UWorld 75 #1

The nurse has received a prescription from the health care provider to administer 80 mg of methyprednisolone IV piggyback. The available vial contains 125 mg in 2 mL. Select the syringe containing the appropriate amount of medication to be administered. 1. 1.28 or 1.30 mL

1.3 mL to be administered.

The occupational health nurse administers an intradermal tuberculin skin test (TST) to a health care worker (HCW). The site must be assessed for a reaction afterward. The nurse instructs the HCW to return in how many hours? 1. 12 hours 2. 24 hours 3. 36 hours 4. 72 hours

Answer: 4 Explanation:

The same-day surgery nurse performs the preoperative assessment for a client with a history of coronary artery disease scheduled for an elective laparoscopic cholecystectomy. Which statement made by the client is critical to report to the health care provider (HCP) before the surgery? 1. "I didn't take the clopidogrel pill for my heart yesterday or today." 2. "I know I should stop smoking completely, but at least I didn't have a cigarette yesterday or today." 3. "I stopped taking my gingko biloba 2 weeks ago even though it really helps relieve leg cramps when I walk." 4. "I stopped taking naproxen for my arthritis pain 1 week ago and have been taking acetaminophen instead."

Answer: 1 Explanation: Clopidogrel (Plavix) is an antiplatelet medication that should be discontinued 5-7 days before surgery to decrease the risk for excessive bleeding. The client took this drug 48 hours ago. Therefore, the nurse must notify the HCP. The surgery may be postponed due to the increased risk for intra- and post-operative bleeding (Option 1). (Option 2) All clients should try to not smoke for at least 24 hours before surgery to help prevent oxygenation problems. (Option 3) The client takes gingko biloba to relieve symptoms of intermittent claudication; it was discontinued 2 weeks ago because it can increase the risk for excessive bleeding. (Option 4) Non steroidal anti-inflammatory drugs (NSAIDS) such as naproxen (Naprosyn) should be discontinued 7 days before scheduled surgery as they can increase the risk for excessive bleeding. Acetaminophen can be taken to control pain up until surgery. Educational objective: Medications (eg, anticoagulants, antiplatelets, NSAIDS, herbal drugs) that increase the risk for excessive bleeding should be discontinued at least 5-7 days before surgery.

A client had a thoracotomy 2 days ago to remove a lung mass and has a right chest tube attached to negative suction. Immediately after turning the client to the left side to assess the lungs, the nurse observes a rush of approximately 125 mL of dark bloody drainage into the drainage tubing and collection chamber. What is the appropriate nursing action? Click on the exhibit button for additional information. 1. Document and continue to monitor chest drainage 2. Immediately clamp the chest tube 3. Notify the health care provider 4. Request repeat hematocrit and hemoglobin levels

Answer: 1 Explanation: Immediately following a thoracotomy, chest tube drainage (50-500 mL for the first 24 hours) is expected to be sanguineous (bright red) for several hours and then change to serosanguineous (pink) followed by serous (yellow) over a period of a few days. A rush of dark bloody drainage from the chest tube when the client was turned following a period of minimal drainage is most likely related to retained blood due to a partial blockage in the tube. Bright red drainage indicates active bleeding and would be of immediate concern. (Option 2) The chest tube should not be clamped because it is placed to drain the fluid leaking after surgery. (Option 3) The nurse would notify the health care provider immediately of bright red drainage or continued increased drainage (>100 mL/hr) and of changes in the client's vital signs and cardiovascular status that could indicate bleeding (eg, hypotension, tachycardia, tachypnea, decreased capillary refill, cool and pale skin). This is not the appropriate action. (Option 4) It would be appropriate to request repeat serum hematocrit and hemoglobin levels if active bleeding is suspected, but the postoperative levels are stable at this time. This is not the appropriate action. Educational objective: A client will usually have a chest tube in place for several days following a thoracotomy to drain blood from the pleural space. A rush of dark bloody drainage from the tube when the client coughs, turns, or is repositioned following a period of minimal drainage is most likely related to retained blood due to a partial blockage in the tube. Bright red chest drainage indicates active bleeding and would be of immediate concern.

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

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

The nurse at a mental health clinic is performing a suicide risk screening on four clients experiencing depression. Which client does the nurse recognize as being most at risk for suicide? 1. Divorced male client with Parkinson disease who was recently laid off from his job 2. Married female client with breast cancer whose daughter is going through a divorce 3. Married male client, newly retired, who is active in community outreach programs 4. Newly divorced female client with type 2 diabetes who has custody of 3 children

Answer: 1 Explanation: Risk Factors for Suicide: Demographic - Females attempt more; males complete more - Advanced age -Socioeconomic extremes - Unemployment (eg, job loss, retirement) Health - Mental health disorder (eg, depression) - Chronic or terminal illness - History of alcohol or substance abuse Interpersonal - Family history of suicide or abuse - Single, divorced, widowed - Sudden loss or change in support system - Social isolation Other - Aggressive or impulsive behavior - Past attempts - Organized or lethal plan A suicide screening considers demographics, mental and physical health history, support systems, coping strategies, family history of suicide, previous attempts, and behavioral patterns. In addition to depression, the divorced male client with Parkinson disease and recent job loss is the most at risk for suicide, with 5 risk factors (Option 1). (Option 2) The client who has depression and breast cancer has 2 known risk factors. The daughter's divorce may be a significant loss or stressor, adding another risk factor. However, marriage is a protective factor against suicide. (Option 3) The recently retired male client who is depressed has 3 risk factors. However, marriage and community involvement are protective factors. (Option 4) The client with chronic illness (eg, type 2 diabetes) who is recently divorced has 3 risk factors (including depression). However, custody of children is a protective factor. Educational objective: A suicide screening considers demographics (eg, age, marital status, gender), mental and physical health history, support systems, coping strategies, family history of suicide, previous attempts, and behavioral patterns.

A client at 20 weeks gestation reports "running to the bathroom all the time," pain with urination, and foul-smelling urine. Which question is most important for the nurse to ask when assessing the client? 1. "Are you having any pain in your lower back or flank area?" 2. "Do you wipe from front to back after urinating?" 3. "Have you found that you urinate more frequently since becoming pregnant?" 4. "Have you had a urinary tract infection in the past?"

Answer: 1 Explanation: Urinary tract infections (UTIs) are common during pregnancy due to physiologic renal system changes (eg, ureter dilation, urine stasis). Most UTIs are confined to the lower urinary tract (ie, cystitis, or bladder infection). Symptoms include urinary frequency, dysuria, urgency, foul-smelling urine, and a sensation of bladder fullness. Diagnostic testing includes urinalysis and urine culture. Oral antibiotics are required to appropriately treat cystitis. If cystitis goes unreported or untreated, the infection may ascend to the kidneys and cause pyelonephritis. During pregnancy, pyelonephritis requires IV antibiotics and hospitalization because of the increased risk of preterm labor. Therefore, priority assessment is to rule out indicators of pyelonephritis (eg, flank pain, fever) in clients who report UTI symptoms to ensure appropriate diagnosis and treatment (Option 1). (Option 2) Wiping front to back after urination may help prevent Escherichia coli (a common UTI pathogen found in stool) from contaminating the urethra. Reviewing toileting hygiene is important but does not help assess current symptoms. (Option 3) Urinary frequency and nocturia are common during pregnancy. However, the nurse should not focus on the normalcy of urinary frequency since the client has reported additional symptoms (eg, dysuria). (Option 4) Pregnancy predisposes clients to UTIs. Furthermore, assessing for history of UTI does little to address the client's current symptoms. Educational objective: Urinary tract infections are common during pregnancy. If the client reports signs and symptoms of cystitis, the nurse's priority is to rule out ascending infection (ie, pyelonephritis), which would require hospitalization and IV antibiotics.

Which pediatric respiratory presentation in the emergency department is a priority for nursing care? 1. Client with an acute asthma exacerbation but no wheezing 2. Client with bronchiolitis with low-grade fever and wheezing 3. Client with runny nose with seal-like barking cough 4. Cystic fibrosis client with fever and yellow sputum

Answer: 1 Explanation: When acute asthma exacerbation occurs, the child has rapid, labored respirations using accessory muscles. The child often appears tired due to the ongoing effort. In the case of severe airway obstruction (from airway narrowing as a result of bronchial constriction, airway swelling, and copious mucus), wheezing/breath sounds are not heard due to the lack of airflow. This "silent chest" is an ominous sign and an emergency priority. In this situation, the onset of wheezing will be an improvement as it shows that air is now moving in the lungs. (Option 2) Bronchiolitis is associated with the respiratory syncytial virus (RSV). Cell debris clumps and clogs the airways. Air can get in but has difficulty getting out. Mild symptoms include low-grade fever, wheezing, tachypnea, and poor feeding; severe infections have more serious distress, including signs of hypoxia. Treatment is supportive. This child should be isolated and will receive supportive care, but the child with no air movement/wheezing is a priority. (Option 3) Croup or laryngotracheobronchitis is a viral inflammation and edema of the epiglottis and larynx. Symptoms include runny nose, tachypnea, inspiratory stridor, and a seal-like barking cough. The child will be treated with medications and oxygen (if needed). The child is still moving air. (Option 4) In clients with cystic fibrosis, fever with yellow or green sputum can be indicative of an infection. The child will receive antibiotics but is not a priority as there are no signs of respiratory distress. Educational objective: Inability to hear any breath sounds or wheezing in an acute asthma client ("silent chest") is an ominous sign and requires emergency intervention.

A child is scheduled to have an electroencephalogram (EEG). Which statement by the parents indicates understanding of the teaching? 1. "I will let my child drink cocoa as usual the morning of the procedure." 2. "I will wash my child's hair using shampoo the morning of the procedure." 3. "My child may have scalp tenderness where the electrodes were applied." 4. "My child will not remember the procedure."

Answer: 2 Explanation: An electroencephalogram (EEG) is a diagnostic procedure used to evaluate the presence of abnormal electrical discharges in the brain, which may result in a seizure disorder. The EEG can be done in a variety of ways, such as with the child asleep or awake with or without sedation. Teaching for the parent includes the following: - Hair should be washed to remove oils and hair care products, and accessories such as ribbons or barrettes should be removed. Hair may need to be washed after the procedure to remove electrode gel. - Avoid caffeine, stimulants, and central nervous system depressants prior to the test. - The test is not painful, and no analgesia is required. (Option 1) Food and liquids are not restricted prior to an EEG except for caffeinated beverages. Cocoa contains caffeine. (Option 3) This test (EEG) is not painful as it only records brain electrical activity. Electrode gel is nonirritating to the skin. (Option 4) A routine EEG is not performed under sedation, and so the child should remember the procedure. Educational objective: An EEG is used to diagnose the presence of a seizure disorder. Electrodes are secured to the scalp to observe for abnormal electrical discharges in the brain. Preprocedure teaching includes avoiding stimulants and CNS depressants and washing the hair.

The nurse makes a home visit to a client with Alzheimer disease. While reviewing the client's home care needs, the client's spouse states, "It's hard to see my spouse worsen each day. I'm not sure I can keep doing this alone anymore." Which response by the nurse is best? 1. "Perhaps finding a caregiver to care for your spouse at night might be helpful." 2. "Tell me about the care you provide in a typical day and its challenges." 3. "Try not to worry. It's normal to feel overwhelmed when you are stressed." 4. "You seem worried that you won't be able to provide the care that your spouse needs."

Answer: 2 Explanation: Caregiver role strain (CRS) is a caregiver's perception of the multifactorial difficulties associated with providing care to another person (usually a family member). The nurse should assess caregivers for signs of physical (eg, fatigue, insomnia, weight loss/gain), emotional (eg, depression, anxiety, anger), and social (eg, isolation, loss of support systems) problems. Monitoring caregivers for CRS is important, as. it can have significant negative impact on their health and well-being. Asking about the nature and requirements of providing daily care allows the caregiver to discuss the demands of providing care and helps the nurse understand stressors and unmet needs (Option 2). This type of inquiry is a therapeutic response that encourages verbalization of thoughts, feelings, and concerns. Assessment of caregiving challenges also helps identify opportunities for assistance (eg, skills training, support groups) and community resources (eg, home health care, food/nutrition services). (Options 1 and 3) Giving opinions and providing false reassurance are non therapeutic, discourage nurse-client communication, and do not help identify CRS. (Option 4) Restating client statements can be therapeutic because it shows that the nurse has analyzed what has been said. However, this response does not prompt the client to discuss potential difficulties in providing care. Educational objective: Caregiver role strain is a caregiver's perception of multifactorial difficulties associated with providing care to another person. The nurse should routinely monitor for signs of caregiver role strain (eg, fatigue, depression, isolation) because it can have a significant negative impact on a caregiver's health and well-being.

The nurse witnessed a signed informed consent for an inguinal hernia repair surgery. During the procedure, the surgeon discovers a secondary ventral hernia that also requires repair. Which action should the nurse perform? 1. Add the secondary hernia to the consent form that the client signed before the procedure 2. Call the client's medical power of attorney to provide consent for the additional procedure 3. Document that an additional hernia was found and that it will require surgery at a later time 4. Witness an additional consent after both procedures are complete and the client is awake

Answer: 2 Explanation: Informed consent is required before any nonemergency procedure. The 3 principles of informed consent include: - The surgeon explains the diagnosis, planned procedure with risks and benefits, expected outcome, alternate treatments, and prognosis without surgery. - The client indicates understanding of the information. - The client is competent and gives voluntary consent. The nurse is responsible for witnessing the client's signature and ensuring that the client is competent and understands information provided by the surgeon. Clients unconscious or under the influence of mind-altering drugs (eg, opioids) cannot provide consent. If the sedated client requires procedures not listed on the consent form, the client's medical power of attorney, legal guardian, or next of kin should be contacted so that the surgeon can explain the situation and obtain consent (Option 2). (Option 1) Modifying a consent form after it has been signed is an illegal falsification of documentation. (Option 3) Unless family members deny consent or cannot be reached, it is in the client's best interest to have the hernia repaired now rather than go through the physical and financial strain of a second surgery. (Option 4) Procedures can be performed without prior consent only when lifesaving measures are necessary. Obtaining consent after a procedure is illegal and considered assault and battery. Educational objective: Informed consent is required before any nonemergency procedure. If the need for an additional procedure is discovered during surgery, the client's medical power of attorney, legal guardian, or next of kin should be contacted to provide consent.

The primary care provider's office nurse must return telephone calls concerning 4 clients. Which client has the most emergent situation and requires an immediate call back? 1. 28-year-old woman is requesting antibiotic to be called to pharmacy due to another bladder infection 2. 55-year-old man who takes trazodone is reporting a painful erection of 3 hours duration 3. 78-year-old man with sinusitis who takes pseudoephedrine is having difficulty voiding 4. 84-year-old man with prostate cancer and spine metastasis is requesting increased pain medication

Answer: 2 Explanation: Priapism is a prolonged, painful erection (>2 hours) caused by trapping of blood in the penile vasculature that can lead to erectile tissue hypoxia and necrosis. The condition is usually idiopathic, secondary to prescription medications (eg, sildenafil, trazodone) or a preexisting medical condition (eg, sickle cell disease, cocaine use). The nurse should return this call first as the condition is a medical emergency that can result in permanent erectile dysfunction; it requires urgent treatment in the emergency department. (Option 1) Urinary tract infections can recur in sexually active women. This client needs antibiotics but is not a priority. (Option 3) This client may have some degree of prostatic hyperplasia given his age. Decongestants (eg, pseudoephedrine) or antihistamines (eg, diphenhydramine) should be used with caution as they can lead to difficulty voiding and acute urinary retention. The client needs to be assessed, but this is not the most emergent call. (Option 4) The client with prostate cancer may need increasing pain medication as clients develop tolerance to opioids. However, this is not a priority. Educational objective: Priapism is a prolonged, painful erection not necessarily related to sexual arousal. It requires urgent treatment in the emergency department as it can lead to erectile tissue ischemia and necrosis.

The triage nurse is assessing an unvaccinated 4-month-old infant for fever, irritability, and open-mouthed drooling. After the infant is successfully treated for epiglottitis, the parents wonder how this could have been avoided. Which response by the nurse would be most appropriate? 1. "It's impossible to know for sure what could have caused this episode." 2. "Most cases of epiglottitis are preventable by standard immunizations." 3. "We are still waiting for the formal report from the microbiology laboratory." 4. "There is nothing you could have done; the important thing is that your child is safe now."

Answer: 2 Explanation: The majority of cases of epiglottitis are caused by Haemophilus influenze type B (HiB), which is covered under the standard vaccinations given during the 2- and 4-month visits. Epiglottitis is rarely seen in vaccinated children. (Option 1) This statement is technically true, but it is not helpful to the parents and misses a critical teaching moment for them. (Option 3) It is reasonable to attribute the cause of the infant's epiglottitis to missing the vaccinations for Haemophilus influenza type B. (Option 4) This statement is both unhelpful and inaccurate as the child is still at risk for further preventable illness. Educational objective: Cases of epiglottitis are preventable, and parents should always be educated on the risks of foregoing vaccinations for their children.

A new nurse is caring for an adolescent transgender client. What question would be appropriate when assessing the client's gender identity? 1. "Do you prefer being referred to as 'he' or 'she'?" 2. "How would you describe your gender?" 3. "What gender were you originally?" 4. "What is your preferred name?"

Answer: 2 Explanation: Transgender clients may fear judgment or embarrassment and withhold information, avoid seeking treatment, or refuse care as a result. This is often related to past experiences of discrimination or stigma when receiving health care. Therefore, it is important to use therapeutic communication and avoid stereotypes to establish trust. Transgender clients may identify as male or female or as neither or both genders. It is important for the nurse to determine clients' gender identity by asking open-ended questions that allow clients to explain their identities in their own words (Option 2). (Option 1) The client may not identify as simply male or female. Asking closed-ended questions (eg, whether the client prefers "he" or "she") does not allow for client elaboration. (Option 3) Because the client does not identify with the gender designated at birth, referring to a transgender client's "original gender" may cause distress and discomfort. The nurse should instead ask what sex the client was assigned on the original birth certificate. (Option 4) Asking "What is your preferred name?" is not open-ended and does not thoroughly assess gender identity. However, the client's preferred and legal names may be different. The nurse should use the client's preferred name to show respect and to develop a therapeutic relationship. Educational objective: Transgender clients may identify as male or female or as neither or both genders. The nurse should use open-ended questions that allow clients to explain their identities in their own words.

The nurse planning teaching for the parents of a child newly diagnosed with hemophilia will include information about which long-term complication? 1. Heart valve injury 2. Intellectual disability 3. Joint destruction 4. Recurrent pneumonia

Answer: 3 Explanation: Hemophilia is a bleeding disorder caused by a deficiency in coagulation proteins. Clients with classic hemophilia, or hemophilia A, lack factor VIII. Clients with hemophilia B (Christmas disease) lack factor IX. When injured, clients with hemophilia should be monitored closely for external as well as internal bleeding. The most frequent sites of bleeding are the joints (80%), especially the knee. Hemarthrosis can occur with minimal or no trauma, with episodes beginning during toddlerhood when the child is active and ambulatory. Over time, chronic swelling and deformity can occur. (Option 1) Heart valve injury is common with rheumatic heart disease not hemophilia. (Option 2) Intellectual disability in children is commonly seen with fetal alcohol syndrome, Down syndrome, hypothyroidism, and lead poisoning. In rare cases, hemophilia can cause life-threatening intracranial bleeding. However, isolated intellectual disability is not seen. (Option 4) Recurrent pneumonia is commonly seen with cystic fibrosis not hemophilia. Educational objective: Clients with hemophilia are at risk for permanent joint destruction due to frequent bleeds into the joint spaces. Assisting clients with decreasing the incidence of bleeding episodes and prompt treatment when bleeding occurs can help minimize joint destruction.

A nurse is preparing an educational presentation on herbal supplements for the local community center. Saw palmetto is one herbal medicine being discussed. Which audience participants would find this information beneficial? 1. Clients diagnosed with heart failure 2. Clients experiencing major depressive disorder 3. Elderly clients with benign prostatic hyperplasia 4. Perimenopausal clients experiencing hot flashes

Answer: 3 Explanation: Herbal preparations are not regulated by governmental agencies and are generally classified as food or dietary supplements. Manufacturers are therefore able to avoid the scientific scrutiny exercise when prescription drugs are readied for the market. Saw palmetto is one such herbal preparation, and clients most often use it to treat benign prostatic hyperplasia. (Option 1) Hawthorn extract is used to treat heart failure and in some countries (eg, Germany) is an approved treatment for this purpose. (Option 2) St John's wort has been used for centuries to treat depression. It may cause hypertension and serotonin syndrome when used with other antidepressants. (Option 4) Black cohosh is an herbal supplement often used by perimenopausal clients experiencing hot flashes. Educational objective: Saw palmetto, a herbal preparation, is often used to treat benign prostatic hyperplasia. St John's wort has been used for centuries to treat depression.

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

Answer: 3 Explanation: Intussusception is an intestinal obstruction that occurs when a segment of the bowel folds (ie, telescopes) into another segment. Pressure gradually increases within the bowel, causing ischemia and leakage of blood and mucus into the lumen, which produces the characteristic stool mixed with blood and mucus (ie, red, "currant jelly"). Initially, some infants may have only general symptoms (eg, irritability, diarrhea, lethargy). Subsequently, episodes of sudden abdominal pain (cramping), drawing the knees up to the chest, and inconsolable crying are seen. After an episode, the infant may vomit and then appear otherwise normal. Assessment may show a sausage-shaped abdominal mass. (Option 1) Melena (dark red or balck, sticky stool) is an indication of an upper gastrointestinal (UGI) bleed. Gastritis is a common cause of UGI bleeding in infants and toddlers. (Option 2) Oily or bulky, foul-smelling stool is an indication of excess fat in the stool (steatorrhea) from malabsorption. This is characteristic of pancreatic insufficiency, cystic fibrosis, or celiac disease. (Option 4) Thin, ribbon-like stool is characteristic of Hirschsprung disease (congenital aganglionic megacolon). Bowel obstruction is caused by failure of the internal sphincter to relax. Educational objective: The classic symptom triad of intussusception is abdominal pain, "currant jelly" stools, and a sausage-shaped abdominal mass. However, it is more common for clients to have episodes of sudden abdominal pain, inconsolable crying, and vomiting followed by periods of normal behavior.

The clinic nurse evaluates the treatment plan of a client with long-standing rheumatoid arthritis. Which question is most important for the nurse to ask? 1. "Have the assistive devices helped with dressing and grooming?" 2. "How do you feel about the changes in your appearance?" 3. "How is your pain control with the current medication regimen?" 4. "Is your level of energy adequate for completing your daily activities?"

Answer: 3 Explanation: Rheumatoid arthritis is an autoimmune disorder that affects joints and other body systems. Chronic inflammation of the synovial joints causes increasing pain and swelling in the joints and eventual joint. deformities with decreased or absent range of motion and loss of function. Clients become easily fatigued and must learn to pace themselves and use assistive devices to accomplish ADL's. Goals of treatment are to manage pain, minimize loss of joint mobility, maximize self-care, and maintain self-esteem and a positive body image. Assessing for adequate pain control is the priority, as inadequate pain control will cause disuse of joints, leading to stiffness and decreased joint mobility (Option 3). (Options 1, 2, and 4) If pain is not adequately controlled, the client will be unlikely to use assistive devices and be too fatigued to perform ADL's. This can lead to being dependent on others, causing frustration and poor self-esteem and body image. Educational objective: Pain control is the priority assessment for clients with RA. Without adequate pain control, clients will have decreased ability to self-manage activities of daily living, maintain mobility and activity tolerance, and maintain self-esteem and a positive body image.

The nurse receives a new prescription for tamoxifen for a client with breast cancer. Which information found in the client's medical record would require follow-up with the health care provider? 1. Documentation of an allergy to shellfish and peanuts 2. History of quitting cigarette smoking 5 years ago 3. Hospitalization with deep venous thrombosis 1 year ago 4. Previous treatment for depression following the death of a parent

Answer: 3 Explanation: Tamoxifen is a selective estrogen receptor modulator that is prescribed to treat certain types of breast cancer and to prevent breast cancer recurrence. Tamoxifen works by blocking estrogen receptors in certain estrogen-sensitive tissues (eg, breast, vagina), but it also increases the affinity for estrogen in some tissues, such as the uterus. In the treatment of breast cancer, tamoxifen inhibits growth of estrogen receptor-positive tumors. Clients typically take tamoxifen for several (eg, 5-10) years after treatment to prevent breast cancer recurrence. Common side effects of tamoxifen therapy, like the effects typically seen in menopause (eg, hot flashes, vaginal dryness, menstrual irregularities), are related to decreased estrogen. Follow-up would be required for clients with symptoms or a history of tamoxifen's most serious side effects, including: - Thromboembolic events (eg, DVT, PE, stroke) (Option 3) - Endometrial cancer (eg, abnormal vaginal bleeding) (Options 1, 2, and 4) Shellfish and peanut allergies, previous smoking history, and history of depression are not contraindications for treatment with tamoxifen. Educational objective: Tamoxifen is a selective estrogen receptor modulator prescribed for the treatment and prevention of estrogen receptor-positive breast cancers. Serious side effects include thromboembolic events (eg, DVT) and endometrial cancer.

A nurse is caring for an older client admitted for failure to thrive and a history of recent falls and weight loss. The client lives in the child's home, but the nurse is questioning the safety of the home. The nurse needs to assess the appropriateness of the living situation and arrange for an alternate living situation or additional support if needed. It is most appropriate for the nurse to consult with which interdisciplinary team member during the assessment? 1. Adult protective services 2. Physical therapist 3. Physician 4. Social worker

Answer: 4 Explanation: An important part of the nursing role is to advocate for the health and safety of the client. This client has fallen and lost weight when living in the child's home, prompting the nurse to advocate for the client by bringing in other members of the interdisciplinary team to assess the home situation. When a nurse is concerned about the client's living situation, the social worker is the most appropriate team member to consult with first. The role of the social worker includes assessing the client's living situation and arranging for an alternate living situation or support services as needed. (Option 1) Adult protective services would be notified when abuse or neglect is suspected. In the hospital setting, a social worker should be contacted to do a detailed assessment of the situation before adult protective services is notified. (Option 2) The physical therapist should be consulted when there is concern about the client's ability to function safely in the home environment. (Option 3) The physician would not be the most appropriate person to appoint when a detailed assessment of the home living situation needs to be conducted. However, the physician should be notified if a social worker is assigned to assess the home living situation. Educational objective: Nursing advocacy for the safety of the client includes the appropriate use of interdisciplinary team members, such as the social worker. Advocacy is especially important in younger and elderly clients and those who are cognitively challenged or have mental health concerns.

The nurse receives an obese client in the postanesthesia care unit who underwent a procedure under general anesthesia. The nurse notes an oxygen saturation of 88%. Which is the most important initial intervention? 1. Assess pupillary response 2. Auscultate lung sounds 3. Inform anesthesia professional 4. Perform head tilt and chin lift

Answer: 4 Explanation: Head tilt and chin lift is a maneuver used to open the airway. The tongue may fall back and occlude the airway due to muscular flaccidity after general anesthesia. Manifestations associated with airway obstruction include snoring, use of accessory muscles, decreased oxygen saturations, and cyanosis. (Option 1) Constricted pupils can help identify opioid overdose. However, this should not be assessed before opening the airway. (Option 2) Auscultation of lung sounds should be done for every client as part of the postoperative assessment. However, the initial goal is to return the oxygen saturation level to normal (95%-100%). Hypoxia in an obese postoperative client who received general anesthesia is most likely due to airway obstruction. (Option 3) The anesthesia profession may need to be informed, but methods to restore the oxygen saturation level should be tried first. The anesthesia professional may then want to assess the sedation level of the client and prescribe a reversal agent. Educational objective: Postoperative client care after general anesthesia requires careful monitoring for hypoxia. One of the first nursing interventions is the head tilt and chin lift to open an occluded airway.

A nurse is discharging a client who is receiving lithium for treatment of a bipolar disorder. It is most important for the nurse to provide which instruction to the client? 1. Avoid a high-potassium diet 2. Exercise regularly and maintain a high-fiber diet 3. Maintain oral hygiene 4. Report excessive urination and increased thirst

Answer: 4 Explanation: Lithium is a mood stabilizer most often used to treat bipolar affective disorders. It has a narrow therapeutic index (0.6-1.2 mEq/L). Risk factors for lithium toxicity include dehydration, decreased renal function (in the elderly), diet low in sodium, and drug-drug interactions (eg, non steroidal anti-inflammatory drugs [NSAIDS] and thiazide diuretics). Chronic toxicity can result in: - Neurologic manifestations - ataxia, confusion or agitation, and neuromuscular excitability (tremor, myoclonic jerks) - Nephrogenic diabetes insipidus - polyuria and polydipsia (increased thirst) (Option 4) Clients should be educated about monitoring for these symptoms and obtaining serum lithium levels at regular intervals. (Option 1) Dietary potassium should be avoided when taking drugs such as potassium-sparing diuretics (eg, spironolactone, triamterene, amiloride) and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. (Option 2) Regular exercise and a high-fiber diet can prevent constipation, which is not a known side effect of lithium. Opioids, anticholinergics, and iron supplements are medications that cause constipation. (Option 3) Good oral hygiene is ideal for every client but is not specially indicated for those taking lithium. Clients taking phenytoin should maintain oral hygiene to prevent gingival hyperplasia. Educational objective: Risk factors for lithium toxicity include dehydration, decreased renal function, low-sodium diet, and drug-drug interactions (eg, NSAIDs and thiazide diuretics). Chronic toxicity manifests with neurologic symptoms (ataxia, confusion or agitation, and neuromuscular excitability) and/or diabetes insipidus (polyuria and polydipsia).

The pediatric nurse is performing an assessment on a 4-week-old client in the clinic. During the assessment, the newborn's mother starts to cry and states, "I am the worst mother in the world." What should the nurse ask next? 1. "Do you have a support system to help process your feelings?" 2. "Do you have any questions about how to care for your newborn?" 3. "Have you experienced difficulty falling asleep or getting rest?" 4. "Have you felt depressed or hopeless over the last 2 weeks?"

Answer: 4 Explanation: Postpartum depression (PPD) is a perinatal mood disorder that affects women following childbirth. Symptoms may include crying, irritability, difficulty sleeping (or sleeping more than usual), anxiety, and feelings of guilt. Symptoms typically arise within 4 weeks of delivery and can affect the mother's ability to care for herself and the newborn. The nurse should ask specific questions about depression or hopelessness to assess for PPD (Option 4). It is also important to ask about thoughts of self-harm or harm to the newborn. (Option 1) Women who do not have strong support systems are at higher risk for PPD. However, it is most important to assess for the presence of PPD. (Option 2) Mothers may have feelings of inadequacy or guilt as they experience challenges in caring for their infant (eg, breastfeeding difficulties, infant colic). The nurse should assess the need for client teaching, which can help to alleviate anxiety and improve outcomes; however, this is not the priority. (Option 3) Sleep disturbances are common when caring for a newborn and may worsen depression or anxiety. However, it is most important to directly ask the client about depression. Educational objective: Postpartum depression (PPD) is a perinatal mood disorder characterized by crying, irritability, sleep disturbances, anxiety, or feelings of guilt. Nurses should assess for PPD by asking specific questions about feelings of depression and hopelessness as well as thoughts about self-harm or harm to the newborn.

The nurse working in an intensive care unit receives a prescription from the primary health care provider to discontinue a triple-lumen subclavian central venous catheter. Which interventions will help prevent air embolism on removal? Select all that apply. 1. Applying an air-occlusive dressing 2. Instructing the client to bear down 3. Instructing the client to lie in a supine position 4. Pulling the line harder if there is resistance 5. Pulling the line out when the client is inhaling

Answers: 1, 2, 3 Explanation: To prevent air embolism when discontinuing a central venous catheter, the nurse should perform the following interventions: - Instruct the client to lie in a supine position. This will increase the central venous pressure and decreases the possibility of air getting into the vessel (Option 3). - Instruct the client to bear down or exhale. The client should never inhale during removal of the line; inhalation will suck more air into the blood vessel via negative suction pressure (Options 2 and 5). - Apply an air-occlusive dressing (usually gauze with a Tegaderm dressing) to help prevent a delayed air embolism. If possible, the nurse should attempt to cover the site with the occlusive dressing while pulling out the line (Option 1). - Pull the line cautiously and never pull harder if there is resistance. Doing so could cause the catheter to break or become dislodged in the client's vessel (Option 4). Educational objective: To prevent air embolism when discontinuing a central venous catheter, it is important for the nurse to pull the line cautiously, have the client in a supine position, have the client bear down or exhale, and apply an air-occlusive dressing.

The nurse admits an 80-year-old client with an altered level of consciousness and left-sided weakness following a recent stroke. The client is dehydrated from multiple episodes of diarrhea. Which interventions should the nurse implement to prevent falls? Select all that apply. 1. Apply color-coded, nonslip socks to the client's feet 2. Move the client to a room closer to the nurse's station 3. Place a bedside commode to the right of the client 4. Raise all bed rails before leaving the room 5. Use a bed alarm to alert staff when the client gets up

Answers: 1, 2, 3, 5 Explanation: Fall Risk Precautions: Standard - Orientation to room & call light - Call light within reach - Bed in lowest position - Uncluttered room - Nonslip socks or shoes - Well-lit room - Belongings within reach High Fall Risk - Bed alarm - High fall risk signs - Room close to nurses' station - Color-coded socks & wristbands The client with right-brain damage following a stroke often experiences left-sided weakness, spatial-perceptual deficits, and impulsiveness, making this client at high risk for falls. Other factors that increase fall risk for older adults include: - Unfamiliar surroundings - Unsteady gait, decreased strength and coordination - Altered mental status - Orthostatic hypotension (related to hydration) - Bowel/bladder urgency and/or frequency Application of color-coded, nonslip socks helps prevent a client from slipping and alerts staff to a client's increased risk for falls (Option 1). Placing a commode by the right (stronger) side of the bed decreases the number of steps and time needed to get to a toilet (Option 3). It also decreases the chance of tripping on equipment (eg, IV pump, tubing). Moving the client to a room close to the nurses' station allows frequent observation and a faster response time to calls for assistance (Option 2). A bed alarm alerts staff when the client attempts to get out of bed, which allows for prompt response (Option 5). (Option 4) Raising all bed rails may be constituted as an unlawful use of restraint. Clients with altered mental status may also attempt to climb the side rails and sustain a fall injury. Educational objective: Many falls are associated with bathroom urgency/frequency. Fall risk precautions include placing the client in a room near the nurses' station, placing a bedside commode by the client's stronger side, applying nonslip socks, and using a bed alarm.

A 2-year-old is admitted to the emergency department for anaphylactic reaction to a bee sting. The nurse teaches the parent about emergency use of the epinephrine injection. Which statement indicates that the parent understands the instruction? Select all that apply. 1. "I will keep an epinephrine injection in close proximity to my child at all times." 2. "I will give the injection if my child has trouble breathing after a bee sting." 3. "I will give the injection in the upper arm." 4. "The injection can be given through clothing." 5. "If I give the injection, I'll still take my child to the emergency room."

Answers: 1, 2, 4, 5 Explanation: A critical part of self-care for a person with a history of anaphylactic reaction is the use of emergency epinephrine (EpiPen or EpiPen Jr). The client and/or caregiver should be taught the following principles: - The EpiPen should always be available for emergency use and so should be taken along (in purse, pocket, backpack) when the client leaves home (Option 1) - The EpiPen should be given when the client first notices any anaphylactic symptoms, such as tightening or swelling of the airway, difficulty breathing, wheezing, stridor, or shock (Option 2) - The injection should be given in the mid-outer thigh and can be given through clothing (Options 3 and 4) - The client should receive emergency care as soon as possible by calling 911 or going to the emergency department to monitor for further problems (Option 5) Educational objective: Emergency self-injection of epinephrine (EpiPen) can be done through clothing into the mid-outer thigh when the client first notices any anaphylactic symptoms.

A client arrives in the emergency department on a cold winter day. The client is calm, alert, and oriented with a respiratory rate of 20/min and a pulse oximeter reading of 78%. The nurse suspects that the client's pulse oximeter reading is inaccurate. Which factors could be contributing to this reading? Select all that apply. 1. Black fingernail polish 2. Cold extremities 3. Elevated WBC count 4. Hypotension 5. Peripheral arterial disease

Answers: 1, 2, 4, 5 Explanation: A pulse oximeter is a noninvasive device that estimates arterial blood oxygen saturation by using a sensor attached to the client's finger, toe, earlobe, nose, or forehead. The sensor (reusable clip or disposable adhesive) contains light-emitting and light-sensing components that measure the amount of light absorbed by oxygenated hemoglobin. Because the sensor estimates the value at a peripheral site, the pulse oximeter measurement is reported as blood oxygen saturation (SpO2). Normal SpO2 for a healthy client is 95%-100%. Any factor that affects light transmission or peripheral blood flow can result in a false reading. Common causative factors of falsely low SpO2 include: - Dark fingernail polish or artificial acrylic nails (Option 1) - Hypotension and low cardiac output (eg, heart failure) (Option 4) - Vasoconstriction (eg, hypothermia, vasopressor medications) (Option 2) - Peripheral arterial disease (Option 5) (Option 3) Abnormal WBC count has no direct influence on light transmission or peripheral blood flow. Educational objective: Any factor that affects light transmission or peripheral blood flow can cause a falsely low reading for oxygen saturation on pulse oximeter. Common causes include dark nail polish, hypotension, low cardiac output, vasoconstriction (eg, hypothermia, vasopressor medications), and peripheral arterial disease.

The nurse is reviewing medical histories with several clients during a community health screening event. Which of the following client statements indicate a risk factor for cervical cancer? Select all that apply. 1. "I have had four sexual partners during my lifetime." 2. "I have smoked cigarettes for many years." 3. "I never used birth control pills because my partners wore condoms." 4. "I received treatment for chlamydia when I was younger." 5. "I tested positive for human papillomavirus a few years ago."

Answers: 1, 2, 4, 5 Explanation: Cervical cancer is a malignancy of the cervix (a portion of the uterus) that normally occurs near the meeting point of the vaginal and uterine epithelia (the transformation zone), located in the endocervical canal. Uterine epithelial cells in this area are rapidly and constantly replaced with squamous cells (ie, squamous metaplasia), a natural process that also increases the risk for abnormal cell changes and cancer. The most important risk factor for cervical cancer is persistent human papillomavirus (HPV) infection, a common, transient, and often asymptomatic sexually transmitted infection (STI) that can be identified in almost all clients with cervical cancer (Option 5). Most other risk factors are related to acquiring, clearing, or increasing the cancer-causing effects of HPV infection, including: - Having multiple sexual partners (ie, >1 lifetime partner), which increases the chance of HPV exposure (Option 1) - Smoking tobacco, which is believed to promote cell mutation and increase the likelihood of HPV infection (Option 2) - Being infected with other STIs (eg, gonorrhea, chlamydia), which increases the likelihood of HPV infection (Option 4) (Option 3) Condoms help to prevent HPV transmission between partners, and not taking oral contraceptives is associated with a decreased risk for cervical cancer. Educational objective: Cervical cancer is a malignancy of the cervix associated with persistent human papillomavirus (HPV) infection. Most other risk factors for cervical cancer relate to increasing risk for or ability to clear HPV infections, including multiple sexual partners, history of other sexually transmitted infections, and smoking.

The nurse is caring for an 11-month-old in the pediatric hospital. Which of these child's findings would be a common criterion to activate the rapid response team? Select all that apply. 1. New-onset right-sided paralysis of extremities 2. Pulse sustained at 120/min 3. Respirations continued at 38/min 4. Sudden inability to be aroused to an awake state 5. Temperature of 101.3 F (38.5 C)

Answers: 1, 4 Explanation: Rapid response teams are formed as a means to get critical care specialists to the bedside of clients who are not in a critical care unit when acute, significant changes occur in their condition. Each institution sets its own criteria, but it usually includes acute changes in heart rate, systolic blood pressure, respiratory rate, oxygen saturation, level of consciousness, and/or urine output. Although strokes occur more commonly in adults, they can occur in children. Symptoms found in both groups can be similar, such as unilateral paralysis, which is usually found with vessel abnormalities or a hematologic complication (eg, sickle cell, cancer) (Option 1). Just as in adults, emergency treatment for children should be activated. A sudden loss of consciousness is emergent in any client (Option 4). (Option 2) Normal heart rate for an infant (1-12 months) is 100-160/min. (Option 3) Normal respiration rate for an infant (1-12 months) is 30-60/min. (Option 5) A fever is ordinarily not an emergency situation that meets the criteria to activate the rapid response team. It can signal a serious condition in infants who are age <1 month or in children age <2 years who have a temperature >104 F (40 C) without a localized source (due to an immature immune system). However, in this case, it would probably be more effective to call a health care provider to prescribe appropriate diagnostic tests (eg, complete blood count, cultures) and treatment (eg, antibiotics). A fever does not usually require immediate life-saving intervention. Educational objective: Rapid response teams are formed as a means to get critical care assistance to the bedside of clients (not in intensive care) with acute significant changes in their condition. Common criteria include sudden, significant changes in pulse rate, respiration rate, systolic blood pressure, oxygen saturation, level of consciousness, and/or urine output.

The nurse in the outpatient treatment facility evaluates the plan of care for a client with alcohol use disorder. Which of the following client statements indicate positive progress toward recover? Select all that apply. 1. "Drinking led to my divorce and the loss of my children." 2. "I am in control now; I drink only on special occasions." 3. "I will have no desire to drink once I get over my divorce." 4. "My focus is now on fitness training and going back to college." 5. "When cravings occur, I call my Alcoholics Anonymous sponsor."

Answers: 1, 4, 5 Explanation: Alcohol use disorder, or alcoholism, occurs when alcohol is consumed in excess over time until dependence develops, causing withdrawal to occur when alcohol is not consumed. Alcohol consumption can become the client's sole focus, which negatively impacts the social, familial, and occupational aspects of the client's life. After the detoxification period, the plan of care includes a goal-setting process to progress the client toward total abstinence from alcohol. Goals for client recovery include: - Expressing accountability for previous behavior, including how abusing alcohol has impacted personal life (Option 1) - Using insight to face reality and overcome rationalization and projection - Using coping skills (eg, support groups, relaxation techniques) to improve reactions to stressful situations (Option 5) - Setting goals for personal growth and self-worth development and using nonchemical alternatives (eg, fitness training) for stress relief (Option 4) - Maintaining abstinence from alcohol consumption (Option 2) This statement represents denial, a common maladaptive defense mechanism in which substance misuse or addiction is minimized and/or clients deny having a problem with substance abuse. (Option 3) This statement represents rationalization, a common maladaptive defense mechanism in which the client makes excuses (eg, divorce) to justify substance use. Educational objective: Clients recovering from alcohol use disorder should demonstrate accountability for past behavior and identify the consequences, use insight to face reality, and use coping skills and nonchemical alternatives. The client should also be encouraged to set goals for personal growth.

The charge nurse in a long-term memory care facility is making assignments for the Alzheimer unit. Which tasks may be delegated to experienced unlicensed assistive personnel? Select all that apply. 1. Assisting clients with bathing and hair care 2. Evaluate safety hazards in clients' rooms 3. Monitoring clients for behavioral changes 4. Placing bed alarms at night for clients at risk for wandering 5. Reporting swallowing difficulties of a client during mealtime

Answers: 1, 4, 5 Explanation: Many clients with advanced Alzheimer disease reside in long-term care centers; therefore, most routine care activities can be delegated to the licensed practical nurse (LPN) and unlicensed assistive personnel (UAP). The role of the LPN includes: - Administration of enteral feedings (if prescribed) - Administration of medications - Monitor for safety hazards - Monitoring for behavioral changes The role of UAP includes: - Assisting with activities of daily living (eg, toileting, bathing, skin care, oral care, personal hygiene) (Option 1) - Assisting with feeding - Reporting changes in ability to eat or difficulty swallowing (Option 5) - Reporting changes in behavior - Placing bed alarms to reduce risk of falls (Option 4) (Option 2) UAP may be directed by a nurse to remove or alter safety hazards in a client's room, but the nurse retains the responsibility of evaluating the environment. (Option 3) The UAP may report changes in client behavior to the nurse. The LPN can monitor for behavioral changes, and the RN can develop strategies to address difficult behavior. Educational objective: While caring for a client with Alzheimer disease, the licensed practical nurse is responsible for administration of medications and enteral feedings (if prescribed) and monitoring for safety hazards and behavioral changes. The role of unlicensed assistive personnel involves helping with activities of daily living and reporting changes in the client.

The nurse provides instructions to a client discharged on warfarin, after being treated for a pulmonary embolism (PE) following surgery. Which statements made by the client indicate the need for further teaching? Select all that apply. 1. "I will need to take my blood thinner for about 3-6 months." 2. "I will place small rugs on my wood floors to cushion a fall." 3. "I will take a baby aspirin if I have mild chest pain." 4. "I will use a soft-bristled toothbrush to clean my teeth." 5. "I will wear a blood thinner MedicAlert tag."

Answers: 2, 3 Explanation: Clients discharged on warfarin (Coumadin) are taught interventions to prevent injury, such as removing scatter rugs in the home to reduce the risk of tripping and falling (especially in elderly) (Option 2). Clients are educated to avoid aspirin, drugs containing aspirin, non steroidal anti-inflammatory drugs (NSAIDs), and alcohol when taking warfarin due to an increased risk for bleeding (Option 3). (Option 1) Warfarin is usually administered for 3-6 months following PE to prevent further thrombus formation. A longer duration (lifelong) of anticoagulation is recommended in clients with recurrent PE. Prothrombin time and INR must be monitored regularly to adjust the dose and maintain a therapeutic anticoagulant level. (Option 4) Clients should be taught to avoid trauma or injury to decrease the risk for bleeding. Preventive measures include gently brushing teeth with a soft-bristled toothbrush, avoiding use of alcohol-based mouthwash, avoiding contact sports or rollerblading, and using a straight razor. Flossing should also be avoided in general, but waxed dental floss may be used with care in some clients. (Option 5) Clients are instructed to wear a MedicAlert tag (eg, necklace, bracelet) when taking anticoagulants (eg, warfarin, heparin). Educational objective: Clients on warfarin or heparin should avoid using aspirin or non steroidal anti-inflammatory drugs, wear a MedicAlert device, avoid activities that increase the risk for bleeding, and limit alcohol intake.

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

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

An infant is born with a cleft palate. Which actions will promote oral intake until the defect can be repaired? Select all that apply. 1. Angle bottle up and toward cleft 2. Burping the infant often 3. Feeding in an upright position 4. Feeding slowly over 45 minutes or more 5. Using a specialty bottle or nipple

Answers: 2, 3, 5 Explanation: A child with a cleft palate (CP) is at risk for aspiration and inadequate nutrition due to eating and feeding difficulties. This is due to the infant's inability to create suction and pull milk or formula from the nipple. Until CP can be repaired, the following feeding strategies increase oral intake and decrease aspiration risk: - Hold the infant in an upright position, which promotes passage of formula into the stomach and decreases risk of aspiration (Option 3). - Tilt the bottle so that the nipple is always filled with formula. Point down and away from the cleft. - Use special bottles and nipples, including cross-cut and preemie nipples and assisted delivery bottles. These devices allow formula to flow more freely, decreasing the need for the infant to create suction. Using a squeezable bottle allows the caregiver to apply pressure in rhythm with the infant's own sucking and swallowing (Option 5). - These infants swallow large amounts of air during feeding and so need to be burped more often to avoid stomach distension and regurgitation (Option 2). - Feeding slowly over 20-30 minutes reduces the risk of aspiration and promotes adequate intake of formula. - Feeding every 3-4 hours: more frequent feedings may be tiring for the infant and the mother. Some infants may need to be fed more frequently if they are not consuming adequate amounts of formula. (Option 1) Bottle should be pointed down, away from the cleft, in order to prevent formula from flowing back into the nose area. This backflow would cause nasal regurgitation, and milk or formula may commonly escape through the nose. This is dangerous and the infant will sneeze or cough in order to clear the nose. (Option 4) Feeding should take about 20-30 minutes. The infant may be working too hard and tire out if feeding takes 45 minutes or more. In addition, the extra work of feeding will burn up calories that are needed for growth. Educational objective: Children with cleft palates are at increased risk for inadequate intake as well as aspiration. Actions to promote intake and reduce aspiration risk include feeding in an upright position, pointing the nipple away from the cleft, feeding over no more than 20-30 minutes, using special nipples or bottles, and feeding every 3-4 hours. The infant should be burped at regular intervals to reduce gastric distension.

A client with Alzheimer disease becomes agitated during mealtime and throws a plate of food on the floor. Which of the following responses by the nurse are appropriate? Select all that apply. 1. Administer a dose of prescribed PRN haloperidol before the client's behavior escalates further 2. Distract and redirect the client by asking for help folding napkins for the following day's meals 3. Inform the client that the health care provider will be notified about the inappropriate behavior 4. Promptly obtain another plate of food and insist that unlicensed assistive personnel feed the client 5. Use direct eye contact and say to the client, "I can see that you are upset; this is a safe place"

Answers: 2, 5 Explanation: Clients with Alzheimer disease (AD) often exhibit behavioral problems (eg, agitation, resisting care) due to cognitive decline. Behavioral management techniques include: - Acknowledgment of the client's emotions, which reduces feelings of being isolated and misunderstood (Option 5) - Reassurance that the client will be kept safe from harm - Distraction (eg, photographs, music, television) to divert the client's attention - Redirection to simple tasks (eg, folding towels/napkins, stacking plates) (Option 2) (Option 1) Antipsychotic medications (eg, haloperidol, risperidone, olanzapine) are associated with increased mortality when used for agitation in clients with dementia. These medications should be used after all other measures have failed. (Option 3) Threatening to call the health care provider disrupts the nurse-client relationship and may worsen the client's agitation and behavioral problems. (Option 4) Offering activities that may have precipitated the behavior will likely worsen the agitation. The nurse should assess the client to determine the cause of the agitation (eg, pain, fear, fatigue) and address it. A new meal can be offered after the client is calm. In addition, the nurse should promote autonomy for as long as possible and should not feed clients who are still able to feed themselves (eg, client with moderate AD). Educational objective: Behavioral management for agitated clients with Alzheimer disease includes acknowledging client feelings, reassuring safety, distracting, and redirecting.

Which of these tasks are appropriate for the registered nurse (RN) to delegate to unlicensed assistive personnel (UAP)? Select all that apply. 1. Assign lunch times to the other UAP on the unit 2. Assist a client with a new ostomy with bathing and changing pouches 3. Collect vital signs on a client 4 hours after a laparoscopic appendectomy 4. Pick up an intravenous antibiotic from the pharmacy 5. Record intake and output for a client with metabolic alkalosis

Answers: 3, 4, 5 Explanation: The UAP can be delegated tasks that do not require nursing judgment. Any task that involves the nursing process (assessment, diagnosis, planning, implementation, evaluation) requires the attention of the RN. The UAP may gather information (eg, vital signs, intake and output) about stable clients, assist stable clients with activities of daily living, and retrieve necessary supplies, but the RN retains accountability for all of the delegated actions and outcomes (Options 3, 4, and 5). The RN is also responsible for determining the competency level of the UAP prior to delegating tasks. (Option 1) Making staff lunch assignments is part of the management of the unit; therefore, the RN cannot delegate this task. The RN must ensure that there is adequate staff coverage to meet client needs during the assigned lunch times. (Option 2) UAPs can give bed baths to stable, appropriate clients. The client with a new ostomy requires assessment and teaching about cleaning and caring for the ostomy; therefore, an RN must perform this task. Educational objective: Client care that involves any part of the nursing process (assessment, diagnosis, planning, intervention, evaluation) can never be delegated to the licensed practical/vocational nurse or the UAP. The UAP can assist with basic care activities and collect data (eg, vital signs, intake and output) for stable clients. The RN is ultimately accountable for the care provided by the UAP.

The registered nurse, licensed practical nurse (LPN), and unlicensed assistive personnel are assigned a client who is being transferred from the post-anesthesia care unit (PACU). Which tasks are the most appropriate to delegate to the LPN? Select all that apply. 1. Assess the client on admission 2. Measure vital signs and pulse oximetry 3. Monitor pain level and administer pain medications 4. Receive verbal report from the PACU nurse 5. Reposition client every 2 hours 6. Titrate oxygen based on unit protocols

Answers: 3, 6 Explanation: Scope of Practice: RN - Clinical assessment - Initial client education - Discharge education - Clinical judgment - Initiating blood transfusion LPN/LVN - Monitoring RN findings - Reinforcing education - Routine procedures (eg, catheterization) - Most medication administrations - Ostomy care - Tube patency & enteral feeding - Specific assessments* UAP - ADL's - Hygiene - Linen change - Routine, stable vital signs - Documenting intake/output - Positioning *Limited Assessments (eg, lung sounds, bowel sounds, neurovascular checks) The registered nurse (RN) should consider the 5 rights of delegation prior to delegating a task. Tasks such as monitoring pain, administering medications, and titrating oxygen may be delegated by the RN to the LPN (Options 3 and 6). (Options 1 and 4) The RN receives report from the PACU nurse, performs initial assessments, and performs other tasks requiring critical judgment (eg, initial teaching, care planning). (Options 2 and 5) Client positioning and measurement of vital signs and pulse oximetry may be delegated to UAP. Although LPNs can carry out these tasks, their time is better spent performing more complex client care (eg, medication administration) if UAP is available. Educational objective: The RN is responsible for the client's initial assessment, plan of care development, evaluation, and initial teaching. The RN can delegate most medication administration, client monitoring, education reinforcement, and routine procedures to the licensed practical nurse.