Archer 6

C Choice C is correct. Twitching or jitteriness is a sign of seizures in the newborn. The nurse should inform the physician. Choices A, B, and D are incorrect. Crying, restlessness, and yawning are all normal for the newborn.

A diabetic client has just given birth to a male neonate. Which assessment finding in the newborn would warrant nursing intervention? A. Crying B. Restlessness C. Twitchiness D. Yawning

B Choice B is correct. After suffering from a femur fracture, a patient is at high risk for developing fat emboli syndrome that can cause occlusions in the bloodstream. Fat embolism syndrome is characterized by hypoxia, pulmonary issues, shortness of breath, and confusion. Choice A is incorrect. Sepsis may be likely due to the new surgical procedure, but a fat embolus is more likely due to the femur fracture. Choice C is incorrect. A pulmonary embolism is possible, but a fat embolus is more likely. Choice D is incorrect. This is likely due to a new surgical procedure, but a fat embolus is more likely due to the femur fracture.

A high school boy was involved in a head-on motor vehicle collision. He suffered a concussion, a femur fracture, and rib fractures. Three days after ORIF surgery, his heart rate increases from 72 to 110 bpm and his respirations from 18 to 24. What complication does the nurse suspect this patient is experiencing? A. Sepsis B. Fat emboli C. Pulmonary embolism D. Deep vein thrombosis

C Choice C is correct. Nasogastric tubes drain gastric contents, which are typically yellow/green in color due to the presence of bile. Sending these contents for culture may cause unnecessary worry for the patient and would not be appropriate since this is an expected assessment. All other actions listed are appropriate. Choice A is incorrect. Non-time-critical scheduled medications are those where early or delayed administration within 1-hour window would not result in harm or substantial sub-optimal therapeutic response. Scheduled IV antibiotics may be given within a 1-hour window unless they are precisely timed. The nurse may administer the IV ceftriaxone up to 30 minutes before the scheduled time. Choice B is incorrect. A diagnosis of influenza requires droplet precautions, which include the patient wearing a surgical mask when transported outside of the room. Choice D is incorrect. Jackson-Pratt drainage systems can be pinned to a patient's gown and should be secured below the exit site to prevent tension on the tubing.

The RN is training a new nurse on a medical-surgical floor. Which action would warrant intervention by the experienced RN? A. The nurse administers ceftriaxone via IV 30 minutes early for a pneumonia client. B. The nurse places a surgical mask on a patient with influenza before transport. C. The nurse obtains green drainage from a nasogastric tube for culture. D. The nurse secures a Jackson-Pratt drain to the patient's gown with a safety pin.

A, D, F Choices A, D, and F are correct. When making client assignments, the RN should be assigned to the unstable client who has the least predictable outcome and may require frequent assessment or teaching. A client newly diagnosed with type II diabetes mellitus will require a large amount of teaching. A client with an AKI and hyperkalemic is at risk for cardiac instability. Finally, a client experiencing acute coronary syndrome receiving IV nitroglycerin will need frequent assessment because of the unpredictable nature of the condition. Choices B, C, and E are incorrect. The LPN should assume care for stable clients with predictable outcomes. The client requiring sterile dressing changes is within the LPN's scope, as well as providing enteral feedings and tracheostomy care. A client two days post-operative is stable.

The charge nurse is planning client care assignments for a registered nurse (RN) and licensed practical/vocational nurse (LPN/VN). Which of the following clients would be most appropriate to assign to the RN? Select all that apply. A client A. A patient newly diagnosed with type II diabetes mellitus. B. requiring sterile dressing changes to an infected wound. C. who requires enteral feedings and tracheostomy care. D. with an acute kidney injury (AKI) with a potassium 5.6 mEq/l. E. who is two days post-operative following a mastectomy. F. receiving intravenous nitroglycerin for acute coronary syndrome.

A Choice A is correct. Inhalation anthrax poses a serious threat because the progression of symptoms may be rapid and become life-threatening. Anthrax may cause hypoxia, and continuous pulse oximetry monitoring is essential. This would enable the nurse to determine if the client's condition is deteriorating and may allow the nurse to immediately apply supplemental oxygen. Choices B, C, and D are incorrect. These actions apply to caring for a client with inhalation anthrax, but they do not prioritize monitoring the client's oxygenation status, which may rapidly deteriorate. A chest x-ray will be obtained to determine any abnormalities in the lung, and a lumbar puncture will be performed to evaluate for meningitis. Anthrax is a bioterrorism agent, and the public health department must be notified promptly, but it does not prioritize over direct client care. Anthrax is a bioterrorism agent and must be taken seriously because it has a high mortality rate. Anthrax may be cutaneous or inhaled and is caused by exposure to the gram-positive bacterium. Nursing care is aimed at stabilizing the client's breathing and promptly initiating treatment, which is antibiotics (levofloxacin) and/or antitoxins such as raxibacumab.

The emergency department nurse is caring for a client exposed to inhalation anthrax. It would be essential for the nurse to take which action? A. Initiate continuous pulse oximetry B. Obtain a prescription for a chest radiograph C. Notify the public health department D. Prepare the client for a lumbar puncture

C Choice C is correct. The most significant threats to a healthcare facility's technological and information security are the failure of employees to log off computer systems and sharing of passwords with others. These actions put the employee and confidential client medical records at risk. Choice A is incorrect. Although foreign countries often engage in computer hacking, this type of event is far less frequent than other types of threats. Choice B is incorrect. Although United States citizens often engage in computer hacking (often for ransom), this type of event is far less frequent than other types of threats. Choice D is incorrect. Although a significant electrical failure can disrupt internal communications and the use of various types of technology, this type of event is far less frequent than other types of threats. In 2021, U.S. Department of Health & Human Services (HHS) received reports of data breaches from 578 healthcare organizations, impacting more than 41.45 million individuals.

The most frequent threat to technological and information security in a healthcare facility is which of the following? A. Computer hacking by a foreign country B. Computer hacking by a United States citizen for ransom C. Failure of employees to log off computer systems and sharing of passwords with others D. A major electrical failure in the facility

B Choice B is correct. Pain in pancreatitis is described as severe and maximal in intensity. It begins mid-epigastrium and radiates to the back; sometimes, it radiates to the chest, flanks, and lower abdomen. Choice A is incorrect. Pain in pancreatitis is described as severe pain, not burning or aching pain. Choice C is incorrect. Pain in pancreatitis is described as severe pain, not burning or aching pain. Choice D is incorrect. Pain in pancreatitis starts in the mid-epigastric area and radiates to the back, chest, and lower abdomen. It does not radiate to the groin. Acute pancreatitis may cause hypovolemic shock, and the client should be resuscitated with isotonic intravenous fluids once a diagnosis is made to prevent this complication. Pancreatitis may be triggered by cholelithiasis or alcoholism. This disorder commonly causes a client to experience intense epigastric pain, nausea/vomiting, and sometimes jaundice.

The nurse is assessing a client with pancreatitis. Which of the following type of pain would be expected? A. Burning, aching pain in the left lower quadrant radiating to the hip. B. Severe pain in the mid-epigastric area radiating to the back. C. Burning, aching pain in the epigastric area radiating to the umbilicus. D. Severe pain in the left lower quadrant radiating to the groin.

C Choice C is correct. Assist-control (AC) is a volume mode on a mechanical ventilator that senses a client's ability for a spontaneous breath. When the client takes a spontaneous breath, it will deliver the tidal volume preset on the ventilator. This is in addition to the client receiving the ventilated breaths preset in the rate. For example, if the client is at a preset rate of 12 and taking 4 spontaneous breaths, each breath of the 16 will receive 515 mL of gas (the tidal volume preset). Choices A, B, and D are incorrect. AC differs from SIMV (synchronized intermittent mandatory ventilation); in SIMV, the client may trigger a spontaneous breath and their own tidal volume. Pressure added at the end of exhalation to prevent alveoli collapse would be a description of PEEP (positive end-expiratory pressure). Inspiratory pressure during ventilation would be a description appropriate for pressure support ventilation. When caring for a client on a ventilator, you should be familiar with the following settings: Mode (Volume [SIMV, A/C] or Pressure [PSV]) Rate (Number of breaths per minute) Tidal volume (the amount of gas delivered to the client) Fraction of inspired oxygen (FiO2 - the percentage of oxygen given per breath) PEEP (pressure added at exhalation to keep the small airways open and mitigate atelectasis) Pressure support (PS - provides added pressure when the client takes a spontaneous breath)

The nurse is caring for a client receiving assist-control (AC) via mechanical ventilation. The nurse understands that this setting is used to do which of the following? A. Allow spontaneous breaths at the client's tidal volume. B. Deliver additional pressure at the end of exhalation. C. Deliver a preset tidal volume during spontaneous breaths. D. Provide inspiratory pressure during ventilations.

A Choice A is correct. Enalapril is an ACE inhibitor and this drug class is indicated in the treatment of heart failure to prevent ventricular remodeling. Choices B, C, and D are incorrect. Verapamil is a calcium channel blocker, which is contraindicated in the management of heart failure because of its adverse effects on cardiac output. Lovastatin and gemfibrozil are medications used to reduce cholesterol and are not directly used in the management of heart failure. For a client with heart failure, self-management strategies include following the MAWDS approach. Medications • Take prescribed medications, including ACE-I's, diuretics, and low-dose beta-blockers. • Avoid NSAIDs to prevent sodium and fluid retention. Activity • Stay as active doing aerobic activities. Weight • Weigh each day at the same time on the same scale to monitor for fluid retention. Report a weight gain of 1-2 pounds overnight; 3-5 pounds in a week Diet • Limit daily sodium intake to 2 to 3 g as directed. Symptoms • Note any new or worsening symptoms and immediately notify the health care provider.

The nurse is caring for a client with congestive heart failure (CHF). The nurse should anticipate a prescription for which medication? A. Enalapril B. Verapamil C. Lovastatin D. Gemfibrozil

D Choice D is correct. Patients under nitroglycerin therapy are at risk for postural hypotension. The client should rise slowly to avoid a sudden drop in blood pressure when standing up. Choice A is incorrect. The nurse should wear gloves when administering a nitroglycerin patch to avoid skin contact with the medication. Choice B is incorrect. The patch should be rotated to ensure optimum absorption through the skin. Choice C is incorrect. The purpose of nitroglycerin in heart failure is to dilate the venous circulation and trap the blood in the veins, decreasing the preload. Placing the client in the supine position and elevating his feet increases venous return, thus increasing preload. This defeats the purpose of nitroglycerin.

The nurse is caring for a client with heart failure. The patient is ordered a nitroglycerin patch to be attached. Which of the following nursing actions regarding the administration of a nitroglycerin patch is most relevant? A. Use a bare hand when putting the patch on the patient. B. Place the patch on the same spot every day. C. Place the client in the supine position with his feet elevated on a pillow. D. Instruct the client to rise slowly.

A, B, C Choices A, B, and C are correct. S1 (Choice A) and S2 (Choice B) are normal heart sounds. These normal heart sounds would still be auscultated in a patient with heart failure. S1 is a benign heart sound caused by the closure of the mitral and tricuspid valves. S2 is a benign heart sound produced by the closure of the aortic and pulmonic valves. S3 ("ventricular gallop") and S4 ("atrial gallop") are abnormal heart sounds that can be auscultated in heart failure. Both of these heart sounds are low-pitched and best heard at the apex with the patient in the left lateral decubitus position. While S3 may sometimes be heard in healthy hearts (normal in children, pregnant women, and trained athletes), S4 is almost always abnormal. While S3 is a sign of systolic heart failure, S4 is heard in diastolic heart failure. It is essential to understand these two types of congestive heart failure (CHF) before discussing how S3 and S4 are produced. The nurse would expect to hear an S3 heart sound (Choice C) in her patient with systolic heart failure. S3 occurs after S2 with the opening of the mitral valve, and a passive flow makes the sound of a large amount of blood hitting a compliant left ventricle. This large amount of blood hitting the left ventricle is because of the underlying fluid volume overload seen with systolic heart failure. Choice D is incorrect. The nurse would not expect to hear an S4 heart sound in her patient with systolic heart failure. This is seen in diastolic heart failure. S4 occurs before S1 when the atria contract to actively force blood into the left ventricle. A stiff, non-compliant left ventricle causes it. When the atrial contraction forces blood through the mitral valve, the force is increased due to resistance offered by a stiff ventricle - in this scenario, S4 is caused by the blood striking the left ventricle. S4 heart sounds can also be heard in active ischemia. Please note that if a patient has atrial fibrillation and the atria are not contracting, it is impossible to have an S4 heart sound.

The nurse is caring for a client with systolic heart failure. Which of the following heart sounds would the nurse expect to auscultate? Select all that apply. A. S1 B. S2 C. S3 D. S4

C Choice C is correct. When a neonate develops hypoglycemia, norepinephrine is released, causing tachycardia which causes an increase in glucose metabolism. This increase in glucose metabolism depletes the neonate's reserve of glucose. If a neonate is experiencing cold stress, the nurse should warm the neonate by applying warm clothes, removing the neonate from any drafts, and ensuring the neonate is dry. The nurse should assess the neonate for hypoglycemia via heel stick once the neonate's temperature stabilizes. Choices A, B, and D are incorrect. Cold stress would deplete glucose stores because of the sympathetic response. Thus, hyperglycemia would not occur. Manifestations of hypoglycemia include poor muscle tone and a weak, jittery cry. Metabolic acidosis would develop due to cold stress because the lack of glucose would cause fat to be the fuel source, causing metabolic acidosis.

The nurse is caring for a neonate experiencing cold stress. The nurse should also assess the neonate for A. hyperglycemia. B. increased muscle tone. C. hypoglycemia. D. metabolic alkalosis.

B Choice B is correct. This patient would be the safest sleeping on their right side. This helps prevent edema in the operative eye. This patient would also benefit from being placed in semi-Fowler's position. Choice A is incorrect. This patient should not sleep on their left side. This may increase the potential for swelling, increased pressure, and bleeding. Choice C and D are incorrect. These positions are not the safest option for this patient after cataract removal surgery.

The nurse is caring for a patient who had a cataract removal from their left eye a few hours ago. Which statement if made by the patient's wife indicates an understanding of the post-operative care instructions? A. "He should sleep on his left side." B. "He should sleep on his right side." C. "He should lay on his stomach to promote draining." D. "He needs to sleep sitting completely upright."

A, C, D, E Choices A, C, D, and E are correct. A halo vest immobilizer is used to stabilize cervical spinal cord injuries. The goal is to stabilize the spinal cord using external fixation. Pin care should be completed every shift using sterile gauze and the prescribed solution. If the client should have the wrench taped to the front of the vest or at the head of the bed in case the device needs to be taken down for emergent cardiopulmonary resuscitation. Loosening of the pins is the most common complication and should be addressed immediately. The client should use a straw for drinking as moving the neck to swallow liquids is not permitted. Choices B are incorrect. The primary goal for a patient with a halo vest immobilizer device is to stabilize the cervical spine. These exercises would be contraindicated as they could worsen the underlying injury. When caring for a client with a halo vest immobilizer, the nurse should instruct the client about pin care, signs of infections at the pin site, not driving while in the vest, and keeping the wrench affixed to the front of the vest. To perform CPR, the wrench may be necessary to let down the metal posts. Before discharge, a client with this type of device will need to meet with an occupational and speech therapist to learn how to perform ADLs safely.

The nurse is developing a plan of care for a patient who has a halo vest immobilizer (halo brace) following a cervical spine fracture. Which of the following should the nurse include in the patient's plan of care? Select all that apply. A. Pin care every shift B. Neck flexion and extension exercises C. Taping the wrench to the vest D. Report loosening of the pins E. Use straws when providing liquids

D Choice D is correct. To test peripheral responses to pain, health care providers should apply pressure to outer body parts such as the toes or fingers. Pressing on the patient's nail bed is the most appropriate action. Choice A is incorrect. Applying pressuring on the patient's mid-back does not evaluate peripheral pain. Choice B is incorrect. Sternal rubs are most often used to test consciousness. Choice C is incorrect. Squeezing, the patient's sternocleidomastoid muscle does not evaluate peripheral pain.

The nurse is evaluating a patient's response to peripheral pain. Which technique should the nurse use to perform this evaluation? A. Pressure on the patient's mid-back B. Sternal rub C. Squeezing the sternocleidomastoid muscle D. Pressing on the patient's nail bed

C Choice C is correct. To prevent rapid gastric emptying, the client needs to lie down after meals. Staying upright promotes gastric emptying due to gravity. Choice A is incorrect. To prevent dumping syndrome, the client needs to avoid sugar, salt, and milk as these promote gastric emptying. Choice B is incorrect. The client is instructed to eat a high protein, high fat, low carbohydrate diet. Pasta, rice, and bread are high carbohydrate foods that the client needs to eliminate from her diet. Choice D is incorrect. To prevent dumping syndrome, clients are instructed to eat small meals and avoid consuming fluids with meals.

The nurse is giving discharge instructions regarding methods that can prevent dumping syndrome for a client that had undergone a pyloroplasty. Which statement from the client indicates a need for further teaching by the nurse? A. "This means I have to give up milk and cookies for my snack." B. "I need to minimize eating pasta, rice, and bread." C. "I have to stay upright after eating my meals." D. "I need to get used to eating smaller, more frequent meals."

C Choice C is correct. Meconium Ileus is frequently the first sign of cystic fibrosis in a newborn. Meconium ileus is a small bowel obstruction that occurs when the infant's first stool is thicker and stickier than usual, causing a blockage in the ileum. Often, it presents within a few hours of birth with bilious vomiting as soon as feedings are initiated. Abdominal distension may be present. Some infants may manifest with just delayed passage of meconium rather than acute symptoms of obstruction. Meconium peritonitis may occur if there is perforation and may manifest with abdominal tenderness, fever, and shock. Choice A is incorrect. Steatorrhea is described as stools that are bulky, frothy, and foul-smelling. Steatorrhea is caused by the excretion of abnormal quantities of fat in the stool. This occurs in cystic fibrosis but is not present yet in a newborn. Choice B is incorrect. Hyperhidrosis is a medical condition in which a person sweats excessively and unpredictably. This is not a sign of cystic fibrosis in the newborn. Newborns with cystic fibrosis will have elevated chloride levels in their sweat, causing it to taste salty, but they will not sweat excessively. Choice D is incorrect. Barrel chest is a long-term complication of cystic fibrosis but not a sign that would be present at birth in the newborn. A barrel chest is a broad, deep chest that is large and cylindrical. It occurs when the patient has been suffering from hypoxemia due to cystic fibrosis for a prolonged period of time. Cystic fibrosis is a multisystem disorder that is caused by a genetic defect. This disorder is inherited as an autosomal recessive trait. ➢ Meconium ileus is one of the earliest manifestations in a newborn with cystic fibrosis. This may occur within the first two weeks of life. Manifestations of a meconium ileus include abdominal distension and failure to pass meconium, with or without vomiting. Treatment includes nasogastric tube (NGT) insertion, which may decompress the abdomen.

The nurse is performing a health assessment on a newborn. Which assessment finding would lead the nurse to suspect cystic fibrosis? A. Steatorrhea B. Hyperhidrosis C. Meconium ileus D. Barrel chest

C Choice C is correct. This information should not be included. Patients should be warned against lifting anything about 5 lbs as the straining can be damaging to the healing eyes following cataract surgery. Choice A is incorrect. Nurses should inform their patients that itchy eyes are normal after this procedure. Eye shields should be utilized after this surgery to prevent scratching the healing eye. Choice B is incorrect. Nurses should educate their patients on wearing eye shields at night to prevent scratching. Choice D is incorrect. Constipation should be avoided to prevent straining because doing so increases intraocular pressure, which could damage the eyes.

The nurse is providing discharge instructions for a patient following cataract surgery. Which of the following guidelines should not be included in the patient teaching? A. Itchy eyes are normal for a few days following the procedure B. Use an eye shield at bed time C. Lift objects only under 10 pounds D. Discuss measures to take if constipation occurs

D Choice D is correct. Eggs, fish, onions, cabbage, and some greens produce foul-smelling stools. Clients are advised to avoid these foods to eliminate foul odors in their ileostomy. Choice A is incorrect. Spinach is a deodorizing food for clients with an ileostomy. Choice B is incorrect. Parsley is a deodorizing food for clients with an ileostomy. Choice C is incorrect. Yogurt and buttermilk are deodorizing food for clients with an ileostomy.

The nurse is talking to a patient that just had an ileostomy created a month ago. He states that he is a bit embarrassed by the odor that the ostomy is producing. The nurse investigates the food that the client consumes and initiates further health teaching when the client mentions the following menu: A. Spinach B. Parsley C. Yogurt and buttermilk D. Eggs

D Choice D is correct. Smoking, obesity, and physical activity are all modifiable risk factors of coronary heart disease. Choice A is incorrect. Gender is a non-modifiable risk factor, whereas cholesterol levels and obesity are modifiable risk factors. Choice B is incorrect. Age is a non-modifiable risk factor, whereas blood pressure is a modifiable risk factor. Choice C is incorrect. Stress is a contributing risk factor, whereas age and gender are non-modifiable risk factors.

The nurse is talking to the patient's son who was just diagnosed with coronary heart disease. He asks about the risk factors that can be modified to decrease the chances of acquiring this medical condition. The nurse educates him by saying that the following are modifiable risk factors for coronary heart disease: A. Gender, cholesterol levels, and obesity B. Age and elevated blood pressure C. Stress, age, and gender D. Smoking, obesity, and physical activity

A Choice A is correct. The client should be advised not to take metronidazole with alcohol since mixing the two can cause abdominal pain, nausea, vomiting, and dizziness. The client should wait for three days after the prescription is complete before drinking any alcohol. Choices B, C, and D are incorrect. Metronidazole can cause photosensitivity (increased sensitivity to sunlight). The client should be advised to stay out of the sun during treatment. Since metronidazole is an antibiotic, the client should understand that the entire prescription should be taken as directed. Taking the medication with food or a full glass of milk is advisable to avoid an upset stomach. Other side effects of metronidazole include a metallic taste in the mouth, decreased appetite, diarrhea or constipation, and a darkening of the color of the urine. Metronidazole is an effective antibiotic for targeting anaerobic pathogens. This medication is commonly utilized for gastrointestinal and sexually transmitted infections. A darkening urine, avoidance of alcohol, and metallic-like taste are all essential teaching points.

The nurse is teaching a client about prescribed metronidazole. Which of the following statements, if made by the client, would indicate effective teaching? A. "I should not drink alcohol while I'm taking metronidazole." B. "It is okay for me to be in the sun while I'm taking this medicine." C. "I should take the medicine until my stomach stops hurting, then stop." D. "I should take the medicine on an empty stomach."

B, D Choices B and D are correct. These two statements should be included in patient education about thoracentesis. A thoracentesis is a procedure indicated for pleural effusions. The client will need to report any dyspnea after the procedure (Choice B). Shortness of breath following the thoracentesis procedure may indicate either iatrogenic pneumothorax or re-expansion pulmonary edema. Pneumothorax is a common complication following thoracentesis (studies report post-thoracentesis pneumothorax rates ranging from 0 to 19%). The nurse should assess the client carefully for any signs of pneumothorax. Symptoms and signs of a pneumothorax include shortness of breath and reduced or absent breath sounds on the affected side. A more severe pneumothorax, such as tension pneumothorax, may present with obstructive shock. A nurse must notify the physician immediately if any of such signs/symptoms were to occur. A chest x-ray (Choice D) must be completed post-procedure to make sure there is no iatrogenic pneumothorax even if the patient did not show any of the above signs or symptoms. Re-expansion pulmonary edema (REPE) is a complication that occurs after rapid re-expansion of a collapsed lung within 1 to 24 hours. It has been reported <1% in most studies are associated with high mortality. The pathophysiologic mechanism of REPE is unknown. Clinical features vary from cough and chest tightness to acute respiratory failure. Treatment is usually supportive and includes continuous non-invasive positive pressure ventilation or mechanical ventilation in severe cases; some patients also require vasopressors, steroids, and diuretics. Choice A is incorrect. Thoracentesis is a bedside procedure and can be completed under local anesthesia. Choice C is incorrect. It would be inappropriate to advise that the client empty their bladder before the procedure. Choice E is incorrect. Finally, a clear liquid diet one day before the procedure would be appropriate for a colonoscopy - not for a Thoracentesis.

The nurse is teaching a patient who is scheduled for a thoracentesis. Which of the following information should the nurse include? Select all that apply. A. "This procedure will require you to receive general anesthesia." B. "You will need to report any shortness of breath following the procedure." C. "You will need to empty your bladder before this procedure." D. "After the procedure, a follow-up chest x-ray will be done." E. "You will need to be on a clear liquid diet one day before the procedure."

A Choice A is correct. This statement is incorrect and requires follow-up. Bronchodilators should be administered before chest physiotherapy to enhance the mobilization of secretions, allowing them to be expelled. Choices B, C, and D are incorrect. These statements are correct and do not require follow-up. Bronchodilators should be administered before strenuous exercise to prevent respiratory distress. Specifically, short-acting bronchodilators such as albuterol need to be administered. Bronchodilators cause a discharge of catecholamines which may cause the client to have insomnia. Increasing the amount of non-caffeinated fluids is recommended during respiratory illnesses to assist with the thinning of secretions.

The nurse is teaching the parents of a client with cystic fibrosis. Which statement, if made by the parents, would require follow-up? A. "Chest physiotherapy should be done before giving bronchodilators." B. "The bronchodilator should be administered before strenuous activity." C. "My child may have trouble sleeping if the bronchodilator is given at night." D. "During a respiratory illness, my child should drink more water."

B Choice B is correct. Before calling a code or contacting the physician, the nurse should ensure that the leads are correctly placed on the patient and have not been removed. Physically looking and assessing the patient as well as the associated equipment should be the first action when an abnormal rhythm is noticed on the cardiac monitor. Choice A is incorrect. The first action is to ensure proper lead placement. Choice C is incorrect. Calling a code is not appropriate until the nurse has confirmed the patient is experiencing asystole. Choice D is incorrect. Contacting the care provider should not be completed until the nurse is sure that the patient's leads are working correctly.

The nurse is watching the monitor of a patient wearing a continuous cardiac monitor when it begins to alarm and fails to display any QRS complexes. Which nursing intervention should the nurse do first? A. Press record on the electrocardiogram B. Check the patient's lead placement C. Call the code team D. Contact the health care provider

B 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 in case an emergency tracheostomy is required. Choice A is incorrect. The nurse should check for urgent or life-threatening situations. The child who fell might have a fracture and would need an x-ray. However, this is not a life-threatening situation. Choice C is incorrect. This child should be assessed but should not be prioritized over the child with epiglottitis. Choice D is incorrect. The client may have type 1 diabetes mellitus, but this is not a life-threatening situation.

The nurse is working on the pediatric clinic and checks the list of clients who are lined up to see the physician for today. Which client would warrant the nurse's attention? A. A 5-year-old who sustained a fall and is complaining of leg pain. B. A 2-year-old who is drooling and does not want to swallow. C. An 8-year-old child with a headache for 2 days. D. A 10-year-old child who is always thirsty and has lost weight.

A Choice A is correct. Respiratory status should always be given priority in any assessment. Residual sedation from anesthesia may cause an impairment in gas exchange. Thus, respiratory assessment is essential. Assessments are continuous, using preoperative and intraoperative data as bases for comparison. The estimates made in the PACU include respiratory status (airway, pulse oximetry), cardiovascular status (blood pressure), temperature, central nervous system status (level of alertness, movement, shivering), fluid status, wound status, GI status (nausea and vomiting), and general condition. These assessments are initially made every 10 to 15 minutes. Choices B, C, and D are incorrect. Although all these answer options are issues that should be addressed, the nurse's priority is the client's respiratory status. The client's pain level, ability to tolerate PO fluids and move extremities are staples in post-operative management.

The nurse plans care for a client immediately post-operative. The nurse should initially assess the client's A. respiratory status. B. tolerance to by-mouth (PO) fluids. C. pain level. D. ability to move the extremities.

C Choice C is correct. This is a true statement. Twisting while lifting an object will increase the likelihood of injury because twisting alters the individual's balance. Choices A, B, and D are incorrect. These statements are incorrect and require follow-up. While lifting, the legs should be appropriately bent, and the back should be straight. Heavy objects should be held near the body to maintain control and balance. A wide support base (feet should be shoulder width apart) is necessary to maintain balance. Effective Measures to Prevent Back Injury Include Have the necessary assistance to move the object. Planning the move and communicating with the other individual who will assist you. Using the shoulder, upper arms, hips, and thighs as the predominant muscles to help with the move. Keep objects close to your body when lifting or carrying objects. Avoid twisting by using your feet to turn your body. Use a mechanical lift when necessary.

The occupational health nurse is conducting an in-service on reducing back injuries. Which of the following statements, if made by a participant, would indicate a correct understanding of the conference? A. "I should keep my legs straight while lifting." B. "Heavy objects should be held away from my body." C. "I shouldn't twist while lifting an object." D. "I should keep a narrow base of support."

C Choice C is correct. The client's current vital signs would NOT be included in a client's pain history. However, these vital signs are part of the initial nursing assessment and ongoing assessments. Choice A is incorrect. The client's affective responses to pain are an integral part of a client's pain history; some emotional responses to pain include the client's feelings such as depression and anxiety in response to pain. Choice B is incorrect. The client's past alleviating measures that lessened their pain are an integral part of a client's pain history; therefore, this would be included in the client's pain history. Choice D is incorrect. The client's meaning of pain is an integral part of a client's pain history; therefore, this would be included in the client's pain history.

Which of the following information would NOT be included in a client's pain history? A. The client's affective responses to pain B. The client's past alleviating measures C. The client's current vital signs D. The client's meaning of pain

A Choice A is correct. Aspirin overdose can lead to metabolic acidosis and cause the development of pulmonary edema. Early symptoms of aspirin poisoning include tinnitus, hyperventilation, vomiting, dehydration, and fever. Late signs include drowsiness, unsteady gait, bizarre behavior, and coma. Abnormal breathing caused by aspirin overdose is usually deep and rapid. Pulmonary edema may be related to an increase in the permeability within the capillaries of the lung leading to "protein leakage" and transudation of fluid in both renal and pulmonary tissues. The alteration in renal tubule permeability may lead to a change in colloid osmotic pressure, therefore facilitating pulmonary edema. Choice B is incorrect Aspirin overdose may lead to metabolic acidosis, not metabolic alkalosis. Choice C is incorrect. Although initial respiratory alkalosis may occur with acute aspirin or salicylates overdose, metabolic acidosis ensues shortly thereafter. Choice D is incorrect. Aspirin overdose is not associated with Parkinson's-type symptoms.

Which of the following is a priority for the nurse to monitor for during the acute management of a patient who has taken an overdose of aspirin? A. Onset of pulmonary edema B. Metabolic alkalosis C. Respiratory alkalosis D. Symptoms that mimics Parkinson's disease

D Choice D is correct. This ABG shows respiratory alkalosis. The pH is higher than 7.45, which is alkalotic. The PCO2 is less than 35, which is alkalotic. Lastly, HCO3 is between 22 and 26, which is normal. The PCO2 shows alkalosis like the pH, so we know this is respiratory alkalosis. Choices A, B, and C are incorrect. These are not the correct acid-base disorder for the patient.

Which of the following is the correct interpretation for the following arterial blood gas? pH: 7.59 PCO2: 30 HCO3: 24 A. Metabolic acidosis B. Respiratory acidosis C. Metabolic alkalosis D. Respiratory alkalosis

B Choice B is correct. Enalapril is an ACE inhibitor used to lower blood pressure. Since clients with nephroblastoma are hypertensive due to increased renin levels, this medication is commonly prescribed to decrease their blood pressure. Any ACE inhibitor reduces blood pressure by inhibiting the formation of angiotensin II in the renin-angiotensin-aldosterone system (RAAS), so they are an excellent choice for treating hypertension caused by nephroblastoma. While ACE-I's may be nephrotoxic, this is still the recommended treatment and is therapeutic as long as the creatinine levels are monitored closely. Choices A, C, and D are incorrect. Propranolol is a beta-blocker used to slow the heart rate. While it can decrease blood pressure in specific client populations, it is not prescribed to clients with nephroblastoma to reduce their hypertension. Nitroprusside is a direct-acting vasodilator. This means it acts on the muscles of your blood vessels to dilate them, lowering the blood pressure. While this drug also lowers blood pressure, it is not the right choice for hypertension associated with nephroblastoma. It does not address the RAAS, which causes hypertension in clients with nephroblastoma. Digoxin is a cardiac glycoside. It increases the force of contraction of the muscle of the heart and is commonly prescribed to clients with heart failure. It would not be administered to clients with a nephroblastoma to lower their blood pressure. ✓ Nephroblastoma is a tumor affecting the kidney(s). ✓ The average age at diagnosis is three years in children with single kidney disease. ✓ It is slightly younger for those with bilateral involvement. Nephroblastoma nursing care involves ✓ Frequent blood pressure monitoring because this tumor may induce renin-related hypertension ✓ Avoid any activities that may cause palpation of the abdomen ✓ Gastrointestinal assessment as obstruction may consequently occur (absent bowel sounds, abdominal distention should be reported) ✓ Assessment of hemorrhage (tachycardia and hypotension)

Which of the following medications may be prescribed to control hypertension associated with a nephroblastoma? A. Propranolol B. Enalapril C. Nitroprusside D. Digoxin

B Choice B is correct. Meconium is defined as the first stool passed by a newborn infant. It is typically a dark black/green sticky stool. In about 99% of healthy full-term infants, meconium is passed within 24 hours of birth. In the absence of any pathology, 100% of full-term infants should pass meconium by 48 hours of delivery. In pre-term infants, there may be a delay in passing the first stool beyond 48 hours. Occasionally, the fetus can pass meconium into the surrounding amniotic fluid while still inside the uterus and may end up aspirating it. Any event that triggers fetal stress may cause the fetus to pass meconium while inside the womb. Decreased fetal oxygenation due to placental or umbilical cord pathology may trigger the fetus to pass meconium. Therefore, meconium-stained amniotic fluid is regarded as a sign of fetal distress. Sometimes, meconium is not passed within 24 hours of birth in a full-term infant. Such presentation may signal conditions that cause intestinal obstruction, including meconium ileus, cystic fibrosis, and Hirschprung's disease. Choice A is incorrect. Melena is a term that refers to dark, sticky feces that contains old, digested blood. It indicates an upper GI bleed. Choice C is incorrect. Diarrhea is a loose, watery stool. Choice D is incorrect. Hematemesis is bloody vomiting.

While you are tending to a one-day-old newborn, the mother tells you that the baby has not had a bowel movement yet. Which of the following terms refers to the first stool passed by a newborn infant? A. Melena B. Meconium C. Diarrhea D. Hematemesis

A Choice A is correct. The petit mal (or absence) seizure is characterized by blank staring and an impaired level of consciousness. This type of seizure usually begins between the ages of 3 and 15 years. Choice B is incorrect. In the simple partial (or Jacksonian) seizure, the patient will be in an awake state but will exhibit abnormal motor or autonomic behaviors that can affect any part of the body. Choice C is incorrect. The grand mal (or tonic-clonic) seizure is the type of seizure in which there is a rapid extension of the arms and legs with sudden jerking and eventual loss of consciousness of the patient. It is often accompanied by incontinence and post-ictal confusion. Choice D is incorrect. During the myoclonic seizure, the patient may be awake or with short periods of loss of consciousness. During this seizure, the patient will have abnormal motor behavior in one or more muscle groups that lasts a few seconds to a few minutes.

You are caring for a 12-year-old patient with a history of seizures. During her stay, you notice that she begins staring blankly. During this period, you are unable to get her attention, and she does not speak. You suspect that this is a: A. Petit mal seizure B. Simple partial seizure C. Grand mal seizure D. Myoclonic seizure

D Choice D is correct. This comment indicates a learning need relating to the therapeutic milieu for this nursing assistant. A therapeutic milieu has consistent boundaries that are adhered to by all members of the healthcare team. A milieu environment is planned and maintained in a manner that eliminates all possible stressors so that psychiatric mental health clients with emotional and behavioral issues can concentrate their energies and thoughts on the things impacting them rather than external stressors, such as changing and inconsistent rules and boundaries that have been eliminated from the environment of care. Choice A is incorrect. This comment indicates something else, although, at first glance, it may appear that the nursing assistant is favoring this client by not adhering to the client's established boundaries. Choice B is incorrect. Although at first glance, it may appear that the nursing assistant is ensuring the equal rights of all clients, this action indicates that this nursing assistant is not adhering to the client's established boundaries. Choice C is incorrect. Although at first glance, it may appear that the nursing assistant is preventing discrimination and ensuring the equal rights of all clients, this action indicates that this nursing assistant is not adhering to the client's established boundaries.

You are caring for a group of psychiatric mental health clients. One of these clients, who has anger management and aggressive behavior concerns, has not yet gained telephone privileges. You notice that the nursing assistant on the unit is escorting this client to the telephone. After you talk to the client about the telephone privileges, the nursing assistant tells you that, "It is unfair for this client to not be able to use the telephone when other clients are free to do so." What should you determine about this nursing assistant's comment? A. This comment clearly shows that the nursing assistant is favoring this client. B. This comment indicates that the nursing assistant is ensuring equal rights. C. This comment indicates that the nursing assistant is preventing discrimination. D. This comment indicates a learning need relating to the therapeutic milieu.

C Choice C is correct. Please note that the question is asking for an age-appropriate and independent nursing intervention. In this case, playing an audiotape of a heartbeat that mimics the mother's heart when the infant was in utero is an age-appropriate, independent nursing intervention that you could implement in terms of managing this pain. Choice A is incorrect. It is not accurate to say that no interventions are needed because infants do not experience pain with a circumcision - infants do experience pain with a circumcision. Some studies have described circumcision as one of the most painful procedures performed in neonatal medicine. Pain in these infants can cause increases in heart rate to as high as 50 percent above the baseline. Their level of pain can be assessed with an infant pain scale like the CRIES scale, which has pain behavior criteria. Choice B is incorrect. The application of topical lidocaine to the penis is not an independent nursing intervention; it is a dependent intervention that requires a doctor's order. Choice D is incorrect. Giving the infant a "magic" blanket to take the pain away is not an age-appropriate, independent nursing intervention that you could implement in terms of managing this pain. Magical and mystical thinking begins when the child is a toddler. So, a toddler, rather than an infant, can benefit from a "magic" blanket to reduce the pain.

You are caring for an infant who may or may not be experiencing pain as a result of circumcision. Which independent nursing intervention would you implement in terms of managing this pain, if any pain is present? A. No interventions are needed because infants do not experience pain with a circumcision. B. Apply topical lidocaine to the penis. C. Play an audiotape of a heartbeat. D. Give the infant a "magic" blanket to take the pain away.

A Choice A is correct. Atonic seizures are drop attacks or drop seizures that cause a sudden loss of muscle tone and result in the client collapsing. This is quite serious as this may cause a client to sustain an injury. Choices B, C, and D are incorrect. Tonic-clonic seizures are characterized by stiffening the muscles (tonic), then the client has muscle jerking (clonic). Absence seizures feature a brief staring gaze with an impaired level of consciousness. These are common in children and may occur multiple times throughout the day. Complex partial seizures cause an impairment in consciousness, so the client may exhibit automatisms such as lip-smacking or repeating certain words/phrases.

The nurse is observing a client with epilepsy have a sudden loss of muscle tone that lasts for a few seconds. The nurse is correct in identifying this as which of the following? A. Atonic seizure B. Tonic-clonic seizure C. Absence seizure D. Complex partial seizure

B Choice B is correct. An INR of 3.5 seconds is elevated and needs to be reported because the client may bleed. Choice A is incorrect. The HbA1c is elevated but would not impact a client scheduled for surgery. Choice C is incorrect. The hematocrit of 42% is within normal limits. Choice D is incorrect. A BUN level of 5 is decreased but poses no threat to the client.

The nurse is reviewing the laboratory results of a patient scheduled for surgery. Which of the following should be reported to the primary health care provider (PHCP)? A. Glycosylated hemoglobin (HbA1c) of 7.2% B. International Normalized Ratio (INR) of 3.5 C. Hematocrit (Hct) of 42% D. Blood urea nitrogen (BUN) level of 5

A, D Choices A and D are correct. Food items that are soft, not hot, non-acidic, and do not have jagged edges are permitted to consume following a tonsillectomy. Items such as ice chips and applesauce are permitted. Choices B, C, and E are incorrect. Citrus fruits are acidic and not permitted. Potato chips have jagged edges and will irritate the surgical incisions. Soup that is room temperature is permitted. However, tomato soup would be disallowed because it is acidic.

The nurse provides discharge education to the parents of a six-year-old who underwent a tonsillectomy. The nurse should recommend which dietary items to this client during their recovery? Select all that apply. A. Ice chips B. Orange slices C. Potato chips D. Applesauce E. Tomato soup

125 ml/HR

The primary healthcare provider (PHCP) prescribes three liters of 0.9% saline to infuse over 24-hours. How many mL per hour will be administered to the client? Fill in the blank.

C Choice C is correct. The nurse should have checked the patient's distal pulse immediately after the cardiac catheterization. Negligence and professional negligence are examples of unintentional torts that may occur in the health care setting. Negligence is misconduct or practice that is below the standard expected of an ordinary, reasonable, and prudent person. Such conduct places another person at risk for harm. Both nonmedical and professional individuals can be liable for negligent acts. Gross negligence involves an extreme lack of knowledge, skill, or decision-making that the person clearly should have known would put others at risk for harm. Malpractice is "professional negligence," that is, negligence that occurred while the person was performing as a professional. Malpractice applies to primary care providers, dentists, lawyers, and generally includes nurses. In some states, nurses cannot be sued for malpractice, only professional negligence. The terms malpractice and professional negligence are often used interchangeably. Six elements must be present for a case of nursing professional negligence to be proven: The nurse must have (or should have had) a relationship with the client that involves providing care and following an acceptable standard of care. Such duty, for example, is evident when the nurse has been assigned to care for a client in the home or hospital. A nurse also has a general duty of care, even if not explicitly assigned to a client, if the client needs help. There must be a standard of care that is expected in the specific situation but that the nurse did not observe. For example, something was done that should not have been done, or nothing was done when it should have been done. This is the failure to act as a reasonable, prudent nurse under the circumstances. The standard can come from documents published by national or professional organizations, boards of nursing, institutional policies and procedures, or textbooks or journals, or expert witnesses may state it. A link must exist between the nurse's act and the injury suffered. It must be proven that the harm occurred as a direct result of the nurse's failure to follow the standard of care and that the nurse could have (or should have) known that failure to comply with the standard of care could result in such harm. Harm or Injury. The client or plaintiff must demonstrate some type of damage or injury (physical, financial, or emotional) as a result of the breach of duty owed to the client. The plaintiff will be asked to document the bodily injury, medical costs, loss of wages, pain/suffering, and any other damages. Damages. If professional negligence caused the injury, the nurse is held liable for damages that may be compensated. The goal of awarding damages is to assist the injured party to his or her original position as far as financially possible. Choices A, B, and D are incorrect. None of these answer choices are examples of negligence on behalf of the nurse.

Which of the following situations is an example of negligence? A. The UAP (Unlicensed Assistive Personnel) fills a water basin with warm water while the patient with depression combs her hair. B. A nurse transcribes a new medication order: Questran powder 2 oz bid with wet food or one full glass of water. C. The nurse checks the distal pulses of a patient's legs two hours after they have returned from a cardiac catheterization. D. The nurse observes a UAP enter the room of a patient on contact precautions wearing gloves and a gown.

C Choice C is correct. Health care practitioners perform digital rectal exams (DRE) to check their aging male patients for benign prostatic hyperplasia (BPH) or prostate enlargement. Patients experiencing BPH may have difficulty starting a stream of urine or completely emptying their bladder. Choice A is incorrect. While asking clients about exercise is a general question asked during most yearly exams, this question does not have an impact on digital rectal examinations. Choice B is incorrect. Dietary questions are common at yearly examinations, especially for aging patients. However, dietary changes should not impact digital rectal exams. Choice D is incorrect. Health care staff may ask the patient about their bowel health during an annual exam if they have complained about any discomfort or concerns. Still, this question does not impact the reasons behind digital rectal examinations.

A 63-year-old male is being seen in the clinic for his annual exam. Before performing a digital rectal exam. Which of the following questions should the nurse ask? A. "Are you exercising regularly?" B. "Has your diet changed dramatically in the past year?" C. "Have you had any difficulty starting a stream of urine when you attempt to use the toilet?" D. "Are you currently experiencing constipation?"

D Choice D is correct. A patient with a recent lower lobe lung removal will have a chest tube drainage system to collect the blood and drainage and to prevent it from accumulating in the chest. Choice A is incorrect. The patient will likely not have a tracheostomy. Choice B is incorrect. A mediastinal tube is unlikely to be prescribed for this client. Choice C is incorrect. The patient may use an incentive spirometer during their recovery; it is not a priority nursing action.

A client with lung cancer recently had a left lower lobe removal. Which postoperative intervention will be performed as a priority in the care of this patient? A. Tracheostomy B. Mediastinal tube C. Incentive spirometer D. Closed chest drainage system

D Choice D is correct. The assessment findings indicate circulatory compromise to the right foot. This may be secondary to arterial injury distal to the fracture or compartment syndrome. It is an emergency and the nurse should notify the physician immediately to obtain appropriate orders for evaluation and intervention. Choice A is incorrect. Although reassessment is important, any sign of circulatory compromise should be addressed immediately. Choice B is incorrect. While readjustment of traction may be necessary, notifying the physician regarding the signs of circulatory impairment is of utmost importance. Physicians may decide on appropriate further interventions. Choice C is incorrect. The nurse should give analgesics to address the child's pain. However, the administration of pain medication will not resolve the issue of circulatory impairment and it is not the priority nursing action that should be taken.

A five-year-old has been hospitalized for 24 hours. He is on skeletal traction for the treatment of a right femur fracture. You walk into the room and find him crying. His right foot is pale, and you feel no pulse. What is your priority nursing intervention? A. Reassess the foot in twenty minutes. B. Readjust the traction. C. Administer the as-needed pain medication. D. Notify the physician.

D Choice D is correct. In most cases of abuse/violence, the victim does not want the family involved. Many times the perpetrator of violence will try to control the victim by threatening his/her family with harm. If the client wants the family to be involved, it is often "not" a warning sign of the presence of violence. Recognizing signs of the possible presence of violence are essential nursing skills, as many victims will not immediately report abuse. Often victims will seem dismissive of what the nurse feels is a sign of violence. The victim may state, "everything is fine" or "we have good days and bad days." Being observant of mood and behavior changes will give the nurse a sense of when there are changes in a patient. Suspicion of violence is not something that should be taken lightly or second-guessed. It's always best to observe and identify warning signs rather than wait for the patient to complain first. Choices A, B, and C are incorrect. Warning signs of violence include behavior changes, withdrawal, depression, agitation, hyperarousal, a new display of anger, noncompliance, sexualized behavior, bowel or bladder problems, sleep problems, and unexplained/curious injuries.

A nurse is assessing a patient for possible domestic violence. The nurse should know that all of the following are warning signs of the presence of violence except: A. Stating that everything is "just fine" B. Expressing sadness over a previous loss C. Displaying mood and behavior changes D. Wanting to have family involved

D Choice D is correct. This action will require follow-up. It is inappropriate to cancel the CT scan if the patient has a history of shellfish allergy. Previously, it was felt that allergy to shellfish/seafood (because they contain iodine) and allergy to topical iodinated products conferred cross-allergy with iodine-containing contrast dyes. Iodine is found ubiquitously in the form of thyroid hormones, and there is no such thing as an allergy to systemic iodine. Minor skin reactions to topical iodine do not confer cross-allergy to IV contrast dyes. There is no evidence to support this notion; therefore, current guidelines do not suggest treatment plan modification based on a history of shellfish or seafood allergy alone. According to the American College of Radiology (ACR) Manual on contrast media, there is no evidence to support the continuation of this old practice of inquiring specifically into a patient's history of "allergy" to seafood, especially shellfish. Choices A, B, and C are incorrect. These actions are most appropriate to ensure patient safety and do not require follow-up. Contrast dye can be toxic to the kidneys and may result in renal failure. The risk of contrast-induced nephropathy is higher in those who are dehydrated, those on diuretics, and those with underlying co-morbidities such as diabetes. The nurse needs to encourage adequate fluid intake (choice A) to promote the flush out of the contrast dye. The consent form must always be signed (choice B) before administering IV contrast to ensure safety and accuracy. During pre-screening, the consent form has a section that inquires about the patient's history of allergies, including any prior reactions to x-ray contrast. Safety measures must be ensured during patient transportation (e.g., transport to the x-ray department). During patient transport, specific safety measures include locking the equipment in a stopped position and keeping side rails up on stretchers (choice C). Before IV contrast administration, prescreening must include questioning the patient regarding prior reactions to contrast dye or allergies to medications/substances. Any allergy (not specifically shellfish) may increase the risk of having an IV contrast dye reaction. If there is a history of severe allergies or prior reaction to contrast dye, such patients may be premedicated with diphenhydramine and steroids. Shellfish allergy is not a contraindication.

A patient is scheduled to undergo a CT scan with intravenous contrast dye. Which of the following actions, if performed by the new nurse, would require follow-up by the supervising nurse? A. Encourage fluids when the patient returns from the scan. B. Confirm that the consent form is signed. C. Raise the side rails of the patient's stretcher during transport. D. Cancel the CT scan if the patient reports a shellfish allergy.

A, B, C ,D Choices A, B, C, and D are all correct. All of these are among the five rights of delegation, according to the NCSBN. The fifth right is the right supervision and evaluation. The proper task means that the responsibility falls within the scope of practice and job description of the person delegated the responsibility. The right circumstance implies that the patient/client is stable enough to have someone other than an RN be responsible for the job. The right person implies that the person doing the job has the skill and knowledge to complete it safely. The right direction and communication mean that the RN must be very specific in what the job involves and how it should be done. This right also means that the LPN/LVN must also communicate back to the RN about the completion of the task or any problems with the completion. Finally, every job must be monitored by the RN to evaluate the outcomes of the procedure. Documentation should be completed per facility policy, but the RN should always ensure that the documentation is correct and complete.

According to the National Council of State Boards of Nursing, the five rights of delegation include: Select all that apply. A. Right task B. Right circumstance C. Right person D. Right direction and communication

B Choice B is correct. Cool and clammy skin, bounding pulses, productive cough, distended neck veins, edema, and polyuria are signs of fluid overload. Choice A is incorrect. Low blood pressure, weak and thready pulse, and a slightly elevated temperature would indicate dehydration. Choice C is incorrect. These are not symptoms of fluid overload and may indicate other co-morbidities. Choice D is incorrect. Fever, warmth, swelling, and redness at the operative site indicate infection.

An elderly client has just finished a total knee replacement surgery. The nurse suspects fluid overload in the client. Which of the following signs and symptoms would confirm the nurse's suspicion? A. Blood pressure of 90/55 mmHg; weak, thready pulse; slightly elevated temperature. B. Cool, clammy skin; bounding pulse; cough. C. Headache, Lethargy, and abdominal pain. D. Fever; warmth, swelling, and redness at the operative site.

D Choice D is correct. Autologous donations are not screened for infectious diseases. According to the Food and Drug Administration (FDA), autologous donations are not screened because autologous donors are not exposed to new transfusion-transmitted infections in receiving their own blood. Choice A is incorrect. Each autologous donation requires an order or prescription by a health care provider (HCP). Choice B is incorrect. Although certain ages are preferable to others, there is no age limit for autologous donations. Active infections, specific cardiac conditions, and decreased hemoglobin levels are the primary methods of disqualification from autologous blood donation. Choice C is incorrect. Unless the client's health care provider (HCP) specifies otherwise, the traditional window for autologous blood donation begins five weeks before the scheduled surgery date, with the donation cutoff occurring 72 hours before the surgery. Depending on the surgical procedure and any unanticipated needs arising during surgery, the autologous units previously stored may be insufficient for the client's needs. If so, the client may receive additional units of blood from the community blood bank. To help maintain the client's blood hemoglobin at an acceptable level, the HCP will often recommend iron supplements for clients who choose to provide autologous blood donations. Although infectious disease testing is not traditionally performed on autologous blood donations, these donations receive ABO/Rh and antibody screenings. Approximately half of all autologous blood collected in the United States is not utilized. Severe transfusion reactions, including fluid overload causing heart failure, are not prevented by autologous donation.

Following a detailed conversation between a nurse and a client regarding autologous blood donations, which of the following statements, if made by the client, would indicate the need for additional education on the topic? A. "Autologous donations require a health care provider's (HCP) order." B. "There is no age limitation for autologous blood donations." C. "I can begin autologous blood donations five weeks before my surgery date and continue up until 72 hours before surgery." D. "My autologous blood donation will be screened for infectious diseases."

B Choice B is correct. The most significant concern at this point is that the client does not fully grasp the gravity of their condition and the current situation. The client must be educated regarding the ramifications of delaying diagnostic testing and the severity of the potential diagnosis. Additionally, the client should be allowed to verbalize their feelings regarding the current situation and ask questions regarding the information they have just received. Choice A is incorrect. Clients with aplastic anemia often have leukopenia, increasing the client's susceptibility to life-threatening infections. While the nurse would be concerned about the client contracting an infection due to the client's exposure to large crowds during spring break, this would not be the nurse's priority concern at this time. Choice C is incorrect. Transfusions of red blood cells, platelets, and growth factors may temporarily increase the client's red blood cells, white blood cells, and platelets. Transfusions can relieve symptoms but do not treat the causes of the underlying disease. Choice D is incorrect. Blood tests are performed in clients who demonstrate symptoms of anemia (e.g., fatigue, weakness, and paleness). When blood tests show that all blood cell numbers are reduced, a bone marrow examination is done. Aplastic anemia is diagnosed when a microscopic examination of a sample of bone marrow (i.e., taken during a bone marrow biopsy) reveals a sharp decrease in bone marrow cells. Aplastic anemia is linked to some cancers and cancer treatments, but it is not a type of cancer. Severe aplastic anemia is linked to a high risk of severe infections. In most aplastic anemia cases, the cause is unknown. In aplastic anemia, hematopoietic stem cell transplantation can be curative and is the treatment of choice, particularly in younger clients with a matched donor. At diagnosis, siblings are evaluated for HLA (human leukocyte antigen) compatibility. A bone marrow transplant may cure aplastic anemia for life. In those clients unfit for transplant or lacking a donor, immunosuppressive treatment with equine antithymocyte globulin (ATG) combined with cyclosporine produces overall response rates of approximately 60 to 80%. Aplastic anemia is a life-threatening condition with very high death rates (about 70% within one year) if untreated.

A 23-year-old college student presents to the emergency department complaining of severe fatigue and exertional dyspnea. The client's skin appears pale and aplastic anemia is suspected. Laboratory values reflect anemia, and the client is advised to undergo a bone marrow biopsy. The client refuses to sign the consent for the procedure, stating, "Just give me a blood transfusion and let me leave. Spring break starts this weekend, and I'm leaving for Florida." The nurse's most significant concern at this time would be: A. The possibility of the client contracting an infection due to exposure to large crowds during spring break. B. The client fails to understand the full impact of their current medical condition. C. The client may require a transfusion before leaving for spring break. D. The causative agent needs to be identified, and the treatment should be initiated immediately.

C Choice C is correct. The nurse should respond to the nursing assistant by saying, "Thank you for letting me know. I will work with you as we transfer the client safely and properly with the mechanical lift." This statement allows the nurse to reeducate the nursing assistant about the use of a mechanical lift and determine the nursing assistant's ability and competency to use it. Choice A is incorrect. The nurse would not respond with a statement such as, "It is your responsibility to be able to use it. You have been taught about its proper and safe use; this is part of your job description." This statement does not address the underlying learning need of the nursing assistant. Choice B is incorrect. The nurse would not respond with a statement such as, "I have looked at your competency checklist, and you were deemed competent to use mechanical lifts during your orientation." This statement does not address the underlying learning need for retraining and education about the use of a mechanical lift. Choice D is incorrect. The nurse would not respond with a statement such as, "Oh, that is okay; I will assign the transfer of this client using a mechanical lift to another nursing assistant." This statement does not address the underlying learning need for retraining and education about the use of a mechanical lift.

As the charge nurse on 3 East, you have assigned a nursing assistant to transfer a client from the bed to the chair using a mechanical lift. This is something that is within the scope of practice and in the job description for nursing assistants. When the nursing assistant sees the written assignment, the nursing assistant says, "I don't know how to use our mechanical lift." How should you respond to this nursing assistant? A. "It is your responsibility to be able to use it. You have been taught about its proper and safe use; this is part of your job description." B. "I have looked at your competency checklist and you were deemed competent to use mechanical lifts during your orientation." C. "Thank you for letting me know. I will work with you as we transfer the client safely and properly with the mechanical lift." D. "Oh, that is okay. I will assign the transfer of this client using a mechanical lift to another nursing assistant."

A Choice A is correct. Clients with anorexia nervosa have the desire to please others. They need to be accurate or perfect to cope with their stress. Choices B, C, and D are incorrect. These statements apply to clients with bulimia nervosa, not anorexia.

The nurse educator is talking to a group of students regarding anorexia nervosa. Which statement by the students indicates an understanding of the condition? A. "Clients with anorexia nervosa are usually perfectionists and overachievers." B. "Clients with anorexia nervosa display a binge-purge syndrome." C. "Clients with anorexia nervosa have poor dental conditions." D. "Clients with anorexia nervosa have stomach ulcers and rectal bleeding."

B Choice B is correct. Post-maturity refers to any baby born at or beyond 42 weeks gestation (42 0/7 weeks) or at or beyond 294 days from the first day of the mother's last menstrual period (LMP). Post-maturity is also referred to as prolonged pregnancy, post-term, and post-dates pregnancy. At about 40-42 weeks, placental insufficiency ensues due to the aging placenta. Therefore, the infants rely on their subcutaneous fat reserves to sustain them after 40 to 42 weeks since the aging placenta is unable to provide the necessary nutrition. Due to these depleted subcutaneous fat reserves, the post-term infant is at risk for hypoglycemia and hypothermia. In at-risk infants, the incidence of neonatal hypoglycemia is highest in the first few hours after birth. In this case (Choice B), a 4-hour old infant delivered at 42 weeks is at-risk. Additionally, the risk of meconium aspiration is high in the post-term fetuses and can cause respiratory distress when the baby is born. The nurse should prioritize and assess this post-term infant first. Choice A is incorrect. According to the World Health Organization (WHO), the average birth weight for a full-term baby is around 7.5 lb. However, a birth weight range between 5.5 lb. (2.5 kg) and 8.2 lb. (4.0 kg) is considered normal. Small for gestational age (SGA) is defined as a birth weight of less than 10th percentile for gestational age. Large for gestational age (LGA) refers to a birth weight equal to or more than the 90th percentile for a given gestational age. Macrosomia refers to a birth weight greater than 4000 to 4500 grams ( 4 to 4.5 kg), regardless of gestational age. The infant weighing 6 pounds (Choice A) is within the normal weight range for a newborn; the nurse does not need to see this infant first. Choice C is incorrect. The average length of full-term babies at birth is 20 inches (50 cm). The normal range is between 18 to 22 inches. Macrosomia is defined based on the birth weight, not the birth length. Twenty-one inches is a bit longer than the average for most infants, but this is not a relevant finding that causes complications soon after birth. The nurse does not need to see this infant first. Choice D is incorrect. The risk of neonatal hypoglycemia is highest in the first few hours after birth in some "at-risk" infants. These "at risk" infants include those who are post-term infants (at or beyond 42 weeks gestation), late preterm (34-36.6 weeks gestation), term infants who are small for gestational age, infants of diabetic mothers, and large for gestational age infants. An infant born at 40 weeks (Choice D) is referred to as a term infant, and there are no reported problems from the previous shift. No risk factors have been mentioned. The American Academy of Pediatrics (AAP) guidelines do not recommend routine screening and monitoring of blood glucose in healthy term infants after a normal pregnancy and delivery. The nurse does not need to assess this newborn first.

The nurse just finished receiving the shift report from the night nurse. Which of the following newborns should the nurse assess first? A. A 3-hour old newborn weighing 6 pounds B. A 4-hour old newborn delivered at 42 weeks C. A 6-hour old newborn that is 21 inches long D. An 8-hour old newborn delivered at 40 weeks

C Choice C is correct. The highest priority action would be to stabilize the patient's cervical spine to prevent further damage and to preserve airway patency. Choice A is incorrect. The nurse should assess the patient for bleeding and other injuries due to the trauma, but it would not be the highest priority/first action. Choice B is incorrect. The patient may require intubation if the airway is not patent. Still, the nurse would first need to stabilize the spine and assess the airway before knowing whether intubation is appropriate. Choice D is incorrect. Inserting a large-gauge IV catheter would be an appropriate action for this patient, but not the highest priority. Fluid replacement would not be a more immediate need than the airway.

The patient presents to the emergency department with back pain and numbness in the extremities after experiencing a fall. The nurse assesses muscle flaccidity and hypotension. What is the nurse's highest priority regarding this patient? A. Assess for external bleeding B. Prepare the patient for intubation C. Stabilize the cervical spine D. Insert an 18g IV for fluid replacement

B Choice B is correct. Tympany is the percussion sound heard over hollow organs. The small intestine and colon are hollow organs; they predominate over most of the abdominal cavity. Choice A is incorrect. Hyperresonance is the sound heard by tapping on the surface of the chest. It is an exaggerated chest resonance heard in various abnormal pulmonary conditions. Choice C is incorrect. Resonance is a low-pitched, hollow sound, is usually heard over healthy lung tissue. Choice D is incorrect. Dullness replaces resonance when fluid or solid tissue replaces air-containing lung tissues, such as occurs with pneumonia, pleural effusions, or tumors.

What percussion sound is heard over most of the abdomen? A. Hyperresonance B. Tympany C. Resonance D. Dullness

B Choice B is correct. Hyperressonance is an abnormal finding over adult lung tissue. It indicates an abnormal increase in the amount of air present, such as with emphysema. Choice A is incorrect. Soft, short, muffled "dull" sounds are normal over dense organs such as the liver and spleen. Choice C is incorrect. Bones produce a "flat" percussion sound in normal healthy adults. Choice D is incorrect. Adult lung tissue should create a "resonant" sound during percussion, but hyperresonance is a normal finding in children's lung tissue.

Which percussion sound would indicate further assessment is needed? A. Dull tone over the spleen B. Hyperressonance over an adult's lung tissue C. Flat tone over bone D. Hyperressonance over a child's lung tissue

B Choice B is correct. The purpose of an incident report is to provide an objective account of an incident/occurrence, in order to identify issues with current practices, improve policies, and potentially investigate situations of negligence/malpractice. Subjectivity should be excluded from a report because subjectivity allows for opinions on details that may not be true (example, stating I believe the client fell because he did not follow instruction) would be inappropriate. Choices A, C, and D are incorrect. An incident report should include the client's account of the fall (stated in quotations). An incident report should include any injuries sustained or adverse effects noted as a result of the fall and the monitoring and assessment performed following the event. An incident report should include the names of any witnesses to the fall. ADDITIONAL INFO Incident (sometimes termed occurrence or event) reporting is a tool to mitigate future risks. Incident reporting should also be completed for events involving clients and visitors. Such events include: Verbal and physical displays of aggression Tampering with medical devices Reports of sexual or physical abuse by staff Adverse reaction to a blood transfusion Client elopement Damage (or loss) of client possessions Falls or injuries Injuries related to a medical device Complaints Medication and treatment errors Interfering with client care The incident should not be logged in the medical record or nursing notes. The documentation should be objective and factual and include what occurred, any injuries, if the provider was notified, care administered after the event, and any witnesses.

The risk manager reviews an incident report completed by a nurse regarding a client's fall. Which finding in the report demonstrates inappropriate documentation? A. The client's explanation of the event. B. Subjective factors preceding the fall. C. Any injuries sustained as a result of the fall. D. The names of all witnesses present.

A Choice A is correct. Because food and fluid do not go through the large intestine, the normal process of absorbing the liquid part of stool does not occur for patients with an ileostomy. An ileostomy produces fluid fecal drainage. Drainage is constant and cannot be regulated. One nursing intervention for clients with an ileostomy is to educate them on what foods may cause stress or irritation (such as more frequent stools). Foods or drinks that are caffeinated and liquids that are high in fat, such as regular milk, should be limited to 1 cup per day to help decrease episodes of diarrhea. Choices B, C, and D are incorrect. Each of these foods may cause a stronger odor, but are not the most likely to cause diarrhea.

Which of the following foods eaten by a patient with an ileostomy is most likely to have caused diarrhea? A. Coffee B. Garlic C. Eggs D. Fish

B Choice B is correct. Clients with a history of asthma may be normal at the baseline. However, they exhibit symptoms and signs such as coughing, dyspnea, chest tightness, anxiety, tachypnea, and wheezing if having an asthma exacerbation. Wheezing is associated with airway inflammation and narrowing ( bronchospasm) that accompany asthma. Wheezes are high-pitched, continuous musical sounds that can be heard during inspiration and/ or expiration. Acute onset of wheezing may indicate an acute exacerbation in an asthmatic client. Bronchospasm should be treated, and often, a rescue inhaler with a short-acting bronchodilator is quickly administered to relieve symptoms. Choice A is incorrect. An oxygen saturation ( Sao2) reading at 94% is not a priority. Instead, pulse oximetry with Sao2 of less than 92% is a cause for concern. Choice C is incorrect. Rhonchi are low-pitched, continuous musical sounds heard during inspiration and/ or expiration. Bronchial rhonchi indicate secretions in the airway, such as those caused by pneumonia. Often, rhonchi are not associated with asthma. Choice D is incorrect. Should the client have an asthma exacerbation, increased respiration ( tachypnea) is expected, not decreased.

Which of the following complaints should be first evaluated in a client with respiratory symptoms who has a history of asthma? A. An oxygen saturation of 94% B. Increased wheezing C. Sustained rhonchi D. Decreased respiratory rate

A, C Choices A and C are correct. Postnatal nursing interventions for omphalocele are aimed at minimizing the complications to the neonate. Although the intestines remain in a peritoneal sac in an omphalocele, there is no skin covering the defect. Therefore, there is an insensible loss of heat and fluids. Complications such as dehydration, electrolyte imbalance, hypothermia, and infection ( necrotizing enterocolitis) may ensue. Because of the defect, infants with omphalocele have reduced chest capacity and respiratory reserve. The pre-operative nursing management of neonates with omphalocele involves airway stabilization, covering the defect with sterile gauze soaked in saline, inserting an orogastric tube for bowel decompression, and establishing peripheral intravenous access. Subsequent interventions include the administration of intravenous fluids and broad-spectrum antibiotics. The defect should be covered with sterile gauze soaked in saline ( Choice A). This keeps the intestines moist and reduces insensible fluid loss. Additionally, such a protective covering will prevent infection. Infection prevention in omphalocele patients is a priority because exposed abdominal contents are prone to severe infection when there is no protective skin covering. Due to insensible heat loss from the exposed viscera, hypothermia is a critical complication of an omphalocele. Affected infants struggle to maintain their body temperature. The affected infants should not be tightly swaddled because this would put pressure on the exposed intestines compromising the blood flow. Strategies such as using a radiant warmer can help with thermoregulation in these infants without compromising the intestines (Choice C). Choice B is incorrect. It is inappropriate to position an infant with an omphalocele in a prone position. Prone positioning would place the exposed intestines directly onto the surface, causing compression of the intestines and blood-flow compromise. Instead, supine positioning is preferred. Choice D is incorrect. Trophic feeding refers to feeding small volumes of enteral feeds to stimulate the development of the infant's immature gastrointestinal tract. Trophic feedings would not be started in an infant with an omphalocele before the surgical repair. The intestines will need to be placed back in position before the feeds can be initiated. Initially, the feeding will be primarily parenteral, with very gradual transitioning to the enteral feeds. Choice E is incorrect. The recommended method is to cover the defect with sterile gauze soaked in thermal-neutral saline. Using excessively wet dressings may increase the hypothermia risk. The nurse must avoid circumferential abdominal wraps and dressings because they can press on the omphalocele sac and compromise blood flow. Two important abdominal wall defects encountered in the neonatal period are omphalocele and gastroschisis. An omphalocele is a midline abdominal wall defect at the base of the umbilical cord, with herniation of the intestine and other viscera. In an omphalocele, the viscera are covered with a peritoneal sac. Gastroschisis is an abdominal wall defect that presents laterally and to the right of the umbilicus. There is no peritoneal sac covering the exposed intestines in a gastroschisis defect.

Which interventions should the nurse anticipate for an infant with omphalocele awaiting surgical repair? Select all that apply. A. Cover the intestines with a sterile gauze soaked in saline B. Prone positioning C. Radiant warmer for thermoregulation D. Trophic feedings E. Wet circumferential abdominal wall wrap to prevent drying of the intestines

A, C Choices A and C are correct. Normal saline (0.9% NS) is an isotonic solution (Choice A). Lactated ringers (LR) is an isotonic solution (Choice C). Choice B is incorrect. ½ Normal saline (.45% NS) is a hypotonic solution. Choice D is incorrect. D10W is a hypertonic solution.

Which of the following IV fluids are isotonic solutions? Select all that apply. A. Normal saline B. ½ Normal saline C. Lactated ringers D. D10W

C Choice C is correct. Oxybutynin is used to treat urinary bladder urgency and incontinence. Anticholinergics are drugs that have actions opposite those of the parasympathetic branch. Their action mimics the fight-or-flight response. Choice A is incorrect. Dicyclomine is used to treat irritable bowel syndrome. Choice B is incorrect. Ipratropium is used to treat asthma. Choice D is incorrect. Scopolamine is used t

Which of the following anticholinergics does the nurse recognize as appropriate for a patient diagnosed with urinary bladder urgency and incontinence? A. Dicyclomine B. Ipratropium C. Oxybutynin D. Scopolamine

B Choice B is correct. Bell's palsy is due to the lower motor neuron pathology of the facial nerve. A client with Bell's palsy typically has ipsilateral ( same side) facial paralysis, but gustatory and auditory sensory disturbances are also noted. While formulating a nursing diagnosis, the nurse should apply Maslow's hierarchy of needs theory to prioritize and plan client's care based on patient-centric outcomes. The nurse must first identify the client's physiological and safety needs and plan nursing care and nursing interventions to address those. According to Maslow, basic physiological needs must be met before higher needs ( self-esteem, aesthetic needs) can be achieved. In this client, motor and sensory deficits are the priority. Bell's palsy causes acute facial paralysis or weakness in the muscles supplied by cranial nerve VII ( facial nerve), which can result in difficulty closing the eyelid, increased sound sensitivity (hyperacusis), altered sense of taste on the affected side of the tongue (gustatory sensation), pain, and difficulty chewing/swallowing. The nurse should plan interventions such as applying artificial tears/ lubricants to the affected eye to prevent corneal dryness/ abrasion ( safety needs). A referral to a physical therapist may be made to help the client with facial muscle exercises. The nurse should provide a soft diet to help with chewing and educate the client to chew on the unaffected side. Choice A is incorrect. Bell's palsy may be caused by inflammation and viral infections, but the patient would not be at a higher risk for developing an infection due to facial muscle weakness. Choice C is incorrect. Bell's palsy causes facial asymmetry. Therefore, the patient would be at risk for disturbed body image, but this would be a psychological nursing diagnosis and would not be a higher priority than facial muscle weakness and disturbed sensory perception. Physiological needs must be met first before higher-level needs are addressed. Choice D is incorrect. Bell's palsy would not put this patient at increased risk for impaired tissue perfusion.

Which nursing diagnosis would be the highest priority for a patient with a medical diagnosis of Bell's palsy? A. Risk for infection B. Risk for disturbed sensory perception C. Risk for disturbed body image D. Risk for ineffective tissue perfusion

B Choice B is correct. The whooshing or blowing sound sometimes heard upon cardiac auscultation is known as a heart murmur and may indicate valve incompetency. Choice A is incorrect. Pericardial friction sounds like a scratching sound caused by the conflict between the heart and the pericardium. Choice C is incorrect. Whooshing and blowing do not indicate normal lub-dub sounds. Choice D is incorrect. S3 is a third heart sound, sometimes referred to as a gallop. This gallop is not the same thing as a murmur.

While performing cardiac auscultation on a client. The nurse notes a whooshing and blowing sound over the heart valves. The nurse knows that this sound can be identified as a: A. Pericardial friction rub B. Heart murmur C. Normal lub-dub sounds D. S3

A Choice A is correct. Infected lymph nodes are usually tender. Choice B is incorrect. Infected lymph nodes are usually tender. Choice C is incorrect. Lymph nodes are movable. Choice D is incorrect. Lymph nodes are usually not irregular in shape.

A patient presents with enlarged tonsillar nodes. Acutely infected nodes would be: A. Firm but movable and tender B. Hard and nontender C. Fixed and soft D. Irregular and hard

B Choice B is correct. Kurt Lewin's theory of leadership is the most similar to the styles of parenting. Lewin describes the leadership styles as the autocratic, participative, democratic, and laissez-faire styles of leadership, which are the same as the different parenting styles. All these styles of leadership and parenting styles have their distinct advantages and disadvantages. Choice A is incorrect. Bass developed the transformational leadership style, which is not similar to the parenting styles of authoritarian parenting, participative parenting, democratic parenting, and laissez-faire parenting. Choice C is incorrect. House developed the Path-Goal situational leadership theory, which is not similar to the parenting styles of authoritarian parenting, participative parenting, democratic parenting, and laissez-faire parenting. Choice D is incorrect. Fiedler is credited with the Contingency situational leadership theory, which is not similar to the parenting styles of authoritarian parenting, participative parenting, democratic parenting, and laissez-faire parenting.

Parenting styles are most similar to whose theory of leadership? A. Bass B. Lewin C. House D. Fiedler

A Choice A is correct. Acetylcysteine is given to convert toxic metabolites to nontoxic ones. Acetaminophen is one of the most commonly used oral analgesics and antipyretics. The maximum dose for an adult is four grams in a 24-hour period. Toxicity starts after the consumption of seven grams. Choices B, C, and D are incorrect. Deferoxamine mesylate is the antidote for iron intoxication. Succimer is the antidote for lead poisoning. Flumazenil is the antidote for the sedative effect of benzodiazepines. Acute hepatic necrosis may result from large ingestion of acetaminophen. Acute hepatotoxicity can usually be reversed with acetylcysteine, whereas long-term toxicity is more likely to be permanent. The issue with acetaminophen toxicity is that most cases come from accidental ingestion because clients are unaware the cold remedies contain acetaminophen. Thus, appropriate education must be provided to avoid this type of toxicity.

The emergency department (ED) nurse is caring for a client with acetaminophen toxicity. The nurse anticipates a prescription for which medication? A. Acetylcysteine B. Deferoxamine mesylate C. Succimer D. Flumazenil

A Choice A is correct. Hyperventilating can cause respiratory alkalosis. This is because there the body is blowing off too much CO2. CO2 is an acid, so when the body is loosing too much of it, the client can become alkalotic. Choice B is incorrect. These values represent typical ABG values, which would not be expected in a patient who is hyperventilation. Choice C is incorrect. These values represent respiratory acidosis, which is not caused by hyperventilation. Respiratory acidosis is more likely to occur when the patient is hypoventilating, and retaining too much CO2. Common causes of this are an overdose or respiratory depression. Choice D is incorrect. These values represent metabolic alkalosis, which would not be expected in the patient who is hyperventilating. Because it is a change in CO2 causing the pH to shift, the cause of the imbalance is respiratory, not metabolic.

A 16-year old patient injures her ankle on the soccer field. She is taken to the emergency department by ambulance. In the ambulance, she starts hyperventilating. Upon arrival to the waiting room, an arterial blood gas is drawn. What values will most likely appear on the results? A. pH: 7.55, CO2: 22, HCO3: 24 B. pH: 7.35, CO2: 39, HCO3: 26 C. pH: 7.32, CO2: 47, HCO3: 25 D. pH: 7.55, CO2: 42, HCO3: 34

C Choice A is incorrect. Abnormal blood sugar levels may result in a client who is confused or unconscious. Low blood sugar values will not cause a fever and will not cause a skin rash. Other interventions will be the priority at this time based on those additional accompanying symptoms of fever and rash. Fever and rash are indicative of an infection. Choice B is incorrect. A Basic Metabolic Panel (BMP) will likely be ordered to show this client's electrolytes, renal, and liver function- but it will not be the priority. The nurse should be most concerned about an acute infection given the client's presentation: febrile, with a noticeable rash, and found unconscious. The concern is that this client has an infection that has travelled to their bloodstream; causing sepsis. This has likely progressed to septic shock causing the client's blood vessels to vasodilate, and decreasing their blood pressure so low that perfusion to the brain is inadequate. This is an emergency. The nurse should immediately obtain blood cultures to determine the source of the client's infection. Choice D is incorrect. ABGs are not indicated to test the source of fever or rash. An ABG would be obtained to check the pH of a client's blood along with their CO2 and HCO3- levels if respiratory failure was suspected. An ABG is a lab that is often obtained to check how well a client is tolerating their ventilator settings or if a client has been on BiPAP for respiratory failure. In this patient presenting with fever and rash, the priority interventions need to be targeted towards treating the infection. Sepsis is a life threatening response of the body to infection and widespread inflammation that can cause multiple organ dysfunction syndrome (MODS). When a patient has become septic there is a large concern that their organ perfusion will be affected. Patient who are septic deteriorate into septic shock. Shock happens when there is abnormal cellular metabolism that occurs when gas exchange and tissue perfusion needs are not met in order to maintain cellular perfusion. This unconscious patient presented with fever and rash. The priority will be to obtain laboratory studies that include blood cultures and other blood work. Blood cultures should be quickly obtained and fluid resuscitation with broad spectrum antibiotics need to be started as soon as possible for this patient if sepsis is suspected.

A 25-year-old is found unconscious with a fever and a noticeable rash. Which of the following ordered tests is essential for the nurse to obtain right away? A. Blood sugar check B. Basic Metabolic Panel (BMP) C. Blood cultures D. Arterial blood gases

C Choice C is correct. The patient is experiencing symptoms of Rocky Mountain Spotted Fever (RMSF): fever, chills, headache, and a macular rash that appears on the palms of hands, wrists, soles of feet, and ankles within ten days of exposure. RMSF occurs due to Rickettsia rickettsii bacteria that can be transmitted to humans via the Ixodes tick (deer tick). The patient has been hiking, which puts them at risk for coming into contact with ticks. RMSF is hard to diagnose in the early stages and without treatment can be fatal. Choice A is incorrect. An amoxicillin allergy is vital for the nurse to be aware of, but does not indicate an emergency. The nurse should ask about the patient's reaction to amoxicillin and document it in the patient's chart. The patient has been experiencing symptoms for several days and there is no information provided that suggests the patient received any antibiotics recently. Choice B is incorrect. Hand-foot-mouth disease is a common childhood virus that may be transmitted to adults but typically results in a blistering rash, not macular. It is not a medical emergency and usually resolves on its own with only supportive treatment. Choice D is incorrect. Allergic contact dermatitis is a hypersensitivity reaction of the skin that can result from changing laundry detergents. The area of rash is usually limited to the skin that is exposed to allergens, so the patient would have a more widespread outbreak if this were the cause. It is not often accompanied by the patient's other symptoms of fever, chills, or headache, and would not be a medical emergency.

A 35-year-old patient presents to the emergency department complaining of fever, chills, and headaches for the past two days. There is a pink, macular rash on the palms, wrists, and soles of the feet. Which statement by the patient would indicate to the nurse a potential medical emergency? A. "I am allergic to amoxicillin." B. "There have been cases of hand-foot-mouth in the child's daycare recently." C. "I went hiking 2 weeks ago." D. "I switched my laundry detergent last week because of my sensitive skin."

D Choice D is correct. The appropriate and initial nursing action is to inquire with the client about their rationale for refusing the medication. Assessment is the initial part of the nursing process, and discussing the refusal with the client is a step the nurse should execute. Choices A, B, and C are incorrect. Documenting the refusal should not prioritize over inquiring with the client about their reasoning for refusing the prescription. If the client still refuses after the nurse has thoroughly educated the client on the medication and its purpose. The nurse should contact the PHCP and document the refusal accordingly. Reviewing the client's platelet count is inappropriate as it is irrelevant to the refusal. This action should have been completed before obtaining the medication. ADDITIONAL INFO As a competent adult, it is the client's right to refuse treatment for any reason, even when refusal might compromise the client's health or death. The nurse should inquire about a refusal and clear up any questions the client may have regarding the medication or treatment. The nurse should also educate the client on the purpose of the prescription and treatment. If that is ineffective, the nurse should contact the PHCP and relay the refusal. All actions, including the client's statements regarding the refusal, should be documented.

A client has refused a prescribed injection of subcutaneous heparin. Which initial action should the nurse take? A. Document the refusal B. Notify the primary healthcare provider (PHCP) C. Review the client's most recent platelet count D. Inquire with the client about the refusal

D Choice D is correct. Platelets are essential for proper blood coagulation. A decreased platelet count increases the client's risk for poor clotting and excessive bleeding. Following the transfusion of platelets, the nurse would anticipate a decrease or discontinuation in the amount of oozing of sanguineous drainage from the client's puncture sites compared to pre-transfusion. Choice A is incorrect. A platelet infusion would not increase the client's hemoglobin level, as a transfusion of red blood cells (also referred to as packed red blood cells (PRBCs)) would be needed to increase the client's hemoglobin level. Choice B is incorrect. A platelet infusion would not affect the client's hematocrit level. To increase this client's hematocrit level, the client would require a transfusion of red blood cells (also referred to as packed red blood cells (PRBCs)). Choice C is incorrect. Platelets do not affect the pathophysiology of a fever. A normal platelet count ranges from 150,000 to 400,000 mm3. Once an individual's platelet count falls below 150,000 mm3, the client is deemed to have thrombocytopenia. Platelet transfusions are traditionally used when a client's platelet counts are less than 10,000/mm3 (10 × 109/L) or when the client has an acute life-threatening bleeding episode.

A client just received a transfusion of one unit of platelets. In order for the nurse to determine that the intervention has been therapeutic, which of the following would the nurse anticipate the client to exhibit? A. An increased hemoglobin level B. An increased hematocrit level C. The client's temperature returns to normal compared to the pre-transfusion febrile state D. Decreased oozing of sanguineous drainage from surgical puncture sites

Choice B is correct. With ascites, free fluid accumulates primarily in the abdominal cavity. As liver dysfunction worsens, ascites typically increase, increasing the abdominal girth. When measuring abdominal girth, standard practice dictates using the umbilicus as the landmark to be utilized when measuring a client's abdominal girth. The technique involves encircling the abdomen with a measuring tape at the level of the umbilicus. Using this method, you ensure the client's future measurements are accurate and comparable to prior measurements, even if performed by other clinicians. Choice A is incorrect. The xiphoid process, located at the inferior portion of the sternum, would not provide an accurate measurement of abdominal girth. Choice C is incorrect. The iliac crest, located at the superior border of the ilium extending from the anterior superior iliac spine to the posterior superior iliac spine, would not accurately measure abdominal girth. Choice D is incorrect. The symphysis pubis, a joint located between the left and right pelvic bones, would not provide an accurate measurement of abdominal girth if used as a landmark. The primary sign of ascites is an increase in abdominal girth and weight gain. Ascites is free fluid in the abdominal cavity, usually caused by portal hypertension or other hepatic or nonhepatic conditions. Moderate amounts of fluid can increase abdominal girth and cause weight gain, and massive amounts can cause abdominal distention, pressure, and dyspnea. Signs may be absent if fluid accumulation is < 1500 mL. Unless the diagnosis is obvious, confirm the presence of ascites using ultrasonography or CT. If ascites is a new diagnosis, the cause is unknown, or spontaneous bacterial peritonitis is suspected, the health care provider (HCP) will often order paracentesis and test ascitic fluid.

A nurse is assigned to care for a client with liver dysfunction and ascites and is ordered to measure the client's abdominal girth daily. To ensure accuracy, the nurse should utilize which landmark? A. Xiphoid process B. Umbilicus C. Iliac crest D. Symphysis pubis

C Choice C is correct. Prior to surgical closure, the sac is kept from drying by the application of a sterile, moist, nonadherent dressing. The moistening solution is usually sterile normal saline. Dressings are changed frequently (every 2 to 4 hours), and the sac is closely inspected for leaks, abrasions, irritation, and signs of infection. Choice A is incorrect. Exposing the sac to open air will result in a dehydrating effect on the sac. This is especially true when an overhead warmer is utilized due to the radiant heat. Choice B is incorrect. Prolonged use of petroleum jelly or ointments can result in the breakdown of the sac tissue. Choice D is incorrect. Dry dressings are irritating to the tissues of the myelomeningocele sac. Myelomeningocele develops during the first 28 days of pregnancy when the neural tube fails to close and fuse. The largest number (75%) of myelomeningoceles occur in the lumbar or lumbosacral area. The location and magnitude of the defect determine the nature and extent of neurologic impairment. Meningoceles are repaired early, especially if the sac is in danger of rupturing.

A nurse is caring for a newborn with a myelomeningocele. Prior to surgery, the most appropriate intervention to keep the sac sterile and protected is to: A. Leave the sac exposed to air. B. Apply petroleum jelly or ointment as a protective covering for the sac. C. Cover the sac with moist, saline dressings. D. Apply a dry dressing over the sac.

B Choice B is correct. Although some vaginal bleeding is anticipated following delivery, soaked perineal pads and a soft fundus are cause for concern. Typically, if a client is utilizing a new perineal pad every 15 minutes, persistent, significant bleeding should become the primary concern. Following a quick assessment for restlessness, increased pulse, decreased blood pressure, skin coolness, clamminess, and color, the nurse should immediately notify the physician. Choice A is incorrect. Although a full bladder interferes with the ability of the uterus to contract and, if not corrected, eventually leads to uterine atony, a distended bladder is not the finding most indicative of a common complication post-cesarean delivery. Choice C is incorrect. Following birth, many mothers often experience tremors that resemble shivering, although they deny feeling cold. These tremors are thought to be due to a vasomotor response involving epinephrine during the birthing process. This shivering should spontaneously resolve within 20 minutes. Choice D is incorrect. An elevated temperature following a cesarean section is highly unlikely. Hypothermia occurs more commonly immediately following. Most post-childbirth complications fall into one of the six following categories: Hemorrhage Mood Disorders Puerperal Infections Shock Subinvolution of the Uterus Thromboembolic Disorders

A nurse is caring for a post-cesarean section client in the maternity ward. Which finding by the nurse would be most indicative of a common post-cesarean delivery complication? A. A distended bladder B. Soaked perineal pads with a soft fundus C. Shivering D. An elevated temperature

A, C, D, F Choices A, C, D, and F are correct. These prescriptions are inappropriate and require follow-up with the PHCP. The client with congestive heart failure should not be prescribed calcium channel blockers because of their negative inotropic effects, worsening heart failure. Further, hydrocortisone would be indicated to treat adrenal insufficiency, whereas vasopressin would be used for diabetes insipidus. Additionally, clopidogrel is an antiplatelet medication used to prevent stroke where a client with a pulmonary embolism requires anticoagulants or thrombolytics. Finally, antibiotics such as ceftriaxone are indicated for bacterial cystitis, not antivirals such as valacyclovir. Choices B and E are incorrect. Clonidine is an antihypertensive used to treat hypertension and psychiatric conditions such as attention deficit hyperactivity disorder. Finally, amiodarone is a drug that may be used for atrial fibrillation. The mainstay of treatment for congestive heart failure is ACE inhibitors and diuretics. The client should avoid any agents that could worsen heart failure, such as NSAIDs and calcium channel blockers.

A nurse is reviewing prescriptions for assigned clients. Which prescriptions require follow-up with the primary healthcare provider? A client with Select all that apply. A. congestive heart failure prescribed diltiazem. B. hypertension prescribed clonidine. C. diabetes insipidus prescribed hydrocortisone. D. pulmonary emboli prescribed clopidogrel. E. atrial fibrillation prescribed amiodarone. F. bacterial cystitis prescribed valacyclovir.

A Choice A is correct. Typically, the posterior fontanel closes by two months of age, while the anterior fontanel fuses between 12 and 18 months. Fontanels facilitate the bony plates of the baby's skull to flex and allow the baby's head through the birth canal. Choice B is incorrect. Although the nurse correctly informs the parent that the "soft spots" are "fontanels," the nurse erroneously provides the wrong ages at which the anterior and posterior fontanels will close, mistakenly switching the ages with one another. Therefore, this statement by the nurse is inaccurate. Choice C is incorrect. Although the nurse correctly informs the parent that the "soft spots" are "fontanels," the nurse incorrectly states the age at which the posterior fontanel will close. Therefore, this statement by the nurse is inaccurate. Choice D is incorrect. Although the nurse correctly informs the parent that the "soft spots" are "fontanels," the nurse incorrectly communicates the age at which the anterior fontanel will close. Based on this error, this statement by the nurse is inaccurate. Six fontanels (also commonly referred to as fontanelles) are present during infancy, with the most notable being the anterior and posterior fontanels. Certain conditions, such as dehydration or infection, can alter the appearance of the fontanelles, causing them to sink or bulge, respectively. Parents and caregivers should be educated to contact their child's health care provider (HCP) if any changes are noted in the appearance of any of their child's fontanels. The primary cause of a sunken fontanel is due to dehydration. Conversely, a bulging fontanel occurs due to a rise in intracranial pressure, typically indicative of one or more of the following pathologies: hydrocephalus, hypoxemia, meningitis, trauma, or hemorrhage (of note, this is not an all-inclusive list).

A parent in a pediatric clinic asks the nurse when the soft spots on their baby's head will harden. The most appropriate response by the nurse would be: A. "These soft spots are called fontanels. Typically, the one towards the front of the head closes between 12 and 18 months, and the one on the back of the head closes by two months old." B. "These soft spots are called fontanels. The one towards the front of the head closes at two months, and the one on the back closes at 12 to 18 months old." C. "These soft spots are called fontanels. The one on the front of the head closes between 12 and 18 months, and the one on the back closes around six months old." D. "These soft spots are called fontanels. The one on the front of the head closes at nine months old, and the one on the back closes at two months old."

A Choice A is correct. Alprazolam (Xanax) is a type of benzodiazepine. The patient is presenting with classic benzodiazepine drug withdrawal symptoms: anxiety, coarse hand/tongue/eyelid tremors, irritability, increased autonomic activity (tachycardia and sweating), orthostatic hypotension, and insomnia. Choice B is incorrect. Typical nicotine withdrawal symptoms include headache, nervousness, poor concentration, anger, hunger, and restlessness. Choice C is incorrect. Adderal is an amphetamine drug. Typical amphetamine withdrawal symptoms include dysphoric mood, fatigue, insomnia or hypersomnia, and psychomotor agitation. Choice D is incorrect. Typical withdrawal symptoms of cocaine are similar to amphetamine withdrawal symptoms: dysphoric mood, fatigue, insomnia or hypersomnia, and psychomotor agitation.

A patient presents with dizziness upon standing, bilateral hand tremors, inability to sleep, irritability, sweating, and a heart rate of 95. From what substance is the patient most likely experiencing these withdrawal symptoms? A. Alprazolam B. Nicotine C. Adderall D. Cocaine

A Choice A is correct. Rh-negative women should have an indirect Coombs' test to determine whether they are sensitized (have developed antibodies) as a result of previous exposure to Rh-positive blood. This testing is done at the first prenatal visit. Choices B, C, and D are incorrect. Coombs' testing (direct or indirect) does not measure clotting time (either maternal or fetus). The blood type, Rh factor, and antibody titer of the newborn are determined by the direct Coomb's test. These tests do not determine the probability of pernicious anemia, as this anemia is predicated on the lack of vitamin B12.

A pregnant client who is Rh-negative is ordered an indirect Coomb's test. The nurse understands that the purpose of this test is to determine if A. antibodies are present from previous exposure to Rh-positive blood. B. the amount of time that it takes for fetal blood to clot. C. blood type, Rh factor, and antibody titer of the newborn D. the fetus has a risk of developing pernicious anemia later in life.

C Choice C is correct. A child with a sore throat that is drooling may be manifesting epiglottitis. Drooling may indicate that the child is going into respiratory distress and warrants timely intervention by the healthcare team. The senior RN should step in and guide the new RN in what to do. Choice A is incorrect. Elevating the foot to relieve swelling and edema in a fractured foot is an accurate nursing action. Choice B is incorrect. For any suspected child abuse, the nurse is obligated by law to report the case to Child Protective Services (CPS). Choice D is incorrect. Giving a nebulization treatment to a child having an asthma attack relaxes the bronchial walls of the child and improves respiratory status.

A senior RN is supervising a newly registered nurse in the emergency department. Which situation would require the senior RN to intervene? A. The new RN elevates the foot of a 13-year-old with a fractured tibia. B. The new RN calls Child Protective services for the child she suspects is being sexually abused. C. The new RN checks the tonsils of a drooling 3-year-old with a sore throat. D. The new RN gives a nebulization treatment to an 8-year-old with asthma.

C Choice C is correct. Prelabor rupture of membranes (PROM) may occur at term (≥ 37 weeks) or earlier (called preterm PROM if < 37 weeks). Upon the prelabor rupture of membranes, amniotic fluid is expelled from the vagina, typically as a sudden gush of fluid from the vagina (unless complications are present). Some women experience membrane rupture as the first sign of labor onset. If this occurs, the woman should go to the birth center for evaluation. Choice A is incorrect. Although the passage of the mucus plug is a sign that the cervix is beginning to dilate, in some cases, the mucus plug is passed weeks prior to the onset of labor. Choice B is incorrect. The mother may experience bladder pressure and frequency as the fetus settles into the pelvis during the final weeks of pregnancy. Choice D is incorrect. The symptoms of nausea and vomiting are not indicative of actual labor. Prelabor rupture of membranes (PROM) may occur at term (≥ 37 weeks) or earlier (called preterm PROM if < 37 weeks). Preterm PROM predisposes to preterm delivery. PROM at any time increases the risk of the following: Infection in the woman (intra-amniotic infection [chorioamnionitis]), neonate (sepsis), or both Abruptio placentae Abnormal fetal presentation Intraventricular hemorrhage in neonates (which may result in neurodevelopmental disabilities (e.g., cerebral palsy)) Compression of the fetal umbilical cord

A woman in her 37th week of gestation is wary about recognizing the signs of labor. She asks the nurse how she will know when it is time to go to the labor and delivery unit. The best response by the nurse is: A. "When the mucus plug comes out." B. "When you feel a heaviness in your bladder." C. "When you see a large gush of fluid coming out of your vagina." D. "When you feel nauseated and vomit simultaneously."

D Choice D is correct. The priority is for the nurse to assess the fetal status following the spontaneous rupture of the client's membranes. Although numerous methods may be utilized to evaluate fetal status, the assessment of fetal heart tones provides reliable information in a relatively prompt manner. Following the assessment of fetal heart tones, the nurse should then assess the color and quality of the amniotic fluid. Choice A is incorrect. Following a spontaneous rupture of the client's membranes, the priority is for the nurse to assess the fetal status via fetal heart tones. Assessment of the color and quantity of the amniotic fluid does not provide any indication regarding the current status of the fetus. Choice B is incorrect. While certain circumstances may justify performing a vaginal examination to assess for cervical dilatation, nothing in this scenario suggests such intervention. As such, in this scenario, the nurse's priority following a spontaneous rupture of the client's membranes remains to assess the fetal status via fetal heart tones. Choice C is incorrect. Fetal head engagement and descent are not dependent on the client's movement during labor. Keeping the client on bed rest is not necessary. Often, the client will be encouraged to ambulate. To confirm the rupture of a client's membranes, the pH of the fluid may be tested. Vaginal fluid may be tested with Nitrazine paper, which turns deep blue at a pH >6.5 (pH of amniotic fluid is 7.0 to 7.6). Amniotic fluid should be assessed for meconium-stained fluid, other discoloration, etc.

Shortly after checking into the obstetrics unit, a client currently at 39 weeks gestation spontaneously ruptured her membranes when ambulating to the bathroom. After the client returns to bed, which of the following should be the nurse's initial action? A. Assess the color and quantity of the fluid. B. Perform a vaginal examination to assess the cervix for dilation. C. Inform the client she is now on strict bed rest until further notice. D. Assess the fetal heart tones.

B Choice B is correct. Extension of the arms and legs indicates decerebrate posturing, an indication of increased intracranial pressure. The nurse should intervene when the client displays this. Choice A is incorrect. Purposeful movement when a painful stimulus is applied indicates an improvement in the client's condition. Choice C is incorrect. Aimless flailing of the client's extremities would mean an improvement in the client's condition and would not need an intervention from the nurse. Choice D is incorrect. This means that the client can follow simple commands. This indicates that the client's condition is improving and would not need any intervention from the nurse.

The ICU nurse is taking care of a client who sustained a head injury due to a motorcycle accident. In the morning, the client is responsive to pain and assumes a decorticate position. After 4 hours, which assessment would indicate to the nurse that the client needs immediate intervention? A. The client displays purposeful movement when the nurse performs a sternal rub. B. The client extends his arms and legs when the nurse rubs his sternum. C. The client flails his arms and legs when a noxious stimulus is applied. D. The client moves his fingers upon request.

B Choice B is correct. Toddlers experience a sense of shame when they are not allowed to develop appropriate independence and autonomy. Autonomy vs. shame and doubt is the second stage of Erikson's psychosocial development and occurs during the toddler age. It is important to allow the toddler to develop autonomy. Choice A is incorrect. Infants develop mistrust when their needs are not consistently gratified. Choice C is incorrect. Preschoolers develop guilt when their initial needs are not met. Choice D is incorrect. School-aged kids develop a sense of inferiority when their industry needs are not met.

The nurse is talking to new parents about their toddler. The mother is concerned that the child is getting independent and she wants to tend to the toddler all the time. The nurse's most appropriate response would be: A. "Your child will develop mistrust." B. "Your child will develop shame." C. "Your child will feel guilt." D. "Your child will feel inferior."

A 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 patient is responsive, with adequate respiratory function (respirations below 30/minute) and perfusion intact (capillary refill under 2 seconds). This patient could wait until the most severe injuries are treated before receiving treatment. Choice B is incorrect. A red triage tag indicates the patient has life-threatening injuries, but a high chance of survival once stabilized, such as large lacerations or compromised lung function due to trauma. These patients are the highest priority and require immediate treatment. Choice C is incorrect. A black triage tag indicates the patient'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 the patient has minor injuries such as cuts or abrasions and can wait several hours before receiving treatment.

The hospital's disaster plan is initiated due to a nearby factory fire. One of the victims is responsive but unable to walk, with a respiratory rate of 28 and capillary refill <2 seconds. What color tag would the ED triage nurse assign to this patient? A. Yellow B. Red C. Black D. Green

B Choice B is correct. The leading and single MOST crucial indicator of the intensity and presence of pain is the client's reports of pain to the nurse and other healthcare providers. Too often, pain is undertreated because we fail to listen to the client and their self-reports of pain; instead, we regularly assess and evaluate client vital signs and pain behaviors, which are less accurate and reliable than the client's reports. Choice A is incorrect. Although a quantitative assessment and measurement of pain with a pain intensity scale can and should be used, this is only one way to obtain the subjective client's reports of pain. Choice C is incorrect. Although a qualitative assessment can and should be used, this is only one way to obtain the subjective client's reports of pain, including its description and characteristics. Choice D is incorrect. Although the nurse will observe and assess pain behaviors such as guarding and moaning, this is not the leading and single most important indicator of the intensity and presence of pain.

The leading and single MOST important indicator of the intensity and presence of pain is: A. A quantitative assessment/measurement of pain with a pain intensity scale. B. The client's reports of pain to the nurse and other healthcare providers. C. A qualitative assessment/measurement of pain with a pain intensity scale. D. The nurse's observation and assessment of pain behaviors such as guarding and moaning.

D Choice D is correct. The excessive ingestion of tricyclic antidepressants (TCAs) results in life-threatening wide QRS complex tachycardia. Tricyclic antidepressants are approved by the Food and Drug Administration (FDA) for treating several types of depression, obsessive-compulsive disorder, and bedwetting. Also, they are used for several off-label (non-FDA approved) uses such as: Panic disorder Bulimia Chronic pain (for example, migraine, tension headaches, diabetic neuropathy, and postherpetic neuralgia) Phantom limb pain Chronic itching Premenstrual symptoms Tricyclic antidepressants should be used cautiously in patients with seizures since they can increase the risk of seizures. They may cause a worsening of urinary retention and narrow-angle glaucoma. Abnormal heart rhythms and sexual dysfunction have also been associated with TCAs. Choice A is incorrect. TCA overdose can induce seizures, but they are typically not life-threatening. Choice B is incorrect. TCAs do not cause an elevation in body temperature. Choice C is incorrect. TCAs do not cause metabolic acidosis.

The most serious adverse effect of tricyclic antidepressant (TCA) overdose is: A. Seizures B. Hyperpyrexia C. Metabolic acidosis D. Cardiac arrhythmias

C Choice C is correct. The movement of a client from a lower to a higher level of care and intensity of care is an example of change along the continuum of care. The continuum of care is a concept involving a system that guides and tracks a client over time through a comprehensive array of health services to span all levels and intensity of care. Choice A is incorrect. The movement of a client from a lower to a higher level or intensity of care indicates that the client has an increased acuity level, not a decreasing level of acuity. Choice B is incorrect. Retrospective reimbursement was a complicated payment system previously utilized by Medicare. Even when retrospective reimbursement was standard, nothing about this reimbursement method correlated with the client's movement from a lower to a higher level of care or the intensity of such care. Choice D is incorrect. Prospective reimbursement is a method of reimbursement currently used by Medicare in which payment is made based on a predetermined, fixed amount. Although reimbursement often correlates with a client's movement through the healthcare system based on medical necessity, compensation is not based solely on the progression of care. Within the continuum of care, healthcare providers follow clients from preventive care through medical incidents, rehabilitation, and maintenance (often referred to as primary prevention, secondary prevention, and tertiary prevention).

The movement of a client from a lower to a higher level of care and intensity of care is an example of: A. A decreasing level of acuity B. Retrospective reimbursement C. Movement along the continuum of care D. Prospective reimbursement

B Choice B is correct. Regular insulin is short-acting and will peak two to four hours after subcutaneous administration. Assessing the client at 1000 would be when the regular insulin would peak and thus, be the likely time for the client to exhibit hypoglycemia symptoms. The second peak will occur four to twelve hours after administering NPH insulin or around noon. Choices A, C, and D are incorrect. Regular insulin peaks within two to four hours after administration, and when combined with NPH, the nurse should assess the client for hypoglycemia after the first peak, which would be 1000. If the nurse waited until noon to assess for hypoglycemia, this could be detrimental as the insulin has already started to peak. Do not mix any other insulin type with insulin glargine, insulin detemir, or any of the premixed insulin formulations such as Humalog Mix 75/25. Regular insulin is the only insulin that may be given intravenously (IV), and when given this route, it peaks within 15-30 minutes.

The nurse administers a combination of regular insulin and NPH insulin subcutaneously to a client at 0800. At which time should the nurse assess the client for hypoglycemia? A. 0830 B. 1000 C. Noon D. 1400

D Choice D is correct. When moisture comes into contact with a sterile dressing, this causes contamination. The nurse should prepare to change the dressing using medical asepsis to remove the old dressing and surgical asepsis to apply the new dressing. Choices A, B, and C are incorrect. Reinforcing the dressing with paper tape would be inappropriate. Moisture causes contamination, and the nurse should intervene and change the dressing. Removing the central line would be inappropriate as the issue is with the dressing - not the catheter. An occlusive dressing does not need to be applied as the old dressing needs to be removed, the site cleaned with chlorhexidine, and a new central line dressing applied. The central line should be anchored with a securement device and covers the site with a sterile bio-occlusive dressing. Central line dressings should be changed at least every 7 days or immediately if dressing integrity is disrupted (e.g., lifted/detached on any border edge or within transparent portion of dressing, visibly soiled, presence of moisture, drainage, or blood).

The nurse assesses a client's central venous catheter dressing, and it appears loose and wet. The nurse should take which action? A. Reinforce the dressing with paper tape B. Remove the dressing and the central vascular device C. Apply a clean occlusive dressing to the site D. Clean the site and apply a new sterile dressing

A, C, E Choices A, C, and E are correct. A tense, bulging fontanel is a classic sign of increased ICP in an infant. Associated symptoms that are concerning include bradycardia and distended scalp veins. Choices B and D are incorrect. Tachycardia is a clinical manifestation of shock but not for increased ICP. The client would exhibit triad symptoms such as bradycardia, bradypnea, and widening pulse pressure. Ptosis is drooping of the eyelid and is not associated with increased ICP. Pupillary changes would be assessed as a late sign of increased ICP, which would be nonreactive on an assessment. For an infant with a TBI, the nurse must assess the newborn for increased intracranial pressure. Manifestations of increased ICP in newborns and infants include a high-pitched cry, bulging fontanels that may also have distended scalp veins, irritability, bradycardia, and an irregular breathing pattern.

The nurse assesses an infant who sustained a traumatic brain injury (TBI). Which assessment finding requires follow-up? Select all that apply. A. Bulging fontanel B. Tachycardia C. Bradycardia D. Ptosis E. Distended scalp veins

A Choice A is correct. Cystic fibrosis is a multisystem disorder that may cause an individual to develop vitamin and mineral deficiencies because of dietary malabsorption. The recommended diet for a client with cystic fibrosis is a well-balanced, high-protein, high-calorie diet with high fat (impaired intestinal absorption). Dietary items rich in sodium are also encouraged because of the salt loss through the skin. Choices B, C, and D are incorrect. A diet rich in sodium is recommended (popcorn, chips). Dietary items low in protein and calories would be detrimental to managing CF. ADDITIONAL INFO Collaboration with a dietician is recommended in the management of cystic fibrosis. General dietary guidelines include - Pancrelipase is taken with snacks and meals to enable absorption of the nutrients. Blood glucose levels should be periodically monitored if diabetes mellitus should develop. DM is a common comorbidity associated with CF. Height and weight should be monitored at every exam.

The nurse assists a client with cystic fibrosis pick out items on a menu. It will indicate effective teaching if the client selects meals that are A. High in fat B. Low in sodium C. Low in calories D. Low in protein

C 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. 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 compression device is applied to achieve hemostasis. If active bleeding continues despite these measures, hypotension can follow. However, hypotension from hypovolemia/ hemorrhage is expected to cause reflex tachycardia, not bradycardia. Applying a sandbag for pressure to the puncture site would not be indicated without signs of active bleeding and would be expected to exacerbate the vasovagal response. Choice D is incorrect. The head end of the bed should be lowered, as elevating the head of the bed would be expected to exacerbate the vasovagal response. 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.

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

B Choice B is correct. Positive end-expiratory pressure (PEEP) is used in clients with acute respiratory distress syndrome (ARDS) because it improves lung compliance and oxygenation. This is accomplished by adding pressure at exhalation to keep the alveoli open. PEEP is a setting that may be added to a variety of ventilator modes. Choices A, C, and D are incorrect. PEEP does not give an amount of pressure upon inspiration. This description is appropriate for pressure support ventilation which provides pressure when the client takes a spontaneous breath. A client allowed to take spontaneous breaths between mandatory ones is a SIMV and AC modes feature. The critical difference between SIMV and AC is that when a client takes a spontaneous breath, they are forced to take in the prescribed tidal volume, whereas SIMV they can take in their own tidal volume during that spontaneous breath. PEEP does not have anything to do with tidal volumes, and giving a preset tidal volume with each breath would be an appropriate description for the AC mode. ADDITIONAL INFO When caring for a client on a ventilator, you should be familiar with the following settings: Mode (Volume [SIMV, A/C] or Pressure [PSV]) Rate (Number of breaths per minute) Tidal volume (the amount of gas delivered to the client) Fraction of inspired oxygen (FiO2 - the percentage of oxygen given per breath) PEEP (pressure added at exhalation to keep the small airways open and mitigate atelectasis) Pressure support (PS - provides added pressure when the client takes a spontaneous breath)

The nurse cares for a client receiving positive end-expiratory pressure (PEEP) while being mechanically ventilated. The nurse understands that this setting is used to A. give a set amount of inspiratory pressure. B. prevent closure of the small airways during expiration. C. allow spontaneous breaths between mandatory ones. D. deliver a preset tidal volume with each breath.

B Choice B is correct. The distinguishing factor in all three types of arthritis is the symmetry of joint involvement. Rheumatoid arthritis is symmetrical and bilateral, while osteoarthritis and gout are unilateral. Choices A, C, and D are incorrect. Osteoarthritis is characterized by crepitus. Gout is manifested by elevated serum uric acid levels, while osteoarthritis is characterized by the involvement of dominant weight-bearing joints.

The nurse educator is giving a lecture on the different types of arthritis. Which of the following should the nurse educator emphasize distinguishes rheumatoid arthritis from gouty arthritis and osteoarthritis? A. Crepitus with range of motion B. Symmetry of joint involvement C. Elevated serum uric acid levels D. Dominance in weight bearing joints

A, D Choices A and D are correct. These statements are incorrect and require follow-up. ➢ Premature discontinuation of antibiotics leads to therapeutic failure. Therefore, all antibiotics must be continued for the entire course, not when the symptoms abate. ➢ Doxycycline absorption may decrease when the client takes it with calcium. ➢ The client should be instructed not to take this medication with calcium-rich foods, dairy products, or antacids containing calcium. The client should take this medication on an empty stomach. Choices B, C, and E are incorrect. These statements are correct and do not require follow-up. ➢ Doxycycline may cause superinfections such as C. diff. Foul-smelling diarrhea that may be accompanied by abdominal cramping should be reported. ➢ Doxycycline can also cause skin reactions, including photosensitivity. The client should be instructed to wear protective clothing, hats, and sunscreen outdoors. ➢ The client should take this medication on an empty stomach to avoid any drug/food interactions. Doxycycline is a commonly used tetracycline antibiotic that effectively treats various bacterial infections, including acne, pelvic inflammatory disease, and Lyme disease. Because dairy products contain calcium, doxycycline should not be concomitantly administered with milk. This also includes avoiding antacids containing calcium, aluminum, and magnesium. Doxycycline intake and ingestion of these products must be separated by 2-3 hours. Doxycycline is recommended to be taken on an empty stomach. Oral contraception and doxycycline: Current literature suggests no evidence of increased contraceptive failure when doxycycline is used concurrently with estrogen-containing oral contraceptives. Older literature recommended additional birth control methods (e.g., barrier methods) during concomitant use of estrogen-based oral contraceptives and doxycycline due to the theoretical risk of decreased contraceptive effect. However, this theory remains unproven. Pregnancy and breast-feeding: Doxycycline crosses the placenta and is excreted in breast milk—doxycycline chelates with calcium in the bones and the teeth. If given to pregnant women, it may lead to skeletal growth retardation and permanent teeth discoloration in the fetus. Doxycycline in breastfed infants and children under eight causes permanent teeth discoloration, tooth enamel damage, skeletal growth retardation, and photosensitivity. Therefore, it should be avoided in these populations.

The nurse is teaching a client about newly prescribed doxycycline. Which of the following statements, if made by the client, would require further teaching? Select all that apply. A. "I should take this medication with milk or cheese." B. "If I develop foul-smelling diarrhea I should contact my doctor." C. "I need to wear sunscreen outdoors while taking this medication." D. "I can stop this medication when I feel better." E. "I should take this medication on an empty stomach."

C Choice C is correct. A hemoglobin of 6.1 g/dL is critical and requires the nurse to immediately initiate the prescribed transfusion of packed red blood cells. Choices A, B, and D are incorrect. A platelet count of 165,000 mm3 is normal (the therapeutic range is 150,000 to 400,000), and administering enoxaparin would not be contraindicated but is not a priority compared to the critical hemoglobin. While a client is receiving a heparin product, the platelet count should be monitored. Although unlikely because enoxaparin is a low molecular weight-based heparin, the platelet count should be observed. An INR of 2.4 (therapeutic range while on warfarin 2-3) is within range and is safe to administer. The client's hyperglycemia (any blood glucose greater than 250 mg/dl) is concerning but not prioritized over the critical hemoglobin. ADDITIONAL INFO The normal hemoglobin is 14-18 g/dL for males and 12-16 g/dL for females. A transfusion of packed red blood cells (PRBCs) is typically prescribed once the hemoglobin drops below 7 g/dL. One unit of packed red blood cells will raise the hemoglobin by 1 g/dL.

The nurse has received the following prescriptions for newly admitted clients. The nurse should first administer which of the following? A. Enoxaparin to a client with a platelet count of 165,000 mm3 B. Warfarin to a client with an international normalized ratio of 2.4 C. Packed red blood cells to a client with a hemoglobin of 6.1 g/dL D. Regular insulin to a client with a blood glucose of 285 mg/dL

C Choice C is correct. Pressure reduction mattresses and beds are available to decrease the pressure on the sacrum when the client is in bed. Implementing measures to relieve sacral stress, however, is the least priority when managing clients in acute pulmonary edema. Choice A is incorrect. Oxygen therapy improves oxygenation by increasing the amount of oxygen available for delivery and can help relieve the client's dyspnea. Continuous oxygen administration can dry the patient's mucus membranes. This should be a priority intervention. Choice B is incorrect. This position facilitates the expansion of the diaphragm and should be a priority intervention. Choice D is incorrect. Turning, deep breathing, coughing, and the use of an incentive spirometer will all help clear the airways and facilitate oxygen delivery.

The nurse in the intensive care unit is caring for a patient that has left-sided heart failure with pulmonary edema as a complication. The nurse identifies a nursing diagnosis of impaired gas exchange related to fluid in the alveoli. Which of the following interventions would be considered the least priority according to the nursing diagnosis? A. Giving oxygen and watching for dry nasal mucus membranes. B. Placing the client in Fowler's position. C. Providing a pressure reducing mattress. D. Encouraging the client to turn, deep breathe, cough, and use the incentive spirometer.

D Choice D is correct. Pain associated with pressure ulcers should be appropriately addressed, specifically with dressing changes. The nurse must provide adequate pain medications to the client before the dressing changes. Pressure ulcers ( pressure injuries/ decubitus ulcers/ bed sores) are caused by prolonged pressure on an area of skin that leads to ischemia ( reduced blood supply), skin breaks down, and underlying tissue injury. Usually, these occur over bony prominences. Depending upon the clinical appearance and the degree of damage, pressure-induced skin and soft tissue injuries are staged from stage 1 to stage 4 and unstageable pressure injuries. Stage 3 and stage 4 ulcers are ulcers with full-thickness tissue loss. Management of these deeper injuries involves debridement and covering with appropriate dressings. Generally, pressure ulcers are very painful, and optimal pain medications ( using the WHO analgesic ladder) should be administered to control pain. In stage 3 and 4 ulcers, there is significant tissue damage, and therefore, only a little or no pain may be experienced at the baseline. However, the pain may be worse than the baseline during dressing changes, even with stage 3 ulcers. The nurse should ensure that the client has been given pain medication at least 30 minutes before changing the dressing. Choices A, B, and C are incorrect. The nurse should prepare all the needed equipment for the procedure before attending to the patient and always use non-sterile gloves to remove the old dressing. The nurse should explain the procedure to the client immediately before starting the dressing change process. While all these actions are essential, these are not the first actions. Addressing pain control before dressing change is the nurse's priority action.

The nurse is about to change a dressing on an older man with a stage 3 pressure ulcer. What should be the nurse's first action? A. Gather all the necessary equipment. B. Use non-sterile gloves to remove the old dressing. C. Explain the procedure to the client. D. Check the medication record to see if pain medications were administered.

A Choice A is correct. Based on the presenting symptoms, the nurse suspects that this child has epiglottitis. Any child presenting with excessive drooling, distress, and stridor is highly suspicious to have this medical emergency. In addition, this client is already showing signs of circulatory compromise including circumoral cyanosis and mottling. The priority nursing action in this emergency is keeping the child calm and calling for emergency airway equipment. The child is at risk of losing their airway and the airway is always the priority. Choice B is incorrect. It is inappropriate to attempt to obtain IV access on a child suspected of epiglottitis before emergency airway equipment is available. The priority action at this time is keeping the child calm and calling for emergency airway equipment. Choice C is incorrect. It is inappropriate to assess the throat for a cherry red epiglottis at this time. Although the presence of a cherry red epiglottis would confirm the diagnosis of epiglottitis, this child is at risk of losing their airway. The priority action will be to protect the airway before IV access is attempted. Choice D is incorrect. Placing the child on a high-flow nasal cannula at 100% FiO2 is not the priority at this time. This answer probably sounded right, because you see the O2 is 82% and they have circumoral cyanosis. Oxygen sounds like the right answer but this intervention addresses the "C" in the ABC's mnemonic - circulation but the priority is always the airway. This child is at risk of losing their airway, so all interventions need to wait until there is emergency airway equipment close by. If anything upsets the child, then their airway could spasm and obstruct completely, making it impossible to intubate them. That is why keeping the child calm and calling for emergency airway equipment is the priority in epiglottitis patients.

The nurse is assessing a 4-year-old client who was sent to the emergency department from urgent care. Assessment reveals tripod positioning, blue lips, mottled skin, inspiratory stridor, and excessive drooling. Vital signs are: Temp: 39 C HR: 188 RR: 46 O2: 82 % What is the priority action for the nurse to take at this time? A. Keep the child calm and call for emergency airway equipment B. Obtain IV access C. Assess the throat for a cherry red epiglottis D. Place the child on a high flow nasal cannula at 100% FiO2

C Choice C is correct. Norepinephrine is a common prescription in treating septic shock. It increases vascular tone and the mean arterial pressure (MAP). One of the critical guidelines in treating sepsis is to maintain a mean arterial pressure ( MAP) of 65 mm Hg or more. Initial steps include isotonic fluid boluses to help increase the MAP. If the client does not respond to the initial fluid bolus, vasopressors such as Norepinephrine are used to achieve and maintain the MAP at the target level. Choices A, B, and D are incorrect. Milrinone is an afterload-reducing agent effective in the treatment of congestive heart failure. This medication lowers blood pressure and would be detrimental to the management of septic shock. Amiodarone and lidocaine are indicated for ventricular dysrhythmias. These medications are not utilized for septic shock. Septic shock is a distributive shock caused by the client failing to respond to the initial fluid challenge. The nurse should focus on implementing prompt interventions for sepsis which include: 1. Establishing large-bore IV access 2. Collecting prescribed laboratory work such as CBC, CMP, lactic acid, blood cultures, urine culture (if applicable), and procalcitonin (if applicable) 3. Implementing an isotonic fluid bolus of 30 mL/kg 4. Infusing an empirical antibiotic

The nurse is caring for a client who has septic shock and has failed to respond to initial treatment. Which of the following infusions would the nurse anticipate if the client has a mean arterial pressure (MAP) of 54 mmHg? A. Milrinone B. Amiodarone C. Norepinephrine D. Lidocaine

B Choice B is correct. Cushing's syndrome is characterized by chronic exposure to a glucocorticoid. This is oftentimes referred to as secondary Cushing's syndrome. This client has been on a steroid for two years, and considering the long duration, this client is at the highest risk of developing this syndrome. Choices A, C, and D are incorrect. A client diagnosed with hyperpituitarism may risk Cushing's disease because of the increase in circulating cortisol and aldosterone. However, this client does not have the greatest risk because this client was recently diagnosed compared to the client with RA, and has been exposed to prednisone for two years. A goiter is a manifestation associated with hyperthyroidism and treating hyperthyroidism with propranolol and PTU would be appropriate. This would not have a relationship to increasing the risk for Cushing's syndrome. Topical steroids do not pose a significant risk for Cushing's syndrome, especially if they are used in short bursts. ADDITIONAL INFO High cortisol and aldosterone levels characterize Cushing's disease and Cushing's syndrome. The client will have clinical features such as truncal obesity, fragile skin, delayed wound healing, hyperglycemia, hypernatremia, hypokalemia, and hyperlipidemia.

The nurse is assessing clients for the risk of developing Cushing's syndrome. The nurse should identify which client is at greatest risk for this syndrome? A client A. recently diagnosed with hyperpituitarism and high blood pressure. B. who has been taking prednisone for 2 years to treat rheumatoid arthritis (RA). C. who has a goiter, and is receiving propranolol and propylthiouracil (PTU). D. experiencing eczema and is prescribed a seven-day course of topical hydrocortisone.

D Choice A is incorrect. Terbutaline is a beta-agonist. By acting on beta-2 receptors in vascular smooth muscle, this medication causes vasodilation. Hypotension is an adverse effect of terbutaline. The nurse should stop the infusion when the blood pressure drops below 90/60 mmHg. As such, the nurse would have discontinued the infusion based on the client's blood pressure of 91/58. Choice B is incorrect. By acting on beta-1 receptors in the heart, terbutaline increases the heart rate, causing tachycardia, one of the well-documented adverse effects of this medication. The nurse should stop the infusion when the client's heart rate is more than 120 bpm. As such, the nurse would have stopped the infusion based on the client's heart rate of 132/bpm. Choice C is incorrect. Hypokalemia is another adverse effect of terbutaline. A serum potassium level of less than 3.5 mEq/L is considered hypokalemia. Here, the client's potassium is 3.3 mEq/L. The client's hypokalemia should alert the nurse to stop the terbutaline infusion.

The nurse is caring for a client in premature labor receiving a terbutaline infusion. All of the following manifestations would alert the nurse to stop the infusion, except: A. Blood pressure of 91/58 mmHg B. Heart rate of 132 beats/minute C. Serum potassium level of 3.3 mEq/L D. Blood glucose level of 130 mg/dL

A, B Choices A and B are correct. A client receiving a heparin infusion will need their aPTT and platelet count monitored closely. Heparin prolongs the aPTT (the goal is 1½ to 2½ times the control value) and should be observed frequently. Platelet counts that decrease by approximately 50% may indicate heparin-induced thrombocytopenia, which should be reported. The normal aPTT is 30-40 seconds. Choices C, D, and E are incorrect. PT and INR are significant if the client takes warfarin rather than heparin. The neutrophil count is irrelevant in this case; this would be appropriate to monitor if the client was also: ➢ Experiencing infection ➢ Taking certain drugs that may affect neutrophil levels, such as clozapine or chemotherapy agents ➢ Known to have neutropenia, an abnormally low count of neutrophils in the blood ➢ Intravenous heparin is typically administered as a bolus dose first, then as a continuous infusion to achieve therapeutic aPTT. ➢ The aPTT levels are drawn daily and 6 hours after the first dose, and 6 hours following any dose adjustments. It is considered critical if the aPTT level rises above 70 seconds (per facility policy). ➢ Platelets should also be monitored for clients receiving heparin, as it is expected that a slight reduction to occur. This usually resolves with continued anticoagulation therapy. Platelet counts of less than 150,000 may indicate heparin-induced thrombocytopenia (HIT), a medical emergency placing the client at high risk for clotting. ➢ All clients on anticoagulation therapy should be assessed for signs of bleeding, such as: Hematuria Blood in the stool Ecchymosis Petechiae Altered level of consciousness Pain

The nurse is caring for a client receiving a continuous heparin infusion. Which of the following laboratory data should the nurse monitor? Select all that apply. A. Activated Partial thromboplastin time (aPTT) B. Platelet count C. Prothrombin time (PT) D. Neutrophil count E. International normalized ratio (INR)

A Choice A is correct. Fentanyl is an opioid. A clinical feature of opioid toxicity includes central nervous system depression that manifests as lethargy leading to somnolence. Further, the client will have pupillary constriction, bradypnea, and decreased gastrointestinal motility. Since this client is receiving mechanical ventilation, respiratory depression would not be a reliable finding. Choices B, C, and D are incorrect. Manifestations of opioid toxicity would consist of hypotension, not hypertension, because of the effects of histamine. Tremors and diarrhea are not a finding consistent with opioid toxicity. Opioids such as fentanyl, morphine, hydromorphone, and oxycodone may produce life-threatening manifestations if taken in excess. Opioid use disorder is a treatable illness through medication-assisted treatment and psychotherapy. Treatment of acute opioid toxicity includes stopping the offending agent and the administration of naloxone.

The nurse is caring for a client receiving mechanical ventilation receiving fentanyl and midazolam. Which of the following assessment findings would indicate fentanyl toxicity? A. Constricted pupils B. Hypertension C. Coarse Tremors D. Diarrhea

A Choice A is correct. Isotretinoin is approved for the treatment of moderate to severe acne vulgaris. Choices B, C, and D are incorrect. Acyclovir is an antiviral indicated for the treatment of herpes infections. Ketoconazole is an antifungal medication that may be used for fungal infections and is available in various preparations. Ethambutol is a medication indicated in the treatment of pulmonary tuberculosis. None of these medications are indicated in the treatment of acne vulgaris. Acne vulgaris is a cutaneous disorder characterized by inflammation of the pilosebaceous unit. The severity of this disorder varies, and moderate to severe forms of acne vulgaris may benefit from topical or oral antibiotics (doxycycline). Isotretinoin may also be utilized as it has demonstrated its ability to shrink the sebaceous glands. ➢ This medication is highly teratogenic, and the client should be counseled on reliable contraception. ➢ A negative pregnancy test is required before the start of treatment. ➢ Laboratory monitoring of the client's liver function tests and triglycerides is essential. This medication may cause liver injury and raise triglyceride levels. ➢ Clients will need to complete an iPLEDGE program before they may obtain the prescription. This ensures safety while they take the medication.

The nurse is caring for a client who has just been diagnosed with severe acne vulgaris. Which of the following medications should the nurse anticipate the primary health care provider (PHCP) will prescribe? A. Isotretinoin B. Acyclovir C. Ketoconazole D. Ethambutol

D Choice D is correct. Glipizide is a sulfonylurea and is given to the client with meals to manage blood glucose. This medication will lower blood glucose and could potentially cause hypoglycemia. The client is NPO and will not receive any food. Thus, the nurse should question the administration of this medication to prevent the client from developing hypoglycemia. Choices A, B, and C are incorrect. Endocrine medications (steroids, thyroid hormone), anticonvulsants, and beta-blockers are okay to give with a sip of water. Beta-blockers are given to clients with a sip of water before surgery to prevent intra- and post-procedure cardiac dysrhythmias. Drugs for cardiac disease, respiratory disease, seizures, and hypertension are commonly allowed with a sip of water before surgery. Clients at risk for intra- and post-procedure cardiac dysrhythmias and hypertension are typically prescribed a presurgical beta-blocker to prevent this complication. Before administering a beta-blocker, the nurse should obtain the client's pulse and blood pressure.

The nurse is caring for a client who has type 2 diabetes mellitus and hypertension. The client is nothing by mouth status (NPO) before a scheduled surgery. Which of the following prescribed medications should the nurse question? A. Metoprolol B. Phenytoin C. Levothyroxine D. Glipizide

B Choice B is correct. Naproxen should not be administered concomitantly with corticosteroids. These two medications taken together will increase the risk of gastrointestinal bleeding. Choices A, C, and D are incorrect. Valsartan, omeprazole, and acetaminophen should be administered concomitantly with corticosteroids. Acetaminophen is highly preferred over non-steroidal anti-inflammatory drugs (NSAIDs) because it does not raise the risk of gastrointestinal bleeding. Corticosteroids may cause an array of adverse effects while they mitigate inflammation. This includes peptic ulcer disease, edema, hypokalemia, hyperglycemia, and hypernatremia. The client should be educated to maintain a low sodium and high potassium diet while taking prednisone, if not contraindicated.

The nurse is caring for a client who is receiving newly prescribed prednisone. Which of the following medications should the client avoid while receiving this medication? A. Valsartan B. Naproxen C. Omeprazole D. Acetaminophen

B Choice B is correct. Saw Palmetto is an over-the-counter supplement purported to decrease symptoms of benign prostatic hyperplasia. This medication should be used with caution if it is administered with warfarin. Warfarin is an anticoagulant; if the client takes both concurrently, it may potentiate the anticoagulant effect. The primary healthcare provider (PHCP) must be made aware of this interaction. Choices A, C, and D are incorrect. Loratidine is a histamine antagonist used for allergies. Furosemide is a loop diuretic used for edema and hypertension. Pantoprazole is used for peptic ulcer disease and GERD. None of these medications interact with saw palmetto. ➢ Saw palmetto is purported to treat benign prostatic hyperplasia and alopecia. ➢ Saw palmetto is believed to inhibit dihydrotestosterone and 5-alpha reductase ➢ This medication should be used with the prescriber's approval if the client is taking anticoagulants or medications for erectile dysfunction, as the medication may potentiate the anticoagulant effects

The nurse is caring for a client who was newly prescribed warfarin. Which medication on the client's medication list requires follow-up with the primary healthcare provider (PHCP)? A. Loratidine B. Saw Palmetto C. Furosemide D. Pantoprazole

A, B, E Choices A, B, and E are correct. Sodium plays a very important role in the brain, so imbalances in the serum sodium level can cause major neurological changes. The patient who is hypernatremic, or has a sodium level greater than 145 mEq/L, is at risk for changes in their level of consciousness ranging from restlessness and agitation to lethargy (Choice A), stupor, and coma. A patient who has a high sodium level will often have dry mucous membranes. Hypovolemic hypernatremia is the most common form of hypernatremia. Other causes include renal losses of free water (osmotic diuresis, post obstructive diuresis) or extrarenal losses (diarrhea, sweating, increased insensible losses). Therefore, the patient is often dehydrated and this fluid volume deficit is manifested by dry mucous membranes (Choice B) and excessive thirst (Choice E). Dry mucosa may also be secondary to the relationship sodium has with water. Water follows sodium, so where there is an increased level of sodium in the extracellular space, water leaves the cells and follows the sodium into the extracellular space. This causes dry mouth and mucous membranes. Choice C is incorrect. Tachypnea, or an increased respiratory rate, is not a symptom of hypernatremia. Sodium plays a very important role in the brain and nerves as well as for water balance. The major symptoms to monitor for will be neurological, not respiratory. Choice D is incorrect. Cyanosis, or bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood, is not a symptom of hypernatremia. Sodium imbalance can cause many devastating neurological symptoms, but will not result in cyanosis.

The nurse is caring for a client whose most recent serum sodium level was 152 mEq/L. Which of the following signs and symptoms can be attributed to the client's sodium level? Select all that apply. A. Lethargy B. Dry mucous membranes C. Tachypnea D. Cyanosis E. Excessive thirst

A Choice A is correct. Acetazolamide is a diuretic and is given either intravenously or orally to a client with angle-closure glaucoma. This medication causes a reduction of aqueous humor which is helpful in the management of angle-closure glaucoma that is marked by an IOP greater than 30 mmHg. Choices B, C, and D are incorrect. Angle-closure glaucoma is an ocular emergency that requires prompt treatment. Anticholinergics, decongestants, and antihistamines should be avoided by raising intraocular pressure.

The nurse is caring for a client with angle-closure glaucoma. Which prescription should the nurse anticipate from the primary healthcare provider (PHCP)? A. Acetazolamide B. Diphenhydramine C. Phenylephrine D. Nortriptyline

C Choice C is correct. All of these actions are correct, but the nurse needs to assess the client for hypoglycemia. Regular insulin, when given intravenously, peaks within 15-30 minutes, and the client given this much insulin could develop hypoglycemic shock. When a client has been prescribed a continuous regular insulin infusion, they usually receive a bolus dose of 0.1 unit/kg first, then the continuous infusion is started. Choices A, B, and D are incorrect. All of these actions are appropriate following a medication error of this magnitude. The PHCP should be contacted once the client's glucose is obtained to receive orders on treatment which may range from parenteral glucagon or modifying the intravenous fluids. 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.

The nurse is caring for a client with diabetic ketoacidosis and is prescribed a regular insulin protocol. 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

A Choice A is correct. Initiative vs. Guilt is the typical stage of development for preschool children, who are 3 to 5-year-olds, so this is correct for your four-year-old client. In Initiative vs. Guilt, children assert control and power over their environment. Success leads to initiative when they feel a sense of purpose, but children who try to exert too much power and experience disapproval and may feel a sense of guilt. Choice B is incorrect. Autonomy vs. Shame and Doubt is the typical stage of development for early childhood, which lasts from ages 2 to 3 years, so this is not the correct developmental stage/care plan for a 4-year-old patient. In Autonomy vs. Shame and Doubt, children seek to develop a sense of personal control over physical skills and knowledge of independence. When they are successful, for example, with a task like toilet training, they feel independent, leading to a sense of autonomy. When unsuccessful, they think they are failures, resulting in shame and self-doubt. Choice C is incorrect. Industry vs. Inferiority is the typical stage of development for school-age children, who are 6 to 11-year-olds. Children need to cope with new social and academic demands at this stage. When they are successful with this, they feel competent and achieve the industry. When they are not successful, they handle failure, resulting in inferiority. Choice D is incorrect. Trust vs. Mistrust is the typical stage of development for infancy, which lasts from birth to 18 months. In this stage, children develop confidence when caregivers provide reliability, care, and affection. When infants do not have that, they will build mistrust.

The nurse is caring for a four-year-old child. While developing a plan of care, the nurse recognizes the child is in which stage of Erikson's stages of psychosocial development? A. Initiative vs. Guilt B. Autonomy vs. Shame and Doubt C. Industry vs. Inferiority D. Trust vs. Mistrust

D 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 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

C Choice C is correct. Anticholinergic medications can increase intraocular pressure (IOP) and worsen the condition of patients with glaucoma. Anticholinergic agents also have the potential for producing central side effects, such as confusion, unsteady gait, or drowsiness in adults. Children may become restless or spastic. Glaucoma is one of the leading causes of blindness in the United States. In some cases, it is genetic. In others, it may occur due to eye injury or disease. Some medications may contribute to the development of glaucomas, such as long-term use of topical glucocorticoids, some antihypertensives, antihistamines, and antidepressants. The primary risk factor associated with glaucoma includes high blood pressure. Choice A is incorrect. Osmotic diuretics are most often used in cases of eye surgery or acute closed-angle glaucoma. Choice B is incorrect. Beta-adrenergic blockers are used more than any other anti-glaucoma medication. Choice D is incorrect. Alpha-2 adrenergic agents are used less frequently than other anti-glaucoma medications. They produce minimal cardiovascular and pulmonary side effects. They may cause drowsiness, dry mucosal membranes, irritated eyelids, and headaches.

The nurse is educating a patient with glaucoma. Which of the following classifications of medications should the nurse instruct the patient to avoid? A. Osmotic diuretics B. Beta-adrenergic blockers C. Anticholinergics D. Alpha-2 adrenergic blockers

A Choice A is correct. This is an accurate statement by the client. The client should be taught how to attach the pouch properly onto the stoma. The pouch should allow only 1/16 to 1/8 of an inch of room around the stoma. The client needs to understand that if the bag does not fit well, it can cause skin breakdown from contact with feces while allowing for passage of effluent through the stoma. Choice B is incorrect. The client must be encouraged to eat spinach, parsley, and yogurt, as these foods reduce drainage odor. Choice C is incorrect. The client should drink at least 2000 mL of water daily to prevent severe fluid and electrolyte imbalance as well as urolithiasis. Choice D is incorrect. It is not advisable to eat a large meal close to bedtime as ingested food passes through the ileostomy within 4-6 hours.

The nurse is explaining the different aspects of ostomy care to a client with a newly created ileostomy. Which statement from the client indicates an understanding of the nurse's teaching? A. "I need to cut the pouch to fit the stoma, allowing one-sixteenth of an inch of room around it." B. "I must avoid eating spinach, parsley, and yogurt." C. "I need to drink at least 800 mL of water daily." D. "I can eat a large meal during dinner."

A Choice A is correct. This statement is untrue and requires follow-up. A CVS is a test utilized to determine the presence of chromosomal abnormalities and involves the aspiration of small samples of the placenta for prenatal genetic diagnosis. Maternal blood and urine specimens are not necessary for this test. Choices B, C, and D are incorrect. These statements are factual and do not require follow-up. The CVS uses ultrasound, and a full bladder allows for an acoustic window to ensure accurate imaging. No eating or drinking restrictions are in place during preprocedure. The client may eat and drink normally. Chorionic villus sampling is a test that may be performed as early as ten gestational weeks to determine if the fetus has any chromosomal abnormalities. Chorionic villus sampling has drawbacks that preclude its use, including possible spontaneous abortion of the fetus and fetomaternal hemorrhage.

The nurse is supervising a nursing student to teach a pregnant client about a scheduled chorionic villus sampling (CVS) test. Which statement, if made by the nursing student, would require follow-up? A. You will need to provide both a urine and blood sample for this test. B. Drink plenty of water prior to this test and do not empty your bladder. C. An ultrasound will be used during this procedure to guide the needle. D. It is okay to eat and drink on the day of the procedure.

C Choice C is correct. Furniture should be arranged so that there are clear paths, free of rugs, cords, or other obstacles. It is unsafe for the client to use furniture for support during walking. The nurse should discuss the risks associated with this action and evaluate the client's need for a mobility aid such as a walker or cane. Choices A, B, and D are incorrect. Falls frequently occur in the bathroom setting. Grab bars, elevated toilet seats, and shower chairs are examples of safety precautions to reduce the risk of falls. A nonskid mat in the shower is a good strategy to reduce falls in the bath tube. Electrical cords should not have rugs placed over them. Instead, electrical and extension cords should be against a wall behind furniture. To promote home safety for the older adult, the nurse should verify the following: ✓ Remove scatter rugs and frayed carpet ✓ Ensure that hallways and steps are well lit ✓ Do not run wires under carpeting ✓ Smoke detectors are present and are tested every six months ✓ The recommendation is one smoke detector per room and one per floor ✓ Ensure fire extinguishers are readily available ✓ Add additional lighting to the bathroom ✓ Medications are clearly labeled and are reviewed periodically by a family member or healthcare provider ✓ Household chemicals are clearly labeled ✓ Rubber mats in the bathtub

The nurse is performing a home safety assessment for an older adult. Which of the following client statements would require follow-up by the nurse? A. "I will have grab bars installed in the bathroom." B. "I placed a nonskid mat in my shower." C. "My furniture is arranged so I can hold onto something if I need it." D. "I secured my electrical cords against the wall behind furniture."

D Choice D is correct. If the cast comes into contact with water, it should be dried immediately. A hairdryer can be used to assist with drying the inner part of the cast. Choice A is incorrect. It is not recommended to cover casts with plastic for an extended period of time; the client should not be taught to cover the cast with plastic during the daytime. Instead, exposing the cast to water should be avoided. If water exposure is possible, Waterproof cast covers are a better option for short-term protection from moisture. Plastic wrap is not completely occlusive and may allow water to enter the cast area. Choice B is incorrect. The patient should be advised not to insert any foreign objects into the cast. Choice C is incorrect. During the first 24-48 hours, ice should be intermittently applied to reduce pain and swelling. The heat application will cause vasodilation and increased blood flow, resulting in swelling during the initial period.

The nurse is preparing discharge information for a patient with a newly placed cast to the left arm. What teaching should the nurse include? A. Cover the cast with plastic wrap during the daytime to prevent any water exposure. B. Use only soft, non-abrasive devices to gently relieve itching under cast edges. C. Alternate ice and heat in 15-minute increments for the first 24 hours to reduce pain/swelling. D. If exposed to water, dry thoroughly with a towel or hair dryer.

A Choice A is correct. An essential aspect of advocacy is speaking on behalf of the patient, to help meet the patient's needs, such as when calling the physician to discuss the need for more effective pain management - since it is the patient's fundamental right to be free from pain. Choices B and D are incorrect. These are nursing interventions that can be employed to enhance the prescribed pain medication but do not meet defining characteristics related to advocacy. Choice C is incorrect. While this is factual information, it does not address the need to provide adequate pain management.

The nurse is providing care for a patient recently transferred from the post-anesthesia care unit [PACU]. The chart indicates that the patient was medicated for pain 1 hour ago, yet the patient reports that he is experiencing extreme pain. He is not due for further medication until another 2 hours. How might the nurse intervene as a patient advocate? A. Contact the physician regarding the need for more effective pain management. B. Assist the patient to use non-pharmacological pain management strategies. C. Explain to the patient that giving the pain medication too soon can be dangerous. D. Provide a quiet environment to help the patient rest and cope with his pain level.

B Choice B is correct. A client taking lithium should be instructed to avoid dehydration and hyponatremia. Lithium is a salt, and when the client has decreased fluid volume, the drug will accumulate and raise the lithium level. HCTZ is a thiazide diuretic and is contraindicated for a client taking lithium because of its ability to decrease fluid and sodium levels. Choices A, C, and D are incorrect. Venlafaxine is a serotonin-norepinephrine reuptake inhibitor and has no contraindication with lithium. Further, gabapentin and verapamil have no contraindications as gabapentin is indicated for neuropathy, and verapamil is indicated for hypertension. ADDITIONAL INFO Key teaching points for a client taking lithium include the avoidance of dehydration, adhering to the dosing schedule to maintain a therapeutic level of 0.6-1.2 mEq/L, and reporting signs of toxicity such as nausea, vomiting, and ataxia. The client should be instructed that the drug level should be obtained twelve hours after the last dose to avoid a falsely elevated level.

The nurse is reviewing newly prescribed medications for a client taking lithium. Which medication requires further follow-up? A. Venlafaxine B. Hydrochlorothiazide C. Gabapentin D. Verapamil

B Choice B is correct. Hyperparathyroidism causes hypercalcemia, and the treatment for hyperparathyroidism is a combination of 0.9% saline infusion followed by furosemide. Hydrochlorothiazide is a thiazide diuretic and causes the retention of calcium. This would be detrimental for a client experiencing hypercalcemia. This prescribed medication requires follow-up with the prescriber. Choices A, C, and D are incorrect. Levothyroxine is the essential treatment for myxedema, a severe form of hypothyroidism. Hydrocortisone is a priority treatment for adrenal insufficiency as the hallmark of this disease is an insufficient amount of mineralocorticoids and glucocorticoids. DKA is an endocrine emergency and requires aggressive fluid resuscitation and intravenous regular insulin. ADDITIONAL INFO Hyperparathyroidism is a disorder in which parathyroid secretion of parathyroid hormone is increased, resulting in hypercalcemia (excessive serum calcium levels) and hypophosphatemia (inadequate serum phosphorus levels). Diuretic and hydration therapies help reduce serum calcium levels. Furosemide, a diuretic that increases kidney excretion of calcium, is used along with IV saline in large volumes to promote calcium excretion.

The nurse is reviewing newly prescribed medications for assigned clients. Which of the following prescribed medications should the nurse question? A. Levothyroxine for a client with a myxedema coma B. Hydrochlorothiazide for a client with hyperparathyroidism C. Hydrocortisone for a client with adrenal insufficiency D. Regular insulin for a client with diabetic ketoacidosis

D Choice D is correct. Vaginal intercourse following a vaginal colposcopy with a biopsy is not advised 48 hours after the procedure. Following the 48-hour pelvic rest, the first intercourse following this procedure may be painful, which is expected. Choices A, B, and C are incorrect. The client does not need to be NPO (nothing by mouth) prior to this procedure. This procedure also does not involve contrast dye or require that the client not drive after the procedure considering sedation is not utilized. ADDITIONAL INFO ✓ A colposcopy is a diagnostic procedure that may be utilized to detect an array of gynecological conditions, including herpes simplex virus, human papillomavirus, cervical cancer, and any other abnormal tissue in the vagina, cervix, and vulva. ✓ This outpatient procedure requires the client to provide consent, and the client should be instructed that after the procedure, a small amount of bleeding is normal if biopsies are obtained. ✓ Vaginal intercourse should not occur 48 hours after this procedure. The first intercourse may bring the woman discomfort but should lessen.

The nurse is teaching a client scheduled for a vaginal and cervical colposcopy with biopsy. Which of the following information should the nurse include? A. You should not eat or drink eight hours before this test B. You will need to have someone drive you home after this test C. A metallic taste is common once you get the contrast dye D. Vaginal intercourse may be painful after the procedure

A 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. 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. 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.

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.

C Choice C is correct. This is a therapeutic statement. It educates the parent about the need to swaddle the baby only very loosely and avoid any pressure on the exposed intestines so that they do not get pushed back inside of the baby. It also promotes bonding with the infant, as it encourages the parent to touch and care for their baby. Choice A is incorrect. This is inappropriate to say to a parent as it would cause panic and upset them. The nurse wants to promote the parent bonding with their infant, so phrases like this will scare the parent and make them afraid to touch the baby, which is not therapeutic. Choice B is incorrect. It is not appropriate to tightly swaddle an infant with an omphalocele. This would place pressure on their exposed intestines and push them back inside the baby, which we do not want. Choice D is incorrect. This is not appropriate. Swaddling is not ideal for an infant with an omphalocele due to the exposed intestines, but if it is done loosely and avoids placing pressure on the defect, it can certainly be done. Telling the parent to stop will not promote bonding and decreases their interaction with the baby. The nurse should educate the parent on the necessary precautions when traveling and develop a positive relationship with their new baby.

The nurse observes a parent swaddling their infant with an unrepaired omphalocele. Which of the following statements would be appropriate? A. "Stop! You will kill your baby." B. "That is a nice, tight swaddle. It will help soothe your new baby." C. "May I help you? We will need to be careful with their intestines since we do not want the swaddle to push them back inside." D. "Swaddling is not allowed for these babies; please stop."

A, C, D Choice A is correct. Many changes occur in the aging body. With age, the loss of adipose tissue causes sagging skin and wrinkles. This is especially noticeable around the head and face. Wrinkles on the face become more pronounced and tend to take on the general "mood" of the client over the years. For example, laugh lines or wrinkles around the lips, cheeks, and eyes are usually more noticeable. Choice B is incorrect. The nose and ears of the aging client become more extended and broader. Over time, the nose and ears appears to grow in size due to gravity. As individuals age, gravity causes cartilage in the ear and nose to break down and sag which gives these features an elongated appearance. Choice C is correct. Changes in hormone levels, especially the androgen-estrogen ratio, often cause an increase in the growth of facial hair in most older adults. As individuals age, they lose estrogen. When estrogen decreases and testosterone levels are unopposed clients will start to grow more hair where men have it, especially on the face. Choice D is correct. The aging process causes the platysma muscle to shorten, which contributes to neck wrinkles. Neck skin is very similar to facial skin. As a client ages, they lose important dermal plumping factors like collagen, elastin and glysosaminoglycans. These factors are gradually lost over time with the aging process and is also enhanced with environmental stressors like frequent exposure to UV light. Aging skin looks thinner, paler, and clear (translucent). Pigmented spots, including age spots or "liver spots," may appear in sun-exposed areas. The medical term for these areas is lentigos. Changes in the connective tissue reduce the skin's strength and elasticity. It becomes thinner, loses fat, and no longer looks as plump and smooth as it once did. Veins and bones can be seen more easily. Scratches, cuts, or bumps can take longer to heal.

The nurse should recognize which of the following are physical changes associated with the aging client? Select all that apply. A. Pronounced wrinkles on the face B. Decreased size of the nose and ears C. Increased growth of facial hair D. Neck wrinkles

C Choice C is correct. Nitroglycerin transdermal patches should be temporarily removed during the procedure because they may burn the client. The transdermal patch may contain aluminum which is contraindicated for an MRI. Moving the patch would not be helpful as it should be totally removed during the procedure. Choices A, B, and D are incorrect. An MRI questionnaire is always completed before this exam to ensure client safety. MRI units can produce sounds up to 120 decibels, resulting in hearing damage. MRIs do not use radiation; this imaging exam uses magnets to create 3D cross-sectional images of the body. ADDITIONAL INFO An MRI is a unique imaging exam that uses magnets (not radiation) to assist clinicians in diagnostic imaging. MRI is most suited to image soft tissue structures in the body with a high water content to utilize the protons in water molecules. The brain and spinal cord are often evaluated using MRI. MRI can differentiate between gray and white matter and blood vessels. Nursing care for a client scheduled for an MRI includes - Completing a comprehensive MRI screening form that is submitted before the exam. MRIs are safe during pregnancy because it does not use radiation. MRIs may be ordered with contrast. The contrast agent of choice is gadolinium-based. The MRI may become unsafe for a pregnant client if this contrast is necessary. MRI safety includes having the client wear ear protective device(s) as this test is extremely loud.

The nurse supervises a student nurse prepare a client for a magnetic resonance imaging (MRI) test. Which of the following actions by the student nurse would require follow-up by the nurse? The student A. asks the client if they have claustrophobia. B. instructs the client to apply earplugs before the exam. C. moves the nitroglycerin patch from the torso to the back. D. tells the client that they will not have any exposure to radiation.

B Choice B is correct. Enterobiasis is an intestinal infestation by the pinworm Enterobius vermicularis, usually in children, but adult members of their household and caregivers are also at risk. The primary symptom is perianal itching due to female pinworms leaving the intestine through the anus and depositing their eggs on the surrounding skin while the infected individual sleeps. Most cases are in school-aged and young children, with thumb-sucking being a primary risk factor. Choices A, C, and D are incorrect. An anal fissure is an acute longitudinal tear or a chronic ovoid ulcer in the squamous epithelium of the anal canal. It causes severe pain, sometimes with bleeding, particularly with defecation. Diagnosis is by inspection. Giardiasis is one of the most common causes of waterborne disease worldwide (especially in areas of poor sanitation) caused by the protozoan Giardia duodenalis. Symptoms include watery malodorous diarrhea, abdominal cramps and distention, flatulence, eructation, intermittent nausea, epigastric discomfort, and sometimes low-grade malaise, fatigue, anorexia, and/or failure to thrive. Celiac disease is a hereditary disorder in genetically susceptible people caused by intolerance to gluten, resulting in mucosal inflammation and villous atrophy, which causes malabsorption. Symptoms usually include diarrhea and abdominal discomfort. Diagnosis occurs via small-bowel biopsy and resolves with a strict gluten-free diet. ✓ Pinworm infestation is the most common helminthic infection in the United States. ✓ Enterobiasis infestation is seldom harmful, and reinfestation is common, as ova deposited in the environment can survive three weeks. ✓ Pinworm eggs may be ingested when people touch their mouth after they scratch their perianal area or after they handle contaminated clothes or other objects (e.g., bed linens). ✓ Treatment is available over the counter and may need to be repeated if the hygiene habits are not implemented. ✓ The nurse should recommend that the child adheres to strict hand hygiene, cut the nails short to prevent ova under the nails, and do daily showering. ✓ It is also recommended that linens are washed with warm water.

The parents of a toddler report that the client is having poor sleeping, intense perianal itching, and scratching. The nurse understands that this client is at the highest risk for which condition? A. Anal fissure B. Enterobiasis C. Giardiasis D. Celiac disease

B Choice B is correct. The first step of any assessment is always inspection. The first step the nurse should take is to compare the knees for symmetry. Choices A, C, and D are incorrect. These answer choices are procedures for assessing joints, which may be indicated, but do not represent the first step the nurse should take.

What is the first assessment the nurse should make when a patient reports he hurt his knee playing baseball and the knee appears swollen? A. Feel the knee for warmth B. Compare the swollen knee with the other knee C. Palpate for crepitus in the knee D. Assess active range of motion in the knee

C Choice C is correct. Acculturation is the process with which members of another culture adopt the culture of the host, predominant religion. This adaptation allows the members of the non-dominant culture to survive and thrive in the new environment. Although acculturation and assimilation are similar, adaptation is the process with which a person develops a new cultural identity, rather than assimilating and adopting a new culture while retaining their own. Immigration is the process by which citizens of one country enter another country, whereas emigration is the process by which individuals of a nation leave it. Both immigration and emigration can lead to cultural dissonance. Choice A is incorrect. Immigration is the process by which citizens of one country enter another country. Choice B is incorrect. Emigration is the process by which individuals of a country leave it. Choice D is incorrect. Assimilation is the process with which a person develops a new cultural identity process.

What is the process with which members of another culture adopt the culture of the host, predominant culture? A. Immigration B. Emigration C. Acculturation D. Assimilation

B Choice B is correct. The 56-year-old male client with a leg amputation would most likely benefit from contralateral stimulation as a nonpharmacological comfort intervention to decrease pain. Contralateral massage, or stimulation, unlike other cutaneous nonpharmacological comfort interventions, entails the stimulation of the opposite part of the body rather than the direct stimulation of the painful, affected area. For this reason, contralateral stimulation of the intact opposite leg will promote comfort and decrease phantom pain that has occurred as a result of the amputation. Choice A is incorrect. A 36-year-old female client with abdominal pain would not benefit from contralateral stimulation to decrease pain; alternative comfort measures and pain management interventions may be indicated. Choice C is incorrect. A 76-year-old female client with terminal cancer would not benefit from contralateral stimulation to decrease pain; alternative comfort measures and pain management interventions may be indicated. Choice D is incorrect. An 84-year-old male client with severe arthritis would not benefit from contralateral stimulation to decrease pain; alternative comfort measures and pain management interventions may be indicated.

Which of the following clients would most likely benefit from contralateral stimulation as a nonpharmacological comfort intervention to decrease pain? A. A 36-year-old female client with abdominal pain. B. A 56-year-old male client with a leg amputation. C. A 76-year-old female client with terminal cancer. D. An 84-year-old male client with severe arthritis.

D Choice D is correct. A breach of duty is a critical and necessary component of a malpractice case. Other vital and essential elements of a malpractice case include an act of commission or omission, an intentional or unintentional act, damages to the client, causation, foreseeability, and causation. Choice A is incorrect. A malpractice case can occur as the result of both acts of omission and commission. Therefore, the commission is not a necessary component of a malpractice case. Choice B is incorrect. A malpractice case can occur as the result of both acts of omission and commission. Therefore, failure is not a necessary component of a malpractice case. Choice C is incorrect. A malpractice case can occur due to intentional and negligent, or unintentional acts; therefore, the intention is not a necessary component of a malpractice case.

Which of the following is a critical and necessary component of a malpractice case? A. An act of omission B. An act of commission C. An intentional act D. A breach of duty

B Choice B is correct. Deep palpation is cautiously done after light palpation when necessary because the client's responses to deep palpation may include their tightening of the abdominal muscles. When this occurs, it could make light palpation less effective, particularly if an area of pain or tenderness has been palpated. A complete health assessment may be conducted starting at the head and proceeding systematically downward (head-to-toe evaluation). However, the procedure can vary according to the age of the individual, the severity of the illness, the preferences of the nurse, the location of the examination, and the agency's priorities and procedures. Choice A is incorrect. Inspection is typically the first step of an assessment. Choice C is incorrect. Percussion of the abdomen should be done before any palpation, especially deep palpation. Choice D is incorrect. Since choices A and C are incorrect, choice D is also wrong.

Which of the following is the final step that is used during the physical assessment of the abdomen? A. Inspection B. Deep palpation C. Percussion D. None of the above

A, C, E Choices A, C, and E are correct. Standards are the levels of performance accepted and expected by the nursing staff or other healthcare team members. They are established by authority, custom, or consent. The Committee on Quality Health Care in America of the Institute of Medicine, in its report Crossing the Quality Chasm, highlights six aims to be met by health care systems about quality care: Safe: Avoiding injury Useful: Avoiding overuse and underuse Patient-centered: Responding to patient preferences, needs, and values Timely: Reducing waits and delays Efficient: Avoiding waste Equitable: Providing care that does not vary in quality to all recipients Choices B, D, and F are incorrect.

Which of the following nursing improvements follow the recommendations of the Institute of Medicine's Committee on Quality Healthcare in America? Select all that apply. A. Basing patient care on continuous healing relationships B. Customizing care to reflect the competencies of the staff C. Using evidence-based decision making D. Having a charge nurse as the source of control E. Using safety as a system priority F. Recognizing the need for secrecy to protect patient privacy

D Choice D is correct. The optic nerve is the second cranial nerve (CN II) responsible for transmitting visual information. Compromise of the CN II results in visual field defects and/or visual loss. As a result, the client's vision will be impaired, and fall risk will increase. "The client will remain free of falls while hospitalized" is an appropriate outcome statement for a newly hospitalized client experiencing a CN II impairment, as the client's current visual impairment places the client at high risk of falls, the client's safety is a priority under Maslow's hierarchy of needs, and this nursing diagnosis includes a clear, measurable outcome. Choice A is incorrect. When creating the plan of care for a newly hospitalized client experiencing an impairment of the second cranial nerve (CN II), concern regarding the client experiencing sensory overload while in the hospital is typically not a concern. Additionally, aside from self-reporting (which is often difficult to measure in a significant aspect of the client population), this outcome is not a measurable outcome, as the measurement would rely solely on subjective and not objective data. Choice B is incorrect. Impairment of a client's second cranial nerve (CN II) would not cause an elevation of a client's blood pressure. Additionally, the manner in which this outcome statement is worded does not provide a specific method in which this outcome statement may be measured. Therefore, this choice is incorrect. Choice C is incorrect. Clients who are experiencing an impairment of the second cranial nerve (CN II) experience visual impairment issues. Any issues related to balance would be a result of the CN II-related visual impairments. The client does not require physical therapy to improve their balance, as the client's balance is not impaired.

Which of the following outcome statements would be most appropriate for a newly hospitalized client experiencing an impairment of the second cranial nerve (CN II)? A. The client will not experience sensory overload in the hospital. B. The client will list ways to effectively decrease their blood pressure. C. The client will participate in physical therapy to improve balance. D. The client will remain free of falls while hospitalized.

C Choice C is correct. The mood is a sustained emotion. Nurses should assess the intensity, depth, and duration of an altered climate. Patients may describe feeling happy, excited, sad, tearful, depressed, angry, anxious, or fearful. When assessing a patient's climate, it is essential to listen to verbal cues but also observe for nonverbal cues. For example, if the patient states, "I am happy," but she seems nervous or is crying, the nurse should document the objective data, as well. Choices A, B, and D are all incorrect. These answer choices reflect abnormal moods, which are described as sad, tearful, depressed, angry, anxious, grandiose, and fearful.

Which of the following represents appropriate nursing documentation of a patient with a normal mood? A. Sad and tearful during conversation B. Grandiose or strongly confident C. Pleasant or appropriate to the situation D. Tearful but mildly humble and meek

A, D Choices A and D are correct. Diaphoresis, or increased sweating (Choice A), is an expected clinical manifestation of heart failure. As the heart works harder and harder to maintain cardiac output, the body starts to tire and this is manifested in signs such as diaphoresis. Diaphoresis is possibly related to a catecholamine surge and can mainly occur during feeding when the infant/child attempts to eat while in respiratory distress. Poor nutrition (Choice D) is another expected clinical manifestation of heart failure in infants and children. As the left side of the heart begins to fail, there is fluid backing up in the lungs (pulmonary edema). This causes dyspnea and makes eating increasingly tricky for patients. Choice B is incorrect. Weight gain, rather than loss, is an expected clinical manifestation of heart failure. Weight gain is secondary to fluid retention. In heart failure (especially with right heart failure), the heart struggles to move fluid forward in the body and therefore liquid begins to back up, causing venous congestion and weight gain. Venous congestion in right-sided heart failure manifest with liver enlargement (hepatomegaly), ascites, pleural effusion, peripheral edema, and jugular venous distension. Venous congestion in left-sided heart failure manifests with tachypnea, intercostal retractions, nasal flaring or grunting, rales, and pulmonary edema. Primary mechanisms of fluid retention in heart failure include reduced renal perfusion and, thereby, activation of the renin-angiotensin-aldosterone system. Increased aldosterone production leads to sodium and water retention. Congestion in patients with chronic heart failure usually develops over weeks or even months. In the case of exacerbations of congestive heart failure (CHF), patients may present 'acutely' having gained several liters of excess fluid and hence several pounds of excess weight. Therefore, management in these acute CHF exacerbation patients involves removing that excess fluid (acutely retained fluid) and transitioning them back to a diagnosis of chronic heart failure. In managing clients with acute CHF exacerbation, daily weight monitoring is a crucial measure to monitor outcomes and achieve desired weight loss (removal of excess fluid). Loop diuretics are the principal agents to attain that target. Choice C is incorrect. Insomnia is not an expected clinical manifestation of heart failure in children. These patients are often very fatigued but do not typically experience insomnia. Although paroxysmal nocturnal dyspnea and orthopnea in left heart failure may cause some sleep disturbances, insomnia is not a commonly reported direct symptom of heart failure.

Which of the following signs does the nurse know to expect for her 1-year-old patient in heart failure? Select all that apply. A. Diaphoresis B. Weight loss C. Insomnia D. Poor feeding

A, B Choices A and B are correct. A is correct. This is a true statement. Physical growth during the preschool years should occur at a rate of about 2 to 3 inches every year. Of course, every child will be slightly different, but most will fall between this range. At each pediatrician appointment, the doctor will weigh and measure the child, plotting their growth on the appropriate growth curve. This will be used to monitor the child's height and assess if they are on track. B is correct. Running, skipping, and hopping on one foot are all gross motor skills that should be developed between 3 and 5 years of age, during the preschool years. Health care providers will ask questions about these milestones at each check-up visit, to ensure the child is on track. If a child is falling behind in their gross motor development, further evaluation and treatment by a physical therapist may be needed. Choice C is incorrect. Preschool-age children should gain about 5 pounds each year, not at least 10 pounds. Gaining weight at a rate of 10 pounds per year for this age group is too much and would be a concern for childhood obesity. At each pediatrician appointment, the doctor will weigh and measure the child, plotting their weight on the appropriate growth curve. This will be used to monitor the child's weight and assess if they are on track. Choice D is incorrect. Writing in cursive is a fine motor skill that will be developed in the school-age years, between the ages of 6 and 12. The nurse would not expect a 5-year-old child to be able to write in cursive. Fine motor skills that are appropriate milestones to monitor for in a 5-year-old include: copying a circle onto a piece of paper, using a spoon and fork, cutting out shapes with scissors, and pasting things onto paper.

Which of the following statements are true regarding growth and development during the preschool years? Select all that apply. A. Between ages 3 and 5, children grow 2 to 3 inches every year. B. Preschool-age children will be able to run, skip, and hop on one foot. C. Preschool-age children should gain at least 10 pounds each year. D. At age 5, children should be able to write in cursive

D Choice D is correct. Spiritual distress, as defined by the North American Nursing Diagnosis Association, is the lack of ability by the client to integrate the purpose and meaning of life into connectedness as well as interrelationships with the higher power, self, and others. Choice A is incorrect. Guilt is defined as a feeling of inner discomfort that occurs when a person believes that they have done something wrong and not the lack of ability by the client to integrate the purpose and meaning of life into connectedness and interrelationships with the higher power, self, and others. Choice B is incorrect. Isolation may occur as a result of spiritual distress. However, separation is quite different from the lack of connectedness with self, others, and a power greater than oneself and not the lack of ability by the client to integrate the purpose and meaning of life into connectedness and interrelationships with the higher power, self, and others. Choice C is incorrect. Religious distress is the feeling that some who are not able to feel that they have followed the mandates of their religion and its traditions and not the lack of ability by the client to integrate the purpose and meaning of life into connectedness and interrelationships with the higher power, self, and others.

Which of the following terms, according to the North American Nursing Diagnosis Association, is defined as the lack of ability by the client to integrate the purpose and meaning of life into connectedness as well as interrelationships with the higher power, self, and others at the end of life? A. Guilt B. Isolation C. Religious distress D. Spiritual distress

A Choice A is correct. A client is often given a loading dose of their ordered pain medication before they can activate their own titrated dosage. For example, the client will be given 4mg of morphine before allowing their individual titrated dosage of 1 mg morphine, as per the doctor's order. Choice B is incorrect. It is not necessary to consider a method of pain management other than patient-controlled analgesia when a client is not able to take morphine. Medications such as fentanyl and hydromorphone can also be used for patient-controlled analgesia when a client is not able to take morphine. Choice C is incorrect. The lockout mechanism controls the amount of medication given at any specific time. It can be activated when a client with patient-controlled analgesia attempts to dose in less than half an hour. At times, the ordered titrated dose can be every several minutes. Choice D is incorrect. The lockout mechanism controls the amount of medications given at any specific time. It can be activated when the client with patient-controlled analgesia attempts to dose in less than 1 hour. At times, the ordered titrated dose can be every several minutes.

Which statement about patient-controlled analgesia (PCA) is accurate? A. A client is often given a loading dose of their ordered pain medication before they are able to activate their own titrated dosage. B. A method of pain management, other than patient-controlled analgesia, must be used when a client is not able to take morphine. C. The lockout mechanism must be activated when the client with patient-controlled analgesia attempts to dose in less than half an hour. D. The lockout mechanism must be activated when the client with patient-controlled analgesia attempts to dose in less than 1 hour.

B Choice B is correct. The most common physical sign of child abuse is bruising. The physical maltreatment of a child can manifest in many ways, but bruising is indeed the most commonly recognized physical sign that starts off the investigation. It is important to note that all nurses are mandatory reporters of abuse. If they have any suspicion that a child is being abused, they are required by law to report it. Choice A is incorrect. Malnourishment is not a sign of physical abuse, rather it is a sign of neglect. Neglect is to fail to care for properly, so if the child is malnourished and the parent is not providing them sufficient or proper nutrition, the child is being neglected. Choice C is incorrect. Poor hygiene is not a sign of physical abuse, rather it is a sign of neglect. Neglect is to fail to care for properly, so if the child is very dirty, disheveled, and clearly uncared for in the home environment, they are being neglected. Choice D is incorrect. Burns are a sign of physical abuse, but they are not the most common type. The most common physical sign of child abuse is bruising.

While working in an outpatient pediatric clinic, the RN knows that as a mandated reporter it is important to monitor for suspected child abuse in all clients. The most common physical sign of child abuse is _________. A. Malnourishment B. Bruising C. Poor hygiene D. Burns

D Choice D is correct. This is the priority nursing action and should be completed first. The infusion should immediately be turned off to minimize any further reaction. As soon as the injection is stopped, the provider can be notified. In priority nursing questions, the priority will always be whatever action you can take that immediately helps the patient. In this question, turning off the infusion will help stop/prevent further reactions to the magnesium infusion, so it is the priority. Choice A is incorrect. It is inappropriate to slow down the infusion rate simply. The patient feeling flushed and warm indicates a high magnesium level and possibly a reaction to the infusion. Their magnesium level could have increased dramatically in response to the injection leading to an increased risk for seizures and arrhythmias. If the reaction is mild, the provider may recommend slowing down the infusion, but this is not the appropriate nursing intervention. Choice B is incorrect. While it is appropriate to notify the healthcare provider of this change, there is another nursing action listed that takes priority and should be carried out first. Choice C is incorrect. It is inappropriate to continue the infusion and reassess the patient after the injection. They are reacting and immediate action is needed.

You are administering IV magnesium to a patient with a magnesium level of 1.5 mEq/L. You check on them halfway through the infusion, and they report that their face feels flushed. What is the priority nursing intervention? A. Slow down the infusion rate. B. Notify the healthcare provider. C. Reassess the patient when the infusion finishes. D. Stop the infusion.

D Choice D is correct. The nurse should evaluate the character of the pulse since one of the toxic effects of theophylline is cardiac arrhythmias. If the pulse rate is significantly increased or erratic, it may alert the nurse regarding a potential arrhythmia from theophylline drug toxicity. Severe adverse events, including arrhythmias, seizures/ status epilepticus, nausea with vomiting, and hypotension, usually occur when the theophylline is at a toxic level in the body (drug toxicity). If such signs are detected, the nurse should hold the next dose of theophylline and immediately notify the healthcare provider. Choices A, B, and C are incorrect. Theophylline does not typically change the patient's temperature (choice A). Theophylline can affect the patient's blood pressure and urinary output, but these effects are less common. The pulse should be assessed first because arrhythmias are more common with theophylline toxicity than hypotension (choice B).

You are caring for an 80-year-old woman with a long-standing history of asthma. You are preparing to give a dose of theophylline to the patient. You know that the most critical sign to assess before giving this dose is: A. Temperature B. Blood Pressure C. Urinary Output D. Pulse

B Choice B is correct. Of all the choices in the question, the best expected client outcome when the client's pain is managed effectively is that "The infant will not demonstrate any behavioral indications of pain." This expected outcome is client-oriented, specific, and measurable. Firstly, it is important to understand a nursing care plan and its components to answer this question appropriately. A nursing care plan provides direction on the type of nursing care the client may need. Six components include Assessment, Diagnosis, Outcomes/Planning, Interventions, Rationale, and Evaluation. Assessment includes both subjective and objective assessment of the client. The diagnostic component of the care plan determines the most likely reason for the client's problems based on the history, assessment, and lab tests. The Outcomes/Planning column of the care plan is client-oriented - a list of measurable goals for the client is set; for example, managing pain with enough medication. Interventions refer to a set of actions that a nurse can undertake to achieve the outcomes. Interventions are nurse-oriented and are aimed at addressing the diagnoses to achieve the desired outcomes. While addressing the diagnoses and planning a specific intervention, prioritizing is crucial. Life-threatening problems should be given high priority and diagnoses are grouped as having a high, medium, or low priority. Maslow's hierarchy of needs is often used when setting priorities. The Rationale column is to provide a scientific explanation to support the reasons why certain nursing interventions were chosen in the care plan. Finally, Evaluation refers to evaluating the client's progress towards achieving the desired outcomes. If the evaluation indicates that the client's progress is not as expected, the nursing care plan should be adjusted or rewritten to define a better strategy and achieve desired outcomes. In this question, the nursing care plan is focused on addressing the infant's pain. The desired client outcome here is that the "infant will not demonstrate behavioral indicators of pain". Nursing interventions (Choices A and D) are delivered to evaluate if such an outcome is achieved. Several parameters can be used in clients' pain assessment, including behavioral indicators, physiological indicators, and self-report measures. Physiological indicators of pain (Choice D) refer to variations in heart rate, blood pressure, oxygen saturation, and breathing patterns. Pain leads to an increase in heart rate and blood pressure, a decrease in oxygen saturation, and more rapid or shallow breathing. However, a big limitation of physiological indicators is that these variations may be due to the underlying illness itself rather than the pain. This makes them less specific for pain. Therefore, this should not be considered the best-expected client outcome for effective pain management While self-report measures (verbal/non-verbal) are considered the 'gold standard' in pain measurement, these cannot be used in infants because you need verbal/non-verbal responses, which is inappropriate for this age group. Therefore, behavioral measures are used as a proxy for objective pain measurement in infants. These include crying, facial expressions, body postures, or a combination of these indicators. Facial expressions are the most used behavioral measure in children. Choices A and C are incorrect. "The nurse will assess pre and post analgesic client responses" (Choice A) and "The nurse will evaluate pre and post analgesic client responses" (Choice C) are appropriate nursing interventions, but they are NOT expected client outcomes. These statements are nurse-oriented and not client-oriented. Choice D is incorrect. "The infant will not demonstrate any physiological indications of pain" is not a very reliable indication of pain outcomes, therefore this is not the best expected client outcome when the client's pain is managed effectively.

You are evaluating a nursing care plan for a 6-month-old infant with severe post-operative pain. Which of the following is the best expected client outcome when the client's pain is managed effectively? A. The nurse will assess pre and post analgesic client responses. B. The infant will not demonstrate any behavioral indications of pain. C. The nurse will evaluate pre and post analgesic client responses. D. The infant will not demonstrate any physiological indications of pain.

C Choice C is correct. "You are getting the NSAID, so the effects of the narcotic analgesic to combat your pain are more effective" is an appropriate response to the client's query. An NSAID is an "adjuvant" medication used in combination with narcotic analgesics to treat moderate to severe pain. Adjuvant pain medications are used to enhance pain relief provided by other analgesics. The primary function of NSAIDs is to reduce inflammation. Therefore, NSAIDs are helpful in treating the pain caused by inflammation. Choice A, B, and D are incorrect. This response ( Choice A) is inappropriate because the nurse is expected to address the client's question without referring the client to the physician. The nurse is expected to have basic understanding of various types of analgesics or be able research why the NSAID is being given. If the nurse is unable to find the information herself, she should ask the physician and attempt to address the client's concern before simply referring the client to the physician. Narcotic analgesic with or without an NSAID is an appropriate intervention for moderate to severe pain. While weaning the client off the opioid analgesic should be definitely considered, there is no information in the question regarding adequate pain control before considering weaning (Choice B). If the client's pain is adequately controlled on non-opioid medications, then opioid weaning can be attempted. Weaning opioids may take 6 months or more depending on the total baseline opioid dose and the individual client's response to the opioid wean. NSAID is not a placebo ( Choice D). NSAIDs can be used primarily to treat inflammatory pain or as an adjuvant analgesic.

Your client is receiving a non-steroidal anti-inflammatory drug (NSAID) in addition to a narcotic analgesic. The client wonders why an NSAID is necessary since the narcotic analgesic offers better pain relief. How would you respond to the client's question? A. I don't know and I suggest that you ask your doctor when you see her the next time. B. You are getting the NSAID because we are trying to wean you off the narcotic analgesic for moderate to severe pain. C. You are getting the NSAID, so the effects of the narcotic analgesic to combat your pain are more effective. D. You are getting the NSAID because it is a placebo, and it is proven to be effective for severe pain.