Fundamentals U world

a) "I will keep an epinephrine injection in close proximity to my child at all times." b) "I will give the injection if my child has trouble breathing after a bee sting." d) "The injection can be given through clothing." e) "If I give the injection, I'll still take my child to the emergency room." A critical part of self-care for a person with a history of anaphylactic reaction is the use of emergency epinephrine injection (EpiPen or EpiPen Jr). The client and/or caregiver should be taught the following principles: - The EpiPen should always be available for emergency use and so should be taken along (in purse, pocket, backpack) when the client leaves home (option 1). - The EpiPen should be given when the client first notices any anaphylactic symptoms, such as tightening or swelling if the airway, difficulty breathing, wheezing, stridor, or shock (option 2) - The injection should be given in the mid-outer and can be given through clothing (options 3 and 4). - The client should receive emergency care as soon as possible by calling 911 or going to the emergency department to monitor for further problems (option 5). Educational objective: Emergency self-injection of epinephrine (EpiPen) can be done through clothing into the mid-outer thigh when the client first notices any anaphylactic symptoms.

A 2 year old is admitted to the emergency department for anaphylactic reaction to a bee sting. The nurse teaches the parent about emergency use of epinephrine injection. Which statement indicates that the parent understands the instruction? Select all that apply. a) "I will keep an epinephrine injection in close proximity to my child at all times." b) "I will give the injection if my child has trouble breathing after a bee sting." c) "I will give the injection in the upper arm." d) "The injection can be given through clothing." e) "If I give the injection, I'll still take my child to the emergency room."

a) Asks another licensed nurse to verify client identifiers and blood before administration c) Prepares O negative blood for an AB positive client e) Uses filtered tubing with normal saline to administer blood Blood transfusions are commonly administered to clients experiencing anemia or acute blood loss. To ensure client safety during blood administration, the nurse should: - Verify two client identifiers (eg, name, medical record number, date of birth), the prescription, and the blood products with another licensed health care provider (option 1). - Ensure that blood type and Rh type are compatible (option 3). An Rh-positive client can safely receive Rh-positive or Rh-negative blood. - Administer the blood via filtered tubing with normal saline to prevent clumping in the tube and hemolysis of red blood cells (option 5). - Monitor vital signs during transfusion per facility-specific protocol (eg, before transfusion, 15 minutes after transfusion begins, periodically). - Transfuse blood products within 4 hours due to the risk for bacterial growth (option 2) The nurse remains with the client for the first 15 minutes (ie, approximately 50 mL) of the transfusion and obtains vital signs directly to monitor for adverse reactions (eg, fever, chest pain). Delegating vital signs to unlicensed assistive personnel after the initial 15-30 minutes may be appropriate for stable clients. (option 4) Infusing blood over 6 hours increases the risk of bacterial contamination and hemolysis of the blood product. Educational objective: The nurse facilitates safe blood administration by verifying the prescription, blood type, and at least two client identifiers with another licensed health care provider; administering blood with normal saline; obtaining vital signs directly for the first 15 minutes (ie, approximately 50 mL of the transfusion); and transfusing blood within 4 hours

A blood transfusion is prescribed for a client experiencing complications of sickle cell anemia with hemoglobin level of 6 g/dL (60 g/L). Which of the following actions by the registered nurse are appropriate? Select all that apply. a) Asks another licensed nurse to verify client identifiers and blood before administration b) Delegates all vital sign measurements to the unlicensed assistive personnel c) Prepares O negative blood for an AB positive client d) Transfuses the blood over a 6 hour period of time e) Uses filtered tubing with normal saline to administer blood

a) Facilitate immediate removal of people from the area When a situation is out of control, safety is the primary concern. The nurse and everyone else should leave the area, and security should be called immediately. (option 2) The situation is no longer diffusible. Quoting authoritative rules will not likely have the desired effect as the client has lost control (and may not be in touch with reality). The nurse's first priority is to move out of harm's way. (option 3) Staff members should call security immediately and/or institute a back-up staff/takedown protocol. The fire alarm will activate a call to a fire department, which is not the type of help needed. However, when security arrives, the "best trained brain" remains in control and the nurse should direct the actions of the team. (option 4) When violence (eg, throwing a fire extinguisher) occurs, trying to defuse the situation verbally is no longer the priority. Educational objective: Safety is the priority when violence occurs. People should leave the area and call security immediately

A client in the mental health unit picks up a fire extinguisher and throws it at a nurse standing by the nurses' station. What is the most important intervention by the nurse? a) Facilitate immediate removal of people from the area b) Inform the client that the client cannot act that way c) Pull the fire alarm to get additional immediate help d) State that the nurse can see the client is upset

Answer: 0.9 mL Educational objective: 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)

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.

a) 1-person stand and pivot with gait belt and walker To determine the most appropriate method to safely transfer a client for the first time, the nurse should assess: 1. Whether the client can bear weight 2. Whether the client is cooperative 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 (option 1). If the client can fully bear weight and is cooperative, the client will not require an assisted transfer. However, a caregiver should standby during the first transfer for safety or for assist (option 2). (option 3) This method would be appropriate for a client who has no weight-bearing ability but can follow instructions and has enough upper body strength to use a motorized stand-assist lift. (option 4) If the nurse determines that the client cannot be safely transferred with assistance from 1 caregiver, a 2-person stand and pivot transfer may be performed. However, the nurse should first encourage the client to use as much own strength as possible. Educational objective: If the client is cooperative and able to partially bear weight, a safe transfer requires 1-person stand and pivot technique with a gait belt or powered stand-assist lift.

A client is able to partially bear weight and follow the nurse's instructions. Which would be the most appropriate method for the nurse to use to safely transfer this client? a) 1-person stand and pivot with gait belt and walker b) 1-person standby assist with walker c) 2-person motorized stand-assist lift d) 2-person stand and pivot with gait belt and walker

b) Keeping the door of the client's room closed at all times c) Maintaining a log of everyone in and out of the client's room e) Restricting visitors from entering the client's room Ebola (viral hemorrhagic fever) is an extremely contagious disease with a high mortality rate. Clients require standard, contact, droplet, and airborne precautions (eg, impermeable gown/coveralls, N96 respirator, full face shield, doubled gloves with extended cuffs, single-use boot covers, single-use apron). The client is placed in a single-client airborne isolation room with the door closed (option 2) Visitors are prohibited unless absolutely necessary for the client's well-being (eg, parent visiting an infected child) (option 5). For disease surveillance, a log is maintained of everyone entering or exiting the room, and all logged individuals are monitored for symptoms (option 3). Procedures and use of sharps/needles are limited whenever possible. There are currently no medications or vaccines approved by the Food and Drug Administration to treat Ebola. Prevention is crucial. (option 1) 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). (option 4) 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. Educational objective: Ebola is an extremely contagious viral disease with a high mortality rate. Infected clients require extensive infection precautions, including an airborne isolation room, strict protective equipment use, restriction of visitors, and a log of individuals who enter and exit the room.

A client with Ebola was just admitted to the unit. Which actions by the nurse would represent appropriate care of this client? Select all that apply a) Ensuring the client wears an N95 respirator at all times b) Keeping the door of the client's room closed at all times c) Maintaining a log of everyone in and out of the client's room d) Removing both pairs of gloves before removing gown and mask e) Restricting visitors from entering the client's room

4.6 mL/ dose Using dimensional analysis, the following steps are performed to calculate the volume of cefuroxime per dose in milliliters: 1. Identify the prescribed, available, and required medication information: prescribed: 30 mg cefuroxime/ kg/ day available: 250 mg cefuroxime/ 5 mL required: mL/ dose 2. Convert the prescription to the volume needed for administration using dimensional analysis. Prescription X available data = mL per dose 3. Round to the first decimal place 4.6363 mL/dose = 4.6 mL/dose Educational objective: To calculate the volume of cefuroxime in milliliters per dose, the nurse should first identify the prescribed dose (eg, 39 mg/kg/day) and available medication (eg, 250 mg/5 mL) and then convert to volume in milliliters per dose (eg, 4.6 mL)

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. Cefuroxime: 250 mg/ 5mL Answer: _________ (mL)

c) Remove all area rugs and install grab bars in the bathroom All choices are appropriate options to reduce falls in the home, but the one with the greatest impact is removal of all area rugs and installation of grab bars in the bathroom. Area rugs can cause falls for the client with a walker, with new glasses, and with someone present. In addition, many falls occur in the bathroom while toileting and bathing, making grab bars highly beneficial. (option 1) Not leaving the client alone is preferable and could decrease the incidence of falls while the spouse is away. However, it is less effective than the removal of area rugs and installation of grab bars in the bathroom (option 2) A walker would be beneficial for this client but could get caught on an area rug. (option 4) Poor eyesight can contribute to falls, but removal of rugs and installation of grab bars will have a greater impact. Educational objective: The nurse should educate the client and family about removing area rugs and installing grab bars in the bathroom to reduce the risk of falls in the home.

A home health nurse is teaching the spouse of an elderly client who experienced a stroke ways of reducing risks for falls in the home. Which suggestion by the spouse would be the most effective plan to prevent falls? a) Have a respite caregiver come once a week to stay with the client so the spouse can go shopping. b) Purchase a walker for the client to use when ambulating around the home c) Remove all area rugs and install grab bars in the bathroom d) Take the client for an annual eye exam and new glasses

a) Blood pressure of 180/100 mmHg Percutaneous kidney biopsy is an invasive diagnostic procedure. It involves inserting a needle through the skin to obtain a tissue sample that is then used to determine the cause of certain kidney diseases. 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 mmHg) using antihypertensive medications before performing a kidney biopsy (option 1) (option 2) An elevated serum creatinine level (normal: 0.6-1.3 mg/dL [53-115 umol/L) can be expected in a client with probable renal disease. This is not the most important finding to report to the HCP. (option 3) A decreased hemoglobin level (normal adult male: 13.2-7.3 g/dL [132-173 g/L]; normal adult female: 11.7-15.5 g/dL [117-155 g/L]) can be expected in a client with probable renal disease due to decreased erythropoietin production. The nurse should continue to monitor the client's hemoglobin post-procedure as it can decrease further (within 6 hours) if bleeding occurs. (option 4) Only neurosurgery and ocular surgery require require a platelet count >100,000/mm^3. Most other surgeries can be performed when the platelet count is >50,000/mm^3. Although the platelet count is low (normal 150,000-400,000/mm^3, it is not the most important finding to report to the HCP. Educational objective: The kidney is a highly vascular organ and the risk of bleeding is a major complication after a percutaneous biopsy. The client should have normal coagulation studies, an adequate platelet count, and well-controlled blood pressure prior to the procedure to reduce bleeding risk.

A hospitalized client is scheduled for a percutaneous kidney biopsy at 10 AM. At 8 AM, the nurse reviews the client's vital signs and most current serum laboratory results. Which finding is most important to report to the health care provider (HCP)? a) Blood pressure of 180/100 mmHg b) Creatinine of 2 mg/dL (176.8 umol/L) c) Hemoglobin of 9.8 g/dL (98 g/L) d) Platelet count of 120,000/mm3 (120 x 10^9/L)

d) Selects a 25-gauge 1/2 inch (1.3 cm) needle to inject ketorolac intramuscularly Ketorolac is a nonsteroidal anti-inflammatory drug (NSAID) analgesic administered (orally, IV, or intramuscularly [IM]) for short-term relief of mild to moderate pain. Usage should not exceed 5 days due to adverse effects (eg, kidney injury, gastrointestinal ulcers, bleeding). Ketorolac IM should be administered into a large muscle using the Z-track method to mitigate burning and discomfort. A 1- to 1.5-in (2.5- to 3.8 cm) needle is recommended to inject medication into the proper muscular space in average-weight individuals. (option 1) The amount of analgesic to administer of a variable dose medication should be based on the client's pain level, level of consciousness, and history of narcotic use. Selecting a smaller first dose is appropriate if the nurse is unsure of how the client will respond to the medication. If needed, the larger amount can be given the next time a dose is requested or an additional one-time dose can be requested from the health care provider if breakthrough pain occurs (eg, nausea, itching). (option 2) Hydromorphone IV push, given undiluted with 5 mL of sterile water or normal saline, should be administered slowly over 2-3 minutes; rapid infusion increases the risk of opioid-induced adverse reactions (eg, nausea, itching) (option 3) Undiluted morphine IV push should be administered slowly over 4-5 minutes; rapid infusion increases the risk of opioid-induced adverse reactions (eg, hypotension, flushing) Educational objective: Ketorolac, a nonsteroidal anti-inflammatory drug, is used for short-term (<5 days) pain relief due to risk of bleeding, gastrointestinal ulcers, and kidney injury. Intramuscular (IM) injections (using Z-track method) should be given deep into a large muscle due to burning and discomfort. A 1- to 1.5 in (2.5 to 3.8- cm) needle is used to reach the proper muscle space.

A new graduate nurse is preparing to administer the following analgesics to clients with postoperative pain. Which situation would require intervention by the precepting nurse? a) Chooses to administer 50 mcg of the prescribed 50-100 mcg of IV fentanyl for the first dose. b) Dilutes hydromorphone with 5 mL of normal saline and injects IV push over 2 minutes c) Injects 1 mg of morphine sulfate undiluted via IV push over 5 minutes d) Selects a 25-gauge 1/2 inch (1.3 cm) needle to inject ketorolac intramuscularly

a) Haloperidol for a client with a fall history who keeps getting out of bed without assistance Chemical restraints are medications (eg, benzodiazepines, psychotropics) used to restrict freedom of movement or to control socially disruptive behavior in clients who have no medical indications for them. Although this client is at risk of injury from falling, the use of a psychotropic drug is not considered the standard treatment for a client with a history of falls who keeps getting out of bed without assistance. The least restrictive method to ensure client safety (eg, bed alarm, sitter, assistive devices) should be tried first before administering a chemical restraint. Therefore, the nurse should question the prescription for haloperidol (Haldol) in this client (option 1). (option 2) Benzodiazepines (eg, lorazepam [Ativan], diazepam, chlordiazepoxide) are considered standard treatment to control agitation in the client in alcohol withdrawal. (option 3) Antipsychotics (eg, olanzapine [Zyprexa], ziprasidone [Geodon], haloperidol) are considered standard treatment to control violent behavior in the client with schizophrenia. (option 4) Propofol (Diprivan) is considered standard treatment to sedate the client receiving mechanical ventilation to provide ventilator control, prevent accidental extubation, and promote comfort. Educational objective: Medications that are standard treatments for specific conditions (eg, alcohol withdrawal, schizophrenia, mechanical ventilation) are not considered chemical restraints. The nurse should question a chemical restraint prescription that may not be medically necessary for a client's safety.

A new nurse attends a risk management class on the indications and legal implications of using chemical restraints to maintain client safety. Which prescription should the nurse question before administering? a) Haloperidol for a client with a fall history who keeps getting out of bed without assistance b) Lorazepam for a client who is in alcohol withdrawal and is extremely agitated. c) Olanzapine for a client with schizophrenia who is exhibiting violent behavior d) Propofol for a client who is intubated and receiving mechanical ventilation

d) Pull the skin 1-1.5" (2.5-3.5 cm) laterally and away from the injection site c) Hold the skin taut with non-dominant hand and insert needle at a 90-degree angle b) Inject medication slowly with dominant hand while maintaining traction f) Wait 10 seconds after injecting the medication and withdraw the needle e) Release the hold on the skin, allowing the layers to slide back to their original position a) Apply gentle pressure at the injection site but do not massage 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: 1. Pull the skin 1-1.5" (2.5-3.5 cm) laterally away from the injection site (option 4) 2. Hold the skin taut with the nondominant hand, and insert the needle at a 90-degree angle; taught skin facilitates entry of the needle and this angle ensures that the needle will reach the muscle (option 3) 3. 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 (option 2) 4. 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 (option 6). 5. Release the hold on the skin; this allows the tissue layers to slide back to their original position, sealing off the needle track (option 5) 6. 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. (option 1) 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. Educational objective: The Z-track technique for administering IM injections prevents tracking (leakage) of the medication into the subcutaneous tissue

A nurse administers an intramuscular (IM) injection using the Z-track technique. Place the steps in chronological order. All options must be used. Unordered options: a) Apply gentle pressure at the injection site but do not massage b) Inject medication slowly with dominant hand while maintaining traction c) Hold the skin taut with non-dominant hand and insert needle at a 90-degree angle d) Pull the skin 1-1.5" (2.5-3.5 cm) laterally and away from the injection site e) Release the hold on the skin, allowing the layers to slide back to their original position f) Wait 10 seconds after injecting the medication and withdraw the needle

b) Pull the pinna upward and back When administering an otic medication to an adult or child age 3 an 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. (option 1) 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. Educational objective: 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

A nurse in a pediatric clinic is preparing to administer ear drops to a 5 year old. Which is an appropriate action by the nurse? a) Have the child sit upright with the chin tilted b) Pull the pinna upward and back c) Remove the medication from the refrigerator just before use d) Touch the dropper to the entrance of the ear canal

b) "I took my prasugrel this morning with just a tiny sip of water." Antiplatelet medication (eg, prasugrel [Effient], clopidogrel [Plavix], ticagrelor [Brilinta]) are often prescribed to a client after a percutaneous coronary intervention such as angioplasty or stent placement. These agents should be stopped at least 5-7 days prior to surgery to reduce the chance of intraoperative and postoperative bleeding. The nurse should immediately report to the HCP that the client is still taking prasugrel and took it the morning of the surgery. Unless the surgery is emergent, it will most likely be postponed at least a week. (option 1) Nothing by mouth for at least 6-8 hours prior to surgery is typical. (option 3) The nurse can assist the client in discussing reasons for anxiety. Anxiety is common prior to surgery, unless the client refuses to go through with the surgery or requests to speak with the HCP, the nurse can usually deal with this issue. (option 4) Difficult IV sticks can be handled by the nurse. Educational objective: Medications that cause increased risk for bleeding include anticoagulants (eg, warfarin, heparin) and antiplatelets (eg, aspirin, clopidogrel, prasugrel, ticagrelor, dipyridamole).

A nurse in the surgical admitting unit is preparing a client for elective coronary artery bypass surgery. Which statement by the client should the nurse report immediately to the health care provider? a) "I haven't had anything to eat or drink since 8 PM yesterday." b) "I took my prasugrel this morning with just a tiny sip of water." c) "I'm really nervous about this surgery." d) "It always takes several attempts to start my IV."

d) Wrap the newborn's upper body in a blanket restraint for the circumcision 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. (option 1) A loose-fitting diaper is put on the newborn after circumcision to avoid irritation to the penis. (option 2) Sterile technique is used during the surgical procedure of the circumcision. (option 3) The infant should not be fed during circumcision to prevent the risk of aspiration. A pacifier dipped in a concentrated sucrose solution is offered as a nonpharmacologic pain management technique. Educational objective: 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.

A nurse is assisting with the care of a newborn during circumcision. Which is an appropriate intervention? a) Apply a snug-fitting diaper following the procedure b) Anticipate the use of clean technique during the circumcision c) Offer oral fluids during the procedure d) Wrap the newborn's upper body in a blanket restraint for the circumcision

a) 0.45% sodium chloride solution for a client with severe gastroenteritis who had 12 episodes of diarrhea and vomiting in the past 4 hours The nurse should question the administration of a hypotonic IV solution (ie, 0.45% sodium chloride) to replace gastrointestinal tract fluid losses as this would create a concentration gradient and shift fluid out of the intramuscular compartment into the interstitial tissue and cells, worsening the client's fluid volume deficit. Isotonic IV solutions (eg, 0.9% sodium chloride, lactated Ringer's) have the same Somali type as plasma and are administered to expand intramuscular fluid volume. These solutions replace fluid losses commonly associated with vomiting and diarrhea, burns, and traumatic injury. (option 2) Anaphylaxis causes increased capillary permeability, leaking intravascular fluid into free spaces; this places the client at risk for hypotension. Therefore, isotonic solutions should be given to such clients. (option 3) Extreme hyperglycemia in a client with diabetic ketoacidosis results in osmotic dieresis and dehydration. The immediate initial treatment is IV fluid resuscitation with isotonic 0.9% sodium chloride to replace fluid losses, stabilize vital signs, reestablish urine output, and dilute the serum glucose concentration before initiating insulin therapy. (option 4) A client with head trauma is at risk for increased intracranial pressure due to inflammation and cerebral edema. IV mannitol is an osmotic diuretic that reduces cerebral edema by pulling water from the cerebral cells into the vasculature. Educational objective: 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.

A nurse is caring for 4 clients. Which prescription by the health care provider would the nurse question and seek further clarification before administering? a) 0.45% sodium chloride solution for a client with severe gastroenteritis who had 12 episodes of diarrhea and vomiting in the past 4 hours b) IV bolus of 1000 mL 0.9% sodium chloride solution for a client in anaphylaxis due to a food allergy c) IV bolus of 1000 mL 0.9% sodium chloride solution for a client with diabetic ketoacidosis who has a serum glucose level of 650 mg/dL (36.1 mmol/L) d) IV mannitol 25% solution for a client with a closed head injury who is exhibiting signs of increased intracranial pressure

a) Frequent hand hygiene Hand hygiene is the most important factor in preventing infection transmission. The nurse should perform hand hygiene before and after client contact, before donning and after removing gloves, and after contact with bodily fluids (option 1). Principles for proper hand hygiene include: - Apply alcohol-based hand rubs liberally, covering the entire surface of the hands, and allow hands to dry completely. Do not use an alcohol-based hand rub if hands are visibly soiled. - When using soap and water, wet the hands; apply soap; scrub all hands surfaces, wrists, and beneath the nails for at least 20 seconds; rinse; dry hands with a paper towel; and then use a new, dry paper towel to turn off the faucet. (option 2) The nurse should not wear artificial nails, especially in high-risk areas (eg, intensive care unit), because artificial nails harbor microorganisms, even after hand washing. However, the priority intervention for infection prevention is hand hygiene. (option 3) The nurse should use chlorhexidine to bathe clients who are critically ill, have central venous catheters, or are scheduled for surgery; and for indwelling catheter care. However, the risk for infection transmission would remain high if the nurse implements client care without performing hand hygiene. (option 4) Personal protective equipment (eg, gloves) is appropriate but is not as important as (and does not replace) hand hygiene to prevent the spread of infection. Educational objective: Hand hygiene is the most important nursing intervention to prevent the spread of infection to clients.

A nurse is caring for a client who is intubated and has a subclavian central venous catheter. Which nursing intervention is most important to prevent the spread of infection to this client? a) Frequent hand hygiene b) No artificial nails c) Use of chlorhexidine bath wipes d) Wearing personal protective equipment

Answer: 3.75 mL/dose Educational objective: To calculate the milliliters per dose of oral amoxicillin, the nurse should first identify the prescribed dose (eg, 25 mg/kg/day divided in two doses) and available medication (eg, 125 mg/5 mL solution) and then convert to milliliters per dose (eg, 3.75 mL/dose).

A nurse is instructing the caregiver of an 8 month old client regarding administration of oral amoxicillin. The client is prescribed 25 mg/kg/day of amoxicillin in 2 divided doses for 5 days. The client weighs 16.5 lb and the amoxicillin solution is prepared as 125 mg/5 mL. How many mL of amoxicillin should the nurse instruct the caregiver to administer for each dose? Record the answer using two decimal places.

c) Wear clean gloves to remove the existing dressing, changing to sterile gloves to apply the new dressing The existing dressing is already contaminated so clean gloves can be worn to remove and discard it. Surgical wounds should be re-dressed using aseptic technique, which would require sterile gloves and sterile dressing supplies. The nurse should carefully remove the soiled dressing to avoid shedding any microorganisms into the air and expose the wound for minimal time to avoid additional contamination. (option 1) It would be better for the nurse to perform the dressing change as the wound is already infected. The client may be able to assist in the home setting. (option 2) Clean gloves can be used for removal but not for application of a new dressing (option 4) Sterile gloves are not needed to remove the existing dressing. A gown and goggles may be required if splashing is possible. Educational objective: 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.

A nurse is performing a dressing change for a hospitalized client with an infected surgical incision. Which actions should the nurse take? a) Have the client remove the existing dressing while the nurse prepares sterile supplies b) Wear clean gloves for removal and application of a new dressing c) Wear clean gloves to remove the existing dressing, changing to sterile gloves to apply the new dressing d) Wear sterile gloves, gown, and goggles to remove the soiled existing dressing

a) Check laboratory values before administering anticoagulants b) Compare medication, dosage, and route to prescription orders prior to administration c) Discard any unlabeled medications 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 Additionally, one of the National Patient Safety Goals (NPSGs) is to "improve the safety of using medications." This includes labeling all medications as soon as prepared, discarding any medications that are found unlabeled, and taking extra care for clients who take anticoagulant drugs. (option 4) Individual dose packages should be opened at the client's bedside and should be placed in a medication cup only immediately prior to administration (option 5) Gloves are generally not required during medication preparation or handling of unopened packages or vials, although hand hygiene should be performed both prior to preparation or handling and again prior to administration. The nurse should wear gloves during medication administration when coming into contact with a route that is potentially contaminated by blood or bodily fluids (eg, administering intramuscular or subcutaneous injections, accessing a closed IV tubing system, placing a pill into a client's mouth using fingers). Educational objective: The nurse should follow the 6 rights of medication administration when preparing and administering drugs to a client. Additionally, the NPSGs of improving the safety of using medications should be followed, including labeling all medications, discarding medications found unlabeled, and taking extra care for clients taking anticoagulant drugs.

A nurse on the telemetry unit is preparing client medications in the medication room at the nurse's station. The nurse should perform which actions to be consistent with client safety practices related to medication administration? Select all that apply. a) Check laboratory values before administering anticoagulants b) Compare medication, dosage, and route to prescription orders prior to administration c) Discard any unlabeled medications d) Open unit dose packages and place medications in a dispensing cup to take to the bedside e) Wear gloves to handle unopened individual unit dose medication packages

d) "The medication should be administered into the deltoid muscle." 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 (option 4). (option 1) For IM injections, the needle length should be 5/8 inch for newborns and 5/8 to 1 inch for infants; these lengths are adequate for reaching the muscle mass while avoiding underlying tissues (eg, nerves, bone). A 22- to 25- gauge needle is appropriate for clients age <12 months. (option 2) The medication should be administered using aseptic technique; cleaning the site with an antiseptic solution (eg, alcohol is appropriate. (option 3) A 1-mL syringe (eg, tuberculin) should be used to measure very small doses in 0.01-mL increments for newborns, infants, and small children. Pediatric medication dosages can be very small and should be measured to two decimal place. Educational objective: 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 5/8-inch, 22- to 25- gauge needle is appropriate for IM injection in a newborn.

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? a) "A 5/8-inch, 25-gauge needle is appropriate for intramuscular injection in newborns." b) "I will clean the injection site with an antiseptic swab before administration." c) "I will draw the medication into a 1-mL syringe." d) "The medication should be administered into the deltoid muscle."

d) Transport the client to the operating room under implied consent. Implied consent in emergency situations includes the following criteria: -There is an emergency -Treatment is required to protect the client's health -It is impractical to obtain consent -It is believed that the client would want treatment if able to consent In this case, it would be assumed that the client would want life-saving surgery; the health care provider should proceed. (option 1) The client's name is not known and there is no national database of healthcare proxy names/power of attorney. (option 2) This should also be done but results may be obtained in a timely manner. The client needs immediate surgery and this should proceed with the client as "John Doe" (placeholder name) in the meantime. (option 3) This would cause considerable delay. Court orders are used for protective custody to take control of the care of a minor when the adult parent is refusing necessary life-saving care. Educational objective: Emergency life-saving care can proceed for a client who cannot give consent if it is essential and believed that the client would want treatment if able to consent. Care is rendered under the principle of implied consent.

An unconscious client is brought to the emergency department by the paramedics after being hit by a car. An emergency craniotomy is required. The client has no identification. What action should be taken next? a) Contact the national database to see if the client has a healthcare proxy b) Contact the police to help identify the client and located family members. c) Obtain a court order for the client's surgical procedure d) Transport the client to the operating room under implied consent.

5.3 Educational objective: 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)

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/5mL. How many milliliters (mL) should the client receive for each dose? Record your answer using one decimal place. Answer: _________ mL

a) Assess the client's breath sounds c) Notify the health care provider (HCP) e) Stop the infusion of PRBCs Signs and symptoms of a blood transfusion reaction typically will occur within the first 15 minutes after initiation of the transfusion. These include shortness of breath, chest tightness, fever, back pain, anxiety, tachycardia, and hypotension. When a transfusion reaction is suspected, the first step is to stop the infusion (option 5). An infusion of normal saline is typically started. It is important that normal saline be administered through a different port of the CVC using new tubing or at the closest access point to the client. Flushing the blood in the IV tubing into the client will expose the client to more of the causative agent and increase complications from the transfusion reaction (option 2). The HCP must then be notified (option 3). Because the client has shortness of breath and chest tightness, an assessment of breath sounds is appropriate. Adventitious sounds could indicate bronchospasm or excess fluid in the lungs (option 1). (option 4) A CVC will not be discontinued due to the transfusion reaction. IV access will be required for administration of fluids and medications. Educational objective: If an adverse blood transfusion reaction is suspected, the first action is to stop the infusion. An infusion of normal saline through a different port for the CVC is typically started. A client assessment and notification of the HCP are also required.

Ten minutes after an infusion of packed red blood cells (PRBCs) is initiated through a central venous catheter (CVC), the client has shortness of breath and slight chest tightness. What initial actions would be appropriate for the nurse to complete? Select all that apply. a) Assess the client's breath sounds b) Flush the blood IV tubing with normal saline c) Notify the health care provider (HCP) d) Remove the CVC e) Stop the infusion of PRBCs

b) "Please go directly to the nearest emergency department for evaluation." Amitriptyline is a tricyclic antidepressant (TCA) that can produce cardiac toxicity and neurological disturbances by altering cholinergic pathways, sodium channels, and calcium channels, causing symptoms such as atrioventricular block, hypotension, cardiac arrest, and seizure. TCAs have a narrow therapeutic index and rapid onset of action, so ingestion of even a small amount may be life-threatening for a toddler. Symptoms of toxicity are usually evident within hours of ingestion, but cardiac failure can develop days after. Neurological and hemodynamic assessments, as well as ECG monitoring in an emergency department setting, are recommended (option 2). (option 1) Syrup of ipecac is no longer routinely recommended for oral poisonings. The uncontrolled vomiting and vagal response induced can be harmful after ingestion of toxic substances. Treatments such as oral activated charcoal may be used in the inpatient setting to remove the ingested toxin if the client presents immediately after the ingestion. (option 3) The caregiver should not be instructed to stay home to monitor for symptoms due to rapid onset of toxicity. (option 4) An outpatient clinic is not sufficiently staffed or equipped for acute management of amitriptyline toxicity. The nurse should refer the client to the nearest emergency department, which is the safest environment for monitoring and treatment. Educational objective: Amitriptyline is a tricyclic antidepressant (TCA) that can cause toxic cardiac and neurological effects in children, even in small doses. Children who have accidentally ingested TCAs should be evaluated immediately in an emergency department.

The caregiver of a toddler calls the clinic because the child has accidentally ingested one capsule of amitriptyline found in the medicine cabinet. The caregiver states that the child appears to be acting normally. Which response by the nurse is appropriate? a) "Give syrup of ipecac immediately and proceed to the hospital" b) "Please go directly to the nearest emergency department for evaluation." c) "Stay home and monitor the child closely for any symptoms." d) "You should come immediately to the clinic with the pill bottle."

c) Removes dried secretions with moistened sterile gauze pads by wiping from the outer to inner canthus If applicable, the nurse requests that the client remove contact lenses. The nurse then dons clean gloves and uses aseptic technique to administer ophthalmic medications (eg, eye drops, lubricant) that lubricate the eye and treat eye conditions (eg, glaucoma, infection). The Joint Commission disallows the use of abbreviations for right eye (OD), left eye (OS), and both eyes (OU). The nurse must verify the prescription if the health care provider (HCP) uses these abbreviations. The general procedure for the administration of ophthalmic medications includes the following steps in sequence: 1. Remove dried secretions with moistened (warm water or normal saline) sterile gauze pads by wiping from the inner to outer canthus to to keep eyelid and eyelash debris from entering the eye and to prevent transfer of debris into the lacrimal (tear) duct (option 3) 2. Place client in the supine or sitting position with head tilted back toward side of the affected eye to prevent excess medication from flowing into the lacrimal duct and minimize systemic absorption through the nasal mucosa 3. Rest hand on client's forehead and hold dropper 1-2 cm (1/2-3/4) in above the conjunctival sac, which keeps the dropper away from the ye globe and avoids contamination (option 4) 4. Pull lower eyelid down gently with thumb or forefinger against bony orbit to expose the conjunctival sac (option 2) 5. Instruct client to look upward and then instill drops of medication into the conjunctival sac. This minimizes the blink reflex and retracts the cornea up and away from the conjunctival sac to avoid instillation onto the cornea. 6. Instruct client to close the eyelid and move the eye around (if able). Then apply pressure to the lacrimal duct for 30-60 seconds if medication has systemic effects (eg, beta blocker, timolol maleate [Timoptic]). This will distribute the medication, prevent overflow into the lacrimal duct, and reduce possible absorption (option 1) 7. Remove excess medication from each eye with a new tissue or gauze pad to prevent cross-contamination 8. Wait 5 minutes before instilling a different medication into the same eye Educational objective: To administer ophthalmic medications, follow these steps: (1) 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)

The nurse precepts a nursing student caring for a client with glaucoma and observes the student administer timolol maleate, an ophthalmic medication. Which student action indicates that further instruction is needed? a) Instructs client to close eyelid and move eye around; applies pressure to the lacrimal duct for 30-60 seconds b) Pulls lower eyelid down gently with thumb or forefinger against bony orbit to expose the conjunctival sac c) Removes dried secretions with moistened sterile gauze pads by wiping from the outer to inner canthus d) Rests hands on client's forehead and holds dropper 1-2 cm (1/2-3/4 in) above the conjunctival sac

d) One-on-one supervision from a sitter Client and staff safety is an ongoing concern when working with clients who are confused and agitated. The least restrictive restraint should be used. One-on-one supervision provided by a trained staff member who stays with the client at all time can promote safety while reducing or eliminating the use of restraints on a client who is confused and agitated. Frequent reassurance, touch, and verbal orientation (regarding name, location, time, and the client's situation) can lessen disruptive behaviors. Placing a large clock and calendar within the client's visibility would also help. (option 1) Ideally, the client will be placed in a room near the nursing station. However, the client with delirium and agitation will also require ongoing supervision to minimize harm to self and others. (option 2) Four-point leather restraints are one of the most restrictive restraint options. These are not appropriate as a first-line option for promoting safety. (option 3) Reducing environmental stimuli is important for an agitated client, but these alone are not most helpful. Educational objective: When caring for clients with behavioral issues that may compromise safety, less restrictive restraint and safety options should be implemented before more restrictive restraint options are used.

The charge nurse is preparing for the admission of an elderly client with delirium and agitation associated with urinary tract infection. To promote client safety, which intervention is most important for the charge nurse to implement? a) A bed near the nursing station b) Four-point leather restraints c) Minimizing environmental stimuli d) One-on-one supervision from a sitter

Answer: 32 mL/hr Educational objective: To calculate the infusion rate of infusion, 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)

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) foes the nurse set the IV infusion pump? Record your answer using a whole number.

d) Question the prescription with the prescriber The nurse needs to have appropriate knowledge about a medication prior to administering it. Hydromorphone (Dilaudid) is a potent narcotic that has 5-10 times the strength of morphine. This client was prescribed a hydromorphone dose that is too high given that the typical maximum dose is 2 mg. As the drug prescription is outside a safe range, it must be questioned and cannot be administered automatically. (option 1) A prescription that greatly exceeds the safety range should not be given without questioning/clarification. However, anytime the outer limit of drug dosing of a potent narcotic is administered, the client should be monitored frequently for adverse effects. This includes the sedation scale and arousability as sedation precedes respiratory depression for narcotics. (option 2) When there is a medication dosing question, authoritative resources (eg, the pharmacist, current drug literature) should be consulted rather than relying on a nursing colleague who could be mistaken. (option 3) Even if the client is opiate-tolerant, the dosage is significantly outside the safety range and the prescription should be questioned or clarified. Educational objective: When a medication prescription is outside the safety range, the nurse must question/clarify the prescription with the prescriber and not administer the drug automatically.

The health care provider writes a prescription for hydromorphone 10 mg intravenous push every 2 hours prn for the post-operative client. The usual recommended dose is 0.2-1 mg every 2-3 hours prn. What action should the nurse initially take? a) Administer the medication and monitor client frequently b) Ask a nursing colleague if this drug amount is used c) Check hydromorphone dose that the client had previously d) Question the prescription with the prescriber

b) Complications, including death, could result Just as there is informed consent, there is informed refusal. The client should be made aware of all the possible complications (including the possible worst-case scenario, which is usually death) when making a decision, and this should be documented. The nurse should try to work with the client to get at least partial compliance when it is in the client's best interest (eg, wear the SCDs for a limited time). (option 1) This would occur, but it is more important to make the client aware of the potential implications of this refusal so that the client can make an informed refusal. (option 3) Safe, quality care is the priority, not financial concerns. The nurse should avoid discussing financial implications when a client is making care decisions. (option 4) Depending on the hospital policy, a refusal documented in the medical record. Documentation should include the information given to the client and the client's understanding of that information. Even if the client refuses to sign the form, the nurse should obtain other witnesses and document the refusal in detail in the medical record. Educational objective: 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.

The male client had a hemicolectomy. The client is refusing to wear the prescribed sequential compression devices (SCDs). What is most important for the nurse to communicate to the client? a) An appropriate form must be signed, verifying refusal b) Complications, including death, could result c) The client will be billed for the equipment regardless d) The surgeon will be informed of the refusal

c) Contact the health care provider to request an x-ray to verify tube placement A nasoenteric feeding tube is used for administration of continual or intermittent enteral feedings and medications. The tube is marked at the exit site (nare) with indelible ink during the initial placement x-ray. The tube may have moved out of the correct position if it's external length changes. If this occurs, the nurse should contact the health care provider (HCP) and request a prescription for a repeat x-ray to determine tube location. Based on the x-ray results, enteral feeding may be resumed or the HCP may prescribe insertion of a new tube according to institution policy (option 3). (option 1) Even if bedside methods to determine placement are used (eg, gastric aspirate pH and appearance), advancing the tube to the original marking does not guarantee correct placement; these methods are not accurate indicators. Tube feedings should not be resumed after tube dislodgment without x-ray verification of correct placement. (option 2) A prescription for hand mitts to keep a confused client from disrupting enteral nutrition may be appropriate if other less restrictive interventions (eg, keeping tubing out of client's sight, one-on-one sitter) are ineffective or unavailable. However, this should not be the nurse's next action. (option 4) The guide wire (stylet) is secured before tube insertion and remains in place until placement is verified by x-ray. Once removed, the guide wire should never be reinserted while the tube is in place as it can protrude and damage both the tube and the client's mucosa. Educational objective: A feeding tube is marked with indelible ink at the exit site (nare). If the external length of the tube changes, the nurse should contact the health care provider and request a prescription for a repeat x-ray to determine tube location before resuming administration of enteral feedings and medications.

The nurse I'd feeding a confused client via a small-bore nascent Eric tube. The nurse observes the client pulling at the tube and then notices an increase in external tube length from the original exit mark. After immediately stopping the feeding, which action is appropriate for the nurse to take next? a) Advance the tube to the original exit mark, check gastric aspirate pH, and resume feeding b) Contact the healthcare provider to request a prescription for hand mitts c) Contact the health care provider to request an x-ray to verify tube placement d) Reinsert the guide wire and advance the tube to its original exit mark

b) The client has an implantable cardioverter defibrillator (ICD) Radio waves and a magnetic field are used to view soft tissue during MRI. This test is especially useful in diagnosing tumors, disc disease, avascular necrosis, ligament tears, cartilage tears, and osteomyelitis. MRIs can have open or closed chambers. The client should be advised that the procedure is painless but the machine will loud tapping noises and may cause claustrophobia in some clients inside a closed chamber. MRI is contraindicated in clients with aneurysm clips, metallic implants such as ICDs, pacemakers, electronic devices, hearing aids, and shrapnel. The large magnet of the MRI can damage the ICD or interfere with its function. (options 1 & 4) MRI is a noninvasive test that does not require anesthesia. The client is not required to have nothing by mouth and can take medications as normally indicated. (option 3) No povidone-iodine (Betadine) is used during an MRI; gadolinium contrast is used. Educational objective: MRI is contraindicated in clients with aneurysm clips, metallic implants such as ICDs, pacemakers, electronic devices, hearing aids, and shrapnel. The large magnet of an MRI can damage implantable devices or interfere with their function.

The nurse at the radiological imaging center is admitting a client for an MRI of the right knee. Which information obtained by the nurse should be reported immediately to the prescribing health care provider? a) The client ate a full breakfast that morning b) The client has an implantable cardioverter defibrillator (ICD) c) The client is allergic to povidone-iodine d) The client took all prescribed cardiac medications before arriving

d) Reposition the client Catheter occlusion is the most common complication of central venous access devices. Kinked tubing, catheter malposition, medication precipitate, or thrombus can occlude the lumen, preventing the ability to flush or aspirate blood. The nurse should first access for mechanical, nonthrombotic problems by: -Repositioning the client (eg, head, arm) as the catheter tip may be resting against a vessel wall (option 4) -Assessing IV tubing for clamps, kinks, and precipitate The nurse should then attempt to flush the device again. If the occlusion remains, the nurse should not flush against resistance as applying force may damage the catheter or dislodge a thrombus. Instead, the nurse should contact the health care provider (HCP), who may prescribe medication (ie, alteplase) to dissolve a thrombus or fibrin sheath (Option 1) Most needleless connector manufacturers recommend flushing with normal saline. Some facilities may use heparinized saline flushes; the nurse should follow HCP prescriptions and institution guidelines. Heparin flushes should be at the lowest acceptable dose (eg, 10 units/mL) to prevent heparin-induced thrombocytopenia (option 2) Flushing with a syringe smaller than 10 mL causes increased intraluminal pressure and may damage the catheter (option 3) The nurse should rule out a mechanical problem before notifying the HCP Educational objective: Occlusion of a central venous access device can be related to mechanical, medication precipitate, or thrombotic causes. The nurse should first attempt to remove the occlusion by eliminating a possible mechanical obstruction (eg, reposition client to adjust catheter tip location) before notifying the health care provider

The nurse attempts to flush a client's subclavian vein central venous access device with normal saline using a 10-mL syringe, but meets resistance, is unable to aspirate blood, and suspects an occlusion. What should the nurse do next? a) Flush and lock with heparinized saline flush b) Flush with normal saline using a 5-mL syringe c) Notify the health care provider d) Reposition the client

d) "This must have happened because I did not wash the bed sheets this week." It is a common misconception that bed bugs are drawn only to dirty environments. They can inhabit any environment and can travel and spread easily in clothing, bags, furniture, and bedding. Although they do not pose significant harm, bed bugs can cause an itchy red rash that can be uncomfortable and affect sleep. Bed bugs should be exterminated, especially in a home with children. (option 1) It is important to treat the entire house for bed bugs. Washing a single pillowcase or blanket will not stop the infestation. Bed bugs multiply quickly and can hide in any crevice. Once pest control is complete, the home will need to be monitored for signs of lingering bugs. (option 2) Bed bug bites can cause a rash that clients, especially children, will be inclined to scratch. Precautions should be taken to help alleviate the rash as itching can cause complications such as secondary skin infections. (option 3) Once a home is infested, the bugs can travel quickly and occupy spaces and crevices. All household members and pets will be afflicted. Educational objective: Bed bugs spread quickly and travel in bedding, clothing, and furniture. It is important to recognize bed bug bites and eliminate this pest from the home. Client treatment aims to minimize itching until the rash is gone.

The nurse cares for a child with bed bug bites. Which parent statement indicates that further teaching is required? a) "I need to have the entire house treated by pest control to ensure the bed bugs are gone." b) "I should concentrate on alleviating scratching as it can cause further complications." c) "My other family members and pets are at risk of bed bug bites." d) "This must have happened because I did not wash the bed sheets this week."

178 mL To measure the urinary output of an infant in diapers, subtract the weight of the diaper when dry from its weight when wet. One (1) gram of weight is equal to one (1) milliliter of fluid. Adequate urinary output for an infant is 2 mL/kg/hr. Calculation: Urinary output in diapers: Diaper 1: 50-30 = 20g Diaper 2: 52-30 = 22 g Diaper 3: 46-30 = 16 g Total mg of urine: 58 g = 58 mL Total output: (emesis) + (urine) = 120 mL + 58 mL = 178 mL Educational objective: Urinary output for a child in diapers is calculated by subtracting the dry weight of the diaper from its weight when wet. One (1) gram of weight is equal to one (1) milliliter of fluid.

The nurse cares for an 11-lb (5-kg) infant admitted with dehydration and prepares to calculate intake and output over an 8-hour shift. Using the data in the exhibit, calculate the total output in milliliters for the 8 hour shift. Record your answer as a whole number. Intake & Output record: emesis: 120 mL wet diaper 1: 50 g wet diaper 2: 52 g wet diaper 3: 46 g *weight of dry diaper =30 g Answer:_________ mL

a) Gloved when contact with body fluids is anticipated b) Gloves when starting an intravenous line d) Hand hygiene before and after providing client care Hand hygiene is performed before and after providing client care. HIV is a blood-borne virus, and standard precautions are sufficient protection against viral transmission. The nurse wears gloved when anticipating exposure to blood or bodily fluids. Isolation gowns are applied if the nurse anticipates splashing of bodily fluids on clothing. A face shield and goggles are applied if splashing in the eyes is a possibility. The nurse should always don gloves when starting an intravenous line. (option 3) This would be an acceptable level of protective equipment if the client undergoes a non-sterile procedure with significant splash risk, such as vaginal delivery. (option 5) Face shields are used when splashing on the face or in the eyes is anticipated. A N95 respirator mask is used when caring for a client with airborne isolation precautions. Educational objective: The Centers for Disease Control and Prevention recommend the use of standard precautions for preventing transmission of HIV.

The nurse caring for a client diagnosed with HIV uses which infection prevention and control measures? Select all the apply. a) Gloved when contact with body fluids is anticipated b) Gloves when starting an intravenous line c) Gown, gloves, face shield, and goggles for every client encounter d) Hand hygiene before and after providing client care e) N95 respiratory mask and face shield

d) Surgical mask Clients with airborne infections such as TB, measles, or chickenpox (varicella) are confined to a negative-pressure room except when traveling to various departments for essential diagnostic procedures for surgery. While being transported through the health care facility, the client on airborne transmission-based precautions wears a surgical mask to protect health care workers (HCWs) and other clients from respiratory secretions. (options 1 & 2) The client on airborne transmission-based precautions must wear a surgical mask to contain exhaled respiratory secretions. The other personal protective equipment is not necessary. (option 3) The Centers for Disease Control and Prevention recommends that HCWs who transport clients wear N95 respirator masks as protection against exposure to airborne droplets. N95 respirator masks protect HCWs by removing particles from inhaled air. The client is already infectious and does not require protection from inhaled air. Educational objective: 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.

The nurse caring for a client with tuberculosis (TB) transports the client to the radiology department for a chest x-ray. The nurse ensures that the client uses which personal protective equipment when out of the negative-pressure room? a) Isolation gown, surgical mask, goggles, and gloves b) Isolation gown and surgical mask c) N95 respirator mask d) Surgical mask

d) Hand hygiene c) Gown e) Mask or respirator b) Goggles or face shield a) Gloves 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: 1. Hand hygiene 2. Gown- fully cover torso from neck to knees, arms to end of wrists, and wrap around back; fasten in back of neck and waist 3. 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 4. Goggles or face shield- place over face and eyes and adjust fit; may be combined with mask (visor) 5. Gloves- don and extend to cover wrist of isolation gown Educational objective: The CDC suggests the following sequence for donning PPE: hand hygiene, gown, mask or respirator, goggles or face shield, and gloves

The nurse dons personal protective equipment (PPE) before providing care for a client in airborne transmission-based precautions. Place the steps for donning PPE in the appropriate sequence. All options must be used. Unordered options: a) Gloves b) Goggles or face shield c) Gown d) Hand hygiene e) Mask or respirator

d) Upright leaning forward over the bedside table, with arms supported on pillows. During a thoracentesis, the needle is inserted into the pleural space to remove fluid for diagnostic or therapeutic purposes. Before the procedure, the nurse places the client in an upright sitting position on the side of the bed, leaning forward over the bedside table, with arms supported on pillows. This position ensures that the diaphragm is dependent, facilitates access to the pleural space through the intercostal spaces, and promotes client comfort. (option 1) The fetal position is appropriate for a client have a lumbar puncture, not a thoracentesis (option 2) If unable to sit. the client can be positioned lying on the unaffected, not affected side. (option 3) Prone position is not used for this procedure, is uncomfortable, and would make it more difficult for a client with dyspnea to breathe Educational objective: Before a thoracentesis, the nurse places the client in an upright sitting position on the side of the bed, leaning forward over the bedside table, with arms supported on pillows. This position ensures that the diaphragm is dependent, facilitates access to the pleural space through the intercostal spaces, and promotes client comfort.

The nurse helps the health care provider perform a thoracentesis at the bedside. In which position does the nurse place the client to facilitate needle insertion and promote comfort? a) Fetal position, lying on unaffected side with knees drawn to the abdomen and hands clasped around them b) Lying on the affected side with head of the bed elevated to 30-45 degrees c) Prone with head turned to the affected side and arms over the head, supported by a pillow d) Upright leaning forward over the bedside table, with arms supported on pillows.

d) Use packaged pre-moistened cloths containing chlorhexidine to bathe the client. Current evidence supports the recommendation for clients with MRSA or other drug-resistant organisms to be bathed with pre-moistened cloths or warm water containing chlorhexidine solution. Bathing clients in this way can significantly reduce MRSA infection. (option 1) This action may be appropriate for a client in the home setting. However, most clients in the ICU are unable to go to the shower or have monitoring equipment and/or invasive lines that would make bathing difficult. Chlorhexidine is recommended in the hospital setting. (option 2) It is not appropriate to delay bathing as the client's skin and incision need to be cleaned. Delay should only occur if the client is unstable. (option 3) This option would be appropriate if the bath water contained a solution of chlorhexidine. Educational objective: Pre-moistened cloths or warm water with a chlorhexidine solution should be used when bathing clients infected with MRSA or other drug-resistant organisms.

The nurse in the intensive care unit (ICU) is giving unlicensed assistive personnel (UAP) directions for bathing a client who has a surgical incision infected with methicillin-resistant Staphylococcus aureus (MRSA). Which instructions would be most effective for reducing infection? a) Assist the client to the shower and provide directions to use antibacterial soap. b) Delay the bath until the client has received antibiotic therapy for 24 hours. c) Use a bath basin with warm water and a new wash cloth for each body area. d) Use packaged pre-moistened cloths containing chlorhexidine to bathe the client.

b) Elevate the affected extremity above the level of the heart d) Notify the health care provider and prepare phentolamine e) Stop the infusion immediately and disconnect the IV tubing Extravasation is the infiltration of a drug into the tissue surrounding the vein. Norepinephrine (levophed) is a vasoconstrictor and vesicant that can cause skin breakdown and/or necrosis if absorbed into the tissue. Pain, blanching, swelling, and redness are signs of extravasation. Norepinephrine should be infused through a central line when possible. However, it may be infused at lower concentrations via a large peripheral vein for up to 12 hours until central venous access is established. The nurse should implement the following interventions to manage norepinephrine extravasation: - Stop the infusion immediately and disconnect the IV tubing (option 5) - Use a syringe to aspirate the drug from the IV catheter; remove the IV catheter while aspirating - Elevate the extremity above the heart to reduce edema (option 2). - Notify the health care provider and obtain a prescription for the antidote phentolamine (regitine), a vasodilator that is injected subcutaneously to counteract the effects of some adrenergic agonists (eg, norepinephrine, dopamine) (option 4) (options 1 & 3) The nurse should not flush the infiltrated IV site or use it for further drug administration. Although new IV access must be obtained, access should be established ideally through a central line or on an unaffected extremity. Educational objective: If extravasation of IV norepinephrine occurs, the nurse should stop the infusion immediately, aspirate the drug, remove the IV catheter, elevate the extremity, and administer the antidote phentolamine into affected tissues as prescribed. IV access is reestablished on an unaffected extremity or through a central line

The nurse initiates a norepinephrine infusion through a client's only IV access into a large peripheral vein. The client reports severe pain at the IV site shortly after the infusion is started, and blanching is visible along the vein pathway. Which nursing interventions are appropriate? Select all that apply. a) Administer morphine IV PRN for pain after flushing the line b) Elevate the affected extremity above the level of the heart c) Establish a new IV access proximal to the affected site d) Notify the health care provider and prepare phentolamine e) Stop the infusion immediately and disconnect the IV tubing

a) Leave the catheter in place and insert a new catheter higher up in the perineal area 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 hat 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 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. Educational objective: If no urine is returned from Foley catheter insertion in a female client after a short time, the nurse has probably not inserted it into the correct opening. The nurse should leave the original catheter in place and reinsert a new sterile catheter above the original position.

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? a) Leave the catheter in place and insert a new catheter higher up in the perineal area b) Leave the catheter in place for 30 minutes and then recheck c) Notify the prescribing health care provider that there is an obstruction d) Remove the catheter and reinsert it at a position higher than the initial insertion

a) Bilateral dorsalis pedis (DP) pulses palpable. Right DP 2+, left DP 1+ 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 (option 2) DP is the correct artery being assessed, but 3+ would indicate a full, bounding pulse and 2+ would indicate a normal pulse. (option 3) The popliteal pulse is assessed just behind the knee area, not on the foot. The description of the right foot being greater than the left foot does not indicate the force of the individual pulse. (option 4) Posterior tibial pulses are palpated just behind the medial malleolus bone on the foot. The description of 2+ and 1+ is accurate. Educational objective: 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+n normal;

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? a) Bilateral dorsalis pedis (DP) pulses palpable. Right DP 2+, left DP 1+ b) Bilateral DP pulses palpable. Right DP 3+, left DP 2+ c) Bilateral popliteal pulses palpable. Right foot > left foot d) Bilateral posterior tibial (PT) pulses palpable. Right PT 2+, left PT 1+

d) Tell the UAP to tell the charge nurse about the needs of the client in the next room With procedural moderate sedation at the bedside, the nurse takes on the role of 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. (option 1) This action would place the UAP in the role of assessing and prioritizing, which is beyond the scope of the UAP's practice. In addition, the nurse must stay in the room and cannot meet the other client's need as a result. (option 2) Taking on the role of assessing/monitoring (related to anesthesia) and/or administering additional intravenous drugs during the procedure is beyond the scope of the UAP's practice. (option 3) The UAP has already communicated that the client's need is urgent. The client should not be kept waiting without further assessment to evaluate the situation. Educational objective: The nurse takes on the role of anesthetist when assisting with bedside procedural moderate sedation and cannot leave the client during the procedure.

The nurse is assisting with procedural moderate sedation (conscious sedation) at a client's bedside. The unlicensed assistive personnel (UAP) comes to the door and indicates that the client in the next room needs the nurse right now. How should the nurse respond? a) Ask the UAP to go back and ask the client what the current needs are b) Ask the UAP to stay and take over while the nurse goes to check on the client in the next room. c) Tell the UAP to inform the client in the next room that the nurse will be there shortly d) Tell the UAP to tell the charge nurse about the needs of the client in the next room

a) Disinfect surfaces with diluted bleach solution d) Wear a protective gown e) Wear no sterile gloves C. difficile poses a unique hazard in health care settings. This infection of the colon may develop /spread through contact with the organism or after prolonged antibiotic therapy alters normal bowel flora, allowing for C. difficile overgrowth. Clients with C. difficile infection should be placed on strict contact precautions in private rooms. These precautions require staff to wear protective gowns and gloves when entering the client's room (options 4 and 5). Hand hygiene using soap and water is the only effective method for removing C. difficile spores (option 2). In addition, alcohol is not an effective agent for killing C. difficile spores; therefore, a diluted bleach solution must be used to disinfect contaminated equipment and surfaces (option 1). (option 3) Contact precautions require the caregiver to wear a gown and gloves. A face mask must be worn as personal protective equipment if an organism is spread via droplets. However, it is not required to prevent the spread of a contact-transmissible infection. The nurse should not wear a mask solely to avoid the unpleasant odor associated with C. difficile diarrhea as this may be offensive and embarrassing to the client. Educational objective: 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.

The nurse is caring for a client who develops Clostridium difficile colitis after multiple days of antibiotic therapy. Which infection control measures are appropriate to implement? Select all that apply. a) Disinfect surfaces with diluted bleach solution b) Hand hygiene with alcohol-based hand rub c) Wear a face mask d) Wear a protective gown e) Wear no sterile gloves

c) Requests that the client be assigned to a single-client room e) Wears a single-use, disposable gown during client care 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 (option 1) Clean, rather than sterile, gloves are required during care of a client with C difficile to prevent transmission of infection to other individuals. (option 2) Surgical masks are required when caring for a client prescribed droplet isolation precautions but are needed only in clients with contact isolation precautions if performing activities with the possibility of body fluid splashing (eg, suctioning, wound care). (option 4) When caring for clients with C difficile, it is critical to perform hand hygiene with soap and water, rather than alcohol-based sanitizers. Alcohol-based sanitizers are unable to effectively kill spore-forming bacteria (eg, C difficile, anthrax). Educational objective: Clostridium difficile is a highly infectious bacteria requiring contact isolation precautions, including a single-client room assignment if available, disposable gowns and clean gloves, and hand hygiene with soap and water. Surgical masks are not necessary unless performing client care with the possibility of bodily fluid splashing.

The nurse is caring for a client with Clostridium difficile colitis. Which of the following infection control measures by the nurse are appropriate? Select all that apply. a) Applies sterile gloves before performing client care b) Ensures surgical masks are worn by staff in the client's room c) Requests that the client be assigned to a single-client room d) Uses alcohol-based sanitizers for hand hygiene e) Wears a single-use, disposable gown during client care

a) Consult with the pharmacist to see if other oral forms of KCl are available Potassium chloride (HCl) is commonly prescribed to correct or prevent hypokalemia. Oral KCl is available in extended-release tablets, capsule, dissolvable packets, and effervescent tablets, and as an oral liquid. If a client has difficulty swallowing large pills, the nurse should consult the pharmacist to see if other forms of KCl are currently available and to determine if the medication is safe to crush. If a more appropriate form (eg, liquid) is available, the nurse would then discuss that change in route with the health care provider and obtain an updated prescription. (option 2) Some pills or capsules are sustained-release formulations, and crushing may alter the release of the drug and cause an overdose of the medication. The nurse should consult the pharmacist before altering the form of the drug. (option 3) The use of a loop diuretic, such as furosemide, is a common cause of potassium depletion. Holding the HCl dose may cause the client's potassium level to fall below normal (<3.5 mEq/L [3.5 mmol/L], which can potentiate digoxin toxicity (eg, cardiac dysrhythmias, gastrointestinal upset). (option 4) Tucking the chin to the chest during swallowing is a technique used to prevent aspiration. This most likely will not help the client swallow the large pill. Educational objective: Oral potassium chloride comes in multiple forms: tablet or capsule, oral liquid, dissolving packets, and effervescent tablets. If a client has difficulty swallowing large pills, the pharmacist can determine availability of other medication forms, which can then be prescribed by the health care provider.

The nurse is caring for a hospitalized client with an acute exacerbation of heart failure. The client receives digoxin 0.5 mg PO once daily, furosemide 40 mg PO twice daily, and potassium chloride (KCl) 20 mEq PO twice daily. The client's child reports that the client has trouble swallowing the large KCl pill. The client's potassium level is 3.7 mEq/L (3.7 mmol/L). What action should the nurse take first? a) Consult with the pharmacist to see if other oral forms of KCl are available b) Crush the pill and mix it with applesauce or pudding c) Hold the KCl until the health care provider makes rounds d) Instruct the client to tuck the chin to the chest when swallowing the pill

c) Perform hand hygiene d) Place the specimen in a biohazard bag e) Scrub the catheter hub with antiseptic prior to use Blood and bodily fluids are considered hazardous materials and must be placed in containers identifying them as biohazards (eg, biohazard bag) (option 4). This alerts staff to take the necessary precautions to prevent infection transmission when handling the specimen. Other procedures to prevent transmission of infection include: -Meticulous hand hygiene (option 3) -Use of disposable gloves during collection and handling of specimen -Cleaning the specimen bag with a disinfecting wipe -Proper and immediate transport of specimen to the lab -Avoiding placing specimen in clean areas (eg, nursing station) An appropriate antiseptic (eg, 70% alcohol) scrub of the catheter hub prior to use inhibits microorganism entry and prevents transmission of infection to the client (option 5) (option 1) When drawing a blood specimen from a central line, the nurse should discard the first blood drawn to prevent an inaccurate lab result, but this will not prevent the transmission of infection. (option 2) Flushing the line prior to specimen collection will clear any previous infusions and assist in checking patency. It is important to flush the line after collection to remove blood and prevent clotting. Neither action prevents infection transmission. Educational objective: When handling blood or body fluid specimens, the nurse should adhere strictly to protocols that will prevent the transmission of infection. including meticulous hand hygiene and the use of gloves. All body fluid specimens should be transported immediately in a container labeled with the biohazard symbol

The nurse is drawing a blood specimen from a client's central line. Identify the steps necessary to prevent transmission of infection while performing this procedure. Select all that apply a) Discard the first 6-10 mL of blood drawn from the line. b) Flush the line with sterile normal saline before and after collection. c) Perform hand hygiene d) Place the specimen in a biohazard bag e) Scrub the catheter hub with antiseptic prior to use

a) Do not leave a tourniquet on more than 1 minute while looking for a vein c) If pulsating red blood is noted, withdraw the needle and apply pressure for 5 minutes 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 (option 2) Skin preparation involves cleaning using an aseptic 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 apply chlorehexidine (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. Educational objective: When performing phlebotomy for a laboratory specimen, allow the cleansed area to air dry, do not use the veins on the ventral side of the wrist, position the tourniquet for no more than 1 minute at a time, and invert the tube gently 5-10 times to mix the solution with blood. Insertion in an artery will cause pulsation; if this happens, immediately remove the needle and apply pressure for 5 minutes.

The nurse is drawing blood from a client's peripheral vein for laboratory specimens. Which of the following are correct nursing actions? Select all that apply. a) Do not leave a tourniquet on more than 1 minute while looking for a vein b) Draw the specimen while the skin is still wet with the alcohol prep c) If pulsating red blood is noted, withdraw the needle and apply pressure for 5 minutes d) Use a highly visible vein on the ventral side of the client's wrist e) Vigorously shake the specimen tube to mix obtained blood with anticoagulant solution

a) Further insert the catheter 1-2 in. (2.5-5.1 cm)' 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 be inserted at least an additional 1 in (2.5 cm) or to catheter bifurcation. (option 2) The client should be told to take slow, deep breaths to help relax the external sphincter and provide distraction. (option 3) The catheter needs to be inserted further before inflating the balloon to prevent urethral trauma. (option 4) Securing the catheter to the leg occurs after the balloon is inflated and placement is assured. Educational objective: Insert the Foley urinary catheter further if drops appear in the tubing to ensure that the tip with the balloon is in the bladder. Inflating the balloon before advancing the catheter could result in urethral trauma.

The nurse is inserting an indwelling (Foley) urinary catheter into a male client. After inserting the catheter about 6 in (15.2 cm), the nurse notes drops of urine in the tubing. What action should the nurse take next? a) Further insert the catheter 1-2 in. (2.5-5.1 cm) b) Have the client hold his breath c) Immediately inflate the 5 mL balloon d) Secure the tubing to the client's leg

Correct response: c) Performs hand hygiene and removes container lid, with sterile side placed upward e) Spreads labia using index finger and thumb of no dominant hand a) Cleanses vulva from front to back with single-use antiseptic

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. All options must be used. Unordered options: a) Cleanses vulva from front to back with single-use antiseptic towelettes b) Initiates urinary stream before passing container into stream for collection c) Performs hand hygiene and removes container lid, with sterile side placed upward d) Removes specimen contained from steam before stopping urinary flow e) Spreads labia using index finger and thumb of no dominant hand

a) Administers 100% oxygen prior to suctioning the client b) Applies suction while withdrawing the catheter from the airway e) Uses sterile gloves and technique throughout the procedure 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 form the airway (option 2) - Use strict sterile technique throughout suctioning (option 5) - Limit suctioning to < 10 seconds on each suction pass (option 3) Instilling sterile normal saline solution or sterile water (ie, lavaging) in the client's airway, a practice no longer supported by evidence, greatly increases the risk for infection by potentially transporting bacteria from the upper airway into the lower airways. (option 4) Suctioning longer than 10 seconds increases risk for collapse of airway structures (eg, alveoli, bronchioles) and hypoxemia (ie, oxygen saturation <90%). Educational objective: Open endotracheal (ET) suctioning is a skill used to clear secretions and maintain airway patency. When performing ET suctioning, the nurse preoxygenates with 100% oxygen, applies suction only while withdrawing the catheter, uses sterile technique, and limits each suction pass <10 seconds.

The nurse is performing open endotracheal suctioning for a client with a tracheostomy tube. Which of the following actions by the nurse are appropriate? Select all that apply a) Administers 100% oxygen prior to suctioning the client b) Applies suction while withdrawing the catheter from the airway c) Instills sterile normal saline into the tracheostomy prior to suctioning d) Limits suctioning to 20 seconds during each suction pass e) Uses sterile gloves and technique throughout the procedure

b) "I got a rash the last time I had IV contrast." c) "I had my last period 6 weeks ago." d) "I have a hearing aid implanted in my ear." Magnetic resonance cholangiopancreatography (MRCP) 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. The nurse must assess for contraindications before the procedure, including the presence of certain metal and/or electrical implants (eg, aneurysm clip, pacemaker, cochlear implant) or any previous allergy or reaction to gadolinium (option 4). A client with a history of ready following prior IV contrast administration should be assessed to determine the type of contrast that caused the reaction. Although allergies to iodine-based contrast material are more common, the nurse must rule out a gadolinium allergy. (option 2) Pregnancy also is a contraindication for MRCP as gadolinium crosses the placenta and may adversely affect the fetus. Delayed/irregular menses may be a normal variation in some clients; however, delayed menses may indicate pregnancy and should be reported for further investigation prior to MRCP (option 3) (option 1) Many clients should be NPO for 4 hours prior to the procedure to allow better visualization of the anatomical features. (option 5) Smoking does not affect MRI visualization and is not a contraindication. Educational objective: Magnetic resonance cholangiopancreatography 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.

The nurse is preparing a client for magnetic resonance cholangiopancreatography. Which statements by the client would require the nurse to obtain further assessment date? Select all that apply. a) "I ate lunch about 4 or 5 hours ago." b) "I got a rash the last time I had IV contrast." c) "I had my last period 6 weeks ago." d) "I have a hearing aid implanted in my ear." e) "I smoked a cigarette about an hour ago."

c) Perform hand hygiene and don clean gloves e) Withdraw air from the vial a) Inject diluent into the vial d) Roll vial between the palms of the hands to mix f) Withdraw reconstituted medication from the vial b) Label syringe with medication name and dosage When reconstituting a powdered medication for parenteral administration, the nurse should: 1. Perform hand hygiene and don clean gloves prior to handling medication (option 3). This is a universal practice for aseptic handling of any medication. Cleanse the vial top with alcohol and let it dry to prevent possible microbial contamination. 2. Withdraw an amount of air from the vial equal to the prescribed amount of diluent to create negative pressure that will be equalized when the diluent is injected into the vial. The medication manufacturer will specify the needed amount and type of diluent (option 5). 3. Inject the appropriate diluent (eg, sterile saline, sterile water) into the vial. The diluent reconstitutes the medication by dissolving the powder. (option 1) 4. Roll the vial between the palms of the hands to gently mix the solution. Avoid shaking the vial as bubbles may develop, making withdrawal of the reconstituted medication difficult (option 4). 5. Withdraw the reconstituted medication from the vial into a sterile syringe for administration (option 6). Verify the dosage by checking the prepared medication against the medication administration record and medication label. 6. Label the syringe with the medication name and dosage to prevent medication errors at the bedside (option 2). Educational objective: To reconstitute powdered medication from a vial, the nurse should perform hand hygiene and don gloves; withdraw air; inject the prescribed amount/type of diluent; mix by rolling the vial between the palms of the hands; withdraw the reconstituted medication into a syringe; and label the syringe with the medication name and dosage

The nurse is reconstituting methylprednisolone sodium succinate for IM injection. Place in order the steps that the nurse should perform to appropriately prepare the medication. All options must be used. Unordered options: a) Inject diluent into the vial b) Label syringe with medication name and dosage c) Perform hand hygiene and don clean gloves d) Roll vial between the palms of the hands to mix e) Withdraw air from the vial f) Withdraw reconstituted medication from the vial

The abdomen Enoxaparin is a low-molecular-weight heparin used in the prevention and treatment of DVT. It is administered as a deep subcutaneous injection and is usually given in the abdomen. Clients or family members may be taught how to administer the injections. The injection should be made on the right or left side of the abdomen, at least 2 in from the umbilicus. An inch of skin should be pinched up and the injection made into the fold of skin with the needle inserted at a 90 degree angle. Educational objective: 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.

The nurse is teaching a client to self-administer enoxaparin subcutaneously for the outpatient treatment of deep-vein thrombosis (DVT). The client points to the site of planned injection. Which site indicates that the client understands the instructions?

c) Measure the difference between Korotkoff sounds auscultated during expiration and throughout the respiratory cycle Muffled heart tones in a client with pericardial effusion can indicate the development of cardiac tamponade. This results in the build-up of fluid in the pericardial sac, which leads to compression of the heart. Cardiac output begins to fall as cardiac compression increases, resulting in hypotension. Additional signs and symptoms of tamponade include tachypnea, tachycardia, jugular venous dissension, narrowed pulse pressure, and the presence of a pulsus paradoxus. Pulsus paradoxus is defined as an exaggerated fall in systemic BP > 10 mmHg during inspiration. The procedure for measurement of pulsus paradoxus is as follows: 1. Place the client in semirecumbent position 2. Have client breathe normally 3. Determine the SBP using a manual BP cuff 4. Inflate the BP cuff to at least 20 mmHg above the previously measured SBP 5. Deflate the cuff slowly, noting the first Korotkoff sound during expiration along with the pressure 6. Continue to slowly deflate the cuff until you hear sounds throughout inspiration and expiration; also note the pressure 7. Determine the difference between the 2 measurements in steps 5 and 6, this equals the amount of paradox 8. The difference is normally <10 mmHg, but a difference >10 mmHg may indicate the presence of cardiac tamponade (option 1) Variation in QRS amplitude is termed electrical alternans. It could be present in cardiac tamponade, but it is not how pulsus paradoxus is determined. Electrical alternans is due to the swinging motion of the heart in a fluid-filled pericardial sac. (option 2) An apical/radial pulse deficit may be present during certain dysrhythmias, but this is not the procedure for measuring pulsus paradoxus. (option 4) This is the formula for calculating mean arterial pressure. Educational objective: The nurse should assess the client for pulsus paradoxus when cardiac tamponade is suspected. The amount of paradox is the difference between the pressure heard at the first Korotkoff sound during expiration and the Korotkoff sound sounds heard throughout inspiration and expiration. A difference of <10 mmHg is normal, but if it is >10 mmHg, this may indicate cardiac tamponade.

The nurse notes muffled heart tones in a client with a pericardial effusion. How would the nurse assess for a pulsus paradoxes? a) Check for variation in amplitude of QRS complexes on on the electrocardiography strip b) Compare apical and radial pulses for any deficit c) Measure the difference between Korotkoff sounds auscultated during expiration and throughout the respiratory cycle d) Multiply diastolic blood pressure (DBP) by 2, add systolic blood pressure (SBP), and divide the result by 3; [(DBP x 2) + (SBP)]/3

b) The client points the spray tip toward the nasal septum during instillation The proper positioning and administration of nasal sprays allow the medication to reach the nasal passages. When educating a client on how to self-administer nasal sprays, the nurse teaches the client to: - Assume a high Fowler's position with head slightly tilted forward (option 1). - Insert the nasal spray nozzle into an open nostril, occluding the other nostril with a finger (option 3) - Point the nasal spray tip toward the side and away from the center of the nose (option 2) - Spray the medication into the nose while inhaling deeply (option 4) - Remove the nozzle from the nose and breathe through the mouth - Repeat the above steps for the other nostril - Blot a runny nose with a facial tissue, but avoid blowing the nose for several minutes after instillation Educational objective: The correct administration of nasal medication includes pointing the nasal spray tip toward the side and away from the center of the nose

The nurse observes a client self-administering nasal fluticasone. Which observation would require the nurse to intervene and provide further teaching? a) A sitting position is assumed as the head is bowed slightly forward b) The client points the spray tip toward the nasal septum during instillation c) The nasal spray tip is inserted into the nostril as the other nostril is occluded d) While administering the medication, the client inhales deeply through the nose

b) Provide for client assistance with ambulation The Romberg test, part of a focused neurological examination, assesses clients' perceptions of their head in space (vestibular function) and body in space (proprioception). It is used to determine the reason for loss of coordination (ataxia). Clients are asked to stand with the feet together and hands at the sides of the body. They are then asked to close their eyes while ability to maintain balance is assessed. A loss of balance is considered to be a positive Romberg sign and indicates that ataxia is sensory in nature rather than cerebellar. Clients demonstrating a positive Romberg test are likely to have ataxia, or be prone to lose balance, and would require assistance with ambulation. (option 1) Damage to the glossopharyngeal and vagus nerves (cranial nerves IX and X) would cause problems with swallowing and the gag reflex. (option 3) Providing for sensory stimulation is important in many disorders of the neurological system. However, this would not be needed for a client with a positive Romberg test. (option 4) Speaking at a normal voice while facing a client directly is a measure used for those with hearing loss. Educational objective: A client with a positive Romberg test has a loss of sense of self in space and needs assistance with ambulation to prevent injury and provide safety.

The nurse plans care for a client who has a positive Romberg test. The nurse will prioritize which intervention? a) Monitor gag and swallowing reflexes closely b) Provide for client assistance with ambulation c) Provide sensory stimulation d) Speak at a normal volume while facing the client directly

a) Assist the client into left lateral position with right knee flexed b) Encourage the client to retain the enema for as long as possible c) Insert tubing into the rectum with the tip directed towards the umbilicus. e) Slow administration rate if the client reports abdominal cramping 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 (option 1) -Hang the enema bag no more than 12 in (30 cm) above the rectum to avoid overly rapid administration. -Lubricate the enema tubing tip and gently insert 3-4 in (7.6-10 cm) into the rectum. -Direct the tubing tip toward the umbilicus (ie, anteriorly) during insertion to prevent intestinal perforation (option 3) -Encourage the client to retain the enema for as long as possible (eg, 5-10 minutes) (option 2) -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 (option 5) (option 4) Enemas are administered at room temperature or warmed, as cold enema solutions can cause intestinal spasms and painful cramping. Enemas may be warmed by placing the container solution in a basin of hot water. Educational objective: When administering an enema, the nurse should place the client in the left lateral position with the right knee flexed, insert the tubing into the rectum with the tip directed toward the umbilicus, and slow the rate of administration if the client reports abdominal cramping. Enemas should be administered at room temperature or warmed.

The nurse prepares to administer a cleansing enema to a client with constipation. Which interventions are appropriate? Select all that apply. a) Assist the client into left lateral position with right knee flexed b) Encourage the client to retain the enema for as long as possible c) Insert tubing into the rectum with the tip directed towards the umbilicus. d) Keep the enema solution refrigerated until ready to administer e) Slow administration rate if the client reports abdominal cramping

a) Date of birth b) First and last name d) Medical record number "The right client" is one of the "6 rights" of medication administration. Two identifiers are used to compare client statements and information on the identification band with the client's medication administration record. An identifier should be permanent and unique to the client. Acceptable identifiers include first and last name and date of birth (options 1 & 2). These two identifiers are commonly used together because there is a chance that more than one client may share a similar surname or date of birth, which increases the risk of administering a medication to the wrong client. Medical record numbers are also an acceptable form of identification and may help further differentiate clients (option 4). (options 3 & 5) The name of the health care provider and room number are not specific or unique to the client and are subject to change based on the client's plan of care or condition Educational objective: During medication administration, the nurse identifies "the right client" using information that is permanent and unique to the client. Acceptable identifiers are first and last name, date of birth, and medical record number.

The nurse prepares to administer medications to a client. Which of the following client data are acceptable for use as client identifiers? Select all that apply. a) Date of birth b) First and last name c) Health care provider d) Medical record number e) Room number

c) Place the call light within the client's reach d) Remove the gown and gloves without contaminating the hands a) Discard the gown and gloves and perform hand hygiene b) Exit the negative-pressure room and close the door e) Remove the N95 respirator mask and perform hand hygiene The 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: 1. Place the call light within the client's reach and ensure that the client's bed is locked and in the lowest position. 2. 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. 3. Discard the gown and gloves and then perform hand hygiene. 4. Exit the negative pressure room and immediately close the door to prevent infectious airborne microorganisms from escaping into the hallway or isolation anteroom. 5. Remove and discard the N95 respirator mask and then perform final hand hygiene Negative pressure rooms continuously filter air out of the room, creating a lower pressure gradient that prevents airborne microorganisms from escaping through the doorway. To prevent exposure to infectious airborne microorganisms, nurses should remove N95 respirator masks only after exiting the room. Educational objective: Personal protective equipment should be removed in order from most to least contaminated. The gown and gloves may be removed together. For clients on airborne precautions, the nurse should exit the negative pressure room and close the door before removing the N95 respirator mask. Removing the mask in the room risks exposure to infection airborne microorganisms.

The nurse prepares to exit the room of a client on airborne and contact isolation precautions. Place the following nursing actions in the correct order. All options must be used. unordered options: a) Discard the gown and gloves and perform hand hygiene b) Exit the negative-pressure room and close the door c) Place the call light within the client's reach d) Remove the gown and gloves without contaminating the hands e) Remove the N95 respirator mask and perform hand hygiene

People with latex allergy usually have a cross-allergy to foods such as bananas, kiwis, avocados, tomatoes, peaches, and grapes because some proteins in rubber are similar to food proteins. Latex sensitivity increases with exposure and should be suspected in the following situations: - Allergic contact dermatitis (rash, itching, vesicles) developing 3-4 days after exposure to a rubber latex product. This is a type IV hypersensitivity reaction (delayed onset). - Anaphylaxis- many cases of anaphylaxis have been reported in both medical and on-medical setting. These represent a type I hypersensitivity reaction and should be treated with intramuscular epinephrine injections. Some common setting include: - glove use - procedures involving balloon-tipped catheters (eg, arterial catheterization) - blowing up toy balloons - use of bottle nipple, pacifiers - use of condoms or diaphragms during sex Clients with severe allergies should wear a Medic Alert bracelet and carry an injectable epinephrine pen due to cross-sensitivity with many food and industrial products that can be impossible to avoid. (option 1) Foods rich in vitamin K reduce the effects of warfarin (which works by inhibiting vitamin K- dependent clotting factors). Consumption of these foods decreases the effectiveness of warfarin; clients must be taught to eat the same amount of or avoid dark, green, leafy vegetables. (option 2) Nitroglycerin is a vasodilator and a headache from dilating cerebral vessels is an expected finding. The side effect is treated with acetaminophen (Tylenol). (option 3) Peripherally acting calcium channel blockers (eg, nifedipine, amlodipine, felodipine) cause vasodilation, and clients may develop peripheral edema. This is an expected, frequent side effect and is not an allergic reaction. Clients are advised to elevate the legs when lying down and to use stockings. Educational objective: Latex allergy is suspected when there is a food allergy to bananas, kiwis, or avocados. Peripheral edema is an expected side effect of peripherally acting calcium channel blockers. Headache is an expected side effect of nitroglycerine. Clients taking warfarin (Coumadin) should consume the same amounts of food high in vitamin K

The nurse should consider which of the following client reports as an indication of an allergic reaction? a) "I can't eat broccoli or cabbage when I take warfarin." b) "I get a headache when using my nitroglycerine patch." c) "My feet swell when I take felodipine." d) "My lips swell when I eat bananas or avocados."

b) 3 month old client with diarrhea has a capillary refill of 4 seconds and mottling in lower extremities d) Client is having contractions every 10 minutes and will be receiving an epidural analgesic e) Client received bolus of IV fluid for hyperemesis gravidarum, and urine output is 80 mL/4hr and pulse is 120/min Isotonic IV fluids expand only the extracellular fluid and are used as fluid replacement for fluid volume deficit. Common examples are normal saline and lactated Ringer's. Capillary refill indicates adequate circulation and perfusion. Normal capillary refill time is less than 3 seconds, and a delay can be an indication of dehydration. Mottling is characterized by patches of pink, pale, and cyanotic skin and can be indicative of poor perfusion. (option 2) Clients in labor usually receive 500-1000 mL of isotonic fluids prior to an epidural anesthesia as vasodilation below the epidural site can occur and result in hypotension. Up to 40% of these clients may experience hypotension after an epidural anesthesia. The preadministration of IV fluids can lessen hypotension. (option 4) Hyperemesis gravidarum is severe vomiting that can result in dehydration. Despite being given some fluids, this client still needs additional fluids. Minimal obligatory urine output 30 mL/hr or 120 mL/4 ht. Urine output is the best indicator of adequate rehydration. Tachycardia with pulse of 120/min indicated dehydration unless there is another clear etiology. (option 5) (option 1) Urinary output of 2 mL/kg/hr and a flat fontanel are normal findings in an infant. (option 3) Normal serum sodium in children is 138-145 mEq/L (138-145 mmol/L). Hyponatremia often results from excess fluids. There would be no need to give this client additional fluids. Normal blood urea nitrogen (BUN) in children 5-18 mg/dL (1.8-6.4 mmol/L), and BUN is elevated with dehydration or a need for fluids. This range is normal and does not indicate that additional fluids are required. Educational objective: Indications of a need for IV isotonic fluids include capillary refill more than 3 seconds and mottling, prehydration before an epidural anesthesia, and inadequate urine output and tachycardia due to hyperemesis gravidarum.

The nurse will anticipate administration of isotonic IV fluids in which clients? Select all that apply. a) 14 year old client has urine output of 2 mL/kg/hr with flat fontanel b) 3 month old client with diarrhea has a capillary refill of 4 seconds and mottling in lower extremities c) 8 year old client has serum sodium of 131 mEq/L (131 mmol/L) and blood urea nitrogen of 15 mg/dL (5.4 mmol/L) d) Client is having contractions every 10 minutes and will be receiving an epidural analgesic e) Client received bolus of IV fluid for hyperemesis gravidarum, and urine output is 80 mL/4hr and pulse is 120/min

c) Flush unused lumens of the CVC with 1000 units heparin every 12 hours Most CVC lumens require anticoagulation in the form of a heparin flush to maintain patency and prevent clotting when not in use. The nurse should check the institution's protocol and the HCP prescription to determine the correct dose. Doses of 2-3 mL containing 10 units/mL - 100 units/mL are the standard of care for flushing a CVC. Doses of 1000 - 10,000 units are given for cases of venous thromboembolism; therefore, this prescription is an error and should be clarified by the nurse. The Centers for Disease Control and Prevention (CDC) recommend that a single-dose vial or prefilled syringe be used to reduce infection risk. Heparin is a high-alert medication (at high risk for causing significant harm to the client if given in error.) (option 1) TPN should not be administered through a CVC. Because of its viscosity and high glucose, lipids, electrolytes, vitamins and minerals, it is safest when administered through a CVC or peripherally inserted central catheter (option 2) According to the CDC, an occlusive dressing should be changed every 7 days. The nurse should check the institution's protocol for frequency of dressing changes. (option 4) The distal port of a triple lumen CVV is the largest lumen (tube) and should be used for CVP (right atrium pressure) monitoring. The distal end of the CVC is in reverse as regards the client; therefore, the distal end is at the tip of the catheter in the superior vena cava vein, closest to the right atrium of the heart. Educational objective: Most CVCs require intravenous heparin flushes to maintain patency and prevent clotting. Single-dose vials 2-3 mL of 10 units/mL or 100 units/mL are the standard of care. A dose of 1000-10,000 units is given for cases of thromboembolism

The nurse working in an intensive care unit cares for a client with a left triple lumen subclavian central venous catheter (CVC). The nurse should call the primary health care provider (HCP) for clarification prior to implementation when recognizing that which prescription is an error? a) Administer intravenous (IV) total parenteral nutrition (TPN) at 50 mL/hr b) Change occlusive central line dressing every 7 days c) Flush unused lumens of the CVC with 1000 units heparin every 12 hours d) Use distal port of CVC to monitor central venous pressure (CVP)

a) Applying an air-occlusive dressing b) Instructing the client to bear down c) Instructing the client to lie in a supine position To prevent air embolism when discontinuing a central venous catheter, the nurse should perform the following interventions: - Instruct the client to lie in a supine position. This will increase the central venous pressure and decrease the possibility of air getting into the vessel (option 3). - Instruct the client to bear down or exhale. The client should never inhale during removal of the line; inhalation will suck more air into the blood vessel via negative suction pressure (options 2 and 5). - Apply an air-occlusive dressing (usually gauze with a Tegaderm dressing) to help prevent a delayed air embolism. If possible, the nurse should attempt to cover the site with the occlusive dressing while pulling out the line (option 1). - Pull the line cautiously and never pull harder if there is resistance. Doing so could cause the catheter to break or become dislodged in the client's vessel (option 4). Educational objective: To prevent air embolism when discontinuing a central venous catheter, it is important for the nurse to pull the line cautiously, have the client is a supine position, have the client bear down or exhale, and apply an air-occlusive dressing.

The nurse working in an intensive care unit receives a prescription from the primary health care provider to discontinue a triple-lumen subclavian central venous catheter. Which interventions will help prevent air embolism on removal? Select all that apply. a) Applying an air-occlusive dressing b) Instructing the client to bear down c) Instructing the client to lie in a supine position d) Pulling the line harder if there is resistance e) Pulling the line out when the client is inhaling

c) "I should measure liquid medications using an oral syringe." d) "I will encourage my child to help me as I prepare the medication." For pediatric clients, liquid medications should be measured with oral syringes, which have small, well-defined increments and provide accuracy for small doses (option 3). Household measuring devices (eg, teaspoon) are inaccurate due to variability of size and differences in measuring methods. Pediatric clients may refuse medication due to a fear of an unpleasant taste. Preschool children (ages 3-6) typically start to take initiative and affirm power over the environment (Erikson's initiative vs. guilt). Encouraging participation (eg, allowing the child to depress the syringe plunger) promotes initiative and cooperation by giving the child a sense of control (option 4). (option 1) The child may not finish eating food mixed with medication and would receive only a partial dose. In addition, some medications cannot be given with food. (options 2) Parents should notify the health care provider if the child vomits after oral medication administration; additional medication may cause an overdose, as some of the medication may have been absorbed. (option 5) Preschool children respond best to positive reinforcement and rewards (eg, stickers) as incentives for desired behavior. A time-out is more effective in interrupting undesired behavior. Educational objective: 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 (ages 3-6), parents should provide positive reinforcement (eg, stickers) and allow children to participate in self-administration.

The pediatric nurse is reinforcing education about medication administration to the parents of a 4 year old client. Which statement made by the parents demonstrates correct understanding? Select all that apply. a) "I can mix the medication in a bowl of my child's favorite cereal." b) "I should give another dose if my child vomits after taking the medication." c) "I should measure liquid medications using an oral syringe." d) "I will encourage my child to help me as I prepare the medication." e) "I will place my child in time-out if the medication is refused.

b) "Keep the urine collection container in the refrigerator or a cooled ice chest when it is not in use." d) "Record the time the urine collection is started and then empty the bladder into the toilet so that the start time coincides with an empty bladder." e) "You will be given a dark plastic jug containing a powder that absorbs into the urine that you will collect in the jug." d) "Record the time the urine collection is started and then empty the bladder into the toilet so that the start time coincides with an empty bladder." e) "You will be given a dark plastic jug containing a powder that absorbs into the urine that you will collect in the jug." 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 (220-330 nmol/day) 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. (options 1 & 5). - 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 (options 3 &4) -Keep the urine in a refrigerator or a cooled ice chest with the lid tightly screwed on for preservation (option 2) Educational objective: 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.

The primary health care provider prescribes a 24-hour urine collection for a client with suspected Cushing syndrome. Which instructions should the nurse give the client regarding this test? Select all that apply. a) "A continuous urinary catheter must be inserted for this test and the urine will collect in an attached bag." b) "Keep the urine collection container in the refrigerator or a cooled ice chest when it is not in use." c) "Only daytime urine should be collected in the container as cortisol levels are higher in the morning." d) "Record the time the urine collection is started and then empty the bladder into the toilet so that the start time coincides with an empty bladder." e) "You will be given a dark plastic jug containing a powder that absorbs into the urine that you will collect in the jug."

b) Left side-lying position after percutaneous liver biopsy c) Semi-Fowler after cardiac catheterization via femoral entry A paracentesis requires the client to be upright (semi- to high Fowler) so that fluid accumulates in the lower abdomen where the trocar will be inserted to drain it (option 1). 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 (option 5). Sims position (left side-lying with right hip and knee flexed) is best for enema administration (option 4). (option 2) After a 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. (option 3) 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. Educational objective: Clients undergoing paracentesis should be upright. After liver biopsy, clients should be in a right side-lying position to prevent hemorrhage. After femoral cardiac catheterization, clients should remain flat. After lumbar puncture, clients should be flat in bed to minimize risk of headache.

The registered nurse (RN) and licensed practical nurse (LPN) are caring for several clients. The RN delegates client positioning to the LPN. While evaluating the delegated task, the RN realizes that which client positions require intervention? Select all that apply. a) High Fowler position in preparation for a paracentesis b) Left side-lying position after percutaneous liver biopsy c) Semi-Fowler after cardiac catheterization via femoral entry d) Sims during soap-suds enema administration e) Supine position after a lumbar puncture

c) Removing the styles before the x-ray is performed Small-bore nasoenteric (eg, nasoduodenal, nasojejunal) tubes are often placed using a styler (guide wire), a metal wire running through the tube that facilitates advancement through the gastrointestinal tract. Once the tube is inserted, the nurse should obtain an x-ray to verify that the tube terminates in the intestine as prescribed, not in the airway or stomach. After placement verification, the nurse should remove the styler to allow tube feeding (option 3). To avoid perforating the gut, the nurse should never reinsert the styler when a feeding tube is in place. If the tube is not properly positioned and the styler has been removed, the nurse must remove the tube and start over. (options 1 & 4) The client should sip water during insertion to close the airway and open the esophagus. With each swallow the nurse should advance the tube a little. The nurse should stop advancing when the client is inhaling or coughing to avoid inserting the tube into the airway and then continue advancing when the client is able to swallow again. (option 2) Marking the exit point from the naris on the tube allows visualization of changes in external tube length that may indicate tube dislodgment. Educational objective: After placing a new, small-bore nasoenteric (eg, nasoduodenal, nasojejunal) feeding tube, the nurse should obtain an x-ray to verify tube placement and should leave the stylet (guide wire) in place until tube placement is verified. The nurse should never reinsert a stylet into a nasoenteric tube.

The registered nurse observes a graduate nurse who is inserting a small-bore nasojejunal feeding tube. Which action by the graduate nurse requires intervention by the registered nurse? a) Asking the client to take small sips of water during insertion b) Marking the tube at the exit point from the naris c) Removing the styles before the x-ray is performed d) Stopping insertion of the tube while the client is coughing

c) Retracts the foreskin before applying the condom sheath Paraphimosis occurs when the uncircumcised make 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 a 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 (option 3) (option 1) The drainage tubing is attached to a leg collection bag in a mobile client to enable ambulation, prevent tube kinking, and facilitate gravity drainage. (option 2) A 1-2 in (2.5-5 cm) space should be left between the tip of the penis and the end of the condom to prevent penile irritation and pooling of urine in the condom (option 4) If the condom catheter is not self-adhesive, elastic adhesive is used in a spiral fashion to secure the device to the penis. Adhesive tape may cause irritation and/or injury and should not be used. Educational objective: Health care providers should ensure a client's foreskin is fully reduced before applying a condom catheter, as prolonged retraction can cause paraphimosis, progressive swelling of the foreskin, vascular compromise, and permanent damage to the glans

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? a) Attached the drainage tubing to a lower leg collection bag b) Leaves a 1-2 in (2.5-5 cm) space at the tip of the condom c) Retracts the foreskin before applying the condom sheath d) Uses elastic adhesive in a spiral fashion to secure device

a) Injects subcutaneous insulin at a 90-degree angle into the lower abdomen of an obese client d) Places client in a side-lying position to access the ventrogluteal site for IM injection Parenteral medications are administered via injection into body tissues aseptic technique (eg, intradermal, intramuscular, subcutaneous, IV). Intradermal - Administer injections at a 5- to 15- degree angle to reduce risk of injection into subcutaneous tissue (option 2). - Apply firm pressure to the injection site reduce bleeding. Massaging the site introduces medication into deeper tissues and should be avoided (option 3). Subcutaneous - Administer injections at 90 degrees if 2 in (5 cm) of subcutaneous tissue can be grasped or at 45 degrees if only 1 in (2.5 cm) can be grasped (option 1) Intramuscular: - Acceptable sites include the deltoid, vastus lateralis, and ventrogluteal. The ventrogluteal is preferred as fewer large blood vessels and nerves are present - Position the client supine, prone, or side-lying with the knee and hip flexed when administering ventrogluteal injections. Flexing the knee and hip reduces muscle tension, improves access, and promotes client comfort (option 4). (option 5) A filter needle must be used when withdrawing medication from a glass ampule to prevent aspiration and injection of glass shards After the medication is withdrawn, the filter needle is discarded and an injection needle (eg, 20-gauge, 1-in [2.5-cm] needle) is attached to the syringe. Educational objective: Use filter needles to withdraw medications from ampules to prevent aspiration and injection of glass shards. Perform intradermal injections at 5- to 5- degree angles and avoid massaging injection sites to prevent accidental subcutaneous administration. Administer subcutaneous injections at 45 or 90 degrees, depending on the volume of subcutaneous tissue.

The unit coordinator is performing skill validations with unit staff. Which of the following actions by the staff nurses demonstrate a correct understanding of parenteral medication administration? Select all that apply. a) Injects subcutaneous insulin at a 90-degree angle into the lower abdomen of an obese client b) Inserts the needle at a 30-degree angle to administer an intradermal injection c) Massages the injection site after administering an intradermal medication d) Places client in a side-lying position to access the ventrogluteal site for IM injection e) Withdraws medication from a glass ampule using a 20-gauge, 1-in (2.5 cm) injection needle

c) Donning personal protective equipment Nursing priorities when implementing a chemical contamination emergency response plan include the following: 1. Restricting other clients, staff, and bystanders from the victims' vicinity to protect non-affected individuals and the health care facility from the contaminant. 2. Donning personal protective equipment to protect the nurse when providing care (option 3) 3. Decontaminating the clients outside the facility before initiating treatment. If the chemical is not removed, it will continue to cause respiratory distress; contaminated clothing is left outside the facility to reduce the risk of contaminating staff and other clients (option 2) 4. Assessing and providing treatment of symptoms. Initial treatment is for the symptoms (eg, wheezing) regardless of the specific cause (option 1 and 4) Educational objective: The nurse should always protect other clients, staff, and the health care facility first in a chemical contamination. Personal protective equipment should be put on before decontamination. Victims should be decontaminated outside the facility before care is administered.

There has been an explosion at a local chemical plant. A private car arrives at the emergency department with 4 victims whose clothes are saturated with a strong-smelling liquid. The victims are wheezing. The nurse should implement which intervention first? a) Assessing the clients' respiratory systems b) Decontaminating the clients c) Donning personal protective equipment d) Providing oxygen by nasal cannula

c) Use long-handed forceps to secure the implant in a lead container An internal radiation implant (ie, brachytherapy) emits radiation in or near a tumor to treat certain malignancies. When caring for clients undergoing brachytherapy, the nurse should monitor closely for evidence of implant dislodgment. The dislodged implant emits radiation that can be dangerous to health care workers at the bedside. Long-handled forceps and a lead-lined container should be kept in a room of the client who has a radioactive implant in case of dislodgment. If dislodgement occurs, the nurse should first use long-handled forceps to place the implant in a lead-lined container to contain radiation exposure (option 3). The nurse should also notify the health care provider (radiation oncologist). (option 1) Containing the source quickly is a priority as the implant continues to emit radiation that could be dangerous to the staff coming to evaluate the client and clean the room. (option 2) The nurse should not handle dislodged radiation implants without the use of forceps. Furthermore, device reinsertion should be performed only by the health care provider. (option 4) Wrapping the implant in linens and placing it within a biohazard bag does not reduce radiation exposure. Educational objective: If an internal radiation implant has dislodged, the nurse should use long-handled forceps to place it in a lead-lined container to contain radiation exposure.

While turning a client, the nurse observes that the client's radiation implant has dislodged and is now lying on the linens. Which action by the nurse is appropriate? a) Get the client out of bed and away from the radiation source b) Manually reinsert the implant and notify the health care provider c) Use long-handled forceps to secure the implant in a lead container d) Wrap the implant in the linens and place it in a biohazard bag