Study set 9 for RN NCLEX (Kaplan)

The nurse instructs a client who is prescribed hydralazine as treatment for hypertension. Which client statements indicate to the nurse that the teaching is effective? (Select all that apply.) 1. "I will take my hydralazine with my breakfast." 2. "I will call my health care provider before taking ibuprofen." 3. "I need to have my blood drawn twice a week." 4. "I will feel hungry while on this medication." 5. "I will sit on the edge of my bed for 2 minutes before I get out of bed."

1) CORRECT - Hydralazine should be taken with food to increase bioavailability of the medication. 2) CORRECT - Over-the-counter medications should be avoided when taking hydralazine unless otherwise directed by the health care provider. 3) INCORRECT - Hydralazine does not require regular laboratory monitoring. 4) INCORRECT - Anorexia, not an increased appetite, is a possible adverse effect. The client should notify the health care provider if anorexia occurs. 5) CORRECT - Orthostatic hypotension is a possible adverse effect of hydralazine. The client should be instructed to sit on the edge of the bed prior to standing to prevent this effect. *Think Like a Nurse: Clinical Decision-Making* During client teaching, the nurse uses the teach-back method to evaluate the client's understanding. The nurse ensures the client understands the indications for hydralazine administration, as well as health management related to the hypertension. Dizziness, which is a potential adverse side effect of hydralazine, may increase the client's risk for falls. Adverse effects such as fainting, tachycardia, edema, or chest pain require immediate care. Dietary recommendations include a low-sodium diet. Reinforce the importance of adhering to the prescribed medication regimen. Educate the client about health risks associated with ineffective management of hypertension, including stroke and heart attack. *Content Refresher* For teaching and learning, ensure a comfortable environment with adequate lighting. Determine the learner's knowledge level regarding hypertension. Allow time for discussion and questions. Stop for a break when the learner indicates that one is needed. Minimize distractions and use clear, brief instructions. Educate the client about the prescribed medication, including the rationale for administration, the dosage and frequency of administration, and the plan for evaluating the medication's effectiveness. Evaluate the effectiveness of the teaching/learning session using the teach-back method.

The nurse provides care for several clients. Which client does the nurse assess first? 1. A middle-age female adult client reporting fatigue, severe nausea, and jaw pain. 2. An older adult male client reporting abdominal pain, vomiting, and diarrhea. 3. A middle-age female adult client reporting productive cough and shortness of breath. 4. An older adult male client reporting urinary hesitancy and weak urinary stream.

1) CORRECT - This client is having atypical symptoms of a myocardial infarction (MI). Women may not have severe, crushing, prolonged chest pain that is typically attributed to an MI. 2) INCORRECT - This client has a potential circulation issue secondary to diarrhea and volume loss. 3) INCORRECT - The client has symptoms of pneumonia, demonstrating the potential for airway/breathing issues. However, the client with jaw pain is experiencing an urgent, actual physiological impairment of circulation. 4) INCORRECT - The client has symptoms of benign prostatic hypertrophy. No airway, breathing, or circulation issues are present. *Think Like A Nurse: Clinical Decision Making* When prioritizing care, the nurse needs to review the clients for primary symptoms, acuity level, and risk for a life-threatening situation. Then the nurse should ask, "Which client is experiencing the most distress?" Of the clients assigned, the one that is most at risk is the older adult demonstrating atypical signs of a myocardial infarction (MI). Women may not experience the typical signs of an MI and instead experience jaw pain, fatigue, and nausea. An MI is a medical emergency that can lead to complete circulatory compromise if not treated immediately. This client is the priority and should be seen before the client experiencing shortness of breath. *Content Refresher* Classic signs of a myocardial infarction (MI) include severe angina that may be described as crushing, burning, constricting, or otherwise excruciating. The pain is not relieved by changing positions, resting, or administering nitrate medication. However, angina associated with MI may also be experienced as chest tightness, pressure, or discomfort. Among women, atypical signs and symptoms of MI are more likely. For example, women may experience shortness of breath, sharp chest pain, abdominal pain, nausea, neck or jaw pain, and/or vomiting. Symptoms of MI also may include fever and cool, clammy skin. Clients diagnosed with diabetes may be asymptomatic when experiencing an MI.

The nurse provides care for a client diagnosed with type 1 diabetes mellitus. Which assessment findings alert the nurse to a hypoglycemic reaction? (Select all that apply.) 1. Tremors. 2. Hot, dry skin. 3. Nervousness. 4. Irritability. 5. Muscle cramps.

1) CORRECT - This is the autonomic nervous system 's response to severely decreased blood sugar. 2) INCORRECT - Hot, dry skin is related to hyperglycemia. 3) CORRECT - This is the autonomic nervous system 's response to severely decreased blood sugar. 4) CORRECT - This is the autonomic nervous system 's response to severely decreased blood sugar. 5) INCORRECT - This is unrelated to hypoglycemia. *Think Like a Nurse: Clinical Decision-Making* The nurse is alert that clients with hypoglycemia often exhibit tachycardia, irritability, restlessness, excessive hunger, diaphoresis, and depressed consciousness (hence the mnemonic TIRED). Some clients with chronically unstable glucose levels will not exhibit these symptoms or will exhibit them only after the glucose level has fallen to a dangerous level, such as 30 mg/dl. The body releases epinephrine in response to low glucose, which causes the characteristic tremors and palpitations, but the primary effect of epinephrine is to release glucose from the liver into the bloodstream for immediate use. *Content Refresher* Hypoglycemia occurs when there is too much insulin in the bloodstream relative to the amount of available glucose. Assess the client 's blood glucose level. Assess the client for tremors, irritability, cool skin, difficulty concentrating, decreased level of consciousness, slurred speech, and reports of hunger, nausea, and headache. Clients with hypoglycemia need 15 to 20 grams of a rapid-acting sugar to correct the condition. If the client is conscious, give three or four glucose tablets, 4 oz. of fruit juice or regular soda, 8 oz. of milk, five to six pieces of hard candy, or a tablespoon of sugar or honey. If the client is unconscious, administer 1 mg of glucagon or 25 to 50 mL of 50% dextrose.

The nurse provides care for a client receiving ranitidine twice daily. The nurse assesses further when the client makes which statements? (Select all that apply.) 1. "I am going to have allergy testing tomorrow." 2. "I increased my intake of fresh vegetables." 3. "I like to smoke a cigarette before bedtime." 4. "I take an occasional ibuprofen if my knees hurt." 5. "I will take all of the medication in the bottle." 6. "I drink a glass of red or white wine every night."

1) CORRECT - This medication is a histamine blocker and may cause false-negative results on allergy skin testing. The client should avoid the ranitidine for 24 hours before testing. 2) INCORRECT - Fresh vegetable intake minimizes constipation. Ranitidine is a histamine H 2 antagonist used to treat active duodenal ulcers or benign gastric ulcers, and can cause constipation by decreasing secretions. 3) CORRECT - Smoking interferes with histamine antagonists. The client should not smoke when taking this medication, and at least should not smoke after the last dose of the day. Also, smoking increases gastric and esophageal irritation. 4) CORRECT - The client should avoid all NSAIDs, including ibuprofen, because of increased gastric irritation. 5) INCORRECT - The client should take all doses as prescribed. 6) CORRECT - The client should avoid alcohol because it may increase gastrointestinal irritation. *Think Like a Nurse: Clinical Decision-Making* Prior to administering a newly prescribed medication, the client should be instructed in the mechanism of action, expected effects, any precautions when taking the medication, and any specific side or adverse effects. This medication is used to control the release of histamine, which can cause gastric erosion. Because of this, the outcome of allergy testing may be affected due to an alteration in the release of histamine as an expected reaction. The client should be instructed to avoid anything that could potentiate gastric irritation such as smoking, alcohol, and the ingestion of other medications that are known gastric irritants. *Content Refresher* Medication administration is the process by which prescribed medications are safely dispensed to a client. As a new medication is prescribed, the nurse needs to teach the client about the medication, reason for its administration, when to take the medication, how and when effectiveness will be determined, and possible adverse effects . In addition, the nurse needs to identify possible drug and/or food interactions and recognize when the medication is contraindicated.

The nurse provides nutrition education to a client who follows a vegan diet. Which nutrients does the nurse include in the teaching session as those that may be deficient? (Select all that apply.) 1. Calcium. 2. Vitamin B 12. 3. Vitamin B 1. 4. Iron. 5. Vitamin D. 6. Vitamin A.

1) CORRECT - Vegans are frequently deficient in calcium because they do not ingest dairy products. 2) CORRECT - Vegans are frequently deficient in vitamin B 12 because they do not eat meat, which is the primary source of B 12. 3) INCORRECT - Vitamin B 1 (thiamine) is found in cereals, nuts, beans, and many other vegetables. 4) CORRECT - Iron is found in muscle meats and in fortified cereals and grains. Vegans consume cereals and grains. 5) CORRECT - Vegans are deficient in vitamin D because it is mostly found in dairy products, which vegans do not consume. 6) INCORRECT - Vitamin A is available in sweet potatoes, carrots, and dark leafy greens, all of which are part of a vegan diet. *Think Like a Nurse: Clinical Decision-Making* Regardless of the kind of meat-free diet practiced, vegans and vegetarians should focus on getting enough protein, iron, calcium, zinc, vitamin B 12, riboflavin, alpha-linolenic acid, and vitamin D. The nutrition warnings are more urgent for pregnant and lactating women who are vegan. Having a vitamin B 12 deficiency, particularly, has been shown to impair neurological development in infants breastfed by vegetarian mothers. The nurse should obtain a comprehensive nutrition history of the client and appropriate referrals made as needed. *Content Refresher* Proper nutrition is the individual's ability to meet the daily recommended nutrients through proper food selections. Factors that influence proper nutrition include general health, age, medications, lifestyle, socioeconomic status, religion, culture, personal food preferences, developmental needs, gender, and psychological issues.

The nurse prepares to administer the Haemophilus influenzae type b (Hib) vaccine to a 4-month-old infant. The nurse teaches the infant's parent about the vaccine. Which information does the nurse include in the teaching? 1. "Monitor your child for signs of allergic reaction for a few hours after the vaccine." 2. "Your child will receive 1 or 2 doses of the vaccine, depending on the vaccine used." 3. "Immediately notify the health care provider of a low-grade fever." 4. "This vaccine cannot be given at the same time as other vaccines."

1) CORRECT -Signs of allergic reaction to the Hib vaccine include hives, facial and airway edema, difficulty breathing, tachycardia, dizziness, and weakness. These typically begin a few minutes to a few hours after the child receives the vaccine. 2) INCORRECT - Several brands of Hib vaccines are available. Depending on the brand used, the child will require 3 or 4 doses of vaccine. 3) INCORRECT - Mild adverse effects, such as low-grade fever and redness and warmth or swelling at the injection site, may occur. They are usually mild and go away on their own. Therefore, it is not necessary to notify the health care provider. 4) INCORRECT - Hib may be given at the same time as other vaccines. In fact it may be given as part of a combination vaccine. *Think Like A Nurse: Clinical Decision Making* Health promotion and disease prevention activities include providing vaccinations at the appropriate age. Even though a vaccination is intended to prevent the onset of disease, the actual vaccination is not without risk. Some individuals will react immediately to the introduction of foreign material into the body, whereas others may not have a reaction until several hours have passed. Since it is not realistic to expect a client to remain in the presence of the health care provider until all risk of a reaction has passed, the nurse should instruct the parent or person receiving the vaccination of what to expect as signs of a reaction, and what actions to take should any of the signs occur. *Content Refresher* Haemophilus influenzaetype b (Hib) disease is a common cause of meningitis in children. The Hib vaccine series provides passive immunity to protect children under 5 years of age from contracting Hib disease. As with any vaccine, side effects such as redness and tenderness at the injection site and/or a slight may occur. Rarely, serious adverse reactions such as hives, facial and laryngeal edema, high fever, tachycardia, and tachypnea may occur. The parent/caregiver should be informed of what to do in case of severe reaction to a vaccine.

The nurse provides a client with a prescribed dose of hydrocodone for pain. Which findings related to the current prescribed pain medication cause the nurse to follow-up with the health care provider? (Select all that apply.) 1. Client reports pain is 8 out of 10. 2. Assesses respiratory rate as 8 breaths per minute. 3. Notes petechiae on the client's abdomen and forearms. 4. Notes potassium level is 3.4 mEq/L (3.4 mmol/L). 5. Notes urine output is 60 mL over the past 2 hours.

1) CORRECT — A pain level of 8 out of 10 indicates pain that is unrelieved by the current medication prescription and requires follow-up by the nurse. The client may need an increased dose or change in pain medication. 2) CORRECT — A respiratory rate of 8 breaths per minute is a sign of over-sedation. The client's prescribed medication dose may need to be altered by the health care provider. 3) CORRECT — Petechiae are a sign of an allergic reaction and should be reported to the health care provider. 4) INCORRECT— This potassium level is concerning, but it is not related to the hydrocodone. 5) INCORRECT— This urine output is within normal limits and does not require follow-up with the health care provider. Urinary retention is an adverse reaction to opioid medication. *Think Like a Nurse: Clinical Decision-Making* When providing care to a client who is prescribed opioid analgesics, the nurse needs to closely monitor the client for potential adverse drug reactions such as respiratory depression and allergic reaction. Naloxone should be readily available when administering opioid medications, as naloxone is prescribed to counteract the adverse reaction of respiratory depression. While monitoring the client for adverse reactions, the nurse must also assess for pain relief. This is typically done 30 to 45 minutes after the medication is administered. Unrelieved or worsening pain warrants further assessment and collaboration with the health care provider. *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. Hydrocodone is an opioid analgesic intended for short-term use. For best results, hydrocodone should be administered before pain becomes severe. Common side effects of opioid medications include constipation and nausea. Potential adverse effects of opioid medications include respiratory depression. Document the medication administration according to institutional policy. Evaluate outcomes of the administered medication.

The nurse prepares to administer amikacin to a client diagnosed with an enterococcal infection. Which client findings cause the nurse to question administration of the medication? (Select all that apply.) 1. Reports nausea and diarrhea. 2. Has an activated partial thromboplastin time (aPTT) value of 28 seconds. 3. Receives warfarin for atrial fibrillation. 4. Smokes one pack of cigarettes a day. 5. Receives hemodialysis three times weekly.

1) CORRECT — Anti-infective medications can eradicate normal intestinal flora and lead to superinfection of the gastrointestinal and genitourinary tracts. Nausea and diarrhea are signs of superinfection. Therefore, the nurse questions the administration of this medication. 2) INCORRECT - An activated partial thromboplastin time (aPTT) of 28 seconds is within normal limits. There is no reason for the nurse to question the administration based on this data. 3) CORRECT — Anti-infective medications can eradicate normal flora, reducing the amount of vitamin K produced by these bacteria. Amikacin is an aminoglycoside and can potentiate the action of warfarin. The nurse questions the administration of this medication based on this data. 4) INCORRECT - Smoking is not a contraindication to antimicrobial therapy. There is no reason for the nurse to question the administration based on this data. 5) CORRECT — Aminoglycosides are nephrotoxic and are contraindicated in clients diagnosed with kidney impairment because toxic levels are reached rapidly. The nurse questions the administration of this medication based on this data. *Think Like a Nurse: Clinical Decision-Making* The nurse should recall the Rights of Medication administration and apply knowledge about the classification and actions of the prescribed medication. The nurse will understand that the prescribed medication is an aminoglycoside antibiotic, which causes toxicity of the kidneys. For this reason, the nurse should question providing the medication to the client because of a risk for additional renal damage. Antibiotics in general destroy normal intestinal flora, causing nausea and diarrhea and interrupting the normal intestinal flora that helps maintain vitamin balance in the body. The medication should be questioned because of the client's existing symptoms, medical treatment, and current medication regimen. *Content Refresher* Administering medication is the process by which prescribed medications are safely dispensed to a client. The nurse must be knowledgeable about the medication, reason for its administration, how and when effectiveness will be determined, and possible adverse effects of medications. Before administering the medication, the nurse must identify drug allergies, possible drug and/or food interactions, and when a medication is contraindicated and should not be administered.

A client is to undergo an electroencephalogram (EEG) the following day as part of the workup for evaluation of seizure activity. Which statement is approrpiate for the nurse to include when preparing the client for the test? 1. "Avoid drinking coffee, tea, or caffeinated beverages before the test." 2. "You will need to wash your hair after the test, so do not bother washing it beforehand." 3. "Be careful not to eat or drink anything for at least 6 hours before the test." 4. "There will be harmless pricking sensations during the test as the electricity enters your brain."

1) CORRECT — Caffeine intake may alter the results of the test, as caffeine is a stimulant. The client should avoid caffeine-containing beverages or foods for 24 to 48 hours prior to the test. 2) INCORRECT— While the hair is washed after the test in order to remove the electrode gel and glue or paste from the scalp and hair, hair should also be shampooed clean before the test. The client should avoid using hair spray, products, oils, or hairpins used in order to ensure that EEG patches or electrodes remain firmly in place during the test. 3) INCORRECT — Because hypoglycemia affects brain activity, food and fluids can be consumed beforehand. There is no need for the client to be NPO (nil per os, or nothing by mouth). However, caffeine-containing fluids such as tea or coffee should be avoided for 24 to 48 hours before the test. 4) INCORRECT — The client will not feel any sensations from the EEG. There are no pricking sensations, and the electricity does not enter the brain. *Think Like A Nurse: Clinical Decision Making* Prior to having an EEG, the client should be instructed to avoid all caffeine beverages or food items since caffeine is a stimulant, which may affect the results of the diagnostic test. The client's hair should be clean and free of any hair products before having the test. *Content Refresher* An electroencephalogram (EEG) is a recording of the brain's spontaneous electrical activity over a period of time, as recorded from multiple electrodes placed on the scalp. Instruct the client to wash hair the night before the EEG and to avoid putting any products (such as sprays or gels) in the hair on the day of the test. Instruct the client to refrain from consuming any food or drinks containing caffeine for at least 8 hours prior to the test, and to hold medications (as prescribed) that may stimulate or depress brain waves. Explain the procedure, emphasizing the importance of cooperation.

The nurse provides care for a client with a history of type 2 diabetes mellitus (DM). The client had an acute MI and is prescribed IV metoprolol. Which nursing interventions are required with IV metoprolol administration? (Select all that apply.) 1. Connect client to ECG. 2. Monitor for tachycardia. 3. Assess blood glucose level. 4. Administration with morphine is to be avoided. 5. Monitor for heart block. 6. Administer undiluted by direct intravenous infusion.

1) CORRECT — Clients receiving IV metoprolol should be monitored with an ECG to observe for dysrhythmias. 2) INCORRECT - Tachycardia is not associated with IV metoprolol, but bradycardia is a possible dysrhythmia. 3) CORRECT — Metoprolol is a beta-blocker and masks the symptoms of hypoglycemia and shock. The blood glucose is closely monitored. Watch for other symptoms of hypoglycemia, such as sweating, fatigue, hunger, or the inability to concentrate. 4) INCORRECT - Metoprolol is compatible with morphine. 5) CORRECT — Heart block is a possible adverse effect resulting from metoprolol, and ECG monitoring is required. 6) CORRECT— Metoprolol is administered undiluted by direct IV infusion at a rate of 5 mg over 60 seconds every 2 minutes for three doses after a myocardial infarction. *Think Like a Nurse: Clinical Decision-Making* The nurse needs to understand the expected effects, adverse affects, and mechanisms for prescribed medications. Metoprolol is a beta-blocker often used in the treatment of an acute myocardial infarction. For this client though, the cardiac rhythm should be monitored for dysrhythmias and potential heart block. Because this medication masks the symptoms of hypoglycemia, the client's blood glucose level should be closely monitored. This medication can be safely administered via the intravenous push route. *Content Refresher* When caring for a client post-myocardial infarction (MI), the nurse should: Promote adequate oxygenation; administer supplemental oxygen as prescribed and position client upright to support effective ventilation. Obtain 12-lead EKG; repeat testing as prescribed. Administer prescribed medications, which may include nitroglycerin, morphine, clotting inhibitors, antihypertensive agents, and thrombolytic agents. Teach effective strategies such as deep-breathing to reduce anxiety. Monitor laboratory tests, including serial cardiac enzymes. Ensure adequate understanding of all planned surgical interventions or procedures. Educate the client regarding needed smoking cessation, increased physical activity, and improved dietary intake, as applicable. Refer to cardiac rehabilitation and support services in the community, as indicated.

The nurse teaches a client diagnosed with Cushing syndrome about the disease process. Which client statements indicate to the nurse that teaching is effective? (Select all that apply.) 1. "My diagnosis helps to explain why my bones are weak." 2. "I need to increase my daily caloric intake." 3. "My health care provider may prescribe a diuretic for me." 4. "I need to avoid people who have infections." 5. "I may have to take potassium supplements." 6. "I feel weak because the syndrome makes my blood glucose low."

1) CORRECT — Cushing syndrome results from chronic exposure to excess corticosteroids. Excess corticosteroids adversely affect the bone structure, leading to weakening. 2) INCORRECT - Weight gain is a common symptom of Cushing syndrome. The client should decrease caloric intake. 3) CORRECT— Edema of the lower extremities is common in Cushing syndrome. A potassium-sparing diuretic may be prescribed. 4) CORRECT— The client is at risk for an infection related to lowered resistance to stress and suppression of immune system caused by excessive corticosteroids. 5) CORRECT— Hypokalemia commonly occurs in Cushing syndrome. Potassium supplements are often prescribed. 6) INCORRECT - While weakness is a common symptom, clients diagnosed with Cushing syndrome have hyperglycemia. The weakness is not being caused by hypoglycemia. *Think Like a Nurse: Clinical Decision-Making* A disease process such as Cushing syndrome requires extensive teaching about the pathophysiological process, symptoms of the disorder, potential complications, and treatment. This disease develops after prolonged use of glucocorticoids. The effects of the syndrome on the body are caused by the steroid and include electrolyte imbalances, increased risk for infection, poor healing, fluid retention that manifests as peripheral edema, and changes in bone metabolism. Although it can develop as a primary condition, it most often occurs after the client has been prescribed long-term steroid use to treat another health problem. *Content Refresher* Cushing syndrome is a disorder characterized by excessive amounts of glucocorticoids. The most common cause of Cushing syndromeis ingestion of glucocorticoid medications. Tumors of the adrenal cortex or the pituitary gland can also cause over-secretion of hormones and increase cortisol levels. Following client education, the client will understand how to manage the disease, including glucose control, self-care for hypertension, and weight gain. The client will also demonstrate how to properly taper glucocorticoids while avoiding infections or slow wound healing as a result of steroid use. Finally, the client will not develop fractures or complications as a result of bone loss.

A client is scheduled for a colonoscopy, and the nurse is completing teaching regarding the procedure. Which client statement indicates to the nurse an appropriate understanding of the procedure? 1. "I need to not eat or drink anything by mouth 8 hours before the procedure." 2. "I need to begin a liquid diet 2 days before the procedure." 3. "I need to stop taking my oral hypoglycemic agent the day before the procedure" 4. "I need to let my health care provider know that I am allergic to iodine before the procedure."

1) CORRECT — The client needs to be NPO 8 hours before a colonoscopy. This statement indicates understanding of the procedure. 2) INCORRECT - The client needs to begin a liquid diet the day before the procedure. This statement indicates that additional teaching is needed. 3) INCORRECT - If iodine is being administered during a procedure, the client needs to stop taking the oral hypoglycemic agent. However, iodine is not administrated during a colonoscopy. This statement indicates that additional teaching is needed. 4) INCORRECT - Iodine is not administrated during a colonoscopy. This statement indicates that additional teaching is needed. *Think Like A Nurse: Clinical Decision Making* Because the client will be given an anesthetic to induce twilight sleep as pre-medication for the colonoscopy, the client should have nothing by mouth for at least 8 hours before the procedure. This ensures that the client will not aspirate during the procedure. The nurse is responsible for knowing about the procedure related to a diagnostic test, in order to assure that the client is safe and the testing is effective. *Content Refresher* When caring for a client scheduled for a colonoscopy, the nurse should determine client 's knowledge of and consent to procedure. Assess client symptoms that may have warranted the exam, such as change in bowel habits, diarrhea, or blood in the stool. Assess for cardiac history. Plan to educate the client about the procedure and preparation necessary prior to test. Anticipate need for blood work before and after procedure. Prepare for tissues samples to be sent to lab.

Plasmapheresis is scheduled for a client diagnosed with Guillain-Barré syndrome. In planning for the procedure, which item is appropriate for the nurse to have readily available? 1. Warm blankets. 2. Magnesium intravenous infusion. 3. Nasogastric tube. 4. Crutchfield tongs.

1) CORRECT — Warm blankets can prevent or manage chills and hypothermia that may occur during plasmapheresis. Plasmapheresis is similar to hemodialysis, in that blood is removed from the body, run through the machine to remove antibodies, and then returned to the client. The blood cools while outside the body and the return of cool blood to the body can cause hypothermia and chills. 2) INCORRECT— Clients may experience symptoms of hypocalcemia due to the plasmapheresis. This is treated with oral administration of calcium tablets, not magnesium. 3) INCORRECT— Clients may experience some transient nausea related to the plasma reinfusion, but a nasogastric tube is not necessary. 4) INCORRECT— Crutchfield tongs are used in skeletal traction for cervical spine injury and are not needed for plasmapheresis. *Think Like A Nurse: Clinical Decision Making* The nurse needs to be knowledgeable about procedures the client undergoes, including needs before, during, and after a procedure. Symptoms during therapeutic plasma exchange tend to be mild and transient, including sensations of being cold with hyperthermia. Because hypersensitivity reactions can occur, any reports of abnormal sensations are monitored closely. The nurse observes the client for flushing, itching, nausea, vomiting, fever, chills, back pain, and other signs of hemodynamic instability. *Content Refresher* If initiated within the first 4 weeks of the disease process, plasmapheresis is effective in reducing recovery time with Guillain-Barré syndrome. Plasmapheresis removes antibodies and other immune factors. During plasmapheresis, whole blood is removed and circulated through the apheresis machine. Monitor for hypotension and citrate toxicity (an anticoagulant used to prevent clotting when blood is outside the body) related to the procedure. Citrate may cause hypocalcemia, so monitor the client for headache, paresthesias, and dizziness.

A client receives isoniazid, rifampin, ethambutol, and pyrazinamide. Which statement made by the client most concerns the nurse? 1. "I seem to be becoming color blind. I can 't see green." 2. "My urine and sweat are a reddish-orange color." 3. "Sometimes I wonder what I did to deserve all this." 4. "My big toe has started hurting so I can hardly walk."

1) CORRECT- A major, common adverse effect of ethambutol is optic neuritis, with reduced visual acuity. The decreased ability to see green is a possible initial sign. Limiting progressive damage to the optic nerve is the priority for this client. 2) INCORRECT- Discoloration of body fluids —urine, sweat, tears, feces, and sputum —is a harmless side effect of rifampin. Explain to the client the difference between the reddish color noted and hematuria. The client should be warned, though, that soft contact lenses may be permanently stained and therefore should not be worn. 3) INCORRECT- This is a psychosocial need and is not a priority. This statement does indicate need for further exploring client 's thoughts and emotions regarding causation and management of disease process, including assessing for possible depression. 4) INCORRECT- Hyperuricemia can occur with pyrazinamide, resulting in acute gout symptoms such as severe pain in the great toe. This indicates that the drug should be discontinued, but it is not an immediate need and can wait until the priority is addressed. *Think Like A Nurse: Clinical Decision Making* The nurse must differentiate between a medication 's therapeutic effects, side effects, and adverse effects, in addition to monitoring for medication interactions. Discoloration of urine is an insignificant side effect. Hyperuricemia is a significant side effect but is not an immediate danger. Using the Maslow hierarchy to evaluate physiological issues first, the nurse is most concerned when a client reports symptoms related to adverse effects, such as vision changes indicating optic neuritis. This adverse effect will progress to permanent and severe damage if the nurse does not intervene. *Content Refresher* Isoniazid, rifampin, ethambutol, para-aminosalicylic acid, pyrazinamide, and streptomycin are common antituberculars used to treat tuberculosis (TB). Direct observation therapy may be implemented to ensure medication adherence and to decrease resistance to the medications. For those with latent TB infection, treatment is focused on preventing active TB from developing. If treated correctly, the majority of clients will return to full health with minor damage to the lungs.

The nurse provides care to a client diagnosed with sinus arrhythmia. The nurse uses which site to assess the client's pulse? 1. Apical. 2. Radial. 3. Femoral. 4. Carotid.

1) CORRECT- Apical pulse assessment is indicated for use during initial cardiac examination or if the client's pulse is irregular. Sinus arrhythmia, which is most common among children and young adults, refers to minor variations in pulse regularity that occur in relationship to the respiratory cycle. In infants and children up to 3 years old, the apical pulse is the routine site for cardiac assessment. Apical pulse assessment is also indicated prior to administration of certain medications, such as digoxin. 2) INCORRECT - Assessment of the radial pulse is appropriate for routine use in the client with a stable, regular pulse rate and rhythm. 3) INCORRECT - Femoral pulse assessment is appropriate for use in newborns. Femoral pulse assessment can also be indicated when the nurse is evaluating circulation to the lower extremities and during cardiopulmonary resuscitation. 4) INCORRECT - Carotid pulse assessment can be indicated during cardiopulmonary resuscitation. *Think Like A Nurse: Clinical Decision Making* The nurse should stop and recall the physiology of a sinus arrhythmia. The nurse is aware that arrhythmia is characterized by a change in rhythm that is associated with the phases of the respiratory cycle. The rate will typically increase during inspiration and slow down during expiration. Because this heart rate is irregular, measurement should be completed at the apical site for a more comprehensive assessment. Using a peripheral pulse measurement may not provide the correct heart rate for this client. *Content Refresher* The apical pulse is located at the apex of the heart, at the 5th intercostal space to the left of the sternum. It is located more centrally among children and youth, and may shift further to the left among older adults who have conditions that cause enlargement of the heart. The apical pulse is best assessed through auscultation. Pulse rate, rhythm, and volume should be assessed, initially for 1 minute. The apical pulse should be assessed prior to the administration of medications that can significantly affect heart rate. It is also assessed when peripheral pulses are weakened and/or irregular, or when clients are being treated for pulmonary, cardiovascular, or kidney diseases.

The school nurse instructs a group of high school students about the prevention of sexually transmitted infections (STIs). Which student statement indicates teaching is successful? 1. "The use of condoms does not totally eliminate the risk of sexually transmitted infections." 2. "Because some sexually transmitted infections have no symptoms in women, they cannot be that serious." 3. "I have had plenty of sex already and have not gotten a single disease. I think I am immune." 4. "I am glad I use birth control pills. I do not have to worry about sexually transmitted infections."

1) CORRECT- Condoms reduce, but do not eliminate, the risk of transmission of HIV and other STIs. 2) INCORRECT - Chlamydia and gonorrhea may be asymptomatic in females, but pelvic inflammatory disease can develop if left untreated. 3) INCORRECT - There is no particular immunity to STIs. Expressing the belief of being immune reflects the "it can't happen to me" attitude, which is characteristic of adolescents. 4) INCORRECT - Birth control pills offer no protection against STIs. *Think Like A Nurse: Clinical Decision Making* Condoms are considered a barrier contraceptive. They reduce the risk of transmitting sexually transmitted infections (STIs), but the risk is not totally eliminated. STIs that have minimal symptoms can be as dangerous as those that produce many symptoms. *Content Refresher* Sexually transmitted infections (STIs) are contracted through sexual intercourse, anal sex, and other skin-to-skin contact in the genital region. Some sexually transmitted infections result in oral or upper respiratory lesions, which are contracted through oral sex. Risks of developing sexually transmitted infections are greatly reduced by being in a mutually monogamous sexual relationship, reducing the number of sex partners, and using a latex condom, which can reduce the risk of disease transmission.

The nurse assesses a client in the emergency department. Which symptoms cause the nurse to suspect that the client is experiencing a panic attack? 1. Decreased perceptual field, diaphoresis, fear of going crazy, and palpitations. 2. Decreased blood pressure, chest pain, choking feeling. 3. Increased blood pressure, bradycardia, shortness of breath. 4. Increased respiratory rate, increased perceptual field, increased concentration ability.

1) CORRECT- Panic disorders are characterized by recurrent, unpredictable attacks of intense apprehension or terror that can render a client unable to control a situation or to perform simple task. The client can experience palpitations, diaphoresis, a decrease in perceptual field, and a fear of "losing it" or going crazy. 2) INCORRECT- The client experiencing a panic attack will have increased blood pressure related to stimulation of the sympathetic nervous system. Chest pain and a choking feeling will occur. 3) INCORRECT- The client experiencing a panic attack will have tachycardia due to stimulation of the sympathetic nervous system. Increased blood pressure and shortness of breath will occur. 4) INCORRECT- The client experiencing a panic attack will have a decrease in perceptual field, become less aware of surroundings, and experience hindered performance. Respiratory rate will be increased. *Think Like A Nurse: Clinical Decision Making* The manifestations of a panic attack can mimic a myocardial infarction and may include diaphoresis, increased blood pressure, chest pain, tachycardia, shortness of breath, and a rapid respiratory rate. The symptoms that suggest a panic attack include a narrowed perceptual field and a fear of "going crazy." The fear of "going crazy" is consistent with the client feeling of "losing control." *Content Refresher* Anxiety is a common, subjective response to a perceived or actual threat. It may range from vague discomfort to total panic leading to loss of control. Clinical manifestations associated with anxiety include agitation, restlessness, hypertension, tachycardia, tachypnea, increased muscle tension, gastric symptoms, headache, nausea, sweating, being easily distracted, and having an inability to focus.

The nurse teaches a client who experiences persistent tachycardia. Which instruction does the nurse include in teaching the client about tachycardia? (Select all that apply.) 1. Avoid becoming overheated while outdoors. 2. Regular propranolol use causes bradycardia. 3. Seek counseling as needed for anxiety management. 4. Use prescribed medications to control asthma. 5. Rest as much as possible and avoid strenuous work.

1) CORRECT- The body responds to hyperthermia by increasing the heart rate to meet metabolic demand to cool off. The client should drink cool liquids, limit time in the sun, and take other reasonable measures to avoid becoming too hot. 2) INCORRECT - Propranolol, a beta blocker, causes decrease in heart rate, but should not result in bradycardia. Propranolol, taken as prescribed, should result in a normal heart rate. 3) CORRECT - Anxiety causes increase in heart rate, and should be managed to prevent this. If the client needs counseling or medication to accomplish this, then they should seek that treatment. 4) CORRECT- An asthma exacerbation causes an increase in heart rate and should be prevented with daily medications as prescribed. Medications such as albuterol may be avoided in this client with an abnormal rhythm. However, even this treatment is preferable to the cardiac strain of an asthma attack. 5) INCORRECT - Walking or other mild to moderate physical activity performed on a regular basis is beneficial to reducing tachycardia. Resting as much as possible and avoiding strenuous work is not a reasonable suggestion. The client should rest when needed, balanced with activity. *Think Like a Nurse: Clinical Decision-Making* Tachycardia, or a rapid heart rate, can be caused by a variety of health problems and situations. Overheating will increase the heart rate to dispel the rising body temperature. Anxiety increases the heart rate as a response by the sympathetic nervous system. Difficulty breathing, as seen in asthma, can increase the heart rate. Beta-blocker medication reduces the heart rat; however, bradycardia is an adverse effect and an indication to stop taking the medication. *Content Refresher* A pulse is the rhythmical throbbing of the arteries as blood passes through them. It is assessed for rate, rhythm, and quality. An abnormal pulse could indicate various conditions, such as coronary artery disease, conduction disorders, impaired circulation, shock, or respiratory or thyroid conditions.

The nurse provides care to an infant client who is diagnosed with heart failure. Which assessment by the nurse best detects fluid retention in the client? 1. Obtaining daily weights. 2. Testing the urine for blood. 3. Measuring abdominal girth. 4. Counting the number of wet diapers.

1) CORRECT- The earliest sign of fluid retention is weight gain. 2) INCORRECT- Blood in the urine or hematuria is caused by glomerulonephritis, urinary tract infections, or lesions of the urinary tract. 3) INCORRECT- Gross fluid retention causes ascites. The best assessment to detect fluid retention is to weigh the client daily. 4) INCORRECT- Counting the number of wet diapers is done to assess hydration. *Think Like A Nurse: Clinical Decision Making* Infants with heart failure often exhibit subtle signs such as difficulty feeding and tiring easily. The nurse should pay close attention to parents' statements such as, "The baby drinks a small amount of milk and stops, but then wants to eat again very soon after," "The baby seems to perspire a lot during feedings," or "The baby seems to be more comfortable sitting up than lying down." Although the earliest sign of fluid retention is weight gain, the nurse should keep in mind that, in general, weight gain is a late sign of heart failure. *Content Refresher* The client with heart failure should be assessed for any deviation in vital signs, oxygen saturation, electrocardiogram (EKG), and urine output. Assess respiratory rate, effort, lung sounds, and use of accessory muscles. Assess heart sounds and check for arrhythmias. Monitor the client 's weight to assess for potential for fluid volume overload related to decreased cardiac output.

The nurse provides care for a client diagnosed with atherosclerosis. Which client statements about clopidogrel require follow-up by the nurse? (Select all that apply.) 1. "This medication may cause my blood pressure to be low. " 2. "I play racquetball three times each week for exercise. " 3. "I need to go back to the health care provider next year. " 4. "I take my medications at the same time each day. " 5. "I take this medication so I don 't have a stroke. " 6. "I will notify my health care provider if I notice bruises. "

1) CORRECT— Adverse effects of clopidogrel include hypertension, so this statement requires the nurse to follow up. 2) CORRECT— Because clopidogrel increases the client 's risk of bleeding, contact sports such as racquetball should be avoided. The nurse will discuss safe exercise choices with the client. 3) CORRECT— Clients taking clopidogrel will need regular medical supervision and periodic blood tests. The nurse should discuss follow-up care with the client. 4) INCORRECT - This statement does not need follow-up by the nurse. Medications should be taken at the same time each day as prescribed. 5) INCORRECT - This is an accurate statement since stroke prevention is one purpose of clopidogrel. 6) INCORRECT - Notifying the health care provider for bruising is a correct understanding about clopidogrel and adverse effects. *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. The client should demonstrate understanding of the medication 's therapeutic effects, side effects, and adverse effects. Clients who are prescribed antiplatelet medications (such as clopidogrel) or anticoagulant medications (such as warfarin or heparin) often require lifestyle changes, including increased health care provider visits and careful choices in activities. The client with atherosclerosis may also require blood pressure management. However, education is indicated to explain that clopidogrel is not used to decrease blood pressure. *Content Refresher* For teaching and learning, ensure a comfortable environment with adequate lighting. Prepare for the teaching activity. Question the learner regarding expectations. Determine the learner 's knowledge level and previous experiences with the topic of education. Allow time for discussion and questions. Stop for a break when the learner indicates that one is needed. Minimize distractions and use clear, brief instructions. Clearly communicate the objectives and expectations. Determine which factors help or hinder the learning process. Evaluate the effectiveness of the teaching/learning session.

An older adult client is admitted to the hospital from a long-term care facility. The nurse establishes a nursing diagnosis of decreased fluid volume related to poor intake and fever. Which symptoms most concern the nurse? 1. The client's temperature is 102°F (38.4°C), pulse is 120 beats per minute, and blood pressure 88/54 mm Hg. 2. The client has difficulty breathing in the supine position or with minimal activity. 3. The client's skin is pale and cool to touch with pitting edema in dependent areas. 4. The client has ascites and prominent veins across the abdomen.

1) CORRECT— An increased pulse rate with thready quality, decreased blood pressure, and elevated temperature indicate that the client may be experiencing hypovolemic shock related to decreased fluid volume. This is a priority concern. 2) INCORRECT — These symptoms are seen with increased, not decreased, fluid volume. 3) INCORRECT — These symptoms are seen with increased, not decreased, fluid volume. 4) INCORRECT — These symptoms are seen with liver failure, not decreased fluid volume. *Think Like A Nurse: Clinical Decision Making* The nurse recognizes that a rapid heart rate and dropping blood pressure indicates low fluid volume. The client also has a fever, which is contributing to fluid losses, as well. This client needs immediate fluid replacement and diagnostic testing to determine the cause for the elevated temperature. The nurse should anticipate that the health care provider will likely order a battery of diagnostic tests, including a complete blood count (CBC), basic metabolic panel (BMP), blood cultures, and urinalysis. *Content Refresher* Fluid volume deficit (FVD) is a condition of proportionate water and solute loss that may occur as a result of fluid loss from the body, inadequate fluid intake, and extracellular ("third spacing") fluid shifts. Thirst, decreased urine output, dry mucous membranes, poor skin turgor, weight loss, hypotension, tachycardia, and lethargy are clinical manifestations of FVD. Treatment includes oral and/or intravenous fluid and electrolyte replacement.

A client with a 20-year history of asthma experiences acute respiratory distress. Which breath sound does the nurse consider as ominous for this client? 1. Absence of wheezing. 2. Presence of crackles. 3. Absence of bilateral rales. 4. Presence of coarse rhonchi.

1) CORRECT— In a client with asthma, the absence of wheezing indicates acute respiratory distress. The small airways are completely constricted. This client needs immediate intervention. 2) INCORRECT - Crackles or rales are abnormal breath sounds caused by air moving through fluid. This breath sound is not associated with asthma. 3) INCORRECT - Bilateral rales are not expected with asthma. Symptoms of asthma include dyspnea, wheezing, nonproductive cough, tachycardia, and tachypnea. 4) INCORRECT - Coarse rhonchi are continuous grating sounds. This sound indicates a disease of the bronchi and is not associated with asthma. *Think Like A Nurse: Clinical Decision Making* In a client experiencing respiratory distress related to asthma, the absence of auscultated breath sounds signifies significantly reduced air entry. The client will shortly suffer from severe hypoxia. The nurse should anticipate immediate intubation, call the rapid response team (in a hospital setting), or call 911 if in the community. The nurse should also anticipate obtaining a portable chest x-ray and administering nebulized rescue medications, such as albuterol, and IV steroids. *Content Refresher* The nurse assesses the client with asthma for respiratory distress: dyspnea, wheezing, cough, chest tightness, decreased airflow upon auscultation, and diminished pulse oximeter reading. Assess breath sounds-wheezing is expected. Absent breath sounds suggests airflow limitation and should be evaluated.

The nurse teaches colostomy care to a client prior to discharge. Which client statements indicate to the nurse that the teaching is effective? (Select all that apply.) 1. "Some mild swelling of my stoma may be seen for 2 -3 weeks." 2. "I should drink no more than 1,500 mL of fluid a day now." 3. "Eating yogurt will decrease odor from the colostomy." 4. "The pouch should be emptied when it is 1/2 -3/4 full." 5. "The opening in the pouch for the stoma may need to be adjusted over time."

1) CORRECT— Some mild swelling of the stoma is expected. The client should report an increase in swelling and change in color from pink to a different color. 2) INCORRECT— The client should not restrict fluids. Increased fluids will decrease the risk of constipation. 3) CORRECT — Less odor is produced if buttermilk and yogurt are consumed. There is an increased risk of odor if broccoli or garlic are consumed. 4) INCORRECT— The bag should be emptied when it is 1/3 full to decrease the risk of leakage. 5) CORRECT— The stoma may decrease in size as healing occurs. *Think Like a Nurse: Clinical Decision-Making* The nurse needs to mentally ask, "What information will the client need to best adjust to a new colostomy?" The nurse will determine whether the client with a new colostomy will need teaching about skin care, appliance application, and dietary control. Each of these areas will take time and patience to instruct. When evaluating the effectiveness of teaching, the nurse should focus on the areas that will ensure the most positive outcome for the client. A new stoma will have some swelling, so the client should expect the stoma size to change over time. Because the excrement is outside of the body with an ostomy, teaching on ways to reduce odor would help the client's comfort and self-esteem. *Content Refresher* Food passes through the esophagus into the stomach and the small intestine. Through peristaltic action, the loose and acidic liquid slowly moves through the small and large intestine where sodium, potassium, calcium, other nutrients, and water are absorbed. As it becomes more formed and less liquid, it is moved into the rectum and then expelled through the anus. As clients experience alterations to the gastrointestinal tract (obstructions to small or large intestine or inflammatory bowel disease, such as Crohn or ulcerative colitis), a colostomy or ileostomy may be required.

A client is brought to the emergency department following a motor vehicle accident. Which observation of the client most concerns the nurse? 1. Client's blood pressure of 96/50 mm Hg, pulse 112 beats/min. 2. Client reports presence of abdominal pain and nausea. 3. Abrasions are present on the client 's abdomen. 4. Client exhibits a staggering gait with ambulation.

1) CORRECT— The client has tachycardia and hypotension, which are indicative of shock. This is a circulatory concern that represents an immediate risk to client safety and is the priority concern. 2) INCORRECT - Nausea and abdominal pain may indicate abdominal trauma, but they require further evaluation to determine the cause. The immediate circulatory issue is the priority concern. 3) INCORRECT - The abdominal abrasions provide clues as to the location and force of the injury that the client experienced. They require further evaluation, but the immediate circulatory issue is the priority concern. 4) INCORRECT - The staggering gait may represent a musculoskeletal issue or may be related to possible shock. This requires further evaluation, but the immediate circulatory issue is the priority concern. *Think Like A Nurse: Clinical Decision Making* The nurse should be able to evaluate the client's vital signs in comparison to normal ranges. Next, the nurse needs to understand the implications associated with the changes of vital signs outside the parameters of normal. A low blood pressure and a rapid heart rate indicates low fluid volume or the beginning of hypovolemic shock. This finding should be immediately reported so that fluid balance or blood volume can be restored as soon as possible. *Content Refresher* The nurse caring for a client at risk of shock should: Assess baseline vital signs. Monitor blood pressure and heart rate for changes. Assess strength of peripheral pulses, color of skin, warmth, and other indicators of perfusion. Assess urinary output. When hypotensive, keep client flat in bed or use modified Trendelenburg position. Administer IV fluids as needed. Assess hemodynamic pressures and titrate medications and fluids as needed. Assess client tolerance of fluid administration. If client has arterial line to monitor blood pressure, assess blood pressure continuously.

A 45-year-old male client presents to the emergency department with acute mid-abdominal pain and acute vomiting. The health care provider wants to rule out pancreatitis. Which question does the nurse ask based on the client's differential diagnosis? 1. "How much alcohol do you drink per day?" 2. "Do you have a family history of diabetes?" 3. "Do you have a history of peptic ulcer disease?" 4. "How frequently do you take laxatives?"

1) CORRECT— The client's symptoms indicate an acute episode of pancreatitis. Pancreatitis is associated with males ages 40 to 45 with a history of heavy drinking and females ages 50 to 55 diagnosed with biliary disease. As this is a 45-year-old male client, asking about alcohol intake will help confirm the diagnosis. 2) INCORRECT - This is not a relevant assessment at this time. The client is not presenting with signs or symptoms of diabetes. 3) INCORRECT - Peptic ulcer disease is associated with abdominal pain, but it is not associated with vomiting. This assessment is not relevant at this time. 4) INCORRECT - Pancreatitis causes diarrhea and passage of fatty stools. This is not a relevant assessment at this time. *Think Like a Nurse: Clinical Decision-Making* Mid-abdominal pain and vomiting are associated with a variety of conditions, including appendicitis, hiatal hernia, and pancreatitis. The nursing assessment should address any health history and lifestyle practices that may potentially be related to the client's symptoms, including alcohol use. Other issues that may lead to an episode of pancreatitis include gallstones, a history of abdominal surgery, smoking, cystic fibrosis, and hyperthyroidism. In rare cases, pancreatitis may be idiopathic. Data collection includes obtaining the client's health history, as well as a focused assessment, to guide the formulation of appropriate nursing interventions. *Content Refresher* Acute symptoms of pancreatitis include severe epigastric or abdominal pain, nausea, vomiting, jaundice, decreased or absent bowel sounds, and, in severe cases, shock related to hemorrhage. Chronic symptoms include weight loss and constipation. Chronic pancreatitis can lead to development of diabetes mellitus. Prepare to administer IV opioids and anti-emetics; ensure the client remains NPO; and monitor for fluid shifts, hypovolemia, respiratory distress, fever, renal failure, paralytic ileus, and changes in level of consciousness. If relevant, teach the client about alcohol consumption and its relationship to pancreatitis.

The nurse provides care for a client during a wellness visit. The nurse teaches the client about the effects of stress. Which statement by the client indicates that teaching was successful? 1. "If I do not do something to relieve my stress, I am putting myself at risk for cancer or infection." 2. "My blood sugar level decreases when I am stressed, putting me at risk for hypoglycemia." 3. "Antianxiety medications are the only effective way to reduce stress." 4. "I will sleep my anxiety away."

1) CORRECT— The effects of stress can suppress the immune system increasing the risk for cancer and severe infections. 2) INCORRECT— Blood glucose levels rise in response to stress as cells become resistant to insulin. 3) INCORRECT— A variety of strategies can reduce stress, such as eliminating the stressor or performing relaxation exercises, in addition to antianxiety medications. 4) INCORRECT— Excessive sleeping is a maladaptive coping strategy used to temporarily relieve stress. *Think Like A Nurse: Clinical Decision Making* Chronic stress requires ongoing support from the nurse and other interdisciplinary team members, such as a counselor. Without proper management, chronic stress will result in negative multi-system effects. The fight or flight response is designed to boost the body's ability to act in an emergency. The effects of a continually activated sympathetic nervous system response are directly related to continually elevated heart rate, blood pressure, and blood glucose level. Increasing daily activity, taking purposeful deep breaths, eliminating distractions during certain hours, sleeping adequately, and taking time to enjoy healthy, balanced meals are all healthful strategies to combat stress. *Content Refresher* Stress is a physical, emotional, or mental strain or concern that causes bodily or emotional pressure or tension. Cortisol is the primary glucocorticoid secreted during stress. Cortisol increases glucose and fatty acid availability to increase energy and help the stress response. Diarrhea or constipation, insomnia, weight loss or gain, and fatigue are common signs and symptoms that occur with prolonged stress. Complications of chronic stress include high blood pressure, anxiety, depression, diabetes, obesity, and suicidal thoughts or suicide. Teach the client relaxation techniques, such as deep breathing, listening to music, or progressive head-to-toe muscle relaxation.

The nurse assesses a client in the outpatient clinic reporting repeated severe headaches. Which action does the nurse take first? 1. Obtain a description of the headache. 2. Determine how the client usually relieves headaches. 3. Ask how long the client has been having headaches. 4. Obtain a list of medication the client is currently taking.

1) CORRECT— The nurse should ask the client to describe the headache in the client's own words. Headache is usually a symptom and not a disease, and can be a result of neurological disease, vasodilation, or skeletal muscle tension. The description of the headache will assist the nurse to determine what course of action is best. 2) INCORRECT - This is an appropriate part of the history, but is unlikely to help the nurse determine what is causing the headaches. 3) INCORRECT - This is appropriate information to obtain, but the nurse should first obtain a description of the headaches. 4) INCORRECT - This is appropriate information to obtain as antihypertensives, diuretics, and anti-inflammatories can cause headaches. However, the nurse should first obtain a description of the headaches. *Think Like A Nurse: Clinical Decision Making* The first nursing action is always to assess, unless the client is in distress. The nurse should ascertain as much information as possible about the characteristics of the headaches. The information will be subjective and should be as detailed as possible, including a description of the kind and level of pain, along with the duration, frequency, and any preemptive events. This assessment will help determine the potential cause and identification of interventions that will be most appropriate to relieve the pain. *Content Refresher* When caring for a client with a migraine headache, provide a quiet environment with dim lighting. Ask client to rate pain and describe headache. Explain etiological factors of migraine headache, monitor pain pattern, and administer pain medications. Prevent or treat increased intracranial pressure and meningitis, if applicable. Assist with non-pharmacologic measures for headache relief. Ensure adequate hydration and nutrition. Help client recognize and prevent situations that aggravate pain. Review treatment plan with client.

The nurse prepares a solution of parenteral nutrition (PN) to infuse through a client's central line. Which piece of equipment is most important for the nurse to obtain before starting the infusion? 1. Glucose monitor. 2. Electronic infusion pump. 3. Pulse oximeter. 4. Urine glucose strips.

1) INCORRECT - A blood glucose meter also will be needed, but this is not the most essential item needed before starting the infusion. 2) CORRECT- Because of the high glucose content, use of an infusion pump is necessary to ensure that the solution does not infuse too rapidly or fall behind. 3) INCORRECT - There is no need for a pulse oximeter related to the parenteral nutrition infusion. 4) INCORRECT - Urine glucose strips are not needed because blood glucose monitoring is standard practice in this case. *Think Like A Nurse: Clinical Decision Making* Nutritional support is a major function of nursing care. For some clients though, this support needs to be provided using an alternative approach. Parenteral nutrition is the administration of a highly concentrated glucose solution mixed with additives to provide the nutrients required for body functioning. Because the client receiving this type of nutrition is most likely physically challenged, the nurse needs to ensure this solution is delivered safely and within expected parameters. An infusion pump is to be used when providing this nutritional support. After the infusion is started, the nurse will need to obtain a glucose meter to check the blood glucose every 6 hours. *Content Refresher* When delivering an infusion of parenteral nutrition (PN), the nurse needs to monitor the client for signs and symptoms associated with fluid, electrolyte, mineral, and glucose imbalances. Closely monitor the client for signs and symptoms of infection. Since PN contains a solution of 10% to 50% dextrose, infusion through a central line using an infusion pump is required. Infusions are started gradually (to prevent hyperglycemia) and increased slowly as the client's pancreas adjusts to required insulin needs. Infusions are weaned gradually to prevent hypoglycemia when discontinuing. Fat emulsion will also be administered. Strict aseptic technique is essential when maintaining a central line.

The client care team at a home care agency consists of a nurse, an LPN/LVN, and a nursing assistive personnel (NAP). Which client will be assigned to the LPN/LVN? 1. Client with hypertension and hypothyroidism who is returning home from the hospital. 2. Client recovering from a kidney transplant and reporting fever and tenderness over the transplant site. 3. Client with regional enteritis who requires a dressing change for an abdominal abscess. 4. Client recovering from a hip fracture and requiring assistance with a bath and hair washing.

1) INCORRECT - A client new to the agency after discharge from an acute care facility requires the assessment and teaching skills of the nurse. 2) INCORRECT - The client reporting fever and tenderness over a kidney transplant site could indicate rejection or an infection. This client requires the assessment skills of the nurse. 3) CORRECT— The client with enteritis and requiring a dressing change for an abdominal abscess is the most stable. It is within the LPN/LVN 's scope of practice to perform a dressing change and identify normal from abnormal changes. 4) INCORRECT - The client requiring assistance with basic care after a hip fracture can be safely assigned to the NAP. *Think Like A Nurse: Clinical Decision Making* Making client care assignments can be challenging and requires two types of decision-making. The first is the acuity level and care needs of the clients. The other is the skill level and scope of practice of the care providers. For this situation, the client who is considered the most stable and requires routine care such as a dressing change should be assigned to the LPN/LVN. Clients who have an acute illness or requiring expert assessment, decision-making, and teaching skills should be assigned to the nurse. Clients requiring basic needs to be met can be safely assigned to nursing assistive personnel (NAP). *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, the nurse needs to review the scope of practice for ancillary staff to include LPNs/LVNs. Delegate tasks or make client assignments that are within their scope of practice. Following the scope of practice ensures client safety.

The nurse provides discharge teaching for a client diagnosed with uric acid renal calculi. Which type of diet does the nurse instruct the client to avoid? 1. Low-calcium. 2. Low-oxalate. 3. High-oxalate. 4. High-purine.

1) INCORRECT - A low-calcium diet decreases the risk for oxalate renal calculi. 2) INCORRECT - A low-oxalate diet is used to control calcium or oxalate calculi. 3) INCORRECT - This type of diet is to be avoided by clients with calcium or oxalate calculi. 4) CORRECT— This diet should be avoided and instead a low-purine diet, which excludes high-purine foods such as organ meats, should be consumed. *Think Like A Nurse: Clinical Decision Making* The nurse is aware that there are a variety of causes for the development of renal calculi. Identification of the cause can help identify actions to prevent calculi formation. In this scenario, the condition associated with a client's renal stones is high uric acid levels. Uric acid is the byproduct of some proteins and the reduction or elimination of purine and should be addressed. A low-purine diet is likely to be prescribed by the health care provider, and the nurse should instruct the client to avoid foods high in purine such as organ meats, some seafood, wild game meat, and products with a high amount of yeast. *Content Refresher* In the kidney, urine normally contains substances that prevent the development of crystals. However, situations such as infections, concentrations of insoluble salts (dietary absorption, gout, renal disease) and urinary stasis may cause stones to form. Lithiasis is the term for stones, hard mineral crystals, which may be present in kidney or bladder. Calcium, uric acid, struvite, and cystine stones can develop. Uric acid stones form as a result from an increased concentration of uric acid in the urine. To prevent future uric acid stones, the nurse needs to discuss dietary practices to decrease foods with high purine content (red meat and shellfish).

As a part of a disaster drill, the school nurse reacts to an announcement that a "dirty" bomb exploded four miles away. According to the disaster plan, which action does the nurse take first? 1. Move food and water to an interior area in the school. 2. Contact parents to immediately pick up their children. 3. Turn off the air conditioners or forced-air heating units. 4. Encourage the staff and children to remain calm.

1) INCORRECT - A radiological dispersion device (dirty bomb) is a chemical explosive containing radioactivity. Food and water should already be stored in a safe area. 2) INCORRECT - This decision is not made by the nurse, although the nurse may be directed to assist in making notifications. Local authorities will determine whether to "shelter in place" or evacuate. 3) CORRECT— Turn off all units that bring fresh air in from the outside, close and lock all doors and windows, and move everyone to an inner room or basement. The primary principles for limiting exposure are to observe time, distance, and shield. 4) INCORRECT - It is important for the nurse to assist in maintaining calm among staff and students, but it is more essential to prevent or reduce exposure to contaminants. *Think Like a Nurse: Clinical Decision-Making* A radiologic dispersal device (RDD), or "dirty bomb," is a device formed by combining an explosive agent with radioactive materials. The school nurse needs to be familiar with the established disaster plan protocol. The nurse should explain her actions in a language that school children can understand. It is essential for the nurse to follow instructions from the Command Center. *Content Refresher* Once client safety is compromised by exposure to such agents as radiation, chemical substances, or toxic gases, measures must be taken to restore client safety. Goals include decontaminating the client if liquid chemical exposure occurs, preventing spread of contamination, cleaning and removing contaminated water and waste (if applicable), and monitoring all persons exposed. If a client is contaminated with a substance, removing the client's clothing will remove 95% of the contaminant. If a client is contaminated with radiation, the client should be scanned with a radiation detector meter, with special attention to body orifices and hairy areas.

The nurse provides care for a client diagnosed with cholelithiasis. Which assessment findings will the nurse identify as risk factors to the development of the cholelithiasis? (Select all that apply.) 1. A vegan diet. 2. A body mass index of 46. 3. Having five children. 4. Taking 81 mg aspirin daily. 5. Age.

1) INCORRECT - A vegan diet is not a risk factor for gallstones. 2) CORRECT — Obesity is a major risk factor for gallstone formation. 3) CORRECT — The incidence of gallstones is higher in women who have had multiple pregnancies. 4) INCORRECT - Aspirin is not associated with gallstone formation. 5) CORRECT — Women between 20 and 60 years of age are twice as likely to develop gallstones as men of the same ages. *Think Like a Nurse: Clinical Decision-Making* The nurse is aware that the mnemonic for cholelithiasis risk factors is the five Fs: fair skin, excess fat (BMI > 30), female, fertile, and forty (or over age 40). Many conditions can result in abdominal pain, but when a client reports abdominal pain and also has these risk factors, gallbladder disease should be ruled out early on. Obesity causes excess estrogen production. Birth control pills also cause an increase in circulating estrogen. Effects of increased estrogen may include an increase in cholesterol production and a reduction in gall bladder contraction. Both of these factors contribute to the development of gallstones. Gallstones can cause damage to the pancreas and liver if not treated promptly. *Content Refresher* Risk factors for the development of cholelithiasis include female gender (especially multiparous women and women over age 40), estrogen replacement therapy, oral contraceptives, sedentary lifestyle, familial tendency, and obesity. If gallstones migrate from the gallbladder into the cystic duct or the common bile duct, bile may be trapped in the gallbladder and lead to cholecystitis. Treatment of cholelithiasis includes medications to dissolve the stones (e.g., ursodiol), laparoscopic cholecystectomy, endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy, and extracorporeal shock-wave lithotripsy (ESWL).

The clinic nurse instructs a client about an ambulatory electrocardiogram (ECG). Which client statements indicate to the nurse a need for additional education? (Select all that apply.) 1. "I will have to use a safety razor while the monitor is in place." 2. "I will keep a log of all of my activities during monitoring." 3. "I will wrap the device with plastic wrap before taking a shower." 4. "I will contact the health care provider if I experience lightheadedness." 5. "I will decrease my fiber during the monitoring."

1) INCORRECT - Ambulatory ECG continuously records cardiac activity and the client needs to avoid electrical equipment while being monitored. Therefore, the client should not use an electric razor or hairdryer while the monitor is in place. This is a correct statement by the client. 2) INCORRECT - The client is required to log all activities while being monitored. This allows the health care provider to correlate cardiac events with client's activities or symptoms. This is a correct statement. 3) CORRECT - The monitor cannot get wet so the client needs to avoid taking a bath or shower during monitoring. The nurse needs to provide additional education based on this statement. 4) CORRECT - If the client experiences dizziness, the client needs to document it in the event log along with pushing the event-marker button on the monitor. The client does not need to call the health care provider. This statement indicates that additional education is needed. 5) CORRECT - There is no reason to change diet while being monitored. This statement indicates that additional education is needed. *Think Like a Nurse: Clinical Decision-Making* Often called a Holter monitor, an ambulatory ECG is a portable device that is used to record a client's heart rhythm for 1 or 2 days. Just like a typical heart monitor, it has leads that attach externally on the torso. The client records symptoms by pushing a button on the device. This device is excellent for capturing episodic dysrhythmias or cardiac conduction abnormalities that only occur under certain circumstances. The client needs explicit instructions about using the device in order for it to be effective and worthwhile. *Content Refresher* For the client undergoing ambulatory ECG monitoring, the nurse should prepare the client's skin before applying electrodes to ensure the best transmission of quality ECG analysis tracings. The client is encouraged to resume normal activities during the monitoring period in order to simulate conditions that produce symptoms. Instruct the client to start recording as soon as symptoms develop. ECG monitoring is typically for a period of 24 to 48 hours. The health care provider can print and analyze strips to assess for any rhythm disturbances and to correlate physical signs or symptoms (e.g. dizziness) with ECG changes.

A nursing team discusses the new nurse manager's leadership style. The unlicensed assistive personnel (UAP) states, "The new nurse manager does not give us any direction or supervision." Which is an accurate response by the nurse? 1. "The nurse manager has an autocratic leadership style. It is best to not challenge the nursing chain of command." 2. "The nurse manager has a democratic leadership style. We will vote on all decisions in staff meetings." 3. "The nurse manager has a situational leadership style. Direction will be provided during a crisis." 4. "The nurse manager has a laissez-faire leadership style. Are there specific issues that you have questions about?"

1) INCORRECT - An autocratic leadership style is one in which the manager makes all decisions and does not ask for input from the group. This nurse manager is exhibiting a laissez-faire leadership style. While the chain of command should be used, all members of the team should feel comfortable voicing questions or concerns about client care. 2) INCORRECT - A democratic leadership style is one in which the manager asks the group to participate in making decisions. This nurse manager is exhibiting a laissez-faire leadership style. 3) INCORRECT - A situational leadership style is one in which the manager assumes a combination of leadership styles depending on the needs of the group. This nurse manager is exhibiting a laissez-faire leadership style. 4) CORRECT - This nurse manager is exhibiting a laissez-faire leadership style, which is one in which little direction is provided to the group. Many people feel confused and frustrated under this style of leadership. The nurse is responsible for supervising the UAP and should respond to any concerns that the UAP expresses. The nurse is acknowledging the situation and uses an open-ended question to elicit further concerns. *Think Like a Nurse: Clinical Decision-Making* The laissez-faire leadership style is characterized by behaviors such as permissiveness, provision of little or no direction, upward and downward communication between members, dispersed decision-making, and lack of criticism. The nurse should keep in mind that the leadership style has a great deal of influence on the climate and outcomes achieved by the nursing unit. *Content Refresher* A leader is anyone who uses interpersonal skills to influence others to accomplish a specific goal. Leadership may be formal (e.g. nurse manager) or informal (e.g. exercised by a staff nurse who has no official authority). No single leadership style works well in every situation. Instead, an individual's leadership style may vary depending on the situation and the needs of the team members. The laissez-faire leadership style, for example, tends to work best for staff who are highly motivated by internal drives and impulses.

A client in a domestic violence shelter asks the nurse to explain why the client continues to be beaten. Which response is the best for the nurse to make? 1. "Can you remember what you said or did just before being hit? " 2. "Let 's focus on getting your face and ribs healed first. " 3. "We can help you when you 're ready. You do not deserve to be abused. " 4. "Only the person who is beating you can tell us what causes the violence. "

1) INCORRECT - Asking a yes/no question is non-therapeutic and this one implies that the client did something to cause the abuse. 2) INCORRECT - Focusing on physical healing is a closed statement and is non-therapeutic. Emotional healing should not be delayed if the client indicates a willingness to participate. 3) CORRECT - Saying that help is available when the client is ready is a reflective statement that is therapeutic. This statement also provides information because it offers support and a path to help, coupled with reinforcement that the client does not deserve to be abused. 4) INCORRECT - Saying that the person doing the beating knows the reason places the focus on the abuser and not the client. This gives power to the abuser to place blame on the victim, and it implies the victim is to blame. *Think Like a Nurse: Clinical Decision-Making* The nurse can help the client understand that the client is not responsible for the perpetrator 's violent behavior (e.g. saying to the client: "You are not responsible for your partner 's violence. ") As a general rule, when communicating with victims of violence, it is best for the nurse not to say anything the nurse is unsure can be followed through. The nurse should inquire if the violence involves children and follow protocol on how to protect them. In some institutions, a standardized screening form is used and an intervention algorithm is implemented. *Content Refresher* A therapeutic relationship is based on caring, respect, and mutual trust. Failure to establish a therapeutic relationship could result in stress, poor communication, and inability to achieve positive client outcomes. Be empathetic when listening and responding. Be respectful, genuine, concrete, and specific. Clarify misconceptions. Consider family relationships and values. Maximize the client 's abilities to participate in decision making and treatments.

The home care nurse visits a young adult with a diagnosis of hepatitis A. Which client statement indicates to the nurse that further teaching is needed? 1. "I have been very careful to wash my hands after I go to the bathroom." 2. "I have taken acetaminophen several times this week for this sinus infection I have." 3. "I have been very careful not to handle my child's toys or eating utensils." 4. "My spouse has been preparing all of the meals since I have been sick."

1) INCORRECT - Because hepatitis A is spread by the oral-rectal route, it is important to protect others by practicing good handwashing techniques. 2) CORRECT — The client should be cautioned about taking any drugs not approved by the health care provider, and this may become dangerous because of the liver's inability to detoxify and excrete acetaminophen. 3) INCORRECT - Because hepatitis A is spread by the oral-rectal route, it is important to protect others by avoiding contact with items that will be placed in others' mouths. 4) INCORRECT - Because hepatitis A is spread by the oral-rectal route, it is important to protect others by avoiding contact with items that will be placed in others' mouths. *Think Like A Nurse: Clinical Decision Making* Acetaminophen is potentially hepatotoxic in people with healthy livers. The daily maximum dose total is 4,000 mg, which is only four doses of extra-strength acetaminophen. Doses exceeding this limit can induce hepatitis . Hepatitis A is a viral infection that causes inflammation of the liver. Symptoms of hepatitis occur as a result of the liver's inability to perform its many functions: bile production, toxin and medication filtering, bilirubin excretion, hormone excretion, fat and carbohydrate breakdown, enzyme activation, synthesis of albumin, and synthesis of clotting factors. In the client with viral hepatitis, acetaminophen should be avoided entirely. *Content Refresher* Hepatitis A is a viral infection that causes inflammation of the liver and is transmitted by consuming contaminated food or fluids. Assess the client for signs and symptoms such as flu-like symptoms, nausea, vomiting, fatigue, joint pain, muscle aches, jaundice, scleral icterus , itching, brown urine, and clay-colored stools. Assess the client's knowledge of disease, treatment, and prevention of disease transmission. Use standard precautions when caring for the client. Plan rest periods. Instruct the client to avoid alcohol and hepatotoxic medications. Provide the client with high-calorie foods, along with nutritional supplements, if needed.

The nurse manager observes a staff nurse perform tracheostomy suctioning and tracheostomy care. Which staff nurse action requires an intervention by the nurse manager? 1. Wearing clean gloves when removing the tracheostomy kit from its outer package. 2. Hyperoxygenating the client prior to suctioning the tracheostomy tube. 3. Wearing clean gloves while inserting the new inner cannula. 4. Leaving the old tracheostomy ties in place until the new ties are secured.

1) INCORRECT - Clean gloves are worn when removing the tracheostomy kit from its outer package. 2) INCORRECT - This is an appropriate, safe action to hyperventilate a client before suctioning to prevent hypoxia. 3) CORRECT — Sterile gloves are worn while inserting the new, sterile inner cannula to prevent introduction of organisms into the client's airway. 4) INCORRECT - This is an appropriate, safe action that helps prevent dislodgement of the tracheostomy during cleaning and replacement of the inner cannula. *Think Like A Nurse: Clinical Decision Making* Before performing tracheostomy care, the nurse needs to remember that tracheostomy care is a sterile procedure and mentally review the process. The nurse will apply knowledge of anatomy and physiology when accessing the tracheostomy, and the body system that is involved, which is the respiratory system. A tracheostomy is an artificial opening created in the trachea to establish either a temporary or permanent airway. Any procedure that involves the tracheostomy tube must be performed using sterile technique in order to prevent infection from developing in the respiratory system. The nurse will apply sterile gloves when changing the inner cannula of a tracheostomy. *Content Refresher* Suctioning clears secretions from the airway of clients who cannot mobilize and expectorate them without assistance. It involves aspirating secretions through a catheter connected to a suction source. Common types of suctioning are oropharyngeal and tracheal suctioning. When performing tracheal suctioning, the nurse should wash hands and don personal protective equipment. Prepare equipment while ensuring items remain sterile. Apply sterile gloves and attach suction catheter to suction source keeping the dominant hand sterile. Hyperoxygenate client with 100% oxygen to prevent hypoxia. With the dominant hand, gently introduce the suction catheter into the tracheostomy tube. Apply intermittent suction and gently rotate the catheter while withdrawing it. Suction should not be applied longer than 5 to 10 seconds.

The nurse provides care for a client at 7 months gestation diagnosed with preeclampsia. An IV of magnesium sulfate is initiated at 2 grams/hour. Which is the most important action for the nurse perform? 1. Darken the client's room. 2. Perform a vaginal exam. 3. Measure the deep tendon reflexes. 4. Assist the client to a comfortable position.

1) INCORRECT - Darkening the room is an appropriate action for seizure precautions. It is more important to assess. 2) INCORRECT - There is no need for a vaginal exam if there is no indication the client is in labor. 3) CORRECT— Magnesium sulfate is given to prevent eclampsia. Hypermagnesemia causes CNS depression, relaxes smooth muscle, and prevents seizures. Assess respirations and tendon reflexes for early signs of toxicity. Vital signs are monitored at least every 15 minutes. 4) INCORRECT - A preferred client position is to lie on left side, which seems to interfere the least with venous blood flow. However, the client may assume a position that is most comfortable for them. *Think Like A Nurse: Clinical Decision Making* The client diagnosed with preeclampsia may be prescribed an infusion of magnesium sulfate. The nurse must differentiate between a medication's therapeutic effects, side effects, and adverse effects. Therapeutic effects of the magnesium infusion are the result of blocked neuromuscular transmission and vasodilation production, and are evidenced by a normal or controlled blood pressure and absence of seizures. Side effects might include flushing, sweating, diplopia, blurred vision, and mild weakness. Adverse effects include respiratory paralysis, circulatory collapse, hypothermia, and hypocalcemia. Adverse reactions are often prevented by careful monitoring of deep tendon reflexes. *Content Refresher* Nursing interventions to implement when caring for the client with pregnancy-induced hypertension or preeclampsia include: Lateral positioning of the pregnant client after 20 weeks to facilitate venous return and increase blood flow to the placenta and fetus. Monitor for preterm labor. Educate client about monitoring BP daily and notifying the health care provider for increases in BP. Treat the client with anti-hypertensive medications as prescribed. Administration of magnesium sulfate IV should be done to decrease uterine contractions if labor ensues. Monitor serum magnesium levels and respirations. Monitor intake and output. Assist with delivery of fetus as soon as possible.

The nurse assesses a client with a physical health problem. Which finding indicates to the nurse that the client might have a history of alcohol use? 1. Depression, difficulty falling asleep, decreased concentration. 2. Elevated liver enzymes, cirrhosis, decreased platelets. 3. Tremors, elevated temperature, nocturnal leg cramps, complaints of pain symptoms. 4. Flulike symptoms, night sweats, elevated temperature, decreased deep tendon reflexes.

1) INCORRECT - Depression, difficulty falling sleep, and decreased concentration are associated with symptoms of dysphoria or mood disorder. 2) INCORRECT - Elevated liver enzymes, cirrhosis, and decreased platelet count might warrant further investigation of alcohol use, but these symptoms are not the best indication. 3) CORRECT- When a client is admitted for another physical problem to a general medical, surgical, or critical care unit, the nurse many times becomes the case finder and must be alert for subtle symptoms of an alcohol-related problem. The client experiencing tremors, elevated body temperature, nocturnal leg cramps, and complaining of pain are all symptoms associated with an alcohol-related problem. 4) INCORRECT - Flulike symptoms, night sweats, elevated temperature, and decreased deep tendon reflexes are associated with withdrawal from narcotics or an infectious process, such as tuberculosis. *Think Like A Nurse: Clinical Decision Making* Chronic use of alcohol can cause changes to the neurologic system, leading to tremors. Alteration in electrolyte balance can cause leg cramps. Fever and generalized pain occur because of irritation to cerebral and peripheral nerve tissue. A client with history of chronic alcohol use may have elevated liver enzymes, cirrhosis, and a decreased platelet count; however, these could also indicate another health problem. *Content Refresher* Alcoholism is a disease that is progressive and fatal, and associated with impaired control over alcohol ingestion and preoccupation with alcohol. Signs of addiction include regular binge or excessive drinking, inability to control drinking, drinking more to achieve the same effect, withdrawal symptoms if alcohol withheld (tremors), and giving up other activities for drinking.

The nurse reviews the documentation by a student nurse after a routine physical on a healthy adult. The nurse determines that the student nurse properly inspected the client's anterior chest if which entry is found in the client's chart? 1. "Diaphragmatic excursion equal bilaterally measuring 4 cm." 2. "Smooth, symmetrical chest expansion noted." 3. "Vesicular breath sounds present over lung periphery." 4. "Ribs with symmetric interspaces and 90-degree costal angle."

1) INCORRECT - Diaphragmatic excursion is percussed on posterior chest wall. 2) INCORRECT - Expansion is palpated over posterior chest wall. 3) INCORRECT - Vesicular breath sounds are auscultated on anterior, posterior, and lateral chest. 4) CORRECT - Inspection of the anterior chest includes shape and configuration of the chest, facial expression, level of consciousness, color and condition of skin, and quality of respirations. *Think Like A Nurse: Clinical Decision Making* The first step in physical assessment of the chest is inspection. Rib location, interspaces, and costal angle would all be observed. Diaphragmatic excursion is assessed through the use of percussion. Chest expansion is assessed through palpation. Breath sounds are assessed with auscultation. *Content Refresher* During physical assessment, in addition to inspecting the client's body, listen for sounds produced within the body, chiefly to assess the condition of the thoracic or abdominal organs and vessels, such as the heart, lungs, aorta, and intestines. Select a stethoscope with both a bell and diaphragm. Use the stethoscope bell to auscultate low-frequency sounds and the diaphragm to auscultate high-frequency sounds. Examine the client in a quiet, well-lit, warm room. Note the presence of normal and unusual heart and lung sounds and the presence or absence of bowel sounds. Notify the health care provider of any abnormal findings.

The nurse provides care to a client with a suspected latex allergy. Which clinical manifestations noted on the nurse's assessment support this diagnosis? (Select all that apply.) 1. Pruritus of the hands. 2. Runny nose. 3. Angioedema. 4. Bronchospasm. 5. Shock.

1) INCORRECT - Dry, irritated skin associated with pruritus occurs with an irritant contact dermatitis. It is not indicative of an immediate hypersensitivity reaction, but should be further investigated. 2) CORRECT - Rhinitis (a runny nose), conjunctivitis, angioedema, bronchospasm, and shock may occur with an immediate hypersensitivity reaction to latex. 3) CORRECT - Angioedema is the result of the histamine released by the type I hypersensitivity reaction to latex. It can involve edema of the mouth, pharynx, or larynx, which can cause respiratory distress. 4) CORRECT - Bronchospasm is the result of the histamine released by the type I hypersensitivity reaction to latex. Respiratory distress must be treated with epinephrine and antihistamines. 5) CORRECT - Shock caused by the anaphylactic reaction can occur quickly and will be life-threatening. *Think Like A Nurse: Clinical Decision Making* The American Latex Allergy Association categorizes latex allergies as type I (immunoglobulin E [IgE] mediated allergic reactions), type IV (localized contact allergic dermatitis), and irritant dermatitis (resulting from alterations in skin integrity). The type I reaction is the immediate hypersensitivity reaction. Histamine release is swift and massive, resulting in bronchospasm, increased capillary permeability dramatically decreasing blood pressure, and runny nose. Clients with this type of allergy are not exposed to latex in any form, including gloves, vials, or catheters. *Content Refresher* Latex allergy is a sensitivity reaction to certain proteins found in natural rubber latex. Triggers include exposure to latex through the skin, through inhalation, and through the blood. If the symptoms are minor, antihistamine or corticosteroid medicines may be sufficient to treat the client. Severe reactions may require epinephrine, IV fluids, and endotracheal intubation. For the client who experiences a hypersensitivity response to latex, bronchospasm may lead to hypotension, anaphylaxis, and cardiopulmonary arrest. Clients who have a latex allergy should wear a medical alert bracelet or carry another type of ID in case of an emergency. The client may also need to carry two epinephrine pens at all times.

The nurse provides care for a client diagnosed with peripheral artery disease (PAD). The client reports leg pain occurs frequently when walking. Which action does the nurse advise the client to take? 1. Lie down with feet elevated above the heart when experiencing pain. 2. Apply a heating pad to the legs for 15 minutes before walking. 3. Walk until client experiences pain, rest, and then resume walking. 4. Perform stretching exercises 20 minutes before starting to walk.

1) INCORRECT - For a client with PAD, elevating the legs above the heart decreases arterial flow to legs. This will increase, not relieve, the pain. 2) INCORRECT - The decreased sensitivity to pain may result in burns. 3) CORRECTnbsp- Exercise increases collateral circulation and should be encouraged. Stopping and resting will usually relieve the pain, and then the client can continue to walk. 4) INCORRECT - Stretching will not reduce the pain due to intermittent claudication. *Think Like A Nurse: Clinical Decision Making* Pain with walking in the client with peripheral vascular disease (PVD) is complex because walking is both the cure and the cause. Peripheral vascular disease causes the lower extremities to receive too little blood flow. The vessels are hardened and narrowed, so blood does not get through in sufficient volume or speed. Walking increases the blood flow to these extremities. However, at the point that the muscles are working hard enough to demand additional blood flow to remove waste products and provide oxygenation, pain results because additional blood flow is not possible. The nurse instructs the client to rest until the pain subsides and then continue to walk to enhance collateral circulation. *Content Refresher* Peripheral vascular disease (PVD) , also called peripheral arterial disease, is caused by atherosclerosis, thrombus, inflammation, and vasospasm. Assess strength of distal pulses (dorsalis pedis, posterior tibial, and popliteal) and color and temperature of extremities. Assess for any non-healing wounds. Pain during ambulation describes intermittent claudication, an ischemic pain that results from lactic acid buildup caused by anaerobic metabolism. When the client stops exercising the lactic acid clears and pain subsides. Educate the client about reducing the risk for disease progression (e.g. diet, exercise, weight reduction, proper management of diabetes mellitus, control hypertension, or smoking cessation).

The nurse provides care to a client who is prescribed conjugated estrogen therapy for management of menopausal symptoms. Which client statement requires immediate follow up by the nurse? 1. "I have trouble falling asleep at night." 2. "I gained five pounds since I started taking this medication." 3. "My left leg is sore behind the knee." 4. "I am still having hot flashes several times each week."

1) INCORRECT - Insomnia is a common complaint during menopause. Hormone replacement therapy (HRT) may help decrease insomnia. However, the individual may still experience impaired sleep patterns. 2) INCORRECT - Weight gain is a common side effect of hormone replacement therapy (HRT). Although this side effect may be undesirable, it does not represent an indication that the client is experiencing a complication of HRT. 3) CORRECT - Complications associated with hormone replacement therapy (HRT) include abnormal clotting and deep vein thrombosis (DVT). Pain or soreness in the popliteal region may be a sign of DVT. The nurse should immediately follow up with the client regarding her statement, assess for additional manifestations of DVT, and notify the health care provider of abnormalities. 4) INCORRECT - Symptoms of menopause, including hot flashes, may persist with use of hormone replacement therapy (HRT). Other common symptoms associated with menopause include insomnia and emotional lability. *Think Like a Nurse: Clinical Decision-Making* Deep vein thrombosis (DVT) prevention is an important nursing goal. This is important not just for the peripheral circulation in the leg, but because DVTs often travel to central circulation where a pulmonary embolism can result in death. Risk factors for DVT include hormone therapy or birth control pills, inherited blood clotting disorders, pregnancy or postpartum status, cancer or cancer treatment, a central venous access device, advanced age, obesity, and smoking. Combinations of any of these factors multiplies the overall risk. *Content Refresher* Side effects from hormone replacement therapy include include spotting, nausea, breast tenderness, headaches, weight gain, mood changes, and decreased libido. Adverse effects include blood clots resulting in deep vein thrombosis, stroke, and myocardial infarction.

An LPN/LVN reports to the nurse that a client admitted with persistent chest pain is experiencing moderate, spastic lower abdominal pain, nausea, and some vomiting. Which action does the nurse take first? 1. Determine what medications the client is receiving. 2. Perform a comprehensive abdominal assessment. 3. Ask the client about a history of GI problems. 4. Notify the admitting health care provider.

1) INCORRECT - Nausea and vomiting are side effects of many medications, but the nurse should first assess the client's abdomen to detect any abnormal findings. 2) CORRECT— Abdominal pain is not usually associated with myocardial infarction. The nurse should assess for GI issues. The nurse should assess the abdomen prior to notifying the health care provider. 3) INCORRECT - The priority is first to assess the current physical status. 4) INCORRECT - This may be needed, but the nurse should obtain assessment data prior to contacting the health care provider. *Think Like A Nurse: Clinical Decision Making* The gastrointestinal symptoms are not consistent with the reason for the client's reason for seeking medical attention. It is not a nursing function to determine if newly developing symptoms are related to an existing condition. The nurse is not a diagnostician, and a complete abdominal assessment needs to be completed prior to notifying the health care provider with the symptom and associated findings. The client's new symptoms are considered a change in status. *Content Refresher* Assessment is the careful observation and evaluation of a client's health status. It is the first step of the nursing process. A holistic assessment is necessary to obtain data that enable the nurse to make an accurate nursing diagnosis, identify and implement appropriate interventions, and assess their effectiveness. Assessment includes questioning the client regarding the chief complaint, history of the present illness, past medical history, family health history, health practices, health beliefs, and functional, psychosocial, and cultural status. The nurse will also conduct a physical assessment. Physical assessment techniques include inspection, palpation, percussion, and auscultation.

The nurse provides care for the client on a sodium-restricted diet. The nurse reinforces dietary teaching if the client makes which menu selections? (Select all that apply.) 1. Applesauce. 2. Cottage cheese. 3. Canned corn. 4. Pretzels. 5. Banana. 6. Bologna sandwich.

1) INCORRECT - One cup of applesauce contains 5 mg sodium and is an appropriate selection for a client on a sodium restricted diet. The American Heart Association recommends a sodium intake of less than 3000 mg per day. Clients on sodium restriction are generally limited to 2000 mg per day. The minimum needed intake is 500 mg per day. 2) CORRECT - Cottage cheese contains 819 mg sodium per cup. Those on sodium restriction are generally limited to 2000 mg per day. This menu choice is high in sodium and requires the nurse to reinforce dietary teaching. 3) CORRECT - Canned corn can contain nearly 500 mg sodium per cup. Canned foods are known to contain a large amount of sodium as a preservative. Individuals on sodium restriction are generally limited to 2000 mg per day. This menu choice is high in sodium and requires the nurse to reinforce dietary teaching. 4) CORRECT - Pretzels contain 359 mg sodium per ounce. Individuals on sodium restriction are generally limited to 2000 mg per day. This menu choice is high in sodium and necessitates that the nurse reinforce dietary teaching. Salt-free pretzels, however, may be acceptable. 5) INCORRECT - A single banana contains 1 mg sodium. Bananas are rich in potassium, which facilitates the elimination of excess sodium. This menu selection indicates correct understanding of foods appropriate for a client on a sodium restricted diet. 6) CORRECT - One medium slice bologna contains 254 mg sodium or more. Cured and salted meats are usually heavy in sodium as a preservative. Individuals on sodium restriction are generally limited to 2000 mg per day. This menu choice is high in sodium and requires the nurse to reinforce dietary teaching. *Think Like a Nurse: Clinical Decision-Making* Client education is an expected competency for every nurse. An essential first step is to assess the client's teaching and learning needs, including literacy issues. Health literacy has been shown to be a stronger predictor of health status than age and educational level. For optimal comprehension and compliance, education materials should be written at a sixth-grade or lower reading level, preferably including pictures and illustrations. The nurse should always use the teach-back method. The client should be encouraged to ask questions. The nurse should inform the client that food sources low in sodium include rice, dried beans, peas and lentils, light turkey, avocado, raw broccoli, potatoes, and apples. *Content Refresher* Provide education regarding the sodium-restricted diet based on the client 's lifestyle, socioeconomic status, culture, and motivation. Identify resources available in the community to help ensure diet compliance based on financial needs and/or ability to prepare food. Provide support and identify social services within the community. Consult a dietitian if needed.

The nurse counsels a client newly diagnosed with hypertension. Which statement by the client indicates to the nurse that teaching is successful? 1. "If I feel dizzy when I wake up, I will skip my morning blood-pressure pill." 2. "I will switch from lifting weights at the health club to doing aerobics." 3. "I will be sure to take chlorothiazide every night before I go to bed." 4. "I will take hot baths or go to the sauna to relax if I feel tension coming on."

1) INCORRECT - Prescribed medication needs to be taken on a regular basis. For an anti-hypertensive medication, instruct the client to rise slowly from lying and sitting positions, and if severely bothered by dizziness, contact the health care provider. 2) CORRECT - Regular aerobic exercises are usually recommended. Isometric exercises, such as heavy weight-lifting, are contraindicated due to a potential vasovagal response during intense isometric muscle contraction. Also, aerobic activity benefits the vascular system and reduces blood pressure readings over time. 3) INCORRECT - Thiazide diuretics such as chlorothiazide nighttime dosing will interfere with sleep by requiring frequent urination and is a safety hazard. 4) INCORRECT - Antihypertensives and diuretics commonly cause hypotension, and heat can facilitate hypotension by causing peripheral vasodilation. *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. The client's verbalized plan to choose aerobic exercise instead of lifting weights indicates accurate understanding of the teaching. The nurse reinforces the safety concerns associated with lifting weights, including a potential vasovagal response. The nurse should also reinforce the client's understanding of benefits associated with aerobic exercise, including promoting cardiovascular health and reducing blood pressure. *Content Refresher* Hypertension refers to a persistent increase in systemic arterial blood pressure. Educate the client about healthy lifestyle changes, including (if applicable) smoking cessation and decreasing alcohol intake, weight loss, incorporating regular moderate physical activity, and stress reduction techniques. Provide dietary counseling to emphasize a low-sodium, low-fat diet with sufficient intake of potassium, magnesium, and calcium. Teach the client how to monitor blood pressure in the home setting. Administer prescribed medications, which may include anti-hypertensive and diuretic medications.

When completing an audit of medical records, the nurse determines that which client is at highest risk for developing hospital-acquired pneumonia? 1. An adolescent client who has diabetes mellitus (DM). 2. An adult client who has smoked for 2 decades. 3. A middle-age adult client diagnosed with hypertension. 4. An older adult client diagnosed with chronic obstructive pulmonary disease (COPD).

1) INCORRECT - Risk factors for developing hospital-acquired pneumonia include chronic lung disease and being an older adult. This client is at risk for community-acquired pneumonia due to DM, but not at the highest risk for developing hospital-acquired pneumonia. 2) INCORRECT - This client is at risk for community-acquired pneumonia due to smoking, but not at the highest risk for developing hospital-acquired pneumonia. 3) INCORRECT - This client does not have any risk factors for developing hospital-acquired pneumonia. 4) CORRECT - The client's age and chronic lung disease place this client at highest risk for developing hospital-acquired pneumonia. *Think Like A Nurse: Clinical Decision Making* Hospital-acquired pneumonia occurs due to aspiration of upper airway secretions, dental plaque, ventilator use, decreased immune system functioning, and increased exposure to infectious agents due to health care worker transmission between clients. Basic nursing care is required to prevent this pneumonia, including providing oral hygiene, frequently turning clients who are not alert, observing transmission-based precautions and hand hygiene, and advocating for the client by ensuring all staff, including health care providers, observe infection control standards. *Content Refresher* Monitor high-risk clients for signs and symptoms of pneumonia, such as cough (may be productive or nonproductive), fever, chills, dyspnea, tachypnea, pleural pain, hypoxia, and crackles upon auscultation. Diagnostic testing for pneumonia includes chest x-ray, pulse oximetry, sputum culture and gram stain, complete blood count (CBC), blood cultures, and arterial blood gas (ABG) results. Cultures must be obtained and appropriate antibiotics given for bacterial pneumonia. For a client with pneumonia, give supplemental oxygen as needed. Bronchodilators and corticosteroids are given intravenously or by inhalation to open airways and facilitate mucus expectoration.

The nurse assesses clients after receiving hand-off communication. Which observation is most important for the nurse to immediately intervene? 1. Scissors placed on the bedside table of a client with a Sengstaken-Blakemore tube. 2. An ambu bag at the bedside of a client on a ventilator. 3. Defibrillator on the crash cart and plugged into the wall in the treatment room. 4. A padded tongue blade taped to the wall above the bed of a client with tonic-clonic seizures.

1) INCORRECT - Scissors at the bedside of a client with a Sengstaken-Blakemore tube is an appropriate action. This esophagogastric tube provides balloon tamponade to stop bleeding of esophageal varices. The inflated esophageal balloon can obstruct the airway. In case of an airway obstruction, scissors are to be used to cut the tube's balloon ports. 2) INCORRECT - An Ambu bag should be at the bedside of a client on a ventilator. If the ventilator fails, the Ambu bag is used to maintain ventilation. 3) INCORRECT - A defibrillator on the crash cart and plugged into the wall in the treatment room is an appropriate action. This device should be charged at all times. 4) CORRECT - Nothing should be inserted into the mouth of a client who is having a tonic-clonic seizure. The padded tongue blade should be removed from the client's room. *Think Like A Nurse: Clinical Decision Making* Nothing should ever be placed in the mouth of a client experiencing a seizure. The padded tongue blade should be removed from the client's room. *Content Refresher* Prioritization of client care is essential. The nurse needs to assess each client and determine what medical/safety needs must be addressed. One method of prioritizing client care is by using Maslow's hierarchy of needs. Physical needs should be addressed first. Assess for physical needs, then move to safety needs and/or concerns.

The nurse provides care for a newborn who was circumcised 30 minutes ago. Assessment reveals a moderate amount of bright red bleeding on the dressing. Which action is the first action for the nurse to take? 1. Put a clean, loose-fitting diaper on the newborn . 2. Apply gentle pressure to the penis. 3. Notify the health care provider. 4. Assess the newborn's pulse and blood pressure.

1) INCORRECT - Since pressure is needed, you do not want a loose-fitting diaper on the newborn. 2) CORRECT - If excessive bleeding occurs, gentle pressure is applied to the site. 3) INCORRECT - If pressure does not alleviate the bleeding, the nurse will notify the health care provider, who may apply Gelfoam or epinephrine or may suture the small blood vessels. 4) INCORRECT - This provides more assessment data, but the nurse has already identified the issue as excessive bleeding. Obtaining this information does not stop the bleeding or protect the client from harm. *Think Like A Nurse: Clinical Decision Making* The nurse needs to review the procedure and understand the principle of actions to prevent complications. The nurse knows circumcision is a minor surgical procedure involving the removal of the foreskin. The procedure is completed a few days after birth and requires diligent monitoring and meticulous care afterwards. If the site begins to bleed, gently pressure should be applied to promote clotting. It is important for the nurse to remember the newborn's liver function is not at maximum maturity and clotting factor function may be delayed. If gentle pressure does not stop the bleeding, additional intervention may be required. *Content Refresher* Wound care includes assessment and cleaning of a wound using sterile or clean technique with application of a dressing. Assessment of the wound is critical to evaluate drainage and healing, as well as to determine the size, location, amount, and type of exudate and stage of healing. In the case of an incisional wound following a circumcision, the nurse should apply pressure to reduce bleeding and then reassess the wound. Document the wound appearance including size, location, amount of exudate, condition of skin surrounding the wound, and client tolerance of dressing change procedure.

The nurse oversees care provided by the LPN/LVN, and the nursing assistive personnel (NAP). Which client will the nurse assign to the NAP? 1. Client with a 5-day-old ostomy requiring stoma care and application of an ostomy appliance. 2. Client in a coma after experiencing a head injury requiring cranial nerve assessment and Glasgow coma scale evaluation. 3. Client with a spinal cord injury requiring range-of-motion exercises and instruction about autonomic dysreflexia. 4. Client with chronic lung disease and type 1 diabetes mellitus requiring a sputum sample for culture and sensitivity and capillary blood glucose monitoring.

1) INCORRECT - The care of a client with a newly created ostomy should be assigned to a nurse. Assessment and teaching is required. 2) INCORRECT - The client in a coma requires frequent assessment and nursing judgment. The nurse should be assigned to this client. 3) INCORRECT - The client with spinal cord injury requires teaching that can only be completed by the nurse. 4) CORRECT - Collecting a sputum specimen and measuring capillary blood glucose are tasks that are standardized. The NAP can be assigned this client. The nurse should instruct the NAP about the type of specimen to collect, the timing, the collection container, and correct way of labeling. *Think Like A Nurse: Clinical Decision Making* The scope of practice for the nursing assistive personnel (NAP) includes routine tasks, specimen collection, and measuring capillary blood glucose level. The nurse could delegate range-of-motion care for the client with a spinal cord injury to the NAP; however, the nurse retains the responsibility for teaching about autonomic dysreflexia. *Content Refresher* Delegation is the process of transferring authority for a specific nursing care task to a competent person in a stable situation with a predictable outcome. The nurse can delegate a task to a nursing assistive personnel (NAP) with clear communication about the task, its purpose, the desired timeline for performance, and expected outcomes.

A client reports falling at home several times over the last 6 months because of difficulty walking and the presence of a pill-rolling tremor. Which prescription does the nurse expect for this client? (Select all that apply.) 1. Prescription for β-interferon. 2. Referral for physical therapy. 3. Appointment for an MRI. 4. Referral to hospice care. 5. Prescription for carbidopa/levodopa.

1) INCORRECT - The client's symptoms are consistent with Parkinson disease. Beta-interferon is not an appropriate medication for this client. 2) CORRECT - A physical therapy referral is appropriate to teach safe ambulation and determine the need for assistive devices. 3) CORRECT - An MRI is appropriate to diagnose this client's health problem and rule out other causes for the symptoms. 4) INCORRECT - Hospice is appropriate for end-of-life care. This client is not demonstrating end-of-life care needs, but rather is demonstrating early stages of a chronic disease. 5) CORRECT - The client's symptoms describe Parkinson disease. Carbidopa/levodopa is a first-line medication for this health problem. *Think Like A Nurse: Clinical Decision Making* The clients symptoms are consistent with Parkinson disease. Because the client is having difficulty walking, a physical therapy referral for balance and safe ambulation would be indicated. An MRI would be prescribed to rule out any other cause for the symptoms. Carbidopa/levodapa is a medication used to treat Parkinson disease. *Content Refresher* Parkinson disease is a progressive neurological disorder caused by degeneration of the basal ganglia and a reduction in dopamine production. Early symptoms include fatigue, loss of smell, and signs of motor dysfunction (e.g. tremor, mask-like facial expression, rigidity, shuffling gait). Later signs are related to autonomic system dysfunction and impaired cognition. Physical, occupational, and speech therapy should be part of the interdisciplinary team. There is no cure for Parkinson disease, but medications and the surgical implantation of a nerve stimulator may assist with symptoms. Coping strategies, nutrition, and adequate rest can promote health.

The nurse prepares to teach a client recovering from a spinal fusion on how to move from a supine to standing position at the left side of the bed with a walker. Which direction by the nurse is appropriate? 1. Raise the head of the bed to sit straight up, bend the knees, and swing the legs to the side and then to the floor. 2. Rock the body from side to side, going further each time until enough momentum is built up to be lying on the right side, and then raise the trunk towards the toes. 3. Reach over to the left side rail with the right hand, pull the body onto the left side, bend the upper leg so the foot is on the bed, and push down to elevate the trunk. 4. With the left elbow as a pivot, grasp the mattress edge with the left hand and push on the mattress with the right hand above the left elbow, and then slide the legs over the side of the mattress.

1) INCORRECT - The entire spine must be kept straight throughout the transfer. Bending the knees and swinging the legs to the side would cause spinal twisting. 2) INCORRECT - The client should lie on the left side, and not right side. Rocking can be stressful to the spine. 3) INCORRECT - The back must be kept in straight alignment. Do not use side rails after spinal surgery because it will cause the spine to twist. 4) CORRECT— Using the arms maintains spinal alignment and prevents injury. *Think Like A Nurse: Clinical Decision Making* The nurse forms a mental view of what needs to be done, paying particular attention to client safety and preventing injury. The nurse considers that spinal fusion is a complicated surgery and requires special post-operative care to maintain the incision and prevent rotation of the vertebra within the surgical site. The first action by the nurse is to assess the client's physical and psychological ability to implement the teaching. Once ability is determined, the client is coached to use the arms and the legs to move the body into position for standing. The nurse observes the client's ability to change position while protecting the surgical site. *Content Refresher* Proper body mechanics is the use of body positioning and assistance from others or device(s) while ambulating and transferring, which reduces the risk of musculoskeletal strain or injury. The nurse should provide information to the client and family about proper body mechanics. Assist the client with proper body alignment when moving from bed to a standing position. Consult physical therapy, if needed. Determine if aids are needed for ambulation, such as a cane or walker. Provide client and family education about exercises to improve balance, coordination, strength, and flexibility and the use of assistive devices, if needed.

The nurse provides care for a client who delivered a neonate at 30 weeks' gestation. The client has one child at home who was delivered at 41 weeks. The client has had two abortions, one spontaneous at 7 weeks' gestation, and one induced at 9 weeks' gestation. Which number, using the 5-digit system, should the nurse record as the client's gravidity and parity? 1. 41112 2. 31122 3. 21122 4. 41122

1) INCORRECT - The first digit of the 5-digit system accounts for the number of times the uterus has been pregnant. The second digit represents the number of term deliveries, whereas the third digit represents the number of preterm deliveries. The fourth digit accounts for the number of abortions, either spontaneous or induced, and the fifth digit represents the number of living children. Therefore, this number is not correct. 2) INCORRECT - The first digit of the 5-digit system accounts for the number of times the uterus has been pregnant. The second digit represents the number of term deliveries, whereas the third digit represents the number of preterm deliveries. The fourth digit accounts for the number of abortions, either spontaneous or induced, and the fifth digit represents the number of living children. Because the client had 4 pregnancies, this number is not recorded properly. 3) INCORRECT - The first digit of the 5-digit system accounts for the number of times the uterus has been pregnant. The second digit represents the number of term deliveries, whereas the third digit represents the number of preterm deliveries. The fourth digit accounts for the number of abortions, either spontaneous or induced, and the fifth digit represents the number of living children. Because the client had 4 pregnancies, this number is not recorded properly. 4) CORRECT— The first digit of the 5-digit system accounts for the number of times the uterus has been pregnant. The second digit represents the number of term deliveries, whereas the third digit represents the number of preterm deliveries. The fourth digit accounts for the number of abortions, either spontaneous or induced, and the fifth digit represents the number of living children. This is the correct number to record because the client had 4 pregnancies, 1 term delivery, 1 preterm delivery, 2 abortions, and 2 living children. *Think Like A Nurse: Clinical Decision Making* Accurate documentation is a key nursing competency. For gravity and parity documentation, it is essential to verify accuracy particularly for multiparous mothers. *Content Refresher* Gravid means pregnant. The term can be used to refer to the woman or to the uterus. It can also indicate the number of pregnancies a woman has experienced. During the initial evaluation, a comprehensive health history emphasizing the current pregnancy and previous pregnancies needs to occur.

The nurse prepares to obtain a blood pressure measurement from a client. Which action does the nurse take? 1. Hold heavy pressure on the bell of the stethoscope while listening. 2. Release the pressure of the cuff 5 to 6 mm Hg per second. 3. Position the client's arm below the level of the heart. 4. Wrap the cuff 2.5 cm (1 in) above the antecubital space.

1) INCORRECT - The nurse should hold the bell of the stethoscope against the skin strongly enough to ensure there is a seal between the bell and the skin, but not so firmly to obliterate sounds. 2) INCORRECT - The nurse should open the valve to release the pressure of the cuff 2 to 3 mm Hg per second. A faster or slower rate can cause an inaccurate reading. 3) INCORRECT - The nurse should position the client's arm at the level of the heart to ensure an accurate reading. If the arm is elevated above the level of the heart, gravity can cause an inaccurately low reading. If the arm is below the level of the heart the reading can be inaccurately high. 4) CORRECT - The nurse should make sure the bladder of the cuff is over the brachial artery in order to compress it during measurement. Therefore, the nurse should be sure to place the cuff is 2.5 cm (1 in) above the antecubital space. *Think Like a Nurse: Clinical Decision-Making* The nurse should recognize and practice correct technique when measuring a client's vital signs. Prior to obtaining the blood pressure measurement, the nurse should recall considerations and actions that provide the most accurate measurement of cardiovascular functioning. The equipment required for this measurement includes a cuff, a sphygmomanometer, and stethoscope. Of the items required for this measurement, the cuff is applied first, the stethoscope is placed second, and the valve of the sphygmomanometer is closed prior to inflation. The nurse knows that selection of the right size cuff is important to avoid false readings. *Content Refresher* A blood pressure is the pressure of the blood in the arterial circulatory system. Blood pressure is measured for diagnostic purposes. Systolic pressure is generated with ventricular systole and diastolic pressure is generated during ventricular diastole. The nurse needs to gather a stethoscope and blood pressure cuff with a mercury or aneroid sphygmomanometer or automated oscillometric blood pressure device. Position client upright. The blood pressure cuff is placed above the elbow, with the stethoscope placed lightly over the brachial artery. The cuff is inflated to a pressure of 30 mm Hg above the level at which the radial pulse is no longer palpable. Slowly deflate the cuff, listen for Korotkoff phase, watch the sphygmomanometer, and listen until the sounds disappear completely.

The nurse develops a teaching plan regarding nutrition during pregnancy. Which information does the nurse include in the plan? (Select all that apply.) 1. Nutritional requirements for protein triple during pregnancy. 2. Caloric requirements increase by 500 calories/day during the first trimester. 3. Nutritional requirements for iron double during pregnancy. 4. Sodium should be restricted to 2 g/day. 5. Nutritional requirements for zinc will increase during pregnancy.

1) INCORRECT - The nutritional requirement for protein during pregnancy is around 60 g/day, which is only a modest increase in protein intake over the recommended levels in adult women. 2) INCORRECT - There are no additional caloric requirements for the first trimester of pregnancy. During the second trimester of pregnancy, the recommended caloric intake is 340 kcal/day greater than the pre-pregnancy needs. During the third trimester, the amount is 462 kcal/day greater than pre-pregnancy needs. 3) CORRECT - Pregnant women should receive a supplement of 30 mg of ferrous iron daily, starting by 12 weeks' gestation. The recommended daily intake for pregnant women is 60 mg/day, as opposed to the 30 mg/day recommended for adult women. 4) INCORRECT - Sodium requirements during pregnancy increase slightly, as fluid volume increases. 5) CORRECT - Because cell growth is rapidly occurring during pregnancy, pregnant women should be encouraged to consume good sources of zinc daily. *Think Like a Nurse: Clinical Decision-Making* Current standard of care during pregnancy shows that clients typically take a vitamin and mineral supplement daily during pregnancy. Ideally, the mother should be given folic acid even before the baby is conceived. For most pregnant women, supplements of 27 mg of iron and between 400 to 800 mcg of folic acid per day are recommended. Generally, the nurse teaches the pregnant client to increase consumption of fruits and vegetables, consume unsaturated fats, choose whole instead of refined grains, avoid hydrogenated fats, abstain from alcohol, eat at least two servings of fish weekly, and consume at least 2 liters of water daily. *Content Refresher* Each day, pregnant women need to eat at least three servings of protein, six or more servings of whole grains, five or more servings of fruits and vegetables, and three or more servings of dairy products. The diet should also consist of eating foods with essential fats, taking daily prenatal vitamins, and drinking at least eight glasses of water per day. Pregnant women should be counseled to avoid alcohol, excessive caffeine, raw meats and seafood, high-mercury fish, uncooked or processed meats, and unpasteurized dairy products.

A client receiving peritoneal dialysis for newly diagnosed renal failure experiences abdominal pain during the dialysate infusion. Which action is appropriate for the nurse to implement? 1. Stop the dialysis treatment immediately. 2. Decrease the amount of dialysate to be infused. 3. Explain that discomfort subsides after the first few exchanges. 4. Slow the infusion of the dialysate to increase comfort.

1) INCORRECT - The procedure should not be stopped. 2) INCORRECT - The amount to be infused should not be decreased. 3) CORRECT — Discomfort is common during the first few dialysis exchanges because of peritoneal irritation. It usually subsides within 1 to 2 weeks of treatment. 4) INCORRECT - The infusion should not be slowed. *Think Like A Nurse: Clinical Decision Making* The nurse is aware that treatment for renal failure can be accomplished through either hemodialysis, or by peritoneal dialysis in which the peritoneal membrane is the filter for waste produces. In this scenario, the client is having peritoneal dialysis, which is the introduction of a fluid into the peritoneal cavity, where toxins from the vascular system are pulled into the peritoneal cavity. At the end of "dwell time" the fluid is drained from the body, carrying waste products with it. This type of treatment can be irritating to the tissues within the peritoneal space and may cause pain and discomfort during the procedure. The nurse should explain the process for this fluid exchange and the reason for the local irritation. In time, the irritation will dissipate. *Content Refresher* When caring for a client receiving peritoneal dialysis, the nurse should educate the client about the technique of peritoneal dialysis and reinforce the procedure as needed. Sterile fluid (dialysate) is infused by gravity into the peritoneal cavity through a surgically-implanted catheter. By using the principles of diffusion, the waste products and toxins in the client's blood are filtered into the dialysate during the dwell time. Using the principle of osmosis, water is also drawn into the dialysate solution so that the client is able to eliminate excess water. Evaluate as the client demonstrates the infusion, dwell, and drain phases. Note color and amount of dialysate after dwell time. Explain the importance of monitoring serum glucose, as the main ingredient in the dialysate is dextrose. Educate the client about potential complications, which includes peritonitis, sepsis, hypotension, and fluid deficit.

The nurse teaches a class for senior citizens about the effects of aging. Which information does the nurse include in the presentation? 1. People lose interest in sex as they age. 2. Most older adults live at the poverty level. 3. All people will become senile if they live long enough. 4. Incontinence is not an expected change related to aging.

1) INCORRECT - There is no evidence to support this statement; many older adults continue to have a satisfying sex life. 2) INCORRECT - While most older adults are on a fixed income after retirement, there is no evidence to support that the majority live at a deprived level. 3) INCORRECT - There is no evidence to support this statement. 4) CORRECT - Although normal changes to all body systems occur with aging, the leaking of urine is not an anticipated or usual expectation in older adults. *Think Like A Nurse: Clinical Decision Making* When preparing teaching material, the nurse needs to consider the age of the participants in order for the content to be meaningful. The nurse should use research sources to assure that information is current and correct. In this scenario, the nurse is focusing on the effects of aging and expected changes. If unexpected or unpleasant changes are addressed, the nurse should always include information and/or suggestions of treatment and management of those conditions. The nurse needs to be cautious not to present normal changes as abnormal, or abnormal changes as being normal. The nurse must never forget that every age group consists of unique individuals. *Content Refresher* Incontinence is the unintentional loss of urine and is caused by different factors, including increased abdominal pressure (stress), increased need without control (urge), increased bladder distention (overflow), and cognitive impairments (functional). Causes of incontinence include weakness of pelvic floor muscles, increased abdominal pressure, infections, over-distention of the bladder, sphincter weakness, and cognitive impairments. Risk factors include obesity, smoking, gender (females are more likely to experience incontinence due to pregnancies), menopause, and cognitive disorders such as dementia. Many types of urinary incontinence can be treated successfully with medications, education, bladder retraining, and/or surgery.

The home care nurse visits a client undergoing continuous ambulatory peritoneal dialysis (CAPD) for chronic kidney disease. Which instruction does the nurse reinforce with the client? 1. "Drink distilled water." 2. "Cap the catheter during dwell time." 3. "Boil the dialysate 1 hour before an infusion." 4. "Clean the arteriovenous fistula site with hydrogen peroxide daily."

1) INCORRECT - There is no reason to drink distilled water. Because of the protein loss from the CAPD, the client is instructed to eat a high-protein, well balanced diet. 2) CORRECT - The most common complication is peritonitis. Use aseptic technique when caring for catheter, fluid, or tubing. Cap the catheter during the dwell time. 3) INCORRECT - The solution arrives in commercially prepared plastic bags with no need to prepare, except to use aseptic technique. 4) INCORRECT - An arteriovenous fistula is used for hemodialysis, not for peritoneal dialysis. Cleaning with hydrogen peroxide is not recommended, as it irritates the skin. *Think Like A Nurse: Clinical Decision Making* Prior to teaching a client a specific treatment, the nurse should mentally ask, "What is the most important information that this client needs?" and "What concerns exist regarding the client's safety?" The nurse needs to consider that peritoneal dialysis is the introduction of dialysis fluid directly into the peritoneal cavity. There is a significant risk of infection during the preparation for the procedure, the introduction of the fluid, and when the fluid is drained. The nurse should emphasize practices to reduce the likelihood of the client developing an infection when performing this procedure in the home. *Content Refresher* Peritoneal dialysis (PD) is an alternative to hemodialysis for clients with chronic kidney failure. It uses the peritoneal membrane as a semipermeable membrane to filter out toxins and wastes, manage azotemia, and restore electrolyte balance. Complications associated with peritoneal dialysis include peritonitis, sepsis, hypotension, and fluid deficit. Client education should focus on the technique of peritoneal dialysis with reinforcement, as needed. The nurse will need to evaluate the skill as the client demonstrates the infusion, dwell and drain phases. Note color and amount of dialysate after dwell time. Explain the importance of monitoring serum glucose as the main ingredient in the dialysate is dextrose. Educate the client about potential complications, especially peritonitis.

The home health nurse completes an assessment of a newborn. Which finding does the nurse expect during assessment? 1. "Machine-like" heart murmur. 2. Occipital frontal circumference 40 cm. 3. Bulging anterior fontanel at rest. 4. Extrusion reflex.

1) INCORRECT - This indicates patent ductus arteriosus, an acyanotic heart problem. 2) INCORRECT - The normal circumference for a newborn's head is 33 to 35 cm. An enlarged circumference would suggest hydrocephalus or increased intracranial pressure. 3) INCORRECT - The fontanels should not bulge at rest, although they may bulge when the infant is crying. 4) CORRECT - A normal neonate reflex that disappears between 3 to 4 months of age, the extrusion reflex is the tongue moving outward when the tongue is touched. *Think Like A Nurse: Clinical Decision Making* The nurse needs to mentally ask, "What are the expected findings when assessing a client of this age?" The client is designated as a "newborn," which should indicate that the client is less than one month in age. Newborns perform certain actions that indicate normal physiologic functioning. The extrusion reflex is one such action that is expected in a newborn. The presence of any of the other conditions indicate an abnormality and should be reported immediately to the health care provider. *Content Refresher* Reflexes follow a pathway called a reflex arc. The reflex arc consists of a receptor, a sensory neuron, a response center in the brain or spinal cord, a motor neuron, and a muscle or gland. Depending on the reflex, a specific response is elicited when stimulated. At birth, the extrusion, palmar grasp, plantar grasp, Moro, and stepping reflexes are present. As the central nervous system develops, the reflexes are expected to disappear within the first year of life. The nurse needs to assess the reflexes when completing a physical assessment. Reflexes should be equal bilaterally. Abnormal or asymmetric reflexes may indicate neurological problems.

The nursing manager is observing a graduate nurse conduct a physical examination on a newly admitted client. Which action made by the graduate nurse requires an immediate intervention by the nurse manager? 1. The nurse uses the ball of the hand to palpate for tactile fremitus. 2. The nurse depresses the client's tongue slightly off center when using a tongue depressor to inspect the uvula. 3. The nurse uses a stethoscope to palpate the client's abdomen, with fingers moving over the edge of the diaphragm. 4. The nurse completes inspection of the client's thorax for cardiac assessment and then begins auscultation.

1) INCORRECT - This is an appropriate action. The ball of the hand is particularly sensitive to vibratory sensation. The ulnar edge of the hand could be used as another option. Tactile fremitus assesses air vibrations in the bronchial tubes as they are transmitted to the chest wall. The client is instructed to say "ninety-nine" repeatedly while the nurse assesses for symmetry of vibratory intensity. 2) INCORRECT - This is an appropriate action. The tongue should be depressed slightly off center in order to avoid eliciting the gag response. 3) INCORRECT - This is an acceptable action used to decrease ticklishness and the voluntary guarding that results. The stethoscope should be warmed prior to use. When the fingers drift over the diaphragm edge, they can palpate without causing ticklishness. 4) CORRECT - The correct sequence during cardiac assessment is inspection, palpation, and then auscultation. *Think Like A Nurse: Clinical Decision Making* The nurse needs to mentally review the correct order of processes before conducting a physical assessment. The nurse will need to consider what each process will do to the area being assessed. When assessing the client's thorax during the cardiac assessment, the order of assessment should be inspection, palpation, and auscultation. The nurse should palpate before auscultating heart sounds. However, when assessing the abdomen, the order becomes inspection, auscultation, and palpation. Palpating the abdomen prior to auscultation can change the characteristics of, or stimulate, bowel sounds. *Content Refresher* When assessing using auscultation, the nurse should: Place the stethoscope directly on the neck, chest, back, or abdomen. Examine the client in supine, sitting, and in left lateral recumbent positions. Utilize a systematic approach to listen to the areas being assessed. Listen to the heart at the top of the heart and proceed down to the apex, or follow the reverse order. Listen to the lungs from side to side and top to bottom. Listen to the abdomen in two or three cycles, assessing for a particular sound each time. Perform auscultation of abdomen prior to percussion or palpation.

The nurse and a new graduate nurse provide care for several clients. The nurse assists the new nurse with establishing client care priorities. Which client care activity does the new graduate nurse address first? 1. Instruct a client how to correctly use an incentive spirometer. 2. Assess the client who is pocketing food in the mouth. 3. Teach a client about a newly prescribed medication. 4. Establish intravenous (IV) access for a client scheduled for surgery tomorrow.

1) INCORRECT - This is an intermediate priority. Teaching is psychosocial, even though the action enhances breathing capabilities. 2) CORRECT—This is a high priority. The new graduate nurse needs to assess the client because food pocketing is an aspiration risk. The new graduate nurse should also assess for other signs of aspiration, such as coughing, wet voice, and gagging. Risk for aspiration is a physical issue. 3) INCORRECT - This is an intermediate priority. Teaching is psychosocial. 4) INCORRECT - This is an intermediate priority. While establishing IV access is a physical need, surgery is not scheduled until tomorrow. The new graduate nurse's highest priority is to protect the client's airway. *Think Like A Nurse: Clinical Decision Making* Before identifying the client who is priority, the nurse should stop and review each client's acuity level, disease process, and risk for infection or life-threatening situation. Any client with a physical need should be addressed first.The client who is pocketing food in the mouth is at risk for aspiration, a physical issue with the potential to compromise airway and breathing. The client requiring IV access does not require priority intervention, as the purpose is for surgery the next day. The nurse may need to spend additional time with the clients requiring teaching. *Content Refresher* Aspiration syndromes are all conditions in which foreign matter is inhaled into the lungs.A swallow evaluation can be used by the nurse to screen and refer for further testing in children, adolescents, and adults at risk for dysphagia (using the Toronto Bedside Swallowing Screening Test or the 3-oz Water Swallow Screening Test). Determine underlying risk condition, history, and treatment plan.For those at risk of aspiration, the nurse should place the client in a high-Fowler position. Do not allow the client to consume foods or fluids until risk evaluation is completed.

A nursing team consists of a nurse, an LPN/LVN, and a nursing assistive personnel (NAP). Which client does the nurse assign to the NAP? 1. A client diagnosed with diabetes mellitus requiring a dressing change for a stasis ulcer. 2. A client diagnosed with terminal cancer being transferred to hospice home care. 3. A client diagnosed with cancer of the bone reporting pain. 4. A client diagnosed with a fracture of the right leg asking to use the urinal.

1) INCORRECT — This is a stable client with an expected outcome. A dressing change is required. The nurse will assign this client to the LPN/LVN. 2) INCORRECT — This client requires nursing evaluation and judgment. The nurse is the appropriate caregiver. 3) INCORRECT — This client requires assessment and judgment. The nurse is the appropriate caregiver. 4) CORRECT — Assisting the client with the urinal is a standard unchanging procedure and may be safely assigned to the NAP. *Think Like A Nurse: Clinical Decision Making* A nursing assistive personnel (NAP) can perform tasks that are standard, unchanging, predictable, and routine for stable clients. The client with diabetes is at high risk for infection, and the nurse will need to assess the wound for infection. The client being transferred requires evaluation to ensure that the transfer can be completed safely, and the nurse must provide hand-off to the hospice home care nurse. The client reporting pain requires assessment and nursing care, including the administration of medications. Providing a client with a urinal is a standard task that the NAP can safely perform. *Content Refresher* Delegation is the process of transferring authority for a specific nursing care task to a competent person in a stable client situation with a predictable outcome. The nurse should delegate a task to a nursing assistive personnel (NAP) with clear communication of the task, its purpose, the desired timeline for performance, and expected outcome. In this situation, it is essential for the nurse to be knowledgeable of the NAP's scope of practice. The nurse is accountable for the provision of client care and will follow through with post task assessment and outcome findings.

The nurse preceptor supervises a new nurse change the dressing of a client with a newly inserted peritoneal dialysis catheter. After removing the old dressing, which new nurse action requires intervention by the preceptor nurse? 1. Cleans the catheter insertion site using a sterile cotton swab soaked in povidone-iodine. 2. Applies two sterile precut 4×4 gauze pads to the catheter insertion site. 3. Cleans the insertion site using a circular motion from the outer abdomen toward the insertion site. 4. Tapes the edges of the sterile dressing with paper tape.

1) INCORRECT- When changing the dressing of a newly inserted peritoneal catheter, the insertion site should be cleansed with sterile cotton swabs soaked in povidone-iodine. 2) INCORRECT- When changing the dressing of a newly inserted peritoneal catheter, sterile gauze 4 x 4 pads should be applied to the insertion site. 3) CORRECT- The insertion site should be cleansed from the insertion site outward towards the outer abdomen. 4) INCORRECT- When changing the dressing of a newly inserted peritoneal catheter insertion site, the new sterile dressing should be taped with paper tape along the outer edges. *Think Like A Nurse: Clinical Decision Making* When cleansing the site of the peritoneal catheter, disinfection should begin at the insertion site and proceed outward. This prevents the introduction of microorganisms from the abdomen being introduced into the catheter insertion site. Povidone-iodine saturated cotton swabs is the recommended disinfectant to cleanse the insertion site of a peritoneal catheter. The insertion site for the catheter is treated as a sterile wound. Sterile gauze swabs should be placed around the catheter at the insertion site. *Content Refresher* Peritoneal dialysis (PD) is an alternative to hemodialysis for clients with chronic renal failure. It uses the peritoneal membrane as a semipermeable membrane to filter out toxins and wastes, manage azotemia, and restore electrolyte balance. Changing the dressing to a newly inserted PD catheter requires assessment and cleansing of the area using sterile technique with application of a new dressing.

A client returns to the unit after placement of a split-thickness autograft to a burn on the right arm. Which intervention does the nurse give the highest immediate priority? 1. Managing pain at the recipient site. 2. Immobilizing the graft. 3. Minimizing light exposure. 4. Observing for signs of rejection.

1) INCORRECT— Managing pain is an issue, but not the highest initial priority. The donor site is usually more painful than recipient site because of exposed nerve endings. An autograft means a layer of the client's own unburned skin is removed and grafted to the burn wound. 2) CORRECT — Graft adherence to the site is essential for vascularization and "taking" or survival of the graft. Immobilization of the graft and the limb is a priority. A thin fibrin network develops quickly after graft placement, but it takes 7 to 10 days for the graft to really adhere and longer than that to mature. 3) INCORRECT— There is no need for minimizing light exposure at this time. A client needs to be taught that, once donor and recipient sites have healed, direct sunlight must be completely avoided for 1 year because of the skin's increased sensitivity to ultraviolet rays. 4) INCORRECT— Rejection is not an immediate concern. Once the pressure dressings are removed in 3 to 5 days, continual assessing of the graft for healing should be done related to vascularization, such as continued adherence to the site, absence of necrotic graft tissue, dusky color, or a sharp line of color demarcation. *Think Like A Nurse: Clinical Decision Making* The priority of care for this client is immobilizing the limb with the graft. Adherence of the graft takes between 7 to 10 days and unnecessary movement can adversely effect this process. Rejection does not occur immediately, but will become a priority after the dressing is removed in 3 to 5 days. *Content Refresher* Burns result in damage to the skin from either heat, radiation, chemical, or electrical sources. Prescribed wound care is provided daily. Excision and grafting of the burn injury may be needed. For full-thickness wounds, skin grafting is required. Skin graft sites are splinted or immobilized in order to keep the graft stable and promote healing. The goal with partial and full-thickness burns is to transition through the acute phase of burn injury with no-to-minimal complications.

The nurse provides care for a client who sustained a fractured right femur. The client has a cast applied. Which type of exercise does the nurse assist the client to perform? 1. Passive exercises for the upper extremities. 2. Active range of motion exercise of the left leg. 3. Passive exercise of the right leg. 4. Quadriceps setting of the right leg.

1) INCORRECT— The client needs to strengthen muscles. Passive exercises do not strengthen muscles. 2) INCORRECT— This action is not the best method to strengthen muscles because the affected leg is the one that most needs strengthening. 3) INCORRECT— In order to accomplish this, the nurse would have to move the leg. Since the right leg is in a cast, the nurse cannot move the leg. 4) CORRECT— Isometric exercise contracts the muscle without movement of the affected joint. This exercise will help maintain strength of the leg. *Think Like A Nurse: Clinical Decision Making* The nurse is aware that isometric exercises while wearing a cast are important in preventing complications such as poor circulation and swelling. The exercises should be performed at least three times a day. The simplest exercise is to have the client wiggle the toes. Isometric, non-weight-bearing exercises, where the muscles are made taut and then relaxed in a repetitive manner, help in maintaining the strength of the leg muscles and in preventing weakness and atrophy. The nurse might consider offering the client pain medication prior to performing the exercises, or recommending the client perform the exercises after receiving medication for injury-related pain. *Content Refresher* Isometric exercises are performed to maintain muscle strength for individuals who are immobile or on bed rest. Determine current activity, exercise history, and limitations. Assess for pain. Assess the client's muscle strength and identify any weakness of extremities. Inspect joints to determine appearance and movement. Observe gait if the client is ambulatory. To perform isometric exercises, the muscles are contracted and held for a period (e.g., approximately 10 seconds). Increase the time in which muscle is contracted, as possible. Resistive isometric exercises occur when muscles are contracted while pushing against an object (e.g., footboard or hands).

The nurse performs a moist-to-dry dressing. In which order does the nurse complete the steps of this procedure? (Please arrange in order. All options must be used.) 1. Observe the appearance of the wound 2. Clean the wound with saline solution 3. Remove dressing material from the wound 4. Assess the clients comfort level 5. Apply moist gauze in a single layer to the wound 6. On the dressing record date and time

First, assess the client's comfort level as the client may require pain medication for dressing removal. Second, remove any dressing material that is present. Wear clean disposable gloves, observe typical biohazard precautions, and be careful to not remove drains or tubes. Third, observe the appearance of the wound, inspecting the wound for color, character of drainage including odor, and presence of drains. Fourth, clean the wound with saline solution, or other solution as prescribed. Fifth, apply moist gauze in a single layer to the wound to absorb drainage and adhere to the wound bed. Cover the moist dressing with a dry sterile dressing. Sixth, on the tape of the new dressing, record the date and time the dressing was applied. *Think Like A Nurse: Clinical Decision Making* Before changing a moist-to-dry dressing, the client's comfort level should be assessed because removing the old dry dressing can cause pain. After the old dressing is removed, assess the wound site for evidence of debridement and healing. After cleaning the wound, apply moistened gauze pads over the site. Complete the dressing change by writing the date and time of the change on the tape that covers the dressing. *Content Refresher* Wound care includes assessment and cleaning of a wound using sterile or clean technique with the application of a dressing. Dressings keep the wound bed moist, help to absorb exudates, decrease bacterial count, and support wound healing. The nurse will review the health care provider's prescriptions for wound care and gather the needed supplies. The moist-to-dry dressing is prescribed when debridement of the wound is desired.

The client is prescribed 1 unit of red blood cells (RBCs). The transfusion is started at 0945. At 1003, the client reports chills and back pain rated at 5 of 10. The client's skin is flushed, blood pressure is 98/66 mm Hg, and pulse rate is 108 beats/min. In which order does the nurse implement these nursing interventions? (Please arrange in order. All options must be used.) 1. Obtain blood and urine specimens 2. Stop the transfusion 3. Call the HCP 4. Hang a new IV infusion set 5. Begin 0.9% NaCL infusion 6. Assess BP, HR, RR

The client has signs and symptoms that suggest a hemolytic reaction. The nurse should first stop the blood transfusion to prevent worsening the client's reaction. Next, the nurse should hang a new intravenous infusion set to allow for the administration of 0.9% sodium chloride. This will provide additional hydration to promote perfusion and to flush the kidneys to reduce the risk of acute kidney injury from the hemolytic reaction. The nurse should then notify the health care provider of the reaction and assess to see whether the client's condition has improved. The nurse has a set of current vital signs in the stem of the question, so there is no need to reassess the vital signs prior to notifying the health care provider. Finally, the nurse should obtain blood and urine specimens for laboratory confirmation of the hemolytic reaction. *Think Like A Nurse: Clinical Decision Making* Because a hemolytic reaction is a medical emergency, the nurse must act quickly to decrease the risk of the client progressing to cardiovascular collapse. The nurse prioritizes discontinuation of the blood transfusion, changing IV infusion set, and administration of isotonic IV fluid to promote filling of the client's dilated blood vessels and expanded intravascular space. If a standing prescription allows for administration of steroids or an antihistamine, these medications are administered next. If the client's condition worsens, notifying the rapid response team (RRT) would be the next step. Ideally, the nurse would delegate reassessment of vital signs to a nurse colleague during this period. *Content Refresher* A blood transfusion reaction is a harmful immune system response to donor blood. Reactions may be immediate or delayed and can be mild or severe. Types of transfusion reactions include hemolytic, febrile non-hemolytic, septic, allergic, circulatory overload, acute lung injury, and graft-versus-host disease. Transfusion reaction symptoms vary depending on the type of reaction, but they can include back pain, headache, hypotension, tachycardia, tachypnea, dyspnea, cough, rales, wheezing, dark urine, chills, fainting or dizziness, fever, flank pain, skin flushing, vomiting, diarrhea, edema, hemolytic anemia, and itching.