Li- Knowledge and clinical judgment/Nursing Concepts / PRIORITY/

A nurse is caring for a neonate who was delivered at 30 weeks of gestation after his mother received two injections of betamethasone (Celestone). Because of the administration of betamethasone to the client's mother, the nurse should monitor the neonate for which of the following effects? A. Tachycardia B. Sternal retractions C. Hypoglycemia D. Hypothermia

- C. Hypoglycemia Betamethasone is a glucocorticoid used in the prevention of respiratory distress syndrome in premature infants. Betamethasone causes hyperglycemia in the mother, which predisposes the neonate to hypoglycemia in the first hours after delivery.

A nurse is performing a cardiovascular assessment on a client. Which of the following findings should the nurse expect?

-A brief thump felt near the fourth or fifth intercostal space near the left midclavicular line. This is where you would inspect and palpate for the point of maximal impulse. Also called an apical pulsation, it occurs as the apex of the heart bumps against the chest wall with each heartbeat. The apical impulse is not always visible but can be felt as a brief thump. This is an expected finding and should be performed when you are preparing to auscultate the apical pulse.

A nurse working the 7pm to 7 am shift on the pediatric unit has receieved report on four postoperative clients. Which of the following requires immediate intervention?

-A preschooler who is postoperative following tonsillectomy and is experiencing frequent swallowing A preschooler who is experiencing frequent swallowing following a tonsillectomy could be bleeding, placing the client at risk for hemorrhage. Bleeding from the surgical site can cause the dripping of blood down the back of the throat, which results in frequent swallowing or clearing of the throat and indicates the client could be unstable. Based on the unstable versus stable priority setting framework and nursing knowledge, the client requires immediate intervention.

A nurse is caring for a client who has a flaccid bladder following a spinal cord injury. which of the following actions should the nurse take first? A. Initiate a bladder training schedule B. Administer solifenacin (Vesicare). C.Insert an indwelling urinary catheter.

-A. Initiate a bladder training schedule Answering this item requires application of the least restrictive, least invasive priority setting framework. This framework assigns priority to nursing interventions that are least restrictive and least invasive to the client, as long as those interventions do not jeopardize client safety. Interventions that are not invasive to the client should be taken before interventions that are invasive. This reduces the number of organisms introduced into the body, decreasing the number of hospital-acquired infections. Bladder retraining is a restorative care method used with clients who have urinary incontinence. Based on the least restrictive, least invasive priority setting framework, this is the first action the nurse should take.

A nurse is reinforcing teaching with a client who is prescribed buspirone (BuSpar) ("BILL 死吧run）（" Bill Spar"). Which of the following statements by the client indicates an understanding of the teaching? A. "I will only be on this medication 4 to 6 months because it can lead to physical dependence." B. "I can have 1 to 2 alcoholic beverages each week." C. "I will need to stop taking Xanax two weeks before I can begin taking this medication." D. "I can have 6 to 8 ounces of grapefruit juice each day."

-B. "I can have 1 to 2 alcoholic beverages each week." Buspirone is an anxiolytic medication used to treat anxiety, but is different from benzodiazepines because of the fact that it is not a CNS depressant. Because of this, buspirone does not interfere with CNS depressants, such as benzodiazepines, alcohol, or barbiturates, and it is acceptable to have 1 to 2 alcoholic beverages each week. This statement by the client is true and indicates an understanding of the teaching. Buspirone can be taken for up to a year without evidence of tolerance or physical or psychologic dependence presenting. Grapefruit juice can increase levels of buspirone leading to drowsiness or dysphoria.

A public health nurse is triaging clients at the site of an explosion. The client with which of the following injuries should the nurse's priority concern? A. Penetrating head wound B. Incomplete amputation of the foot

-B. Incomplete amputation of the foot Answering this item requires application of the survival potential priority setting framework. Use of this framework is typically reserved for mass casualty situations, when resources are scarce and are allocated to save the greatest number of lives. While it might seem that the client least likely to survive should receive priority care, this is the client who is the lowest priority. The highest priority is assigned to the client who has injuries that are severe, but has the potential to survive with treatment. A client with an incomplete amputation of the foot should be assigned to the immediate triage category because injuries are life-threatening, but survivable if immediate care is received. The nurse should place highest priority on this client. A client with a penetrating head wound should be assigned to the expectant triage category because survival is unlikely even with immediate and thorough treatment.

A nurse is caring for a client who had a cerebrovascular accident 2 days ago. Which of the following is the first sign of increased intracranial pressure (ICP)? A. Pupil dilation B. Ataxia C. Lethargy D. Bradycardia

-C. Lethargy Lethargy occurs when pressure is placed on the reticular activating system within the brainstem. Along with other indicators of a change in the level of consciousness, such as restlessness, irritability, and disorientation, lethargy is the first sign of increased ICP. others are later signs of increased ICP.

A nurse is caring for an older adult client who has an allergy to sulfa, is taking valproic acid (Depakote) for a seizure disorder, and has been newly diagnosed with osteoarthritis. The client states, "I keep seeing commercials on TV for Celebrex and I want to try it and see if it will help my pain." Upon review of scientific evidence, the nurse should inform the client of which of the following?

-Celecoxib is contraindicated in clients with an allergy to sulfonamide. Celecoxib (Celebrex) is a nonsteroidal anti-inflammatory, cyclooxygenase-2 (COX-2) inhibitor, which is indicated to relieve some manifestations caused by rheumatoid arthritis and osteoarthritis in adults. Celecoxib contains a sulfa molecule; therefore, celecoxib is contraindicated in clients who have an allergy to sulfa.

A nurse is caring for a client who is diagnosed with active pulmonary tuberculosis and is taking isoniazid(INH) and ethambutol(Myambutol). Which of the following manifestations reported by the client necessitate the discontinuation of ethambutol?

-Loss of color discrimination Ethambutol and isoniazid are both antitubercular medications. The most commonly reported toxic reaction to normal therapeutic doses of ethambutol is ocular toxicity as evidenced by visual disturbances. Examples include changes of color vision (especially red and green) and loss of visual acuity. Treatment with ethambutol should be stopped immediately if ocular toxicity develops.

A nurse is inspecting the sinuses of a client who has allergies. Which of the following findings should the nurse expect? 1. Pale mucosa 2. Bright red mucosa 3. Green discharge 4. Yellow discharge

-pale mucosa The nurse should identify that a client who has allergies can have pale mucosa, as well as clear discharge.

lithium level

0.6-1.2 meq/L over 1.5 is toxic (can go up to 1.5 for acute manic issues)

A nurse is performing a head and neck assessment on a client. The client reports a high-pitched ringing in their ears. In which of the following sections of the client's electronic health record (EHR) should the nurse document this finding? 1. Encounter 2. Vital signs 3. Patient information 4. Allergies and home medications

1. Encounter The nurse should include the client's report of "high-pitched ringing in their ears" in the encounter section of the client's EHR. This is subjective data the nurse is obtaining from the client and the purpose of the client's visit.

A nurse is caring for a client who had a suspected stroke? Which of the following actions should the nurse take? (Select all that apply) 1. Make the client NPO. 2.Assess the client's orientation. 3.Check cranial nerves I, II, and V .4.Inspect the client's muscular symmetry. 5. obtain the VS

1. Make the client NPO 2. Assess the client's orientation 5. obtain the VS Make the client NPO is correct. Although there is not a definitive diagnosis of a stroke yet, it is still important to put safety precautions into place for a suspected stroke to prevent client injury. The nurse should have the client's swallowing ability tested if a stroke has occurred to prevent aspiration due to dysphasia. Assess the client's orientation is correct. The nurse should assess the client's orientation for a baseline assessment at the time of the suspected stroke for a comparison to previous orientation and any future changes. Obtain the client's vital signs is correct. The nurse should obtain the client's vital signs at the time of the suspected stroke for a baseline reference and comparison. The vital signs will include heart function and blood pressure, which are contributors to stroke events. -The nurse does not need to check cranial nerves I, the olfactory nerve, II, the optic nerve, and V, the trigeminal nerve, at this time. Assessment of cranial nerves could be indicated at a later time when there is a definitive diagnosis, but not when there is a suspected diagnosis of a stroke. Cranial nerve II would be the most beneficial to assess if it were indicated. Assessing cranial nerves I and V would not provide good assessment findings for a stroke. -A client who is suspected of having a stroke can experience potential asymmetrical muscular movements or muscle weakness. Therefore, there is no need for the nurse to inspect the client's muscle mass for symmetry.

A nurse is teaching an older adult client about health promotion. The nurse should instruct the client to have which of the following examinations preformed on a regular basis? (Select all that apply) 1.Vision screening every year 2.Hearing test every 5 years 3.Dental examination every 6 months 4.Skin cancer screening every 2 years 5.Neurological check every 3 months

1.Vision screening every year 3.Dental examination every 6 months Vision screening every year is correct. The nurse should instruct the client to have their vision screened every year after the age of 60.Hearing test every 5 years is incorrect. The nurse should instruct the client to have their hearing tested at least every 3 years after the age of 50.Dental examination every 6 months is correct. The nurse should instruct the client to have a dental examination and cleaning every 6 months.Skin cancer screening every 2 years is incorrect. The nurse should instruct the client to have a skin cancer screening every year after the age of 40.Neurological check every 3 months is incorrect. A neurological check should only be recommended by the provider. A neurological check is typically recommended if there has been a change in the client's cognition or the client has a neurological disorder.

A nurse is preforming a head and neck assessment on a client. After checking the client's vision, the nurse notes the client has a difficulty reading fine print. In which of the following sections of the client's electronic health record should the nurse document this finding? 1. Vital signs 2. Review of system 3. Allergies and home medications4. Patient information

2. Review of system The nurse should document this finding in the review of systems section of the client's EHR because this section contains objective data that the nurse obtains while performing the assessment.

A nurse is preforming a focused assessment on a client who reports having difficulty swallowing and a continuous headache. The nurse should identify that these findings can indicate which of the following conditions? 1. Chest disorder 2. Thyroid disorder 3. Musculoskeletal disorder 4. Central nervous system disorder

4. Central nervous system disorder

A nurse is assessing an older adult client's mouth. The nurse should identify that which of the following is an expected variation for this client? 1.Yellowing of the hard palate 2. Red spots on the hard palate 3. White patches not he Tonge 4. Darkening of the mucosa

4. Darkening of the mucosa The nurse should identify that darkening, or hyperpigmentation, of the mucosa is an expected variation for an older adult client due to the lack of saliva and dryness of the mouth. -Yellowing of the client's hard palate can indicate a liver disorder. -Red spots, or petechiae, on the client's hard palate can indicate an infection. -White patches on the client's tongue can indicate candidiasis, which is an oral infection known as thrush.

A nurse is planning to obtain blood pressure on four clients. On which of the following clients should the nurse perform an electronic blood pressure measurement?

A client who is recovering from a cardiac catheterization Electronic blood pressure measurement is attained through a sensor that detects vibrations caused by blood rushing through the arteyr, is appropriate for use when the blood pressure must be monitored frequently, and should not be taken on clients with conditions that can result in an inaccurate reading. A client who is recovering from a cardiac cath requires frequent blood pressure measurements. It is appropriate to perform an electronic blood pressure measurement on this client. Rationales: -A client in stage 4 of Parkinson's disease has bilateral limb involvement and resting tremors. Associated tremors can result in an inaccurate reading by causing the sensor to detect these vibrations instead of blood rushing through the artery. It is not appropriate to perform an electronic blood pressure measurement on this client. - A client who has anorexia and hypotension. Electronic blood pressure sensors are often unable to detect the vibrations associated with low blood pressure, which can result in an inaccurate reading. It is not appropriate to perform an electronic blood pressure measurement on this client.

A nurse is caring for a client who is 48 hr postoperative following an abdominal aortic aneurysm resection. Which of the following findings is the most urgent?

Absent dorsalis pedis pulses Absence of these pulses indicates that a graft occlusion following an abdominal aortic aneurysm repair is blocking circulation. Using the urgent versus non-urgent priority setting framework and nursing knowledge, this is the finding that represents the most urgent need. This option is further supported by the ABC priority setting framework.

A nursing supervisor is determining bed placement for four clients. Which of the following clients should be placed on droplet precautions? A rubella (droplet cuz droplets larger than 5mcg) B measles (airborne cuz droplet smaller than 5mcg) C hepatitis A (standard precaution ) D Rocky Mountain spotted fever ( standard )

Ans : Rubella Rocky Mountain spotted fever is transmitted through the bite of an infected tick and is only transmissible person-to-person through a blood transfusion. The Centers for Disease Control and Prevention recommends the use of standard precautions when caring for a client who has Rocky Mountain spotted fever.

FYI: Cromolyn sodium (Intal)

Anti-inflammatory (mast cell stabilizer) Inhibits release of histamine Used for chronic asthma, allergic rhinitis Safest of all asthma meds

A nurse is caring for a client who was admitted for acute alcohol delirium withdrawal 2 days ago. Which of the following findings is associated with this diagnosis? A. Increased appetite B. Elevated temperature C. Bradycardia D. Drowsiness

B. Elevated temperature Elevated Temp, anorexia, tachycardia, insomnia are the s/sx of acute alcohol delirium

A nurse is preparing to inspect the outer ears of a client who has been in a motor-vehicle crash. The nurse should identify that which of t the following findings indicates the client might have. Skull fracture?1. Edema 2. Bloody drainage 3. yellow drainage 4. crushed skin Bloody drainage

Bloody drainage clear, watery, or bloody drainage can indicate that the client has a skull fracture. The nurse should notify the provider immediately.

A nurse is caring for a child who is 24 hr postoperative following a supratentorial craniotomy. The nurse should maintain the child in which of the following positions? A. Prone with head of the bed flat B. Dorsal recumbent with head of the bed elevated to 15° C. Supine with head of the bed elevated to 30° D. Side-lying with head of the bed elevated to 45°.

C. Supine with head of the bed elevated to 30° Following a supratentorial craniotomy, the client should be maintained in a position that facilitates drainage of cerebrospinal fluid and prevents hemorrhage by reducing blood flow to the brain. Positioning the client supine with the head of the bed elevated to 30° is appropriate.

A nurse is providing education to the parent of an infant who is newly diagnosed with biliary atresia. The nurse should teach the parent that which of the following is a clinical manifestation associated with the illness?

Dark urine Dark urine is a clinical sign of biliary atresia because of conjugated bilirubin escaping from the liver and being excreted in the urine. The nurse should teach the parent that dark urine is a clinical manifestation associated with the illness Rationales: - Tar-colored stools Biliary atresia is a progressive process that leads to destruction of the biliary tree. The biliary tree begins as many small ducts that join together into one main common bile duct, similar to the joining of branches to a tree trunk. Bilirubin, created from the breakdown of heme in RBCs and the main pigment in bile, travels to the liver where the liver cells, known as hepatocytes, secretes it into bile. The bile then passes into the small ducts and then travels to the small intestine where bacteria break it down into urobilinogen to be excreted in the feces. The nurse should not teach the parent that tar-colored stools are a clinical manifestation associated with the illness. White or tan stools, not tar-colored stools, are a clinical sign of biliary atresia because of the lack of bilirubin in the intestinal tract.

Betamethasone (Celestone)

Glucocorticoid administered IM in 2 injections 24 hr apart, given to stimulate fetal lung maturity if early delivery is anticipated and to prevent respiratory distress. Can cause pulmonary edema (crackles, chest pain, SOB)

A nurse is caring for a client who is scheduled for a lumbar puncture. The nurse should teach the client that which of the following is a post-procedure complication?

Headache a headache is a manifestation experienced by 15 to 30% of clients following a lumbar puncture that results from cerebrospinal fluid leakage at the puncture site. These headaches are managed primarily with analgesics, hydration, and bed rest

why hyperkalemia is metabolic acidosis?

Hyperkalemia decreases proximal tubule ammonia generation and collecting duct ammonia transport, leading to impaired ammonia excretion that causes metabolic acidosis.

Celecoxib (Celebrex) "Sally call see b" (" Sally brex")

NSAID

biliary atresia 先天性胆管闭合

No opening of the bile ducts (into the duodenum) that is congenital

A nurse is caring for a school-age client who was diagnosed with sickle cell anemia and has been admitted for a vaso-occlusive crisis. Which of the following findings has the highest priority? A. Slurred speech B. WBC 16/mm3

Slurred speech Slurred speech can indicate a cerebrovascular accident (CVA), which is a severe complication of sickle cell anemia. The blockage of blood vessels in the brain by sickled cells results in cerebral infarction, which leads to neurological impairment. Because a CVA threatens the life of the client, this is highest priority finding. -A WBC count of 16/mm3 is not the priority finding. The WBC level of clients who have sickle cell anemia is often above the expected reference range because of chronic inflammation caused by tissue hypoxia and ischemia.

A nurse is reinforcing teaching about the diet for dumping syndrome to a client who is postoperative following a gastrectomy. Which of the following food selections by the client indicates the teaching was effective?

Toast with peanut butter Dumping syndrome results from rapid emptying of the stomach into the small intestine after eating, and manifests as a group of vasomotor symptoms, such as vertigo, tachycardia, syncope, sweating, pallor, and palpitations. Additionally, abdominal distension occurs because of the shift of fluid into the intestines. A diet that restricts some foods and includes others as appropriate food choices reduces the occurrence and severity of dumping syndrome. Peanut butter and toast are allowed or encouraged foods for a client who has dumping syndrome. -Beverages with high sugar content, such as apple juice, lead to rapid gastric emptying because of high osmolarity and should be avoided. -Salty foods, such as broths, lead to rapid gastric emptying because of high osmolarity and should be avoided. -Dairy products and sugars, such as yogurt with fresh fruit, lead to rapid gastric emptying because of high osmolarity and should be avoided.

A nurse is caring for a toddler who has acute otitis media and is prescribed benzocaine (Americaine) ear drops for pain relief. Which of the following actions by the nurse is appropriate when administering the ear drops?

Warm refrigerated drops to room temperature prior to instillation. Because of the anatomy of internal ear structures, it is important to remember that the ear is sensitive to extremes in temp. Ear drops should be warmed to room temp prior to instillation to reduce the risk of painful stimuli

supratentorial

above the tentorium cerebelli

urticaria

hives, allergic reaction

Maslow's Hierarchy of Needs

physiological, safety, love/belonging, esteem, self-actualization

FYI: hard palate

roof of the mouth

FYI: tentorium cerebelli 小脑幕

separates cerebrum and cerebellum

angioedema

swelling of the blood vessels. possibility of an anaphylactic reaction, which is life-threatening;

A nurse is collecting data on a client who is diagnosed with schizophrenia and is taking clozapine (Clozaril). Which of the following findings indicates the client is experiencing an adverse effect of the medication?

​WBC 2,800/mm3 Adverse effects of clozapine include tachycardia, weight gain, sedation, and agranulocytosis. Agranulocytosis, which is a decrease in one of the WBCs called neutrophils, reduces the ability to fight infection and can be fatal. Because of the potential for agranulocytosis, clients who are taking clozapine are monitored frequently for a decrease in WBC count below 3,000/mm3. The client's WBC and absolute neutrophil count is monitored weekly during the first 6 months of therapy, then every 2 weeks during the next 6 months. A WBC level of 2,800/mm3 indicates the client is experiencing an adverse effect of the medication. - weight gain is an adverse effect that can occur in clients who are taking clozapine because of the blockage of H1 histamine receptors. -tachycardia is an adverse effect that can occur in clients who are taking clozapine because of the blockage of muscarinic cholinergic receptors. -sedation is an adverse effect that can occur in clients who are taking clozapine because of the blockage of H1 histamine receptors.