NCLEX notes/ uworld *

Bumetanide (Bumex)

(C) Loop diuretic, antihypertensive,sulfomanide derivative.Edema, ascites, heaptic/renal disease. CI:anuria, thiazides/sulfonamides sensitivity. AE:Hypotension/calcemia/kalemia/magnesimia/natremia, loss of hearing,hypochloremic alkalosis, hyperurecimia/glycemia, jaundice,polyuria, SJS. NC: FL.status, electrolytes,dig tox, weight record, take early in AM w. food or milk, not exercise in hot weather or stand prolonged

Clients prescribed phenytoin should receive education about the potential need for nonhormonal birth control as well as the importance of good oral hygiene and not abruptly stopping anticonvulsants. Other teaching for epilepsy includes avoiding seizure triggers and wearing a medical identification bracelet.

(Dilantin), a hydantoin anticonvulsant, may decrease the effectiveness of some medications (eg, oral contraceptives, warfarin) due to stimulation of hepatic metabolism. An alternate, nonhormonal birth control method (eg, condoms, copper intrauterine device) should be used in addition to or instead of oral contraceptives (Option 5). Clients should discuss pregnancy plans with their health care provider, as phenytoin can cause fetal abnormalities (eg, cleft palate, heart malformations, bleeding disorders). Clients taking phenytoin should also receive education about practicing good oral hygiene as gingival hyperplasia is a potential complication. Anticonvulsants should not be stopped abruptly, as this increases the risk of seizure

Myasthenia gravis (MG) is a chronic, neurologic autoimmune disorder that involves damage to acetylcholine receptors at the neuromuscular junctions, which results in skeletal muscle weakness. The ocular (ptosis) and facial muscles, along with those responsible for chewing and swallowing, are affected initially; however, weakness can progress to the respiratory muscles(eg, intercostal, diaphragm). Pyridostigmine (Mestinon) is a first-line drug that inhibits acetylcholine breakdown and is prescribed to temporarily increase muscle strength in clients with MG. It is the priority medication as difficulty swallowing indicates weakness of the muscles involved in swallowing and increases aspiration risk.

(Option 1) Acetylsalicylic acid (Aspirin) is prescribed daily to prevent ischemic attacks and myocardial infarction in clients with coronary artery disease and ischemic stroke; it is not the priority medication. (Option 2) Metformin (Glucophage) is an anti-hyperglycemic drug that can cause lactic acidosis in clients with kidney disease. Contrast used for CT scan can cause kidney injury. It is recommended that the drug be held before and resumed 48 hours after the CT scan (if renal function [creatinine] is normal). (Option 3) Analgesia with opioids is appropriate to treat chronic pain associated with terminal cancer. However, decreasing the aspiration risk is more urgent than providing pain relief.

Burn injuries are caused by direct tissue damage from exposure to caustic (eg, thermal, chemical, electrical) sources. These injuries may be life-threatening, depending on the extent of tissue injury and organ damage. To prioritize the initial management of burn injuries, nurses should use the ABCs (ie, airway, breathing, circulation). Circulatory compromise is common after sustaining a burn, as extensive tissue injury combined with the systemic inflammatory response causes increased capillary permeability, fluid and electrolyte shifts, and decreased intravascular volume. These intravascular losses begin rapidly after a burn and may lead to hypovolemic shock and death. Therefore, the nurse should prioritize initiation of fluid resuscitation (Option 3).

(Option 1) Although full-thickness burns destroy nerves and may be painless, clients with burns often have severe pain. However, pain is not life-threatening and may be treated after restoration of ABCs. (Option 2) Burn injuries impair immune system function and skin integrity, increasing the risk for infection. Prevention of infection with topical antimicrobials (eg, bacitracin, silver sulfadiazine) is important. However, restoration of ABCs is the priority. (Option 4) An escharotomy is a surgery involving incisions made through eschar (burned tissue) and is performed to prevent tissue ischemia and necrosis from impaired circulation. However, stabilizing circulatory status is the priority.

DKA is a life-threatening complication of type I diabetes characterized by hyperglycemia (>250 mg/dL) that results in ketosis, a metabolic acidosis. Glucose cannot be taken out of the bloodstream and used for energy without insulin. The body begins to break down fat stores into ketones, as it does in a state of starvation, causing a metabolic acidosis (low pH and low HCO3). The lack of insulin also results in increased glucose production in the liver, worsening the hyperglycemia. Hyperglycemia causes osmotic diuresis, and clients are severely dehydrated. The cardinal signs of dehydration are poor skin turgor, dry mucosal membranes, tachycardia, orthostatic hypotension, weakness, and lethargy. Despite laboratory values showing hyperkalemia on admission, clients with DKA have a net potassium deficiency and will need careful replacement after fluid resuscitation.

(Option 1) Although it is important to insert an indwelling catheter to monitor fluid balance, rehydrating the client is a life-saving measure with higher priority. (Option 2) Although it is important to monitor serum potassium results before and during insulin administration, rehydrating the client is the highest priority. Dilution will also improve the hyperkalemia. (Option 3) The priority intervention in DKA is to start an IV infusion for bolus rehydration therapy with normal saline. This should occur before insulin infusion as insulin will result in water, potassium, and glucose entering the cells, worsening the dehydration and electrolyte imbalances

Warfarin (Coumadin) is an anticoagulant given to clients with a mechanical valve replacement. To determine if the client is receiving an appropriate dose, the INR needs to be checked regularly. A therapeutic INR for a client with a mechanical heart valve is 2.5-3.5. The nurse should not administer warfarin without checking the INR first. If the INR is >3.5, the nurse should hold the dose and contact the health care provider for further direction.

(Option 1) Although the nurse should assess the client's potassium level prior to administering supplemental potassium, this medication was scheduled at 0900 and is not indicated at this time. There is no pharmacologic interaction between potassium levels and warfarin. (Option 3) The client's vital signs should be measured routinely, but administration of warfarin and simvastatin are not contingent on the results. (Option 4) Verification of the client's name and date of birth is an important safety measure that should be performed at the bedside, immediately before medication administration.

Irritable bowel syndrome (IBS) is a common, chronic bowel condition caused by altered intestinal motility. Peristaltic action is affected, causing diarrhea, constipation, or a combination of both. Management focuses on reducing diarrhea or constipation, abdominal pain, and stress. Clients can manage symptoms with diet, medications, exercise, and stress management. To manage IBS, clients should restrict gas-producing foods (eg, bananas, cabbage, onions); caffeine; alcohol; fermentable oligo-, di-, and monosaccharides and polyols (FODMAPs) (eg, honey, high-fructose corn syrup, wheat); and other gastrointestinal (GI) irritants (eg, spices, hot/cold food or drink, dairy products, fatty foods). Clients should gradually increase fiber intake (eg, whole grains, legumes, nuts, fruits, vegetables) as tolerated. Foods that are generally well tolerated include proteins, breads, and bland foods (Option 4).

(Option 1) Although they are a great source of fiber, beans are gas-producing and should be avoided. Most dairy products are GI irritants; however, yogurt is often better tolerated and may be included in the diet. (Option 2) Gas-producing cruciferous vegetables (eg, broccoli, cabbage) should be avoided. Alcohol exacerbates IBS symptoms. (Option 3) Hot beverages and caffeine (eg, coffee) irritate the GI tract. Bagels are gas-producing.

Buspirone (Buspar) is an anxiolytic medication that differs from other medications used to manage anxiety disorders (eg, benzodiazepines) because it typically lacks central nervous system depressant effects and has a low abuse potential. Therefore, buspirone has a favorable side-effect profile because it usually does not produce withdrawal symptoms, dependence, or psychomotor slowing (eg, slowing of thought, impaired movement). However, unlike other anxiolytic medications, buspirone does not work immediately. Onset of symptom relief occurs after 1 week of therapy, with full effects occurring between 2 and 4 weeks (Option 3).

(Option 1) As with any medication, the nurse should advise clients to avoid driving until individual effects are known. However, it is unlikely that buspirone will cause psychomotor impairment and require cessation of driving or operating machinery for the duration of treatment. (Option 2) Buspirone should be taken as prescribed and is not indicated for relief of acute anxiety or panic attacks. The health care provider may prescribe an additional medication with a fast-acting effect for panic attacks. (Option 4) Buspirone does not cause physical dependence or tolerance, and withdrawal symptoms do not occur with discontinuation of use.

Iron-deficiency anemia occurs when the body lacks sufficient iron to form red blood cells and synthesize hemoglobin. Iron-deficiency anemia can result from: Diets low in iron (eg, vegetarian and low-protein diets) Iron not being absorbed (eg, following many gastrointestinal [GI] surgeries, malabsorption syndrome) Increased iron requirement (eg, children's growth spurts, pregnancy, breastfeeding) Blood loss (eg, menstruation, bleeding in the GI tract [eg, ulcers, hemorrhoids]) Foods rich in iron include: Meats (eg, beef, lamb, liver, chicken, pork) Shellfish (eg, oysters, clams, shrimp) Eggs, green leafy vegetables, broccoli, dried fruits, dried beans, brown rice, and oatmeal Eating foods rich in vitamin C (eg, citrus fruits, potatoes, tomatoes, green vegetables) with iron-rich foods will enhance iron absorption but coffee and tea consumption interferes with this process.

(Option 1) Chicken in a salad is a good source of iron. However, bread, pudding, and milk do not contain significant amounts of iron. (Option 2) Fat-free yogurt, carrot sticks, apple slices, and diet soda do not offer a significant source of iron. (Option 3) Ham is a good source of iron. However, carrots, green beans, and gelatin desserts are not significant sources. Furthermore, the tea will inhibit iron absorption.

Coarse crackles (loud, low-pitched bubbling) are heard primarily during inspiration and are not cleared by coughing. The sound is similar to that of Velcro being pulled apart. Coarse crackles may be confused with fine crackles (eg, atelectasis), which have a high-pitched popping sound. Coarse crackles are present when fluid or mucus collects in the lower respiratory tract (eg, pulmonary edema, pulmonary fibrosis). In heart failure, the left ventricle fails to eject enough blood, causing increased pressure in the pulmonary vasculature. As a result, fluid leaks into the alveoli (pulmonary edema). Diuretics (eg, furosemide) treat pulmonary edema by increasing fluid excretion by the kidneys.

(Option 1) Clients with asthma or chronic obstructive pulmonary disease (eg, emphysema) develop wheezing due to bronchospasm. Bronchodilators (eg, albuterol, ipratropium) are indicated for these clients. (Option 3) Emphysema is a chronic hyperinflation of the alveoli. Clients with emphysema are taught the pursed-lip breathing technique to prevent alveolar collapse during exhalation. Emphysema causes diminished lung sounds, prolonged expiration, and wheezing. (Option 4) Chest tubes are inserted into the pleural space to remove trapped air (eg, pneumothorax) or fluids (eg, hemothorax, pleural effusion). Lung sounds are diminished or absent when lung tissue is compressed by air or fluids in the pleural space.

Myxedema coma refers to a state of severe hypothyroidism causing decreased level of consciousness (eg, lethargy, stupor) that may progress to a comatose state. Myxedema coma is characterized by hypothermia, bradycardia, hypotension, and hypoventilation. Hypoventilation may occur as a result of respiratory muscle fatigue and mechanical obstruction by an edematous tongue. Clients with signs of respiratory failure (eg, slow or shallow breathing, low oxygen saturation) require emergency endotracheal intubation and mechanical ventilation. The nurse should provide respiratory support (eg, ventilation with a bag-valve-mask) and prepare to assist with intubation (Option 4).

(Option 1) Clients with myxedema coma require thyroid hormone replacement with IV levothyroxine to correct the hypothyroid state but only after respiratory status is secured. Improvement in clinical status may not occur for up to a week after initiation of hormone replacement. (Option 2) A serum thyroid panel (eg, TSH, triiodothyronine, thyroxine) is required to confirm hypothyroidism, and these measurements should be monitored during treatment; however, the nurse should ensure that the client is stable before reviewing laboratory values. (Option 3) A warming blanket should be placed on the client to treat hypothermia; however, respiratory support is the priority.

Lithium is a mood stabilizer most often used to treat bipolar affective disorders. It has a narrow therapeutic index (0.6-1.2 mEq/L [0.6-1.2 mmol/L]). Risk factors for lithium toxicity include dehydration, decreased renal function (in the elderly), diet low in sodium, and drug-drug interactions (eg, nonsteroidal anti-inflammatory drugs [NSAIDS] and thiazide diuretics). Chronic toxicity can result in: Neurologic manifestations - ataxia, confusion or agitation, and neuromuscular excitability(tremor, myoclonic jerks) Nephrogenic diabetes insipidus - polyuria and polydipsia (increased thirst) (Option 4) Clients should be educated about monitoring for these symptoms and obtaining serum lithium levels at regular intervals.

(Option 1) Dietary potassium should be avoided when taking drugs such as potassium-sparing diuretics (eg, spironolactone, triamterene, amiloride) and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. (Option 2) Regular exercise and a high-fiber diet can prevent constipation, which is not a known side effect of lithium. Opioids, anticholinergics, and iron supplements are medications that cause constipation. (Option 3) Good oral hygiene is ideal for every client but is not specially indicated for those taking lithium. Clients taking phenytoin should maintain oral hygiene to prevent gingival hyperplasia.

Acyclovir (Zovirax), famciclovir, and valacyclovir are commonly used to treat herpes infection as they shorten the duration and severity of active lesions. Genital herpes is a sexually transmitted infection caused by a herpes simplex virus and is highly contagious, especially when lesions are active. It remains dormant in the body even when active lesions are healed. There is no cure for genital herpes; treatment is aimed at relieving symptoms and preventing the spread of infection. Touching the lesions and then rubbing or scratching another part of the body can spread the infection. Therefore, gloves should be used when applying topical antiviral or analgesic (eg, lidocaine) medications. .

(Option 1) Herpetic lesions should be kept clean and dry. They can be cleansed with warm water and soap or other solutions. Bandages are not applied to the lesions. (Option 2) There is no cure for herpes infection. Genital herpes often leads to local recurrence. Some clients may need long-term suppressive therapy. (Option 3) During periods of active lesions, abstinence from sexual intercourse is indicated. Condoms should be used during periods of dormancy due to viral shedding

Thyroid storm is a life-threatening condition that can occur in uncontrolled hyperthyroidism or Graves' disease when a stressful incident, such as this client's motor vehicle accident, triggers a sudden surge of thyroid hormone. Manifestations of thyroid storm include a rapid onset of fever, tachycardia, and elevated blood pressure. The client often feels anxious, tremulous, or restless. Confusion and psychosis can occur, as can seizures and coma. Rapid treatment is necessary.

(Option 1) Hypertensive crisis alone would not cause fever. (Option 2) Malignant hyperthermia would occur in the perioperative setting in response to anesthesia. This client has no risk factors for malignant hyperthermia. (Option 3) Serotonin syndrome would occur in the client taking more than one or an overdose of antidepressant medication that increases serotonin levels.

A balloon tamponade tube (eg, Sengstaken-Blakemore, Minnesota) is used to temporarily control bleeding from esophageal varices. It contains 2 balloons and 3 lumens. The gastric lumen drains stomach contents, the esophageal balloon compresses bleeding varices above the esophageal sphincter, and the gastric balloon compresses from below. A weight is attached to the external end of the tube to provide tension and hold the gastric balloon securely in place below the esophageal sphincter. Airway obstruction can occur if the balloon tamponade tube becomes displaced and a balloon migrates into the oropharynx. Scissors are kept at the bedside as a precaution; in the event of airway obstruction, the nurse can emergently cut the tube for rapid balloon deflation and tube removal (Option 2).

(Option 1) If airway obstruction occurs, the nurse should first clear the airway and then ensure that the client is stable before contacting the health care provider. (Option 3) Low intermittent suction to the gastric lumen of a balloon tamponade tube is used to drain stomach contents. Increasing the suction would not be indicated if the tube has become displaced. (Option 4) If the balloon tamponade tube is displaced and obstructing the airway, changing the client's position will not help until the client's airway is cleared by removing the tube.

The client with acute pancreatitis will report a sudden onset of unrelenting, severe pain in the left upper quadrant or midepigastric area of the abdomen that often radiates to the back. The pain is referred to the back as the pancreas is a retroperitoneal organ. Pain improves with leaning forward and worsens with lying flat. The pain is often preceded or made worse by a high-fat meal. Nausea and vomiting are common due to severe pain. Clients are at risk of developing hypovolemia (third spacing of fluids), acute respiratory distress syndrome (due to intense systemic inflammatory response), and hypocalcemia (necrosed fat binding calcium).

(Option 1) Kidney stones cause sudden, excruciating pain in the flank, back, or lower abdomen due to stretching of the ureter. The pain radiates to the groin area. (Option 3) Appendicitis presents as periumbilical pain progressing to the right lower quadrant. Tenderness at McBurney's point is present as pressure is applied, and rebound tenderness occurs when pressure is released. (Option 4) Cholecystitis (inflammation of the gallbladder) causes pain in the right upper quadrant that often radiates to the right shoulder area.

Shingles (herpes zoster) is a reactivation of the varicella-zoster (chicken pox) virus. It is more likely to occur when a client's immune system is compromised by disease (eg, HIV infection) or treatments (eg, chemotherapy). Shingles lesions that are open may transmit the infection by both air and contact. The client with disseminated shingles that are not crusted over will require contact precautions, airborne precautions, and a negative airflow room to prevent transmission of the infection to others in the hospital. Negative airflow pulls air from the hospital environment into the room, and the air from the hospital room then goes directly to the outside rather recirculating to the rest of the hospital. Localized shingles require only standard precautions for clients with intact immune systems and contained/covered lesions.

(Option 1) Negative airflow and airborne precautions are also required in addition to contact precautions. Droplet precautions are not necessary. (Option 3) Positive airflow would pull fresh air from outside into the hospital room, and then the air from the room would circulate throughout the rest of the hospital. It is not appropriate for this type of infection. Instead, positive airflow would be used for protective isolation in a client who is immunocompromised.

Normal serum calcium is 8.6-10.2 mg /dL (2.15-2.55 mmol/L). Hypocalcemia (serum calcium <8.6 mg/dL [2.15 mmol/L]) is a potential complication of parathyroidectomy because the parathyroids regulate calcium levels in the blood. When one or more parathyroids are removed, it may take some time for others that have been dormant during hyperparathyroidism (which causes an increase in serum calcium) to begin regulating serum calcium. Trousseau's sign may indicate hypocalcemia before other signs and symptoms of hypocalcemia, such as tetany, occur. Trousseau's sign can be elicited by placing the BP cuff on the arm, inflating to a pressure > than systolic BP, and holding in place for 3 minutes. This will occlude the brachial artery and induce a spasm of the muscles of the hand and forearm when hypocalcemia is present. Chevostek's sign another early indicator of hypocalcemia, should also be assessed. It may be elicited by tapping the face at the angle of the jaw and observing for contraction on the same side of the face.

(Option 1) Phalen's maneuver is used to diagnose carpal tunnel syndrome. (Option 2) The heel-to-shin test is another means of assessing cerebellar function. An abnormal examination is evident when the client is unable to keep the foot on the shin. (Option 3) The Romberg test is a component of a neurological examination to assess vestibular function (perception of head position in space), proprioception (perception of the body in space), and vision.

Endometrial cancer arises from the inner lining of the uterus and forms after the development of unregulated endometrial overgrowth (ie, hyperplasia). Although typically slow growing, it can metastasize to the myometrium (ie, uterine muscle tissue), cervix, and nearby lymph nodes and eventually beyond the pelvis. Many signs of endometrial cancer are nonspecific (eg, lower back or abdominal pain), but the hallmark symptom is abnormal uterine bleeding (eg, heavy, prolonged, intermenstrual, and/or postmenopausal bleeding). As with many cancers, the client's family and genetic history (eg, BRCA mutation carrier) are significant risk factors; however, prolonged estrogen exposure without adequate progesteroneis the greatest risk factor for developing endometrial cancer. Factors increasing estrogen exposure and endometrial cancer risk include: Conditions associated with infrequent or anovulatory menstrual cycles (eg, polycystic ovary syndrome, infertility, late menopause, early menarche) (Option 3) Obesity Tamoxifen (a medication given for breast cancer)

(Option 1) Progestin-containing contraceptives (ie, birth control pills) are associated with a decreased endometrial cancer risk because progestins thin the uterine lining, therefore preventing endometrial hyperplasia. (Option 2) Ectopic pregnancy with a ruptured ovary or preterm birth is not associated with endometrial cancer, although never giving birth at term gestation may increase ovarian cancer risk. (Option 4) Infection with a high-risk type of human papillomavirus increases cervical (not endometrial) cancer risk.

The rotator cuff is a group of 4 shoulder muscles and tendons that attach to the humeral head. It allows for rotation of the arm. A partial or full thickness rotator cuff tear can occur gradually over time as a result of aging, repetitive use, or an injury to the shoulder. It can also occur as a result of a sports injury involving repetitive overhead arm motion (eg, swimming, tennis, baseball, weight lifting). Characteristic symptoms of rotator cuff injury usually include shoulder pain and weakness. Severe pain when the arm is abducted between 60 and 120 degrees (painful arc) is characteristic (Option 3).

(Option 1) Restriction of active and passive ranges of motion of the shoulder (complete stiffness) is seen with frozen shoulder. (Option 2) Pain and paresthesia over the first 3½ fingers suggest carpal tunnel syndrome. (Option 4) Tenderness over the lateral epicondyle is seen with tennis elbow.

A low-residue, high-protein, high-calorie diet, along with daily vitamin and mineral supplements, is encouraged to meet the nutritional and metabolic needs of the client with ulcerative colitis. The low-residue diet limits trauma to the inflamed colon and may lessen symptoms. Easily digested foods such as enriched breads, rice, pastas, cooked vegetables, canned fruits, and tender meats are included in the diet. Raw fruits and vegetables, whole grains, highly seasoned foods, fried foods, and alcohol are avoided. The well-balanced diet includes at least 2000-3000 mL/day of fluid to maintain fluid and electrolyte balance and hydration.

(Option 1) Small, frequent meals are encouraged to lessen the amount of fecal material present in the gastrointestinal tract and to decrease stimulation. (Option 2) Caffeine, alcohol, and tobacco are gastric irritants that stimulate the intestine and should be avoided. (Option 5) The prescribed sulfasalazine should be continued even when symptoms subside to prevent relapse. Because sulfasalazine hinders the absorption of folate, folic acid supplements are encouraged.

Pressure injuries are staged from 1 to 4 to classify the degree of tissue damage and determine the most effective wound treatment. Unstageable pressure injuries have full-thickness skin loss with slough and/or eschar, which prevents visualization of the wound base. Slough in a wound base appears as yellow or tan stringy tissue; eschar is dried, black or brown necrotic tissue. The wound cannot be staged until slough and eschar are debrided by a wound care nurse or health care provider and the base can be visualized (Option 4).

(Option 1) Stage 2 pressure injuries present as shallow, open wounds with partial-thickness skin loss of the dermis. The wound bed is red or pink, and may be shiny or dry. (Option 2) Stage 3 pressure injuries have full-thickness skin loss. Subcutaneous fat may be observed; however, underlying tendon, muscle, or bone is not visible. The wound bed may tunnel or extend under the edge of surrounding skin, as a lip or pocket (undermining). (Option 3) A deep-tissue injury presents as an area of dark purple or maroon discolored, intact skin, which is caused by a pressure or shearing injury to underlying tissue.

To measure pressures accurately using continual arterial and/or pulmonary artery pressure monitoring, the zeroing stopcock of the transducer system must be placed at the phlebostatic axis. This anatomical location, with the client in the supine position, is at the 4th ICS, at the midway point of the AP diameter (½ AP)of the chest wall. If the transducer is placed too low, the reading will be falsely high; if placed too high, the reading will be falsely low. This concept is similar to the positioning of the arm in relation to the level of the heart when measuring blood pressure indirectly using a sphygmomanometer or noninvasive blood pressure-monitoring device. The upper arm should be at the level of the phlebostatic axis.

(Option 1) The angle of Louis is the palpable raised notch where the manubrium and sternum are joined. This anatomical location is useful in counting the ICSs and in finding auscultatory areas. (Option 2) The aortic area is an auscultatory area located at the 2nd ICS to the right of the sternal border. (Option 4) The mitral area (apex), an auscultatory area, and the point of maximal impulse are located at the 5th ICS at the MCL.

The normal range for a WBC count is 4,000-11,000/mm3 (4.0-11.0×109/L). Clients with neutropenia (a reduction in WBCs) are predisposed to infection. The absolute neutrophil count (ANC) is determined by multiplying the total WBC count by the percentage of neutrophils. Neutropenia is an ANC below 1,000/mm3 (1.0×109/L). An ANC below 500/mm3 (0.5×109/L) is defined as severe neutropenia and is a critical emergency. This client's neutropenia is probably a result of bone marrow suppression from the chemotherapy. The client needs reverse or protective isolation from organisms that people or objects may have that the client lacks resistance to. A hospitalized client needs to be in a private room, and the room may need to be equipped with HEPA (high-efficiency particulate air) filtration (or positive pressure air flow). Until the room can be readied, the client should be protected with a mask and separated from infectious clients. Additional neutropenic precautions include avoiding raw fruits/vegetables, standing water, and undercooked meat. In addition, no infectious health care providers (eg, with colds) should care for the client.

(Option 1) Thrombocytopenia (low platelets) can result from bone marrow suppression caused by chemotherapy. This client's platelets are at the low end of the normal range (150,000-400,000/mm3 [150-400× 109/L]). Spontaneous or surgical bleeding from thrombocytopenia rarely occurs with a platelet count of >50,000/mm3 (50 × 109/L). (Option 2) This client's potassium level is slightly low (normal 3.5-5.0 mEq/L [3.5-5.0 mmol/L]). Low potassium, if it affects the cardiac tracing, causes flattened T waves. Peaked or tented T waves on a cardiac tracing are related to hyperkalemia. (Option 3) Epoetin alfa (human recombinant erythropoietin) is a hematopoietic growth factor. The erythropoietin is produced in the kidney and stimulates bone marrow production of red blood cells (RBCs), a process called erythropoiesis. Epoetin alfa is used to stimulate RBC production but is not typically prescribed unless the client has symptomatic anemia with hemoglobin of <10 g/dL (100 g/L).

Opioids (eg, morphine sulfate), anticholinergic medications, and tricyclic antidepressants can cause urinary retention; they increase bladder sphincter tone and/or relax bladder muscle. The nurse should assess the client's suprapubic area to determine if the client has urinary retention. If the area is distended and dull to percussion, the nurse should proceed with interventions.

(Option 1) While asking if a bedpan is needed is an important nursing intervention, it does not aid in the assessment of urinary retention. (Option 2) Gathering assessment data indicating the presence of urinary retention is necessary prior to other interventions. The nurse should assess for fluid intake after assessing bladder distension. (Option 3) The client's skin turgor is assessed after the nurse checks for urinary retention and fluid intake. There is no need to assess skin turgor until other indicators of adequate fluid intake are reviewed.

Repositioning and transferring clients can be delegated to unlicensed assistive personnel (UAP) when it is deemed safe and appropriate. The nurse must provide UAPs with detailed instructions, including when to move the client, which techniques to use, and when to use assistive persons or devices. The nurse must also notify UAPs of any client mobility restrictions. Unstable clients and spinal cord stabilization require the presence of a nurse for repositioning or moving (Option 4). The client who is 8 hours postoperative total hip replacement requires assessment prior to repositioning as the client is at risk for hip dislocation. A wedge may be needed to maintain abduction; nursing judgment is required

(Option 1). To reduce the risk of client and staff injury, safe transfers and repositioning are achieved using the following guidelines: Use a gait/transfer belt to transfer a partially weight-bearing client to a chair (Option 2). Use 2 or more caregivers to reposition clients who are uncooperative or unable to assist (eg, comatose, medicated) (Option 3). Use a full-body sling lift to move/transfer nonparticipating clients. Use 2-3 caregivers to move cooperative clients weighing less than 200 lb (91 kg). Use 3 or more caregivers to move cooperative clients weighing more than 200 lb (91 kg)

Individuals with type I or II diabetes mellitus are at increased risk for developing an infection or ulcer on their feet due to the chronic complication of peripheral neuropathy. Peripheral neuropathy results from damage to the nerves in the extremities. Clients may be unable to feel injuries if they occur and must take extra measures in caring for their feet. Clients should be taught to wear closed-toed, leather-based shoes to prevent injury. Careful, daily attention to foot care can prevent long-term complications. The following instructions can be used in teaching diabetic foot care: Proper footwear - Wear shoes that are comfortable, supportive, and well-fitting (preferably leather). Avoid high-heeled, open-heeled, and open-toed shoes. Wear clean, absorbent (eg, cotton) socks. Daily hygiene and inspection - Use a mild soap and warm water; dry feet thoroughly, especially between toes. Apply lanolin lotion to prevent drying (but not between toes)

(Option 1). Inspect for any break in skin integrity using a mirror or a second person to visualize the bottom of the feet. Trim toenails straight across; file edges along contour of the toes. Injury avoidance - Do not walk barefoot, use hot water or heating pads, wear restrictive shoes or clothing, or cross the legs for extended periods (Options 3 and 4). Report problems - Do not self-treat corns, calluses, or ingrown toenails. Cleanse cuts or abrasions with mild soap and water; report non-healing or infected injuries to the health care provider immediately.

Hypotension, tachycardia, and low central venous pressure (normal: 2-8 mm Hg) may indicate hypovolemic shock. Central venous pressure is a measurement of right ventricular preload (volume within the ventricle at the end of diastole) and reflects the client's fluid volume status. This client is recovering from major abdominal surgery and has a low-grade fever, placing the client at risk for fluid volume losses (eg, blood loss during surgery, insensible losses [sweating]). This client should be treated with isotonic fluids (eg, normal saline, lactated Ringer solution) to restore adequate fluid volume status. IV boluses of isotonic fluids (ie, fluid resuscitation) increase intravascular volume, which increases blood pressure and end-organ perfusion (Option 4). (Option 1) Acetaminophen is an analgesic and antipyretic that reduces fever and pain; however, the client's hemodynamic stability should be addressed first.

(Option 2) Cefazolin, a cephalosporin antibiotic, may be prescribed prophylactically to prevent intra-abdominal infection after major abdominal surgery. Medications timed "now" should be administered within 90 minutes. This intervention should be performed after stabilizing the client's hemodynamic status. (Option 3) If the client remains hypotensive following a fluid bolus, vasopressor or inotropic medications (eg, norepinephrine, dopamine) should be initiated. However, vasopressor medications are not effective without first restoring circulatory fluid volume as there is insufficient volume to compress within the vascular space.

Marfan syndrome is a connective tissue disorder that causes visual and cardiac defects and a distinct long, slender body type. In Marfan syndrome with aortic vessel involvement, the root of the aorta is dilated or weakened, increasing the risk of aortic dissection and aortic rupture. Increases in blood volume and cardiac workload that occur during pregnancy may worsen aortic root dilation and further increase the risk of aortic dissection/rupture. Pregnancy in clients with Marfan syndrome, especially those with aortic root dilation, poses a high risk of maternal mortality. Clients should be instructed about the importance of consistently using reliable birth control methods to prevent pregnancy (Option 3). (Option 1) Beta blockers are commonly used to treat clients with Marfan syndrome to limit aortic root dilation. Such medications are generally safe to use during pregnancy, so the client should not discontinue therapy unless directed to do so by the health care provider.

(Option 2) Clients with Marfan syndrome considering pregnancy should be counseled to complete childbearing in early adulthood because aortic root dilation and the risk of aortic dissection/rupture increase with time. (Option 4) Marfan syndrome is an autosomal dominant condition with a 50% chance of inheritance in offspring.

A tracheostomy tube, an artificial airway inserted into the trachea through the neck, may be secured with sutures or tracheostomy ties. Accidental dislodgment of a tracheostomy tube is a medical emergency often resulting in respiratory distress from closure of the stoma and airway loss. If accidental dislodgment of mature tracheostomies (ie, >7 days after insertion) occurs where the tract is well formed, the nurse should attempt to open the airway by inserting a curved hemostat to maintain stoma patency and insert a new tracheostomy tube with an obturator (Option 3). (Option 1) Application of supplemental oxygen via nonrebreather face mask may not resolve respiratory distress because air can escape from the stoma.

(Option 2) Covering the stoma with a sterile, occlusive dressing (eg, petroleum gauze, foam tape) and ventilating the lungs with a bag-valve mask over the nose/mouth may be necessary if the tube cannot be reinserted or the stoma is immature. Dry gauze is porous and does not adequately seal the stoma for ventilation. (Option 4) Tracheal suctioning may be necessary once the airway is resecured. However, suctioning prior to establishing an airway does not improve ventilation and may further reduce the oxygen supply.

Parkinson disease (PD) is a progressive neurological disorder characterized by bradykinesia (loss of autonomic movements), rigidity, and tremors. Clients with PD have an imbalance between dopamine and acetylcholine in which dopamine is not produced in high enough quantities to inhibit acetylcholine. Anticholinergic medications (eg, benztropine, trihexyphenidyl) are commonly used to treat tremor in these clients. However, in clients with benign prostatic hyperplasia or glaucoma, caution must be taken as anticholinergic drugs can precipitate urinary retention and an acute glaucoma episode. As a result, such medications are contraindicated in these clients.

(Option 2) Decreased ability to exercise is common in clients with PD due to tremors and bradykinesia, and they require physical and occupational therapy consultations. However, acute glaucoma can be sight threatening and is the priority. (Option 3) Esomeprazole is safe to take with benztropine and will not cause an adverse reaction. (Option 4) Constipation is a common side effect of benztropine. Due to the characteristic decreased mobility, PD can also cause constipation. The client should be instructed to increase dietary fiber intake and drink plenty of water. However, this is not

Fluticasone/salmeterol (Advair) is a combination drug containing a corticosteroid (fluticasone) and a bronchodilator (salmeterol). Salmeterol is a long-acting inhaled β2-adrenergic agonist that promotes relaxation of the bronchial smooth muscles over 12 hours. Fluticasone decreases inflammation. This medication is used as part of the treatment plan for prevention and long-term control of asthma. Client instructions include: After inhalation, rinse the mouth with water without swallowing to reduce the risk of oral/esophageal candidiasis Avoid smoking and using tobacco products Receive the pneumococcal and influenza vaccines if there is a risk for infection

(Option 2) Fluticasone/salmeterol is not a rescue inhaler and does not treat acute exacerbations of asthma. The client should always have a rescue inhaler (eg, albuterol [short-acting β2-adrenergic agonist] or ipratropium [Atrovent]) for sudden changes in breathing and call 911 if the rescue inhaler does not relieve the breathing problem.

Third-spacing of fluids can occur 24-72 hours after extensive abdominal surgery as a result of increased capillary permeability due to tissue trauma. It occurs when too much fluid moves from the intravascular into the interstitial or third space, a place between cells where fluid does not normally collect (ie, injured site, peritoneal cavity). This fluid serves no physiologic purpose, cannot be measured, and leads to decreased circulating volume (hypovolemia) and cardiac output. The priority intervention is to assess vital signs as the manifestations associated with third-spacing include weight gain, decreased urinary output, and signs of hypovolemia, such as tachycardia and hypotension. If third-spacing is not recognized and corrected early on, postoperative hypotension can lead to decreased renal perfusion, prerenal failure, and hypovolemic shock (Option 1).

(Option 2) Increasing the IV flow rate of the isotonic solution may be an appropriate intervention once the nurse has assessed the client, including taking a full set of vital signs. The nurse should intervene only after assessing to rule out other problems for which an increase in IV fluid intake would not be an appropriate solution (eg, Foley catheter obstruction). (Option 3) The nurse will notify the health care provider to report oliguria (<0.5 mL/kg/hr) after collecting all of the data necessary (ie, vital signs). This is not the nurse's first action. (Option 4) Urinary retention is possible following surgery due to the adverse effects of anesthesia, opioids, anticholinergic drugs, and immobility. However, a bladder scan is not an appropriate action in this situation as the client has a Foley catheter. Irrigating the catheter is the appropriate intervention if the nurse questions its patency.

Blunt-force trauma to the head is associated with potentially severe complications (eg, brain damage and herniation, retinal detachment, seizures). Prompt recognition of potential complications is essential to prevent irreversible changes to the client's neurological status and level of function. Retinal detachment is a separation of the retina from the posterior wall of the eye that may occur following head trauma. This is an ocular emergency as permanent blindness may result without intervention. Signs of retinal detachment include perception of lightning flashes or floaters and a curtain-like or gnats/hairnet/cobweb effect throughout the visual field (Option 1).

(Option 2) Loss of memory about the accident, or retrograde amnesia, is commonly reported after mild head injuries. The client should be monitored for decreased level of consciousness or alterations in mental status, which may indicate intracranial bleeding. (Option 3) Headache is expected after mild head injury, and is not innately concerning except if the pain acutely worsens or is not relieved by over-the-counter analgesics (eg, acetaminophen, ibuprofen). (Option 4) A bleeding tongue laceration may occur when the force of the trauma causes the client to accidentally bite the tongue. Oozing blood, although disturbing to the client, does not pose an immediate threat.

Asthma is an inflammatory condition in which the smaller airways constrict and become filled with mucus. Breathing, especially on expiration, becomes more difficult. Pharmacologic treatment for acute asthma includes the following: Oxygen to maintain saturation >90% High-dose inhaled short-acting beta agonist (albuterol or levalbuterol) and anticholinergic agent (ipratropium) nebulizer treatments every 20 minutes Systemic corticosteroids (Solu-Medrol) to control the underlying inflammation. These will take some time to show an effect.

(Option 2) Nonsteroidal anti-inflammatory agents (eg, ibuprofen, naproxen, indomethacin) and aspirin can worsen asthma symptoms in some clients and are not indicated unless necessary. (Option 4) Montelukast (Singulair) is a leukotriene (chemical mediator of inflammation) inhibitor and is not used to treat acute episodes. It is given orally in combination with beta agonists and corticosteroid inhalers (eg, fluticasone, budesonide) to provide long-term asthma control. (Option 5) Tobramycin is an aminoglycoside antibiotic. It is used in aerosolized form to treat cystic fibrosis exacerbation when Pseudomonas is the predominant organism causing lung infection.

Prolonged morning stiffness of the affected joints is a major complication of rheumatoid arthritis (RA). Taking a warm shower or bath first on awakening would be the best intervention as heat decreases stiffness and promotes muscle relaxation and mobility. With increased flexibility and decreased stiffness, the client's usual morning activities (eg, dressing, making breakfast) would be easier and less painful and tiring to perform. (Option 1) A balanced diet and weight control are important. Diet and exercise should be proportional, especially during periods of disease exacerbation and decreased physical activity as excess weight exerts additional stress on weight-bearing joints.

(Option 2) Range of motion exercises are more effective after a warm bath or shower as stiffness is decreased, thereby improving flexibility. (Option 4) Nonsteroidal anti-inflammatory drugs (NSAIDS) (eg, naproxen [Naprosyn], ibuprofen [Motrin]) should not be taken on an empty stomach as these can cause gastrointestinal upset. If prescribed once daily, these are probably best taken in the evening after dinner as RA symptoms slowly increase during the night and worsen in the morning. A higher serum drug level in the morning can help to reduce inflammation and stiffness. Therefore, if NSAIDS are prescribed twice daily, taking them in the morning with breakfast and in the evening with dinner is recommended.

Ringworm, or tinea corporis, is a fungal infection on the superficial keratin layers of the skin, hair, and/or nails. Ringworm is a misleading name as the condition is not caused by a worm infestation. However, it is highly contagious and spreads via contact. Management includes teaching appropriate hygiene (eg, washing hands after touching infected areas), limited contact with personal items (eg, hair brush), and treatment with the prescribed shampoos as well as topical and/or oral medications (eg, terbinafine [Lamisil], miconazole). (Option 1) Antifungal cream (terbinafine [Lamisil]) is the preferred treatment and is applied to infected areas twice a day. It may take 1-4 weeks to complete treatment depending on infection severity.

(Option 2) Ringworm is spread via contact with shared surfaces (eg, bathroom floors, gymnasium mats, car seats), personal items, or pets. Important preventive measures include cleaning surfaces frequently, not sharing personal items, and practicing hand hygiene. (Option 4) This is not a dangerous condition; however, the client will be uncomfortable due to itching. Efforts should be made to discourage scratching as this facilitates spread of infection.

Coup-contrecoup injury occurs when a body in motion stops suddenly (eg, head hits car windshield), causing contusions (bruising) of brain tissue as the brain moves back and forth within the skull. First, the soft tissue strikes the hard skull in the same direction as the momentum (coup). As the body bounces back, the brain strikes the opposing side of the skull (contrecoup). When the forward collision occurred, the frontal lobe most likely suffered the primary impact (coup). Executive function, memory, speech (Broca area), and voluntary movement are controlled by the frontal lobe. The contrecoup most likely injured the occipital lobe, where visionis processed. (Option 2) The temporal lobe (lateral aspect of the brain) controls hearing and integrates sensory data (eg, auditory, visual, somatic). The Wernicke speech area in the temporal lobe is responsible for language comprehension. Light touch is processed by the sensory cortex in the parietal lobe.

(Option 3) An interruption of sensory function indicates injury to either the spinal column or the parietal lobe. These injuries affect proprioception (awareness of body positioning) and graphesthesia (ability to identify writing on the skin, by touch). (Option 4) The Weber test screens for conductive hearing loss by checking whether a tuning fork held along the midline of the head is heard evenly in both ears. Cranial nerve I is the olfactory nerve. Hearing and smell are both processed by the temporal lobe.

The influenza virus has an incubation period of 1-4 days, with peak transmission starting at about 1 day before symptoms appear and lasting up to 5-7 days after the illness stage begins (Option 1). (Option 2) Influenza is transmitted by inhaling droplets that an infected individual exhales into the air when sneezing, coughing, or speaking. If contact with others is unavoidable, wearing a mask can offer some protection against virus transmission.

(Option 3) Individuals with the influenza virus can transmit the virus during the incubation period and illness stage of the infection. It is not appropriate to assume that the spouse can no longer transmit the infection. (Option 4) Although vaccination provides immunity against influenza in about 2 weeks after inoculation, it does not offer complete protection against all virus strains. Therefore, close contact with others should be avoided during the illness stage, especially those with an impaired immune system.

Hemophilia is a bleeding disorder caused by a deficiency in coagulation proteins. Treatment consists of replacing the missing clotting factor and teaching the client about injury prevention. Clients with hemophilia who are injured should be monitored closely for bleeding (eg, intracranial bleeds, bleeding into joints). Signs of an intracranial bleed include lethargy, headache, irritability, and vomiting. An intracranial bleed is lethal if unchecked, so administration of factor VIII to a client with hemophilia A is the first order of action, followed by a CT scan. (Option 2) Ondansetron (Zofran) can be given to treat nausea/vomiting, but administration of factor VIII is the priority.

(Option 3) Laboratory studies, particularly hemoglobin and hematocrit levels, are necessary, but the priority is to administer factor VIII. (Option 4) A CT scan should be performed for diagnostic purposes, but the bleeding must be stopped emergently. Even if bleeding is evident on CT scan and the client is taken to the operating room, surgery cannot be performed without simultaneous factor VIII replacement.

Normal eosinophil count is 1%-2%. Elevated eosinophils are seen in allergy. In a client with an asthma exacerbation, a high eosinophil count would indicate an allergic trigger for the asthmatic response. The nurse should explore the client's allergy history and ways to reduce the allergic exposure that may be contributing to the exacerbation. (Option 2) Lymphocytes form the major part of immune system. Elevated levels are seen with viral infections and hematologic malignancies.

(Option 3) Normal neutrophils are 55%-70%. Elevated neutrophils indicate infection. (Option 4) Reticulocytes are immature red blood cells. Normal reticulocyte count is 0.5%-2.0%. Levels are elevated in hemolytic anemia or hemorrhage when the marrow is attempting to compensate for lost blood.

The immediate postoperative priority goal for a client with a new tracheostomy is to prevent accidental dislodgement of the tube and loss of the airway. If dislodgement occurs during the first postoperative week, reinsertion of the tube is difficult as it takes the tract about 1 week to heal. For this reason, dislodgement is a medical emergency. The priority nursing action is to ensure the tube is placed securely by checking the tightness of ties and allowing for 1 finger to fit under these ties. (Option 1) Changing of the inner cannula and tracheostomy ties is not usually performed until 24 hours after insertion; this is due to the risk of dislodgement with an immature tract. However, the dressing can be changed if it becomes wet or soiled. Suctioning can be performed to remove mucus and maintain the airway.

(Option 3) The cuff is kept inflated to prevent aspiration from secretions and postoperative bleeding. Cuffs are not regularly deflated and re-inflated. The respiratory therapist should monitor the amount of air in the cuff several times a day to prevent excessive pressure and mucosal tissue damage. (Option 4) Frequent mouth care to help prevent stomal and pulmonary infection is important in a client with an artificial airway, but it is not the priority action immediately following tracheostomy.

The UAP has the skills and knowledge to perform standard procedures to prevent immobility hazards for a client in traction (eg, pneumonia, pressure ulcers, foot drop, thromboembolism). When providing care for a stable client, the RN can safely delegate these tasks to the UAP: Assist with active and passive ROM exercises after the client has been taught how to perform them by the RN or physical therapist (Option 1) Notify the RN of client reports of pain, tingling, or decreased sensation in the affected extremity Remind the client to use the incentive spirometer after the client has been taught proper use by the RN or respiratory therapist

(Option 4) Maintain proper use of pneumatic compression devices (Option 5) Remind the client to move frequently using the overhead trapeze (Option 2) The UAP changes the linens from the top to the bottom of the bed with assistance; clients are instructed to lift themselves using the overhead trapeze. This approach maintains immobilization of the injured extremity. Logrolling the client will require multiple staff members, including one person to stabilize weights. (Option 3) The RN is responsible for peripheral circulation, neurovascular, and skin assessments.

A physical restraint that restricts body movement should be the last resort to keep a client from interfering with medical treatment. Restraints can cause bodily injury such as pressure ulcers, neurovascular and peripheral circulatory deficits, and psychological trauma. Therefore, less restrictive methods should always be tried first. Concealing the IV site and tubing by wrapping the forearm in gauze and an elastic stockinette can be effective in keeping a confused client from pulling at the IV line.

(Options 2, 3, and 4) Applying a hand mitt, soft wrist restraint, or arm board may be necessary if less restrictive techniques, such as concealing the IV site or encouraging family member or sitter involvement, are ineffective in keeping the client from pulling at the IV line. However, applying one of these restraints should not be the nurse's next action

Defibrillation is indicated in clients with ventricular fibrillation (Vfib) and pulseless ventricular tachycardia.

(asystole and pulseless electrical activity) do not need defibrillation.

melena

(dark red or black, sticky stool) is an indication of an upper gastrointestinal (UGI) bleed. Gastritis is a common cause of UGI bleeding in infants and toddlers

Manifestations of neurogenic shock

- hypotension - bradycardia, slow bounding pulse (caused be PNS) - late tachycardia - warm pink extermities early d/t vasodilation (flushed and red) and cool pale late (body trying to vasoconstrict) - hypothermia - anxious/restless early, lethargic comatose late

Bacterial meningitis with hypotension and sepsis: fever, severe headache, nausea/vomiting, and nuchal rigidity. Other symptoms include photophobia, altered mental status, and other signs of increased intracranial pressure (ICP).

-Priority of care is fluid resuscitation to increase the client's blood pressure -Administer vasopressors. - blood cultures before antibiotics. - empiric antibiotics, preferably within 30 minutes of admission -Prior to a lumbar puncture (LP), obtain a head CT scan as increased ICP or mass lesions may contraindicate a LP due to the risk of brain herniation Assist with a LP for cerebrospinal fluid (CSF) examination and cultures - CSF is usually purulent and turbid in clients with bacterial meningitis.

A client with epistaxis (ie, nosebleed) that does not resolve with external pressure will require further hemostatic interventions, such as cauterization or nasal packing (eg, gauze, nasal tampon, balloon catheter).

-pinch the nose - cold towel on top of nose -hold head forward

Tetracycline, Doxycycline, Demeclocycline, Minocycline

-stains/discoloration in teeth don't give to younger than 8, -nephrotoxic -hepatotoxic -phototoxic -avoid lasix

In cystic fibrosis (CF), a protein responsible for transporting sodium and chloride is defective and causes the secretions from the exocrine glands to be thicker and stickier than normal. These abnormal secretions plug smaller airway passages and ducts in the gastrointestinal (GI) tract. The thick secretions block pancreatic ducts, resulting in a deficient amount of pancreatic enzymes entering the bowel to aid in digestion and nutrient absorption

. Clients require multiple vitamin supplements and supplemental pancreatic enzymes that are administered with meals. To meet the growth needs of clients with CF, a diet high in calories, fat, and protein is required.

ALT and AST are the enzymes released when hepatic cells are injured (hepatitis). There are smaller amounts in the cardiac, renal, and skeletal tissues, but ALT/AST are used to diagnose hepatic disorders. Besides viral hepatitis, liver injury can occur with excessive chronic alcohol intake some over-the-counter medications (eg, acetaminophen), and certain herbal and dietary supplements

. IV illicit drug use increases the risk for hepatitis B and C infection Black tarry stool (melena) is an expected finding from a gastrointestinal bleed (from the digested blood). Melena can be seen in clients with gastric or esophageal varices, which are often complications of hepatic disease (eg, cirrhosis). However, melena is not an etiology of liver injury. Immunizations do not cause liver damage. It is possible to get a small elevation with an intramuscular injection, but not values this high.

The client with atrial fibrillation is at increased risk for the development of atrial thrombi due to blood stasis, which can embolize and lead to an ischemic brain attack.

. The INR (normal 0.75-1.25) is a measurement used to assess and monitor coagulation status in clients receiving anticoagulation therapy. The therapeutic INR level for a client receiving warfarin (Coumadin) to treat atrial fibrillation is 2-3. The subtherapeutic INR of 1.3 is the most important result to report to the health care provider (HCP) as the client is at increased risk for a stroke and dose adjustment is needed.

Colonoscopy evaluates colonic mucosa. Therefore, clients should follow instructions to keep the colon clean with no stool left for better visualization during the procedure. These instructions include: Clear liquid diet the day before Nothing by mouth 8-12 hours prior to the examination The health care provider prescribes a bowel-cleansing agent such as a cathartic, enema, or polyethylene glycol (GoLYTELY) the day before the test

. The type of prep depends on the health care provider's preference and client health status. (Option 2) Healthy clients screened for colon disease do not require antibiotics prior to the procedure. (Option 3) The instructions prior to a nuclear gastric emptying scan include teaching the client to avoid smoking the day of the examination as delay of gastric emptying occurs with tobacco use. Smoking cessation per se has no role in colonoscopy, but it is good for general health.

During the admission assessment of a client with a small-bowel obstruction, the nurse anticipates which clinical manifestations? Select all that apply. 1. Abdominal distension 2. Absolute constipation 3. Colicky abdominal pain 4. Frequent vomiting 5. Pain during defecation

.When a small-bowel obstruction develops, fluid and gas collect proximal to the obstruction, producing rapid onset of nausea and vomiting (Option 4), colicky intermittent abdominal pain (Option 3), and abdominal distension (Option 1). The nurse should recognize symptoms of bowel obstruction quickly as delay could lead to vascular compromise, bowel ischemia, or perforation. Nursing management of an obstruction includes placing the client on NPO status, inserting a nasogastric tube, administering prescribed IV fluids, and instituting pain control measures.

Lithium level (therapeutic)

0.6-1.2 mEq/L

Cranial nerves: "Oh oh oh to touch and feel very good velvet ah" olfactory - smell optic - vision oculomotor - innervates eye muscle trochlear - innervates eye muscle trigeminal - sensory from face; motor to chewing muscles abducens - innervates eye muscle facial - innervates muscle of facial expresion; sensory taste vestibulocochlear - sense of hearing and equilibrium glossopharyngeal - moves tongue and pharynx muscles vagus - innervates visceral smooth muscle accessory - innervates neck muscles hypoglossal- moves tongue

1- sensory 2 - sensory 3 - motor 4 - motor 5 - mixed 6 - motor 7 - mixed 8 - sensory 9 - mixed 10 - mixed 11 - motor 12 - moto

Partial weight bearing

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

Central venous pressure -Measure of right ventricular preload (pressure in the ventricle after filling) -Indicates fluid volume status

2-8 mm Hg

Cardiac index -CO adjusted for body surface area -More precise measure of cardiac function

2.2 - 4.0 L/min

Hemoglobin A1c : Hemoglobin A1C is a diagnostic test used to measure the percentage of glycosylated hemoglobin in the blood over a period of 2-3 months. A normal hemoglobin A1C is 4%-6% in clients without diabetes; the goal is to keep the level <7% in clients with diabetes.

4-6% in non-diabetic, goal is <7% in diabetic The A1C test measures blood glucose control over a period of 2-3 month

Cardiac output -Volume of blood ejected by heart -Indicates cardiac function

4-8L/min

Pulmonary artery wedge pressure -Measure of left ventricular preload -Indicates left-sided heart function

6-12 mm Hg

Mean arterial pressure -Average arterial pressure -Indicates perfusion of organs & tissues MAP = (SBP + [2 × DBP])/3

70-105 mmHg

Systemic vascular resistance -Measure of vascular resistance(eg, vessel dilation or constriction)

800-1200 dynes/sec/cm−5

An elderly client with osteoporosis falls onto an out-stretched hand and injures the wrist. The client has severe wrist edema, deformity, and pain rated a 10 on a pain scale of 0-10. What should be the nurse's firstaction? 1. Administer analgesia 2. Apply an ice pack to the wrist 3. Assess capillary refill and sensation 4. Elevate the wrist above heart level

A Colles' fracture is a type of wrist fracture (distal radius fracture) that causes a characteristic dinner fork deformity of the wrist. It usually occurs when the client tries to break a fall with an outstretched arm or hand, and lands on the heel of the hand. It is one of the most common fractures in women age >50 and is related to osteopenia or osteoporosis. While the client is undergoing evaluation by the health care provider (HCP) in the emergency department (ED), nursing interventions should include: Performing a neurovascular assessment (eg, pulse, temperature, color, capillary refill, sensation, movement). This is the priority nursing action as neurovascular insufficiency related to swelling (eg, compartment syndrome) or arterial/nerve damage by the bone fragments is associated with a Colles' fracture. If neurovascular status is compromised, urgent reduction of the fracture is indicated. Administering analgesia to promote comfort (Option 1). Applying an ice pack to the wrist to help reduce edema and inflammation (Option 2). Elevating the extremity on a pillow above heart level to reduce edema (Option 4). Instructing the client to move the fingers to reduce edema, increase venous return, and help improve range of motion.

RAIU test

A RAIU test involves administering a low dose of radioactive iodine, in contrast to radioactive iodine treatment for some types of thyroid cancer, which uses a high dose to destroy all thyroid tissue. The thyroid gland is the only tissue that uses iodine, which is a key component of thyroid hormones. A scan is performed at 2, 6, and 24 hours to assess the areas actively absorbing iodine, which can narrow the diagnosis to hyperfunctioning thyroid disorders (eg, Graves' disease). Important nursing considerations: Notify the primary health care provider (PHCP) if computerized tomography scan or other recent x-ray using iodine contrast has been performed; the iodine may alter the test results. Antithyroid or thyroid hormone medication should be held for 5-7 days before undergoing a RAIU test as these can also alter results. All premenopausal women must take a pregnancy test before the procedure, as radioactive iodine could adversely affect the development of the fetal thyroid gland. Important aspects of client education: Maintain nothing by mouth (NPO) status for 2-4 hours prior to the procedure (Option 5). Eating may resume 1-2 hours after swallowing the iodine; a normal diet can be restarted when the test ends. Remove dentures and jewelry/metal around the neck to allow clear visualization during the scan. Drink plenty of fluids after the procedure to clear RAI from the system. Notify the PHCP if you are allergic to any medications (eg, iodine). However, a RAIU test is generally safe (even in the presence of an iodine allergy) due to the diminutive amount of iodine used. You will be awake during the procedure but there should be no discomfort (Option 4). Do not breastfeed immediately after this procedure, and ask your PHCP when breastfeeding may resume. Educational objective: RAIU measures the metabolic activity in the thyroid gland in order to differentiate between the many types of thyroid disorders. For an accurate measurement, medications affecting the thyroid should be held 7 days prior to the test date and clients are NPO for 4 hours prior to iodine administration. Premenopausal women must take a pregnancy test. Dentures, metal, and jewelry should be removed.

Following a carotid endarterectomy, the client should be monitored for alterations in mental status that are unexpected in the context of typical postanesthesia symptoms (eg, diminished gag reflex, altered affect, drowsiness). The FAST assessment (Facial drooping, Arm weakness or drift, Speech difficulties, Time) assists with identifying alterations that may indicate stroke.

A carotid endarterectomy is a surgical procedure performed to remove plaque from the carotid artery to improve cerebral perfusion. The nurse must closely assess for signs of new or worsening alterations in neurologic status, as surgical manipulation of arteries and blood flow increases the risk of stroke.

carotid endarterectomy

A carotid endarterectomy is a surgical procedure that removes atherosclerotic plaque from the carotid artery. Clients with carotid artery disease are at increased risk for transient ischemic attack and stroke. Post-surgical risks include cerebral ischemia and infarction as well as bleeding. Blood pressure is closely monitored during the first 24 hours post surgery. Hypertension may strain the surgical site and trigger hematoma formation, which can cause hemorrhage or airway obstruction. Systolic blood pressure is maintained at 100-150 mm Hg to ensure adequate cerebral perfusion and avoidance of hemorrhage or strain. (Option 2) It can take 24-48 hours for peristalsis to return after bowel surgery due to manipulation of the bowels and anesthesia. This client should be monitored for return of bowel function and should be assessed last. (Option 3) Clients with atrial fibrillation may experience tachycardia and irregular heart rhythm even with treatment. This client should be assessed after the client with an endarterectomy. (Option 4) Total parenteral nutrition (TPN) should never be discontinued abruptly (due to the risk for hypoglycemia). This client should be seen third so that TPN is not interrupted. Educational objective: Clients post carotid endarterectomy are at risk for cerebral ischemia and infarction as well as hemorrhage. Systolic blood pressure is maintained at 100-150 mm Hg to ensure adequate cerebral perfusion and reduce the likelihood of hematoma formation or hemorrhage at the surgical site.

The initial plan of care for a client with an acute stroke should include performing baseline neurologic assessment to begin monitoring neurologic status trend, obtaining an immediate CT scan of the head to determine stroke type, and anticipating administration of thrombolytics such as ALTEPLASE (if indicated) within 4.5 hours of symptom onset. Baseline neurologic assessment is essential for tracking ongoing neurologic symptoms that indicate improvement or complications which guide later treatments

A client with stroke symptoms must have an immediate CT scan or MRI of the head to determine the type and location of the stroke (Option 3). Determining exactly when symptoms began is essential for diagnosis and planning treatment. Thrombolytic therapy (eg, alteplase, tissue plasminogen activator [tPA]) is used to dissolve blood clots and restore perfusion to brain tissue in clients with an ischemic stroke unless contraindicated (eg, active bleeding, uncontrolled hypertension, aneurysm). It must be administered within 4.5 hours from onset of sympto. ms

An ischemic stroke is a loss of brain tissue perfusion due to blockage in blood flow. Elevated blood pressure is common and permitted after a stroke and may be a compensatory mechanism to maintain cerebral perfusion distal to the area of blockage. This permissive hypertension usually autocorrects within 24-48 hours and does not require treatment unless the hypertension is extreme (systolic blood pressure >220 mm Hg or diastolic blood pressure >120 mm Hg) or contraindicated due to the presence of another illness requiring strict blood pressure control (eg, active ischemic coronary disease, heart failure, aortic dissection). A blood pressure of 178/95 mm Hg should be monitored, along with the client's other vital signs and status

A client with stroke symptoms must have an immediate CT scan or MRI of the head to determine the type and location of the stroke (Option 3). Determining exactly when symptoms began is essential for diagnosis and planning treatment. Thrombolytic therapy (eg, alteplase, tissue plasminogen activator [tPA]) is used to dissolve blood clots and restore perfusion to brain tissue in clients with an ischemic stroke unless contraindicated (eg, active bleeding, uncontrolled hypertension, aneurysm). It must be administered within 4.5 hours from onset of symptoms

Care for ascending colostomy: Ensure sufficient fluid intake (at least 3,000 mL/day unless contraindicated) to prevent dehydration; identify times to increase fluid requirements (hot weather, increased perspiration, diarrhea). Identify and eliminate foods that cause gas and odor (broccoli, cauliflower, dried beans, brussels sprouts) .Empty the pouch when it becomes one-third full to prevent leaks due to increasing pouch weight.Stool produced in the ascending and transverse colon is semiliquid, which eliminates the need for irrigation. Irrigation to promote a bowel regimen may be useful for descending or sigmoid colostomies as the stool is more formed.

A colostomy is a surgical procedure that creates an opening (stoma) in the abdominal wall for the passage of stool to bypass an obstructed or diseased portion of the colon. Stool drains through the intestinal stoma into a pouch device secured to the skin. Colostomies can be performed on any part of the colon (ascending, transverse, descending, and sigmoid). Depending on the location of the colostomy, characteristics of the stool will vary, with the stool becoming more solid as it passes through the colon.

Coup-contrecoup head injuries are common in motor vehicle accidents and shaken baby syndrome. Damage to the occipital lobe of the brain during coup-contrecoup head injury will result in visual disturbances.

A coup-contrecoup head injury occurs when the head strikes an object and the brain receives an injury under the area of impact (coup), after which it rebounds to the opposite side of the skull and sustains injury on that side as well (contrecoup). This type of injury is common in motor vehicle accidents and shaken baby syndrome. Visual processing occurs in the occipital lobe.

Postoperative care of a client with gastroduodenostomy includes initiation of thromboembolism prophylaxis; turning, coughing, and deep breathing; and aspiration precautions (eg, elevating the head of the bed). The nurse should keep clients NPO until bowel sounds return and should not manipulate clogged nasogastric tubes. Clogged nasogastric tubes should be reported to the surgeon.

A gastroduodenostomy (Billroth I) involves removing the distal two-thirds of the stomach with anastomosis of the remaining stomach to the duodenum. Following partial gastrectomy, clients should remain NPO until bowel sounds return. Once tolerated, consumption of small, frequent meals will help prevent the occurrence of dumping syndrome (ie, rapid emptying of stomach contents into the small intestine). Postoperative clients are at risk for developing venous thromboembolism (VTE) due to reduced mobility levels and require VTE prophylaxis (eg, sequential compression devices, compression hose). Clients are also at risk for hypoventilation and respiratory compromise due to sedation, pain, and immobility. Encourage clients to turn, cough, and deep breathe while splinting the surgical site to prevent development of atelectasis. In the postoperative period, the nurse should elevate the head of the bed to improve ventilation and reduce the risk of aspiration. Only clients who experience dumping syndrome should lay supine for a short period after eating.

Narrow therapeutic index medications have a higher chance of producing adverse effects due to a very small difference between therapeutic and toxic levels. These medications require close monitoring of serum drug levels for adequate, but not toxic, dosing. Clients should also be monitored for signs of toxicity, which are specific to each medication. Phenytoin (Dilantin) is an antiseizure medication with a therapeutic index of 10-20 mcg/mL (40-79 mcmol/L) (Option 1). Tube feedings decrease phenytoin absorption, which reduces serum drug concentrations and may precipitate seizures. The nurse should pause tube feedings for 1-2 hours before and after phenytoin administration to ensure adequate absorption. Phenytoin toxicity produces nystagmus, dysarthria, ataxia, and encephalopathy.

A heart rate of 62/min is expected in a client taking digoxin (therapeutic index 0.5-2.0 ng/mL [0.6-2.6 nmol/L]). Digoxin toxicity produces gastrointestinal symptoms (nausea, vomiting, diarrhea), bradycardia, and visual disturbances (blurred vision, yellow-green halos). The therapeutic INR for a client with a mechanical heart valve is 2.5-3.5. (Option 4) Anorexia is a common side effect of lithium (therapeutic index 0.6-1.2 mEq/L [0.6-1.2 mmol/L]). Lithium toxicity produces nausea, vomiting, ataxia, and tremors.

Normal lymph

A lymph node that is superficial, palpable, small (≤1 cm ), mobile, firm, and nontender is a normal finding.

Ramsay Scale Scoring Sedation

A sedation scale such as the Ramsay Scale is used to assess level of sedation. It is preferable to keep the client minimally sedated (asleep but arousable). This helps decrease the risk of aspiration.

Strokes cause different neurological deficits depending on the location and extent of injury. Cerebellar deficits affect balance and require fall precautions, cranial nerve IX and X injuries can impair swallowing, and a client with homonymous hemianopsia will not see objects on the affected side. Blindness in the same half of each visual field, homonymous hemianopsia, is suspected when clients ignore objects on one side. Initially, the nurse assists (eg, places utensil in unaffected visual field), but the client must learn to turn the head to scan the environment

A stroke affecting cranial nerve VII, the facial nerve, can cause an asymmetrical smile or inability to raise one eyebrow. Increased light is unnecessary as vision is not affected. Clients experiencing receptive aphasia, impaired comprehension of speech and writing, typically have injury to the Wernicke area of the brain, located in the left temporal lobe. The nurse would not speak louder as this does not aid comprehension. The nurse should speak clearly, ask "yes" or "no" questions, and use gestures and pictures to increase understanding.

Metabolic syndrome is the presence of ≥3 metabolic health factors that increase a client's risk for stroke, diabetes mellitus, and cardiovascular disease.

Abdominal obesity: Waist circumference (≥40 inches [102 cm] in men, ≥35 inches [89 cm] in women) High serum triglycerides >150 mg/dL (1.7 mmol/L) or hypertriglyceridemia drug treatment Low levels of high-density lipoprotein (HDL) cholesterol (<40 mg/dL [1.0 mmol/L] in men, <50 mg/dL [1.3 mmol] in women) Hypertension ≥130/85 mm Hg or hypertension drug treatment Fasting blood glucose ≥100 mg/dL (5.6 mmol/L) or hyperglycemia drug treatment

Refeeding syndrome is a potentially lethal complication of nutritional replenishment in significantly malnourished clients and can occur with oral, enteral, or parenteral feedings. After a period of starvation, carbohydrate-rich nutrition (glucose) stimulates insulin production along with a shift of electrolytes from the blood into tissue cells for anabolism. The key signs of refeeding syndrome are rapid declines in phosphorous, potassium, and/or magnesium (mnemonic PPM). Other findings may include fluid overload, sodium retention, hyperglycemia, and thiamine deficiency.

Actions to prevent refeeding syndrome include the following: Obtaining baseline electrolytes Initiating nutrition support cautiously with hypocaloric feedings Closely monitoring electrolytes Increasing caloric intake gradually. Normal ranges for phosphorus (2.4-4.4 mg/dL [0.78-1.42 mmol/L]), potassium (3.5-5.0 mEq/L [3.5-5.0 mmol/L]), and magnesium (1.5-2.5 mEq/L [0.75-1.25 mmol/L]).

Lithium levels should be checked frequently given the narrow therapeutic index (0.6-1.2 mEq/L [0.6-1.2 mmol/L]). A level >1.5 mEq/L (1.5 mmol/L) is considered toxic. Chronic toxicity manifests with neurologic symptoms (eg, confusion, tremor, ataxia) and/or diabetes insipidus (eg, polyuria, polydipsia).

Acute or acute-on-chronic toxicity presents predominantly with gastrointestinal symptoms (eg, nausea, vomiting, diarrhea); neurologic manifestations occur later. However, neurologic manifestations occur early in chronic toxicity. Common neurologic manifestations include ataxia, confusion, or agitation, and neuromuscular excitability (eg, tremor, myoclonic jerks). Chronic toxicity also manifests as diabetes insipidus (eg, polyuria, polydipsia).

Acute urinary retention is best treated with rapid complete bladder decompression. The nurse should carefully assess for hypotension and bradycardia, which are potential complications.

Acute urinary retention is best treated with rapid, complete bladder decompression rather than the intermittent urine drainage that is limited to 500 to 1000 mL at a time. Rapid decompression can be associated with hematuria, hypotension, and postobstructive diuresis. However, these are rarely clinically significant if appropriate supportive care is administered, whereas inability to relieve the obstruction can be associated with infection and kidney injury

Scarlet fever (ie, scarlatina), a complication of group A streptococcal infection (eg, streptococcal pharyngitis), is common in early childhood and is characterized by a distinctive red rash. The rash begins on the neck and chest and spreads to the extremities, resembles a bad sunburn, blanches with pressure, and has fine bumps like sandpaper.

Additional manifestations of streptococcal pharyngitis (eg, exudative pharyngitis, fever, swollen anterior cervical lymph nodes) are typically present. Because the clinical presentation (ie, rash plus sore throat) is characteristic, but not diagnostic, of scarlet fever, the health care provider will prescribe a rapid streptococcal antigen test to confirm symptom etiology

SVT adenosine (vagal maneuver first if possible)

Adenosine is the drug of choice to treat SVT and has a 5- to 6-second half-life (the time it takes for the drug to be reduced to half of its original concentration). Placing the IV line as close as possible, not distal, to the heart is essential for the drug to have full effect. Adenosine is given rapidly over 1-2 seconds and then followed by a rapid 20-mL normal saline flush. Transient asystole is common, and clients often experience flushing and dizziness.

Risks associated with suctioning include hypoxemia, microatelectasis, and cardiac dysrhythmias. Suctioning removes secretions and oxygen. To minimize both the amount of oxygen removed and mucosal trauma, suctioning is applied when removing not inserting, the catheter into the artificial airway. If secretions are thick and difficult to remove, increasing hydration, not suctioning time, is indicated.

Aerosols of sterile normal salineor mucolytics such as acetylcysteine (Mucomyst) administered by nebulizer can also be used to thin the thick secretions, but water should not be used. Aerosol therapy may induce bronchospasm in certain individuals and can be relieved by use of a bronchodilator (albuterol).

Following a needlestick injury, the nurse's immediate actions should be to remove their gloves and thoroughly wash the affected area with soap and water. Exposure should be reported to the nurse's supervisor and the facility exposure hotline as soon as possible to facilitate the evaluation process. The nurse should then seek evaluation and treatment from the employee health clinic or emergency department. Blood should be drawn for baseline testing, and postexposure prophylaxis will be given based on the risk of exposure. Postexposure prophylaxis for HIV infection is most effective when given within two hours of an exposure incident.

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

Ziprasidone hydrochloride (Geodon) is an atypical antipsychotic drug that is used for acute bipolar mania, acute psychosis, and agitation. Its use carries a risk for QT prolongation leading to torsade de pointes. A baseline electrocardiogram and potassium are usually checked. At a minimum, the client should be placed on a cardiac monitor. The client should also be monitored for hypotension and seizures, especially if the previous medical history is not known or obtainable. The risk for adverse effects is increased with the interaction of alcohol.

After ziprasidone hydrochloride administration, clients should be monitored for cardiac effects (including prolonged QT interval), hypotension, and/or seizure activity. Alcohol interacts with ziprasidone and increases the potential for an adverse effect from the drug.

The nurse is teaching about cervical cancer prevention during a women's health conference. Which of the following factors should be taught as risks for cervical cancer? Select all that apply. 1. Human immunodeficiency virus (HIV) 2. Human papillomavirus (HPV) 3. Multiple sexual partners 4. Nulliparity 5. Sexual activity before age 18

Almost all cases of cervical cancer result from persistent infection due to human papillomavirus (HPV), a primary risk factor (Option 2). HPV is the most common sexually transmitted infection but is usually transient and resolves spontaneously. However, persistent HPV infection can cause abnormal changes in cervical epithelial tissue that slowly progress to invasive cancer if not treated. Most other risk factors for cervical cancer are related to behaviors that increase the client's risk of contracting HPV or an inability to clear the infection. Clients who have multiple sexual partners or initiate sexual activity at an early age (<18) increase their risk for exposure to HPV (Options 3 and 5). Clients with weakened immunity (eg, HIV, immunosuppressive therapy) may have an impaired ability to clear HPV, which increases the risk for cervical cancer due to persistent infection (Option 1). (Option 4) Nulliparity (ie, no previous pregnancies) is not a risk factor for cervical cancer; however, it is a risk factor for breast cancer.

Human papillomavirus is the most common sexually transmitted infection and is a primary risk factor for cervical cancer. Other cervical cancer risk factors include sexual activity at an early age (age <18), multiple sexual partners, and weakened immune system function (eg, HIV infection).

Almost all cases of cervical cancer result from persistent infection due to human papillomavirus (HPV), a primary risk factor . HPV is the most common sexually transmitted infection but is usually transient and resolves spontaneously. However, persistent HPV infection can cause abnormal changes in cervical epithelial tissue that slowly progress to invasive cancer if not treated.

Terazosin is an alpha-adrenergic blocker that can relieve urinary retention in clients with BPH. It relaxes the smooth muscle in the bladder neck and prostate gland; however, it also relaxes smooth muscle in the peripheral vasculature, which can cause orthostatic hypotension, syncope (blacking out), and falls. This is particularly common when the drug is started (first-dose hypotension) or when the dosage is increased. The serious effects can be avoided by instructing the client to take the medication at bedtime, change positions slowly when going from lying to standing, and avoid any medications that also increase smooth muscle relaxation (eg, phosphodiesterase-5 inhibitors [sildenafil or vardenafil] used to treat erectile dysfunction). Some clients may also experience ejaculatory dysfunction (decreased or absent ejaculation) .Grapefruit juice can cause significant interactions with drugs such as calcium channel blockers and sildenafil. However, it does not appear to interact with alpha blockers such as terazosin.

Alpha-1-adrenergic antagonists (eg, terazosin, doxazosin, tamsulosin, alfuzosin) should be taken at bedtime, not in the morning, to avoid orthostatic hypotension.

ALS

Amyotrophic lateral sclerosis (ALS, Lou Gehrig disease) is a debilitating neurodegenerative disease with no cure. ALS causes progressive degeneration of motor neurons in the brain and spinal cord. Physical symptoms include fatigue, progressive muscle weakness, twitching and muscle spasms, difficulty swallowing, difficulty speaking, and respiratory failure (Options 2, 3, and 4). Most clients survive only 3-5 years after the diagnosis as there is no cure. Treatment focuses on symptom management. Interventions include: Respiratory support with noninvasive positive pressure (eg, bilevel positive airway pressure [BiPAP]) or invasive mechanical ventilation (eg, via tracheostomy) Feeding tube for enteral nutrition Medications to decrease symptoms (eg, spasms, uncontrolled secretions, dyspnea) Mobility assistive devices (eg, walker, wheelchair) Communication assistive devices (eg, alphabet boards, specialized computers) (Option 1) Constipation due to decreased mobility is more common in ALS. Diarrhea is not seen. (Option 5) Resting tremor is characteristic of parkinsonism. Educational objective: Amyotrophic lateral sclerosis causes motor neuron degeneration that leads to progressive muscle weakness, twitching and muscle spasms, difficulty swallowing, difficulty speaking, and respiratory failure. There is no cure. Treatment focuses on symptom management.

Atropine

An anticholinergic drug, such as atropine, is used for treatment in a cholinergic crisis (eg, the medication is too high or there is excess acetylcholine). The need would not be anticipated during a myasthenic crisis (eg, exacerbation of myasthenia gravis), which is usually a result of too little medication related to noncompliance, illness, or surgery.

The emergency nurse is triaging clients. Which report is most concerning and would be given priority for definitive diagnosis and care? 1. Abrupt, tearing, moving (upper to lower) back pain and epigastric pain 2. Severe lower back pain after lifting heavy boxes 3. Sharp calf ache with ambulation that improves with rest 4. Unilateral leg swelling with 2+ pitting edema after an airplane trip

An aortic dissection occurs when the arterial wall intimal layer tears and allows blood between the inner (intima) and middle (media) layers. Clients with ascending aortic dissections typically have chest pain, which can radiate to the back. Descending aortic dissection is more likely associated with back pain and abdominal pain. It is frequently abrupt in onset and described as "worst ever," "tearing," or "ripping" pain. Hypertension is a contributing factor. Extending dissection from uncontrolled hypertension can cause cardiac tamponade or arterial rupture, which is rapidly fatal. Emergency treatment includes surgery and/or lowering the blood pressure. (Option 2) Severe lower back pain after lifting heavy boxes is likely due to disc herniation. Some clients may report radiculopathy pain radiating down the leg below the knee. While uncomfortable, this is not life-threatening. (Option 3) This is a description of intermittent claudication in the lower extremity due to peripheral artery disease. It is an ischemic muscle pain (due to the buildup of lactic acid from anaerobic metabolism) related to exercise that resolves with rest. (Option 4) This is a description of a deep venous thrombosis (DVT) resulting from immobility during a flight. The embolization of DVT can cause life-threatening pulmonary embolism; the client with aortic dissection already has a life-threatening condition. Educational objective: An aortic dissection, which classically includes moving, "ripping" back pain, is a medical emergency. Hypertension is the most important contributing factor.

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.

Clients with diabetes mellitus should be monitored for signs of hypoglycemia (eg, shakiness, sweating, pallor, alterations in mental status). Conscious clients experiencing hypoglycemia should receive a snack of 15 g of a quick-acting carbohydrate.

An emergency glucagon IM injection is indicated if the client is somnolent, unconscious, seizing, or unable to swallow.

The nurse is providing nutritional teaching for a client with a new ileostomy. Which foods should the nurse instruct the client to avoid? Select all that apply. 1. Bananas 2. Broccoli with cheese 3. Multigrain bagel 4. Popcorn 5. Spaghetti with sauce

An ileostomy is a surgically created opening (stoma) in the abdominal wall that connects the small intestine to the external abdomen. Stool from the small intestine bypasses the colon and exits through the ileostomy. Functions of the colon (eg, fluid and electrolyte absorption, vitamin K production) do not occur, resulting in liquid stool that drains into an external ostomy appliance attached to the skin. In the immediate postoperative period of an ileostomy, a low-residue diet (low-fiber) is prescribed to prevent obstruction of the narrow lumen of the small intestine and stoma (1-in [2.54-cm] diameter or less). After the ileostomy heals, the client reintroduces fibrous foods one at a time. The client is instructed to thoroughly chew food and monitor for changes in stool output. Foods to be avoided include: High fiber: popcorn, coconut, brown rice, multigrain bread (Options 3 and 4) Stringy vegetables: celery, broccoli, asparagus (Option 2) Seeds or pits: strawberries, raspberries, olives Edible peels: apple slices, cucumber, dried fruit (Option 1) After an ileostomy, a client may consume fruits and vegetables that are pitted, peeled, and/or cooked (eg, peaches, bananas, potatoes). (Option 5) Low-fiber carbohydrate options include white rice, refined grains, and pasta.

An underage client whose parents or guardians cannot be contacted and who needs emergency care should receive all necessary medical care until a parent or guardian can be reached to provide consent.

An unaccompanied minor should be treated if the medical condition is an emergency and should be assessed and stabilized. This client clearly has a medical need and could suffer consequences if not treated. In this scenario, care should be rendered and then explained later to the parent or guardian. This approach is supported by the ethical principles of beneficence and nonmaleficence. In addition, underage clients may consent in certain circumstances without parental consent. These circumstances usually include treatment for substance abuse problems, psychiatric disorders, or sexual transmitted diseases.

A client suffering from chronic kidney disease is scheduled to receive recombinant human erythropoietin and iron sucrose. The client's hemoglobin is 9.7 g/dL (97 g/L) and hematocrit is 29% (0.29). What is the appropriate nursing action? 1. Administer the erythropoietin in the client's ventrogluteal muscle[42%] 2. Check blood pressure prior to administering the erythropoietin[39%] 3. Hold the client's next scheduled iron sucrose dose[3%] 4. Hold the erythropoietin and inform the health care provider[15%]

Anemia associated with chronic kidney disease is treated with recombinant human erythropoietin (Epogen/Procrit, epoetin). Therapy is initiated when hemoglobin is <10 g/dL (100 g/L) to alleviate the symptoms of anemia (eg, fatigue) and the need for blood transfusions. Therapy should be discontinued or the dose reduced for hemoglobin >11 g/dL (110 g/L) to prevent venous thromboembolism and adverse cardiovascular outcomes from blood thickened by high concentrations of RBCs. Hypertension is a major adverse effect of erythropoietin administration. Therefore, uncontrolled hypertension is a contraindication to recombinant erythropoietin therapy. Blood pressure should be well controlled prior to administering erythropoietin (Option 2). (Option 1) Erythropoietin is administered intravenously or in any subcutaneous area (not intramuscularly). (Option 3) Iron in the form of iron sucrose (Venofer) or ferric gluconate (Ferrlecit) may be prescribed to promote an adequate response to erythropoietin. Adequate stores of iron, vitamin B12, and folic acid are required for the erythropoietin to work. (Option 4) The dose should be held if the client has a hemoglobin level >11 g/dL (110 g/L) or uncontrolled hypertension. Educational objective: Anemia of chronic kidney disease is treated with recombinant human erythropoietin for hemoglobin <10 g/dL (100 g/L). Hemoglobin levels >11 g/dL (110 g/L) are associated with thromboembolic and cardiovascular events. Uncontrolled hypertension is a contraindication to recombinant human erythropoietin therapy.

Ringworm, or tinea corporis, is a fungal infection on the superficial keratin layers of the skin, hair, and/or nails.

Antifungal cream (terbinafine [Lamisil]) is the preferred treatment and is applied to infected areas twice a day. It may take 1-4 weeks to complete treatment depending on infection severity.

Prasugrel (Effient)

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 the 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 the 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).

Varicella-zoster virus (VZV) infection (chickenpox) is characterized by lesions that begin as a maculopapular rash, progress to weeping vesicular lesions, and typically crust over within approximately 1 week. The lesions are often pruritic and/or painful, and clients frequently have an accompanying fever. In most cases, treatment is supportive in nature and includes: Cool oatmeal baths and topical antihistamines (eg, diphenhydramine) applied to lesions for itching. Acetaminophen as needed for fever or pain. Immunocompromised clients (eg, clients with acute myelogenous leukemia [AML]) are at risk for severe varicella (eg, disseminated, pneumonia) and require aggressive therapy, including an antiviral agent (eg, acyclovir).

Antiviral therapy should be continued until all the lesions have crusted over. VZV is spread via airborne and contact transmission. Clients are most infectious in the days leading up to the rash and continue to be infectious until the entire rash reaches the crusting stage.Immunocompromised clients should not receive live attenuated vaccines (eg, varicella virus vaccine). In addition, the vaccine is not indicated for a client who has already developed immunity after recovering from VZV infection.

The facial nerve, cranial nerve VII, is tested by assessing exaggerated facial movements. The client is directed to raise the eyebrows, furrow the eyebrows, draw up the cheeks in a large smile, pull the cheeks down in a frown, and open the lips to show the teeth.

Any asymmetrical movements are documented, and if unexpected, the health care provider is notified.

The nurse is caring for a client on a mechanical ventilator. The settings on the ventilator have just been changed, and the standing prescription is to draw arterial blood gases 30 minutes after a ventilator change. In anticipation of this blood draw, what intervention should the nurse implement? 1. Avoid suctioning the client [36%] 2. Pre-oxygenate the client [21%] 3. Raise the head of the bed [31%] 4. Reduce the amount of sedation medication [11%]

Arterial blood gases (ABGs) indicate the acid-base balance in the body and how well oxygen is being carried to the tissues. It is common to measure ABGs after a ventilator change to assess how well the client has tolerated it. Factors such as changes in the client's activity level or oxygen settings, or suctioning within 20 minutes prior to the blood draw can cause inaccurate results. Unless the client's condition dictates otherwise, the nurse should avoid suctioning as it will deplete the client's oxygen level and cause inaccurate test results.

Malignant hyperthermia (MH) is a rare and life-threatening condition precipitated by certain medications used for anesthesia, including inhaled anesthetics (eg, desflurane, isoflurane, halothane) and succinylcholine. (MH s/sx are tachypnea, tachycardia, and a rigid jaw or generalized rigidity)

As the condition progresses, the client develops a high fever. Muscle tissue is broken down, leading to hyperkalemia, cardiac dysrhythmias, and myoglobinuria.MH requires emergent treatment with IV dantrolene to reverse the process by slowing metabolism. Succinylcholine should be discontinued. Other interventions include applying cooling blankets to reduce temperature and treating high potassium levels.

When administering IV vancomycin, the nurse should assess for and work to prevent possible complications by performing the following: Draw the prescribed trough level prior to administration. Therapeutic vancomycin levels range from 10-20 mg/L (6.9-13.8 µmol/L) for hemodynamically stable clients. Adverse effects of vancomycin toxicity include nephrotoxicity (eg, elevated creatinine levels) and ototoxicity (eg, hearing loss, vertigo, tinnitus). Infuse medication over at least 60 minutes (≤10 mg/min). Faster rates increase the likelihood of complications. Monitor blood pressure during the infusion. Hypotension is a possible adverse effect (Option 4)

Assess for hypersensitivity. Red man syndrome is a nonallergic histamine reaction characterized by sudden onset of severe hypotension, flushing, and/or maculopapular rash of the face, neck, chest, and upper extremities .Monitor for anaphylaxis (eg, rash, pruritus, laryngeal edema, wheezing). Observe IV site every 30 minutes for pain, redness, or swelling. Vancomycin is a vesicant and may cause thrombophlebitis or, if extravasation occurs, tissue necrosis. Administration using a central venous catheter is preferred; however, a peripheral IV may be used for short-term therapy

Following a thyroidectomy, place the client in semi-Fowler position with a neutral head and neck position. Keep a tracheostomy kit, suction, and oxygen at the bedside in case airway compromise develops. Monitor frequently for signs of hypocalcemia and changes in voice strength and quality.

Assessing for and immediately reporting signs of hypocalcemia (eg, facial or extremity numbness or tingling, stridor, Trousseau and Chvostek signs), which may occur from parathyroid gland trauma during surgery. Assessing for stridor and new or worsening changes in voice strength and quality(eg, hoarseness, whispering), which may indicate laryngeal nerve damage that can result in respiratory arrest

Prevent aspiration critically ill

Assessing gastric residual volumes and level of sedation at regular intervals, checking enteral feeding tube placement, and administering continual rather than bolus tube feeding are interventions that help prevent aspiration in critically ill high-risk clients.

Pertussis can occur despite vaccination. Characteristic features include a cough lasting ≥2 weeks with ≥1 of the following: paroxysms of cough, inspiratory whooping sound, and posttussive vomiting. Clients need oral antibiotics, droplet precautions (no negative pressure) , no cough suppressant and supportive measures (humidified oxygen and oral fluids). Vaccination against whooping cough is available, but some individuals will still develop the disease, although in a milder form.

At first, symptoms similar to the common cold and a mild fever occur, but eventually these clients develop a characteristic violent, spasmodic cough. Coughing is so severe that the person is forced to inhale afterward, resulting in a distinctive, high-pitched "whooping" sound. Coughing episodes may continue until a thick mucus plug is expectorated and are sometimes followed by vomiting (posttussive emesis).

The "death rattle" is a loud rattling sound with breathing that occurs in a client who is actively dying. When the client cannot manage airway secretions, the movement of these secretions during breathing causes a noisy rattling sound. This can distress family and friends at the bedside of the dying client. The "death rattle" can be treated using anticholinergic medications to dry the client's secretions. Medications include atropine drops administered sublingually or a transdermal scopolamine patch.

Atropine is also used to stimulate the sinoatrial node in bradycardia with systemic symptoms. An electrocardiogram (ECG) should be obtained prior to administering atropine. In this client, there is no evidence of a cardiac etiology or systemic symptoms of poor perfusion/circulation from the bradycardia.

An AFB sputum culture and smear test are performed to detect the presence of M. tuberculosis and confirm a diagnosis of TB. The QuantiFERON-TB blood test is performed to screen for TB and can be used as an alternate to the TST. The advantages it offers include the following: there are fewer false-positive results, only a single client visit is required, and results are available in 24 hours. However, it is more expensive.

Bacteriologic testing is performed in clients with suspected TB disease to confirm the diagnosis. A stained sputum smear is examined microscopically for the presence of Mycobacterium tuberculosis (tubercle bacillus), and a culture identifies the growth of the microorganisms. Collect an early morning sputum sterile specimen on 3 consecutive days for an acid-fast bacilli (AFB) smear and culture. Fluids and expectorants can be given at bedtime to help liquefy secretions. It is usually easier for clients to produce a specimen upon awakening as secretions collect in the airways during the night.

Lithium, a mood stabilizer commonly prescribed for clients with mania, has a narrow therapeutic range. Clients with conditions that increase serum lithium levels (eg, dehydration, hyponatremia, severe renal dysfunction) are at increased risk for toxicity (>1.5 mEq/L [1.5 mmol/L]).

Because lithium has a narrow therapeutic range (eg, 0.6-1.2 mEq/L [0.6-1.2 mmol/L]), serum levels should be monitored regularly (eg, following dose changes) to prevent toxicity (>1.5 mEq/L [1.5 mmol/L]). Lithium is excreted through the kidneys. To prevent toxicity the nurse should hold doses and clarify prescriptions for clients who have: Conditions/illnesses in which the kidneys try to conserve sodium (eg, hyponatremia, dehydration) as sodium and lithium are absorbed in proximal tubules simultaneously

A client is diagnosed with right-sided Bell's palsy. What instructions should the nurse give this client for care at home? Select all that apply. 1. Apply a patch to the right eye at night 2. Avoid driving 3. Chew on the left side 4. Maintain meticulous oral hygiene 5. Use a cane on the left side

Bell's palsy is an inflammation of cranial nerve VII (facial) that causes motor and sensory alterations. Clients are usually managed as outpatients, with corticosteroids to reduce inflammation, and taught eye/oral care. In Bell's palsy, the eyelids do not close properly. This may result in eye dryness and risk of corneal abrasions. However, weakness of the lower eyelid may cause excessive tearing due to overflow in some clients. Facial muscle weakness results in poor chewing and food retention. Client teaching should include the following: Eye care: Use glasses during the day; wear a patch (or tape the eyelids) at night to protect the exposed eye. Use artificial tears during the day as needed to prevent excess drying of the cornea (Option 1). Oral care: Chew on the unaffected side to prevent food trapping; a soft diet is recommended. Maintain good oral hygiene after every meal to prevent problems from accumulated residual food (eg, parotitis, dental caries) (Options 3 and 4). (Options 2 and 5) Vision, balance, consciousness, and extremity motor function are not impaired with Bell's palsy.

(TURP) today and has a 3-way Foley urinary catheter with continuous bladder irrigation (CBI). Causes of postoperative pain from TURP with a CBI include a kinked blocked catheter, bladder spasms, and general postoperative pain. The nurse should ensure first that urinary flow is intact prior to treating the pain with analgesics.

Blood and mucus can obstruct the Foley catheter if the CBI is not infused at a sufficient rate. Bladder pain will result from distention if the flow is obstructed. The nurse should ensure that there is adequate urinary drainage and no blockage from blood clots before treating the pain. If the urinary flow is obstructed, manual irrigation with sterile normal saline should be performed until there are no clots or the urine is clear/pink. (Options 1 and 2) Belladonna-opium suppositories or antispasmodics (eg, oxybutynin) are used for bladder spasms, an expected complication of the TURP procedure. Clients should be instructed not to urinate around the catheter as this would increase bladder pressure and spasms. Narcotics can be used for postoperative pain.

Bupropion (Wellbutrin, Zyban) and varenicline (Chantix, Champix) are commonly prescribed for smoking cessation.

Both bupropion and varenicline can cause serious neuropsychiatric effects (eg, depression, suicide); however, there is no contraindication for clients with emphysema.

Caregivers for clients with Alzheimer disease should communicate with the client using yes-or-no questions and simple, step-by-step instructions; treat the client as an adult; limit the number of choices; and allow plenty of time for task completion. Agitated clients can be redirected with new activities (eg, going for a walk). Do not try to rationalize with the client. Use visual cues when giving directions. Interact with the client as an adult, even as the client regresses to childlike affect and behavior; respect client dignity by avoiding use of pet names (eg, "honey," "sweetie," "darling").

Break down complex activities into steps with simple instructions. Decrease the client's anxiety by limiting the number of choices. Allow plenty of time for task completion. The client cannot process information rapidly, and hurrying or rushing can cause agitation or anxiety. Ask questions that can be answered with yes, no, or very few words. Do not ask open-ended questions, which can overwhelm the client and cause increased stress and frustration.

Immediately following a thoracotomy, chest tube drainage (50-500 mL for the first 24 hours) is expected to be sanguineous (bright red) for several hours and then change to serosanguineous (pink) followed by serous (yellow) over a period of a few days. A rush of dark bloody drainage from the chest tube when the client was turned following a period of minimal drainage is most likely related to retained blood due to a partial blockage in the tube. Bright red drainage indicates active bleeding and would be of immediate concern.

Bright red drainage indicates active bleeding and would be of immediate concern. (Option 2) The chest tube should not be clamped because it is placed to drain the fluid leaking after surgery. (Option 3) The nurse would notify the health care provider immediately of bright red drainage or continued increased drainage (>100 mL/hr) and of changes in the client's vital signs and cardiovascular status that could indicate bleeding (eg, hypotension, tachycardia, tachypnea, decreased capillary refill, cool and pale skin). This is not the appropriate action. (Option 4) It would be appropriate to request repeat serum hematocrit and hemoglobin levels if active bleeding is suspected, but the postoperative levels are stable at this time. This is not the appropriate action.

C. difficile

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.

11 month old exposed to measles 2 days ago

CDC) recommends that the first dose of MMR vaccine be given to children between age 12-15 months to ensure optimal vaccine response. However, the vaccine is safe for children age <12 months; it could provide some protection or modify the clinical course of the disease if administered within 72 hours of the child's initial measles exposure. Immunoglobulin, if administered within 6 days of exposure, is also utilized as post-exposure prophylaxis. A child who receives the MMR vaccine prior to the first birthday will need to be revaccinated at age 12-15 months and again between age 4-6 years. -fever is one of the first emerging signs- After receiving the MMR vaccine, the child can be around other children. - If the child does not receive the MMR vaccine, exposure to other children would not be advised. - fever and rash are 2 of the clinical signs of measles, the measles incubation period is 7-21 days. The clinical indicators of measles would not be seen only 2 days after exposure.

Carpal tunnel wrist immobilization

Carpal tunnel syndrome (CTS) is pain and paresthesia of the hand caused by median nerve compression within the carpal tunnel at the wrist. Nerve compression can occur due to inflammation of the tendons; narrowing or compression of the carpal tunnel; or wrist flexion or extension. Symptoms of CTS are often exacerbated during sleep due to prolonged and unintentional wrist flexion. Most clients with CTS can conservatively manage symptoms with wrist immobilization splints (Option 4). Splinting and immobilization of the wrist (particularly during sleep) reduces pain by preventing flexion or extension and subsequent nerve compression. Clients with CTS may require surgery to permanently relieve symptoms. (Options 1 and 3) Instructing clients to perform repetitive hand exercises or wear elastic compression hose could worsen symptoms of CTS by increasing median nerve compression. (Option 2) Although educating clients to avoid tobacco and caffeinated products is appropriate to improve general health, avoidance of such substances does not impact symptoms of CTS. Educational objective: Carpal tunnel syndrome (CTS) is pain and paresthesia of the hand caused by compression of a median nerve within the carpal tunnel of the wrist. Clients with CTS are taught to wear wrist immobilization splints, particularly at night, to prevent wrist flexion and subsequent nerve compression to reduce symptoms.

VAP is an HAI that usually occurs within ≥2-3 days after the initiation of mechanical ventilation.

Characteristic manifestations of VAP include purulent secretions, positive sputum culture, leukocytosis, elevated temperature, and new or progressive pulmonary infiltrates on chest x-ray.

Children can have strokes. Ischemic strokes are more common in children with sickle cell disease. Other causes can include carotid abnormalities/dissection. The most common presentation of an ischemic stroke is the sudden onset of numbness or weakness of an arm and/or leg. These are handled with a similar emergent approach as for stroke in an adult. Children may require exchange blood transfusion to prevent the stroke from worsening.

Children can have strokes. These usually are caused by clotting or vascular issues and require similar emergent care as adults. Desmopressin (DDAVP) is used to treat hemophilia.

Fifth disease ("slapped face," or erythema infectiosum) is a viral illness caused by the human parvovirus and affects mainly school-age children. The virus spreads via respiratory secretions, and the period of communicability occurs before onset of symptoms. The child will have a distinctive red rash on the cheeks that gives the appearance of having been slapped. The rash spreads to the extremities and a maculopapular rash develops, which then progresses from the proximal to distal surfaces. The child may have general malaise and joint pain that are typically well controlled with nonsteroidal anti-inflammatory drugs such as ibuprofen. Affected children typically recover quickly, within 7-10 days. Once these children develop symptoms (eg, rash, joint pains), they are no longer infectious. Isolation is not usually required unless the child is hospitalized with aplastic crisis or immunocompromising condition.

Children with fifth disease are communicable only prior to onset of symptoms (eg, rash, joint pains). The causative agent, human parvovirus, spreads via respiratory secretions. Fifth disease is self-limiting and short-lived; treatment is given to alleviate symptoms. Isolation is not usually required for a non-hospitalized child.

A client with cirrhosis may experience pruritus (itching) due to buildup of bile salts beneath the skin. Clients with cirrhosis are also at an increased risk for skin breakdown due to the development of edema, which increases skin fragility and impedes wound healing, and the loss of muscle and fat tissue from pressure points (eg, heels, sacrum). The nurse encourages the client to cut the nails short, wear cotton gloves, and wear long-sleeved shirts to avoid injury to the skin from scratching (Options 2 and 5). Other comfort measures include baking soda baths; calamine lotion; and cool, wet cloths, which cool and soothe irritated skin (Options 1 and 4).

Cholestyramine (Questran) may be prescribed to increase the excretion of bile salts in feces, thereby decreasing pruritus. It is packaged in powdered form, must be mixed with food (applesauce) or juice (apple juice), and should be given 1 hour after all other medications. (Option 3) Temperature extremes (eg, hot baths/showers) may intensify pruritus. The nurse should instruct the client to bathe with tepid water until the pruritus has subsided.

Clamping a chest tube

Clamping the chest tube during transport is contraindicated. Doing so can cause air to accumulate in the pleural cavity as it has no means of escape. This can lead to the development of a tension pneumothorax, a potentially life-threatening condition. A tension pneumothorax results in compression of the unaffected lung and pressure on the heart and great vessels. As the pressure increases, venous return is decreased and cardiac output falls. (Option 2) The wall suction needs to be temporarily disconnected during transport. It should be reconnected promptly at the destination. (Option 3) The chest tube collection unit should be hung below the level of the chest to promote drainage and keep fluids from re-entering the chest cavity. (Option 4) All connections should be secured with tape to prevent accidental disconnection or air to enter the system. Educational objective: Chest tubes should not be clamped during transport of a client. A clamped chest tube may cause a tension pneumothorax, a potentially life-threatening event.

Following lung surgery, a chest tube is inserted into the pleural space to create a negative vacuum to re-inflate the lung and prevent air from re-entering the space. A client with a chest tube should be assessed for signs of air/fluid in the chest (eg, diminished breath sounds), excessive drainage (>100 mL/hr), pain, and infection at the drainage site. The collection chamber should be inspected every hour for the first 8 hours following surgery, then every 8 hours until it is removed. Excess drainage of frank red blood is indicative of hemorrhage and must be managed immediately. The priority action is to contact the health care provider for further management.

Clamping the chest tube prevents air or fluid from leaving the pleural space, which may cause a reciprocal tension pneumothorax. The chest tube is clamped only a few hours prior to removal, momentarily to check for an air leak, or if the drainage apparatus needs to be changed. Although a pulse oximetry of 92% is low, this is an expected finding following lung surgery. (Option 3) Pain following surgery is a concern and the client will require medication; however, hemorrhage is the priority.

When caring for an unconscious client during admission, the nurse should assess for medical alert devices and any prescriptive materials (eg, medication patches, contact lenses). The nurse should remove personal belongings and foreign objects that could harm the client if not removed (eg, tampons, rings/jewelry).

Clients are often prescribed transdermal patches for chronic conditions (eg, clonidine for hypertension, nitroglycerin for angina). Removing and discarding a medication patch without additional information may harm the client.

Dumping syndrome (rapid emptying of hypertonic gastric contents) -Small/frequent meals - Replace simple sugars with complex carbohydrates - Incorporate high-fiber & protein-rich foods - lay flat after eating Symptoms Abdominal pain, diarrhea, nausea Hypotension/tachycardia Dizziness/confusion, fatigue, diaphoresis

Clients should avoid consuming fluids with meals, which causes stomach contents to pass faster into the jejunum and worsens symptoms. Fluid intake should occur at least 30 minutes before/after meal An upright or sitting position increases the force of gravity, which increases the rate of gastric emptying.

Belladonna-opium suppositories or antispasmodics (eg, oxybutynin) are used for bladder spasms, an expected complication of the TURP procedure

Clients should be instructed not to urinate around the catheter as this would increase bladder pressure and spasms. Narcotics can be used for postoperative pain. If the urinary flow is adequate, a description of the pain would help to determine whether to give the client a narcotic or an antispasmodic. Before treating the resulting pain, the possibility of a physiological etiology for procedure-related pain (eg, blockage of urinary flow from blood clots) should be ruled out first.

Clients who follow a vegan diet eat only plant-based foods, omitting animal proteins (eg, meat, poultry, fish) and products (eg, dairy, eggs). Clients who are vegan are at risk for deficiency of vitamin B12 (cobalamin), which is primarily supplied by animal products. Chronic vitamin B12deficiency may precipitate megaloblastic anemia and neurological symptoms across the entire nervous system, from peripheral nerves to the spinal cord and brain. Manifestations of chronic deficiency include: Peripheral neuropathy (eg, tingling, numbness) (Option 4) Neuromuscular impairment (eg, gait problems, poor balance) Memory loss/dementia (in cases of severe/prolonged deficiencies)

Clients who follow a vegan diet are encouraged to take supplemental vitamin B12 to prevent severe neurological complications. In addition, clients are taught to incorporate vitamin B12-fortified foods (eg, cereals, grain products, soy and nut milks, meat substitutes). (Options 1, 2, and 3) Visual disturbances, difficulty sleeping, and scaly patches of skin are likely not complications of a nutritional deficiency related to a vegan diet.

Clients with acute pancreatitis are at risk for pancreatic abscess development. This mainly results from secondary infection of pancreatic pseudocysts or pancreatic necrosis. High fever, leukocytosis, and increasing abdominal pain may indicate abscess formation. The abscess must be treated promptly to prevent sepsis. The health care provider should be notified immediately as antibiotic therapy and immediate surgical management may be required.Elevated blood glucose is an expected finding in clients with pancreatitis. Elevated blood glucose is associated with pancreatic dysfunction and may necessitate insulin administration, but this is not the most concerning finding.

Clients with acute pancreatitis often report severe, burning midepigastric abdominal pain that radiates to the back. Clients may seek relief from pain by positioning themselves in the knee-chest position, which decreases intra-abdominal pressure. Pain relief interventions should be attempted, but this is not the priority. The client with pancreatitis may develop steatorrhea (eg, fatty, yellow, foul-smelling stools) due to a decrease in lipase production. Although fluid and nutritional status are important, this does not take precedence over a possible surgical emergency.

Unless otherwise indicated by the health care provider, antihypertensives and other blood pressure-lowering medications (eg, furosemide), antibiotics, digoxin, and water-soluble vitamins (B, C, and folic acid) should be held prior to dialysis. Vitamin E is a fat-soluble vitamin that is not affected by dialysis. It is given to some clients to prevent leg cramps that can be experienced by dialysis clients. Lispro is a fast-acting insulin that should be given 15-30 minutes before meals. It is appropriate to give scheduled lispro with breakfast prior to dialysis.

Clients with chronic kidney disease have high phosphorus levels as the kidney is unable to filter the phosphate from the body; dialysis also does not filter it. Therefore, the client should still take phosphate binders prior to dialysis. Phosphate binders (eg, calcium containing [calcium carbonate and calcium acetate]) and non-calcium containing [sevelamer and lanthanum]) block absorption of ingested phosphate from the intestine and excrete it through feces.

Damage to the frontal lobe of the brain may cause Broca (expressive) aphasia. Clients with this condition demonstrate effortful and sensible speech characterized by short, limited sentences, with retained ability to comprehend speech. This impairment often causes clients with Broca aphasia to be frustrated when speaking.

Clients with damage to the temporal portion of the brain may develop Wernicke (fluent) aphasia (ie, the inability to comprehend the spoken and/or written word) and exhibit a long, but meaningless, speech pattern.

Congenital hypothyroidism occurs when abnormal development of the thyroid gland causes complete or decreased secretion of thyroid hormone (TH). Untreated hypothyroidism can cause severe intellectual disability in infants if undetected. Screening occurs after birth for all infants in the United States and Canada to prevent disability and encourage early treatment (ie, levothyroxine). TH plays an important role in growth, development, and regulation of many bodily functions (eg, heat production, muscle tone, skin function, cardiac function, metabolism). Expect: Lethargy Enlarged fontanelle Protruding tongue Umbilical hernia Poor feeding Constipation Dry skin Jaundice

Clinical manifestations in affected infants reflect the pathophysiology of decreased TH and may include: Difficulty awakening, lethargy, or hyporeflexia due to alterations in central nervous system function (Option 1) Dry skin due to alterations in skin function (Option 2) Hoarse cry caused by swelling of the vocal cords due to fluid retention (Option 4) Constipation due to slowed metabolism Bradycardia due to the effect of TH on cardiac function

PE : pleuritic chest pain, dyspnea, hypoxemia, tachypnea, cough, tachycardia, and unilateral leg swelling.

Clinical manifestations of PE range from mild (eg, anxiety, cough) to severe (eg, heart failure, sudden death). However, many clients initially have mild, nonspecific symptoms that are often misdiagnosed and inadequately managed, greatly increasing the likelihood of progression to shock and/or cardiac arrest. Clinical manifestations of PE include: Pleuritic chest pain (ie, sharp lung pain while inhaling) Dyspnea and hypoxemia Tachypnea and cough (eg, dry or productive cough with bloody sputum) Tachycardia Unilateral leg swelling, erythema, or tenderness related to deep vein thrombosis Tachycardia, rather than bradycardia, is expected with PE because the heart attempts to compensate for hypoxemia, right ventricular overfilling, and decreased left ventricular cardiac output.

Systemic inflammatory response syndrome (SIRS) is a pathophysiologic response mediated by the release of large quantities of inflammatory cytokines from the inflammatory cascade. Overwhelming release of inflammatory cytokines triggers vasodilation and capillary leakage, leading to hypotension and impaired end-organ perfusion. SIRS may occur in response to trauma, tissue ischemia, infection (ie, sepsis), and shock and can rapidly progress to hemodynamic instability, respiratory failure, and multi-organ dysfunction.

Clinical manifestations of SIRS include fever or hypothermia, tachycardia, leukocytosis or leukopenia, and tachypnea (often associated with a low PaCO2 value). Clients who develop multiple symptoms of SIRS require aggressive fluid resuscitation and treatment to address possible causes (eg, antibiotics for infection) as SIRS may be life-threatening

Clopidogrel (Plavix) is a platelet aggregation inhibitor used to prevent blood clot formation in clients with recent myocardial infarction, acute coronary syndrome, cardiac stents, stroke, or peripheral vascular disease. Because it can cause thrombocytopenia and increase the risk for bleeding, the nurse should notify the health care provider(HCP) of the low platelet count (normal: 150,000-400,000/mm3 [150-400 × 109/L]) before administering clopidogrel.

Clopidogrel (Plavix) can cause thrombocytopenia (platelet count <150,000/mm3 [150 × 109/L]) and increase a client's risk for bleeding.

Tamoxifen is a selective estrogen receptor modulator that is prescribed to treat certain types of breast cancer and to prevent breast cancer recurrence. Tamoxifen works by blocking estrogen receptors in certain estrogen-sensitive tissues (eg, breast, vagina), but it also increases affinity for estrogen in some tissues, such as the uterus. In the treatment of breast cancer, tamoxifen inhibits growth of estrogen receptor-positive tumors. Clients typically take tamoxifen for several (eg, 5-10) years after treatment to prevent breast cancer recurrence. Can increase cholesterol and triglyceride

Common side effects of tamoxifen therapy, like the effects typically seen in menopause (eg, hot flashes, vaginal dryness, menstrual irregularities), are related to decreased estrogen. Follow-up would be required for clients with symptoms or a history of tamoxifen's most serious side effects, including: Thromboembolic events (eg, deep venous thrombosis, pulmonary embolism, stroke). Endometrial cancer (eg, abnormal vaginal bleeding). Shellfish and peanut allergies, previous smoking history, and history of depression are not contraindications for treatment with tamoxifen.

Isocarboxazid Phenelzine Tranylcypromine

Commonly used monoamine oxidase inhibitors (MAOIs) include isocarboxazid, phenelzine, and tranylcypromine. These first-generation antidepressants are used only for resistant depression due to serious adverse affects. These medications inhibit the enzyme that breaks up norepinephrine, serotonin, and dopamine, thereby increasing their availability in the body. Clients taking MAOIs or other antidepressants are at increased risk for suicidal ideation, particularly children, adolescents, and young adults. The risk of suicidal thoughts can be more prevalent when starting the medication or with dose increases. Feelings of hopelessness or despair must be evaluated to assess if suicidal ideation or thoughts of self-harm are present *take MORNING * nausea, constipation are adverse effects *avoid cheese, overripe fruit, liquor, beef/chicken liver, fermented products

Prostatitis is inflammation of the prostate gland, usually caused by a bacterial infection. Symptoms include rectogenital pain, burning, urinary hesitancy, and/or urinary urgency. Management of prostatitis includes antimicrobial and anti-inflammatory medications (eg, ibuprofen). Alpha-adrenergic blockers (eg, tamsulosin, alfuzosin) help relax the bladder and prostate. Suprapubic catheterization may be necessary for urinary retention in severe cases of acute prostatitis. Urethral catheterization is contraindicated due to the risk of exacerbating pain and urethral inflammation. Hydrate with clear liquids (eg, water, fruit juices). Avoid coffee, tea, and other caffeinated beverages due to diuretic and stimulant properties, which may worsen symptoms (Option 2).

Complete the full course of antibiotics regardless of symptom improvement to ensure infection resolution (Option 3). Engage in sexual intercourse or masturbation to reduce discomfort related to retained prostatic fluid. Clients should use a barrier prophylactic method (eg, condoms) when engaging in sexual activity with a partner to prevent transmission of the causative organism (Option 1). Take stool softeners as prescribed to reduce straining during defecation; tension of the pubic muscles presses against the prostate, causing pain (Option 4). Take sitz baths, in which the hips and buttocks are immersed in warm water, to help relieve symptom

Theophylline plasma concentrations >20 mcg/mL (111 µmol/L) are associated with theophylline drug toxicity. Seizures (central nervous system stimulation) and cardiac arrhythmias are the most serious and lethal consequences. Symptoms of toxicity usually manifest as central nervous system stimulation (eg, headache, insomnia, seizures), gastrointestinal disturbances (eg, nausea, vomiting), and cardiac toxicity (eg, arrhythmia).

Conditions associated with chronic toxicity include advanced age (>60), drug interactions (eg, alcohol, macrolide and quinolone antibiotics), and liver disease. Acute toxicity is associated with intentional or accidental overdose.

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

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

Knee arthroplasty is the surgical replacement of the knee joint. Following a knee arthroplasty, the nurse should avoid placing a pillow behind the client's operative knee due to the risk of contracture. Proper postoperative care includes applying intermittent cold packs to reduce pain and edema, using a continual passive motion device for flexibility, and obtaining a leg immobilizer for joint stability during ambulation. Applying a leg immobilizer during ambulation provides support, maintains alignment, and prevents dislocation of unstable operative joints.

Contracture of the operative joint is a serious complication of knee arthroplasty that impairs the client's mobility. To prevent contracture formation, the nurse should maintain the operative knee in an extended position with a knee immobilizer or pillow placed under the lower leg or heel. Placing a pillow behind the knee causes joint flexion, which increases the risk of contracture Cold packs may be applied intermittently over the operative joint to reduce postoperative swelling and pain. Using a continual passive motion device, if prescribed, may improve range of motion through knee flexion and extension and prevent contractures.

Neurologic injury is the most common cause of mortality in clients who have had cardiac arrest, particularly ventricular fibrillation or pulseless ventricular tachycardia. Inducing therapeutic hypothermia in these clients within 6 hours of arrest and maintaining it for 24 hours has been shown to decrease mortality rates and improve neurologic outcomes. It is indicated in all clients who are comatose or do not follow commands after resuscitation.The client is cooled to 89.6-93.2 F (32-34 C) for 24 hours before rewarming.

Cooling is accomplished by cooling blankets; ice placed in the groin, axillae, and sides of the neck; and cold IV fluids. The nurse must closely assess the cardiac monitor (bradycardia is common), core body temperature, blood pressure (mean arterial pressure to be kept >80 mm Hg), and skin for thermal injury. The nurse must also apply neuroprotective strategies such as keeping the head of the bed elevated to 30 degrees. After 24 hours, the client is slowly rewarmed.

The oculomotor (cranial nerve III), trochlear (cranial nerve IV), and abducens (cranial nerve VI) are motor nerves of the eye that are tested by having the client track an object, such as a finger, through the fields of vision. The oculomotor nerve is also tested by checking for pupillary constriction and accommodation (constriction with near vision). Deficits in cranial nerves III, IV, and VI can include disconjugate gaze (eyes do not move together), nystagmus (fine, rapid jerking eye movements), or ptosis (drooping of the eyelid).

Cranial nerve II is the optic nerve and a sensory nerve. This nerve is assessed by testing the fields of vision for the client's ability to see objects in the field. In contrast to cranial nerves III, IV, and VI, the client does not track the object in the fields of vision, but instead keeps the eyes fixed and uses the peripheral vision to recognize objects or deficits in the field of vision. Cranial nerve V is the trigeminal nerve. The sensory portion of this nerve is assessed by testing sensation at the ophthalmic (forehead), maxillary (cheekbone), and mandibular (jaw line) branches by light touch. Corneal sensation is also a portion of the trigeminal nerve, but this is typically not tested by the nurse.

cranial nerve IX

Cranial nerve IX (glossopharyngeal) is involved in the gag reflex, ability to swallow, phonation, and taste. Postoperative partial laryngectomy clients will need to undergo evaluation by a speech pathologist to evaluate their ability to swallow safely to prevent aspiration. Clients are taught the supraglottic swallow, a technique that allows them to have voluntary control over closing the vocal cords to protect themselves from aspiration. Clients are instructed to: Inhale deeply Hold breath tightly to close the vocal cords Place food in mouth and swallow while continuing to hold breath Cough to dispel remaining food from vocal cords Swallow a second time before breathing (Option 1) This would be considered "passing the buck." The nurse should try to address the client's concerns before calling the health care provider. (Option 2) Cranial nerve VIII (vestibulocochlear) affects hearing and equilibrium, not swallowing. (Option 3) The speech pathologist conducts a swallowing assessment early on to evaluate a client's ability to swallow safely. This consult is not done at discharge. Educational objective: Clients who undergo a partial laryngectomy are at increased risk for aspiration. As a result, they are taught a swallowing technique (supraglottic swallow) to decrease this risk.

Further clarification is required: Cyclobenzaprine for muscle spasms in a client with hepatitis. Like many medications, skeletal muscle relaxants (eg, cyclobenzaprine) are metabolized hepatically. In the presence of hepatic impairment (eg, hepatitis), drug metabolism is reduced and results in the accumulation of medication in the body, which leads to toxicity and serious adverse effects.

Cyclobenzaprine (Flexeril) is a common, centrally acting skeletal muscle relaxant prescribed for muscle spasticity, muscle rigidity, and acute or chronic muscle pain/injury. Centrally acting muscle relaxants interfere with reflexes within the central nervous system (CNS) to decrease muscle spasm and rigidity. Like many medications, muscle relaxants are metabolized by the liver.

Central diabetes insipidus results from head trauma.

Damage to the hypothalamus or pituitary gland leads to decreased antidiuretic hormone secretion, resulting in increased serum osmolality (>295 mOsmol/kg [295 mmol/kg]). Treatment is necessary, but polyuria (>200 mL/hr) and hypernatremia (sodium >145 mEq/L [145 mmol/L]) due to dehydration are expected manifestations.

Death from PE

Death from pulmonary embolism is often attributed to a missed diagnosis. Early identification of risk factors (eg, venous stasis, hypercoagulability of blood, endothelial damage) can have a positive effect on client outcome. This postoperative client is at greatest risk due to the presence of the following 4 risk factors: Abdominal cesarean section surgery (endothelial damage) Engorged pelvic vessels from pregnancy (venous stasis, hypercoagulability of blood) Inactivity/immobility ≥6 hours related to positioning during surgery and the immediate postoperative period and epidural anesthesia (venous stasis) Postpartum state (hypercoagulability of blood) (Option 2) In atrial fibrillation, stasis and turbulence of blood increases risk of thrombus formation. Once mobilized, emboli can get trapped in blood vessels causing ischemia. Smaller vasculature and increased blood flow in the brain increases the probability of a stroke, rather than PE. This client has 1 risk factor and is not at greatest risk for PE. (Option 3) The presence of a subdural hematoma does not pose a significant risk for PE unless the client has been immobile. Many clients with subdural hematomas are asymptomatic and walking. This client is not at greatest risk for PE. (Option 4) Any acute medical illness (eg, pneumonia) can predispose a client to PE from inflammation and the client's relative immobility. However, this risk is lower than the risk for PE from major surgery. Educational objective: Death from pulmonary embolism (PE) is often attributed to a missed diagnosis. Nurses must recognize any condition or situation that predisposes a client to venous stasis, hypercoagulability of blood, and endothelial damage, as these factors increase the risk for PE.

Alzheimer disease (AD) is a form of dementia that causes progressive decline of cognitive and physical abilities. The nurse should educate the client/caregiver to prepare for current and future safety needs. Interventions evolve to meet client needs at each stage of disease progression. Safety promotion for the client with moderate AD includes: Keyed deadbolts (with keys removed) and close supervision to provide a controlled environment for wandering (Option 3) Medical identification/location devices (eg, bracelets, shoe inserts) in case the client wanders outside the designated area (Option 2)

Decreased water heater temperature and "hot" and "cold" labels on faucets to prevent burns Household hazards (eg, gas appliances, rugs, toxic chemicals) removed to prevent injury (Option 5) Grab bars installed in showers and tubs (Option 1) (Option 4) All medications should be out of the client's reach or locked away. A confused person may not remember the day of the week and take more or less medication than prescribed.

Scarlet Fever Etiology Streptococcus pyogenes Clinical features Fever & pharyngitis Tonsillar erythema & exudates Strawberry tongue Tender anterior cervical nodes Sandpaper rash Rash on the neck and chest Bad sunburn-look

Diagnosis Rapid streptococcal antigen test Throat culture Treatment Penicillin (eg, amoxicillin)

Management of acute diverticulitis focuses on bowel rest (NPO status, NG suction, bed rest), and drug therapy (IV antibiotics, analgesics). Any procedure or treatment that increases intraabdominal pressure or may cause rupture of the inflamed diverticula should be avoided. Acute care for diverticulitis focuses on allowing the colon to rest and the inflammation to resolve. This includes the following: IV antibiotic therapy - to cover the gram-negative and anaerobic organisms that reside in the colon and contribute to diverticulitis; these commonly include metronidazole (Flagyl) plus trimethoprim/sulfamethoxazole (TMZ) (Bactrim or Bactrim DS; Septra) or ciprofloxacin (Cipro) (Option 1)

Diverticular disease of the colon occurs when saclike protrusions form in the large intestine. When diverticula become infected and inflamed, the client has diverticulitis. NPO status - more acute cases require complete rest of the bowel (NPO status); less severe cases may be handled at home, and clients may tolerate a low-fiber or clear liquid diet (Option 3) NG suction - in severe cases of abdominal distention, nausea, or vomiting (Option 2) IV fluids - prevent dehydration Bed rest (Option 4) Any procedure or treatment that increases intraabdominal pressure (lifting, straining, coughing, bending), increases peristalsis (laxative, enema), or could lead to perforation or rupture of the inflamed diverticula should be avoided during the acute disease process. A barium enema may be used after treatment with antibiotics and the inflammation is resolved. Diagnostic examinations, such as abdominal x-rays or CT scans, may be used without risking rupture.

St. john's wort for depression and insomnia

Drug interactions: Antidepressants (serotonin syndrome), OCs, anticoagulants (↓ INR), digoxin Hypertensive crisis

NPH insulin is an intermediate-acting insulin that peaks in 4-12 hours and duration of 8-12 hrs. In asymptomatic clients, the best intervention to prevent low blood glucose levels related to an evening dose of NPH is to consume a bedtime snack of protein and complex carbohydrates.

Due to its long peak, hypoglycemia (blood glucose <70 mg/dL [<3.9 mmol/L]) can result from use of NPH, especially because the overnight hours (during sleep) typically represent the longest interval between meals. To prevent hypoglycemia related to an evening dose of NPH, the client should eat a bedtime snack consisting of protein and complex carbohydrates (eg, cereal with milk, crackers with peanut butter)

Weakness of the shoulder muscle occurs with impairment of CN XI, the spinal accessory nerve. Impairment of visual acuity occurs with disorders affecting CN II (optic).

Dysphagia may occur with impairment of CN IX (glossopharyngeal) and CN X (vagus), Instructing the client to tuck the chin while eating is a technique for those who have difficulty swallowing.

age 50 screening colonoscopy

Early signs of colorectal cancer are usually nonspecific and include fatigue, weight loss, anemia, and occult gastrointestinal bleeding. Clients should have regular screening colonoscopy for colon cancer starting at age 50 if their risk is average or earlier if their risk is high. Colorectal screening can also include fecal occult blood test or fecal immunochemical test annually. New-onset anemia should be taken seriously at this client's age, and colon cancer must be ruled out. The etiology of anemia must be determined prior to recommending treatment. (Options 1 and 2) The cause of anemia must be determined before recommendations can be provided for iron deficiency. There are many causes of anemia (including pernicious anemia) in older adults that involve deficiencies in vitamin B12, not iron. (Option 4) Waiting for 6 months will delay care. Educational objective: The etiology of new-onset anemia in an adult should be determined prior to treatment. Clients age ≥50 should be screened for colorectal cancer. Early signs include anemia.

Fall prevention

Educational objective: Many falls in the home can be prevented by exercising regularly, getting regular vision exams, maintaining a well-lit, clutter-free environment, using grab bars in the bathroom, periodically reviewing medications and side effects with a pharmacist and/or HCP, and wearing an electronic fall alert device.

Clients in ventricular tachycardia (VT) can be pulseless or have a pulse. Treatment is based on this important initial assessment. VT with a pulse should be further assessed for clinical stability or instability. Signs of instability include hypotension, altered mental status, signs of shock, chest pain, and acute heart failure. The unstable client in VT with a pulse is treated with synchronized cardioversion. The stable client in VT with a pulse is treated with antiarrhythmic medications (eg, amiodarone, procainamide, sotalol). (Option 2) Oxygen saturation should be assessed after the presence of a pulse has been established. (Options 3 and 4) CPR and defibrillation should be initiated only in a client who is pulseless.

Educational objective:The client in VT must be assessed for the presence or absence of a pulse before further assessment or treatment is initiated. The unstable (hypotensive) client in VT with a pulse is treated with synchronized cardioversion.

Acute pancreatitis, a potentially life-threatening complication, can occur following an endoscopic retrograde cholangiopancreatography. Manifestations include acute abdominal pain, often radiating to the back, and a rise in pancreatic enzymes (eg, amylase, lipase).

Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure in which an endoscope is passed through the mouth into the duodenum to assess the pancreatic and biliary ducts. Using fluoroscopy with contrast media, the ducts can be visualized and treatments including removal of obstructions, dilation of strictures, and biopsies can be performed. Perforation or irritation of these areas during the procedure can cause acute pancreatitis, a potentially life-threatening complication after an ERCP.

A sharp object that pierces the skin and lodges in the body may result in penetrating trauma to nearby tissue and organs. Common types of impaled (embedded) objects include bullets or blast fragments from firearms as well as sharp objects such as scissors, nails, or knives. The embedded object creates a puncture wound and then controls potential bleeding by putting pressure on the wound. First responders should not manipulate or remove the impaled object. Manipulation or removal may cause further trauma and bleeding; therefore, stabilization of the object is the first priority to prevent it from moving during initial client assessment and later during transport to a health care facility where skilled trauma care is available.

Exception to the rule: First responders (EMS providers) may remove the impaled object if it obstructs the airway and prevents effective cardiopulmonary resuscitation. An IV line may be inserted and fluids begun on scene after stabilization of the object and initial assessment. Blood may be drawn after stabilization of the object and initial assessment. (Option 3) Clothing may be removed on scene after stabilization of the object and initial assessment.

A sprain is a stretch and/or tear of a ligament. Treatment for a sprained ankle includes: Rest - Activity should be stopped and movement limited for 24-48 hours to promote healing. The health care provider may prescribe no weight-bearing on the joint for 48 hours, and crutches may be required. Ice (cold, cryotherapy) - Cold therapy or an ice pack should be applied for 10-15 minutes every hour for the first 24-48 hours. Vasoconstriction helps to reduce pain, inflammation, and swelling. Ice should not be applied directly to the skin. Compression (eg, ACE wrap, splint) - Pressure/compression can help prevent edema and promote fluid return (Option 6). Elevation - The extremity should be kept elevated above the heart on pillows for 24-48 hours to help reduce swelling by promoting fluid return (Option 3). Analgesia - Mild analgesia with a nonsteroidal anti-inflammatory drug (eg, ibuprofen) can be taken every 6 hours as needed to relieve pain and reduce swelling (Option 5).

Exercise rehabilitation program - This should be initiated as soon as possible after the injury (ie, when pain subsides) to restore range of motion, flexibility, and strength and prevent reinjury (Option 2). (Option 1) Cold therapy or ice should be used initially; after the first 24-48 hours, moist heat can be applied for 20-30 minutes at a time to reduce swelling, with a cooldown between applications. (Option 4) Rest is indicated during the acute injury phase (24-48 hours). After this acute phase, the client is encouraged to use the extremity and move the joint to improve circulation and reduce swelling as long as the joint is protected with some type of immobilizer (eg, brace, tape, splint).

Medications such as duloxetine, pregabalin, and amitriptyline have neuropathic pain-relieving effects. They are commonly used for treating pain associated with diabetic neuropathy and FM. Duloxetine is particularly effective for treating both depression and pain. Duloxetine (Cymbalta) is a serotonin-norepinephrine reuptake inhibitor that has both antidepressant and pain-relieving effects. It is used to relieve chronic pain that interferes with normal sleep patterns in clients with FM. With the restoration of normal sleep patterns, fatigue often improves as well

Fibromyalgia (FM) results from abnormal central nervous system pain transmission and processing. It is characterized by chronic, bilateral musculoskeletal axial pain (above and below the waist), multiple tender points, fatigue, and sleep/cognitive disturbances.

Clients with one-sided weakness or injury, increased joint pressure, or poor balance can use a cane to provide support and stability when walking. Cane length should equal the distance from the client's greater trochanter to the floor as incorrect cane length can cause back injury. A cane measured from the waist would be too long to provide optimal support. Teaching points to assist a client in appropriate use of a cane include: Hold the cane on the stronger side to provide maximum support and body alignment, keeping the elbow slightly flexed (20-30 degrees). Place the cane 6"-10" (15-25 cm) in front of and to the side of the foot to keep the body weight on both legs to provide balance.

For maximum stability, move the weaker leg forward to the level of the cane, so that body weight is divided between the cane and the stronger leg. If minimal support is needed, the cane and weaker leg are advanced forward at the same time. Move the stronger leg forward past the cane and the weaker leg, so the weight is divided between the cane and the weaker leg. Always keep at least 2 points of support on the floor at all times.

Bubbling in suction chamber

Gentle, continuous bubbling in the suction control chamber (section A) of a chest tube drainage unit indicates that suction is present and the unit is functioning appropriately. The nurse should document the finding and continue to monitor. (Option 1) Subcutaneous emphysema is air that has leaked into the tissue surrounding the chest tube insertion site. A crackling sensation is felt when palpating the skin. It does not affect bubbling within the chest tube drainage unit. (Option 2) An air leak would cause bubbling in the air leak gauge (section C) or water seal chamber not in the suction control chamber. (Option 4) Turning down the wall suction would effectively negate the presence of suction in the chest tube drainage unit. Educational objective: Gentle, continuous bubbling in the suction control chamber of a chest tube drainage unit indicates the presence of suction in the system and is an expected finding.

Following a motor vehicle crash, the nurse stops to help a victim who has a laceration with spurting blood. The nurse giving reasonable assistance could be held liable despite Good Samaritan laws in which situations? Select all that apply. 1. The nurse accepts money from the victim 2. The nurse does not accompany the victim on the ambulance 3. The nurse does not apply direct pressure to the artery 4. The nurse knows the victim from college 5. The victim dies after reaching the hospital

Good Samaritan laws prevent civil action against nurses who stop of their own accord (eg, not part of their job duties) to help injured individuals after an accident. The nurse cannot receive payment for any care given (Option 1). It is essential for the nurse to perform in the same manner as any reasonable and prudent medical professional would in the same or similar circumstances. A reasonable, prudent nurse would apply pressure to help control an arterial bleed (Option 3).

Gout

Gout is an inflammatory condition caused by ineffective metabolism of purines, which causes uric acid accumulation in the blood. Uric acid crystals typically form in the joints. Kidney stones can also develop, increasing the risk of kidney damage. Clients with medical risk factors (eg, obesity, hypertension, dyslipidemia, insulin resistance) and other lifestyle factors (eg, poor diet, alcohol consumption, sedentary lifestyle) have increased risk for future gout attacks. Improvements in uric acid control are often seen when weight loss is accompanied by dietary modifications (Option 1). Suggested modifications include: Increasing fluid intake (2 L/day) to help eliminate excess uric acid (Option 3) Implementing a low-purine diet, particularly avoiding organ meats (eg, liver, kidney, brain) and certain seafood (eg, sardines, shellfish) Limiting alcohol intake, especially beer (Option 5) Following a healthy, low-fat diet, as excess dietary fats impair urinary excretion of urates (Option 2) It is unpalatable and impractical to avoid all foods containing protein. The risk of developing gout increases with high dietary purine intake but not necessarily with protein intake. Low-fat dairy products are good sources of protein that are associated with a reduced risk of gout. (Option 4) Increasing intake of meat, especially organ meats, will not prevent future gout attacks but may precipitate them. Educational objective: Weight loss and dietary modifications may reduce the frequency of acute episodes of gout. These strategies include increasing fluids, limiting daily alcohol consumption, and avoiding organ meats and seafood to reduce purine load.

ephedra: tx of cold and flu, weight loss and improved athletic performance

HTN, arrhythmia, MI, sudden death, stroke, seizure

licorice for stomach ulcers, bronchitis/viral infections

HTN, hypokalemia

abnormal lymph node

Hard and fixed nodes are most concerning as they are likely due to malignancy. Tender nodes usually indicate inflammation/infection.

Hepatic encephalopathy is a serious complication of end-stage liver disease caused by high levels of ammonia in the blood. Assessment findings include confusion, lethargy, and asterixis; coma and death can occur if this condition remains untreated. Pharmacologic treatments include lactulose and antibiotics (eg, rifaximin). The client with worsening encephalopathy is not stable enough for discharge. *Cautious in diabetic pts, it could raise BG

Hepatic encephalopathy is a serious complication of end-stage liver disease (ESLD) that results from inadequate detoxification of ammonia from the blood. Symptoms include lethargy, confusion, and slurred speech; coma can occur if this condition remains untreated. Asterixis, or a flapping tremor of the hands when the arms are extended with the hands facing forward, may also be noted in the client with encephalopathy.

The transmission of hepatitis A occurs most commonly through the fecal-oral route through poor hand hygiene and improper food handling by infected persons. It is seen primarily in developing countries. After infection, the hepatitis A virus reproduces in the liver and is secreted in bile. Therefore, hand hygiene (especially after toileting and before meals) is the most important intervention to reduce the occurrence of hepatitis A infection. Vaccination against hepatitis A is recommended for all children at age 1 and for adults at risk of contracting the virus (health care workers, men who have sex with men, drug users, those who travel to areas with a high prevalence, those with clotting disorders, and those with liver disease).

Hepatitis A is secreted in bile and is more often transmitted via the fecal-oral route. However, the virus can also be spread through needle sharing between intravenous drug users and unsafe sexual practices. These practices should be discouraged and hand hygiene encouraged as the most important intervention for prevention.

Dark-colored urine and yellow skin can indicate the presence of hepatotoxicity, which is associated with many drugs used to treat tuberculosis (eg, isoniazid, pyrazinamide, rifampin).

However, hepatotoxicity is not common with ethambutol.

Vancomycin is a very potent antibiotic that can cause nephrotoxicity and ototoxicity. Measuring for serum concentrations is a way to monitor for risk of nephrotoxicity as well as for therapeutic response. Trough serum vancomycin concentrations are the most accurate and practical method for monitoring efficacy. A trough should be obtained just prior (about 15-30 minutes) to administration of the next dose. (Option 1) Unlike some chemotherapy medications, vancomycin does not commonly cause nausea or vomiting. Premedication with antiemetics is not required..

However, premedication with antihistamines (diphenhydramine) is recommended if the client had developed red man syndrome, also known as red neck syndrome, with prior vancomycin infusion. This syndrome is characterized by red blotching of the face, neck, and chest due to too rapid administration. Vancomycin should be administered over a minimum of 60 minutes. Too rapid administration can cause red man syndrome, considered a toxic effect rather than an allergic reaction. The nurse would want to verify patency of the IV line prior to administration as thrombophlebitis is a possibility with vancomycin; however, a new IV line is not necessarily required

Albuterol (Proventil) is a short-acting inhaled beta-2 agonist used to control airway obstruction caused by chronic obstructive pulmonary disease, asthma, or bronchitis. It also is used to prevent exercise-induced asthma. The therapeutic effect is relaxation of the smooth muscles of the airways, which results in immediate bronchodilation. Bronchodilation decreases airway resistance, facilitates mucus drainage (expectorates mucus plugs), decreases the work of breathing, and increases oxygenation. As a result of these actions, the respiratory rate will decrease and peak flow will be increased (if tested).

However, short-acting beta-2 agonists are associated with the following side effects (not therapeutic effects): tremor (most frequent), tachycardia and palpitations, restlessness, and hypokalemia. These side effects are due to the oral deposition of medication (subsequent systemic absorption) and can be reduced with the use of a spacer or chamber device.

Hydroxychloroquine (Plaquenil) is used to treat the skin and arthritic manifestations of SLE. Taking the medication with food can help alleviate gastrointestinal upset. Serious adverse drug reactions include retinopathy and visual disturbances; therefore, regular ophthalmologic examination every 6-12 months is required.

Hydroxychloroquine can also help to reduce lupus exacerbations in clients with inactive to mild disease, but several months can pass before its therapeutic effects become apparent. Some clients with severe SLE are prescribed long-term corticosteroid (prednisone) therapy to prevent organ damage and are at risk for adverse reactions, such as accelerated osteoporosis. Osteoporosis is not an adverse reaction of hydroxychloroquine, and vitamin D and calcium supplementation is not required.

Cephalosporin HAIRY

Hyperglycemic Anaphylactic shock if allergic Insufficient platelet (thrombocytopenia) Renal problem if they are allergic Yellow poop (diarrhea)

65-year-old client with end-stage renal disease comes to the emergency department after missing 5 hemodialysis sessions. Serum potassium level is 7.5 mEq/L (7.5 mmol/L) and ECG shows tall, peaked T waves. Which prescription will immediately protect the client from experiencing dysrhythmias associated with hyperkalemia? 1. Intravenous calcium gluconate[28%] 2. Intravenous regular insulin with dextrose[45%] 3. Oral sodium polystyrene sulfonate[15%] 4. Transport to hemodialysis unit[10%]

Hyperkalemia can be asymptomatic but may cause fatigue, generalized weakness, or in severe cases muscle paralysis and/or dysrhythmias. Management includes preventing life-threatening dysrhythmias and correcting serum potassium levels. Intravenous calcium gluconate is administered to hyperkalemic clients with ECG changes (eg, peaked T waves). Calcium gluconate itself does not decrease the serum potassium level but temporarily stabilizes the myocardium by raising the threshold for dysrhythmia occurrence. Once the nurse stabilizes the client by administering calcium gluconate, other prescriptions may then be implemented to decrease serum potassium level (eg, intravenous regular insulin with dextrose, sodium polystyrene sulfonate, hemodialysis) (Option 1). (Option 2) Intravenous regular insulin temporarily corrects hyperkalemia by shifting potassium into the cells. Dextrose is administered concurrently to prevent hypoglycemia. Although intravenous regular insulin will effectively decrease serum potassium levels, calcium gluconate will provide immediate protection from dysrhythmias. (Option 3) Sodium polystyrene sulfonate causes excretion of potassium from the body via the gastrointestinal tract. Although this will effectively decrease serum potassium levels, calcium gluconate will provide immediate protection from dysrhythmias. (Option 4) Although hemodialysis will effectively decrease serum potassium levels, calcium gluconate will provide immediate protection from dysrhythmias. Educational objective: The priority in treatment of hyperkalemia with ECG changes (eg, peaked T waves) is administration of intravenous calcium gluconate to prevent life-threatening dysrhythmias. Once calcium gluconate is administered, prescriptions to correct serum potassium (eg, intravenous regular insulin with dextrose, sodium polystyrene sulfonate, hemodialysis) may be implemented.

Glycoprotein (GP) IIb/IIIa receptor inhibitors are (eg, abciximab, eptifibatide, tirofiban) used as platelet inhibitors to prevent the occlusion of treated coronary arteries during percutaneous coronary intervention procedures and prevent acute ischemic complications. GP IIb/IIIa receptor inhibitors can cause serious bleeding. The nurse should closely monitor the client for any bleeding at the groin puncture site after the percutaneous coronary intervention. he nurse should check the client's baseline complete blood count (eg, hemoglobin, platelet count). Some clients may develop serious thrombocytopenia within a few hours, further increasing the bleeding risk

Hypotension, tachycardia, changes in heart rhythm, blood in the urine, abdominal/back pain, mental status changes, and black tarry stools may also indicate internal bleeding and should be monitored carefully when GP IIb/IIIa receptor inhibitors are administered. During and after the infusion of GP IIb/IIIa receptor inhibitors, no traumatic procedures (initiation of IV sites, intramuscular injections) should be performed unless absolutely necessary due to the risk of bleeding.

Glycoprotein IIb/IIIa receptor inhibitors (eg, abciximab, eptifibatide, tirofiban) inhibit platelet aggregation and increase bleeding risk. Serious thrombocytopenia can occur within few hours, further increasing bleeding risk. After administration, the nurse should monitor the client's blood counts, blood pressure, and heart rate and rhythm, as well as watch for signs of bleeding.

Hypotension, tachycardia, changes in heart rhythm, blood in the urine, abdominal/back pain, mental status changes, and black tarry stools may also indicate internal bleeding and should be monitored carefully when GP IIb/IIIa receptor inhibitors are administered. No traumatic procedures (initiation of IV sites, intramuscular injections) should be performed unless absolutely necessary

Hypovolemic shock

Hypovolemic shock, the most common type of shock, occurs when blood volume decreases through hemorrhage or movement of fluid from the intravascular compartment into the interstitial space (third-spacing). Treatment involves preventing additional fluid loss, restoring volume through IV fluids, and improving hemodynamic stability through vasoactive medications (eg, norepinephrine, dopamine). Norepinephrine causes vasoconstriction and improves heart contractility/output, but the effects end quickly. It should be tapered slowly and cautiously to avoid the progression or relapse of shock. (Option 1) Oxygen via facemask is used to improve tissue oxygenation during shock. With improvement, it would be appropriate to wean the client to a nasal cannula. This client has an oxygen saturation of 99%; therefore, weaning is appropriate. (Option 3) Postponing antibiotics would be a greater concern if the client were in septic, rather than hypovolemic, shock. It is more important to confirm that norepinephrine is available to ensure hemodynamic stability. (Option 4) 0.45% normal saline (½ NS) is a hypotonic fluid that decreases circulatory volume. Clients in hypovolemic shock require isotonic solutions (eg, 0.9% NS, lactated Ringer) to increase circulatory volume. Infusion of ½ NS is more appropriate for a client with hypertonic dehydration (eg, excessive perspiration). Educational objective:Hypovolemic shock occurs when blood volume decreases via hemorrhage or third-spacing. Stopping the source of blood loss, increasing blood volume through IV fluids, and improving blood pressure with vasoactive medications are the first steps in treating this condition. Abruptly discontinuing vasoactive medications can cause hemodynamic instability; these medications should always be tapered slowly. Additional Information Physiological Adaptation NCSBN Client Need

erythropoietin administered not IM

IV , SUBQ

Shrugging the shoulders against resistance (as well as turning the head against resistance) is a test for cranial nerve (CN) XI (spinal accessory).

Identify the number 8 traced on the palm. This is a test of sensory function, specifically fine touch (graphesthesia). Other tests for this include identifying an object in the hand (stereognosis) and two-point discrimination.

Neurovascular integrity should always be tested first after cast application by performing circulation, motor, and sensory checks. The client should have no numbness or tingling.

If pain is not relieved (especially with passive range of motion) by prescribed pain medication or is out of proportion to the injury, the nurse should notify the health care provider (HCP). Permanent damage to the circulatory and nervous systems (compartment syndrome) can occur if this is not addressed immediately Pallor, pulselessness, and paralysis are late signs of compartment syndrome.

Carbidopa-levodopa is a medication used to reduce symptoms of tremor and rigidity in clients with Parkinson disease. Teach clients that the medication takes several weeks to become effective; urine, perspiration, or saliva discoloration is a common side effect; and fall precautions should be implemented for client safety. Avoiding high-protein meals, which interfere with the absorption of carbidopa-levodopa.

Implementing fall precautions (eg, changing positions slowly, removing rugs), as orthostatic hypotension is a common side effect (Option 1) Knowing that carbidopa-levodopa takes several weeks to reach its maximum effectiveness (Option 2) Understanding that harmless discoloration (eg, red, brown, black) of secretions (eg, urine, perspiration, saliva) may occur while taking carbidopa-levodopa Dyskinesia (eg, facial or eyelid twitching, tongue protrusion, facial grimacing) may indicate overdose or toxicity of carbidopa-levodopa and should be reported immediately to the health care provider.

Osteomalacia is a reversible bone disorder caused by vitamin D deficiency and is characterized by weak, soft, and painful bones that can easily fracture or become deformed. In vitamin D deficiency, calcium and phosphorus cannot be absorbed from the gastrointestinal tract and are unavailable for calcification of bone tissue. Vitamin D deficiency is also associated with increased risk of falls, especially in elderly clients, due to muscle weakness.

Implementing safety measures such as canes or walkers to prevent falls and injury (Option 5) Encouraging light to moderate activity, which can help promote bone strength and health (Option 3) Increasing dietary intake of:Calcium (eg, leafy green vegetables, dairy) (Option 1)Phosphorus (eg, milk, organ meats, nuts, fish, poultry, whole grains)Vitamin D (eg, vitamin D-fortified milk and cereal, egg yolks, saltwater fish, liver); exposure to sunlight is also recommended as it synthesizes vitamin D. Taking over-the-counter or prescription supplemental vitamin D

A positive reaction to TST means that the client is infected with TB bacteria. The infectious bacteria are concealed by the body's defense and do not lead to active TB disease in most individuals. When the client has a decreased immunity (eg, immunosuppression), bacteria cause an active TB disease. Additional diagnostic tests (eg, chest x-rays, bacteriologic sputum smear for acid-fast bacilli and culture) are needed to determine if this client has active TB disease. (Option 4) A positive reaction indicates a TB infection only. Further evaluation and bacteriologic testing is necessary. If active TB is suspected before testing is completed, airborne transmission precautions will then be initiated.

In a heathy client, an induration >15 mm indicates a positive TST; this means that the client was exposed to TB, developed antibodies to the disease, and has a TB infection. Additional tests are needed to determine if the client has latent TB infection (LTBI) or active TB disease. Clients with LTBI are asymptomatic and cannot transmit the microorganism to others. Clients with active TB disease usually are symptomatic and can transmit the microorganisms through the air. The elderly have decreased immunity and may be unable to develop antibodies to react to the tuberculin; this can result in a false-negative TST reaction.

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, N95 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 Visitors are prohibited unless absolutely necessary for the client's well-being (eg, parent visiting an infected child)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.

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). 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.

A client with chronic obstructive pulmonary disease and chronic bronchitis has chronic alveolar hypoxia, which stimulates erythropoiesis (red blood cell production) and leads to polycythemia (hematocrit >53% [0.53] in males, >46% [0.46] in females; hemoglobin >17.5 g/dL [175 g/L] in males, >16 g/dL [160 g/L] in females).

Increased hematocrit and hemoglobin are expected in this client and are not the most important results to report to the HCP.

FULL WEIHT BEARING

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

Fat Embolism Syndrome is a rare, but life-threatening complication that occurs in clients with long bone and pelvis fractures. It can also occur in nontrauma-related conditions, such as pancreatitis and liposuction. It usually develops 24-72 hours following the injury or surgical repair. There are no specific diagnostic tests to identify FES. FES presents with a triad of respiratory distress, mental status changes, and petechial skin rash. Fever and thrombocytopenia can also be present.

Initial characteristic signs and symptoms include: Respiratory problems (eg, dyspnea, tachypnea, hypoxemia) after a fat embolus travels through the pulmonary circulation and lodges in a pulmonary capillary, leading to impaired gas exchange and acute respiratory failure. This pathophysiology is similar to that of a pulmonary embolus Neurologic changes (eg, altered mental status, confusion, restlessness), which occur due to cerebral embolism and hypoxia (Option 1). Petechial rash (eg, pin-sized purplish spots that do not blanch with pressure), which appears on the neck, chest, and axilla due to microvascular occlusion. This defining characteristic differentiates a fat embolus from a PE (Option 4). Fever (>101.4 F [38.6 C]), which is due to a cerebral embolism leading to hypothalamus dysfunction.

lymphedema

Interventions to manage lymphedema include: Decongestive therapy (massage technique to mobilize fluid) Compression sleeves or intermittent pneumatic compression sleeve (Option 5)Compression sleeves are graduated with increased distal pressure and less proximal pressure.Clothing should also be less constrictive at the proximal arm and over the chest. Elevation of arm above the heart (Option 3) Isometric exercises (Option 4) Avoidance of venipunctures (eg, IV catheter insertion, blood draw), blood pressure measurements, and injections (eg, vaccinations) on the affected limb (Option 2) Injury prevention (limb less sensitive to temperature changes)Infection prevention (limb more prone to infection through skin breaks) (Option 1) Clients often learn massage techniques (ie, decongestive therapy) from physical therapists to increase lymphatic drainage and promote circulation of the extremity. Educational objective:Management for lymphedema includes decongestive massage therapy, compression bandages or sleeves, elevation of the arm above heart level, isometric exercises, and avoidance of venipuncture or blood pressure measurements on the affected limb.

Conditions that increase intraabdominal pressure (eg, pregnancy, obesity, ascites, tumors, heavy lifting) and weaken the muscles of the diaphragm may allow a portion of the stomach to herniate through an opening in the diaphragm, causing a hiatal hernia. A sliding hernia occurs when a portion of the upper stomach squeezes through the hiatal opening in the diaphragm. A paraesophageal hernia (rolling hernia)occurs when the gastroesophageal junction remains in place but a portion of upper stomach folds up along the esophagus and forms a pocket. Paraesophageal hernias are a medical emergency. Although hiatal hernias may be asymptomatic, many clients experience signs and symptoms commonly associated with gastroesophageal reflux disease (GERD), including heartburn, dysphagia, and pain caused by increased intraabdominal pressure or supine positioning.

Interventions to reduce herniation include the following: Diet modification—avoid high-fat foods and those that decrease lower esophageal sphincter pressure (eg, chocolate, peppermint, tomatoes, caffeine). Eat small, frequent meals, and decrease fluid intake during meals to prevent gastric distension. Avoid consumption of meals close to bedtime and nocturnal eating. Lifestyle changes—smoking cessation, weight loss. Avoid lifting or straining. Elevate the head of the bed to approximately 30 degrees—this can be done at home using pillows or 4 - 6 inch blocks under the bed. Wearing a girdle or tight clothes increases intraabdominal pressure and should be avoided.

A 2-year-old in the emergency department is suspected of having intussusception. Which assessment finding should the nurse expect? 1. Black, sticky stools 2. Greasy, foul-smelling stools 3. Stools mixed with blood and mucus 4. Thin, "ribbon-like" stools

Intussusception is an intestinal obstruction that occurs when a segment of the bowel folds (ie, telescopes) into another segment. Pressure gradually increases within the bowel, causing ischemia and leakage of blood and mucus into the lumen, which produces the characteristic stool mixed with blood and mucus (ie, red, "currant jelly"). Initially, some infants may have only general symptoms (eg, irritability, diarrhea, lethargy). Subsequently, episodes of sudden abdominal pain (cramping), drawing the knees up to the chest, and inconsolable crying are seen. After an episode, the infant may vomit and then appear otherwise normal. Assessment may show a sausage-shaped abdominal mass. (Option 1) Melena (dark red or black, sticky stool) is an indication of an upper gastrointestinal (UGI) bleed. Gastritis is a common cause of UGI bleeding in infants and toddlers. (Option 2) Oily or bulky, foul-smelling stool is an indication of excess fat in the stool (steatorrhea) from malabsorption. This is characteristic of pancreatic insufficiency, cystic fibrosis, or celiac disease. (Option 4) Thin, ribbon-like stool is characteristic of Hirschsprung disease (congenital aganglionic megacolon). Bowel obstruction is caused by failure of the internal sphincter to relax. Educational objective: The classic symptom triad of intussusception is abdominal pain, "currant jelly" stools, and a sausage-shaped abdominal mass. However, it is more common for clients to have episodes of sudden abdominal pain, inconsolable crying, and vomiting followed by periods of normal behavior.

Iron deficiency anemia r/t Excessive intake of milk

Iron deficiency anemia is the most common chronic nutritional disorder in children. There are many risk factors for iron deficiency, including insufficient dietary intake, premature birth, delayed introduction of solid food, and consumption of cow's milk before age 1 year. One common cause in toddlers is excessive milk intake, over 24 oz/day. In addition to becoming overweight, toddlers who consume too much milk develop iron deficiency due to the likely exclusion of iron-rich foods in favor of milk, a poor source of available iron. Treatment of iron deficiency anemia includes oral iron supplementation and increased consumption of iron-rich foods (eg, leafy green vegetables, red meats, poultry, dried fruit, fortified cereal). It is also important to limit milk intake (16-24 oz/day) in toddlers to ensure a balanced diet. (Option 1) Red meat and other meat products are considered good sources of dietary iron. However, clients may be at risk for obesity if meat consumption exceeds protein and caloric needs. (Option 3) Gastrointestinal blood loss, which can occur if infants under age 1 year are fed cow's milk, is a potential cause of iron deficiency anemia. However, excessive milk intake is a more common cause, particularly in clients over age 1 year. (Option 4) Impaired or decreased iron transfer is a potential cause of iron deficiency anemia, particularly in preterm infants or infants born in multiples. However, iron stores received from the mother are typically depleted by age 5-6 months (2-3 months for preterm infants); after this point, iron must be acquired through dietary sources. Because this client is a toddler (age 1-3 years), impaired iron transfer is not a likely cause of the current anemia. Educational objective: Iron deficiency anemia is the most common nutritional disorder in children. Risk factors include premature birth, cow's milk before age 1 year, and excessive milk intake in toddlers. Prevention and treatment are achieved through proper nutrition (eg, meat, leafy green vegetables, fortified cereal) and supplementation.

Most cases of iron deficiency anemia result from inadequate intake of iron-rich foods. The richest dietary sources of iron include meat, fish, and poultry. Consuming fruits or juices high in vitamin C may enhance the absorption of iron.

Iron deficiency is the leading cause of anemia worldwide. Most cases of iron deficiency anemia (IDA) result from inadequate intake of foods high in iron. In IDA, red blood cells are small (microcytic) with reduced hemoglobin content, appearing paler (hypochromic) under a microscope.

Atorvastatin (Lipitor) is a statin prescribed for hyperlipidemia.

It is used for primary and secondary prevention of cardiovascular disease and would not warrant further clarification when used in a client with angina pectoris.

The charge nurse should assign the most stable clients to the LPN. Tasks exclusive to the RN includes assessment of an unstable client and intravenous medication administration. Routine procedures such as urinary catheterization fall well within the LPN scope of practice, the other clients are in crisis, requiring acute care.

LPNs are trained in many nursing skills; these include but are not limited to nasotracheal suctioning, Foley catheter and nasogastric tube insertion, dressing changes, and subcutaneous, intramuscular, and oral medication administration. However, IV medication administration is typically reserved for the RN.

Anaphylactic shock is a medical emergency and the most severe form of an allergic reaction. Hives, itching, or a skin rash may or may not appear before rapid swelling of the mouth and throat (angioedema) makes breathing difficult or impossible within a span of minutes. Quick application of an epinephrine auto-injector (Epi-pen) into the thigh is the only acceptable option for treating anaphylactic shock. The intramuscular adrenaline injection immediately counteracts the life-threatening swelling, hypotension, and vasodilation that characterize anaphylaxis. Diphenhydramine (Benadryl) is also given to treat any associated rash or itching (hives, wheals, urticaria) but is not sufficient as a monotherapy.

Latex products are everywhere. Clients and staff members should be educated and reminded about exposure to plastic products, condoms, and all other medical products containing latex. (Option 2) Numerous products may contain trace amounts of latex; this crucial information may be omitted on the labels. (Option 4) Bananas, avocados, chestnuts, and kiwifruit have been classified as having high-risk potential for cross-reaction allergy development. Clients should be advised to watch for potential allergic reactions due to a cross-allergen

A client is receiving lithium carbonate 900 mg/day for a schizoaffective disorder. The laboratory notifies the nurse that the client's lithium level is 1.0 mEq/L (1.0 mmol/L). Based on this result, which prescription does the nurse anticipate receiving from the health care provider? 1. Continue at the current dosage 2. Decrease the dosage 3. Discontinue the medication 4. Increase the dosage

Lithium carbonate is used as a mood stabilizer in clients with schizoaffective disorder (combination of schizophrenia and a mood disorder) and bipolar disorders. Lithium has a very narrow therapeutic index (0.6-1.2 mEq/L [0.6-1.2 mmol/L]); levels >1.5 mEq/L (1.5 mmol/L) are considered toxic. Lithium toxicity can be acute (eg, ingesting a bottle of lithium tablets in a suicide attempt) or chronic (eg, slow accumulation due to decreased renal function or drug-drug interactions). Acute or acute-on-chronic toxicity presents predominantly with gastrointestinal symptoms (eg, nausea, vomiting, diarrhea); neurologic manifestations occur later. However, neurologic manifestations occur early in chronic toxicity. Common neurologic manifestations include ataxia, confusion, or agitation, and neuromuscular excitability (eg, tremor, myoclonic jerks). Chronic toxicity also manifests as diabetes insipidus (eg, polyuria, polydipsia). (Options 2, 3, and 4) No dose adjustment is needed as this client's lithium level is therapeutic.

MAP of at least 60 mm Hg is required to adequately perfuse vital organs, but MAP ≥70 mm Hg is optimal. Without intervention, MAP <60 mm Hg may progress to ischemia, organ damage, and death Common causes of low MAP include hypovolemia (eg, hemorrhage, severe dehydration), sepsis, and heart failure. Typical interventions include replacing intravascular volume (eg, IV fluids, albumin, blood products) and administering IV medications such as vasopressors (eg, norepinephrine, vasopressin) to induce peripheral vasoconstriction and inotropes (eg, dobutamine) to increase cardiac contractility.

MAP is calculated automatically by intra-arterial blood pressure monitors and some noninvasive blood pressure machines. MAP can also be calculated manually using the systolic blood pressure (SBP) and diastolic blood pressure (DBP) readings and the following formula: MAP = (SBP + [2 × DBP])/3.

Calcium acetate (PhosLo) is used to control hyperphosphatemia in clients with end-stage kidney disease by binding to phosphate in the intestines and excreting it in the stool. Because the phosphate level is high (normal adult: 2.4-4.4 mg/dL [0.78-1.42 mmol/L]), it is not necessary to notify the HCP.

Magnesium sulfate is used to correct hypomagnesemia and treat torsades de pointes and seizures associated with eclampsia. Because the magnesium level is low (normal adult: 1.5-2.5 mEq/L [0.75-1.25 mmol/L]), it is not necessary to notify the HCP.

osteoporosis: Bisphosphonate medication (eg, alendronate [Fosamax], risedronate [Actonel], zoledronic [Reclast]) Calcium and Vitamin D supplementation Smoking cessation and alcohol avoidance, as these increase bone resorption and contribute to falls Weight-bearing exercise (eg, walking, dancing) and resistance training (eg, weights) ≥3 times a week for 30 minutes, as increasing mechanical stress on bone increases bone density .

Maintain bed in low and locked position Ensure that call light and personal belongings are within reach Orient client and ensure use of non-skid footwear, eyeglasses and hearing aids, and assist devices if needed Keep environment well-lit and free of clutter

During cardiopulmonary resuscitation, chest compressions are performed at a rate of 100-120/min. Defibrillator pads are placed on the right upper chest and on the left lateral chest. Paused every 2 minutes to assess the client's pulse. This pause should be no longer than 10 seconds

Manual breaths 2 breaths per 30 chest compressions in clients without advanced airways or once every 6 seconds without chest compression interruption with advanced airway placement.Chest compressions are performed at a rate of 100-120/min and a depth of 2.0-2.4 inches (5-6 cm), allowing complete chest recoil between compressions

Gingko biloba

Memory enhancer -increase bleeding risk

Methotrexate (Rheumatrex) is classified as a folate antimetabolite, antineoplastic, immunosuppressant drug to treat various malignancies and as a nonbiologic disease-modifying antirheumatic drug (DMARD) to treat rheumatoid arthritis and psoriasis. The client's statement about getting an eye examination every 6 months indicates that further teaching is necessary as these examinations are not indicated for clients prescribed methotrexate (Option 3). However, frequent eye examinations are required for clients prescribed the nonbiologic antimalarial DMARD hydroxychloroquine (Plaquenil) as it can cause retinal damage.

Methotrexate is an immunosuppressant and can cause bone marrow suppression. Clients are at risk for infection. They should avoid crowded places and individuals with known infection and should receive appropriate killed (inactivated) vaccines (eg, influenza, pneumococcal). Live vaccines (eg, herpes zoster) are contraindicated. (Option 2) Clients should not become pregnant while taking methotrexate or for at least 3 months after it is discontinued as the drug is teratogenic and can cause congenital abnormalities and fetal death. (Option 4) Clients taking methotrexate should avoid alcohol as the prescription drug is hepatotoxic and drinking alcohol increases the risk for hepatotoxicity.

Stimulant medications (eg, methylphenidate, dextroamphetamine, lisdexamfetamine) are first-line agents in the treatment of attention-deficit hyperactivity disorder (ADHD).

Methylphenidate (Ritalin) is administered in divided doses 2 or 3 times daily, usually 30-45 minutes before meals. As a stimulant, methylphenidate may interfere with sleep and should be given no later than around 6 PM

Hirschsprung disease (HD) occurs when a child is born with some sections of the distal large intestine missing nerve cells, rendering the internal anal sphincter unable to relax. As a result, there is no peristalsis and stool is not passed. These newborns exhibit symptoms of distal intestinal obstruction. They have a distended abdomen and will not pass meconium within the expected 24-48 hours. They also have difficulty feeding and often vomit green bile. Surgical removal of the defective section of bowel is necessary and colostomy may be required. A potentially fatal complication is Hirschsprung enterocolitis, an inflammation of the colon, which can lead to sepsis and death. Enterocolitis will present with fever; lethargy; explosive, foul-smelling diarrhea; and rapidly worsening abdominal distension.

Mild to moderate abdominal distension is an expected finding with a diagnosis of HD; however, increasing abdominal girth is a serious finding that must be reported. Failure to pass meconium or stool within 24-48 hours after birth is an expected finding of HD. Bilious vomiting and excessive crying are expected findings of HD. In enterocolitis, vomiting can occur more frequently and the client appears more ill.

Breast cancer is the unregulated growth of abnormal breast tissue cells and the second most common cause of cancer deaths among women. When palpated, the breast lump is usually described as hard, irregularly shaped, non-mobile, and nontender. Mammography usually detects breast cancer. Non-modifiable breast cancer risk factors include: Female sex and age ≥50. First-degree relative (mother or sister) with history of breast cancer. BRCA1 and BRCA2 genetic mutations. Personal history of endometrial or ovarian cancer Menarche before age 12 or menopause after age 55

Modifiable breast cancer risk factors include: Hormone therapy with estrogen and/or progesterone (increased risk if taken after menopause) Postmenopausal weight gain and obesity as fat cells store estrogen History of smoking and alcohol consumption Dietary fat intake Sedentary lifestyle A client whose menstrual period began at age 17 would not be at increased risk for breast cancer. Clients who began menarche early (before age 12) or had late menopause (after age 55) are at increased risk for breast cancer.

Clinical manifestations characteristic of moderate to severe asthma exacerbations include tachycardia (>120/min), tachypnea (>30/min), saturation <90% on room air, use of accessory muscles to breathe, and peak expiratory flow (PEF) <40% of predicted or best (<150 L/min). Pharmacologic treatment modalities recommended by the Global initiative for Asthma (2014) to correct hypoxemia, improve ventilation, and promote bronchodilation include the following: Oxygen to maintain saturation >90% High-dose inhaled short-acting beta agonist (SABA) (albuterol) and anticholinergic agent (ipratropium) nebulizer treatments every 20 minutes Systemic corticosteroids (Solu-Medrol)

Montelukast (Singulair) is a leukotriene receptor blocker with both bronchodilator and anti-inflammatory effects; it is used to prevent asthma attacks but is not recommended as an emergency rescue drug in asthma. A long-acting beta agonist (Salmeterol) is administered with an inhaled corticosteroid for long-term control of moderate to severe asthma; it is not used as an emergency rescue drug in asthma.

None weight bearing

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

Compartment syndrome (CS) results from compression of vascular structures by either external compression (restrictive dressings/casts) or increased pressure within a compartment (bleeding, inflammation, and edema). After an injury or trauma (eg, surgery), the vessels surrounding the injury site are compressed by swelling muscle and connective tissues.

Muscle is encapsulated by a fibrous layer of fascia (ie, a compartment), which does not yield to swelling. Eventually, compression of tissues within the compartment restricts blood flow to the extremity. Signs of CS include the 6 Ps - pain (unrelieved by repositioning or analgesics), pallor, pulselessness, paresthesias, poikilothermia (coolness), and paralysis. The nurse should notify the health care providerimmediately as CS is a limb-threatening emergency and requires immediate surgery (fasciotomy)

The development of hives, angioedema, wheezing, and respiratory distress in a client receiving IV vancomycin indicates anaphylaxis. The infusion must be stopped immediately and IM epinephrine administered. Red Man Syndrome is a rate-related infusion reaction to IV vancomycin that is characterized by flushing, erythema, and pruritus, typically on the face, neck, and chest.

Muscle pain, spasms, dyspnea, and hypotension may also occur. RMS is usually a rate-related infusion reaction and not an allergic reaction. It can be reduced by infusing vancomycin over a minimum of 60 minutes. It can be difficult to differentiate severe RMS from anaphylaxis as flushing and hypotension can occur in both conditions.

Myasthenia gravis exacerbation -low in acetylcholine so give Acth drug (pyridostigmine [Mestinon]) that are administered before meals -Semi-solid foods -annual vaccine

Myasthenia gravis is an autoimmune disease involving a decreased number of acetylcholine receptors at the neuromuscular junction. As a result, there is fluctuating weakness of skeletal muscles, most often presented as ptosis/diplopia, bulbar signs(difficulty speaking or swallowing), and difficulty breathing. Muscles are stronger in the morning and become weaker with the day's activity as the supply of available acetylcholine is depleted. Treatment includes anticholinesterase drugs (pyridostigmine [Mestinon]) that are administered before meals so that the client's ability to swallow is strongest during the meal Semi-solid foods (easily-chewed foods) are preferred over solid foods (to avoid stressing muscles involved in chewing and swallowing) or liquids (aspiration risk)

Creatinine level of 2.5 mg/dL (221 µmol/L) is the most important abnormal value (normal 0.6-1.3 mg/dL [53-115 µmol/L]) for the nurse to report to the health care provider. An elevated creatinine level increases the risk for intra- and postoperative complications. Nothing-by-mouth (NPO) status preoperatively, dehydration (ie, fluid shift from peritonitis), intraoperative fluid losses, antibiotic therapy, and advanced age affect renal function and increase the risk for postoperative exacerbation of kidney injury in this client.

NPO status preoperatively, dehydration, intraoperative fluid losses, antibiotic therapy, and advanced age can negatively affect renal function. An elevated serum creatinine level preoperatively increases the risk for postoperative kidney injury.

The goals of emergency care for the client with suspected substance abuse who exhibits signs of central nervous system depression (eg, altered level of consciousness, bradypnea, hypotension, bradycardia) are to promote adequate ventilation and oxygenation and preserve hemodynamic stability. Interventions are prioritized according to the ABCs (ie, airway, breathing, circulation). Initial actions involve maintaining patency of the client's airway, including appropriate positioning, oropharyngeal suctioning, and artificial airway placement (if needed). Respiratory depression occurring after the ingestion of an unknown substance (eg, depressants [opioids, benzodiazepines, barbiturates]) should initially be treated with administration of reversal agents (eg, naloxone, flumazenil).

Naloxone rapidly reverses the effects of opioids and may restore spontaneous respiration and normal ventilatory pattern, averting initiation of mechanical ventilation, the possibility of respiratory arrest, and death (Option 1). (Options 2 and 4) Obtaining blood and urine for toxicology screening assists in guiding care decisions but should occur after interventions that support the client's airway, breathing, and circulation. (Option 3) Administration of IV fluids to support blood pressure and prevent dehydration should be performed after securing the client's airway and supporting effective breathing.

Near drowning most severe injury

Near-drowning occurs when a client is under water and unable to breathe for an extended period. In a matter of seconds, major body organs begin to shut down from lack of oxygen and permanent damage results. Decerebrate posturing is a sign of severe brain damage. During assessment, the nurse would observe arms and legs straight out, toes pointed down, and the head/neck arched back. These assessment findings indicate that severe injury has occurred. (Option 1) Hypothermia is generally seen in near-drowning victims. One of the first goals of treatment is to warm the client. This is done using warmed IV fluids, blankets, and air. Sustained hypothermia will eventually lead to organ failure, making this an urgent finding but not initially life-threatening. (Option 3) A weak and thready pulse is generally detected in near-drowning victims due to hypothermia. Once the client is properly warmed, the pulse generally returns to normal. Sometimes the client is so cold that a pulse cannot be detected; this is why a client is not dead until warm and dead. Such clients may require prolonged resuscitation. (Option 4) When wheezing is heard on auscultation after a near-drowning, the first observation would be that the client is still moving air and providing oxygen to the body. The wheezing may indicate that the client has bronchospasm. If the client has aspirated fluid, crackles would be heard. Most such clients will develop acute respiratory distress syndrome. Educational objective: Decerebrate posturing (arms and legs straight out, toes pointed down, head/neck arched back) usually indicates severe brain injury.

Cerebrospinal fluid (CSF) rhinorrhea (or CSF otorrhea) can confirm that a skull fracture has occurred and transversed the dura. If the drainage is clear, dextrose testing can determine if it is CSF. However, the presence of blood would make this test unreliable as blood also contains glucose. In this case, the halo/ring test should be performed by adding a few drops of the blood-tinged fluid to gauze and assessing for the characteristic pattern of coagulated blood surrounded by CSF. Identification of this pattern is very important as CSF leakage places the client at risk for infection. The client's nose should not be packed.

No nasogastric or oral gastric tube should be inserted blindly when a basilar skull fracture is suspected as there is a risk of penetrating the skull through the fracture site and having the tube ascend into the brain. These tubes are placed under fluoroscopic guidance in clients with such fractures.A bruise is an expected finding after direct trauma. It would be a concern if the ecchymosis were around the eyes (periorbital, "raccoon eyes") or postauricular (Battle's sign) as this generally indicates a basilar skull fracture, a tear in the dura, and a potential CSF leak.

Criteria for activating RRT: any staff is worried about the client's condition. The rapid response team (RRT) consists of a group of health care providers who bring critical care expertise to the bedside of clients demonstrating early signs of deterioration such as dyspnea, confusion, and restlessness. This team differs from the "Code" team that is called when a client stops breathing or goes into cardiac arrest. Any health care worker can call the RRT.

OR acute change in any: - HR < 40 or >130/min - SBP < 90 -RR < 8 or > 28 - O2 saturation < 90% despite oxygen - Urine output < 50 mL in 4 hrs -LOC

Polycythemia vera (PV) is a hematological disorder in which too many RBCs (and often WBCs and platelets) are produced, causing increased blood viscosity, venous stasis, and increased risk for thrombus formation. The nurse should teach clients with PV measures to prevent thrombus (eg, wearing graduated compression stockings, elevating legs when sitting, maintaining adequate hydration). Clients should also learn to monitor for and report signs and symptoms of thrombus (eg, redness, tenderness, or swelling in one leg). Reports of possible thrombus require immediate intervention to avoid serious injury (stroke, PE)

Occasional headaches or blurred vision can result from sluggish, viscous blood flow in the brain. Aspirin therapy is used for its antiplatelet and analgesic action. The nurse should assess the client's headaches; however, they are not the priority. Pruritis is a common occurrence in clients with PV, often after bathing. Clients should bathe with cool water and pat (not rub) themselves dry with a towel to avoid histamine release and use antihistamine creams for relief. Venous stasis can also cause itching, and aspirin can help.

The tell-tale symptom of bladder cancer, seen in >75% of cases, is painless hematuria; the client will report seeing blood in the urine with no associated pain. As with many other types of cancer, the primary cause of bladder cancer is cigarette smoking or other tobacco use Poorer outcomes are seen with increased length of time as a smoker and higher number of packs per day. Clients who have family members with bladder cancer have an increased risk of developing bladder cancer themselves; however, the primary risk factor is tobacco use.

Occupational carcinogen exposure is the second most common risk factor. Occupational exposures include printing, iron and aluminum processing, industrial painting, metal work, machining, and mining. Clients are exposed to carcinogens through direct skin contact and inhalation (aerosols and vapors).Consuming a high-fat diet and using artificial sweeteners are risk factors for developing bladder cancer, but they are not the primary cause.

steatorrhea

Oily or bulky, foul-smelling stool is an indication of excess fat in the stool (steatorrhea) from malabsorption. This is characteristic of pancreatic insufficiency, cystic fibrosis, or celiac disease.

Clients with insulin deficiency (Type 1 D) frequently have increased serum potassium levels due to the extracellular shift despite having total body potassium deficit from urinary losses, resulting in DKA

Once insulin is given, serum potassium levels drop rapidly, often requiring potassium replacement. Potassium is never given as a rapid IV bolus, as cardiac arrest may result.

Peritoneal dialysis uses the abdominal lining (ie, peritoneum) as a semipermeable membrane to dialyze a client with insufficient renal function. A catheter is placed into the peritoneal cavity, and dialysate (ie, dialysis fluid) is infused. The tubing is clamped to allow the fluid to remain in the cavity, usually for 20-30 minutes (dwell phase). The catheter is then unclamped to allow dialysate to drain via gravity. Insufficient outflow results most often from constipation when distended intestines block the catheter's holes. If outflow becomes sluggish, the nurse should assess the client's bowel patterns and administer appropriate prescribed medications (eg, stool softeners) (Option 1). The nurse should also check the tubing for kinks and reposition the client to a side-lying position or assist with ambulation

Options 3 and 5). The drainage bag should be maintained below the abdomen to promote gravity flow. The nurse should assess for fibrin clots and milk the tubing to dislodge or administer fibrinolytics (eg, alteplase) as prescribed. If these measures are ineffective, an x-ray may be needed to check the catheter location.(Options 2 and 4) The nurse should identify the problem before instilling additional fluids and perform routine assistive measures before contacting the health care provider.

Oseltamivir (Tamiflu)

Oseltamivir is an appropriate antiviral medication for this client who reports onset of influenza symptoms 36 hours ago.

Levonorgestrel Plan B

Over-the-counter EC pills (eg, high-dose levonorgestrel [Plan B One-Step]) should be taken within 3 days (72 hr) of unprotected sexual intercourse

The nurse is providing discharge instructions to a client receiving oxybutynin for overactive bladder. Which client statement indicates that further teaching is required? 1. "I am looking forward to our summer vacation at the beach."[57%] 2. "I plan to eat more fruits and vegetables to prevent constipation."[10%] 3. "I should not drive until I know how this drug affects me."[17%] 4. "I will drink at least 6-8 glasses of water daily."[14%]

Oxybutynin (Ditropan) is an anticholinergic medication that is frequently used to treat overactive bladder. Common side effects include: New-onset constipation Dry mouth Flushing Heat intolerance Blurred vision Drowsiness Decreased sweat production may lead to hyperthermia. The nurse should instruct the client to be cautious in hot weather and during physical activity (Option 1). (Options 2 and 4) Increasing dietary intake of fluids and bulk-forming foods (eg, fruits, vegetables) promotes normal bowel function and prevents constipation. (Option 3) Sedation is a common side effect of anticholinergic drugs. Clients should be taught not to drive or operate heavy machinery until they know how the drug affects them. Educational objective: Anticholinergic medications are commonly associated with constipation, urinary retention, flushing, dry mouth, and heat intolerance. Clients should be taught to prevent these side effects by increasing intake of fluids and bulk-forming foods (prevents dry mouth and constipation) and by avoiding locations or activities that may lead to hyperthermia.

3rd Degree Heart Block Treatment

Pacemaker (temporary or permanent)

Pain during defecation

Pain during defecation usually indicates a rectal problem such as inflammation, anal fissure, or thrombosed hemorrhoids.

In CF, unusually thick mucus obstructs the pancreatic ducts, preventing pancreatic enzymes (amylase, trypsin, and lipase) from reaching the small intestine. The result is malabsorption of carbohydrates, fats, and proteins; the inability to absorb fat-soluble vitamins (A, D, E, and K) is of particular concern. Gastrointestinal signs and symptoms of CF include flatulence, abdominal cramping, ongoing diarrhea, and/or steatorrhea.

Pancreatic enzyme supplements are used to aid the absorption of carbohydrates, fats, and proteins in a child with CF. They are taken with or just before every meal (not as needed); should be swallowed whole or sprinkled on an acidic food; and should not be crushed or chewed. They should not be taken with milk. Excessive intake could result in fibrosing colonopathy.

Hiatal hernia is characterized by abnormal movement of the stomach and/or esophagogastric junction into the chest due to diaphragmatic weakness. Nurses educating clients with hiatal hernias about symptom management should instruct them to avoid activities that increase abdominal pressure (eg, weight lifting), sleep with the head of the bed elevated, and remain upright for several hours after meals.

People experience heartburn, chest pain, dysphagia, and shortness of breath when the abdominal organs move into the chest. Symptoms of hiatal hernias are often exacerbated by increased abdominal pressure, which promotes upward movement of abdominal organs.

Consuming adequate nutrition is difficult for clients with advanced chronic obstructive pulmonary disease (COPD), as chewing and swallowing increase work of breathing and a full stomach increases pressure on the diaphragm. As a result, clients often lose weight because their energy expenditure is greater than their nutritional intake. To optimize nutritional intake, clients should: Drink fluids between meals, rather than before or during, to prevent stomach distension and decrease pressure on the diaphragm while eating (Option 1). Eat small, frequent meals, snacks, and supplements that are high in calories and protein. Smaller meals require less energy to chew and swallow, resulting in less fatigue and dyspnea (Option 2).

Perform oral hygiene before meals. Chronic mouth breathing leads to dry mouth; excessive sputum and medication side effects can alter the taste of food, decreasing the appetite (Option 5). (Option 3) For clients with advanced COPD, exercise is discouraged for 1 hour before and 1 hour after eating as it increases oxygen demand and fatigue. (Option 4) Gas-forming foods (eg, broccoli, beans, cabbage) and carbonated beverages should be avoided as they cause intestinal bloating and increased pressure on the diaphragm.

Mechanically ventilated clients are at risk for developing ventilator-associated pneumonia (VAP) due to sedation and impairment of natural defenses (eg, coughing) by artificial airways. Interventions to reduce the risk of VAP include: Elevating the head of the bed 30-45 degrees (ie, semi-Fowler position) (Option 1) Providing oral care with antiseptic solutions (eg, chlorhexidine mouthwash) and suctioning subglottic secretions (Option 4)

Performing scheduled daily sedation vacations and maintaining appropriate client sedation levels (Option 5) Practicing strict hand hygiene (Option 3) (Option 2) Endotracheal suctioning should be performed only when clinically indicated (eg, adventitious breath sounds, coughing, elevated peak airway pressure). Frequent suctioning increases the risk for tracheal and bronchial trauma, bleeding, and hypoxia.

Phenazopyridine hydrochloride (Pyridium) is a urinary analgesic prescribed to relieve the pain and burning associated with a urinary tract infection. The urine will turn bright red-orange while on this medication; other body fluids can be discolored as well. Because staining of underwear, clothing, bedding, and contact lenses can occur, the nurse should suggest that the client use sanitary napkins and wear eyeglasses while taking the medication.

Phenazopyridine hydrochloride provides symptomatic relief but no antibiotic action, and so it is important that the client take a full course of antibiotics. (Options 1, 2, and 4) Constipation, difficulty sleeping, and dry mouth are not common adverse effects of phenazopyridine hydrochloride.

LMWH (Enoxaparin) requires monitoring of CBC (thrombocytopenia) but not coagulation studies. Administration of unfractionated heparin requires monitoring with PTT, whereas warfarin requires PT/INR monitoring. Clients on these medications should avoid aspirin and NSAIDs.

Pinch an inch of skin upwards and insert the needle at a 90-degree angle into the fold of skin. Continue to hold the skin fold throughout the injection and then remove the needle at a 90-degree angle. Mild pain, bruising, irritation, or redness of the skin at the injection site is common. Do NOT rub the site with the hand. Using an ice cube on the injection site can provide relief

Untreated Acromegaly

Pituitary enlargement, visual field defects, headache Musculoskeletal/skin Gigantism, maloccluded jaw, arthralgias/arthritis, hyperhidrosis, skin tags Cardiovascular Hypertension, heart failure Enlarged organs Tongue, thyroid, salivary glands, liver, spleen, kidney, prostate Endocrine Galactorrhea, decreased libido, diabetes mellitus

A halo external fixation device stabilizes a cervical or high thoracic fracture when there is insignificant damage to the ligaments or spinal cord. Sensory and muscle function should be monitored to determine any new deficits, and pin sites should be regularly assessed for loose pins or infection. Care for the client with a halo device includes: Cleaning pin sites with sterile solution (eg, chlorhexidine, water) to prevent infection (Option 1) Keeping the vest liner clean and dry (eg, changing weekly or when soiled, using a cool blow-dryer to dry) to protect the skin (Option 5) Placing foam inserts under pressure points to prevent pressure injury Placing a small pillow under the client's head when supine to reduce pressure on the device (Option 4) Keeping the correct-sized wrench available at all times in case of emergency (Option 2) Only the health care provider can adjust the pins. (Option 3) The nurse should avoid grabbing the device frame when moving or positioning the client, as this may cause the screws to loosen or alter device alignment.

Placing foam inserts under pressure points to prevent pressure injury Placing a small pillow under the client's head when supine to reduce pressure on the device (Option 4) Keeping the correct-sized wrench available at all times in case of emergency (Option 2) Only the health care provider can adjust the pins. (Option 3) The nurse should avoid grabbing the device frame when moving or positioning the client, as this may cause the screws to loosen or alter device alignment.

Client has severe COPD. Nurse anticipates

Polycythemia. When body is hypoxemic, more RBCs are produced

Prevention of ventilator-associated pneumonia General Hand hygiene Noninvasive ventilation when possible Daily sedation & weaning protocols Orogastric tubes

Prevent aspiration Semirecumbent position (30°-45° angle) Aspiration of subglottic secretions Endotracheal tube cuff pressure >20 cm H2O Reduce colonization Oral antiseptics Routine prophylaxis not recommended Avoid proton pump inhibitors & histamine receptor-blocking agents, if possible

pediculosis capitis

Preventing the spread of pediculosis capitis (head lice) may be accomplished by using hot water to launder clothing, sheets, and towels in the washing machine; these items should then be placed in a hot dryer for 20 minutes. Treatment of head lice consists of the use of pediculicides and the removal of nits (eggs). (Option 2) Head lice are not spread by oral contact with eating utensils. Instead, they are spread by direct person-to-person contact or by nits that hatch in the environment and remain on clothing, combs, and pillows. (Option 3) Spraying insecticides around children and pets in the home is not recommended due to the risk of inhalation or skin contact. (Option 4) Items that cannot be washed or dry cleaned may be placed in sealed plastic bags for 14 days to kill active lice or lice that hatch from the nits in 7-10 days. Vacuuming of furniture, carpets, stuffed toys, rugs, and mattresses is also recommended to prevent the spread of lice and nits. Educational objective: Pediculosis capitis (head lice) is a common parasitic infestation of the scalp that is typically seen in school-aged children. It is spread by contact with personal items such as clothing, combs, and bedding.

Esophageal atresia (EA) and tracheoesophageal fistula (TEF) are congenital malformations in which, most commonly, the upper esophagus ends in a blind pouch (ie, atresia) and the lower esophagus connects to the primary bronchus or trachea.

Priority nursing interventions include continuous monitoring for signs of complications related to aspiration (eg, respiratory distress); inserting and maintaining a peripheral IV for continuous fluids; frequent suctioning of the nasal and oropharyngeal secretions to maintain a patent airway; and supine positioning, with the head of the bed elevated to prevent aspiration of secretions

In pyloric stenosis, there is gradual hypertrophy of the pylorus until symptom onset at age 3-5 weeks. It is common in first-born boys and the etiology is unclear. Pyloric stenosis presents with postprandial projectile vomiting (ejected up to 3 feet) followed by hunger (eg, "hungry vomiter"). This is clearly distinguished from the "wet burps" infants have due to a weak lower esophageal sphincter. The emesis is nonbilious as the obstruction is proximal to the bile duct. Infants have poor weight gain and are often dehydrated (eg, sunken fontanelle, decreased skin turgor, delayed capillary refill). The amount of milk consumed (particularly with bottle feedings) along with the mother's technique (mainly adequate burping) should be assessed to ensure there is no excessive air swallowing or overfeeding as an etiology.

Pyloric stenosis is a hypertrophy of the pyloric sphincter that eventually causes complete obstruction. Classic signs include projectile nonbilious vomiting, an olive-shaped right upper quadrant mass, weight loss, dehydration, and/or electrolyte imbalance (metabolic alkalosis).

The cerebellum is involved in coordination of voluntary movements and maintenance of balance and posture. Balance is assessed with heel-to-toe gait testing. Coordination is assessed with finger tapping, rapid alternating movements, finger-to-nose testing, and heel-to-shin testing.

Rapid alternating movements - rapid supination and pronation Finger-to-nose testing - clients touch the clinician's finger and then their own nose as the clinician's finger varies in location Heel-to-shin testing - client runs each heel down each shin while in a supine position

Thyroid surgery stridor

Respiratory distress is a life-threatening complication of thyroid surgery that occurs when swelling in the surgical area at the base of the neck compresses the airway. Stridor and/or difficulty breathing in the client who has had thyroid surgery should be reported immediately to the registered nurse, and a rapid response should be activated. (Option 1) Although elevated blood pressure is important to monitor, it is a less serious symptom than stridor. (Option 2) An irregular heart rate is a less serious symptom than stridor, and it may be a baseline finding in the client with hyperthyroidism. (Option 3) Although low oxygen saturation is a sign of impending airway compromise, it is also commonly seen in all types of postoperative clients, making it a less specific sign of airway obstruction than noisy breathing in the thyroidectomy client. Educational objective: Airway swelling is a life-threatening complication of thyroid surgery. Signs of respiratory distress such as stridor and dyspnea require rapid intervention.

Chronic hyperglycemia can cause microvascular damage in the retina, leading to diabetic retinopathy, the most common cause of new blindness in adults.

Retinal detachment requiring emergency management. A partial retinal detachment may be painless and cause symptoms such as a curtain blocking part of the visual field, floaters or lines, and sudden flashes of light. An unrepaired complete retinal detachment can cause blindness.

The nurse is educating a client recently diagnosed with rheumatoid arthritis about home care and symptom management. Which of the following client statements indicates a need for further teaching? 1. "Daily range-of-motion exercises are important to keep my joints flexible." 2. "I can use a moist heat pack to help with joint stiffness." 3. "I should elevate my knees with pillows when I'm sleeping." 4. "I will make sure to rest in between activities throughout the day."

Rheumatoid arthritis (RA) is a chronic, autoimmune disorder characterized by inflammation and damage to synovial joints; progressive fibrosis of joint membranes results in pain, deformity, and stiffness. Over time, remodeling of joint capsules and associated pain reduce the ability to perform activities of daily living(eg, toileting, bathing, dressing) and engage in routine tasks (eg, walking, opening doors). Perform gentle range-of-motion exercises daily to maintain joint flexibility (Option 1). Apply moist heat packs to stiff joints and ice packs to painful joints (Option 2). Plan frequent rest periods to reduce fatigue and inflammation of affected joints during activities (Option 4). (Option 3) Clients with RA should be instructed to sleep and rest in a flat, neutral position. Body aligners or immobilizers may be used to keep joints straight, but prolonged flexion of joints (eg, elevating knees on pillows) increases the risk of contracture and may hasten decline of joint function. Educational objective:Rheumatoid arthritis, a chronic autoimmune disorder, causes inflammation and remodeling of synovial joints, with progressive loss of functional capacity. Clients should be educated to protect the joints with range-of-motion exercises, allow for periods of rest during activities, use moist heat for stiffness and cold packs for pain, and sleep in a flat, neutral position.

rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic, relapsing autoimmune disorder causing painful inflammation of synovial joints and fibrosis and stiffening of synovial membranes. Contracture of ligaments and joint remodeling may occur, resulting in weakness and deformity. Clients with RA require education on prevention of disease progression, including: Joint protection - Fibrosis from RA can shorten tendons and ligaments when joints are flexed for prolonged periods. Body aligners or immobilizers should be used when resting to keep extremities straight (especially with advanced disease). Medications - RA is often treated using a regimen of disease-modifying antirheumatic drugs (eg, methotrexate), and clients should take their medication as prescribed regardless of symptoms (Option 3). (Option 1) Joint deformity can be prevented with appropriate treatment, including use of disease-modifying antirheumatic drugs and joint protection. (Option 2) Obesity is a risk factor for osteoarthritis, in which mechanical erosion of joint cartilage occurs. However, obesity is unrelated to RA, and clients with RA experience chronic fatigue and pain that may limit oral intake and cause weight loss. The nurse should ensure that clients with RA have access to adequate nutrition. (Option 4) During painful episodes, periods of rest are encouraged; however, clients should frequently perform range of motion exercises to prevent loss of function. Educational objective: Rheumatoid arthritis (RA) is a chronic autoimmune disorder that causes pain and joint deformity. Clients with RA should be taught to remain active to prevent contracture, take immunosuppressant medications consistently, use body aligners to prevent joint contracture, and eat a balanced diet.

Clients taking rifampin or rifapentine (Priftin) as part of antitubercular combination therapy should be taught to prevent pregnancy with non-hormonal contraceptives, notify the health care provider of any signs or symptoms of hepatotoxicity (eg, jaundice, fatigue, weakness, nausea, anorexia), and expect red-orange-colored body secretions. Dentures and contact lenses may be permanently stained.Take with meals . liver function tests are required at least every month

Rifapentine (Priftin), a derivative of rifampin, is an antitubercular agent used with other drugs (eg, isoniazid) as a combination therapy in active and latent tuberculosis infections. Both rifampin and rifapentine reduce the efficacy of oral contraceptives by increasing their metabolism; therefore, this client will need an alternate birth control plan (non-hormonal) to prevent pregnancy during treatment. Rifapentine should be taken with meals for best absorption and to prevent stomach upset. Hepatotoxicity may occur; therefore, liver function tests are required at least every month. Signs and symptoms of hepatitis include jaundice of the eyes and skin, fatigue, weakness, nausea, and anorexia. Rifapentine may cause red-orange-colored body secretions, which is an expected finding.

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

Risk factors for skin cancer include: Family or personal history of skin cancer. Celtic ancestry traits (eg, light skin, red or blond hair, blue or green eyes, many freckles) Aging Atypical or high number of moles because some skin cancers develop from pre-existing moles Immunosuppression (eg, immunosuppressant medications, HIV), which lowers the body's ability to defend against cancerous mutations. Ultraviolet light exposure (eg, chronic sun exposure, outdoor occupation, tanning bed use, history of severe sunburns)

SBFT (small bowel follow through)

SBFT examines the anatomy and function of the small intestine using x-ray images taken in succession. Barium is ingested, and x-ray images are taken every 15-60 minutes to visualize the barium as it passes through the small intestine (Option 2). Using this technique, decreased motility (eg, ileus), increased motility (eg, malabsorption syndromes), fistulas, or obstructions are identified. Clients should be instructed as follows: Fast 8 hours prior to the examination. The test usually takes 60-120 minutes, but if obstruction or decreased motility is present, it can take longer. Drink plenty of fluids after the examination to facilitate barium removal. Chalky stools may be present 24-72 hours after the examination. If brown stools do not return after 72 hours or abdominal pain or fullness is present, contact the HCP. (Option 1) Black, tarry stools (melena) are not an expected symptom of an SBFT; melena is indicative of gastrointestinal bleeding and should be reported immediately to an HCP. (Option 3) An endoscope is not used to complete an SBFT. (Option 4) Clients should refrain from eating 8 hours prior to the examination. Polyethylene glycol (Nu-LYTELY) is prescribed as a bowel preparation for a colonoscopy, not an SBFT. Educational objective: An SBFT uses sequential x-ray images to visualize the structure and function of the small intestine. The client should fast for 8 hours prior to the examination. Stools may be chalky for up to 72 hours. Black, tarry stools indicate a potential gastrointestinal bleed and should be reported immediately.

UTIs are one of the most common conditions in children, with a higher occurrence in girls (due to the short urethra and its close proximity to the vagina and anus). Girls should be taught to wipe from front to back; this will help minimize the chances of bacteria entering the urethra from the perianal area (Option 4). Urinary stasis (incomplete emptying of the bladder) is the most common contributing factor to UTIs; sedentary urine provides an ideal environment for bacterial growth. Constipation and straining increase the pressure on the bladder neck and may prevent the bladder from emptying completely. The child should be encouraged to drink plenty of fluids and use the restroom as soon as the urge to go is felt, which will decrease the risk of constipation and promote frequent urination. Avoiding "holding in" urine and voiding regularly help to prevent urinary retention and flush bacteria out of the urinary tract

Scented soaps or commercially prepared bubble bath products should be avoided as they cause irritation to the urethra. Antibacterial soap should not be used for bathing a child as it may reduce the presence of normal flora. The bathtub should be filled with water only, and the hair should be washed last (Options 3 and 5). (Option 1) Tight clothing and synthetic fabrics (eg, nylon, spandex, Lycra) should be avoided as they seal in moisture and promote bacterial growth. Cotton underwear is recommended as it absorbs moisture.

An air leak is indicated by bubbling of fluid in the base of the water seal chamber of a chest tube drainage unit. The client with a known pneumothorax is expected to have an intermittent air leak, with bubbling in the water seal chamber. Continuous bubbling indicates an air leak somewhere in the chest tube system

Section A is the suction control chamber. Gentle, continuous bubbling indicates that suction is present. Section B is part of the water seal chamber, but an air leak will not be evident in this upper portion. Tidaling of fluid is expected in this portion of the chamber and indicates patency of the tube. Section D is the collection chamber, where drainage from the client will accumulate. The nurse will assess amount and color of the fluid and record these as output.

SSRI side effects

Selective serotonin reuptake inhibitors (SSRIs) are commonly used to treat major depression and anxiety disorders. SSRIs (eg, fluoxetine, paroxetine, citalopram, escitalopram, sertraline) are generally well tolerated except for sexual dysfunction. Clients often underreport this side effect. However, when asked specifically, over 50% of clients taking SSRIs may be experiencing some type of sexual dysfunction. This can be a decrease in sexual desire, arousal, or orgasm and may vary by gender. The nurse should discuss this with the client. The side effect may decrease or cease after a 2- to 4-week waiting period for the therapeutic effect, or the client may be able to switch to a different antidepressant medication (eg, bupropion). (Option 1) Constipation is uncommon with SSRIs. Drugs with anticholinergic activity (eg, tricyclic antidepressants such as amitriptyline) may result in constipation or urinary retention. (Option 2) Sedation is a common side effect of benzodiazepines (eg, alprazolam, lorazepam, diazepam, and chlordiazepoxide), first generation antihistamines, and narcotic medications. SSRIs may cause insomnia. (Option 4) Weight gain is a common side effect of most SSRIs, especially with long-term therapy. Educational objective: SSRIs (eg, fluoxetine, paroxetine, citalopram, escitalopram, sertraline) can cause sexual dysfunction. The client should be encouraged to report this to the health care provider if they are still present 2-4 weeks after treatment initiation.

Allergy skin testing involves introducing common environmental and food allergens (ie, antigens) into the skin surface and then observing the site for an allergic reaction (eg, formation of a wheal, erythema).

Several different antigens, as well as positive and negative controls, are usually tested at the same time for accuracy. To ensure an accurate result, the client should avoid antihistamines (eg, diphenhydramine [Benadryl], loratadine [Claritin], promethazine [Phenergan]) for up to 2 weeks prior to the test (Options 3 and 5). Antihistamines block mast cell release of histamines that are responsible for allergic symptoms. Systemic corticosteroids, used to treat the inflammatory component of asthma, may also affect the accuracy of allergy skin testing; therefore, the use of these medications is assessed by the health care provider.

Clients with COPD disease benefit from breathing techniques to facilitate effective coughing. Huff coughing is a forced expiratory technique in which the client sits relaxed, upright, and leaning forward; slowly inhales using the diaphragmatic muscle; holds breath for 2-3 seconds and then quickly exhales; and repeats as necessary until remaining secretions are clear.

Sit upright in a chair with feet spread shoulder-width apart and lean forward with shoulders relaxed; forearms supported on thighs or pillows; head and knees slightly flexed; and feet touching the floor. Perform a slow, deep inhalation through the mouth or nose using the diaphragmatic muscle Hold breath for 2-3 seconds, keeping the throat open, and then perform a quick, forceful exhalation, creating an audible "huff" sound. Repeat the "huff" once or twice more to expectorate any mucus Rest for 5-10 regular breaths and repeat as necessary until all mucus is cleared

Acanthosis nigricans is a velvety light brownish to black skin thickening seen in the axillae, neck, or flexures and is indicative of insulin resistance (diabetic dermopathy). Skin tags (acrochordons) are commonly present on regions affected by acanthosis nigricans.

Skin tags (acrochordons) are commonly present on regions affected by acanthosis nigricans. Both indicate insulin resistance (diabetic dermopathy). The client should be referred to the primary health care provider for evaluation of undiagnosed diabetes mellitus and/or metabolic syndrome.

Buck traction is a type of skin traction used to immobilize hip fractures and reduce pain and spasm until the client can undergo surgical repair of the fracture. A traction boot is applied to the leg, below the fracture site. A weight gently and continuously pulls on the leg and hip, helping maintain alignment of the limb. The nurse should ensure that the traction boot is fitted properly and that the limb remains straight in a neutral position (Option 3).

Skin traction exerts pressure on nerves, blood vessels, and soft tissue. The nurse should frequently assess neurovascular status (eg, pulse, capillary refill, color, temperature, sensation, movement) and skin integrity in the limb to which the boot is applied (Options 1 and 4). Overall pain level and efficacy of administered pain medications should be monitored closely, as increasing pain in the limb in traction may indicate neurovascular compromise (Option 2). (Option 5) Side-to-side repositioning of the client in Buck traction can cause injury. Side-to-side position changes cause the affected leg to be adducted or abducted, which, when paired with the force of traction, can increase spasm and pain and contribute to neurovascular and orthopedic compromise.

Spermicide (eg, nonoxynol 9) is applied to the rim of the device to increase effectiveness.

Spermicide (eg, nonoxynol 9) is applied to the rim of the device to increase effectiveness. Neither provides reliable protection against sexually transmitted infections (STIs), and spermicide may increase the risk of HIV transmission.

Hepatic encephalopathy (HE) is a frequent complication of liver cirrhosis. Precipitating factors include hypokalemia, constipation, gastrointestinal hemorrhage, and infection. It results from accumulation of ammonia and other toxic substances in blood. Clinical manifestations of HE range from sleep disturbances (early) to lethargy and coma. Mental status is altered, and clients are not oriented to time, place, or person (Option 1). A characteristic clinical finding of HE is presence of asterixis (flapping tremors of the hands). It is assessed by having the client extend the arms and dorsiflex the wrists (Option 2). Another sign is fetor hepaticus (musty, sweet odor of the breath) from accumulated digestive byproducts.

Spider angiomas (eg, small, dilated blood vessels with bright red centers), gynecomastia, testicular atrophy, and palmar erythema are expected findings in cirrhosis due to altered metabolism of hormone in the liver. (Option 4) Jaundice occurs when bilirubin is 2-3 times the normal value. Jaundice can occur in hepatitis and tends to worsen in cirrhosis due to increasing functional derangement. It is not related specifically to encephalopathy.

St. John's Wort

St John's wort is an herbal supplement commonly used to treat depression and anxiety. Some clients with mild or moderate depression claim that its antidepressant effect is comparable to that of prescription medications. The herbal supplement mimics the action of selective serotonin reuptake inhibitors (SSRIs) by increasing available serotonin in the brain. Taken in combination with an SSRI (eg, sertraline, fluoxetine, citalopram, paroxetine), St John's wort may cause an excess of serotonin, resulting in serotonin syndrome, which is characterized by mental status changes, autonomic dysregulation, and neuromuscular hyperactivity. The client with a newly diagnosed depressive disorder will likely be prescribed an antidepressant. The nurse should teach the client not to take St John's wort concurrently with SSRIs to prevent serotonin syndrome

Methylphenidate for ADHD (loss of appetite and restlessness)

Stimulant medications are commonly used to treat ADHD in children and adults. Methylphenidate (Ritalin) and amphetamines (eg, dextroamphetamine, lisdexamfetamine) are the most commonly used stimulants. The major problems with stimulant medications include: Decreased appetite and weight loss - can lead to growth delays Cardiovascular effects - hypertension and tachycardia (particularly in adults) Appearance of new or exacerbation of vocal/motor tics Excess brain stimulation - restlessness, insomnia Abuse potential - misuse, diversion, addiction

Signs of a transfusion reaction include chills, fever, low back pain, flushing, and itching. Nursing interventions include:

Stop transfusion immediately and disconnect tubing at the catheter hub. Maintain IV access with normal saline, using new tubing to prevent hypotension and vascular collapse (Option 2). Notify health care provider (HCP) and blood bank. Monitor vital signs. Recheck labels, numbers, and the client's blood type. Treat client's symptoms according to the HCP's prescription. Collect blood and urine specimens to evaluate for hemolysis. Return blood and tubing set to the blood bank for additional testing. Complete necessary facility paperwork to document the reaction.

Difficulty hearing (tinnitus, subjective hearing loss) is an adverse reaction to streptomycin.

Streptomycin, an aminoglycoside antibiotic, is a second-line drug sometimes used to treat multi-drug-resistant tuberculosis, with ototoxic and nephrotoxic adverse effects.

A student nurse asks why enteral (tube) feedings, rather than total parenteral nutrition (TPN), are being administered to a client with sepsis and respiratory failure. Which is the best response by the registered nurse? 1. "Enteral feedings have no complications." 2. "Enteral feedings maintain gut integrity and help prevent stress ulcers." 3. "Enteral feedings provide higher calorie content." 4. "Risk of hyperglycemia is lower with enteral feedings than with TPN."

Stress ulcers are a common complication in critically ill clients because the gastrointestinal tract is not a preferential organ. In the presence of hypoxemia, blood is shunted to the more vital organs, increasing the risk of stress ulcers. The early initiation of enteral feedings helps preserve the function of the gut mucosa, limits movement of bacteria (translocation) from the intestines into the bloodstream, and prevents stress ulcers. Enteral feedings are also associated with lower risk of infectious complications compared with TPN. However, the mortality is the same. (Option 1) Complications/problems commonly associated with enteral feedings include aspiration, tube displacement, hyperglycemia, diarrhea, abdominal distension, enteral tube misconnections, and clogged tubes. (Option 3) Caloric and metabolic needs can usually be met adequately using enteral feedings or TPN. Multiple enteral or TPN formulas are available to meet individual client needs. If metabolic demands are not being met using enteral feedings alone, TPN can be added. (Option 4) Illness-related stress hyperglycemia (gluconeogenesis) occurs in clients receiving both enteral feedings and TPN. Educational objective:The enteral route is preferred for feeding. Enteral feedings maintain the integrity of the gut, prevent stress ulcers, and help prevent the translocation of bacteria into the bloodstream.

Stress-induced hyperglycemia causes complications in the hospitalized client. To minimize complications, the recommended target glucose range for critically ill clients is 140-180 mg/dL [7.8-10.0 mmol/L]. For non-critically ill clients, <140 mg/dL (7.8 mmol/L) fasting and <180 mg/dL (10.0 mmol/L) random blood glucose are recommended.

Stress-induced hyperglycemia (gluconeogenesis) can occur in hospitalized clients in relation to surgery, trauma, acute illness, and infection. Hyperglycemia (glucose level >140 mg/dL [7.8 mmol/L]) affects both diabetic and non-diabetic hospitalized clients, especially those who are critically ill. Approximately 80% of clients in the intensive care unit who develop hyperglycemia have no history of diabetes before admission. Hyperglycemia is associated with increased risk of complications (eg, health care-associated infection, increased length of stay, acute kidney injury).

Serotonin syndrome, a potentially life-threatening condition, develops when drugs affecting the body's serotonin levels are administered simultaneously or in overdose. Drugs, which may trigger this reaction, include selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors (MAOIs), dextromethorphan, ondansetron, St. John's wort, and tramadol. The diagnosis is primarily clinical and based on medication history and clinical findings.

Symptoms may include mental status changes (eg, anxiety, agitation, disorientation), autonomic dysregulation (eg, hyperthermia, diaphoresis, tachycardia/hypertension), and neuromuscular hyperactivity(eg, tremor, muscle rigidity, clonus, hyperreflexia). (Option 1) The client experiencing serotonin syndrome would exhibit hyperreflexia. (Option 2) The client experiencing serotonin syndrome would exhibit warm moist skin and a fever.

Alteration in color perception and visual changes are commonly seen with digoxin toxicity. Gum hypertrophy is seen with phenytoin toxicity. Hyperthermia and tinnitus are often seen with aspirin overdose.

Symptoms of THEOPHYLLINE toxicity usually manifest as central nervous system stimulation (eg, headache, insomnia, seizures), gastrointestinal disturbances (eg, nausea, vomiting), and cardiac toxicity (eg, arrhythmia).

Impairment of cranial nerve (CN) VIII, the vestibulocochlear or auditory nerve, may cause dizziness, vertigo, loss of hearing, and motion sickness. To assist the client with impairment of CN VIII, needed items should be placed nearby to decrease the risk of the client getting out of bed and falling.

Symptoms of impairment may include loss of hearing, dizziness, vertigo, and motion sickness, which place the client at a high risk for falls. Therefore, when instructing the unlicensed assistive personnel (UAP) about helping the client with activities of daily living, the nurse emphasizes the need to keep items at the bedside within the client's reach

Defibrillation is indicated in clients with ventricular fibrillation (Vfib) and pulseless ventricular tachycardia. Cardiopulmonary resuscitation (CPR) should be initiated and compressions continued until the shock is ready to be delivered (Option 3). Certain pulseless rhythms (asystole and pulseless electrical activity) do not need defibrillation. Steps to perform defibrillation are as follows: Turn on the defibrillator Place defibrillator pads on the client's chest (Option 1) Charge defibrillator. Chest compressions should continue until defibrillator has charged and is ready to deliver the shock. Before delivering the shock, ensure that the area is "all clear." Confirm that no personnel are touching the client, bed, or any equipment attached to the client (Option 2). Deliver the shock Immediately resume chest compressions

Synchronized cardioversion delivers a shock on the R wave of the QRS complex and would not be appropriate for a client in Vfib (no identifiable QRS complexes). Rhythms that are ideal for synchronized cardioversion are supraventricular tachycardia, ventricular tachycardia with a pulse, and atrial fibrillation with rapid ventricular response. If the defibrillator is not synchronized with the R wave in a client with a pulse, the shock may be delivered on the T wave and can cause a lethal arrhythmia (eg, Vfib).

IV sedation is not necessary for defibrillation as the client (who is is in Vfib) is already unconscious. It is often given prior to elective synchronized cardioversion to ease anxiety and decrease pain.

Synchronized cardioversion for: 1. SVT 2. VTach pulse 3. Afib w rapid ventricular response

Synchronized cardioversion delivers a shock on the R wave of the QRS complex and would not be appropriate for a client in Vfib (no identifiable QRS complexes). Rhythms that are ideal for synchronized cardioversion are supraventricular tachycardia, ventricular tachycardia with a pulse, and atrial fibrillation with rapid ventricular response. If the defibrillator is not synchronized with the R wave in a client with a pulse, the shock may be delivered on the T wave and can cause a lethal arrhythmia (eg, Vfib).

Synchronized cardioversion for: 1. SVT 2. VTach pulse 3. Afib w rapid ventricular response

In the intensive care unit, the nurse cares for a client admitted with a head injury who develops syndrome of inappropriate antidiuretic hormone. Which data should the nurse expect with the onset of this condition? Select all that apply. 1. Decreased serum osmolality 2. High serum osmolality 3. High urine specific gravity 4. Increased urine output 5. Low serum sodium

Syndrome of inappropriate antidiuretic hormone (SIADH) is potential complication of head injury. In SIADH, the extra ADH leads to excessive water absorption by the kidneys. Low serum osmolality and low serum sodium are the result of increased total body water (dilution). As ADH is secreted and water is retained, urine output is decreased and concentrated, resulting in a high specific gravity. (Options 2 and 4) Increased urine output is associated with diabetes insipidus (DI). In DI, ADH is suppressed, causing polyuria, severe dehydration, and high serum osmolality if the client is unable to drink enough to maintain a fluid balance.

Sepsis is an overwhelming response to infection that causes impaired organ function. Septic shock occurs when sepsis causes cardiovascular collapse and/or impairs the body's ability to maintain normal metabolic and cellular processes. Manifestations of septic shock include: Fever or hypothermia (>100.4 F [38 C]; <96.8 F [36 C]) - Either fever or low body temperature is found in sepsis and septic shock. Fever occurs in response to infection, whereas low body temperature can occur as shock worsens due to metabolic alterations and inadequate tissue perfusion (Option 3). Hypotension - Systolic blood pressure <90 mm Hg or mean arterial pressure <65 mm Hg in a client with infection may indicate septic shock. Altered perfusion from hypotension may cause lactic acid accumulation and metabolic acidosis (Option 1). Prolonged capillary refill - A refill time >3-4 seconds in adults indicates inadequate tissue perfusion as a result of altered peripheral circulation and hypotension (Option 2).

Tachycardia - A resting heart rate >90/min is common in septic shock to compensate for decreased systemic vascular tone and hypotension. WBC count >12,000/mm3 (12 x 109/L) or immature neutrophils (bands) of >10% - An increased WBC count, especially with bands, indicates severe infection (Option 5). (Option 4) Clients with septic shock typically develop decreased urine output (ie, <0.5 mL/kg/hr) due to inadequate organ perfusion.

The client with an ICD that is firing is receiving electrical shocks from the internal defibrillator to interrupt the dysrhythmia. It is still imperative that the client receive chest compressions in the form of cardiopulmonary resuscitation (CPR) to provide circulation of blood to the vital organs. The nurse should implement the pulseless arrest algorithm, allowing 30-60 seconds for the ICD to complete its therapy cycle before applying external defibrillation pads/paddles. Epinephrine should be administered after CPR and defibrillation. The ICD is firing as it was programmed to do. It should not be deactivated. The nurse should let the ICD work but needs to implement CPR in addition.

The ICD is designed to defibrillate potentially life-threatening dysrhythmias. Although the device is able to sense electrical activity of the heart and respond, it is unable to sense or treat pulselessness. CPR should be initiated in the pulseless client with an ICD.

Peritonsillar abscess is an emergent complication of tonsillitis that can lead to life-threatening airway obstruction. Symptoms of peritonsillar abscess include fever, trismus (inability to open the mouth), drooling, muffled voice, and deviation of uvula to one side.

The abscess can progress to life-threatening airway obstruction (eg, dysphagia, stridor, restlessness). The nurse should immediately assess the client with symptoms of peritonsillar abscess and monitor for signs of airway obstruction

Ethambutol (Myambutol) is used in combination with other antitubercular drugs (eg, isoniazid, rifampin, pyrazinamide) to treat active tuberculosis. The client must have baseline and periodic eye examinations during therapy as optic neuritis is a potentially reversible adverse effect.

The client is instructed to report signs of decreased visual acuity and loss of color (red-green) discrimination.

The peak flow meter is a hand-held device used to measure peak expiratory flow rate (PEFR) and is most helpful for clients with moderate to severe asthma. Exhaling as quickly and forcibly as possible through the mouthpiece of the device evaluates the degree of airway narrowing by measuring the volume of air that can be exhaled in one breath. Use of the device permits self-management and provides information to guide and evaluate treatment.

The client moves the indicator on the numbered scale to 0 or to the lowest number on the scale before using the device. The personal best reading is the highest peak flow reading the client can attain, usually over a 2-week period, when asthma is in good control. The peak flow meter is used after a short-acting bronchodilator rescue MDI to evaluate response, not after a corticosteroid MDI.

To prevent hip prosthesis dislocation following hip arthroplasty, a client must not force the hip into >90 degrees of flexion. Clients should use a chair with armrests and a high firm seat and proceed to place the hands on the armrests for support while lowering themselves onto the seat and when rising from it. Bending forward when getting into a chair creates excessive hip flexion (>90 degrees) and must be avoided. The client performs leg exercises 2-3 times a day to help strengthen the muscles surrounding the hip and continues them for several months after discharge. These include isometric quadriceps and gluteal setting, leg raises, and abduction exercises from the supine and standing positions.

The client must not twist from the waist, reach across the affected extremity, or bend forward >90 degrees when dressing or putting on slippers, shoes, and socks. The client is instructed to use assistive equipment when getting dressed, such as a reacher/grabber, sock puller, or a long-handled shoehorn. The client should use a toilet riser or a bedside commode chair with arms to prevent excessive hip flexion when getting on and off the toilet seat.

Casts (eg, fiberglass, plaster) are applied to immobilize fractured extremities during healing. Instructions for cast care include: Report foul odors or hot areas (hot spots) in the cast, which may indicate infection (Option 1). Avoid getting the cast wet, which may damage the cast and cause skin irritation/infection (Option 2). Elevate the affected extremity above heart level for the first 48 hours to reduce edema (Option 3). Regularly perform isometric and range of motion exercises to prevent muscle atrophy.

The client should also be instructed to contact the health care provider about symptoms of impaired circulation in the affected extremity, including numbness or tingling, pallor, coolness, loss of pulse distal to the cast, or pain that is unrelieved by ice, elevation, and pain medication. Swelling within the cast may result in compartment syndrome, a condition that involves limb-threatening tissue ischemia due to compression of blood vessels and nerves within the extremity's internal compartments. (Option 5) The client should never insert objects inside the cast due to the risk of tissue injury and infection. Directing air inside the cast with a hair dryer on the cool setting may help relieve itching.

Medications for the treatment of Alzheimer disease, such as donepezil and rivastigmine, are used to improve cognition and memory.

The combination medication carbidopa-levodopa is most helpful for treating bradykinesia in Parkinson disease and can also improve tremor and rigidity to some extent. It is started in low doses to prevent orthostatic hypotension and neuropsychiatric adverse effects. Carbidopa-levodopa once started should never be stopped suddenly as doing so can lead to akinetic crisis (complete loss of movement).

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

The definition of this minimum acceptable level of care reflects what reasonable, prudent, and careful nurses would do in specific circumstances. The state or province/territory boards of nursing help to regulate these standards. Sources used to define standard of care include statements from professional organizations, agency policies and procedures, textbooks, current literature, expert consensus, the Nurse Practice Act, and statutes from regulatory organizations

Trigeminal neuralgia is sudden, sharp pain along the distribution of the trigeminal nerve. The symptoms are usually unilateral and primarily in the maxillary and mandibular branches. Clients may experience chronic pain with periods of less severe pain, or "cluster attacks" of pain between long periods without pain. Triggers can include washing the face, chewing food, brushing teeth, yawning, or talking. Pain is severe, intense, burning, or electric shock-like. The primary intervention for trigeminal neuralgia is consistent pain control with medications and lifestyle changes. Room should be kept at an even and moderate temperature Avoid rubbing or facial massage. Use cotton pads to wash the face if necessary. Have a soft diet with high calorie content; avoid foods that are difficult to chew. Chew on the unaffected side of the mouth.

The drug of choice is carbamazepine. It is a seizure medication but is highly effective for neuropathic pain. Carbamazepine is associated with agranulocytosis (leukopenia) and infection risk. Clients should be advised to report any fever or sore throat. Behavioral interventions include the following: Oral care - use a small, soft-bristled toothbrush or a warm mouth wash Use lukewarm water; avoid beverages or food that are too hot or cold. A high-fiber diet is not required for a client with trigeminal neuralgia, and the additional chewing with higher-fiber foods may serve as a pain trigger.

Sickle cell crisis is managed with IV hydration, frequent IV pain medication, and as-needed blood transfusion. Many orthopedic clients require medication with opioids to control pain, IV fluids, and blood transfusion (blood loss with surgery/trauma).

The float nurse is familiar with the policies and procedures for pain assessment and administering opioid medications, which should be the same on non-specialty units within the same facility.

celiac disease

The following are important principles to teach clients with celiac disease: All gluten-containing products should be eliminated from the diet. These include wheat, barley, rye, and oats. Rice, corn, and potatoes are gluten free and are allowed on the diet. Deficient vitamins (mainly fat-soluble vitamins), iron, and folic acid should be replaced. Processed foods (eg, chocolate candy, hot dogs) may contain "hidden" sources of gluten such as modified food starch, malt, and soy sauce. Food labels should indicate that the product is gluten free. Clients will need to be on a gluten-free diet for the rest of their lives. Eliminating gluten from the diet reduces the risk of nutritional deficiencies and intestinal cancer (lymphoma). Eating even small amounts of gluten will damage the intestinal villi although the client may have no clinical symptoms. All sources of gluten must be eliminated from the diet (Option 3). Educational objective: All sources of gluten must be eliminated from the diet of a client with celiac disease; consuming small amounts, even in the absence of clinical symptoms, will increase the risk of damage to the intestinal villi. Clients can have foods containing rice, corn, and potatoes. They should read food labels and follow the diet for the rest of their lives.

Fever after an esophagogastroduodenoscopy (EGD) or colonoscopy could be a sign of infection from perforation and should be reported. A sudden temperature spike 1-2 hours after an esophagogastroduodenoscopy (EGD) could be a sign of perforation or a developing infection. The nurse should notify the health care provider immediately.

The gag reflex may take a few hours to return as the EGD involves applying a topical anesthetic to the throat. Absent gag reflex after a prolonged period (6 hours) would require reporting to the health care provider.

Adalimumab (Humira) is a tumor necrosis factor (TNF) inhibitor, a biologic disease-modifying antirheumatic drug (DMARD) classified as a monoclonal antibody. Its major adverse effects are similar to those of other TNF inhibitor drugs (eg, etanercept [Enbrel], infliximab [Remicade]) and include immunosuppression and infection (eg, current, reactivated). An elevated white blood cell count in this client can indicate underlying infection and should be reported immediately. This client with Clostridium difficile infection will have an elevated white blood cell count. The client is receiving appropriate therapy (eg, metronidazole, oral vancomycin). The nurse will need to monitor the white cell count and, if it keeps increasing, report it.

The liver produces most blood clotting factors. Clients with liver cirrhosis will lose this ability and are at risk for bleeding. This client's International Normalized Ratio is mildly elevated (normal 0.75-1.25), which is expected with cirrhosis. (Option 3) Corticosteroids increase blood glucose. This is expected, and the client may need treatment if the glucose levels are markedly increased for a prolonged period. Most clients with asthma exacerbation are expected to take a 5- to 7-day course of steroids.

Dopamine (Intropin) is a sympathomimetic inotropic medication used therapeutically to improve hemodynamic status in clients with shock and heart failure. It enhances cardiac output by increasing myocardial contractility, increasing heart rate, and elevating blood pressure through vasoconstriction. Renal perfusion is also improved, resulting in increased urine output.

The lowest effective dose of dopamine should be used as dopamine administration leads to an increased cardiac workload. Significant adverse effects include tachycardia, dysrhythmias, and myocardial ischemia. A heart rate of 120/min may indicate that the dopamine infusion needs to be reduced

Refractory hypoxemia is the hallmark of acute respiratory distress syndrome (ARDS), a progressive form of acute respiratory failure that has a high mortality rate. It can develop following a pulmonary insult (eg, aspiration, pneumonia, toxic inhalation) or nonpulmonary insult (eg, sepsis, multiple blood transfusions, trauma) to the lung. The insult triggers a massive inflammatory response that causes the lung tissue to release inflammatory mediators (leukotrienes, proteases) that cause damage to the alveolar-capillary (A-C) membrane. As a result of the damage, the A-C membrane becomes more permeable, and intravascular fluid then leaks into the alveolar space, resulting in a noncardiogenic pulmonary edema.

The lungs become stiff and noncompliant, which makes ventilation and oxygenation less than optimal and results in increased work of breathing, tachypnea and alkalosis, atelectasis, and refractory hypoxemia. Profound hypoxemia despite high concentrations of oxygen is a key sign of ARDS and is the most important assessment finding to report to the HCP. (Options 1 and 3) Cough with mucus production and scattered rhonchi and crackles are expected findings in a client with pneumonia. (Option 4) Temperature is an expected finding in a client with pneumonia who is receiving antibiotic therapy. The white blood cell count can still be elevated after 2 days of antibiotic therapy.

Malignant hyperthermia (MH) is a rare, life-threatening inherited muscle abnormality that is triggered by certain drugs used to induce general anesthesia in susceptible clients. The triggering agent leads to excessive release of calcium from the muscles, leading to sustained muscle contraction and rigidity. It can occur in the operating room or in the post-anesthesia care unit (PACU). he most specific characteristic signs and symptoms of MH include hypercapnia (earliest sign), generalized muscle rigidity (eg, jaw, trunk, extremities), and hyperthermia. Hyperthermia is a later sign and can confirm a suspicion of MH.

The nurse monitors the temperature as it can rise 1 degree Celsius every 5 minutes and can exceed 105 F (40.6 C). The nurse would notify the health care provider, indicating the need for immediate treatment (eg, dantrolene, cooling blanket, fluid resuscitation)

SIADH is an endocrine condition in which antidiuretic hormone overproduction leads to water retention, increased total body water, and dilutional hyponatremia (low serum sodium). Hyponatremia can cause confusion, seizures, or other neurologic complications. It is important for the nurse to anticipate these problems and institute seizure precautions. SIADH treatment includes: Fluid restriction to <1000 mL/day Oral salt tablets to increase serum sodium (Option 3) Hypertonic saline (3%) during the first few hours for clients with markedly decreased serum sodium and severe neurologic manifestations Vasopressin receptor antagonists (eg, conivaptan)

The nurse should also maintain a strict fluid intake and output chart and daily weights and carefully monitor neurologic status to evaluate for improvement or deterioration. (Option 1) Normal saline fluid bolus would worsen the hyponatremia as the client already has excess fluid volume. Symptoms are caused by a low sodium level. If the sodium level must be raised, the client will need hypertonic (3%) saline or salt tablets as these contain mainly sodium and little free fluid.

The client is exhibiting the cardinal signs and symptoms of diabetic ketoacidosis (DKA). DKA is an acute life-threatening complication, typically of type I diabetes, characterized by hyperglycemia, ketosis, and acidosis. It is caused by an intense deficit of insulin. Glucose cannot be used properly for energy when this deficit occurs and the body begins to break down fat stores, producing ketones, a byproduct of fat metabolism, resulting in metabolic acidosis. The lack of insulin also results in increased production of glucose in the liver, further exacerbating hyperglycemia. Because some of the symptoms of hypoglycemia and DKA overlap, a blood glucose level should be checked to ensure that hyperglycemia is present. Hyperglycemia can cause osmotic diuresis, leading to dehydration. In addition, ketones are excreted in the urine as the body tries to restore its pH balance. Vital electrolytes such as sodium, potassium, chloride, phosphate, and magnesium become depleted during the process. Cardinal signs of dehydration such as poor skin turgor, dry mucous membranes, tachycardia, orthostatic hypotension, weakness, and lethargy can occur.

The nurse should start an IV and bolus the client with normal saline or 1/2 normal saline to reverse dehydration. This should occur prior to treating the hyperglycemia with regular insulin IV infusion. Because insulin promotes water, potassium, and glucose entrance into the cell, it can exacerbate vascular dehydration and imbalance of electrolytes, particularly potassium. A potassium level (along with other electrolytes) should also be assessed prior to beginning the prescribed insulin therapy. Other signs associated with DKA include Kussmaul respirations, deep, rapid respirations that have a fruity/acetone smell as the carbon dioxide is exhaled. This compensatory mechanism results in a lowered PaC02 in an attempt to restore the body's normal pH level and should not be reversed (Option 2). (Option 1) IV dextrose is administered during acute hypoglycemic episodes and would worsen DKA.

Clients with an allergy to penicillin antibiotics (eg, amoxicillin, ampicillin) can possibly experience a cross-sensitivity reaction to cephalosporin antibiotics (eg, cefazolin, cephalexin, ceftriaxone), because the drug molecules are structurally similar. The nurse should obtain more information about this client's reported allergies, as reactions range from mild to severe. In particular, the nurse must first assess the type of reaction the client had to amoxicillin (Option 3).

The nurse should then clarify the prescription with the health care provider (HCP) prior to administration. If this client's reaction to amoxicillin was a rash or other mild reaction that was not life-threatening, the HCP may decide that cephalosporin can be safely administered. However, cephalosporins are contraindicatedfor a client with a history of anaphylactic reactions to penicillin, and a different antibiotic should be prescribed.

Ventilators may sound an alarm when set parameters are not being met (eg, low tidal volumes, high peak pressures). These alarms may indicate a client condition or ventilator malfunction. If a ventilator alarm cannot be readily resolved, the nurse should manually ventilate the client's lungs with a resuscitation bag device. A low tidal volume alarm indicates that the volume of air the ventilator is delivering is lower than the set volume. This is most often due to a disconnection, loose connection, or leak in the circuit.

The nurse should troubleshoot the most common causes of the alarm, but if the client's condition is deteriorating clinically (eg, decreasing oxygen saturation), then the nurse should disconnect the ventilator and manually ventilate the client's lungs with a resuscitation bag device at 10-15 L/min oxygen until the ventilator alarm state can be resolved.

Fatigue and weight gain are classic manifestations of hypothyroidism. Features of hypothyroidism typically result from decreased metabolic rate and include cold intolerance, constipation, dry skin, irregular or prolonged menstrual periods, and mental slowing or difficulty concentrating.

The presenting symptoms of a hyperthyroid client would likely include weight loss despite an increased appetite and difficulty sleeping. Fever, tachycardia, and sweating are signs of hyperthyroidism, which is a hypermetabolic state.

- CO poisioning - what are the symptoms?

The purpose of hemoglobin (Hgb) is to pick up oxygen in the lungs and deliver it to the tissues. It must be able to pick up oxygen and release it in the right places. Carbon monoxide (CO) has a much stronger bond to Hgb than oxygen does. Consequently, CO displaces oxygen from Hgb, causing hypoxia that is not reflected by a pulse oximeter reading. The nurse's primary action is to administer highly concentrated (100%) oxygen using a nonrebreather mask at 15 L/min in order to reverse this displacement of oxygen. (Option 1) Albuterol is not a priority action as bronchoconstriction is not a consequence of CO poisoning. (Option 3) Administration of corticosteroids is not a priority/primary action as direct inflammation of the lungs is not an underlying cause for hypoxemia and hypoxia associated with CO poisoning. (Option 4) When all available Hgb binding sites are occupied (oxyhemoglobin or carboxyhemoglobin), saturation (SaO2) is 100%. The conventional pulse oximeter cannot differentiate carboxyhemoglobin from oxyhemoglobin as both absorb the oximeter's red and infrared light wavelengths. Consequently, the pulse oximeter reading may be adequate (>90%), but severe hypoxemia and hypoxia may be present. Alternate methods of CO saturation measurement (eg, multiple wavelength CO pulse oximeter, spectrographic blood gas analysis) are recommended. Educational objective: The conventional pulse oximeter is not effective in identifying hypoxia in CO poisoning; diagnosis requires co-oximetry of a blood gas sample. The priority action is to administer 100% oxygen using a nonrebreather mask to treat hypoxia and help eliminate CO.

Metformin (Glucophage) is a first-line drug for the control of blood sugar in clients with type 2 diabetes mellitus. Glycosylated hemoglobin (A1C) measures the total hemoglobin that has glucose attached to it, expressed as a percentage. Glucose remains attached to the red blood cell for the life of the cell (about 120 days) and reflects glycemic control over an extended period.

The recommended A1C level for a client with diabetes is <7%. Although the A1C level is elevated (11%) , the medication would be administered regardless of the result (unless the client is hypoglycemic), so it is not necessary to notify the HCP.

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

The skin of the casted extremity should be assessed as the client could have damaged it by inserting a pointed object. Regular neurovascular checks should be performed on a client with a new cast as the client is at risk for compartment syndrome. However, there is no indication of peripheral vascular impairment (eg, changes in extremity color, temperature, or pulse) or peripheral neurologic impairment (eg, loss of sensory or motor function) of the casted extremity; therefore, this is not the priority at this time.

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

The vagus nerve is stimulated when bearing down; this temporarily slows the heart and decreases cardiac output, leading to potential cardiac complications in clients with heart disease (Option 3). Straining increases intra-abdominal and intrathoracic pressure and should be avoided in clients diagnosed with portal hypertension related to cirrhosis due to the risk of variceal bleeding. The maneuver increases intraocular pressure and is contraindicated in clients with glaucoma and recent eye surgery

The initial management of a near-drowning victim focuses on airway management due to potential aspiration (leading to acute respiratory distress syndrome), pulmonary edema, or bronchospasm (leading to airway obstruction). Hypoxia is managed and prevented by ensuring a patent airway via intubation and mechanical ventilation as necessary (Option 3). Careful handling of the hypothermic client is important because as the core temperature decreases, the cold myocardium becomes extremely irritable. Frequent turning could cause spontaneous ventricular fibrillation and should not be performed during the acute stage of hypothermia. Continuous cardiac monitoring should be initiated

There are passive, active external, and active internal rewarming methods. Passive rewarming methods include removing the client's wet clothing, providing dry clothing, and applying warm blankets. Active external rewarming involves using heating devices or a warm water immersion. Active internal rewarming is used for moderate to severe hypothermia and involves administering warmed IV fluids and warm humidified oxygen (Options 1 and 5). (Option 4) Unless blood loss has occurred from trauma during the near-drowning incident, administration of blood products is not indicated.

Metronidazole (Flagyl) is an antibiotic that can be used to treat a Trichomonasinfection.

There is no contraindication for its use in clients with Crohn disease.

Pancreatic enzyme supplements are used to aid the absorption of carbohydrates, fats, and proteins in a child with CF. They are taken with or just before every meal (not as needed); should be swallowed whole or sprinkled on an acidic food; and should not be crushed or chewed. They should not be taken with milk. Excessive intake could result in fibrosing colonopathy.

These enzymes are enteric-coated beads designed to dissolve only in an alkaline environment similar to that of the small intestine. They must not be mixed with a substance that would cause them to dissolve prior to reaching the jejunum. Capsule contents may be sprinkled on applesauce, yogurt, or acidic, soft, room-temperature foods with pH <4.5. Capsules should be swallowed whole and not crushed or chewed; chewing the capsules could cause irritation of the oral mucosa.

It is appropriate to suction the client when the high-pressure alarm on the MV sounds, saturations drop, rhonchi are auscultated, and secretions are audible or visible.

These manifestations can indicate excessive secretions impairing airway patency.

The major goals in acute pancreatitis are symptom management (eg, opioids, NPO status, nasogastric suction) and monitoring and prevention of complications (eg, IV fluids), giving the pancreas time to heal. The client should maintain positions that flex the trunk and draw the knees up to the abdomen (semi-Fowler's) to decrease tension on the abdomen. A side-lying position with the head elevated to 45 degrees will help relieve the pain even better.

These strategies include: NPO status - The client is maintained on NPO status as any ingestion of food will stimulate the excretion of pancreatic enzymes. A nasogastric tube is used to suction out gastric secretions; this will reduce nausea and lessen stimulation of the pancreas as these juices will move to the duodenum. Pain management - Intravenous opioids (eg, hydromorphone, fentanyl) are frequently utilized for pain management. Morphine can also be used; worsening pancreatitis due to increase in sphincter of Oddi pressure has not been proven in studies. IV fluids - Aggressive fluid replacement to prevent hypovolemic shock is critical. Inflammation of the pancreas releases chemical mediators that increase capillary permeability and cause third spacing (fluid going into empty spaces).

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

They are: Diagnostic (delay in diagnosis, failure to employ indicated tests, failure to act on results of monitoring) Treatment (error in performance of procedure, treatment, dose; avoidable delay) Preventive (failure to provide prophylactic treatment, inadequate follow-up/monitoring of treatment) Other (failure of communication, equipment failure, system failure)

Clients with ankylosing spondylitis often take nonsteroidal anti-inflammatory drugs to control back pain and are at risk of developing gastric ulcers.

They can cause melena (black stools). The client needs further assessment of orthostatic vital signs and hemoglobin level.

Ribbon like stool

Thin, ribbon-like stool is characteristic of Hirschsprung disease (congenital aganglionic megacolon). Bowel obstruction is caused by failure of the internal sphincter to relax.

Splenic sequestration crisis is a potentially life-threatening emergency of sickle cell disease. A rapidly enlarging spleen and hypotension are the characteristic assessment findings. Normal red blood cells live about 120 days. Sickle cells break apart and die within less than 20 days; therefore, the client always has a shortage of red blood cells (anemia). Due to anemia, clients often report feeling fatigued.

This client is exhibiting signs and symptoms of sickle cell crisis, which occurs when the client's sickle-shaped cells block blood flow through the vessels. These clients tend to have a small spleen due to repeated small splenic infarctions (autosplenectomy). Splenic sequestration crisis occurs when a large number of "sickled" cells get trapped in the spleen, causing splenomegaly. This is a life-threatening emergency as it can lead to severe hypovolemic (hypotensive) shock. The classic assessment finding is a rapidly enlarging spleen.

The recovery position is used as a first aid measure for an unconscious client who is still breathing. The client is placed on the left or right side in a three-fourths prone position with the top leg flexed.

This position maintains the airway and ensures that the client does not choke on vomit.

Tiotropium (Spiriva)

Tiotropium capsules should not be swallowed. These capsules are placed inside the inhaler device, and the capsule is pierced, allowing the client to inhale its contents

Who can't leave under AMA

To leave against medical advice (AMA), the client must be legally competent to make an educated decision to stop treatment. Disqualifications for legal competency include altered consciousness, mental illness (ie, a danger to self or others), and being under chemical influence (eg, drugs or alcohol). The client who drank a 1 L bottle of vodka is intoxicated (Option 2). The client who hears voices has psychotic symptoms and is potentially homicidal (Option 3). The manic client who has not eaten in 5 days is a potential danger to self and cannot leave AMA (Option 4). For a competent client to leave AMA, the health care provider must explain the risks of discontinuing treatment. The nurse must witness and document the discussion on risks of leaving AMA and the client's understanding of these risks ("informed refusal"). A client leaving AMA can, and should, receive discharge instructions and the option to return at any time. (Options 1 and 5) Clients have the right to leave AMA, even if it is not in their best interests to leave (eg, even if potentially life-threatening). Not allowing a competent client to leave AMA is a form of false imprisonment, a legally liable action by the nurse. Educational objective: The client must be legally competent to leave against medical advice. Disqualifications for legal competency include impairment by drugs or alcohol, altered consciousness, and mental illness (ie, a danger to self or others).

Loop diuretics (eg, furosemide [Lasix], bumetanide [Bumex]) are "potassium-wasting" diuretics, meaning that clients may experience potassium loss and hypokalemia. Hypokalemia in a client with heart failure creates a risk for life-threatening cardiac dysrhythmias. Therefore, clients taking loop diuretics usually require potassium supplementation. Potassium is an erosive substance that can cause pill-induced esophagitis.

To prevent esophageal erosion, the client should take potassium tablets with plenty of water (at least 4 oz [120 mL]) and remain sitting upright for ≥30 minutes after ingestion. This prevents the tablet from becoming lodged in the esophagus or refluxing from the stomach. Pill-induced esophagitis is also common with tetracyclines (eg, doxycycline) and bisphosphonates ("dronates": alendronate, ibandronate, pamidronate, risedronate), so clients taking these medications should be given similar instructions.

Individuals with type I or II diabetes mellitus are at increased risk for developing an infection or ulcer on their feet. This is due to the chronic complication of peripheral neuropathy, which results from nerve damage in the extremities. Instructions for diabetic foot care include: Wash feet daily with warm water and mild soap; test water temperature with thermometer beforehand. Gently pat feet dry, particularly between the toes (Option 2). Use lanolin to prevent dry and cracked skin, but do not apply between the toes. Inspect for abrasions, cuts, or sores. Have others inspect the feet if eyesight is poor.

To prevent injury, use cotton or lamb's wool to separate overlapping toes. Cut toenails straight across and use a nail file to file along the curves of the toes. Avoid going barefoot and wear sturdy leather shoes. Use mild foot powder to absorb perspiration and wear clean, absorbent socks with seams aligned. Avoid using over-the-counter products (eg, iodine, alcohol, strong adhesives) on cuts or abrasions. To improve circulation, do not sit with legs crossed or for extended periods, avoid tight-fitting garments, and perform daily exercise. Report other types of problems such as infections or athlete's foot immediately

Clients hospitalized with influenza should be on droplet precautions, wear a mask during transport, be instructed to cover coughs and sneezes, and be assisted in performing hand hygiene frequently. Antiviral medications (eg, zanamivir [Relenza], oseltamivir [Tamiflu]) are most beneficial if given within 48-72 hours of symptom onset. Influenza treatment includes rest, hydration, humidified air, and antipyretics/analgesics.

To prevent spreading influenza, infected clients should be on droplet precautions (eg, surgical mask, private room), wear a mask when being transported out of the room, and be taught to cover the mouth and nose while coughing or sneezing. Symptoms include fever, chills, severe muscle aches, headache, cough, sore throat, nasal congestion, and malaise.

INH interferes with the action of vitamin B6 (pyridoxine), resulting in peripheral neuropathy; it manifests as ataxia and paresthesia. Individuals who are most predisposed to becoming neurotoxic from taking INH include older adults, those who are malnourished, diabetic clients, pregnant or breastfeeding clients, alcoholics, children, those with liver or renal disease, and HIV-positive individuals.

To prevent these complications, a vitamin B6 supplement at a dose of 25-50 mg/day is recommended for those at high risk.

Lyme disease develops after a bite from a deer tick infected with Borrelia burgdorferi. Clients initially develop flulike symptoms (eg, headache, fever, myalgia, fatigue). Many clients develop erythema migrans, a bull's-eye rash; however, it is not always present. Any of these symptoms should be reported immediately to a health care provider (Option 4). The client will likely be prescribed antibiotics (eg, doxycycline, amoxicillin) to treat Lyme disease and prevent it from causing complications (eg, carditis, chronic arthritis, meningitis, facial paralysis).

To prevent tick bites during outdoor activities, clients should: Apply an insect repellent spray that contains tick-repelling ingredients (eg, DEET, picaridin). Avoid tall grass and thick underbrush, and hike only in the center of the trails. Wear long-sleeved shirts tucked into pants, long pants tucked into socks or boots, and closed-toed shoes. Covering attached ticks with petroleum jelly or nail polish is a folk remedy that actually increases the chance of infection by keeping the tick on the skin. Ticks should be promptly removed using tweezers, being careful to grasp the tick close to the attachment site and not crush it during removal.

The client has just returned from having a cast placed on the right forearm and is found putting a lead pencil in the cast to "reach the itch." What is the nurse's priority action? 1. Offer the client a straw to reach the itch instead of a lead pencil 2. Perform a peripheral neurovascular check of the casted extremity 3. Pour a generous amount of baby powder or corn starch in the cast to reach the itch 4. Review appropriate itch relief technique using the cool setting of a hair dryer

To relieve itching underneath a casted area, clients should use the cool setting of a hair dryer to direct air under the cast. Clients should never place any object, lotions, or powders in or around the casted area as skin irritation, injury, or infection may occur. Signs and symptoms of infection (eg, sores, purulent drainage, foul odors) and persistent itching should be reported to the health care provider. (Options 1 and 3) Nothing should be placed inside a cast due to the risk for injury and infection. (Option 2) The skin of the casted extremity should be assessed as the client could have damaged it by inserting a pointed object. Regular neurovascular checks should be performed on a client with a new cast as the client is at risk for compartment syndrome. However, there is no indication of peripheral vascular impairment (eg, changes in extremity color, temperature, or pulse) or peripheral neurologic impairment (eg, loss of sensory or motor function) of the casted extremity; therefore, this is not the priority at this time.

The formation of renal calculi (ie, kidney stones) can be due to various factors (eg, family history, dietary imbalances, immobilization, dehydration). Manifestations include sudden, severe abdominal or flank pain and nausea/vomiting. Client management focuses on analgesics administered at regularly scheduled intervals, rehydration of up to 3 L/day unless contraindicated by other comorbidities, and ambulation to facilitate the passage of calculi (Options 1 and 2).

To retrieve stones that the client may pass, the nurse should strain all urine obtained (Option 5). The collected stones are analyzed to determine their composition (eg, calcium oxalate, calcium phosphate, struvite, uric acid, cystine), which can then direct preventive measures, such as dietary and lifestyle changes, after discharge. (Option 3) Immobilization is a contributing cause of renal calculi formation and should be avoided. Ambulation and frequent mobilization are encouraged as tolerated to help facilitate the passage of calculi. (Option 4) Massage therapy to the flank should not be performed to prevent further instigation of renal colic. Other interventions, such as monitored heat therapy, would be acceptable.

Tolterodine (Detrol)

Tolterodine (Detrol LA), oxybutynin (Ditropan), and solifenacin (Vesicare) are antimuscarinic/anticholinergic medications used for overactive bladder and urge urinary incontinence. They decrease urinary urgency and frequency. The most common side effects are anticholinergic (eg, dry mouth, constipation, cognitive dysfunction). The client's report of not urinating the entire day while at work may indicate that the dosage is too high and is causing urinary retention. Urinary retention can lead to bladder infections and distension. This information should be reported to the health care provider (HCP).

The nurse is assisting with cardiopulmonary resuscitation of a client in cardiac arrest. The rhythm in the exhibit is displayed on the cardiac monitor. Which medication administration should the nurse anticipate? Click the exhibit button for additional information. 1. Adenosine IV 2.Dopamine IV 3. Magnesium IV 4. Metoprolol IV

Torsades de pointes (ie, "twisting of the points") is a polymorphic ventricular tachycardia characterized by QRS complexes that change size and shape in a characteristic twisting pattern. Torsades de pointes is usually due to a prolonged QT interval (more than half the RR interval), which is the result of electrolyte imbalances, especially hypomagnesemia, or some medications. The first-line treatment is IV magnesium (Option 3). Treatment may also include defibrillation and discontinuation of any QT-prolonging medications. (Option 1) Adenosine is an antiarrhythmic used to treat supraventricular tachycardia. (Option 2) Dopamine is a vasopressor used to treat symptomatic hypotension. (Option 4) Metoprolol is a beta blocker used for heart rate control in tachyarrhythmias. Educational objective: Torsades de pointes is usually due to a prolonged QT interval, which is the result of electrolyte imbalances, especially hypomagnesemia, or some medications. First-line treatment is magnesium IV. Treatment may also include defibrillation and discontinuation of QT-prolonging medications.

Third-degree atrioventricular (AV) block, or complete heart block, occurs when electrical conduction from the atria to the ventricles is blocked, causing decreased cardiac output (eg, dizziness, syncope, mental status changes, heart failure, hypotension, bradycardia). The client with third-degree AV block is a high priority, as the client may decompensate to cardiogenic shock and even periods of asystole

Treatment includes administration of atropine and temporary pacing (eg, transcutaneous) until a permanent pacemaker can be placed.

Parkinson disease is caused by low levels of dopamine in the brain. Levodopa is converted to dopamine in the brain, but much of this drug is metabolized before reaching the brain. Carbidopa helps prevent the breakdown of levodopa before it can reach the brain and take effect. This combination medication is particularly effective in treating bradykinesia (generalized slowing of movement).

Tremor and rigidity may also improve to some extent. Carbidopa-levodopa (Sinemet) once started should never be stopped suddenly as this can lead to akinetic crisis (complete loss of movement). However, prolonged use can also result in dyskinesias (spontaneous involuntary movements) and on/off periods when the medication will start or stop working unpredictably.

ulcerative colitis.: 1. "I need to eat a diet high in calories and protein so that I avoid losing weight." 2. "I need to take multivitamins containing calcium daily." 3. "I should avoid consuming alcoholic beverages." 4. "I should drink at least 2 liters of water daily and more when I have diarrhea." 5. "I will keep a symptom journal to note what I eat and drink during the day."

Ulcerative colitis (UC) is a form of inflammatory bowel disease characterized by remitting periods of mucosal irritation in the large intestine, resulting in profuse, bloody diarrhea. Management of clients with UC often includes dietary interventions to reduce symptoms and prevent reoccurrence, malnutrition, and dehydration. Nutrition and hydration management: Diets consisting of high-calorie, high-protein foods are recommended to prevent weight loss and muscle wasting (Option 1). Multivitamins containing calcium are often prescribed to supplement nutrition and should be taken regardless of symptoms (Option 2). Oral hydration is critical in UC as >10 liquid stools may occur daily during flares, placing clients at risk for dehydration. Instruct clients to drink at least 2 liters of water daily (Option 4). Dietary triggers for UC vary greatly between individuals and may include dairy, nuts/legumes, cereal, alcohol, caffeine, and fatty and processed foods. Diet journaling is recommended to assist with identifying triggers Caffeine, alcohol, and tobacco are gastric irritants that stimulate the intestine and should be avoided

A client is admitted to the hospital for severe headaches. The client has a history of increased intracranial pressure (ICP), which has required lumbar punctures to relieve the pressure by draining cerebrospinal fluid. The client suddenly vomits and states, "That's weird, I didn't even feel nauseated." Which action by the nurse is the most appropriate? 1. Document the amount of emesis 2. Lower the head of the bed 3. Notify the health care provider (HCP) 4. Offer anti-nausea medication

Unexpected and projectile vomiting without nausea can be a sign of increased ICP, especially in the client with a history of increased ICP. The unexpected vomiting is related to pressure changes in the cranium. The vomiting can be associated with headache and gets worse with lowered head position. The most appropriate action is to obtain a full set of vital signs and contact the HCP immediately. (Option 1) Documentation is important, but it is not the priority action. (Option 2) The head of the bed should be raised, not lowered, for clients with suspected increased ICP. Raising the head of the bed to 30 degrees helps to drain the cerebrospinal fluid via the valve system without lowering the cerebral blood pressure. (Option 4) The vomiting is caused not by nausea but by pressure changes in the cranium. Anti-nausea medications are often not effective. Decreasing intracranial pressure will help the vomiting. Educational objective: Notify the HCP of signs/symptoms of increased ICP, including unexpected vomiting. The vomiting is often projectile, associated with headache, and gets worse with lowering the head position.

The family practice clinic nurse is conducting client intake histories. Which client findings or histories indicate a need for heightened concern that the client may have cancer? Select all that apply. 1. The 60-year-old client was just diagnosed with benign prostatic hyperplasia (BPH) 2. The client reports a mobile, golf ball-sized lesion under the skin over the right thigh that feels doughy 3. The client reports a nagging cough with hoarseness for the past 3 months 4. The female client who weighed 150 lb (68.0 kg) has lost 15 lb (6.8 kg) in 3 months without dieting 5. The male client reports a skin change on the breast that looks like an orange peel

Unintentional weight loss of >10% of usual weight (in non-obese clients) requires evaluation and could indicate underlying cancer. Nausea, anorexia, and dysgeusia (altered taste sensation) are also clinical features of cancer and contribute to weight loss (Option 4). The warning signs of cancer can be remembered with the acronym CAUTION: Change in bowel or bladder habits A sore that does not heal Unusual bleeding or discharge from a body orifice Thickening or a lump in the breast or elsewhere Indigestion or difficulty in swallowing Obvious change in a wart or mole Nagging cough or hoarseness (Option 3) Although 99% of breast cancers are found in women, men can also develop breast cancer, especially if risk factors, such as past chest radiation, are present. Later signs of breast cancerinclude a newly retracted nipple or an orange-peel appearance of the breast tissue (peau d'orange) caused by the plugging of dermal lymph drainage (Option 5). (Option 1) BPH is caused by hormonal changes related to aging. Growth is not related to cancer. (Option 2) Lipomas are benign, fatty masses and rarely become malignant. They are subcutaneous, have a soft doughy feel, and are mobile and asymptomatic. Masses that are hard and fixed, not soft and mobile, usually indicate malignancy. Educational objective:Signs of potential cancer include unplanned weight loss, nagging cough/hoarseness, and dimpled skin (orange peel) on the breast. Hard, fixed masses, non-healing ulcers, and changing moles may also indicate malignancy and require further workup.

Upper GI bleed

Upper gastrointestinal bleeding (UGIB) is a potentially life-threatening condition commonly caused by bleeding gastroesophageal varices or peptic ulcers. Gastroesophageal varices are distended, fragile blood vessels within the stomach and/or esophagus that frequently occur secondary to cirrhosis. Due to the fragility of these veins, clients are closely monitored for variceal rupture. Rupture of gastroesophageal varices is an emergency complication that rapidly results in massive gastrointestinal bleeding, hypovolemic shock, and death. Variceal rupture commonly occurs due to a sudden increase in portal venous pressure (eg, coughing, straining, vomiting) and from mechanical injury (eg, chest trauma, consuming sharp/hard foods). In UGIB, nasogastric tube insertion may be prescribed for gastric decompression or evacuation. However, nasogastric tube insertion without visualization of the esophagus may traumatize and rupture varices, causing hemorrhage (Option 3). (Option 1) Pantoprazole is prescribed for clients with UGIB to reduce gastric acid secretion and help prevent ulceration of the gastric mucosa. (Option 2) Octreotide may be used to help control UGIB related to bleeding gastroesophageal varices, as it reduces portal venous pressure, which reduces bleeding. (Option 4) NPO status may be prescribed in cases of UGIB to prepare the client for invasive diagnostic or therapeutic procedures (eg, esophagogastroduodenoscopy, variceal ligation). Educational objective: Gastroesophageal varix rupture/hemorrhage is a potentially lethal complication of cirrhosis that may occur from increased portal venous pressure (eg, coughing) and mechanical injury (eg, nasogastric tube insertion). The nurse should question prescriptions for activities that increase the risk of such rupture.

Pregnant health care workers should not be exposed to clients with TORCH infections (Toxoplasmosis, Other [VZV/parvovirus B19], Rubella, Cytomegalovirus, Herpes simplex virus), as these infections can cause fetal abnormalities

Varicella-zoster virus (ie, chickenpox, shingles) is transmitted through airborne particles or contact with open vesicles. For chickenpox and disseminated shingles, the nurse should use precautions for both airborne isolation (ie, N95 particulate respirator mask, room with negative air pressure) and contact isolation (eg, gown, gloves, disposable equipment) until vesicles have crusted.

Ventricular bigeminy in a client following a myocardial infarction indicates risk for developing ventricular tachycardia or ventricular fibrillation, both potentially life-threatening dysrhythmias. The nurse should assess the client's vital signs, electrolytes (mag and K) , and apical-radial pulse, before giving meds (amiodarone) and notify the health care provider.

Ventricular bigeminy is a rhythm in which every other heartbeat is a premature ventricular contraction (PVC). PVCs in the presence of a myocardial infarction (MI) indicate ventricular irritability and increase the risk for a more serious dysrhythmia (eg, ventricular tachycardia, ventricular fibrillation). Possible causes of ventricular bigeminy include electrolyte imbalances and ischemia. After assessing the client's vital signs, the nurse should assess potassium and magnesium levels and apical-radial pulse, administer the scheduled amiodarone, and notify the health care provider (HCP).

cranial nerve VIII

Vestibulocochlear

Folic acid deficiency does not cause peripheral neuropathy. It is associated with macrocytic anemia and neural tube defects in children.

Vitamin B12 deficiency can cause peripheral neuropathy; however, it is not seen with INH therapy Vitamin D deficiency causes osteomalacia but not peripheral neuropathy.

Which of the following drug administrations should be reported as a practice error? Select all that apply. 1. Cephalexin administered; client has history of anaphylaxis from penicillin 2. Hydromorphone 2 mg administered; client reports pruritus 3. Immunization for 3-month-old administered in ventrogluteal site 4. Oral niacin (nicotinic acid) administered; client has facial flushing 5. Warfarin administered; client at 12 weeks gestation

Warfarin (Coumadin) is generally contraindicated in pregnancy. Warfarin is a teratogen and exposure during early pregnancy can result in fetal malformations (warfarin embryopathy). It crosses the placenta, resulting in fetal anticoagulation; dangerous fetal bleeding, including intracranial hemorrhage, can occur. As a result, a client on warfarin is taught to use effective contraception (Option 5). For children age <7 months, the site for immunizations is the anterolateral thigh (vastus lateralis). The gluteus medius muscle (muscle injected with a ventrogluteal injection) is developed through crawling and walking. The muscles are not developed enough at this age to be used as an acceptable site (Option 3). History of penicillin hypersensitivity should be determined prior to administration. Clients who are truly allergic to penicillins (eg, anaphylaxis) have an increased risk of allergy to other beta-lactam antibiotics. The incidence of cross-reactivity is 1%-4% (Option 1). (Option 2) Pruritus (itching) is a known side effect of narcotic administration, particularly if the client is opioid naïve. It does not represent true allergy and is often treated with an antihistamine. Nausea is also quite common when opioid therapy is initiated, but clients quickly develop tolerance. (Option 4) Niacin (nicotinic acid or B3) is used in large doses for lipid-lowering properties. In large doses, it may produce cutaneous vessel vasodilation. The resulting warm sensation within the first 2 hours after oral ingestion is uncomfortable but harmless. It may last for several hours. Effects usually subside as therapy continues. Educational objective: Do not administer warfarin if the client is pregnant. Intramuscular injections are given in the vastus lateralis to children age <7 months. Penicillins and cephalosporins can have a cross-sensitivity response. Narcotic-induced pruritus is not a true allergy.

The characteristic signs and symptoms associated with pulmonary TB disease include cardinal (major) signs (eg, cough, sputum production, dyspnea) and constitutional (minor) signs (eg, anorexia, weight loss, fatigue, fever, night sweats). Isolation is mandatory for clients with conditions that involve airborne transmission, and rooms must use both negative air pressurization and high-efficiency particulate air (HEPA) filters to avoid contamination. A class N95 or higher particulate respirator must be worn during client care. All clients with symptoms consistent with a suspected airborne illness should be given a surgical mask to wear as soon as they are assessed during triage. Good hand hygiene is always the first and last element of infection control in any client care setting.

Wearing a gown and face shield would be necessary only if the nurse suspected splash of body fluids from procedural client care, not from routine care such as assessment or medication administration. Contact precautions may also be necessary if the tuberculosis is extrapulmonary with draining lesions (eg, cutaneous tuberculosis).

Buck's skin traction maintains proper alignment of an injured body part by using weights to apply a continuous pulling force. Appropriate actions for a client in Buck's skin traction include: The client should be supine or in semi-Fowler's position (maximum of 20-30 degrees). Elevating the head of the bed more than 30 degrees would promote sliding (Option 1). Regularly assess the neurovascular status and skin integrity of the limb in traction. Loosen Velcro straps if the boot is too tight as they can impair neurovascular status and skin integrity; tighten the straps if the boot is too loose as this can decrease effectiveness of the traction. When a change is made in the application of the boot or traction pulley system, the nurse should reassess neurovascular status in 30 minutes (Option 3). Provide a fracture pan, which is smaller than a bedpan, for elimination needs to minimize client movement and provide comfort (Option 4).

Weights should be free-hanging at all times and should never be placed onto the bed or touch the floor. A staff member should support the weight while the client is repositioned up in bed to prevent excessive pull on the extremity (Option 2). Skeletal traction is applied directly to the bone with a metal wire or pin and is used to immobilize, position, or align a fracture when continuous traction is needed and skin traction is not possible. Removing the weights can cause injury to the client and should never be removed unless there is a life-threatening situation.

The nurse should assess breath sounds, encourage coughing and deep breathing, and reposition the client who has a decrease in chest tube drainage

When chest drainage stops abruptly, the nurse must perform assessments and interventions to ascertain if this is an expected finding. -Auscultating breath sounds helps the nurse detect whether breath sounds are audible in all lung fields, potentially indicating that the lung has re-expanded and there is no more drainage. Other interventions to facilitate drainage include having the client cough and deep breathe and repositioning the client. If a client has been in one position for a prolonged period, drainage may accumulate and a position change may facilitate improved drainage. -A change in suction level should be performed only after obtaining a health care provider (HCP) prescription. In general, suction above 20 cm H2O is not indicated. -Milking chest tubes to maintain patency is performed only if prescribed. It is generally contraindicated due to potential tissue damage from highly increased pressure changes in the pleural space.

The nurse is forming a plan of care for an 82-year-old client with a history of anxiety, hypertension, urinary incontinence, and arthritic back pain. Which nursing diagnosis should be addressed first? Click on the exhibit button for additional information. 1. Anxiety 2. Chronic pain 3. Risk for acute confusion 4. Risk for falls

When determining which nursing diagnosis to address first, the nurse should consider factors that affect client safety. Risk for falls is an immediate safety concern (Option 4). Nursing diagnoses that relate to chronic conditions (eg, anxiety, chronic pain) are addressed after risk for falls. The nurse should immediately implement fall risk precautions by placing the bed in the lowest position, ensuring that the call light is within reach, and turning on the bed alarm. Interventions for addressing other client needs may be carried out after measures to ensure client safety. Advanced age is associated with decreased visual acuity, muscle mass, strength, and reaction time. Medications that cause dizziness or drowsiness increase the risk for falls. Diuretics (eg, furosemide) increase urinary frequency and may cause hypotension. Antihypertensive medications (eg, lisinopril, metoprolol) may cause bradycardia and dizziness. (Option 1) Safety needs are addressed before love and belonging needs (eg, anxiety). Anxiety interventions (eg, therapeutic touch, medication) may be implemented after safety interventions. (Option 2) Safety is the immediate concern for a client with a high fall risk. Arthritic joint changes are a source of chronic pain. Pain interventions (eg, medication, repositioning) may be implemented after safety interventions. (Option 3) A client with advanced age in an unfamiliar environment may develop acute confusion during the hospital course, but a high fall risk is a more immediate concern on admission. Educational objective:The nursing diagnosis of risk for falls should be addressed first for a client who has multiple risk factors for falls. Advanced age, incontinence, certain medications, and limited mobility increase fall risk.

Side effect of tiotropium (Spiriva) and other anticholinergics (eg, ipratropium, benztropine)

Xerostomia (dry mouth) due to the blockade of muscarinic receptors of the salivary glands, which inhibits salivation. Sugar-free candies or gum may be used to alleviate dry mouth and throat

Dysgeusia

altered taste sensation

Echinacea: tx and prevention of cold and flu, not effective in HIV patient, causes liver toxicity in renal pts

anaphylaxis,

Rib Fractures

are often the result of blunt thoracic trauma (eg, motor vehicle collision). In the absence of significant internal injuries (eg, pneumothorax, pulmonary contusion, spleen laceration), interventions focus on pain management and pulmonary hygiene techniques (eg, coughing, deep breathing, incentive spirometry Breaths may become shallow as the client experiences pain with inspiration, which can result in a buildup of secretions, atelectasis, and pneumonia. The nurse should ensure adequate pain control prior to encouraging pulmonary hygiene techniques (Option 1)

Tinnitus (ie, ringing in the ears) uncommon SE of NSAID (naproxen)

associated with toxicity related to salicylate-containing NSAIDs (eg, aspirin) or aminoglycosides (eg, gentamicin, neomycin, tobramycin); its onset should be reported by a client taking these medications. The medication may need to be discontinued to prevent permanent hearing loss.

atropine

bradycardia

Prednisone with Naproxen Glucocorticoids (eg, prednisone), when taken in combination with aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) such as naproxen,

can increase the risk of gastrointestinal ulceration and bleeding. The client should report black, tarry stools (ie, melena) to the health care provider as they could indicate gastrointestinal bleeding

frontal lobe

controls higher-order processing, such as executive function and personality. Injury to the frontal lobe often results in behavioral changes.

Ventricular bigeminy

every other beat is a PVC

Saw Palmetto

for BPH, mild stomach discomfort, increase bleeding risk

black cohosh cause premature labor

for postmenopausal symptoms, s/e hepatic injury

Give erythropoietin

hgb less than 10

C. diff

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 body fluid splashing.

Peaked T waves

hyperkalemia

Eryhtropoietin (EPO) hold

if Hgb greater than 11

ginseng

improved mental performance -increase bleeding risk

Zolpidem (Ambien) is a hypnotic medication that

induces sleep for clients with sleep disturbances (eg, acute mania).

Parietal lobe

integrates somatic and sensory input. Injury to the parietal lobe could result in a deficit with sensation. The nurse would verify the client's injuries and documented imaging studies to confirm that this was an expected deficit and document it accordingly. If it is a new or unexpected deficit, the nurse should inform the health care provider immediately.

temporal lobe

integrates visual and auditory input and past experiences. Temporal lobe injury clients cannot understand verbal or written language.

Clomiphene

is a selective estrogen receptor modulator that is used as a first-line treatment for infertility for women and works by stimulating ovulation. This medication blocks estrogen receptors in the hypothalamus and pituitary, which causes the release of hormones (ie, gonadotropin-releasing hormone, follicle-stimulating hormone, luteinizing hormone) that stimulate the ovaries to release an egg. The medication is taken orally for 5 days early in the menstrual cycle (eg, beginning on days 3-5 of menses). Ovulation typically occurs 5-9 days after completing the medication. Therefore, it is necessary for the client to understand the importance of engaging in frequent sexual intercourse (eg, every other day for 1 week) 5 days after completing the medication for the best chance of successful conception (Option 3). (Option 1) One of the risks of taking clomiphene is that more than one ovarian follicle sometimes develops, causing 2 or more eggs to be released, which may result in multiple gestation. (Option 2) Mood swings, nausea, hot flashes, and headaches are common side effects associated with clomiphene. (Option 4) This statement shows correct understanding of how clomiphene works. Educational objective: Clomiphene is an infertility treatment for women that works by stimulating ovulation. It is necessary to engage in frequent sexual intercourse 5 days after completing the medication regimen. Clomiphene may cause mood swings, nausea, hot flashes, and headaches and increases the risk of multiple gestation.

Intusussception

is an intestinal obstruction that occurs when a segment of the bowel folds (ie, telescopes) into another segment. Pressure gradually increases within the bowel, causing ischemia and leakage of blood and mucus into the lumen, which produces the characteristic stool mixed with blood and mucus (ie, red, "currant jelly"). Initially, some infants may have only general symptoms (eg, irritability, diarrhea, lethargy). Subsequently, episodes of sudden abdominal pain (cramping), drawing the knees up to the chest, and inconsolable crying are seen. After an episode, the infant may vomit and then appear otherwise normal. Assessment may show a sausage-shaped abdominal mass.

Infertility

is diagnosed when a couple fails to conceive after 12 months (women age <35) or 6 months (women age ≥35) of frequent, unprotected intercourse.

infant botulism

is food poisoning that occurs after consuming Clostridium botulinum, a bacteria found in soil and animal products (eg, raw honey, milk). In infants, the bacteria often colonize the gastrointestinal tract and release an exotoxin that causes rapid, life-threatening paralysis. In addition to young age, absence of competitive bowel flora predisposes infants (age <1 year) to this infection. Therefore, infants should not be fed honey. Early clinical manifestations of infant botulism often include constipation, difficulty feeding, decreased head control, and diminished deep-tendon reflexes (Option 1). It is essential to recognize symptoms early, because botulism progresses rapidly to respiratory failure and arrest. Management of infant botulism often includes administering intravenous botulism immune globulin (BIG-IV), which reduces severity and duration of symptoms by improving immune response. In addition, close monitoring and supportive care (eg, mechanical ventilation, enteral tube feedings) are provided. (Option 2) Pain, swelling, and deformity of the elbow after falling may indicate a fracture. However, a fracture should not delay care of clients at risk for imminent respiratory failure. (Option 3) Right-sided abdominal pain, fever, and inability to tolerate food may indicate acute appendicitis, which requires prompt care. However, clients with suspected botulism remain the priority. (Option 4) Painful urination, back pain, and lethargy are clinical manifestations of urinary tract infection. Laboratory analysis and antibiotics may be required but should not delay care of suspected botulism. Educational objective: Infant botulism is food poisoning causing life-threatening paralysis, which occurs after consuming Clostridium botulinum. Infants (age <1 year) with signs of botulism (eg, constipation, difficulty feeding, decreased head control, diminished deep-tendon reflexes) require prompt intervention because respiratory failure may develop rapidly.

Pantoprazole

is prescribed for clients with UGIB to reduce gastric acid secretion and help prevent ulceration of the gastric mucosa

Octreotide (Sandostatin)

may be used to help control UGIB related to bleeding gastroesophageal varices, as it reduces portal venous pressure, which reduces bleeding.

Aortic dissection

occurs when the arterial wall intimal layer tears and allows blood between the inner (intima) and middle (media) layers. Clients with ascending aortic dissections typically have chest pain, which can radiate to the back. Descending aortic dissection is more likely associated with back pain and abdominal pain. It is frequently abrupt in onset and described as "worst ever," "tearing," or "ripping" pain. Hypertension is a contributing factor. Extending dissection from uncontrolled hypertension can cause cardiac tamponade or arterial rupture, which is rapidly fatal. Emergency treatment includes surgery and/or lowering the blood pressure.

occipital lobe

of the brain registers visual images. Injury to the occipital lobe could result in a deficit with vision.

Clostridium botulinum in honey

or soil can colonize an infant's immature gastrointestinal system and release a toxin that causes botulism, a rare but serious illness. The toxin attacks the neuromuscular system, causing progressive muscle paralysis that can potentially lead to respiratory failure and death. Initial manifestations may include constipation, generalized weakness, difficulty feeding, and decreased gag reflex. Iron-fortified infant cereals (eg, oatmeal) mixed with formula or breastmilk are appropriate for infants >6 months; however, honey (especially raw or wild) is not recommended for infants age <12 months due to the risk of botulism (Option 3). (Option 1) Although apple pie adds excessive amounts of fat and sugar to the infant's diet, this is not the priority over honey, which can be life-threatening. (Option 2) Small portions (<1 tablespoon) of solid food are appropriate for infants. Continuing to feed an infant who acts disinterested in food (eg, turns away) can contribute to future obesity. The nurse should explore this behavior further; however, the priority is to address the danger of feeding an infant honey. (Option 4) TV dinners and various canned foods have high sodium and sugar content and therefore are not the best sources of nutrition for an infant. However, TV dinners are not immediately life threatening. Educational objective: Clostridium botulinum spores in honey can colonize an infant's (age <12 months) immature gastrointestinal system and release a toxin that causes botulism, a rare but potentially life-threatening illness.

Morphine is administered to promote breathing synchrony with the mechanical ventilator, .

reduce anxiety, and promote comfort in clients receiving MV

Copper intrauterine device (IUD) insertion and oral ulipristal (eg, Ella)

require a prescription and offer EC for up to 5 days (120 hr) after unprotected intercourse.

Decreased vibrancy of colors is a sign of diabetic retinopathy

requires intervention, it is not indicative of a partial or complete retinal detachment; therefore, it is not an emergency.

Hyperthyroidism

results from excessive secretion of thyroid hormones. Affected clients are at risk for developing thyroid storm, a life-threatening form of hyperthyroidism. Symptoms of thyroid storm include fever, tachycardia, cardiac dysrhythmias (eg, atrial fibrillation), nausea, vomiting, diarrhea, and altered mental status. Client management includes reducing fever, maintaining hydration, and preventing cardiac compromise (eg, heart failure). (Option 1) The post-thyroidectomy client who needs a refill of the thyroid replacement medication should be contacted third. Without thyroid replacement therapy, this client would experience signs and symptoms of hypothyroidism (eg, extreme fatigue, bradycardia). (Option 2) Clients on corticosteroids may report moods swings and irritability; these are common side effects. (Option 3) The client with diabetes who is asymptomatic but has elevated blood sugars should be contacted second as prolonged hyperglycemia may lead to dehydration and acidosis. Educational objective: Clients with hyperthyroidism are at risk for developing thyroid storm, a life-threatening condition. Symptoms include fever, tachycardia, cardiac dysrhythmias, nausea, vomiting, diarrhea, and altered mental status. Client management includes reducing fever, maintaining hydration, and preventing cardiac compromise.

Sodium polystyrene sulfonate (Kayexalate) is used to treat mild to moderate hyperkalemia: Clients receiving sodium polystyrene sulfonate must have normal bowel function to avoid the risk of intestinal necrosis. The nurse must assess for constipation, signs of impaction, and recent bowel patterns.

severe hypokalemia (palpitations, lethargy, cramping) can develop. Frequent monitoring of electrolyte status is required. Because potassium exchanges with sodium content of the resin, excess sodium absorption could put clients at risk of developing volume overload(water follows sodium). The client should be monitored for signs of fluid overload (eg, crackles, jugular venous distension, edema) and have daily weights and intake and output assessment.

Kava for anxiety and insomnia

severe liver damage

large-bowel obstruction

symptoms of a large-bowel obstruction differ slightly from small-bowel obstruction and include gradual onset of symptoms, cramping abdominal pain, abdominal distension, absolute constipation, and lack of flatus. Constipation and decreased flatus resulting from small-bowel obstruction would occur later, as the stool and gas in the large colon would be expelled for a few days.

Side-lying positioning is utilized in hypoxic clients with unilateral pneumonia

to increase perfusion to the healthy lung by gravity and improve oxygenation by positioning the client with the unaffected (good) side down. However, side-lying position alone does not improve secretion clearance

Preoxygenation with 100% oxygen for 30 seconds before suctioning, unless otherwise specified, is the recommended practice

to reduce suctioning-associated risks for hypoxemia, microatelectasis, and cardiac dysrhythmias.

afib

warfarin , amiodarone

Clients with acute diverticulitis (inflammation of the diverticula) are at risk for perforation,

which can be manifested by increasing abdominal pain, rigidity, guarding, and rebound tenderness (peritoneal signs).

Guaifenesin (Mucinex) is an expectorant used to facilitate mobilization of mucus and should not have the potential to exacerbate asthma or cause an attack. Loratadine (Claritin) is an antihistamine and should not have the potential to exacerbate asthma or cause an attack. Vitamin D is used to help maintain bone density and should not have the potential to exacerbate asthma or cause an attack

wo groups of commonly used drugs, nonsteroidal anti-inflammatory drugs and beta-adrenergic antagonists (beta blockers), have the potential to cause problems for clients with asthma. Ibuprofen (Motrin) and aspirin are common over-the-counter anti-inflammatory drugs that are effective in relieving pain, discomfort, and fever. About 10%-20% of asthmatics are sensitive to these medications and can experience severe bronchospasm after ingestion.