Basic care and comfort UW

For pediatric clients, liquid medication should be

measured with an oral syringe for accuracy. To prevent inaccurate dosing, parents should not mix medications with meals or give additional medication if vomiting occurs. To promote initiative and cooperation from preschool children (age 3-6), parents should provide positive reinforcement (eg, stickers) and allow children to participate in self-administration.

Shortness of breath and tachycardia with activity related to decreased hemoglobin level, red cells, and oxygen-carrying capacity would be expected in a client with

moderate to severe anemia

Initial management of heat exhaustion includes

moving the client from the heat to a cooler area and providing a cool, electrolyte-containing sports drink or water. Early intervention in heat exhaustion can prevent the development of heat stroke, a potentially fatal condition leading to brain and additional organ damage.

With procedural moderate sedation at the bedside, the nurse takes on the role of an anesthetist. The nurse's role is to monitor the client's condition while the health care provider focuses on performing the procedure. The nurse should

never leave the client during the procedure. The best response is to have an available nurse (the charge nurse) go assess and deal with the needs of the client next door.

can deliver 60%-95% oxygen concentrations and is usually used short-term. It is often used for clients with low saturations resulting from asthma, pneumonia, trauma, and severe sepsis; it is not the most appropriate device for a COPD client.

non-rebreathing reservoir mask

For high-quality adult cardiopulmonary resuscitation

compressions should be in the center of the chest; at a rate of 100-120/min; and at least 2 in (5 cm) but no more than 2.4 in (6 cm) deep for adequate perfusion without unnecessary client injury. Compression interruption should be minimized (eg, 30 compressions to 2 rescue breaths)

When preparing medication from a glass ampule, the nurse breaks the ampule away from the body and discards it in the sharps container. The nurse withdraws medication using a filter needle to prevent the injection of glass shards, avoids touching the needle to

contaminated ampule edges, and avoids injecting air to prevent spillage

polymigratory arthritis

swollen painful joints swelling inflammation and effusion of the joints

Total thyroidectomy ... totals get

tetany, need lifelong hormone replacement

A heparin infusion is used to treat deep venous thrombosis. An activated partial thromboplastin time of 60 seconds is a therapeutic value. The therapeutic range for a client on anticoagulation is

usually 46-70 seconds (1½ -2 times the normal value)

Ebola is an extremely contagious viral disease with a high mortality rate. Infected clients require extensive infection precautions, including an airborne isolation room, strict personal protective equipment use, restriction of

visitors, and a log of individuals who enter and exit the room.

Tidaling is the fluctuation that occurs in the

water seal chamber in relation to the client's respiratory movements. The level of sterile water will rise with inspiration and fall with expiration, indicating proper function of the chest tube drainage system.

Clinical manifestations of Cushing syndrome include

weight gain, truncal obesity, moon face, buffalo hump, skin thinning, easy bruising, purple striae, muscle wasting, bone loss, hypertension, and hyperglycemia. The associated excess of androgen can result in acne, hirsutism, and menstrual irregularities

When an interpreter is needed, the nurse should attempt to use a trained, proficient, same-sex individual rather than a family member or personal friend. The nurse should speak slowly and directly to the client, not the interpreter; provide

information in the sequence it will occur; and obtain feedback of comprehension beyond merely nodding.

In the home care setting, infection control procedures for changing a dressing include washing the hands before and after gloving, opening sterile supplies carefully to avoid contamination, and placing old dressings

inside a glove or plastic bag before disposal in the household trash

Metoprolol IV

is a beta blocker used for heart rate control in tachyarrhythmias

In the event of an air embolus, the head of the bed should be

lowered (Trendelenburg) and the client positioned on the left side; this will cause the air to rise to the right atrium. The registered nurse and health care provider should be notified immediately while the practical nurse remains with the client

Hirshsprung's Disease

descending colon not innervated properly by parasympathetic NS / scaphoid shaped abdomen, hollowed abdomen

When deciding which client to see first, the nurse should apply the

"ABC" (airway, breathing, circulation) guideline to problems that clients may have or could develop.

A female client performs a clean catch urine specimen by completing hand hygiene and opening the specimen container, spreading the labia using the index finger and the thumb of the nondominant hand, and cleansing the vulva in a front-to-back motion. The client then initiates a urine stream before introducing the container midstream for urine collection. The container is removed when well filled

(30-60 mL) and before urinary flow ends.

Latex allergy is an exaggerated immune reaction to exposure to latex-containing products (eg, gloves, catheters, tape). Risk factors include swelling, hives, or itching after exposure to common latex-containing products (eg, balloons); certain food allergies

(eg, banana, avocado, tomato); and a history of multiple latex exposures (eg, self-catheterization, multiple surgeries).

Clients with multiple sclerosis experience fatigue, incoordination, balance impairment, muscle weakness, and muscle spasticity from demyelination of nerve fibers. Gait training

(eg, walking with the feet apart) and assistive devices can help prevent falls and injury and preserve independence as long as possible

To perform ear irrigation, assess for contraindications

(fever, ear infection, tympanic membrane injury); tilt the affected ear down; straighten the ear canal; and use a solution at body temperature to irrigate gently, aiming toward the top of the ear canal until it is clear.

atrophy

(n.) the wasting away of a body organ or tissue; any progressive decline or failure; (v.) to waste away

The nurse should teach clients with insomnia good sleep hygiene such as using the bed for sleep only

(no reading or television), avoiding stimulants (eg, caffeine) before bedtime, keeping the bedroom cool and dark, and developing a consistent sleep-wake pattern (ie, same bedtime and wake time each day).

Antidiarrheal medications

*KLIP* Kaopectate, Pepto-Bismol Lomotil Imodium Paregoric

Negative pressure room

- a room in which air flows into the room and away from adjacent rooms, which results in positive pressure in the room

Positive pressure room

- a room in which air flows out of or toward adjacent rooms, which results in a lower pressure in the room

The nurse should teach a client receiving a clonidine patch to:

-Apply patch to a dry hairless area on the upper arm or chest -Wash hands before and after application -Rotate sites with each new patch application -Discard patch away from children or pets with sticky sides folded together -Never wear more than 1 patch at a time -Never stop using the patch abruptly

droplet precautions require (2)

-masks for providers & visitors -a private room or a room with clients of the same disease

Proton Pump Inhibitors

-prazole

2 point gait

-weight bearing 1) start w/ feet together, crutches slightly in front 2) move right foot forward to level of right crutch + left crutch forward 3) move left foot forward to level of left crutch + right crutch forward 4) repeat

The DP pulse is located on the top or dorsal part of the foot. The nurse should compare the characteristics of the arteries on the right and left extremities simultaneously to determine symmetry. The force of the pulse should be rated on the following scale.

0 Absent 1+ Weak 2+ Normal 3+ Increased, full, bounding

The Heimlich maneuver (ie, upward abdominal thrusts under the rib cage) is the primary rescue intervention for children over age

1 with a foreign body airway obstruction causing respiratory distress. Back blows and chest thrusts are appropriate interventions for a choking infant under age 1. Blind sweeping of a child's mouth should not be attempted.

Partial Recommended bed-to-chair transfer method

1-person assist stand & pivot transfer with gait belt or motorized assist device if cooperative 2-person assist with full-body sling if client is uncooperative

The charge nurse in the telemetry unit has delegated the task of giving a bed bath to a male Arab client who practices traditional Islamic customs. Which communication to the female nursing assistant demonstrates appropriate cultural sensitivity to this client?

1. "Ask the client's wife if she would like to give the bed bath." / The nurse should be aware that in many Arab cultures a man is not allowed to be alone with a woman other than his wife. In addition, cultural customs may not allow physical care by a member of the opposite sex. The nurse needs to plan accordingly to provide culturally sensitive care.

A 7-year-old client is being treated for a scalp laceration with yellow drainage. The nurse prepares to irrigate the wound. Place the steps of wound irrigation in the correct sequence

1. Confirm two client identifiers, confirm prescription, and assemble supplies 3. Fill a 30-mL syringe with irrigation solution and attach an irrigation tip 4. Irrigate the wound with a steady, gentle stream from the innermost region outward 5. Obtain wound cultures from the wound base using sterile culturette swabs 2. Dry wound by patting gently with sterile gauze and apply dressing

A client with a tracheostomy is alert and oriented and able to tolerate oral intake. Which action would be appropriate to reduce the client's risk of aspiration pneumonia?

Partially or fully deflate cuff

If the client is cooperative and able to partially bear weight, a safe transfer requires

a 1-person stand and pivot technique with a gait belt or powered stand-assist lift.

Promethazine (Phenergan)

Antiemetic. Side effects: drowsiness, anticholinergic effects, EPSs, potentiates effects when given with narcotics. Nursing interventions: monitor VS, safety precautions, IM (large muscle)

Thiamine (Vitamin B1)

1. Wernicke-Korsakoff 2. Deficiency

When flushing the lumen of a central venous catheter, the nurse should use the safest syringe possible and the "push-pause" method to avoid exerting too much pressure, which may damage the catheter. The smaller the syringe, the greater the amount of pressure exerted during the flush. A

10-mL syringe is generally recommended; however, it is also important to consult the manufacturer's guidelines.

Clostridium difficile colitis

10-15 watery episodes of diarrhea. Lower abdominal pain with fever. S/S usually start 5-10 days after initiation of antibiotics (clindamycin is common culprit) Rec probiotics with antibiotic Rx to prevent

1 liter = ____ milliliters

1000 mL

A neonate's resting pulse is

110-160/min

1 tbsp = ? mL

15 mL

When obtaining blood from a client, insert the needle at

15-degree angle, limit attempts to 2, and avoid the side of a mastectomy. A capillary specimen should be obtained at the side of the finger pad. Never draw a specimen above an IV infusion.

chest compressions

2 in (5 cm) deep to adequately pump blood / recoil completely / a cycle of 30 compressions followed by 2 rescue breaths / Correct hand placement is in the center of the chest, on the lower half of the sternum (breastbone) / rate of 100-120/min

Hemoglobin A1C is a diagnostic test used to measure the percentage of glycosylated hemoglobin in the blood. A normal hemoglobin A1C is 4%-6% in clients without diabetes; the goal is to keep the level <7% in clients with diabetes. The A1C test measures blood glucose control over a period of

2-3 months; higher measurements indicate higher glycemic levels. High levels may indicate poor adherence to the recommended diet and exercise plan or ineffective antihyperglycemic medication regimen. It is important for the nurse to review the diet, exercise, and medication plan with the client who has a high hemoglobin A1C.

INR lab values

2-3, critical value if off, potential for patient to bleed. Use default order for order ?'s (hold all coumadin, assess for bleeding, prepare Vit K (antidote for Coumadin), Call or notify

The contagious period for strep throat starts at the onset of symptoms and lasts through the first 24 hours of antibiotic treatment

This client is able to return to activities and does not require an immediate callback.

NPH insulin is an intermediate-acting insulin that peaks in 4-12 hours. In asymptomatic clients, the best intervention to prevent low blood glucose levels related to an evening dose of NPH is to consume

a bedtime snack of protein and complex carbohydrates.

The nurse is reinforcing education about ascending stairs using a modified 3-point gait to a client prescribed crutches after a left ankle sprain. Place the instructions for ascending the stairs in the correct order.

2. Assume the tripod position, then bear body weight on the crutches 3. Place the unaffected leg onto the stair 4. Transfer body weight to the unaffected leg and raise the body onto the stair 1. Advance the affected leg and crutches up the stair

myoma

a benign tumor made up of muscle tissue

Multiple Sclerosis (MS)

destruction of the myelin sheath on neurons in the CNS and its replacement by plaques of sclerotic (hard) tissue

Clients in any form of restraint should not be in the

supine position as it may lead to aspiration

Allen test

determining the patency of the radial and ulnar arteries by compressing one artery site and observing return of skin color as evidence of patency of the other artery

peripherally inserted central catheter (PICC)

a catheter used for long-term intravenous access and inserted in the basilic or cephalic vein just above or below the antecubital space with the tip of the catheter resting in the superior vena cava

Absolute Neutrophil Count (ANC)

2000

Serum Osmolality

285-295

Meniere disease (Meniere syndrome)

a chronic condition of the inner ear characterized by dizziness, tinnitus, hearing loss, and a sensation of pressure in the ear

The nurse is instructing a female client how to collect a clean catch urine specimen. Place in order the steps indicating that client teaching has been effective.

3. Performs hand hygiene and removes container lid, with sterile side placed upward 5. Spreads labia using index finger and thumb of nondominant hand 1. Cleanses vulva from front to back with single-use antiseptic towelettes 2. Initiates urinary stream before passing container into stream for collection 4. Removes specimen container from stream before stopping urinary flow

Ménière disease, Ménière syndrome

a chronic condition of the inner ear characterized by dizziness, tinnitus, hearing loss, and a sensation of pressure in the ear

1 oz = ? mL

30 mL

A normal respiratory rate for an infant is

30-60/min. This infant is currently stable

Gastric residual should be checked at least every

4 hours with continuous feedings.

The nurse should teach the client that possible memory impairment and problems with concentration, language comprehension, social integration, and emotional lability are common following major surgery. Symptoms typically resolve after

4-6 weeks or when healing is complete. Persistent problems should be reported to the health care provider.

Which advanced crutch gait that most closely resembles normal walking

4-point gait

Increased urine output is associated with

diabetes insipidus (DI). In DI, ADH is suppressed, causing polyuria, severe dehydration, and high serum osmolality if the client is unable to drink enough to maintain a fluid balance

Cellulitis

diffuse, acute infection of the skin marked by local heat, redness, pain, and swelling

The IV site should be monitored for redness, edema, discomfort, drainage, hardness, warmth, or coolness. If infiltration occurs

discontinue the IV line immediately and restart it in another site.

While away from the negative-pressure isolation room, all clients on airborne transmission-based precautions must wear a

surgical mask to contain exhaled respiratory secretions

after liver biopsy

clients are at risk for internal bleeding due to the vascular nature of the liver. Place clients in the right side-lying position for ≥3 hours afterward to promote direct internal pressure of the liver against itself, which minimizes bleeding

The nurse is preparing to administer a continuous enteral feeding for a client with a nasogastric tube. Place the steps in the correct order

4. Identify the client using 2 identifiers 2. Elevate the head of the bed 30-45 degrees 5. Validate tube placement 3. Flush the tube with 30 mL of water 1. Administer the prescribed feeding solution

The nurse is preparing to administer a continuous enteral feeding for a client with a nasogastric tube. Place the steps in the correct order. All options must be used.

4. Identify the client using 2 identifiers 2. Elevate the head of the bed 30-45 degrees 5. Validate tube placement 3. Flush the tube with 30 mL of water 1. Administer the prescribed feeding solution

Nontherapeutic communication techniques (eg, expressing approval or disapproval, giving advice, asking why)

discourage expression of feelings and ideas and close down the conversation between the nurse and client.

The nurse caring for a female client reviews a prescription for insertion of an indwelling urinary catheter. The nurse assesses for allergies, explains the procedure to the client, and asks the unlicensed assistive personnel to perform perineal care while equipment is gathered. Place in order the steps the nurse should take when inserting the urinary catheter. All options must be used

4. Perform hand hygiene 1. Apply sterile gloves 5. Use nondominant hand to spread the labia 2. Cleanse labial fold with antiseptic swab 6. Wipe meatus with antiseptic swab 3. Insert catheter until urine is visualized

The nurse assesses the breath sounds of a 2-day postoperative total laryngectomy client and determines that suctioning is needed to clear secretions. The client is off the mechanical ventilator and is receiving humidified oxygen via a tracheostomy mask. Place the steps for suctioning the tracheostomy tube in the correct order.

4. Place client in semi-Fowler's position 5. Preoxygenate (hyper-oxygenate) with 100% oxygen 3. Insert catheter the length of the airway without applying suction 2. If resistance is felt, withdraw the catheter 0.4-0.8 in (1-2 cm) 1. Apply intermittent suction while rotating the suction catheter while withdrawing

Anticoagulant injections should be administered in the abdominal subcutaneous tissue at a

45- to 90-degree angle. A 45-degree angle is used for clients with minimal adipose tissue to avoid accidental intramuscular injection, which would cause rapid absorption and result in hematoma and painful muscle irritation.

The nurse prepares to insert a large-bore nasogastric tube for gastric decompression. After obtaining equipment, the nurse identifies the client, performs hand hygiene, applies clean gloves, assesses nares, and selects a naris. Place the remaining steps in the correct order.

5. Measure, mark, and lubricate tube 4. Instruct client to extend neck back slightly 3. Gently insert tube just past nasopharynx 2. Ask client to flex head forward and swallow 1. Advance tube to the marked point 6. Verify tube placement and anchor

Kohlberg's stages of moral development

6 identifiable developmental stages of moral reasoning which form the basis of ethical behavior, the pre-conventional (level 1) contains the first stage (obedience and punishment orientation and second stage (self-interest orientation)), the conventional (level 2) contains the third stage (interpersonal accord and conformity) and fourth stage (authority and social-order maintaining orientation) the post-convential (level 3) contains the 5th stage (social contract orientation) and 6th stage (universal ethical principles)

The occupational health nurse administers an intradermal tuberculin skin test (TST) to a health care worker (HCW). The site must be assessed for a reaction afterward. The nurse instructs the HCW to return in how many hours?

72 hours 2- 3 days

Peripheral IV (PIV) catheter sites should be changed no more frequently than every

72-96 hours unless signs of complications (eg, phlebitis, infiltration) develop. Signs of phlebitis include erythema, edema, warmth, pain, and a palpable venous cord. Coolness to touch may indicate infiltration (Option 1). The nurse should monitor for infiltration under the involved limb, particularly in the elderly. Infiltrated fluid may leak into loose skin and accumulate in dependent areas with no obvious signs of infiltration at the PIV site

When injecting a prefilled enoxaparin syringe, a nurse should choose an injection site on the right or left side of abdomen, at least 2 inches from umbilicus; avoid expelling the air bubble in the syringe; insert the needle at a

90-degree angle into a pinched-up area of skin; and discourage the client from rubbing the site

The normal temperature range for an infant is

97.7-99.7 F (36.5-37.6 C). This infant is currently stable.

Fasting total cholesterol

<200 mg/dL

The nurse should monitor infants for hypoglycemia by assessing for symptoms and monitoring the blood glucose level. A blood glucose level

<40 mg/dL (2.2 mmol/L) indicates hypoglycemia and the client should be treated immediately by feeding or administering a glucose bolus

Although any change in or growth of a mole should be reported, a pale pink or brown round mole

<5 mm is typically a normal finding

The primary health care provider prescribes a 24-hour urine collection for a client with suspected Cushing syndrome. Which instructions should the nurse reinforce with the client regarding this test?

A 24-hour urine is collected to test for increased cortisol levels when evaluating for Cushing syndrome. The client should be taught to collect the urine in a dark jug issued by the lab, start time and then empty the bladder and discard the 1st urine, and collect all the urine for 24 hours; it is kept in the refrigerator or ice chest with a secure lid. Exactly 24 hours after start time, empty bladder once more into the collection container.

Willebrand disease

A bleeding disorder caused by low levels of clotting protein in the blood

Betadine

A brand of povidone-iodine solution used as an antiseptic can alter thyroid function

The nurse is preparing to administer medications to the clients. Which client attributes are acceptable for use as client identifiers?

A client identifier to ensure "the right client" should be permanent and unique to the client. Acceptable identifiers are FIRST and LAST name, medical record number, and birth date

Cellulitis is a common bacterial skin infection that is usually treated with IV antibiotics in clients with diabetes mellitus. Room 2 is the best assignment option for this client with cellulitis. The client with dementia and urinary incontinence who has an external urinary condom catheter is the least susceptible to infection compared to those in rooms

A client with an infection should not be assigned to a semi-private room with a client who had surgery or is immunocompromised and receiving immunosuppressants as such clients are highly susceptible to infection. Post-splenectomy clients are also at lifelong risk for rapid sepsis

elbow restraint

A type of restraint that is used in the care of infants or small children to prevent flexing an arm to scratch or touch skin on the face or head, primarily during surgery

In a private airborne isolation room, the client does not require a respirator mask. However, all other individuals entering the room must

don appropriate personal protective equipment (PPE)

otalgia or otodynia

earache

Before lumbar puncture

clients are placed in the side-lying fetal position or hunched seated position to separate the vertebrae. Afterwards, clients remain supine in bed for 4-12 hours to minimize the risk of a post-puncture headache from the loss of cerebrospinal fluid

Hyperosmolar Hyperglycemic State (HHS)

ACUTE COMPLICATION SEEN IN PERSONS WITH TYPE 2 DIABETES, THAT IS CHARACTERIZED BY EXTREME HYPERGLYCEMIA, HYPEROSMOLARITY WITH DEHYDRATION, THE ABSENCE OF KETOACIDOSIS, AND CNS DYSFUNCTION

The nurse cares for a group of clients on a medical surgical floor. The client with which condition is at highest risk for developing syndrome of inappropriate antidiuretic hormone (SIADH)?

ADH is sometimes produced and secreted by cancer cells, especially lung cancer cells causing SIADH, a condition in which too much ADH causes water retention, increased total water, and dilutional hyponatremia.

After cardiac catheterization via femoral entry, place clients

flat or in low Fowler position with the affected extremity straight for about 4-6 hours to avoid pressure at the insertion site and prevent hemorrhage or hematoma

It is normal to auscultate crackles in an infant during the first hour of life. This is because

fluid is still being pushed out of and absorbed by the lungs. This infant is currently stable

Flushing (red skin) is commonly seen with fever, polycythemia vera, and sexual intercourse. Flushing is not seen with

hypoglycemia

When working with an interpreter, the nurse should apply the following best practices to maximize communication and understanding with the client:

Address the client directly in the first person Speak in short sentences, pausing to allow the interpreter to speak Ask only one question at a time Avoid complex issues, idioms, jokes, and medical jargon Hold a pre-conference with the medical interpreter to review the goals of the interview Use a qualified professional interpreter whenever possible

Purines are

Adenine (A) and Guanine (G)

Ensure proper measurement prior to inserting a large-bore NG tube by measuring from the

tip of the nose, extending the tube to the earlobe, and then down to the xiphoid process. Mark the distance with a small piece of tape that can be easily removed.

C difficile infection requires strict contact precautions, including wearing

a gown and gloves at all times. Alcohol cannot kill C difficile spores, so caregivers must use soap and water in place of alcohol-based hand sanitizers. Contaminated surfaces and equipment should be disinfected using a diluted bleach solution

pancreatitis

inflammation of the pancreas give meperidine / Demerol

Neutropenic precautions should be used to prevent infection in clients who have

low white blood cell and absolute neutrophil counts and are receiving chemotherapy. Infections in these clients are life-threatening.

A school nurse observes a 3-year-old begin to choke and turn blue while eating lunch. What should be the nurse's initial action?

Abdominal thrusts

The nurse walks into the client's inpatient room and sees a fire in the wastebasket. The nurse should take which action first?

Activate fire alarm

A grade-school client has type 1 diabetes controlled with glargine and aspart. The client becomes shaky, diaphoretic, and has slurred speech. What action should the nurse take first? 1. Administer 1 tbsp (15 mL) honey 2. Give crackers with peanut butter 3. Inject 1 mg intramuscular glucagon 4. Provide an 8-oz glass (237 mL) of juice with 4 packs of sugar

Administer 1 tbsp (15 mL) honey/Hypoglycemia should be treated with 15-20 g of quick-acting carbohydrate. Treatment should be repeated if there is no improvement in 15 minutes. Common initial treatment options include 1 tbsp (15 mL) syrup or honey, 4 tsp (20 mL) jelly, 4-6 oz (118-177 mL) orange juice, or 8 oz (237 mL) low-fat milk. Avoid overtreatment to prevent rebound hypoglycemia

Interventions to prevent dehiscence include:

Administer stool softeners (docusate [Colace]) to prevent straining during defecation and alleviate constipation from postoperative immobility and opioid medications Administer antiemetics (ondansetron [Zofran]) as needed to prevent straining with vomiting. Apply an abdominal binder to provide hemostasis, support the incision, and reduce mechanical stress on the wound when coughing/moving Monitor blood sugar to maintain tight glycemic control (fasting glucose <140 mg/dL, random glucose <180 mg/dL) to help prevent infection and promote wound healing Splint the abdomen by holding a pillow or folded blanket against the wound for support when coughing/moving

use of epinephrine injection

Administer the injection in the mid-outer thigh; it can be given through clothing

A student nurse is preparing to administer the hepatitis B vaccine to a newborn. Which statement by the student nurse requires the preceptor to provide further teaching?

Administered in deltoid wrong vastus lateralis

lumbar puncture

After the procedure, the pt should be supine for 4-12 hours as prescribed.

A client with ascites had 5400 mL of fluid removed during paracentesis. The health care provider prescribes 8 g of albumin IV per 1000 mL of fluid removed. If the albumin is supplied as 25 g in 100-mL bottles, how many mL will the nurse administer? Record your answer using one decimal place.

Albumin may be given after paracentesis to prevent volume depletion. To calculate the volume per dose of albumin, the nurse should first identify the prescribed dose (eg, 8 g/L peritoneal fluid) and available medication (eg, 25 g/100 mL) and then convert to volume in milliliters per dose (eg, 172.8 mL)

High purine foods include?

Alcoholic beverages (all types) Some fish, seafood and shellfish, including anchovies, sardines, herring, mussels, codfish, scallops, trout and haddock. Some meats, such as bacon, turkey, veal, venison and organ meats like liver.chicken

Droplet precautions are for what 2 diseases?

All meningitis and all influenza Pertusis, Diptheria, Mumps, All Meningitis

The radial artery site at the wrist is preferred for collecting an arterial blood gas sample because it is near the surface, easy to palpate and stabilize, and has good collateral supply from the ulnar artery. The patency of the ulnar artery must be confirmed by performing a modified

Allen's test to assure adequate circulation to the hand before proceeding with the arterial blood gas collection.

The nurse is caring for a client with hyperosmolar hyperglycemic state. The nurse understands which characteristic is most consistent with HHS?

Altered level of concusses

Basaljel, Amphojel, combos such as Maalox, Mylanta, Di-Gel

Aluminum antacid. May cause constipation. Often used for patients with renal failure

occlusive dressing

An airtight dressing that protects a wound from air and bacteria; a commercial vented version allows air to passively escape from the chest, while an unvented dressing may be made of petroleum jelly-based (Vaseline) gauze, aluminum foil, or plastic.

The nurse cares for a client with aortic stenosis who was admitted due to syncope on exertion and dyspnea. Identify the area where the nurse would best auscultate the client's heart murmur

Aortic stenosis is a type of valvular heart disease causing narrowing of the valve between the left ventricle and aorta, impairing ejection of blood from the heart. Nurses attempting to auscultate heart murmurs associated with aortic stenosis should listen at the right sternal border, second intercostal space (ie, aortic area).

During circumcision, the newborn is restrained in a wrapped blanket or placed on a special board to prevent injury. Non-nutritive sucking of a concentrated sucrose solution is offered for pain management.

Application of a blanket restraint or the use of a special board prevents injury during circumcision. Swaddling and the use of non-nutritive sucking are nonpharmacologic approaches to manage pain during circumcision.

Cimitidine (Tagamet)

Antacid and antihistamine It can reduce acid in the stomach to treat ulcers and acid reflux. Common side effect of prednisone is gastric ulcers

Metronidazole (Flagyl)

Antibacterial/Antiprotozoal

Tiotropium Bromide (Spiriva)

Anticholinergic

Enoxaparin (Lovenox)

Anticoagulant

Imodium (loperamide)

Antidiarrheal

The correct procedure for administration of a suppository to an adult client includes:

Assisting the client into Sims position and draping for privacy Assessing the client for hemorrhoids prior to administering the suppository Lubricating the tapered end of the suppository prior to insertion Inserting the suppository 4 inches (10 cm) into the rectum

Incentive spirometry is recommended in postoperative clients to prevent atelectasis associated with incisional pain, especially upper abdominal incisions (close to the diaphragm). Adequate pain medication should be administered before using the incentive spirometry. Guidelines recommend 5-10 breaths per session every hour while awake. The client instructions for using a volume-oriented SMI device include:

Assume a sitting or high-Fowler's position, which optimizes lung expansion, and exhale normally While holding the device at an even level, seal the lips tightly on the mouthpiece to prevent leakage of air around it Inhale deeply and slowly through the mouth until the ball or piston is elevated to the predetermined level of tidal volume. The piston is visible on the device and helps provide motivation. Hold the breath for at least 2-3 seconds (up to 6 seconds) as this maintains maximal inhalation Exhale slowly to prevent hyperventilation Breathe normally for several breaths before repeating the process Cough at the end of the session to help with secretion expectoration

Clients prescribed crutches after a musculoskeletal injury must be educated on appropriate device use to facilitate independent ambulation, promote wound healing, and prevent reinjury. A common method used to climb stairs is the modified three-point gait ("leading with the good leg"), which is used to prevent weight-bearing on the injured leg. Nurses should instruct clients with crutches to use the following steps to ascend the stairs with the modified three-point gait:

Assume the tripod position (ie, crutch stance) and place body weight on the crutches while preparing to move the unaffected leg. Place the unaffected leg (ie, good leg) onto the step. Transfer body weight from the crutches to the unaffected leg and then use the unaffected leg (ie, good leg) to raise the body up onto the step. Advance the affected leg and the crutches together up the step. Realign the crutches with the unaffected leg on the step before repeating the process.

Clients with diabetes should eat foods with

a low glycemic index and high fiber content. Saturated fats and sodium should be restricted.

antiemetic

a medication that is administered to prevent or relieve nausea and vomiting

CD4+ cell count provides information about: A. The level of HIV in the body B. The number of T-cells in the body C. The body's ability to respond to HIV

B. The number of T-cells in the body

Because the nurse is unfamiliar with the client, the prescriptions from the HCP should be reviewed before giving any fluids. It is common for clients admitted from the emergency department to be designated nothing by mouth (NPO) until appropriate diagnostics have been completed or in case of possible surgery. Caffeine would be questionable as it can interfere with certain diagnostic tests, such as nuclear cardiac studies

Before giving any client oral fluids, the nurse should verify HCP prescriptions related to oral intake and prescribed diagnostics or procedures

The nurse is assessing a client's peripheral pulses. The nurse palpates the top portion of the client's foot. The right pulse is easily palpable, and the left pulse is diminished but still palpable. How should the nurse document these findings?

Bilateral dorsalis pedis (DP) pulses palpable Right DP 2+,Left DP 1+. The nurse should palpate and compare the characteristic and quality of the pulses on the right and left extremities simultaneously to determine symmetry. The force of the pulse should be rated as 0, absent; 1+, weak; 2+, normal; and 3+, increased, full, bounding. These descriptions should be documented in the client's record.

Potential risks of a thyroidectomy include:

Bleeding or infection. Difficulty breathing. Permanent hoarseness or weak voice due to nerve damage. Injury to parathyroid glands (glands near the thyroid) or their blood supply, which can cause low blood calcium levels and sometimes muscle spasms or other neuromuscular symptoms.

Which of the following drug administrations should be reported as a practice error?

Do not administer warfarin if the client is pregnant. Intramuscular injections are given in the vastus lateralis to children age <7 months. Penicillins and cephalosporins can have a cross-sensitivity response. Narcotic-induced pruritus is not a true allergy

Acanthosis nigricans

a skin condition related to insulin resistance from obesity and diabetes, appears as velvet-like patches of darkened, thick skin, typically on the back of the neck and in the groin and armpits.

Methicillin-resistant Staphylococcus aureus (MRSA)

a strain of the bacterium Staphylococcus aureus that has become resistant to the antibacterial action of the antibiotic methicillin, a form of penicillin

The nurse reinforces teaching to a client with HIV during a follow-up clinic visit after being on antiretroviral drugs for the past 2 months. Which statement by the client indicates a need for further instruction?

Clients with HIV must be educated to strictly adhere to prescribed antiretroviral therapy to prevent disease progression. Clients with HIV who are sexually active should seek testing for sexually transmitted infections and use latex condoms/barriers during sex. Clients with HIV should use a needle exchange program if using IV drugs.

Therefore, the imaging health care provider should determine the client's eligibility for MRI. Absolute contraindications include the following:

Cardiac pacemaker (Option 1) Implantable cardioverter defibrillator Cochlear implant Retained metallic foreign body, especially in organs such as the eye (Option 3) Relative contraindications include the following: Prosthetic heart valve Metal plate, pins, brain aneurysm clip, or joint prosthesis (Option 4) Select devices; those composed of nonferrous MRI-safe materials should be verified first Implanted device (eg, insulin pump, medication port) Other factors that can affect the client's eligibility include inability to remain supine for 30-60 minutes and claustrophobia; sedation can be prescribed or an open MRI machine can be used in such cases.

The warning signs of cancer can be remembered with the acronym CAUTION:

Change in bowel or bladder habits A sore that does not heal Unusual bleeding or discharge from a body orifice Thickening or a lump in the breast or elsewhere Indigestion or difficulty in swallowing Obvious change in a wart or mole Nagging cough or hoarseness

CPM machine

Continuous Passive Motion machine- for passive ROM exercises.

The nurse is administering a pink pill to a hospitalized medical-surgical client. The alert, oriented client says, "This is a pill I haven't seen before." What follow-up action should the nurse take next

Check the health care providers prescription in the medical record

A nurse is preparing to administer 2 continuous IV medications concurrently via a 20-gauge IV. What is the nurse's priority action?

Checking for drug compatibility is a priority before administering 2 IV medications concurrently in the same IV site. Incompatible drugs will deteriorate or form a precipitate that is visible as a color change, cloudiness, or particulates.

A carotid endarterectomy is a surgical procedure that removes atherosclerotic plaque from the carotid artery. Clients with carotid artery disease are at increased risk for transient ischemic attack and stroke. Post-surgical risks include cerebral ischemia and infarction as well as bleeding. Blood pressure is closely monitored during the first 24 hours post surgery. Hypertension may strain the surgical site and trigger hematoma formation, which can cause hemorrhage or airway obstruction. Systolic blood pressure is maintained at 100-150 mm Hg to ensure adequate cerebral perfusion and avoidance of hemorrhage or strain.

Clients post carotid endarterectomy are at risk for cerebral ischemia and infarction as well as hemorrhage. Systolic blood pressure is maintained at 100-150 mm Hg to ensure adequate cerebral perfusion and reduce the likelihood of hematoma formation or hemorrhage at the surgical site

To collect the urine specimen:

Clean the collection port with an alcohol swab Aspirate urine with a sterile syringe Use aseptic technique to transfer the specimen to a sterile specimen cup

The nurse is caring for a client who had a laparoscopic cholecystectomy 3 days ago. The client's WBC count has increased from 11,200/mm3 (11.2 × 109/L) to 14,600/mm3 (14.6 × 109/L) over the last 24 hours. The nurse understands that which of the following assessment findings indicate potential infection?

Cholecystectomy (removal of the gallbladder) is performed through laparoscopic or open surgery. Signs of postoperative infection typically appear 3-7 days after surgery. Systemic signs may include fever, elevated WBC count, and fatigue. Some potential postoperative infections include: Pneumonia can occur when atelectasis (alveolar collapse) prevents clearing of secretions, promoting bacterial growth. Symptoms include cough with or without sputum, tachypnea, and shortness of breath. Postoperative incentive spirometry, ambulation, and cough/deep breathing exercises help keep alveoli open and prevent pneumonia (Option 3). Surgical site infections present with localized redness, warmth, swelling, and purulent drainage. Proper wound care and sterile dressing changes help prevent infection (Options 2 and 5). Urinary tract infections (UTIs), caused by the use of indwelling urinary catheters during surgery, can present with frequency, urgency, and dysuria. Prompt removal of catheters after surgery helps prevent UTIs. Peritonitis (peritoneal infection) presents with rebound tenderness, boardlike abdominal rigidity, and shallow breathing related to abdominal distension. Peritonitis may lead to sepsis and death if untreated (Option 4). (Option 1) Clients recovering from laparoscopic surgery may experience referred left shoulder pain during the first few postoperative days. This is due to diaphragmatic nerve irritation caused by the carbon dioxide used to inflate the abdomen during laparoscopic surgery. Educational objective: Some potential postoperative infections related to abdominal surgery include pneumonia, surgical site infection, and peritonitis. Signs of infection may include cough, tachypnea, and shortness of breath; warmth or redness around the incision; purulent incisional drainage; or rigid, painful abdomen.

The nurse is assisting in planning care for a client experiencing an acute attack of Ménière disease. Which action is a high priority to include in the plan of care?

Clients with Ménière disease (endolymphatic hydrops) can have severe vertigo, tinnitus, hearing loss, and aural fullness. The priority is for the nurse to institute safety measures, such as fall precautions, for these clients. Clients will require a salt-restricted diet.

A physical restraint that restricts body movement should be the last resort to keep a client from interfering with medical treatment. Restraints can cause bodily injury such as pressure ulcers, neurovascular and peripheral circulatory deficits, and psychological trauma. Therefore, less restrictive methods should always be tried first.

Concealing the IV site and tubing by wrapping the forearm in gauze and an elastic stockinette can be effective in keeping a confused client from pulling at the IV line.

The nurse performs nasogastric (NG) tube insertion using a large-bore NG tube on a hospitalized client with a gastrointestinal bleed. During insertion, after the tube passes the nasopharynx, the client begins to cough and gag. Which action should the nurse take first?

Coughing and gagging commonly occur during NG tube insertion if the tube coils in the throat or slips into the larynx. When this happens, the nurse should pull back on the tube slightly and then pause to give the client time to recover and breathe before advancing the tube.

truncal obesity

Cushing syndrome

Artificial airways (eg, tracheostomies, endotracheal tubes) impair the cough mechanism and ciliary function, causing an increase in thick secretions that may occlude the airway. Focused respiratory assessments are critical to determine the need for suctioning and to maintain a patent airway. To decrease the risks associated with the procedure (eg, atelectasis, hypoxemia, trauma, infection), suctioning should be performed only when necessary. Assessment findings that indicate a need for suctioning include:

Decreased oxygen saturation Altered mental status (eg, irritability, lethargy) Increased heart rate (normal infant range: 90-160) Increased respiratory rate (normal infant range: 30-60) Increased work of breathing (eg, flared nostrils, use of accessory muscles) Adventitious breath sounds (eg, crackles, wheezes, rhonchi) Pallor, mottled, or cyanotic skin coloring. Respiratory rate of 30/min and heart rate of 105/min are within normal limits for an infant and would not indicate distress or a need for suctioning.

Adverse event is an injury to a client caused by medical management rather than a client's underlying condition. It may or may not be preventable. The Institute of Medicine (2000) recognizes 4 types of errors. They are:

Diagnostic (delay in diagnosis, failure to employ indicated tests, failure to act on results of monitoring) Treatment (error in performance of procedure, treatment, dose; avoidable delay) Preventive (failure to provide prophylactic treatment, inadequate follow-up/monitoring of treatment) Other (failure of communication, equipment failure, system failure) Adverse events cause injury that is related to medical management, not the client's underlying condition.

Over use of magnesium containing antacids

Diarrhea

A client who had a bowel resection 5 days ago says, "I felt like I split open when I coughed." The nurse finds the incision edges separated and bowel protruding through the wound. Which of the following actions are appropriate?

Dehiscence (eg, surgical incision separation) with evisceration (eg, internal organ protruding through incision) is a medical emergency that can lead to localized ischemia, peritonitis, and shock. Emergency surgical repair is necessary. Clients at risk for poor wound healing (eg, obesity, diabetes mellitus) are at increased risk for evisceration. Emergency management includes: Stay with the client and instruct the client not to strain. Have someone notify the health care provider immediately (Option 4). Place the client in the low Fowler position with knees slightly flexed to relieve abdominal pressure (Option 5). Cover the viscera with sterile dressings saturated in normal saline solution to prevent bacterial invasion and keep the area from drying out (Option 3). Assess vital signs to monitor for shock (eg, hypotension, tachycardia, tachypnea) (Option 2). Document wound and organ assessments (eg, color) and interventions taken. If the blood supply is interrupted, the protruding organs can become ischemic (dusky) and necrotic (black). (Option 1) This client should be kept NPO in preparation for emergency surgery. Only IV analgesics should be administered if the client reports pain. Educational objective: Dehiscence (eg, surgical incision separation) with evisceration (eg, internal organ protruding through incision) is a medical emergency. The nurse should stay with and continuously monitor the client, who should be positioned in the low Fowler position and instructed not to strain. The wound should be covered with sterile, moist dressings, and the health care provider must be notified immediately in preparation for emergency surgery. Vital signs should be collected and interventions documented.

Varicella (chickenpox)

Direct contact and airborne precautions. 2-3 week incubation. Contagious until all lesions have scabbed. Pregnant women should not be in contact. is transmitted through airborne particles or contact with open vesicles. For chickenpox and disseminated shingles, the nurse should use precautions for both airborne isolation (ie, N95 particulate respirator mask, room with negative air pressure) and contact isolation (eg, gown, gloves, disposable equipment) until vesicles have crusted.

exacerbation of multiple sclerosis

Double vision / diplopia

Palifermin (Kepivance)

Drugs used to protect against Chemotherapy Toxicity

Interdisciplinary client care rounds and hand-off communication are examples of strategies used to improve communication in health care settings. What is the most important outcome of effective communication among care givers?

Effective communication among caregivers is necessary to deliver safe client care and reduce the number of medical errors.

A nurse caring for a postoperative client is reinforcing proper technique for an incentive spirometer device. Place the teaching steps in the proper order. All options must be used.

Exhale normally and place the mouthpiece in the mouth 5. Seal lips tightly on mouthpiece 4. Inhale deeply, until ball or piston rises to predetermined level 3. Hold breath for at least 2-3 seconds 2. Exhale slowly around the mouthpiece

Cachexia/cachectic

Extremely thin, malnourished as a result of weight and muscle loss due to disease

Important aspects of care for Muslim clients include accommodating the following client needs:

Facing Kaaba in the holy city of Mecca for prayer, modesty considerations, adherence to dietary practices (halal or kosher meals and possibly fasting during Ramadan), and involvement of family.

A client who is diagnosed with breast cancer asks the nurse, "Am I going to die?" Which statement by the nurse promotes a therapeutic relationship?

Fear of dying is a common concern for many clients with a terminal disease. The nurse should acknowledge these feelings and use open-ended statements and active listening to invite clients to talk about death.

When a client leaves against medical advice (AMA), it should be an informed refusal. The nurse should inform the health care provider immediately. The most important action is for the nurse to remove the

IV catheter prior to discharge. A client cannot be held against his/her will if the client refuses to sign an AMA form.

H. pylori treatment

PPI + 2 of the following antibiotics --Clarithromycin --Metronidazole --Amoxicillin One week treatment: 90% cure rate Two weeks of PPI + 1 antibiotic (typically clarithromycin): 10-20% lower cure rate MHD notes: --Tetracycline can be 1 of the 2 antibiotics --Bismuth salts, doxycycline, and metronidazole for 14 days is cheap and effective

Prioritization of care

First-level priority problems Airway Breathing Circulation & cardiac (become first priority in cardiac arrest) Vital signs Second-level priority problems Altered mental status Acute pain Untreated medical problems (eg, hyperglycemia in a client with diabetes) Chronic pain Acute elimination issues Abnormal laboratory results Risk for infection, safety

A glass ampule is a single-dose medication container with a scored area on the neck that must be broken to withdraw the medication. When preparing medication from a glass ampule, the nurse ensures safety and prevents contamination during medication administration by:

Flicking the upper stem of the ampule with a fingernail several times to ensure removal of medication from the ampule neck Using sterile gauze to break the ampule neck away from the nurse's body to prevent injury from glass shards (Option 2) Setting the ampule on a flat surface or inverting it to withdraw the medication Disposing of the ampule in a sharps container (Option 3) (Option 1) Glass shards may be present in the medication after an ampule is opened. To prevent the accidental administration of glass shards, the nurse must use a filter needle, rather than an injection needle, when withdrawing medication. (Option 4) Unlike when withdrawing medication from a vial, air should not be injected into a glass ampule; this causes the contents to spill from the container. (Option 5) Ensure that the filter needle does not touch the glass edges, which are not sterile, as this can introduce bacteria.

vastus lateralis

For children age <7 months, the site for immunizations is the anterolateral thigh

contact precautions

Gown and gloves for contact with patient or environment of care (e.g., medical equipment, environmental surfaces)

PPE for the health care worker protects the mucous membranes, airways, skin, and clothing from contact with potentially infectious agents. The category of transmission-based precautions (eg, contact, droplet, airborne) required determines the type of PPE that the health care worker will wear. The exact procedure for donning and removing PPE varies with the level of precautions required. Guidelines are provided by the Centers for Disease Control and Prevention (CDC) and by institution policy and procedure. The sequence for donning PPE includes:

Hand hygiene Gown - fully cover torso from neck to knees, arms to end of wrists, and wrap around back; fasten in back of neck and waist Mask or respirator - secure ties or elastic bands at middle of head and neck; fit flexible band to nose bridge; fit snugly to face and below chin; fit-check respirator Goggles or face shield - place over face and eyes and adjust fit; may be combined with mask (visor) Gloves - don and extend to cover wrist of isolation gown

Standard Precautions include

Hand hygiene. Use of personal protective equipment (e.g., gloves, gowns, masks) Safe injection practices.

For medical procedures, the nurse should ensure that the client:

Has an empty bladder and is in high Fowler's or a sitting position for paracentesis Is Trendelenburg on the left side for suspected air embolism Has the arm raised above the head on the affected side for chest tube insertion Lies on the right side (for 2 hours) and then supine (12-14 hours) after liver biopsy Is side-lying with the head, back, and knees flexed for lumbar puncture

Cyanocobalamin (Vitamin B12)

Hematological Agent

Exstrophy of the bladder

Herniation of the bladder through the abdominal wall place on side

delivery devices (eg, Venturi mask, mechanical ventilator) deliver oxygen concentrations that do not vary with breathing patterns. They are appropriate for clients who cannot tolerate varying concentrations (eg, COPD exacerbation).

High-flow oxygen

Clients with one-sided weakness or injury, increased joint pressure, or poor balance can use a cane to provide support and stability when walking. Cane length should equal the distance from the client's greater trochanter to the floor as incorrect cane length can cause back injury. A cane measured from the waist would be too long to provide optimal support (Option 4). Teaching points to assist a client in appropriate use of a cane include:

Hold the cane on the stronger side to provide maximum support and body alignment, keeping the elbow slightly flexed (20-30 degrees) (Option 1). Place the cane 6"-10" (15-25 cm) in front of and to the side of the foot to keep the body weight on both legs to provide balance (Option 3). For maximum stability, move the weaker leg forward to the level of the cane, so that body weight is divided between the cane and the stronger leg (Option 2). If minimal support is needed, the cane and weaker leg are advanced forward at the same time. Move the stronger leg forward past the cane and the weaker leg, so the weight is divided between the cane and the weaker leg. Always keep at least 2 points of support on the floor at all times.

Hypoglycemia (blood glucose <70 mg/dL [3.9 mmol/L]) is the most life-threatening condition listed. It occurs when the proportion of insulin exceeds the glucose in the blood. Counterregulatory hormones (eg, epinephrine) are then released and the autonomic nervous system is activated, causing multiple hypoglycemia-associated symptoms, including increased heart rate, shakiness, sweating, hunger, anxiety, and pallor. The lack of glucose in the brain is also responsible for other symptoms, including disorientation, impaired vision and speech, seizures, and coma. However, most clients respond rapidly to the correction of hypoglycemia.

Hypoglycemia (blood glucose <70 mg/dL [3.9 mmol/L]) is a serious condition that occurs when the proportion of insulin exceeds the glucose in the blood. Clients respond rapidly to nursing intervention (eg, sugar tablets, orange juice).

The steps for administering a continuous enteral feeding include:

Identify the client using 2 identifiers (eg, first and last name, medical record number, date of birth) and explain the procedure to the client. Perform hand hygiene and apply clean gloves. Elevate the head of the bed ≥30 degrees and keep it elevated for at least 30 minutes after feeding to minimize the risk of aspiration Validate tube placement by checking the gastric pH as well as assessing the external tube length and comparing it with the measurement at the time of insertion. The tube should be marked at the nostril with a permanent marker during the initial x-ray validation Check gastric residual volume. Flush the tube with 30 mL of water after checking residual volume, every 4-6 hours during feeding, and before and after medication administration Administer the prescribed enteral feeding solution by connecting the tubing and setting the rate on the infusion pump

The nurse prepares to administer an oral expectorant to a client with pneumonia. The client tells the nurse, "That pill is too big. I won't be able to swallow it." What is the best action by the nurse? Click the exhibit button for additional information.

If a client is unable to swallow an extended-release (ER) tablet, the nurse should contact the health care provider to clarify the prescription (eg, request liquid medication). The nurse should not crush ER tablets

The nurse reviews prescriptions for assigned adult clients. Which prescription should the nurse question?

In the setting of SIADH, the nurse should question a prescription for a hypotonic solution (eg, 0.45% NaCl; or dextrose water) as it would worsen the fluid and electrolyte imbalance. A prescription for fluid restriction and a hypertonic IV solution (eg, 3% NaCl) administered in small quantities would be appropriate to shift fluid back into the vascular compartment and correct hyponatremia.

Full Recommended bed-to-chair transfer method

Independent; no assistance required 1-person standby assistance or observation for clients who are uncooperative or at high risk for falls

In addition, one of the 2015 National Patient Safety Goals (NPSGs) is to "improve the safety of using medications." This includes labeling all medications as soon as these are prepared, discarding all unlabeled medications (Option 3), and being extra careful with clients taking anticoagulant drugs (eg, assessing laboratory values prior to administration)

Individual dose packages should be opened at the client's bedside and placed in a medication cup only immediately before administration. (Option 5) Gloves are generally not required during medication preparation/handling of unopened packages or vials. However, hand hygiene should be performed both prior to preparation/handling and before administration. The nurse should wear gloves during medication administration when coming into contact with a route that is potentially contaminated by blood or body fluids (eg, administering intramuscular or subcutaneous injections, accessing a closed IV tubing system, placing a pill into a client's mouth using fingers).

The radial artery site at the wrist is preferred for collecting an arterial blood gas sample because it is near the surface, is easy to palpate and stabilize, and has good collateral supply from the ulnar artery. The patency of the ulnar artery can be confirmed with a positive modified Allen's test. The modified Allen's test includes the following steps:

Instruct the client to make a tight fist (if possible) Occlude the radial and ulnar arteries using firm pressure Instruct the client to open the fist; the palm will be white if both arteries are sufficiently occluded Release the pressure on the ulnar artery; the palm should turn pink within 15 seconds as circulation is restored to the hand, indicating patency of the ulnar artery (positive Allen's test) If the Allen's test is positive, the arterial blood gas can be drawn; if negative and the palm does not return to a pink color, an alternate site (eg, brachial artery, femoral artery) must be used.

Gastric lavage and aspiration

Intubation and suction supplies should always be available at the bedside during GL in case the client develops aspiration or respiratory distress

The nurse responds to a client room where a resuscitation effort is in progress. The client's immediate family member refuses to leave the room. How should the nurse handle this situation?

Let family member stay and assign a staff person to explain what is happening

Phlebitis is an inflammation of a vein. Common manifestations include pain, swelling, warmth at the site, and redness extending along the vein. Causes include irritating drugs (eg, vancomycin), catheter movement within the vein (eg, inadequate stabilization), or bacteria (eg, poor aseptic technique). If signs of phlebitis are present, immediate removal of the catheter is necessary as phlebitis can lead to thrombophlebitis and emboli or a bloodstream infection.

Manifestations of phlebitis associated with a peripheral IV catheter include pain, swelling, warmth at the site, and redness extending along the vein. If phlebitis is present, immediate removal of the catheter is necessary as the condition can lead to a serious bloodstream infection or thrombophlebitis.

The nurse prepares a community education program about health promotion strategies for postmenopausal women. Which of the following teaching points are appropriate to include?

Loss of ovarian function during menopause causes a decrease in estrogen production, leading to reduced osteoblast activity and cardioprotective effect. Therefore, postmenopausal clients are at increased risk for osteoporosis and coronary artery disease (CAD). Other physiological changes after menopause may include weight gain, sleep disturbances, fat redistribution, and vaginal atrophy. Clients should utilize health promotion strategies to reduce the effects of decreased estrogen levels, including: Consuming optimal amounts of dietary calcium (green, leafy vegetables; dairy products) and engaging in weight-bearing exercise to promote bone health (Options 3 and 4) Closely monitoring cholesterol levels (eg, HDL, LDL, triglycerides), as increased LDL cholesterol increases risk for CAD (Option 2) Considering seeking the assistance of a dietitian, and maintaining a low-calorie diet rich in fruits and vegetables, as hormone changes may cause a predisposition to weight gain (Option 1) Seeking support to cope with any emotional symptoms (eg, depression, mood swings, sadness, difficulty concentrating) caused by changing hormone levels (Option 5) Educational objective: Postmenopausal women should consume plenty of calcium-rich foods (eg, dairy products; green, leafy vegetables), engage in weight-bearing exercise, monitor cholesterol levels, consider dietary counseling to maintain a healthy weight, eat a diet rich in fruits and vegetables, and seek support for any emotional symptoms.

delivery devices (eg, nasal cannula, simple face mask) deliver oxygen concentrations that vary with breathing patterns. They are appropriate for clients who can tolerate varying concentrations (eg, stable chronic obstructive pulmonary disease [COPD])

Low-flow oxygen

Polycythemia Vera (PV)

Neoplastic proliferation of mature myeloid cells, especially RBCs

Beneficence (Definition)

Maximize possible benefits and minimize possible harms.

chelating agents

Medications that bind with heavy metals in the body and create a compound that can be eliminated; used in cases of ingestion or poisoning. / lead poisoning

The nurse is reinforcing education about lifestyle modifications for a client newly diagnosed with Meniere disease. Which statement by the client indicates a need for further teaching?

Meniere disease (endolymphatic hydrops) results from excess fluid accumulation in the inner ear. Clients have episodic attacks of vertigo, tinnitus, hearing loss, and feelings of fullness or pressure in the ear. The disorder typically affects only one ear and can lead to permanent hearing loss. Attacks of Meniere disease can result in a total loss of proprioception, and clients often report feeling "pulled to the ground" (drop attacks), making client safety a priority. Vertigo can be severe and is associated with nausea, vomiting, and feelings of anxiety. Self-care for Meniere disease may include: Consuming a low-sodium diet to decrease the potential for fluid excess within the inner ear. Intake of potassium and other electrolytes does not need to be restricted (Option 2). Limiting or avoiding aggravating substances (eg, nicotine, caffeine, alcohol) and stimuli (eg, flickering lights, watching television) (Options 1 and 4) Adhering to prescribed therapies for relief of symptoms (eg, antiemetics, antihistamines, sedatives, and mild diuretics) Avoiding sudden changes in the position of the head (eg, bending over) during vertigo spells Participating in vestibular rehabilitation therapy Implementing safety measures during attacks (eg, assistance with walking, bed rest) (Option 3) Educational objective: Meniere disease results from excess fluid accumulation in the inner ear. Attacks involve severe vertigo, nausea, and hearing loss. Clients with Meniere disease should be taught to adhere to a low-sodium diet; eliminate tobacco products; limit caffeine and alcohol; and limit or avoid exacerbating factors (eg, flickering lights).

None Recommended bed-to-chair transfer method

Motorized assist device if client is cooperative & has upper body strength 2-person assist with full-body sling if client is uncooperative &/or has no upper body strength

A quadriplegic client is prescribed baclofen (Lioresal), 5 mg by mouth three times daily. What is the principal indication for baclofen?

Muscle spasms with paraplegia or quadriplegia from spinal cord lesions

On arrival in the postanesthesia care unit, the practical nurse assists the registered nurse in performing the initial assessment of a client who had surgery under general anesthesia. Which assessment finding is the most concerning?

Muscle stiffness

A postoperative client who is receiving continuous enteral feedings via a nasoenteric tube becomes dyspneic with a productive cough, and the nurse auscultates crackles and diminished breath sounds in lung bases. Which action is appropriate at this time?

Nasoenteric tubes can become dislodged, causing the tube to enter the stomach or lungs. Feedings should be stopped immediately and tube placement checked if the client develops signs of aspiration

Medication administration record Allergies: No known allergies Sliding-Scale Blood Glucose Levels Regular Insulin Dose <150 mg/dL (<8.3 mmol/L) 0 units 150-199 mg/dL (8.3-11.0 mmol/L) 3 units 200-249 mg/dL (11.1-13.8 mmol/L) 5 units 250-299 mg/dL (13.9-16.6 mmol/L) 7 units ≥300 mg/dL (≥16.7 mmol/L) 9 units and notify the health care provider. The nurse is preparing to administer the prescribed 25 units of neutral protamine Hagedorn insulin and sliding-scale regular insulin. The client's blood glucose level is 237 mg/dL (13.2 mmol/L). How many units of insulin will the nurse administer in an injection? Record your answer using a whole number. Click on the exhibit button for additional information.

Neutral protamine Hagedorn (NPH) insulin and regular insulin may be mixed together in 1 syringe. Using both an intermediate-acting and a short-acting insulin enhances glycemic control, and mixing insulins minimizes the number of injections given to a client, which promotes comfort and reduces risk of infection. Five units of regular insulin are needed to address the client's blood glucose reading of 237 mg/dL (13.2 mmol/L) in addition to the scheduled 25 units of NPH insulin, equaling a total of 30 units. In preparing the mixed dose, first inject 25 units of air into the NPH insulin vial without inverting the vial or passing the needle into the solution. Then inject 5 units of air into the regular insulin vial and withdraw the dose, leaving no air bubble in the syringe. The NPH should then be drawn into the syringe, totaling 30 units. Any overdraw of NPH insulin into the syringe will necessitate wasting the total quantity of insulin in the syringe. Educational objective: Neutral protamine Hagedorn (NPH) (intermediate-acting) and regular (short-acting) insulin can be safely mixed and given together in a single injection. When the injection is prepared, the regular insulin should be drawn up before the NPH insulin.

The nurse is caring for a client who just had a total thyroidectomy. Which finding does the nurse recognize as most important to report immediately?

Noisy breathing / Airway swelling is a life-threatening complication of thyroid surgery. Signs of respiratory distress such as stridor and dyspnea require rapid intervention

A nurse is caring for an older client admitted for failure to thrive and a history of recent falls and weight loss. The client lives in a relative's home and the nurse is questioning the safety of the home, knowing it may be necessary to arrange for an alternate living situation or additional support. To address this concern, it is most appropriate for the nurse to consult with which interdisciplinary team member?

Nursing advocacy for the safety of the client includes the appropriate use of interdisciplinary team members, such as a social worker. Advocacy is especially important in young and older clients and those who are cognitively challenged or have mental health concerns

The nurse is caring for an adolescent client who just had placement of an external fixation device for long-term stabilization of a fractured tibia. Which interventions should the nurse expect to implement when caring for this client?

Nursing interventions to prevent common complications (eg, infection, loosening of pins) associated with an external fixator include sterile pin care with an antimicrobial solution, regularly checking pin tightness, and notifying the registered nurse immediately if there are loose pins or signs of infection.

Septic hip

Orthopedic emergency Toddler with febrile illness, won't move the hip - not even passively. Dx: aspirate hip under general anesthesia.

is a nasal reservoir cannula device that conserves oxygen use. Clients can be sustained on a prescribed oxygen level using much less oxygen to reach the same saturation (eg, 3 L/min nasal cannula is equivalent to 1 L/min Oxymizer). It is not the best choice in an unstable COPD client with varying tidal volumes as the inspired oxygen concentration is not guaranteed

Oxymizer

The nurse receives report on 4 clients. Which client should be seen first?

Pain, limited range of motion, and fever indicate joint infection (septic joint). A septic hip is a surgical emergency as impaired blood supply may lead to permanent joint destruction, sepsis, and/or death. The nurse should expect management to include cultures, antibiotics, and surgical debridement.

The student nurse is applying a condom catheter for an ambulatory client who is uncircumcised and incontinent of urine. The precepting nurse should intervene when the student performs which action?

Paraphimosis occurs when the uncircumcised male foreskin cannot be returned (reduced) to its original position, after being pulled back (retracted) behind the glans penis, resulting in pain, progressive swelling of the foreskin, and impaired lymph and blood flow. Paraphimosis can occur when a health care worker accidentally leaves the foreskin in the retracted position for an extended period of time (eg, under a condom catheter sheath). It is critical for the precepting nurse to intervene when the student nurse retracts the foreskin before applying the condom catheter to avoid permanent damage to the glans resulting from impaired circulation

Clinical manifestations of compartment syndrome (7 Ps)

Paresthesia (early sign) Tingling, numbness, burning Pain Out of proportion to injury, unrelieved by medication Pressure Taut skin, cast fits too tightly Pallor Pale skin tone, decreased color, white, gray Pulselessness (uncommon) Possibly weakened or lost Poikilothermia Cool skin temperature, matches room temperature Paralysis (late sign) Weakness, loss of motor activity

Sulfamylon

Penetrates eschar and provides anti-bacterial control

he order of removal for personal protective equipment (PPE) should be from most to least contaminated, because this reduces the risk of contaminating the nurse's skin and clothes. When exiting the room of a client on both contact and airborne precautions, the nurse should perform the following actions in order:

Place the call light within the client's reach and ensure that the client's bed is locked and in the lowest position. Remove the gown and gloves (ie, contact isolation PPE) in order of most to least contaminated. The nurse can remove gloves and then gown, or alternately, can remove gown and gloves together. Discard the gown and gloves and then perform hand hygiene. Exit the negative pressure room and immediately close the door to prevent infectious airborne microorganisms from escaping into the hallway or isolation anteroom. Remove and discard the N95 respirator mask and then perform final hand hygiene.

The general steps for preparing the sterile field for a wet-to-damp dressing change include:

Perform hand hygiene. Open a sterile gauze package that has a partially sealed edge with ungloved hands by grasping both sides of the edge, one with each hand, and pull them apart while being careful not to contaminate the gauze (Option 2). Hold the inverted opened gauze package 6" (15 cm) above the waterproof sterile field so it does not touch the field, and then drop the gauze dressing onto the sterile field (Option 1). Place the sterile dressings on the sterile field 2" (5 cm) from the edge; the 1" (2.5 cm) margin at each edge is considered unsterile because it is in contact with unsterile surfaces (Option 3). Use sterile NSS from a recapped bottle that was opened <24 hours ago (if policy permits).

Arteriovenous (AV) graft placement involves surgical connection of an artery to a vein using a synthetic material to graft a hemodialysis access site. Postoperative infection usually manifests approximately 3-5 days after surgery (eg, fever, purulent drainage, swelling) and may cause thrombosis (clotting), graft failure, or systemic infection.The health care provider (HCP) should be notified, as this client may require antibiotics and surgical revision or removal of the graft.

Postoperative infection of an arteriovenous graft may result in thrombosis (clotting), graft failure, or systemic infection. The nurse should immediately assess the client with signs of postoperative infection (eg, fever) and notify the health care provider.

Health care workers are required to abide by Occupational Safety and Health Administration standards and regulations to reduce work-related injuries (eg, sharps) and exposure to bloodborne pathogens (eg, HIV, hepatitis B and C). A sharps disposal container should not be overfilled and should be replaced on a regular basis to reduce the risk for a needle stick during disposal.

Prevention of injury and safety in the workplace should be a priority when the nurse is delegating, planning, or providing nursing care.

Magnesium (IV)

Prevention/treatment of seizures or cardiac arrrhythmias caused by hypomagnesemia Electrolyte Supplement

The nurse is caring for a client newly prescribed crutches. Which finding indicates the need for further teaching?

Proper crutch fit includes a 3-4 finger-width space between the axillary pad and axilla and a handgrip location that allows 20-30 degrees of elbow flexion. Clients should support their body weight on the hands and arms, not the axillae. Wear and tear on the crutch pads may indicate improper use or fit. Clients progress from 3-point gait (no to partial weight-bearing) to 2-point gait and then 4-point gait as rehabilitation continues.

-zole

Proton pump inhibitors

The nurse prepares to administer a dose of radioactive iodine (RAI) to a 39-year-old female client with Graves' disease. Which action is most important for the nurse to take?

RAI destroys the thyroid gland, making clients permanently hypothyroid and requiring life-long thyroid supplements. In female clients, a nonpregnant status should be confirmed with a valid pregnancy test prior to administering RAI. RAI is contraindicated in pregnancy and may cause harm to a fetus

Contact precautions are used for what 4 types of diseases?

RSV, Herpatic infection, Staph infections and Enteric (bowel) infections

National Pressure Ulcer Advisory Panel pressure ulcer prevention guidelines

Skin care Barriers for incontinence Hydration Moisturizer Repositioning Pad bony prominences Pad medical devices Lift, do not pull Limit chair time Minimize shearing & frictional forces Turn every 2-4 hr Nutrition Calorie counting (30-35 kcal/kg/day) Enteral nutrition High-protein nutritional supplements (1.25-1.5 g/kg/day) Deficiency assessment Support surfaces Alternating pressure Avoid donut-type devices & synthetic sheepskins Heel protection Mattress Overlay

Epiphysis fracture

Repair of this can result in stunted growth (short) or abnormal growth (long).

Echolia

Repeating the last heard sound, word, or phrase

Residual limb

Remaining part of limb following surgery. - maintains good skin coverage and vascularization

nasogastric suction

Removal of gastric contents by tube with suction, monitor output, tube may be irrigated, normal saline is used for irrigation to prevent loss of electrolytes / abdomen is soft

To administer ophthalmic medications, follow these steps:

Remove secretions from the eyelid by wiping from the inner to outer canthus; (2) pull lower eyelid downward, have client look upward, and instill drops into the conjunctival sac; and (3) apply pressure to the lacrimal duct if medication has systemic effects (eg, beta blocker, timolol maleate)

Place the call light within the client's reach and ensure that the client's bed is locked and in the lowest position. Remove the gown and gloves (ie, contact isolation PPE) in order of most to least contaminated. The nurse can remove gloves and then gown, or alternately, can remove gown and gloves together. Discard the gown and gloves and then perform hand hygiene. Exit the negative pressure room and immediately close the door to prevent infectious airborne microorganisms from escaping into the hallway or isolation anteroom. Remove and discard the N95 respirator mask and then perform final hand hygiene.

Removing the mask in the room risks exposure to infectious airborne microorganisms.

RACE is the acronym used to remember how to deal with fires in inpatient settings. RACE represents the following actions:

Rescue (remove clients from immediate danger) Alarm (activate the fire alarm, call "code red," alert nearby appropriate personnel) Confine (close the doors and windows) Extinguish the fire or evacuate clients—first horizontally, then vertically

The nurse is participating in a staff presentation to review risk factors for skin cancer. Which of the following risk factors should the nurse include? Immunosuppression (eg, immunosuppressant medications, HIV), which lowers the body's ability to defend against cancerous mutations

Risk factors for skin cancer include family or personal history of skin cancer, Celtic ancestry traits (eg, light skin, blue eyes), aging, atypical or high number of moles, immunosuppression, and ultraviolet light exposure (eg, chronic sun exposure, outdoor occupation).

Glascow Coma Scale

Severe <8 Moderate 9-12 Minor >13

The nurse is reinforcing instructions to a client with obstructive lung disease in the correct use of a short-acting beta agonist metered-dose inhaler without the use of a spacer. Place the steps in the correct order

Shake canister well for 3-5 seconds 5. Tilt head back slightly and exhale slowly for 3-5 seconds 3. Place mouthpiece between teeth and wrap lips around mouthpiece 1. Compress canister while inhaling slowly through the mouth for about 3-5 seconds 2. Hold breath for 10 seconds, if possible, before exhaling 6. Wait at least 1-2 minutes before taking a second puff, if prescribed

A tourniquet is applied 3-5 inches above the desired puncture site for no longer than 1 minute when looking for a vein. If longer time is needed, release the tourniquet for at least 3 minutes before reapplying. Prolonged obstruction of blood flow by the tourniquet can change some test results

Skin preparation involves cleaning using an antiseptic solution and friction and allowing the skin to air dry. Remaining solution may hemolyze and/or dilute the blood sample. Traditionally, alcohol (alone or with povidone iodine) is applied in a circular motion, from insertion site outward (clean to dirty). Current research suggests that the most effective method is applying chlorhexidine (2%) in a back and forth motion, followed by adequate drying time. (Option 4) The veins on the ventral aspect of the wrist are located near nerves, resulting in painful venipuncture and a higher risk of nerve injury. There is also an increased risk of arterial access on the ventral aspect of the wrist, and so this site should be avoided. (Option 5) The filled tube should be gently inverted 5-10 times to mix anticoagulant solution with the blood. Vigorously shaking the tube can cause hemolysis and false results.

General manifestations of hyperthyroidism/Graves' disease

Symptoms Anxiety & insomnia Palpitations Heat intolerance Increased perspiration Weight loss without decreased appetite Physical examination Goiter Hypertension Tremors involving fingers/hands Hyperreflexia Proximal muscle weakness Lid lag Atrial fibrillation

In the intensive care unit, the nurse cares for a client admitted with a head injury who develops syndrome of inappropriate antidiuretic hormone. Which data should the nurse expect with the onset of this condition?

Syndrome of inappropriate antidiuretic hormone (SIADH) is potential complication of head injury. In SIADH, the extra ADH leads to excessive water absorption by the kidneys. Low serum osmolality and low serum sodium are the result of increased total body water (dilution). As ADH is secreted and water is retained, urine output is decreased and concentrated, resulting in a high specific gravity.

Pregnant health care workers should not be exposed to clients with

TORCH infections (Toxoplasmosis, Other [VZV/parvovirus B19], Rubella, Cytomegalovirus, Herpes simplex virus), as these infections can cause fetal abnormalities

Total parenteral nutrition (TPN) should never be discontinued abruptly (due to the risk for hypoglycemia). This client should be seen third so that

TPN is not interrupted

A child on the playground is experiencing an anaphylactic reaction. The school nurse arrives with an EpiPen. The weather is cold and the child is wearing several layers of clothing. How should the nurse proceed with the EpiPen?

The EpiPen is designed to be delivered through clothing in the mid-outer thigh area. The nurse should not delay anaphylaxis treatment by attempting to remove the client's clothing

Clients with Alzheimer disease experience eating and nutritional problems throughout the course of the disease. During the earlier stages, it is common for them to forget that they have eaten recently

The best approach is for caregivers to give clients something to eat when they say they are hungry.

The practical nurse is assisting the registered nurse in caring for 4 clients in the pediatric emergency department. Which client should be seen first?

The client with abdominal pain has abnormal vital signs, which is a sign of a systemic condition. Adult criteria apply to adolescent clients in terms of physiological signs/symptoms. A pulse of 120/min signals dehydration, and this client's respirations are above normal. This is the most serious acuity. (Option 2) The client with cystic fibrosis (CF) should be treated second as clients with this disease have chronic respiratory issues related to thick mucus plugging the airways. This client will probably need antibiotics but is currently stable and can wait. The severity of the situation is considered when prioritizing client care based on airway, breathing, and circulation (ABC). The seriousness of the adolescent client's condition related to "C" (dehydration) is a priority over a relatively stable "B" in the client with CF. There are no signs indicating that this client is in respiratory distress. (Option 3) The infant has diaper dermatitis from irritation of urine and stool on the skin. A secondary infection with Candida albicans can occur. Diaper dermatitis is most common in infants age 9-12 months. Ointment will be provided. Mild diaper dermatitis is treated with a topical water-impermeable barrier (eg, zinc oxide). If the infant has a C albicans infection, an antifungal topical medication is also used. When care must be prioritized, young children do not automatically go first. Prioritization is based on client acuity. (Option 4) The grade-school client has a lower extremity injury, and the priority principle is always "life before limb." Therefore, the client with abdominal pain is more important. Educational objective: In prioritization, the severity of ABC (airway, breathing, and circulation) is more important than its absolute order. As a result, a severe "C" client comes before a stable "B" client. The priority principle is to save "life before limb." When care must be prioritized, young children do not automatically go first.

A health care provider (HCP) is screaming, "Why didn't you get surgery scheduled sooner!?," at the nurse in the hallway. People in the hallway are staring. What is the best initial reaction by the nurse?

The first response to public displays of disruptive behavior is to take action to make the conversation private.

Gluconeogenesis

The formation of glucose from noncarbohydrate sources, such as amino acids.

The risk of post-tonsillectomy hemorrhage persists for up to 14 days after surgery, and resuming strenuous activity too early increases this risk

The potential for bleeding is higher 7-10 days postoperatively while sloughing occurs.

The nurse must follow the 6 rights of medication administration

The right client The right medication The right dose The right time The right route The right documentation

It can take 24-48 hours for peristalsis to return after bowel surgery due to manipulation of the bowels and anesthesia.

This client should be monitored for return of bowel function and should be assessed last.

Tension pneumothorax causes marked compression and shifting of mediastinal structures (tracheal deviation), including the heart and great vessels, resulting in reduced cardiac output and hypotension.

This is a life-threatening emergency that requires urgent large-bore needle decompression followed by chest tube placement.

Parenteral and oral anticoagulant medications are administered concurrently until the International Normalized Ratio reaches a therapeutic range of 2-3, at which time the heparin infusion can be discontinued and the warfarin continued

This is an expected response to therapy.

The nursing role in advocating for the client includes ensuring the use of interpreters for clients who speak a different language, particularly during the informed consent process. Using medical interpreters promotes adequate client understanding and participation in the decision-making process. The person interpreting for the client should ideally possess the following:

Training in medical terminology and procedures Ability to understand and protect the client's rights in a medical setting (HIPAA) Fluency in the language Understanding of cultural beliefs and nuances For these reasons, and to protect client confidentiality, family members should not be used as medical interpreters unless the situation is urgent and no one else qualified is available to fill this role. The nurse should privately discuss the need for a properly trained medical interpreter with the health care provider. This discretion allows the health care provider to maintain a relationship of trust with the family

Airborne precautions

Tuberculosis Varicella zoster* (chickenpox) Herpes zoster** (shingles) Rubeola (measles) Components N95 respirator or powered air-purifying respirator Negative-pressure isolation room with high-efficiency particulate air filter As needed if contact with body fluid is anticipated: clean gloves, disposable gown, goggles/face shield

Medications with anticholinergic properties (eg, antihistamines [diphenhydramine]; tricyclic antidepressants [amitriptyline]) can precipitate urinary retention, especially in susceptible clients (eg, those with benign prostatic hyperplasia)

Urinary catheterization is needed as soon as possible but is not a priority over strangulated bowel.

For TB skin testing:

Use a 27-gauge 1/4 inch needle with a 1 mL tuberculin syringe Administer injection on inner forearm at a 10-degree angle with bevel up Make a wheal (bleb) Avoid rubbing site after injection

Droplet precautions

Usually, the droplets can only travel about three feet. Examples of droplet precaution illnesses include whooping cough and influenza. If you are treating a patient in droplet precautions you need to wear a mask, gown and gloves

Health care catheter-associated urinary tract infections (UTIs) are prevalent among hospitalized clients with indwelling urinary catheters. Staff members should take the following steps to prevent infections in clients with these catheters:

Wash hands thoroughly and regularly. Perform routine perineal hygiene with soap and water at each shift and after bowel movements. Keep drainage system off the floor or contaminated surfaces. Keep the catheter bag below the level of the bladder. Ensure each client has a separate, clean container to empty collection bag and measure urine. Use sterile technique when collecting a urine specimen. Facilitate urine drainage from tube to bag to prevent pooling of urine in the tube or backflow into the bladder. Avoid prolonged kinking, clamping, or obstruction of the catheter tubing. Encourage oral fluid intake if not contraindicated. Secure the catheter in accordance with hospital policy (tape or Velcro device). Inspect the catheter and tubing for integrity, secure connections, and possible kinks.

Clients are taught the following steps for self-administration of ophthalmic ointments:

Wash hands. Tilt the head back, pull the lower lid down, and look upward. Squeeze a thin strip of ointment onto the lower eyelid, from the inner to the outer edge. Close the eyes gently for 2-3 minutes after applying the ointment

3 point gait

Weight is distributed on both crutches and then on the *unaffected* leg -- then repeat sequence

Clients undergoing lower-extremity amputation may experience surgical site pain or phantom limb pain. However, shoulder pain radiating down the arm is an unexpected finding following an extremity amputation and may indicate myocardial ischemia. Women, older adults, or clients with diabetes may have atypical presentations (eg, indigestion, jaw/shoulder pain, dyspnea, diaphoresis, nausea/vomiting) other than chest pain during a myocardial infarction

Women, older adults, or clients with diabetes may have atypical presentations (eg, indigestion, jaw/shoulder pain, dyspnea, diaphoresis, nausea/vomiting) other than chest pain during a myocardial infarction

is a skin condition characterized by dark, thick, velvety skin, commonly seen in the axillae, flexures, or on the neck. It is indicative of insulin resistance and requires further evaluation. Skin tags (acrochordons) are commonly present on regions affected by

acanthosis nigricans

Osmotic Diuretics (Mannitol)

acute phase kidney injury, cerebral edema, prevent kidney failure in shock, monitor for heart failure, kidney failure, lithium excretion is increased

Oral cancer typically manifests as a nonhealing lesion on the lip, tongue, oral cavity, or oropharynx. Modifiable risks for oral cancer include

chronic alcohol and/or tobacco use, poor oral hygiene, chronic irritation to the mucosa, increased exposure to ultraviolet light, and sexually transmitted infections in the oral cavity due to unprotected sexual activity

Varicella (chickenpox) is a highly contagious infection characterized by a generalized rash of itchy, vesicular lesions. Both chickenpox and shingles are caused by the varicella-zoster virus (VZV), which is transmitted through airborne particles or contact with open vesicles. For chickenpox and disseminated (widespread) shingles, the nurse should use precautions for both

airborne isolation (ie, N95 respirator mask), negative air pressure room) and contact isolation (eg, gown, gloves, disposable equipment)

clients in restraints should be placed in the side-lying, semi-Fowler, or high-Fowler position to promote

airway patency and allow the client to safely swallow or expectorate secretions or emesis.

Amikacin (Amikin)

aminoglycoside antibiotic

Trichomoniasis

an STD caused by a microscopic protozoan that results in infections of the vagina, urethra, and bladder

Pneumothorax (PTX)

an abnormal collection of air in the pleural space which can cause all or part of the lung to collapse

Before chest tube removal, the client is given

analgesic and then asked to perform Valsalva during the procedure. The nurse should also bring sterile suture removal equipment and a sterile airtight occlusive dressing. Post-procedure chest x-ray is necessary within 2-24 hours

Silvadene Cream

antimicrobial produces cooling sensation when applied

Femoral central venous catheters may be placed in emergency situations but should be removed/replaced

as soon as possible due to the high risk of contamination and infection

Latex allergies

assess for allergies to bananas, apricots, cherries, grapes, kiwis, passion fruit, avocados, chestnuts, tomatoes and peaches

The nurse should support a family member who wants to be present during the resuscitation of a client. The family member should be allowed to sit or stand in an area that is out of the way of the resuscitation team. A staff member should be

assigned to stay with the family member to explain the interventions taking place

Fall risks include using

assistive ambulatory devices, orthostasis, taking sedatives or antiparkinson medications, or being age >65-70

asthmaticus

asthmaticus - life threatening asthma attack

Using a syringe to measure medication for an infant is the most accurate technique to ensure that the proper amount is being administered. The extrusion reflex and a decreased gag reflex in infants age <4 months increase the risk of choking and aspiration. Using a syringe to instill the medication at the

back of the cheek decreases the risk of choking and ensures that the correct amount is consumed.

Clostridium difficile (C. diff)

bacterial infection, generally associated with antibiotic use, causing severe, watery loose stools

The nurse should first see the client who had bowel surgery, as hypotension can be a manifestation of

bleeding, hypovolemia, and early septic shock. The nurse should check vital signs and perform a cardiovascular exam, comparing findings with those documented in the immediate postoperative period from the post-anesthesia care unit (PACU).

occlusion

blockage

Therefore, it is critical for the perioperative nurse to screen for MH susceptibility by asking if any of the client's

blood relatives have ever experienced an adverse reaction to general anesthesia, including unexplained death

SIADH is an endocrine condition in which too much ADH is produced, causing water retention, increased total body water, and dilutional hyponatremia (low serum sodium). Some

cancer cells, particularly those of small cell lung cancer, have the ability to produce and secrete ADH, leading to SIADH. Other causes include central nervous system disorders (eg, stroke, trauma, neurosurgery) and some commonly used medications (eg, desmopressin, carbamazepine)

The nurse takes on the role of anesthetist when assisting with bedside procedural moderate sedation and

cannot leave the client during the procedure

Non-tropical sprue

celiac disease, gluten-induced enteropathy

CD4+ count < 200

cell count of 500/mm3 is within normal limits (500-1,200/mm3).

Nephrotic syndrome is characterized by massive proteinuria and hypoalbuminemia, which results in severe edema most evident in the abdomen, face, and perineum. Daily dipstick urinalysis determines the presence and pattern of urine protein loss to monitor for exacerbations. To collect a nonsterile urine specimen from a child who is not toilet trained, the nurse can place several

cotton balls in a dry diaper and later squeeze urine onto a dipstick. The diaper is checked frequently and the sample collected and tested within 30 minutes of urination for the most accurate result.

Legg-Calve-Perthes Disease

degeneration of femoral head due to avascular necrosis. disease is self limiting and has 4 phases: condensation, fragmentation, re-ossification and remodeling. presents with pain, decreased ROM, antalgic gait, positive Trendelenburg sign. primary treatment focus is to relieve pain and maintain femoral head in proper psition.

Gastric lavage is used to remove ingested toxins and irrigate the stomach after a drug overdose. It should be initiated within one hour of overdose. The nurse should position the client to prevent aspiration and have

emergency respiratory equipment at the bedside

Therapeutic conversation techniques (eg, active listening, using open-ended questions)

encourage the client to express feelings and ideas and establish an open, trusting relationship with the nurse.

Evidence-based practice guidelines recommend changing a continuous IV peripheral tubing administration set no earlier than

every 72 hours unless it becomes contaminated (institutional policies and procedures vary). Intermittent infusions and hypertonic solutions (eg, total parenteral nutrition, propofol, blood) require more frequent changes (eg, 4-24 hours) due to increased risk for infection.

myomectomy

excision of a fibroid tumor (myoma) from the uterus

Client falls can be prevented with

exercise programs, good lighting, handrails, and hourly staff rounds

Isotonic IV solutions, which have the same osmolality as plasma, are administered to

expand intravascular fluid volume and replace the fluid losses commonly associated with vomiting and diarrhea, burns, and traumatic injury.

Urine could be in the urethra and evident in the tubing even though the tip with the balloon is not in the bladder. It is necessary to

further insert the catheter before inflating the balloon to make sure the tip is in the bladder and not the urethra (causing urethral trauma). In the male client, it is recommended that the catheter be inserted 7-9 in (17-22.5 cm) or until urine flows out, due to the longer urethra. The catheter should then be inserted at least an additional 1 in (2.5 cm) or to catheter bifurcation.

When elder abuse is suspected, the nurse needs to perform further assessment to validate and confirm any initial findings and to determine the extent of the abuse and/or neglect. Areas of assessment for elder abuse include the client's

general hygiene, clothing, nutritional and hydration status, presence of other injuries, inappropriate medication administration, signs of depression, and other statements suggesting neglect.

The CDC suggests the following sequence for donning PPE:

hand hygiene, gown, mask or respirator, goggles or face shield, and gloves

Postoperative client care after general anesthesia requires careful monitoring for hypoxia. One of the first nursing interventions is

head tilt and chin lift to open an occluded airway.

Nosocomial infections are

hospital acquired infections

0.45 sodium chloride

hypotonic

A tracheostomy tube with inflated cuff is used in clients who are at risk for aspiration (eg, who are unconscious or on mechanical ventilation). However, an inflated cuff is uncomfortable for clients who are awake because it is difficult to swallow or talk. The cuff is deflated when the client is improving, is determined not to be at risk of aspiration, and is awake. Before the cuff is deflated, the client is asked to cough

if possible) to expectorate the oropharyngeal secretions that have built up above the inflated cuff. In addition, suction is applied through the tracheostomy tube and then the mouth; the cuff is then deflated.

The 45-year-old client has clinical findings of fatigue, abdominal pain, and a blood glucose level of 690 mg/dL (38.3 mmol/L) that indicate diabetic ketoacidosis. This client is at risk of life-threatening hemodynamic instability and needs

immediate treatment but can be seen after the child with status asthmaticus and impending respiratory deterioration. Severe respiratory instability takes precedence over hemodynamic instability.

When a client experiences an acute change or possible emergency, the nurse should

immediately obtain further clinical data about the client's status to ensure safety and physiological integrity. Additional clinical data on the client's respiratory status, circulation, and mentation should be obtained and appropriate actions taken

magnetic resonance cholangiopancreatography

is a noninvasive diagnostic test used to visualize the biliary, hepatic, and pancreatic ducts via MRI. MRCP uses oral or IV gadolinium (noniodine contrast material) and is a safer, less-invasive alternative to endoscopic retrograde cholangiopancreatography to determine the cause of cholecystitis, cholelithiasis, or biliary obstruction. uses MRI to visualize the biliary and hepatic ductal system. Contraindications, including pregnancy, the presence of certain metal implants, and an allergy to gadolinium (ie, noniodine contrast agent), should be assessed before the procedure.

Dopamine IV

is a vasopressor used to treat symptomatic hypotension.

adenosine (IV) (indication)

is an antiarrhythmic used to treat supraventricular tachycardia

portal hypertension

is an increase in the blood pressure within a system of veins called the portal venous system. Veins coming from the stomach, intestine, spleen, and pancreas merge into the portal vein, which then branches into smaller vessels and travels through the liver.

IV mannitol

is an osmotic diuretic that reduces cerebral edema by pulling water from the cerebral cells into the vasculature.

acromegaly

is an uncommon condition caused by growth hormone overproduction, leading to overgrowth of soft tissues of the face, hands, feet, and organs. Presence of extra heart sounds (ie, S3, S4) may indicate cardiomyopathy or heart failure.

Glargine (Lantus)

long acting insulin

Clients with diabetic ketoacidosis and in a hyperosmolar hyperglycemic state require IV

normal saline as a priority due to severe dehydration. Once fluids are given as a bolus, insulin is initiated. The serum potassium levels can be elevated in the initial stages despite low total body potassium. Potassium repletion is started once the elevated serum potassium levels are normal or low.

A BMI of 18.5-24.9 kg/m2 indicates a

normal weight

Children can have strokes. Ischemic strokes are more common in children with sickle cell disease. Other causes can include carotid abnormalities/dissection. The most common presentation of an ischemic stroke is the sudden onset of

numbness or weakness of an arm and/or leg. These are handled with a similar emergent approach as for stroke in an adult. Children may require exchange blood transfusion to prevent the stroke from worsening.

Left antecubital region

of or relating to the region of the arm in front of the elbow; "blood was drawn from the antecubital region

The client receiving teletherapy is taught measures to implement to protect the skin from infection and promote healing. Recommended skin care measures include taking a lukewarm shower daily, avoiding rubbing or scratching the skin, using

only approved lotions, shielding the skin from the effects of the sun, and avoiding extremes in temperature

The most important strategy to prevent accidental drug overdoses in children is teaching parents and caregivers to keep medicines

out of sight, in a locked drawer or cabinet. Parents/caregivers should also be advised to put drugs away after each use

Syndrome of Inappropriate Antidiuretic Hormone (SIADH)

overproduction of the antidiuretic hormone ADH, leading to bloating, water retention, and electrolyte imbalance

Acute exacerbation of chronic back pain is usually associated with inflammation triggered by (strenuous and/or repetitive) activities that stress the previously injured area. Interventions should be directed toward reducing inflammation. Nonpharmacological interventions to treat the inflammation include

postponing/avoiding pain-aggravating activities that may continue to promote inflammation and delay healing

Tympanostomy tubes or grommets are

pressure-equalizing tubes placed in the tympanic membrane to facilitate drainage of middle ear fluid (eg, for eustachian tube dysfunction or recurrent otitis media with effusion). One of this child's tubes has most likely fallen out of the eardrum. No immediate intervention is required; however, the health care provider should be notified.

Cardiac catheterization uses IV contrast to assess for artery obstruction. Complications include allergic reactions, lactic acidosis, and kidney injury. Contrast is avoided in clients who had a

previous allergic reaction to contrast agents, took metformin in the last 24 hours, or have renal impairment.

Airborne precautions protective equip

private room, neg pressure with 6-12 air exchanges/hr mask & respirator N95 for TB

tonsillectomy and adenoidectomy (T&A)

procedure to remove the tonsils and adenoids in patients with chronic tonsillitis and hypertrophy of the tonsils and adenoids

Seizure precautions are safety measures that typically include

raising the upper side rails, placing padding on the side rails, and preparing bedside suction and oxygen equipmen

Aspart insulin (Novolog®)

rapid acting insulin

The client with serious illness who exhibits anger may be experiencing anxiety, grief, or fear. The nurse should remain at a safe distance while attempting to diffuse the situation; assess the client's concerns using a calm, non-threatening approach;

reflect the client's statements; and try to understand the client's feelings, perceptions, and beliefs to address the priority problem

orchiectomy

removal of the testes

adenotonsillectomy

removal of tonsils and adenoids

After a needlestick injury, the nurse should

remove gloves, wash the area, report the incident to the facility exposure office, and proceed to employee health for baseline blood draw and possible postexposure prophylaxis.

The nurse can teach a client or caregiver to inject subcutaneous enoxaparin. The appropriate site of injection is on the

right or left side of the abdomen at least 2 in from the umbilicus

Enoxaparin comes in a prefilled syringe from the manufacturer. To ensure complete medication delivery, the air bubble should not be expelled prior to injection.The injection site should be on the

right or left side of the abdomen at least 2 inches from the umbilicus (Option 4). The needle should be inserted at a 90-degree angle into a pinched-up area of tissue (Option 3). To prevent excessive bruising, the nurse should discourage the client from rubbing the area around the injection site

Collection of a sputum specimen by expectoration is a sterile procedure that requires the client to breathe deeply and cough effectively. The nurse should instruct the client to

rinse the mouth with water, sit upright, inhale deeply several times, and cough prior to expectorating. The client should avoid touching the inside of the sterile container or lid. Sputum should be collected in the morning to improve sample quality.

The nurse can reinforce measures to minimize oral mucositis from chemotherapy and radiation therapy, including

rinsing the mouth with normal saline, brushing with a soft-bristle toothbrush, using a water-soluble lubricating agent, avoiding hot liquids and spicy/acidic foods, and applying prescribed viscous lidocaine

Routine catheter care to prevent health care catheter-associated urinary tract infections includes performing

routine hand hygiene and cleansing of the perineal area with soap and water, keeping the catheter bag below the bladder and off the ground, keeping the catheter and tubing free of kinks, facilitating urine drainage into the bag, and using sterile technique when collecting urine specimens.

Tracheostomy cuff

seals trachea, helps to prevent aspiration

Immediately post mastectomy, the client is placed in a

semi-Fowler's position to promote ease of breathing. The affected side's arm and hand should be elevated on several pillows to promote drainage and prevent lymphatic pooling

The Valsalva maneuver

straining during defecation) involves holding the breath while bearing down on the perineum to pass a stool. Straining to have a bowel movement is to be avoided in clients recently diagnosed with increased intracranial pressure, stroke, or head injury as straining increases intra-abdominal and intrathoracic pressure, which raises the intracranial pressure

When changing the dressing of a surgical incision, the nurse may wear clean gloves to remove the existing dressing but should wear

sterile gloves to apply a new one.

Clients with a health care-associated infection, such as methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant enterococci, are placed in contact precautions to limit the transmission of microorganisms through direct or indirect contact. A designated

stethoscope is usually kept in the client's isolation room. The health care practitioner should clean the stethoscope and earpieces with alcohol before use but should not remove them from the room

Docusate sodium (Colace)

stool softener

The client with a limited life expectancy will have concerns about completing personal business, such as ensuring that possessions go to the appropriate people. The nurse should assess

the client's needs and ensure that the plan of care will facilitate the client's life closure activities (eg, legacy building

When a feeding tube becomes clogged

the nurse should first attempt to unclog the tube by using a large-barrel syringe to flush and aspirate warm water in a back-and-forth motion through the tube. A digestive enzyme solution may help if warm water flushing is not effective.

When ambulating a client who is legally blind

the nurse uses the sighted-guide technique by walking slightly ahead with the client holding the nurse's elbow

The most important aspect of a client's refusal for treatment is to make sure that the client is informed of

the potential results of the refusal.

Respiratory distress is a life-threatening complication of

thyroid surgery that occurs when swelling in the surgical area at the base of the neck compresses the airway. Stridor and/or difficulty breathing in the client who has had thyroid surgery should be reported immediately to the registered nurse, and a rapid response should be activated

The most important measures to prevent bed bugs from getting onto apparel is to launder clothes in hot water, dry them using the highest temperature setting on a dryer, and then store them in

tightly sealed plastic bags. This will help to prevent additional bed bug infestation and transportation to other locations.

The nurse should instruct the client with chest and leg incisions from coronary artery bypass grafting to wash them daily with soap and water in the shower. In addition, the client must be instructed not to apply any powders or lotions to the incisions;

to report any redness, swelling, or drainage increase; and to wear an elastic compression hose on the legs

Quadriplegic CP

total body affected including face, neck, trunk, all equal involvement. usually seen in dyskineti and ataxic types.

Many Latin Americans believe in "mal de ojo," or "evil eye," a cultural belief in an illness thought to be manifested in children by vomiting, fever, and crying. It is believed to be caused when a stranger admires a child without

touching the child at the same time or immediately afterward.

When language is a barrier to effective communication and teaching, the nurse should use a

trained medical interpreter for translation purposes.

Early signs and symptoms of diabetic hypoglycemia include:

trembling, palpitations, anxiety/arousal, restlessness, diaphoresis, and pallor

Touching the client before speaking is appropriate for a client with hearing loss but may

upset or agitate a client with AD.

Hyperosmolar hyperglycemic state (HHS) is a serious complication of type 2 diabetes mellitus (DM). In HHS, the pancreas can produce enough insulin to prevent the breakdown of fats that would result in diabetic ketoacidosis (DKA) but not enough to prevent extreme hyperglycemia, osmotic diuresis, and extracellular fluid deficit. Therefore, DKA is usually associated with type 1 DM,

whereas HHS is usually associated with type 2 DM.

A nurse administers an intramuscular (IM) injection using the Z-track technique. Place the steps in chronological order

4. Pull the skin 1-1 ½" (2.5-3.5 cm) laterally and away from the injection site 3. Hold the skin taut with non-dominant hand and insert needle at a 90-degree angle 2. Inject medication slowly with dominant hand while maintaining traction 6. Wait 10 seconds after injecting the medication and withdraw the needle 5. Release the hold on the skin, allowing the layers to slide back to their original position 1. Apply gentle pressure at the injection site but do not massage

A category 4 hurricane has disrupted a rural, local health care system, creating a significant increase in emergency department admissions. Which client would the nurse anticipate as the priority for intervention?

A client with status asthmaticus is at risk for rapid deterioration of respiratory status and respiratory failure. The combination of status asthmaticus and an oxygen saturation ≤92% qualifies for the highest priority level of triage at any age.

Epiglottis

A flap of tissue that seals off the windpipe and prevents food from entering.

Cytomegalovirus (CMV)

A herpesvirus that can produce the symptoms of prolonged high fever, chills, headache, malaise, extreme fatigue, and an enlarged spleen.

isolation precautions

A method of infection control that assumed that all human blood and body fluids were potentially infectious.

C-reactive protein

A nonspecific protein, produced in the liver, that becomes elevated during episodes of acute inflammation or infection.

The nurse can prioritize care according to degree of urgency, extent of threat to the client's survival, and potential for complications. At this time, the other client's pain issue is of medium urgency and does not pose an immediate threat to survival. The most appropriate nursing action is to inform the second client that the nurse will be there soon and to complete the sterile dressing change Interrupting the sterile dressing change for an infected wound puts the client at risk for injury, as microorganisms can invade the uncovered wound. However, if the dressing change is lengthy, the nurse can delegate the task of medicating the second client to another nurse

A nurse can prioritize client needs and problems according to degree of threat to the client's survival and potential for complications. The nurse uses clinical judgment to decide which client situations require immediate attention and which can wait

The client's laboratory results show severe neutropenia, with a reduced white blood cell count and lowered absolute neutrophil count (normal >1500/mm3 [1.5x109/L]). Protection against infection is the most important goal for this client. The following neutropenic precautions are indicated:

A private room Strict handwashing Avoid exposure to people who are sick Avoid all fresh fruits, vegetables, and flowers Ensure that all equipment used with the client has been disinfected

Urine specimens are collected aseptically from the port located on the tubing of an indwelling urinary catheter; therefore, the client's collected urine should be measured and discarded (Option 1). Colonization and multiplication of bacteria within the stagnant urine in the collection bag may occur and cause incorrect results. Some urinary drainage bags are impregnated with an antimicrobial agent to help prevent catheter-associated urinary tract infections. However, the antimicrobial agents can also affect the results of urinalysis and culture.

A urine specimen is collected aseptically from the specimen port of an indwelling urinary catheter. Urine that has been collected from a bag does not yield accurate urinalysis and culture results.

A client with active herpes lesions has new prescriptions for oral acyclovir and topical lidocaine. What discharge teaching will the nurse reinforce to the client?

Acyclovir (Zovirax), famciclovir, and valacyclovir are commonly used to treat herpes infection as they shorten the duration and severity of active lesions. Genital herpes is a sexually transmitted infection caused by a herpes simplex virus and is highly contagious, especially when lesions are active. It remains dormant in the body even when active lesions are healed; however, it is still contagious, even when dormant. The infection can be spread to other people or other parts of the body via skin-to-skin contact; therefore, gloves should be used when applying topical antiviral or analgesic (eg, lidocaine) medications. There is no cure for genital herpes; treatment is aimed at relieving symptoms and preventing the spread of infection. (Option 1) Herpetic lesions should be kept clean and dry. They can be cleansed with warm water and soap or other solutions. Bandages should not be applied to the lesions. (Option 2) There is no cure for herpes infection, and recurrence of active lesions is common. Some clients may need long-term suppressive therapy. (Option 3) During periods of active lesions, barrier contraception is not sufficient to prevent the spread of infection; therefore, abstinence from sexual intercourse is indicated. Condoms should be used during periods of dormancy due to viral shedding. Educational objective: Genital herpes is a highly contagious, sexually transmitted infection for which there is no cure. Recurrences are common. Clients should be taught methods to prevent the spread of infection (using gloves to apply topical medication to active lesions, practicing abstinence from sexual intercourse when active lesions are present, using condoms when the virus is dormant).

Nursing interventions that help alleviate pain and anxiety include:

Administering anxiolytics (eg, lorazepam) and analgesics (eg, fentanyl) as needed to promote comfort and manage pain Using aromatherapy (eg, lavender oil) and music therapy, which can have calming effects Placing a fan at the bedside to circulate cool air to reduce the dyspnea and air hunger that can contribute to anxiety

Which client event would be considered an adverse event and would require completion of an incident/event/irregular occurrence/variance report?

Adverse events cause injury that is related to medical management, not the client's underlying condition. Identified areas are diagnostic, treatment, preventive or failure of communication, and equipment or other systems. Adverse events include falls, unreasonable delay in diagnostic tests, and failure to provide a prescribed treatment.

renal system physical assessment

Advise client to empty the bladder completely 4. Observe skin and contour of abdomen and lower back 2. Auscultate the renal arteries in right and left upper quadrants 5. Percuss and palpate both the right and left kidneys 3. Document the assessment of renal system function. Physical assessment of the renal system includes the techniques of inspection, auscultation, percussion, and palpation, in that order. Allow the client to empty the bladder before beginning the assessment and auscultate immediately after inspection as percussion or palpation may increase bowel motility and interfere with sound transmission during auscultation. Always document the findings.

A critical part of self-care for a person with a history of anaphylaxis is to use an emergency epinephrine injection (EpiPen or EpiPen Jr) when an anaphylactic reaction occurs. The client and/or the client's caregiver should be taught the following principles:

Always have the EpiPen readily accessible for emergency use, and carry (eg, purse, pocket, backpack) or have it within reach at all times Administer EpiPen at the first notable sign of anaphylactic symptoms, such as tightening or swelling of the airway, difficulty breathing, wheezing, stridor, or shock Administer the injection in the mid-outer thigh; it can be given through clothing Call 911 or go to the emergency department (ED) to receive care as soon as possible; ED staff will monitor for further complications

The nurse is caring for a client who has hospital-acquired pneumonia and is receiving amikacin. Which of the following findings indicate a possible adverse effect from the medication? Select all that apply.

Aminoglycoside antibiotics (eg, amikacin, gentamicin, tobramycin) are used to treat severe bacterial infections (eg, gram-negative bacteria, Staphylococcus, Mycobacterium tuberculosis) when other drugs have been ineffective or are contraindicated. Serious adverse effects of aminoglycosides include: Ototoxicity manifested by vertigo (vestibular damage) and tinnitus (cochlear damage) (Option 1) Nephrotoxicity manifested by: Elevated BUN (normal: 6-20 mg/dL [2.1-7.1 mmol/L]) Elevated serum creatinine (normal: 0.6-1.3 mg/dL [53-115 µmol/L]) (Option 2) Another potential adverse effect of aminoglycoside antibiotics is superinfection (eg, Clostridium difficile, pseudomembranous colitis) (Option 3). (Option 4) Fatigue, shortness of breath, and general malaise are common symptoms associated with hospital-acquired pneumonia. (Option 5) An elevated white blood cell count (normal: 4000-11,000/mm3 [4.0-11.0 × 109/L]) is an expected finding in a client with an active infection.

silver nitrate

An antiseptic and astringent with caustic properties causes dark staining of surrounding skin

An automated external defibrillator (AED) should be used as soon as it is available. Pediatric AED pads or a pediatric dose attenuator should be used for children age birth to 8 years if available. Standard adult pads can be used as long as they do not overlap or touch. If adult AED pads are used, one should be placed on the chest and the other on the back ("sandwiching the heart")

An automated external defibrillator (AED) should be used as soon as it is available. Adult AED pads can be used on a pediatric client if pediatric pads are unavailable. One pad is placed on the chest and the other is placed on the back ("sandwiching the heart")

External fixation stabilizes bone by inserting metal pins through skin into the bone and attaching them to a metal rod outside the skin. The nurse should assess this client first as any signs and symptoms of an infection (eg, low-grade fever, drainage, pain, redness, swelling) warrant immediate evaluation and treatment. Localized pin tract infection can progress to osteomyelitis, a serious bone infection that requires long-term treatment with antibiotics.

An external fixator stabilizes bone by inserting metal pins through skin into the bone and attaching them to a metal rod outside the skin. Signs and symptoms of infection (eg, fever, drainage, pain, redness, swelling) warrant immediate evaluation and treatment with antibiotics as these can progress to osteomyelitis, a serious bone infection.

The best option is room 4 with the client who has severe epistaxis and decreased platelet count (normal 150,000-400,000/mm3) as this does not place the immediate post-operative client at increased risk for infection.

An immediate post-operative client should not be assigned a bed in a room with a client who is contagious or potentially infected as this poses an increased risk for infection

Assigning the immunocompromised client to the room with a client with an upper gastrointestinal bleed is the best option as it does not put the client with AIDS at increased risk for infection. All the other options increase the risk for infection in this client

An immunocompromised client should not be assigned to a room with a client who is contagious or potentially infectious as there is an increased risk for infection

Menires disease

An inner ear disorder that causes episodes of vertigo (spinning). Self-care Low sodium diet A diet that restricts salt (sodium chloride) and other forms of sodium to no more than 2,000 mg per day Avoid caffeine Reduces risk of aggravating certain conditions. Avoid tobacco Reduces risk of developing or worsening certain medical conditions. Avoid chocolate Reduces risk of aggravating certain conditions.

The health care provider (HCP) explains the risks and benefits of a procedure to the client through an interpreter. The HCP leaves after asking the nurse to witness the client's signature on the consent. The interpreter and client now have a lengthy discussion in the foreign language. The nurse should take which action at this time?

An interpreter should only provide literal translation of the words spoken by the HCP, not adding any personal advice/information. The nurse should clarify if there is any question about the accuracy or content of the translation and ensure the client's concerns have been addressed prior to obtaining the signature on the consent.

An elderly war veteran with prostate cancer and coronary artery disease is hospitalized for urosepsis. The client becomes angry with one of the unlicensed assistive personnel (UAP) who is trying to help the client bathe. Later, the UAP expresses frustration with the client to the nurse. Which statement would be the most appropriate response?

Anger is often a symptom of psychological distress associated with anxiety, fear, or loss of control. An appropriate response to an angry client is to listen with an open, accepting attitude and collaborate with the client and other staff to create a care plan that addresses psychological and physical needs.

The PPE removal process after caring for a client with Ebola requires strict monitoring by a trained observer. The outer gloves are first cleaned with disinfectant and removed. The inner gloves are

wiped between removal of every subsequent piece of PPE (eg, respirator, gown) and removed last.

Kussmaul breathing is characterized by regular but rapid, deep respirations and is associated with conditions that cause metabolic acidosis (eg, renal failure, diabetic ketoacidosis, shock). Kussmaul breathing would be

expected in this client as it is a compensatory action by the lungs to excrete excess acid from the body by hyperventilating, thereby blowing off carbon dioxide (acid gas).

The suppository must be inserted past both the

external and internal sphincters for proper placement. If not inserted far enough, it may be expelled before achieving a therapeutic effect

Myxedema coma

extreme hypothyroidism(abrupt med cessation), rare with a high mortality rate = decreased cardiac output leads to decreased tissue perfusion which leads to brain and organ depletion leading to multi-organ failure. The nurse should provide respiratory support (eg, ventilation with a bag-valve-mask) and prepare to assist with intubation

The nurse should ensure that multiple interventions are put in place for the client at high risk for falls. These include

placing the bed in the lowest position with 2-3 side rails up, identifying the client with a fall risk ID band, using bed alarms, and making frequent rounds on the client.

Basic steps for suppository administration include the following:

Apply clean gloves and position the client appropriately based on age and size (eg, infant supine with knees and feet raised, older child side-lying with knees bent) (Option 4). Lubricate the tip of the suppository with water-soluble jelly. Petroleum-based products can reduce absorption. Insert the suppository past the internal sphincter using the fifth finger if the child is under 3 years (Option 5). Use of the index finger may cause injury to the colon or sphincters in children younger than age 3 years. Angle suppository and guide it along the rectal wall. The suppository should remain in contact with the rectal mucosa (and not be buried inside stool) to ensure systemic absorption (Option 2). Hold the buttocks together for several minutes, or until the urge to defecate has passed, to prevent immediate expulsion (Option 3). If a bowel movement occurs within 10-30 minutes, observe for the presence of the suppository. (Option 1) The suppository must be inserted past both the external and internal sphincters for proper placement. If not inserted far enough, it may be expelled before achieving a therapeutic effect.

Ear irrigation may be prescribed to remove impacted or excess cerumen; the following steps describe this procedure:

Assess client for contraindications (eg, fever, ear infection). Use an otoscope to inspect the external ear canal. Verify that the tympanic membrane is intact and ensure there are no foreign bodies Explain the procedure to the client, including possible sensations (eg, vertigo, fullness, warmth). Place the client in a side-lying or sitting position with the head tilted toward the affected ear (Option 4). Place a towel and an emesis basin under the ear Verify that the irrigation solution is at body temperature (98.6 F [37 C]) to minimize discomfort. Straighten the ear canal, pulling the pinna up and back for adults or down and back for children age ≤3 years Irrigate gently with a slow, steady flow of solution, directing the syringe tip toward the top of the ear canal Avoid occluding the canal to prevent increased pressure and rupture of the tympanic membrane. Stop immediately if the client experiences severe pain, nausea, or dizziness. Repeat as tolerated until the ear canal is clear or the prescribed amount is instilled. Document the type, temperature, and volume of solution; exudate characteristics; response to the irrigation; and client teaching.

Nursing interventions to reduce aspiration risk in clients receiving enteral tube feedings include:

Assess client for gastrointestinal intolerance to feedings every 4 hours by monitoring gastric residual and assessing for abdominal distension and pain, bowel movements, and flatus Assess feeding tube placement at regular intervals. Keep head of the bed at ≥30 degrees, with 30-45 degrees being optimal, to reduce gastroesophageal reflux and aspiration risk unless otherwise indicated Keep the endotracheal cuff inflated at appropriate pressure (about 25 cm H2O) for intubated clients as low cuff pressure increases the risk for aspirating oropharyngeal secretions and/or gastric contents Suction any secretions that may have collected above the endotracheal tube before deflating the cuff, if deflation is necessary. Use caution when giving sedatives and frequently monitor for oversedation, which can slow gastric emptying and reduce gag reflex Avoid bolus tube feedings for clients at high risk for aspiration.

The correct administration of nasal medication includes

pointing the nasal spray tip toward the side and away from the center of the nose.

Skin assessment, proper skin care, repositioning every 2 hours, adequate nutrition, and proper support surfaces are effective in helping

prevent pressure injuries

If an IV infusion pump displays an alarm without an identifiable problem, the nurse should

replace the pump. Malfunctioning equipment may harm the client and should be removed from the care area. The equipment is labeled as out of service and sent for maintenance.

Active Pulmonary Tuberculosis

requires airborne precautions. Clients suspected of having tuberculosis should be given a surgical mask to wear on entering any health care setting. Clients are placed in negative-pressure isolation rooms. Nurses must use a class N95 or higher particulate respirator

If a client reports cramping or pain during instillation of an enema, the infusion should be

stopped for 30 seconds and then resumed at a slower rate

A hospitalized client is scheduled for a percutaneous kidney biopsy at 10 AM. The practical nurse reviews the client's vital signs and most current serum laboratory results at 8 AM. Which client finding is most important to report to the registered nurse? 1. Blood pressure of 180/100 mm Hg [41%] 2. Creatinine of 2 mg/dL (177 µmol/L) [19%] 3. Hemoglobin of 9.8 g/dL (98 g/L) [14%] 4. Platelet count of 120,000/mm3 (120 × 109/L)

Blood pressure The kidney is a highly vascular organ; therefore, uncontrolled hypertension is a contraindication for kidney biopsy as increased renal arterial pressure places the client at risk for post-procedure bleeding. Blood pressure must be lowered and well controlled (goal <140/90 mm Hg) using antihypertensive medications before performing a kidney biopsy

cholecystectomy (chole)

surgical removal of the gallbladder / Postoperative clients are at an increased risk for vomit aspiration due to nausea and an altered level of consciousness (caused by anesthesia). These clients should be placed on their side and should receive antiemetics to prevent potential airway and breathing complications.

A client expresses concern about facial appearance after surgery for excision of a melanoma on the side of the nose. What is the best response by the nurse?

Clients facing surgery often have concerns and anxiety over the procedure, postoperative course, outcome, and altered body image. Providing information about the surgical procedure, healing process, and self-care activities, and giving support will lessen anxiety and give the client a sense of control.

The nurse cares for an elderly client with type II diabetes who was diagnosed with diabetic retinopathy. Which statement by the client requires the most immediate action by the nurse?

Chronic hyperglycemia can cause microvascular damage in the retina, leading to diabetic retinopathy, the most common cause of new blindness in adults. Option 1 indicates a retinal detachment requiring emergency management. A partial retinal detachment may be painless and cause symptoms such as a curtain blocking part of the visual field, floaters or lines, and sudden flashes of light. An unrepaired complete retinal detachment can cause blindness. (Option 2) The need for reading glasses is associated with presbyopia and is a common, nonemergency, age-related visual disorder. (Option 3) Cloudy vision with a glare is associated with a cataract, a nonemergency, age-related visual disorder. (Option 4) Although decreased vibrancy of colors is a sign of diabetic retinopathy and requires intervention, it is not indicative of a partial or complete retinal detachment; therefore, it is not an emergency. Educational objective: Chronic hyperglycemia can cause microvascular damage in the retina, leading to diabetic retinopathy, the most common cause of new blindness in adults. A partial retinal detachment may be painless and cause symptoms such as a curtain blocking part of the visual field, floaters or lines, and sudden flashes of light.

Repositioning and transferring clients are tasks that the nurse can assign to unlicensed assistive personnel (UAP) when they are deemed safe and appropriate. The nurse is responsible for providing UAP with detailed instructions, including when to move the client, which techniques to use, and when to ask for assistance or use assistive devices. The nurse must also notify UAP of any client mobility restrictions. However, certain clients (eg, critical illness, spinal cord stabilization) will require the presence of a nurse for repositioning or moving (Option 4). The client who is 8 hours post hip replacement surgery would require a nursing assessment prior to a position change. The nurse should intervene in this case as the client could be at risk for hip dislocation with position changes. In addition, the client may have a wedge device to maintain abduction; nursing judgment is required

Client repositioning and transferring can be assigned to unlicensed assistive personnel if these tasks are deemed safe and appropriate. However, the nurse is responsible for providing instructions to maintain client safety. The nurse should intervene if a task is performed inappropriately or if it requires the presence of a nurse (eg, spinal cord stabilization).

following adenotonsillectomy due to irritation of the ninth cranial nerve (glossopharyngeal) in the throat, causing referred pain to the ears. This is a normal, expected finding.

Clients often report ear pain (otalgia)

Postprocedure care of a client who has undergone cardiac catheterization should focus on monitoring hemodynamics (eg, blood pressure, heart rate, strength of distal pulses, temperature of extremities). The client should be also assessed several times per hour (eg, approximately every 15 minutes) for active bleeding or hematoma formation at the incision. Any report of back or flank pain should be investigated for possible retroperitoneal bleeding. Back pain, tachycardia, and hypotension may be the only indications of bleeding as it can take up to 12 hours before a significant drop in hematocrit can be measured. Hemorrhage after cardiac catheterization is particularly dangerous due to the frequent use of anticoagulant prescriptions in these clients.

Clients with any indication of compromised airway, breathing, or circulation always take priority. The onset of back pain after angiography always requires further assessment to monitor for retroperitoneal bleeding

The nurse is caring for a client with immune thrombocytopenic purpura. Which client statements indicate a need for further teaching?

Clients with immune thrombocytopenic purpura (ITP) have low platelet counts and an increased risk of bleeding. Appropriate care for clients with ITP includes safe exercise; using stool softeners, electric razors, and soft-bristle toothbrushes; and avoiding nonsteroidal anti-inflammatory

Catheter-associated urinary tract infections are prevalent in hospital settings. Indwelling urinary catheters should only be used when appropriate. Appropriate uses include the following:

Clients with urinary obstruction or retention, or a need for strict intake and output in critically ill clients Perioperative use for surgical procedures such as urologic surgery or prolonged surgeries, or when large doses of fluid or diuretics are given during surgery During prolonged immobilization when bedrest is essential To improve end-of-life comfort To facilitate healing of an open perineal or sacral wound in incontinent clients

A nurse prepares to administer an intermittent enteral feeding via nasogastric tube to a client with a prescription for gastric residual checks before each feeding. The nurse obtains a gastric residual volume of 80 mL. Which action should the nurse perform next?

Collect gastric pH measurement / Before administering enteral feedings, the nurse must verify tube placement (eg, gastric pH measurement). Administration of enteral feeding through a misplaced feeding tube may result in life-threatening aspiration / However, GRV of 80 mL is not excessive and should be returned to the stomach.

The nurse is caring for a 6-year-old who is postoperative open right tibial fracture reduction with cast placement. Which finding requires priority action?

Compartment syndrome is a limb-threatening emergency that can occur after fracture reduction. Neurovascular checks should always be performed first. The client should not have numbness or tingling. If pain is not relieved (especially with passive range of motion) by prescribed pain medication or is out of proportion to the injury, the nurse should notify the health care provider.

Antacids containing calcium and aluminum cause

Constipation

The clinic nurse is caring for a client who had cataract surgery with intraocular lens implantation 2 days ago. Which client report requires priority intervention?

Constipation / straining / Following cataract surgery, the client will be instructed that, for several days (or until approved by the surgeon), activities that may increase intraocular pressure should be avoided to decrease the risk of damage to sutures or surgical sites. These include bending (eg, vacuuming floors, playing golf), lifting more than 5 lb, sneezing, coughing, rubbing or placing pressure on the eye, or straining during a bowel movement. The nurse should encourage this client to increase fluids and fiber in the diet as well as consider an over-the-counter stool softener or laxative. (Option 1) It may take 1-2 weeks before visual acuity is improved. (Option 3) It is common for the client to experience itching ("sand" in the eye), photophobia, and mild pain for several days following surgery. Purulent drainage, increased redness, and severe pain should be reported. (Option 4) Sleeping on 2 pillows will elevate the head and decrease intraocular pressure. Educational objective: Following cataract surgery, the client should be instructed to avoid for several days those activities that may increase intraocular pressure, such as coughing, sneezing, lifting over 5 lb, bending, rubbing the eye, or straining during bowel movements. It is common for the client to experience itching ("sand" in the eye), photophobia, and mild pain during this time frame.

The nurse is caring for an elderly client after hip replacement surgery. The client is distressed because he has not had a bowel movement in 3 days. Which action by the nurse would be most appropriate?

Constipation may be a side effect of anesthesia, pain medication, physiological stress, and/or immobility. The nurse's first priority is to assess the client perform a focused abdominal assessment

A chronic subdural hematoma involves bleeding into the subdural space that can occur several weeks to months following a mild head trauma. Those clients taking anticoagulants are at high risk. Older individuals are also at high risk as they are vulnerable due to age-related changes in the brain and increased risks for falls. Manifestations indicating a chronic subdural hematoma (eg, headache, gait disturbance, memory loss, decreased level of consciousness) should be investigated immediately as the condition can lead to increased intracranial pressure and death.

Elderly clients and individuals taking anticoagulants are especially vulnerable to developing a chronic subdural hematoma. Manifestations of the condition (eg, headache, gait disturbance, memory loss, confusion) should be investigated immediately as this neurologic emergency can lead to increased intracranial pressure and death.

The nurse is to administer prescribed heparin 70 units/kg IV bolus before initiating the continuous infusion as prescribed. Heparin 1,000 units/mL is available. The client weighs 108 lb. How many milliliters of heparin bolus should the nurse administer? Record your answer using one decimal place.

To calculate the volume per dose of heparin, the nurse should first identify the prescribed dose (eg, 70 units/kg/dose) and available medication (eg, 1000 units/mL) and then convert to volume in milliliters per dose (eg, 3.4 mL)

The American Diabetes Association recommends a simple "Create My Plate" method for meal planning. Specific dietary recommendations include the following:

Monitor carbohydrate intake Manage caloric intake if weight loss is desired Consume high-fiber foods (30-35 g of fiber per day), including whole grains, legumes, fruits, vegetables, and low-fat dairy products Use monounsaturated fats, limit use of saturated fat, and eliminate trans fatty acids Choose foods with a low glycemic index Consume <300 mg per day of total cholesterol Reduce sodium intake Limit intake of foods containing sucrose Limit intake of alcoholic beverages

During IV therapy, the nurse should monitor the site to assess for patency and signs of infection (eg, redness, drainage, edema, discomfort, warmth, coolness, hardness). Infiltration is a complication that occurs when solution infuses into the surrounding tissues of the infusion site.

Interventions include: Discontinuing the IV line immediately and starting a new IV, preferably on the opposite extremity Continuing to monitor the infiltration site for swelling or other abnormalities (eg, redness, warmth, coolness) Elevating the affected extremity to decrease swelling Notifying the health care provider if severe complications (eg, cellulitis, tissue necrosis, nerve damage) develop Applying a cold or warm, moist compress based on the solution infiltrated. Heat is avoided when extravasation of a vesicant (ie, drug capable of causing tissue necrosis) occurs.

An inguinal hernia is a protrusion of intraperitoneal contents (eg, bowel, tissue) through a weakened area in the abdominal wall (eg, groin, scrotum). Clients may experience dull pain exacerbated by exercise or straining and a palpable bulge on assessment. A hernia is reducible if the organs can be returned to the peritoneal cavity by applying pressure to the bulge; and incarcerated, if they cannot. Manifestations of a mechanical bowel obstruction (eg, pain, distension, nausea, vomiting) are caused by compressed loops of bowel incarcerated by the hernia. Subsequent bowel ischemia and strangulation can lead to infection and death. Immediate evaluation and urgent surgical intervention are critical.

Intestinal obstruction and strangulated bowel are life-threatening complications associated with an incarcerated hernia and require immediate evaluation and urgent surgical intervention.

occurs when one portion of the intestine prolapses and then telescopes into another. It is a frequent cause of intestinal obstruction during infancy. Onset is abrupt, initially with pain and brown stool. The condition then progresses to bilious emesis, palpable abdominal mass, and stools with a red, "currant jelly" appearance due to blood and mucus. This is an expected finding for this condition

Intussusception

Cushing syndrome (overproduction of steroid hormones) produces "opposite" symptoms from Addison disease. Clients have

truncal obesity, "buffalo hump" (fat deposits in the shoulders), hyperglycemia from excess glucocorticoids, and hypertension from excess aldosterone. Increased sex hormones cause hirsutism (male-pattern hair growth in females). Immune suppression from increased glucocorticoids increases the risk of infection and delays healing.

The N95 respirator should be worn to reduce the risk of contracting what disease?

tuberculosis

Palliative care focuses on quality of life and symptom management (eg, pain, dyspnea, fatigue, constipation, nausea, loss of appetite, difficulty sleeping, depression).

It can be given concurrently with life-prolonging treatment in the setting of terminal disease. Palliative care is provided by a multidisciplinary care team with a focus on the clients and their families. / The main difference between palliative care and hospice is that clients receiving palliative care can receive concurrent curative treatment. Hospice care is only started once the client decides to forego curative treatment.

The nurse administers 15 units of aspart insulin subcutaneously at 7:00 AM to a hospitalized client with type 1 diabetes mellitus for a fasting blood glucose of 180 mg/dL (10.0 mmol/L). Which nursing action is a priority?

It is important for the nurse to ensure that the client eats within 15 minutes of administration of rapid-acting insulins such as aspart (NovoLog), lispro (Humalog), and glulisine (Apidra) to prevent an insulin-related hypoglycemic reaction

Thorazine (chlorpromazine)

typical antipsychotic watch for sore throat signs of infection

Signs of potential cancer include

unplanned weight loss, nagging cough/hoarseness, and dimpled skin (orange peel) on the breast. Hard, fixed masses; nonhealing ulcers; and changing moles may also indicate malignancy and require further workup

When administering otic medication to children age 3 and older, the pinna is pulled

upward and back to straighten the ear canal. The child is placed in a prone or supine position with the head turned to the appropriate side, and the medication is allowed to drop against the wall of the canal.

Open endotracheal (ET) suctioning is a skill performed to remove pulmonary secretions and maintain airway patency in clients who are unable to clear secretions independently. ET suctioning is important to promote gas exchange and prevent alveolar collapse, but inappropriate technique increases the client's risk for complications (eg, pneumonia, hypoxemia) or tracheal injury (eg, trauma, bleeding). To reduce the risk of complications and injury during ET suctioning, the nurse should:

Preoxygenate with 100% oxygen and allow for reoxygenation periods between suction passes (Option 1) Suction only while withdrawing the catheter from the airway (Option 2) Use strict sterile technique throughout suctioning (Option 5) Limit suctioning to ≤10 seconds on each suction pass

The nurse is caring for a client with a history of type 2 diabetes mellitus who reports feeling lightheaded and shaky. The client's finger-stick blood glucose is 58 mg/dL. Which action should the nurse take next?

For alert clients with hypoglycemia (blood glucose <70 mg/dL), the nurse should provide 15 g of simple carbohydrates (eg, 4 oz fruit juice, 8 oz low-fat milk). Blood glucose is rechecked 15-30 minutes later. After resolution of hypoglycemia, a carbohydrate snack with fats and proteins is given to prevent relapse

Alzheimer disease & eating problems

Forgetting that a meal was consumed due to short-term memory loss Anorexia & weight loss secondary to depression &/or recognition of the disease Middle stages Forgetting to eat at all Not recognizing the sensations of hunger & thirst Forgetting how to use utensils Consuming nonfood items Refusing to eat Restlessness: Inability to sit long enough to consume a meal Later stages Inability to feed oneself Dysphagia

The practical nurse is collaborating with the registered nurse to develop a care plan for a homeless client just brought into the emergency department with frostbite to the fingers and toes. The client is experiencing numbness, and assessment shows mottled skin. Which interventions should be included in the client's plan of care? nonadherent, sterile dressings

Frostbite involves tissue freezing, resulting in ice crystal formation in intracellular spaces that causes peripheral vasoconstriction, reduced blood flow, vascular stasis, and cell damage. Superficial frostbite can manifest as mottled, blue, or waxy yellow skin. Deeper frostbite may cause skin to appear white and hard and unable to sense touch. This can eventually progress to gangrene. Treatment of frostbite should include the following: Remove clothing and jewelry to prevent constriction. Do not massage, rub, or squeeze the area involved. Injured tissue is easily damaged (Option 3). Immerse the affected area in water heated to 98.6-102.2 F (37-39 C), preferably in a whirlpool. Higher temperatures do not significantly decrease rewarming time but can intensify pain (Option 5). Avoid heavy blankets or clothing to prevent tissue sloughing. Provide analgesia as the rewarming procedure is extremely painful (Option 4). As thawing occurs, the injured area will become edematous and may blister. Elevate the injured area after rewarming to reduce edema (Option 2). Keep wounds open immediately after a water bath or whirlpool treatment and allow them to dry before applying loose, nonadherent, sterile dressings (Option 1). Monitor for signs of compartment syndrome. Educational objective: Care of the client with frostbite focuses on preventing further injury and reducing pain. This includes removing items that can cause constriction or sloughing; no massaging or rubbing of the injured area; providing warm water soaks and analgesia; elevating injured areas; applying loose, nonadherent, sterile dressings; and monitoring for compartment syndrome.

The nurse performs tracheostomy care for a client with a disposable inner cannula and tracheostomy dressing. Place the steps in the correct order. All options must be used

Gather supplies and position client 2. Don mask, goggles, and clean gloves 5. Remove soiled dressing 3. Don sterile gloves; remove old disposable cannula and replace with a new one 1. Clean around stoma with sterile water or saline; dry and replace sterile gauze pad

When performing tracheostomy care, the nurse follows institution policy and observes principles of infection control and client safety. Sterile technique is used to prevent infection of the lower airway. The steps for performing the procedure for a client with a disposable inner cannula include the following:

Gather supplies to the bedside, then place client in semi-Fowler's position, if not contraindicated, to promote lung expansion and oxygenation and prevent aspiration of secretions. Don personal protective equipment (mask, goggles, and clean gloves) to maintain universal precautions. Auscultate lungs and suction secretions if necessary. Remove soiled dressing and also remove clean gloves. Don sterile gloves; remove old disposable cannula and replace with a new one. While stabilizing the back plate with the nondominant hand, unlock (unclip) the old cannula with the dominant hand; remove gently by pulling it out in line with its curvature; pick up the new cannula, touching only the outer locking portion (to prevent contamination and maintain asepsis); insert; and lock (clip) into place. Clean around stoma with sterile water or saline, dry and replace sterile gauze pad to remove dried secretions, and dry around stoma well to limit the growth of microorganisms. Some tracheostomy tubes are sutured in place and do not require a dressing. If secretions are copious, apply a dressing.

The practical nurse is reinforcing discharge teaching to a client seen for treatment of a second episode of acute gout. Which instructions should be included to prevent future exacerbations? Select all that apply.

Gout is an inflammatory condition caused by ineffective metabolism of purines that results in an accumulation of uric acid in the blood. Uric acid crystals typically form in the joints. Kidney stones can also develop, increasing the risk of kidney damage. Increasing fluid intake (2-3 L/day) reduces the risk of urate crystal deposits and prevents formation of kidney stones. Obese clients with medical risk factors (eg, hypertension, dyslipidemia, insulin resistance) and other lifestyle factors (eg, poor diet, alcohol consumption, lack of exercise) have increased risk for future gout attacks. Prevention should focus on lifestyle and dietary modifications. (Option 2) An increased risk of gout is not seen with consumption of diet sodas. (Option 3) Avoiding all foods containing protein is unpalatable and impractical. Educational objective: Weight loss and dietary modifications may reduce the frequency of acute gout episodes. These strategies include increasing fluids, restricting alcohol consumption, and avoiding red meat and seafood to reduce purine accumulation.

In this scenario, it is unknown when home care visits will resume due to severe inclement weather. The high-priority clients are those who are at risk for harm if a scheduled visit cannot be made in 24 hours or more. The client who fell could have sustained a head injury and needs assessment. The client in need of pre-filled insulin syringes could become hyperglycemic if insulin is unavailable. The client with the stage 3 pressure injury has a scheduled dressing change for a serious wound and this should not be postponed. (Option 2) Maintenance doses of cyanocobalamin for vitamin B12 deficiency are usually administered every 4 weeks. Although this client should receive the injection as soon as possible, postponing the home care visit for 1 or 2 days will not harm the client. (Option 4) This client can be provided with telephonic care management; the nurse can perform medication reconciliation over the phone and provide instructions regarding care.

High priority - unstable clients who need care and are at risk for hospitalization if not seen. Moderate priority - clients who are moderately stable and will suffer no harm if a visit is postponed; telephonic care management can be provided to these clients. Low priority - clients who are stable and can engage in self-care and/or have a caregiver who can provide or assist with care.

The target serum glucose level for clients receiving nutritional support (eg, total parenteral nutrition [TPN]) is 140-180 mg/dL. Hypoglycemia (serum glucose <70 mg/dL) may occur with an interruption or slowed rate of tube feedings or TPN infusion, insufficient dextrose in TPN formula, or excessive insulin administration. Although hyperglycemia (serum glucose of >180 mg/dL) is a more common adverse effect of nutritional support, hypoglycemia can occur and cause life-threatening complications (eg, seizures, nervous system dysfunction).

Hypoglycemia (serum glucose <70 mg/dL) can result in life-threatening complications (eg, seizures, nervous system dysfunction). It should be treated with supplemental glucose, and the health care provider should be notified.

Addison disease (chronic adrenal insufficiency) occurs when the adrenal glands produce inadequate amounts of steroid hormones (eg, mineralocorticoids, glucocorticoids, androgens). It is characterized by:

Hypoglycemia, weight loss, and muscle weakness: A deficit of glucocorticoids (eg, cortisol) decreases the amount of liver glycogen and prevents gluconeogenesis (Option 4). Hyperpigmented skin, especially on the knees, elbows, buccal area, and palmar creases: Low cortisol triggers the production of excess ACTH from the pituitary gland. Hypotension: A deficit of aldosterone prevents the retention of water and sodium. Hyperkalemia: Potassium is retained when sodium is lost in urine.

An elderly client at the end of life is visited by family members. One begins to cry and asks the nurse, "Will you please stay for a few minutes?" The nurse has other clients to care for as well. Which statement by the nurse is the most helpful?

I can stay and sit with you if you would like / During the end-of-life process, the client and family members typically go through several emotional stages, each requiring therapeutic communication techniques by the nurse. The nurse can help the client and family by providing a few minutes of time and attention. The nurse should validate the family's needs by providing emotional support.

Contact precautions Organisms MDR organisms (eg, MRSA, VRE) Enteric organisms (eg, Clostridium difficile) Scabies

Infection-control measures Hand hygiene (soap & water for C difficile) Nonsterile gloves Gown Private room preferred

Contact precautions are used for what diseases?

Infections caused by methicillin-resistant Staphylococcus aureus(MRSA), C difficile, vancomycin-resistant Enterococcus (VRE), and scabies require contact precautions to be used.

Oral mucositis/stomatitis

Inflammation & ulceration of oral mucous membranes; can increase risk for pain, oral & systemic infection, & nutritional compromise

Glyburide is used to treat diabetes mellitus, and it can cause significantly low blood sugar if ingested by a client who does not have diabetes, especially a child. Based on the symptoms the child is exhibiting (irritability, confusion), hypoglycemia is likely. This client requires immediate intervention as severe hypoglycemia can result in coma and/or death.

Ingestion of antidiabetic drugs (eg, glyburide, glipizide, glimepiride) by a nondiabetic client (eg, child) is an emergency as severe hypoglycemia can result in coma and/or death.

Exophthalmos is a complication of hyperthyroidism (hypermetabolic state due to thyroid hormone overproduction) from Graves disease. It is defined as protrusion of the eyeballs caused by increased orbital tissue (connective, adipose, muscular) expansion and can be irreversible. The exposed cornea is at risk for dryness, injury, and infection. Nursing care for a client with exophthalmos includes the following:

Maintaining the head of the bed in a raised position to facilitate fluid drainage from the periorbital area Using artificial tears or similar products to moisten the eyes to prevent corneal drying (causes abrasions/ulcers) (Option 1) Taping the client's eyelids shut during sleep if they do not close on their own (Option 2) Teaching the client the following: Regular visits to the ophthalmologist are necessary to measure eyeball protrusion and evaluate the condition. If recommended, anti-thyroid drugs should be used to prevent further exacerbation of exophthalmos. Smoking cessation is necessary as smoking increases the risk of Graves disease and associated eye problems (Option 4). Restrict salt intake to decrease periorbital edema. Use dark glasses to decrease glare and prevent external irritants and infection

A female client is admitted to the emergency department after a motor vehicle collision. The client is unresponsive and on a mechanical ventilator. Which actions should the nurse perform?

Medication patches should not be removed / Medical alert bracelets/necklaces: Indicating allergy status, emergency contact, or code status Contact lenses: Remove to prevent corneal injury Medication patches: To prevent drug interactions and determine conditions currently being treated Tampons (in female clients): Remove to prevent toxic shock syndrome or infection Rings and jewelry: Remove to prevent constrictive injury or vascular damage if edema develops

A Native American client is hospitalized for depression and attempted suicide. Family members have requested that they be allowed to bring in a medicine healer to perform a ritual on the client. Which of the following is the best action by the nurse?

Medicine healers, or shamans, are an important component of Native American and other cultural groups. Allowing medicine healers to perform rituals and ceremonies will ensure that clients' spiritual needs are met and may contribute to the healing process. The nurse needs to recognize and be tolerant of health practices and beliefs that are different from those of traditional Western medicine

The nurse working in an extended care facility transcribes a prescription from the health care provider for a single daily dose of 150 mg of ranitidine; this is to be taken orally at bedtime for treatment of gastroesophageal reflux disease. Of the following prescriptions, which one is transcribed correctly?

Using approved abbreviations when transcribing health care provider prescriptions promotes client safety and prevents potential medication administration errors. Common abbreviations (per os, qhs, qd) can result in errors and should not be used

The nurse is monitoring a client with suspected pulmonary tuberculosis. Which characteristic signs and symptoms does the nurse expect? Select all that apply.

Mycobacterium tuberculosis (TB) is a gram-positive, acid-fast bacillus that is transmitted through the airborne route. TB is usually (85%) pulmonary but can also be extrapulmonary (eg, meninges, genitourinary, bone and joints, gastrointestinal). Clinical manifestations of TB, regardless of location, include: Low-grade fever Night sweats Anorexia and weight loss Fatigue Additional symptoms depend on the location of the infection. Pulmonary TB typically includes: Cough Purulent or blood-tinged sputum (hemoptysis) Shortness of breath Dyspnea Dyspnea and hemoptysis are typically seen in the late stages. The classic manifestations of TB can be absent in immunocompromised clients and the elderly. (Option 1) Dysuria is a symptom of extrapulmonary genitourinary TB. (Option 2) Jaundice can be present in disseminated TB with liver involvement. It can also be a side effect associated with drugs used to treat pulmonary TB (eg, isoniazid). (Option 3) Back pain is a symptom of spinal TB. Educational objective: Characteristic signs and symptoms associated with tuberculosis (TB) infection, regardless of location, include low-grade fever, night sweats, anorexia, weight loss, and fatigue. Pulmonary TB will also include respiratory symptoms (eg, cough, hemoptysis, dyspnea).

Intake and output record Time Oral intake Parenteral intake Output 0700 180 mL juice 0800 1 L normal saline IV 150 mL liquid stool 1000 5 tablespoons vancomycin 1200 240 mL tea 250 mL metronidazole IV 1500 360 mL water 1600 1300 mL urine from collection bag. The nurse is caring for a client with gastroenteritis and dehydration who is prescribed strict intake and output monitoring with calculation of net fluid balance each shift. Calculate the client's net fluid balance for the shift. Record your answer as a whole number. Click the exhibit button for additional information

Net fluid balance is calculated by subtracting total output from total intake. All values must first be converted to milliliters. / 655

Vasculature

Network of blood vessels in a particular organ

Glascow Coma Scale (GCS)

Neurologic assessment of a patient's best verbal response, eye opening, and motor function.

Von Willebrand disease is a genetic bleeding disorder caused by a deficiency of von Willebrand factor (vWF), which plays an important role in coagulation. Intranasal desmopressin or topical therapies (eg, thrombin) may be prescribed to stop minor bleeding, whereas major bleeding may require replacement of vWF. Clients should wear medical identification bracelets in case of emergency. Client teaching includes:

Notify the health care provider of signs of bleeding (eg, severe joint pain or swelling, headache [especially after injury], blood in urine/stool, uncontrollable nosebleed) Use a humidifier or nasal spray to keep the mucosa moist, reducing the risk of nosebleeds Avoid aspirin and NSAIDs Avoid activities with a higher risk for injury (eg, contact sports) Avoid gum injury (eg, use soft-bristled toothbrush, perform gentle flossing) and use an electric razor for shaving to minimize bleeding potential Report heavy menstrual bleeding (eg, soaking a pad in <3 hours) Clients should avoid medications that can exacerbate bleeding, including aspirin and NSAIDs (eg, ibuprofen, naproxen, ketorolac). Clients can instead use rest, ice, compression, and elevation (RICE), as well as acetaminophen, to help with pain and inflammation.

Intramuscular (IM) injections (eg, hepatitis B vaccine, vitamin K) are commonly administered to newborns shortly after birth or before discharge. The

vastus lateralis muscle in the anterolateral middle portion of the thigh is the preferred site for IM injections in newborns (age <1 month) and infants (age 1-12 months). The deltoid muscle is an inappropriate injection site for newborns due to inadequate muscle mass

The nurse assesses a client who had a thyroidectomy 8 hours ago. The nurse finds the client anxious, with tingling around the mouth and muscle twitching in the right arm. Which action is most important for the nurse to implement first?

Obtain serum calcium level/ Normal serum calcium is 8.6-10.2 mg /dL (2.15-2.55 mmol/L). Hypocalcemia (serum calcium <8.6 mg/dL [2.15 mmol/L]) is a potential complication of thyroidectomy because the parathyroids that regulate calcium levels in the blood are accidentally removed during this surgical procedure. The nurse should monitor the client closely for signs of hypocalcemia, which include tetany (overactive neurological responses such as tingling in the hands, feet, and around the mouth; spasms or cramps that can occur even in the larynx; positive Trousseau or Chvostek sign). A serum calcium level should be drawn, and the nurse should ensure that calcium gluconate is readily available in case this complication occurs.

A client comes to the emergency department reporting alkaline drain cleaner splashed into the eye. The conjunctiva of the affected eye is erythematous, and the client reports a burning sensation. What action is appropriate at this time?

Ocular chemical burns require emergency care to prevent permanent vision loss. Alkali burns (eg, ammonia, cement, lye-containing drain cleanser) are particularly dangerous as they will quickly penetrate deep into the eye, causing severe, irreversible damage. For all types of ocular chemical burns, copious eye irrigation with sterile saline or water should begin immediately to flush the chemical irritant out of the eye (Option 3). Before transport to an emergency care facility, tap water can be used for eye irrigation. If transported by ambulance, emergency care personnel continue irrigation during transport with IV tubing or a Morgan lens. Irrigation is continued until the pH of the eye returns to normal (pH 6.5-7.5), which typically requires 30-60 minutes depending on the type of chemical. (Option 1) Depending on the severity of the burn, anesthetic eye drops may be instilled prior to irrigation because ocular burns are very painful, but systemic analgesia is not a priority. (Option 2) Care of ocular burns may include covering the eye with an eye patch and use of eye drops to prevent eye muscle spasms; however, eye irrigation should be performed first. (Option 4) The Snellen eye chart is commonly used to assess visual acuity. However, eye irrigation is essential and should not be delayed. Educational objective: Ocular chemical burns require immediate, copious irrigation with sterile saline or water to flush the chemical irritant out of the eye. Irrigation is continued until the pH of the eye returns to normal, which typically takes 30-60 minutes.

The nurse should create a therapeutic and safe environment for the client who is blind while fostering as much independence as possible. Nursing interventions include the following:

Offer the client an elbow for guidance while walking slightly ahead and describing the environment (Option 2). Announce room entry and exit to orient and avoid startling the client (Option 3). Describe the location of items (eg, food, hygiene supplies) using a clock-face orientation so the client can find them easily (Option 5). Instruct the client to use a cane with the dominant hand and to sweep areas in front from side to side for orientation. Orient the client to the room and maintain this orientation for safety. / Asking the caregiver or family member about the client's personal preferences does not promote independence or self-advocacy. The nurse should ask the client directly about the desired room arrangement.

An adolescent client is brought to the emergency department after being in a serious motor vehicle crash. The client is undergoing cardiopulmonary resuscitation. The nurse calls the family to inform them to come to the hospital and a family member asks how the client is doing. Which is an example of the ethical principle of beneficence when responding to the client's family?

Stating that the client is critically ill and is being cared for meets the ethical principle of veracity (telling the truth) but also avoids overwhelming the family before they travel to the hospital. The nurse does not want the family to be too distressed to process the situation and arrive safely.

suction control chamber

which is usually set at -20 cm H2O to maintain negative pressure in the system. Bubbling will occur when suction is applied.

The nurse assessing a client notices pearly white plaque-like lesions on the mouth mucosa. The nurse understands that which client is at highest risk for oral candidiasis?

Oral candidiasis or thrush (moniliasis), is an infection of the mucous membranes generally caused by the yeastlike fungus Candida albicans. The fungus causes pearly, "milk-curd" lesions on the oral or laryngeal mucosa that may bleed when removed. Immunosuppressed individuals such as those taking corticosteroid medications, clients undergoing chemotherapy or radiation, or clients with immune deficiency states (eg, AIDS) have an increased incidence. Clients receiving prolonged or high-dose antibiotic treatment are at increased risk as the normal microbial flora of the mouth is reduced, allowing other opportunistic infections to arise (Option 2). Individuals with dentures and infants also commonly experience monilial infections. Treatment is antifungal medications (eg, nystatin) and proper oral hygiene. (Option 1) Inhaled beta-2 agonists (eg, albuterol) do not increase the risk for fungal infections. However, individuals taking an inhaled corticosteroid (eg, budesonide, fluticasone) are at increased risk for oral candidiasis. To reduce this risk, the client should rinse the mouth after each inhaled dose and maintain good oral hygiene. (Options 3 and 4) Proper oral hygiene and nutrition are important in prevention of oral candidiasis. However, the client with braces or poor hygiene and inadequate nutrition is at lower risk than one who is immunosuppressed or taking antibiotics. Educational objective: Immunosuppressed clients (eg, taking steroids, undergoing chemotherapy or radiation, with immunodeficient states) and those taking prolonged or high-dose antibiotics are at increased risk of oral candidiasis. Elderly clients with dentures are also at high risk. Infection is treated with antifungals (eg, nystatin) and proper oral hygiene.

The nurse is reinforcing home care instructions to a client newly diagnosed with osteomalacia. Which of the following client statements indicate proper understanding of teaching?

Osteomalacia is a reversible bone disorder caused by vitamin D deficiency. It is characterized by weak, soft, and painful bones that can fracture easily or become deformed. In vitamin D deficiency, calcium and phosphorus cannot be absorbed from the gastrointestinal tract and are unavailable for calcification of bone tissue. Vitamin D deficiency is also associated with increased risk of falls, especially in elderly clients due to muscle weakness. Nursing management focuses on: Implementing safety measures, such as canes or walkers, to prevent falls and injury (Option 5) Encouraging light to moderate physical activity, which can help promote bone strength and health (Option 4) Promoting increased dietary intake of: Calcium (eg, leafy green vegetables, dairy) (Option 1) Phosphorus (eg, milk, organ meats, nuts, fish, poultry, whole grains) Vitamin D (eg, vitamin D-fortified milk and cereal, egg yolks, saltwater fish, liver); exposure to sunlight is also recommended as it stimulates vitamin D synthesis (Options 2 and 3) Teaching about over-the-counter or prescription vitamin D supplements Educational objective: Osteomalacia occurs when the body is unable to use calcium and phosphorus for bone calcification due to a vitamin D deficiency. Nursing management focuses on implementing safety measures, encouraging activity, and promoting increased intake of vitamin D, calcium, and phosphorus.

The mnemonic PASS is often used to help people remember the steps used in operating a fire extinguisher:

P - Pull the pin on the handle to release the extinguisher's locking mechanism A - Aim the spray at the base of the fire S - Squeeze the handle to release the contents/extinguishing agent S - Sweep the spray from side to side until the fire is extinguished

MALT lymphoma restricted to the mucosa with no lymph node involvement

PPI + clarithromycin + amoxicillin ( most common cause is H-pylori) then use

Critical steps to indwelling catheter insertion for the female client include the following:

Perform hand hygiene After ensuring privacy, position client in the dorsal recumbent position and drape Open the catheterization kit on a clean bedside table or between client's legs Touching only the outside 1" border, place sterile drape under the client's hips Apply sterile gloves Apply fenestrated drape over perineum Organize remaining items in the kit. Place top tray on a sterile field and ensure the clamp on the catheter is closed. Open antiseptic swabs with stick end up or pour antiseptic solution over cotton balls Squirt lubricant into tray Remove protective sheath from catheter and place the tip in lubricant Using the nondominant hand, spread the labia to expose the urethral meatus Use the antiseptic swab (or cotton ball with forceps) to cleanse the perineum. Wipe in the direction from clitoris to anus. Always use a new swab or cotton ball with each swipe. Cleanse far labial fold, near labial fold and finally the meatus. Using the dominant hand, pick up catheter and insert until urine is visualized (usually about 3"), then advance another 1-2". If obstruction occurs, do not force the catheter. Let go of the labia but hold the catheter securely in place with the nondominant hand. Inflate the balloon according to manufacturer instructions (most manufacturers now warn against testing the balloon prior to insertion) Anchor indwelling catheter and secure drainage bag to the bed frame

Wound cultures identify microorganisms to aid in prescribing appropriate antibiotics and are obtained as follows:

Perform hand hygiene, and apply clean gloves. Remove the old dressing. Remove and discard gloves. Perform hand hygiene, and apply sterile gloves. Assess the wound bed. Cleanse the wound bed and surrounding skin with normal saline (eg, flushing, swabbing with gauze) to remove drainage and debris (Option 2). Remove and discard gloves. Perform hand hygiene, and apply clean gloves. Gently swab the wound bed with a sterile swab, from the wound center toward the outer margin (Options 4 and 5). Avoid contact with skin at the wound edge as it can contaminate the specimen with skin flora. Place the swab in a sterile specimen container; avoid touching the swab to the outside of the container. Apply prescribed topical medication (eg, bacitracin) after obtaining cultures to prevent interference with microorganism identification (Option 1). Apply new dressing. Remove and discard gloves, and perform hand hygiene. Label the specimen, and document the procedure. Pooled purulent exudate likely contains skin flora different from the pathogen(s) responsible for the infection. Microorganisms responsible for infection are most likely found in viable tissue

To administer otic medications in an adult client, use the following steps:

Perform hand hygiene; position the client side-lying with the affected ear up; pull pinna up and back; administer prescribed number of ear drops; instruct the client to remain side-lying for 2-3 minutes; and place a cotton ball loosely in the outer ear canal for 15 minutes (if needed)

Colorectal cancer is the third most common cancer and the second leading cause of cancer deaths; it affects both genders equally. Various risk factors for colorectal cancer include:

Personal or family (first-degree relative) history of colorectal cancer or polyps (Option 5) Personal history of inflammatory bowel disease, Crohn disease, or ulcerative colitis (Option 3) History of hereditary nonpolyposis colorectal cancer (Lynch syndrome) Lifestyle factors such as a diet high in red meat and saturated fat and low in fiber, obesity (eg, body mass index >30 kg/m2), cigarette smoking, and alcohol consumption

Common applications of droplet precautions Personal protective equipment Neisseria meningitidis Haemophilus influenzae type B Diphtheria Mumps Rubella Pertussis Group A Streptococcus (strep throat) Viral influenza

Personal protective equipment Surgical mask private room As needed for procedures with risk of splash or body fluid contact: gloves, gown, goggles/face shield

Cleansing enemas (eg, normal saline, soapsuds, tap water) relieve constipation by stimulating intestinal peristalsis. When administering an enema, appropriate interventions include:

Place the client in a left lateral position with the right knee flexed (ie, Sims position) to promote flow of the enema into the colon Hang the enema bag no more than 12 in (30 cm) above the rectum to avoid overly rapid administration. Lubricate the enema tube and gently insert the tip 3-4 in (7.6-10 cm) into the rectum (Option 1). Direct the tubing tip toward the umbilicus (ie, anteriorly) during insertion to prevent intestinal perforation. Encourage the client to retain the enema for as long as possible (eg, 5-10 minutes) Open the roller clamp on the tubing to allow the solution to flow in by gravity. If the client reports abdominal cramping, use the roller clamp to slow the rate of administration Enemas are administered at room temperature or warmed, as cold enema solutions cause intestinal spasms and painful cramping. Enemas may be warmed by placing the container of solution in a basin of hot water.

Contact precautions include:

Placing client in private room (preferred) or cohorting clients with the same infection Using dedicated equipment (must be disinfected when removing from room) Wearing gloves when entering room Perform proper hand hygiene before exiting room (use soap and water or alcohol-based hand rubs for MRSA and VRE, but only soap and water for C difficile and scabies) Wearing gown with client contact and removing before leaving room Place door notice for visitors Having client leave room only for essential clinical reasons (ie, tests, procedures). If an x-ray is needed, try to arrange for a portable one.

Clostridium difficile is a highly infectious bacteria causing severe colitis in infected clients. When caring for a client with C difficile, it is critical that the nurse implement contact isolation precautions to prevent transmission of microorganisms between clients, including:

Placing the client in a single-client room, if possible, or in a cohort with other clients infected with C difficile (Option 3) Wearing a single-use, disposable gown and clean gloves during all client care and discarding the equipment before leaving the room (Option 5) Performing hand hygiene before and immediately after client care with soap and water Using dedicated medical equipment (eg, stethoscope, blood pressure cuff) that is not shared between clients and always remains in the client's room

A bronchoscopy is an invasive procedure that allows visualization of the internal air passages via a flexible tube (bronchoscope) passed through either the nose or mouth to the internal airways. Following the procedure, the client will need to be monitored for complications such as bleeding, bronchial perforation, pneumothorax, and bronchial spasm.

Potential for airway compromise requires that this client be seen first.

Clients infected with methicillin-resistant Staphylococcus aureus or other drug-resistant organisms.

Pre-moistened cloths or warm water with a chlorhexidine solution should be used when bathing /chlorhexidine is recommended in the hospital setting.

A chest tube is removed when drainage is minimal (<200 mL/24 hr) or absent, an air leak (if present) is resolved, and the lung has reexpanded. The general steps for chest tube removal include:

Premedicate the client with analgesic (eg, IV opioid, nonsteroidal anti-inflammatory drug [ketorolac]) 30-60 minutes before the procedure to promote comfort as evidence indicates that most clients report significant pain during removal Provide the health care provider (HCP) with sterile suture removal equipment Instruct the client to breathe in, hold it, and bear down (Valsalva maneuver) while the tube is removed to decrease the risk for a pneumothorax. Most HCPs use this technique to increase intrathoracic pressure and prevent air from entering the pleural space Apply a sterile airtight occlusive dressing to the chest tube site immediately; this will prevent air from entering the pleural space Perform a chest x-ray within 2-24 hours after chest tube removal as a post-procedure pneumothorax or fluid accumulation usually develops within this time frame.

The client recently admitted to the assisted living center has impaired vision related to primary open-angle glaucoma. Select the graphic that best illustrates the effects of glaucoma on the client's vision.

Primary open-angle glaucoma (POAG) is an eye condition characterized by an increase in intraocular pressure and gradual loss of peripheral vision (ie, tunnel vision). The signs/symptoms of POAG develop slowly and include painless impairment of peripheral vision with normal central vision, difficulty with vision in dim lighting, increased sensitivity to glare, and halos observed around bright lights. POAG can lead to blindness if left untreated. (Option 1) Retinal detachment is separation of the retina from the underlying epithelium that allows fluid to collect in the space. The signs/symptoms include sudden onset of light flashes, floaters, cloudy vision, or a curtain appearing in the vision. (Option 2) Age-related macular degeneration is a degenerative eye disease that brings about the gradual loss of central vision, leaving peripheral vision intact. (Option 4) A cataract is cloudiness (ie, opacity) of the lens that may occur at birth or more commonly in older adults. The signs/symptoms of a cataract include painless, gradual loss of visual acuity with blurry vision; scattered light on the lens producing glare and halos, which are worse at night; and decreased color perception. Educational objective: Primary open-angle glaucoma is characterized by an increase in intraocular pressure and gradual loss of peripheral vision (ie, tunnel vision).

A client with rheumatoid arthritis (RA) tells the home health nurse, "My fatigue and stiffness are getting worse and I'm having trouble moving around, especially in the morning. What can I do?" Which intervention would be best for the client to perform first?

Prolonged morning stiffness of the affected joints is a major complication of rheumatoid arthritis (RA). Taking a warm shower or bath first on awakening would be the best intervention as heat decreases stiffness and promotes muscle relaxation and mobility. With increased flexibility and decreased stiffness, the client's usual morning activities (eg, dressing, making breakfast) would be easier and less painful and tiring to perform. (Option 1) A balanced diet and weight control are important. Diet and exercise should be proportional, especially during periods of disease exacerbation and decreased physical activity as excess weight exerts additional stress on weight-bearing joints. (Option 2) Range of motion exercises are more effective after a warm bath or shower as stiffness is decreased, thereby improving flexibility. (Option 4) Nonsteroidal anti-inflammatory drugs (NSAIDS) (eg, naproxen [Naprosyn], ibuprofen [Motrin]) should not be taken on an empty stomach as these can cause gastrointestinal upset. If prescribed once daily, these are probably best taken in the evening after dinner as RA symptoms slowly increase during the night and worsen in the morning. A higher serum drug level in the morning can help to reduce inflammation and stiffness. Therefore, if NSAIDS are prescribed twice daily, taking them in the morning with breakfast and in the evening with dinner is recommended. Educational objective: A nonpharmacologic intervention such as taking a warm bath/shower or applying heat can decrease morning stiffness and improve flexibility in clients with RA.

A handoff of care report is the critical communication that occurs when transferring client care to another nurse (eg, shift change, department transfer). Transitions of care require thorough, precise communication to ensure client safety and wellness. Appropriate handoff communication allows for continuity of care and provides a synopsis of client needs and details of the client's care. To ensure appropriate and effective handoff communication, the nurse should:

Provide identifying information (eg, client's name and room number) Provide exact, pertinent information (eg, medication dose, time, measurable outcomes) Note care priorities and upcoming or outstanding tasks (eg, time to replace a medication infusion bag, need to perform delayed wound care and cause of delay) Include multidisciplinary plans (eg, radiology examinations, family meetings, physical therapy) Relay significant client changes in a clear manner (ie, assessment, interventions, outcomes, evaluation)

The Z-track technique prevents tracking (leakage) of the medication into the subcutaneous tissue and is universally recommended for the administration of IM injections. Displacing the skin while injecting the medication, and then releasing the skin back to its normal position after removing the needle creates a zigzag track. The procedure for administering an IM injection using the Z-track technique includes these steps:

Pull the skin 1-1 ½" (2.5-3.5 cm) laterally away from the injection site Hold the skin taut with the nondominant hand, and insert the needle at a 90-degree angle - taut skin facilitates entry of the needle and this angle ensures that the needle will reach the muscle Inject the medication slowly into the muscle while maintaining traction - slow injection promotes comfort and allows time for tissue expansion to facilitate absorption of the medication Wait 10 seconds after injecting the medication and withdraw the needle while maintaining traction on the skin; this allows the medication to diffuse before needle removal and helps to prevent tracking Release the hold on the skin - this allows the tissue layers to slide back to their original position, sealing off the needle track Apply gentle pressure at the injection site, but do not massage as this can cause the medication to seep back up to the skin surface and cause local tissue irritation There is no clear evidence to support the need for aspiration prior to IM injection. Aspiration may be indicated if the dorsogluteal site (last resort) is used for IM injection due to its proximity to the gluteal artery. The preferred areas for IM injection are the ventrogluteal site in adults and the vastus lateralis site in children.

The nurse is caring for a client with tobacco-related pharyngeal cancer who is receiving external radiation treatments and has developed oral mucositis. Which of the following nursing interventions are appropriate for promoting oral intake and preventing weight loss?

Radiation therapy to the head and neck can cause mucositis (inflammation of the mouth, esophagus, and oropharynx) and xerostomia (dry mouth), leading to decreased nutrition and weight loss. Care includes consuming soft, bland foods; using liquid nutritional supplements to boost caloric intake; applying topical oral anesthetics to treat pain; avoiding irritants (eg, alcohol, acidic foods); and performing frequent (eg, 4 times daily) oral hygiene

Clients with seizures are at increased risk for injury during seizure activity. Seizure precautions are nursing interventions that can help protect a client during a seizure. These precautions typically include:

Raising the upper side rails on the bed to prevent the client from falling to the floor during a seizure. The side rails are also padded to prevent client injury due to hitting the hard plastic rails during a seizure (Option 1). During a seizure, a client may be unable to control secretions, increasing the risk for an impaired airway. Suction equipment and oxygen equipment are set up at the bedside (Options 2 and 5). Some facilities also encourage the use of a continuous pulse oximeter.

The nurse is assigned to care for 4 clients at an outpatient ophthalmology clinic. Which client report would most likely indicate a serious pathology that should be given priority?

Retinal detachment is separation of the sensory retina from the underlying pigment epithelium with fluid accumulation. It can be a result of spontaneous atrophic retinal breaks or acute trauma. Common symptoms include a painless loss of vision "like a curtain" coming across the field of vision, lightning flashes, or a gnat/hairnet appearance in the vision field. This report needs emergent evaluation. Untreated symptomatic retinal detachment usually leads to blindness in that eye. In addition, this is the only listed presentation that is acute: the rule for prioritization is acute before chronic. (Option 1) Myopia (nearsightedness) is an inability to accommodate for objects at a distance. It is not emergent and will require refractive correction with glasses/contacts. (Option 3) Macular degeneration is related to retinal aging and causes progressive, irreversible central vision loss. However, it is not an acute condition. (Option 4) Conjunctivitis is an infection or inflammation of the conjunctiva that can be caused by bacteria, viruses, allergens, or chemical irritants. Bacterial infections tend to cause purulent drainage; allergic or viral causes result in serous discharge; and an allergic conjunctivitis usually involves pruritus (itching). The client will probably need eye drops and a reminder about good handwashing technique, but the condition is not emergent. Educational objective: Acute retinal detachment includes the sensation of a curtain coming across the field of vision, lightning flashes, or a gnat/hairnet appearance in the vision field. It requires an emergent evaluation.

The practical nurse is assisting the registered nurse with completing a health history of a client with suspected rheumatic fever. Which question is most important to ask the client in order to establish a diagnosis?

Rheumatic fever (RF) is an acute inflammatory disease of the heart that can occur as a complication 2-3 weeks after streptococcal pharyngitis. RF is caused by a delayed-onset autoimmune reaction involving anti-streptococcal antibodies that cross-react with antigens in the heart and other organs. Recurrent, untreated streptococcal pharyngitis will lead to faster onset and increased severity of rheumatic heart disease due to increased autoimmune activity. RF affects the heart, skin, joints, and central nervous system. Evidence of a preceding streptococcal infection with the presence of either 2 major criteria or 1 major and 2 minor criteria indicate a high probability of RF. (Option 1) Failing to complete a course of antibiotics is the cause of resistant infection strains and can result in recurring illness. It could contribute to the risk for RF but is not part of the criteria for diagnosing it. (Option 2) Family history is not a risk factor for RF. (Option 4) Fever is a symptom of many illnesses, not just RF. Educational objective: Streptococcal pharyngitis can precede the development of rheumatic fever (RF) by 2-3 weeks. The nurse should ask about streptococcal throat infection when collecting health history information in a client suspected of having RF.

Sputum culture and sensitivity testing is used to identify infectious organisms in the respiratory tract and determine which antimicrobials are most effective at treating the identified organism. Nurses assisting a client to collect sputum should instruct the client to:

Rinse the mouth with water before collecting the sputum sample to reduce bacteria in the mouth and prevent specimen contamination by oral flora Avoid touching the inside of the sterile container or lid to avoid accidental specimen contamination by normal flora of the skin Inhale deeply several times and then cough forcefully, which promotes expectoration of lower lung secretions and increases sample volume Assume a sitting or upright position before specimen collection, if possible, to promote cough strength during collection

The neonatal heel stick (heel lancing) is used to collect a blood sample to assess capillary glucose and perform newborn screening for inherited disorders (eg, congenital hypothyroidism, phenylketonuria). Proper technique is essential for minimizing discomfort and preventing complications and includes:

Select a location on the medial or lateral side of the outer aspect of the heel (Option 1). Avoid the center of the heel to prevent accidental insult to the calcaneus. Puncture should not occur over edematous or infected skin. Warm the heel for several minutes with a warm towel compress or approved single-use instant heat pack to promote vasodilation (Option 3). Cleanse the intended puncture site with alcohol. Sucrose and nonnutritive sucking on a pacifier may reduce procedural pain (Option 2). Use an automatic lancet, which controls the depth of puncture. Lancing the heel too deeply can result in penetration of the calcaneus bone, leading to osteochondritis or osteomyelitis. An acceptable alternate method of blood collection in the neonate is venipuncture (ie, drawing blood from a vein). Venipuncture is considered less painful and often requires fewer punctures to obtain a sample, especially if a larger volume is needed

The nurse is caring for a client admitted 3 days ago with bacterial pneumonia who has become short of breath, restless, and difficult to rouse. Which additional finding indicates to the nurse that the client may be developing sepsis?

Sepsis is an exaggerated, life-threatening response by the body to a bloodstream infection that can result in hemodynamic instability, respiratory failure, and multiorgan dysfunction. Sepsis typically occurs when bacteria from a local or regional infection (eg, pneumonia, urinary tract infection) enters the bloodstream. Clients with sepsis often have manifestations of a systemic inflammatory response (eg, tachycardia, fever, elevated WBCs) and may exhibit signs of impaired organ function, such as: Absent bowel sounds: Ileus occurs in response to sepsis as blood is shunted away from the gastrointestinal tract to vital organ systems (eg, brain, lungs). Capillary refill time >3 seconds (in adults): Prolonged capillary refill indicates inadequate perfusion of peripheral tissues (Option 1). Increased blood glucose in the absence of diabetes: Gluconeogenesis occurs in response to the physiologic stress of infection. Altered mentation: Changes in mental status (eg, difficulty rousing, agitation, confusion) occur from impaired cerebral perfusion and oxygenation. (Option 2) Diminished breath sounds in the lung bases are expected in a client with pneumonia. (Option 3) Hyperactive bowel sounds are associated with gastrointestinal distress, not sepsis. (Option 4) Urine output of 35 mL/hr is within normal range (ie, ≥30 mL/hr or ≥0.5 mL/kg/hr). Oliguria is a possible sign of sepsis, however. Educational objective: Sepsis is an exaggerated, life-threatening response by the body to a bloodstream infection that results in multiorgan dysfunction. Manifestations of sepsis include tachycardia, tachypnea, and fever. Additional findings include altered tissue perfusion (eg, prolonged capillary refill, absent bowel sounds) and oliguria.

Sickle cell disease (SCD) is a group of hereditary blood disorders characterized by red blood cells (RBCs) that become sickle-shaped, rather than oval, when deoxygenated. Sickled RBCs are prone to clump together and obstruct blood vessels, particularly in periods of dehydration or stress (eg, infection), which cause a sickle cell crisis (SCC). When caring for clients with SCD, it is critical to observe for indicators of SCC. Severe, acute pain is a common symptom of SCC caused by impaired capillary blood flow (ie, vasoocclusion) and tissue ischemia. Without prompt recognition and intervention, vasoocclusion may lead to irreversible tissue damage (eg, myocardial infarction, limb necrosis, stroke) and death (Option 3). (Option 1) New or worsening tachycardia in clients with Graves disease, a common cause of hyperthyroidism, may be an indicator of acute thyrotoxicosis (thyroid storm). However, tachycardia also may occur normally in clients with hyperthyroidism and is less concerning in the presence of other normal vital signs. This client requires further assessment once ischemic events are prevented. (Options 2 and 4) Administration of antibiotics and correction of hyperglycemia can be safely addressed after resolving potentially life-threatening complications.

Severe, acute pain in clients with sickle cell disease is a common indicator of vasoocclusion and tissue ischemia from a sickle cell crisis. The nurse should immediately report signs of sickle cell crisis so that interventions may be implemented to prevent irreversible tissue damage (eg, myocardial infarction) and death.

Correct use of the MDI is necessary to receive the full benefit from inhaled medication. The steps are as follows:

Shake canister well for about 3-5 seconds. Tilt head back slightly and exhale slowly for 3-5 seconds. Hold canister mouthpiece about 1½ inches in front of open mouth; as an alternative, place the mouthpiece in the mouth with lips sealed around it. Holding it in front of an open mouth prevents impaction of the particles into the tongue and sides of mouth. Compress canister while inhaling slowly through the mouth for about 3-5 seconds. Hold breath for 10 seconds, if possible, before exhaling. Wait at least 1-2 minutes before taking a second puff of a bronchodilator, if prescribed. The first puff of medication dilates the bronchioles and allows easy passage of the second puff.

A client is being discharged with plans to return home alone. The client cannot get up from a chair without help and is very unsteady when standing, even with a walker. The nurse expresses concern, but the primary health care provider is adamant that the client be discharged today. Which team member would be most appropriate to assist the nurse in advocating for this client?

Social worker/The nurse concerned about client safety at discharge should advocate for the client. Other interdisciplinary team members, such as the case manager or social worker, should be brought in to advocate for the client and explore alternate discharge resources or settings

To provide full support when climbing stairs, clients should hold the cane on the stronger side and move the cane before moving the weaker leg, regardless of the direction of the stairs (Option 2). They should also keep 2 points of support on the floor at all times (eg, both feet, cane and foot) and face forward when going up or down the stairs, especially if there is no handrail (Option 1). The nurse should instruct the client on the following: When ascending stairs:

Step up with the stronger leg first (in this client, the right leg) Move the cane next while bearing weight on the stronger leg Finally, move the weaker leg (in this client, the left leg) When descending stairs: Lead with the cane Bring the weaker leg down next Finally, step down with the stronger leg

The clinic nurse reinforces teaching to a client with systemic lupus erythematosus. Which instructions will the nurse include?

Systemic lupus erythematosus (SLE) is an autoimmune disorder (the body's immune system erroneously attacks body tissues) that results in inflammation and damage to many body parts. Symptoms vary widely among affected individuals, but most experience painful/swollen joints, extreme fatigue, skin rashes, and kidney problems. The symptoms typically appear for periods of time (called flares) alternating with periods of remission. There is no cure for SLE, but it can be treated with immunosuppressants (eg, corticosteroids) or immunomodulators (eg, hydroxychloroquine). Pneumonia and annual influenza vaccinations are recommended for those with SLE as they are more susceptible to infections. These individuals should avoid contact with sick people and report fever to their health care provider (Options 1 and 4). Both physical and emotional stress can exacerbate SLE. Therefore, clients should follow a healthy lifestyle (eg, 7-8 hours of sleep, no smoking). Balanced exercise with alternating periods of rest is recommended (Option 2). Sunlight is known to worsen the rash of SLE and should be avoided when possible (especially between 10 AM-4 PM); protective clothing and sunscreen application are recommended during periods of sun exposure (Option 3). (Option 5) The rash of SLE should be cleansed only with mild soap. Harsh soap and chemicals should be avoided. The rash is not due to bacterial infection. Educational objective: Clients with SLE should be advised to avoid harsh sunlight and ultraviolet light exposure as well as harsh soaps and chemicals. These clients often receive corticosteroids and are susceptible to infection; therefore, annual influenza vaccination (eg, killed vaccines) is important.

is a high-flow device that delivers a guaranteed oxygen concentration regardless of the client's respiratory rate, depth, or tidal volume. The adaptor or barrel can be set to deliver 24%-50% (varies with manufacturer) oxygen concentration. In the presence of tachypnea, shallow breathing with decreased tidal volume, hypercarbia, and hypoxemia, it is the most appropriate oxygen delivery device for this client as rapid changes in inspired oxygen concentration can blunt the hypoxemic drive to breathe in clients with chronic obstructive pulmonary disease (COPD).

Venturi mask

The nurse is calculating IV fluid resuscitation for a client weighing 85 kg with visible partial-thickness burns covering 40% of the body. Using the Parkland formula, how many liters of IV fluid resuscitation are needed during the first 8 hours? In liters

The Parkland formula (4 mL × weight [kg] × body surface area burned [%]) is used to calculate the amount of IV fluid required for a burn victim during the initial 24 hours after injury. Half of the calculated volume is administered within the first 8 hours.

A physical restraint is a device or method used to immobilize or limit physical mobility or body movement to prevent falls, injury to self or others, or removal of medical devices. The client situation, rather than the device, determines whether it is classified as a restraint. Prescribed orthopedic immobilizers and protective devices used temporarily during routine procedures or examinations are not considered physical restraints and do not require authorization for use from a health care provider. Restraints should be used only after less invasive methods have failed and must be discontinued at the earliest time possible once it is safe to do so.

The belt restraint is applied at the waist and tied to the bed frame under the mattress with straps using a quick-release knot. It is used to protect a confused or disoriented client who is on bed rest. Although the client can turn, it is considered a restraint because it restricts physical mobility and confines the client to the bed involuntarily (Option 1). Soft limb restraints (eg, wrist, ankle) immobilize one or more extremities and are used for the prevention of falls or attempted removal of devices. Following a procedure requiring sedation, clients may require restraints to protect them from disrupting a surgical site or medical device until they are alert enough to follow instructions independently (Option 5). Limb restraints should be applied loosely enough that 2 fingers can be inserted underneath the secured restraint. The nurse should closely monitor the peripheral neurovascular status and skin integrity of a client's restrained extremity.

The nurse reinforces education to a female client about the use of a cervical cap to prevent pregnancy. Which statement by the client indicates a need for further teaching?

The cervical cap is a barrier method of contraception used with spermicide (eg, nonoxynol-9). The reusable, cup-shaped cap is placed over the cervix before intercourse to block sperm from the uterus. To allow time for sperm to die, the cap should remain in place for ≥6 hours after intercourse but should not remain for more than 48 hours (Option 3). The cap may remain in place for multiple acts of intercourse, but clients should confirm correct placement and insert additional spermicide into the vagina each time. (Option 1) Prior to insertion, spermicide is applied to the cervical cap to maximize contraceptive effectiveness. Spermicide should be applied inside the cap, along the rim of the cap, and in the groove on the underside of the cap. (Option 2) Use of cervical caps during menses (or during the postpartum period in clients with lochia discharge) increases the risk of toxic shock syndrome; an alternate contraceptive method should be used during this time. (Option 4) Inserting the cervical cap several hours before intercourse is acceptable and may improve correct use. Before each use, the client should inspect the cap for holes, cracks, or tears to ensure its effectiveness for blocking sperm. Educational objective: The cervical cap is a barrier method of contraception used with spermicide. It can be inserted several hours before intercourse and should be left in place for at least 6 hours after. Its use during menses increases the risk of toxic shock syndrome.

When administering an otic medication to an adult or child age 3 and older, the pinna is pulled upward and back to straighten the external ear canal (Option 2). For an infant, the pinna is pulled downward and straight back.

The child should be placed in the prone or supine position with the head turned to the appropriate side. (Option 3) Otic medication should be warmed to room temperature if removed from a refrigerator prior to administration. Holding the bottle in the palm of the hand is an effective method of warming. Instilling cold drops into the ear can cause a vestibular reaction, resulting in dizziness and vomiting. (Option 4) The medication dropper should be held near the entrance to the ear canal without touching it. This technique allows the drops to fall against the wall of the canal, reducing discomfort while avoiding contamination of the dropper. After instilling the drops, the child should remain with the affected ear up for several minutes to allow full coverage of the medication.

The client has just returned from having a cast placed on the right forearm and is found putting a lead pencil in the cast to "reach the itch." What is the nurse's priority action?

The client should be taught that nothing should be placed in a cast. Attempting to reach an itch with any instrument (eg, pencil, coat hanger) or applying powder or lotion may cause skin breakdown and infection. Cool air from a hair dryer may alleviate the itch.

It is 0700 and the nurse is caring for an 84-year-old client with dementia and a fractured hip. The client has been disoriented to time, place, and person since admission. The client moans frequently and grimaces when moving. He is prescribed morphine IV every 2 hours as needed for pain and was last medicated at 0530. He is scheduled for surgery at 1000 to repair the hip fracture, but the consent has not yet been signed. The client's spouse and child are to arrive at 0900. Which intervention should the nurse carry out first?

The morning shift assessment should be completed first to collect baseline assessment data (eg, vital signs, lung sounds, level of consciousness), assess pain, and collect necessary information for the preoperative checklist. / The preoperative checklist can be completed after consent is obtained

When clients and families are faced with significant life changes, the nurse should support the process of coping by encouraging emotional expression

The nurse provides support by expressing empathy, actively listening, and encouraging therapeutic communication.

The nurse has received a prescription from the health care provider to administer 80 mg of methylprednisolone IV piggyback. The available vial contains 125 mg in 2 mL. Select the syringe containing the appropriate amount of medication to be administered.

The nurse should fill the syringe appropriately based on dosage calculation. To calculate the dose in milliliters of methylprednisolone, the nurse should first identify the prescribed dose (eg, 80 mg/dose) and available dose (eg, 125 mg/2 mL), then convert to milliliters per dose (eg, 1.3 mL).

The nurse should be assertive and deal with the issue directly now. The nurse is using an "I" statement; the nurse is not attacking the UAP's character but is focusing only on the task at hand, which the UAP can perform. The request should be given as a directive, not as an option. Putting the request in the scope of a universal goal on which everyone can agree, such as quality care, makes it harder for the UAP to refuse. It is also helpful to say please/thank you and to stand and wait expectantly until the UAP starts the requested action.

The nurse should use assertive communication techniques to deal with a staff member directly and immediately by telling rather than asking for certain actions. The nurse should not attack the individual's character or initially make threats (aggression) and should not avoid the issue by just performing the action itself (avoidance)

A client newly returned to the unit after knee surgery asks the nurse for assistance to a chair. What action should the nurse implement first?

The nurse should verify activity prescriptions before getting clients out of bed after surgery or a procedure. The nurse should be present when these clients begin ambulating and may need assistance from another nurse or unlicensed assistive personnel.

Grave's Disease/ hyperthyroidism

wide ranging, anxiety, irritability, fatigue, rapid or irregular heartbeat, fine tremor, sensitivity to heat, enlargement of thyroid disease, weight loss, change in menstrual cycle, ED, reduced libido, frequent BM, bulging eyes, and thick red skins on shins or tops of feet.

The nurse employed in a woman's health care clinic would be most concerned about which client statement?

The nurse would be most concerned about the client who describes symptoms of inflammatory breast cancer. In this aggressive form of cancer, breast lymph channels are blocked by cancer cells, creating breast tissue that becomes red, warm, and has an orange peel (peau d'orange), pitting appearance on the skin surface. The nurse would be most concerned about this client and make an immediate referral to the health care provider for examination and evaluation. (Option 1) Clients usually describe lumps related to fibroadenoma, a benign breast disorder, as small, round, painless, mobile lumps with no breast tissue retraction or discharge. (Option 2) Further assessment is needed to determine if the client is at risk for developing mastitis. Mastitis may develop in lactating women when the nipples become dry and crack. The cracked nipples may provide a portal of entry for microorganisms, especially Staphylococcus. The client should be taught appropriate care of the breast during lactation. The client diagnosed with mastitis will experience warm, red, painful, and edematous breasts. (Option 4) Clients usually describe fibrocystic breast nodules as soft, movable nodules that change size at various times during the menstrual cycle. Fibrocystic breast changes are a common benign breast disorder. Educational objective: Inflammatory breast disease is an aggressive breast cancer with symptoms of red, warm, peau d'orange breast tissue. A breast mass may or may not be present.

Standards of nursing practice and care are universal criteria that are used when determining if appropriate, professional care has been delivered. The definition of this minimum acceptable level of care reflects what reasonable, prudent, and careful nurses would do in specific circumstances. The state or province/territory boards of nursing help to regulate these standards. Sources used to define standard of care include statements from professional organizations, agency policies and procedures, textbooks, current literature, expert consensus, the Nurse Practice Act, and statutes from regulatory organizations The standard of care includes objective criteria and does not consider intention. Guidelines are used in determining if duties were performed in an appropriate manner. A nurse can have good intentions but still fail to meet the standards of professional nursing practice.

The standards of professional nursing practice and care are defined by what reasonable, prudent nurses would do in specific circumstances. These are based on objective, third-party authoritative sources, including literature, laws (Nurse Practice Act), and professional organizations.

ventral side

The underside, belly, or the lower body surface

The nurse is caring for a client who was struck in the face by the airbag during a motor vehicle collision. The client reports black spots floating in the field of vision. Which intervention should the nurse implement first?

This client is showing symptoms of retinal detachment (separation of sensory retina from pigment epithelium and choroid with fluid accumulation). This condition can be caused by aging or head trauma. Classic symptoms include flashes of light, floaters or black spots across the field of vision, the sense of a curtain being drawn over the eye, and loss of a portion of the visual field. This is an emergent condition that can result in blindness if left untreated. The primary intervention should include covering both eyes with patches to prevent further detachment (Option 1). Up to 25% of clients who experience retinal detachment in one eye will also develop this in the other eye. Additional immediate interventions include placing the client on bed rest (Option 4), notifying the health care provider or ophthalmology specialist (Option 3), performing a visual acuity examination, and making the client npo for possible emergency surgery (Option 2). Educational objective: Emergent treatment of a client with possible retinal detachment should include covering both eyes with patches to prevent further detachment, notifying the health care provider or ophthalmology specialist, placing the client on bed rest, and making the client npo for possible emergency surgery.

The clinic nurse is reinforcing client teaching about the tiotropium that has been prescribed for chronic obstructive pulmonary disease (COPD). Which statement indicates that the client has a correct understanding of this medication?

Tiotropium (Spiriva) is a long-acting, 24-hour, anticholinergic inhaled medication used to control chronic obstructive pulmonary disease (COPD) and is administered most commonly using a capsule-inhaler system called the HandiHaler. The powdered medication dose is contained in a capsule. The client places the capsule in the inhaler device and pushes a button on the side of the device, which pokes a hole in the capsule. As the client inhales, the powder is dispersed through the hole. Unlike most inhaled medications, tiotropium looks like an oral medication because it comes in a capsule. Therefore, it is important to teach the client how to administer the medication prior to the first dose, emphasizing that the capsules should not be swallowed and that the button on the inhaler must be pushed to allow for medication dispersion. During future appointments, the nurse should assess/reassess the client's ability to use this medication correctly.

The nurse is caring for a client who is prescribed ampicillin 1.5 g in 100 mL of normal saline IV to be administered over 30 minutes every 6 hours. The nurse has IV tubing with a drip factor of 15 gtt/mL. At what rate in drips per minute (gtt/min) should the nurse administer the IV ampicillin? Record your answer using a whole number

To calculate the drip rate of ampicillin, the nurse should identify the prescribed dose (eg, 1.5 g/dose) and available medication (eg, 1.5 g/100 mL) and then convert to the rate in drips per minute (50 gtt/min).

The health care provider prescribes 2 mEq (2 mmol)/kg of 8.4% sodium bicarbonate IV to be administered over the next 4 hours. The client weighs 150 lb, and the pharmacy supplies the following IV solution: 8.4% sodium bicarbonate in 1000 mL of D5W with 150 mEq (150 mmol) of sodium bicarbonate. At what rate in milliliters per hour (mL/hr) should the nurse set the infusion pump? Record your answer using a whole number.

To calculate the hourly infusion rate of sodium bicarbonate, the nurse should first identify the prescribed dose (eg, 2 mEq [2 mmol]/kg/dose) and available medication (eg, 150 mEq [150 mmol]/1000 mL) and then convert to volume in milliliters per hour (eg, 227 mL

The health care provider prescribes a continuous heparin infusion at 18 units/kg/hr for a client who has a pulmonary embolus and weighs 198 lb. The infusion bag contains 25,000 units of heparin in 500 mL of D5W. At what rate in milliliters per hour (mL/hr) does the nurse set the IV infusion pump? Record your answer using a whole number.

To calculate the infusion rate of heparin, the nurse should first identify the prescribed dose (eg, 18 units/kg/hr) and available dose (eg, 25,000 units/500 mL) and then convert to milliliters per hour (eg, 32 mL/hr).

An infant is experiencing respiratory depression immediately after a vaginal delivery using epidural analgesia with morphine. The health care provider prescribes 0.1 mg/kg naloxone IM to be given STAT once. The client weighs 3600 grams and naloxone 0.4 mg/mL is available. How many milliliters will the nurse administer? Record your answer using one decimal place. 1000 grams is 1 kilogram

To calculate the milliliters per dose of naloxone, the nurse should first identify the prescribed dose (eg, 0.1 mg/kg/dose) and available dose (eg, 0.4 mg/mL), then convert to milliliters per dose (eg, 0.9 mL/dose).

A health care provider prescribes cefuroxime 30 mg/kg/day PO divided in equal doses every 12 hours for a child with a urinary tract infection. The child weighs 34 lb. Based on the available concentration of cefuroxime, how many mL would the nurse administer per dose? Click the exhibit button for additional information. Record your answer using one decimal place.

To calculate the volume of cefuroxime in milliliters per dose, the nurse should first identify the prescribed dose (eg, 30 mg/kg/day) and available medication (eg, 250 mg/5 mL) and then convert to volume in milliliters per dose (eg, 4.6 mL)

The nurse is preparing to administer an antibiotic to a child with pneumonia. The prescription reads: 7.5 mg/kg every 24 hours divided into 2 doses, PO in liquid form. The client weighs 78 lb. The pharmacy has supplied the drug in 125 mg/5 mL. How many milliliters (mL) should the client receive for each dose? Record your answer using one decimal place

To calculate the volume per dose of antibiotic, the nurse should first identify the prescribed dose (eg, 7.5 mg/kg/day) and available medication (eg, 125 mg/5 mL) and then convert to volume in milliliters per dose (eg, 5.3 mL).

A child with congenital heart disease weighing 44 lb is prescribed furosemide 1 mg/kg PO every 8 hours. It is available as an oral solution of 10 mg/mL. How many milliliters (mL) of furosemide should the nurse administer to the client each dose? Record your answer using a whole number.

To calculate the volume per dose of furosemide, the nurse should first identify the prescribed dose (eg, 1 mg/kg/dose) and available medication (eg, 10 mg/mL) and then convert to volume in milliliters per dose (eg, 2 mL).

The nurse is caring for a client with partial hearing loss. Which interventions would be appropriate to promote effective communication?

When speaking to a client with hearing impairment, the nurse should have the room lights on, directly face the client, speak at a normal volume toward the least-affected ear, and ensure that any hearing aids are functional and in place. Hearing impairment signs may be posted to promote safety.

The student nurse is preparing to perform a heel stick on a neonate to collect blood for diagnostic testing. Which statement by the student nurse indicates a need for further education?

To perform a neonatal heel stick, select a location on the medial or lateral side of the outer aspect of the heel to avoid insult to the calcaneus bone. Provide comfort measures (eg, nonnutritive sucking), warm the selected puncture site to promote vasodilation, cleanse with alcohol, and puncture using an automatic lancet.

The nurse prepares a client for discharge following a vasectomy. The client asks, "When can I have sexual intercourse with my wife without using a condom?" What is the best response by the nurse?

To prevent an unwanted pregnancy following a vasectomy, alternative methods of birth control should be used until semen samples are found to be free of sperm.

It is important to maintain the client's normal circadian rhythms in the intensive care unit (ICU). Interventions that help to maintain the normal sleep-wake cycle include dimming the lights at night, allowing quiet and uninterrupted periods of sleep when possible, scheduling interventions and activities during the day, frequently reorienting the client as necessary, and opening the window shades in the morning. Excessive stimuli and lack of sleep can predispose the client to delirium.

To prevent disorientation and delirium in the intensive care unit, it is important to provide care that maintains the client's normal circadian rhythm (dimming lights at night, allowing uninterrupted sleep when possible, scheduling interventions and activities during the day, frequent reorientation, and opening window shades in the morning).

An experienced nurse is precepting a new graduate nurse on the orthopedic unit. Which action by the graduate nurse requires the precepting nurse to intervene?

To prevent hip flexion contractures in clients with above-the-knee amputation, the residual limb should not be elevated, especially after 24 hours. Instead, edema should be managed using a figure eight compression bandage. The bandage should be worn at all times until the residual limb is healed, and care should be taken not to wrap it too tightly. Hip flexion contractures can also be avoided by placing the client in prone position with the hip in extension for 30 minutes 3 or 4 times a day. (Option 2) Following total hip replacement, hip dislocation is prevented by using an abductor pillow to maintain the hip in a straight and neutral position. The nurse should also remind the client not to bend more than 90 degrees at the hip or cross the legs or ankles. (Option 3) Buck traction immobilizes hip and femur fractures. A boot or traction tape is applied to the affected extremity and a prescribed weight pulls the limb into traction. The client is typically placed in supine position with the foot of the bed raised to maintain countertraction. (Option 4) After a new cast is placed, the nurse should elevate the client's limb above the heart for the first 48 hours to increase venous return and decrease edema in the affected extremity. However, the extremity should be positioned at the level of the heart if compartment syndrome develops. Educational objective: Care of the client with above-the-knee amputation includes placement in prone position for 30 minutes 3 or 4 times a day and using a figure eight compression bandage to decrease edema. The client's residual limb should not be elevated as this will promote flexion contractures.

The nurse observes a client who is postoperative left total knee replacement use a cane. Which action by the client indicates an understanding of the correct technique when walking down the stairs?

To remember the order, use the mnemonic "up with the good and down with the bad." The cane always moves before the weaker leg. To prevent falls after a total knee replacement, clients should use a cane to provide maximum support when climbing up and down any stairs. Clients should hold the cane on the stronger side and move the cane before moving the weaker leg, regardless of the direction. Clients must also keep 2 points of support on the floor at all times (ie, both feet, foot and cane). When descending stairs, the client should: Lead with the cane Bring the weaker leg down next (in this client, it is the left leg) Finally, step down with the stronger leg (Option 1) When ascending stairs, the client should: Step up with the stronger leg first Move the cane next, while bearing weight on the stronger leg Finally, move the weaker leg

Torsades de pointes (ie, "twisting of the points") is a polymorphic ventricular tachycardia characterized by QRS complexes that change size and shape in a characteristic twisting pattern. Torsades de pointes is usually due to a prolonged QT interval (more than half the RR interval), which is the result of electrolyte imbalances, especially hypomagnesemia, or some medications. The first-line treatment is IV magnesium (Option 3). Treatment may also include defibrillation and discontinuation of any QT-prolonging medications.

Torsades de pointes is usually due to a prolonged QT interval, which is the result of electrolyte imbalances, especially hypomagnesemia, or some medications. First-line treatment is magnesium IV. Treatment may also include defibrillation and discontinuation of QT-prolonging medications.

The client with multidrug-resistant organism (MRSA or VRE) infections, C difficile diarrhea, or scabies will require institution of

contact precautions such as good hand hygiene on entry and exit of the client's room, gloves on entry, and a gown for direct client care. The client's room should have dedicated equipment, and the door should have a sign informing visitors about these precautions.

A client diagnosed with trichomonal vaginal infection (trichomoniasis) is prescribed metronidazole. Which directions are essential for the nurse to reinforce? Select all that apply.

Trichomoniasis is a sexually transmitted infection (STI). Many women are asymptomatic but can have profuse frothy gray or yellow-green vaginal discharge with a fishy odor. Small red lesions (strawberry color) may be present in the vagina or cervix. Pruritus is common. Metronidazole (Flagyl) is the initial drug of choice. Clients should avoid alcohol while taking metronidazole and for 24 hours after completion of the therapy due to the risk of a reaction that includes flushing, nausea/vomiting, and abdominal pain. The medication can have a metallic taste and turn the urine a deep red-brown color. It is essential to treat the affected client's partner(s) simultaneously to avoid reinfection. Clients should abstain from sexual intercourse until the infection is cleared, usually about 1 week after treatment. (Option 2) Routine vaginal douching (with a mixture of water and vinegar) is not recommended as it increases the risk of infections such as bacterial vaginosis. (Option 3) Birth control pills do not protect against STIs. However, condom use can help prevent the spread of infection. Educational objective: Trichomoniasis is a sexually transmitted infection. Expected symptoms include yellow-green, frothy discharge with a fishy odor and an accompanying itch. Metronidazole is the initial drug of choice; common side effects include darker urine and a metallic taste to the medication. Partners must be treated simultaneously. Clients taking metronidazole should be taught to avoid alcohol.

The nurse needs to consider several factors when selecting teaching strategies; these include client characteristics (eg, age, educational background, language skills, culture), subject matter, and available resources. Learning can be improved as follows:

Using pictures and simplified text is beneficial to the older adult with low literacy. Including a family member in the teaching process will assist the client in reinforcement of the material at a later date. Professionally produced programs are beneficial as they contain high quality visual content as well a delivery of auditory content in lay person's language

dialysate solution

Various combo of electrolytes, osmolarity in a sterile solution Glucose concentrations; 1.5%, 2.5%, 3.5%, glucose pulls fluid out of the peritoneal cavity during exchange Heparin; added to prevent catheter clotting Antibiotics; may be added as prophylaxis

The nurse inserts a urinary catheter into a female client who has not voided for 6 hours. No urine is returned. What action should the nurse take next?

Urine output would be expected as this client has not voided for 6 hours (obligatory amount is at least 30 mL x 6 = 180 mL). The most common explanation is that the catheter was unintentionally inserted into the vagina. The nurse should leave that catheter as a landmark and insert a new sterile catheter into the urethra which is located above the vagina. (Option 2) There sometimes can be a brief (15 second) delay from the water-based lubricant partially blocking the opening before quickly "melting." 30 minutes is too long a delay without an additional intervention. There is no reason to wait that long. (Option 3) There is no sign that there is an obstruction; the catheter was not adequately inserted. (Option 4) A urinary catheter should never be reused as it is no longer sterile and may introduce bacteria in the urinary tract; a new one should always be obtained. By removing the first catheter, the nurse will be more likely to re-insert it into the same (wrong) opening

A 24-hour urine is collected to evaluate Cushing syndrome (a condition that results from chronic increased corticosteroids). The urine is tested for free cortisol, and results >80-120 mcg/24 hr indicate that Cushing syndrome is present. Instructions for collecting a 24-hour urine are as follows:

Use a dark jug containing a special powder (obtained from the lab) to protect the urine from light during collection. The powder helps preserve the urine and adjusts its acidity Collection of the 24-hour urine should span over exactly 24 hours. It is important to first record the time and empty the bladder into the toilet so that the start time coincides with an empty bladder. At that exact time the next day, the bladder should be emptied for a final time and collected into the jug. All urine between the start time and end time should be collected into the container. The time for each urination between start and end does not need to be recorded Keep the urine in a refrigerator or a cooled ice chest with the lid tightly screwed on for preservation

To prevent pressure injuries:

Use emollients and barrier creams to hydrate, protect, and strengthen the skin Use foam padding on chairs, commode seats, and other surfaces to help reduce pressure on bony prominences Provide prompt incontinence care and use additional barrier cream to keep skin clean and dry; this will further help reduce irritation and associated breakdown of the skin Reposition clients with a turn sheet every 2 hours using devices (eg, pillows, foam wedges) to maintain position; avoid pulling/dragging the client up in bed, as shearing can occur

Before an open wound may be closed (eg, sutured), irrigation is performed to wash out debris and bacteria, which assists in healing and infection prevention. To perform wound irrigation, the nurse should:

Verify the client's identification, confirm the prescription, and assemble necessary supplies. Don a gown, face mask with shield (to protect from splashing fluid), and sterile gloves (to maintain surgical asepsis and prevent infection). Fill a 30- or 60-mL syringe with nonirritating irrigation fluid (eg, sterile saline), and attach an 18- or 19-gauge irrigation tip or angiocatheter. Irrigate 1 in (2.5 cm) above the area, using a steady, gentle stream from the innermost part of the wound to the outermost margin until the drainage becomes clear. If required, obtain wound cultures after irrigation using sterile culturette swabs, swabbing from the center of the wound toward the outer margin. Gently dry the skin with sterile gauze sponges to prevent microorganism growth and skin irritation from residual moisture, and apply a dressing.

The liver is very vascular, which places it at risk for internal bleeding after a tissue sample is removed for biopsy. Liver dysfunction typically results in coagulopathy as many coagulation factors are synthesized in the liver, thereby increasing the risk for bleeding. Early signs of blood loss/shock are tachypnea, tachycardia, and agitation. A later sign is hypotension. Black stools (melena) indicates slow upper gastrointestinal bleeding; tachycardia may indicate significant blood loss. Therefore, this client needs immediate assessment.

Vital sign changes that are early signs of concern for hypovolemic shock are tachypnea, tachycardia, and agitation; hypotension is a late finding

The nurse is assessing a client in the outpatient clinic who has a cast on for a distal humerus fracture. Which statements made by the client would be the priority to assess further?

Volkmann contracture occurs as a result of compartment syndrome associated with distal humerus fractures. Swelling of antecubital tissue causes pressure within the muscle compartment, restricting arterial blood flow (brachial artery). The resulting ischemia leads to tissue damage, wrist contractures, and an inability to extend the fingers. A Volkmann contracture is a medical emergency that can cause permanent damage to the extremity if left untreated. Any restrictive dressing should be removed immediately, and the health care provider (HCP) must be notified for possible surgical intervention (eg, fasciotomy). (Option 2) The nurse should educate the client about ways to prevent medication-related nausea, or the HCP may consider switching pain medications. This would be addressed last. (Option 3) The client must be instructed to never stick anything inside the cast; this can lead to altered skin integrity and infection. This would be addressed third. (Option 4) A warm spot on the cast with a foul odor can indicate infection under the cast, especially if the client has been sticking objects inside to scratch the skin. This would be addressed second. Educational objective: Volkmann contracture (wrist contracture, inability to extend the fingers) occurs as a result of ischemia from compartment syndrome after a distal humerus fracture. It is a medical emergency that requires immediate intervention.

telephonic case management (TCM)

When a case manager provides care coordination and management services virtually via the telephone and/or other modes of electronic communication. Usually TCM programs are supported by state-of-the-art software systems, digital tools, and communication technologies.

The first step in management issues, just as in nursing care, is assessment. The charge nurse must first determine what happened before deciding the next course of action. The client could have misperceived certain actionsyttr

When a client complains about staff treatment, the first response should be to assess the client's perceived wrong. The nurse can then determine what follow-up action is needed.

During a camping trip, a camp counselor falls and gets a small splinter of wood embedded in the right eye. What action should the volunteer camp nurse take first? 1. Gently flush the eye with cool water 2. Instill optic antibiotic ointment 3. Patch both eyes with eye shields 4. Remove the splinter using tweezers

When a foreign body becomes accidentally embedded in the eye, both eyes should be shielded to prevent eye movement and additional injury. The nurse should immediately refer the client to an ophthalmologist for further evaluation and treatment.

A charge nurse suspects that the unlicensed assistive personnel (UAP) is falsifying the documentation of clients' capillary glucose results rather than performing the test. What is the best action by the charge nurse to handle this situation?

When deliberate inaccurate documentation is suspected, gather evidence before confronting the staff member. One way of doing this is by checking the data personally and comparing it to what has been documented.

Children with nephrotic syndrome often require daily urinalysis to monitor for proteinuria. Urine collection bags or dipsticks in the diaper risk breakdown of edematous skin. To collect a nonsterile urine specimen from a child in diapers, the nurse can place

cotton balls in a dry diaper and later squeeze urine onto a dipstick.

The nurse is assigned to care for a hospitalized confused client with an indwelling urinary catheter. On entering the client's room, the nurse notes the client pulling at the catheter and grimacing in pain. Blood is trickling from the client's meatus and the urine in the drainage bag is pink. Which action should the nurse take first?

When the urinary catheter balloon occludes the urethra, it should be deflated immediately to prevent further injury or complication. After balloon deflation, gently and slowly remove the catheter. If there is resistance, notify the urologist

The nurse is preparing to administer several medications through a client's feeding tube. None of the medications are extended release. Which of the following actions should the nurse implement?

When using a feeding tube, medications should be crushed, dissolved, and administered separately to prevent interactions. Feeding tubes should be flushed before and after each medication is given. Liquid medications should be used if possible.

The nurse prepares a client for scheduled surgery. Which actions are the nurse's legal responsibility with regard to informed consent?

Written consent is required for invasive procedures and surgery. Clients must be informed of and competent to understand information about the procedure, alternate treatments, and risks. They must also be informed that they have the right to refuse the procedure or surgery. The nurse's role in informed consent is to witness that the client signed the consent voluntarily and was competent at the time of signing (Options 1 and 5). The nurse should ensure that the client received necessary information and has no remaining questions about the procedure. After obtaining the signature, the nurse should document in the client's medical record that the informed consent was given and the date/time of the signature (Option 2). (Options 3 and 4) The health care provider is responsible for explaining all aspects of the procedure, ensuring that the client has a correct understanding of the procedure and its potential risks, providing the names/qualifications of those who will be involved, describing available alternate treatments, and reinforcing that the client has the right to refuse the procedure. The health care provider should be contacted if the client does not have a correct understanding of the procedure. The nurse should not try to explain procedures as he/she could be held liable for giving incorrect/incomplete information

Osteomalacia/rickets

bones become softer because of a vitamin D deficiency

The client with open lesions from a zoster virus infection, such as shingles or chicken pox, will require

both contact and airborne precautions along with a private room with negative airflow

Addison disease, or primary adrenal insufficiency, is due to the undersecretion of glucocorticoids and mineralocorticoids. Manifestations include

bronze skin, hypovolemia, hypotension, hyponatremia, hyperkalemia, and vitiligo.

When speaking with a client with Alzheimer disease, the nurse should provide a quiet, nondistracting environment (eg, remove background noises such as television and music) and use

clear and simple explanations to facilitate better understanding and reduce frustration.

Only when uncrusted lesions are present; contact precautions also required. **Only in disseminated disease or immunocompromised clients;

contact precautions also required.

After talking to a client, the health care provider tells the nurse that the client's signature is needed on the consent form that has been completed. While the nurse is obtaining the signature, the client states, "I'm not clear on what is included in the low-fat diet that I'll be on after the cholecystectomy." What action should the nurse take?

f the client has a question about the procedure or the risks, alternatives, or outcomes, the HCP should be contacted to provide additional teaching to the client. However, an ordinary question about general care or health care teaching can be answered by the nurse as this is part of the nurse's role.

A client who can bear weight partially but is unable to cooperate with instructions will require a

full-body sling lift and 2 caregivers for safe transfer

Elevated creatinine is expected in a client scheduled for

hemodialysis. The nurse should review the prescribed medications as many are removed by dialysis. The nurse should follow institution guidelines on holding medications before and after dialysis and seek direction from the health care provider if necessary.

Erythropoietin (EPO)

hormone secreted by the kidney to stimulate the production of red blood cells by bone marrow

Interventions to reduce falls in high-risk clients include

hourly rounding, moving the client to a room close to the nurses' station, and using bed alarms. Lines, tubes, drains (eg, indwelling urinary catheters), and restraints (eg, all side rails raised) increase fall risk and should be used only when clinically indicated

The client with excessive yellow, foul-smelling drainage will need a dressing change;

however, these findings are expected in a client with an infected venous leg ulcer.

Grave's Disease/ hyperthyroidism

hyperactivity, sensitivity to heat, weight loss, tachycardia, diarhea, expphthalumis( bulging eyes), nervousness, jittery, irradiation, surgery, light cloth

Malignant hyperthermia (MH) is a rare, life-threatening inherited muscle abnormality triggered by certain drugs used to induce general anesthesia. The most specific characteristic signs and symptoms of MH include

hypercapnia, muscle rigidity, and hyperthermia

Hyperosmolar hyperglycemic state is associated with type 2 diabetes mellitus. Because the pancreas of clients with type 2 diabetes produces some insulin, severe hyperglycemia develops gradually. Manifestations include severe

hyperglycemia, blurry vision, and altered level of consciousness

Polyuria and weight loss are usually associated with

hyperglycemia, not hypoglycemia

Addison disease occurs when the adrenal glands produce inadequate amounts of steroid hormones (eg, mineralocorticoids, glucocorticoids). It is characterized by

hyperpigmented skin, hypoglycemia, weight loss, muscle weakness, hypotension, and hyperkalemia

African Americans have the highest incidence of

hypertension in the world as well as increased incidence of stroke and cervical cancer. Whites have a high incidence of osteoporosis and skin cancer

Cardiac catheterization uses IV contrast to assess for artery obstruction. Complications include allergic reactions, lactic acidosis, and kidney injury. Contrast is avoided

in clients who had a previous allergic reaction to contrast agents, took metformin in the last 24 hours, or have renal impairment

The Valsalva maneuver is contraindicated in the client diagnosed with

increased intracranial pressure, stroke, head injury, heart disease, glaucoma, eye surgery, abdominal surgery, and liver cirrhosis.

Osteomyelitis

infection of the bone

Epotein alfa

is a human erythropoietin produced in cell culture using recombinant DNA technology. Authorised by the European Medicines Agency on 28 August 2007, it stimulates erythropoiesis and is used to treat anemia, commonly associated with chronic renal failure and cancer chemotherapy.

Gastric lavage (GL)

is performed through an orogastric tube to remove ingested toxins and irrigate the stomach. GL is rarely performed as it is associated with a high risk of complications (eg, aspiration, esophageal or gastric perforation, dysrhythmias). GL is only indicated if the overdose is potentially lethal and if GL can be initiated within one hour of the overdose. Activated charcoal administration is the standard treatment for overdose, but it is ineffective for some drugs (eg, lithium, iron, alcohol).

Proper gait - The 3-point gait

is used for restrictions of partial or no weight-bearing on the affected extremity. The injured extremity and crutches are moved simultaneously (Option 3). The client who is rehabilitating from an injury of the lower extremity usually progresses from non-weight-bearing status (3-point gait) to partial weight-bearing status (2-point gait) to full weight-bearing status (4-point gait).

Levothyroxine sodium (eg, Levoxyl, Levothroid, Synthroid)

is used to replace thyroid hormone in clients with hypothyroidism (inadequate thyroid hormone) and for those who have had their thyroid removed. These clients must understand that this medication must be taken for the rest of their lives (Option 5). A client's dose is adjusted based on serum thyroid-stimulating hormone (TSH) levels to prevent too much or too little hormone. Clients must be taught to report signs of excess thyroid hormone such as heart palpitations/tachycardia, weight loss, and insomnia

0.9 sodium chloride

isotonic

Maintenance of skin integrity through perineal and perianal hygiene is the highest priority. Implementation of containment products (eg, adult briefs, rectal tubes) should only be considered after

less invasive hygiene practices fail

Following thoracentesis, the nurse should monitor for signs of pneumothorax, including

level of alertness, respiratory rate, respiratory effort, oxygen saturation, and lung sounds.

Clients receiving thyroid hormone replacement therapy (levothyroxine sodium) should understand that treatment is

lifelong and be taught the signs of excess hormone (eg, tachycardia/palpitations, weight loss, insomnia). The medication is best absorbed on an empty stomach and is safe to take during pregnancy

Chronic illness can result in role changes that negatively influence a client's self-concept. The nurse can positively influence self-concept by empathizing, communicating acceptance, and

listening to the client's feelings and perceptions on the issue.

Interventions to promote safety and reduce the risk of falling when using axillary crutches in the home include

looking forward when walking, maintaining a clutter-free environment, resting crutches upside down on the axilla pads when not in use, using a small bag to hold personal items, wearing sturdy rubber-soled shoes, and keeping crutches in good repair

A client facing the end of life often has unfinished business that needs to be completed, which may motivate the client to become anxious or insist on discharge. The nurse should assess the client's concern and use this information to design a care plan that will allow the client to

make necessary preparations while ensuring medical care to control symptoms.

When caring for an unconscious client during admission, the nurse should assess for

medical alert devices and any prescriptive materials (eg, medication patches, contact lenses). The nurse should remove personal belongings and foreign objects that could harm the client if not removed (eg, tampons,

can deliver adequate oxygen concentrations and is best for clients with adequate tidal volume and normal vital signs. It is not the best choice in an unstable COPD client with varying tidal volumes because the inspired oxygen concentration is not guaranteed.

nasal cannula

Although this site has been in use for 6 days, it is a preferred site; the CVC was inserted in the operating room, where surgical asepsis was easily accomplished. The site can be used as long as there is a clinical need and

no evidence of infection.

Rest from activities that aggravate pain and inflammation is a

nonpharmacologic comfort intervention to decrease the inflammation due to acute pain.

Although pressure injuries can develop in any client with limited mobility and activity, those at most risk include

older adults; those with quadriplegia; the critically ill; and those with fracture of a long bone or hip, incontinence, nutritional deficits, chronic illness, renal failure, anemia, oxygenation and circulation problems, infection, or fever.

endotracheal intubation

placement of a tube through the mouth into the pharynx, larynx, and trachea to establish an airway

Safety is a priority for the client experiencing an acute attack of Meniere disease. Fall precautions include

placing the bed in low position, raising 2 or 3 side rails, and assisting the client with arising and ambulating. Vertigo can be minimized by staying in a quiet, dark room without a television or flickering lights

The general procedure for the administration of ophthalmic medications includes the following steps in sequence:

wiping from the inner to outer canthus / head tilted back toward side of the affected eye / Pull lower eyelid down gently with thumb or forefinger against bony orbit to expose the conjunctival sac/look upward and then instill drops of medication into the conjunctival sac/apply pressure to the lacrimal duct for 30-60 seconds if medication has systemic effects/Wait 5 minutes before instilling a different medication into the same eye

Clients at highest risk for developing hospital-acquired MRSA are older adults and those

with suppressed immunity, long history of antibiotic use, invasive tubes or lines, or in the ICU. Nurses should follow infection control procedures diligently with these clients

Visualization of NG tube placement by

x-ray is the standard protocol to ensure proper placement prior to initiating enteral tube feedings. Verification by auscultating air is not an evidence-based method of placement verification.

The preferred site for intramuscular (IM) injection in newborns is the vastus lateralis muscle in the anterolateral portion of the middle thigh. A 1-mL syringe should be used, and medication dosages should be calculated to two decimal places. A

⅝-inch, 22- to 25-gauge needle is appropriate for IM injection in a newborn.

When administering bolus enteral feedings, the nurse should place the client in semi-Fowler position, check gastric residual volumes (GRVs) as prescribed, verify acidic pH

≤5, return aspirated GRV to the stomach, and flush the tube before and after feedings

An infant's blood glucose level should be

≥40 mg/dL within the first 24 hours after delivery. A level <40 mg/dL (2.2 mmol/L) indicates hypoglycemia. Symptoms of hypoglycemia include jitters, cyanosis, tremors, pallor, poor feeding, retractions, lethargy, low oxygen saturation, and seizures. This infant with borderline low glucose level is symptomatic and should be assessed first.