NCLEX Questions & Explanations (PT 2)

The nurse is caring for a 56-year-old client in the emergency department.

Educational objective: An aortic dissection is a tear in the inner lining of the aorta that causes severe, sharp chest or back pain that is abrupt in onset and often described as "tearing." Management includes administering IV opioids and beta blockers and monitoring for aortic rupture (eg, muffled heart sounds, narrowed pulse pressure).

The nurse is teaching a client who is scheduled for a cardiac pharmacologic stress test in 2 days. Which of the following information should the nurse include? Select all that apply.

A cardiac pharmacologic stress test uses vasodilators (eg, adenosine, dipyridamole) to simulate exercise when clients are unable to tolerate continuous physical activity or when their target heart rate is not achieved through exercise alone. These medications produce vasodilation of the coronary arteries in clients with suspected coronary heart disease. Preprocedure instructions include: Avoid smoking cigarettes on the day of the test because nicotine is a stimulant Expect to experience transient nausea and/or flushing as vasodilators are injected In addition, report symptoms such as chest pain and/or dyspnea during the test. Note that a peripheral venous access device will be inserted prior to the test to administer vasodilators and other medications as necessary - Clients should avoid caffeine and decaffeinated beverages before the test because these products may contain trace amounts of caffeine.

A client comes to the emergency department after being assaulted. Imaging studies show a simple fracture of the mandible. The nurse assesses edema of the face and jaw, drooling, and bleeding in the mouth; the client rates pain as a 9 out of 10. What is the priority nursing intervention?

Educational Outcome: A direct blow to the face or a motor vehicle collision is usually the cause of mandibular fracture. The client drools due to inability to close the mouth from edema and misalignment of the jaw. Structural damage, excessive saliva, and bleeding with pooled blood in the mouth can compromise the airway. Therefore, the priority nursing intervention is to suction the mouth and oropharynx to maintain airway patency.

The nurse is caring for a client receiving peritoneal dialysis. Which findings are essential for the nurse to report to the health care provider? Select all that apply.

During peritoneal dialysis (PD), a catheter is placed into the peritoneal cavity to infuse dialysate (dialysis fluid); the tubing is then clamped to allow the fluid to dwell for a specified period. After the dwell time, the catheter is unclamped and the fluid (effluent) drains out via gravity. Cloudy outflow (effluent), tachycardia, and low-grade fever are signs of peritonitis, an infection of the peritoneal cavity and a major concern with PD. Bloody fluid can indicate intestinal perforation or that the client may be menstruating. Brown effluent can indicate fecal contamination from perforation. All these findings need to be reported to the health care provider.

An experienced nurse precepts a graduate nurse in the intensive care unit while caring for a client with a right subclavian triple-lumen central venous catheter (CVC). Which statement by the graduate nurse indicates understanding of the CVC?

Educational Outcome: A central line or central venous catheter (CVC) is inserted by the health care provider in a "central" vein (eg, subclavian, internal jugular, femoral) and is used to administer fluids, medications, and parenteral nutrition and for hemodynamic monitoring. Proper hand hygiene should be performed when caring for a CVC to prevent infection, and nonsterile gloves should be worn to protect the nurse from blood or body fluids at the port site as one or more lumens are often used to draw blood. The Centers for Disease Control and Prevention recommend that catheter hubs always be handled aseptically to prevent catheter-associated infections. The hubs should be disinfected with a hospital-approved antiseptic (eg, 70% alcohol sterile pads; > 0.5% chlorhexidine with alcohol; 10% povidone-iodine). CVCs may have multiple lumens. These are used to administer incompatible drugs simultaneously, for blood draws, and for hemodynamic monitoring.

The nurse on the orthopedic unit is observing staff members caring for assigned clients. The nurse should intervene if a staff member is observed

Educational outcome: To prevent hip flexion contractures following an above-the-knee amputation, a client's residual limb should not be elevated, especially after 24 hours. Instead, the client should wear a figure eight compression bandage at all times to control edema until the residual limb is healed (Option 4). Hip flexion contractures can also be avoided by placing the client in the prone position with the hip in extension for 30 minutes 3 or 4 times daily. Other info: A halo external fixation device is used to stabilize a cervical or high thoracic fracture when there is no damage to the spinal cord, thereby allowing the client to ambulate.

A client with throat cancer receives radiation therapy to the head and neck. Which of the following strategies are appropriate to decrease the adverse effects associated with radiation therapy? Select all that apply.

Educational outcome: Using artificial saliva to manage xerostomia and the production of thick saliva due to altered salivary gland function

The nurse is interviewing a non-English-speaking client. Which best practices will the nurse use when working with a professional medical interpreter for clients of limited English proficiency? Select all that apply.

Educational outcome: When working with an interpreter, the nurse should apply the following best practices to maximize communication and understanding with the client: Address the client directly in the first person Speak in short sentences, pausing to allow the interpreter to spea. Ask only one question at a time Avoid complex issues, idioms, jokes, and medical jargon Hold a pre-conference with the medical interpreter to review the goals of the interview. Use a qualified professional interpreter whenever possible The nurse should be mindful of any gender preferences to ensure the client is comfortable speaking with the interpreter

The nurse is preparing to admit a client with endometrial cancer to the oncology unit for brachytherapy via a sealed cervical implant. Which of the following interventions are appropriate to include in the plan of care for this client? Select all that apply.

Educational outcome: those with temporary brachytherapy (eg, sealed cervical radium implants) require safety precautions because the client emits radiation while the source is in place and poses a risk of exposure to others. The plan of care for a client with temporary brachytherapy implants should include the following interventions: Use appropriate shielding (eg, place client in a lead room, use lead shields and apron) to limit exposure Limit each person's time of exposure to the client (eg, cluster care, 30 minutes per shift) Assign all staff members involved in the client's care their own dosimeter badge to measure radiation exposure, and instruct them to wear it during every shift Instruct the client to remain on bed rest, and use caution when repositioning to avoid device dislodgement Maximize distance from the client (eg, 6 ft [1.8 m] is recommended)

he nurse is reviewing recommended dietary modifications with the parents of a 6-month-old client with phenylketonuria. Which of the following information should the nurse include? Select all that apply.

Phenylketonuria (PKU) is one of a few genetic inborn errors of metabolism. Individuals with PKU have a phenylalanine hydroxylase (PAH) enzyme deficiency. PAH enzyme is required for converting the amino acid phenylalanine into the amino acid tyrosine. As unconverted phenylalanine accumulates; irreversible neurologic damage can occur. A low-phenylalanine diet is essential in the treatment of PKU Phenylalanine cannot be entirely eliminated from the diet because it is an essential amino acid and necessary for normal development. The diet must meet nutritional needs while maintaining safe phenylalanine levels (2-6 mg/dL [120-360 µmol/L] for clients age <12). Other management strategies for clients with PKU include: Eliminating high-phenylalanine foods (eg, meats, eggs, milk) from the diet Feeding infants specially prepared formulas that are low in phenylalanine Encouraging consumption of natural foods low in phenylalanine (ie, most fruits and vegetables)

The nurse is assisting during a scheduled cardioversion for a client who is experiencing supraventricular tachycardia. It would require follow-up if the nurse

Synchronized cardioversion is a procedure used to convert tachydysrhythmias (eg, supraventricular tachycardia) with a pulse to stable cardiac rhythms via transcutaneous electrical shock. The synchronizer feature of a defibrillator ensures the shock is delivered only during ventricular depolarization (ie, the R wave of the QRS complex). The nurse must ensure that the synchronizer switch is turned on during cardioversion. Disabling or failing to enable the synchronizer feature may result in delivery of a potentially lethal, asynchronous shock to the client Accidentally delivering shocks during the T wave, when heart ventricles are repolarizing, would cause R-on-T phenomenon, which frequently results in a lethal dysrhythmia (eg, ventricular fibrillation).

The nurse is caring for a client who had a transsphenoidal hypophysectomy and developed diabetes insipidus. Which of the following findings would the nurse expect to observe? Select all that apply.

Transsphenoidal hypophysectomy is the surgical removal of the pituitary gland, an endocrine gland that produces, stores, and excretes hormones (eg, antidiuretic hormone [ADH], growth hormone, adrenocorticotropic hormone). Clients undergoing hypophysectomies are at risk for developing neurogenic diabetes insipidus (DI), a metabolic disorder of low ADH levels. ADH promotes water reabsorption in the kidneys. Therefore, loss of circulating ADH results in massive diuresis of dilute urine. Clinical manifestations associated with DI include: Polydipsia (ie, increased/excessive thirst) Polyuria (ie, increased urine output) Increased serum osmolality (ie, water-electrolyte balance in the blood) due to dehydration from polyuria Clients with DI experience hypernatremia (ie, increased serum sodium level) due to free water loss in the urine.

A client with a history of diverticular disease is being discharged after an episode of acute diverticulitis. Which instructions should be included in the discharge teaching plan to reduce the risk of future episodes? Select all that apply.

Educational Outcome: A low-residue diet, which avoids all high-fiber foods, may be used in treating acute diverticulitis. However, after symptoms have resolved, a high-fiber diet is resumed to prevent future episodes.

The nurse receives morning report on 4 clients who were admitted 24 hours earlier for injuries incurred in motor vehicle collisions. Which client should the nurse assess first?

Educational Outcome: A lung contusion (bruised lung) caused by blunt force can occur when an individual's chest hits a car steering wheel. This injury is potentially life-threatening because bleeding into the lung and alveolar collapse can lead to acute respiratory distress syndrome. Clients should be monitored for 24-48 hours as symptoms (eg, dyspnea, tachypnea, tachycardia) are usually absent initially but develop as the bruise worsens. Inspiratory chest pain can lead to hypoventilation, and an oxygen saturation of 90% (normal: 95%-100%) indicates hypoxemia. Therefore, the nurse should assess this client with lung contusion first and then notify the health care provider as immediate interventions to decrease the work of breathing and improve gas exchange (eg, supplemental oxygen, medications, ventilatory support) may be necessary.

The nurse completes a neurological examination on a client who has suffered a stroke to determine if damage has occurred to any of the cranial nerves. The nurse understands that damage has occurred to cranial nerve IX based on which assessment finding?

Educational Outcome: Mnemonic: On Old Olympus's Towering Top, AFinn And German Viewed Some Hops - Cranial nerves IX and X work together to create movement of the pharynx and tongue. An absent gag reflex, asymmetrical uvular and palate movement, or a change in voice quality indicates damage.

The nurse enters the room of a client who had a tracheostomy created 2 months ago. The nurse notes that the client is in respiratory distress and the tracheostomy tube is lying on the bed next to the client. Which of the following actions should the nurse take?

Educational Outcome: A tracheostomy tube is an artificial airway inserted into the trachea through the neck. Accidental decannulation or dislodgment of a tracheostomy tube is a medical emergency that often results in respiratory distress. If accidental decannulation of a mature tracheostomy (ie, >7 days after insertion) occurs, the nurse should attempt to open the stoma with a curved hemostat and insert a new tracheostomy tube with an obturator (Option 2). The obturator is then removed to allow air to flow through the tube. An obturator and new tracheostomy tube should be kept at the bedside for clients with a tracheostomy. Covering the stoma with a sterile, occlusive dressing (eg, petroleum gauze, foam tape) and ventilating with a bag-valve mask over the mouth and nose are indicated for immature tracheostomies (ie, <7 days after insertion). Reinsertion of the tube is preferred for clients with a mature tracheostomy.

The nurse in the outpatient clinic is speaking with a client diagnosed with cerebral arteriovenous malformation. Which statement would be a priority for the nurse to report to the health care provider?

Educational Outcome: An arteriovenous malformation (AVM) is a tangle of veins and arteries that is believed to form during embryonic development. The tangled vessels do not have a capillary bed, causing them to become weak and dilated. AVMs are usually found in the brain and can cause seizures, headaches, and neurologic deficits. Treatment depends on the location of the AVM, but blood pressure control is crucial. Clients with AVMs are at high risk for having an intracranial bleed as the veins can easily rupture because they lack a muscular layer around their lumen. Any neurologic changes, sudden severe headache, nausea, and vomiting should be evaluated immediately as these are usually the first symptoms of a hemorrhage Other info The report of dyspnea may prompt further evaluation depending on the type of exercise performed, but it is not the priority. Clients with AVMs should be discouraged from engaging in heavy exercise as it increases blood pressure. Clients with AVMs should

The nurse is assessing a client with suspected hepatitis. Which of the following questions would be important for the nurse to ask the client? Select all that apply.

Educational Outcome: Black, tarry stool (ie, melena) is an expected finding with gastrointestinal bleeding (from the digested blood) and can occur in clients with gastric or esophageal varices. Pale stools are typically associated with hepatitis.

The nurse in the emergency department is assessing a client who is reporting headache, nausea, and dizziness after being stranded at home without electricity during a winter storm. Which of the following questions would be most important for the nurse to ask the client?

Educational Outcome: Carbon monoxide (CO) is a colorless, odorless gas produced by burning fuel (eg, oil, kerosene, coal, wood) in a poorly ventilated setting. CO toxicity (poisoning) is most often associated with smoke inhalation from structure fires but is also generated by furnaces/water heaters fueled by natural gas or oil, coal or wood stoves, fireplaces, and engine exhaust. Clients with CO toxicity often have nonspecific symptoms (eg, headache, nausea, dizziness) and the diagnosis can be missed. It is important to assess for possible CO exposure to initiate appropriate emergency care and prevent hypoxic neurologic impairment. To help identify elevated CO levels in the home, the nurse can ask about the following: Similar symptoms in other family members or an illness in an indoor pet that developed at the same time. Fuel-burning heating/cooking appliances; the risk for CO toxicity increases in the fall and winter due to increased use of heat sources in an enclosed space

The nurse is teaching about cervical cancer prevention at a women's health conference. Which of the following factors should be taught as risks for cervical cancer? Select all that apply.

Educational Outcome: Clients with weakened immunity (eg, HIV infection, immunosuppressive therapy) may have an impaired ability to clear HPV, which increases the risk for cervical cancer due to persistent infection

The nurse is talking with a client with chronic obstructive pulmonary disease who is reporting recent weight loss. The client states that bloating, exhaustion, and dyspnea make eating difficult. Which of the following responses would be appropriate for the nurse to make? Select all that apply.

Educational Outcome: Drink fluids between meals, rather than before or during, to prevent stomach distension and decrease pressure on the diaphragm while eating - Although exercise (eg, walking) can help stimulate appetite, clients with COPD should refrain from exercise for at least 1 hour before and 1 hour after eating because it increases oxygen demand and fatigue.

The nurse is caring for a client at risk for aspiration pneumonia due to a stroke. What nursing actions help prevent this potential complication during hospitalization? Select all that apply.

Educational Outcome: Encourage clients to facilitate swallowing by flexing the neck (chin to chest)

A client is being discharged home after an open radical prostatectomy. Which statement indicates a need for further teaching?

Educational Outcome: Following open radical prostatectomy, any rectal interventions such as suppositories or enemas must be avoided to prevent stress on the suture lines and problems with healing in the surgical area. The client should not strain when having a bowel movement for these reasons. Therefore, interventions to prevent constipation are an important part of postoperative care and discharge teaching. Prevention of constipation is particularly important while the client remains on opioid analgesics, which can cause constipation

The nurse is caring for a client who had a gastrojejunostomy and is reporting episodes of nausea, dizziness, and sweating that occur shortly after eating. Which of the following actions should the nurse take?

Educational Outcome: Gastrojejunostomy (ie, Billroth II procedure) removes part of the stomach and shortens the upper gastrointestinal tract. After a partial gastrectomy, many clients experience dumping syndrome, which occurs when rapid gastric emptying causes a fluid shift into the small intestine. Symptoms include dizziness, sweating, nausea, abdominal cramping, tachycardia, and diarrhea shortly after meal consumption. To reduce the occurrence of symptoms, clients should recline after eating meals to slow the emptying of gastric contents.

The nurse is preparing to discharge a client who is stable following a head injury. Which statement by the client indicates a need for further discharge instructions?

Educational objective: Clients should avoid opioid pain medications and CNS depressants (eg, alcohol) when recovering from a head injury. They should also avoid driving, using heavy machinery, playing contact sports, or taking hot baths for 1-2 days.

The emergency nurse is admitting a 12-year-old client who reports palpitations. Which action should the nurse anticipate? Click the exhibit button for additional information.

Educational Outcome: Once an ECG confirms SVT, the nurse should anticipate nonpharmacological interventions (ie, vagal maneuvers) to convert SVT to sinus rhythm if the client is stable. Placing an ice bag to the client's face and instructing the client to hold their breath while bearing down (Valsalva) are vagal maneuvers that can slow electrical conduction through the heart's atrioventricular node . If these maneuvers are ineffective, or if the client becomes unstable, administration of adenosine or synchronized cardioversion is indicated.

The nurse is teaching the parents of an 8-year-old client with newly diagnosed pediculosis capitis. Which of the following information should the nurse include? Select all that apply.

Educational Outcome: Pediculosis capitis (ie, head lice) is a contagious parasitic infestation in which a female louse lays eggs (nits) on the hair shaft, close to the scalp. Head lice are most common in school-aged children and are spread by direct contact with infested individuals or personal items. The treatment of head lice involves applying pediculicide shampoo (usually permethrin 1% cream) to the hair. The pediculicide usually kills only adult lice, so a nit comb (ie, a fine-tooth comb) should be used daily to remove nits ). A second treatment in 7-10 days may be necessary to kill newly hatched lice. Parents should also: Soak all brushes, combs, and hair accessories in a lice-killing solution or hot water for 10 minutes Vacuum all carpets, mattresses, and upholstered furniture frequently Wash the client's bedding and clothing in hot water and dry it on the hottest dryer setting Seal nonwashable items in a plastic bag for 2 weeks It is not necessary to dispose of hats, h

The clinic nurse cares for a 4-year-old who has been diagnosed with a pinworm infection. Which client symptom supports this diagnosis?

Educational Outcome: Pinworms (ie, enterobiasis) are very common in childhood and easily transmitted when microscopic pinworm eggs, which can be found on contaminated food, drink, toys, and linens, are inhaled or swallowed. Once ingested, the eggs hatch in the intestines. During the night, the female pinworm lays thousands of microscopic eggs in the skin folds around the anus, resulting in anal itching and troubled sleep. When the infected person scratches, eggs are transferred from the fingers and fingernails to other surfaces. Pinworm infection is treated with antiparasitic medications

The nurse assesses a client with left-sided pneumonia who has an intermittent, productive cough with copious amounts of thick, yellow sputum. Which of the following interventions help to facilitate secretion removal? Select all that apply.

Educational Outcome: Pneumonia is an inflammatory reaction in the lungs, often due to infection, that causes alveoli to fill with cellular debris and thick, purulent exudate (ie, consolidation), which may cause impaired ventilation and oxygenation. Interventions to facilitate secretion removal in clients with pneumonia include: Performing chest physiotherapy (percussion, vibration, postural drainage) to loosen and break up thickened secretions Assisting the client to perform huff coughing, which raises secretions from the lower to the upper airway for expectoration - 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

A parent calls the nursing triage line during the evening. The parent says that a 7-year-old was found playing in an area with poison ivy and asks what to do. Which is the most important instruction to give the parent?

Educational Outcome: Poison ivy can cause a contact dermatitis rash in those who are sensitive to the oily resin found on the leaves, stems, and roots of the plant. About 50% of people who come in contact with the plant develop a rash. It is often linear in appearance where the plant brushed against the skin. The rash develops 12-48 hours after exposure and can last for several weeks. The severity of the rash depends on the amount of resin on the skin. It is most important to first thoroughly wash the area to remove the resin and prevent its spread to other areas of the body.

The primary care provider's office nurse must return telephone calls concerning 4 clients. Which client has the most emergent situation and requires an immediate call back?

Educational Outcome: Priapism is a prolonged, painful erection (>2 hours) caused by trapping of blood in the penile vasculature that can lead to erectile tissue hypoxia and necrosis. The condition is usually idiopathic, secondary to prescription medications (eg, sildenafil, trazodone) or a preexisting medical condition (eg, sickle cell disease, cocaine use). The nurse should return this call first as the condition is a medical emergency that can result in permanent erectile dysfunction; it requires urgent treatment in the emergency department.

An 8-month-old infant with congenital pulmonic stenosis is scheduled for a femorally inserted balloon angioplasty in the cardiac catheterization laboratory. Which finding should the nurse report to the health care provider that could possibly delay the procedure?

Educational Outcome: Pulmonic stenosis causes increased pressure in the right side of the heart as the ventricle tries to push blood through the narrowed opening of the pulmonary artery to the lungs. In severe pulmonic stenosis, higher pressure in the right side of the heart causes unoxygenated blood to travel to the left side through the foramen ovale (or other congenital defect) and into the systemic circulation, leading to chronic hypoxia and cyanosis and requiring repair (interventional catheterization or surgery). The presence of severe diaper rash should be reported to the health care provider (HCP). This could delay the procedure if the rash is in the groin area where access is planned for a femorally inserted arterial cannula. Yeast or bacteria may be present on the rash which could be introduced into the bloodstream with the arterial stick. Children should be NPO for ≥4-6 hours before the procedure. Younger children and infants may have a shorter period of NPO status and

The nurse gathers a health history from a 58-year-old male client with acute urinary retention. Which of the following questions should the nurse ask to aid in assessing for benign prostatic hyperplasia? Select all that apply.

Educational objective: Benign prostatic hyperplasia (BPH) occurs with increasing age (usually in men age >50) and is often undiagnosed until voiding difficulties and abnormalities are observed. Typical BPH symptoms include acute urinary retention, voiding urgency, incomplete emptying, straining to void, weak urinary stream, urinary frequency, and nocturia.

The nurse has provided instructions about home care management to the parents of a child diagnosed with rotavirus infection. Which of the following statements by the parents indicate that the teaching has been effective? Select all that apply.

Educational Outcome: Rotavirus is a contagious virus and the leading cause of diarrhea in children age <5; it is also the cause of many nosocomial infections each year. Rotavirus is spread via the fecal-oral route. Because the virus is stable in the environment, transmission to a human host can occur via contact with objects (eg, toys, diapers), food, and hands. Meticulous handwashing and proper diaper disposal prevent spreading the virus. Symptoms include foul-smelling, watery diarrhea that lasts 5-7 days and is often accompanied by fever and vomiting. Vaccination is available and must be given before the child is age 8 months. Because the virus can easily lead to dehydration, parents should be taught the symptoms of dehydration (eg, lack of tears, extremely fussy or sleepy, decreased urination, dry mucous membranes). Oral rehydration solutions should be used to combat dehydration

A client who is 24 hours postoperative bowel resection is receiving IV opioids PRN for severe pain. The nurse reviews the health care provider's prescription to discontinue the continuous IV normal saline. What is the nurse's most appropriate action?

Educational Outcome: The nurse should discontinue the IV infusion of normal saline and apply a saline lock to maintain IV access while preventing clotting. The prescription of the health care provider (HCP) to lock the IV catheter is implied, as the client is currently receiving PRN IV opioids . A saline lock is sufficient to maintain the line patency and allows greater mobility than a continuous infusion. The client is only 24 hours postoperative abdominal surgery, so IV access is necessary to administer medications (eg, antibiotics, analgesics, antiemetics). The HCP's prescription specifies discontinuing IV fluids but not removing the IV catheter or slowing the infusion to a keep-vein-open (KVO) rate. Also, the nurse would need to clarify a KVO prescription with the HCP for a precise rate.

The nurse is caring for a client who had a laparoscopic cholecystectomy 6 hours ago. The client has not urinated since surgery. Which of the following actions should the nurse take? Select all that apply.

Educational Outcome: The nurse should promote spontaneous voiding and use invasive methods only if non invasive ones fail. For a client who has not voided 6 hours after surgery, appropriate interventions include: Assisting the client to ambulate to the bathroom because ambulation, normal body position, and privacy promote spontaneous urination Encouraging oral fluid intake to stimulate adequate urine production Performing a bladder scan, which can be used noninvasively to assess the volume of urine in the bladder Turning on the water in the bathroom sink or pouring warm water over the perineum, which can stimulate the urge to void spontaneously Urinary catheterization is prescribed if the client has significant urine in the bladder assessed via bladder scan and is unable to void voluntarily. However, indwelling urinary catheters increase the risk for UTI and should be avoided if possible.

Which of the following observations by the charge nurse would require immediate follow-up?

Educational Outcome: To maintain gravity flow, the drainage bag should be hung below the level of the bladder. Impaired urine flow can lead to urinary retention and distension of the bladder. The nurse should immediately follow-up if the drainage bag is hung above the level of the bladder (eg, wheelchair handle) because this will impede urine flow - Fluid intake of 3000 mL/day should be encouraged in clients after surgery involving the urinary system. Increased fluid intake ensures the maintenance of a high urinary output, reducing the risk for infection and calculi. Dilute urine is less irritating to the skin surrounding the stoma site.

The nurse is answering questions at a hospital-sponsored health fair. What actions should the nurse encourage to help prevent contracting the West Nile virus? Select all that apply.

Educational Outcome: West Nile virus is a mosquito-borne disease (encephalitis) that occurs mainly during the summer months, especially during humid weather. Prevention focuses on avoiding mosquitoes and using an insect repellent. Prevention also includes wearing long sleeves, long pants, and light colors and avoiding outdoor activities at dawn and dusk when mosquitoes are most active

The nurse is caring for a client with a chest tube to evacuate a hemopneumothorax after a motor vehicle accident. The drainage has been consistently 25-50 mL/hr for the majority of the shift. However, over the past 2 hours there has been no drainage. Which actions should the nurse take? Select all that apply.

Educational Outcome: 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 client sustained a concussion after falling off a ladder. What are essential instructions for the nurse to provide when the client is discharged from the hospital? Select all that apply.

Educational objective: A client sent home with a head injury requires the presence of a responsible adult. This person should observe for the signs/symptoms of increased intracranial pressure including change in level of consciousness, projectile vomiting, motor alteration (eg, ataxia), ipsilateral pupil dilation, and seizures.

What is the priority when caring for a 6-month-old diagnosed with atopic dermatitis?

Educational objective: Atopic dermatitis (eczema) is a chronic skin disorder manifested in infants by pruritus, dry skin, and red, crusted, scaly lesions. The priority management is to prevent scratching as this would promote formation of new lesions and predispose to secondary infections.

The home health nurse is visiting a client discharged 2 days ago after a coronary artery bypass graft. The client reports fatigue and palpitations, and the nurse connects the client to a portable heart monitor. The nurse recognizes the displayed rhythm as which type? Click on the exhibit button for additional information.

Educational objective: Atrial fibrillation on ECG is characterized by an irregular rhythm with fibrillatory waves instead of P waves. Treatment includes rate control and anticoagulation.

The nurse plans teaching for an adolescent client being discharged home with a Boston brace for treatment of scoliosis. Which instruction will the nurse include in the discharge teaching plan?

Educational objective: Clients wearing a brace during treatment for scoliosis must perform proper skin care, wear a cotton t-shirt under the brace, and understand the importance of wearing the brace as prescribed to slow curvature progression. Psychosocial issues (eg, body image, socialization) should also be addressed to promote compliance.

The nurse receives report on 4 clients. Which client should the nurse see first?

Educational objective: Clients with a history of chronic hypertension should immediately be assessed for hypertensive encephalopathy (ie, emergency syndrome caused by hypertensive crisis) if signs of increased intracranial pressure (eg, epistaxis, visual impairment, confusion) are present.

The nurse is reviewing dietary teaching with a client who has chronic kidney disease. Which of the following statements by the client would indicate a correct understanding of the teaching? Select all that apply.

Educational objective: Clients with chronic kidney disease are at risk for fluid overload and electrolyte disturbances caused by decreased renal function. Dietary modifications include drinking water instead of soft drinks or cola to limit phosphorus intake and using fresh herbs instead of table salt to limit sodium intake. Clients should avoid foods high in potassium (eg, salt substitutes, raisins, bran, peanut butter), sodium (eg, saltines), and phosphorus (eg, milk).

A speeding driver sustained a closed-head injury in an acceleration/deceleration accident from striking a tree front end first. Based on the coup-contrecoup phenomenon, which assessments are most likely to be affected related to the involved areas of the brain?

Educational objective: Coup-contrecoup injuries usually affect the frontal and occipital lobes. The frontal lobe controls executive function, memory, speech, and motor skills. The occipital lobe processes vision.

The nurse provides discharge instructions to a client who was hospitalized for deep venous thrombosis (DVT) that is now resolved. Which of the following instructions should the nurse include to prevent the reoccurrence of DVT? Select all that apply.

Educational objective: Discharge teaching for a client with resolved deep vein thrombosis includes interventions to prevent reoccurrence (eg, take in adequate fluids, elevate the extremities, exercise regularly, change positions frequently, stop smoking). - Clients do not need to avoid traveling in a car or airplane. However, during extended travel (>4 hours), clients must use preventive measures (eg, wear compression stockings, exercise calf and foot muscles frequently, walk every hour).

A client with Ebola was just admitted to the unit. Which actions by the nurse would represent appropriate care of this client? Select all that apply.

Educational objective: Ebola is an extremely contagious viral disease with a high mortality rate. Infected clients require extensive infection precautions, including an airborne isolation room, strict personal protective equipment use, restriction of visitors, and a log of individuals who enter and exit the room.

The nurse is caring for a client who is having a thoracentesis. Following the procedure, the nurse monitors for complications. The initial postprocedure monitoring plan should include what? Select all that apply.

Educational objective: Following thoracentesis, the nurse should monitor for signs of pneumothorax, including level of alertness, respiratory rate, respiratory effort, oxygen saturation, and lung sounds.

The nurse is caring for a 65-year-old client who had an acute myocardial infarction 3 days ago and is reporting tenderness and warmth of the left calf. Which of the following actions would be a priority for the nurse to take?

Educational objective: For a client with suspected deep venous thrombosis, the nurse should perform a complete neurovascular assessment of the client's extremities, including assessment of color, edema, temperature, pulses, and capillary refill.

The nurse is assisting with cardioversion for a client with supraventricular tachycardia who has become hemodynamically unstable. It would be a priority for the nurse to

Educational objective: For performing cardioversion, the synchronize button must be activated prior to delivering the shock. The synchronize function allows the unit to sense the client's rhythm and avoid delivering a shock during the T wave that could cause the client to experience a more lethal dysrhythmia.

The nurse on the pediatric unit is caring for assigned clients. The nurse should first assess the client with

Educational objective: Foreign body aspiration can be life threatening. Battery ingestion can quickly cause corrosive damage to the esophagus and intestines, resulting in perforation, peritonitis, sepsis, and even death. Other info: Osteogenesis imperfecta (ie, brittle bone disease) is a rare genetic condition that can cause blue scleras. Bisphosphonates (eg, alendronate) are used to increase bone density, thus reducing the risk for fractures. These are expected findings; therefore, care of this client can be safely delayed.

The nurse is performing an initial assessment on a client in hypertensive crisis. What is the nurse's priority assessment? Click on the exhibit button for additional information

Educational objective: Hypertensive crisis is a life-threatening medical emergency characterized by severely elevated blood pressure (systolic ≥180 mm Hg and/or diastolic ≥120 mm Hg). The client may have symptoms of hypertensive encephalopathy, including severe headache, confusion, nausea/vomiting, and seizure. Hypertensive crisis poses a high risk for end-organ damage (eg, hemorrhagic stroke, kidney injury, heart failure, papilledema). The nurse should prioritize neurological assessment (eg, level of consciousness [LOC], cranial nerves) as decreased LOC may indicate onset of hemorrhagic stroke, which requires immediate surgical intervention. Treatment for hypertensive crisis typically includes IV nitrates or antihypertensives (eg, nitroprusside, labetalol, nicardipine) and continuous monitoring (eg, blood pressure, telemetry, urine output) in a critical care setting.

The nurse is preparing to administer an IV infusion of nitroprusside to a newly admitted client who is experiencing a hypertensive crisis and has a blood pressure of 250/145 mm Hg. The nurse should recognize that it is a priority to

Educational objective: Hypertensive crisis is a medical emergency characterized by severely elevated blood pressure (BP). Initially, the priority is to lower the mean arterial pressure (MAP) by 25% or less, or to maintain a MAP of 110-115 mm Hg. Lowering BP too quickly may cause decreased organ perfusion and damage.

A nurse in the emergency department cares for 4 clients with orthopedic injuries. Which client should the nurse assess first?

Educational objective: Joint dislocations may constitute an orthopedic emergency. Because articular tissues, blood vessels, and nerves are stretched and compressed, neurovascular compromise may occur. Prolonged disruption of the vasculature and nerves may cause permanent injury and even loss of the distal extremity.

The nurse is caring for a client with a mandibular fracture whose jaw is wired together. While the nurse is in the room, the client begins to choke on oral secretions. Which of the following actions would be a priority for the nurse to take?

Educational objective: Maintaining a patent airway is the priority for a client with a mandibular fracture whose jaw is wired together. If choking occurs, the nurse should suction the mouth along the gum line to clear secretions. If suctioning is ineffective and the client develops respiratory distress, cutting the wires may be necessary.

The nurse is talking with the parent of a 1-day-old female client who has a small amount of blood-tinged, mucoid vaginal drainage. Which of the following statements would be most appropriate for the nurse to make?

Educational objective: Mammary gland enlargement, nonpurulent vaginal discharge (leukorrhea), and pseudomenstruation are benign transient findings commonly seen in female newborns. They are physiologic responses to transplacental maternal estrogen exposure.

A nurse is assessing a 58-year-old client with blurred vision and reduced visual fields. Which manifestation is of most concern to the nurse?

Educational objective: Manifestations of acute angle-closure glaucoma include sudden onset of severe eye pain, reduced central vision, blurred vision, ocular redness, and report of seeing halos around lights. This condition requires immediate medical intervention to reduce IOP and prevent permanent blindness.

A client with type 1 diabetes is prescribed NPH insulin before breakfast and dinner. Although the client reports feeling well, the 6 AM blood glucose level has averaged 60 mg/dL (3.3 mmol/L) over the past week. Which of the following actions is appropriate for the nurse to recommend to the client? Click the exhibit button for additional information.

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

The nurse is talking with a client who has phenylketonuria (PKU) and plans to become pregnant. Which of the following statements by the client would require follow-up?

Educational objective: Phenylketonuria (PKU) is an inherited metabolic disease that results from a deficiency or absence of an enzyme needed to metabolize phenylalanine, an amino acid that is present in proteins. A low-phenylalanine diet before and during pregnancy is essential in the treatment of PKU. If the newborn is also diagnosed with PKU, the nurse should teach the client to provide the infant with special formulas that are low in phenylalanine. PKU is a genetically inherited autosomal recessive trait. Genetic counseling should be completed prior to conception as parents may not realize they are carriers of a recessive gene. Adequate observation of newborn feeding is important in order to obtain accurate results as PKU cannot be detected if the newborn has not been exposed to phenylalanine via breastmilk or formula.

A nurse is completing discharge teaching to the parent of a child who had a tonsillectomy 2 hours ago. Which finding should be reported as a priority?

Educational objective: Postoperative bleeding is a primary concern after a tonsillectomy because the surgical site is not easily visualized and is vulnerable to irritation and trauma from swallowing and coughing. The nurse should observe for signs of postoperative bleeding (eg, frequent, increased swallowing).

Which statements made by the client demonstrate a correct understanding of the home care of an ascending colostomy? Select all that apply.

Educational objective: Proper care of the ostomy and pouching device in clients with a colostomy includes ensuring sufficient fluid intake, preventing gas and odor, and clarifying enteric-coated medications. - 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 because the stool is more solid.

The nurse is providing teaching to the parent of a 6-year-old client with scabies. Which of the following information should the nurse include? Select all that apply.

Educational objective: Scabies is easily spread through skin-to-skin contact. Clients with scabies and all persons in close contact should receive treatment with a scabicide cream applied to all skin surfaces, avoiding contact with the eyes. Potentially infested belongings should be washed and dried on the hottest dryer setting or sealed in plastic bags for at least 3 days.

Which actions are appropriate for the registered nurse to delegate to an experienced licensed practical nurse? Select all that apply.

Educational objective: Under the direction of a registered nurse (RN), the licensed practical nurse can perform higher-level skills within the scope of practice defined by the state. Appropriate tasks include administering routine medications for expected needs, monitoring RN findings, and performing focused assessments (eg, breath sounds, bowel sounds, neurovascular status).

The nurse is preparing to change the wound dressing for a client who is receiving negative pressure wound therapy. Which of the following actions should the nurse take? Select all that apply.

Educational objective: When changing a negative pressure wound therapy dressing, the nurse should administer analgesics, apply a skin protectant to intact skin around the wound, cut the foam dressing to the shape and size of the wound, ensure the prescribed pressure is applied, and verify that the occlusive dressing is free of air leaks.

The nurse is drawing blood from a client's peripheral vein for laboratory specimens. Which of the following are correct nursing actions? Select all that apply.

Educational objective: When performing phlebotomy for a laboratory specimen, allow the cleansed area to air dry, do not use the veins on the ventral side of wrist, position the tourniquet for no more than 1 minute at a time, and invert the tube gently 5-10 times to mix the solution with blood. Insertion in an artery will cause pulsation; if this happens, immediately remove the needle and apply pressure for 5 minutes. - The veins on the ventral aspect of the wrist are located near nerves, resulting in painful venipuncture and a higher risk of nerve injury. There is also an increased risk of arterial access on the ventral aspect of the wrist, and so this site should be avoided.

The nurse is caring for a 73-year-old client in the emergency department.

Educational objective:Early treatment for clients with sepsis is critical to prevent progression to septic shock and death. Initial management includes IV fluid resuscitation to restore intravascular volume, blood cultures to identify the pathogen, and broad-spectrum antibiotics to treat the infection. These interventions should be performed within 1 hour of suspecting sepsis for maximal benefit. - Vasopressors (eg, norepinephrine) may be initiated if the client does not respond to IV fluid resuscitation. However, this is not indicated yet.

The nurse is caring for a client diagnosed with a deep venous thrombosis 1 day ago. Which action by the client would require an immediate intervention by the nurse?

Educational objective:Interventions for deep venous thrombosis (DVT) include anticoagulants, warm compresses, limb elevation while in bed, and early ambulation. Clients with DVT are at risk for developing a pulmonary embolism (PE). Massaging the site of thrombosis can cause the clot to become dislodged and result in life-threatening PE.

The nurse teaches a parent how to administer an oral liquid medication to a 2-month-old client. The nurse knows that the parent understands the teaching when the parent does which of the following?

Educational objective:The extrusion reflex and a decreased gag reflex in infants less than 4 months old increase the risk for choking and aspiration. Instilling the medication using a syringe at the back of the cheek decreases the risk for choking and ensures that the correct amount of medication is consumed.

The nurse is talking with the parent of a 15-month-old client who is scheduled to receive the varicella vaccine. Which of the following statements would be appropriate for the nurse to make? Select all that apply.

Educational objective:The varicella vaccine provides protection against the varicella-zoster virus and may cause mild adverse reactions, including low-grade fevers, swelling and erythema at the injection site, irritability, and a rash that may appear up to 1 month after the injection. A second dose of the vaccine is required to reach optimal immunity.

The nurse on a pediatric unit is caring for a preschooler who exhibits separation anxiety when the parents go to work. Which interventions should the nurse implement? Select all that apply.

Educational objective:Toddlers and preschool-age children experience separation anxiety in response to the stress of illness and hospitalization. Key nursing interventions to alleviate separation anxiety include encouraging the presence of favorite items, establishing a daily routine, providing opportunities for play, facilitating phone calls with the parents, and providing support when the child is upset.

The nurse is caring for a client who experienced an ischemic stroke and is not a candidate for thrombolytic therapy. The client has a blood pressure (BP) of 240/124 mm Hg and is receiving IV nicardipine. Which of the following actions would be most important for the nurse to take?

Educational outcome Calcium channel blockers (eg, nicardipine) can be used to correct extreme hypertension. However, BP should be gradually lowered (eg, lowered 15% over 24 hours) to maintain cerebral perfusion. Therefore, it is most important that the nurse maintains a systolic BP ≥170 mm Hg to preserve brain function

The clinic nurse is reviewing self-care management of acne vulgaris with an adolescent client. Which client statement indicates a need for further instruction?

Educational outcome : Treatment includes topical and oral medications such as tretinoin (Retin-A), benzoyl peroxide, isotretinoin (Accutane), and oral contraceptives. Antibacterial soaps are harsh and ineffective, increase the pH of the skin, and can dry the skin . The client should instead gently wash the face with a mild facial cleanser. Additional self-care measures include: Using noncomedogenic skin care products (ie, products that do not clog pores) to avoid creating new lesions Maintaining a healthy lifestyle (eg, moderate exercise, balanced diet, adequate sleep) to reduce stress and promote healing Refraining from squeezing, picking, and vigorously scrubbing lesions to prevent additional inflammation and worsening the acne

A client with mitral valve prolapse (MVP) has been experiencing occasional palpitations, lightheadedness, and dizziness. The health care provider prescribes a beta blocker. What additional teaching should the nurse include for this client?

Educational outcome: Clients with MVP may have palpitations, dizziness, and lightheadedness. Chest pain can occur but its etiology is unknown in this client population. It may be a result of abnormal tension on the papillary muscles. Chest pain that occurs in MVP does not typically respond to antianginal treatment such as nitrates. Beta blockers may be prescribed for palpitations and chest pain. Client teaching for MVP includes the following: Adopt healthy eating habits and avoid caffeine as it is a stimulant and may exacerbate symptoms (Option 3) Check ingredients of over-the-counter medications or diet pills for stimulants such as caffeine or ephedrine as they can exacerbate symptoms Reduce stress and avoid alcohol use -There is no need for a medical alert bracelet. MVP is usually a benign condition.

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

Educational outcome: 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

The post-anesthesia care unit nurse receives report on a client after abdominal surgery. What sounds would the nurse expect to hear when auscultating the bowel?

Educational outcome: - Borborygmi sounds are loud, gurgling sounds suggesting increased peristalsis. Potential disease processes resulting in borborygmi include gastroenteritis, diarrhea, and the early phases of mechanical obstruction. High-pitched, gurgling sounds signify normal bowel sounds and are unlikely to be heard immediately following abdominal surgery.

A nurse is preparing a presentation about behavioral modifications to support weight loss for clients at an obesity clinic. Which of the following points should the nurse include in the teaching plan? Select all that apply.

Educational outcome: Developing health goals unrelated to weight (eg, climbing stairs without shortness of breath) to measure progress regardless of current weight

The nurse is preparing to flush a client's central venous catheter. Which size syringe is best for the nurse to choose?

Educational outcome: A 10-mL syringe is generally preferred for flushing the lumen of a CVC (Option 3). The smaller the syringe, the greater the amount of pressure per square inch exerted during injection, increasing the risk for damage to the CVC. The "push-pause" method involves slowly injecting normal saline into the CVC catheter and stopping for any resistance. Injecting against resistance can damage the CVC, which may result in complications, including embolism and malfunction. The nurse should always consult the specific manufacturer guidelines and facility policy when caring for a CVC. A smaller syringe (eg, 1 mL, 3 mL) creates more pressure, which increases the risk for damage to the CVC. A 30-mL syringe is unnecessarily large to flush a CVC.

The nurse is caring for a client with cirrhosis who has ascites, peripheral edema, shortness of breath, fatigue, and generalized discomfort. Which of the following actions should the nurse take? Select all that apply.

Educational outcome: A client with ascites often experiences discomfort due to pressure of the fluid on the surrounding organs. Shortness of breath occurs due to the upward pressure exerted by the abdominal ascites on the diaphragm, which restricts lung expansion. Meticulous skin care is a priority due to the increased susceptibility of skin breakdown from edema, ascites, and pruritus. The nurse should provide a specialty mattress (eg, alternating air pressure mattress) and implement a turning schedule of every 2 hours. Clients with ascites experience fatigue and activity intolerance and bed rest is often indicated. Clients should be allowed to rest and increase activity as tolerated and as their condition improves.

The nurse is caring for a client after a lumbar puncture (spinal tap). Which client assessment is most concerning and requires a nursing response?

Educational outcome: A lumbar puncture involves removing a sample of cerebrospinal fluid through a needle inserted between vertebrae. Elevated intracranial pressure is a contraindication to performing a lumbar puncture. The client is placed in the fetal position or sitting and leaning over a table. Continued leaking fluid indicates that the site did not seal off and a blood patch (autologous blood into the epidural space) is required. Fluids are encouraged to help replace the cerebrospinal fluid. The client should lie flat for at least 4 hours. The prone or supine position is recommended to help prevent a headache. Up to 5%-30% of clients have the common complication of headache. It is thought to be a result of leakage of fluid through the dural puncture site. The symptom is treated and is normally self-limiting.

The nurse is providing safety teaching to the adult child of a client with Alzheimer disease who is forgetful and wanders. Which of the following responses by the adult child demonstrates correct understanding of the teaching? Select all that apply.

Educational outcome: 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.

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

Educational outcome: An interpreter's job is to literally translate the words/concepts spoken (as much as possible). The role does not include personally editorializing or embellishing with advice beyond what the health care provider (HCP) said. It is important to find out if there was any discussion related to the procedure or if the follow-up conversation was about other topics (eg, social). The nurse needs to obtain feedback to be certain that the client understands about the procedure and had no additional questions that the interpreter personally answered. The nurse can ask the client additional questions using this interpreter or use a different interpreter/a language line. After the nurse is satisfied that no additional information was provided and the client understands what the client is signing, the nurse (as the hospital employee) should then witness the signature. The nurse should indicate that an interpreter was used in the process.

The nurse is caring for a client who has a radial arterial catheter for continuous invasive blood pressure monitoring. Which of the following locations would indicate correct placement of the transducer at the phlebostatic axis?

Educational outcome: An invasive arterial blood pressure (BP) monitoring system is a closed system that provides continuous BP monitoring via a catheter in the radial or femoral artery. The transducer should be placed at the phlebostatic axis, which is located at the intersection of the fourth intercostal space and midaxillary line and is the anatomic reference point for the right atria. Placement of the transducer below the phlebostatic axis results in falsely high readings, while placement above the phlebostatic axis results in falsely low readings.

The nurse is assessing a client with aortic stenosis. Which of the following findings would be consistent with the condition?

Educational outcome: Aortic stenosis is a narrowing of the aortic valve, which obstructs blood flow from the left ventricle to the aorta. As stenosis progresses, the heart cannot compensate and ejects a smaller fraction of blood volume from the left ventricle during systole. This decreased ejection fraction results in a narrowed pulse pressure (ie, the difference between systolic and diastolic blood pressures), ejection systolic murmur over the aortic area, and weak, thready peripheral pulses. With exertion, the volume of blood pumped to the brain and other parts of the body is insufficient to meet metabolic demands, resulting in exertional dyspnea, anginal chest pain, and syncope

The nurse is assessing a client with chronic peripheral venous insufficiency. Which of the following findings would be consistent with the condition? Select all that apply.

Educational outcome: CVI may lead to venous ulcers, which are typically diffuse and boggy with irregular borders and often occur over the medial malleolus. Arterial ulcers are typically dry and rounded, with well-demarcated borders or a "punched out" appearance, and often occur on the toes.

A client with chronic kidney disease has an arteriovenous fistula placed in the left wrist for hemodialysis. Which of the following statements indicate that the client understands how to care for the fistula properly? Select all that apply.

Educational outcome: Check the function of the vascular access several times per day by feeling for vibration (thrill) to assess for AVF patency

A client with terminal cancer is prescribed fentanyl patches for pain management while receiving hospice care at home. Which instructions related to this medication should the nurse provide? Select all that apply.

Educational outcome: Fentanyl, a potent opioid analgesic, is administered IV to treat acute pain and as a transdermal patch (Duragesic) dosed in mcg/hr to treat chronic pain. When given via transdermal patch, fentanyl is absorbed systemically through the skin to provide continuous analgesia. Patches are replaced every 72 hours, and the used patch must be removed before applying a new one - The site should be clean, with little hair. Unlike transdermal patches, topical analgesic patches (eg, lidocaine, capsicum) deliver drug locally and are placed near the site of pain. - Used patches must be folded and discarded immediately, as some medication remains in a used patch. Opioid medications must be stored and disposed of securely (eg, flushed down the toilet, discarded in a sharps container) as accidental exposure is potentially fatal for children, pets, and caregivers

The nurse is assessing a client an hour after a left lung lobectomy. The client is awake, alert, and oriented, and reports pain of 6 on a 0-10 scale. Pulse oximetry is 92% on 4 L oxygen via nasal cannula. The chest tube is set to continuous water seal suction at -20 cm H2O. The collection chamber has accumulated 320 mL of frank red drainage in the last hour. What is the priority nursing action?

Educational outcome: 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.

The nurse has been made aware of assigned client situations. Which of the following clients would require follow-up? Select all that apply.

Educational outcome: Hydromorphone is an opioid medication used to treat pain. Pain relief may cause reduced blood pressure. Opioids may also cause histamine release, which may lead to vasodilation and hypotension.

A nurse prepares a client for knee arthroscopy requiring general anesthesia. Which actions should the nurse complete? Select all that apply.

Educational outcome: If an IV line has not been started, an 18-gauge catheter is preferred. However, if a functioning IV line is already present, a 20-gauge is acceptable. Blood products, if needed during surgery, can be transfused through a 20-gauge catheter if necessary.

The charge nurse is planning assignments for the day. Which clients will require the nursing staff to institute contact precautions? Select all that apply.

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

The nurse is reinforcing teaching about ulcer prevention with a client newly diagnosed with peptic ulcer disease. Which of the following client statements indicate appropriate understanding of teaching? Select all that apply.

Educational outcome: Meal timing: Eating multiple small meals throughout the day or eating shortly before sleeping may actually worsen PUD by increasing stomach acid secretion.

The charge nurse is observing the nurse apply a condom catheter for a client who is uncircumcised. The charge nurse should intervene if the nurse

Educational outcome: Paraphimosis occurs when the uncircumcised male foreskin cannot be returned (reduced) to its original position, after being pulled back (retracted) behind the glans penis, resulting in pain, progressive swelling of the foreskin, and impaired lymph and blood flow. Paraphimosis can occur when the foreskin is in the retracted position for an extended period (eg, under a condom catheter sheath). Before applying a condom catheter, the nurse should ensure the client's foreskin is fully reduced (not retracted) to avoid impairing circulation and causing permanent damage to the glans penis . If the condom catheter is not self-adhesive, elastic adhesive may be used to secure the device to the penis, and should be applied in a spiral, not circular, manner to prevent restricting circulation. - A 1- to 2-inch (2.5- to 5-cm) space should be left between the tip of the penis and the end of the condom to prevent penile irritation and pooling of urine in the condom.

The nurse is caring for a client who had a percutaneous nephrolithotripsy 3 hours ago. The nurse notes that the nephrostomy tube has drained 0 mL since the procedure, and the client is reporting flank discomfort and nausea. Which of the following actions would be most appropriate for the nurse to take?

Educational outcome: Percutaneous nephrolithotripsy involves the insertion of a nephroscope through the skin into the pelvis of the kidney to break up and remove kidney stones (ie, renal calculi) that are too large to remove with other methods. A temporary percutaneous nephrostomy tube may be placed to prevent postoperative obstruction by stone fragments and to promote healing. Flank discomfort/pain, nausea, and no drainage from the nephrostomy tube may indicate obstruction of urine flow that can lead to kidney injury. Gentle irrigation of the nephrostomy tube with a small volume of sterile saline (as prescribed or per protocol) using aseptic technique is the most appropriate intervention

The nurse is caring for a 45-year-old female client in the clinic.

Educational outcome: Perimenopause is the transitional phase preceding menopause when ovarian function declines, and estrogen levels decrease. Symptoms include amenorrhea, emotional lability, vasomotor symptoms (eg, hot flashes, sweating), urogenital changes, and decreased bone density. -Management of perimenopause includes hormone therapy and promoting bone health (eg, vitamin D and calcium supplementation, performing weight-bearing exercise). Contraindications to hormone therapy include history of thromboembolic events (eg, deep vein thrombosis, ischemic stroke); estrogen therapy increases the risk for blood clot formation.

The nurse is assessing a 6-year-old client who has tonsillitis. Which of the following findings would require immediate follow-up?

Educational outcome: Peritonsillar or retropharyngeal abscess is a complication of tonsillitis that occurs when an abscess (ie, collection of pus) forms near the tonsil. Manifestations include throat pain, fever, muffled voice, uvula deviation to one side, and trismus (ie, inability to open the mouth due to a tonic contraction of the muscles used for chewing). A peritonsillar abscess can lead to life-threatening airway obstruction and is a medical emergency. The nurse should immediately report a muffled voice to the health care provider and monitor for signs of obstruction (eg, excessive drooling, stridor) . Surgical intervention (eg, tonsillectomy, incision and drainage) is often required. Other info: The most common bacterial cause of tonsillitis is group A beta-hemolytic Streptococcus, which can also cause scarlet fever. Manifestations include a fine, sandpaper-like rash, strawberry tongue (ie, red, swollen tongue), and fever. Streptococcal infections can be effectively trea

The nurse has just received report. Which client should the nurse assess first?

Educational outcome: Post-procedure care of a client who has undergone heart catheterization should focus on evaluating hemodynamics - blood pressure, heart rate, strength of the distal pulses, color, and temperature of extremities. The client should be also assessed several times per hour for active bleeding, hematoma, or pseudoaneurysm formation at the incision. The first hour after cardiac catheterization requires assessment every 15 minutes. Any report of back or flank pain should be assessed for possible retroperitoneal bleeding as back pain, tachycardia, and hypotension may be the only indication of internal bleeding. More than a liter of blood can pool behind the peritoneum in the pelvis undetected, and it may take up to 12 hours before a significant drop in hematocrit can be measured. Internal bleeding after cardiac catheterization is particularly dangerous due to frequent use of anticoagulant prescriptions in these clients.

A graduate nurse is caring for a client with a triple-lumen peripherally inserted central catheter in the right arm. Which actions by the graduate nurse indicate that more education is needed? Select all that apply.

Educational outcome: Routine care includes sterile dressing changes every 48 hours with a gauze dressing or 7 days with a transparent semipermeable dressing (biopatch) as well as immediately if dressing is loose/torn, soiled, or damp. The line should be flushed before and after medication administration and per facility protocol (Option 1). Blood pressure and venipuncture should not be performed on the affected arm as compression of the vein can alter its integrity. All infusing medications (except vasopressors) must be paused before drawing blood from the PICC to prevent false interpretation of the client's serum levels Dressings that no longer occlude the insertion site must be changed immediately. Loose corners may be temporarily reinforced with tape.

The nurse is planning teaching for a client newly diagnosed with Sjögren's syndrome. Which measures will the nurse include in the teaching plan? Select all that apply.

Educational outcome: Sjögren's syndrome is a chronic autoimmune disorder in which moisture-producing exocrine glands of the body are attacked by white blood cells. The most commonly affected glands are the salivary and lacrimal glands, leading to dry eyes (xerophthalmia) and dry mouth (xerostomia). Dryness in these areas can lead to corneal ulcerations, dental caries, and oral thrush. Other areas that can be affected and their symptoms include: Skin - dry skin and rashes Throat and bronchi - chronic dry cough Vagina - vaginal dryness and painful intercourse Treatment is focused on alleviating symptoms as there is currently no cure for Sjögren's syndrome. Over-the-counter or prescribed drops are used to relieve itching, burning, dryness, and gritty sensation in the eyes. Wearing goggles may offer further protection from drying caused by the wind. Dry mouth is treated with sugarless gum and candy or artificial saliva. Regular dental appointments to prevent dental caries are recommend

The nurse is caring for a client with chronic obstructive pulmonary disease. Which of the following would be the most appropriate oxygen delivery device to use for this client? Click the exhibit button for additional client information.

Educational outcome: Supplemental oxygen should be titrated to the minimum amount necessary to maintain an oxygen saturation of 88%-92%. A Venturi mask is the most appropriate choice for clients with COPD because the adapter allows precise control of the fraction of inspired oxygen (FiO2) that the client will receive. A partial nonrebreather mask delivers a very high FiO2 and is not indicated for clients with COPD due to the risk of overoxygenation. A simple face mask is not indicated for clients with COPD because the FiO2 fluctuates based on the client's respiratory pattern. In addition, CO2 rebreathing may reoccur, worsening hypercapnia. Oxygen-conserving cannulas use a reservoir to conserve oxygen and are typically indicated for long-term use. Although much less oxygen is used, this device is not indicated for clients with COPD because the FiO2 fluctuates based on the client's respiratory pattern.