uworld apr 27
The nurse is assessing a client who had surgery 12 hours and is receiving IV morphine for incisional pain. it would require immediate follow-up if the client? 1. has a blood pressure of 108/60 2. falls asleep while speaking with the nurse 3. reports burning at the IV site during administration of the medication 4. reports dizziness when getting out of bed to use the bathroom
2
A parent Call the nurse Telehealth triage line with concerns about an allergic reaction To something a child ate. Which symptoms should the nurse instruct the parent to assess for to determine if the child is having an anaphylactic reaction? select all that apply. 1 Dyspnea 2 Fever 3 Light-headedness 4 skin rash or hives 5 wheezing
Dyspnea Light-headedness skin rash or hives wheezing the nurse should instruct the parent to First assess for signs of swelling of the mouth tongue lips and upper Airway the child will have wheezing and difficulty breathing next followed soon by cardiovascular symptom these include lightheadedness due to hypotension loss of consciousness and cardiovascular collapse and anaphylactic reaction is life-threatening requires rapid assessment and intervention option 2 fever is not a symptom of an anaphylactic reaction that would be included in the rapid assessment
The health care provider prescribes naproxen for a client who has degenerative joint disease. What instructions regarding this drug does the nurse include in the client's discharge plan? Select all that apply Avoid driving while taking this medicine Change positions slowly Discontinue immediately if suicidal thoughts occur Notify the HCP of tarry stools Take the medicine with food
Notify the HCP of tarry stools Take the medicine with food Naproxen - NSAID are associated with the following: GI toxicity, kidney injury, HTN, HF, bleeding risk
A client with cancer pain is prescribed oxycodone. Which teaching is most essential to help prevent long term complications? 1. teach the client how to assess blood pressure daily 2. teach the client to prevent constipation 3. teach the client how to prevent itching 4. teach the lient how to prevent nausea
b
A client having an ischemic stroke arrives at the emergency department. The health care provider prescribes tissue plasminogen activator (tPA). Which client statement would be most important to clarify before administering tPA? 1. "I can't believe this is happening right after my stomach surgery." 2. "I had a concussion after a car accident a year ago." 3. "I started noticing my right arm becoming weak approximately an hour ago." 4. "I stopped taking my warfarin 4 weeks ago."
1 TPA is contraindicated in a ct with surgery within the last 2 weeks as tPA dissolves all clots in the body and may disrupt the surgical site. option 2 hx of stroke or head trauma in the last 3 mon could exclude tPA use option 3 the nruse should determine when the ct first developed stroke symptoms. tPA can be administered if symptoms started within the last 3 to 41/2 hr or based on facility guidelines option 4 duration of action of warfarin is 2-5 days this ct can safely recieve tPA as warfarin was discontinued 4 weeks ago.
The nurse prepares to insert an indwelling urinary catheter in a client who is disoriented to time, place and person and cannot follow directions or commands. Which interventions is most important when inserting the urinary catheter? 1. ensure the client understands the procedure prior to implementation 2. maintain a sterile field and keep the urinary catheter sterile 3. place the catheter supply kit between the client's legs in the center of the bed 4. throw swabs used to clean the perineum directly into the biohazard bin
2
A client allergic to bee stings was stung about 20 minutes ago at a picnic. based on the assessment data the nurse anticipates which immediate actions? select all that apply. click on the exhibit button for additional information. vital signs Blood pressure 92/40 pulse 140 beats per minute and regular respirations 36 breaths per minute and labored oxygen saturation 89% 1. Inhaled Albuterol 2 intramuscular epinephrine 3 intravenous methylprednisolone 4 intravenous metoprolol 5 intravenous nitroglycerin
123 Anaphylactic shock has an acute onset of manifestation that usually develops quickly; it is caused by systemic IgE immediate hypersensitivity allergic reaction to Foods drugs or Venom. Anaphylactic shock results in hypertension and respiratory manifestations including laryngeal edema from inflammation and bronchial construction primarily from the release of histamine; these can lead to cardiac and respiratory arrest. the management of anaphylactic shock includes: call for help activating Emergency Management Systems first action maintain Airway and breathing - administer high flow oxygen via non-rebreather mask epinephrine intramuscular the drug of choice and should be given next epinephrine stimulates both Alpha and beta adrenergic receptors dilates bronchial smooth muscle beta 2 and provides vasoconstriction Alpha One the I am root is better than the subcutaneous root the dough should be repeated every 5 to 15 minutes if there is no response Elevate the legs volume resuscitation with IV fluids bronchodilator such as albuterol is administered to dilate the small Airway and reverse bronchoconstriction antihistamine is administered to modify the hypersensitivity reaction and relieve itchiness corticosteroids are administered to decrease the airway inflammation swelling associated with the allergic reaction Option 4 metoprolol a beta blocker should not be given as a blood pressure is already low Option 5 natural cause hypertension should not be given morphine is avoided as it can worsen pruritus and hypotension
The home health nurse visits a client with hand osteoarthritis whose health care provider has recommended topical capsaicin for pain relief. which instruction about capsaicin should the nurse provide the client? 1. apply a heating pad or warm compress for 20 mins after applying cream 2. apply cream to hands and wait at least 30 mins before washing them 3. continue immediately if burning or stinging sensation occurs 4. use only if oral pain medications haven ot been effective
2 option 1 the application of heat with capsaicin is contraindicated as heat causes vasodilation which increases medication absorption and can possibly lead to a chemical burn option 3 local irritation (burning, stinging, erythema) is quite common and usually subsides within the first week of regular use. if the clietn experiences persistent pain redness or blistering the cream should be discontinued and the HCP notified option 4 topical capsaicin is often used concurrently with acetaminophen or NSAID to effectively treat osteoarthritis pain. capsaicin should be used regularly for weeks to months of time to achieve the desired effect.
The clinic nurse supervises a student nurse who is preparing to administer routine vaccinations to a child diagnosed with hemophilia. Which instructions should the clinic nurse provide to the student? Select all that apply Administer ibuprofen for pain relief Administer vaccines via the subcutaneous route Apply a warm compress to the injectio nsite Hold firm pressure on the site for 5 mins Massage the injection site to disperse the medication
24 ANS 24 Hemophilia is a bleeding disorder caused byA deficiency in coagulation proteins increasing the risk for bleeding the nurse should avoid procedures that can cause bleeding for example intramuscular injections or rectal temperature measurement vaccinations are administered subcutaneously whenever possible to prevent intramuscular hematoma option one the smallest gauge needle is used and firm continuous pressure is apply that the site for 5 minutes option four option one children with hemophilia should avoid aspirin and an a anti-inflammatory drugs to do the risk of bleeding acetaminophen is recommended for pain relief options three and five firm pressure should be held on the site without rubbing our massaging due to the risk of bleeding and hematoma formation superficial bleeding can we controlled using ice packs which promote bass or constriction applying a warm compression would cause vasodilation and prolong bleeding
The nurse is planning postmortem care for a client who died during the shift. Which of the following client situations might cause the nurse to delay or not perform postmortem care? select all that apply 1. client died following a prolonged illness 2. client died in the emergency department following a suicide attempt 3. client family requests to assist with the care 4. client's family was present at the time of death 5. client's religious beliefs require special ceremonial treatment of the body
25
The clinic nurse prepares to administer a newly prescribed dose of sumatriptan to a client with a migraine headache. which item in the client's history would cause the nurse to question the prescription? 1. BUN 12 mg/dl 2. BMI 34 kg/m2 recorded during today's exam 3. past medical hx of uncontrolled hypertension 4. takes alprazolam as prescribed for anxiety
3 option 1 normal value BUN 6-20 option 2 not contraindicated for overweight cts option 3 contraindicated for cts with coronary artery disease and uncontrolled HTN option 4 not contraindicated for alprazolam
Which of the following are violations of protected client health information? select all that apply. 1 client overhears the nurse give report on the client's roommate through the room curtain 2 nurse calls a client by the first and last names in the public waiting room 3 nurse gives a pregnancy results to the client's partner without the client's permission 4 nurse tells a transporting tech that the client has breast cancer 5 unlicensed assistive personnel tells a discharged client, " you take care now!"
3, 4
The nurse assistant reports vital signs on four clients. Which client should be the priority for the nurse to assess? 28-year-old with an infective endocarditis and a heart rate of 105/min 45 year old with acute pancreatitis and sinus tachycardia of 120/min 65 year old with tachycardia of 110/min after liver biopsy 74-year-old on diltiazem drip with atrial fibrillation in the heart rate of 115/min
65 year old with tachycardia of 110/min after liver biopsy The liver is a highly vascular organ and bleeding is a major complication. tachycardia is an early sign of internal hemorrhage. The 65-year-old client should be assessed first. Option 1 Tachycardia can be caused by underlying infection and can resolve with treatment of the infection. valve infections can require several weeks of antibiotics. This client is not the priority. Option 2 pancreatitis is a very painful condition and sinus tachycardia is expected. these clients are also at risk for developing complications such as third spacing of volume and require large quantities of IV fluids. this client is a second priority. Option 4 atrial fibrillation is commonly treated with calcium channel blockers such as diltiazem. the dosage needs to be adjusted to achieve a goal heart rate of less than 100/min. atrial fibrillation is usually not immediately life- threatening.
A nurse in the emergency department assesses 4 clients. Based on the laboratory results, which client is the highest priority for treatment? Client with abdominal pain, respiration 28/min, and blood alcohol level 80 mg/dL (0.08% [17.4 mmol/l]) Client with chronic obstructive pulmonary disease, pH 7.34, pO2 86 mmhg, pCO2 48 mmhg, and HCO3 30 mEq/L Client with dull headache, pulse oximeter reading 95% and serum carboxyhemoglobin level 20% Client with emesis of 100ml coffee-ground gastric contents and serum hemoglobin 15g/dL
Client with dull headache, pulse oximeter reading 95% and serum carboxyhemoglobin level 20% Carbon monoxide is a toxic inhalant that enters the blood and binds more readily to hemoglobin than oxygen does. When hemoglobin is saturated with CO, the pulse solidar reading is supposed to be normal as conventional devices to text saturated hemoglobin Only and cannot differentiate between carbon monoxide and oxygen. the diagnosis of carbon monoxide poisoning is often missed in the emergency department because symptoms are not specific for example headache dizziness fatigue nausea dyspnea and the pulse oximeter reading often appears with the normal limits. a serum carboxyhemoglobin test is needed to confirm the diagnosis. Normal values are less than <5% and not smokers and slightly higher in smokers. current with carbon monoxide poisoning is the highest priority for treatment requires immediate administration of 100% oxygen to increase the rate at which carbon monoxide dissipates from the blood to prevent tissue hypoxia and severe hypoxemia option 3 Option 1 normal blood alcohol content is 0 mg/dl and the legal level for driving under the influence is 80 mg/dL ( 0.08mg% [17.4mmol/l]). The client's abdominal pain increased respiratory rate requires adequate assessment but is not the highest priority. Option 2 The arterial blood gasses indicate compensated respiratory acidosis, which is characteristic for a client with chronic obstructive pulmonary disease; this is not the highest priority. Option 4 Emissions of 100 ml coffee ground gastric contents would indicate an older not fresh gastrointestinal bleed; the hemoglobin level is normal (13.2 to 17.3 g/dL 132 to 173 g/l for males, 11.7 to 15.5 g/dl for females. The cause of the gastrointestinal bleed must be determined, but this is not the highest priority. educational objective clients with carbon monoxide poisoning have elevated serum carboxyhemoglobin levels normal is less than 5% in non-smokers and false normal pulse oximeter readings they require immediate administration of 100% oxygen to correct hypoxemia and eliminate toxic carbon monoxide from the blood.
Q38 A nurse reviews the most current serum laboratory results for assigned clients. Which result is the highest priority to report to the healthcare provider? Albumin of 3.0 g/dl in a client with chronic hepatitis B type natriuretic peptide of 400 pg/dml in a client with heart failure Magnesium f 1.7 meq/l in a client with alcohol withdrawal Sodium of 120 meq/l in a client with small cell lung cancer
Sodium of 120 meq/l in a client with small cell lung cancer Syndrome of an inappropriate antidiuretic hormone secretion is often caused by the atopic production of ADH by a malignant lung tumor. increased ADH leads to increased water reabsorption and intravascular volume, which results in dilutional hyponatremia. severe neurologic dysfunction includes confusion seizures can occur when serum sodium drops below 120 MEQ/L. therefore hyponatremia is the highest priority to report as it poses the greatest threat to survival hyponatremia requires immediate evaluation and treatment (eg seizure precautions, fluid restriction, intravenous hypertonic Saline) by the healthcare provider optio 4 Option 1 albumin is a protein formed in the liver. Hepatocytes lose the ability to synthesize I'll be even when the cells are diseased. Hypoalbuminemia <3.5 g/dl should be expected in this client Option two b-type natriuretic peptide Is a substance secreted from the cardiac ventricles in response to increases in ventricular pressures and volume therefore BNP is a marker for heart failure and is elevated in clients with both stable and decompensated heart failure. BNP is an expected finding in this client. option 3 clients and alcohol withdrawal usually require magnesium supplements I put magnesium results from poor dietary intake, malnutrition, and increased renal excretion and is common inclines with chronic alcoholism. this finding is Within normal limits
The home health nurse revews the serum lab test for a ct with seizures. The phenytoin level is 27mcg/ml. The client makes which statement that may indicate the presence of dose-related drug toxicity and prompt the nrues to notify the HCP? 1. i am feeling unsteady when i walk 2. i am getting up to urinate about 4 times during the night 3. i have a metallic taste in my mouth when i eat 4. my gums are getting so puffy and red
a option 2 nocturia is an expected side effect of diuretics but not phenytoin. option 3 metallic taste in the mouth is often seen with metronidazole but not with phenytoin option 4 gingival hyperplasia is a common expected side effect of phenytoin and does not indicate drug toxicity
The nurse in the same-day surgery unit admits a client who will receive general anesthesia. The client has never had surgery before. Which question is most critical for the nurse to ask the client during the preoperative assessment and health history? 1. "Has any family member ever had a bad reaction to general anesthesia?" 2. "Have you ever experienced low back pain?" 3. "Have you ever had an anaphylactic reaction to a bee sting?" 4. "Have you ever received opioid pain medications?"
1 Malignant hyperthermia (MH) is a rare but life-threatening inherited muscle abnormality that is triggered by specific, inhaled anesthetic agents and the depolarizing muscle relaxant succinylcholine (Anectine) used to induce general anesthesia. In MH-susceptible clients, the triggering agent leads to excessive release of calcium from the muscles, leading to sustained muscle contraction and rigidity (usually of the jaw and upper body [early sign]), increased oxygen demand and metabolism, and dangerously high temperature (later sign). As MH is an inherited condition, proper screening and a thorough preoperative nursing assessment and health history can help minimize the client's risk (Option 1). (Option 2) Cervical spine problems should be assessed before the intubation. Low back pain history is not a priority for general anesthesia. (Option 3) It would be appropriate to ask about allergies (eg, drugs, latex). However, asking about an anaphylactic reaction to a bee sting is not the most critical question. (Option 4) History of prior opioid intake may be helpful, but the most important question is to ask about side effects and allergies. Educational objective: Malignant hyperthermia (MH) is a rare, life-threatening inherited muscular abnormality that is triggered by specific drugs used to induce general anesthesia. Therefore, it is critical for the perioperative nurse to screen for MH susceptibility by asking if any of the client's blood relatives had ever experienced an adverse reaction to general anesthesia, including unexplained death.
The nures is preparing to infuse 2 units of packed red blood cells to a client with a gastrointestinal bleed. Which actions should the nurse take? select all that apply 1. assess client's vital signs 2. infuse both unit simultaneously 3. obtain a Y tubing set and prime with normal saline (NS) 4. plan to remain with client during the 1st 15 minutes of transfusion 5. set infusion pump to deliver unit over 30 to 45 mins 6. spike filtered intravenous IV tubing with dextrose 5% water (D5W)
134 The procedure for safe blood administration includes the following: 1. obtain a unit of blood from the blood bank and verify the blood product with type and crossmatch results and at least 1 client identifiers with another nurse at the client's bedside. The blood is obtained and infused one unit at a time (option 2) 2. assess the client, obtain vital signs for baseline and teach signs of a transfusion reaction and how to call for help 3. use a y tubing prime with NS and them clamp the NS side (option 6) 4. spike the blood product leaving the blood side of the Y tube open when keeping the saline side clamped for infusion. the saline is only used to prime the tubing and flush after the infusion. it does not infuse simultaneously. 5. set the infusion pump to deliver blood over 2-4 hours as prescribed (option 5). rapid infusion of the blood puts the client at greater risk for transfusion reaction and fluid volume overload. 6. remain with the ct for at least the 1st 15 mins and watch for signs of blood transfusion reaction including FEVER, CHILLS, N/V, PRURITUS, HYPOTENSION, DECREASED URINE OUTPUT, BACK PAIN and DYSPNEA. stop the transfusion immediately if a reaction occurs .the first 15 mins of infusion should be slow to watch for these reactions. 7. take another set of VS 15 min after infusion starts and continue to accordance with facility policy. always take a final set of vital signs after the infusion is complete. 8. in complete of the blood transfusion open the saline side clamp of the y tubing to flush all blood in the tubing through the NS 9. return the blood bag with the attached set up to the laboratory after completion or dispose of in accordance with hospital policy. use the new IV Y tubing set up for the second unit of blood.
A postoperative client is prescribed patient-controlled analgeisa (pca). The client tells the nurse, "I am pushing the button but I'm still having a lot of pain". What is the priority nursing action? 1. administer a bolus dose of pain medication 2. notify the health care provider to request a higher dose 3. perform a thorough pain assessment 4. reinforce the proper use of a PCA pump
3 the nurse should assess pain on a regular and as needed basis. the clients self report is the most reliable indicator of pain therefore the priority is to perform a thorough pain assessment to determine the cause of worsening/continuous pain despite the medication.
The nurse reviews the serum laboratory results of a client who was seen in the clinic 2 days ago for worsening joint pain from a flare of systemic lupus erythematosus. Which result is greatest concern and prompts the nurse to notify the HCP? 1. creatinine of 1.8 mg/dl 2. elevated erythrocyte sedimentation rate 3. positive antinuclear antibody titer 4. white blood cell count of 3600/mm3
ANS 1
The nurse is providing discharge teaching to a client with newly diagnosed systemic lupus erythematosus. Which of the following statements by the client indicate a correct understanding of the teaching? select all that apply. 1. I know that sun exposure can worsen my lupus symptoms 2. i plan to continue my daily exercise routine of walking and stretching 3. i should avoid exposure to large crowds while taking prednisone 4. i will have periods when the illness flares and periods of remission 5. i will take short breaks between activities to help manage my fatigue
ANS 12345
The nurse is caring for a client who needs an indwelling urinary catheter inserted for urinary retention. which tasks would be appropriate to delegate to the unlicensed assistive Personnel? select all that reply. 1 document output from urinary collection bag 2 hold adipose tissue out of the way during catheter insertion 3 monitor color of the urine after the nurse has assessed it 4 reinforce education about the purpose of the urinary catheter 5 secure the catheter to the client's thigh with an anchor
ANS 125 it is within the unlicensed assistive personnel's (UAP) scope of practice to document output from a urinary collection bag (option 1). The UAP can assist the nurse during a procedure by helping to position a client or holding part of the client's body (option2). The UAP may also perform routine tasks such as securing a catheter to the clients that with an anchor device (option 5) Option 3 a licensed practical nurse May monitor for changes after an initial assessment has been performed by a registered nurse but this is not within the uap scope of practice Option 4 education should be provided by the RN. reinforcement may be performed by the LPN but it is not within the UAP scope of practice.
While caring for a client in skeletal traction, which tasks can the registered nurse (RN) delegate to experienced unlicensed assistive personnel (UAP) to help prevent immobility hazards? Select all that apply Assist with active and passive range of motion ROM exercises Change bed linens while logrolling the client from side to side Check the color and temperature of the affected extremity Remind the client to use the incentive spirometer Reapply pneumatic compression device after bathing the client
ANS 145 The UAP has the skills and knowledge to perform standard procedues to prevent immobility hazards for a client in traction (eg pneumonia, pressure ulcers, foot drop, thromboembolism). When providing care for a stable client the RN can safely delegate these tasks to the UAP. Assist with active and passive r o m exercises after the clan has been taught how to perform them by the RN or physical therapist option one notify the RN of client reports of pain tingling or decrease sensation in the affected extremity remind the client to use the incentive spirometer after the client has been taught proper use of the RN respiratory therapist option 4 maintain proper use of pneumatic compression devices option 5 reminder client to move frequently using the overhead trapeze Option 2 the UAP Changes the Linens from the top to the bottom of the bed with assistance clients are instructed to lift themselves using the overhead trapeze this approach maintains immobilization of the injured extremity log rolling the clan will require multiple staff members including one person to stabilize weights. Option 3 responsible for peripheral circulation or a vascular and skin assessments educational objective: to prevent immobility hazards for a client and skeletal traction the iron can delegate the following tests to the UAP: assist with active and passive Rom exercises notify the RN of client reports of pain, tingling, or decrease sensation in the affected extremity remind the client to use the incentives spirometer Maintain proper use of pneumatic compression devices
Which actions are appropriate for the registered nurse to delegate to an experienced licensed practical nurse? Select all that apply Administer heparin continuous infusion to a client with a venous thromboembolism Auscultate bowel sounds 2 days after repair of an inguinal hernia Discus concerns about last shift's care with an irate family member Monitor flow rate and drainage in a client receiving bladder irrigation Teach kegel exercises after a client has a catheter removed
ANS 2,4 Discus concerns about last shift's care with an irate family member Monitor flow rate and drainage in a client receiving bladder irrigation
The clinic nurse is instructing a client who is newly prescribed transdermal scopalamine to prevent motion sickness during an upcoming vacation on. cruise ship. Which of the following statements made by the nurse are appropriate? select all that apply. 1. apply the patch when the ship starts moving and not before 2. dispose of the patch out of reach of children and pets 3. make sure to remove the old patch before applying a new one 4. place the patch on a hairless clean dry area behidn the ear 5. wash your hands with soap and water after handling the patch
ANS 2345 Scopolamine is an anticholinergic med used to prevent nausea and vomiting from motion sickness and as an adjunct to anestheia to control secretions. Transdermal scopolamine is placed on a hairless clean dry area behind the ear for proper absorption (option 4). Clients should be instructed to: apply patch >4h before starting travel to allow for absorption and med onset. transdermal patches have a slower onset but a longer duration of action. replace the patch every 72 h as prescribed to ensure continuous med delivery. remove and discard old patch before placing a new one to prevent accidental overdose(option 3), dispose of the old patch out of reach of children and pets to avoid accidental ingestion (option 2) and wash hands with soap and water after handling the patch to avoid inadvertent drug absorption or contact with the eyes (option 5)
The nurse is caring for a client after a motor vehicle collision. The client's injuries include two fractured ribs and a concussion. Which of the following are expected neurological changes for clients with a concussion? select all that apply asymmetrical pupillary constriction brief period of confusion Headache loss of vision retrograde amnesia
ANS 235 brief period of confusion Headache retrograde amnesia A concussion is considered a minor traumatic brain injury that can result from blunt force trauma or acceleration/deceleration damage. Typical clinical manifestations of concussion include: a brief period of confusion with or without loss of consciousness (option 2) Headache (option 3) Amnesia regarding events immediately preceding the head trauma (ie retrograde amnesia) option 5 Clients with the concussion should be observed closely by family members and should not participate in strenuous or athletic activities for at least one to two days as long as symptoms have resolved. Rest in a light diet encouraged during this time. Options 1 and 4 asymmetrical pupillary constriction and vision loss would indicate a more serious brain injury. these manifestations are not expected with the concussion Educational objective: expected neurological changes with the concussion include a brief period of confusion, headache, and retrograde amnesia. these clients should be observed closely by family members and should not participate in strenuous or athletic activities for at least one to two days as long as symptoms have resolved.
The nurse receives a handoff report from the Night Nurse. Which client should the nurse assess first? 1 client with anemia who began receiving a unit of packed red blood cells 1 hour ago 2 Client with hemoglobin of seven g/dl who needs to be started on IV iron therapy 3 Client with seizure activity who received Lorazepam 20 minutes ago 4 Client would suspected leukemia scheduled for a bone marrow biopsy in 1 hour ago
ANS 3 The nurse should assess the client with seizure activity first. This client is at increased risk for injury, aspiration, and airway obstruction. The nurse should obtain Baseline neurological vital signs (e.g. level of consciousness, pupillary reaction, speech, hand grasps) against which to compare subsequent findings and to evaluate the client's response to lorazepam. The client requires a safe environment, so the nurse should also ensure that fall and seizure precautions (e.g. full side rail pads, low bed, floor mats, suction equipment, oxygen at bedside) have been initiated. Option 1 A serious a b o incompatibility/ transfusion reaction typically occurs within the first 15 minutes or 50ml transfusion. The unit of packed red blood cells was hung one hour ago; therefore the baseline 15 and 30 minute interval vital signs have already been recorded. The nurse will assess the client and infusion rate and site but does not need to check on this client first. Option 2 hemoglobin of 7g/dl is not life-threatening and many clients can tolerate this level. IV iron Administration is not a priority Option 4 the nurse should ensure that the consent form is signed and the client understands the bone marrow biopsy procedure, but this client should not be assessed first. BMB is not done at the bedside and usually does not have major complications.
The nurse just administered routine immunizations to a healthy 15 month old. what information Should the nurse provide to the caregivers before they leave the clinic? 1 call the office at the toddlers temperature reaches 100 Fahrenheit or 37.7 Celsius 2 fussiness and anorexia are common for one week after immunizations 3 redness at the injection site and a mild fever are common 4 toddler's activities should be restricted for 24 hours
ANS 3 common adverse effects of immunizations include a mild fever and soreness and redness at the injection site option 3. caregiver should be instructed to apply a cool compress to the injection site and taught how to correctly calculate the dose of acetaminophen or ibuprofen needed for these symptoms. OPTION 1 A fever is generally considered as a temperature of greater or equal to 100.4 Fahrenheit or 38° c. a mildly elevated temperature may be present within 24 hours after immunization but the healthcare provider should be notified if the temperature is higher than 38 and or persist for more than one to two days Option 2 children may have increased fussiness and anorexia following immunizations these symptoms should not last more than 24 hours Option 4 a child activity level should be not restricted following immunizations being active may actually help any soreness of the child moves the infected extremity educational objective: , adverse effects of immunizations include a mild fever and soreness and brightness of the injection site anorexia and fussing his can be present it should not last for more than 24 hours
Several 12 month old infants are brought to the clinic for routine immunizations. Which situation would be most important for the nurse to clarify with the provider before administering the vaccination? 1. Haemophilus influenzae type b vaccine for for our client allergic to penicillin 2. hepatitis a vaccine for a client with a "cold" and temperature of 37.2 3 Pneumococcal vaccine for client with local swelling after last immunization 4. Varicella zoster vaccine for client recently diagnosed with leukemia
ANS 4 Vaccine should be administered at specific ages and intervals as possible placental immunity decreases in the child's immune system and develops enough to produce antibodies in response to the vaccine. the nurse should always assess for allergies to vaccine components (eg neomycin, gelatin, yeast) and screen for an allergy to latex (eg. lip swelling from contact with bananas, kiwis or latex balloons). severely immunocompromised children (e.g. corticosteroid therapy chemotherapy AIDS) generally should not receive live vaccines (eg varicella zoster vaccine, MMR, rotavirus, yellow fever) option 4. Passive immunization may be the only option for children with severe immunosuppression who are unable to mount an antibody immune response. Common misperceptions of contraindications to immunization: penicillin allergy option 1 mild illness (with or without an elevated temperature) option 2 mild site reactions (Eg swelling erythema, soreness) option 3 recent infection exposure current course of antibiotic
The nurse is caring for a client who taking riluzole for amyotrophic lateral sclerosis (ALS). The client asks, "there's no cure for ALS so why should i keep taking this expensive drug?" What is the nurse's best response? 1. It may be able to slow the progression of ALS 2. It reduces the amount of glutamate in your brain 3. The case manager may be able to find a program to assist with cost 4. You have the right to refuse the medication
ANS A
The nurse is caring for a client with scleroderma. Which assessment finding indicates the most serious complication of the disease and requires priority intervention? 1. abrupt onset hypertension ahd headache 2. blue and cold fingertips 3. dry cough and exertional dyspnea 4. heart burn and difficulty swallowing
ANS A
The nurse is caring for the assigned clients on a pediatric inpatient unit. Which client is the priority? 8 year old sickle cell crisis who has sudden onset unilateral arm weakness 11 year old with viral meningitis requesting pain medication for headache Male child scheduled for surgery for intussusception who has reddish mucoid stool Male child with hemophilia who has hemarthrosis and is receiving desmopressin
ANS A Children can have strokes. ischemic Strokes are most common in children with sickle cell disease. other causes can include carotid abnormalities/ dissection. The most common presentation of an ischemic stroke is that sudden onset of numbness or weakness of an arm and or like these are handled with a similar emergent approach as for stroke in an adult. children may require blood transfusion to prevent the stroke from worsening. Option 2 viral meningitis can cause fever, headache, and meningeal signs (neck stiffness). headache is expected and not a priority over a client with stroke Option3 intussusception occurs when one portion of the intestine prolapses and then telescopes into another. This is a frequent cause of intestinal obstruction during infancy. onset is abrupt initially with pain and brown stool. The condition then progresses to bilious emesis, probable abdominal Mass, and stool with a red, "currant jelly" appearance due to blood and mucus. This is an expected finding for this condition and surgeries already scheduled to address it. Option4 hemophilia is primarily seen in males and it's due to a lack of clotting factors. symptoms include spontaneous bleeding into the joints, especially the knee, ankle or elbow. treatment includes placing the missing clotting Factor. Desmopressin stimulates the release of factor VIII. The child is receiving treatment already and Joint rest has been prescribed. The sudden neurological change in the client child with Sickle cell crisis is a priority.
The charge nurse on the telemetry unit is making client assignments. Which client is appropriate to assign to the licensed practice nurse LPN? Client 2 days after aortic valve surgery who needs a urinary catheter reinserted due to inability to void Client being discharged after deep vein thrombosis who needs teaching on how to self administer enoxaparin injections Client who has just been admitted to the telemetry unit from the emergency department with a rule out myocardial infarction Client with a nitroglycerin infusion with prescription to titrate to keep systolic blood pressure <!50mmHg; currently is 110/62 mmHg
ANS A Option 2 the RN is responsible for initial client teaching. Teaching self administration of enoxaparin can be complex and should be done by the RN. the LPN can reinforce the teaching done by the RN Option 3 the client being admitted from the emergency department requires clinical assessment and clinical judgement which should be handled by the RN Option 4 the client on nitroglycerin is complex and requires titration of an intravenous medication; this client should be assigned to an RN
Apparent rushes a four-year-old child to the emergency department after finding the child sitting on the kitchen floor holding an empty bottle of aspirin. The parent has no idea how many tablets were left in the container. the child is sniffling and quietly crying. The nurse anticipates initially implementing which treatment? activated charcoal gastric lavage sodium bicarbonate syrup of ipecac
ANS A activated charcoal Activated charcoal is an important treatment in early acetylsalicylic acid (ASA) toxicity; it is recommended for gastrointestinal decontamination and clients with clinical signs of ASA poisoning (disorientation, vomiting, hyperpnea, diaphoresis, and restlessness) as well as in those who are asymptomatic. Activated charcoal binds to available salicylates, that is limiting further absorption in the small intestine enhancing elimination. Option 2 Similar to syrup of ipecac, gastric lavage is associated with the risk of aspiration. In addition, there is no convincing evidence that it decreases morbidity. it is not routinely recommended but maybe perform for the injection a massive or life-threatening amount of drug. if necessary, it should be administered with 1 hour of ingestion and requires a protected Airway and possible sedation. Option 3 IV sodium bicarbonate is an appropriate treatment for aspirin toxicity after the administration of activated charcoal. It is given to make the blood and urine more alkaline, therefore promoting urinary excretion of salicylate. Option 4 syrup of ipecac has been shown to have minimal benefit in treating aspirin overdose; in addition it is not recommended due to the risk of aspiration pneumonia secondary to induced vomiting.
Nurse receives a report on 4 pediatric clients of the emergency department. which client should be seen first? A 3-week-old with a fever who's sleeping more than usual and refuses to feed, B 4-month-old who has painless new onset bilateral testicular swelling C 8-month-old who ingested a bottle of children's bubble soap 30 minutes ago D 2-year-old with fever, runny nose, cough, and a sore throat for the past two days
ANS A three week old with a fever who's sleeping more than usual and refuses to feed. Sepsis neonatorum is a medical Emergency. newborns may not exhibit obvious signs of infection but instead may have elevated temperature or be hypothermic. subtle changes such as irritability, increased sleepiness, and poor feeding should be considered red flags. blood urine cerebral spinal fluid culture should be obtained immediately and broad spectrum antibiotics started. Option B this infant has signs of hydrocele, a fluid-filled testicular Mass. it resolves before the first birthday and are not a medical emergency. Option C children's bubble soap is non-toxic. as a precaution the Poison Control Center should be contacted but this is not a priority over a newborn with fever. Option D this child likely has upper respiratory viral or bacterial infection. this localized infection is not a priority over a generalized bloodstream infection i e a neonatal sepsis.
The nurse is reinforcing education to a client newly prescribed LEVETIRACETAM for seizures. Which statement bade by the client indicates a need for further instruction? 1. Drowsiness is a common side effect of this medication and will improve over time 2. I can begin driving again after I have been on this medication for a few weeks 3. I need to immediately report any new or increased anxiety when on this medication 4. I need to immediately report any new rash when on this medication
ANS B LEVETIRACETAM (KEPPRA) is an anticonvulsant prescribed for seizure disorders. as with other antiseizure meds levetiracetam has a depressing effect on the CNS which may cause drowsiness, somnolence and fatigue as clients adjust to the med. Ct should be assured that this is common and typically improves within 4-6 weeks (option 1). However, the CNS depressing effect of levetiracetam may be enhanced if taken with other CNS depressing substances (Eg alcohol) or medications. new or increased agitation, anxiety, and/or depression or mood changes should be reported immediately as levetiracetam is associated with suicidal ideation (option 3). Like other anticonvulsants levetiracem can trigger Stevens-Johnson syndrome a rare but life threatening blistering reaction of the skin. Rash, blistering, muscle/joint pain or conjunctivitis should be reported and assessed immediately (option 4). option 2 clients with seizure disorders should avoid driving or operating heavy machinery until they have permission from their health care provider and have met the requirements of their department of transportation. typically the client must be free from seizure for an allotted time period.
A visiting family member of a hospitalized client report sudden onset of a headache and numbness in half of the body. the visitor asks the nurse to take a blood pressure reading. what is the most appropriate response by the nurse? encourage the visitor to lie down to see if symptoms change initiate protocol to assist the visitor to the emergency department proceed to take the visitor's blood pressure suggest that the visitor called the healthcare provider
ANS B initiate protocol to assist the visitor to the emergency department providing care established as legal caregiver obligation/ relationship between the nurse and the visitor. if a relationship is started the nurse has a duty to continue care until the visitor is stable or other Healthcare Personnel can take over. if proper care is not continued, the nurse could be accused of negligence (ie failure to act in a prudent manner as what a nurse with similar education/ experience) this visitor's symptoms are potentially serious a sudden onset of headache and numbness in half of the body May indicate stroke. in an event of a visitor emergency the nurse should not establish your caregiver relationship with rather Implement facility protocol to help the desert get to the emergency department promptly to receive immediate assessment for further evaluation option 2 Option 1 and 4 asking the visitor to call the healthcare provider or giving advice to lie down to Lazy essential assessment and treatment that this visitor with potentially serious symptom require. Option 3 when a nurse provides care (eg takes blood pressure) a client caregiver relationship is established. the nurse caring for a visitor is ill-equipped to provide care without any hcp prescriptions in place and risks being negligent.
A school age child is brought to the emergency department due to nausea, vomiting and severe right lower quadrant pain. The child's white blood cell count is 17000/mm3. Which statement by the child is of most concern to the nurse? 1. i am hungry and they will not let me eat 2. i dont like hospitals and i want to go home 3. im so tired 4. my belly doesnt hurt anymore
ANS D may be Appendicitis? Option 1 needs surgery thus npo Option 2 normal state Option 3 tiredness is nonspecific and could be due to many reasons (Eg pain med)
The nurse has received a report on the following pediatric clients. Which action should the nurse perform first? Administer water enema to the 2 year old with intussusception who has severe abdominal pain call the healthcare provider about the four year old with leukemia who has a low-grade fever measure head circumference of the three month old with ventriculoperitoneal shunt placement Suction the 3 month old with bronchiolitis who is irritable and scheduled for a feeding
ANS D suction the 3 month old with bronchiolitis who is irritable and scheduled for a feeding bronchiolitis is a lower respiratory tract infection most commonly caused by respiratory syncytial virus (RSV) (fyi: under contact precautions). It causes inflammation and obstruction of the lower respiratory tract. Depending on the severity of the infection, infants with bronchiolitis can experience mild cold symptoms or respiratory distress. the infant will have difficulty feeding and can become dehydrated. Medical Care is supportive and includes suctioning, oxygen, and hydration. the infant with irritability may be exhibiting signs of hypoxia. The nurse should see the client first. Option 1 intussusception can be reduced with hydrostatic enema ( non-operative approach). this is important but it is not a priority over a child with bronchiolitis and respiratory distress. Option 2 chemotherapy can result in neutropenia and immunosuppression. even a low-grade fever should be taken seriously as it can result in Lethal sepsis. the client needs cultures and empiric antibiotics. however the client with a bronchiolitis is the priority. Option 3 increased intracranial pressure will occur with shunt function. the nurses routinely measure the head circumference, but it is not a priority over a client with respiratory distress.
Unlicensed assistive Personnel report for situations to the RN. which situation warrants the nurse's intervention first? room 1: applying on a 24-hour urine collection had a specimen discarded by mistake Room 2: client and family request clergy to administer last rites room 3: puncture resistant Sharps disposable container on the wall is full room 4: client with diabetes mellitus has an 8:00 a.m. finger stick glucose of 80 mg per deciliter ( 4.4 mmol/l)
ANS c room 3: puncture resistant Sharps disposable container on the wall is full option one if any urine is discarded by accident during a 24-hour collection test the procedure must be restarted and you container will be needed to be labeled with an appropriate time and day but immediate intervention is not required option to the nurse or arrange for a visit from clergy to administer the last rites a religious ceremony for Roman Catholic clients who are extremely or terminally ill although the situation requires prompt intervention does not involve safety hazard option 4 finger finger stick glucose of 80 mg/dl is normal and require no intervention unless the client received insulin and refuses or is unable to eat. educational objective: prevention of injury and safety in the workplace should be a priority when the nurse is delegating planning or providing nursing care
the nurse cares for a group of clients in a medical surgical unit. the client with which diagnosis and condition requires the most immediate assistance by the nurse? Post cholecystectomy, reporting incision pain of a 5 on a scale of 1 to 10 Post open reduction of the right femur, reporting nausea Type 1 diabetes mellitus with a blood glucose of 55 mg/dl (3.1 mmol/l) Type 2 diabetes mellitus with the blood glucose of 250 mg/dl (!3.9 mmol/l)
ANS c Type 1 diabetes mellitus with a blood glucose of 55 mg/dl (3.1 mmol/l) Hypoglycemia is the most life-threatening condition listed. It occurs when the proportion of insulin exceeds the glucose in the blood. Counterregulatory hormones (eg epinephrine) are then released and the autonomic nervous system is activated, causing multiple hypoglycemia Associated symptoms, including increased heart rate, shakiness, sweating, hunger, anxiety, and pallor. The lack of glucose in the brain is also responsible for other symptoms, including disorientation, impaired vision and speech, seizures and coma. However, most clients respond rapidly to the correction of hypoglycemia. (MARK KLIMEK "DRUNK s/s + SHOCK s/s" = s/s for hypoglycemia) Options 1 and 2 the client with cholecystectomy with incisional pain and the client reporting nausea after open reduction of the right femur are in need of nursing attention. however these are not life-threatening problems. (they'd prob differ) Option 4 the client with type 2 diabetes has a blood glucose level of 13.9 mmol/l but this is not immediately life-threatening compared to the client with HYPOGLYCEMIA.
