Study set 16 for RN NCLEX (Kaplan)

The nurse prepares several clients for discharge. Which client statement indicates to the nurse the need for further teaching? 1. "Because my colostomy is pink and moist, I can take a relaxing bath." 2. "Now that I've had this old hip replaced, I can get back on the tennis court." 3. "In about a week, I'll need to have the stitches removed from my head. Perhaps I should wear a hat while I'm outdoors." 4. "I can't wait to go for a walk in the park. My knee feels so much better with the new joint in place."

) INCORRECT - After a colostomy, the client may resume usual hygiene practices. 2) CORRECT - Playing tennis would put the client at risk for dislocating the new hip prosthesis. 3) INCORRECT - Wearing a hat may help the client's self-image by hiding the sutures and protecting the surgical site from weather conditions. 4) INCORRECT - The client with a joint replacement is encouraged to walk to establish joint mobility. *Think Like A Nurse: Clinical Decision Making* Recovering from hip replacement surgery includes following a prescribed exercise and rehabilitation plan. Tennis is a strenuous activity that places stress on the joints of the lower extremities. This client should be counseled to avoid playing tennis until approved by the health care provider. *Content Refresher* A total hip replacement involves the replacement of the neck and head of the femur with a prosthetic device. Dislocation of the femur within the prosthetic joint replacement is a complication. The nurse needs to assess the client's post-operative knowledge of strategies to prevent hip dislocation and improve mobility.

The nurse teaches a client who was admitted and diagnosed with hyperkalemia. Which statement best indicates to the nurse that the client understands the teaching to prevent hyperkalemia? 1. "I should take the potassium supplements on an empty stomach." 2. "I should cut the potassium tablet in half to administer a decreased dose." 3. "I should consume bananas and other foods rich in potassium." 4. "I should avoid salt substitutes until my potassium level is under control."

1) INCORRECT - Potassium supplements should be taken with meals to prevent stomach upset. This client, however, should not take potassium supplements due to the current hyperkalemia. Potassium supplements are prescribed to treat hypokalemia. 2) INCORRECT - Potassium supplements may or may not be scored. Only scored pills can be cut in half to safely administer a decreased dose. This client, however, should not take potassium supplements due to the current hyperkalemia. 3) INCORRECT - Bananas are a good source of potassium. This client should be taught to avoid foods rich in potassium because hyperkalemia indicates too much potassium. 4) CORRECT - Many salt substitutes are potassium-based, which can cause continued hyperkalemia. This response indicates that the client understands the teaching. *Think Like A Nurse: Clinical Decision Making* When providing care for a client experiencing hyperkalemia, the nurse must provide education regarding the need to limit potassium-rich foods and supplements. Once the information is presented to the client, the nurse needs to evaluate understanding. The client statement indicating the need to limit salt substitutes in the diet indicates to the nurse an appropriate understanding of the information presented. *Content Refresher* Potassium is the primary cation inside the cell and is involved in electrical conduction of the heart and acid-base balance. The sodium-potassium pump and the kidneys regulate the potassium level in the body. The body's level is maintained through dietary intake and excreted through the kidneys. The normal range for potassium is 3.5 to 5 mEq/L (3.5 to 5 mmol/L). Hyperkalemia is a serum potassium level greater than 5 mEq/L (5 mmol/L). Clinical manifestations include muscle weakness and changes to an electrocardiogram (ECG). When caring for a client diagnosed with hyperkalemia, the nurse needs to plan education about limiting potassium-rich foods, supplements, and salt substitutes (salt substitutes are rich in potassium). Consult a dietitian, if needed.

The nurse provides care for the client diagnosed with septic shock. Which observation most concerns the nurse? 1. The peripheral pulses are strong and bounding and the respiratory rate is 26 breaths per minute. 2. The white blood cell differential results indicate that there are predominantly band neutrophils rather than segmented neutrophils. 3. The skin changes from warm, dry, and flushed to cool, clammy, and pale. 4. There is blood at a venipuncture site and around an intravenous catheter.

1) INCORRECT - Strong bounding peripheral pulses occur in the early hyperdynamic stage of septic shock. The peripheral pulses are weak or absent in the late stage of septic shock. Tachypnea (greater than 20 breaths per minute) and hyperventilation occur in the early stages of septic shock. A decreased (greater than 12 breaths per minute) rate and depth occur in the later stages. 2) INCORRECT - The data results indicate infection, and in this case it is septic shock. Segmented neutrophils are mature cells, whereas band neutrophils are immature cells. Normally, the bone marrow releases mostly mature neutrophils. If immature neutrophils predominate, it indicates that the bone marrow cannot produce enough mature neutrophils to cope with microorganisms present and it is releasing the immature neutrophils. 3) INCORRECT - The cool clammy skin changes indicate that shock has progressed from the initial or hyperdynamic phase of septic shock (symptoms are mostly opposite to symptoms seen in other types of shock) to the hypodynamic or late stages of septic shock (wherein symptoms are like those of later stages of all forms of shock). 4) CORRECT - The bleeding is an indicator of disseminated intravascular coagulation (DIC), a life-threatening problem. Sepsis is the most frequent cause of DIC. *Think Like a Nurse: Clinical Decision-Making* Disseminated intravascular coagulation (DIC) is an adverse effect of septic shock. This complication causes bleeding, which would occur at the intravenous catheter insertion site. Early signs of shock include full and bounding pulses and a rapid respiratory rate. Signs that shock is progressing include cool, clammy, and pale skin. *Content Refresher* Assessment of the client in shock should include assessing baseline vital signs; assessing strength of peripheral pulses, color of skin, warmth, and other indicators of perfusion; assessing urinary output; assessing cardiac rhythm; assessing hemodynamic parameters; and assessing breathing and oxygenation status. Nursing interventions include instituting continuous cardiac monitoring, inserting two large bore IV catheters, and administering isotonic fluids (0.9% normal saline or ringer's lactate). Monitor urinary output, as it reflects cardiac output. Monitor skin temperature and color. Support respirations as required.

A nurse assesses a female client who reports her last menstrual period was 2 months ago. Which finding does the nurse identify as a positive verification of pregnancy? 1. Auscultation of fetal heart tones. 2. Breast sensitivity. 3. Urinary frequency. 4. Uterine enlargement

1) CORRECT - Auscultation of fetal heart tones can occur at 8 to 12 weeks of pregnancy with the use of a Doppler ultrasound stethoscope. There is no other cause for the presence of fetal heart tones except for pregnancy. 2) INCORRECT - Presumptive signs of pregnancy are changes the client can feel, such as breast tenderness. Breast tenderness can be due to other causes, such as the use of oral contraceptives. 3) INCORRECT - Presumptive signs of pregnancy are changes the client can feel, such as urinary frequency. Urinary frequency can be due to other causes, such as increased fluid intake or a urinary tract infection. 4) INCORRECT - The examiner can observe probable signs of pregnancy, such as uterine enlargement, but there can be other causes for these signs. Uterine enlargement can be due the presence of a tumor. *Think Like A Nurse: Clinical Decision Making* The nurse is aware there are many reasons why a female client may stop menstruating. The most common reason is pregnancy. Even though many female clients experience signs of pregnancy in the early weeks, others may not. Even when present, early signs of pregnancy are considered presumptive. One way to validate pregnancy is through a urine pregnancy test; however, a more definitive way is to palpate the abdomen, identify uterine structures, and assess for fetal heart sounds. The presence of the fetal heart beat is a positive confirmation once the fetus reaches 2 to 3 months of gestation. *Content Refresher* Fetal development is characterized by physiological growth and development that takes place over approximately 40 weeks. The first 8 weeks of development is called the embryonic stage. By the end of this stage, all essential external and internal structures have been formed. Prenatal development is most dramatic during the remaining 32 weeks, the fetal stage. Organ systems continue to develop and grow. The heart is beating and the lungs have developed sufficiently that breathing is possible. During this stage, the fetus becomes more active, and the mother begins to feel fetal movements. Towards the end of this stage, organ systems have matured and the fetus is ready to live outside the womb.

The nurse provides care to an intrapartum client on the labor-and-delivery unit. Which observation requires follow up? (Select all that apply. ) 1. The partner answers questions that are directed toward the the client. 2. The client screams and uses obscenities during the delivery. 3. The partner refuses to leave the client's side when asked to do so. 4. The client reports excitement about the birth experience. 5. Fetal heart rate varies from 130 bpm and 150 bpm. 6. Each contraction lasts longer than 90 seconds.

1) CORRECT - Indicators of intimate partner violence (IPV) include when one partner speaks on behalf of the other partner. The issue should be privately and tactfully explored with the client. 2) INCORRECT- Especially during the transition phase of labor, maternal behaviors such as screaming and swearing are not uncommon. 3) CORRECT - A partner's refusal to allow the other partner privacy may be an indicator of intimate partner violence (IPV). The issue should be privately and tactfully explored with the client. 4) INCORRECT- Excitement about the birth is a normal reaction among women who are preparing for the delivery of a newborn. 5) INCORRECT- The healthy fetal heart rate (FHR) ranges from 120 to 160 bpm. The FHR is within normal limits. 6) CORRECT - Uterine contractions of greater than 90 seconds should be reported, as prolonged uterine contraction may cause fetal distress or lead to uterine rupture. *Think Like A Nurse: Clinical Decision Making* Assessment is the first step of the nursing process. During the assessment, the nurse monitors the client for both physical, and psychosocial, data. Observations requiring follow-up are those that fall outside of what is expected. While labor can be a stressful time, a partner who is answering questions for the client and refusing to leave the client's bedside when asked to do so, are red flags to the nurse as these may indicate an abusive relationship necessitating further assessment. The client who experiences contractions lasting greater than 90 seconds is at risk for a uterine rupture while the fetus is at risk for distress; therefore, this is also data necessitating further assessment, and likely, intervention. *Content Refresher* As labor progresses, there is an increase in frequency, duration, and intensity of contractions. As the uterus contracts, blood flow is interrupted to the placenta, which decreases oxygen levels to the fetus. The intensity and pattern of contractions influences the laboring process. As the client enters the transition phase of labor, symptoms include uterine contractions every 2 to 3 minutes, lasting 60 to 90 seconds, and are strong in intensity. During the intrapartum period, it is necessary to establish rapport and trust with the client. Through this process, the nurse needs to assess if the client feels safe in the home.

A young adult female client is prescribed atorvastatin to treat familial hypercholesterolemia. Which teaching points will the nurse make to this client while conducting medication instruction? (Select all that apply.) 1. "It is important to use contraception while taking statin medications." 2. "Most people taking statin medications experience few adverse effects." 3. "Statins have not been found to be effective in women." 4. "Follow a fat-free diet and you will not have to worry about having a stroke." 5. "Plan to have blood work done at least yearly if you take atorvastatin." 6. "Since your cholesterol level is only 220 mg/dL (5.7 mmol/L), you are not a candidate for a statin medication."

1) CORRECT - Statin medications are classified as pregnancy risk category X and should not be taken during pregnancy. 2) CORRECT - Statin medications are well-tolerated by most people. 3) INCORRECT - Statin medications are effective for everyone. 4) INCORRECT - Although a low-fat diet may reduce the risk for a stroke, a fat-free diet is unhealthy and difficult to follow. 5) CORRECT - When taking a statin medication, the client will need to have liver function tests monitored to make sure no adverse effects occur. 6) INCORRECT - Optimal total cholesterol is less than 200 mg/dL (5.2 mmol/L). *Think Like a Nurse: Clinical Decision-Making* Genetic mutations can alter the way the liver removes excess cholesterol. Familial hypercholesterolemia (FH) and high cholesterol differ in that FH has a genetic component. Compared to an elevation in cholesterol due to modifiable dietary factors or lifestyle choices, FH is more difficult to treat and is associated with a higher risk for major complications, including heart disease and premature death. Most individuals with FH require treatment with medication, as changes in diet and lifestyle will not sufficiently reduce blood lipid levels. Further assessment by the health care provider is needed to determine whether the client is experiencing high cholesterol or FH. *Content Refresher* Risk factors for the development of hypercholesterolemia include a family history, a diet high in fat, and a sedentary lifestyle. Anticipate blood being drawn for laboratory tests, including total cholesterol, high density lipoproteins (HDL), low density lipoproteins (LDL), and triglycerides. Review dietary habits and suggest foods low in cholesterol if indicated. Encourage exercise and weight reduction if the client is overweight. Educate the client about potential complications associated with elevated cholesterol, including hypertension, coronary artery disease, myocardial infarction, and stroke.

The nurse teaches staff members about developmental considerations related to bowel elimination. Which statements are appropriate for the nurse to include in the teaching? (Select all that apply.) 1. "An infant 's stool will vary depending on how the infant is fed. " 2. "Bowel control is usually achieved before bladder control. " 3. "Voluntary control of anal and urethral sphincters begins at about 30 months of age. " 4. "Constipation in the older adult can be related to decreased gastrointestinal motility. " 5. "Fecal impaction may be associated with oozing of liquid feces. "

1) CORRECT - The formula-fed infant excretes pale yellow to light brown stools. They are firmer in consistency than those of the breastfed infant. The stools of infants fed with breastmilk are seedy, and the color and consistency of mustard with a sweet-sour smell. 2) CORRECT - Bowel control is usually achieved before bladder control. 3) INCORRECT - Voluntary control of anal and urethral sphincters begins at about 18 to 24 months 4) CORRECT - Older adults may experience slowed peristalsis related to the loss of muscle elasticity, reduced intestinal mucous secretion, or a low-fiber diet. 5) CORRECT - The cardinal sign of impaction is continuous oozing of liquid stool, with no normal stool. Oozing occurs as the liquid portion of feces higher in the intestines seeps around the mass. *Think Like a Nurse: Clinical Decision-Making* Comprehensive bowel assessment requires an understanding of normal gastrointestinal (GI) functions in various developmental stages. During the interview of clients with diarrhea or constipation, the nurse should inquire about its onset, duration, and character, as well as associated symptoms and alleviating factors. The nurse can inquire about the client 's usual bowel patterns, routines followed to promote bowel elimination, diet and fluid intake history, medication use, and medical-surgical conditions affecting the GI function. *Content Refresher* Constipation in infancy may be attributed to organic causes, such as Hirschsprung disease , hypothyroidism, and strictures. Constipation is less common in breastfed infants because breastfed infants have softer stools. If constipation occurs when transitioning from human milk to cow 's milk, increase the infant 's intake of fruit, vegetables, and sorbitol-rich juices. For the adult client with constipation, teach the client or caregiver about healthy bowel habits, including regular exercise, consumption of high-fiber foods, adequate fluid intake, and not ignoring the urge to defecate.

The nurse receives report on the client who had an extensive stroke and is aphasic with a do not resuscitate (DNR) prescription. Initial assessment reveals pulse is 102 beats/min, respirations 28 breaths/min, BP 82/42 mm Hg, temperature 96.7°F (35.9°C) orally, and O 2 saturation of 84% on 4 L/min oxygen by nasal cannula. Which actions will the nurse implement based on these data? (Select all that apply.) 1. Assess for advance directives. 2. Contact the health care provider. 3. Confirm the DNR prescription. 4. Contact the family about impending death. 5. Provide pain medication. 6. Place the client in high-Fowler's position.

1) CORRECT - The nurse should confirm specific client wishes for end of life. A DNR prescription simply means that resuscitation will not be initiated if the client's heart beat or breathing stops. However, other life-sustaining measures may be desired by the client. 2) CORRECT - The health care provider should be notified of potential impending death. 3) CORRECT - The DNR prescription must be legally documented in the medical record. 4) CORRECT - Families may need education about dying and end-of-life care. They may wish to be present when the client dies. 5) CORRECT - Comfort measures and symptom management continue. 6) INCORRECT - The client should be maintained with the head of bed elevated only 15 to 20 degrees after a stroke. *Think Like A Nurse: Clinical Decision Making* Based on the vital signs and oxygen saturation level, this client's condition is deteriorating. The first action would be to evaluate the client's advance directive to determine which additional treatment will be prescribed and to validate the do not resuscitate order. The health care provider should be notified of the client's change in status. The family should be contacted about the client's status since they might want to be present when the client reaches end-of-life. Pain medication should be provided to ensure comfort. The head of the bed should be at a 15- to 20-degree angle poststroke. *Content Refresher* Nursing care is focused on the fact that the client has ineffective cerebral perfusion related to a stroke. Interventions include providing supplemental oxygen, instituting airway management procedures for respiratory depression, administering IV fluids if hypotensive, and maintaining the head of bed in semi-Fowler's to increase venous outflow. Another appropriate nursing concern is the risk for undesirable treatments based on lack of advance directives. Interventions include obtaining documents for inclusion in the medical record, supporting the client and family, honoring the client's wishes, and providing education about advance directives and their benefits.

The nurse provides care for a client diagnosed with pneumonia and acute respiratory distress syndrome (ARDS). The client asks about the benefits of pulmonary rehabilitation. Which results of the rehabilitation program will the nurse include in the teaching? (Select all that apply.) 1. Improved exercise capacity. 2. Decreased anxiety. 3. Decreased depression. 4. Increased oxygen needs. 5. Decreased hospitalizations.

1) CORRECT - The program will help improve endurance and oxygenation. 2) CORRECT - Decreased anxiety is one of the major anticipated goals of the program. 3) CORRECT - Decreased depression is one of the major anticipated goals of the program. 4) INCORRECT - The goal of the program is to decrease oxygen needs. 5) CORRECT - Decreased hospitalizations is one of the major anticipated goals of the program. *Think Like a Nurse: Clinical Decision-Making* Recovery from acute respiratory distress syndrome (ARDS) could take time and requires pulmonary rehabilitation. This is partly because the fibrotic changes in the lung tissue may cause lasting damage, leading to chronic hypoxia. Exercise, diet, and health maintenance activities, such as influenza and pneumonia vaccination and avoiding contact with sick persons, are warranted. If the client requires home oxygen therapy, oxygen handling safety is reviewed with the client and caregiver. The nurse should use the teach-back method in all educational encounters, giving the client and caregiver an opportunity to ask questions. *Content Refresher* Pulmonary rehabilitation (PR) may occur in the inpatient or outpatient setting, or in the client 's home. Exercise training with a particular focus on the muscles used for ambulation is a mandatory component of any PR program. Smoking cessation, nutritional counseling, and education regarding disease management are also components of PR. Benefits of PR include fewer hospitalizations and improvements in dyspnea, fatigue, exercise tolerance, and emotional functioning.

The nurse assesses a client diagnosed with pheochromocytoma. Which finding indicates the need for further intervention by the nurse? 1. Cardiac arrhythmia noted on the monitor. 2. Urinary output of 50 mL/hour. 3. Coagulation time of 5 minutes. 4. Blood urea nitrogen of 20 mg/dL (7.14 mmol/L).

1) CORRECT - This is a life threatening complication associated with the disorder due to the excessive release of catecholamines. 2) INCORRECT - This is an adequate urine output (at least 30 mL/hr). This finding does not indicate a possible complication. 3) INCORRECT - This is a normal coagulation finding and does not indicate the client is experiencing a possible complication. 4) INCORRECT - This is a normal blood urea nitrogen (BUN) finding and does not indicates the client is experiencing a possible complication. *Think Like A Nurse: Clinical Decision Making* The nurse should mentally review the pathophysiology of the disease process related to pheochromocytoma. The nurse should be aware that the client has a tumor on the adrenal gland, which increases the release of catecholemines, the fight or flight hormones. The client experiences the symptoms of an extreme stress response, specifically hypertension. The inconsistent and unpredictable release of hormones from the tumor can adversely effect overall cardiovascular functioning, causing an erratic heart rhythm. This finding can be life-threatening and should be immediately reported to the health care provider for further evaluation and treatment. *Content Refresher* The adrenal glands are located above the kidneys. The medulla of the glands produces epinephrine and the cortex produces cortisol and aldosterone. A pheochromocytoma is a tumor that affects the adrenal gland and releases excessive hormones that results in high blood pressure. Clinical manifestations of hypertension include headache, nausea, dyspnea, dizziness, heart palpitations, fatigue, and angina. Persistent high blood pressure can result in coronary artery disease, left ventricular hypertrophy, heart failure, stroke, encephalopathy, dementia, renal disease, peripheral vascular disease, and retinal damage. Surgical removal of the tumor is required to treat the hypertension.

The nurse conducts an admission assessment for an older adult client who is at risk for developing deep vein thrombosis (DVT). Which preventive measures does the nurse expect to be prescribed? (Select all that apply.) 1. Low molecular weight heparin. 2. Bed rest. 3. Leg massage. 4. Compression stockings. 5. Sequential compression devices.

1) CORRECT - This is utilized as an anticoagulant to prevent DVT. 2) INCORRECT - Clients, who are able to get out of bed, need to be in a chair for meals and ambulate four to six times per day to increase circulation and to prevent thrombosis. 3) INCORRECT - This is contraindicated in clients at risk for deep vein thrombosis. Massage can dislodge a thrombus and cause it to become a pulmonary embolus. 4) CORRECT - These promote effective blood flow in the deep veins of the legs to prevent thrombosis. 5) CORRECT - Air pressure in sequential compression devices squeeze leg tissues to promote blood flow towards the heart. Effective blood flow in the deep veins assists to prevent thrombosis. *Think Like A Nurse: Clinical Decision Making* Deep vein thrombosis (DVT), which is a preventable complication, is considered a "never event" by the Centers for Medicare & Medicaid Services ( CMS ). According to the CMS, never events include dangerous, costly errors in health care that should never happen. DVTs are more likely to occur after surgery or as a consequence of certain health alterations, especially conditions that impair blood circulation (e.g. peripheral vascular disease) or increase the viscosity (thickness) of blood (e.g. dehydration). Additional risk factors for DVT include but are not limited to smoking, obesity, and certain medications. Decreased mobility, which is almost always a risk factor for the hospitalized client, can lead to decreased circulation and blood stasis, which can result in blood clot formation. Strategies that help prevent DVTs include interventions aimed at increasing blood movement in the legs and reducing hypercoagulability (increased tendency for clot formation). *Content Refresher* One of the best ways to prevent deep vein thrombosis (DVT) is early and progressive mobilization. Clients who must remain on bed rest should be encouraged to change position every 2 hours. Unless contraindicated, the client should be instructed to flex and extend the feet, knees, and hips at least every 2 to 4 hours while awake. Compression stockings and sequential compression devices, when correctly fitted and applied, decrease the incidence of DVTs. When applying compression stockings, ensure the toe hole is under the toes, the heel patch is over the heel, the thigh gusset is on the inner thigh, and no wrinkles are present in the stockings.

The client is admitted with extreme fatigue, shortness of breath, anxiety, and chest pressure. Which intervention does the nurse implement? (Select all that apply.) 1. Place the client on bed rest. 2. Administer supplemental oxygen. 3. Administer ketorolac for pain. 4. Assess serum troponin level. 5. Monitor intake and output.

1) CORRECT — The client is experiencing the symptoms of a myocardial infarction. Bed rest decreases stress on the heart by decreasing muscle metabolism and therefore oxygen demand. 2) CORRECT — In a myocardial infarction, administering oxygen is a priority action as this client is experiencing poor oxygenation to the heart muscle. 3) INCORRECT— Morphine is the appropriate medication for cardiogenic pain. Ketorolac is a nonsteroidal anti-inflammatory drug (NSAID) that can increase the client 's blood pressure. This would result in a negative outcome for the client. 4) CORRECT — The troponin level is sensitive to cardiac damage and can confirm that the client is having a myocardial infarction. 5) CORRECT — The nurse should monitor intake and output to assess for fluid overload. The client is at high risk to experience heart failure due to death of myocardial tissue. *Think Like a Nurse: Clinical Decision-Making* These symptoms suggest that the client is experiencing a myocardial infarction. The first action is to place the client on bedrest to reduce myocardial oxygen demand and apply supplemental oxygen to ensure adequate oxygenation of myocardial tissue. Monitoring intake and output is essential for early detection of fluid overload, which can occur when myocardial tissue is damaged. A troponin level is used to evaluate for myocardial tissue damage. *Content Refresher* A classic sign of myocardial infarction (MI) includes severe angina. The pain is not relieved by changing positions, resting, or administering nitrate medication. Among women, atypical symptoms of MI are more likely, including shortness of breath, abdominal pain, nausea, and vomiting. Clients with diabetes may be asymptomatic. Priority interventions include administration of supplemental oxygen as prescribed and high-Fowler's position to support effective ventilation. Obtain a 12-lead electrocardiogram (ECG) and repeat testing as prescribed. Monitor intake and output and laboratory tests, including serial cardiac enzymes.

A client with a history of diabetes mellitus (DM) and asthma takes high-dose corticosteroids. Which dermatologic complications will the nurse assess in this client? (Select all that apply.) 1. Delayed wound healing. 2. Skin pigmentation changes. 3. Alopecia. 4. Erythematous plaques on legs. 5. Decreased subcutaneous fat over extremities.

1) CORRECT- Corticosteroids delay wound healing. 2) INCORRECT - Corticosteroids and diabetes mellitus do not cause skin pigmentation changes. 3) INCORRECT - Corticosteroids, diabetes mellitus, or asthma do not cause alopecia. 4) CORRECT- Erythematous plaques on the legs is related to diabetes mellitus. 5) CORRECT- Decreased subcutaneous fat in the extremities is related to both diabetes mellitus and corticosteroids. *Think Like a Nurse: Clinical Decision-Making* Long-term steroid therapy may be prescribed for treatment of clients with various conditions, including chronic asthma or autoimmune disorders, such as lupus or rheumatoid arthritis. Both long-term systemic steroid therapy and Cushing syndrome result in multisystem effects of cortisol. Cortisol causes catabolism, altering the strength of tissues such as muscles and blood vessels. Collagen and elastic fibers in the epidermis are ruptured, resulting in decreased skin elasticity. While systemic steroid therapy does not typically cause changes in skin pigmentation, integumentary changes can include fragile skin, easy bruising, dry skin, acne, stretch marks, or infection. Topical corticosteroid cream misuse can cause integumentary effects such as skin thinning and telangiectasia . *Content Refresher* Examples of corticosteroids include dexamethasone, hydrocortisone, prednisone, and methylprednisolone. Side effects of corticosteroids include fluid retention, hypertension, increased susceptibility to infection, hunger, insomnia, hypokalemia, hypocalcemia, hyperglycemia, osteoporosis, fractures, and gastrointestinal ulceration and hemorrhage. Measure the client 's weight and monitor blood pressure, serum electrolytes, and intake and output. If the client develops an infection while taking a corticosteroid, symptoms may be blunted (decreased) because of the corticosteroid 's anti-inflammatory effects.

The nurse provides care to clients in a skilled nursing facility. Which client requires the nurse's immediate attention? 1. Recovering from a cerebral vascular accident whose prescription for warfarin expired two days ago. 2. Experiencing pain after receiving morphine in an acute care facility and was transferred with a prescription for acetaminophen with codeine. 3. Voiding foul-smelling, cloudy, dark amber urine associated with dysuria. 4. Needing influenza immunization because of immunosuppression.

1) CORRECT- The duration of warfarin therapy for the client recovering from a cerebral vascular (CVA) accident is 2 to 5 days. This client is at risk for another CVA and should be assessed first. 2) INCORRECT - client requiring anticoagulation is a priority even though pain should be addressed as soon as possible. 3) INCORRECT - Foul-smelling, cloudy, dark amber urine associated with pain upon urination may indicate an infection. This client should be assessed soon. However, this client does not take priority over the client requiring anti-coagulation therapy. 4) INCORRECT- The need for influenza vaccination is not life-threatening, and does not take priority over the client requiring anti-coagulation therapy. *Think Like A Nurse: Clinical Decision Making* Warfarin is routinely prescribed as a treatment for ischemic/embolic stroke. Failure to take warfarin can result in new clot formation and place the client at risk for experiencing another stroke. This is a circulatory issue and should be assessed first. The client experiencing pain when voiding foul-smelling, cloudy, dark amber urine most likely has a urinary tract infection and should be assessed second. This is a physical need, but not a circulatory need. *Content Refresher* Assess client needs based on priorities, remembering Maslow's hierarchy of needs. Physical needs should be addressed first. The ABCs are the most critical physical needs, as they are required for life. After physical needs, the nurse should address safety and security needs, followed by love and belonging needs.

The nurse discharges a client with a permanent pacemaker. Which instruction is most important for the nurse to include? 1. "Take your pulse every day. " 2. "Eat foods that are low in sodium. " 3. "Weigh yourself on the same scale weekly. " 4. "Measure your abdominal girth daily. "

1) CORRECT— A change in heart rhythm or rate can signal a malfunction of the pacemaker. Instruct client to take the pulse for 1 full minute at the same time each day and document. Client should also take the pulse if feeling any symptoms, 2) INCORRECT - A pacemaker is inserted to treat dysrhythmia. A low-sodium diet is useful to treat heart failure (which may cause dysrhythmia), hypertension, or cirrhosis; however, monitoring the pulse is the priority for this client. 3) INCORRECT - A weekly weight is not necessary unless the client's dysrhythmia is related to heart failure. This client is taught to avoid tight clothing over the pacemaker. 4) INCORRECT - Measuring the girth assesses ascites. This client has a pacemaker for a dysrhythmia. *Think Like A Nurse: Clinical Decision Making* The nurse needs to stop and think about the purpose of a permanent pacemaker. The device is inserted into the body and has wires that provide the electrical impulse to generate a heart beat. The device is battery operated and can fail if the power in the battery becomes low. The best way to assess the functioning of the pacemaker is for the client to assess the radial pulse once a day. The client should also assess the pulse if experiencing symptoms such as dizziness or lightheadedness, since this may indicate that the pulse is too slow and the pacemaker battery is malfunctioning. *Content Refresher* Dysrhythmias are cardiac rhythm disturbances that affect perfusion. Administration of medications is a primary treatment for dysrhythmias. Other interventions include pacemaker insertion, internal cardioverter/defibrillator insertion, cardioversion, defibrillation, and ablation. The nurse needs to educate the client with a pacemaker about monitoring, medications, and treatments that may be prescribed by the health care provider and when the health care provider needs to be notified.

The nurse obtains a history from a client scheduled to undergo electroconvulsive therapy (ECT). Which finding does the nurse report to the health care provider (HCP)? 1. The client takes alendronate once a day. 2. The client reports feelings of lethargy and fatigue. 3. The client has received the therapy in the past. 4. The client walks for a half hour three times per week.

1) CORRECT— Alendronate is used to treat osteoporosis. Osteoporosis places the client at risk for an injury during the contractions of muscles during the ECT procedure. This finding should be reported to the HCP. 2) INCORRECT - Lethargy and fatigue are symptoms of depression. ECT is used to treat depression. 3) INCORRECT - Previous ECT is not a contraindication. 4) INCORRECT - Walking is a good form of weight bearing exercise and is appropriate to prevent osteoporosis. Regular walking is not contraindicated with ECT. *Think Like A Nurse: Clinical Decision Making* The nurse evaluates each statement to identify risks for client harm. Alendronate is prescribed to treat osteoporosis. Because the client is scheduled for electroconvulsive therapy, there is a risk for a bone fracture caused by the muscle tension that occurs during the procedure. The client's use of this medication should be reported to the health care provider. The other statements do not pose a risk of harm to the client. *Content Refresher* When caring for a client receiving electroconvulsive therapy (ECT), the nurse should: Assess the client for suicidal tendencies. Assess vital signs and mental status. Assess the client's ability to understand the procedure and the intended results. Clients who may be harmed during ECT include those with a recent heart attack or stroke, pregnant clients, and those with musculoskeletal disorders.

A client diagnosed with a myocardial infarction is prescribed IV morphine sulfate. Which reason will the nurse use when explaining the purpose of the medication to the client? 1. Decreases blood return to the right side of the heart and decreases peripheral resistance. 2. Increases blood return to the right side of the heart and increases peripheral resistance. 3. Decreases blood return to the right side of the heart and maintains peripheral resistance. 4. Increases blood return to the right side of the heart and decreases peripheral resistance.

1) CORRECT— Morphine sulfate decreases preload and afterload pressures and cardiac workload. It causes vasodilation and pooling of fluid in extremities and provides relief from anxiety. 2) INCORRECT - Vasoactive medications increase blood return to the right side of the heart and increase peripheral vascular resistance. 3) INCORRECT - Morphine sulfate decreases blood return to the right side of the heart. However, it does not maintain peripheral resistance. 4) INCORRECT - Morphine sulfate decreases peripheral resistance, but it does not increase blood return to the right side of the heart. *Think Like A Nurse: Clinical Decision Making* Most clients know that morphine treats pain and therefore think the morphine is just for the chest pain. While morphine is a powerful opioid analgesic, morphine provides special benefits when used for treatment of clients with angina. Morphine relieves anxiety and pain, which decreases sympathetic nervous system activity and, in turn, decreases the production and effects of catecholamines . Morphine decreases heart rate and blood pressure, reducing the heart's oxygen demand, thereby decreasing ischemia. Morphine is thought to reduce inflammation and inflammatory damage activated during cardiac stress, as well. *Content Refresher* Medication administration is the process by which prescribed medications are knowledgeably and safely dispensed to a client. Perform appropriate client assessments and check for contraindications, including allergies, prior to administering medications. Verify the Rights of Medication Administration, which minimally include right client, right medication, right time, right dose, right route, right site, and right documentation. Educate the client about the medication. Morphine is an opioid analgesic. After administration, monitor the client for pain relief, hypotension, and respiratory depression. Document the medication administration according to institutional policy. Evaluate outcomes of the administered medication.

The nurse observes prominent U waves on a client's electrocardiogram (ECG) rhythm strip. Based on this abnormality, for which condition will the nurse assess the client? 1. Hypokalemia. 2. Hyperkalemia. 3. Hypocalcemia. 4. Hypercalcemia.

1) CORRECT— Prominent U waves on a client's ECG strip signal hypokalemia, an abnormally low serum potassium level. 2) INCORRECT - Hyperkalemia, an abnormally high serum potassium level, causes P-wave flattening, QRS complex widening, and peaking of the T waves. 3) INCORRECT - The QT interval and ST segment may be prolonged with hypocalcemia, an abnormally low calcium level. Torsades de pointe, a lethal ventricular arrhythmia, also may occur with hypocalcemia. 4) INCORRECT - Shortening of the QT interval and ST segment may occur with hypercalcemia, an abnormally high serum calcium level. *Think Like A Nurse: Clinical Decision Making* Prior to analyzing a client's cardiac rhythm, the nurse needs to first recall the elements that make up a normal rhythm. Normal elements include a PR interval, a QRS complex, and an ST segment. One element that is not considered normal is the presence of a U-wave. This wave indicates a potassium deficiency and only occurs when the deficiency is present. Should the nurse identify a U-wave, the finding should be immediately reported to the health care provider for evaluation and treatment. *Content Refresher* Hypokalemia is a serum potassium level less than 3.5 mEq/L and is caused by decreased dietary intake, increased loss or a shift into the cells that can occur with alkalotic conditions, and the use of loop and thiazide diuretics. Client may report muscle weakness and/or paresthesias. Other symptoms include cardiac arrhythmias, hypotension, constipation, decreased bowel sounds, and hyporeflexia. Diagnostic testing include serum chemistry and 12 lead electrocardiogram (EKG). Electrocardiogram changes, such as a U-wave, may accompany hypokalemia. Treatment depends on the potassium level and severity of symptoms. Supplemental potassium is administered along with increasing foods high in potassium (green leafy vegetables, raisins, bananas, oranges, and lentils).

The nurse admits an older adult client to the unit. The client demonstrates decreased ability to problem-solve, psychomotor deficits, and social isolation. Which nursing action is most appropriate? 1. Prepare a schedule of activities and monitor the client's participation in the activities. 2. Encourage the client to choose the client's own activities. 3. Allow the client time to get acclimated to the milieu before scheduling activities. 4. Allow the client to rest quietly to restore energy level.

1) CORRECT— The client displays symptoms of depression. For the client with depression, a regular daily routine of scheduled activities provides structure and decreases the amount of problem solving required. Participating in activities will increase self-esteem and assist the client to engage with others. 2) INCORRECT - The client is having difficulty making decisions. Choosing or planning the client's own activities will increase social isolation, increase impairment, and decrease self-esteem. 3) INCORRECT - This will increase social isolation. 4) INCORRECT - The client is having difficulty making decisions. Allowing the client to rest quietly will increase social isolation, increase impairment, and decrease self-esteem. *Think Like A Nurse: Clinical Decision Making* Cognitive deficits are frequently comorbidities to mental illness. The client does not display the ability to make decisions. While the client might benefit from rest periods and being offered choices, the nurse will initially schedule the client's activities to ensure the client is getting optimal treatment benefit. Clients with depression will not always willingly engage in activities and so the nurse must arrange this. *Content Refresher* Nursing interventions when working with a client with a major depressive disorder include establishing a trusting relationship. Provide care with unconditional positive regard. Maintain a safe environment if suicide or self-harm is present. Teach client/family about disease and treatment including anti-depressant medications, if prescribed. Assist client to recognize and identify feelings and associated thoughts. Challenge negative thoughts. Support positive thoughts and associated behaviors. Help client focus on strengths. Involve in structured social and physical activities. Assist with self-care activities and offer small, frequent meals if eating less than body requirements. Promote sleep hygiene measures. Refer to psychotherapy and support group as needed.

The nurse completes an admission for a client diagnosed with depression to the psychiatric unit. It is important for the nurse to take which action? 1. Give the client a brief orientation to the unit. 2. Explain the activities available to the client. 3. Introduce the client to the nursing staff. 4. Ask the client to choose activities in which to participate.

1) CORRECT— The client experiencing depression will benefit from a brief orientation to the unit upon admission. A more in depth orientation can occur at a later time. 2) INCORRECT - Explaining available activities may not be of interest at this time or may overwhelm the client. The nurse avoids long, complex explanations. 3) INCORRECT - Introducing the nursing staff may overwhelm the client. If possible, it is important to provide consistent daily care with the same nurse. 4) INCORRECT - The nurse avoids giving choices. It is important to provide a structured written schedule. *Think Like A Nurse: Clinical Decision Making* Routine admission procedure to the psychiatric unit includes orientation to the unit. However, the nurse should keep information simple and not overwhelm the client. The nurse should be cognizant of possible low self-esteem of the client and changes in self-care behavior. The nurse should be alert for signs of self-destructive behavior, help client to reduce anxiety and decisiveness, and support self-esteem. *Content Refresher* Depression is defined as a chronic or acute mood disorder characterized by sadness and irritability, difficulty concentrating, negative thinking, weight gain or loss, lack of interest in activities, and problems sleeping. Complete a mental status examination and a comprehensive health history. Establish a trusting relationship by spending time with the client and being authentic, honest, and consistent. Maintain a safe environment if suicide or self-harm is present. Assess the client 's level of functioning and support system. Ask about traumatic or stressful experiences.

Which post-operative recommendation by the nurse is best when assisting a client prepare for cataract surgery? 1. "Have someone do the vacuuming." 2. "Eat foods high in antioxidants." 3. "Have loperamide 2 mg available." 4. "Ask someone to sit with you for 2 days."

1) CORRECT— The client should not vacuum following cataract surgery because the jerky movements and bending at the waist can increase intraocular pressure. This is the best recommendation by the nurse to prevent postoperative complications. 2) INCORRECT - Eating foods high in antioxidants provides a protective function against age-related macular degeneration and does not affect cataracts. This is not an appropriate recommendation by the nurse for a client having cataract surgery. 3) INCORRECT - Loperamide is an antidiarrheal medication. Diarrhea usually does not occur after cataract surgery, nor is it a risk. The client needs to avoid straining with bowel movements as this increases intraocular pressure. This is not the best recommendation by the home health nurse. 4) INCORRECT - While some ophthalmologists may require that the client have someone sit with the client for up to 24 hours post surgery, it is not appropriate to tell the client that someone will need to stay with the client for a period of 2 days. *Think Like A Nurse: Clinical Decision Making* The client post-cataract surgery should be taught not to do any activities that may increase intraocular pressure, such as pushing or pulling on a vacuum sweeper. The client should also be encouraged to eat a high-fiber, high-fluid diet to avoid constipation. Additional teaching includes instructing the client and caregiver about prescribed eye drops to prevent infection, reduce inflammation, and control eye pressure. The client should be informed to call the provider if the client experiences vision loss, persistent pain, increased eye redness, or if the client reports light flashes or multiple new spots (floaters) in front of the eye. *Content Refresher* A cataract is an opacity in the lens of the eye. Cataracts cause decreased visual acuity and glare. The nurse should prepare the client for surgery and provide support and plan discharge education to include the following: instill prescribed eye drops; keep follow-up appointments; avoid activities that increase intraocular pressure (coughing, sneezing, bending, lifting over 15 pounds, straining with bowel movements, and sleeping on operative side); wear an eye patch at night and glasses during the day to protect eye; avoid getting water in eye (showering and/or washing face); signs of complications and when to call the health care provider; and to avoid prolonged reading to reduce eye strain.

The nurse assesses the records of an infant scheduled to see the health care provider for the 6-month checkup. Which immunization records are required for the nurse to determine that the infant is up to date on immunizations? 1. Two doses of diptheria, tetanus, and acellular pertussis (DTaP). and two doses of inactivated polio vaccine (IPV). 2. One dose of measles, mumps, and rubella (MMR). 3. A tuberculin skin test and one dose of diptheria, tetanus, and acellular pertussis (DTaP). 4. One dose of smallpox vaccine and one dose of measles, mumps, and rubella (MMR).

1) CORRECT— The infant should receive doses of diphtheria, tetanus, and acellular pertussis (DTaP) at 2 months and 4 months, and will receive a third dose at the 6-month appointment. The inactivated polio is given at 2 months and 4 months. 2) INCORRECT - The MMR vaccination is administered at 15 months. 3) INCORRECT - Tuberculin skin testing is completed at approximately 12 months. 4) INCORRECT - The small pox vaccine is not recommended routinely at this time. *Think Like A Nurse: Clinical Decision Making* Nurses may be called upon to provide client teaching and promote immunization. The nurse should be aware that immunization is important for a variety of reasons, such as the process of controlling or eradicating contagious diseases, preventing the manifestations that can negatively impact a client who contracts a disease, and protecting community members from being exposed to communicable diseases. The nurse should first make sure that the client received the required immunizations at 2 and 4 months. Then the nurse should determine which immunizations are required during the current wellness visit. The nurse should be prepared to administer any vaccinations that are lacking along with those that are expected. *Content Refresher* Babies are classified as infants beginning at 1 month of age and lasting until the child reaches 1 year old. During this time, the nurse should educate parents about illness prevention. Primary illness prevention includes activities that promote health and prevent illness, such as administering immunizations.

A nurse assesses an older adult client who reports a 2-day history of vomiting and diarrhea. Which findings will the nurse expect during the physical exam? (Select all that apply.) 1. Blood pressure 150/90 mm Hg. 2. Moist crackles. 3. Urine specific gravity 1.035. 4. Hematocrit 55% (0.55). 5. Weak, thready pulse.

1) INCORRECT - A client with a 2-day history of vomiting and diarrhea is likely to have an isotonic fluid volume deficit and decreased vascular volume, resulting in blood pressure below the expected reference range. 2) INCORRECT - A client who has fluid volume excess, such as from heart failure, is likely to have moist crackles, dyspnea, and shortness of breath as fluid backs up into the pulmonary system. 3) CORRECT - Fluid volume deficit from gastrointestinal losses results in decreased vascular volume, decreased urine volume, and more concentrated urine. Therefore, the client's urine specific gravity is likely to be greater than the expected reference range. 4) CORRECT - Fluid volume deficit leads to decreased blood volume, which results in more concentrated blood and a hematocrit greater than the expected reference range. 5) CORRECT - Fluid volume deficit leads to decreased vascular volume and a weak, thready pulse. *Think Like a Nurse: Clinical Decision-Making* The older adult client has increased susceptibility to fluid and electrolyte imbalances. This is partly due to reduced renal blood flow, reduced glomerular filtration, and narrowed limits for excretion of water, sodium, potassium, and hydrogen ions. Older adults have decreased thirst mechanism. The nurse should pay particular attention to the frail older adult. Vital signs are closely monitored for orthostatic changes (a sign of hypovolemia). Electrolyte imbalances may manifest as delirium. Clients with fine motor function deficits should be assisted with meals and hydration. Clients on enteral feeding should be given supplemental water via the nasogastric (NG) or percutaneous endoscopic gastrostomy (PEG) tube, unless contraindicated. *Content Refresher* Causes of fluid volume deficit (FVD) include inadequate fluid intake, diarrhea, vomiting, and disorders that result in fluid losses (e.g. diabetes mellitus, diabetes insipidus, fluid shifts, burns, and hemorrhage). Certain medications, such as diuretics, may cause fluid volume deficit (FVD). Signs and symptoms of FVD include thirst, decreased urine output, dry mucous membranes, poor skin turgor, weight loss, hypotension, tachycardia, and lethargy. Treatment includes oral or IV fluids and electrolyte replacement. Evaluate the client's response to fluid therapy by monitoring urine output, lung sounds, blood pressure and pulse, and laboratory values (e.g. blood and urine chemistry, urine specific gravity, complete blood count, and serum osmolality).

The nurse provides care for a client who anticipates using a prosthesis after an above-the-knee amputation. Which action should the nurse take when caring for this client? 1. Encourage the client to sit in a chair for extended periods of time. 2. Maintain the compression dressing to the amputation site. 3. Provide range-of-motion exercises twice a day. 4. Elevate the residual limb for 72 hours.

1) INCORRECT - A client with an above-the-knee amputation needs to avoid sitting in a chair for prolonged periods of time, as this may cause hip flexion contracture. 2) CORRECT - When caring for a client after an above-the-knee amputation, the nurse needs to maintain the compression dressing to the amputation site. This minimizes edema and prevents infection. 3) INCORRECT - Range-of-motion exercises should be performed every 2 to 4 hours and not just twice a day. 4) INCORRECT - After 24 hours, the residual limb should remain flat or extended to prevent hip flexion contracture. *Think Like a Nurse: Clinical Decision-Making* Proper residual limb bandaging fosters shaping and molding for eventual prosthesis fitting. A compression dressing is typically ordered to reduce edema, support soft tissues, and promote limb shrinkage and maturation. The delayed prosthetic fitting may be the best choice for clients who had above knee or below the elbow amputations, older adults, debilitated individuals and those with infections. The compression bandage should be worn at all times except during physical therapy and bathing. *Content Refresher* Amputation is the surgical removal of all or part of an extremity. Closed amputations involve suturing a flap of skin over the amputation site. Care is focused on reducing pain and improving wound healing. Administer pain medications and evaluate effectiveness, especially before and after moving the client or carrying out procedures. Teach about relaxation, visualization, and deep breathing to reduce anxiety and pain. Provide nutritional support for healing. Assess the wound during dressing changes and report excess bleeding or signs of infection. Use compression dressings to reduce edema and to facilitate the use of a prosthetic device.

The nursing assistive personnel (NAP) reports to work on the oncology unit with a cough, a runny nose, and has an elevated temperature. The NAP reports having no sick leave and being the breadwinner of the family. Which response by the nurse is most appropriate? 1. "Did you take a flu shot?" 2. "Can you work at the desk and help the unit secretary with the charts?" 3. "I will call one of the other units where clients are less vulnerable." 4. "I'm sorry, but you will have to go home."

1) INCORRECT - All health care personnel should take an annual flu shot, but is not relevant to this conversation. The issue is immunosuppressed client safety from pathogens. 2) INCORRECT - Influenza is spread by droplets, and even though the NAP will not be caring for clients, the NAP will still come in contact with other staff members. Clients in oncology are immunocompromised. 3) INCORRECT - A hospital is full of immunocompromised clients, not just on an oncology unit. 4) CORRECT— During community outbreaks of the flu, it is responsible management to exclude staff with febrile infections from caring for high-risk clients. *Think Like A Nurse: Clinical Decision Making* Nurses on a bone marrow transplant or oncology unit are, rightly so, protective of the clients in their care and avoid exposing them to infections that could prove lethal in the immunocompromised population. A cough and runny nose with fever is too symptomatic to work, especially with this client population. Often, if a staff member has only a low grade fever or sore throat, they might continue to work while wearing a mask, but even this is not wise to do when caring for clients with decreased immune systems in which simple infections have serious consequences. *Content Refresher* The American Nurses Association (ANA) and the International Council of Nurses (ICN) developed nursing codes of ethics that incorporate primary ethical principles relevant to nursing practice. These include accountability, competency, advocacy, confidentiality, privacy, responsibility, and judgment. Nurses are responsible for planning care that is reflective of the ethical principles that govern professional nursing practice. As individuals and as a profession, nurses are responsible for using ethics as the basis for decision-making processes and behavior. Ethical nursing practice includes accountability (answering for one's personal actions), responsibility (ensuring appropriate completion of all assigned or delegated tasks), and advocacy (promoting humane, dignified care that is reflective of the client's wishes).

The nurse provides care to an unconscious client with a cuffed endotracheal tube inserted after a drug overdose. Which observation most concerns the nurse? 1. The pilot balloon does not fill when air is injected. 2. Food-like material is present in the endotracheal tube. 3. An inner cannula is lying on the chest of the client. 4. There is condensation in the endotracheal tube on exhalation.

1) INCORRECT - Although a malfunction of the balloon is cause for concern, it is not the priority because there is still an airway via the tube. The pilot balloon indicates the presence or absence of air in the cuff. A deflated balloon indicates a cuff leak, which may have been caused by a tear or rupture in the cuff or pilot system. The tube needs to be replaced. 2) CORRECT - Food in the endotracheal tube indicates esophageal intubation. Therefore, there is no airway and the tube needs to be removed immediately. The client should be hyperventilated to prevent hypoxia before attempting another intubation with a new sterile tube. 3) INCORRECT - There is no inner cannula in an endotracheal tube. Inner cannulas are present in most tracheostomy tubes. 4) INCORRECT - Condensation indicates correct positioning of the tube in the trachea. *Think Like a Nurse: Clinical Decision-Making* The nurse is alarmed when food is found in the airway, whether a tube is present or not. However, in the case of an endotracheal tube, the presence of food matter indicates the tube is malpositioned. This means the client does not have a working artificial airway and also has likely aspirated vomitus from the esophagus into the lungs. Ventilation is performed carefully until an airway can be placed. *Content Refresher* After endotracheal intubation, auscultate the chest bilaterally for equal breath sounds, which may indicate a right mainstem intubation, and the abdomen for evidence of esophageal intubation. A portable chest radiograph is obtained to verify correct tube placement. Waterproof tape is used to secure the tube, and the nurse should mark the centimeter mark at the lips, teeth, or nostrils, as doing so provides a point of reference to assess whether the tube migrates during position changes.

The nurse provides care for clients in the emergency department. Which client does the nurse assess first? 1. A client with a burn to the palm of the hand. 2. A client reporting a bee sting, causing diffuse redness. 3. A client reporting blood and blood clots in the urine. 4. A client reporting right lower leg pain, edema, and warmth.

1) INCORRECT - Burns to the palm of the hand may result in loss of function if scar tissue forms as the burn heals. This often requires evaluation by a plastic surgeon. The client likely requires pain mediation as well, but this client is not the priority. 2) CORRECT - A sting should cause a local reaction. What is described is the start of a systemic reaction, which may lead to anaphylaxis and airway loss if not treated promptly. 3) INCORRECT - This client requires evaluation for the cause of the bleeding, such as bladder cancer, but is likely not losing enough blood in the urine to experience cardiac output decrease and is not the priority. 4) INCORRECT - This client may have a deep vein thrombosis and requires prompt treatment. The nurse instructs the client to avoid walking around, to report shortness of breath, and to wait for the HCP to evaluate further. *Think Like a Nurse: Clinical Decision-Making* Bee stings can potentially cause a life-threatening anaphylactic reaction. The nurse should examine this client first and assess the client for airway patency and adequate oxygenation. The nurse should also anticipate providing epinephrine and diphenhydramine as needed and supplemental oxygen. Local care for the stung area includes cleaning with soap and water, applying ice to ease pain and swelling, and applying creams, such as hydrocortisone. The client's vital signs should be monitored closely. *Content Refresher* Anaphylaxis is a type of distributive shock caused by an allergic response that involves angioedema, urticaria, hypotension, and bronchospasm. It is a medical emergency and must be assessed and treated immediately. Anaphylaxis develops from a prior sensitization to an allergen and then a later re-exposure. If respiratory distress is evident, initiate Basic and Advanced Cardiovascular Life Support (ACLS) protocols, provide supplemental oxygen, and assist with intubation or airway management. Administer IV fluids rapidly to support perfusion. Prescribed medication therapy often includes inhaled bronchodilators, epinephrine, antihistamines, and corticosteroids. Vasopressor medications may also be needed for continued hypotension.

The nurse notes an increase in the number of families seeking care for infants with bronchiolitis and respiratory syncytial virus (RSV). Which item is most important for the nurse to have available to provide to the parents of these infants? 1. Antibacterial soap. 2. Bulb syringe. 3. Stool sample kit. 4. Thermometer.

1) INCORRECT - Consistent hand washing and avoiding touching mucous membranes is more important than the type of soap for these infections. 2) CORRECT - A bulb syringe is required for airway management. Infants with these infections can have nasopharyngeal secretions that block airway passages. Young infants are obligatory nose breathers. Parents should be instructed on how to use the syringe before feedings and as necessary. 3) INCORRECT - Nasal secretions or nasopharyngeal washing is used to diagnose RSV. A stool sample kit is not required. 4) INCORRECT - A fever is not a primary concern with RSV. *Think Like A Nurse: Clinical Decision Making* An infant is unable to clear the airway and would need to have secretions removed through the use of a bulb syringe. This is the item that the nurse should provide to the parents of infants with an upper respiratory or respiratory syncytial virus (RSV) infection. Thorough and frequent hand washing with warm water and soap should also be emphasized with the parents. Fever is not an issue with an RSV infection. *Content Refresher* Bronchiolitis is an infection of the lower respiratory tract causing inflammation and obstruction of the bronchioles. It may be of viral or bacterial origin and the most frequent causative organism is the respiratory syncytial virus (RSV). Treatment includes respiratory assessments to monitor changes in the infant/child's condition, maintaining elevation of the head of bed, and suctioning to facilitate breathing. Administer oxygen and medications as prescribed to dilate bronchioles and improve gas exchange at the alveolar level. Address hydration and provide fluids via oral and intravenous routes as prescribed.

The nurse screens clients for the risk for developing pulmonary tuberculosis (TB). Which client is at risk for developing this type of TB? 1. Client with cystic fibrosis. 2. Client with chronic obstructive pulmonary disease. 3. Client who has a tuberculin (Mantoux) test site that has a 4 mm area of induration. 4. Client with positive test results for the human immunodeficiency virus.

1) INCORRECT - Cystic fibrosis is not a risk factor for TB. 2) INCORRECT - Chronic obstructive pulmonary disease is not a risk factor for TB. 3) INCORRECT - A tuberculin (Mantoux) test site that has a 4 mm area of induration is negative for TB. 4) CORRECT - The client who is positive for the human immunodeficiency virus can be immunocompromised. The TB organism is opportunistic. This client is at a high risk for developing active TB. *Think Like a Nurse: Clinical Decision-Making* The nurse is in a situation in which several clients are being evaluated for risk for developing or contracting pulmonary tuberculosis. Before identifying the client who is most at risk; however, the nurse should stop and think about the pathophysiological process of tuberculosis and the health conditions that potentiate the development of the infection. The mycobacterium that causes tuberculosis is believed to cause an opportunistic infection. This means that if a client has a healthy immune system, exposure to the bacteria will not necessary lead to disease. If the nurse keeps this in mind, the client who is the most at risk is the one whose immune system is compromised. *Content Refresher* Tuberculosis (TB) is an infectious disease caused by Mycobacterium tuberculosis. It primarily affects the lungs, but it can infect any organ. Infection can be dormant or active. Active infection is known as TB disease. Tuberculosis that is dormant is known as latent TB infection (LTBI). Tuberculosis risk factors include immunocompromised clients (especially those who are HIV/AIDS positive); clients who have traveled to places with high rates of TB; and those residing or working in hospitals, prisons, skilled nursing facilities, and homeless shelters. Age at time of exposure, including the very young and the very old, are at increased risk of infection.

The nurse assesses the client who is diagnosed with metastatic prostate cancer for complications related to hypercalcemia. The nurse understands that which assessment finding represents a late manifestation of hypercalcemia? 1. Restlessness. 2. Muscle weakness. 3. Heart block. 4. Constipation.

1) INCORRECT - Early signs and symptoms of cancer-related hypercalcemia include restlessness. 2) INCORRECT - Muscle weakness is an early manifestation of cancer-related hypercalcemia. 3) CORRECT- Late manifestations of cancer-related hypercalcemia include a variety of cardiac complications, such as heart block, widened T waves, ventricular dysrrhythmias, and asystole. For the client with cancer, early signs and symptoms of hypercalcemia include restlessness, muscle weakness, and constipation. 4) INCORRECT - Early manifestations of cancer-related hypercalcemia include constipation. *Think Like A Nurse: Clinical Decision Making* A client with prostate cancer is at risk for the cancer to spread to the bone. Should this occur, the client's serum calcium level will increase, because the calcium within the bones is being released into the blood stream. Manifestations of an elevated calcium level begin with muscle weakness and constipation. If the condition continues without effective treatment, the rising calcium level can adversely effect the conduction system of the heart. The client is at risk for developing a life-threatening dysrhythmia or complete heart block. The nurse needs to closely monitor the client's cardiac rhythm and report changes to the health care provider for prompt treatment. *Content Refresher* Hypercalcemia is caused by increase in parathyroid hormone (hyperparathyroidism), increased absorption of calcium, or decreased excretion of calcium. Elevated calcium levels can negatively affect bones, kidneys, and cardiac output. Signs and symptoms include muscle weakness, headache, irritability, depression, bone pain, anorexia, nausea, vomiting, and constipation. Can also be associated with renal lithiasis. Bradycardia or arrhythmias may also be noted. Heart block is a late sign. The condition is often referred to as "Bones, stones, moans, and groans."

The nurse provides care to a client who just underwent left modified radical mastectomy. When assisting the client with positioning, the nurse implements which action? 1. Extend the client's left arm flat along the affected side. 2. Elevate the client's left arm on a pillow. 3. Rest the client's left arm across her chest. 4. Place the client's left arm below the level of her torso.

1) INCORRECT - Extending the arm flat along the affected side may limit circulation and impede lymphatic drainage, resulting in lymphedema. Following modified radical mastectomy, elevation of the affected arm on a pillow is recommended. 2) CORRECT- Following modified radical mastectomy, the client should be placed in semi-Fowler position. To promote lymphatic drainage without compromising circulation, the arm on the affected side should be elevated on a pillow. Elbow flexion or dependent positioning of the arm may impede lymphatic drainage and compromise circulation. 3) INCORRECT - Resting the arm across the chest requires significant flexion of the elbow, which may impede lymphatic drainage and circulation, and ultimately lead to the development of lymphedema. 4) INCORRECT - Dependent positioning of the arm to below the level of the torso may impede lymphatic drainage and circulation, and promote the development of lymphedema. *Think Like A Nurse: Clinical Decision Making* The nurse needs to mentally ask, "What is a likely manifestation for a client following a mastectomy?" Reviewing the surgical procedure for a modified radical mastectomy, the nurse recalls it is likely that many, if not all, of the lymph nodes and glands surrounding the breast tissue were removed. The nurse can now conclude the removal of lymph tissue increases the client's risk of developing lymphedema in the extremity that is on the same side of the surgery. Lymphedema can increase pain and complicate healing. To reduce the risk of lymphedema, the nurse should make sure that the limb on the same side of the surgery is elevated on a pillow. *Content Refresher* Mastectomy is the removal of the whole breast. There are five different types of mastectomy: radical mastectomy, total mastectomy, modified radical mastectomy, partial mastectomy, and subcutaneous mastectomy. Mastectomy may be elected for those at high risk of breast cancer. It is also recommended in cases where tumors are large or widespread, or when prior treatment was not effective. Complications following mastectomy include bleeding, pain, infection, andlymphedema. Elevation of the affected side of the body and the involved arm can reduce the development of lymphedema. The client is closely monitored for manifestations of the other possible complications.

A client returns from surgery after a thyroidectomy. Which observation causes the nurse the most concern? 1. Moderate amount of serosanguinous drainage on the neck dressing. 2. Verbal expression of moderate pain at the incision site. 3. Hand tremors and facial twitching. 4. Nasogastric tube draining a moderate amount of clear fluid.

1) INCORRECT - Hemorrhage is a complication after a thyroidectomy but a moderate amount of drainage is expected due to the placement of the drain. The nurse needs to check for accumulation of drainage at the back of the client's neck. 2) INCORRECT - Moderate pain at the incision site is expected and pain medication should be provided as prescribed. 3) CORRECT - Hand tremors and facial twitching indicate tetany. This occurs because of the accidental removal of the parathyroid glands, which regulate calcium balance. This finding should be reported to the health care provider. 4) INCORRECT - A moderate amount of clear fluid draining from the nasogastric tube is an expected finding. *Think Like A Nurse: Clinical Decision Making* Following thyroidectomy, the client is at risk of routine post-operative complications such as hemorrhage, infection, and damage to surrounding structures. The thyroid gland also produces hormones that regulate multiple bodily functions, as do the parathyroid glands, which often cannot be retained or are damaged during surgery. Hormonal complications are related to manipulation of these glands during surgery and include excess release of thyroid hormone into the bloodstream and the inability to produce sufficient parathyroid hormone. Impairment, removal, and destruction of the parathyroid glands will lead to impaired serum calcium regulation. *Content Refresher* For the client who undergoes thyroidectomy, compare pre-operative vital signs with post-operative vital signs and monitor for changes. Assess for bleeding, swelling, or laryngeal edema that may cause airway obstruction. Assess the surgical dressing frequently. Assess electrolytes, specifically calcium and phosphorus if parathyroid glands are removed. Assess levels of T3, T4, and TSH (thyroid hormones) if prescribed. The presence of Chvostek sign (facial twitching) and Trousseau sign (hand tremors) suggest hypocalcemia is present.

The nurse provides discharge planning for a group of clients. For which client does the nurse request a health care provider's referral for home health care services? 1. A client who reports incisional pain 48 hours following an appendectomy. 2. A client diagnosed with diabetes mellitus who had a cardiac catheterization 8 hours earlier. 3. A client who reports left knee pain 72 hours following a left total knee arthroplasty. 4. A client diagnosed with heart failure who underwent diuresis 4 days earlier.

1) INCORRECT - Incisional pain 48 hours post-operative is an expected finding that does not warrant a home health referral. Discharge instructions should include administering analgesics as prescribed and seeking medical treatment for increasing pain or any worsening in the client's condition. 2) INCORRECT - Clients who undergo cardiac catheterization typically do not require an overnight hospital stay unless complications develop. The client is not likely to require home health care services. Discharge instructions should include instructing the client not to bend, strain, or lift heavy objects for 24 hours. The client should observe the puncture site for bleeding, swelling, or new bruising, and seek medical treatment if complications develop or any worsening in the client's condition is noted. 3) INCORRECT - Post-operative pain is an expected outcome. A referral for home health care services is not likely to be required. Discharge instructions should include administering analgesics as prescribed and seeking medical treatment for increasing pain or any other worsening of the client's condition. 4) CORRECT - The client is at risk for complications related to heart failure and altered fluid balance. As such, requesting a referral for home health services is warranted to ensure the client's safety. Skilled nursing care will include assessing the client for decreased circulating volume, hypotension, tachycardia, and signs or symptoms of hypokalemia. *Think Like a Nurse: Clinical Decision-Making* Readmission of clients with heart failure is common and costly. Government incentives to reduce readmissions are provided, and hospitals with high readmissions rates can lose nearly 3% of their Medicare reimbursement. Discharge planning of heart failure clients should include provision for home health care services. Other interventions shown to lower readmissions include partnering with community physicians, having nurses responsible for medication reconciliation, arranging for follow-up visits before discharge, having a process in place to send all discharge or electronic summaries directly to the client 's primary care provider, and assigning staff to follow up on test results after the client is discharged. *Content Refresher* Without treatment, heart failuremay progress to cardiovascular collapse, failure of systemic organs, and death. Even with treatment, outcomes for the client diagnosed with heart failure vary depending on the severity of cardiac dysfunction. Cardiac rehabilitation and use of community-based home health services may greatly improve outcomes for the client with heart failure.

The nurse provides care for the client after abdominal surgery, and the client reports gas pains. Which action by the nurse is appropriate? 1. Encourage the client to increase intake of vegetables. 2. Instruct the client to ambulate frequently. 3. Show the client how to splint the abdomen. 4. Position the client on the right side.

1) INCORRECT - Increased vegetable intake is appropriate for clients who are constipated but have not just had abdominal surgery. Assuming this client's diet is advanced to regular, increased vegetable intake will cause increased gas pains. 2) CORRECT— Frequent ambulation increases the return of peristalsis and facilitates the expulsion of flatus. This is the best way to relieve the gas pain. 3) INCORRECT - Abdominal splinting decreases discomfort when the client coughs and breathes deeply, but it will not relieve gas pains. 4) INCORRECT - Repositioning will sometimes help intestinal gas to move, but it is not really helpful in expelling the gas. The client needs to get up and walk in the hall. *Think Like A Nurse: Clinical Decision Making* The impact of early mobilization on perioperative comorbidities and length of stay (LOS) has shown benefits in medical-surgical sub-specialties. For clients recovering from abdominal surgeries, ambulation can promote return of peristalsis and prevent post-operative ileus. The nurse should assess the client's hemodynamic stability for ambulation and offer use of assistive devices such as a walker. Secondary gains from early ambulation include reduced respiratory decompensation and reduced risk of pneumonia, deep venous thrombosis, pulmonary embolism, and urinary tract infections. *Content Refresher* Following surgery, the nurse will assess bowel sounds, abdominal girth, position and patency of nasogastric tube (if applicable), and color, amount, and odor of gastric drainage. The nurse will assess the surgical wound and assess the client's pain level. The nurse will also assess the client's body alignment (posture), gait, and movement of joints and identify any limitations such as weakness and activity intolerance. The nurse will determine if aids are needed for ambulation and consult physical therapy, if appropriate. The nurse will provide education to the client/family regarding the importance of ambulation.

The nurse provides care for a client receiving lithium carbonate 300 mg orally three times per day. Which clinical manifestations will the nurse identify as early indications of toxicity? (Select all that apply.) 1. Mild thirst. 2. Nausea and vomiting. 3. Coarse hand tremor. 4. Ataxia. 5. Slurred speech. 6. Muscle weakness.

1) INCORRECT - Lithium is a mood stabilizer used to treat bipolar disorder. Mild thirst is an expected side effect. Other common side effects include fine hand tremor and polyuria. 2) CORRECT— Nausea and vomiting are early signs of toxicity. The nurse should withhold the medication and obtain a blood lithium level before the dose is re-evaluated. 3) INCORRECT - A coarse hand tremor is an advanced sign of toxicity. Other indications include persistent GI upset, mental confusion, and poor coordination. 4) INCORRECT - Defective, uncoordinated muscle movements indicate a severe toxicity. 5) CORRECT— Slurred speech is an early sign of lithium toxicity, along with possible diarrhea, thirst, and polyuria. 6) CORRECT— Muscle weakness is an early sign of toxicity, and the nurse should withhold the medication and obtain a blood lithium level. *Think Like a Nurse: Clinical Decision-Making* The nurse will sort the side effects of lithium into early and late or expected categories. The nurse then needs to ask, "What information do I need to address this issue?" Acquiring information about the lithium level is important before contacting the prescriber. The lithium level will directly impact the actions of the prescriber and the nurse. The nurse needs to know that lithium toxicity can occur if the client alters fluid or sodium intake. Early manifestations of lithium toxicity include gastrointestinal and neurologic effects such as nausea, vomiting, slurred speech, and muscle weakness. *Content Refresher* Lithium is a mood stabilizing agent that stimulates neuronal growth and reduces brain atrophy in people with long-standing mood disorders. It is prescribed for clients with bipolar disorder, specifically to help control manic episodes. Assess client's mood and adherence with treatment regimen. Identify barriers to adherence. Determine client's use of concurrent medications. Assess renal function, as well as electrolyte levels. A sodium deficit causes more lithium to be reabsorbed and increases the risk of lithium toxicity. If the dose of lithium is not well controlled, the client can experience side effects and signs/symptoms associated with toxicity. These may include muscle weakness, tremors, fever, mental confusion, seizures, coma, and death.

The nurse assumes care of a client returning from surgery after a total abdominal hysterectomy. The client rates the pain as 4 out of 10 on the pain scale. Which intervention by the nurse is most appropriate? 1. Assist the client to a more comfortable position. 2. Administer narcotic pain medications as prescribed. 3. Encourage the client to watch television or read a book. 4. Continue to monitor the client for alterations in pain.

1) INCORRECT - Non-pharmacologic interventions such as repositioning and rest are appropriate alternatives; however, moderate pain should be more aggressively addressed. 2) CORRECT— There is a known etiology for the pain (surgery), so it is most appropriate to provide pain medications immediately for moderate pain and use other methods as adjunct therapy. 3) INCORRECT - Distraction may be an appropriate adjunct therapy, but it is an unrealistic intervention immediately post-anesthesia. 4) INCORRECT - Providing no intervention for the client's report of moderate pain is an unacceptable solution. *Think Like A Nurse: Clinical Decision Making* Non-pharmacologic interventions should not be used as a first resort for treatment of the client who experiences moderate to severe pain. Instead, non-pharmacologic interventions should be implemented as adjuncts when pain medication does not fully alleviate pain or while waiting for pain medication to take effect. Ultimately, if the client's pain is not relieved by a prescribed analgesic regimen, the nurse strongly advocates for a safe, evidence-based increase in the medication dosage amount or frequency of administration. While mild pain or discomfort may be effectively relieved by way of non-pharmacologic interventions, for moderate to severe pain, adequate pharmacologic treatment is essential. *Content Refresher* Pain is an unpleasant feeling conveyed to the brain by sensory neurons in response to injury, disease, and actual or potential tissue damage. The client who experiences pain may exhibit increased blood pressure, rapid respirations, increased perspiration, increased muscle tension, increased neuromuscular activity, nausea, vomiting, and irritability. Treatment for pain includes medications, relaxation techniques, meditation, yoga, distraction, guided imagery, herbal remedies, biofeedback, acupuncture, heat or cold applications, therapeutic touch, massage, and hypnosis. Surgical intervention may be indicated, depending on the underlying cause of pain.

The nurse provides care to a client who is prescribed an IV infusion of lactated Ringer (LR) solution for treatment of dehydration. The client appears restless and reports difficulty breathing. Auscultation of the client's lungs reveals bibasilar crackles. Which intervention does the nurse perform first? 1. Notify the health care provider. 2. Lower the head of the client's bed. 3. Administer furosemide as prescribed. 4. Discontinue the client's infusion.

1) INCORRECT - Notification of the health care provider about the client's condition will be necessary. However, immediate action is indicated. The client's signs and symptoms indicate potential fluid volume overload. Discontinuing the IV infusion is a priority nursing intervention. 2) INCORRECT - Lowering the head of the client's bed is an inappropriate action, as this intervention may increase the client's work of breathing. Based on the client's signs and symptoms, fluid volume overload may be developing. Priority nursing interventions include discontinuing the client's IV infusion. 3) INCORRECT - The client's signs and symptoms are consistent with fluid volume overload. Priority nursing interventions include discontinuation of the IV infusion. Administration of furosemide may be appropriate to promote diuresis of excess fluid. However, the health care provider should be notified of the client's condition prior to administration of furosemide. 4) CORRECT - Manifestations of fluid volume overload include restlessness, dyspnea, and development of crackles (rales) in the lung bases. Priority interventions for the client who demonstrates signs and symptoms of fluid overload include discontinuing the infusion of IV fluids. *Think Like A Nurse: Clinical Decision Making* The nurse will use knowledge about anatomy and physiology and the assessment step of the nursing process step to protect the client from harm. The nurse mentally asks, "What are the risks associated with administration of IV fluids?" and "What action is need to prevent harm to the client?" The nurse recalls that a sudden increase in fluid volume may overwhelm the circulation, and excess fluid may be routed to other areas of the body such as the lungs and peripheral tissues. If fluid is in the lungs, oxygenation and ventilation is affected, causing concern related to the ABCs. The nurse will implement action to protect the client's airway, breathing, and circulation. However, the priority action is to stop the infusion of fluid, which is the cause for the manifestations noted by the nurse. *Content Refresher* Fluid volume excess is a condition in which there is a retention of water and sodium in the body. Signs and symptoms of fluid volume excess (or fluid overload) include weight gain, increased central venous pressure (CVP), hypertension, tachycardia, distended neck veins, dyspnea, peripheral edema, crackles upon auscultation, and anxiety. Treatment involves monitoring and responding to fluid and electrolyte changes. The nurse monitors the client's vital signs, urine output, weight, and lung sounds and administers prescribed diuretics along with stopping (or reducing) IV fluids the client is receiving.

The nurse receives four new admissions. Which client is placed in a private room? 1. A client diagnosed with Pneumocystis jiroveci pneumonia. 2. A client diagnosed with group A streptococcus cellulitis. 3. A client diagnosed with Guillain-Barré syndrome. 4. A client diagnosed with cutaneous anthrax.

1) INCORRECT - Pneumocystis jiroveci requires standard precautions. This is an opportunistic infection commonly affecting those with acquired immune deficiency syndrome. 2) CORRECT— An integumentary infection caused by group A strep requires contact precautions until 24 hours after initiation of effective therapy. This type of bacteria can result in necrotizing fasciitis. 3) INCORRECT - Guillain-Barré is not a risk to others and only requires standard precautions. This is an autoimmune-type illness. 4) INCORRECT - Cutaneous anthrax infection only requires standard precautions. Aerosolized anthrax is a danger to others. *Think Like A Nurse: Clinical Decision Making* Streptococcus pyogenes (group A Streptococcus) is one of the most common bacterial causes of skin and soft tissue infections (SSTIs) worldwide. Infection control measures vary according to the specific body organ-system affected. For example, if the client has a major Streptococcal disease affecting the skin, wound, or burnt areas, that client should be placed on contact, droplet, and standard precautions. If the Streptococcal disease affects the pharynx in infant and children, the clients should be placed in droplet and standard precautions. When uncertain, the nurse should consult with the infection preventionist. *Content Refresher* Necrotizing fasciitis is a rapid, progressive inflammatory infection of the soft tissue in which pathogens enter the tissue through an open wound and spread rapidly in the extracellular space between the subcutaneous tissue and the fascia. If proper precautions are not taken, health care workers can develop infections. In addition to standard precautions, wear a gown and gloves upon room entry and use disposable, single-use, or client-dedicated equipment with a client on contact precautions. Failure to use proper precautions could result in the spread of infection, sepsis, and death.

While irrigating the eyes of a client who was splashed with battery acid, the nurse is called to address another client emergency. Which direction is the most important for the nurse to give to the LPN/LVN who will care for the client with the eye injury? 1. "Wait here with the client until I can locate another nurse. " 2. "Cover the eye with a patch and tape a metal eye shield securely in place. " 3. "Continue to irrigate the eyes until the pH is within normal limits. " 4. "Notify the client 's boss that discharge from the emergency department will be delayed. "

1) INCORRECT - Rinsing the client 's eyes should not be interrupted until the pH is within normal limits. 2) INCORRECT - The eye should be covered but only after the chemical is removed. 3) CORRECT— It is imperative to remove the acid. Checking the pH helps verify if all of the chemical has been removed. This direction is appropriate to provide to the LPN/LVN who will be caring for the client and falls within the LPN/LVN 's scope of practice. 4) INCORRECT - The client 's care needs are a priority. The employer can be contacted at a later time. *Think Like A Nurse: Clinical Decision Making* The nurse is in the midst of providing a treatment to a client who experienced a battery acid splash to the eyes. The nurse understands that this scenario requires immediate intervention in order to prevent addition harm to the client. Before delegating this client's care to another care provider, the nurse needs to stop and ask, "Who can provide care that ensures the client's safety?" The scope of practice for an LPN/LVN includes providing care to a client who is stable and has a predictable outcome. Because of the situation, the nurse should direct the LPN/LVN to continue the treatment and test the eyes for an appropriate pH level, which is used to indicate that all of the acid has been removed. The nurse should periodically follow-up to ensure that the treatment is being provided appropriately and the pH is being measured as expected. *Content Refresher* Each state has a nurse practice act, which protects the public by legally defining and describing the scope of nursing practice. Nurse practice acts also regulate the functions of nurses through licensing requirements. When assigning client care or delegating tasks, the nurse needs to review the scope of practice for ancillary staff to include LPN/LVNs and nursing assistive personnel (NAPs). The nurse should delegate tasks or make client assignments that are within their scope of practice. Following the scope of practice ensures client safety.

The client reports pain at an IV site. The nurse observes that the IV insertion site is pale, cool to the touch, and mildly swollen. Which intervention does the nurse implement? 1. Decrease the infusion rate and monitor the client's response. 2. Stop the infusion and notify the health care provider. 3. Discontinue the IV and apply a heating pad to the site. 4. Remove the IV and elevate the client's arm on a pillow.

1) INCORRECT - Signs and symptoms of infiltration include blanching or pallor of the skin, edema, and pain and tenderness at the IV insertion site. Continued infusion of fluid will worsen the infiltration. Intervention is necessary, including removal of the IV and elevation of the affected extremity. Application of a warm, moist compress to the affected area also may be appropriate. 2) INCORRECT - Manifestations of infiltration include blanching or pallor of the skin, edema, and pain and tenderness at the IV insertion site. The IV catheter should be removed, followed by elevation of the affected extremity. Notification of the health care provider should occur if the client's signs and symptoms are severe, if they persist, or as is indicated by the facility's policy. The client's condition should be appropriately documented and monitored. 3) INCORRECT - Infiltration produces signs and symptoms that may include blanching or pallor of the skin, edema, and pain and tenderness at the IV insertion site. The IV catheter should be removed, followed by elevation of the affected extremity. Application of a warm, moist compress may be indicated. However, heating pad application is not appropriate, as heating pad will cause extreme dilation of the blood vessels and may lead to extravasation, which involves absorption of medication into the surrounding tissues. Direct application of a heating pad to the site also may cause skin and tissue damage. 4) CORRECT - Signs and symptoms of infiltration may include blanching or pallor of the skin, edema, and pain and tenderness at the IV insertion site. Management of infiltration includes removal of the IV catheter and elevation of the affected extremity. Application of a warm, moist compress to the affected area may be indicated. *Think Like A Nurse: Clinical Decision Making* Prior to implementing any action for this client, the nurse mentally asks, "What do the symptoms indicate about the IV site?" The nurse recognizes that an IV site that is painful, edematous, and cool to the touch indicates an infiltration of the medication or fluid. The nurse's first action is to reduce risk and prevent harm by stopping the infusion and removing the IV catheter. Once the catheter is removed, the nurse will apply the principles of basic care by elevating the limb to encourage the absorption of the interstitial fluid. A new IV catheter can be placed in an alternative site once the symptoms manifested in the affected site are addressed. *Content Refresher* Intravenous therapy (IV) is a method of treatment used to manage fluid disturbances for clients. Select the prescribed solution and determine the appropriate equipment based on central or peripheral line access, intent of therapy, and intended duration of therapy. Aseptic technique should be used when accessing and managing the IV access site and equipment. Maintain the infusion rate as prescribed and check the infusion and infusion equipment hourly along with monitoring the IV access site for signs of infiltration, phlebitis, and infection. The goal is that the client will demonstrate improvement in fluid volume while exhibiting no signs of complications related to either the infusion or the IV access site.

A nurse provides care for a client who gave birth to a neonate 24 hours ago. The client and the newborn both have the AB negative blood type. Which action does the nurse implement based on this data? 1. Assess the need for Rh o(D) immune globulin. 2. Determine if the mother has any Rh antibodies. 3. Assess the blood type of the father. 4. Document the client and newborn's blood types.

1) INCORRECT - Since both mother and newborn are Rh negative, there is no issue of Rh sensitization, so no further intervention is needed. 2) INCORRECT - Since both mother and newborn are Rh negative, there is no issue of Rh sensitization, so no further assessment is needed at this time. 3) INCORRECT - Since both mother and newborn are Rh negative, there is no issue of Rh sensitization, so no further assessment is needed. 4) CORRECT - The nurse can document the findings, as no further action is required. *Think Like A Nurse: Clinical Decision Making* One situation that is of utmost importance during pregnancy and after delivery is the compatibility of blood types between the mother and baby. If the mother is of one blood type and the baby another, there is a risk that the mother will develop antibodies to the baby's blood type, which will place the fetus of any future pregnancies at risk. Since the mother and baby both have the same blood type and Rh factor, the mother does not need medication to prevent the development of antibodies. The blood types of both mother and baby should be documented in the medical record. *Content Refresher* Blood types are labeled as A, B, AB, or O as well as positive or negative, which represents the Rh factor. Compatibility refers to avoiding any antigen-antibody reactions. Clients with Rh negative blood develop antibodies when exposed to the Rh factor. Rh o(D) immune globulin is administered to Rh negative women who have delivered an Rh positive newborn or had a miscarriage or abortion of a Rh positive fetus. Rh o(D) immune globulin prevents the development of antibodies in the woman, which decreases the incidence of Rh hemolytic disease in future pregnancies.

The nurse provides care for a client with a fractured right femur in skeletal traction. Before administering care to the pin sites, it is most important for the nurse to take which action? 1. Observe for correct alignment of the right leg. 2. Assess the appearance of the pin sites. 3. Gather gauze and other required supplies. 4. Obtain the client 's pain level and medicate.

1) INCORRECT - The alignment of the leg is important and is done anytime the nurse cares for the leg, but it does not pertain to caring for the pin sites unless the nurse assesses that the pins are loose. 2) CORRECT - Carefully examine each pin site for drainage or redness. The nurse ensures the pins are in the correct placement before beginning pin care. 3) INCORRECT - The nurse assesses the pin sites first. This informs the nurse about which supplies to gather. 4) INCORRECT - While it is important for the nurse to assess the client's pain level and medicate, if necessary, prior to pin care, assessing the pin sites for infection is the priority. If the pins have moved or have become infected, the nurse will not perform pin care at this time. *Think Like a Nurse: Clinical Decision-Making* The condition of the pins and the surrounding tissue should be assessed for type and amount of drainage and skin color before beginning pin care. The condition of the pins should be assessed before gathering the supplies, since different supplies may be needed if the sites appear infected or inflamed. Assessing for pain is appropriate, but addresses a psychosocial need. Assessment of the site condition addresses a physical need and should be done first. *Content Refresher* Wound care includes assessment and cleaning of a wound using sterile or clean technique. Assessment of the wound is critical to evaluate drainage and healing.

The nurse instructs a client receiving captopril 25 mg TID. Which client statements indicate to the nurse that further teaching is necessary? (Select all that apply.) 1. "I will take the medication one hour before meals." 2. "I will eat a banana every morning for breakfast." 3. "I will cook with a potassium salt substitute." 4. "If I miss a dose, I can take two pills for the next dose." 5. "I take the medication at the same time every day." 6. "I should change positions slowly when standing."

1) INCORRECT - The client should take this medication either 1 hour before or 2 hours after meals. This statement indicates appropriate understanding of the information presented. 2) CORRECT - The nurse teaches the client to limit foods high in potassium. Therefore, this statement indicates the need for further teaching. 3) CORRECT - The nurse teaches the client that potassium-based salt substitutes should be limited or avoided. Therefore, this statement indicates the need for further teaching. 4) CORRECT - The client should skip a missed dose, not double up on this antihypertensive. Therefore, this statement indicates the need for further teaching. 5) INCORRECT - An ACE inhibitor is used to treat hypertension and works best when taken on a schedule. This statement indicates appropriate understanding of the information presented. 6) INCORRECT - Changing positions slowly is an appropriate action to prevent orthostatic hypotension. Additional adverse effects of this medication include cough, hypotension, taste disturbances, and proteinuria. *Think Like a Nurse: Clinical Decision-Making* Prior to administering a newly prescribed medication, the nurse should provide teaching that focuses on the actions, expected effects, and any adverse effects. Angiotensin-converting enzyme (ACE) inhibitors are associated with a risk for hyperkalemia. For this reason, the nurse should emphasize that potassium should be avoided in foods, supplements, and seasonings. It is important for the nurse to evaluate a client's understanding of prescribed medications and treatments. The best way for a nurse to determine if teaching is effective is to evaluate the client's verbal feedback. *Content Refresher* Hypertension refers to a persistent increase in systemic arterial blood pressure. Anti-hypertensive medications may be prescribed including alpha-adrenergic antagonists, alpha-adrenergic blockers, beta-adrenergic blockers, calcium channel blockers, and/or angiotensin-converting enzyme (ACE) inhibitors. The nurse needs to teach the client about the various medications used to treat hypertension, how to take the prescribed medications, how and when effectiveness will be determined, and possible adverse effects. In addition, the nurse must teach the client about lifestyle changes, including dietary recommendations.

The nurse assesses assigned clients. Which client does the nurse identify as being the greatest risk for accident and injury? 1. Client with rheumatoid arthritis. 2. Client with a stroke of the right hemisphere. 3. Client recovering from a bilateral oophorectomy. 4. Client recovering from a right hip replacement.

1) INCORRECT - The client with rheumatoid arthritis is not the greatest safety risk. 2) CORRECT- The client with a right hemispheric stroke is often disoriented to time, place, and person. This client will also have visual spatial defects and proprioception difficulties. Additional changes include impulsive behavior, poor judgment, decreased attention span, lack of awareness, or denial of neurologic deficits. All of these potential changes increase this client's risk for injury. 3) INCORRECT - The client had removal of both ovaries. This client is not a safety risk. 4) INCORRECT - The client recovering from a right hip replacement needs to have the legs abducted to prevent hip displacement. This client is not a risk for injury. *Think Like a Nurse: Clinical Decision-Making* Safety is a priority concern when planning care for clients. The nurse must assess each assigned client to determine the risk for accident and/or injury and plan care accordingly. The client recovering from a stroke affecting the right hemisphere of the brain is likely to exhibit impulsive behavior and altered mental status; specifically, disorientation. These cognitive challenges, along with potential left sided weakness, places this client at the high risk for injury when compared to the other clients who have physical conditions that place them at risk for accident and/or injury. *Content Refresher* Safety is the ability to perform tasks without fear of accidents or trauma and security in one's environment. A client diagnosed with a stroke may experience a change in level of consciousness, behavior or affect, as well as hypertension, facial droop, dizziness, pronator drift or muscle weakness on one side, gait changes, and visual and speech difficulties. These signs and symptoms place this client at a high risk for injury.

The home health nurse visits a client with a history of cerebral vascular attack (CVA) who uses a condom catheter due to incontinence. Which observation causes the most concern for the nurse? 1. The penis and surrounding skin are red and irritated. 2. The urine output for 8 hours is 500 mL. 3. The penis appears swollen and dark in color. 4. The condom keeps slipping off the penis.

1) INCORRECT - The irritation may indicate breakdown from urine or a possible allergy to the latex. Remove the condom, notify the health care provider, and allow the skin to heal. While this finding requires intervention, it is not the most concerning. 2) INCORRECT - This is an appropriate output for an 8 hour period. 3) CORRECT— The swollen and dark appearance indicates impaired circulation. The condom catheter was applied improperly, or the adhesive was applied too tightly. The condom may also be too small. Assess the circulation 30 minutes after a condom catheter is applied and then every 4 hours. 4) INCORRECT - Assess that the catheter is being applied correctly. It should be reapplied as necessary to help keep the client dry. *Think Like A Nurse: Clinical Decision Making* The nurse evaluates each assessment for risk of client harm. The nurse identifies that reddened, irritated skin and a penis that is edematous and dark in color both pose a risk of client harm. The nurse knows that a penis that is edematous and dark in color indicates circulatory compromise. Circulatory compromise poses a greater risk of immediate harm to the client than the deficit in skin integrity. The catheter should be removed and another one applied appropriately. The nurse should then assess the penis shortly afterward to ensure that the organ is receiving necessary circulation. *Content Refresher* Incontinence may happen for various reasons. Urinalysis and urine culture should be obtained to rule out infection. A voiding history, intake and output, and bladder residual testing should be performed. Medications (diuretics, sedatives) can affect voiding and should be assessed. Causes of incontinence include weakness of pelvic floor muscles, increased abdominal pressure, infections, over-distention of the bladder, sphincter weakness, and cognitive impairments. Age-related changes in bladder size and sensory impairments can also cause urinary incontinence. Clients with incontinence or neurogenic bladder may require bladder training and scheduled toileting. Intermittent or indwelling urinary catheters and suprapubic catheters may be required.

When providing care for a client diagnosed with primary adrenocortical insufficiency, which laboratory findings does the nurse expect? 1. Sodium 148 mEq/L (148 mmol/L), glucose 110 mg/dL (6.1 mmol/L), potassium 3.7 mEq/L (3.7 mmol/L). 2. Sodium 130 mEq/L (130 mmol/L), glucose 50 mg/dL (2.8 mmol/L), potassium 5.3 mEq/L (5.3 mmol/L). 3. Sodium 160 mEq/L (160 mmol/L), glucose 45 mg/dL (2.5 mmol/L), potassium 5.5 mEq/L (5.5 mmol/L). 4. Sodium 140 mEq/L (140 mmol/L), glucose 90 mg/dL (5 mmol/L), potassium 3.9 mEq/L (3.9 mmol/L).

1) INCORRECT - The normal sodium range is 135 to 145 mEq/L (135 to 145 mmol/L). The normal glucose range is 60 to 110 mg/dL (3.3 to 6.1 mmol/L). The normal potassium range is 3.5 to 5 mEq/L (3.5 to 5.0 mmol/L). For a client with adrenocortical insufficiency, the nurse expects the sodium and glucose to be decreased and the potassium increased due to a lack of glucocorticoids. 2) CORRECT— Hyponatremia, hypoglycemia, and hyperkalemia are expected findings in this client. 3) INCORRECT - The nurse expects the sodium to be decreased, rather than increased. 4) INCORRECT - These are all within normal ranges. The nurse expects to see hyponatremia, hypoglycemia, and hyperkalemia. *Think Like A Nurse: Clinical Decision Making* Prior to analyzing the laboratory values, the nurse needs to recall the pathophysiological process of primary adrenocortical insufficiency. In this disease process, there is a lack of glucocorticoids in the body, which need to be replaced. The glucocorticoids deficiency causes the sodium and glucose level to be low and the potassium level to be elevated. Treatment begins with steroids and fluid support. The nurse will monitor the client for manifestations of the imbalances and indicators that the imbalances are being resolved. *Content Refresher* In Addison disease, the outer cortex of the adrenal glands are slowly destroyed, most often as a result of the development of antibodies against the cells of the adrenal cortex. As plasma cortisol is reduced, there is an accompanying increase in the secretion of adrenocorticotropic hormone (ACTH) from the pituitary. When aldosterone is deficient, sodium and water are lost and hypotension and tachycardia occur. In most cases, symptoms appear when about 90% of the functional capacity of the adrenal cortex has been lost. They include progressive fatigue and weakness, muscle spasm, irritability and depression, confusion, tremors, nausea, and a craving for salty foods. Other signs include postural hypotension, tachycardia, weight loss, and tanned or darkened skin not associated with sun exposure. Ensure the client/family know how to prevent, recognize, and obtain treatment for Addisonian crisis.

The nurse performs a physical assessment on a client to assess cranial nerve function. Which actions will the nurse take to assess the client's trigeminal nerve? (Select all that apply.) 1. Check the client's six cardinal positions of gaze. 2. Palpate the temporal and masseter muscles while the client clenches teeth. 3. Ask the client to stick out tongue. 4. Use a cotton swab on the client's face to test light touch. 5. Place a vibrating tuning fork in the midline of the client's skull.

1) INCORRECT - The nurse should check the six cardinal positions of gaze when assessing the oculomotor (cranial nerve III), trochlear (cranial nerve IV), and abducens nerves (cranial nerve VI). 2) CORRECT- Checking the strength of the temporal and masseter muscles allows the nurse to assess the motor function of the trigeminal nerve (cranial nerve V). The nurse should check for equality of strength on both sides. 3) INCORRECT - The nurse should ask the client to stick out tongue and move it quickly from side to side when assessing the hypoglossal nerve (cranial nerve XII). The nurse should observe for fasciculations or deviations to either side. 4) CORRECT- The nurse should check for light touch on the forehead, maxillary area and chin on both sides of the face to assess the sensory function of the trigeminal nerve. The nurse should note for decreased or unequal sensation. 5) INCORRECT - The nurse should place a vibrating tuning fork in the midline of the client's skull to assess the acoustic nerve (cranial nerve VIII). The client should hear the sound equally in both ears, but will hear the sound louder in the affected ear with a conductive hearing loss and will hear the sound louder in the unaffected ear with a sensorineural hearing loss. *Think Like a Nurse: Clinical Decision-Making* It is important for the nurse to understand the functions of each cranial nerve, in order to perform a complete physical assessment. Functions of the fifth cranial nerve (the trigeminal nerve) include transmitting touch, pain, and temperature sensations between the face and the brain and controlling the muscles that are needed to chew. The trigeminal nerve has three branches: opthalmic, maxillary, and mandibular. Damage to this nerve can result from aging, multiple sclerosis, viral infection, oral or sinus surgery, facial trauma, or stroke. Trigeminal neuralgia is one condition that affects this nerve. Similar to nerve pain from shingles or from peripheral neuropathy, trigeminal neuralgia results in shocklike, sporadic, extreme pain. *Content Refresher* Twelve pairs of nerves lead directly from the brain to various parts of the head, neck, and trunk of body. The cranial nerves are: olfactory, optic, oculomotor, trochlear, trigeminal, abducens, facial, vestibulocochlear, glossopharyngeal, vagus, accessory, and hypoglossal. Trigeminal neuralgia is a chronic, intense, intermittent pain condition that affects the trigeminal nerve (cranial nerve V). The trigeminal nerve supplies the motor and sensory fibers to the face and jaw. Primary treatment involves use of medications to treat neuropathic pain and anticonvulsant medications, such as carbamazepine (Tegretol).

The nurse plans care for a client diagnosed with dementia. Which nursing intervention is the priority? 1. Encourage the family to perform activities of daily living (ADLs) for the client. 2. Provide a flexible schedule for the client. 3. Limit reminiscing by the client. 4. Assume a face-to-face position when speaking to the client.

1) INCORRECT - The nurse should encourage the client to do as much as possible. To assist with ADLs, the nurse should give one instruction at a time and allow the client plenty of time to complete the activity. 2) INCORRECT - Clients with dementia respond better to a routine that is regular and reinforced. 3) INCORRECT - Reminiscence therapy allows the client to share memories of the past to increase self-esteem and socialization. The nurse should encourage, rather than limit, this activity. 4) CORRECT - By speaking face-to-face, the nurse maximizes verbal and nonverbal cues. The nurse should use short, simple words and phrases, and speak slowly to give the client time to process information. *Think Like A Nurse: Clinical Decision Making* It is vital for the nurse to understand the characteristics and needs of clients with cognitive disorders. The client with dementia may be easily distracted. To reduce distraction, the nurse should directly face the client when talking. The nurse should also give the client time to process any verbal and nonverbal information and not push the client to respond or perform an action hastily. When caring for clients with cognitive needs, the nurse should be an advocate when necessary. *Content Refresher* With dementia, the client may demonstrate memory and cognitive impairment with or without associated behavioral problems. The nurse should determine the client's ability to perform activities of daily living and assess the client's social and physical support, work history, cognitive ability, memory, communication, and behavior changes. The nurse should provide frequent verbal, written, and visual orientation. The nurse should also use simple language when communicating with the client, make eye contact, and reduce environmental stimulation.

The nurse administers medication on the pediatric unit. Which is the first action action by the nurse? 1. Validate the prescription with the medical record after the medication has been administered. 2. Verify the client by looking at the armband before administering the medication. 3. Contact the pharmacist to find out about possible adverse reactions. 4. Administer the medication mixed in the client's formula.

1) INCORRECT - The nurse should validate the prescription before, rather than after, administering the medication. 2) CORRECT - Medication errors often occur because of improper identification. The nurse should remember the rights of medication administration. 3) INCORRECT - Nursing responsibilities includes knowing about side effects and adverse effects of medication. The nurse only contacts the pharmacy if unable to review the medication in a reliable drug formulary. 4) INCORRECT - The nurse should not mix all prescribed medications in formula during a medication pass. The compatibility of each medication with the formula, along with the other medications due to be administered, needs to be checked. *Think Like a Nurse: Clinical Decision-Making* The nurse always implements the rights of medication administration when administering prescribed drugs to the client. One of these rights is identifying the right client. The client's identity is confirmed using two approved identifiers, such as name and date of birth. The nurse asks the client to state this information. The nurse verifies this information using the armband on the client's wrist. *Content Refresher* Medication administration is the process by which prescribed medications are safely dispensed to a client. To ensure safe medication administration, the nurse needs to determine the rights of medication administration, which minimally include the right medication, the right dose, the right route, the right time, and the right client.

A client arrives at the emergency department experiencing tingling and weakness in the lower extremities that started when getting out of bed. The client reports the symptoms seem to be progressing upward. Which statement by the client is most important for the nurse to pursue during the assessment process? 1. "My grandfather had polio when he was young." 2. "I have been a vegetarian for several months now." 3. "Things have been stressful at work lately." 4. "We have been in the final preparations for a trip overseas."

1) INCORRECT - These symptoms are not characteristic of polio. Furthermore, polio is an infectious disease, not an inherited condition. 2) INCORRECT - There may be some deficiencies in the diet if the client is not knowledgeable about how to select appropriate foods. However, vitamin deficiencies are unlikely to cause the symptoms being described. 3) INCORRECT - While a concern, this is not the most important statement for the nurse to evaluate. Stress can cause or exacerbate almost any symptoms, and psychologically, people sometimes develop conversion disorders to keep themselves away from the stressful situation. However, the nurse should first explore a physical cause of the symptoms. 4) CORRECT - This needs immediate further investigation. Immunizations may have been given in preparation for this trip and an immunization could trigger the onset of the neurologic symptoms of Guillain-Barré syndrome. The symptom onset in Guillain-Barré is usually abrupt and can progress rapidly. Symptoms often, but not always, progress in an ascending direction (from feet toward head). It is an emergency condition. The most immediate concern is potential respiratory compromise from respiratory muscle weakness. *Think Like A Nurse: Clinical Decision Making* Initial symptoms of Guillain-Barré syndrome (GBS) include weakness and strange neurological sensations in the legs bilaterally. If the client reports strange sensations and weakness in the upper legs, the nurse suspects the nerves that provide bladder control will be affected next. At this point, placement of an indwelling catheter is indicated. Phrenic nerve demyelination may result in a poor respiratory pattern or hiccups, alerting the nurse to impending respiratory failure. Knowing that GBS occurs in an ascending fashion helps the nurse predict what will be affected next and to intervene proactively. *Content Refresher* Guillain-Barré syndrome is an autoimmune disorder that manifests as an acute inflammatory polyneuropathy. Assess cranial nerve function with attention to facial expression, speech, and gag and swallowing reflexes. Mechanical ventilation may be required. Plan for prevention of health alterations resulting from immobility (e.g. pressure injuries, deep vein thrombosis, and paralytic ileus) and address psychological concerns arising from increasing dependency and loss of function. Administer anticoagulant therapy as prescribed. Apply antiembolism stockings and sequential compression devices to prevent deep vein thrombosis. The client may show signs of recovery within 4 weeks, but complete recovery may take several months.

The inpatient unit is unusually hectic with admissions, discharges, and procedures. The unit secretary goes to the emergency department to get a client's paperwork. The secretary returns to the unit, angrily commenting how rude the emergency department staff were. The secretary exclaims, "I am going home!" and walks away. What is the best response by the charge nurse? 1. "Take a deep breath. Give it some thought and let me know what you decide." 2. "You must stay here and do your job. If you leave, that is insubordination." 3. "Calm down. Overreacting does not do you or anyone else any good." 4. "We are not the ones who were rude to you. Do not leave us, because we need you."

1) INCORRECT - This addresses the staff member's feelings, but does not solve the immediate need for the unit's functioning calmly and safely. Also, this response does not set a clear limit, which could then later be used if disciplinary actions were to be taken. 2) INCORRECT - It would be insubordination or defiance because the secretary would not be recognizing or accepting the authority of a superior. However, it does not acknowledge the secretary's feelings or possible validity of her concerns. 3) INCORRECT - Use of the word "overreacting" is certain to trigger an angry or defensive response, because it implies that something is wrong with the unit secretary and that the emergency department incident was not serious. "Calm down" can also convey these thoughts. 4) CORRECT - The priority is getting through the immediate situation on the unit. This statement points out reality; conveys genuineness, empathy, and positive regard; and accepts the secretary's judgment without setting up a conflict by disagreeing or challenging by choice of words. *Think Like A Nurse: Clinical Decision Making* For the best practices in handling crucial conversations, it is important to encourage the free flow of meaning and help others explore their path of action. The nurse manager can use these listening skills to retrace the unit secretary's path to action. Ask: Start by expressing interest in the unit secretary's views. Mirror: Promote safety by respectfully acknowledging the unit secretary's emotions. And Paraphrase: The nurse manager can restate the unit secretary's story, not only to show that the nurse manager understands but also to convey that it is safe for the unit secretary to share. *Content Refresher* Conflict resolution is managing the opposition, friction, disagreement, or discord that arises between individuals or within a group. Assess which conflict resolution strategy works best in a specific situation. Instances of conflict are minimized by using appropriate resolution strategies. Resolve the conflict in ways to gain respect, improve self-esteem, and build courage. Use effective communication skills. As conflict arises, it is addressed in productive ways to achieve positive results for the client, the nursing unit, and the health care organization.

The nurse provides care for a client receiving fluoxetine. The nurse determines that teaching is effective when the client makes which statements? (Select all that apply.) 1. "I should take a missed dose as soon as I remember. " 2. "I will chew sugarless gum frequently. " 3. "I will sit on the side of the bed before standing. " 4. "I will use sunscreen when I go outdoors. " 5. "I 'm glad that this medication will change my sex drive. " 6. "I should stop the medication if I start having side effects. "

1) INCORRECT - This client statement indicates the need for further instruction. If a dose is missed, the client is instructed to omit that dose and return to the regular dosing schedule. 2) CORRECT - This client statement indicates effective teaching. Sugarless gum may minimize dry mouth while avoiding cavities. Instruct the client to use good oral hygiene and rinse the mouth often. 3) CORRECT - This client statement indicates effective teaching. Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) used to treat depression and obsessive compulsive disorder, and it may cause dizziness. 4) CORRECT - This client statement indicates effective teaching. Photosensitivity results from this medication and precautions are necessary, such as wearing sunscreen while outdoors. 5) INCORRECT - This client statement indicates the need for further instruction. Fluoxetine may decrease the client's sex drive. This statement indicates the client thinks it will increase their libido. 6) INCORRECT - This client statement indicates the need for further instruction. The client should not abruptly discontinue the medication but should contact the health care provider regarding side effects, which include rapid heartbeat, anorexia, weight loss, and severe headache. *Think Like a Nurse: Clinical Decision-Making* Prior to administering a newly prescribed medication, the nurse should provide teaching about the mechanism of action, expected effects, any precautions when taking the medication, and any side or adverse effects. The prescribed medication is used to treat some psychiatric disorders and may cause drying of the oral mucosa and dizziness. This medication also interacts with natural sunlight, causing photosensitivity. The nurse should evaluate the client's ability to understand the precautions and be able to adhere to the prescribed medication regimen to prevent any adverse effects. *Content Refresher* Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) used for treatment of depression and is given orally once or twice a day. It can be given with or without food. Fluoxetine must be tapered and not stopped abruptly. If the client has been taking monoamine oxidase inhibitors (MAOIs), fluoxetine cannot be started for 14 days after completion due to risk of serotonin syndrome. When taking fluoxetine, the client may have an increased risk of suicide during early therapy. Other side effects of fluoxetine include headache, insomnia, anxiety, drowsiness, diarrhea, and decreased appetite. The client should be instructed to not drink alcohol while taking fluoxetine.

A client receiving phenelzine sulfate is diagnosed with Cushing syndrome and found to be hypokalemic. Which diet selection is appropriate for this client? 1. Banana and fruit salad with raisins. 2. Spinach and tuna fish salad. 3. Whole-wheat bread and cream cheese. 4. Guacamole and brown rice.

1) INCORRECT - This diet selection is high in potassium, but bananas are also high in tyramine. When tyramine is ingested with a monoamine oxidase inhibitor (MAOI) such as phenelzine, it can cause a hypertensive crisis. 2) CORRECT - This diet selection is high in potassium and does not contain foods high in tyramine. Most vegetables are acceptable with MAOIs. 3) INCORRECT - This diet selection is not high in potassium and does contain tyramine-containing foods as well. Whole-wheat bread is likely to have yeast, which is contraindicated with MAOIs. 4) INCORRECT - Avocados are high in potassium but also contain tyramine. When ingested with an MAOI such as phenelzine, it can cause a hypertensive crisis. Brown rice is an acceptable grain with an MAOI because it does not contain yeast. *Think Like A Nurse: Clinical Decision Making* The client diagnosed with Cushing syndrome is taught about signs and symptoms of hypokalemia and how to increase potassium in the diet. Some potassium-rich foods also contain tyramine, which is contraindicated with the consumption of a monoamine oxidase inhibitor (MAOI) medication. To reduce the risk of tyramine consumption, the client whose treatment plan includes this prescription may be prescribed a potassium supplement. The client is also advised to eat fresh produce within 2 days of purchase since overripe fruits contain higher tyramine levels. Periodic monitoring of serum potassium level is indicated for this client. *Content Refresher* Cushing syndrome is caused by excess endogenous cortisol production or exogenous administration of glucocorticoid medications. Symptoms of Cushing syndrome include obesity, "moon face," fat pad between shoulders (buffalo hump), thin skin that bruises easily, osteoporosis, hypertension due to sodium and water retention, hypokalemia, insulin resistance, edema, weakness, insomnia, depression, psychosis, and hirsutism (in women). Assess for signs and symptoms of hypokalemia, such as muscle weakness, paresthesias, palpitations, and ECG changes suggestive of hypokalemia (e.g. prominent U wave, ST-segment depression, and peaked P wave). Educate the client about the importance of following the prescribed diet.

A client with a diagnosis of type 1 diabetes mellitus reports severe continuous pain of the right leg and foot. Which assessment finding most concerns the nurse? 1. The skin on the right lower leg appears brown and leathery. 2. The client cannot distinguish between sharp and dull pressure on the right leg. 3. The client says the right leg is more comfortable when elevated on pillows. 4. The client has 2+ edema distal to the malleolus on the right foot.

1) INCORRECT - This finding is associated with chronic venous insufficiency, which is not associated with severe pain. The client's symptoms and history of diabetes mellitus suggest that the client may be experiencing peripheral arterial occlusion. 2) CORRECT— This client may be experiencing peripheral arterial occlusion. Symptoms of occlusion include pain, pulselessness, pallor, paresthesia, and paralysis. 3) INCORRECT - Elevating the leg increases venous return but decreases arterial supply. If the client is experiencing peripheral arterial occlusion, elevating the leg will likely worsen the pain. If the pain is alleviated with elevation, that suggests that the client is not experiencing an occlusion. 4) INCORRECT - Edema is seen with chronic venous insufficiency, which does not cause pain and is not an acute concern. *Think Like A Nurse: Clinical Decision Making* The client's symptom of continuous pain of the foot and leg could indicate arterial occlusion. The inability to discern between sharp and dull pressure is a major indicator of this health problem. The client needs to be assessed for the additional symptoms of pulselessness, pallor, and paralysis. The other signs or symptoms are indicators of chronic venous insufficiency, which does not pose a risk of immediate harm. Arterial occlusion needs to be reported immediately to the health care provider to prevent tissue damage or loss. *Content Refresher* Occlusive artery disease occurs when arteries become blocked and arterial circulation is impaired. Arteries that are more commonly affected are the carotids, the coronaries, and those feeding the lungs and the periphery of the body. Question the client about any occurrence of chest pain or shortness of breath or dizziness. Correctly apply and monitor ECG. Auscultate for a carotid bruit. Assess peripheral pulses. Monitor vital signs and pulse oximetry. Review cholesterol results. The signs and symptoms will depend on the area that is affected and may include bruits, pain, dizziness, paleness, shortness of breath, and non-palpable peripheral pulses.

The graduate nurse prepares to apply a sequential compression device (SCD) for the first time. Which statement by the nurse to the nurse manager reflects a correct understanding of the proper procedure? 1. "I will wrap the sleeves snugly, but I will be certain I can fit one finger between the sleeve and the leg." 2. "I will put the antiembolism stockings on before I wrap and secure the sleeves." 3. "I will start by positioning each sleeve under the leg so that the opening is at the ankle." 4. "I will measure the circumference of the midcalf and the midthigh to ensure that the sleeves are the correct size."

1) INCORRECT - This is an incorrect statement. The nurse needs to be able to fit two fingers, not just one, between the sleeve and the leg. The correct fit prevents irritation to the leg. It also allows for the device to reach adequate inflation pressure and prevents slipping out of position when deflation occurs. 2) CORRECT - This is a correct action. It is acceptable, though not essential, to apply antiembolism stockings prior to applying the sequential compression device sleeves. The stockings can decrease the itching, sweating, and heat that can build up under the plastic sleeves, thereby causing discomfort and skin irritation. 3) INCORRECT - This is an incorrect statement. The the opening should be at the knee (in front) and at the popliteal pulse point (in back). 4) INCORRECT - This is an incorrect statement. The circumference of the thigh is measured at the gluteal fold. The correct sleeve size ensures proper fit and function. *Think Like A Nurse: Clinical Decision Making* Oftentimes, anti-embolism stockings are prescribed for use with sequential compression devices. If they are prescribed, they should be applied to the legs prior to placing the compression devices. These stockings reduce skin irritation and promote comfort. The nurse should remember that anti-embolism stockings come in a variety of sizes. The nurse needs to measure the largest part of the client's lower leg (calf), and the length of the client's leg from the top of the lower leg to the heel. The stockings that fit the measurement parameters best are selected. *Content Refresher* Anti-embolism stockings are elastic stockings that compress the veins in the legs, facilitating return of venous blood to the heart. They are applied after surgery or when the client is at risk for deep venous thrombosis. Obtain stockings in appropriate size and length. A tape measure may be necessary to determine the correct size. For application, reach down length of stocking to pull heel toward the top of the stocking. Apply with client pointing toes, pulling from area that will cover ankle rather than the top of the stocking. Make sure there are no folds or creases in the stockings. Remove stockings every 8 hours and check status of skin and circulation.

The nurse provides care for clients on an acute pulmonary unit. The nurse prepares a written report for the next shift. Which information is most critical to communicate to the next shift? 1. Abnormal laboratory work, arterial blood gas reports, nutritional intake, and vital signs for the shift. 2. Abnormal assessment findings, activity tolerance, and variances in vital signs during the shift. 3. Name of each client 's health care provider, the date each client was admitted, dietary intake for each client, and each client's general condition. 4. Urinary output, fluid intake, visits by the attending health care provider, vital signs, and any respiratory problems encountered.

1) INCORRECT - This is important information, but the oncoming nurse can find this information in the documentation. 2) CORRECT— This information is documented, but because it may reflect variances in the client's status, it should be included in the hand-off report. The nurse on the next shift may not be able to review all client records immediately. 3) INCORRECT - Health care provider information and dates of admission can be obtained from client 's record. It is fine to include these in the report, but they are not essential. 4) INCORRECT - Most of this information is available in the medical record for the oncoming nurse to read before or after assuming care of the client. This information is only reported if abnormal. *Think Like A Nurse: Clinical Decision Making* Hand-off communication should include information that is the most critical for the oncoming nurse to know in order to provide safe effective care. Abnormal assessment findings, activity tolerance, and changes in vital signs would be the most pertinent for the clients on this care area. Items that can be found in the medical record are not necessarily reported, unless there is a change such as an abnormal laboratory value, change in urine output, or exacerbation of the health problem. *Content Refresher* Communication between health care team members, such as during change of shift report, will facilitate effective teamwork and collaboration. Become familiar with models of interdisciplinary communication such as the Situation, Background, Assessment, Recommendation (SBAR) Model. When providing care, it is the nurse's responsibility to effectively lead the team, clearly identify each member 's roles and responsibilities, and use written and verbal communication strategies to collaborate in care delivery.

The nurse provides care for a client diagnosed with paranoia. Two days after admission, the client refuses to give any information other than name and age. Which action is most important for the nurse to take? 1. Tell the client that the hospital is a safe place. 2. Urge the client to reveal more information. 3. Focus on developing a trusting relationship with the client. 4. Introduce the client to other clients on the unit.

1) INCORRECT - This is important, but the client needs to trust the nurse enough to share more information. The priority is establishing a trusting nurse/client relationship. 2) INCORRECT - The nurse should first establish trust with the client. Then the nurse should use open-ended questions to encourage sharing of information. The client is unlikely to share more information until trust is established. 3) CORRECT— When caring for a client who is resistant and paranoid, the first priority is to develop a trusting relationship with the client. 4) INCORRECT - This is not a priority and may provoke anxiety for this client. *Think Like A Nurse: Clinical Decision Making* The client experiencing paranoia has an issue with trust. The most important action for the nurse to take is to establish a trusting relationship with the client. Without trust, the nurse-client relationship cannot move forward. One way for the nurse to earn the client's trust is to follow through on things promised to the client. When the client realizes that the nurse will follow through when needed, the client will be inclined to share more information with the nurse. This is essential to developing a beneficial and realistic plan of care. *Content Refresher* A therapeutic relationship is one in which the relationship between the client and the caregiver is to promote and/or restore health. When caring for a client diagnosed with paranoia, the nurse needs to establish a trusting relationship, providing care with unconditional positive regard. The nurse should be empathetic when listening and responding to the client while clarifying misconceptions. In addition, be respectful, genuine, concrete, and specific when communicating with the client. The nurse must decrease stimuli, ensure a safe environment, and assist the client to recognize and cope effectively with anxiety. The goal when working with a paranoid client is that the client will be receptive to communication and work collaboratively with the nurse to achieve positive outcomes.

A tornado has just leveled a large housing division near the hospital, and the disaster alarm has been announced at the hospital. The nurse working on the postpartum/pediatric unit considers which client is most appropriate for discharge within the next hour? 1. A postpartum client who delivered 4 hours ago and has an intact perineum. 2. A postpartum client diagnosed with an infection who has been receiving antibiotics for the past 24 hours. 3. A toddler with newly diagnosed type 1 diabetes mellitus, diarrhea, and vomiting. 4. A 3-day-old breastfeeding neonate with a total serum bilirubin of 14 mg/dL (239 µmol/L).

1) INCORRECT - This is the second most stable client. The client still has a potential risk of bleeding postpartum. 2) INCORRECT - There is not enough information to judge the status of the client with the infection, or whether the antibiotics are effective. 3) INCORRECT - This is the most unstable client. This client requires frequent assessment of hydration status and blood glucose levels. 4) CORRECT- This is the most stable client. Phototherapy is considered for the neonate with a total serum bilirubin greater than 15 mg/dL (257 µmol/L) at 72 hours of age. The upper limit for the breastfed neonate is 15 mg/dL (257 µmol/L). Therefore, the current serum bilirubin level does not indicate the need for treatment. *Think Like A Nurse: Clinical Decision Making* In response to such a disaster as a tornado, the hospital activates its emergency operations plan (EOP). Planning for coordinated care of clients into and out of the hospital is an essential component of the EOP. This involves identifying the clients which can be discharged to make beds readily available for disaster victims. A client with newly diagnosed diabetes mellitus, nausea, and vomiting requires frequent monitoring. A client with a postpartum infection receiving antibiotics for 24 hours may or may not be responding to treatment, and subsequently requires further monitoring. A postpartum client who delivered 4 hours ago is at risk for postpartum hemorrhage. A total serum bilirubin level of 14 mg/dL (239 µmol/L) in a neonate who is 3 days old and being breastfed falls within normal limits. *Content Refresher* A client with physiological jaundice is fairly stable. Signs of physiological jaundice begin 24 hours after birth and are not present at birth. Total serum bilirubin levels will rise during the first few days postnatally, peaking at day 5 and declining after that time. Mild jaundice may be noted in the sclera and skin of the neonate. Total or direct serum bilirubin levels measure the amount of bilirubin that is produced when the liver breaks down red blood cells and are used to determine the severity of the presenting jaundice.

A client with an eating disorder states, "I can't help it. When I get stressed out, I need to gorge myself with food." Which response by the nurse is appropriate? 1. "Do you understand the harm you are doing to your body?" 2. "There are healthier ways of coping with stress than gorging." 3. "What types of foods do you overeat during stressful periods?" 4. "Tell me about things in your life that are difficult for you."

1) INCORRECT - This response is nontherapeutic and instills guilt. The client is probably already aware of harmful effects. 2) INCORRECT - This is lecturing and is not conducive to the client expressing their feelings. The client needs to talk because illness tends to be secretive. 3) INCORRECT - This is barely relevant, is likely to induce further guilt, and is nontherapeutic. 4) CORRECT - Open-ended, therapeutic communication techniques focusing on the client's feelings encourages further verbalization. *Think Like A Nurse: Clinical Decision Making* In addition to asking open-ended questions, the nurse may also use active listening to enhance communication. Active listening is a way of listening and responding to another person that improves mutual understanding. Often when people talk to each other, they do not listen attentively. They are distracted, half listening, half thinking about something else. The client's statement requires further clarification and investigation by the nurse. The nurse should keep in mind to maintain privacy and confidentiality when interacting with clients in the presence of other members of the health team or the roommate. *Content Refresher* A therapeutic relationship is one in which the relationship between the client and the caregiver is to promote and/or restore health. The relationship is based on caring, respect, and mutual trust. Failure to establish a therapeutic relationship could result in stress, poor communication, and an inability to achieve positive client outcomes. Be empathetic when listening and responding. Be respectful, genuine, concrete, and specific. Clarify misconceptions with a client. Consider family relationships and a client's values. Maximize a client's abilities to participate in decision making and treatments.

The nurse teaches a young adult female client about preventing sexually transmitted infections (STIs). Which information does the nurse include in the teaching? 1. "After having intercourse, use a douche that contains a vinegar solution. " 2. "Before having intercourse, insert a diaphragm with spermicide. " 3. "Use a condom and spermicide each time you have intercourse. " 4. "Limit your sexual encounters only to individuals that you know well. "

1) INCORRECT - Vaginal douching does does not kill bacteria or viruses, and may force the organisms higher into the reproductive tract. 2) INCORRECT - Spermicide effectively destroys some of the organisms that cause STIs. However, use of a diaphragm still allows for the deposit of semen into the vagina, which may lead to STI transmission. 3) CORRECT - A condom prevents the deposit of semen into the vagina. In addition, spermicide effectively destroys some of the organisms that are responsible for causing STIs. 4) INCORRECT - Limiting the number of sexual partners does not guarantee protection against STI transmission. *Think Like a Nurse: Clinical Decision-Making* The nurse offers the adolescent frank, factual, and specific information regarding sex. The only two ways to prevent sexually transmitted infections (STIs) are the use of condoms or abstinence. Abstinence is a personal choice that adolescent clients may or may not make, and useful alternative methods are taught for STI and pregnancy prevention. Additionally, the adolescent is taught when to seek treatment and about privacy laws protecting that treatment information. *Content Refresher* The sexually transmitted infection educational process ideally should begin in the middle school and continue annually at each physical examination. Utilize informational pamphlets, videos, individualized and structured instruction, and supplement with web site programs that explain risk factors and specific information regarding methods of transmission, signs and symptoms, and treatment of sexually transmitted infections (STIs). Educate the client that if she or he has a STI, it is important to inform sexual contacts so they can receive treatment. Recommend vaccine for vaccine-preventable infections, based on clinical guidelines.

The nurse assigns a client after a left mastectomy to an LPN/LVN. The nurse reminds the LPN/LVN to take the client 's blood pressure on the right arm. Later in the shift, the nurse notes that the deflated blood pressure cuff is on the client 's left arm. Which action does the nurse take? 1. Talk with the LPN/LVN after the shift is over. 2. Ask why the LPN/LVN did not follow directions. 3. Explain to the LPN/LVN the importance of taking the blood pressure on the right side . 4. Write a report about the incident and place it in the LPN/LVN 's personnel folder.

1) INCORRECT - Waiting will cause continued harm to the client. Incorrect behavior is addressed when it is noted. 2) INCORRECT - The nurse does not ask why. This sets an accusatory tone and places the other person in a defensive position. 3) CORRECT— Explain the importance of taking the client's blood pressure on the right side now to prevent or reduce harm to the client. 4) INCORRECT - The nurse will file an incident report, but does not have authority to place it in the personnel folder. Also, filing an incident report without providing an explanation to the LPN/LVN will not prevent further harm to the client. *Think Like A Nurse: Clinical Decision Making* The nurse needs to first reinforce the reason why the left arm should not be used. This should be done immediately to prevent further harm to the client. An incident report should be completed and given to the nurse manager, but the nurse should first address the issue with the LPN/LVN to prevent harm. The nurse should not wait until the end of the shift to discuss the issue. Asking "why" questions will place the LPN/LVN on the defensive and should be avoided. *Content Refresher* The planning required to take a client's blood pressure includes the following: Gather stethoscope and blood pressure cuff with a mercury or aneroid sphygmomanometer or automated oscillometric blood pressure device. Position client upright. Avoid obtaining a blood pressure in the same arm in which there is an arteriovenous fistula, where lymphedema exists, or after lymph node dissection for treatment of breast cancer. Ensure that client avoids consumption of caffeinated products, smoking, or exercise for at least 30 minutes prior to obtaining measurement.

An older adult client states to the visiting nurse, "I noticed some of my house numbers are missing. I am glad you found me." Which response is the most appropriate for the nurse to make? 1. "I am going to get you an appointment with the ophthalmologist. " 2. "You always had something critical to say in the hospital. " 3. "We need to clean your glasses. " 4. "I 'll check to see if the house numbers are visible. "

1) INCORRECT - While this may be an appropriate response by the nurse, further assessment of the the situation is the most appropriate response by the nurse. 2) INCORRECT - Making a comment about the client being critical assumes that the older adult client can see adequately. This comment is also judgmental and non-therapeutic. 3) INCORRECT - Responding about cleaning the glasses assumes that the client is unable to see because of dirty glasses. 4) CORRECT - The client might have macular degeneration. The nurse needs to validate what the client is reporting. *Think Like a Nurse: Clinical Decision-Making* This scenario indicates a possible alteration in sensory function. The nurse mentally asks, "Is the client reporting an existing problem, or does this comment indicate another problem?" When the nurse assesses the accuracy of the client's perception, attention should be given to what the client reports seeing. The nurse is aware that with macular degeneration, central vision is lost while peripheral vision is preserved. If the client was outside and looking at the house numbers, it is possible for the client to think the numbers are missing if the central visual fields are affected. The nurse needs to first look at the house numbers to determine if they are present and then assess the client accordingly. *Content Refresher* Assessment is the careful observation and evaluation of a client 's health status. It is the first step of the nursing process. Assessment includes questioning the client regarding the potential problems, history of the present illness, past medical history, family health history, health practices, health beliefs, and functional, psychosocial, and cultural status. The nurse needs to establish a rapport and interview the client for the purpose of collecting relevant data. Using open ended questions are preferred. Assessment will provide accurate and appropriate data that will contribute to the holistic treatment of the client.

During the initial period following a spinal cord injury, which action is most important for the nurse to take? 1. Prevent contractures and atrophy. 2. Prevent urinary tract infections. 3. Promote rehabilitation. 4. Prevent flexion or hyperextension of the spine.

1) INCORRECT — Although important, this is not a priority in the immediate post-injury period. It relates to chronic disease management, but not to acute care. 2) INCORRECT — Infection generally occurs as a result of prolonged immobility. While important, it is not the priority for acute care. 3) INCORRECT — Safety and surviving injury take priority. Rehabilitation should begin when the client's condition stabilizes. 4) CORRECT — The primary goal in the acute period is to protect the spine from strain and further damage while the injury heals. *Think Like A Nurse: Clinical Decision Making* The nurse considers the safety risks that the client faces. In a spinal cord injury, the integrity of the vertebral column is compromised. The client is a risk for further injury at this time. Actions to prevent additional damage and injury include preventing flexion and hyperextension of the spinal segments. The nurse should frequently assess the client's vital signs, pain level, sensation, motor strength, movement, and reflexes. *Content Refresher* A spinal cord injury is damage to the spinal cord that results from fracture or herniation of vertebral discs, ligament tears, contusions, and partial tears or complete tears (transection) of the spinal cord. Initial treatment consists of immobilization, stabilization, prevention of complications, and possibly surgery. Potential complications related to spinal cord injury include skin breakdown, loss of bowel and/or bladder control, autonomic dysreflexia with severe hypertension, and spinal shock with bradycardia, hypotension, and weakness. Sepsis and pneumonia may also occur.

A client had a permanent pacemaker implanted 1 year ago and returns to the outpatient clinic because of not feeling well. Which question is important for the nurse to ask? 1. "Have you experienced abdominal pain?" 2. "Are you having wheezing on exertion?" 3. "Have you noticed shortness of breath and dizziness?" 4. "Have you had any headaches?"

1) INCORRECT — This question assesses gastrointestinal symptoms, which are not relevant to the client with an implanted pacemaker. 2) INCORRECT — This question assesses respiratory symptoms due to a narrowed airway, which is not relevant for a client with an implanted pacemaker. 3) CORRECT — This question assesses symptoms of decreased cardiac output, which occurs with pacemaker battery failure. 4) INCORRECT — This question is not relevant for a client with an implanted pacemaker. *Think Like A Nurse: Clinical Decision Making* The nurse understands the importance of encouraging the client to periodically have the pacemaker interrogated. This can be easily achieved by visiting a pacemaker clinic or home monitoring using a telephone transmitter device. Reinforce safety precautions with regards to the pacemaker (i.e. avoid direct blows to the chest, avoid standing near anti-theft devices, ensure the health care provider knows about the pacemaker before having a magnetic resonance imaging [MRI] exam). *Content Refresher* Dysrhythmias are cardiac rhythm disturbances that affect perfusion. Clinical manifestations of dysrhythmias include palpitations, skipped beats, syncope, confusion, dyspnea, chest pain, and fatigue. Treatment for dysrhythmias include medications, pacemaker insertion, internal cardioverter/defibrillator insertion, external cardioversion/defibrillation, and ablation.

Which intervention is appropriate when developing a plan of care for an older adult who is hospitalized from home for an acute illness? 1. Use a standardized general nursing care plan. 2. Plan for likely long-term care transfer. 3. Assess pre-admission functional abilities. 4. Minimize physical activity during the hospitalization.

1) INCORRECT- Care should be individualized. Standardized plans are often ineffective in addressing specific functional needs. 2) INCORRECT- Planning for transfers to long-term care is not the priority. The priority care goal is to maintain functional abilities at pre-admission levels so the older adult can continue to live and manage at home when discharged. 3) CORRECT- Pre-admission assessment of functional abilities provides a baseline for comparison. It is a key consideration in preventing decline and deconditioning. 4) INCORRECT- Maintenance of physical mobility and independence is important to preserve functional abilities. *Think Like A Nurse: Clinical Decision Making* To effectively plan client care, the nurse must know the client's baseline health status. The plan of care has, as its central goal, the client's return to the desired functional status or state of being. Client goals should be measurable and realistic. For example, if the client typically requires the use of a wheelchair, anticipating the client's ambulation upon hospital discharge likely is an unrealistic goal. If the client engaged in gardening, mowing the lawn, and tending to grandchildren prior to the acute illness, the nurse would not anticipate the client's need for a referral to a long-term care facility unless some debilitating event or major change in health status has occurred. *Content Refresher* The older adult population faces multidimensional problems that affect health and quality of life. Therefore, older adult care delivery requires strategies to attain the highest possible level of quality functioning. For the hospitalized older adult client: Assess changes in body systems and organs related to aging and resulting from disease. Assess visual, hearing, and cognitive problems that may interfere with daily life. Assess losses in taste and smell that may lead to poor nutrition. Assess mental health. Assess for impediments to mobility. Provide training to improve muscular strength, balance, and reaction time. Teach cognitive enhancement strategies, accident and fall prevention, and provide education on nutrition.

The nurse instructs a client diagnosed with cholecystitis. The nurse determines that teaching is effective when the client selects which meal? 1. Liver with onions, cucumber salad, skim milk. 2. Scrambled eggs, bagel with cream cheese, apple juice. 3. Guacamole with chips, bean burrito, herbal iced tea. 4. Barbecued chicken, green peas, lemonade.

1) INCORRECT- Liver is high in fat, and onions and cucumber promote gas production. 2) INCORRECT- Eggs and cream cheese are both high in fat. 3) INCORRECT- Guacamole has avocado, which is high in fat. The chips are likely to be fried and high in fat, and beans are high in gas-producing substances. 4) CORRECT- The client diagnosed with cholecystitis should consume a low-fat, low-carbohydrate, and high-protein diet. Barbecued chicken, green peas, and lemonade are all low-fat, low-carbohydrate, and high-protein foods. *Think Like A Nurse: Clinical Decision Making* To evaluate the effectiveness of teaching, the nurse uses the teach-back method to assess the client 's understanding. Diet is an essential component of managing gallbladder disease. The gallbladder stores bile. Inflammation or stones change how the stored bile is released, causing it to be released directly into the intestines instead of when it is needed to digest fat. Bile in the intestines causes a laxative effect. Fat without bile is mostly undigested and causes diarrhea, as well. The client must limit fat intake to avoid significant gastrointestinal discomfort. *Content Refresher* Cholecystitis is inflammation of the wall of the gallbladder. It is usually associated with obstruction related to the presence of gallstones or biliary sludge. However, it can occur alone as a result of fasting, prolonged parenteral nutrition, diabetes mellitus, infection, or serious illness. The gallbladder stores bile made by the liver. Bile helps digest fat. Bile moves from the gallbladder to the small intestine through the cystic duct and the common bile duct. Observe for indigestion, clay-colored stools, fever, jaundice, palpable gallbladder, dyspepsia, colicky pain in right upper quadrant of abdomen, and abdominal distention, which may indicate internal bleeding.

The nurse receives an informal mid-shift report from the nursing assistive personnel (NAP) assisting with client care. Which report does the nurse respond to first? 1. A client diagnosed with lung cancer keeps coughing, is on oxygen, and can hardly breathe, but asked me for a cigarette. It makes me so mad that the client is sick because of smoking and still wants to smoke. 2. A client after a Billroth II procedure (gastrojejunostomy) wanted to lie down right after eating even after I told the client to sit up for at least half an hour to let the food digest. 3. A client recovering from a myocardial infarction started crying while I was providing care stating, "I should be grateful but I am terrified thinking about what if it happens again." 4. A client after a right-below-the-knee amputation keeps complaining of pain in the toes and calf of the right leg. Although reminded that the leg is no longer there, the client insists that the leg hurts.

1) INCORRECT— The nurse should allow the NAP to further express feelings. Often it is difficult for staff to deal with clients who seem addicted to or intent on self-destruction when the providers are intent on saving lives. Such an expression should be followed with discussion of ways to be objective and how to avoid judgment. 2) CORRECT — The client action requires immediate intervention. After a gastrojejunostomy, dumping syndrome can occur, and lying down after eating is recommended in order to delay the gastric emptying process. Eating lying down or semirecumbent is another measure that can be taken. The desire to lie down may be one of the early manifestations of dumping syndrome, which also includes vasomotor disturbances of syncope. The client needs evaluation and clarification of proper procedure, and the NAP needs to be taught that this client situation is the exception to the rule of not lying down after eating. 3) INCORRECT— The client has a psychosocial need to express feelings and fears and to have them acknowledged by professional staff so that appropriate teaching, guidance, and support can be given. 4) INCORRECT— The nurse needs to instruct the NAP about phantom limb pain. The nurse would assess a client to determine if pain intervention is required, such as medication or complementary or alternative therapy. It is not therapeutic to remind a client that because the limb is missing it cannot be hurting. *Think Like A Nurse: Clinical Decision Making* The client recovering from gastric surgery is at risk for developing dumping syndrome, which occurs when ingested carbohydrates move too rapidly into the small intestines. Reclining after eating is recommended to delay the gastric emptying process. This client has a physical need. *Content Refresher* Care for the client experiencing gastric surgery involves providing pre-operative care and teaching. Review the health care provider's orders for specifics of post-operative management. Assess bowel sounds, abdominal girth, position and patency of the nasogastric tube, and the color, amount, and odor of gastric drainage. Assess pain level and medicate as needed. Observe for bleeding. Administer IV fluids. Monitor labs. Assess for dumping syndrome when food/fluids are introduced. Educate the client/family about dietary restrictions and follow up treatment. Provide emotional support.

The nurse prepares to give a newborn the first bath after birth. Which action does the nurse take next? 1. Wash the newborn's eyes from the outer canthus to the inner canthus. 2. Remove the vernix from the newborn's body. 3. Use a pH neutral soap for cleansing the newborn. 4. Expose the newborn's body while washing the hair.

1) INCORRECT— The nurse should use a new washcloth when cleaning the eyes, cleaning from the cleanest area (inner canthus) to the least clean area (outer canthus) to prevent introducing bacteria into the newborn's eyes. 2) INCORRECT— The fetus is covered in vernix caseosa in utero to provide protection from amniotic fluid and to moisturize the skin. Much of this is lost during birth, but the nurse should avoid removing any that is left during the first bath. This white, cheesy substance helps maintain heat and can provide protection to the skin against bacteria. The nurse should try to leave as much on the skin as possible. 3) CORRECT— The nurse should use a mild, pH neutral or slightly acidic soap to minimize injury to the skin. 4) INCORRECT— The nurse should wrap the newborn in a warm blanket and only expose the head when washing the hair to prevent heat loss. *Think Like A Nurse: Clinical Decision Making* Newborns cannot effectively regulate body temperature, so if a bath is given during the time in the hospital (and it usually is), great care is taken to keep the newborn as warm as possible before, during, and after the bath. For the newborn, decreased body temperature causes a significant increase in metabolism and negatively affects early feeding. The waxy vernix caseosa is protective to the newborn, so the aim of the first bath is simply to remove blood from the birth process. Parents should be allowed the option to delay or to be present and assist with the first bath. This is a good bonding and teaching opportunity, especially for first-time parents who are unsure how to handle the newborn. *Content Refresher* Skin-to-skin holding and breastfeeding (to prevent hypoglycemia) generally should occur before the newborn's first bath. Because the newborn's skin is covered with host-defense proteins that help protect a newborn against bacterial infections, only plain warm water should be used for routine bathing. If a cleanser is required, it should be mild and have a neutral pH. Alkaline soaps, oils, powder, and lotions provide a medium for bacterial growth. For the first 2 to 4 weeks, the newborn should be bathed no more than two to three times per week. When teaching the parents, emphasize the need for safety in terms of water temperature and constant supervision of the newborn during bath time.