ATI: Board Vital

A nurse is providing education to a client with chronic low back pain on non-pharmacological pain management strategies. The nurse knows that ambulation and music are nonpharmacological modalities of pain relief that use which of the following strategies? A. Physical therapy B. Distraction C. Cutaneous stimulation D. Imagery

Correct Answer: B. Distraction Factors that increase a client's experience of pain and reduce pain tolerance include monotony, lack of knowledge, fatigue, and fear. Distraction is used to help individuals pay less attention to the presence of pain, which may decrease the level of pain perceived. Methods of distraction include music, ambulation, deep breathing, socializing with friends and family, prayer, television, and music. Other non-pharmacological modalities used to relieve pain include guided imagery, massage, and relaxation. Incorrect Answers: A. Physical therapy is directed at rehabilitation of a muscle group to strengthen or compensate for muscle or joint disability through exercise. C. Cutaneous stimulation refers to stimulation of the nerves through transcutaneous currents, such as a TENS (transcutaneous electrical stimulation) unit. A TENS unit may interrupt pain pathways to reduce painful stimuli. Other types of cutaneous stimulation include massage, therapeutic touch, and use of heat or cold. D. Imagery is a type of distraction that requires an ability to concentrate on a pleasant thought to divert the focus from pain. Vital Concept: An individual's experience of pain can be increased or precipitated by monotony, fatigue, fear, or lack of knowledge. The perception of pain can be reduced by non-pharmacological techniques that include distraction, relaxation, massage, and guided imagery.

The nurse is assessing the muscle tone of a 19-year-old client admitted with muscular dystrophy. The nurse's assessment shows that the client has greater-than-expected muscle tone (see image). How will the nurse document this finding? A. The patient's muscle tone appears flaccid B. The patient's muscle tone appears atonic C. The patient's muscle tone seems spastic D. The patient appears hypotonic

Correct Answer: C. The patient's muscle tone seems spastic Spasticity is caused by an imbalance of signals from the central nervous system to the muscles, resulting in increased muscle tone. Incorrect Answers: A. Flaccid is a lack of or decreased muscle tone. B. Atonic is a lack of muscle tone. D. Hypotonic is decreased muscle tone. Vital Concept: A muscle with a greater-than-expected tone is described as spastic. A lack of muscle tone is described as atonic. A lack of or decreased muscle tone is described as flaccid. Hypotonic muscle tone is decreased muscle tone

Which of the following is a necessary condition of proving malpractice? A. There was a violation of confidentiality of information. B. Reckless disregard of life or limb. C. The standard of care was violated. D. The patient did not contribute in any way to the harmful outcome. E. The misconduct was intentional.

Correct Answer: C. The standard of care was violated. There are four conditions required to establish malpractice. A standard of care must be established. There must be a demonstration that the standard of care was violated by the accused. There must be evidence that loss or injury was caused by the person being sued and there must be a demonstration that loss or injury occurred and was the result of negligence. Invasion of privacy is an intentional misconduct. Reckless disregard of life or limb is not necessary to prove malpractice. If the patient contributed in any way to the adverse outcome, this is known as contributory negligence and does not prevent a finding of malpractice. Intentional misconduct includes assault, battery, false imprisonment, and invasion of privacy, libel, and slander. Negligence is unintentional misconduct and must be proven to establish malpractice.

A nurse is providing community education on risk reduction and health promotion for adolescents. The greatest cause of death among adolescents is: A. Suicide B. Cancer C. Accidents D. Eating disorders

Correct Answer: C.Accidents Accidents, including motor vehicle accidents as well as accidents that occur as a result of poor decision making, are the leading cause of death among teens ages 12-19. Incorrect Answers: A. While suicide may be a more common cause of death among adolescents than other age groups, accidents are the leading cause of death. B. While some adolescents do develop cancer that leads to death, accidents are the leading cause of death in adolescents. D. Some adolescents do develop eating disorders, but the leading cause of death in this age group is accidents. Vital Concept: More than 50% of all deaths among children between the ages of 1 to 14 years and almost 75% of deaths among youths aged between 15 and 24 years are caused by injuries, including unintentional injuries (accidents), suicides, and homicides. Adolescents should be screened for problems related to alcohol or substance use. Early intervention after trauma incidents involving alcohol misuse can reduce the risk of injury recurrence by about 50%. Other measures to reduce injuries include restricting access to firearms, use of seat belts, helmets, and smoke detectors.

The nurse is caring for a 43-year-old client with a peptic ulcer. The client asks the nurse what a peptic ulcer is. Which of the following best describes a peptic ulcer? A. Inflammation of the lining of the stomach B. Bleeding from the lining of the stomach C. Infection of the lining of the stomach D. Erosion of the lining of the stomach

Correct Answer: D. Erosion of the lining of the stomach Correct Answer: D. A peptic ulcer is the erosion of the lining of the stomach. The most common reasons for the breakdown of the lining of the stomach are infection with H. pylori bacteria or long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs). Incorrect Answers: A. A peptic ulcer is not inflammation of the lining of the stomach. This is gastritis. B. A peptic ulcer is not bleeding from the lining of the stomach. C. A peptic ulcer is not an infection of the lining of the stomach. Vital Concept: A peptic ulcer is the erosion of the inner lining of the stomach or intestine. The most common reasons for the breakdown of the lining of the stomach are infection with H. pylori bacteria or long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs). Common symptoms include burning or indigestion, nausea, or weight loss. Inflammation of the lining of the stomach is gastritis. A GI bleed can be caused by an ulcer, but this is not always the case. Infection of the lining of the stomach can contribute to the development of an ulcer.

Which of the following is not a cause of mechanical obstruction of the intestine? A. Meconium ileus B. Carcinoma C. Volvulus D. Paralytic ileus E. Intussusception

Correct Answer: D. Paralytic ileus Explanation: Paralytic ileus refers to a loss of peristalsis that results in functional, not mechanical, obstruction. Incorrect answers: A. Meconium ileus is a mechanical obstruction in the neonate that is caused by impaction of the meconium, which is the first feces of a neonate. B. Carcinoma is a frequent cause of intestinal obstruction. C. Volvulus is a mechanical obstruction that occurs when the intestine twists upon itself. E. Intussusception is a mechanical obstruction that occurs when the bowel invaginates or telescopes back upon itself.

A transfer truck carrying toxic chemicals derails, spilling the contents and emitting toxic fumes over several miles. As a result, many of the area residents complain of nausea, vomiting, and headache. According to the agent-host model, the host is: A. The train carrying the toxic chemicals B. Toxic fumes emitted by the derailed box cars C. Physical problems experienced by the residents D. The residents living in the area

Correct Answer: D. The residents living in the area The host is the person affected by the toxic waste.

Which of the following is true concerning placement of an intravenous catheter? A. A combination unit has a flexible catheter inside of the needle. B. The catheter should be withdrawn and the needle left in place during use of an IV catheter. C. IV catheters cannot be used for injection of contrast medium. D. Use of an IV catheter allows greater flexibility compared to a hypodermic needle. E. If a serious contrast reaction occurs, the catheter should be withdrawn and a hypodermic used to inject medications.

Correct Answer: D. Use of an IV catheter allows greater flexibility compared to a hypodermic needle. An intravenous catheter is a combination unit used for venipuncture that has a needle inside of a flexible plastic catheter. The unit is inserted into the vein, with the needle first, pushing the catheter over the needle once the needle is in place. After insertion of the catheter, the needle should be withdrawn. The catheter hub may be connected to a syringe with contrast medium or may be attached to IV tubing that leads to a bag or bottle, which provides flexibility if there is a serious contrast agent reaction. Intravenous catheters are more flexible than hypodermic needles or butterfly needles.

A public health nurse is giving a talk at a wellness fair on the topic of testicular cancer. Which of the following statements about testicular cancer is NOT true? A. Testicular cancer is highly responsive to treatment B. Testicular cancer usually presents with a painless enlargement of the testicles C. Self-examination allows for early detection and treatment of testicular cancer D. It is most common in men over 65

Correct Answer: D. It is most common in men over 65 Testicular cancer is most common in younger men, usually in the late 20s to early 30s. Incorrect Answers: A. Testicular cancers are highly responsive to treatment. B. Testicular cancer usually presents with a painless enlargement of the testicles. C. Self-examination allows for the early detection and treatment of testicular cancer. Vital Concept: Testicular cancer is most common among men in their late 20s to early 30s. Testicular cancer most often produces a painless enlargement of the testicle. Testicular cancers metastasize early but are one of the most curable solid tumors. They are highly responsive to chemotherapy, particularly when treated in its early stage. In addition, self-examination allows for early detection and facilitates the early initiation of treatment.

A nurse is providing teaching at a health fair about nutritional guidelines for the prevention of cancer. Which of the following instructions should the nurse include? (Select all that apply). A. "Eat foods that are high in vitamin A." B. "Add nonstarchy vegetables to your diet." C. "Female clients should limit alcohol intake to two drinks per day." D. "Use saturated fats for cooking." E. "Consume refined grains."

Correct Answers: A. "Eat foods that are high in vitamin A." B. "Add nonstarchy vegetables to your diet." Consuming foods high in vitamin A, such as apricots, carrots, and leafy green vegetables, reduces the risk of cancer. Consuming nonstarchy vegetables, such as broccoli and cabbage, reduces the risk for cancer. Incorrect Answers:C. To encourage cancer prevention, the nurse should recommend that female clients limit alcoholic beverages to one per day and male clients limit to two per day. D. The use of polyunsaturated and monounsaturated fats is beneficial in lowering the risk of many types of cancer. E. Consuming whole grains reduces the risk for colon cancer. Vital Concept:Aside from nutritional guidelines, other lifestyle choices to reduce the risk of cancer include maintaining a healthy weight, smoking cessation, and avoiding sun exposure.

The nurse is reviewing their patient assignment before the start of the shift. The nurse recognizes which of the following clients would be at risk of elevated sodium levels (hypernatremia)? (Select all that apply). A. A client who has had decreased water intake B. A client who has had a fever for a few days C. A client who has had watery diarrhea D. A client who uses corticosteroids E. A client who has a burn

Correct Answers: A. A client who has had decreased water intake B. A client who has had a fever for a few days C. A client who has had watery diarrhea D. A client who uses corticosteroids Correct Answers: A. A client who is dehydrated is at risk of hypernatremia because there is less water in the body. B. A client who has had a fever for a few days is at risk of hypernatremia due to the loss of bodily fluids from excess perspiration. C. A client who has had watery diarrhea is at risk of hypernatremia due to excess water loss through the GI tract. D. A client who uses corticosteroids is at risk of hypernatremia because these medications can cause sodium and water retention. Incorrect Answers: E. A client who has a burn is at risk of hyponatremia, not hypernatremia because burns cause intravascular volume loss in the tissues. Vital concept: Causes of hypernatremia are decreased water intake, using corticosteroids, having a fever, watery diarrhea, excessive perspiration, dehydration, Cushing's syndrome, impaired kidney function, and hyperventilation.

The nurse in the emergency room is caring for a 45-year-old client reporting abdominal pain with a suspected diagnosis of peritoneal irritation (peritonitis). Which of the following signs and symptoms would the nurse expect in this client? (Select all that apply). A. Abdominal swelling B. Bruising C. Changes in bowel sounds D. Muscular rigidity E. Rebound tenderness

Correct Answers: A. Abdominal swelling C. Changes in bowel sounds D. Muscular rigidity E. Rebound tenderness Correct Answers: A. Abdominal swelling is expected with a diagnosis of peritonitis. C. Changes in bowel sounds are expected with a diagnosis of peritonitis n. D. Muscular rigidity is expected with a diagnosis of peritonitis. This may be voluntary (in response to an abdominal exam), or it may be involuntary. Clients usually try to avoid moving as this causes abdominal wall tension. E. Rebound tenderness is expected with a diagnosis of peritonitis. As the examiner pushes on the irritated area and then releases, there is pain caused by manual pressure release. Incorrect Answers:B. Bruising is not expected with a diagnosis of peritonitis. Vital Concept:Signs and symptoms of peritonitis include progressive abdominal swelling, involuntary guarding, tenderness, pain, muscular rigidity, rebound tenderness, or changes in bowel sounds.

Several factors affect bone resorption and formation. Which of the following hormones and nutrients play a role in the resorption and formation of adult bones? (Select all that apply). A. Activated vitamin D B. Thyroid hormone C. Parathyroid hormone (PTH) D. Estrogen E. Luteinizing hormone

Correct Answers: A. Activated vitamin D B. Thyroid hormone C. Parathyroid hormone (PTH) D. Estrogen Correct Answers: A. Activated vitamin D or calcitriol influences the resorption and formation of bones. B. Thyroid hormone influences the resorption and formation of bones. C. Parathyroid hormone influences the resorption and formation of bones. D. Estrogen influences the resorption and formation of bones. Incorrect Answers: E. Luteinizing hormone does not influence the resorption and formation of bones, but it plays a role in sexual development and functioning. Vital Concept:The balance between bone resorption and formation is influenced by many factors such as physical activity, dietary intake of certain nutrients, and several hormones. The following play a role in bone resorption and formation: calcitriol (activated vitamin D), PTH, calcitonin, thyroid hormone, cortisol, growth hormone, and the sex hormones estrogen and testosterone. Luteinizing hormone does not play a role in bone formation or resorption, but it plays a role in sexual development and functioning.

A healthcare provider has prescribed intravenous vancomycin (Vancocin) for a client with osteomyelitis. Which of the following measures will the nurse implement during administration of the infusion ? (Select all that apply.) A. Assess the client's skin for facial flushing or redness/rash on upper extremities and torso B. Limit the infusion rate to 1 mg/min C. Monitor blood pressure during the infusion D. Monitor deep tendon reflexes E. Draw a trough level 30 minutes after administration

Correct Answers: A. Assess the client's skin for facial flushing or redness/rash on upper extremities and torso C. Monitor blood pressure during the infusion Hypersensitivity reactions to vancomycin (Vancocin) infusion include anaphylaxis and red man syndrome. Red man syndrome is characterized by rapid onset of flushing and maculopapular rash on the face, neck, torso, and upper extremities. Muscle pain or spasm may occur. Red man syndrome is not a true allergic reaction and may develop in clients without prior exposure to vancomycin. Onset is related to the rate of infusion. The maximum rate recommended for infusion is 10 mg/minute. Vital signs should be monitored during the infusion. If flushing or rash occur, the nurse should reassure the client that the reaction is not life-threatening. The nurse should monitor the client for signs of an anaphylactic reaction, including laryngeal edema, wheezing, pruritus, and syncope. An antihistamine, epinephrine, and resuscitation equipment should be readily available in case of anaphylaxis. The IV site should be monitored every 30 minutes for signs of extravasation or thrombophlebitis. Vancomycin is a vesicant and extravasation can cause tissue necrosis. Incorrect Answers:B. The infusion rate should be no more than 10 mg/min. D. Loss of deep tendon reflexes occurs with magnesium toxicity. E. A trough level should be obtained prior to administration of vancomycin. Therapeutic levels range from 10-20 mg/dL. Toxicity can result in nephrotoxicity and/or ototoxicity, including hearing loss, tinnitus, and vertigo. Vital Concept: Hypersensitivity reactions associated with vancomycin (Vancocin) infusion include red man syndrome and anaphylaxis. Red man syndrome is a common reaction related to rapid infusion of vancomycin. It is not a true allergic reaction and can occur in individu

The nurse is caring for an 86-year old client and recognizes that there are expected changes in older adults' cardiovascular structure and function. Which of the following are age-related changes that may occur in the older adult? (Select all that apply). A. Decreased elasticity of the aorta B. Widening of the aorta C. Thinning of the cardiac valves D. Decreased left ventricular ejection time E. Decreased connective tissue in the sinoatrial (SA) and atrioventricular (AV) nodes

Correct Answers: A. Decreased elasticity of the aorta B. Widening of the aorta Correct Answers: A. Decreased elasticity of the aorta is an expected finding in an older client. B. The widening of the aorta is an expected finding in an older client. Incorrect Answers: C. Thickening of the cardiac valves, not thinning, is an expected finding in an older client. D. Increased left ventricular ejection time, not decreased time, is an expected finding in an older client. E. Increased connective tissue in the SA and AV nodes, not decreased tissue, is an expected finding in an older client. Vital Concept: .Changes in cardiovascular structure and function are observable in the aging heart and associated vessels. For example, aging results in decreased elasticity and widening of the aorta, thickening or rigidity of the cardiac valves, increased connective tissue in the SA and AV nodes, and an increased left ventricular ejection time.

The nurse is caring for a 37-year-old male client with epididymitis. Which of the following treatments would the nurse suggest for the client? (Select all that apply). A. Elevating the scrotum B. Sitz baths C. Bed rest D. Heating pad E. Ice packs

Correct Answers: A. Elevating the scrotum B. Sitz baths C. Bed rest E. Ice packs Correct Answers:A. Keeping the scrotum elevated is an appropriate intervention for epididymitis and will help improve blood flow, promote healing, and may also help alleviate pain. B. Sitz baths are an appropriate intervention for epididymitis and can help decrease inflammation. C. Bed rest is an appropriate intervention for epididymitis and may help relieve discomfort. E. Ice packs are an appropriate intervention for epididymitis that will help decrease swelling and improve pain. Incorrect Answers:D. Heating pads are not an appropriate intervention for epididymitis. Heating pads should not be used directly on the skin because direct heat can increase inflammation and swelling. Vital Concept:Epididymitis is the inflammation of the epididymis, a tube at the back of the testicle that carries sperm. Some of the acceptable interventions for epididymitis include bed rest, sitz baths, ice packs, and elevation of the scrotum. Heating pads should not be used directly on the skin because direct heat can increase inflammation and swelling.

A nurse is caring for a client with a nursing diagnosis of impaired skin integrity, related to decreased mobility and mechanical factors. Which of the following interventions would be appropriate for this client? (Select all that apply) A. Encourage food and fluid intake B. Encourage continuous chair sitting to keep the client out of bed. C. Use talcum powder to keep skin dry D. Assist the client with ambulation and encourage mobility. E. Assist the client to change positions every four hours.

Correct Answers: A. Encourage food and fluid intake D. Assist the client with ambulation and encourage mobility. Impaired skin integrity is a nursing diagnosis assigned to a client who has had skin breakdown or any other break in skin integrity. Risk factors include reduced levels of activity or poor nutrition. The nurse should encourage proper nutrition and adequate fluid intake; help the client with ambulation and encourage mobility to improve circulation; and assist the client to change position to avoid continuing pressure on bony prominences. Incorrect Answers:B. The nurse should encourage mobility; sitting in a chair or remaining in bed does not promote mobility. C. Talcum powder is not recommended. E. If the client is immobile, the nurse should turn the client at least every two hours. Vital Concept:Impaired skin integrity refers to breakdown in the epidermis/dermis of the skin. It is primarily the result of impaired blood supply as a result of prolonged pressure on tissue. Skin integrity may also be impaired as a result of shearing or friction. If the client is mentally alert and compliant, the nurse should encourage the client to shift weight every 30-45 minutes. If the client is unable to shift weight, the nurse should reposition the client every 2-3 hours. The client should be positioned so that the skin is not exposed to constant pressure. Pressure-lowering devices like foam cushions or alternating pressure mattresses may be helpful.

A 47-year-old client was recently diagnosed with Hodgkin's disease. Which of the following signs and symptoms would the nurse expect the client to display? (Select all that apply). A. Enlarged lymph nodes B. Shortness of breath C. Weight gain D. Fatigue E. Night sweats

Correct Answers: A. Enlarged lymph nodes D. Fatigue E. Night sweats Correct Answers: A. Enlarged lymph nodes are expected with Hodgkin's disease since it is a cancer of the lymphatic system. The swelling is caused by an excess of affected white blood cells that collect in the lymph node. D. Fatigue is expected with Hodgkin's disease and is a common complaint; it is usually persistent. E. Night sweats are expected with Hodgkin's disease. Incorrect Answers:B. Shortness of breath is not expected with Hodgkin's disease. C. Weight gain is not expected with Hodgkin's disease, although weight loss is common. Vital Concept:Hodgkin's disease or lymphoma is a cancer of the lymphatic system. It is characterized initially by painless enlargement of the lymph nodes and could progress to other sites such as the liver and spleen. Signs and symptoms of lymphoma include fatigue, weakness, enlarged lymph nodes, night sweats, and weight loss.

A 47-year old male client with obesity reports disturbed sleep. The nurse identifies the client is exhibiting signs and symptoms of obstructive sleep apnea. Which of the following signs and symptoms relates to this diagnosis? (Select all that apply). A. Excessive daytime sleepiness B. Snoring loudly C. Waking up at night gasping for air D. Low blood pressure E. Insomnia

Correct Answers: A. Excessive daytime sleepiness B. Snoring loudly C. Waking up at night gasping for air E. Insomnia Correct Answers: A. Excessive daytime sleepiness is a sign/symptom related to obstructive sleep apnea. B. Snoring loudly is a sign/symptom related to obstructive sleep apnea. This occurs because the throat muscles intermittently relax and block the airway while sleeping. C. Waking up at night gasping for air is a sign/symptom related to obstructive sleep apnea. This occurs because the throat muscles intermittently relax and block the airway while sleeping. E. Insomnia is a sign/symptom of obstructive sleep apnea related to numerous breathing lapses and temporary sleep interruptions. Incorrect Answers: D. Low blood pressure is not a sign/symptom of obstructive sleep apnea. Vital Concept: Obstructive sleep apnea occurs more often in men, especially those who are older and overweight. It causes the throat muscles to intermittently relax and block the airway while sleeping. Symptoms include excessive daytime sleepiness, insomnia, waking up at night gasping for air, and snoring loudly.

A 67-year-old male client came to the urgent care center, appearing acutely ill. Which of the following nursing assessment findings would indicate that the client has an abdominal aortic aneurysm? (Select all that apply). A. Lower back pain B. Cool or cyanotic extremities C. Diarrhea D. Constipation E. A pulsating abdominal mass

Correct Answers: A. Lower back pain B. Cool or cyanotic extremities E. A pulsating abdominal mass Correct Answers: A. Lower back pain is a sign of an abdominal aortic aneurysm. B. Cool or cyanotic extremities is a sign of an abdominal aortic aneurysm. E. A pulsating abdominal mass is a sign of an abdominal aortic aneurysm. Incorrect Answers:C. Diarrhea is not a sign of an abdominal aortic aneurysm. D. Constipation is not a sign of an abdominal aortic aneurysm. Vital Concept:An abdominal aortic aneurysm is a stretched or bulging area of the aorta that forms due to weakness in the vessel wall. Signs and symptoms of an abdominal aortic aneurysm include abdominal pain, lower back pain, chest pain, a pulsating abdominal mass, and cold or cyanotic extremities. These findings are emergent, and the patient would need to be transferred immediately to a higher level of care.

A nurse is providing teaching to a client who has a vitamin B12 deficiency. Which of the following foods should the nurse instruct the client to consume? (Select all that apply.) A. Meat B. Flaxseed C. Whole grains D. Eggs E. Milk

Correct Answers: A. Meat D. Eggs E. Milk Meat is a food source that is high in vitamin B12. Eggs are a food source that is high in vitamin B12. Milk Sources of Vitamin B12: • Animal products such as milk, dairy, and eggs • Meats such as liver, beef, chicken • Fish such as clams, trout, and salmon • Fortified breakfast cereals Incorrect Answers: B. Flaxseed is a good source of fiber, not vitamin B12. C. Whole grains are a good source of thiamin, not vitamin B12. Vital Concept: Animal products including milk, dairy, eggs, fish, and poultry are excellent sources of Vitamin B12. Some clients might face potential vitamin B12 deficiency due to dietary choices, such as clients who follow vegan and vegetarian diets. Clients can consult their provider for information regarding oral supplements and guidance in selecting vitamin B12-fortified foods.

A 7-year-old is brought to the emergency room after ingesting food that contains peanut butter. The caregiver reports that the child is allergic to peanuts, and they lost the child's epinephrine autoinjector (EpiPen). The nurse notes urticaria. The client states, "my tongue feels like a balloon." The healthcare provider orders an epinephrine autoinjector to be administered. How will the nurse prioritize care for this client? Drag and drop all options into the appropriate order. 1. Administer the epinephrine autoinjector as ordered by the healthcare provider. 2. Monitor vital signs. 3. Obtain a replacement prescription for the lost epinephrine autoinjector (EpiPen). 4. Provide discharge teaching on home safety practices for peanut allergies.

the appropriate order. 1. Administer the epinephrine autoinjector as ordered by the healthcare provider. 2. Monitor vital signs. 3. Obtain a replacement prescription for the lost epinephrine autoinjector (EpiPen). 4. Provide discharge teaching on home safety practices for peanut allergies.

A 66-year-old client is diagnosed with peripheral neuropathy. The nurse knows they should include which of the following teaching points in the client's plan of care? (Select all that apply). A. Use assistive devices if indicated to reduce the risk of falls B. Inspect the lower extremities for skin breakdown C. This condition is genetic D. Check the bathwater temperature with the hands to avoid burning skin without realizing E. Shoes should be properly fitted by a professional

Correct Answers: A. Use assistive devices if indicated to reduce the risk of falls B. Inspect the lower extremities for skin breakdown D. Check the bathwater temperature with the hands to avoid burning skin without realizing E. Shoes should be properly fitted by a professional Correct Answers: A. A client with peripheral neuropathy should use assistive decides if indicated to reduce the risk of falls. B. A client with peripheral neuropathy should inspect their lower extremities for signs of skin breakdown. Nerve damage reduces the sensation of pain in the feet. They may be unaware or be unable to feel the damage in their lower extremities. D. A client with peripheral neuropathy should check the bathwater temperature with their hands because they may not be able to feel changes in temperature with their lower extremities due to the neuropathy dulling their sensory perception. Nerve damage reduces the sensation of heat in the feet. E. A client with peripheral neuropathy should have shoes that are measured and fitted by a professional to provide sufficient room inside the toe box, cushioning, and support, all of which are important for clients with peripheral neuropathy. Incorrect Answers:C. Peripheral neuropathy is not a genetic condition. Diabetes is a common cause of peripheral neuropathy, but it can also occur due to vascular insufficiency, neurological disorders, or metabolic disorders. Vital Concept:Clients with peripheral neuropathy suffer from pain and numbness in their feet. They may experience a loss of sensation, weakness, burning, or tingling in the lower extremities. The plan of care for a client with peripheral neuropathy includes inspection of the lower extremities for skin breakdown, using assistive devices such as a walker or cane if indicated to decrease the risk of falls, checking the bathwater temp

Question 2 of 6 Click the corresponding boxes to indicate which symptoms are consistent with the listed conditions. Condition: Diabetic ketoacidosis (DKA) Urinary tract infection (UTI) Strep pharyngitis Gastroenteritis symptoms : Fever Tachycardia Vomiting Urinary frequency Dysuria Incontinence Abdominal pain Decreased appetite Ketones in the urine

Fever - (UTI), Strep pharyngitis, Gastroenteritis Tachycardia - (UTI)Strep pharyngitis, Gastroenteritis, (DKA) Vomiting - (UTI), Strep pharyngitis, Gastroenteritis, (DKA) Urinary frequency - (UTI), (DKA) Dysuria - (UTI), (DKA) Incontinence - (UTI), (DKA) Abdominal pain - (UTI) ,Strep pharyngitis, Gastroenteritis, (DKA) Decreased appetite - (UTI), Strep pharyngitis, Ketones in the urine - (DKA) The nurse should analyze the cues from the client's history and clinical findings to differentiate between some common causes of urinary symptoms, tachycardia, and vomiting. For example, urinary tract infection (UTI) symptoms could mimic other diagnoses, such as gastroenteritis and diabetic ketoacidosis (DKA). A UTI can be associated with urinary frequency, dysuria, incontinence, abdominal pain, and vomiting. Clients may also experience fever and tachycardia, especially if left untreated for numerous days. The client may also report decreased oral intake. Ketones may be present in the urine with a UTI if the child has an acute fever but are not characteristic of all UTIs. Gastroenteritis is characterized by nausea, vomiting, diarrhea, and abdominal pain. The client may also experience fevers. For clients experiencing numerous episodes of vomiting and diarrhea, tachycardia and ketones in the urine may be due to dehydration or acute febrile illness. Urinary symptoms are not associated with gastroenteritis. DKA is characterized by elevated blood glucose levels, fruity breath, ketones in the urine, and abdominal pain. Acute illnesses that involve vomiting or dehydration can cause tachycardia and precipitate DKA. The client may also experience urinary frequency, but not typically dysuria or incontinence, although enuresis is possible in young children. Clients experiencing DKA are not often febrile. Strep pharyngitis is a bac

Question 6 of 6 Based on the most recent findings, click to highlight the client data that has improved significantly with treatment. Temperature 102° F (38.9° C) Heart rate 88/min Respiratory rate 18/min Blood pressure110/80 mm Hg Oxygen saturation 96% on room air Pain 2/10 pelvic

Heart rate 88/min Respiratory rate 18/min Blood pressure110/80 mm Hg Pain 2/10 pelvic When evaluating outcomes, the nurse should identify which findings indicate an improvement in the client's condition. For example, administering a fluid bolus followed by maintenance fluids in a septic client is intended to resuscitate the cardiovascular system. Ideally, this fluid therapy will increase the client's blood pressure if hypotensive and improve tachycardia and tachypnea. This client has also had a significant improvement in their pain.

The nurse is caring for a 4-year-old child in the pediatric emergency department (ED). Question 6 of 6 The nurse has performed the interventions as ordered by the provider for the client. For each piece of data collected at 1230, select if it indicates that the client's condition has improved, not changed, or declined. Data Collected: Mucous membranes Emesis Temperature Bilateral CVA tenderness Heart rate

Mucous membranes -not changed Emesis-improved Temperature-improved Bilateral CVA tenderness-declined. Heart rate-improved After implementing the interventions selected, the nurse should collect new data to evaluate the outcome and determine if the client's condition has improved, worsened, or remained unchanged. Several findings indicate improvement. The client's temperature and heart rate have improved after IV fluids and antipyretic medication. The client's nausea and vomiting have resolved with the antiemetic. Unfortunately, the client's mucous membranes are still dry, and bilateral CVA tenderness is a new finding; this could indicate that the UTI has progressed to pyelonephritis and requires IV antibiotics.

The nurse is caring for a 4-year-old child in the pediatric emergency department (ED). History of presents illness: The client was brought to the pediatric ED by their parent for painful urination. The parent reports that the client has been urinating every 1 to 2 hrs for the past 2 days and today began stating that it hurts when they urinate. The parent reports that the urine was foul-smelling this morning and that the Pt has been more irritable. The parent says they have also noticed that the Pt's underwear has been damp several times over the last few days. The parent also reports that the client has not been eating and drinking as normally and vomited this morning. The client does have a hx of a previous UTI from about 6 months ago. Question 3 of 6 Select the two conditions for which the client is at the highest risk. Pyelonephritis Hyperglycemia Stress incontinence Sepsis Bladder carcinoma

Pyelonephritis Sepsis When prioritizing hypotheses, the nurse must identify the complications or conditions for which the client is at the highest risk. A UTI left untreated or poorly managed can increase the risk of pyelonephritis and sepsis. A client experiencing cystitis (a bladder infection) is at risk of developing pyelonephritis if the bacteria travel up to one or both kidneys. UTIs also place the client at risk for sepsis. The longer a UTI is left untreated, the greater the risk of sepsis.

A nurse in the emergency department (ED) is caring for an 8-year-old client who presents with vomiting, frequent urination, and a 2-lb weight loss in the last two weeks. Select the most appropriate options from the choices below to complete the following sentence. At 1830, the unlicensed assistive personnel (UAP) notifies the nurse that the client's blood glucose is 50. The nurse immediately goes in to collect data on the client. The LPN is aware that the signs of hypoglycemia include confusion/altered level of consciousness, _________________and ________________. Options: - Shakiness -Tachycardia - Dry mouth - Bradycardia - Fruity Breath.

Shakiness and Tachycardia The nurse must quickly analyze cues to identify any potential indicators of hypoglycemia or hyperglycemia. The signs and symptoms of hypoglycemia can include an altered level of consciousness, confusion, shakiness, tachycardia, dizziness, nausea, fatigue, and seizures.

A 26-year-old ...... Nurse's Notes 2/2/20211000:Ten pound (4.5 kg) unintentional weight loss since physical exam last year. The client is alert and oriented. Lung sounds are clear bilaterally. The apical pulse is irregular and tachycardic. Bowel sounds are active in all quadrants. The last bowel movement was reported on 2/1/2021. No GU concerns. The client reports recent palpitations, weight loss, blurry vision, and excessive sweating. Vitals signs: Temp 99.1°F (37.6°C) HR 115/min RR 16/min BP 138/74 mm Hg O2 Sat 99% on room air Ht 5'4" (64") Wt 132 lb (60 kg) Question 2 of 6 Select the most appropriate options from the choices below to complete the following sentence. The nurse recognizes that the client's symptoms correlate with hyperthyroidism, such as __________, ___________, and _______. Tokens: -weight loss, -heart palpitations -altered mental status -blurry vision -constipation -respiratory rate

weight loss, tachycardia/heart palpitations, and blurry vision, When analyzing cues, the nurse should recognize that symptoms of hyperthyroidism may include nervousness/anxiety, fatigue, mood changes, heat sensitivity, weight loss, tachycardia/heart palpitations, blurry vision, and diaphoresis. This client exhibits several signs and symptoms of hyperthyroidism, including unintentional weight loss, heart palpitations, blurry vision, diaphoresis, and tachycardia.

The nurse is caring for a 4-year-old child in the pediatric emergency department (ED). Nurses Notes 1100:The client is alert and cooperative. Lung sounds are clear bilaterally. S1 and S2 were auscultated without murmur, gallop, or rub. Regular rate and rhythm. Mucous membranes are dry. Capillary refill is less than 2 seconds. The abdomen is soft and tender on palpation in the lower quadrants. The client states, "my pee hurts." Vital signs: 1100: T 100.8° F (38.2° C) HR 130 bpm BP 90/48 mm Hg RR 18/min Oxygen saturation 99% on room air Weight 33.7 lb (15.3 kg) Question 1 of 6 Select the four client findings that should be reported to the RN. Vomiting Blood pressure Temperature Heart rate Client orientation Urine characteristics Capillary refill

Temperature Heart rate Capillary refill Vomiting Urine characteristics When this client initially presents to the emergency department (ED), the nurse should recognize the cues from the client's initial assessment and health history that require immediate follow-up. An elevated temperature and heart rate are findings that could indicate an infection. The fever is consistent with the symptoms of a urinary tract infection (UTI) and requires follow-up. Based on the client's age and elevated heart rate, this could indicate an infection or dehydration and requires follow-up. The parent's report of the episode of vomiting and the urine characteristics (foul-smelling, frequent urination, and dysuria) could indicate a UTI and require follow-up.

The nurse is caring for a 4-year-old child in the pediatric emergency department (ED). Providers order: Insert a peripheral IV 0.9% normal saline bolus of 306 mL IV over 1 hour Draw a basic metabolic profile (BMP) and a complete blood count (CBC). Question 5 of 6 The provider has entered new orders for this client. While the RN inserts a peripheral intravenous catheter, draws blood for laboratory tests, and initiates a fluid bolus, select the three additional orders the LPN should perform immediately based on the client's condition. - Administer ondansetron (Zofran) 4 mg oral disintegrating tablet (ODT) every 6 hours as needed. - Administer acetaminophen (Tylenol) 240 mg oral suspension every 6 hours as needed. - Encourage the client to drink fluids - Encourage the client to ambulate - Obtain a clean-catch urine sample for urinalysis and culture - Regular diet

- Administer ondansetron (Zofran) 4 mg oral disintegrating tablet (ODT) every 6 hours as needed. - Administer acetaminophen (Tylenol) 240 mg oral suspension every 6 hours as needed. - Obtain a clean-catch urine sample for urinalysis and culture When taking action, the nurse should recognize that the focus of care is stabilizing the client's vital signs, fluid, and electrolyte status, confirming the causative agent responsible for the presumptive UTI, and enhancing their comfort. The client is febrile, tachycardic, and vomiting. The nurse should prioritize actions based on these identified issues. While the RN administers IV fluids, an antiemetic, antipyretic, and urinalysis are priorities. An antiemetic medication will stop the vomiting and stabilize the client's fluid and electrolyte status. A urinalysis would confirm the suspected infection. However, the causative organism must first be identified through a urine culture to prescribe and administer the most appropriate antimicrobial medication. An antipyretic medication should be given to reduce the insensible fluid losses associated with a fever and improve client comfort.

The nurse is caring for an older adult with signs and symptoms of an acute urinary tract infection (UTI). Question 3 of 6 Select the most appropriate options from the choices below to complete the statement regarding how the nurse should prioritize the plan of care given the client's changing condition. The nurse should first address the client's _____________________and _________________. Tokes: - BP -Temperature -nausea - serum Potassium -Serum Lactic acid

- BP --Serum Lactic acid When prioritizing hypotheses, the nurse must identify the findings that require intervention first. Sepsis is a life-threatening complication of infection with high morbidity and mortality rates that must be recognized quickly to ensure effective management. Within the SIRS criteria for identifying sepsis, this client demonstrates several indicators. Their hypotension and elevated lactic acid levels are characteristics of sepsis that should be recognized and communicated to the rest of the healthcare team to ensure rapid intervention. Based on the ABC algorithm and Maslow's hierarchy of needs, cardiovascular instability that affects circulation and ventilation should be prioritized over client comfort. An elevation in lactic acid may indicate sepsis, a life-threatening infection complication with high morbidity and mortality rates that must be recognized quickly to ensure effective management. While this client's fever indicates systemic infection, the nurse has already administered an antipyretic half an hour ago and should prioritize the client's cardiovascular system and stabilize their vital signs before addressing their fever again with alternate methods.

Question 4 of 6 The nurse collects new client data at 1130 and is planning care. For each potential nursing intervention, click to specify whether it is indicated or nonessential/contraindicated for this client. Interventions: - Encourage the client to ambulate - Request an order for an antipyretic medication - Place the client on a telemetry monitor - Insert a nasogastric (NG) tube - Insert an indwelling urinary catheter - Request an order for an antiemetic medication

- Encourage the client to ambulate- nonessential/contraindicated - Request an order for an antipyretic medication- indicated - Place the client on a telemetry monitor- nonessential/contraindicated - Insert a nasogastric (NG) tube- nonessential/contraindicated - Insert an indwelling urinary catheter- indicated - Request an order for an antiemetic medication- indicated When generating solutions, the nurse should plan to address the client's symptoms by administering the most appropriate medications or interventions. The client has a UTI and possible pyelonephritis and is currently febrile, tachycardic, and vomiting. An antiemetic and antipyretic medication are indicated for this client to manage their vomiting and fever, respectively. Telemetry and ambulation are nonessential interventions for the client.

A 26-year-old previously healthy female client presents for their annual physical exam. Fasting lab results were drawn 3 days prior to the exam appointment. Question 1 of 6 The nurse reports the initial data collected to the RN and health care provider. Click to highlight the findings below that will require follow up. - Ten pound (4.5 kg) unintentional weight loss since physical exam last year. - The apical pulse is irregular and tachycardic. - Bowel sounds are active in all quadrants. - The client reports recent palpitations, weight loss, blurry vision, and excessive sweating. - Serum glucose 89 mg/dL (70 to 120 mg/dL) - Sodium 137 mEq/L (136 to 145 mEq/L) - Thyroid panel:Thyroid-stimulating hormone (TSH) 0.2 mIU/L (0.5 to 4.0 mU/L)Total T3 300 ng/dL (80 to 180 ng/dL)Free T4 2.4 ng/dL (0.8 to 1.8 ng/dL)

- Ten pound (4.5 kg) unintentional weight loss since physical exam last year. - The apical pulse is irregular and tachycardic. - The client reports recent palpitations, weight loss, blurry vision, and excessive sweating - Thyroid panel:: (TSH) 0.2 mIU/L (0.5 to 4.0 mU/L)Total T3 300 ng/dL (80 to 180 ng/dL)Free T4 2.4 ng/dL (0.8 to 1.8 ng/dL) The nurse should recognize the cues from the client's assessment and history that require follow up. This client has a high total T3 and free T4, which indicate an overactive thyroid gland. The client is also experiencing irregular tachycardia, weight loss, palpitations, blurry vision, and diaphoresis, corresponding manifestations of hyperthyroidism. Significant unintentional weight loss and cardiac irregularities always require further evaluation. The recent palpitations, blurry vision, and excessive sweating (along with current vital signs and lab findings) require further evaluation because they correlate with hyperthyroidism complications. The client's thyroid panel is abnormal. The reference range for TSH is typically 0.3 to 5 mU/L, total T3 is 115 to 190 ng/dL, and free T4 is 0.8 to 1.8 ng/dL.

Question 5 of 6 The RN has just infused the first fluid bolus as ordered. Select the parameters below that the LPN should monitor and report back to the RN immediately. Select all that apply. - urinary odor - hematocrit - Intake and output - vitals sign -laboratory results - appetite

- vitals sign -laboratory results The nurse should take action to monitor the client's response to the fluid bolus carefully, which typically includes an improvement in vital signs and laboratory results as well as tracking intake and output. As the nurse is evaluating a critically ill older adult following the administration of a fluid bolus, they would expect an improvement in their BUN, hypotension, and tachycardia. Their output should start to resume or increase slightly. This client's BUN should be rechecked and would be expected to decrease following the fluid bolus administration. This client's blood pressure and heart rate should be monitored closely and would be expected to increase with the fluid bolus. However, the client's urinary odor, appetite, and hematuria are unlikely to change with a single fluid bolus.

Question 4 of 6 For each potential provider order, specify if the intervention is indicated, nonessential, or contraindicated for this client. Potential orders/Interventions -Administer methimazole (Tapazole) - Place on NPO status - Administer levothyroxine (Synthroid) - Provide a heated blanket to promote comfort - Perform electrocardiogram (ECG)

-Administer methimazole (Tapazole) - indicated - Place on NPO status - nonessential - Administer levothyroxine (Synthroid) -contraindicated - Provide a heated blanket to promote comfort - contraindicated - Perform electrocardiogram (ECG) - indicated The nurse should generate solutions to address the client's hyperthyroidism and related complications, which include administering antithyroid medication and monitoring cardiac function via ECG. Methimazole (Tapazole) is an antithyroid drug and would be indicated as it is often used in the urgent treatment of severe hyperthyroidism. Antithyroid drugs should be given, not thyroid replacement (e.g., levothyroxine [Synthroid]). An ECG is indicated because of the client's dyspnea, diaphoresis, tachycardia, hypertension, and chest pain. Cardiac abnormalities are concerning manifestations of untreated hyperthyroidism. The client is febrile, and a heated blanket would be contraindicated. There is no need for this client to be NPO.

The Licensed Practical Nurse (LPN/LVN) is working on a pediatric unit and is assigned to care for a 10-year-old boy who has leukemia. The client is no longer eating or drinking, oral needs have been discontinued because the client is unable to swallow them and urine output is negligible. The physician expects that the client will expire within the next 24 hours. The client is semi-conscious and is moaning. Facial grimacing is also apparent. The client's blood pressure is low and his respirations are 8 per minute. The parents ask the LPN/LVN to administer an opioid because the client is moaning and appears to be in pain. What should the LPN/LVN do? AA. Administer the prescribed prn medication B. Refuse to administer the narcotic because giving the narcotic could further decrease the client's respiratory rate C. Give half the dose of the prescribed pain medication D. Ask the client's parents if they are aware that

A. Administer the prescribed prn medication

The Licensed Practical Nurse (LPN/LVN) makes a medication error that results in the client requiring further treatment. In this case, the purpose of the incident report is to: AA. Identify the circumstances leading up to the error and prevent it from happening again B. Provide a factual accounting of events in case the patient decides to sue C. Determine whether disciplinary action should be taken against the LPN/LVN's license D. Provide documentation for the LPN/LVN's permanent record

A. Identify the circumstances leading up to the error and prevent it from happening again

A nurse is administering pre-op medication to an adult client who is scheduled for surgery. The client tells the nurse she does not want to receive blood transfusions during surgery even if they are needed since it is against her religion. The client has already signed consent for surgery. How should the nurse respond? AA. Withhold the medication and contact the client's physician B. Explain to the client that she has already signed a consent form for surgery and that included the use of transfusions if required C. Explain to the client that her surgeon will most likely not perform surgery if she refuses to allow a transfusion D. Have the client sign an addendum to the operative consent excluding transfusions

A. Withhold the medication and contact the client's physician

Question 6 of 6 Which of the following data collected at 1500 indicate that treatment has been effective? Select all that apply. A. Blood pressure B. Level of consciousness and orientation C. Urine output D. Skin E. Lung sounds F. Temperature G. Pain rating

A. Blood pressure D. Skin F. Temperature G. Pain rating The nurse should reassess the client to evaluate the outcomes of the interventions and determine if the client's condition has improved/worsened. Despite persistent tachycardia, a regular heart rate and improved blood pressure indicate an effective response to thyroid storm treatment. The client's blood pressure was initially elevated and has returned to the normal range. The client initially presented with 8/10 chest pain and is now pain-free. The client initially presented with a high fever and is now afebrile. The client presented with diaphoresis, a manifestation of thyroid storm, and now their skin is dry.

The nurse in the emergency department (ED) is caring for a 15-year-old client who presents with abdominal pain and vomiting for 2 hr. The provider suspects appendicitis. While the RN establishes IV access and initiates a fluid bolus, which of the following additional orders should the LPN anticipate based on the client's condition? Select all that apply. Administration of an antiemetic medication Initiating contact precautions Insertion of a nasogastric (NG) tube Abdominal ultrasound Clear liquid diet

Administration of an antiemetic medication Abdominal ultrasound When generating solutions for a client with possible appendicitis, the nurse must keep in mind that surgical intervention is a potential likelihood. The nurse should anticipate an order for a CT scan or abdominal ultrasound. The client's findings are consistent with appendicitis, and advanced imaging studies are required to confirm this diagnosis and plan for surgical intervention. The nurse should also anticipate an order for antiemetic medication. The client should remain NPO in case surgery is warranted.

Four clients are ringing their call lights asking for assistance. Which of the clients should the nurse check on first? A. An elderly client who is in a geriatric chair BB. A 20-year-old client who has just been given penicillin C. A post-op client who is asking for pain medication D. A 40-year-old client who needs assistance walking to the restroom

B. A 20-year-old client who has just been given penicillin

The Licensed Practical Nurse (LPN/LVN) has just received her client assignment for the day. After listening to report and reviewing the clients' charts, which of the following clients should the LPN/LVN assess first? A. A client with 6/10 pain who had an appendectomy the day before BB. A client with asthma requiring frequent bronchodilators C. A client admitted for urinary retention who has not voided since his catheter was removed 2 hours ago D. A client complaining of nausea

B. A client with asthma requiring frequent bronchodilators

A resident of a long term care facility has a history of repeated falls after attempting to get up from the wheelchair. Which instruction to the nursing team is most appropriate to prevent client falls? A. Use of a sheet to tie the client to the wheelchair B. Keep the client within view at all times CC. Assess client needs on a frequent basis D. Determine if the client should receive sedation

C. Assess client needs on a frequent basis

A home health nurse is providing care to a frail elderly client in the client's home. Which of the following should the nurse report to her supervisor as a potential indication of abuse? A. The client states, "My son doesn't like me anymore. He yells at me all the time." B. The client has several brown spots on her arms. C. The client is frequently left in bed, at home alone, for several hours at a time. D. The client's son is trying to be declared the client's legal power of attorney.

C. The client is frequently left in bed, at home alone, for several hours at a time.

Question 5 of 6 After reviewing the provider's orders, while the RN administers the beta blocker, which two orders should the LPN implement first? A. Apply 2 liters of oxygen via nasal cannula PRN to maintain pulse oximetry above 92% B. Administer acetaminophen 1g PO x1 dose C. Administer methimazole (Tapazole) 60 mg PO daily D. Thyroid ultrasound E. Perform ECG and apply continuous cardiac monitor

C. Administer methimazole (Tapazole) 60 mg PO daily E. Perform ECG and apply continuous cardiac monitor When taking action, the nurse should recognize that the focus of care for a client experiencing a thyroid storm includes assessing cardiac function and administering methimazole (Tapazole). Assessment is the first step in the nursing process. The client is tachycardic and hypertensive, making ECG and cardiac monitoring a priority order to perform. Methimazole (Tapazole) is an antithyroid medication that is a priority to administer during thyroid storms to decrease thyroid hormones. A beta-blocker lowers heart rate, blood pressure, and cardiac output.

A 26-year-old previously healthy female client presents for their annual physical exam. Fasting lab results were drawn 3 days prior to the exam appt. The HCP dx the Pt with hyperthyroidism, Rx methimazole (Tapazole), & recommended ff-up labs and a HCP visit in 4 weeks. The Pt did not show up for the ff-up office visit. On 7/21/21, the Pt presents to the ED with the following findings. Lab. Results :Serum glucose 89 mg/dL (70 to 120 mg/dL) (WBC) 9,000/mm3 (4,500 to 11,000/mm3) (Hgb) 13.5 g/dL (12.0 to 16.0 g/dL) (Hct) 37% (36% to 46%) K - 4.1 mEq/L (3.5 to 5.0 mEq/L) Na 137 mEq/L (136 to 145 mEq/L) (TSH) 0.2 mIU/L (0.5 to 4.0 mU/L) Total T3 300 ng/dL (80 to 180 ng/dL) Free T4 2.4 ng/dL (0.8 to 1.8 ng/dL) Question 3 of 6 Based on the data collected, which of the following complications is this client at the highest risk for developing? A. Tetany B. Myxedema coma C. Thyroid storm D. Exophthalmos

C. Thyroid storm When prioritizing hypotheses, the nurse must identify the conditions for which the client is at the highest risk based on their past medical history. For example, a thyroid storm is a potential complication of hyperthyroidism. Due to their elevated thyroid hormones, this client is at risk of developing a thyroid storm.

The nursing student is learning about nursing diagnoses. Which organization is responsible for developing the taxonomy of a nursing diagnosis? A. American Nurses Association (ANA) B. American Academy of Nursing (AAN) CC. North American Nursing Diagnosis Association (NANDA) D. National League for Nursing (NLN)

CC. North American Nursing Diagnosis Association (NANDA

A 76-year-old client with chronic obstructive pulmonary disease (COPD) is admitted to the unit. The client is experiencing shortness of breath, and the nurse is obtaining an order for a nasal cannula. What oxygen flow rate does the nurse expect would be ordered for this client? A. 2 L/minute B. 4 L/minute C. 6 L/minute D. 8 L/minute

Correct Answer: A. 2 L/minute Incorrect Answers: B. 4 L/minute is too much oxygen for a client with COPD until the oxygen saturation is established. C. 6 L/minute is too much oxygen for a client with COPD until the oxygen saturation is established. D. 8 L/minute is too much oxygen for a client with COPD until the oxygen saturation is established. Vital Concept: A client with COPD should not be administered oxygen by nasal cannula at a rate greater than 2 or 3 L/minute unless they are in extreme respiratory distress, in which case the oxygen level should be titrated to the oxygen saturation (pulse oximetry). In a client with COPD, the stimulus to breathe comes from low levels of oxygen, so administering high levels of oxygen can depress their respiratory drive.

A client is receiving IV gentamicin. Which of the following may indicate an adverse response to gentamicin? A. Decreased urine output B. Blurred vision C. Orange sputum D. Hypertension

Correct Answer: A. Decreased urine output A major toxicity of gentamicin is nephrotoxicity. Diminished urine output indicates damage to the kidneys. Incorrect Answers: B. Blurred vision is not a common adverse response to gentamicin. The major adverse responses are nephrotoxicity and ototoxicity. C. Orange sputum is not an adverse response to gentamicin. Orange-colored sputum may occur with Rifampin. The major adverse responses are nephrotoxicity and ototoxicity. D. Hypertension is not an adverse response to gentamicin. The major adverse responses are nephrotoxicity and ototoxicity.

Preoperatively, which information is important to teach the client before the subtotal thyroidectomy? A. Techniques for changing positions B. Reasons for performing leg exercises C. The necessity for daily dressing changes D. Postoperative use of the incentive spirometer

Correct Answer: A. Techniques for changing positions Preoperative instructions must include how to support the head and neck when turning or rising to a sitting position. This prevents tension on the sutures in the neck. Incorrect Answers: B. The client who has had a subtotal thyroidectomy will usually be ambulatory and will not need to do leg exercises. C. The client who has had a subtotal thyroidectomy does not usually require dressing changes as the incision is sealed using tissue bind adhesive and daily dressings are not required. D. The client who has had a subtotal thyroidectomy will usually be ambulatory and will not need to use an incentive spirometer. Vital Concept: When a client has had a subtotal thyroidectomy it is critical they protect their incision from harm. This will prevent damage to the incision site and potential edema near the airway.

Which of the following positions will be most comfortable for a patient who is experiencing orthopnea? A. Prone B. Recumbent C. Trendelenburg D. Erect E. Fowler

Correct Answer: D. Erect Orthopnea is a condition in which a patient experiences difficulty breathing when reclining or flat. Relief is obtained by placing the patient in an erect position, either standing or sitting. Trendelenburg position refers to a position in which the patient's head is lower than the rest of the body. In the Fowler position, the patient is semi-erect. Recumbent refers to lying down. Prone refers to a face down position.

Which leadership style leaves decision-making to the group, with the leader providing little or no feedback or guidance? A. Bureaucratic B. Democratic C. Situational DD. Laissez-faire

D. Laissez-faire

The nurse is caring for an older adult with signs and symptoms of an acute urinary tract infection (UTI). Nurses Notes: same Vitals Signs: same Health History: Hypertension, well-controlled on lisinopril (Zestril) 20 mg PO daily Allergy to penicillin Records indicate four episodes of acute UTI in the last year. The last episode was one month ago. Question 2 of 6 Click to indicate whether each symptom in the table correlates with an acute urinary tract infection (UTI): cystitis, pyelonephritis, or urosepsis. S/SX : -Dysuria/urgency/frequency -Fever -Low back/flank pain -Hypotension Tachypnea/tachycardia

-Dysuria/urgency/frequency - Cystitis, Pyelonephritis, Urosepsis -Fever - Pyelonephritis , Urosepsis -Low back/flank pain - Cystitis , Pyelonephritis -Hypotension - Urosepsis Tachypnea/tachycardia - Pyelonephritis , Urosepsis When analyzing cues, the nurse should recognize that symptoms of an acute UTI may vary based on the extent of infection (i.e., cystitis, pyelonephritis, or urosepsis). Any form of UTI may present with urgency, frequency, or dysuria. However, these symptoms are not required for the diagnosis, especially in an older adult whose presentation may be atypical. Cystitis will not present with systemic signs of illness, such as vital sign changes (i.e., tachypnea, fever, tachycardia). Low back or flank pain are primarily present in the early/acute phases of infection and may be less prominent or obvious once the client has developed sepsis. While pyelonephritis and sepsis typically present with fever, tachypnea, and/or tachycardia, these are not required to diagnose sepsis and may not be present in an older adult. Regardless of the primary infection source, clients with sepsis often present with tachycardia, tachypnea, and hypotension.

The nurse is caring for an older adult with signs and symptoms of an acute urinary tract infection (UTI). Question 4 of 6 The collaborating RN is busy inserting a peripheral IV and starting IV fluid resuscitation as ordered. For each additional potential nursing intervention listed, select whether that intervention is currently indicated, nonessential, or contraindicated for this client. Nursing Intervention: -Monitor intake and output -Encourage the client to ambulate as tolerated to avoid prolonged stasis -Request an order to insert a nasogastric (NG) tube -Monitor blood glucose q2 hours, administer insulin to maintain 110 mg/dL-150 mg/dL -Request an order for aerobic and anaerobic blood cultures -Administer lisinopril (Zestril) 20 mg orally as ordered

-Monitor intake and output - ( indicated) -Encourage the client to ambulate as tolerated to avoid prolonged stasis - (Contraindicated) -Request an order to insert a nasogastric (NG) tube - (Nonessential) -Monitor blood glucose q2 hours, administer insulin to maintain 110 mg/dL-150 mg/dL - ( indicated) -Request an order for aerobic and anaerobic blood cultures - ( indicated) -Administer lisinopril (Zestril) 20 mg orally as ordered - (Contraindicated) When generating solutions, the nurse should plan to address the client's hypotension, tachycardia, and elevated BUN/Cr by monitoring intake and output, monitoring blood glucose (BG), and drawing a set of blood cultures. This acutely ill client would benefit from rapid fluid resuscitation and will likely require other injectable medications. Therefore, while the RN is establishing IV access and a fluid bolus the LPN should be tracking the client's intake and output. Monitoring intake and output allows the healthcare team to assess the client's response to fluid resuscitation. This client has a fever and leukocytosis, indicating an underlying infection that is likely systemic. Therefore, a set of blood cultures drawn before initiating antibiotics is crucial to correctly and efficiently identify the causative organism. Hyperglycemia is common in sepsis clients and correlates with poor outcomes, so BG should be monitored closely.

The nurse is caring for an older adult with signs and symptoms of an acute urinary tract infection (UTI). Nurses Notes: 0900 The client presents to ED with urinary frequency, urgency, and bouts of nausea. In addition, the family reports that the client has been confused on and off over the last two days with a poor appetite. The client is alert and oriented to person and place on exam but disoriented regarding the date and time. Reports abdominal/pelvic pain 6/10. Urine is cloudy with a foul smell and gross hematuria. 0900 Temperature 101.8° F (37.8° C) Heart rate 108/min Respiratory rate 24/min Blood pressure 118/72 mm Hg Oxygen saturation 96% on room air Pain 6/10 pelvic Question 1 of 6 The nurse has just collected their initial data. Please select the three findings that require immediate follow-up from the options listed. - BP -Poor appetite -RR -Temp. -Mental status -O2 sat.

-RR -Temp. -Mental status The nurse should recognize the cues from the client's assessment that require immediate follow-up and those that can be triaged for another time. In this case, the client's tachypnea should be prioritized (based on the ABC algorithm). Tachypnea is not a typical finding with an acute UTI and may indicate systemic infection. Sepsis and metabolic acidosis often lead to a compensatory increase in the respiratory rate to reduce the CO2 level. The new onset of confusion indicates that this client may be experiencing a change in mental status or delirium related to their infection. This should be evaluated further, as mental status changes are not an expected finding in an uncomplicated UTI. In combination with acute UTI symptoms, a fever may indicate pyelonephritis or other systemic infection in this client. By contrast, blood pressure that is still within the standard range, an oxygen saturation above 90 or 92%, and a poor appetite are not immediate priorities in this client.

A post-operative client has an NG tube following bowel surgery and has a temperature of 101.4. The physician has left orders that read "Acetaminophen 650 PRN for fever above 101." What is the most appropriate action for the nurse to take? A. Administer the acetaminophen by rectal suppository B. Administer the acetaminophen by elixir through the NG tube and turn the suction off for 30 minutes C. Administer the acetaminophen by crushing two tablets and giving it via the NG tube and turning the suction off for 30 minutes D. Call the physician and question the order

Correct Answer: D. Call the physician and question the order Call the physician and question the order The order is incomplete. It does not specify the route of administration, the dosage units (mg) are not specified and the frequency of administration is not specified. The order must be clarified before the medication can be administered. Incorrect Answers: A. The order is incomplete. It does not specify the route of administration, the dosage units (mg) are not specified and the frequency of administration is not specified. The order must be clarified before the medication can be administered. B. The order is incomplete. It does not specify the route of administration, the dosage units (mg) are not specified and the frequency of administration is not specified. The order must be clarified before the medication can be administered. C. The order is incomplete. It does not specify the route of administration, the dosage units (mg) are not specified and the frequency of administration is not specified. The order must be clarified before the medication can be administered. Vital Concept:A PCP's order must be complete in its entirety to be initiated. This includes the route of administration and dosage.

A student nurse is shadowing a nurse on the renal floor. Together they are caring for a client who is waiting for a kidney transplant. The client asks the nurse what signs and symptoms most likely indicate post-transplant rejection. Which of the following is the best response? ✔ Correct answer AA. "Oliguria is a sign of rejection." B. "Shortness of breath is a sign of rejection." C. "Decreasing blood pressure is a sign of rejection." D. "Weight loss is a sign of rejection."

Correct Answer: A. "Oliguria is a sign of rejection." Correct Answer:A. Oliguria, or low urine output, is a sign of kidney rejection.

Which of the following is included as part of the handwashing when performing hand hygiene? ✔ Correct answer AA. Always wash hands before and after a medical procedure B. Lather with soap and rub hands together for 5-10 seconds C. Carefully scrub under rings and bracelets D. Only dry hands using an air dryer

Correct Answer: A. Always wash hands before and after a medical procedure The Centers for Disease Control and Prevention have outlined the appropriate method for handwashing to best reduce the spread of pathogens in the health care environment when performed properly. The nurse should always wash her hands both before and after performing a medical procedure. She should remove any rings or bracelets, as these items can harbor bacteria. After lathering with soap, the nurse should scrub her hands for at least 20 seconds. A clean paper towel or air dryer is acceptable for drying hands. It is also necessary to wash hands after removing gloves.

A nurse is providing teaching to student nurses about cultural blindness when caring for clients of diverse ethnicity. Cultural blindness is best described as: A. An inability to recognize cultural values and beliefs among different populations B. Treating people differently based on their cultural backgrounds C. A fixed or set belief about a group of people D. Seeking more ways to reach out to people of other cultures and provide care as needed

Correct Answer: A. An inability to recognize cultural values and beliefs among different populations Cultural blindness is an inability to recognize cultural values and beliefs among different populations of people. While the individual with cultural blindness may appear to demonstrate acceptance of all races, religions, and backgrounds by treating everyone the same, they may be ignoring important aspects particular to or part of different cultures that should to be considered when providing care.

The nurse is caring for a pregnant client who is in labor and receiving epidural anesthesia. Which position should the nurse avoid when positioning this client? A. Supine B. Semi-Fowler's C. Right side lying D. Left side lying

Correct Answer: A. Supine The supine position is contraindicated for a client receiving an epidural anesthetic because it causes vena cava compression and results in maternal hypotension. Hypotension reduces placental perfusion and fetal oxygenation.

The nurse is to instill ear drops in an adult. To do this properly, the nurse should pull the pinna of the ear: A. Back and down ✔ Correct answer BB. Back and up C. Forward and down D. Forward and up

Correct Answer: B. Back and up The canal should be pulled up and back

A 61-year-old client has been diagnosed with heart failure. When evaluating this client, what adventitious breath sounds would the nurse expect to hear? A. Wheezing B. Crackles C. Stridor D. Diminished breath sounds

Correct Answer: B. Crackles Crackles are commonly heard in pneumonia, bronchitis, adult respiratory distress syndrome, and early congestive heart failure. Incorrect Answers:A. Wheezing is a high-pitched whistling sound usually heard in conditions such as asthma or COPD.C. Stridor is a harsh squeaking or vibrating sound that indicates something is blocking the airway.D. Diminished breath sounds are weakened due to shallow breathing, airway obstruction, pneumothorax, pleural effusion, or obesity. Vital Concept: Crackles reflect underlying inflammation or congestion. It typically sounds like bubbling, rattling, or clicking. It is common to hear bilateral crackles in pneumonia, bronchitis, adult respiratory distress syndrome, and early congestive heart failure. Unilateral crackles may indicate an infection such as pneumonia.

The nurse is caring for a client with pancreatitis who objects to being questioned about his alcohol use. The nurse should explain to the client that the most important reason for collecting this information is that: A. The physician has asked the nurse to ask about the client's alcohol use B. There is a known link between alcohol use and pancreatitis C. Alcohol use can interfere with the lab tests used to diagnose pancreatitis D. All clients are asked about alcohol use

Correct Answer: B. There is a known link between alcohol use and pancreatitis Alcohol intake is the most common cause of acute pancreatitis. The client's health history should include information about alcohol and tobacco use, but since alcohol is one of the major causes of pancreatitis, this information is more critical in these clients. Alcohol does not interfere with the tests used to diagnose pancreatitis.

The nurse is preparing to administer eye drops for a 28-year-old client. Which of the following steps would the nurse take to administer eye drops correctly? (Select all that apply). A. Wash hands B. Put on gloves C. Pull the lower lid down against the cheekbone D. Aim the eye drop towards the conjunctival sac E. Instruct the client to squeeze the eyes closed tightly after administering the drops

Correct Answers: A. Wash hands B. Put on gloves C. Pull the lower lid down against the cheekbone D. Aim the eye drop towards the conjunctival sac Correct Answers: A. Washing hands is a correct nursing action before administering eye drops, even if gloves are being used. B. Putting on gloves is a correct nursing action before administering eye drops, and hands should always be washed before donning gloves. C. Pulling the lower lid downwards against the cheekbone is a correct nursing action when administering eye drops because this forms a pocket that will help catch the medication. D. Aiming the eye drops towards the conjunctival sac is a correct nursing action when administering eye drops. Incorrect Answers: E. Clients should be instructed to close their eyes gently and not squeeze them tightly to avoid rapid loss of the medication and allow for maximal absorption of the medication in the eyes. Vital Concept: To administer eye drops correctly, the nurse would first wash their hands and then put on gloves. The client should be instructed to tilt their head back and look upwards while the nurse pulls the lower lid downwards against the cheekbone. To administer the drops, the nurse should squeeze the medication bottle gently and aim towards the conjunctival sac. The client should be advised to gently close the eyes and not squeeze them closed to avoid medication loss and allow for maximal absorption of the medication in the eyes.

A nurse is reviewing discharge teaching with a client who had a total hip arthroplasty. Which of the following instructions should the nurse include? (Select all that apply.) A. Clean the incision daily with soap and water. B. Legs should be crossed at the ankles only. C. Sit in a straight-backed armchair. D. Bend at the waist when putting on socks. E. Use a raised toilet seat.

Correct Answers: A.Clean the incision daily with soap and water. C. Sit in a straight-backed armchair. E. Use a raised toilet seat. The client should wash the surgical incision daily with soap and water to decrease the risk for infection. Using a straight-backed armchair decreases the chance of bending at greater than a 90° angle, which can cause dislocation of the hip prosthesis. Using a raised toilet seat decreases the chance of bending at greater than a 90° angle, which can cause dislocation of the hip prosthesis. Incorrect Answers:D. Bending at the waist places the hip in a position greater than a 90° angle, which can cause dislocation of the hip prosthesis. B. When sitting, feet should be placed flat on the floor to prevent the legs from crossing beyond the midline of the body, which can cause dislocation of the hip prosthesis. Vital Concept:A client who has had a total hip arthroplasty should not cross their legs beyond the midline of the body, bend their hips more than 90°, sit or stand for prolonged periods of time, or twist their bodies when standing. They should use assistive devices for ambulating and dressing and should avoid putting more weight on the affected leg than instructed. The client should cleanse the incision with mild soap and water daily and dry the incision thoroughly. Pain medications should be taken as prescribed, and if pain is increased or not controlled, the client should contact the provider. The client should continue walking and performing exercises as directed and report any signs of infection.

A nurse is providing instructions to a student nurse about administering an intermittent enteral feeding. Which of the following statements indicates understanding of this teaching? (Select all that apply.) A. Fill the feeding bag with enough formula to last 24 hr. B. Change administration set every six hours. C. Leave unused portions of formula at the bedside. D. Label the unused portion of the formula. E. Elevate the head of the client's bed for 15 min after administration.

Correct Answers: B. Change administration set every six hours. D. Label the unused portion of the formula. Feeding equipment, such as the bag holding the formula, should be discarded every 6 hours to prevent bacterial contamination. Extension tubing should be changed every 24 hours. The unused portion of the formula should be labeled with the time and date the formula was opened and the client's name and room number. Incorrect Answers: A. Intermittent feedings are administered four to six times a day in equal portions, with each feeding lasting 30 to 45 min. C. The unused portion of formula should be refrigerated up to 24 hr to prevent bacterial contamination. E. The nurse should elevate the head of the client's bed for 30 to 60 min following administration to prevent aspiration. Vital Concept: Intermittent tube feedings are generally administered 4 to 6 times a day, with each feeding infusing 30 to 45 min. The feedings can be infused without a pump as long as care is taken to monitor carefully. Gastric residuals should be measured before each feeding is started.

A nurse is caring for a client who has a central line in place. Which of the following actions is indicated for client safety when flushing a central line? (Select all that apply) A. Use a syringe that is 5 milliliter or larger to flush B. Flush with 20 milliliter of 0.9% sodium chloride at least every 3 hours C. Do not apply force if resistance occurs with flushing D. Flush the catheter before and after administering medication E. Flush with heparin if occlusion occurs.

Correct Answers: C. Do not apply force if resistance occurs with flushing D. Flush the catheter before and after administering medication While flushing a central venous catheter, the nurse should follow established safety guidelines in accordance with the facility policy. A central line should be flushed with a 10 mL-size syringe or larger, using approximately 5 to 10 mL of 0.9% sodium chloride (normal saline). The nurse should flush before and after administering medications. If resistance occurs, forcing the catheter to flush should be avoided, as it may lead to catheter rupture. Incorrect Answers:A. The nurse must use a 10 milliliter syringe or larger when flushing a central line, not a 5 milliliter syringe. B. The nurse should use 5 to 10 milliliter of flush, not 20 mL. E. Thrombolytic drugs (alteplase, urokinase) are used for catheter thrombosis. The catheter may need to be replaced in a different site. Vital Concept:The catheter must be flushed to maintain patency and to avoid sluggish flow. Without flushing, blood and medication will build up on the inside of the catheter, forming fibrin that leads to occlusion. A biofilm may also form, which can lead to infection and catheter malfunction. Central catheters should be flushed with normal saline solution before and after medication administration, using 10 mL normal saline solution. The catheter should be flushed with 20 mL when withdrawing blood. If resistance occurs during flushing or there is no blood return, the nurse should assess catheter patency before administering medications and fluids. Force should not be used to flush the catheter. The nurse should aspirate for blood return to confirm patency before administering medication and solutions and during every shift. If there is no blood return, the nurse should assume the catheter is malpositioned or an