazem may cause dangerously low blood pressure and bradycardia. ✓ Other calcium channel blockers include amlodipine, nifedipine, and verapamil. ✓ Only verapamil and diltiazem lower both the blood pressure and heart rate. ✓ Calcium channel blockers are contraindicated in a client with systolic heart failure. Choices B, C, and D are incorrect. The physician should be notified, and oxygen saturation should be assessed. However, the priority action is to discontinue the offending agent first, the diltiazem. IV atropine is inappropriate as the offending agent (diltiazem) must be discontinued.

The nurse, assigned to triage in the emergency room, has four people check in at the same time. Which client should receive immediate priority care? A. A 29-year-old female two-day post-cesarean section that complains of a headache and leg swelling. B. A 15-year-old female with LLQ pain for three days. C. A 55-year-old male with dull RUQ pain & history of pancreatitis. D. A 2-year-old female child with pain upon urination.

Choice A is correct. This client is at risk for pre-eclampsia which is a severe condition that can lead to seizures, stroke, and other complications if not promptly treated. Pregnant women are at risk for preeclampsia anytime through pregnancy as well as 6-10 weeks post-partum. Post-partum pre-eclampsia usually develops in 48 hours post-partum but the risk can extend up to 6 to 10 weeks. Symptoms include headache, blurred vision, proteinuria, swelling in the hands/face, and high blood pressure. If treatment is started, this condition can be controlled. Choice B is incorrect. While LLQ pain for three days is concerning and warrants medical attention, it does not pose an immediate life-threatening situation compared to the potential complications of a post-cesarean section client. Choice C is incorrect. Dull RUQ pain with a history of pancreatitis is concerning but does not constitute an immediate emergency, especially without additional information on the severity of symptoms. Choice D is incorrect. Pain upon urination in a 2-year-old child is concerning and requires medical attention, but it is not an immediate emergency.

The nurse is performing medication administration for four clients. Which client and medication should be administered first? See the image below. A. Client one B. Client two C. Client three D. Client four

Choice A is correct. This medication is prescribed for a client with an asthma exacerbation which is an acute problem. Prednisone is often used in combination with bronchodilators to manage severe asthma exacerbations more effectively. It helps to reduce inflammation and relieve symptoms when bronchodilators alone are not providing adequate relief. While oral prednisone is commonly used for managing asthma exacerbations, in certain severe cases, especially when a client cannot take oral medications due to respiratory distress or other reasons, intravenous (IV) corticosteroids may be considered. IV corticosteroids like methylprednisolone may provide faster and more predictable absorption in such situations. Additional Info ✓ Collaborate with the healthcare team, including physicians, respiratory therapists, and pharmacists, to ensure the client's asthma exacerbation is effectively managed. ✓ Continuously monitor the client's response to treatment, including the resolution of asthma symptoms, improvement in oxygen saturation, and decreased work of breathing. ✓ If the client receives a course of prednisone, educate them about the importance of following the tapering schedule provided by the healthcare provider, especially after high-dose or long-term treatment. Choice B is incorrect. The client with a fever prescribed acetaminophen will require treatment but does not prioritize the acute respiratory ailment of an asthma exacerbation. Choice C is incorrect. Chronic medical problems that would not require immediate administration of the prescribed medications when competing with a client with an acute asthma exacerbation. Choice D is incorrect. Chronic medical problems that would not require immediate administration of the prescribed medications when competing with a client with an acute asthma exacerbation.

The nurse is caring for assigned clients. The nurse should immediately follow up on the client with A. chronic obstructive pulmonary disease (COPD) and has respiratory acidosis on the most recent arterial blood gas (ABG). B. atrial fibrillation taking prescribed warfarin and reports black, tarry stools. C. diabetes mellitus who refuses to eat following the administration of glargine insulin. D. acute pancreatitis and reports nausea with epigastric pain rated as a 3 on the Numerical Rating Scale.

Choice B is correct. For the client taking warfarin reporting black, tarry stool, this is an immediate concern for internal bleeding. The nurse needs to follow up with this client and contact the physician to order an occult blood test for the stool. This, coupled with an order for an international normalized ratio (INR) level, should be a priority. Additional Info ✓ Warfarin is an oral anticoagulant ✓ Efficacy with warfarin is measured by obtaining the client's international normalized ratio, which should be between 2-3 for VTE prophylaxis ✓ For the client prescribed warfarin, they are educated to follow up with their physician to obtain their INR level ✓ The client should be educated to avoid supplements that may potentiate the effects of warfarin, such as garlic, Ginko Biloba, ginger, and ginseng Choice A is incorrect. Respiratory acidosis is an expected assessment finding for a client with COPD. As the client's collagen and elastin get destroyed with this illness, this decreases gas exchange and causes the client to retain CO2. Choice C is incorrect. This client's situation does not require follow-up because glargine insulin has no peak. Thus, the client does not have a risk for hypoglycemia. Choice D is incorrect. Epigastric pain, nausea, and vomiting are all expected findings associated with acute pancreatitis. Prescriptive management of a client with acute pancreatitis includes opioids, anti-emetics, and aggressive fluid resuscitation. This situation does not prioritize the client possibly experiencing internal bleeding.

The nurse in a clinic is triaging clients. Which of the following clients should the nurse see first? A. A 17-year-old complaining of abdominal cramping with moderate bloody vaginal discharge B. A 25-year-old primigravida reporting blurred vision. C. A 50-year-old menopausal client expelling dark red blood clots. D. A 70-year-old client who states her uterus is going to "fall out."

Choice B is correct. Signs and symptoms of preeclampsia include blurred vision, hypertension, generalized edema, and proteinuria. The client is also a primigravida (first-time pregnant), predisposing her to preeclampsia. The nurse should prioritize the client to include further assessment and intervention. Choice A is incorrect. The 17-year-old with severe lower abdominal cramping with moderate vaginal bleeding suggests the client has her menstrual cycle. It does not, however, take priority over a client with signs of preeclampsia. Choice C is incorrect. Clients who undergo menopause experience the expulsion of dark red blood clots. This should not cause concern to the nurse. Choice D is incorrect. This may indicate a possible uterine prolapse, but this is not life-threatening. The client may need a hysterectomy or a pessary device to remove the uterus.

The nurse is caring for assigned clients. The nurse should initially follow up on the client who A. has a basilar skull fracture and has bruises under their eyes. B. had a craniotomy and has a change in the Glasgow coma scale (GCS) from 13 to 11 in the last hour. C. has amyotrophic lateral sclerosis (ALS) and is requesting to have resuscitation efforts withheld. D. has Guillain-Barré syndrome (GBS) and is reporting lower extremity muscle weakness.

Choice B is correct. The decrease in the GCS is concerning because this indicates worsening neurological functioning. If the GCS were increasing, that would be a reassuring factor. This client requires follow-up, a rapid neurological assessment, and notification to the primary healthcare provider (PHCP) regarding the condition change. Choice A is incorrect. A basilar skull fracture has clinical manifestations such as vision changes, bruising around the eyes, postauricular ecchymosis, and altered mental status. This client does not require follow-up because this is an expected finding. Choice C is incorrect. ALS has a poor prognosis and has no cure. Treatment is symptomatic, and a discussion about advanced directives should occur in the event of respiratory failure. This is not an acute or concerning finding compared to the client with a decreased GCS. Choice D is incorrect. Lower extremity weakness is an expected finding with Guillain-Barré syndrome (GBS). Ascending paralysis, painful neuropathy, and dysautonomia are other findings associated with this condition.

The nurse is caring for a client with suspected meningitis. Which priority action should the nurse take following a lumbar puncture (LP) procedure? A. Assess the gag reflex B. Elevate the head of the bed to 30 degrees C. Encourage oral fluid intake D. Assess the client for Brudzinski sign

Choice C is correct. A lumbar puncture (or spinal tap) procedure is used to obtain cerebrospinal fluid (CSF) to diagnose meningitis and identify the cause. Following this procedure, the nurse would encourage oral fluid intake to replace lost CSF volume. Choice A is incorrect. A lumbar puncture procedure would involve local anesthetic at the site of the lower spine but would not involve sedation that would affect the gag reflex. Choice B is incorrect. The patient should be positioned lying flat for several hours following the lumbar puncture procedure to reduce the risk of spinal fluid leakage and spinal headache. Choice D is incorrect. A positive Brudzinski sign indicates meningeal irritation and may be used to screen for meningitis, but would not be appropriate to perform after the lumbar puncture procedure.

The nurse is caring for a client with a percutaneous endoscopic gastrostomy tube. Prior to administering the next tube feeding, the nurse aspirates 80 mL of gastric residual. The nurse should then A. notify the physician. B. hold the tube feeding and recheck residual volume in one hour. C. administer the prescribed feeding. D. reposition the patient in low-Fowler's position.

Choice C is correct. According to the current American Society for Parenteral and Enteral Nutrition ( ASPEN) guidelines for nutrition support, enteral nutrition should not be stopped for a gastric residual volume (GRV) of less than 500 mL unless there are other signs of feeding intolerance. Signs/symptoms of feeding intolerance include nausea, vomiting, abdominal distention, constipation, and abdominal pain. If no bowel sounds are present, the nurse should assess the client's abdomen for changes from the baseline, such as tenderness or distension. If there are no changes from the baseline, the feeding bolus may be administered as ordered. Additional Info ✓ Assessing gastric residual volume has limited clinical utility, and some facilities may not require this practice ✓ If a client is not tolerating their tube feeding, the client would experience vomiting, high gastric residual, diarrhea, and gastrointestinal bleeding Choice A is incorrect. In the absence of signs of feeding intolerance, the feeding can be continued as long as the GRV is less than 500 mL. However, the providers should implement methods to reduce aspiration risk for the GRVs ranging from 200 to 500 mLs. Such measures include administering prokinetic agents such as metoclopramide and erythromycin (to stimulate gastric motility), optimizing glucose control (hyperglycemia can delay gastric emptying), and using continuous rather than bolus feeding for high-risk clients. Choice B is incorrect. The client's gastric residual is within normal limits, and the nurse does not need to alter the feeding schedule. Choice D is incorrect. Prior to administering bolus feedings, the client should be positioned with the head of the bed elevated to administer the prescribed feedings. Administering the feedings while the client is in a low-Fowler's position would increase

The nurse is triaging phone calls for the primary healthcare provider (PHCP). Which client situation requires immediate notification to the PHCP? A. A client with heart failure that reports an overnight weight gain of three pounds. B. A client with peritoneal dialysis who has not had a bowel movement in two days. C. A client with irritable bowel syndrome (IBS) that reports frequent diarrhea. D. A client with nephrolithiasis that reports bloody urine and flank pain.

Choice A is correct. The PHCP should be immediately notified about the client who gained three pounds overnight. Two pounds convert to one kilogram, and that converts to one liter of fluid. Thus, this client is retaining a significant amount of fluid and requires immediate follow-up to ensure they do not develop complications such as pulmonary edema. Additional Info It is essential for a client with heart failure to weigh themselves daily. This weight should be completed first thing in the morning and after the morning void. The weight should be obtained with the same amount of clothing each day. The client should report a weight gain of 1-2 pounds overnight or 3-5 pounds in a week. Choices B, C, and D are incorrect. A client with peritoneal dialysis should be evaluated for their complaints of constipation because it is a major cause of poor outflow. A client with IBS reporting frequent diarrhea is an expected finding, as this condition is manifested by constipation, diarrhea, and abdominal spasms. Nephrolithiasis characteristically presents with hematuria and flank pain. Each client calls about symptoms expected with the corresponding disease process; thus, they do not need to be reported immediately to the PHCP.

The nurse administers intravenous levofloxacin instead of the prescribed azithromycin. Which of the following actions should the nurse take first? A. Stop the infusion B. Complete an incident report C. Obtain vital signs D. Notify the primary healthcare provider (PHCP)

Choice A is correct. The nurse should immediately stop the infusion. The nurse discovered a medication error, and halting the infusion is essential. Additional Info ✓ Levofloxacin is a fluoroquinolone antibiotic indicated in the treatment of certain infections, such as enteric infections, pneumonia, or urosepsis ✓ Other fluoroquinolone antibiotics include ciprofloxacin and moxifloxacin ✓ Tendinopathies and neuropathies can be permanent and/or disabling. Clients who have a history of tendon problems should not use these medications Choice B is incorrect. The nurse should complete an incident report. However, this is not a priority compared to stopping the infusion. The incident report will be done once the infusion has stopped, the physician is notified, and, if necessary, appropriate interventions are implemented. Choice C is incorrect. Obtaining vital signs is necessary but should not be prioritized over stopping the infusion. Obtaining vital signs is essential to determine if any adverse reactions have occurred, but terminating the infusion is essential. Choice D is incorrect. Before notifying the physician, the nurse should execute an immediate action, such as terminating the current infusion. Prior to notifying the physician, the nurse should collect vital signs to determine if any reaction has occurred.

The nurse has become aware of the following client situations. The nurse should first follow up with the client who A. has an irregular pulse that is receiving treatment for atrial fibrillation. B. has pneumonia who had an increase in temperature to 102°F (39°C). C. is receiving nebulizer treatments for asthma that suddenly stops wheezing. D. has active pulmonary tuberculosis (TB) and refuses prescribed medications.

Choice C is correct. Wheezing, tachypnea, and dyspnea are all expected findings during an acute asthma exacerbation. The sudden cessation of wheezing highly concerns the nurse, indicating that the client is no longer oxygenating because they are not moving air. This warrants immediate follow-up as it is a sudden change. A gradual improvement in symptoms is expected, but a sudden cessation of wheezing suggests respiratory failure, which requires immediate attention. Additional Info ✓ Clinical features of an asthma exacerbation include the following: Tachypnea Dyspnea Persistent cough Use of accessory muscles for breathing Tachycardia Wheezing in the lung fields ✓ The priority treatment is administering oxygen followed by prescribed albuterol via nebulizer. ✓ A client may be prescribed adjunctive agents such as systemic glucocorticoids or magnesium sulfate. ✓ The nurse should avoid the administration of beta-adrenergic blockers as this may worsen or induce an exacerbation. Choice A is incorrect. An irregular pulse is an expected finding associated with atrial fibrillation as this is an irregular arrhythmia. This client does not require immediate follow-up. Choice B is incorrect. Pyrexia, a productive cough, and chest discomfort are standard features of pneumonia and do not require immediate follow-up. Choice D is incorrect. A client refusing medications is concerning but does not override a physical threat to a client's breathing. Clients have the right to refuse medications, and the nurse should plan to educate the client on the medication's purpose. However, this education does not require a client with possible respiratory arrest.

The nurse is caring for a group of clients. It is a priority to follow up on which client situation? A client A. admitted with an asthma exacerbation that is wheezing while receiving albuterol via nebulizer. B. admitted with pulmonary emphysema who puts on their nasal cannula oxygen before eating. C. with pneumonia is ambulating around the nursing unit while wearing a surgical mask. D. receiving oxygen via nonrebreather and has an oxygen saturation of 92%.

Choice D is correct. A client receiving oxygen via a non-rebreather is receiving approximately 80%-95% Fio2. This is concerning if the best oxygen saturation is 92% and may warrant more aggressive measures to improve oxygen saturation. The client receiving this type of supplemental oxygen device should have a much higher oxygen saturation. Additional Info ✓ Nonrebreather is an oxygen delivery device that may deliver the highest oxygen level in the low-flow systems. ✓ This device features a reservoir bag, allowing the client to draw oxygen. Additionally, flaps prevent room air from entering the exhalation ports. ✓ If a client is not responding favorably to this therapy, the primary healthcare provider (PHCP) may consider intubation and mechanical ventilation. ✓ When nonrebreather therapy is initiated, the oxygen delivery device should be set at 10 to 15 L/min to keep the bag inflated. Choices A, B, and C are incorrect. A client admitted with an asthma exacerbation would have manifestations such as tachypnea and wheezing. This is not a priority because the prescribed treatment is being administered. A concern would be if the wheezing does not improve or if the sudden cessation of wheezing should occur. A client with pulmonary emphysema should eat while using a nasal cannula as this increases the oxygen demand. A client with pneumonia should be encouraged to ambulate around the nursing unit. The appropriate PPE is applied to this client, which is a surgical mask.

The nurse is caring for assigned clients. The nurse should initially follow up on the client who A. is being treated for uterine fibroids and reports painful menstrual bleeding. B. has type II diabetes mellitus (type two) and has a capillary blood glucose of 124 mg/dL (6.882 mmol/L) [70-110 mg/dL, 4.0-11.0 mmol/L] C. has emphysema and refused prescribed medications. D. is six hours postoperative following an abdominal aortic aneurysm repair and has no urine output.

Choice D is correct. Following an abdominal aortic aneurysm repair, the client has an array of complications, including bleeding from the graft site. This bleeding may divert blood flow from the kidneys, causing significant renal injury. This renal injury may cause acute kidney injury that may rapidly progress to end-stage renal disease. No urine output at this time needs to be reported to the surgeon. Additional Info ✓ Following an abdominal aortic aneurysm repair, the client is at risk for several complications, including acute kidney injury, decreased distal blood flow, and infection. ✓ An abdominal aortic aneurysm may be asymptomatic and be detected incidentally on computed tomography scans. ✓ An AAA 5.5 cm or greater usually requires surgical repair. Choice A is incorrect. This is an expected finding and does not require immediate follow-up, as uterine fibroids may cause a woman to experience pelvic pressure and pain, heavy menstrual bleeding, and fertility issues. Choice B is incorrect. The client with diabetes has an elevated blood glucose, but 124 mg/dL (6.882 mmol/L) [70-110 mg/dL, 4.0-11.0 mmol/L] glucose is not clinical hyperglycemia. Hyperglycemia is defined as glucose of 250 mg/dL or greater. This is not a priority for the nurse. Choice C is incorrect. Refusing prescribed medications is within a client's right. The nurse should investigate and determine if the client is informed about the purpose of the medication and complications of refusal. However, this is not a priority compared to the client six hours postoperative experiencing a complication.

The nurse is caring for the following assigned clients. It would be a priority to follow up with a client who A. is being treated with acute glomerulonephritis (AGN) and has periorbital edema. B. discarded their first urine sample upon starting a 24-urine collection. C. is receiving continuous bladder irrigation and reports the need to void. D. just returned from a hemodialysis session and reports dizziness.

Choice D is correct. Hypotension is a complication associated with hemodialysis. Dizziness may explain this finding, and the nurse should immediately intervene because the client risks falling. The hypotension may be caused by too much fluid removed during the dialysis. This is a safety issue, and the nurse should prioritize this client's needs. Additional Info Hypotension is a common occurrence after hemodialysis and needs to be recognized because the client is at risk for falls and injuries. The most common reason an individual develops hypotension after dialysis is that too much fluid was removed. The nurse should ensure client safety by establishing fall precautions and notifying the provider. Choices A, B, and C are incorrect. AGN has a clinical feature of periorbital edema often present in the morning. This is an expected finding and does not require follow-up. During a 24-hour urine collection, it is appropriate for the first urine to be discarded, which marks the start of the 24-hour collection. During continuous bladder irrigation, a large catheter is utilized and the client reporting that they need to urinate despite having an indwelling catheter is a normal finding not requiring follow-up.

The nurse is caring for assigned clients. The nurse should initially follow-up on the client who A. has chronic back, neck, and shoulder pain and is crying. B. is being treated for pneumonia and reports a persistent cough with thick, yellow mucus. C. had a colostomy placed three hours ago and has an edematous stoma with scant bloody drainage. D. is being treated for diabetes insipidus, and the family member reports the client has developed confusion.

Choice D is correct. Individuals with diabetes insipidus (DI) run the risk of fluid volume deficit progressing to severe dehydration. This severe dehydration results from water loss, causing the client to develop dangerously high sodium levels. High sodium levels may result in altered mental status and neuromuscular weakness. Additional Info ✓ DI is a condition that may be central or nephrogenic ✓ The client is at risk for fluid volume deficit because the client may experience polyuria ✓ This may manifest as tachycardia, hypotension, and a thready pulse ✓ Common laboratory findings for an individual with DI include hypernatremia, decreased urine specific gravity (it is dilute), and increased hematocrit (hemoconcentration) ✓ If the client diuresis too much, they run the risk of severe hypernatremia. ✓ Treatment for central diabetes insipidus is by administering desmopressin (intranasal or tablet) ✓ Sodium levels should be monitored closely for a client receiving desmopressin because the increase in antidiuretic hormone may cause dilutional hyponatremia ✓ Nephrogenic diabetes insipidus is treated by withdrawing the offending agent (such as lithium) and administration of thiazide diuretics or NSAIDs Choice A is incorrect. This client is clearly expressing pain and should be seen once the nurse handles the acute concern of the client with diabetes insipidus experiencing an acute complication. Choice B is incorrect. Pneumonia causes a persistent cough, often productive with thick and tenacious sputum. This client is not the priority because coughing indicates a patent airway, and the manifestations are expected. Choice C is incorrect. It is common for individuals postoperative following the placement of a colostomy to experience an edematous stoma with some bloody drainage. The edema tends to subside 4-6 weeks after surge

The nurse is caring for a 13-year-old in the pediatric unit with a left-side below-the-knee cast. The client reports pain and numbness in the foot. The nurse notes that the toes of the left foot are cold. Which of the following actions should the nurse take first? A. Remove the cast. B. Have the child ambulate. C. Notify the physician. D. Elevate the leg on two pillows.

Choice C is correct. The client is already showing the signs of compartment syndrome. The client has pain, numbness, and cold feet (low perfusion). The "5 Ps" associated with compartment syndrome. Pain Pulselessness Pallor Paresthesias Paralysis Compartment syndrome is an emergency. The nurse should be able to recognize signs and symptoms of compartment syndrome and notify the physician STAT. Compartment syndrome often results after trauma and is more common in the anterior compartment of the leg. Following a trauma, there may be decreased intra-compartmental space or increased intra-compartmental fluid volume (due to fracture, hematoma, etc.). Because the surrounding fascia is noncompliant, the compartment pressure increases. In normal circumstances, there is a balance between venous outflow and arterial inflow. However, increasing compartmental pressure results in a reduction of venous outflow. Consequently, venous pressure increases, further fueling an increase in compartmental pressure. Once compartmental pressure increases more than arterial pressure, arterial blood flow gets affected, and ischemia ensues. If ischemia lasts longer, irreversible necrosis/death of the tissue occurs. Additional Info ✓ Continue to assess the child's condition, paying close attention to any changes in symptoms, including pain, numbness, tingling, and the temperature and color of the toes. Document these findings accurately. ✓ If present, keep the child's family informed about the situation, the need for physician evaluation, and any potential interventions or treatments. Address any concerns or questions they may have. ✓ Remember that prompt assessment and communication are crucial in situations like this to prevent potential complications and ensure the child's safety and well-being. Choice A is incorrect. The child is displaying si

The nurse cares for a client immediately following a percutaneous coronary intervention (PCI). Upon sheath removal, the client develops bradycardia and hypotension. Which intervention would be the nurse's priority? A. Assess bilateral pedal pulses B. Apply sandbag to the puncture site C. Administer prescribed bolus of intravenous (IV) fluids D. Elevate the head of the bed

Choice C is correct. The client presents with signs of vasovagal response. A vasovagal response may occur due to pain and baroreceptor stimulation from manual pressure during femoral sheath removal. Decreased heart rate (bradycardia) and reduced blood pressure (hypotension) are typical of a vasovagal (para-sympathetic) response. The nurse's priority would be to address the hypotension by administering a bolus of intravenous isotonic fluids and lowering the head end of the bed (elevating lower extremities > 30 degrees). If bradycardia persists, atropine is used. With timely and accurate treatment, vasovagal reactions typically resolve without clinical complications. Additional Info Percutaneous coronary intervention is performed in the cardiac catheterization laboratory and combines clot retrieval, coronary angioplasty, and stent placement. Under fluoroscopic guidance, the cardiologist performs initial coronary angiography, inserting an arterial sheath and advancing a catheter retrograde through the aorta. Here the physician may determine which arteries are narrowed and require intervention. Intervention may come in the form of angioplasty with or without stenting. Choice A is incorrect. The nurse should check pedal pulses before and after femoral sheath removal. If the previously felt pedal pulse is absent after sheath removal, one must exclude femoral artery dissection or arterial thromboembolism. The nurse should regularly monitor the pedal pulses. However, this intervention would not address the client's symptoms of vasovagal response. Choice B is incorrect. Following a femoral sheath removal, hypotension can occur. Hypotension may be caused by the vasovagal response, medications, hypovolemia due to fasting, and/ or bleeding at the puncture site. Hemorrhage is expected; therefore, manual pressure or a FemoStop com

The nurse is caring for assigned clients. Which client should the nurse see first? A client A. with a right femur fracture who reports pain rated as 4 on a scale of 0 (no pain) to 10 (severe pain). B. with chronic obstructive pulmonary disease (COPD) who is reporting shortness of breath while ambulating in the hallway. C. with a history of T6 spinal injury 6 months ago, now reports a severe headache and is diaphoretic. D. one day postoperative from an open cholecystectomy with green drainage from the t-tube.

Choice C is correct. This client may develop autonomic dysreflexia (AD), a medical emergency. One of the first signs/symptoms of autonomic dysreflexia is a severe, throbbing headache following spinal cord injury (SCI) - commonly seen with SCI at T6 or above. Clients usually develop autonomic dysreflexia one month to one year after the SCI. However, it has also been described in the first days or weeks after the original trauma. An episode can be objectively recognized by an increase in systolic blood pressure of 20 to 40 mm Hg above the baseline. Clients with AD develop dangerously high blood pressure that can result in severe, fatal complications such as stroke, seizures, pulmonary edema, retinal hemorrhage, myocardial infarction, and cardiac arrest. Assessing this client would be the nurse's highest priority. Additional Info ✓ In susceptible patients, the most common stimuli that trigger autonomic dysreflexia are bladder or bowel distention, urinary tract infections, pressure ulcers, or other noxious stimuli below the level of the spinal cord injury. ✓ Treatment for autonomic dysreflexia involves identifying and removing the noxious stimulus, which may require urgent medical attention. ✓ Medications to lower blood pressure may also be given if necessary. ✓ Individuals with SCI at risk for autonomic dysreflexia should be educated about the condition and its symptoms and instructed on how to prevent and manage it. Choice A is incorrect. Right leg pain is expected in a client with an acute right femur fracture. The nurse must address this pain; however, the client with AD should be attended urgently. Choice B is incorrect. The client with COPD would be expected to have shortness of breath while ambulating (exertional dyspnea). This is an expected finding and would not require immediate follow-up. Choice D is incorrect

The nurse has been made aware of the following client situations. The nurse should first assess the client who has A. bacterial meningitis and is receiving a third dose of intravenous doxycycline and reports a rash on their torso. B. a cerebral aneurysm and is nervous about their scheduled surgery in one hour. C. amyotrophic lateral sclerosis (ALS) and coughs when attempting to eat and drink. D. a migraine headache and has developed flushing after receiving prescribed intranasal sumatriptan.

Choice C is correct. This client requires follow-up because they are demonstrating manifestations consistent with aspiration. ALS is a neurodegenerative condition that causes muscle weakness. Eventually the client will need to have respiratory support via tracheostomy. Additional Info ✓ ALS is a progressive neurodegenerative condition that has a poor prognosis. ✓ There is no established treatment or cure for the disease. ✓ Manifestations associated with ALS include fatigue, muscle atrophy (including tongue), muscle weakness, twitching of the face. and tongue, dysarthria, dysphagia, abnormal reflexes, and ataxia. Choice A is incorrect. Rashes are common with antibiotics, and there is no indication that the client is experiencing anything other than a common side effect. Anaphylaxis is unlikely, considering this is not the initial dose. This client does not require immediate follow-up. Choice B is incorrect. Nervousness before surgery is common, especially before a high-risk surgery such as cerebral aneurysm repair. This psychosocial need is not a priority compared to the client with ALS experiencing aspiration. Choice D is incorrect. Flushing and tingling sensations are commonly experienced by a client who has received sumatriptan. This is an abortive treatment for migraine headaches and may adversely cause angina and hypertensive crisis. However, the cutaneous manifestations are expected. This is not the nurse's priority compared to the client with ALS who is currently aspirating.

The nurse is triaging clients in the emergency department (ED). Which client should the nurse triage as emergent? A client A. reporting pleuritic chest pain with a productive cough. B. who is pregnant and reporting intermittent nausea and vomiting. C. who has an isolated area of reddened vesicles and malaise. D. with sudden onset of ataxia and dysarthria.

Choice D is correct. Sudden onset of dysarthria and ataxia concerns for stroke. These manifestations require emergent prioritization because treatment is necessary to prevent further tissue damage. Additional Info The emergent triage category implies that a condition exists that poses an immediate threat to life or limb. Conditions that should be triaged as emergent include: active hemorrhage, unstable vital signs, significant trauma, chest pain, and manifestations of a stroke. The urgent triage category indicates that the client should be treated quickly but that an immediate threat to life does not exist at the moment. Conditions that typically fall into the urgent category are those with a new onset of pneumonia (as long as respiratory failure does not appear imminent), renal colic, abdominal pain, complex lacerations not associated with major hemorrhage, displaced fractures or dislocations, and temperature higher than 101°F (38.3°C). Those triaged as non-urgent can generally tolerate waiting several hours for health care services without a significant risk for clinical deterioration. Conditions within this classification include clients with sprains and strains, simple fractures, general skin rashes, and uncomplicated urinary tract infections. Choices A, B, and C are incorrect. Pleuritic chest pain would not be categorized as urgent because coughing indicates airway patency. Intermittent nausea and vomiting, without abdominal pain and cramping, would be triaged as nonurgent as this could be a normal part of pregnancy. An area of vesicles and the client reporting malaise would also be categorized as nonurgent.

The nurse is caring for a group of assigned clients. The nurse should immediately follow up on the client who A. has a closed-chest drainage system and has redness at the insertion site. B. is receiving treatment for ulcerative colitis and has had three bloody stools in the past hour. C. is being treated for a concussion and reports a headache rated as 4 on a scale of 0 (no pain) to 10 (severe pain). D. is being treated for an ischemic stroke and has a blood pressure of 100/58 mm Hg.

Choice D is correct. The client with an ischemic stroke will require intense blood pressure monitoring because a low blood pressure will decrease cerebral perfusion, which is necessary for the unaffected areas of the brain. An optimal blood pressure for an ischemic stroke is 150/100 mm Hg to ensure cerebral perfusion. Allowing the blood pressure to be this high is considered permissive hypertension. Blood pressure lower than 150/100 mm Hg may cause further injury because of decreased cerebral perfusion. Likewise, the blood pressure should not exceed 185/110 mm Hg in an ischemic stroke because this may cause an extension of the stroke. Additional Info ✓ Manifestations of a stroke include facial drooping, slurred (or absent) speech, visual disturbances, headache, and difficulty with walking (ataxia) ✓ Risk factors for a stroke include diabetes mellitus, smoking, atrial fibrillation, sickle cell anemia, hypertension, and illicit drug use (cocaine) Choices A, B, and C are incorrect. Redness at the insertion site of a chest drainage system may signify infection, but this client does not require immediate follow-up because they are not in immediate harm. Multiple bloody stools are an expectation for an exacerbation of ulcerative colitis; this client does not require immediate follow-up. The client with a concussion can expect headaches. A headache that would be concerning is if the client describes the headache as accompanied by visual loss, vomiting, and alterations in their level of consciousness.

The nurse is caring for a client with diabetic ketoacidosis and is prescribed a bolus of regular insulin followed by a continuous infusion of regular insulin. Prior to starting the continuous infusion, the nurse administers 1 unit/kg of regular insulin to the client instead of the 0.1 unit/kg bolus. The nurse should take which initial action? A. Notify the primary healthcare provider (PHCP) B. Complete an incident report C. Assess the client for hypoglycemia D. Withhold the client's regular insulin infusion

Choice C is correct. All of these actions are correct, but the nurse needs to assess the client for hypoglycemia. The nurse administered the wrong dose; the ordered dose was 0.1 unit/kg, and the nurse administered 1 unit/kg. Assessing the client first is the priority. This included assessing the client for hypoglycemia (slurred speech, perspiration, tachycardia) and obtaining a capillary blood glucose. Most facilities require a second nurse to verify insulin initiation and titration to prevent this error because it is categorized as a high-risk medication. Considering that regular insulin peaks 15-30 minutes when given intravenously, it is prudent for the nurse to evaluate the client and intervene as necessary. Additional Info Regular insulin is a high-risk medication, requiring a second nurse verification because of the high risk of injury associated with this medication. When given intravenously, regular insulin peaks within fifteen to thirty minutes. When given subcutaneously, regular insulin peaks within two to four hours. Choice A is incorrect. This should not be the nurse's initial action, as the client's well-being is the priority. Once the nurse has assessed the client, the nurse should contact the PHCP for orders. Choice B is incorrect. This should not be the nurse's initial action, as the client's well-being is the priority. Completing an incident/occurrence report is necessary to determine the root cause of the error. However, documentation is not prioritized over direct client care. Choice D is incorrect. This should not be the nurse's initial action. The PHCP should be contacted once the client's glucose is obtained and the client is assessed to receive orders on treatment, which may range from parenteral glucagon to terminating the infusion.

The nurse is triaging phone calls at a clinic for a group of clients. Which client situation requires immediate notification to the primary healthcare provider (PHCP)? A client who A. reports a strong metallic-like taste while taking newly prescribed metronidazole. B. reports a localized rash after starting prescribed sulfamethoxazole-trimethoprim. C. takes prescribed lithium and reports blurred vision. D. feels restless and reports difficulty sleeping while taking prescribed prednisone.

Choice C is correct. Blurred vision usually occurs with advanced lithium toxicity (levels between 2.0 to 2.5 mEq/L (mmol/L)). This client's situation requires immediate follow-up because death may occur if this level of toxicity is not promptly treated. The maintenance level of lithium is 0.6-1.2 mEq/L (mmol/L). Choice B is incorrect. Rash with sulfamethoxazole-trimethoprim (TMP-SMZ) is expected. This antibiotic is often prescribed for infections caused by Methicillin-resistant Staphylococcus aureus. The client should be advised to wear sunscreen when outdoors to prevent photosensitivity. A more serious rash, Stevens Johnson's syndrome, has been associated with this medication, but this complication does not feature a localized rash; it is more generalized and painful. This client situation does not require immediate follow-up because it is expected. Choice A is incorrect. It is common for an individual taking metronidazole, an antibiotic, to experience a metallic-like taste. This sensation can be mitigated by having the client rinse their mouth frequently with oral rinses and using sugar-free candy. This is an expected finding and does not require immediate follow-up. Choice D is incorrect. Prednisone has activating effects. This corticosteroid is used to treat an array of conditions, including dermatitis, exacerbations of autoimmune disorders, and adrenal insufficiency. Insomnia, agitation, and weight gain are expected, and the nurse should recommend that the client take this medication as early as possible in the day. This situation does not require immediate follow-up.

The nurse is caring for a client who is six hours post-operative from a laparoscopic appendectomy. Which of the following findings requires immediate follow-up? A. Incisional pain rated 6 on a scale of 0 (no pain) to 10 (severe pain) B. Oral temperature of 99.5°F (37.5°C) C. Heart rate of 112 beats-per-minute (BPM) D. Hypoactive bowel sounds in all four quadrants

Choice C is correct. Immediately following abdominal surgery, shock (distributive, hypovolemia) is a concern to the nurse. A heart rate of 112 would indicate tachycardia, one of the earliest manifestations of shock, and the nurse needs to assess the client further. Additional Info ✓ One of the earliest manifestations of shock is tachycardia. ✓ Tachycardia does not always indicate shock. However, it is reasonable for the nurse to be concerned because this vital sign is concerning. ✓ Other manifestations of hypovolemic shock include hypotension, restlessness, thready pulse, and pallor. Choice B is incorrect. A low-grade temperature is an expected finding following surgery because of the inflammation. Choice A is incorrect. Incisional pain is expected after this surgery. A pain rated '6' is moderate pain that can be treated with prescribed pain medication and repositioning. Choice D is incorrect. Hypoactive bowel sounds are expected after surgery. General anesthesia causes peristalsis to slow, and normal GI functioning returns within 72 hours following surgery.

The nurse is planning client assignments for a licensed practical/vocational nurse (LPN/VN). Which client assignment would be appropriate? A client A. in an arm cast who is suspected to have compartment syndrome. B. immediately post-operative from a prostate resection reporting bladder spasms. C. with a paralytic ileus requiring the insertion of a nasogastric tube. D. newly diagnosed with Hepatitis A and requires discharge teaching.

Choice C is correct. LPNs may insert and manage a nasogastric tube. This is within the scope of practice and can be safely delegated to this nurse. Choices A, B, and D are incorrect. Compartment syndrome is a medical emergency requiring RN care because the client is unstable and is at risk for neurovascular compromise. A client immediately post-operative should not be delegated to an LPN until stability has been established. Following a prostate resection, the client is at risk for hemorrhage and must be assessed for this potential complication. Therefore, such a potentially unstable scenario is not an appropriate assignment for the LPN. The client requiring discharge teaching will need the RN, as the "initial" teaching is not within the LPN's scope of practice.

A nurse caring for an oncology client notes the client is receiving a vesicant chemotherapy medication via intravenous (IV) infusion. Which assessment finding would warrant immediate action by the nurse? A. An inflamed and sore mouth B. Nausea and vomiting C. Pain and increasing edema at the infusion site D. Abdominal pain

Choice C is correct. Pain and edema at an infusion site indicate extravasation (i.e., the leakage of a vesicant intravenous solution or medication into the subcutaneous tissue). Here, it is essential to note that the infusing medication is a vesicant. Vesicants are medications that cause severe damage to surrounding tissue if they escape into subcutaneous tissue. Specifically, extravasation results in severe tissue integrity impairment as manifested by blistering, tissue sloughing, or necrosis from vesicant infiltration into the surrounding tissues. If extravasation occurs, the initial action should be to stop the infusion and disconnect the administration set. The nurse should aspirate as much medication as possible from the vascular access device. Additional Info ✓ Medications with vasoconstrictive actions (e.g., dopamine or chemotherapeutic agents) are vesicants that can cause extravasation. ✓ Infiltration and extravasation are risks of intravenous administration therapy involving unintended leakage of solution into the surrounding tissue, with consequences ranging from local irritation to amputation. Extravasation, by far, is more concerning because of the result of tissue damage. ✓ If extravasation should occur, the nurse should stop the infusion and aspirate any remaining medication from the vascular access device. The nurse should not flush any more medicine through the vascular access device. ✓ Midline catheters should not be used for infusion of vesicant medications. Choice A is incorrect. An inflamed and sore mouth is a common side effect of chemotherapy, typically resulting from oral lesions and ulcers. These symptoms are not indicative of extravasation. Choice B is incorrect. Nausea and vomiting are two of the most common side effects of chemotherapy agents. These symptoms are not indicative of extravasat

The nurse is reviewing the plan of care for a client admitted to the behavioral health unit with anorexia nervosa. The nurse understands that the priority goal for this client is A. attending scheduled group therapy. B. adhere to the medication regimen. C. gain one pound (half a kilogram) a week. D. demonstrate increased self-esteem.

Choice C is correct. Physical needs always prioritize over other needs. For the client with anorexia nervosa, the priority is to stabilize and increase the client's weight. Anorexia nervosa may lead to life-threatening electrolyte disturbances if it goes untreated. Choices A, B, and D are incorrect. Group therapy helps treat anorexia nervosa, but having the client attend is not essential compared to weight gain. Medication plays little role in treating anorexia because no approved medication is available directly for anorexia. However, medications may be used off-label such as mirtazapine, to treat depressive symptoms and to promote weight gain. A decrease in self-esteem is common with anorexia nervosa. Still, it does not prioritize the client's physical needs, which is dangerously low weight as the diagnostic criteria for anorexia nervosa are body mass index of less than 18.5 kg/m2.

The nurse is caring for assigned clients. The nurse should prioritize seeing the client who A. has a chest tube attached to a closed-chest drainage system to treat a pneumothorax and reports increased dyspnea and dizziness. B. is being treated for acute pancreatitis and reports nausea and pain rated 6 on a scale of 0 (no pain) to 10 (severe pain). C. is being treated for pheochromocytoma reports a headache, and most recent blood pressure is 149/84 mm Hg. D. has pneumonia with atelectasis and has had decreased breath sounds in the affected lobe.

Choice A is correct. A client being treated for pneumothorax with a chest tube connected to a drainage system reporting dizziness and increased dyspnea suggests a tension pneumothorax. This complication of a pneumothorax requires immediate follow-up by the nurse. Manifestations of a tension pneumothorax include tracheal deviation to the unaffected side, increased dyspnea, and dizziness. The dizziness comes from the reduced cardiac output caused by the increased intrathoracic pressure. Additional Info ✓ A tension pneumothorax arises when air in the pleural space builds up enough pressure to interfere with venous return. ✓ Hemodynamic compromise (e.g., tachycardia, hypotension) is an ominous sign and suggests a tension pneumothorax and/or impending cardiopulmonary collapse. ✓ Tracheal deviation away from the affected side is a late sign of tension pneumothorax. Choice B is incorrect. Acute pancreatitis causes a client significant pain. Nausea and vomiting are also expected findings. This is an expected finding and does not require immediate follow-up. Treatment of pain associated with acute pancreatitis includes intravenous opioids. Choice C is incorrect. Pheochromocytoma is a condition caused by a tumor on the adrenal medulla, causing the discharge of excessive catecholamines. These catecholamines caused the individual with pheochromocytoma to experience hypertension, headache, hyperhidrosis (excessive sweating), and hyperglycemia. Choice D is incorrect. For an individual with pneumonia and atelectasis it is expected for the individual to have decreased breath sounds in the affected lobe. Atelectasis is when the alveoli have collapsed, resulting in diminished gas exchange, which explains why the client has reduced breath sounds.

The nurse is caring for the following assigned clients. The nurse should initially follow-up on the client who A. is taking lithium that reports nausea and vomiting. B. is refusing their prescribed quetiapine. C. is reporting a headache following the first dose of citalopram. D. gets drowsy following a dose of alprazolam.

Choice A is correct. A client taking lithium needs to be monitored closely for nausea and vomiting. These are early manifestations of lithium toxicity. Lithium toxicity must be recognized promptly as it may lead to more severe symptoms. Additional Info ✓ Lithium levels should be maintained between 0.6 - 1.2 mEq/L (mmol/L.). ✓ Lithium requires the client to maintain adequate fluid and salt. Failing to do so for the client may result in lithium toxicity. ✓ Lab findings expected with lithium include leukocytosis and hypothyroidism (long-term use). ✓ The client should avoid medications such as diuretics, NSAIDs, and ACE inhibitors, as these medications may cause lithium toxicity. ✓ Lithium levels should be drawn twelve hours following the client's last dose. If not, this may falsely elevate the lithium level. ✓ Lithium toxicity signs and symptoms include nausea, vomiting, lethargy, confusion, delirium, coma, seizures, and hypotension. Choice B is incorrect. A client refusing a medication should always be followed up on because the client needs to be counseled on the purpose of the medication and its effects. If the client continues to refuse medication the nurse should inquire as to why and notify the provider. Choice C is incorrect. A headache following the administration of citalopram is a common side effect and warrants no immediate follow-up. Choice D is incorrect. Drowsiness following the administration of a benzodiazepine is an expected finding. Drowsiness is the most common side-effect associated with a benzodiazepine.

The emergency department (ED) nurse cares for a client with diabetes mellitus (type one) with diabetic ketoacidosis (DKA). Which assessment finding requires immediate follow-up? A. Pulse 112/minute B. Nausea and vomiting C. Respiratory rate 21/minute D. Blood glucose 299 mg/dL (16.5 mmol/L) [70-110 mg/dL (4-6 mmol/L)]

Choice A is correct. A complication associated with DKA is hypovolemic shock. The client having tachycardia is demonstrating early signs of this type of shock. The treatment modalities of DKA include fluid repletion and insulin administration. Considering the client's tachycardia, the nurse should initially administer the prescribed isotonic fluids to treat the significant fluid volume deficit. Choice B is incorrect. Persistent nausea and vomiting is a manifestation of gastroparesis, which may be found with DKA. The nurse must address this finding by administering prescribed antiemetics (metoclopramide) and isotonic fluids. However, this is not the most immediate concern because the client is demonstrating early manifestations of shock. Choice C is incorrect. Tachypnea is an expected finding of DKA. The tachypnea is an attempt for the client to remedy the acid-based imbalance by having the client blow off the excess CO2. Having the client blow off the excess CO2 can treat the acidosis. The nurse is not concerned about an expected finding. Choice D is incorrect. The client diagnosed DKA with hyperglycemia and ketones, which a urine or blood specimen may detect. Clinical hyperglycemia is a blood glucose is greater than 250 mg/dL (13.8 mmol/L). This is not a priority because the client has DKA, manifested by hyperglycemia, which is an expected finding.

The nurse is caring for assigned clients. The nurse should initially follow up on the client who is A. three days postoperative following transsphenoidal hypophysectomy and has a temperature of 101°F (38.3°C). B. connected to a chest tube for a pneumothorax and has absent breath sounds on the affected side. C. receiving albuterol via a nebulizer and telling the unlicensed assistive personnel they feel nervous. D. receiving peritoneal dialysis and reports cramping as the solution is being instilled.

Choice A is correct. A complication of transsphenoidal hypophysectomy is meningitis. The client needs to be immediately assessed for other manifestations of meningitis, including photophobia, nuchal rigidity, and altered mentation. Complications following this surgery include CSF leakage, infection, optic nerve damage, and diabetes insipidus. Additional Info ✓ Hypophysectomy is a surgery to remove a pituitary tumor or remove the pituitary gland ✓ The approach is most likely transnasal via endoscopy ✓ Complications of this surgical procedure include CSF leak, infection, diabetes insipidus, and hypopituitarism ✓ Postoperatively, the head of the bed should be elevated semi- to high-Fowler's ✓ The client should be instructed not to cough, sneeze, or blow their nose ✓ The client should not bend at their waist to prevent the rising of intracranial pressure ✓ The client should use mouthwash or dental floss for several days to allow the surgical incision to heal ✓ Fever and photophobia should be reported because this is a concerning finding for postoperative meningitis ✓ Drainage should be monitored for CSF which would be a light yellow color at the edge of the clear drainage on the dressing is called the halo sign and indicates CSF Choices B, C, and D are incorrect. These findings do not require follow-up because all of these situations are expected. Pneumothorax produces diminished to absent breath sounds on the affected side because of lung collapse. Thus, the treatment of the chest tube is to increase negative pressure in the pleural space to promote expansion. Albuterol causes a discharge of the body's epinephrine, thus causing the client to feel nervous or jittery. This, along with an elevation in the heart rate, is an expectation and will resolve a few hours after the treatment. Peritoneal dialysis is when the client

The nurse is caring for a group of children on the medical-surgical unit. The nurse should initially follow up on the child who A. is receiving treatment for Hirschsprung's disease and has a temperature of 101°F (38.3°C). B. has an indwelling urinary catheter and reports burning at the insertion site. C. has scant blood in their newly established ostomy pouch. D. has friends writing words on their fiberglass cast with different colored markers.

Choice A is correct. A major complication of Hirschsprung's disease is the development of enterocolitis manifested by fever, abdominal distention, vomiting, and increased abdominal pain. Emergent intervention is necessary because the child may develop sepsis leading to septic shock. Additional Info ✓ Hirschsprung disease (congenital aganglionic megacolon) is a congenital disease characterized by insufficient peristalsis because of the absence of ganglion cells (nerve cells) in the distal colon and the rectum. This results in functional obstruction, causing the collapse of the aganglionic segments of the bowel and distension of the colon proximal to the aganglionic segment. ✓ Clinical features of this disease include abdominal distention, failure to pass meconium within the first 24 to 48 hours as an infant, bilious vomiting, and altered bowel habits such as constipation alternating with diarrhea. ✓ Treatment is with surgical intervention such as a colectomy. ✓ Enterocolitis is the most severe complication manifested by severe abdominal pain, abdominal distention, and fever. Choices B, C, and D are incorrect. Burning at the insertion site of the indwelling urinary catheter site is concerning because this may be an early manifestation of a catheter-associated urinary tract infection. This client does require follow-up but would not prioritize over the client experiencing life-threatening enterocolitis (choice B). Scant blood in a newly established ostomy is expected. This is expected, along with a reddened stoma that is edematous. This will resolve in a couple of days (choice C). Writing on a fiberglass cast with markers is permitted and does not require follow-up (choice D).

The nurse working on a medical-surgical unit is caring for assigned clients. The nurse should plan to initially assess the client who A. had a subtotal thyroidectomy 12 hours ago and reports difficulty swallowing. B. reports increased pain following a sterile dressing change for a stage IV pressure ulcer. C. has bilateral lower lobe pneumonia and has not used the incentive spirometer in six hours. D. is scheduled for an adrenalectomy in eight hours and has not signed the informed consent.

Choice A is correct. A subtotal thyroidectomy requires the nurse to monitor the client for complications such as laryngeal edema. This may be manifested as a hoarse voice, difficulty swallowing, and stridor. The primary healthcare provider (PHCP) may prescribe post-operative steroids to prevent this complication. The nurse needs to follow up with this client to assess the client's airway patency. Additional Info Common complications following thyroidectomy surgery are as follows: ✓ Hypocalcemia: accidental injury or removal of the parathyroid gland can reduce the circulating blood calcium levels. Acute hypocalcemia may present with the Chvostek Sign (tapping on the cheek causes facial twitching), Trousseau's Sign (applying pressure on the arm causes carpopedal spasms), muscle cramps, paresthesia, peri-oral numbness, tetany, seizures, and cardiac arrhythmias. If untreated, it can be life-threatening. To prevent this complication, every thyroidectomy patient is started on 3 grams of elemental calcium per day as soon as they can begin an oral diet. ✓ Recurrent laryngeal nerve (RLN) injury: hoarseness of voice from RLN injury is common due to the damage of RLN intra-operatively. ✓ Following a thyroidectomy, the nurse should have readily available airway equipment and calcium gluconate. Choices B, C, and D are incorrect. Pain following a dressing change is quite common and requires general follow-up. The nurse can mitigate this pain by medicating the client with prescribed analgesics before the dressing change. A key intervention for a client with pneumonia is to mobilize and use the incentive spirometer (IS). The IS is commonly prescribed hourly while the client is awake. This requires general follow-up but is not the priority. Finally, the client's consent will need to be evaluated for completion. However, the surgical

The nurse is triaging a client involved in a chemical spill at a local chemical plant. The nurse assesses the client as responsive but unable to walk, with a respiratory rate of 28 and capillary refill < 2 seconds. It would be correct for the nurse to triage this client with a A. yellow tag. B. red tag. C. black tag. D. green tag.

Choice A is correct. A yellow triage tag indicates the victim has injuries that are not immediately life-threatening and can wait up to an hour before receiving treatment. This client is responsive, with adequate respiratory function (respirations below 30/minute) and perfusion intact (capillary refill under 2 seconds). This client could wait until the most severe injuries are treated before receiving treatment. Additional Info ✓ Emergent (red tags) include life-threatening injuries, including obstruction to the airway, severe hemorrhage, or shock. Immediate treatment is necessary. ✓ Urgent (yellow tags) include alterations in blood glucose (hypoglycemia), disorientation, and large wounds that need treatment within 30 minutes to 2 hours. ✓ Nonurgent (green tags) include minor injuries such as strains, sprains, simple fractures, or abrasions. Treatment may be delayed up to four hours. Choice B is incorrect. A red triage tag indicates the client has life-threatening injuries but a high chance of survival once stabilized, such as large lacerations or compromised lung function due to trauma. These clients are the highest priority and require immediate treatment. Choice C is incorrect. A black triage tag indicates the client's injuries are so severe that there is little to no chance of survival, such as being unresponsive with multiple severe injuries or extensive blood loss. Choice D is incorrect. A green triage tag indicates that the client has minor injuries, such as cuts or abrasions, and can wait several hours before treatment.

The nurse is caring for assigned clients. The nurse should initially A. administer prescribed antibiotics to a client with bacterial meningitis. B. reposition a client with chronic back pain who reports pain rated 6/10 on the Numerical Rating Scale. C. remove a nitroglycerin transdermal patch for a client with chronic angina. D. assess a client who had a coronary artery bypass grafting (CABG) three days ago and has a serum glucose of 135 mg/dL (7.5 mmol/L) [70-110 mg/dL, 3.9-6.1 mmol/L].

Choice A is correct. Bacterial meningitis has a high mortality rate and requires aggressive and prompt antibiotic treatment. The nurse should prioritize this client because this is a serious, acute concern that may result in death. Prescribed ceftriaxone and vancomycin are the preferred antibiotics in treating this pathogen. Additional Info ✓ Neisseria meningitidis is a common cause of bacterial meningitis in children and adolescents. ✓ Symptoms classically have an abrupt onset and include headache, fever, nuchal rigidity, rash, photophobia, and myalgias. ✓ The nurse's immediate concern is to protect the safety of the staff and the other clients by placing the client in isolation with droplet precautions. ✓ Treatment for N. meningitidis includes prompt initiation of antibiotics such as ceftriaxone. Choice B is incorrect. This client is not a priority because the client's concern is chronic. The nurse must prioritize acute, life-threatening problems over tasks such as repositioning for a chronic illness. Choice C is incorrect. Removing a nitroglycerin patch for a client with chronic angina is routine. The client receiving transdermal nitroglycerin needs a nitro-free period to avoid developing a tolerance. Again, this task is for a client with a chronic condition. Choice D is incorrect. Following a CABG, the client has a target glucose between 110-180 mg/dL (6.1-10 mmol/L). If the client should exceed 180 mg/dL, this has been shown to decrease healing time and compromise outcomes. This client's glucose level is acceptable, considering the standard after this surgery is to have a glucose level of less than 180 mg/dL (10 mmol/L) [70-110 mg/dL, 3.9-6.1 mmol/L]. The stress of this surgery increases glucose levels which causes the client to receive prescribed insulin for several days following the surgery.

The home health nurse is assessing a client in their home with suspected carbon monoxide poisoning. The nurse should take which priority action? A. Move the client outdoors B. Notify the primary healthcare provider (PHCP) C. Auscultate the client's lung sounds D. Assess the client's pulse oximetry

Choice A is correct. Carbon monoxide poisoning is a serious emergency that is often fatal if not promptly treated. This medical emergency requires the client to be immediately relocated away from the carbon monoxide. Moving the client outside is effective because of the fresh air. Once this has been completed, the nurse should notify the PHCP or call emergency medical services (EMS) for further treatment. Another priority treatment is providing the client with 100% high-flow oxygen regardless of their pulse oximetry, lung sounds, or arterial blood gas results. Additional Info ✓ Carbon monoxide binds to a red blood cell approximately 200x more than oxygen ✓ Carbon monoxide poisoning may occur from smoke inhalation from fires, poorly functioning heating systems, and motorboat and motor vehicle exhaust exposure in a closed setting ✓ Manifestations include headache, dizziness, weakness, malaise, altered mental status, and visual changes ✓ This poisoning is tasteless, odorless, and colorless ✓ Treatment includes removing the client from the source of the poison, putting them outside, calling EMS, and administering 100% high-flow oxygen Choices B, C, and D are incorrect. Moving the client outdoors is an essential action. Once this action has been completed, the nurse should call EMS or the PHCP for guidance and treatment. The client's lung sounds have little clinical value in this acute emergency. The client's oxygen saturation would not provide the nurse with valuable information because the nurse needs to act immediately to cease exposure to this poison. The nurse understands that high-flow oxygen will be administered to the client regardless of their oxygen saturation; thus, this assessment has limited clinical value. Finally, pulse oximetry cannot screen for exposure to carbon monoxide.

The nurse has been made aware of the following client situations. The nurse should initially follow up with the client who A. had an adrenalectomy 24 hours ago and has become restless with the most recent blood pressure (BP) of 98/60 mm Hg. B. has a continuous infusion of heparin for the treatment of a pulmonary embolism (PE) and has an activated partial thromboplastin time (aPTT) of 70 seconds. C. is receiving mechanical ventilation to treat hospital-acquired pneumonia (HAP) and was last suctioned via the endotracheal (ET) tube two hours ago. D. has a newly placed chest tube for hemothorax and has had 45 mL of bright red drainage in the past hour.

Choice A is correct. The client experiencing restlessness and low blood pressure is the priority for the nurse. Following an adrenalectomy, the client is at risk for an adrenal (Addisonian) crisis from insufficient corticosteroids and aldosterone. The nurse needs to prioritize this client's situation because restlessness is an early sign of shock, and if the nurse does not follow up with the client, they run the risk of lethal cardiac dysrhythmias. Additional Info ✓ During an adrenal crisis, the priority treatment is administering hydrocortisone intravenously. ✓ The client is often volume depleted, hypoglycemic, and hyponatremic and will need rapid fluid resuscitation. ✓ Dangerously high potassium levels (hyperkalemia) are also evident in an adrenal crisis and require cardiac monitoring and potassium-reducing medications such as sodium polystyrene. Choices B, C, and D are incorrect. An aPTT of 70 seconds is therapeutic for a client receiving a continuous heparin infusion. The goal for a client receiving an infusion of heparin is to have their aPTT 1.5x - 2.5x the control (baseline) value. The normal aPTT range is 30-40 seconds. The client receiving mechanical ventilation should be suctioned when clinically warranted. They should be assessed for the need to be suctioning every two hours, but that does not necessarily warrant suctioning at every interval. The client with a hemothorax with a chest drainage system in place does not require follow-up because the drainage is only 45 mL. Any drainage exceeding 70 mL would concern the nurse and require investigation for potential hemorrhage.

The nurse is caring for the following assigned clients. It would be a priority to follow up with a client who A. has atrial fibrillation and a heart rate of 112/minute. B. has glomerulonephritis with a blood pressure of 137/86 mm Hg. C. is receiving amphotericin b, and the most recent temperature is 100.4°F (38°C). D. has chronic obstructive pulmonary disease (COPD) with an oxygen saturation of 91% on room air.

Choice A is correct. The client with atrial fibrillation and has two treatment goals. 1. The prevention of a stroke 2. Rate control between 60-100. The client with atrial fibrillation with an elevated heart rate requires priority follow-up because the increased rate likely means the client has atrial fibrillation with a rapid ventricular response. The client with this type of arrhythmia requires medications such as diltiazem or amiodarone to achieve rate control. Additional Info ✓ The treatment goals for a client with atrial fibrillation include stroke prevention and rate control (between 60-100 bpm). ✓ Medications such as diltiazem, digoxin, amiodarone, and dronedarone may be used to control the rate. ✓ Anticoagulants are also indicated as ischemic strokes are commonly associated with atrial fibrillation. ✓ Anticoagulants commonly used include rivaroxaban, apixaban, and warfarin. Choices B, C, and D are incorrect. These clients are experiencing expected findings and do not require follow-up. A client with glomerulonephritis will have elevated blood pressure, proteinuria, and hematuria. An infusion of amphotericin b would cause a client to experience fever and chills and does not require imminent follow-up. This side effect can be avoided by the client being premedicated with isotonic fluids and acetaminophen. An oxygen saturation of 88% or greater is optimal for a client with COPD.

The nurse is caring for a client diagnosed with multiple myeloma. The nurse reviews the client's lab values and notes a serum calcium level of 14 mg/dL (3.5 mmol/L) [9-10.5 mg/dL, 2.12-2.52 mmol/L]. What is the priority action the nurse should take? A. Notify the primary healthcare provider (PHCP) B. Document the finding C. Continue to monitor the client D. Remove the client from the telemetry monitor

Choice A is correct. The normal range for serum calcium is 9-10.5 mg/dL [2.12-2.52 mmol/L]. This client's serum calcium level is above 10.5 mg/dL [2.52mmol/L]; therefore, the client is experiencing hypercalcemia. At a calcium level of 14 mg/dL (3.5 mmol/L), most clients may experience symptoms. Often, these may include polyuria, polydipsia, and dehydration. If not addressed, clients may develop renal failure and altered mental status. The nurse must notify the PHCP regarding this abnormal lab value. Choice B is incorrect. Documenting abnormal lab values is a standard nursing practice. However, in the case of a critically elevated serum calcium level, mere documentation is insufficient. Immediate action is required to address the situation and prevent potential complications associated with hypercalcemia. Choice C is incorrect. Continuously monitoring the client is essential in any healthcare setting. However, in the context of a severely elevated serum calcium level, a proactive approach is necessary. Continuous monitoring alone does not address the urgency of the situation and may lead to delayed intervention. Choice D is incorrect. It is inappropriate for the nurse to remove the client from the telemetry monitor. Not only has the nurse identified that this finding falls outside of normal limits and needs to notify the attending PHCP, but the nurse should also be aware that a client experiencing hypercalcemia may have EKG changes such as a shortened QT interval and a prolonged PR interval. Cardiac monitoring is essential for this client.

The emergency department (ED) nurse is caring for a client brought in after being found walking around a neighborhood without shoes, confused and disoriented. The nurse should initially A. obtain vital signs. B. perform a mental status exam. C. attempt to locate the client's family. D. request an order for a psychiatry consultation.

Choice A is correct. The nurse must prioritize the client's physical needs. Thus, the nurse should initially assess the client's vital signs to determine the client's stability. Additional Info ✓ If the nurse suspects the client is experiencing a psychiatric illness, the nurse still prioritizes physical needs. ✓ Before the nurse tends to psychiatric needs, the nurse should assess and treat any physical needs as directed by the physician. ✓ Confusion and disorientation may be caused by a multitude of conditions such as - hepatic encephalopathy delirium dementia hyponatremia severe dehydration psychosis traumatic brain injury Choice B is incorrect. Part of the nurses' assessment is to perform a mental status exam. Still, it does not prioritize obtaining and assessing the client's vital signs, essential to their overall physical condition. This assessment can wait until the client's physical stability is assessed. Choice C is incorrect. The nurse should not attempt to locate the client's family to provide collateral medical information because it diverts the nurse's attention from the client's physical needs. While this may be a pertinent task, the client's physical stability must first be established by collecting and assessing vital signs. Choice D is incorrect. In this case, a psychiatric consultation may be warranted to determine the etiology and potential treatment of the client's confusion and bizarre behavior. Still, the client's physical stability must be established by collecting and assessing vital signs.

The nurse is caring for assigned clients in the mental health unit. The nurse should initially follow up on the client who A. is admitted for psychosis and is pacing in the hallway, mumbling to themselves. B. is being treated for obsessive compulsive disorder and has increased the number of times they wash their hands. C. has a substance use disorder and refuses to attend group therapy for the second time. D. is diagnosed with borderline personality disorder and is insisting on seeing the charge nurse for an allegation of abuse two days ago.

Choice A is correct. This client is demonstrating signs of aggression (mumbling, pacing), and the nurse should intervene to avoid any escalation and to prevent disruption to the milieu. Manifestations of aggressive behavior include pacing, hyperactivity, a rigid posture, clenched jaw or fist, mumbling to themselves, intense eye contact, or stone silence. The client's diagnosis of psychosis also supports intervention from the nurse because psychosis features impulsivity and irrational acts. Additional Info ✓ For a client demonstrating aggression the nurse should Maintain distance from the client to promote safety Communicate with assertiveness - not anger towards the client Provide clear options Demonstrate authenticity and empathy - statements like "That sounds frustrating to experience" Do not argue ✓ If signs of aggression escalate, the nurse should intervene promptly to prevent harm to the client and others. Implement de-escalation techniques and ensure the safety of everyone involved. ✓ If appropriate involve other members of the healthcare team, such as psychiatrists or behavioral health specialists, when dealing with aggressive clients. They can provide expertise and guidance in managing the situation. Choice B is incorrect. A client with obsessive-compulsive disorder increases their handwashing; this is likely because the client is experiencing anxiety, which is causing an increase in compulsive behavior. The behavior is not physically harmful to either the client or others. Therefore, the nurse does not need to intervene immediately. Clients with OCD experiencing anxiety often engage in ritualistic behavior. Choice C is incorrect. The refusal to attend group therapy equates to nonadherence to the treatment plan. The nurse should interview the client regarding their refusal, and the nurse should take an empath

The nurse reviews the client's emergency department (ED) triage note. Which action should the nurse take first? See the image below. A. Establish continuous cardiac monitoring B. Obtain an order for a complete metabolic panel C. Obtain a prescription for acetaminophen (APAP) D. Apply a cool compress to the client's forehead

Choice A is correct. This client is showing manifestations of digitalis toxicity. The client's bradycardia, anorexia, and vomiting are classic signs of this potentially fatal toxicity. The nurse should immediately establish continuous cardiac monitoring because, if untreated, digitalis toxicity may cause multifocal premature ventricular contractions (PVCs) that may transition to ventricular tachycardia or ventricular fibrillation. Because of digitalis' ability to have a negative chronotropic effect, bradycardia is often seen in toxicity. Additional Info ✓ Digoxin, a cardiac glycoside, is used to increase myocardial contractions' force and is indicated in the treatment of atrial fibrillation and congestive heart failure. ✓ Renal impairment, temporary dehydration, and nonsteroidal anti-inflammatory drug (NSAID) use (all common among older adults) can reduce the renal clearance of digoxin, increasing the likelihood of digoxin toxicity in older adults. ✓ Hypokalemia is a significant precipitator of digitalis toxicity. ✓ This medication has fallen out of favor because of the numerous drug-to-drug interactions. Choices B, C, and D are incorrect. Obtaining a CMP (or BMP) is appropriate to determine the client's potassium level because hypokalemia may trigger digitalis toxicity. However, obtaining and interpreting lab work will take time, and this client's heart rate is low, requiring further investigation and treatment. The client does have a temperature of 100o F (37.8o C), but this elevation in temperature is likely caused by dehydration from the vomiting. An infectious process cannot be excluded, but when an individual is infectious with a sub-clinical fever or dehydrated, their heart rate increases - not decreases. Finally, influenza does not cause visual changes, as digitalis toxicity does. This client's low heart rate

The emergency department (ED) nurse performs triage. Which client should the nurse prioritize care for? A client with A. hemophilia reporting knee and ankle stiffness with dizziness. B. chronic obstructive pulmonary disease (COPD) reporting a productive cough. C. chronic pericarditis reporting intermittent chest pain during inspiration. D. pain over the cheek radiating to the teeth, tenderness to percussion over the sinuses.

Choice A is correct. This client is the priority because strong evidence of internal bleeding is evident. Clients with hemophilia often bleed at the joints (ankles and knees) because they absorb the most impact. This client's situation is quite serious because they report dizziness, which is also collateral support for internal bleeding. This client should be prioritized. Additional Info ✓ Hemophilia is transmitted as an X-linked recessive disorder ✓ The two most common forms of the disorder are factor VIII deficiency (hemophilia A, or classic hemophilia) and factor IX deficiency (hemophilia B, or Christmas disease) ✓ Severe forms of the disease may cause significant internal bleeding from a slight fall, a bruise, or the loss of deciduous teeth ✓ Bleeding is commonly found in the joints that manifest as joint stiffness, limited range of motion, and swelling ✓ A client with hemophilia should be educated to avoid contact sports, the manifestations of bleeding, and adherence to follow-up care ✓ Clients with hemophilia should avoid aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) because they inhibit platelet function Choices B, C, and D are incorrect. A classic manifestation of COPD is a prolonged expiratory phase during breathing, a productive cough, and changes to the diaphragm (flattening). This is an expected finding, and coughing indicates a patent airway. A client with pericarditis experiences intermittent chest pain, especially during inspiration. Considering that this is a chronic problem and that chest pain is intermittent, this is not the nurses' priority. A client with pain over the cheek radiating to the teeth and tenderness to percussion over the sinuses likely has rhinosinusitis, a low acuity illness.

The charge nurse reviews medical records for clients ready for discharge from the nursing unit. Which client should be recommended for disease management services? A client with A. congestive heart failure (CHF), who has been admitted three times in the past two months. B. epilepsy who had one seizure after switching prescribed antiepileptics. C. diabetes mellitus, with an increase in hemoglobin A1C from 6.7% to 6.9%. D. schizophrenia being switched from daily dosing to long-acting injectable antipsychotic.

Choice A is correct. This client requires a disease management referral because the client has been admitted multiple times to the hospital. Disease management is a coordinated set of interventions that aim to maximize the client's functionality while minimizing disease-related complications. The cost associated with hospitalizations and the risk of complications during hospitalizations make this client an ideal candidate for disease management services. Additional Info ✓ Disease management effectively minimizes costly hospitalizations, maximizes resources, and promotes quality outcomes. ✓ Disease management utilizes evidence-based practices and may contain multiple disciplines (pharmacist, physical/occupational therapy, nursing). ✓ Conditions likely recommended for disease management include uncontrolled diabetes mellitus, asthma, chronic obstructive pulmonary disease, and obesity. Choices B, C, and D are incorrect. A client having a seizure while switching anti-epileptics is quite common. The reasoning is that when one therapeutic level declines, it takes time for the other to increase. An isolated seizure does not necessitate a disease management referral. The client with diabetes had an increase in their hemoglobin A1C. However, it is still below the desired goal of 7%. The nurse should trend the A1C and continue to advocate for more frequent blood glucose monitoring and adherence to prescribed medications. A client with schizophrenia being switched to a long-acting injectable is an excellent strategy to maximize adherence and minimize exacerbations (psychosis). These long-acting injectables are given in a single shot, and the client will return in a few weeks for another injection.

The nurse on the medical-surgical unit has received two new client admissions simultaneously. Which assessment is essential to determine which client the nurse should see first? A. Vital signs B. Number of prescribed medications C. Medical history D. Code status

Choice A is correct. Vital signs are essential to obtain, which will help the nurse determine which client should be seen first by the nurse. If a client's vital signs are unstable, the nurse must prioritize the client's care. Getting clients simultaneously is common, and a strategy a nurse may use to help differentiate which client is stable or unstable is obtaining vital signs. Additional Info Factors that influence the prioritization of client care ✓ Vital signs (look for unstable vital sign trends such as tachycardia) ✓ Admitting diagnosis (CHF exacerbation over lower extremity cellulitis) ✓ Potential for injury (falling, hostility towards other clients) ✓ Expected vs. unexpected manifestations (expected with atrial fibrillation, irregular pulse; unexpected with atrial fibrillation manifestations of a stroke) ✓ Elapsed time from a surgical procedure (the closer the client is to the surgery, the more risk for harm) Choices B, C, and D are incorrect. The number of prescribed medications should have little influence on the nurse's decision to prioritize client care. The client's overall condition and stability is the primary factor in this judgment. Medical history is a factor that may help shape the nurses' care; for example, a client with multiple sclerosis may require care with frequent rest breaks. But this would not be a deciding factor in priority. Code status is relevant during client care and delivering handoff report, however, it will not influence the nurses' decision on who should receive care. If a client is a do not resciutate status, that does not mean do not treat.

The nurse is reviewing tasks for assigned clients. Which action is a priority to implement? A. Visual acuity test for a client reporting blurred vision in one eye. B. 12-lead electrocardiogram for a client reporting chest pain. C. Orthostatic vital signs for a client complaining of syncope. D. Discharge teaching for a client newly diagnosed with hypertension.

Choice B is correct. A 12-lead electrocardiogram (ECG) is essential for a client with chest pain. This test will help determine if the client has an acute myocardial infarction by showing ST elevations. In suspected acute myocardial infarction (MI), guidelines recommend obtaining an ECG within 10 minutes of the client's arrival in the emergency room. If the client is experiencing an ST-elevation myocardial infarction (STEMI), a delay in obtaining a diagnosis and/or therapeutic intervention can lead to poor clinical outcomes (increased morbidity and mortality). Additional Info The client's complaint of chest pain may likely indicate a circulation problem and thus is the nurse's initial priority. In this case, the client experiencing chest pain is potentially threatening their circulation. When prioritizing client needs, the strategy of "ABCs" airway, breathing, and circulation may be used. A 12-lead electrocardiogram (ECG) may identify ST-changes which are associated with myocardial damage. Choices A, C, and D are incorrect. It is important to obtain orthostatic vital signs in a client with syncope. Still, it is not more of a priority than obtaining an electrocardiogram for a client with suspected MI. A visual acuity test using a Snellen chart is not a priority for a client complaining of blurred vision in one eye. This is also true for the client awaiting discharge teaching, as this is low-priority.

The nurse is triaging a group of pediatric clients. The nurse should initially follow-up on the client who is a A. 5-year-old who burned her right forearm in scalding hot water. B. 2-year-old who is drooling and does not want to swallow. C. 8-year-old child with a headache for two days. D. 10-year-old child who reports excessive thirst and has a fever.

Choice B is correct. A child who is drooling and does not want to swallow is indicative of epiglottitis, which can be a life-threatening situation. The nurse should assess this child first and inform the physician if an emergency tracheostomy is required. Additional Info ✓ Epiglottis is a cartilaginous flap present at the back of the throat. Its primary function is to close over the airway during swallowing so that the food does not enter the airway. Acute epiglottitis is a medical emergency that has an abrupt onset. In epiglottitis, the epiglottis becomes inflamed and swollen and obstructs the airway. ✓ Classic symptoms of epiglottis include - Sore throat and pain in swallowing Fever The child insists on sitting upright and leaning forward (tripod position), with the chin thrust out, mouth open, and tongue protruding. Drooling of saliva Red and inflamed mucous membranes Large, cherry red, edematous epiglottis ✓ Prevention: The key prevention for epiglottitis is immunization with H. influenzae type B conjugate beginning at two months of age. Choice A is incorrect. The child who sustained a burn to the forearm requires medical attention. However, this does not prioritize the client who has an impaired airway with what appears to be epiglottitis. Choice C is incorrect. This child should be assessed but should not be prioritized over the child with epiglottitis. Many conditions may cause a headache. However, this would not prioritize a threat to a client's airway. Choice D is incorrect. Excessive thirst and a fever may be an array of pathologies, including hyperglycemia and dehydration. While this is a concern because the client faces circulatory compromise, this does not prioritize the client's obstructed airway.

The nurse is caring for assigned clients in the behavioral health unit. The nurse should initially assess the client who A. has postpartum depression who appears unkempt and dejected. B. recently lost their family in an accident and currently states, "I want to be with them." C. has anorexia nervosa and demands that she get reweighed. D. refused their second dose of prescribed lithium because of a fine hand tremor.

Choice B is correct. A client stating they want to be with their recently deceased family members may likely be verbalizing suicidal ideation. This statement by the client should immediately concern the nurse, and the nurse should recognize the client's statements as potential signs of suicidal ideation. The nurse should prioritize this client and implement suicide precautions per facility policy. Choice A is incorrect. Clients with depression often neglect personal hygiene. More specifically, postpartum depression interferes with the client's ability to care for themselves and often the infant. Therefore, the client's unkempt and dejected appearance is anticipated in a client with postpartum depression, and these symptoms would not necessitate the client being prioritized by the nurse. Choice C is incorrect. Clients with an eating disorder, such as anorexia nervosa, may request that their weight be obtained often. The nurse should not allow this as this further fuels the narrative that their weight is central to their life. The client should be weighed at specific intervals with no compromise. Choice D is incorrect. A client refusing their prescribed lithium for the second time because of a fine hand tremor requires follow-up, but not over the client with suicidal ideations. Fine hand tremors are common in the first few weeks of therapy and typically decrease with time.

The community health nurse has been notified of several incidents. Which situation requires immediate follow-up? A client with A. pulmonary tuberculosis (TB) is still testing positive despite 2 months of treatment. B. hepatitis A who works as a cook at a local healthcare facility. C. human immunodeficiency virus (HIV) with an undetectable viral load (VL) and reports having recent unprotected sexual intercourse. D. Lyme disease and is refusing further treatment with intravenous antibiotics because of nausea and vomiting.

Choice B is correct. A client with hepatitis A virus (HAV) should be excused from working from handling food until they have been successfully treated. This client is at high risk of spreading the virus to others as it may be spread by contaminated food caused by the client not engaging in hand hygiene practices. The nurse must intervene to ensure a hepatitis A outbreak does not occur, especially in a healthcare facility. Additional Info ✓ Hepatitis A is an infection contracted through the consumption of raw or undercooked food, fecal-oral route, or contaminated water. ✓ Most cases are self-limiting, with complete clinical recovery within three to six months. ✓ Vaccination for hepatitis A is a two-dose series beginning as early as six months for international travel; 12 months for routine vaccination. Choice A is incorrect. For a client with pulmonary tuberculosis, they will need to undergo 6-9 months of antitubercular treatment. The client will also need to have three consecutive negative TB tests (sputum) to affirm that the client has latent TB. Choice C is incorrect. For a client with HIV with a sustained undetectable VL, they have no chance of passing the virus to others. While the nurse should advocate for protected sexual encounters because this can prevent the transmission of other sexually transmitted infections, this is not as serious compared to the worker with HAV, who has the potential to infect dozens of individuals at the healthcare facility. Choice D is incorrect. Lyme disease is successfully treated with antibiotics such as doxycycline. Lyme disease is not transmitted from human to human; ticks spread it. This client situation requires low priority because the client has no risk of transmitting this infection to other humans.

The nurse is caring for assigned clients. The nurse should first assess the client A. with pericarditis who reports increasing chest pain while laying down flat. B. with cystic fibrosis who has a temperature of 102.5° F (39.2° C). C. who has rhinosinusitis and is reporting facial pain that increases when bending forward. D. who has hypertrophic cardiomyopathy and has dyspnea after ambulating in the hallway.

Choice B is correct. A fever in someone with cystic fibrosis supports the client's having pneumonia. An individual with CF has a higher risk for pneumonia because of the mucous stasis in their airway. Pseudomonas aeruginosa is commonly the organism implicated in causing pneumonia. Treatment of this bacteria is with antibiotics such as levofloxacin. A significant cause of death for individuals with CF is pneumonia. This client requires immediate follow-up because prompt and aggressive treatment with bronchodilators, antibiotics, and chest physiotherapy is necessary. Additional Info ✓ Living with a chronic condition like cystic fibrosis can be challenging. Nurses provide psychosocial support by addressing emotional needs, facilitating support groups, and connecting clients and families with resources for coping and mental health support. ✓ Regular respiratory function, nutritional status, and overall health monitoring are essential. Nurses collaborate with the healthcare team to promptly assess and address changes in the client's condition. ✓ Individuals with CF are at higher risk of pneumonia, and prescribed measures such as chest physiotherapy, prescribed bronchodilators, and meticulous hand hygiene may assist in reducing the risk of pneumonia. Choice A is incorrect. Pericarditis classically causes the individual to have an intensification of their chest pain while lying down flat. This is an expected finding and is relieved by having the client lean forward. This is an expected finding and does not require initial follow-up by the nurse. Choice C is incorrect. A client with rhinosinusitis reporting facial pain that increases when bending forward is expected. This is because the congestion in the sinus cavities intensifies while the client is leaning forward. This is an expected finding and does not require initial f

The nurse working in the emergency department is caring for a client with carbon monoxide poisoning. Which of the following would be the priority action to treat this condition? A. Initiate continuous pulse oximetry monitoring B. Administer high-flow oxygen C. Insert a peripheral vascular access device D. Obtain a 12-lead electrocardiogram (ECG)

Choice B is correct. Carbon monoxide (CO) poisoning is a serious emergency that is often fatal if not promptly treated. This medical emergency requires the priority treatment of 100% high-flow oxygen. CO has a strong affinity for hemoglobin 200x more than oxygen. Providing the client with high-flow oxygen is an essential treatment because, if untreated, death may occur. Additional Info ✓ Carbon monoxide binds to a red blood cell approximately 200x more than oxygen ✓ Carbon monoxide poisoning may occur from smoke inhalation from fires, poorly functioning heating systems, and motorboat and motor vehicle exhaust exposure in a closed setting ✓ Manifestations include headache, dizziness, weakness, malaise, altered mental status, and visual changes ✓ This poisoning is tasteless, odorless, and colorless ✓ Treatment includes removing the client from the source of the poison, putting them outside, calling EMS, and administering 100% high-flow oxygen Choice A is incorrect. Pulse oximetry cannot screen for exposure to carbon monoxide. However, continuous monitoring is a standard of care whenever oxygen is administered. Choice C is incorrect. A peripheral vascular access device is often inserted to obtain a metabolic panel to screen for electrolyte disturbances. If the CO level rises high enough, the client is at risk for fatal dysrhythmias and ST-segment depression. Choice D is incorrect. An ECG should be obtained, but it does not prioritize administering the client high-flow oxygen.

Which of the following is the first nursing action for a patient experiencing dyspnea? A. Remove pillows from under the patient's head B. Elevate the head of the bed C. Elevate the foot of the bed D. Take the patient's blood pressure

Choice B is correct. Elevating the head of the bed allows the abdominal organs to descend, giving the diaphragm more room and facilitating lung expansion. Dyspnea is difficult or labored breathing. A dyspneic patient usually has rapid, shallow respirations. Because of this "shallow" breathing, ventilation is affected, and Co2 accumulates. Dyspneic clients can often breathe better in an upright position. When standing or sitting, gravity pulls the abdominal organs down and away from the diaphragm, creating more space in the thoracic cavity. This allows the lungs more room for expansion and allows the client to take more air with each breath (better ventilation). Additional Info Patients may be dyspneic because of several reasons. COPD is one of the commonest causes. The lungs are hyper-inflated in clients with Chronic Obstructive Pulmonary Disease (COPD). Because of decreased elastic recoil of the lungs, the air is trapped in the lungs leading to poor ventilation. Because the lungs are hyper-inflated, the diaphragm is flattened and functions poorly. Clients with COPD should be educated about forward-lean positions, allowing the diaphragm to assume a more domed position and work better. Such positions include: High side-lying. Forward lean sitting without pillows. Forward lean sitting with pillows. Upright sitting in a chair. Forearm support to assist breathing using a trolley. Forward lean standing. Standing with back support. Choices A, C, and D. None of these answer choices are appropriate as the first nursing action for a patient experiencing dyspnea. Recumbent positions ( choices A and C) limit expiratory flow and cause a decrease in the elastic recoil of the lung. Therefore, such positions do not improve ventilation. The nurse should check the client's blood pressure (choice D), but the priority should be positio

The nurse is caring for a client who fell at an outdoor park. On assessment, the client is unconscious and does not have a pulse. The nurse should initially A. provide two rescue breaths. B. begin chest compressions. C. assess the client to determine if they are wearing any emergency alert tag(s). D. ask another health care professional to check the carotid pulse.

Choice B is correct. If the nurse has found an unconscious and pulseless patient, they should begin chest compressions. Immediate chest compressions are the most effective way to maintain total body oxygenation. Additional Info When performing CPR, the nurse needs to minimize interruptions and focus on providing effective compressions and ventilations ✓ A compression rate of 100-120/minute is desired ✓ An AED should be made available as urgently as possible ✓ Assessing for a pulse should not take more than ten seconds ✓ When obtaining a pulse for an infant, the nurse should assess the brachial artery. For a child and adult, the nurse will use the carotid artery ✓ Immediate family members should be allowed to be present during resuscitation as this has promoted better grieving Choice A is incorrect. Rescue breaths, while important, should not be initiated at this point. Instead, rescue breaths should be started if the patient is apneic and after chest compressions have been undertaken. Choice C is incorrect. Determining if the client is wearing any medical alert tags will not alter the nurse's intervention to provide chest compressions. Doing this action would delay providing the necessary chest compressions. Choice D is incorrect. Having a second individual assess the carotid pulse is not necessary and would delay the critical intervention of providing chest compressions.

The emergency department (ED) nurse cares for a client who presents with irritability, nuchal rigidity, and a fever. Which of the following actions should the nurse take first? A. Administer prescribed ibuprofen. B. Place the client on droplet precautions. C. Notify the public health department. D. Obtain prescribed blood cultures.

Choice B is correct. Initiating droplet precautions is a high priority for this client. The classic bacterial meningitis triad is fever, neck stiffness, and altered mental status. The nurse must protect the other clients and staff from disease transmission. Thus, the nurse should initiate droplet precautions by placing the client in a room with all visitors and staff wearing surgical mask in the client's presence. Additional Info Neisseria meningitidis is a common cause of bacterial meningitis in children and adolescents. Symptoms classically have an abrupt onset and include headache, fever, nuchal rigidity, photophobia, and myalgias. The nurse's immediate concern is to protect the safety of the staff and the other clients by placing the client in isolation with droplet precautions. Treatment for N. meningitidis includes prompt initiation of antibiotics such as ceftriaxone. Choices A, C, and D are incorrect. Medications to lower fever, such as acetaminophen or ibuprofen, would be helpful for a client with bacterial meningitis. If bacterial meningitis is confirmed, the public health department must be notified to initiate contact tracing. However, these actions are not a higher priority than the safety and infection control of the clients and staff within the ED.

The nurse is caring for assigned clients. After administering prescribed medications, the nurse should immediately intervene if the client reports A. nausea during an infusion of amphotericin b. B. palpitations after receiving rapid-acting insulin. C. drowsiness after receiving fentanyl. D. itching in the perineal area while receiving intravenous dexamethasone.

Choice B is correct. Insulin may adversely cause the client to experience hypoglycemia (blood glucose <70 mg/dL, <3.88 mmol/L) [70-110 mg/dL, 4.0-11.0 mmol/L]. This is the nurses' priority because the client may be shocked without intervention. Manifestations of hypoglycemia are adrenergic (palpitations, tachycardia) and cholinergic (diaphoresis) and should not be ignored. Additional Info ✓ The three rapid-acting insulins are lispro, aspart, and glulisine ✓ The client needs to take this insulin 5-10 minutes before a meal or while actively eating ✓ A rapid-acting insulin is utilized as correctional insulin before meals to prevent post-prandial hyperglycemia ✓ This type of insulin is commonly loaded into an insulin pump ✓ Alternatively, short-acting insulin may be loaded into the insulin pump Choice A is incorrect. Amphotericin B is a highly effective antifungal medication. In medicine, this medication may be called 'AmphoTerrible' because the client feels terrible during the infusion. Thus, the client is often given prescribed medications before the infusion to temper the nausea/vomiting, fever/chills, and potential for acute kidney injury. This client is not the priority over a client experiencing hypoglycemia. Choice C is incorrect. Drowsiness is expected following the administration of an opioid. The client does not require immediate follow-up. It is somnolence that is concerning as somnolence may proceed to respiratory depression. Choice D is incorrect. itching and burning in the perineal area while receiving intravenous dexamethasone is common. These unpleasant, non-life-threatening sensations, can be tempered by diluting the dexamethasone with plenty of sodium chloride and infusing it slowly. This is not a priority as these sensations are expected.

The nurse is caring for assigned clients. The nurse should initially assess the client who was admitted for A. intermittent chest pain fourteen hours ago, and the most recent serial troponin level showed no elevation. B. syndrome of inappropriate antidiuretic (SIADH) and has developed disorientation within the last two hours. C. an acute kidney injury (AKI) four hours ago and has been urinating 15 mL/hr in the indwelling urinary catheter. D. observation following a laparoscopic cholecystectomy six hours ago, reporting abdominal cramping radiating to the shoulder.

Choice B is correct. SIADH is characterized by fluid retention without the client experiencing peripheral edema. SIADH is characterized by the excessive secretion of antidiuretic hormone (ADH), leading to water retention, dilutional hyponatremia, and concentrated urine. Hyponatremia is a significant complication of SIADH, and considering sodium's considerable role in neuromuscular functions, a client exhibiting disorientation signifies severely low sodium levels, which warrants immediate follow-up, especially since this development was quite recent (within the last two hours). Additional Info SIADH is characterized by excessive antidiuretic hormone release ✓ The most common cause of SIADH is small-cell lung cancer. Other causes include traumatic brain injuries and medications (carbamazepine, fluoxetine). ✓ This excess of ADH causes the client to retain water without peripheral edema. ✓ They may have a slight increase in their weight and blood pressure. ✓ Other clinical features include hyponatremia, oliguria, excessive thirst, and hemodilution (decreased hematocrit). ✓ Immediate treatment restricts the client's fluid intake to 800 mL/day. The client's sodium level will need to be closely monitored. ✓ Medications such as tolvaptan or demeclocycline may be used. ✓ A good memory device to use is the SI in SIADH stands for soaked inside because the client is soaked inside with water. Choice A is incorrect. A client admitted for intermittent chest pain with no elevation in troponin level does not require follow-up. This is a reassuring finding that the troponin level is not elevated, which would signify an insult to the myocardium. Choice C is incorrect. For a client with an AKI, it is expected that they experience an oliguric phase that is marked by a significant reduction in urinary output. This phase may last several d

The nurse is conducting a teaching session with the parents of a child newly diagnosed with asthma. The priority topic for the nurse to cover is A. how to use a peak flow meter. B. signs and symptoms of an asthma attack. C. the need to stay current with immunizations. D. community resources available for asthma management.

Choice B is correct. The nurse should emphasize the manifestations associated with an asthma attack. Although deaths from asthma attacks have considerably declined, the nurse needs to convey that symptoms such as chest tightness, increased respirations, accessory muscle use, and audible wheezing are to be immediately addressed by administering prescribed albuterol via an inhaler. Additional Info Use of a Peak Expiratory Flow Meter 1. Before each use, ensure the sliding marker or arrow on the peak expiratory flow meter is at the bottom of the numbered scale. 2. Stand up straight. 3. Remove gum or food from your mouth. 4. Close your lips tightly around the mouthpiece. Be certain to keep your tongue away from the mouthpiece. 5. Blow out as hard and as quickly as you can, a "fast, hard puff." 6. Note the number by the marker on the numbered scale. 7. Repeat the entire routine three times, but wait at least 30 seconds between each. 8. Record the highest of the three readings, not the average. 9. Measure your peak expiratory flow rate (PEFR) close to the same time and the same way each day (e.g., morning and evening, before and 15 minutes after taking medication). 10. Keep a record of your PEFRs. Choices A, C, and D are incorrect. These are pertinent topics to discuss with the child and his parents. However, unlike an unrecognized asthma attack, they do not present any danger to the child. Teaching for asthma can be lengthy and best completed using written and verbal instructions.

The nurse is caring for a client taking prescribed captopril. What abnormal laboratory values should the nurse prioritize when notifying the healthcare provider? A. Serum creatinine 1.3 mg/dL (114.92 µmol/L) [Male: 0.6-1.2 mg/dL, Female: 0.5-1.1 mg/dL, Male 49-93 µmol/L, Female 22-75 µmol/L] B. Serum potassium 5.2 mEq/L (mmol/L) [3.5-5 mEq/L (mmol/L)] C. Serum phosphorus 4.6 (1.48 mmol/L) [2.5-4.5 mg/dL, 0.81-1.58 mmol/L] D. Blood glucose 135 mg/dL (7.5 mmol/L) [70-110 mg/dL, 4.0-11.0 mmol/L]

Choice B is correct. The nurse should prioritize notifying the healthcare provider about the serum potassium level. Captopril, an ACE inhibitor, can cause hyperkalemia. Hyperkalemia can lead to cardiac arrhythmias and other serious complications. Additional Info ✓ The ACE inhibitors are a large group of antihypertensive drugs. Currently, there are 10 ACE inhibitors available for clinical use. ✓ Hyperkalemia from ACE inhibitors directly results from its mechanism of action. The blockade of angiotensin II prevents the downstream secretion of aldosterone. ✓ Aldosterone causes reabsorption of sodium and, subsequently, water. Consequently, protons and potassium get secreted into the urine. ✓ Without potassium secretion through aldosterone, potassium can easily increase in clients on ACE inhibitors. ✓ Potassium plays a crucial role in maintaining the heart's electrical activity. When potassium levels are too high, it can disrupt the normal electrical signals in the heart, leading to cardiac arrhythmias. ✓ Angioedema is the most serious adverse effect associated with ACE inhibitors, as it may cause airway obstruction. Choice A is incorrect. A serum creatinine level of 1.3 mg/dL (114.92 µmol/L) is slightly elevated but not a critical value requiring immediate notification over the potassium level. Choice C is incorrect. A serum phosphorus level of 4.6 mEq/L (mmol/L) is slightly elevated but not a critical value that requires immediate notification. Choice D is incorrect. A 135 mg/dL blood glucose level is slightly elevated but not significantly high. It is not an urgent concern that requires immediate notification to the healthcare provider.

Which of the following clients should the nurse assess first when preparing to do initial rounds? A. The client with diabetes who is being discharged today. B. A 32-year-old female with a tracheostomy experiencing copious secretions. C. A 16-year-old scheduled for physical therapy this morning. D. An 80-year-old male with a decubitus ulcer that needs a dressing change.

Choice B is correct. The patient with airway compromise should always be given the highest priority. Remember ABC (Airway, Breathing, Circulation). Choices A, C, and D are incorrect. None of the patients in these answer options indicate a priority for the initial assessment. NCSBN Client Need Topic: Safe and Effective Care Environment - Coordinated Care, Subtopic: Prioritizing Patient Care

The nurse has administered prescribed medications to assigned clients. Which follow-up assessment requires immediate follow-up? A client who received prescribed A. intravenous hydromorphone for chronic back pain and is drowsy. B. intravenous metoclopramide for nausea and vomiting and now has involuntary movements of the jaw. C. intravenous dexamethasone for chronic bronchitis reporting perineal itching. D. nitroglycerin infusion for chest pain and reports a headache.

Choice B is correct. This client reports follow-up because dystonic movements of the face are a significant adverse reaction to metoclopramide. Metoclopramide is a dopaminergic and carries a risk for extrapyramidal syndrome. The nurse can avoid having the client experience this by administering this medication with prescribed diphenhydramine and diluting metoclopramide when giving it parenterally. Additional Info ✓ Metoclopramide is a dopaminergic medication used to treat nausea and vomiting ✓ Dystonia may occur if it is given intravenously. To prevent this, the nurse should administer the medication diluted and with a prescribed antihistamine such as diphenhydramine ✓ The nurse should not give metoclopramide if the client has diarrhea because this medication is gastric emptier and may worsen diarrhea Choice A is incorrect. Drowsiness with opioids, like hydromorphone, is expected. It is sedation that is concerning. Drowsiness is a state where the client can quickly awaken, where sedation requires more noxious stimuli for arousal. Sedation is critical to recognize because it occurs right before respiratory depression. Choice C is incorrect. Intravenous dexamethasone for chronic bronchitis carries a risk of perineal itching, which is uncomfortable for the client but not life-threatening. This can be avoided by diluting the medication and infusing the medication slowly. Dexamethasone is a steroid used to treat inflammatory conditions. Choice D is incorrect. Intravenous nitroglycerin is a vasodilating medication where a headache is expected. This client does not require follow-up because this is an expected finding.

The nurse is caring for a group of preoperative clients. Which client situation requires follow-up? A client Select all that apply. stating that they took their prescribed carbamazepine with a sip of water. receiving dextrose 5% in water (D5W) and has a blood glucose of 266 mg/dL (14.77 mmol/L) [ [70-110 mg/dL, 4.0-11.0 mmol/L]]. reporting that they shaved their abdomen for their scheduled appendectomy. reporting difficulty with their last surgery, stating they got 'a really high fever'. reporting burning upon urination and increased urinary frequency.

Choice B is correct. This client requires follow-up because preoperative (and postoperative) hyperglycemia is detrimental to optimal outcomes. This client has a glucose of 266 mg/dL (14.77 mmol/L) [ [70-110 mg/dL, 4.0-11.0 mmol/L]], which is hyperglycemia. This client should also have the prescribed infusion of D5W questioned, as this solution would further increase the glucose. Choice C is correct. This client situation requires follow-up because clipping hair at the operative site is the best practice because it reduces the risk of surgical site infection. If shaving has to be done, it is completed immediately before the incision to reduce the chance of postoperative infection. Clipping is the preferred method to remove hair - not shaving. Choice D is correct. This client's situation requires follow-up because the client stated that they got a high fever after their previous surgery and requires follow-up. This could be a concern for malignant hyperthermia. Although rare, this genetic disorder can be life-threatening when the client is exposed to certain anesthesia. Choice E is correct. This client's situation requires follow-up because the client reported burning upon urination. This is suspicious for a preoperative urinary infection, and infections may cause surgery cancellation as they complicate healing. Additional Info ✓ When performing a preoperative surgical assessment, the nurse assesses the client's physical status and reviews elements such as Adherence to nothing by mouth (NPO) status Preoperative laboratory and diagnostic data Basic understanding of the procedure Discharge planning Postoperative education ✓ The nurse should collaborate closely with the healthcare provider to manage the client's hyperglycemia. This may involve adjusting the client's medication regimen or insulin dosage to achieve better gl

The nurse is caring for assigned clients. The nurse should initially follow-up on the client who A. has a blood glucose of 250 mg/dL (13.875 mmol/L) while being treated with prednisone for pneumonia. B. is receiving a continuous infusion of heparin and has a 50% reduction in platelets over the past five days. C. has diabetes mellitus (type two) and reports burning and tingling in both feet. D. is being treated for acute post-streptococcal glomerulonephritis and has an hourly urinary output of 20 ml/hr.

Choice B is correct. This client shows signs of heparin-induced thrombocytopenia (HIT): a 50% decrease in platelets 5-10 days after initiating heparin therapy. This is a thrombotic emergency, and the nurse should assess the client, notify the physician, discontinue the heparin drip, and obtain a prescription for a non-heparin-based anticoagulant. Choice A is incorrect. This client is being treated for pneumonia and is likely on antibiotics and corticosteroids. Both of these medications are known to increase blood glucose levels. This blood glucose result is high, and the client may require a change in the insulin dose, but this would not be an emergency or the nurse's top priority. Choice C is incorrect. The client complaining of tingling and numbness in the toes indicates peripheral neuropathy, a common problem in individuals with diabetes mellitus, specifically if it is poorly controlled. This is not a priority because this complication is not life-threatening. Choice D is incorrect. This client presents symptoms typical of acute post-streptococcal glomerulonephritis (APSGN): hypertension due to fluid retention, decreased urinary output, rust-colored hematuria due to upper urinary tract bleeding, and proteinuria due treduceded filtration. The symptoms that are expected are not the highest priority.

The nurse has been made aware that the following clients require assistance. The nurse should first assist the client A. experiencing a flare-up of ulcerative colitis and has had 2 bloody bowel movements in the past hour. B. with a cerebral aneurysm, has developed nausea and vomiting. C. taking prescribed prednisone for an allergic reaction and reports indigestion. D. being treated for Bell's palsy and reports ringing in their ears.

Choice B is correct. This is a concerning finding that the aneurysm has ruptured. Immediate care is needed for this client, as surgical intervention is necessary to stop the bleeding. Other manifestations indicating that the aneurysm has ruptured include nausea, vision changes, severe headaches, and ataxia. Additional Info ✓ A cerebral aneurysm may develop from uncontrolled hypertension, which eventually may cause it to rupture. ✓ Adequate blood pressure control is essential in the prevention of an aneurysm and its rupture. ✓ Manifestations of a cerebral aneurysm include nausea, vomiting, severe headache, ataxia, and altered mental status. Choice A is incorrect. This is an expected finding and does not require immediate follow-up. Other manifestations associated with a flare-up of ulcerative colitis include abdominal cramping, fatigue, and manifestations consistent with fluid volume deficit. Choice C is incorrect. Indigestion is a common finding when an individual takes prednisone. Corticosteroids increase gastric acid secretion and may cause a client to experience indigestion and gastric reflux. This is not the nurses' initial priority. Choice D is incorrect. A manifestation of Bell's palsy is tinnitus. Bell's palsy also manifests as facial drooping, headache, decreased facial sensations, and tearing of the affected eye. This is an expected finding and does not require the nurses' immediate attention.

The nurse is caring for four clients on a medical-surgical unit. Which of the following tasks would be a priority for the nurse to complete? A. teaching a client scheduled for discharge how to ambulate with crutches B. witnessing informed consent for a client needing an emergency laparotomy C. irrigating a client's ostomy who reports abdominal cramping D. calculating the intake and output of a client with diabetes insipidus (DI)

Choice B is correct. Witnessing consent is within the scope of an RN. The client needing emergency surgery will require the RN's initial attention to avoid a delay in care. While the primary healthcare provider (PHCP) may override consent, this is usually reserved for clients who cannot communicate because of their condition. Additional Info ✓ Prioritizing patient care is central to functioning as a nurse. High-priority client situations include an unstable patient or reporting an acute change. The nurse should always address high-priority items and appropriately delegate intermediate to low-priority items, if necessary. ✓ Once the nurse knows all of their client's problems, they can determine the relationships among the problems. Setting priorities is a dynamic process and will change frequently. Highest priority is given to client and family caregiver safety. ✓ Problems can be clarified into three levels of priority: Assign high priority to first-level problems using ABC+VL (airway, breathing, cardiac and circulation problems, vital signs concerns, and life threatening lab values). Attend to these immediately. Second-level problems include concerns in mental status changes, untreated medical issues, acute pain, acute elimination problems, abnormal lab results, and risks. Lastly tend to third-level problems which include health problems other than those in the first two levels, such as long-term issues in health management, rest, and family coping. Choice A is incorrect. Discharge teaching is a low-priority task, and the nurse should focus on client situations of immediate concern. Choice C is incorrect. Irrigating an ostomy for a patient with abdominal cramping is a priority but does not override the client needing emergency surgery. Choice D is incorrect. Calculating intake and output is a low-priority task.

You are the nurse manager of the surgical acute care unit. You have noticed that several clients have almost been sent to the preoperative suite when they are not scheduled for a planned surgical procedure. Fortunately, no clients have gotten a "wrong surgery" because this possible error was caught in time. What is your priority action as the nurse manager? A. Praise the staff for catching these near misses before a surgical error occurs. B. Investigate and explore this near miss. C. Investigate and explore this medical error. D. Report the nature and frequency of these medical errors to the State Department of Health.

Choice B is correct. You, as the nurse manager of this surgical unit, should investigate and explore this near miss to prevent further medical errors in the future. This is your priority action. It's important to conduct near-miss investigations within 24 to 48 hours of the incident while memories are fresh about what happened and how the incident could have been prevented. Know these definitions: Near miss: A near miss is defined as "any event that could have had adverse consequences but did not and was indistinguishable from fully-fledged adverse events in all but outcome." In a near miss, an error was committed, but the patient did not experience clinical harm, either through early detection or sheer luck. In the above question, the clients have not undergone the wrong surgery and therefore, it's a near miss. Sentinel event: An unexpected occurrence involving death or serious physical/psychological injury. These events are called "sentinel" because they signal the need for immediate investigation and response. In the above question, the harm has not occurred. Therefore, it's not a sentinel event. Note that the terms "sentinel event" and "error" are not synonymous. Not all sentinel events occur because of an error and not all errors result in sentinel events. Choice A is incorrect. Although you should praise the staff for catching these near misses before a surgical error occurs, the priority is to investigate what led to the near miss. Choice C is incorrect. These near misses are not an actual medical error. Choice D is incorrect. These near misses are not an actual medical error, so it does not have to be reported to the State Department of Health.

The nurse cares for a client who intentionally overdosed on their prescribed lithium. The nurse plans on initially A. developing a therapeutic rapport with the client. B. inserting a peripheral vascular access device. C. obtaining the client's vital signs. D. collecting a serum lithium level on the client.

Choice C is correct. An overdose of lithium may be fatal if not treated. Lithium has a narrow therapeutic index (0.6-1.2 mEq/L, mmol), and manifestations of toxicity include gastrointestinal symptoms of nausea, vomiting, and diarrhea predominate, and neurologic symptoms are delayed. The neurological findings may consist of confusion, ataxia, and coarse tremors. Obtaining vital signs is a priority to determine the client's overall health status. Choice A is incorrect. Developing a therapeutic rapport with a client who has attempted suicide is key to the care. The client is vulnerable and often hopeless. The nurse should convey caring and empathy. This psychosocial need does not override the client's potential physical instability from a lithium overdose. Physical needs are prioritized over psychosocial needs. Choice B is incorrect. The nurse will need to insert a vascular access device but does not prioritize obtaining the client's vital signs. This is because if the client's pulse oximetry is low, the nurse must correct it before starting an IV. Choice D is incorrect. Collecting the client's lithium level will be helpful, but it would not prioritize obtaining the client's vital signs. The vital signs need to be obtained because they shed light on the client's immediate needs and assist in determining the client's current stability. A lithium level would not provide this information.

The nurse has been made aware of the following client situations. The nurse should first follow up with the client A. receiving a chemotherapy infusion who reports nausea and vomiting. B. newly diagnosed with polycystic kidney disease reporting hematuria and flank pain. C. being treated for aplastic anemia and has a temperature of 101.1° F (38.4° C). D. being treated for pulmonary tuberculosis and ambulating in the hallway wearing a surgical mask.

Choice C is correct. Aplastic anemia (AA) can cause a critically low neutrophil count because of the pancytopenia it induces. The low neutrophil count puts the client at risk for a life-threatening infection. The client's remarkable fever warrants prompt follow-up so the nurse may initiate measures such as blood culture collection, administer prescribed antibiotics and antifungals, and provide supportive measures such as antipyretics. Additional Info ✓ Aplastic anemia ranges in severity but causes a client to develop pancytopenia (low red blood cells; low white blood cells; low platelets) ✓ Life-threatening complications include bleeding due to thrombocytopenia, fatigue due to anemia, and serious infection because of neutropenia ✓ Treatment includes a stem cell transplant Choice A is incorrect. Chemotherapy-related nausea and vomiting are common side effects and require treatment with antiemetics and intravenous fluids. This is an expected occurrence. Choice B is incorrect. Polycystic kidney disease (PKD) has a cardinal feature of flank pain and hematuria. This is an expected finding and is treated with dry heat and acetaminophen. Choice D is incorrect. The client with pulmonary tuberculosis may ambulate while wearing a surgical mask. The healthcare worker must wear a respirator (N95 mask) when providing care to the client.

The emergency department (ED) nurse is caring for a client with suspected bacterial meningitis. The nurse should take which priority action? A. Notify public health services B. Dim the lights in the assigned room C. Obtain blood cultures D. Explore the client's feelings regarding the diagnosis

Choice C is correct. Bacterial meningitis is a medical emergency, and priority actions for the nurse are to assess the client's airway, breathing, and circulation; beyond the assessment of the ABCs and vital signs, the nurse should immediately establish a peripheral vascular access device and obtain blood cultures and laboratory work such as lactic acid and complete blood count. Lactic acid is a marker that may support the co-existing diagnosis of sepsis. The client will need an immediate lumbar puncture which will definitively exclude or confirm the diagnosis of bacterial meningitis. Considering this client has been diagnosed with bacterial meningitis, the nurse must collect blood cultures and then administer prescribed antibiotics that are aggressively dosed. Antibiotics commonly prescribed for bacterial meningitis include ceftriaxone and vancomycin. Additional Info ✓ Symptoms of meningitis classically have an abrupt onset and include headache, fever, nuchal rigidity, photophobia, and myalgias. ✓ The nurse should plan to isolate the client via droplet precautions. Interventions for meningitis include ✓ Close monitoring of the client's neurological status and prompt administration of prescribed antibiotics after the lumbar puncture and collection of blood cultures. Choices A, B, and D are incorrect. These are all actions the nurse should take when it comes to caring for a client with bacterial meningitis. Notifying public health services is required because it can be spread via infected droplets. A manifestation associated with bacterial meningitis is a significant headache and photophobia; thus, part of caring for the client is to dim the lights and provide a low-stimulation environment. However, that does not prioritize the collection of blood cultures and the administration of empiric antibiotics. Exploring the c

The nurse is triaging clients who were involved in a bus accident. Which client should be prioritized for transport to the local trauma center? A client who A. has pain and significant swelling in the right forearm with an intact distal pulse and sensation. B. has profuse bleeding from a chest laceration and is experiencing apnea. C. has a crushed leg reporting no sensation and has no distal pulse. D. is experiencing severe anxiety and has abrasions on both arms.

Choice C is correct. Because of their compromised circulation, this client would be red-tagged using the emergency triage tagging system (red, yellow, green, and black). Red tags require emergent care because of an immediate threat to their life. This client has a crushed leg with no distal sensation or pulse, significantly threatening their circulation. Thus, this client is prioritized for immediate evacuation to the nearest trauma center as a red tag. Additional Info ✓ Emergent (red tags) include life-threatening injuries, including obstruction to the airway, severe hemorrhage, or shock. Immediate treatment is necessary. ✓ Urgent (yellow tags) include alterations in blood glucose (hypoglycemia), disorientation, and large wounds that need treatment within 30 minutes to 2 hours. ✓ Nonurgent (green tags) include minor injuries such as strains, sprains, simple fractures, or abrasions. Treatment may be delayed up to four hours. Choice A is incorrect. Pain and swelling are expected with a potential fracture. This client is a green tag because the distal pulse and sensation are present. Choice B is incorrect. The client who is experiencing apnea would be a black tag. A black tag is assigned when death has occurred or is imminent. An individual with apnea signifies death or impending death. Thus, the nurse should focus on the immediate (red tag) client with a crushed leg with no distal sensation or pulse. Green-tagged injuries include closed fractures, sprains, strains, abrasions, and contusions. Choice D is incorrect. The client experiencing severe anxiety and abrasions to the arms would be classified as a green tag. Nothing in this client's situation suggests a physiological injury that needs to be seen immediately.

The nurse is reviewing laboratory data for assigned clients. Which laboratory result requires immediate follow-up with the primary healthcare provider (PHCP)? A. Elevated amylase result in a client diagnosed with acute pancreatitis B. Elevated white blood cell (WBC) count in a client with an infected leg wound. C. Urinalysis positive for leukocytes and nitrites for a client receiving chemotherapy D. Serum glucose of 235 mg/dL (13.05 mmol/L) [70-110 mg/dL, 4.0-11.0 mmol/L] in a client with diabetes mellitus (type one)

Choice C is correct. Chemotherapy agents increase clients' risk of infection due to immune suppression, specifically by decreasing neutrophils. Neutropenia, a reduction in the blood neutrophil count, is common in chemotherapy clients. The client's risk of bacterial and fungal infections increases with worsening neutropenia. Furthermore, if a bacterial or fungal infection occurs, the infection's likelihood of spreading to other parts of the body increases. Early antibiotic intervention may prevent sepsis. In a urinalysis, the presence of leukocytes and nitrites is indicative of a urinary tract infection. This result should alert the nurse regarding a potential urinary tract infection in this immunocompromised client, warranting the nurse to notify the PHCP of the result so a complete blood count (CBC) can be obtained and antibiotic therapy may be initiated immediately. Additional Info ✓ Neutropenia predisposes the client to bacterial and fungal infections. ✓ The risk of infection is proportional to the severity of neutropenia, with clients with severe neutropenia [absolute neutrophil counts < 500/mcL (< 0.5 × 109/L)] at the most significant risk. ✓ Febrile neutropenic clients are typically treated with broad-spectrum antibiotics pending definitive identification of the infection. ✓ Antibiotic prophylaxis may be indicated for some high-risk clients. Choice A is incorrect. An elevated amylase result in a client diagnosed with acute pancreatitis is an anticipated finding and would not warrant reporting the result to the PHCP. Choice B is incorrect. In a client diagnosed with an infected leg wound, an elevated white blood cell count (leukocytosis) is an anticipated finding. Leukocytosis usually occurs in response to infection, trauma, or inflammation. Since this client is known to be septic, the leukocytosis is an expecte

The nurse in the emergency department (ED) is reviewing triage data for assigned clients. The nurse should initially follow-up on the client who A. is requesting screening for pulmonary tuberculosis after traveling domestically in the United States. B. is being treated for a diabetic foot ulcer and requires a dressing change. C. is pregnant and has a fever accompanied by a generalized vesicular rash. D. is concerned they may have acquired human immunodeficiency virus (HIV) following unprotected sexual activity.

Choice C is correct. Chickenpox (Varicella) is transmitted airborne and can be easily transferred to other clients in the emergency unit. The pregnant woman with suspected varicella who is symptomatic (vesicular rash and febrile) should be isolated right away from other clients through placement in a negative pressure room. If this is not available, the client should be instructed to wear a surgical mask while in the waiting room. Maternal varicella infections are serious because the infant is at risk of developing congenital varicella syndrome. Additional Info ✓ Suspected cases of varicella (chickenpox) should be isolated using contact + airborne precautions. ✓ Precautions should be maintained until the lesions dry and crusted. Choice A is incorrect. International travel is a significant risk factor for pulmonary tuberculosis. Domestic travel in the United States is not a risk factor. Pulmonary tuberculosis is higher in certain areas such as India, China, and Indonesia. Choice B is incorrect. For a client with a diabetic foot ulcer, a specific dressing may need to be applied. Nothing in this item indicates that the wound is infected, requiring transmission-based precautions. Choice D is incorrect. For a client concerned they may have contracted HIV, the client may be a candidate for receiving postexposure prophylaxis. This will not prioritize the client at risk of transmitting varicella to other individuals.

The nurse is caring for assigned clients. The nurse should first A. administer acetaminophen to a client with a temperature of 101.1° F (38.4° C). B. complete pin care for a client with a halo fixation device. C. administer diazepam for a client with delirium tremens (DTs). D. insert an indwelling urinary catheter for a client with retention.

Choice C is correct. Delirium tremens (DTs) is a severe form of alcohol withdrawal. This prescription/order should be implemented immediately, as the risk of seizure activity is quite significant. Additional Info ✓ Delirium tremens (DTs) is the most severe form of alcohol withdrawal. ✓ Manifestations of DTs include disorientation, hyperthermia, psychomotor agitation, hypovolemia, hallucinations, hypertension, and seizure activity. ✓ To prevent seizure activity and mitigate agitation, benzodiazepines are commonly used. ✓ Maintenance dosing of benzodiazepines may be used along with PRN dosing for additional mitigation of symptoms. ✓ DTs occur within 48 to 96 hours following the last alcoholic drink. Choice A is incorrect. This client has a fever and should receive the prescribed antipyretic medication. This would not be prioritized over the client experiencing severe alcohol withdrawal, who has a very high risk for seizure. Choice B is incorrect. Completing pin care and dressing changes is a low priority. The nurse should focus on the client at high risk for seizure activity. Choice is D incorrect. The nurse should focus on preventing potentially lethal seizure activity for the client experiencing delirium tremens. Inserting an indwelling catheter would require considerable time and is a low priority.

The nurse has received the following prescriptions for newly admitted clients. Which medication should the nurse administer first? A. Subcutaneous (SubQ) epoetin for anemia B. By-mouth (PO) oxycodone pain C. Intravenous (IV) fluids for sepsis D. Intramuscular (IM) hydroxyzine for anxiety

Choice C is correct. IV fluids indicated for sepsis are crucial to administer. The nurse must understand that sepsis protocol includes timely fluid and antibiotic administration. Based on their diagnosis, this client is the most critical client, and the nurse should prioritize this medication. Additional Info Sepsis can be life-threatening and may progress to shock if the patient is not treated promptly. Isotonic fluid boluses and appropriate antibiotics are a staple in sepsis treatment. The nurse must implement these interventions quickly to avoid the client experiencing deterioration. Choices A, B, and D are incorrect. The other choices are not a priority as epoetin will take weeks for full therapeutic benefit. Further, by-mouth pain control will take some time for onset. Finally, the diagnosis of anxiety will not prioritize over the physiological threat of sepsis.

The nurse is caring for an infant who is experiencing a tetralogy of Fallot (tet) spell. Which of the following is the nurse's priority action? A. Administer propranolol B. Administer sodium bicarbonate C. Calm the infant D. Notify the healthcare provider

Choice C is correct. Immediately calming the infant is the nursing priority during a tet spell. While the infant is crying, their pulmonary vascular resistance is increasing leading to decreased oxygenated blood and more cyanosis. By calming them down you will immediately be decreasing their pulmonary vascular resistance so that blood can flow to the lungs and provide oxygen to the body. This is the first action that the nurse should take. Additional Info ✓ Tetralogy of Fallot is a congenital heart defect characterized by a combination of four specific heart abnormalities. Ventricular Septal Defect (VSD) Pulmonary Stenosis Right Ventricular Hypertrophy Overriding Aorta ✓ These structural abnormalities result in a condition where oxygen-poor blood from the right side of the heart is pumped into the aorta and circulates throughout the body. As a consequence, insufficiently oxygenated blood reaches the body's tissues. ✓ Promptly notify the healthcare provider of the Tet spell to ensure timely intervention. ✓ Document the episode, interventions performed, and the infant's response. Accurate and timely documentation is essential for continuity of care. Choice A is incorrect. While propranolol may be used in children with tetralogy of Fallot, it will not be the priority nursing action for the infant experiencing a tet spell. It will be given much later if necessary. Choice B is incorrect. Sodium bicarbonate may be needed at some point during a tet spell if it is not resolving, but would not be indicated as soon as it starts and would not be the priority nursing action. Choice D is incorrect. While the nurse will need to notify the healthcare provider of the spell and may need additional assistance, this still isn't the priority action. There is another action listed that will immediately help the infant and should be the p

The charge nurse has received a change-of-shift report on the following clients in the maternity unit. The nurse should first assess the client who A. delivered a term newborn 2 days ago and reports sweating and increased urinary frequency. B. is 15 weeks pregnant and is being treated for hyperemesis gravidarum and reports increased nausea following a meal. C. is 32 weeks pregnant and admitted 2 hours ago with placenta previa, who reports increased lower back pain. D. is in the first stage of labor, and the most recent fetal heart rate pattern showed early decelerations.

Choice C is correct. This client requires immediate assessment because of the report of increased lower back pain, which is an ominous suggestion of abruptio placentae. The client already has placenta previa, and constant surveillance for abruptio placentae is the standard of care. Signs and symptoms of abruptio placentae include - uterine tenderness, uterine irritability, vaginal bleeding, abdominal or low back pain. Additional Info ✓ Placental abruption (also called abruptio placentae) describes the separation of the placenta prior to delivery. ✓ Placental abruption can present as either incomplete (partial detachment of placental) or complete (full detachment of placental). Incomplete placental abruption causes internal bleeding due to the pooling of blood behind the placenta. Complete placental abruption is extremely painful and causes significant external bleeding. ✓ Placental abruption poses a risk to both the mother (hemorrhage, hypovolemic shock, clotting issues) and the fetus (asphyxia, blood loss, prematurity). Choice A is incorrect. Diaphoresis and diuresis following the delivery of a newborn are common findings. This is because the body is ridding itself of the excessive plasma volume. This client does not require immediate follow-up because it is expected. Choice B is incorrect. Hyperemesis gravidarum (HEG) is characterized as persistent, uncontrollable vomiting that begins in the first weeks of pregnancy and may continue throughout pregnancy. HEG may have serious consequences if untreated because it may cause maternal dehydration and malnutrition. This client is not the priority because nausea following a snack is consistent with HEG. The nurse should focus on the client manifesting symptoms of abruptio placentae. Choice D is incorrect. Early decelerations are benign, and this client does not require im

The nurse in the emergency department (ED) is caring for a client admitted with diabetic ketoacidosis (DKA). Which clinical data requires immediate follow-up? A. Respiratory rate (RR) 23/minute B. Capillary blood glucose 319 mg/dL (17.70 mmol/L) [70-110 mg/dL, 4.0-11.0 mmol/L] C. Mean arterial pressure (MAP) 51 mm Hg D. PaO2 90 mm Hg [80-100mm Hg]

Choice C is correct. This client's mean arterial pressure (MAP) is critically low. The MAP for an adult should be at least 60 mm Hg (this will ensure adequate perfusion to critical organs), with the ideal MAP being 70 mm Hg. This client's MAP requires immediate correction because of the end-organ damage the client is likely experiencing. Additional Info ✓ DKA is a medical emergency that requires emergent treatment. ✓ This complication is exclusive to those with type I diabetes mellitus. A client with diabetes mellitus (type two) rarely develops DKA. ✓ Manifestations of DKA include hyperglycemia, fluid volume deficit, lethargy, tachypnea, and metabolic acidosis. ✓ The treatment goals for a client with DKA include repleting critically lost volume and normalizing the blood glucose. ✓ Achieving both would help correct the underlying metabolic acidosis. ✓ Isotonic saline replacement is utilized initially, and then once the blood glucose approaches 250 mg/dL (13.88 mmol/L) to 300 mg/dL (16.65 mmol/L), the fluids change to 5% dextrose and 0.45 saline with potassium additive. ✓ Monitoring parameters include hourly blood glucose and the client's potassium. Choice A is incorrect. A slightly elevated respiratory rate may be expected in a client with DKA due to metabolic acidosis. While it should be monitored, it does not require immediate follow-up unless it becomes significantly abnormal. Choice B is incorrect. Elevated blood glucose levels are a characteristic feature of DKA and require treatment, but they do not necessitate immediate follow-up as long as the client is receiving appropriate interventions to lower blood glucose levels. Choice D is incorrect. A PaO2 level of 90 mm Hg falls within the normal range and indicates adequate oxygenation. While it should be monitored, it does not require immediate follow-up unless it

The nursing student inserts an indwelling urinary catheter for a female patient prior to surgery. Which of the following would require immediate intervention by the RN? A. The patient states she feels the need to urinate. B. Patient reports a pinching sensation as the catheter is advanced. C. The student nurse notes resistance when inflating the balloon. D. The student separates the labia majora and labia minora with non-dominant hand.

Choice C is correct. This may indicate the balloon is within the urethra, not the bladder. If inflated within the urethra, the balloon may cause significant damage. Any complaints or nonverbal signs of discomfort or resistance is noted by the nurse during balloon inflation, are indications to stop this procedure immediately. Choice A is incorrect. The patient may feel the urge to void as the catheter is advanced through the internal urethral sphincter, this would not be a reason to stop the procedure. Choice B is incorrect. The student nurse should explain to the patient that she may feel pressure upon catheter insertion. A brief pinching sensation indicates the catheter is passing through the internal urethral sphincter and would not be a reason to stop the procedure. Choice D is incorrect. This action is appropriate. The student should use the non-dominant hand to position the patient and the dominant hand should remain sterile for insertion.

The nurse is caring for a client experiencing an acute episode of vertigo. Which of the following actions would be a priority for the nurse? A. Instruct the client to avoid sudden, jerky movements. B. Request a prescription for an antihistamine. C. Raise the upper side rails of the client's bed. D. Assess the client for nausea and vomiting.

Choice C is correct. Vertigo places the client at a high risk for falls. The priority for the nurse is to promote client safety, and doing so for a client with vertigo would be by raising the upper side rails to reduce their risk for falls. Additional Info ✓ Vertigo is characterized as a sense of whirling or turning in space. ✓ Many conditions may cause vertigo, including dehydration and inner ear disorders. ✓ A client with vertigo has a significant fall risk, and the nurse should mitigate this risk with fall precautions and frequent reinforcement to call for assistance before the client gets out of bed. Interventions for a client experiencing vertigo include ✓ Fall precautions ✓ Propping the client's head up with additional pillows (may decrease the sensation) ✓ Avoid any sudden or jerky movements, especially with the head ✓ Administer medications, such as anticholinergics, as prescribed Choice A is incorrect. This is a correct statement to make to a client with vertigo. However, this does not prioritize reducing the client's high risk of falling. Choice B is incorrect. Antihistamine medication (diphenhydramine, cetirizine) may treat certain types of vertigo. This action does not prioritize keeping the client safe from falls and injuries. Choice D is incorrect. Associated symptoms of vertigo include nausea and vomiting. This assessment does not prioritize keeping the client safe from falls and injuries.

The charge nurse is observing a newly hired nurse caring for a client who sustained a closed head injury, is receiving mechanical ventilation, and is at risk for developing increased intracranial pressure (ICP). In this situation, which of the following actions, if performed by the newly hired nurse, would require immediate intervention? A. Suctioning the client when the high-pressure alarm sounds. B. Hyperventilating with 100% FiO2 prior to suctioning. C. Performs oral care every 2 hours D. Maintaining the head of the client's bed more than 90 degrees.

Choice D is correct. Maintaining a client's head of the bed at more than 90 degrees is detrimental for a client with a traumatic brain injury (TBI). The client should avoid hip and neck flexion as this raises ICP. While elevating the head end of the bed beyond 30 degrees may drop the ICP further, it can also cause an unwanted drop in the mean arterial pressure (MAP). A decrease in MAP reduces cerebral perfusion pressure (CPP). A fall in CPP is detrimental to the client with a TBI. Therefore, the head of the bed recommendation for a client with a risk for increased ICP is 30 degrees. Such an angle decreases the ICP while maintaining adequate CPP around 70 to 80 mm Hg. In this scenario, the head of the bed elevation is also necessary to prevent the client from developing ventilator-acquired pneumonia. Additional Info ✓ When caring for a client with a TBI, the nurse should maintain a low-stimulating environment. The client should be positioned with the neck midline with their body. ✓ The earliest indicator of a client having increased ICP is alterations in the level of consciousness. ✓ If the client has an ICP monitoring device in place, ensure it is properly zeroed and leveled. Monitor ICP readings closely and report any deviations from the baseline. ✓ Maintain strict fluid balance to prevent fluid overload, as excessive intravascular volume can contribute to increased ICP. Choice A is incorrect. Suctioning is a necessary procedure for clients with artificial airways. Suctioning the client when the high-pressure alarm sounds is an appropriate intervention. A high-pressure alarm is triggered when an obstruction is evident in the tubing. Not intervening immediately may cause airway compromise and put the client at risk of death. While suctioning may cause an increase in the ICP Choice B is incorrect. Hyperventilating wit

The nurse has become aware of the following client situations. The nurse should first follow up with which client? A client A. with a chest tube that has tidaling in the water seal chamber. B. that is receiving mechanical ventilation and is occasionally biting on the tube. C. that is receiving albuterol via a nebulizer and reports headache and nervousness. D. with pneumonia that has become restless and confused.

Choice D is correct. One of the dreaded complications of pneumonia is acute respiratory distress syndrome (ARDS) which is manifested by hypoxia. The client demonstrating confusion and restlessness is quite concerning for hypoxia. The nurse should quickly assess the client and intervene by calling a rapid response if this should occur in the acute care setting. Additional Info ✓ For a client with pneumonia, the nurse must constantly monitor for ARDS since this syndrome is characterized by an inflammatory injury to the lungs. Classic findings include hypoxemia, progressive dyspnea, and adventitious lung sounds. ✓ Medical treatment includes positive airway pressure with oxygen, prone position, glucocorticoids, glucose control, and antimicrobials or antivirals. ✓ The prone position is preferred because this position improves ventilation in the dorsal region of the lung, therefore improving oxygenation. Choice A is incorrect. Tidaling in the water seal chamber is a normal finding when a client has a chest tube. Choice B is incorrect. Biting on an endotracheal tube is a common finding and does require follow-up as the client could be in pain. Choice C is incorrect. Headache and nervousness are common effects associated with albuterol treatments.

The nurse is caring for a patient recovering from cardiac catheterization via the right femoral artery. The nurse notes stable vitals one hour after the procedure but cannot palpate the patient's right pedal pulse. Which action would be the nurse's highest priority? A. Assess bilateral lower extremity capillary refill B. Notify the physician C. Place bed in Trendelenburg D. Recheck pedal pulse with doppler

Choice D is correct. Peripheral pulses may be diminished following cardiac catheterization, but the complete absence of a pulse indicates a serious complication. If unable to palpate the patient's pulse, the nurse's priority action should be to attempt to locate it with a doppler. Choice A is incorrect. This assessment data would not be a priority for treatment/intervention. If the pulse remains absent upon doppler examination, the nurse can expect the patient's circulation will be compromised. Choice B is incorrect. Pulses may be diminished following this procedure, but non-palpable pulses may be heard with the doppler. In the absence of any patient distress, the nurse should first evaluate the pulse distal to the incision site with a doppler before notifying the physician. Choice C is incorrect. This position (supine with both feet elevated 15-30 degrees above head) is appropriate for patients with a low pulse due to vagal nerve stimulation. This action would not address this patient's problem of a non-palpable pulse.

The nurse is caring for assigned clients. The nurse should initially A. evaluate a client's Mantoux tuberculin skin (TB) for reactivity 48 hours after it has been administered. B. assess a client with atrial fibrillation who has an irregular pulse (P) of 90 beats/minute. C. apply the prescribed lidocaine patch to the lumbar back region of a client with chronic back pain. D. administer prescribed ciprofloxacin scheduled for a client with peritonitis.

Choice D is correct. Peritonitis is a life-threatening infection that has a high mortality rate if it is not treated early and aggressively. It is appropriate for the nurse to prioritize this client because of their acute status. Finally, scheduled antibiotics must be administered on time so the client maintains a therapeutic blood level of the medication. Additional Info ✓ Peritonitis is a life-threatening infection that may originate from a ruptured appendix, perforated intestine, peritoneal dialysis catheter, and ascites. ✓ Abdominal rigidity, abdominal tenderness, fever, and tachycardia suggest this infection. ✓ Exploratory laparotomy and the aggressive administration of antibiotics are standard treatments. ✓ This infection can quickly progress to septic shock. Choice A is incorrect. The nurse has 48-72 hours to determine the reactivity of a Mantoux tuberculin skin test. This type of testing for pulmonary tuberculosis is not the most accurate (sputum culture is the most accurate) and has a window of time to be read. This does not prioritized over the acute need to administer a scheduled antibiotic. Choice B is incorrect. Atrial fibrillation causes an individual to have an irregular pulse. This client's situation is stable as long as the rate is maintained between 60 and 100 beats/minute. Choice C is incorrect. Chronic back pain would not be prioritized over the client with peritonitis, which is an acute, life-threatening infection that requires aggressive medical and possible surgical management.

The nurse has become aware of the following client situations. The nurse should first assess the client A. with chronic obstructive pulmonary disease (COPD), who is using pursed-lip breathing and reporting a productive cough. B. who had a laparoscopic cholecystectomy three hours ago and is reporting right shoulder pain and abdominal cramping. C. with ulcerative colitis, who had three bloody stools in the past two hours and reporting abdominal cramping. D. two hours postoperative following a tonsillectomy and is reporting throat pain while vomiting.

Choice D is correct. The client's vomiting following a tonsillectomy requires immediate follow-up because vomiting and coughing may trigger hemorrhage. This client requires immediate follow-up so the nurse may treat the vomiting with prescribed anti-emetics and assess the client for potential hemorrhage. Additional Info ✓ Following a tonsillectomy, the nurse should discourage coughing as this may stress the operative site and lead to hemorrhage ✓ Nausea and vomiting following a tonsillectomy should be promptly treated to prevent stress to the operative that may lead to hemorrhage Choices A, B, and C are incorrect. A client with COPD experiencing a productive cough and experiencing pursed-lipped breathing is an expected finding. Further, coughing indicates a patent airway. This client does not require immediate follow-up. A client recovering from laparoscopic procedures will likely have abdominal cramping and shoulder pain because of gastric insufflation (the process of instilling air or carbon dioxide into the abdominal cavity to visualize the abdominal organs); this is often relieved by having the client ambulate. An exacerbation of ulcerative colitis often causes a client to have multiple bloody stools accompanied by abdominal cramping. This is an expected finding.

A 30-year old patient presents to the Emergency Department with alcohol withdrawal seizures. The psychiatry nurse understands that the patient will soon be admitted to the non-medical psychiatric care unit. To keep this patient safe, the nurse must perform which priority nursing action? A. Ask the physician for a clonazepam prescription, an anxiolytic that may help with the withdrawal symptoms. B. Ensure that a working IV pump is set up at the patient's bedside. C. Order a STAT arterial blood gas (ABG). D. Pad the side rails of the patient's assigned bed.

Choice D is correct. The patient presented with alcohol withdrawal seizures. The priority nursing action is to pad the patient's bed's side rails to prevent injury since the patient is at high risk of a recurrent seizure. In an acute care setting, side rails are often used as a medical assistive device and not a restraint. Side rails are considered a restraint only if the intent is to prevent the patient's free access and keep them in bed. In the setting of seizure precautions, side rails are raised, and the bumper pads are used as a medical assistive device. Choice A is incorrect. While clonazepam may help with the anxiety associated with alcohol withdrawal, it is not the drug of choice in managing alcohol withdrawal. Instead, diazepam, lorazepam, and chlordiazepoxide are used most frequently to treat or prevent alcohol withdrawal. Furthermore, providing the patient with this medication is not the priority action in patient safety. Choice B is incorrect. Since the patient will be admitted to a non-medical psychiatry floor, continuous intravenous infusion is not permitted while on that unit. However, necessary injections, oral medications, or other non-invasive procedures are performed while on the non-medical unit. Choice C is incorrect. Ordering a STAT arterial blood gas is not necessary when the patient arrives at the psychiatry unit. Before the patients are sent to the non-medical psychiatry floor, they are already deemed clinically stable and medically cleared.

The nurse in the emergency department (ED) is triaging clients. The nurse should immediately follow up on the client who A. is being treated for depression and is requesting a refill of the prescribed antidepressant. B. is receiving external-beam radiation for breast cancer and reports blistering at the site. C. fell while riding their bicycle and has bruising and abrasions to the right upper extremities. D. reports left testicular pain and swelling with nausea and vomiting.

Choice D is correct. This client is demonstrating manifestations of testicular torsion, which is highly concerning. Testicular torsion, if not treated promptly, can result in nonviability of the affected teste. The client needs an immediate scrotal ultrasound to confirm these findings, followed by surgical intervention. Additional Info ✓ Testicular torsion is a medical emergency that can result in the loss of viability of a teste if not treated promptly ✓ Manifestations usually occur abruptly and include testicular pain that may radiate to the lower abdomen ✓ The affected testicle is typically hardened, swollen, and tender to touch ✓ Nausea and vomiting may be present with this condition ✓ Immediate diagnostic testing of a testicular ultrasound is necessary to confirm this emergency ✓ Surgical intervention is necessary to treat the torsion Choice A is incorrect. A client requesting a medication refill from the emergency department is a low priority. The nurse needs to prioritize physical needs. Choice B is incorrect. Adverse reactions to external beam radiation include an impairment in skin integrity. Medicated ointments may be prescribed to treat the affected area. This is a low priority. Choice C is incorrect. Bruising and abrasions following a bicycle crash are expected. This client would likely be the next assisted with treatment following the client's intervention with testicular torsion.

The nurse is caring for a client with suspected sepsis. After reviewing the client's vital signs, which prescription by the primary healthcare provider (PHCP) should the nurse administer first? See the images below. A. Ceftriaxone B. Doxycycline C. Acetaminophen D. 0.9% sodium chloride (normal saline) bolus

Choice D is correct. This client is in shock. A blood pressure of 90/60 mm Hg is clinical hypotension combined with the client's tachycardia. The client needs immediate fluid volume resuscitation to prevent further clinical decline. Sepsis is a medical emergency, and the client will require prompt antibiotics. Still, it will not prioritize treating the client's hypovolemia which is the immediate concern illustrated by the low blood pressure. Additional Info ✓ Treatment goals for a client with septic shock include the following Optimal perfusion as demonstrated by a MAP ≥ 65 mmHg. Normal respiratory rate, pulse, temperature, pulse oximetry, mentation, and urine output. Prompt collection of blood cultures. Prompt administration of antibiotics. Clearance of lactic acid. A falling lactic acid indicates a favorable response to fluids and oxygenation. Lactic acid is produced when tissue is not being perfused. A serum lactic acid level of 2 mmol/L or greater may indicate the severity of sepsis. ✓ Besides vital signs like blood pressure and heart rate, the nurse should assess the client for other signs and symptoms of sepsis, including fever or hypothermia, altered mental status, increased respiratory rate, and laboratory findings such as an elevated white blood cell count and abnormal blood gases. ✓ Collecting blood cultures and other relevant cultures before administering antibiotics is crucial for identifying the causative microorganism and guiding antibiotic selection. Choice A is incorrect. Antibiotics are a critical component of sepsis management. However, administering antibiotics should typically follow initial fluid resuscitation in sepsis cases. Fluid resuscitation helps improve blood pressure and tissue perfusion, allowing antibiotics to work more effectively. Choice B is incorrect. In sepsis cases, antibiotics ar

The nurse has been made aware of the following client situations. The nurse should first assess the client A. with chronic obstructive pulmonary disease (COPD) who has an oxygen saturation of 90%. B. being treated for hypertension and has a blood pressure of 151/95 mm Hg and complaints of a headache. C. with a urinary catheter in place who is experiencing fever and chills. D. with a chest tube attached to a closed-chest drainage system that reports the onset of dyspnea.

Choice D is correct. This client requires immediate follow-up because of the development of dyspnea. The dyspnea may indicate various complications, such as dislodgment or chest tube drainage system malfunction. Dislodging the chest tube can worsen the client's condition and lead to complications such as a tension pneumothorax. The nurse should always have emergency chest tube supplies at the bedside, including a clamp, occlusive gauze, and a bottle of saline (or sterile water). Additional Info ✓ Indications for a chest tube include Removal of an air collection in the pleural space. Removal of fluid collection or accumulation between visceral and parietal pleura Use as a delivery conduit to introduce medication or fluid into the pleural space ✓ Proper technique for chest tube removal is critical for preventing recurrent pneumothorax. The thoracostomy site needs to be kept occluded during the removal and an occlusion dressing needs to be placed over the site immediately. ✓ Chronic obstructive lung disease is a lung disease characterized by lung airflow limitation and can be from exposure to harmful substances. Choice A is incorrect. The client has an acceptable oxygen saturation level of 90%, given that the client has COPD. An oxygen saturation of 88% or greater is generally acceptable. Choice B is incorrect. The client with a blood pressure of 151/95 mm Hg has a high blood pressure reading; however, this client is being treated for hypertension. The headache could be related to elevated blood pressure, but the client is not presenting with acute distress or severe symptoms. Choice C is incorrect. The client with an indwelling urinary catheter experiencing fever and chills is concerning for urosepsis. However, the client with a chest tube reporting dyspnea prioritizes this client because of the problem related to the

The emergency department nurse cares for a client who sustained multiple rib fractures and a nasal fracture from a motor vehicle crash. Which assessment finding requires immediate follow-up? A. shallow respirations B. chest pain with repositioning C. bruising on the chest D. vomiting

Choice D is correct. This client sustained a nasal fracture caused by facial trauma, which may have consequently caused brain trauma. Vomiting is an early manifestation of increased intracranial pressure requiring immediate follow-up. The nurse should notify the physician of the condition change and prepare the client for an immediate computed tomography (CT) scan of the head to confirm the findings. Interventions the nurse should take are keeping the client's head of the bed elevated between 30-45 degrees and the client's head neutral. This may help mitigate some of the increasing ICP. Other findings associated with increased ICP include restlessness, altered level of consciousness, and headache. Additional Info ✓ Rib fractures are quite painful and are commonly caused by chest trauma from a motor vehicle accident or physical assault ✓ A concern following rib fractures is that the client may develop pneumothorax (tachypnea, diminished or absent breath sounds, hypoxia) ✓ Treatment of rib fractures is prescribed anti-inflammatories, ice, and incentive spirometry because of the increased risk of atelectasis Choices A, B, and C are incorrect. Shallow respirations are commonly expected following any chest trauma. The pain the client experiences with inspiration causes a shallow breathing pattern. This suggests to the nurse that the client may need prescribed pain medication but does not require immediate follow-up. Please note shallow breathing does not mean hypoxia. A client may breathe shallowly and may adequately oxygenate. Respiratory acidosis may develop because the client is less inclined to take a full exhalation because of the pain-causing increased carbon dioxide. While rib fractures may cause a pneumothorax, tachypnea with increased respiratory effort is classically observed. Chest pain with repositioning is al

The emergency department (ED) nurse is triaging clients in the ED. It would be appropriate for the nurse to triage which client as nonurgent? A client Select all that apply. with a localized abscess on the right leg. reporting that they have chest pressure. with nausea, vomiting, and painful urination. requesting a refill of their prescribed antidepressant. with a single laceration to the left hand.

Choices A, D, and E are correct. These client situations require a triage of non-urgent. The non-urgent triage category signifies that the client can be placed in the waiting area for a set of times without risking clinical deterioration. Additional Info The emergent triage category implies that a condition exists that poses an immediate threat to life or limb. Conditions that should be triaged as emergent include: active hemorrhage, unstable vital signs, significant trauma, chest pain, and manifestations of a stroke. The urgent triage category indicates that the client should be treated quickly but that an immediate threat to life does not exist at the moment. Conditions that typically fall into the urgent category are those with a new onset of pneumonia (as long as respiratory failure does not appear imminent), renal colic, abdominal pain, complex lacerations not associated with major hemorrhage, displaced fractures, or dislocations, and temperature higher than 101°F (38.3°C). Those triaged as non-urgent can generally tolerate waiting several hours for health care services without a significant risk for clinical deterioration. Conditions within this classification include clients with sprains and strains, simple fractures, general skin rashes, and uncomplicated urinary tract infections. Choices B and C are incorrect. A client reporting chest pressure should be triaged as emergent as they need to be evaluated by a primary healthcare provider (PHCP) immediately. Nausea, vomiting, and pain with urination are suggestive of renal colic, which should be triaged as urgent.

The emergency department (ED) nurse cares for a client who just arrived with a major thermal burn to 22.5% of the total body surface area (TBSA). Which actions should the nurse perform? Place the actions below in the appropriate order that the nurse should perform. 1. Assess the client's airway, breathing, and circulation and obtain vital signs 2. Administer supplemental oxygen if indicated and cover burns with sterile gauze 3. Establish a large bore peripheral vascular access device to unburned skin 4. Administer prescribed isotonic fluids intravenously to maintain fluid balance 5. Insert an indwelling urinary catheter to maintain urinary output 0.5 mL/kg/hr 6. Administer tetanus prophylaxis as prescribed

Explanation For a client experiencing a major thermal burn, the nurse should assess the client's airway, breathing, and circulation and obtain vital signs. This is crucial in determining the client's hemodynamic status and will point the nurse toward where to prioritize treatment. Once the assessment is completed, the nurse should administer supplemental oxygen if indicated and cover burns with sterile gauze. The nurse should remove any jewelry to affected extremities as swelling is likely to occur. Keeping the wound covered with sterile gauze will reduce infection. The nurse must establish a large bore peripheral vascular access device to unburned skin. This is essential to obtain blood for laboratory work and to provide fluids. An isotonic fluid replacement will be necessary for such a significant thermal burn. Once the peripheral vascular access device is established, the nurse will administer prescribed isotonic fluids intravenously to maintain fluid balance. This client sustained a major thermal burn to 22.5% of their body, and isotonic fluid replacement will be necessary. The nurse should then place an indwelling urinary catheter to determine the effectiveness of the fluid replacement. This step needs to occur after administering the IV fluids because the administration of these fluids is crucial to maintaining the client's hemodynamic stability. The goal is to have the client's urinary output be 0.5 mL x their weight in kilograms per hour. For example, if the client weighs 120 kilograms, the client's hourly UOP should be 60 mL/hr. The Parkland formula may be used to guide fluid replacement therapy. Finally, prescribed tetanus prophylaxis is administered because, for a major thermal burn, the wound bed serves as a reservoir for the client getting this bacterial infection. This step is not prioritized over measur

The nurse at the summer camp is caring for a child who sustained a compound fracture of the arm following a fall. Place the following actions in order of nursing priority when dealing with this injury: 1. Assess the injury while calling for help 2. Cover the open wound with a clean dressing 3. Elevate the arm 4. Apply an ice pack to the site around the fracture

Explanation A compound fracture (open fracture) is a fracture with bone fragments protruding through the skin. Because there's an open wound or skin breach near the fracture site, bacteria can enter the wound and lead to infection. It is essential to treat the open fracture early to prevent infection. The infection can progress to osteomyelitis ( bone infection) if not addressed. The following are the steps in addressing an open fracture:- Assess: As always, the priority nursing action is to assess the extent of the injury. The nurse should also assess for any neurovascular compromise and immobilize the extremity. Protect: The nurse should cover the open wound with a sterile dressing to prevent infection. A clean dressing is acceptable if a sterile dressing is not available. Apply pressure over the surrounding wound, not over the protruding bone. Elevate: Elevate the arm to reduce the swelling; however, this may have to be done carefully in an open fracture setting without greatly mobilizing fracture fragments. Apply an ice pack to the site above and around the fracture. Avoid applying ice directly to the skin because it may cause skin damage. Also, care should be taken not to contaminate the open wound. These nonpharmacological interventions will reduce swelling and pain while waiting for help. The child will need to be transported to the nearest hospital for possible surgery and casting of the extremity.

The nurse is caring for a group of clients. Which client should the nurse see first? Place the clients in order based on the priority that the nurse should see them. 1. A 65-year-old newly admitted client with acute coronary syndrome (ACS) who is receiving a heparin infusion. 2. A 46-year-old client two days post-operative from a vaginal hysterectomy reporting burning at the indwelling catheter site. 3. A 31-year-old client three days post-operative who requires a sterile dressing change. 4. A 51-year-old client who has a discharge prescription following a heart failure exacerbation and has questions.

Explanation The nurse should prioritize seeing the client with acute coronary syndrome (ACS) who is receiving a heparin infusion first. This is because ACS is a life-threatening condition that requires close monitoring and prompt intervention. The heparin infusion also requires frequent monitoring to ensure that the client is receiving the appropriate dose and to detect any signs of bleeding. The site should be assessed and this medication would need to be verified between the oncoming and off-going nurse. The client, who is two days post-operative, reporting burning at the urinary catheter site, should be assessed next. This could indicate a urinary tract infection or other complication related to the catheter and needs to be addressed however, this does not take priority over the client with ACS. After that, the client requiring a sterile dressing change who is three days post-operative should be evaluated. While this is an important aspect of care, it is not as time-sensitive as the other two clients. Finally, the client requesting discharge teaching should be seen last because this would be considered low priority. This client is no longer in an acute phase of their illness and does not require immediate attention. However, the nurse should ensure that the client understands their discharge instructions and has all necessary prescriptions and follow-up appointments. Additional Info When prioritizing client care, the nurse may use several strategies, including: ✓ Expected vs. unexpected - the nurse should always look for unexpected findings associated with disease processes ✓ Acute vs. chronic - the nurse should prioritize acute needs over chronic needs ✓ Stable vs. unstable - using a client's vital signs or labs, the nurse should prioritize the unstable client