ADULT HEALTH RN TEST 1

The nurse is teaching about constipation prevention to a client. Which of the following client statements indicate appropriate understanding of the teaching? Select all that apply

. 1. "Drinking more caffeinated drinks such as tea and soda helps to stimulate the bowel." 2. "Having a routine for bowel movements is important, but I should not wait if I feel the urge." 3. "I can use an over-the-counter laxative every other day if needed." 4. "I should try to eat more fruits and vegetables every day." 5. "Increasing my daily exercise level may help keep my bowel movements regular." Constipation is a symptom of many disease processes (eg, Parkinson disease, diabetic neuropathy, depression), procedures (eg, abdominal surgery, bowel manipulation), and medications (eg, anticholinergics, diuretics, opioids). Immobility, a low-fiber diet, decreased fluid intake, and irregular bowel habits increase the likelihood of constipation. Educate clients to prevent constipation by: Encouraging a healthy bowel regimen by avoiding delaying defecation. If the urge is felt, defecate at the same time daily, and when possible, track bowel movements to identify changes in patterns (Option 2) Increasing consumption of fruits and vegetables to reach a daily fiber intake of at least 20 g (unless contraindicated) because fiber softens and increases the bulk of stool, which promotes defecation (Option 4) Increasing daily exercise levels because activity stimulates peristalsis and promotes defecation (Option 5) Drinking 2-3 L of noncaffeinated fluids daily (unless contraindicated), which prevents drying and hardening of stool in the colon (Option 1) Clients should avoid caffeinated beverages, which promote diuresis and dehydration and may lead to constipation. (Option 3) Clients should avoid using laxatives and enemas unless prescribed by a health care provider because overuse can cause physical and psychological dependence. Educational objective: Constipation is a symptom of many disease processes, procedures, and medications. To prevent constipation, educate the client to increase daily fiber intake, drink 2-3 L of fluids daily, increase daily activity levels, and initiate a bowel regimen (avoiding delay of defecation, defecating at the same time each day).

The nurse is planning care for a client with a fractured femur who was placed in balanced suspension skeletal traction 2 hours ago. Which of the following interventions should the nurse include? Select all that apply.

1. Encourage intake of at least 2 L of fluid per day to prevent constipation 2. Ensure that the weights hang freely and do not touch the ground 3. Monitor skin integrity and signs of infection at the pin insertion sites 4. Perform frequent neurovascular checks on the affected extremity 5. Remove the weights briefly every 4 hours to prevent muscle spasms Skeletal traction involves surgically inserting screws, wires, and/or pins directly into a fractured bone and applying a pulling force (traction) via a pulley system and a rope. The pulley system allows free-hanging weights to suspend from the foot of the client's bed and pull on the skeletal pins to maintain alignment of the proximal and distal portions of the fractured bone. Appropriate nursing interventions for clients in skeletal traction include: Encouraging increased fluid intake (≥2 L/day) to reduce the risk for constipation caused by immobility (Option 1) Ensuring that the weights hang freely and are not resting on the ground or on medical equipment (Option 2) Monitoring skin integrity and pin insertion sites for signs of infection (eg, erythema, drainage, swelling, malodor) (Option 3) Performing frequent neurovascular checks, especially in the first 24 hours of traction therapy (Option 4) Inspecting the rope for fraying and ensuring its correct position in the pulley track Ensuring proper alignment of the client and the pulley system to facilitate union of the fractured bone (Option 5) Skeletal traction not only provides proper alignment during bone healing, but also helps reduce muscle spasms that result from malalignment of the fracture. The weights should not be removed, even briefly, unless prescribed by the health care provider. Educational objective: When caring for clients in skeletal traction, the nurse should encourage increased fluid intake, ensure that pulley weights hang freely, inspect pin sites for signs of infection, and perform frequent neurovascular checks on the affected extremity.

The nurse in the cardiac intensive care unit receives report on 4 clients. Which client should the nurse assess first?

Client who is receiving IV antibiotics for infective endocarditis with a temperature of 101.5 F (38.6 C) (3%) 2. Client who underwent coronary artery stent placement via femoral approach 3 hours ago and is reporting severe back pain (81%) 3. Client who underwent coronary bypass graft surgery 3 days ago and has swelling in the leg used for the donor graft (4%) 4. Client who underwent heart transplantation 2 months ago with sustained sinus tachycardia of 110/min at rest A client who undergoes percutaneous coronary intervention (PCI) and intracoronary stent placement using the femoral approach is at increased risk for retroperitoneal hemorrhage. Administration of antithrombotic drugs before, during, and after PCI can exacerbate potentially life-threatening bleeding from the femoral artery. Hypotension, back pain, flank ecchymosis (eg, Grey Turner sign), hematoma formation, and diminished distal pulses can be early signs of bleeding into the retroperitoneal space and require immediate intervention (eg, notify health care provider, serial complete blood count, CT scan of the abdomen) (Option 2). (Option 1) Infective endocarditis is often associated with cardiac valve disease and requires long-term antibiotic therapy (4-6 weeks). Characteristic manifestations include fever, myalgia, chills, joint pain, anorexia, and petechiae. (Option 3) Some clients notice swelling in the leg used for donor venous graft (interruption of blood flow). Elevating the leg and wearing compression stockings can help decrease symptoms. (Option 4) During heart transplantation, the donor heart is cut off from the autonomic nervous system (denervated), altering the heart rate during rest and exercise after the procedure. The heart rate of the transplanted heart is expected to be at the high end of normal or tachycardic (eg, 90-110/min). Educational objective: Percutaneous coronary intervention via the femoral approach places the client at increased risk for retroperitoneal hemorrhage, which can be exacerbated by antithrombotic drugs. Back pain, hypotension, flank ecchymosis (eg, Grey Turner sign), hematoma formation, and diminished distal pulses can be early signs of bleeding into the retroperitoneal space and require immediate intervention.

A client with chronic kidney disease is admitted with urosepsis. Based on the admitting diagnosis and laboratory results, which of the following prescriptions should the nurse question? Select all that apply. Click the exhibit button for additional information.

SATA 1. Administer IV ceftriaxone 2. Continue home dose of valsartan 3. Initiate continuous cardiac telemetry 4. Obtain blood and urine cultures 5. Obtain CT scan of the abdomen with contrast Urosepsis is a bloodstream infection that originates from the urinary tract. Standard immune responses are insufficient, thereby triggering an exaggerated immune response. Tissue perfusion decreases and causes potentially life-threatening organ impairment. Clients with preexisting disease of one or more organ systems (eg, chronic kidney disease [CKD]) are at increased risk for septic shock in which overwhelming sepsis causes cardiovascular collapse and impaired ability to meet the body's metabolic and cellular demands. CKD impairs the excretion of excess potassium and can potentiate hyperkalemia, leading to life-threatening cardiac arrhythmias (eg, ventricular fibrillation). Angiotensin II receptor antagonists (eg, valsartan) can be used to manage hypertension associated with CKD; however, these medications should be avoided because of the risk for worsening hyperkalemia (Option 2). Clients with CKD and elevated creatinine are unable to adequately excrete the iodinated contrast administered for CT scans, resulting in toxic effects from the contrast (Option 5). (Options 1 and 4) Blood and urine cultures should be obtained prior to antibiotic initiation to identify the specific pathogen affecting the client. While waiting for the results of the cultures, a nonnephrotoxic, broad-spectrum antibiotic (eg, ceftriaxone) may be administered. (Option 3) Continuous cardiac telemetry and vital sign monitoring should be initiated because hyperkalemia and sepsis can lead to cardiovascular complications (eg, dysrhythmias, hypotension). Educational objective: When caring for clients with chronic kidney disease and urosepsis, the nurse should question the administration of iodinated contrast due to decreased excretion and angiotensin II receptor antagonists because of the risk for worsening hyperkalemia.

After addressing a group of female high school students about sexual health and hygiene, the nurse recognizes that teaching about human papillomavirus (HPV) and genital warts has been effective when hearing which of the following client statements?

1. "A person's genital warts may come back again, even after receiving treatment." 2. "I need Pap testing as soon as I am sexually active, regardless of age." 3. "Infection with HPV increases my risk of cervical cancer." 4. "Since I am sexually active, I should receive the HPV vaccine series." 5. "Using condoms during sex eliminates the risk of spreading the virus." Human papillomavirus (HPV) is a common sexually transmitted infection (STI) that is often asymptomatic and resolves spontaneously in young, healthy people. However, certain HPV strains can persist, resulting in genital warts. Treatment for genital warts (eg, topical podophyllin, cryotherapy) is usually effective but does not prevent warts from recurring (Option 1). High-risk HPV strains (eg, types 16 and 18) increase the risk of oral, genital, and cervical cancers (Option 3). The HPV vaccine helps prevent several HPV strains and is most effective if received before initiation of sexual activity. Clients who are already sexually active may still benefit from HPV vaccination (Option 4). (Option 2) Because HPV infection in females age <21 rarely progresses to malignancy, most clinical organizations recommend initiation of cervical cancer screening (eg, Pap testing) at age 21, regardless of sexual history. Subsequently, overdiagnosis and treatment (eg, cervical excision procedures) leading to negative future reproductive outcomes (eg, preterm birth) are minimized. (Option 5) Barrier methods (eg, condoms) can reduce the risk of HPV transmission. However, abstinence is the only definitive way to eliminate the risk of contracting STIs. Educational objective: Human papillomavirus (HPV) increases the risk of genital warts and cervical cancer. Women should receive HPV vaccination even if already sexually active and begin cervical cancer screening at age 21. Genital warts may also recur after treatment.

The nurse is reinforcing education with a client with Marfan syndrome who is recovering from an aortic root repair and mechanical aortic valve replacement via sternotomy and is prescribed warfarin. Which of the following client statements indicate a correct understanding of the teaching? Select all that apply.

1. "Because I have a mechanical valve, I will not need antibiotics for dental procedures." 2. "I will have to have my spouse lift and carry heavy objects for me for several months." 3. "I will need to take prescribed warfarin for the rest of my life." 4. "If I gain more than 5 lb (2.3 kg) in 1 week, I will need to tell my health care provider." 5. "My usual razor blades will need to be replaced with an electric shaver." Aortic root repair with mechanical heart valve replacement is a procedure often performed for clients with Marfan syndrome a connective tissue disorder that increases the risk for aortic rupture. Clients with mechanical valve replacement via sternotomy require education on lifestyle changes and prevention of complications, including: Avoiding heavy lifting (ie, objects over 10 lb [4.5 kg]) for 3-6 months after surgery to prevent disruption of the sternotomy sutures/wires and allow the breastbone to heal (Option 2). Maintaining lifelong anticoagulant therapy (eg, warfarin, apixaban) after a mechanical valve replacement to prevent thromboembolic events (eg, stroke) and valve thrombosis (Option 3). Reporting signs and symptoms of heart failure (eg, weight gain >5 lb [2.3 kg] in 1 week) immediately which may indicate valve failure (Option 4). Initiating bleeding precautions (eg, using an electric shaver) because anticoagulant therapy increases the risk of uncontrolled bleeding (Option 5). (Option 1) Clients with mechanical heart valves are at high risk for infective endocarditis because bacteria can adhere to and proliferate on components of the valve. The client should receive prophylactic antibiotics before invasive respiratory and dental procedures, including routine dental cleanings. Educational objective: Clients who have received mechanical valve replacement via sternotomy require education regarding avoidance of heavy lifting, anticoagulant therapy, signs and symptoms of heart failure, and bleeding precautions. Clients with mechanical heart valves are at risk for infective endocarditis, and prophylactic antibiotics should be given before dental and respiratory procedures.

The nurse cares for a client with an established ascending colostomy. Which statement made by the client indicates that further teaching is required?

1. "I always try to drink 3 liters of water each day." (11%) 2. "I avoid eating beans, onions, broccoli, and cauliflower." (9%) 3. "I change the appliance and bag every other day." (69%) 4. "I empty the bag when it is about one-third full." (9%) Colostomies may be performed on any part of the colon (ascending, transverse, descending, sigmoid). Stool becomes more solid as it passes through the colon, so stool drainage characteristics vary with location of the ostomy. Ascending colostomies produce semiliquid stool. Stool is contained in an ostomy appliance bag secured to the skin. The appliance opening is cut to fit closely around the stoma. If the appliance does not fit well, liquid stool may leak onto the peristomal skin, and skin irritation occurs due to the digestive enzymes in stool. Peristomal skin irritation may also occur if the ostomy appliance is removed and changed too frequently. The appliance should be changed every 5-10 days (Option 3). (Option 1) The semiliquid consistency of stool from an ascending colostomy results in increased fluid loss. The client is encouraged to drink plenty of fluids to prevent dehydration. (Option 2) The client with a colostomy has few dietary restrictions, but the client may be encouraged to decrease intake of odorous and gas-forming foods (eg, beans, onions, broccoli). (Option 4) The ostomy bag is emptied when it becomes onethird full. Leaking and skin irritation may occur if the appliance becomes too heavy and pulls away from the skin. Educational objective: Peristomal skin irritation is prevented by ensuring that ostomy appliances fit closely around the stoma and that the appliance is changed every 5-10 days. The ostomy bag is emptied when one-third full. The client with a colostomy is encouraged to drink plenty of fluids and decrease intake of gas-forming foods.

The nurse reinforces teaching to a client recently diagnosed with urge incontinence. Which of the following client statements about self-management strategies indicate that teaching has been effective? Select all that apply.

1. "I drink diet cola with meals because it contains fewer calories than regular soda." 2. "I have an appointment with a nutritionist to help me manage my diet so that I can lose my excess weight." 3. "I joined a smoking cessation support group at the community center." 4. "I plan to do my daily Kegel exercises when I am riding the train to and from work." 5. "I will make sure to urinate every 2 hours to reduce urgency and have fewer accidents." Urge incontinence (UI), also known as overactive bladder, occurs when the bladder contracts randomly, causing a strong, sudden urge to urinate followed by urine leakage. UI may occur without cause or may result from neurological system dysfunction (eg, Parkinson disease, stroke) or spinal cord injury. Interventions for clients with UI include: Losing excess weight to reduce pressure on the pelvic floor (Option 2) Avoiding dietary bladder irritants (eg, caffeine, nicotine, artificial sweeteners, citrus juices, alcohol, carbonated drinks) (Option 3) Performing pelvic floor exercises (eg, Kegel) to strengthen the pelvic muscles and help prevent urinary leakage (Option 4) Taking anticholinergic medications (eg, tolterodine, oxybutynin), which reduce bladder spasms Using bladder training, such as voiding every 2 hours while awake and gradually lengthening the intervals between voiding (Option 5) (Option 1) Clients with UI should avoid bladder irritants such as drinks that contain caffeine and artificial sweeteners because these ingredients can exacerbate UI symptoms. Educational objective: Urge incontinence (UI) involves random bladder contractions that cause a strong, sudden urge to urinate followed by urine leakage. Interventions for UI include losing excess weight, avoiding dietary bladder irritants, performing pelvic floor exercises, taking anticholinergic medications, and using bladder training techniques.

The nurse is reinforcing education about lifestyle choices to help reduce symptoms for a client with gastroesophageal reflux disease. Which of the following statements by the client indicate a correct understanding? Select all that apply.

1. "I have switched from coffee to decaffeinated herbal tea in the mornings." 2. "I plan to join a smoking-cessation program." 3. "I prefer to eat three large meals a day and avoid snacking." 4. "I prop myself up on a couple of pillows when I go to sleep." 5. "I will switch to low-fat dairy products and avoid highfat foods." Gastroesophageal reflux disease (GERD) occurs when chronic reflux of stomach contents causes inflammation of the esophageal mucosa. The lower esophageal sphincter normally prevents stomach contents from entering the esophagus. Factors that decrease the tone of the lower esophageal sphincter (eg, caffeine, alcohol), delay gastric emptying (eg, fatty foods), or increase gastric pressure (eg, large meals) can precipitate GERD. Lifestyle and dietary measures that may help prevent GERD and associated symptoms include: Weight loss because excessive abdominal fat may increase gastric pressure Avoiding GERD triggers such as caffeine, alcohol, nicotine, high-fat foods, chocolate, spicy foods, peppermint, and carbonated beverages (Options 1 and 5) Chewing gum to promote salivation, which may help neutralize and clear acid from the esophagus Sleeping with the head of the bed elevated (Option 4) Discontinuing the use of tobacco products (Option 2) Refraining from eating at bedtime and/or lying down immediately after eating (Option 3) Clients with GERD should eat small, frequent meals with sips of water or fluids to help facilitate the passage of stomach contents into the small intestine and help prevent reflux from an overly full stomach during and after meals. Educational objective: Lifestyle and dietary measures that help prevent or minimize symptoms of gastroesophageal reflux disease include avoiding dietary triggers such as alcohol, caffeine, chocolate, peppermint, and high-fat foods. Sleeping with the head of bed elevated may help prevent reflux. Clients should consume small, frequent meals and discontinue the use of tobacco products.

The nurse in the public health clinic is caring for a client with pubic lice. Which of the following statements should the nurse include in the education? Select all that apply.

1. "Pubic lice are only passed through sexual contact." 2. "Remove nits from pubic hair with a fine-toothed nit comb." 3. "Sexual partners should also receive treatment." 4. "Wash clothes and linens with hot water." 5. "Wash pubic hair with lice treatment shampoo." Pediculosis pubis (ie, "crabs") is an infestation of pubic lice. Pubic lice are most often passed via sexual contact and feed on human blood for nourishment. Clients with pubic lice have intense itching in the affected area. The nits (ie, lice eggs) are attached to hair shafts and appear as yellow-white ovals. Pubic lice may also infest eyelashes, facial hair, and body hair (eg, chest, axilla). Clients with pubic lice should be given the following instructions: Use lice treatment shampoo (1% permethrin) or rinse on pubic and body hair to kill lice (Option 5) After treatment, remove nits with a fine-toothed nit comb, fingernails, or tweezers (Option 2) Wash and dry clothes, towels, and bedding with hot water and highest-heat dryer setting (Option 4) Sexual partners should also receive pubic lice treatment (Option 3) (Option 1) Pubic lice may be passed through close contact and sharing of linens. All household members are at risk for developing a pubic lice infestation and should be screened. Educational objective: Clients with pubic lice are instructed to use lice treatment shampoo (1% permethrin) or rinse on pubic and body hair, remove nits with a fine-toothed comb, and launder clothes and linens with hot water and highest-heat dryer setting. Sexual partners should also receive treatment, and all household members should be screened for lice.

The nurse precepting a graduate nurse (GN) reviews age-related changes that increase older adult clients' risk for respiratory infections. Which of the following statements by the GN indicate a correct understanding? Select all that apply.

1. "The ability to cough forcefully decreases." 2. "The chest wall may become less flexible." 3. "The immune system response is diminished." 4. "The mucous membranes become drier." 5. "The number and motility of cilia decrease." Older adults experience expected, age-related physiologic changes, several of which increase their risk for respiratory illnesses and infection. With aging, mucus becomes thicker and more difficult to clear because the mucous membranes produce and secrete less mucus. Costal cartilage becomes calcified, reducing lung compliance and expansion (Option 2). The respiratory muscles become weaker and the cough is less forceful (Option 1). The number of respiratory cilia is decreased, and they become less effective in their brushing motion (Option 5). All these changes reduce the body's ability to clear mucus and pathogens. The immune system of older adults is also diminished as the function and quality of lymphocytes (ie, T cells, B cells) are altered and respiratory defenses (eg, mucus clearance) are impaired (Option 3). The older adult's dry mucous membranes are also more vulnerable to respiratory pathogens and infection (Option 4). Educational objective: As clients age, several expected physiologic changes occur that increase the risk for respiratory infections. These changes include a decrease in the force of cough, chest wall stiffening, a diminished immune system, dry mucous membranes, and a decrease in the number and motility of respiratory cilia.

The nurse assists with medication reconciliation for a client visiting the clinic for a follow-up appointment. Which medication reported by the client requires further investigation? Click the exhibit button for additional information. 1. 0.3 mg of nitroglycerin sublingual PRN (5%) 2. 10 mg of ezetimibe PO once daily (31%) 3. 20 mg of lisinopril PO once daily (4%) 4. 200 mg of celecoxib PO once daily (58%)

1. 0.3 mg of nitroglycerin sublingual PRN (5%) 2. 10 mg of ezetimibe PO once daily (31%) 3. 20 mg of lisinopril PO once daily (4%) 4. 200 mg of celecoxib PO once daily (58%) NSAIDs (eg, naproxen, ibuprofen, celecoxib) are used for their analgesic, antipyretic, and anti-inflammatory properties. However, they increase the risk of thrombotic events (eg, myocardial infarction [MI], stroke), especially in clients with cardiovascular disease (eg, coronary artery disease). The nurse should investigate why a client with a history of cardiovascular disease is taking an NSAID and alert the health care provider of its use (Option 4). (Option 1) Sublingual nitroglycerin may be prescribed to alleviate an exacerbation of acute angina in a client with a history of chronic stable angina. Nitrates promote coronary vasodilation, thereby improving blood flow and relieving ischemic chest pain. (Option 2) Ezetimibe inhibits cholesterol absorption from the small intestine, which reduces the risk of atherosclerosis and helps to treat coronary artery disease. (Option 3) ACE inhibitors (eg, lisinopril, enalapril, captopril) are prescribed to treat hypertension. These medications interfere with the conversion of angiotensin I to angiotensin II, which lowers blood pressure by reducing vasoconstriction and promoting sodium excretion. ACE inhibitors also inhibit ventricular remodeling after an MI, which reduces the risk of recurrent MI. Educational objective: NSAIDs increase the risk of thrombotic events (eg, myocardial infarction, stroke), especially in clients with cardiovascular disease. The nurse should contact the health care provider for clarification if a client with cardiovascular disease reports NSAID use.

A nurse in the cardiac intensive care unit assesses a client with diabetes mellitus who underwent a percutaneous coronary intervention with stent placement via the left femoral artery 3 hours ago. Which assessment finding requires priority notification of the health care provider?

1. 1+ palpable pedal pulses bilaterally (21%) 2. 2-cm area of ecchymosis in the left groin (29%) 3. Angina rated as 4 on a pain scale of 0-10 (39%) 4. Blood glucose of 220 mg/dL (12.2 mmol/L) (9%) Percutaneous coronary intervention (PCI) with stent placement is performed to improve coronary artery patency and increase cardiac perfusion. A balloon and stent are inserted via a catheter through a large artery (eg, femoral artery) and threaded toward the blocked coronary artery. The balloon expands the stent against the arterial wall, compressing plaque and improving patency. The stent remains in the client after the balloon and catheter are removed. Potential complications of PCI include thrombosis, stent occlusion, bleeding/hematoma, and limb ischemia. The nurse should immediately notify the health care provider of postprocedure angina, which indicates possible thrombosis or stent occlusion; necessary prescriptions (eg, nitroglycerin, second PCI) should be obtained and promptly initiated (Option 3). (Option 1) Neurovascular assessments of the affected extremity should be compared with the unaffected extremity and the client's baseline; this client's 1+ pulses are not a concern because they are bilateral, not unilateral. Most clients with diabetes mellitus and coronary artery disease may also have baseline peripheral artery disease. (Option 2) A small amount of bleeding/ecchymosis is expected at the access site due to anticoagulation therapy, which is initiated prior to PCI. The nurse should assess for signs of hematoma formation and retroperitoneal hemorrhage. (Option 4) Increased blood glucose must be treated but is not a priority over stent occlusion. Educational objective: Acute complications from stent placement include thrombosis, stent occlusion, bleeding/hemorrhage, and limb ischemia. The nurse should immediately notify the health care provider to evaluate postprocedure angina, which indicates possible thrombosis or stent occlusion.

While the nurse is transporting a client to a new unit, the client's chest tube drainage system falls off the bed and the tube becomes dislodged from the chest wall. What is the nurse's priority action?

1. Activate the hospital emergency response system (2%) 2. Apply supplemental oxygen and quickly transport to the new unit (3%) 3. Check the client's respiratory pattern and effort and oxygen saturation (15%) 4. Firmly cover the insertion site with the palm of a clean, gloved hand Chest tubes are inserted into the pleural cavity to facilitate drainage of air (pneumothorax), blood (hemothorax), or other fluids. Chest tubes are sutured in place, but dislodgement can occur. If this happens, a sterile occlusive dressing (eg, petrolatum gauze) must immediately be placed over the insertion site until the health care provider can assess the client and insert a new chest tube. If such dressings are not immediately available, the nurse should cover the insertion site with something clean and occlusive (eg, gloved hand) to prevent air from entering the pleural cavity (Option 4). (Option 1) The nurse should cover the site and assess the client prior to activating the emergency response system. ( Option 2) It may be necessary to provide supplemental oxygen if a chest tube is accidentally dislodged. This intervention would be done after the site is occluded. (Option 3) After the chest tube insertion site is covered, the client should be reassessed. The nurse should not delay covering the chest tube site as pneumothorax or tension pneumothorax may occur quickly. Educational objective: Chest tubes are inserted into the pleural cavity to drain air (pneumothorax), blood (hemothorax), or other fluids. If the tube is accidentally dislodged, a sterile occlusive dressing is placed over the site. If such dressings are not immediately available, a clean gloved hand can be placed over the site to prevent air entry into the pleural space. After dressing the site, the nurse should reassess the client and notify the health care provider immediately.

A client with emphysema arrives at the clinic for a routine follow-up visit. Which manifestations are characteristic of emphysema? Select all that apply.

1. Activity intolerance 2. Barrel chest 3. Hyperresonance on percussion 4. Stridor 5. Tracheal deviation Chronic obstructive pulmonary disease (COPD) is most commonly caused by inhaling irritants (eg, cigarette smoke, air pollution) and may include emphysema and/or chronic bronchitis. Emphysema is characterized by alveolar wall destruction. Lung tissues lose elasticity (recoil) due to permanently enlarged, "floppy" alveoli. This causes hyperinflation of the lungs (air trapping), manifested by hyperresonance on percussion and prolonged expiration (Option 3). Hyperinflation of the lungs causes the client to develop a barrelshaped chest (Option 2). Hyperinflated lungs also prevent the client from meeting oxygen demands during increased activity, leading to activity intolerance and anxiety (Option 1). Pursed lip breathing ("puffing"), accessory muscle use, and the tripod position (leaning forward with hands on the knees) are seen during exertion and as the disease progresses. (Option 4) Stridor (harsh, high-pitched breathing) is due to obstruction or constriction of the large (upper) airway (eg, aspiration of a foreign object, anaphylaxis, epiglottitis). Stridor indicates life-threatening airway compromise and requires prompt intervention. It is not a manifestation of emphysema. (Option 5) Tracheal deviation occurs with a tension pneumothorax, not emphysema. When an injury causes air to become trapped in the pleural space, intrapleural pressure increases and pushes on the heart and great vessels. This causes a mediastinal shift that manifests externally as tracheal deviation. Educational objective: Emphysema is characterized by loss of elasticity in the lungs due to permanently enlarged, "floppy" alveoli. The lungs become hyperinflated (eg, hyperresonance on percussion, prolonged expiration, barrel chest). The client has activity intolerance and anxiety due to inability to meet oxygen demands during exertion.

A client comes to the emergency department with crushing substernal chest pain. Which of the following interventions should the nurse anticipate? Select all that apply.

1. Administer IV pain medication 2. Check blood pressure and heart rate 3. Obtain a 12-lead ECG 4. Obtain blood specimens 5. Position client in the supine position The nurse needs to quickly identify the signs and symptoms of myocardial infarction and initiate interventions to preserve cardiac muscle. The nurse should also recognize that female and older clients may have nonspecific symptoms (eg, fatigue, indigestion, shortness of breath). Initial interventions in the emergency management of chest pain include: Insert 2 large-bore IV lines and administer prescribed medications (eg, nitroglycerin, analgesic) (Option 1). The nurse should also anticipate a prescription for an antiplatelet agent (eg, aspirin) if the client has not already received a dose. Assess airway, breathing, circulation (eg, vital signs, heart and lung sounds), and pain (Option 2). Obtain diagnostics (eg, 12-lead ECG, chest x-ray, blood specimens for cardiac markers and electrolytes) (Options 3 and 4). Administer oxygen if required (eg, capillary oxygen saturation [SpO ] <90%, dyspnea). Initiate continuous cardiac monitoring. Prepare client for additional therapy (eg, percutaneous coronary intervention, fibrinolytics). (Option 5) Unless contraindicated, the client should be placed in an upright, seated position because upright positioning improves ventilation and reduces pressure on the heart. Educational objective: The nurse should rapidly assess clients (eg, vital signs, heart and lung sounds, pain level) with acute chest pain and intervene (eg, 2 large-bore IV lines, oxygen, nitroglycerin, pain medication, aspirin) to preserve cardiac muscle. A 12-lead ECG and blood specimens should be obtained, and the client placed on continuous cardiac monitoring. Clients should be placed in an upright position, unless contraindicated, to improve ventilation and reduce pressure on the heart.

A nurse reviews the plan of care for a client who has increased intracranial pressure. Which of the following nursing actions should be included? Select all that apply.

1. Administer a stool softener 2. Dim the lights when not providing care 3. Elevate the head on several pillows 4. Maintain the body in the midline position 5. Perform oral suctioning only when necessary For clients with increased intracranial pressure (ICP), the goal is to reduce ICP while managing basic needs. Nursing interventions to decrease ICP include: Administering stool softeners to prevent straining when defecating (Option 1). Straining and coughing increase intrathoracic and intraabdominal pressure, which increases ICP. Keeping the client in a calm environment with minimal noise and disturbances (eg, dimmed lights, limited visitors) (Option 2). Keeping the head and body midline and avoiding extreme hip or neck flexion because it impedes venous drainage (Option 4). Positioning the head of the bed to 30 degrees to promote venous return from the head, which decreases cerebral edema. Elevating the head >30 degrees decreases blood pressure, which can decrease cerebral perfusion pressure (CPP); therefore, positioning the client to balance ICP and CPP. Suctioning only when needed to maintain the airway and for no more than 2 passes lasting ≤10 seconds per pass (Option 5). Treating fever aggressively (eg, acetaminophen) but keeping the client from shivering to reduce metabolic demands. Frequently monitoring arterial blood gases to prevent hypercapnia, which can increase ICP by causing cerebral vasodilation. (Option 3) For clients with increased ICP, elevating the head of the bed is preferred over using pillows, which may flex the neck, decrease venous drainage, and increase ICP. Educational objective: For clients with increased intracranial pressure, the nurse should administer stool softeners, maintain a quiet environment, promote venous blood return (eg, keep the head midline at 30 degrees), suction only when needed, and reduce metabolic demands (eg, treat fever).

The nurse is caring for a client with a central venous catheter (CVC) who reports feeling nauseated and chilled. The nurse notes that the CVC insertion site is red and inflamed and that the client has a temperature of 102 F (38.8 C). Which new prescription from the health care provider should the nurse implement first?

1. Administer ondansetron 4 mg IV push PRN for nausea or vomiting (3%) 2. Document the occurrence and notify the hospital's epidemiology team (1%) 3. Initiate the first dose of IV piperacillin/tazobactam via a new peripheral IV (13%) 4. Obtain blood cultures and discontinue the central venous catheter Central venous catheters (CVCs) are used in the treatment of clients who require long-term IV access or are prescribed hypertonic solutions (eg, total parenteral nutrition) or vesicant medications. CVCs can serve as a portal of entry for bacteria, which increases the risk of developing serious bloodstream infections. Nurses caring for clients with CVCs should report any new or worsening signs of infection (eg, fever, chills, erythema at the CVC site) to the health care provider because central line-related bloodstream infections (CRBSIs) require prompt treatment to prevent possible sepsis. In response to a possible CRBSI, the CVC should be removed as soon as possible to prevent continued exposure to the infection source. Blood cultures should be obtained before initiating antibiotic therapy, as antibiotics may contaminate the sample and prevent identification of the infectious organism (Option 4). (Options 1 and 2) Administering medications for comfort, completion of documentation, and facility-based report protocols should be done as soon as possible. However, to prevent progression to sepsis, treatment of a suspected CRBSI should not be delayed. (Option 3) Initiation of antibiotics is essential in treating infection and preventing its progression. However, the nurse should first draw blood cultures and remove the CVC, if possible. Educational objective: When caring for a client with signs of a central line-related bloodstream infection, the nurse should obtain blood cultures and remove the device, if possible, before beginning antibiotic therapy. Other nursing interventions (eg, symptom management, documentation) should be done after initiating treatment of the infection.

A client with a history of a seizure disorder has a seizure while sitting in a chair. Which nursing interventions are appropriate for a client experiencing a seizure? Select all that apply.

1. Administer oxygen as needed if client becomes cyanotic 2. Insert a flexible nasopharyngeal airway for airway protection 3. Move the client from the chair to the floor to prevent a fall 4. Record the duration of seizure activity for documentation 5. Restrain the client's arms and legs to prevent injury During seizure activity, the priority is client safety. Nursing interventions include: Administer oxygen as needed in response to signs of hypoxia (eg, cyanosis, pallor) (Option 1). Assist seated or standing clients to lie down while protecting the head, and position the client on the side to maintain a patent airway and prevent aspiration (Option 3). Loosen restrictive clothing and clear the area near the client (eg, furniture corners, sharp or hard objects) to prevent injury. Record and document the time and duration of the seizure (Option 4). (Option 2) Although clients may require oxygen if they are symptomatic (decreased oxygen saturation level), artificial airways or other objects are never inserted into the mouth or nose during a seizure due to the risk for trauma. A nasopharyngeal airway would not prevent the tongue from obstructing the airway during a seizure. When seizure activity has stopped, suctioning and/or insertion of an oral airway may be necessary if the client's airway is obstructed. (Option 5) The client should never be restrained during a seizure. Strong muscle contractions occur during seizures; therefore, if the client is restrained, injury could occur. Educational objective: During seizure activity, the priority nursing interventions are to provide oxygen as needed, assist the client to safely lie down (if seated or standing), position the client on the side to maintain a patent airway, loosen restrictive clothing, and remove objects from the immediate area. The nurse also documents the time and duration of seizure activity

The nurse is caring for a client who had an anterior wall myocardial infarction 2 days ago. The telemetry technician notifies the nurse at 8:30 AM that the client is in ventricular trigeminy. What is the nurse's priority intervention?

1. Administer potassium replacement (74%) 2. Administer the dose of amiodarone (10%) 3. Attach cardiac defibrillator pads (5%) 4. Notify the health care provider (10%) In ventricular trigeminy, premature ventricular contractions (PVCs) occur every third heartbeat. Myocardial injury (eg, myocardial infarction) predisposes the client to ectopy (eg, PVCs), which increases the client's risk for lethal dysrhythmias (eg, ventricular tachycardia). PVCs are caused and/or exacerbated by hypoxia, electrolyte imbalances, emotional stress, stimulants, fever, and exercise. This client's morning laboratory results show hypokalemia (potassium <3.5 mEq/L [3.5 mmol/L]); therefore, the priority is treatment of the underlying cause of the ectopy by administering the prescribed potassium replacement (Option 1). Health care providers (HCPs) often prescribe electrolyte replacement algorithms to clients at risk for electrolyte imbalances (eg, myocardial injury, receiving diuretics) unless a contraindication exists (eg, serum creatinine >1.5 mg/dL [133 µmol/L], anuric, weight <99.2 lb [45 kg]). (Option 2) Amiodarone is an antiarrhythmic medication with a long duration of action (ie, 13-107 days). An acute drop in the drug level is not likely the cause of the ectopy. The nurse should administer amiodarone as prescribed after initiating the potassium replacement. (Option 3) Correcting the electrolyte imbalance should resolve the client's ectopy, preventing the need for defibrillation. (Option 4) The HCP should be notified; however, the nurse should first assess the client and initiate potassium replacement. Educational objective: Myocardial injury can predispose a client to premature ventricular contractions (PVCs), placing the client at risk for lethal dysrhythmias (eg, ventricular tachycardia). PVCs are caused and/or exacerbated by hypoxia, electrolyte imbalances, emotional stress, stimulants, fever, and exercise. Treatment of the underlying cause is the priority.

The charge nurse is teaching other nurses about prevention of venous thromboembolism. Which interventions should be included in the teaching? Select all that apply.

1. Administer scheduled anticoagulants 2. Apply sequential compression devices 3. Elevate the legs with pillows behind the knees 4. Have clients ambulate regularly as tolerated 5. Instruct clients to point and flex the feet in bed Venous thromboembolism (VTE) occurs when a thrombus (eg, deep venous thrombosis) forms and embolizes into the bloodstream (eg, pulmonary embolism). Hospitalized clients tend to have multiple risk factors for VTE, including venous stasis from prolonged immobility and endothelial damage from surgeries or IV catheter placement. VTE prophylaxis should be implemented in all hospitalized clients. Measures include: Administration of anticoagulants (eg, enoxaparin), usually prescribed in clients with a moderate or high risk of VTE (eg, postsurgical) unless contraindicated (eg, active bleeding) (Option 1) Application of compression devices or elastic compression stockings to limit venous stasis (Option 2) Frequent ambulation, 4-6 times daily as tolerated, to improve circulation and promote venous return (Option 4) Foot and leg exercises (eg, extend and flex the feet and knees) to promote venous return by activating calf muscles (Option 5) (Option 3) Elevating the legs while in bed promotes venous return by gravity. However, the nurse should ensure that any pillows used to elevate the legs do not place pressure directly behind the knees, as pressure on the posterior knees compresses leg veins. Clients should also avoid crossing the legs to prevent pressure on the back of the knees. Educational objective: Hospitalized clients have many risk factors for venous thromboembolism (VTE), including immobility and damage to the endothelium from surgeries or IV catheters. VTE prophylaxis measures include anticoagulation, ambulation, leg exercises, compression devices, and prevention of pressure behind the knees (eg, crossing legs).

A client with sickle cell crisis reports severe generalized pain. Which intervention is a priority for correcting vasoocclusion?

1. Administering high-flow IV fluids (72%) 2. Applying oxygen via nasal cannula (17%) 3. Maintaining strict bed rest (3%) 4. Transfusing packed red blood cells (6%) Sickle cell crisis occurs when inadequate oxygenation or hydration exacerbates sickling and causes red blood cells (RBCs) to clump together in the capillaries (vasoocclusion). Vasoocclusion causes severe ischemic pain, hypoxia, and possible organ dysfunction if left untreated. Adequate oxygenation and hydration may reverse the acute sickling response. In the sickled state, RBCs cannot carry enough oxygen from the lungs to the tissues, even with supplemental oxygen. The priority intervention is the administration of IV fluids to reduce blood viscosity and restore perfusion to the areas previously affected by vasoocclusion (Option 1). Only after IV rehydration reverses vasoocclusion can nonsickled RBCs effectively carry supplemental oxygen to the tissues (Option 2). (Option 3) Bed rest improves oxygen use and reduces energy consumption during sickle cell crisis but does not directly resolve vasoocclusion. (Option 4) Blood transfusions provide the client with nonsickled RBCs, increasing the oxygen-carrying capacity of the blood. However, this therapy is generally reserved for clients with sickle cell disease who do not respond to rehydration with IV fluids. Educational objective: Sickle cell crisis results from vasoocclusion of sickled red blood cells in the microcirculation, resulting in severe ischemic pain. The administration of IV fluids reduces blood viscosity and restores perfusion to the areas previously affected by vasoocclusion.

The nurse auscultates the lung sounds of a client with shortness of breath. Then, the nurse notifies the health care provider about the adventitious sounds heard. Which medication prescription should the nurse anticipate? Listen to the audio clip. (Headphones are required for best audio quality.)

1. Albuterol (27%) 2. Bumetanide (42%) 3. Guaifenesin (19%) 4. Methylprednisolone (10%) Coarse crackles (loud, low-pitched bubbling) are heard primarily during inspiration and are not cleared by coughing. The sound is similar to that of Velcro being pulled apart. Coarse crackles may be confused with fine crackles (eg, atelectasis), which have a high-pitched, popping sound. Coarse crackles are present when fluid or mucus collects in the lower respiratory tract (eg, pulmonary edema, pulmonary fibrosis). During heart failure, the left ventricle fails to eject enough blood, causing increased pressure in the pulmonary vasculature. As a result, fluid leaks into the alveoli (pulmonary edema). Loop diuretics (eg, bumetanide, furosemide) treat pulmonary edema by reducing intravascular fluid volume through significant increase of fluid excretion by the kidneys (Option 2). (Options 1 and 4) Clients with asthma or chronic obstructive pulmonary disease (eg, emphysema) develop wheezing due to bronchospasm. Bronchodilators (eg, albuterol, ipratropium) and systemic corticosteroids (eg, methylprednisolone) may be prescribed to these clients. (Option 3) Clients with acute upper respiratory infections or chronic bronchitis (ie, inflammation of the upper airways) may be prescribed guaifenesin to loosen and improve the expectoration of mucus. Clients with chronic bronchitis typically develop rhonchi (ie, sonorous wheezes), which are continuous, lowpitched adventitious breath sounds that resemble moaning or snoring. Educational objective: Auscultation of coarse crackles indicates the presence of fluid or mucus in the lower respiratory tract. This may indicate pulmonary edema or pulmonary fibrosis. Administration of a loop diuretic (eg, bumetanide) is appropriate for treating pulmonary edema.

A nurse is reading a client's tuberculin skin test 48 hours after placement and notes an 11-mm area of induration. The client emigrated from Nigeria 1 year ago and reports no symptoms. Which of the following actions would be appropriate by the nurse? Select all that apply.

1. Ask the client about a history of bacille CalmetteGuérin vaccination 2. Document the negative result in the client's electronic medical record 3. Have the client return in 1 week to receive a second skin injection 4. Implement droplet precautions and wear a surgical mask during care 5. Obtain a prescription for a chest x-ray from the health care provider Tuberculin purified protein derivative (PPD) skin tests (ie, Mantoux test) screen individuals for tuberculosis (TB) exposure. The skin is assessed at the administration site 48-72 hours after placement. Positive results include an induration of ≥5 mm in high-risk populations, ≥10 mm in clients with potential risk or mild immunosuppression, and ≥15 mm in healthy individuals. If a client's tuberculin skin test (TST) is positive, the nurse should: Ask clients who emigrated from high-prevalence countries if they have received the bacille Calmette-Guérin (BCG) vaccine. It is commonly administered to children in highprevalence countries but causes false-positive PPD tests (Option 1). Interferon-gamma release assay testing is preferred in BCG-vaccinated clients because it does not produce false-positive results. Obtain a prescription for a chest x-ray to differentiate latent TB from active disease in asymptomatic clients (Option 5) (Options 2 and 3) PPD test is positive because there is an induration >10 mm and the client emigrated from a highprevalence country <5 years ago. There is no indication to repeat the TST. (Option 4) Clients with active TB are placed under airborne isolation precautions (eg, N95 respirator mask, negativepressure room) , not droplet precautions (eg, surgical mask). In addition, this client has no symptoms of active disease, so precautions are not warranted. Educational objective: Tuberculin purified protein derivative (PPD) skin tests screen individuals for tuberculosis exposure. Prior administration of the bacille Calmette-Guérin vaccine can produce a false-positive tuberculin skin test. Positive PPD reactions in clients who are asymptomatic require evaluation with chest x-ray to rule out active disease.

The nurse is preparing a client with atrial fibrillation for scheduled cardioversion. What action by the nurse requires the charge nurse to intervene?

1. Assembles the required equipment and obtains a prescription for preprocedural IV sedation (10%) 2. Ensures that the defibrillator is programmed as prescribed and that the synchronize function is off (73%) 3. Uses electric clippers to remove the client's chest hair prior to placing the defibrillation pads (11%) 4. Verifies that the client understands the procedure and that the informed consent document is signed Synchronized cardioversion uses a specifically timed, lowenergy electrical impulse to momentarily disrupt the electrical cardiac cycle and "reset" the heart to a slower, regular rhythm. Tachyarrhythmias (eg, atrial fibrillation or flutter) with a pulse may be managed with cardioversion. Cardioversion requires the defibrillator's synchronize function to be activated so the shock is delivered during the R wave (Option 2). Failing to enable the synchronize feature may result in the delivery of a potentially lethal, asynchronous shock. Delivering shocks during the T wave (ie, when the heart ventricles are repolarizing) causes R-on-T phenomenon (ie, premature ventricular contraction that falls on the T wave), frequently producing lethal arrhythmias (eg, ventricular fibrillation). (Option 1) During nonemergency cardioversion of a hemodynamically stable client, a sedative (eg, midazolam) is often administered for client comfort. (Option 3) Removing chest hair with electric clippers is preferred over a razor to help preserve skin integrity and, along with ensuring that the chest is clean and dry, improves defibrillator pad adherence. (Option 4) If the cardioversion is elective and not an emergency, the client should sign a consent form. The nurse should verify that the client is competent and understands the procedure and witness the client's signature. Educational objective: In synchronized cardioversion, a timed shock momentarily disrupts the electrical cardiac cycle to convert tachyarrhythmias with a pulse (eg, atrial fibrillation) and "reset" the heart to a slower, regular rhythm. The defibrillator must be set to "sync" to prevent R-on-T phenomenon and lethal arrhythmias (eg, ventricular fibrillation).

The nurse is reviewing the medical history of a client who has sustained a right tibia/fibula fracture from a fall. The nurse identifies which finding as most likely to hinder healing?

1. BMI of 29.5 kg/m (8%) 2. Family history of osteoporosis (16%) 3. History of a daily glass of wine (1%) 4. Peripheral arterial disease (74%) Bone healing depends on multiple factors, including nutrition, adequate circulation, and age. A client with peripheral arterial disease has decreased perfusion to the extremities due to atherosclerotic changes in the arteries. Without adequate perfusion, the bone is not supplied with the oxygen and nutrients required for healing (Option 4). (Option 1) A BMI of 25-29.9 kg/m indicates that the client is overweight. A sedentary lifestyle often leads to elevated BMI and also correlates with decreased bone density, which places the client at risk for fractures. However, neither sedentary lifestyle nor elevated BMI directly affects bone healing. (Option 2) Osteoporosis (low bone density) increases the risk of fractures and delays bone healing. Although a family history does increase the risk of osteoporosis, the family history itself would not directly hinder bone healing as this client has not been diagnosed with osteoporosis. (Option 3) Heavy alcohol use is associated with inadequate nutrition and can decrease osteoblastic activity (ie, bone formation). However, a single serving of alcohol (ie, 12 oz of beer, 5 oz of wine, 1.5 oz of liquor) per day is considered moderate usage and is not a risk factor for delayed healing. Educational objective: Bone healing after fracture depends on multiple factors, including age, nutritional status, and perfusion. A client with peripheral arterial disease is at risk for impaired bone healing.

The nurse helps a client with end-stage renal disease and a serum potassium level of 5.2 mEq/L (5.2 mmol/L) to plan menu choices. Which items would be best to include in the meal plan?

1. Black beans and rice, sliced tomatoes, half a cantaloupe (10%) 2. Grilled chicken sandwich on white bread, applesauce (61%) 3. Hamburger patty on whole wheat bun, carrot sticks, chocolate pudding (10%) 4. Poached salmon, green peas, baked potato, strawberries Clients with end-stage renal disease are unable to excrete potassium; therefore, the nurse should teach them to choose foods low in potassium to maintain normal serum potassium levels (3.5-5.0 mEq/L [3.5-5.0 mmol/L]). Grilled chicken sandwich on white bread and applesauce are low in potassium (Option 2). (Options 1, 3, and 4) Legumes (eg, black beans), tomatoes, melons (eg, cantaloupe), beef, whole grains, carrots, chocolate, fish (eg, salmon), potatoes, and strawberries are all high in potassium. Educational objective: The kidneys' ability to excrete potassium is compromised in clients with end-stage renal disease. These clients should avoid foods high in potassium (eg, green leafy and cruciferous vegetables; legumes; melons; bananas; strawberries; milk and milk products; most beef, fish, and shellfish; and whole grains) to maintain normal serum potassium levels (3.5-5.0 mEq/L [3.5-5.0 mmol/L]).

A client arrives in the emergency department with right-sided paralysis and slurred speech. The nurse understands that the client cannot receive thrombolytic therapy due to which reason?

1. Client had gallbladder surgery 2 months ago (12%) 2. Client has a blood pressure of 175/100 mm Hg (17%) 3. Client has experienced loss of the gag reflex (3%) 4. Client's symptoms started 12 hours earlier (65%) Thrombolytic therapy (ie, t-PA) is used to dissolve blood clots and restore perfusion in clients with ischemic stroke. The nurse should assess for contraindications to t-PA due to the risk for hemorrhage. Clients have a 3- to 4.5-hour window from onset of symptoms to receive t-PA to achieve full effectiveness of thrombolytic therapy (Option 4). (Option 1) Recent major surgery (ie, within the past 14 days) is a contraindication because t-PA dissolves all clots in the body and may therefore disrupt the surgical site. Gallbladder surgery 2 months prior is outside the window of contraindication. (Option 2) To receive t-PA, clients must have a systolic blood pressure (BP) ≤185 mm Hg and diastolic BP ≤110 mm Hg. In addition, BP should be maintained at ≤180/105 mm Hg throughout the administration of thrombolytic therapy and 24 hours thereafter. (Option 3) Loss of the gag reflex and other major functions would most likely make the client a candidate for thrombolytics due to proof of deficits from stroke. Other contraindications include hemorrhagic stroke and stroke or head trauma within the past 3 months. Educational objective: Thrombolytic therapy (ie, t-PA) is used to treat and dissolve blood clots in clients with ischemic stroke. This therapy should be administered within 3-4.5 hours of symptom onset. Contraindications include severe hypertension (ie, blood pressure >185/110 mm Hg), coagulation disorders, and major surgery within the past 14 days.

The nurse on the cardiac unit reviews a current rhythm strip from a client who experienced an inferior wall myocardial infarction. What action should the nurse take first? Click on the exhibit button for additional information.

1. Document the rhythm as an expected finding (30%) 2. Obtain the transcutaneous pacemaker (20%) 3. Prepare to administer adenosine IV (13%) 4. Review medications the client is receiving (35%) The client is experiencing a second-degree type 2 atrioventricular (AV) block (Mobitz II), which is characterized by more P waves than QRS complexes. The PR intervals are consistent or constant, reflecting regular conduction of electrical impulses through the AV node, but dropped QRS beats randomly occur as ventricular conduction is blocked. A second-degree type 2 AV block can rapidly deteriorate to complete heart block (third-degree AV block), which is lifethreatening. The nurse should quickly obtain a transcutaneous pacemaker, assess the client for symptoms (eg, bradycardia, hypotension, syncope), and be prepared to pace the client if symptoms occur (Option 2). If the client is asymptomatic, the pacemaker is kept nearby in case the rhythm deteriorates, and the health care provider is alerted. (Option 1) A common complication following myocardial infarction is the development of new arrhythmias. Although a second-degree type 2 AV block is not completely unexpected in this client, it indicates a concerning situation that requires assessment and monitoring. (Option 3) Adenosine is used to treat supraventricular tachycardia. Adenosine creates a transient heart block, which then allows the heart to resume normal sinus rhythm. It is never given for bradyarrhythmias. (Option 4) Medications should be reviewed as drug toxicity (eg, beta blockers, digoxin) can cause this type of block. However, this can be done after other interventions. Educational objective: Second-degree type 2 atrioventricular heart blocks are characterized by consistent PR intervals and dropped QRS complexes. Clients should have temporary pacing immediately available as rapid deterioration to complete heart block can occur.

The nurse is reinforcing discharge teaching for a client who is experiencing age-related hearing loss. Which of the following actions should the nurse implement? Select all that apply.

1. Encourage the client to repeat back teaching 2. Ensure adequate lighting in the client's room 3. Provide teaching to the family instead of the client 4. Sit directly in front of the client while speaking 5. Use printed materials with pictures and illustrations Clients who have presbycusis (ie, age-associated hearing loss) require accommodations to promote engagement in care and ensure understanding of teaching. Nursing interventions should focus on facilitating effective and inclusive communication with clients to maintain their safety, including: Encouraging the client to repeat back instructions (ie, closed-loop communication) (Option 1). If the client is unable to repeat them back, provide further clarification with an alternative approach. Sitting directly in front of the client in a well-lit room so all visual cues, such as facial expressions and hand gestures, can be seen (Options 2 and 4). Using printed materials with visuals, such as pictures and illustrations, or acting out demonstrations to supplement verbal instructions (Option 5). (Option 3) The client should always remain the focus of teaching. With the client's consent, including the family in teaching can be helpful; however, the client should not be excluded. Educational objective: Clients with hearing loss require accommodations to ensure effective communication and understanding. Nursing interventions include encouraging clients to repeat back teaching, sitting directly in front of the client when speaking in a well-lit room, and using printed materials with visual aids.

The nurse is reviewing new laboratory results for a client with an exacerbation of chronic obstructive pulmonary disease. The client's serum pH is 7.39. Which result is a priority for the nurse to report to the health care provider?

1. HCO of 35 mEq/L (35 mmol/L) (9%) 2. Hemoglobin of 19 g/dL (190 g/L) (4%) 3. PaCO of 67 mm Hg (8.91 kPa) (38%) 4. PaO of 52 mm Hg (6.92 kPa) (47%) Chronic obstructive pulmonary disease (COPD) is a progressive respiratory disease caused by alveolar destruction and loss of lung elasticity, resulting in impaired gas exchange. Because clients with COPD usually maintain a state of compensated respiratory acidosis, the urge to breathe becomes unresponsive to increasing levels of carbon dioxide gas (CO ). Instead, low oxygen levels promote respiratory efforts (ie, hypoxic drive) in clients with COPD. Manifestations of COPD exacerbation (eg, tachypnea, wheezing) may progress to respiratory failure without treatment. Whereas a slight decrease in PaO (normal: 80-100 mm Hg [10.6-13.3 kPa]) may be an expected finding for a client with COPD, PaO <60 mm Hg (7.98 kPa) indicates severe hypoxia requiring immediate reporting to the health care provider (Option 4). (Options 1 and 3) Compensated respiratory acidosis occurs when renal resorption of HCO increases, causing elevated serum HCO (normal: 21-28 mEq/L [21-28 mmol/L]) secondary to chronic CO retention (ie, PaCO >45 mm Hg [5.99 kPa]), which helps normalize serum pH (ie, normal arterial pH: 7.35- 7.45). (Option 2) Clients with COPD often experience chronic hypoxia and may demonstrate a compensatory increase in hemoglobin levels (ie, polycythemia) to maximize oxygen transport. Educational objective: Whereas a slight decrease from the normal parameters of PaO (normal: 80-100 mm Hg [10.6-13.3 kPa]) may be an expected finding for a client with COPD, a value <60 mm Hg (7.98 kPa) is indicative of severe hypoxia, requiring immediate reporting to the health care provider

The registered nurse supervises a licensed practical nurse (LPN) and unlicensed assistive personnel (UAP) caring for clients receiving brachytherapy. Which action would require the nurse to intervene?

1. LPN who reinforces the purpose of prescribed bed rest for a client with a radium implant for cervical cancer (2%) 2. LPN who, when caring for a client with a radium implant, turns away from the client while wearing a lead apron (45%) 3. UAP who changes the bed linens of a client with a radium implant and leaves the removed linens in the room (14%) 4. UAP who empties the urinal of a client with implanted radioactive seeds for prostate cancer into the toilet Brachytherapy is an internal radiation treatment that is ingested, injected into a cavity or bloodstream, or implanted (eg, seeds, capsules, wires). Brachytherapy emits radiation in or near a tumor to treat certain malignancies. When caring for clients undergoing brachytherapy, nurses should maintain specific precautions to ensure safety, including: Limit the time of exposure (eg, 30 min/day). Cluster care and wear a designated (ie, not shared with anyone else) dosimeter badge. Maximize distance from the source; 6 feet (1.8 m) is recommended. Use shielding (eg, lead apron, portable lead shields) appropriately. Lead aprons typically shield the front of the body; turning the back to the client is a risk for exposure (Option 2). Pregnant women and children should not be exposed to clients undergoing brachytherapy. (Option 1) Clients receiving cervical brachytherapy should remain on bed rest to prevent dislodgment of the implant. (Option 3) Dressings, bed linens, and trash must remain in the client's room until the implant is removed. (Option 4) The body fluids of clients with implanted radioactive seeds in the prostate are generally not radioactive. Some seeds may be passed through the urine; however, they emit very little radiation. Educational objective: Nurses caring for clients undergoing brachytherapy should limit radiation exposure time, maximize distance from the radiation source, and use shielding appropriately to ensure safety. When wearing a lead apron that covers the front of the body, the nurse should not turn and expose the posterior body to the radiation source.

The nurse in the emergency department is assessing telemetry strips for assigned clients. Which client tracing is a priority for the nurse to assess?

An ST-segment elevation myocardial infarction (STEMI) occurs when at least one of the coronary arteries is completely occluded. The ST segment is the portion of the ECG between the QRS complex and the T wave. Prompt treatment (eg, percutaneous coronary intervention, thrombolytics) is needed to restore myocardial oxygen supply and limit myocardial damage (Option 3). (Option 1) Atrial fibrillation is characterized by an irregularly irregular rhythm with P waves replaced by fibrillatory waves, resulting in ineffective atrial contraction. Clients are at increased risk for clot formation (long-term), which can cause a stroke or pulmonary embolism; however, signs of cardiac injury take priority. (Option 2) First-degree heart block is characterized by a prolonged PR interval. Clients are usually asymptomatic and do not require immediate assessment. (Option 4) Premature ventricular contractions are early contractions of the ventricles that originate from an ectopic focus and result in a wide, distorted QRS complex. They are usually not harmful and can occur as a response to stimulants (eg, caffeine, nicotine, alcohol) or electrolyte imbalances. Educational objective: An ST-segment elevation myocardial infarction occurs when at least one of the coronary arteries is completely occluded; it is characterized by elevation of the ST segment. Prompt treatment (eg, percutaneous coronary intervention, thrombolytics) restores myocardial oxygen and limits myocardial injury.