UWorld Fundamentals

A client with hypokalemia is prescribed IV potassium chloride (KCl) to infuse at 10 mEq/hr. The pharmacy sends 20 mEq of KCl in 250 mL of D5W. To deliver the prescribed dose, the nurse sets the infusion pump at how many milliliters per hour (mL/hr)? Record your answer using a whole number. Answer: (mL/hr)

125 mL/hr Educational objective: To calculate the infusion rate of potassium chloride, the nurse should first identify the prescribed dose (eg, 10 mEq/hr) and available medication (eg, 20 mEq/250 mL) and then convert to volume in milliliters per hour (eg, 125 mL/hr).

The charge nurse must assign rooms to 4 clients who are scheduled for admission. Which client has the highest priority for a private room assignment? 1. Client who is a known IV drug abuser who has osteomyelitis of the arm and chronic hepatitis C 2. Client with chronic obstructive pulmonary disease who has a latent tuberculosis infection 3. Client with diabetes mellitus and HIV infection who is in diabetic ketoacidosis 4. Client with pneumonia who has a positive methicillin-resistant Staphylococcus aureus nose culture

4 A client with a positive nose swab for methicillin-resistant Staphylococcus aureus (MRSA) is colonized and can transmit the bacteria to others. If signs of infection are absent, treatment is not required. Colonized clients are at increased risk for infection with MRSA; if signs (eg, fever, wound drainage, purulent mucus) are present, treatment is required. The Centers for Disease Control and Prevention (CDC) recommends placing a colonized client on contact precautions and in a private room. The CDC also recommends that the highest priority be given to placing a colonized client who may transmit the bacteria through body secretions or excretions (eg, sputum, wound drainage) in a private room. Therefore, the client with pneumonia should be placed in the private room. (Options 1 and 3) The CDC recommends standard precautions for clients with hepatitis C and those who are HIV positive. A private room is not necessary for a client who has osteomyelitis or diabetic ketoacidosis. (Option 2) A client with a latent tuberculosis infection (LTBI) has a positive tuberculin skin test, has no symptoms of infection, and is not contagious. Immunosuppressant drugs, chemotherapy, and debilitating disease can convert a LTBI to active disease. At this time, the client requires only standard precautions. Educational objective: The Centers for Disease Control and Prevention recommends contact precautions and private room placement for a client who is colonized with methicillin-resistant Staphylococcus aureus, especially if the client can transmit the bacteria through body secretions or excretions.

The registered nurse (RN) is providing nursing care with a licensed practical nurse and unlicensed assistive personnel. The RN administers hydromorphone 1.5 mg IVP per STAT order to a client with severe abdominal pain. Three hours later, the client rates pain as a 9 on a scale of 0-10 and requests pain medication. What is the most appropriate action for the RN to take? 1. Administer the hydromorphone 2. Ask the licensed practical nurse to administer the medication 3. Ask the unlicensed assistive personnel to take repeat vital signs 4. Contact the health care provider

4 A STAT order indicates that the medication should be given immediately and only one time. A new prescription for the medication must be acquired before the dose can be repeated. The most appropriate action is to contact the health care provider to request an as-needed prescription for pain medication. (Option 1) A STAT medication dose was administered and cannot be repeated without a new prescription. (Option 2) In most states, the registered nurse (RN) cannot delegate the administration of IV opioids to the licensed practical nurse, and it cannot be administered without a new prescription. (Option 3) The RN can delegate repeat vital sign checks to the unlicensed assistive personnel, but it is not the most appropriate action. Educational objective: A STAT order indicates that a medication is to be given immediately and only once.

The nurse dons personal protective equipment (PPE) before providing care for a client in airborne transmission-based precautions. Place the steps for donning PPE in the appropriate sequence. All options must be used. 1. Gloves 2. Goggles or face shield 3. Gown 4. Hand hygiene 5. Mask or respirator

4, 3, 5, 2, 1 PPE for the health care worker protects the mucous membranes, airways, skin, and clothing from contact with potentially infectious agents. The category of transmission-based precautions (eg, contact, droplet, airborne) required determines the type of PPE that the health care worker will wear. The exact procedure for donning and removing PPE varies with the level of precautions required. Guidelines are provided by the Centers for Disease Control and Prevention (CDC) and by institution policy and procedure. The sequence for donning PPE includes: 1. Hand hygiene 2. Gown - fully cover torso from neck to knees, arms to end of wrists, and wrap around back; fasten in back of neck and waist 3. Mask or respirator - secure ties or elastic bands at middle of head and neck; fit flexible band to nose bridge; fit snugly to face and below chin; fit-check respirator 4. Goggles or face shield - place over face and eyes and adjust fit; may be combined with mask (visor) 5. Gloves - don and extend to cover wrist of isolation gown Educational objective: The CDC suggests the following sequence for donning PPE: hand hygiene, gown, mask or respirator, goggles or face shield, and gloves. Safety and Infection Control

A 2-year-old who swallowed an overdose of adult cough syrup is being discharged from the emergency department. The parent says to the nurse, "From now on, I'm going to store all medicines in my top dresser drawer." Which is the best response by the nurse? 1. "Can you lock your dresser drawer?" 2. "Make sure all of your medicines have childproof caps." 3. "That sounds like a safe plan." 4. "You need to keep an eye on your child at all times."

1 Children are naturally curious and attracted to medicine, especially if it is sweet and syrupy like many over-the-counter cold products. They usually find medicines when exploring their environment and "getting into everything" when no one is watching. Children may find medicine in a parent's coat pocket or purse, under a counter cabinet, or on a nightstand. Even if a drug is stored in a place that seems out of reach, children can climb on a chair or stool to reach it. Medications are the leading cause of child poisoning. The best preventive measures include placing all medications out of sight, placing them in a drawer or cabinet with a childproof lock, and putting them away after each use (Option 1). (Option 2) Advising a parent/caregiver to ensure that medicine containers have childproof caps is an appropriate instruction; however, it is not the priority response in this situation. (Option 3) Storing medicines in a dresser drawer is not a safe plan unless the drawer can be locked. (Option 4) Although it is impossible for a parent or caregiver to watch a child every minute of the day, toddlers need adult supervision when active and exploring their environment. Educational objective: The most important strategy to prevent accidental drug overdoses in children is teaching parents and caregivers to keep medicines out of sight, in a locked drawer or cabinet. Parents/caregivers should also be advised to put drugs away after each use.

A student nurse assesses and obtains a urine specimen from a client with methicillin-resistant Staphylococcus aureus (MRSA) who is on contact precautions. The registered nurse intervenes when the student performs which action? 1. Cleans the disposable stethoscope with chlorhexidine solution before reuse with a different client 2. Removes the urine specimen cup from the room in a sealed biohazard bag 3. Scrubs the Foley catheter collection port with alcohol for 15 seconds before withdrawing a urine specimen 4. Uses an alcohol-based hand antiseptic solution after removing gloves

1 Clients with a health care-associated infection, such as methicillin-resistant Staphylococcus aureus, are placed on contact precautions to prevent transmission of microorganisms. Contact precautions include standard precaution measures in addition to use of a gown and gloves and single-client-use equipment (eg, stethoscopes, blood pressure cuffs, thermometers). Disposable or single-client-use equipment must not be shared between clients or transferred to other care areas. Dedicated equipment should be kept in the room for client care, and then disinfected or discarded when no longer needed (Option 1). (Option 2) The urine specimen should be placed in a leak-proof specimen cup and then sealed in a biohazard bag before transport to the laboratory. (Option 3) To prevent specimen contamination and the introduction of bacteria into the client's urinary tract, the nurse should scrub the Foley collection port with alcohol or chlorhexidine for 15 seconds before withdrawing a specimen. (Option 4) Hand hygiene with an alcohol-based hand rub is recommended, unless there is visible soiling of the hands with body fluids, or after contact with Clostridium difficile. In both situations, hand hygiene must be performed with soap and water to thoroughly remove contaminants left behind by alcohol-based rubs. Educational objective: Nurses should implement contact precautions (eg, gown/gloves, single-client-use equipment) for clients with methicillin-resistant Staphylococcus aureus to prevent transmission of microorganisms. Single-client-use or disposable equipment should not be shared between clients. Hand hygiene with alcohol-based hand rubs is appropriate unless visible soiling or exposure to Clostridium difficile occurs. Safety and Infection Control

The nurse is caring for a client on droplet precautions who has a prescription for a CT scan. When transporting the client to radiology, the nurse should ensure that the transporter uses protective equipment correctly to reduce the environmental spread of infection when the client is outside the room. Which instruction should the nurse give the transporter? 1. Have the client wear a mask 2. Have the client wear gloves 3. Wear a mask 4. Wear an isolation gown

1 Droplet precautions are used to prevent transmission of respiratory infection. These precautions include the use of a mask and a private room. When the client is in the room, staff should wear masks and follow standard precautions. The client on droplet precautions should wear a mask at all times when outside the hospital room. (Option 2) Gloves are not required as part of droplet precautions. Standard precautions should guide the use of gloves in clients on droplet precautions. (Option 3) The transporter does not need to wear a mask outside of the client's room as long as the client keeps a mask on to prevent transmission of infection. (Option 4) An isolation gown is not required for droplet precautions. Educational objective: Droplet precautions require the use of regular masks to prevent the transmission of infection. A mask should be worn by the client when outside the hospital room and by staff when in the client's room.

The nurse observes a student nurse administer a tuberculin skin test using the intradermal route. The nurse intervenes when the student performs which action? 1. Advances tip of needle through epidermis until the bevel is no longer visible under the skin 2. Chooses a 1 mL tuberculin syringe with a 27-gauge 1/4 inch needle; dons clean gloves 3. Injects medication slowly while raising a small wheal (bleb) on the skin 4. Inserts needle at a 10-degree angle almost parallel to skin with the bevel up

1 Intradermal dermal injections deliver a small amount of medication (0.1 mL) into the dermal layer of the skin, just under the epidermis. This parenteral route is used to perform allergy testing and tuberculosis (TB) screening. The correct procedure for administering a TB intradermal injection is as follows: 1. Choose a 1 mL tuberculin syringe with a 27-gauge 1/4 inch needle then don clean gloves - the syringe is calibrated in hundredths of a millimeter and the intradermal needle is short enough to remain in the dermis with length range of 1/4-5/8 inch (Option 2). 2. Position the left forearm to face upward, and cleanse site that is a hands width above the wrist - the left arm is commonly used for TB testing; the forearm has little hair and subcutaneous tissue and is readily accessible to observe a skin reaction. 3. Place non-dominant hand 1 inch below the insertion site and pull skin downward so that it is taut - taut skin makes it easier to insert the needle and promotes comfort. 4. Insert the needle almost parallel to skin at a 10-degree angle with bevel up - this is important as the medication can enter the subcutaneous tissue if the angle is >15 degrees (Option 4). 5. Advance the tip of the needle through epidermis into dermis; outline of bevel should be visible under the skin - verify that the medication will be injected into dermis (Option 1). 6. Inject medication slowly while raising a small wheal (bleb) on the skin - verify that the medication is being deposited into the dermis (Option 3). 7. Remove needle and do not rub the area - rubbing promotes leakage through the insertion site and medication deposition into the tissue. 8. Circle the area with a pen to assess for redness and induration (according to institution policy) - this delineates the border for measurement of reaction. Educational objective: For TB skin testing: Use a 27-gauge 1/4 inch needle with a 1 mL tuberculin syringe Administer injection on inner forearm at a 10-degree angle with bevel up Make a wheal (bleb) Avoid rubbing site after injection Pharmacological and Parenteral Therapies

The HCP prescribes IV fluid resuscitation for a client in hypovolemic shock. The nurse should anticipate the rapid infusion of which IV solution initially? 1. 0.9% sodium chloride 2. 5% albumin 3. dextrose 5% and LR 4. dextrose 5% and water

1 Normal saline is the fluid of choice for rapid correction of hypotension in most situations, including hypovolemic and septic shock. It can be administered in large quantities rather rapidly and is inexpensive. (Option 2) When 5% albumin, a colloid solution, is infused into the intravascular space, it mobilizes fluid from the extravascular tissues into the extracellular vascular space. Although it is equally effective in expanding intravascular fluid volume, it is expensive and not the initial fluid of choice. It can be used in clients with low intravascular protein (albumin) content and hypotension but increased fluid in extravascular tissues (eg, cirrhosis with ascites). (Option 3) When dextrose 5% and LR, a hypertonic solution, is infused into the intravascular space, it mobilizes fluid from the extravascular tissue into the extracellular vascular space. Although it may be used to expand fluid volume, it is not the initial IV fluid of choice. (Option 4) When the dextrose in dextrose 5% and water is metabolized, a hypotonic solution is left. In large volumes, it can cause shift of the fluid into the extravascular compartment, which may cause further hypotension in clients with low BP. Hypotonic solutions (0.45% saline or dextrose 5% and water) are typically used to treat hypernatremia. Educational objective: Isotonic solutions are used for immediate fluid resuscitation in clients with hypovolemic shock. Physiological Adaptation

A hospitalized client is scheduled for a percutaneous kidney biopsy at 10 AM. At 8 AM, the nurse reviews the client's vital signs and most current serum laboratory results. Which finding is most important to report to the health care provider (HCP)? 1. Blood pressure of 180/100 mm Hg 2. Creatinine of 2 mg/dL (176.8 µmol/L) 3. Hemoglobin of 9.8 g/dL (98 g/L) 4. Platelet count of 120,000/mm3 (120 x 109/L)

1 Percutaneous kidney biopsy is an invasive diagnostic procedure. It involves inserting a needle through the skin to obtain a tissue sample that is then used to determine the cause of certain kidney diseases. The kidney is a highly vascular organ; therefore, uncontrolled hypertension is a contraindication for kidney biopsy as increased renal arterial pressure places the client at risk for post-procedure bleeding. Blood pressure must be lowered and well-controlled (goal <140/90 mm Hg) using antihypertensive medications before performing a kidney biopsy (Option 1). (Option 2) An elevated serum creatinine level (normal: 0.6-1.3 mg/dL [53-115 µmol/L) can be expected in a client with probable renal disease. This is not the most important finding to report to the HCP. (Option 3) A decreased hemoglobin level (normal adult male: 13.2-17.3 g/dL [132-173 g/L]; normal adult female: 11.7-15.5 g/dL [117-155 g/L]) can be expected in a client with probable renal disease due to decreased erythropoietin production. The nurse should continue to monitor the client's hemoglobin post-procedure as it can decrease further (within 6 hours) if bleeding occurs. (Option 4) Only neurosurgery and ocular surgery require a platelet count >100,000/mm3 (100 x 109/L). Most other surgeries can be performed when the platelet count is >50,000/mm3 (50 x 109/L). Although the platelet count is low (normal 150,000-400,000/mm3 [150-400 x109/L]), it is not the most important finding to report to the HCP. Educational objective: The kidney is a highly vascular organ and the risk of bleeding is a major complication after a percutaneous biopsy. The client should have normal coagulation studies, an adequate platelet count, and well-controlled blood pressure prior to the procedure to reduce bleeding risk.

The nurse is administering a pink pill to a hospitalized medical-surgical client. The alert, oriented client says, "This is a pill I haven't seen before." What follow-up action should the nurse take next? 1. Check the health care provider's prescription in the medical record 2. Explain that the health care provider has prescribed the medication 3. Look up the medication in the pharmacology reference 4. Teach the client about the purpose of the medication

1 Safe medication administration is conducted according to 6 rights: Right client using 2 identifiers Right medication Right dose Right route Right time Right documentation When a mentally competent client questions a drug administration, the safest option is to first check the prescription to verify the 6 rights of medication administration (Option 1). If an error is ruled out (eg, different brand, new order) the nurse should follow up with appropriate teaching. (Option 2) The nurse must first verify all aspects of proper medication administration. If they are correct, the nurse should provide appropriate teaching on why the health care provider prescribed the medication. Explaining that the nurse is just following orders is rarely the correct answer. (Option 3) A pharmacology reference can verify information about the medication but will not confirm that the client is the correct recipient. Acceptable identifiers include first and last name, medical record number, and birth date. (Option 4) The nurse can teach the client about the purpose of the medication after the 6 rights have been verified. Educational objective: When a competent client questions a new medication, the nurse should first verify the 6 rights of safe medication administration: right client, medication, dose, route, time, and documentation. If safe administration has been confirmed, the nurse should then provide appropriate teaching to the client.

The nurse is assessing a client's peripheral pulses. The nurse palpates the top portion of the client's foot. The right pulse is easily palpable, and the left pulse is diminished but still palpable. How should the nurse document these findings? 1. Bilateral dorsalis pedis (DP) pulses palpable. Right DP 2+, left DP 1+. 2. Bilateral DP pulses palpable. Right DP 3+, left DP 2+. 3. Bilateral popliteal pulses palpable. Right foot > left foot. 4. Bilateral posterior tibial (PT) pulses palpable. Right PT 2+, left PT 1+.

1 The DP pulse is located on the top or dorsal part of the foot. The nurse should compare the characteristics of the arteries on the right and left extremities simultaneously to determine symmetry. The force of the pulse should be rated on the following scale. 0 Absent 1+ Weak 2+ Normal 3+ Increased, full, bounding (Option 2) DP is the correct artery being assessed, but 3+ would indicate a full, bounding pulse and 2+ would indicate a normal pulse. (Option 3) The popliteal pulse is assessed just behind the knee area, not on the foot. The description of the right foot being greater than the left foot does not indicate the force of the individual pulse. (Option 4) Posterior tibial pulses are palpated just behind the medial malleolus bone on the foot. The description of 2+ and 1+ is accurate. Educational objective: The nurse should palpate and compare the characteristic and quality of the pulses on the right and left extremities simultaneously to determine symmetry. The force of the pulse should be rated as 0, absent; 1+, weak; 2+, normal; and 3+, increased, full, bounding. These descriptions should be documented in the client's record. Health Promotion and Maintenance

The clinic nurse is assessing the client's understanding of tiotropium, which has been prescribed for chronic obstructive pulmonary disease (COPD). Which statement indicates that the client has a correct understanding of this medication? 1. "A capsule holds the powdered medication that I have to put in a special inhaler." 2. "I do not need to rinse my mouth with water after taking tiotropium." 3. "I have been taking tiotropium every time I have difficulty breathing." 4. "Tiotropium helps control my COPD by reducing inflammation in my airway."

1 Tiotropium (Spiriva) is a long-acting, 24-hour, anticholinergic, inhaled medication used to control chronic obstructive pulmonary disease (COPD). It is administered most commonly using a capsule-inhaler system called the HandiHaler. The powdered medication dose is contained in a capsule. The client places the capsule in the inhaler device and pushes a button on the side of the device, which pokes a hole in the capsule. As the client inhales, the powder is dispersed through the hole. Unlike most inhaled medications, tiotropium looks like an oral medication because it comes in a capsule. Therefore, it is important to teach the client proper administration prior to the first dose, emphasizing that the capsule should not be swallowed and that the button on the inhaler must be pushed to allow for medication dispersion. During future appointments, the nurse should assess/reassess the client's ability to use this medication correctly. (Option 2) Clients should rinse the mouth after using tiotropium and inhaled steroids (eg, beclomethasone, budesonide, fluticasone) to remove any medication remaining in the mouth, which decreases the risk of developing thrush. (Option 3) Tiotropium is a controller medication for COPD with a peak effect of approximately 1 week; therefore, it should not be used as a rescue medication. Instead, short-acting bronchodilators (eg, albuterol and/or ipratropium) should be used for symptom rescue. Clients must discontinue ipratropium before taking tiotropium as both are anticholinergic. (Option 4) Anticholinergic inhaled medications (eg, ipratropium, tiotropium, umeclidinium) do not reduce inflammation in the airway. Instead, they relax the airway by blocking parasympathetic bronchoconstriction. They also help dry up airway secretions. Educational objective: Tiotropium and umeclidinium are long-acting, 24-hour, anticholinergic medications. Ipratropium is a short-acting anticholinergic used as a rescue medication for COPD and asthma. Tiotropium is typically administered as a powder via a special inhaler.

A client is able to partially bear weight and follow the nurse's instructions. Which would be the most appropriate method for the nurse to use to safely transfer this client? 1. 1-person stand and pivot with gait belt and walker 2. 1-person standby assist with walker 3. 2-person motorized stand-assist lift 4. 2-person stand and pivot with gait belt and walker

1 To determine the most appropriate method to safely transfer a client for the first time, the nurse should assess: - Whether the client can bear weight - Whether the client is cooperative If the client is cooperative and able to partially bear weight, a safe transfer requires a 1-person stand and pivot technique with a gait belt or powered stand-assist lift (Option 1). If the client can fully bear weight and is cooperative, the client will not require an assisted transfer. However, a caregiver should stand by during the first transfer for safety or for assistance (Option 2). (Option 3) This method would be appropriate for a client who has no weight-bearing ability but can follow instructions and has enough upper body strength to use a motorized stand-assist lift. (Option 4) If the nurse determines that the client cannot be safely transferred with assistance from 1 caregiver, a 2-person stand and pivot transfer may be performed. However, the nurse should first encourage the client to use as much own strength as possible. Educational objective: If the client is cooperative and able to partially bear weight, a safe transfer requires a 1-person stand and pivot technique with a gait belt or powered stand-assist lift.

The nurse is inserting an indwelling (Foley) urinary catheter into a male client. After inserting the catheter about 6 in (15.2 cm), the nurse notes drops of urine in the tubing. What action should the nurse take next? 1. Further insert the catheter 1-2 in (2.5-5.1 cm) 2. Have the client hold his breath 3. Immediately inflate the 5 mL balloon 4. Secure the tubing to the client's leg

1 Urine could be in the urethra and evident in the tubing even though the tip with the balloon is not in the bladder. It is necessary to further insert the catheter before inflating the balloon to make sure the tip is in the bladder and not the urethra (causing urethral trauma). In the male client, it is recommended that the catheter be inserted 7-9 in (17-22.5 cm) or until urine flows out, due to the longer urethra. The catheter should then be inserted at least an additional 1 in (2.5 cm) or to catheter bifurcation. (Option 2) The client should be told to take slow, deep breaths to help relax the external sphincter and provide a distraction. (Option 3) The catheter needs to be inserted further before inflating the balloon to prevent urethral trauma. (Option 4) Securing the catheter to the leg occurs after the balloon is inflated and placement is assured. Educational objective: Insert the Foley urinary catheter further if drops appear in the tubing to ensure that the tip with the balloon is in the bladder. Inflating the balloon before advancing the catheter could result in urethral trauma.

The nurse is caring for a client with bacterial meningitis, identified as Neisseria meningitidis who has a stage 4 pressure injury. What personal protective equipment is most appropriate for the nurse to wear when performing a dressing change? Select all that apply. 1. Disposable gown 2. Face shield 3. Gloves 4. N95 respirator 5. Surgical mask

1, 2, 3, 5 Bacterial meningitis (eg, Neisseria meningitidis) and many respiratory illnesses (eg, influenza) are transmitted through large droplets of secretions spread into the air by coughing, sneezing, or talking. These droplets can land on surfaces up to 6 feet (1.8 meters) away from the client. Droplet precautions for routine care (eg, medication administration) require the use of a surgical mask, as the highest risk of transmission is through inhalation of droplets (Option 5). Wearing a face shield, gown, and gloves is required if there is a risk of splash or contact with body fluids from procedural client care (eg, suctioning, wound care) (Options 1, 2, and 3). Dedicated medical equipment (eg, stethoscope, blood pressure cuff) should remain in the room to limit spread of infection. (Option 4) For client care involving airborne precautions, a class N95 or higher respirator must be used instead of a surgical mask to avoid potential exposure to aerosolized particles. Surgical masks are rated only for barrier protection from droplet splashing and for filtration of large respiratory particles. Educational objective: When caring for clients on droplet precautions, a surgical mask is needed for routine care, such as assessment or medication administration. If there is risk of contact with body fluids during procedures (eg, wound care, suctioning), gloves, gown, and face shield are used.

Which measures will help prevent falls in the elderly clients of a long-term care facility? Select all that apply. 1. Exercise programs 2. Good room lighting 3. Handrails in stairwell 4. Smooth-soled shoes 5. Staff hourly rounds

1, 2, 3, 5 Falls are a leading predictor of mortality and morbidity in older adults. General exercise programs, especially those including gait, balance, and strength training, not only reduce the risk of falls but also prevent injuries from falls (Option 1). Vision impairment can contribute to fall risks; most adults need additional light by age 50. The nurse should ensure that clients are wearing needed prescription glasses (Option 2). Handrails, particularly in stairwells, hallways, and bathrooms, have been shown to reduce falls (Option 3). Studies show that staff rounds at regular intervals (hourly or every other hour) decrease falls and call light use. The practice allows staff to intervene early in needs. Typically staff checks on the "Ps": potty, position, pain, and placement/proximity of personal items (eg, bed height, call light, water, tissues, urinal). A common reason clients get out of bed unassisted is to use the bathroom (Option 5). (Option 4) Non-slip rubber-soled shoes are recommended to prevent falls. Educational objective: Client falls can be prevented with exercise programs, good lighting, handrails, and hourly staff rounds. Safety and Infection Control

The nurse is reinforcing instructions to a client on collection of a sputum specimen for culture and sensitivity. Which of the following client statements indicate that teaching has been effective? Select all that apply. 1. "I should rinse my mouth with water before collecting the sputum." 2. "I will be careful not to touch the inside of the specimen cup or lid." 3. "I will inhale deeply a few times and then cough forcefully." 4. "It is best to collect the sputum mid-day when my secretions are loose." 5. "It is helpful if I am sitting upright when I collect the sputum."

1, 2, 3, 5 Sputum culture and sensitivity testing is used to identify infectious organisms in the respiratory tract and determine which antimicrobials are most effective at treating the identified organism. Nurses assisting a client to collect sputum should instruct the client to: - Rinse the mouth with water before collecting the sputum sample to reduce bacteria in the mouth and prevent specimen contamination by oral flora (Option 1) - Avoid touching the inside of the sterile container or lid to avoid accidental specimen contamination by normal flora of the skin (Option 2) - Inhale deeply several times and then cough forcefully, which promotes expectoration of lower lung secretions and increases sample volume (Option 3) - Assume a sitting or upright position before specimen collection, if possible, to promote cough strength during collection (Option 5) (Option 4) Sputum specimens should be collected early in the morning after awakening, which improves the quality of the sample because secretions accumulate overnight due to cough inhibition. A nebulizer treatment may be prescribed to help mobilize thick secretions. Educational objective: Collection of a sputum specimen by expectoration is a sterile procedure that requires the client to breathe deeply and cough effectively. The nurse should instruct the client to rinse the mouth with water, sit upright, inhale deeply several times, and cough prior to expectorating. The client should avoid touching the inside of the sterile container or lid. Sputum should be collected in the morning to improve sample quality. Reduction of Risk Potential

The nurse admits an 80-year-old client with an altered LOC 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 nurses' 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

1, 2, 3, 5 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 dehydration) - 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).

A client with suspected foot osteomyelitis is scheduled for an MRI. Which findings should the nurse notify the health care provider about before the test? Select all that apply. 1. Aneurysm clip 2. Cardiac pacemaker 3. Colostomy 4. Retained metal foreign body in eye 5. Transdermal testosterone patch

1, 2, 4 Clients must be screened for contraindications before exposure to a magnetic field (MRI) as it can damage implanted devices or metallic implants. Absolute contraindications can preclude testing, and relative contraindications can pose a hazard to the client's devices or implants, affect the quality of the images, or cause discomfort. Absolute contraindications: - Cardiac pacemaker (Option 2) - Implantable cardioverter defibrillator - Cochlear implant - Retained metallic foreign body, especially in organs such as the eye (Option 4) Relative contraindications: - Prosthetic heart valve - Metal plate, pin, brain aneurysm clip, or joint prosthesis (Option 1) - Some of these devices have nonferrous MRI-safe materials and should be verified. - Implanted device (eg, insulin pump, medication port) Other factors that can affect the client's eligibility include inability to remain supine for 30-60 minutes and claustrophobia; however, these concerns are often controllable (eg, sedation can be prescribed, open MRI machine can be used). (Option 3) A colostomy is not a contraindication for MRI. (Option 5) Transdermal metal-containing medication patches (clonidine, nicotine, scopolamine, testosterone, or fentanyl) are not a contraindication for MRI. However, the nurse should remove the patch beforehand due to the risk of burns and replace after testing. Educational objective: Usual contraindications for MRI include implanted devices (eg, pacemaker, implantable cardioverter defibrillator, medication ports), certain metal implants (eg, plates, pins, brain aneurysm clips, joint prostheses), and presence of a retained metal foreign body. However, some of these devices are now manufactured with MRI-safe materials that should be verified.

A client diagnosed with hypertension has been prescribed a clonidine patch. Which instructions should the nurse include? Select all that apply. 1. Apply patch to the upper arm or chest 2. Fold used patches in half with sticky sides together before discarding 3. Remove patch if dizziness occurs when getting up 4. Rotate sites each time a new patch is applied 5. Shave hair before applying patch

1, 2, 4 Clonidine is a potent antihypertensive agent and is available as a transdermal patch. The patches should be replaced every 7 days and can be left in place during bathing. Instructions for using the clonidine (transdermal) patch: 1) Apply the patch to a dry hairless area on the upper outer arm or chest once every 7 days (Option 1). 2) Do not shave the area before applying the patch. The skin should be free from cuts, scrapes, calluses, or scars (Option 5). 3) Wash hands with soap and water before and after applying the patch as some medication may remain on the hands after application. 4) Wash the area with soap and water, then rinse and wipe with a clean, dry tissue. 5) Remove the patch from the package. Do not touch the sticky side. 6) Rotate sites of patch application with each new patch (Option 4). Remove the old patch only when applying a new one. Do not wear more than 1 patch at a time unless directed by your health care provider (HCP). 7) When removing the patch, fold it in half with the sticky sides together. Discard the patch out of the reach of children and pets. Even after it has been used, the patch contains active medicine that may be harmful if accidentally applied or ingested (Option 2). 8) Notify the HCP if you are experiencing side effects such as dizziness or slow pulse rate. Do not remove the patch without discussing this with the HCP as rebound hypertension can occur (Option 3). Educational objective: The nurse should teach a client receiving a clonidine patch to: - Apply patch to a dry hairless area on the upper arm or chest - Wash hands before and after application - Rotate sites with each new patch application - Discard patch away from children or pets with sticky sides folded together - Never wear more than 1 patch at a time - Never stop using the patch abruptly

The charge nurse is planning assignments for the day. Which clients will require the nursing staff to institute contact precautions? Select all that apply. 1. 38-year-old with methicillin-resistant Staphylococcus aureus 2. 42-year-old with Clostridium difficile diarrhea 3. 69-year-old with pertussis infection 4. 72-year-old with vancomycin-resistant Enterococcus 5. 80-year-old with influenza

1, 2, 4 Infections caused by methicillin-resistant Staphylococcus aureus(MRSA), C difficile, vancomycin-resistant Enterococcus (VRE), and scabies require contact precautions to be used. Contact precautions include: - Placing client in private room (preferred) or cohorting clients with the same infection - Using dedicated equipment (must be disinfected when removing from room) - Wearing gloves when entering room - Perform proper hand hygiene before exiting room (use soap and water or alcohol-based hand rubs for MRSA and VRE, but only soap and water for C difficile and scabies) - Wearing gown with client contact and removing before leaving room - Place door notice for visitors - Having client leave room only for essential clinical reasons (ie, tests, procedures). If an x-ray is needed, try to arrange for a portable one. (Option 3) Clients with pertussis infection (whooping cough) need droplet precautions. (Option 5) Influenza requires droplet precautions. Educational objective: Clients with multidrug-resistant organisms (MRSA, VRE), C difficile diarrhea, and scabies require nursing staff to implement contact precautions.

Which procedures are appropriate for the nurse to use when obtaining an adult client's blood for a laboratory test? Select all that apply. 1. Avoid the arm on the affected side after a mastectomy 2. Do not make further attempts to draw blood if unsuccessful on first 2 attempts 3. If necessary to use an arm with IV infusing, draw proximal to infusion point 4. Insert the needle bevel up at a 15-degree angle to the skin 5. Obtain a finger capillary specimen from the middle of the finger pad

1, 2, 4 When performing phlebotomy, clean the site, "fix" or hold the vein taut, and then insert the needle bevel up at a 15-degree angle (no steeper than 30 degree). Some recommend bevel down for children. This will help prevent going through the vein completely. The Infusion Nurses Society (INS) identifies the standard of care as no more than 2 attempts by any 1 individual. If the nurse is unable to successfully draw blood after 2 attempts, a phlebotomist or a different nurse should be asked to complete the blood draw. The affected side of a client who has had a mastectomy (especially with lymph node removal) should not be used. It places the client at risk for infection and lymphedema. (Option 3) An arm without IV infusion is preferred. If it is necessary to use the arm with the IV infusion, the specimen should be collected from a vein several centimeters below (distal to) the point of IV infusion, with the tourniquet placed in between. (Option 5) The finger specimen should be obtained from the third or fourth finger on the side of the fingertip, midway between the edge and midpoint. The puncture should be made perpendicular to the fingerprint ridges. Puncture parallel to the ridges tends to make the blood run down the ridges and will hamper collection. A heel stick collection on an infant should be done on the plantar surface. Educational objective: When obtaining blood from a client, insert the needle at 15-degree angle, limit attempts to 2, and avoid the side of a mastectomy. A capillary specimen should be obtained at the side of the finger pad. Never draw a specimen above an IV infusion.

The student nurse verbalizes the procedure for obtaining a wound culture to the nurse preceptor. Which of the following statements by the student indicate a correct understanding? Select all that apply. 1. "I will apply the prescribed bacitracin ointment after collecting the wound culture." 2. "I will cleanse the wound by gently flushing it with normal saline." 3. "I will obtain a sample of the drainage accumulated since the last dressing change." 4. "I will perform hand hygiene and apply new gloves before obtaining the wound culture." 5. "I will swab the wound from the outermost margin toward the center."

1, 2, 4 Wound cultures identify microorganisms to aid in prescribing appropriate antibiotics and are obtained as follows: 1. Perform hand hygiene, and apply clean gloves. Remove the old dressing. Remove and discard gloves. 2. Perform hand hygiene, and apply sterile gloves. Assess the wound bed. Cleanse the wound bed and surrounding skin with normal saline (eg, flushing, swabbing with gauze) to remove drainage and debris (Option 2). Remove and discard gloves. 3. Perform hand hygiene, and apply clean gloves. Gently swab the wound bed with a sterile swab, from the wound center toward the outer margin (Options 4 and 5). Avoid contact with skin at the wound edge as it can contaminate the specimen with skin flora. 4. Place the swab in a sterile specimen container; avoid touching the swab to the outside of the container. 5. Apply prescribed topical medication (eg, bacitracin) after obtaining cultures to prevent interference with microorganism identification (Option 1). Apply new dressing. 6. Remove and discard gloves, and perform hand hygiene. Label the specimen, and document the procedure. (Option 3) Pooled purulent exudate likely contains skin flora different from the pathogen(s) responsible for the infection. Microorganisms responsible for infection are most likely found in viable tissue. Educational objective: Wound cultures are used to identify microorganisms and select appropriate antibiotics. The nurse should assess and clean the wound, swab from the wound center toward the outer margin, and avoid contamination (eg, hand hygiene, not touching intact skin with swab) to prevent misidentification of microorganisms. Reduction of Risk Potential

Which interventions should the nurse perform when assisting the health care provider with removal of a client's chest tube? Select all that apply. 1. Ensure the client is given an analgesic 30-60 minutes before tube removal 2. Instruct the client to breathe in, hold it, and bear down while the tube is being removed 3. Place the client in the Trendelenburg position 4. Prepare a sterile airtight petroleum jelly gauze dressing 5. Provide the health care provider with sterile suture removal equipment

1, 2, 4, 5 A chest tube is removed when drainage is minimal (<200 mL/24 hr) or absent, an air leak (if present) is resolved, and the lung has reexpanded. The general steps for chest tube removal include: 1) Premedicate the client with analgesic (eg, IV opioid, nonsteroidal anti-inflammatory drug [ketorolac]) 30-60 minutes before the procedure to promote comfort as evidence indicates that most clients report significant pain during removal (Option 1). 2) Provide the health care provider (HCP) with sterile suture removal equipment (Option 5). 3) Instruct the client to breathe in, hold it, and bear down (Valsalva maneuver) while the tube is removed to decrease the risk for a pneumothorax. Most HCPs use this technique to increase intrathoracic pressure and prevent air from entering the pleural space (Option 2). 4) Apply a sterile airtight occlusive dressing to the chest tube site immediately; this will prevent air from entering the pleural space (Option 4). 5) Perform a chest x-ray within 2-24 hours after chest tube removal as a post-procedure pneumothorax or fluid accumulation usually develops within this time frame. (Option 3) The client should be placed in semi-Fowler's position or on the unaffected side to promote comfort and facilitate access for tube removal. Educational objective: Before chest tube removal, the client is given an analgesic and then asked to perform Valsalva during the procedure. The nurse should also bring sterile suture removal equipment and a sterile airtight occlusive dressing. Post-procedure chest x-ray is necessary within 2-24 hours.

The nurse is drawing blood from a client's peripheral vein for laboratory specimens. Which of the following are correct nursing actions? Select all that apply. 1. Do not leave a tourniquet on more than 1 minute while looking for a vein 2. Draw the specimen while the skin is still wet with the alcohol prep 3. If pulsating red blood is noted, withdraw the needle and apply pressure for 5 minutes 4. Use a highly visible vein on the ventral side of the client's wrist 5. Vigorously shake the specimen tube to mix obtained blood with anticoagulant solution

1, 3 A tourniquet is applied 3-5 inches above the desired puncture site for no longer than 1 minute when looking for a vein. If longer time is needed, release the tourniquet for at least 3 minutes before reapplying. Prolonged obstruction of blood flow by the tourniquet can change some test results. Pulsating bright red blood indicates that an artery was accessed. If this happens, the needle should be removed immediately and pressure should be applied for at least 5 minutes, followed by a pressure dressing to prevent a hematoma. (Option 2) Skin preparation involves cleaning using an antiseptic solution and friction and allowing the skin to air dry. Remaining solution may hemolyze and/or dilute the blood sample. Traditionally, alcohol (alone or with povidone iodine) is applied in a circular motion, from insertion site outward (clean to dirty). Current research suggests that the most effective method is applying chlorhexidine (2%) in a back and forth motion, followed by adequate drying time. (Option 4) The veins on the ventral aspect of the wrist are located near nerves, resulting in painful venipuncture and a higher risk of nerve injury. There is also an increased risk of arterial access on the ventral aspect of the wrist, and so this site should be avoided. (Option 5) The filled tube should be gently inverted 5-10 times to mix anticoagulant solution with the blood. Vigorously shaking the tube can cause hemolysis and false results. Educational objective: When performing phlebotomy for a laboratory specimen, allow the cleansed area to air dry, do not use the veins on the ventral side of wrist, position the tourniquet for no more than 1 minute at a time, and invert the tube gently 5-10 times to mix the solution with blood. Insertion in an artery will cause pulsation; if this happens, immediately remove the needle and apply pressure for 5 minutes.

The nurse is preparing to infuse 2 units of packed red blood cells (PRBCs) 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 units 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 minutes 6. Spike filtered intravenous (IV) tubing with dextrose 5% water (D5W)

1, 3, 4 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 2 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 then clamp the NS side (Option 6). 4. Spike the blood product, leaving the blood side of the Y tube open while 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 client for at least the 1st 15 minutes and watch for signs of blood transfusion reaction, including fever, chills, nausea, vomiting, pruritus, hypotension, decreased urine output, back pain, and dyspnea. Stop the transfusion immediately if a reaction occurs. The first 15 minutes of infusion should be slow to watch for these reactions. 7. Take another set of vital signs 15 minutes after infusion starts and continue in accordance with facility policy. Always take a final set of vital signs after the infusion is complete. 8. On completion of the blood transfusion, open the saline side clamp of the Y tubing to flush all blood in the tubing through with 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 new IV Y tubing set-up for the second unit of blood. Educational objective: Always verify blood products, type and crossmatch results, and client identifiers with another nurse prior to transfusion. Obtain vital signs before, during, and after blood administration. Use Y tubing primed with NS and an IV pump for administration. Watch for transfusion reaction and stop the transfusion immediately if a reaction occurs.

The home health nurse visits a client who is rehabilitating after a tibial fracture. Which interventions are appropriate to include in the client's teaching plan to promote safety in the home when using crutches? Select all that apply. 1. Keep a clear path to the bathroom 2. Look down at the feet when walking 3. Remove scatter rugs from floors 4. Use a small backpack/shoulder bag to hold personal items 5. Wear rubber-soled shoes, preferably without laces

1, 3, 4, 5 Interventions to promote safety when using crutches in the home include the following: - Keep the environment free of clutter and remove scatter rugs to reduce fall risk (Options 1 and 3) - Look forward, not down at the feet, when walking to maintain an upright position, which will help prevent muscle and joint strain, maintain balance, and reduce fall risk (Option 2) - Use a small backpack, fanny pack, or shoulder bag to hold small personal items (eg, eyeglasses, cell phone), which will keep hands free when walking (Option 4) - Wear rubber- or non-skid-soled slippers or shoes without laces to reduce fall risk (Option 5) - Rest crutches upside down on the axilla crutch pads when not in use to prevent them from falling and becoming a trip hazard - Keep crutch rubber tips dry. Replace them if worn to prevent slipping. Educational objective: Interventions to promote safety and reduce the risk of falling when using axillary crutches in the home include looking forward when walking, maintaining a clutter-free environment, resting crutches upside down on the axilla pads when not in use, using a small bag to hold personal items, wearing sturdy rubber-soled shoes, and keeping crutches in good repair.

A blood transfusion is prescribed for a client experiencing complications of sickle cell anemia with a hemoglobin level of 6 g/dL (60 g/L). Which of the following actions by the registered nurse are appropriate? Select all that apply. 1. Asks another licensed nurse to verify client identifiers and blood before administration 2. Delegates all vital sign measurements to the unlicensed assistive personnel 3. Prepares O-negative blood for an AB-positive client 4. Transfuses the blood over a 6-hour period of time 5. Uses filtered tubing with normal saline to administer blood

1, 3, 5 Blood transfusions are commonly administered to clients experiencing anemia or acute blood loss. To ensure client safety during blood administration, the nurse should: - Verify two client identifiers (eg, name, medical record number, date of birth), the prescription, and the blood products with another licensed health care provider (Option 1). - Ensure that blood type and Rh type are compatible (Option 3). An Rh-positive client can safely receive Rh-positive or Rh-negative blood. - Administer the blood via filtered tubing with normal saline to prevent clumping in the tube and hemolysis of red blood cells (Option 5). - Monitor vital signs during transfusion per facility-specific protocol (eg, before transfusion, 15 minutes after transfusion begins, periodically). - Transfuse blood products within 4 hours due to the risk for bacterial growth. (Option 2) The nurse remains with the client for the first 15 minutes (ie, approximately 50 mL) of the transfusion and obtains vital signs directly to monitor for adverse reactions (eg, fever, chest pain). Delegating vital signs to unlicensed assistive personnel after the initial 15-30 minutes may be appropriate for stable clients. (Option 4) Infusing blood over 6 hours increases the risk of bacterial contamination and hemolysis of the blood product. Educational objective: The nurse facilitates safe blood administration by verifying the prescription, blood type, and at least two client identifiers with another licensed health care provider; administering blood with normal saline; obtaining vital signs directly for the first 15 minutes (ie, approximately 50 mL of the transfusion); and transfusing blood within 4 hours.

The nurse is caring for a postoperative client who has D5W/0.45% normal saline with 10 mEq potassium chloride infusing through a peripheral IV catheter. What are appropriate reasons for the nurse to change the site? Select all that apply. 1. Area around the insertion site feels cool to the touch 2. Client reports mild arm discomfort since the infusion was started 3. Edema is observed on the dependent side of the involved arm 4. Intraoperative peripheral IV catheter is placed in the left antecubital region 5. Serous fluid leaks from the site despite secure connections

1, 3, 5 Peripheral IV (PIV) catheter sites should be changed usually no more frequently than every 72-96 hours unless signs of complications develop. Signs of phlebitis include erythema, edema, warmth, pain, and palpable venous cord. Manifestations of infiltration include edema and coolness to the touch around the insertion site (Option 1). The nurse should also monitor for edema related to infiltration under the involved limb. Infiltrated fluid may leak into loose skin, causing edema in dependent areas without obvious signs of infiltration at the PIV site, particularly in the elderly (Option 3). If a PIV site is leaking fluid, the tubing and catheter connections should be assessed. If all connections are intact, possible problems include infiltration/extravasation, a thrombus at the catheter tip, or damage to the catheter; all of these issues require a site change (Option 5). (Option 2) Potassium is a known irritant to veins. Discomfort is not a sign of infiltration, although the site should be regularly monitored for complications. (Option 4) Locations where flexion occurs (eg, antecubital region) are generally avoided; however, these sites may be required for certain medications or situations. Unless a problem develops, PIV sites are not changed based solely on location. Educational objective: Peripheral IV catheter sites should be changed no more frequently than every 72-96 hours unless signs of complications develop. The nurse should check for signs of infiltration by assessing the insertion site and areas dependent from it (ie, edema, cool skin).

Ten minutes after an infusion of packed RBCs is initiated through a central venous catheter (CVC), the client has SOB and slight chest tightness. What initial actions would be appropriate for the nurse to complete? Select all that apply. 1. assess the client's breath sounds 2. flush the blood IV tubing with normal saline 3. notify the HCP 4. remove the CVC 5. stop the infusion PRBCs

1, 3, 5 S & S of a blood transfusion reaction typically will occur within the 1st 15 minutes after initiation of the transfusion. These include SOB, chest tightness, fever, back pain, anxiety, tachycardia, and hypotension. When a transfusion reaction is suspected, the 1st step is to stop the infusion (option 5). An infusion of NS is typically started. It is important that NS be administered through a different port of the CVC using new tubing or at the closest access point to the client. Flushing the blood in the IV tubing into the client will expose the client to more of the causative agent and increase complications from the transfusion reaction (option 2). The HCP must then be notified (option 3). Because the client has SOB and chest tightness, an assessment of breath sounds is appropriate. Adventitious sounds could indicate bronchospasm or excess fluid in the lungs (option 1).

The nurse is suctioning the artificial airway of a conscious client. Which actions demonstrate correct technique? Select all that apply. 1. Apply suction for no longer than 5-10 seconds 2. Insert catheter with low, intermittent suction applied 3. Set suction higher than 130 mm Hg for thick, copious secretions 4. Wait at least 1 minute between suction passes 5. Withdraw catheter immediately if client begins coughing

1, 4 The process of suctioning a client's airway removes oxygen in addition to the secretions; therefore, the client should be preoxygenated with 100% O2, and suction should be applied for no more than 10 seconds during each pass to prevent hypoxia (Option 1). The nurse must wait 1-2 minutes between passes for the client to ventilate to prevent hypoxia (Option 4). In addition, deep rebreathing should be encouraged. (Option 2) The suction catheter should be no more than half the width of the artificial airway and inserted without suction. (Option 3) The nurse should don sterile gloves if the client does not have a closed suction system in place. Suction should be set at medium pressure (100-120 mm Hg for adults, 50-75 mm Hg for children) as excess pressure will traumatize the mucosa and can cause hypoxia. (Option 5) Clients usually cough as the catheter enters the trachea, and this helps loosen secretions. The catheter should be advanced until resistance is felt and then, to prevent mucosal damage, retracted 1 cm before applying suction. Educational objective: Proper airway suctioning technique includes preoxygenation, limiting a suction pass to 10 seconds, and allowing 1-2 minutes between passes to prevent hypoxia. Medium suction pressure should be set at 100-120 mm Hg for adults, with the catheter inserted without suction.

Which of these are correct nursing actions related to client positioning? Select all that apply. 1. Position client in high Fowler's for a paracentesis related to end-stage cirrhosis 2. Position client on left side after liver biopsy 3. Position client on side with head, back, and knees flexed after lumbar puncture 4. Position client Trendelenburg on left side if air embolism is suspected 5. Position client with arm raised above head for chest tube placement

1, 4, 5 Abdominal paracentesis is used to remove ascitic fluid from the peritoneal cavity in end-stage liver disease (cirrhosis). The client should be positioned in high Fowler's or sat upright to facilitate the flow of fluid to the bottom of the peritoneal cavity, where the needle will be inserted. The client should void prior to the procedure to decrease the risk of bladder puncture (Option 1). In the event of an air embolus, the head of the bed should be lowered (Trendelenburg) and the client positioned on the left side; this will cause the air to rise to the right atrium. The health care provider should be notified immediately and the nurse should remain with the client (Option 4). Chest tube insertion should be performed with the client's arm raised above the head on the affected side. If possible, the head of the bed should be raised 30-60 degrees to reduce risk of injury to the diaphragm (Option 5). (Option 2) After a liver biopsy, the client should lie on the right side for a minimum of 2 hours (to apply pressure and splint the puncture site) and then supine for an additional 12-14 hours. The risk for bleeding is increased due to the high vascularity of the liver, but correct positioning reduces this risk. (Option 3) During a lumbar puncture, the client is positioned side-lying, with the head, back, and knees flexed. A small pillow may be placed between the legs and under the head for comfort and to maintain the spine in a horizontal position. Following the procedure, the client will be positioned according to the health care provider's prescription (usually supine or with head of the bed elevated 30 degrees). Educational objective:For medical procedures, the nurse should ensure that the client: - Has an empty bladder and is in high Fowler's or a sitting position for paracentesis - Is Trendelenburg on the left side for suspected air embolism - Has the arm raised above the head on the affected side for chest tube insertion - Lies on the right side (for 2 hours) and then supine (12-14 hours) after liver biopsy - Is side-lying with the head, back, and knees flexed for lumbar puncture Reduction of Risk Potential

The nurse is performing a central line tubing change when the client suddenly begins gasping for air and writhing. Order the interventions by priority. All options must be used. Clamp the catheter tubing Place the client in Trendelenburg position on the left side Administer oxygen as needed Notify the health care provider (HCP) Stay with the client and provide reassurance

1. Administer oxygen as needed 2. Clamp the catheter tubing 3. Notify the health care provider (HCP) 4. Place the client in Trendelenburg position on the left side 5. Stay with the client and provide reassurance Leakage of more than 500 mL of air into a central venous catheter is potentially fatal. An air embolism in the small pulmonary capillaries obstructs blood circulation. A central venous catheter leaks air rapidly at 100 mL/sec. This client requires immediate intervention to prevent further complications (eg, cardiac arrest, death). The nurse should not delay emergency treatment, not even to stop and contact the HCP or the rapid response team (RRT). Priority interventions for active or suspected air embolism are as follows: 1) Clamp the catheter to prevent more air from embolizing into the venous circulation. 2) Place the client in Trendelenburg position on the left side, causing any existing air to rise and become trapped in the right atrium. 3) Administer oxygen if necessary to relieve dyspnea. 4) Notify the HCP or call an RRT to provide further resuscitation measures. 5) Stay with the client to provide reassurance and monitoring as the air trapped in the right atrium is slowly absorbed into the bloodstream over the course of a few hours. Educational objective: Any delay in treatment of an air embolism could prove fatal. There is no time to call the HCP. Seal off the source of the leak, and ensure stabilization of the air bubble via left lateral positioning.

The nurse is teaching a postoperative client to use a volume-oriented incentive spirometer device. Place the teaching steps in the proper order. All options must be used. Hold breath for at least 2-3 seconds Exhale normally and place the mouthpiece in the mouth Exhale slowly around the mouthpiece Seal lips tightly on mouthpiece Inhale deeply, until piston is elevated to predetermined level

1. Exhale normally and place the mouthpiece in the mouth 2. Seal lips tightly on mouthpiece 3. Inhale deeply, until piston is elevated to predetermined level 4. Hold breath for at least 2-3 seconds 5. Exhale slowly around the mouthpiece Incentive spirometry is recommended in postoperative clients to prevent atelectasis associated with incisional pain, especially in upper abdominal incisions (close to the diaphragm). Adequate pain medication should be administered before using the incentive spirometry. Guidelines recommend 5-10 breaths per session every hour while awake. Volume-oriented or flow-oriented sustained maximal inspiration (SMI) devices can be used. The client instructions for using a volume-oriented SMI device include: 1) Assume a sitting or high Fowler position, which optimizes lung expansion, and exhale normally 2) While holding the device at an even level, seal the lips tightly on the mouthpiece to prevent leakage of air around it 3) Inhale deeply through the mouth until the piston is elevated to the predetermined level of tidal volume. The piston is visible on the device and helps provide motivation. 4) Hold the breath for at least 2-3 seconds (up to 6 seconds) as this maintains maximal inhalation 5) Exhale slowly to prevent hyperventilation 6) Breathe normally for several breaths before repeating the process 7) Cough at the end of the session to help with secretion expectoration Educational objective: Incentive spirometry is recommended to prevent atelectasis in postoperative clients. Clients with incisional pain should receive adequate pain medication prior to the inhalations. The client is instructed to use the device while sitting upright, seal the lips tightly around the mouthpiece, inhale deeply, sustain the maximal inspiration for at least 2-3 seconds, exhale slowly before repeating the procedure, and cough at the end of the session.

The 70-year-old client with type 2 diabetes and hypertension is scheduled for ureteral stent removal in 2 hours. The preoperative protocol ECG is done in the inpatient unit, and results indicate a "possibly acute" ST segment elevation. What action is most important for the nurse to take? 1. Document the test results on the preoperative checklist 2. Notify the health care provider about the test results 3. Place the printed ECG in the front of the chart 4. Report the results to the surgical nurse to tell the surgeon

2 This is a high-risk client (eg, older age, hypertension, diabetes), and the acute, new, significant finding needs further evaluation and possible intervention before undergoing the stress of surgery. In addition, clients with a long history of diabetes often have associated neuropathy and may not experience the chest pain typical of myocardial infarction (MI), known as silent MI. As a result, the nurse must ensure that the health care provider (HCP) is made aware of this client's new findings in a timely manner. (Options 1, 3, and 4) All of these actions should also be performed. However, the most important action is for the nurse to personally notify the client's HCP in a timely manner so that appropriate treatment can be provided. Educational objective: When significant abnormal results are obtained on a presurgical client, it is the nurse's responsibility to ensure that the health care provider is notified in a timely manner.

The nurse is preparing to give a heparin injection to a client who is malnourished and cachectic. Which method of injection would be appropriate for this client? 1. 27 G; 1/4 in long; 15 degree angle 2. 25 G; 1/2 in long; 45 degree angle 3. 25 G; 1/2 in long; 90 degree angle 4. 18 G; 1.5 in long; 90 degree angle

2 When administering subcutaneous anticoagulant injections (eg, heparin, enoxaparin), the nurse must select the appropriate needle length and angle to avoid accidental intramuscular injection, especially in clients with insufficient adipose tissue (eg, cachexia). Intramuscular injection of heparin would cause rapid absorption, resulting in a hematoma and painful muscle irritation. The nurse should administer subcutaneous injections at 90 degrees if 2 in (5 cm) of subcutaneous tissue can be grasped, or at 45 degrees if only 1 in (2.5 cm) can be grasped (Option 2). Anticoagulants are best absorbed if administered in the abdomen at least 2 in (5 cm) away from the umbilicus. (Option 1) A 15-degree angle is used for intradermal injections and would not deliver medication into the subcutaneous tissue. (Option 3) A 90-degree injection angle is appropriate for clients with sufficient adipose tissue (ie, at least 2 in [5 cm] can be grasped). (Option 4) Needles longer than 5⁄8 in (1.6 cm) are used to administer intramuscular injections. Educational objective: Anticoagulant injections should be administered in the abdominal subcutaneous tissue at a 45- to 90-degree angle. A 45-degree angle is used for clients with minimal adipose tissue to avoid accidental intramuscular injection, which would cause rapid absorption and result in hematoma and painful muscle irritation.

A client with a nasogastric tube is prescribed intermittent bolus enteral feedings with routine gastric residual checks. Which of the following actions by the nurse are appropriate? Select all that apply. 1. Discard aspirated gastric residual in a biohazard container 2. Flush the nasogastric tube before and after administering the feeding 3. Place the client in the semi-Fowler position 4. Start the feeding after obtaining a gastric residual volume of 75 mL 5. Start the feeding when the gastric residual has pH of 6

2, 3, 4 When administering bolus enteral feedings, the nurse should elevate the head of the bed to 30-45 degrees (semi-Fowler position) and keep it elevated for 30-60 minutes afterwards to decrease aspiration risk (Option 3). Many institutions require the nurse to hold feeding if the client must remain supine (eg, diagnostic tests). Feeding tubes should be flushed before and after feedings to keep the tube patent (Option 2). Gastric residual volumes (GRVs) are traditionally checked every 4 hours with continuous feeding or before each bolus feeding. Per facility policy, enteral feedings may be held for high GRV (eg, >500 mL) to reduce aspiration risk. Low GRV indicates that the client is tolerating feedings well (Option 4). Some facilities no longer routinely check GRVs because recent evidence shows that the procedure may not truly indicate aspiration risk and actually impairs calorie delivery. Regardless of GRV checks, the nurse should closely monitor clients for symptoms of intolerance (eg, abdominal distension, nausea/vomiting), which may indicate that feedings should be held or reduced in volume. (Option 1) Aspirated GRV should be returned to the stomach. If acidic gastric juices are repeatedly discarded, there is risk for hypokalemia and metabolic alkalosis. (Option 5) Gastric pH should be acidic (pH ≤5). A pH ≥6 requires x-ray confirmation of tube placement. Newly inserted nasogastric tubes also require x-ray confirmation before feedings are initiated. Educational objective: When administering bolus enteral feedings, the nurse should place the client in semi-Fowler position, check gastric residual volumes (GRVs) as prescribed, verify acidic pH ≤5, return aspirated GRV to the stomach, and flush the tube before and after feedings. Basic Care and Comfort

The nurse prepares to assist the health care provider with a lumbar puncture on a child with suspected meningitis. Place the procedural steps in the correct order. All options must be used. 1. Assist the child into the side-lying position with the knees drawn up 2. Check the medical record for parental consent 3. Gather the lumbar puncture tray and supplies 4. Have the child empty the bladder 5. Label specimen vials as they are collected 6. Place a bandage on the insertion site

2, 3, 4, 1, 5, 6 A lumbar puncture (spinal tap) is a sterile procedure used to gather a specimen of cerebrospinal fluid (CSF) for diagnostic purposes (eg, meningitis). A needle is inserted into the vertebral spaces between L3 and L4 or L4 and L5, and a sample of CSF is drawn. The nurse's role when assisting with a lumbar puncture includes the following: 1. Verify informed consent 2. Gather the lumbar puncture tray and needed supplies 3. Explain the procedure to older child and adult 4. Have client empty the bladder 5. Place client in the appropriate position (eg, side-lying with knees drawn up and head flexed or sitting up and bent forward over a bedside table) 6. Assist the client in maintaining the proper position (hold the client if necessary) 7. Provide a distraction and reassure the client throughout the procedure 8. Label specimen containers as they are collected 9. Apply a bandage to the insertion site 10. Deliver specimens to the laboratory Educational objective: When assisting with a lumbar puncture, the nurse verifies informed consent, gathers supplies, explains the procedure, has the client void, and then assists the client into position. During the procedure, the nurse provides a distraction, helps the client stay in position (if needed), and labels specimens as they are collected. Afterward, the nurse applies a bandage and ensures that the specimens are delivered to the laboratory. Reduction of Risk Potential

The pediatric nurse is preparing to administer an acetaminophen suppository to an 11-month-old with pyrexia. Which actions are appropriate? Select all that apply. 1. Advance past the external sphincter only 2. Guide suppository along the rectal wall 3. Hold buttocks together firmly after insertion 4. Position client supine with knees and feet raised 5. Use gloved fifth finger for insertion

2, 3, 4, 5 Pediatric administration of rectal suppositories is similar to the adult technique, with a few key modifications due to the small size of a child's colon and varying developmental needs. Age-appropriate explanations and/or distractions should be implemented to reduce distress. Toddlers and infants may benefit from distraction with a toy; preschoolers and older children can be instructed to take deep breaths or count during the procedure. Basic steps for suppository administration include the following: 1. Apply clean gloves and position the client appropriately based on age and size (eg, infant supine with knees and feet raised, older child side-lying with knees bent) (Option 4). 2. Lubricate the tip of the suppository with water-soluble jelly. Petroleum-based products can reduce absorption. 3. Insert the suppository past the internal sphincter using the fifth finger if the child is under 3 years (Option 5). Use of the index finger may cause injury to the colon or sphincters in children younger than age 3 years. 4. Angle suppository and guide it along the rectal wall. The suppository should remain in contact with the rectal mucosa (and not be buried inside stool) to ensure systemic absorption (Option 2). 5. Hold the buttocks together for several minutes, or until the urge to defecate has passed, to prevent immediate expulsion (Option 3). 6. If a bowel movement occurs within 10-30 minutes, observe for the presence of the suppository. (Option 1) The suppository must be inserted past both the external and internal sphincters for proper placement. If not inserted far enough, it may be expelled before achieving a therapeutic effect. Educational objective: In children younger than age 3 years, suppositories are inserted with the fifth finger of the nurse's gloved hand. Age-appropriate explanations and/or distractions are implemented to reduce distress.

A female client is admitted to the emergency department after a motor vehicle collision. The client is unresponsive and on a mechanical ventilator. Which actions should the nurse perform? Select all that apply. 1. Locate and remove any medication patches 2. Locate possible medical alert band or necklace 3. Remove rings and jewelry and lock in a secure location 4. Remove tampon and replace with menstrual pad 5. Take out contacts if no presence of eye trauma

2, 3, 4, 5 The unconscious client requires a thorough head-to-toe assessment on admission to assess for foreign objects, devices, or belongings that have potential for harm. This includes checking for: - Medical alert bracelets/necklaces: Indicating allergy status, emergency contact, or code status (Option 2) - Contact lenses: Remove to prevent corneal injury (Option 5) - Medication patches: To prevent drug interactions and determine conditions currently being treated - Tampons (in female clients): Remove to prevent toxic shock syndrome or infection (Option 4) - Rings and jewelry: Remove to prevent constrictive injury or vascular damage if edema develops (Option 3) (Option 1) Medication patches should not be removed without first consulting the health care provider. Clients are often prescribed transdermal patches for chronic conditions (eg, clonidine for hypertension, nitroglycerin for angina). Removing and discarding a medication patch without additional information may harm the client. Educational objective: When caring for an unconscious client during admission, the nurse should assess for medical alert devices and any prescriptive materials (eg, medication patches, contact lenses). The nurse should remove personal belongings and foreign objects that could harm the client if not removed (eg, tampons, rings/jewelry).

The nurse is caring for a client with newly prescribed hearing aids. Which of the following actions by the client indicate proper use and care of hearing aids? Select all that apply. 1. Keeps hearing aids clean by rinsing them with water 2. Lowers television volume when talking with nurse 3. Places hearing aids on food tray when not in use 4. Turns volume completely down prior to insertion of aid into the ear 5. Verifies that battery compartment is closed before insertion

2, 4, 5 Proper use and care of hearing aids is essential to the success of hearing aid therapy and is associated with improved outcomes. Proper hearing aid use and care include: - Minimize distracting sounds (eg, television, radio) during conversation to enhance effectiveness (Option 2). - Turn the volume off prior to insertion, then gradually turn up the volume to a comfortable level (Option 4). - To adjust to the new hearing aids, initially wear them for a short time (eg, 20 minutes) and gradually increase length of wear time. - Do not wear the hearing aids when using hair dryers or heat lamps. - Regularly check that the battery compartment is clean, the batteries are inserted correctly, and the compartment is shut before insertion (Option 5). - Remove the battery (if possible) at night and when the aid is not in use to extend battery life. (Option 1) Each aid must be cleaned with a soft cloth. Hearing aids should not be immersed in water, as this can damage the electrical components. (Option 3) Store hearing aids in a safe, dry place when not in use. This will help prevent the hearing aids from becoming lost or damaged. Educational objective: The nurse should ensure that clients with hearing aids understand proper hearing aid use and care. Principles of hearing aid care include: turning volume off and ensuring the battery compartment is shut before insertion; minimizing background noise; cleaning the aids with a soft cloth; keeping the aids in a safe, dry place; and not immersing them in water.

The nurse is caring for a client who has deep venous thrombosis and is prescribed a continuous IV infusion of heparin 25,000 units in 500 mL of D5W at 1300 units/hr. After 6 hours of the heparin infusion, the client's PTT is 44 seconds. The nurse must adjust the infusion rate according to the heparin drip protocol (shown in the exhibit). According to the protocol, at what rate in milliliters per hour (mL/hr) should the nurse set the IV infusion pump? Click on the exhibit button for additional information. Record your answer using a whole number. Heparin drip protocol PTT (seconds) Hold infusionInfusion <34No↑ by 100 units/hr 34-44No↑ by 100 units/hr 45-54No↑ by 50 units/hr 55-70No(Therapeutic range) No change 71-85No↓ by 100 units/hr 86-100Yes, 1 hr; inform HCP↓ by 150 units/hr 101-125Yes, 1 hr; inform HCP↓ by 200 units/hr >125Yes, 1½ hr; inform HCP↓ by 200 units/hr Answer: (mL/hr)

28 mL/hr The original heparin dose is 1300 units/hr. This client's PTT is 44 seconds, which is below the therapeutic range of 55-70 seconds (as shown in the exhibit), indicating that the client requires a higher dose of heparin for adequate anticoagulation. According to the heparin drip protocol (protocols vary per institution), the rate should be increased by 100 units/hr, or to an infusion rate of 1400 units/hr, which converts to 28 mL/hr. Using dimensional analysis, use the following steps to calculate the rate in milliliters per hour at which the IV infusion pump should be set to deliver 1400 units/hr (original dose of 1300 units/hr increased by 100 units/hr per protocol): 1. Identify the prescribed, available, and required medication information Prescribed: 1400 units heparin/hr Available: 25,000 units heparin/500 mL Required: mLhr 2. Convert prescription to infusion rate needed for administration Prescription×available medication =mL/hr OR (Units heparin/hr)(mL/ units heparin)=mL heparin/hr OR (1400 units heparin/hr) (500 mL/25,000 units) =28 mL heparin/hr Educational objective: To calculate the IV infusion rate of heparin, the nurse should first adjust the dosage as prescribed (eg, 1300 + 100 units/hr). After identifying the prescribed dose (eg, 1400 units/hr) and available medication (eg, 25,000 units/500 mL), the nurse converts to the rate in milliliters per hour (28 mL/hr).

The nurse has unlicensed assistive personnel (UAP) caring for a client with an acute attack of Meniere disease. Which action by the UAP will require follow-up by the nurse? 1. Assist the client in ambulating to the bathroom 2. Dim the room lights 3. Place the bed in low position with all side rails up 4. Turn off the television

3 Meniere disease (endolymphatic hydrops) results from excess fluid accumulation in the inner ear. Clients have episodic attacks of vertigo, tinnitus, hearing loss, and aural fullness. The vertigo can be severe and is associated with nausea and vomiting. Clients report feeling being pulled to the ground (drop attacks). Fall precautions that should be instituted include assisting the client when arising and ambulating (Option 1), placing the bed in low position, and raising side rails. However, raising all side rails is considered a restraint and would be inappropriate. The nurse would need to intervene and instruct the UAP that 2 or 3 side rails lifted up would be sufficient (Option 3). (Options 2 and 4) Vertigo may be minimized by staying in a quiet, dark room and avoiding sudden head movements. The client should reduce stimulation by not watching television and not looking at flickering lights. Educational objective: Safety is a priority for the client experiencing an acute attack of Meniere disease. Fall precautions include placing the bed in low position, raising 2 or 3 side rails, and assisting the client with arising and ambulating. Vertigo can be minimized by staying in a quiet, dark room without a television or flickering lights.

There has been an explosion at a local chemical plant. A private car arrives at the emergency department with 4 victims whose clothes are saturated with a strong-smelling liquid. The victims are wheezing. The nurse should implement which intervention first? 1. Assessing the clients' respiratory systems 2. Decontaminating the clients 3. Donning personal protective equipment 4. Providing oxygen by nasal cannula

3 Nursing priorities when implementing a chemical contamination emergency response plan include the following: 1. Restricting other clients, staff, and bystanders from the victims' vicinity to protect non-affected individuals and the health care facility from the contaminant 2. Donning personal protective equipment to protect the nurse when providing care (Option 3) 3. Decontaminating the clients outside the facility before initiating treatment. If the chemical is not removed, it will continue to cause respiratory distress; contaminated clothing is left outside the facility to reduce the risk of contaminating staff and other clients (Option 2). 4. Assessing and providing treatment of symptoms. Initial treatment is for the symptoms (eg, wheezing), regardless of the specific cause (Options 1 and 4). Educational objective: The nurse should always protect other clients, staff, and the health care facility first in a chemical contamination. Personal protective equipment should be put on before decontamination. Victims should be decontaminated outside the facility before care is administered.

A nurse has received report from the off-going shift that a client is confused and has been identified as a high risk for falls. The nurse shares this information with the unlicensed assistive personnel (UAP). Which finding by the nurse requires intervention? 1. UAP has attached a bed alarm to the client's gown and bed 2. UAP has been making hourly rounds on the client 3. UAP has lowered the bed and raised all 4 side rails 4. UAP has placed a fall risk ID bracelet on the client's wrist

3 Placing the client's bed in the lowest position is appropriate, but raising all 4 side rails is considered a form of restraint. Having all 4 side rails up may actually increase clients' risk for falls as they may try to climb up and over the rails. Raising 2-3 side rails is appropriate. The nurse should lower at least one side rail and communicate to the UAP that having all 4 up is inappropriate. (Option 1) Placing a bed alarm would be an appropriate intervention for this client. (Option 2) Making rounds at least hourly is appropriate for this client. The nurse should assess if more frequent rounds are warranted. (Option 4) Placing a fall risk ID band will help communicate to other members of the interdisciplinary team that the client is at risk for falls. Educational objective: The nurse should ensure that multiple interventions are put in place for the client at high risk for falls. These include placing the bed in the lowest position with 2-3 side rails up, identifying the client with a fall risk ID band, using bed alarms, and making frequent rounds on the client.

A client is seen in the clinic for the third time for a nonhealing, infected diabetic foot ulcer. The client is able to verbalize the correct procedure for wound care but reports not adhering to the ordered routine at home. What intervention does the nurse prioritize to promote proper self care? 1. Assess the client's feelings about placement at a skilled nursing facility for care 2. Educate the client on the risks of tissue death if not properly cared for at home 3. Explore the client's abilities and motivation to perform care at home 4. Provide the client with the supplies needed to change dressings as recommended

3 Self care is a critical component of health. However, barriers to self care are multifactorial, and include: - Knowledge (lack of experience, cognitive abilities) - Skills/supplies (lack of dexterity, experience, financial barriers) - Motivation (lack of assumed threat to health, denial, hopelessness) The nurse must assess for adequate knowledge and ability to perform self-care activities and the desire to complete such activities (Option 3). Once the barriers have been identified, the nurse can work with the client to create an individualized plan to meet health care needs. (Option 1) Without understanding the barriers to self care, the nurse cannot identify proper resources to assist the client in meeting needs. Placement for skilled nursing may be excessive for a client who lives independently. (Option 2) Education on tissue death may be perceived as threatening and not therapeutic. (Option 4) Financial resources or supplies may not be the barrier; therefore, this intervention may not effectively assist the client in performing self care successfully. Educational objective: The nurse must assess a client's knowledge, skills, and motivation to identify barriers to self care. Through this identification, the nurse can help develop an individualized plan to meet health care needs. Reduction of Risk Potential

The registered nurse observes a graduate nurse who is inserting a small-bore nasojejunal feeding tube. Which action by the graduate nurse requires intervention by the registered nurse? 1. Asking the client to take small sips of water during insertion 2. Marking the tube at the exit point from the naris 3. Removing the stylet before the x-ray is performed 4. Stopping insertion of the tube while the client is coughing

3 Small-bore nasoenteric (eg, nasoduodenal, nasojejunal) tubes are often placed using a stylet (guide wire), a metal wire running through the tube that facilitates advancement through the gastrointestinal tract. Once the tube is inserted, the nurse should obtain an x-ray to verify that the tube terminates in the intestine as prescribed, not in the airway or stomach. After placement verification, the nurse should remove the stylet to allow tube feeding (Option 3). To avoid perforating the gut, the nurse should never reinsert the stylet when a feeding tube is in place. If the tube is not properly positioned and the stylet has been removed, the nurse must remove the tube and start over. (Options 1 and 4) The client should sip water during insertion to close the airway and open the esophagus. With each swallow the nurse should advance the tube a little. The nurse should stop advancing when the client is inhaling or coughing to avoid inserting the tube into the airway and then continue advancing when the client is able to swallow again. (Option 2) Marking the exit point from the naris on the tube allows visualization of changes in external tube length that may indicate tube dislodgement. Educational objective: After placing a new, small-bore nasoenteric (eg, nasoduodenal, nasojejunal) feeding tube, the nurse should obtain an x-ray to verify tube placement and should leave the stylet (guide wire) in place until tube placement is verified. The nurse should never reinsert a stylet into a nasoenteric tube.

A child on the playground is experiencing an anaphylactic reaction. The school nurse arrives with an EpiPen. The weather is cold and the child is wearing several layers of clothing. How should the nurse proceed with the EpiPen? 1. Inject into the upper arm where the sleeve can be pulled up 2. Inject into the most accessible vein 3. Inject through the clothing into thigh and hold in place for 10 seconds 4. Take the child inside, remove excess clothing, and inject into the thigh

3 The EpiPen is designed to be administered through clothing with a swing and firm push against the mid-outer thigh until the injector clicks. The position should be held for 10 seconds to allow the entire contents to be injected (Option 3). The site should be massaged for an additional 10 seconds. Timing is essential in the delivery of epinephrine during an anaphylactic reaction. The nurse should administer the medication immediately on the playground without removing the child's clothing. Any delays can cause client deterioration and make maintenance of a patent airway difficult (Option 4). (Option 1) The EpiPen should be injected into the mid-outer thigh, not the upper arm. (Option 2) IV epinephrine is not administered outside the hospital setting. It requires cardiac monitoring and is indicated in clients with profound hypotension (shock) or those who do not respond to intramuscular epinephrine and fluid resuscitation. Educational objective: The EpiPen is designed to be delivered through clothing in the mid-outer thigh area. The nurse should not delay anaphylaxis treatment by attempting to remove the client's clothing.

The orthopedic health care provider instructs a client with a fractured right femur, who has been non-weight bearing for the past 5 weeks, to progress to full weight bearing on the right leg. Which advanced crutch gait that most closely resembles normal walking should the office nurse teach the client? 1. 2-point gait 2. 3-point gait 3. 4-point gait 4. 5-point gait

3 The client who is rehabilitating from an injury of the lower extremity usually progresses from no touch down, non-weight bearing status, using the 3-point gait (Option 2) to touch down with partial weight bearing status, using the 2 point-gait (Option 1), to full weight bearing status, using the 4-point gait. The nurse teaches the client how to use the most advanced gait, the 4-point crutch gait. It requires weight bearing on both legs and is the most stable as there are 3 points of support on the ground at all times (eg, 2 crutches and 1 foot; 2 feet and 1 crutch). It is the easiest to use as it resembles normal walking: advance right crutch, then left foot, and advance left crutch, then right foot. (Option 3) (Option 4) There are 5 crutch gaits: 2-point, 3-point, 4-point, swing-to, and swing-through. There is no 5-point crutch gait. Educational objective: The 4-point crutch gait is appropriate for a client with leg weakness, who can bear partial or full weight with both legs. It is the easiest gait to use as it resembles normal walking and provides the most stability with 3 points of support on the ground at all times.

A nurse is preparing to administer 2 continuous IV medications concurrently via a 20-gauge IV. What is the nurse's priority action? 1. Assess the condition of the IV site 2. Check 2 client identifiers before administering medications 3. Consult a medication guide for compatibility 4. Wash hands prior to administering medications

3 The priority when administering 2 IV medications concurrently is to determine drug compatibility. Incompatible drugs given through the same IV line will deteriorate or form a precipitate. This change is visualized through either a color change, a clouding of the solution, or the presence of particles. If 2 or more drugs are not compatible, the nurse may consider inserting a second IV or consulting the pharmacist and the health care provider to determine the safest and most beneficial plan for the client. (Option 1) Assessing the IV site for complications (eg, infiltration, phlebitis) should always be performed before giving any IV medication. This will be completed after determining drug compatibility. (Option 2) Verification using 2 client identifiers pertains to the "right client" in the "6 rights" of medication administration. Drug compatibility should be determined prior to entering the client's room and verifying identity. (Option 4) Hand hygiene is a standard precaution taken before any type of client interaction to prevent contamination and infection; hand washing will be completed after checking for drug compatibility. Educational objective: Checking for drug compatibility is a priority before administering 2 IV medications concurrently in the same IV site. Incompatible drugs will deteriorate or form a precipitate that is visible as a color change, cloudiness, or particulates.

A client with right-sided weakness becomes dizzy, loses balance, and begins to fall while the nurse is assisting with ambulation. Which nursing actions would best prevent injury to the client and nurse while guiding the client to a horizontal position on the floor? 1. Step behind client with arms around waist, squat using the quadriceps, and lower client to the floor 2. Step in front of client, brace knees and feet against the client's, and assist to the floor gently 3. Step slightly behind client with feet apart, extend one leg, and let client slide against it to the floor 4. Step 12 inches behind the client, support under axillae, tighten back, and lower client to the floor

3 To prevent injury to the nurse and the client if the client is falling, the nurse uses good body mechanics to try to break the fall and guide the client to the floor if necessary. These actions include: - Step slightly behind the client and place the arms under the axillae or around the client's waist - Place feet wide apart with knees bent - creates a broad base of support, provides stability, and reduces the risk for back injury to the nurse - Place one foot behind the other and extend the front leg - allows the nurse to bring the client backward by using the leg muscles to rock backward while supporting the client's weight - Let the client slide down the extended leg to the floor - lowers the client gently to the floor while keeping the client's head protected from injury (Options 1 and 4) These actions do not provide close proximity to the client, a broad base of support, or a lower center of gravity to increase the nurse's stability and help prevent back injury. (Option 2) These actions are appropriate for helping a client rise from the bed or chair but not for assisting a falling client to the floor. Educational objective: These nursing actions can help prevent injury if a client is falling while the nurse is assisting with ambulation: step slightly behind the client with feet wide apart and knees bent, place arms under the axillae or around the client's waist, place one leg behind the other and extend the front leg, and let the client slide down the extended leg to the floor.

A client with terminal cancer is prescribed fentanyl patches for pain management while receiving hospice care at home. Which instructions related to this medication should the nurse provide? Select all that apply. 1. Apply a heating pad over the patch to aid drug absorption 2. Cut the patch in half before application if less medication is needed 3. Fold the used patch in half so that the edges adhere and immediately discard 4. Place the patch 1 in (2.5 cm) from the source of pain for maximal effectiveness 5. Remove the old patch when applying a new patch every 72 hours

3, 5 Fentanyl, a potent opioid analgesic, is administered IV to treat acute pain and as a transdermal patch (Duragesic) dosed in mcg/hr to treat chronic pain. When given via transdermal patch, fentanyl is absorbed systemically through the skin to provide continuous analgesia. Patches are replaced every 72 hours, and the used patch must be removed before applying a new one (Option 5). Used patches must be folded and discarded immediately, as some medication remains in a used patch. Opioid medications must be stored and disposed of securely (eg, flushed down the toilet, discarded in a sharps container) as accidental exposure is potentially fatal for children, pets, and caregivers (Option 3). (Option 1) Heat (eg, heating pad) should not be placed over a patch as this accelerates absorption. (Option 2) Cutting a transdermal patch damages the drug-delivery system, results in administration of an imprecise dose, and risks exposure to the person cutting the patch. (Option 4) Transdermal patches should be applied to an area of flat, intact skin (eg, upper back, chest) to prevent accidental removal. The site should be clean, with little hair. Unlike transdermal patches, topical analgesic patches (eg, lidocaine, capsicum) deliver drug locally and are placed near the site of pain. Educational objective: Fentanyl patches are changed every 72 hours, and used patches must be folded and discarded securely before a new one is applied. Patches should be applied to flat, intact skin to prevent accidental removal. Patches should not be cut, and heat should not be placed over them. Pharmacological and Parenteral Therapies

A nurse is instructing the caregiver of an 8-month-old client regarding administration of oral amoxicillin. The client is prescribed 25 mg/kg/day of amoxicillin in 2 divided doses for 5 days. The client weighs 16.5 lb and the amoxicillin solution is prepared as 125 mg/5 mL. How many mL of amoxicillin should the nurse instruct the caregiver to administer for each dose? Record the answer using two decimal places. Answer: (mL/dose)

3.75 Using dimensional analysis, the following steps are performed to calculate the volume of amoxicillin per dose: Identify the prescribed, available, and required medication information Prescribed: 25 mg amoxicillinkg/day Available: 125 mg amoxicillin5 mL solution Required: mLdosePrescribed: 25 mg amoxicillinkg/day Available: 125 mg amoxicillin5 mL solution Required: mLdose Convert prescription to volume needed for administration using dimensional analysis Prescription×available medication=mL/dosePrescription×available medication=mL/dose OR (mg amoxcillinkg/day)(kglbs)(lbs )(daydose)(mL mg amoxicillin)=mL amoxicillindosemg amoxcillinkg/daykglbslbs daydosemL mg amoxicillin=mL amoxicillindose OR ⎛⎝⎜⎜25 mg amoxicillinkg/day⎞⎠⎟⎟⎛⎝⎜⎜kg2.2 lbs⎞⎠⎟⎟(16.5 lbs )⎛⎝⎜⎜day2 doses⎞⎠⎟⎟⎛⎝⎜⎜5 mL 125 mg amoxicillin⎞⎠⎟⎟=3.75 mL amoxicillindose 25 mg amoxicillinkg/daykg2.2 lbs16.5 lbs day2 doses5 mL 125 mg amoxicillin=3.75 mL amoxicillindose Educational objective: To calculate the milliliters per dose of oral amoxicillin, the nurse should first identify the prescribed dose (eg, 25 mg/kg/day divided in two doses) and available medication (eg, 125 mg/5 mL solution) and then convert to milliliters per dose (eg, 3.75 mL/dose).

The nurse caring for a client with tuberculosis (TB) transports the client to the radiology department for a chest x-ray. The nurse ensures that the client uses which personal protective equipment when out of the negative-pressure room? 1. Isolation gown, surgical mask, goggles, and gloves 2. Isolation gown and surgical mask 3. N95 respirator mask 4. Surgical mask

4 Clients with airborne infections such as TB, measles, or chickenpox (varicella) are confined to a negative-pressure room except when traveling to various departments for essential diagnostic procedures or surgery. While being transported through the health care facility, the client on airborne transmission-based precautions wears a surgical mask to protect health care workers (HCWs) and other clients from respiratory secretions. (Options 1 and 2) The client on airborne transmission-based precautions must wear a surgical mask to contain exhaled respiratory secretions. The other personal protective equipment is not necessary. (Option 3) The Centers for Disease Control and Prevention recommends that HCWs who transport clients wear N95 respirator masks as protection against exposure to airborne droplets. N95 respirator masks protect HCWs by removing particles from inhaled air. The client is already infectious and does not require protection from inhaled air. Educational objective: While away from the negative-pressure isolation room, all clients on airborne transmission-based precautions must wear a surgical mask to contain exhaled respiratory secretions.

The nurse performs nasogastric (NG) tube insertion using a large-bore NG tube on a hospitalized client with a gastrointestinal bleed. During insertion, after the tube passes the nasopharynx, the client begins to cough and gag. Which action should the nurse take first? 1. Ask the client to take several small sips of water 2. Continue to slowly advance the tube until placement is reached 3. Gently remove the tube and reinsert in the other naris if possible 4. Pull back on the tube slightly and then pause to give the client time to breathe

4 During NG tube insertion, the tube sometimes slips into the larynx or coils in the throat, which can result in coughing and gagging. The nurse should withdraw the tube slightly and then stop or pause while the client takes a few breaths. After the client stops coughing, the nurse can proceed with advancement (Option 2), asking the client to take small sips of water to facilitate advancement to the stomach (Option 1). The client should not be asked to swallow during coughing or aspiration may occur. If resistance or obstruction occurs during tube advancement, the nurse should rotate the tube while trying to advance it. If resistance continues, the tube should be withdrawn and inserted into the other naris if possible (Option 3). Educational objective: Coughing and gagging commonly occur during NG tube insertion if the tube coils in the throat or slips into the larynx. When this happens, the nurse should pull back on the tube slightly and then pause to give the client time to recover and breathe before advancing the tube.

An unconscious client is brought to the emergency department by the paramedics after being hit by a car. An emergency craniotomy is required. The client has no identification. What action should be taken next? 1. Contact the national database to see if the client has a healthcare proxy 2. Contact the police to help identify the client and locate family members 3. Obtain a court order for the client's surgical procedure 4. Transport the client to the operating room under implied consent

4 Implied consent in emergency situations includes the following criteria: 1) There is an emergency 2) Treatment is required to protect the client's health 3) It is impractical to obtain consent 4) It is believed that the client would want treatment if able to consent In this case, it would be assumed that the client would want life-saving surgery; the health care provider should proceed. (Option 1) This client's name is not known and there is no national database of healthcare proxy names/power of attorney. (Option 2) This should also be done but results may not be obtained in a timely manner. The client needs immediate surgery and this should proceed with the client as a "John Doe" (placeholder name) in the meantime. (Option 3) This would cause considerable delay. Court orders are used for protective custody to take control of the care of a minor when the adult parent is refusing necessary life-saving care. Educational objective: Emergency life-saving care can proceed for a client who cannot give consent if it is essential and believed that the client would want treatment if able to consent. Care is rendered under the principle of implied consent.

The nurse cares for a child with bed bug bites. Which parent statement indicates that further teaching is required? 1. "I need to have the entire house treated by pest control to ensure the bed bugs are gone." 2. "I should concentrate on alleviating scratching as it can cause further complications." 3. "My other family members and pets are at risk of bed bug bites." 4. "This must have happened because I did not wash the bed sheets this week."

4 It is a common misconception that bed bugs are drawn only to dirty environments. They can inhabit any environment and can travel and spread easily in clothing, bags, furniture, and bedding. Although they do not pose significant harm, bed bugs can cause an itchy red rash that can be uncomfortable and affect sleep. Bed bugs should be exterminated, especially in a home with children. (Option 1) It is important to treat the entire house for bed bugs. Washing a single pillowcase or blanket will not stop the infestation. Bed bugs multiply quickly and can hide in any crevice. Once pest control is complete, the home will need to be monitored for signs of lingering bugs. (Option 2) Bed bug bites can cause a rash that clients, especially children, will be inclined to scratch. Precautions should be taken to help alleviate the rash as itching can cause complications such as secondary skin infections. (Option 3) Once a home is infested, the bugs can travel quickly and occupy spaces and crevices. All household members and pets will be afflicted. Educational objective: Bed bugs spread quickly and travel in bedding, clothing, and furniture. It is important to recognize bed bug bites and eliminate this pest from the home. Client treatment aims to minimize itching until the rash is gone. Safety and Infection Control

A new graduate nurse is preparing to administer the following analgesics to clients with postoperative pain. Which situation would require intervention by the precepting nurse? 1. chooses to administer 50 mcg of the prescribed 50-100 mcg of IV fentanyl for the first dose 2. dilutes hydromorphone with 5 mL of normal saline and injects IV push over 2 minutes 3. injects 1 mg of morphine sulfate undiluted via IV push over 5 minutes 4. selects a 25-gauge 1/2-inch (1.3 cm) needle to inject ketorolac IM

4 Ketorolac is a NSAID analgesic administered (orally, IV, or IM) for short-term relief of mild to moderate pain. Usage should not exceed 5 days due to adverse effects (eg, kidney injury, GI ulcers, bleeding). Ketorolac IM should be administered into a large muscle using the Z-track method to mitigate burning and discomfort. A 1- to 1.5-inch needle is recommended to inject medication into the proper muscular space in average-weight individuals.

The graduate nurse (GN) is inserting an oropharyngeal airway into a client emerging from general anesthesia. Which action by the GN causes the nurse preceptor to intervene? 1. Measures the oropharyngeal airway against the cheek and jaw angle before insertion 2. Rotates the device tip downward once it reaches the soft palate 3. Suctions secretions from the mouth and pharynx prior to device insertion 4. Tapes the external portion of the inserted oropharyngeal airway to the client's cheek

4 Oropharyngeal airways (OPAs) are temporary artificial airway devices used to prevent tongue displacement and tracheal obstruction in clients who are sedated or unconscious. As consciousness and the ability to protect the airway return, the client often coughs or gags, indicating a need to remove the OPA; clients may also independently remove or expel it. Nurses caring for a client with an OPA must ensure that the device is easily removable from the client's mouth because an obstructed (eg, taped) OPA may cause choking and aspiration (Option 4). (Option 1) Appropriate OPA size should be measured prior to insertion because an inappropriate size could push the tongue back and cause airway obstruction. The OPA should be measured with the flange next to the client's cheek. With correct sizing, the OPA curve reaches the jaw angle. (Options 2 and 3) When inserting an OPA, the nurse should initially suction the upper airway to remove secretions. The OPA is then inserted with the distal end pointing upward toward the roof of the mouth to prevent tongue displacement and tracheal obstruction. Once the OPA reaches the soft palate, the nurse rotates the OPA tip downward toward the esophagus, which pushes the tongue forward and maintains airway patency. Educational objective: An oropharyngeal airway (OPA) is a temporary artificial airway used to prevent tongue displacement and tracheal obstruction in clients who are sedated or unconscious. An OPA should never be taped in place because of the risk of choking and aspiration when the client awakens.

The triage nurse has one isolation room left in the emergency department. Which priority client should be assigned to this room? 1. Child with chickenpox for the past 14 days; all lesions are crusted and dried 2. Child with impetigo who has been on antibiotics for 3 days 3. Child with leg rash secondary to poison ivy exposure 4. Child with suspected pertussis who has paroxysms of coughing

4 Paroxysms of rapid coughing that lead to vomiting are a key feature of pertussis infection. Pertussis is a highly contagious disease and requires droplet precautions. It can be deadly if contracted in infancy before vaccination is started. This client should be placed in isolation immediately to prevent the spread of disease. (Option 1) Chickenpox is no longer contagious after the lesions have crusted and dried, but this process can take as long as 3 weeks. This client would not require isolation. (Option 2) Impetigo is no longer contagious after 24 hours of antibiotics. This client would not require isolation. (Option 3) Poison ivy rash is not considered contagious. A person develops the rash only on contact with the urushiol oil itself. The pustules do not contain this oil, and therefore the rash cannot be spread via person-to-person contact. Educational objective: Chickenpox is no longer contagious after the lesions have crusted and dried. Pertussis is a highly contagious disease that requires droplet precautions.

A client with type 1 diabetes has a prescription for 20 units of NPH insulin daily at 7:30 AM and regular insulin before meals, based on a sliding scale. At 7:00 AM, the client's blood glucose level is 220 mg/dL, and the client's breakfast tray has arrived. Which action should the nurse take? 1. administer 20 units of NPH insulin now and then 6 units of regular insulin after the morning meal 2. administer 26 units of insulin: 20 units of NPH insulin and 6 units of regular insulin in 2 separate injections 3. administer 26 units of insulin: 20 units of NPH mixed with 6 units of regular insulin in the same syringe, drawing up the NPH into the syringe first 4. administer 26 units of insulin: 20 units of NPH mixed with 6 units of regular insulin in the same syringe, drawing up the regular insulin first

4 Prepare the mixed dose: 1. inject the NPH insulin vial with 20 units of air without inverting the vial or passing the needle into the solution 2. inject 6 units of air into the regular insulin vial and withdraw the dose, leaving no air bubble 3. draw NPH, totaling 26 units in one syringe. Any overdraw of NPH into the syringe will necessitate wasting the total quantity.

The student nurse is preparing to perform a heel stick on a neonate to collect blood for diagnostic testing. Which statement by the student nurse indicates a need for further education? 1. "I can perform the stick on either the medial or lateral side of the outer aspect of the heel." 2. "Sucrose and a pacifier can help alleviate the infant's pain and stress during the puncture." 3. "The heel area should be warmed for 3-5 minutes prior to puncture." 4. "Venipuncture should be reserved only for failed heel sticks because it is more painful."

4 The neonatal heel stick (heel lancing) is used to collect a blood sample to assess capillary glucose and perform newborn screening for inherited disorders (eg, congenital hypothyroidism, phenylketonuria). Proper technique is essential for minimizing discomfort and preventing complications and includes: - Select a location on the medial or lateral side of the outer aspect of the heel (Option 1). Avoid the center of the heel to prevent accidental insult to the calcaneus. Puncture should not occur over edematous or infected skin. - Warm the heel for several minutes with a warm towel compress or approved single-use instant heat pack to promote vasodilation (Option 3). Cleanse the intended puncture site with alcohol. Sucrose and nonnutritive sucking on a pacifier may reduce procedural pain (Option 2). - Use an automatic lancet, which controls the depth of puncture. Lancing the heel too deeply can result in penetration of the calcaneus bone, leading to osteochondritis or osteomyelitis. An acceptable alternate method of blood collection in the neonate is venipuncture (ie, drawing blood from a vein). Venipuncture is considered less painful and often requires fewer punctures to obtain a sample, especially if a larger volume is needed (Option 4). Educational objective: To perform a neonatal heel stick, select a location on the medial or lateral side of the outer aspect of the heel to avoid insult to the calcaneus bone. Provide comfort measures (eg, nonnutritive sucking), warm the selected puncture site to promote vasodilation, cleanse with alcohol, and puncture using an automatic lancet.

The nurse performs tracheostomy care for a client with a disposable inner cannula and tracheostomy dressing. Place the steps in the correct order. All options must be used. 1. Clean around stoma with sterile water or saline; dry and replace sterile gauze pad 2. Don mask, goggles, and clean gloves 3. Don sterile gloves; remove old disposable cannula and replace with a new one 4. Gather supplies and position client 5. Remove soiled dressing

4, 2, 5, 3, 1 When performing tracheostomy care, the nurse follows institution policy and observes principles of infection control and client safety. Sterile technique is used to prevent infection of the lower airway. The steps for performing the procedure for a client with a disposable inner cannula include the following: 1. Gather supplies to the bedside, then place client in semi-Fowler's position, if not contraindicated, to promote lung expansion and oxygenation and prevent aspiration of secretions. 2. Don personal protective equipment (mask, goggles, and clean gloves) to maintain universal precautions. Auscultate lungs and suction secretions if necessary. 3. Remove soiled dressing and also remove clean gloves. 4. Don sterile gloves; remove old disposable cannula and replace with a new one. While stabilizing the back plate with the nondominant hand, unlock (unclip) the old cannula with the dominant hand; remove gently by pulling it out in line with its curvature; pick up the new cannula, touching only the outer locking portion (to prevent contamination and maintain asepsis); insert; and lock (clip) into place. 5. Clean around stoma with sterile water or saline, dry and replace sterile gauze pad to remove dried secretions, and dry around stoma well to limit the growth of microorganisms. Some tracheostomy tubes are sutured in place and do not require a dressing. If secretions are copious, apply a dressing.

The nurse is to administer an albuterol nebulizer treatment to a client with acute bronchospasm. The prescribed dosage is 5 mg every 4 hours. The available solution is albuterol (0.083%) inhaled, 2.5 mg/3 mL. How many milliliters (mL) should the nurse administer with each dose? Record your answer as a whole number. Answer: (mL)

6 mL Educational objective: To calculate the milliliters per dose of nebulized albuterol, the nurse should first identify the prescribed dose (eg, 5 mg) and available dose (eg, 2.5 mg/3 mL) and then convert to milliliters per dose (eg, 6 mL/dose).

The nurse is assessing the abdomen of a client experiencing gastrointestinal distress. Place the answer choices in the correct order of assessment. All options must be used. - inspection - percussion - placement in supine position - auscultation - palpation

Nursing assessments are generally performed in order of least to most invasive. To perform an abdominal assessment, the nurse places the client in the supine position to promote relaxation of the abdominal muscles. Standing on the right side of the client, the nurse makes a visual inspection of the abdomen before touching the client. After inspection, the nurse auscultates the abdomen. Auscultation is performed next because percussion and palpation may increase peristalsis, potentially leading the nurse to make an erroneous interpretation of bowel sounds. The nurse should lightly place the diaphragm of the stethoscope in the right lower quadrant because high-pitched bowel sounds are normally present in this region. After auscultation, the nurse proceeds to percussion. Palpation is performed last because it may induce pain, resulting in abdominal rigidity, guarding, and a change in respirations. This rigidity may affect the tone heard on percussion. Percussion is also intended to identify borders of organs that move with respiration (eg, liver, spleen). A client in pain from abdominal tenderness will likely take quick, shallow breaths, which will change how far organs are displaced and make it more difficult for the examiner to identify true borders of organs. Educational objective: Abdominal examination is performed with the client in the supine position using the following sequence: inspection, auscultation, percussion, and palpation.

Which of the following drug administrations should be reported as a practice error? Select all that apply. 1. Cephalexin administered; client has history of anaphylaxis from penicillin 2. Hydromorphone 2 mg administered; client reports pruritus 3. Immunization for 3-month-old administered in ventrogluteal site 4. Oral niacin (nicotinic acid) administered; client has facial flushing 5. Warfarin administered; client at 12 weeks gestation

1, 3, 5 Warfarin (Coumadin) is generally contraindicated in pregnancy. Warfarin is a teratogen and exposure during early pregnancy can result in fetal malformations (warfarin embryopathy). It crosses the placenta, resulting in fetal anticoagulation; dangerous fetal bleeding, including intracranial hemorrhage, can occur. As a result, a client on warfarin is taught to use effective contraception (Option 5). For children age <7 months, the site for immunizations is the anterolateral thigh (vastus lateralis). The gluteus medius muscle (muscle injected with a ventrogluteal injection) is developed through crawling and walking. The muscles are not developed enough at this age to be used as an acceptable site (Option 3). History of penicillin hypersensitivity should be determined prior to administration. Clients who are truly allergic to penicillins (eg, anaphylaxis) have an increased risk of allergy to other beta-lactam antibiotics. The incidence of cross-reactivity is 1%-4% (Option 1). (Option 2) Pruritus (itching) is a known side effect of narcotic administration, particularly if the client is opioid naïve. It does not represent true allergy and is often treated with an antihistamine. Nausea is also quite common when opioid therapy is initiated, but clients quickly develop tolerance. (Option 4) Niacin (nicotinic acid or B3) is used in large doses for lipid-lowering properties. In large doses, it may produce cutaneous vessel vasodilation. The resulting warm sensation within the first 2 hours after oral ingestion is uncomfortable but harmless. It may last for several hours. Effects usually subside as therapy continues. Educational objective: Do not administer warfarin if the client is pregnant. Intramuscular injections are given in the vastus lateralis to children age <7 months. Penicillins and cephalosporins can have a cross-sensitivity response. Narcotic-induced pruritus is not a true allergy. Safety and Infection Control

The health care provider prescribes 2 mEq (2 mmol)/kg of 8.4% sodium bicarbonate IV to be administered over the next 4 hours. The client weighs 150 lb, and the pharmacy supplies the following IV solution: 8.4% sodium bicarbonate in 1000 mL of D5W with 150 mEq (150 mmol) of sodium bicarbonate. At what rate in milliliters per hour (mL/hr) should the nurse set the infusion pump? Record your answer using a whole number. Answer: (mL/hr)

227 mL/hr 2 mEq (150 lb/2.2)/4 hr X 1000 mL/150 mEq = 227 Educational objective: To calculate the hourly infusion rate of sodium bicarbonate, the nurse should first identify the prescribed dose (eg, 2 mEq [2 mmol]/kg/dose) and available medication (eg, 150 mEq [150 mmol]/1000 mL) and then convert to volume in milliliters per hour (eg, 227 mL/hr). Pharmacological and Parenteral Therapies

A continuous regular insulin IV infusion of 0.2 units/kg/hr is prescribed for a 10-year-old client who weighs 51 lb and has diabetes mellitus. How many units per hour (units/hr) would the nurse administer to this client? Record your answer using one decimal place. Answer: (units/hr)

4.6 units/hr Educational objective: To calculate the hourly dose of regular insulin, the nurse should first identify the prescribed dose (eg, 0.2 units/kg/hr) and then convert to units per hour (eg, 4.6 units/hr).

A client with ascites had 5400 mL of fluid removed during paracentesis. The health care provider prescribes 8 g of albumin IV per 1000 mL of fluid removed. If the albumin is supplied as 25 g in 100-mL bottles, how many mL will the nurse administer? Record your answer using one decimal place. Answer: (mL)

172.8 mL Educational objective: Albumin may be given after paracentesis to prevent volume depletion. To calculate the volume per dose of albumin, the nurse should first identify the prescribed dose (eg, 8 g/L peritoneal fluid) and available medication (eg, 25 g/100 mL) and then convert to volume in milliliters per dose (eg, 172.8 mL).

The nurse is obtaining orthostatic vital signs on a client admitted for dehydration. The nurse measures the client's blood pressure and pulse using the left brachial site with the client lying supine and then sitting. Which action by the nurse is appropriate? Click on the exhibit button for additional information. Supine BP 153/83 mm Hg; HR 70/min Sitting BP 119/70 mm Hg; HR 95/min 1. Assist the client to a standing position and measure a third set of vital signs 2. Place the client in reverse Trendelenburg position and take an apical pulse 3. Reassess the client's blood pressure in the supine position using the popliteal site 4. Return the client to a recumbent position and notify the health care provider

4 Orthostatic vital signs help assess the body's ability to compensate hemodynamically during postural changes. Changing position normally triggers vasoconstriction in the extremities to promote venous return. Without this response, hypotension and subsequent hypoperfusion of internal organs and the brain occur. Clients with impaired compensatory mechanisms (eg, hypovolemia, sepsis) may exhibit orthostatic hypotension, in which hypotension and/or neurologic impairment (eg, syncope) occur with position change. This increases the client's risk for falls. Orthostatic vital signs involve measuring the client's blood pressure (BP) and heart rate in the supine, sitting, and standing positions. Each measurement should be obtained after maintaining each position for 2 minutes. If any position change produces decreased systolic BP ≥20 mm Hg, decreased diastolic BP ≥10 mm Hg, and/or increased pulse ≥20/min from supine values, the nurse should discontinue assessment, place the client in a recumbent position, and notify the health care provider (Option 4). (Option 1) It is unsafe to assist the client to a standing position after identifying orthostatic hypotension, as a syncopal event may occur and the client may fall. (Options 2 and 3) Positioning the client in reverse Trendelenburg position and reassessing BP at a different site in the supine position are unnecessary and delay treatment of orthostatic hypotension. Educational objective: Nurses measuring orthostatic vital signs should discontinue further measurements if the client experiences decreased systolic blood pressure ≥20 mm Hg, decreased diastolic blood pressure ≥10 mm Hg, and/or increased pulse ≥20/min in any position. Return the client to a recumbent position and notify the health care provider.

The nurse is drawing a blood specimen from the client's right basilic vein. The client cries out, retracts the arm, and reports feeling "pins and needles" in the right arm. Which action by the nurse is appropriate? 1. Obtain a smaller-gauge needle and reattempt at the same site 2. Partially withdraw and then reinsert the needle at a different angle 3. Provide reassurance and firmly stabilize the arm to complete the collection 4. Withdraw the needle and reattempt in a different site with new equipment

4 The preferred site for venipuncture when collecting blood specimens is the antecubital fossa's median cubital vein. The basilic vein lies close to the brachial nerve and artery. When severe, shooting pain radiates down a client's arm during venipuncture, nerve injury may be occurring. The client may also report feelings of "pins and needles" or numbness at and/or near the venipuncture site. If this occurs, the nurse should promptly withdraw the needle, obtain new equipment, and choose a different site for specimen collection (Option 4). (Options 1 and 2) Because the pain and numbness during venipuncture indicate a nerve injury, the nurse should reattempt the specimen collection using a different site. Reattempting at the same site with a smaller-gauge needle or from a different angle could cause nerve damage. (Option 3) Reassurance may help calm an anxious client, and stabilization may help prevent injury if a client attempts to withdraw the arm during routine venipuncture. However, this client has nerve pain, which indicates that the attempt should be stopped immediately to prevent nerve damage. Educational objective: The presence of pain and feelings of "pins and needles" during venipuncture may indicate nerve pain and require prompt cessation of the attempt. The nurse should withdraw the needle, obtain new equipment, and choose a different site for the specimen collection.

The nurse is contributing to the plan of care for a client who has active varicella with open, moist lesions. Which of the following actions are appropriate to include in the plan of care? Select all that apply. 1. Don gown, gloves, and N95 respirator when entering the client's room 2. Ensure that pregnant staff members are not assigned to care for this client 3. Place single-use, disposable thermometer and stethoscope in the room 4. Place the client in a private room with negative air pressure 5. Request discontinuation of isolation precautions once all lesions are dry and crusted

ALL Varicella (chickenpox) is a highly contagious infection characterized by a generalized rash of itchy, vesicular lesions. Both chickenpox and shingles are caused by the varicella-zoster virus (VZV), which is transmitted through airborne particles or contact with open vesicles. For chickenpox and disseminated (widespread) shingles, the nurse should use precautions for both airborne isolation (ie, N95 respirator mask), negative air pressure room) and contact isolation (eg, gown, gloves, disposable equipment) (Options 1 and 3). Once the vesicles have crusted, the client is no longer contagious, and isolation precautions may be discontinued (Option 5). Rooms with negative air pressure are equipped with specialized air equipment that continuously filters air out of the room and creates a negative pressure gradient that prevents infectious airborne particles from escaping through the doorway (Option 4). Pregnant health care workers should not be exposed to clients with TORCH infections (Toxoplasmosis, Other [VZV/parvovirus B19], Rubella, Cytomegalovirus, Herpes simplex virus), as these infections can cause fetal abnormalities (Option 2). Educational objective: Varicella-zoster virus (ie, chickenpox, shingles) is transmitted through airborne particles or contact with open vesicles. For chickenpox and disseminated shingles, the nurse should use precautions for both airborne isolation (ie, N95 particulate respirator mask, room with negative air pressure) and contact isolation (eg, gown, gloves, disposable equipment) until vesicles have crusted.

The nurse is instructing a female client how to collect a clean catch urine specimen. Place in order the steps indicating that client teaching has been effective. All options must be used. - Performs hand hygiene and removes container lid, with sterile side placed upward - Removes specimen container from stream before stopping urinary flow - Initiates urinary stream before passing container into stream for collection - Cleanses vulva from front to back with single-use antiseptic towelettes - Spreads labia using index finger and thumb of nondominant hand

A clean catch urine specimen is commonly performed in clients requiring urinalysis. The correct collection method for a female client is as follows: 1. Perform hand hygiene and open the specimen container, leaving the sterile side of the collection lid positioned upward to prevent contamination. 2. Spread the labia using the index finger and the thumb of the nondominant hand so that the specimen cup can be held with the dominant hand. 3. Cleanse the vulva in a front-to-back motion with provided antiseptic wipes, using a new towelette with each wipe to prevent contamination. 4. Initiate the urinary stream to flush any remaining microorganisms from the urethral meatus before passing the container into the stream for the collection of 30-60 mL of urine. 5. Remove the specimen container from the stream before the urinary flow ends and the labia are released to prevent contamination. 6. Replace the sterile cap without contaminating it and repeat hand hygiene. Educational objective: A female client performs a clean catch urine specimen by completing hand hygiene and opening the specimen container, spreading the labia using the index finger and the thumb of the nondominant hand, and cleansing the vulva in a front-to-back motion. The client then initiates a urine stream before introducing the container midstream for urine collection. The container is removed when well filled (30-60 mL) and before urinary flow ends.

The nurse cares for a client with aortic stenosis who was admitted due to syncope on exertion and dyspnea. Identify the area where the nurse would best auscultate the client's heart murmur. Left-clicking the mouse will place an X to show the answer before submitting the question.

Aortic stenosis (AS) is a type of valvular heart disease characterized by narrowing of the aortic valve opening, which limits the left ventricle's ability to eject blood into the aorta. AS may occur from hardening (ie, calcification) of the valves, congenital heart disorders, or inflammation. If left untreated, AS may result in heart failure and pulmonary hypertension as compensatory mechanisms fail. When assessing a client with AS, the nurse should auscultate in the aortic area (ie, second intercostal space at the right sternal border) for a loud, systolic ejection murmur heard following the first heart sound. The aortic area, rather than directly over the heart valve, is the preferred location for auscultation as the heart sounds travel in the direction the blood flows. Additional clinical manifestations of aortic stenosis include chest pain, shortness of breath, and/or syncope that are worsened by exertion. Educational objective: Aortic stenosis is a type of valvular heart disease causing narrowing of the valve between the left ventricle and aorta, impairing ejection of blood from the heart. Nurses attempting to auscultate heart murmurs associated with aortic stenosis should listen at the right sternal border, second intercostal space (ie, aortic area).

The nurse is teaching a client to self-administer enoxaparin subcutaneously for the outpatient treatment of deep-vein thrombosis (DVT). The client points to the site of planned injection. Which site indicates that the client understands the instructions?

Enoxaparin is a low-molecular-weight heparin used in the prevention and treatment of DVT. It is administered as a deep subcutaneous injection and is usually given in the abdomen. Clients or family members may be taught how to administer the injections. The injection should be made on the right or left side of the abdomen, at least 2 in from the umbilicus. An inch of skin should be pinched up and the injection made into the fold of skin with the needle inserted at a 90-degree angle. Educational objective: The nurse can teach a client or caregiver to inject subcutaneous enoxaparin. The appropriate site of injection is on the right or left side of the abdomen at least 2 in from the umbilicus.

The nurse is forming a plan of care for an 82-year-old client with a history of anxiety, hypertension, urinary incontinence, and arthritic back pain. Which nursing diagnosis should be addressed first? Click on exhibit button for additional information. Medication prescriptions: furosemide 40 mg by mouth daily metoprolol XL 100 mg by mouth daily oxybutynin XL 5 mg by mouth daily potassium chloride 10 mEq by mouth twice a day hydrocodone/acetaminophen 5/325 mg by mouth every 6 hours PRN for pain lorazepam 1 mg by mouth 3 times daily PRN for anxiety 1. anxiety 2. chronic pain 3. risk for acute confusion 4. risk for falls

4 When determining which nursing diagnosis to address first, the nurse should consider factors that affect client safety. Risk for falls is an immediate safety concern. Nursing diagnoses that relate to chronic conditions (eg, anxiety, chronic pain) are addressed after risk for falls. The nurse should immediately implement fall risk precautions by placing the bed in the lowest position, ensuring that the call light is within reach, and turning on the bed alarm. Interventions for addressing other client needs may be carried out after measures to ensure client safety. Advanced age is associated with decreased visual acuity, muscle mass, strength, and reaction time. Medications that cause dizziness or drowsiness increase the risk for falls. Diuretics increase urinary frequency and may cause hypotension. Antihypertensive medications may cause bradycardia and dizziness.

The nurse cares for a confused client who continues to pull at the intravenous (IV) catheter on the left forearm despite frequent instructions not to do so. What is the nurse's next action? 1. Apply a gauze wrap and elastic stockinette around the IV site 2. Apply a mitt on the right hand 3. Apply a soft wrist restraint on the right wrist 4. Apply an arm board to the left arm

1 A physical restraint that restricts body movement should be the last resort to keep a client from interfering with medical treatment. Restraints can cause bodily injury such as pressure ulcers, neurovascular and peripheral circulatory deficits, and psychological trauma. Therefore, less restrictive methods should always be tried first. Concealing the IV site and tubing by wrapping the forearm in gauze and an elastic stockinette can be effective in keeping a confused client from pulling at the IV line. (Options 2, 3, and 4) Applying a hand mitt, soft wrist restraint, or arm board may be necessary if less restrictive techniques, such as concealing the IV site or encouraging family member or sitter involvement, are ineffective in keeping the client from pulling at the IV line. However, applying one of these restraints should not be the nurse's next action. Educational objective: The least restrictive device or method to keep a client from interfering with medical treatment should always be tried first, before applying a physical restraint.

A nurse is performing a dressing change for a hospitalized client with an infected surgical incision. Which actions should the nurse take? 1. Have the client remove the existing dressing while the nurse prepares sterile supplies 2. Wear clean gloves for removal and application of a new dressing 3. Wear clean gloves to remove the existing dressing, changing to sterile gloves to apply the new dressing 4. Wear sterile gloves, gown, and goggles to remove the soiled existing dressing

3 The existing dressing is already contaminated so clean gloves can be worn to remove and discard it. Surgical wounds should be re-dressed using aseptic technique, which would require sterile gloves and sterile dressing supplies. The nurse should carefully remove the soiled dressing to avoid shedding any microorganisms into the air and expose the wound for minimal time to avoid additional contamination. (Option 1) It would be better for the nurse to perform the dressing change as the wound is already infected. The client may be able to assist in the home setting. (Option 2) Clean gloves can be used for removal but not for application of a new dressing. (Option 4) Sterile gloves are not needed to remove the existing dressing. A gown and goggles may be required if splashing is possible. Educational objective: When changing the dressing of a surgical incision, the nurse may wear clean gloves to remove the existing dressing but should wear sterile gloves to apply a new one.

The nurse assesses the breath sounds of a 2-day postoperative total laryngectomy client and determines that suctioning is needed to clear secretions. The client is off the mechanical ventilator and is receiving humidified oxygen via a tracheostomy mask. Place the steps for suctioning the tracheostomy tube in the correct order. All options must be used. 1. Apply intermittent suction while rotating the suction catheter while withdrawing 2. If resistance is felt, withdraw the catheter 0.4-0.8 in (1-2 cm) 3. Insert catheter the length of the airway without applying suction 4. Place client in semi-Fowler's position 5. Preoxygenate (hyper-oxygenate) with 100% oxygen

4, 5, 3, 2, 1 When performing the suctioning procedure, the nurse follows institution policy and observes principles of infection control and client safety. Strict aseptic technique is maintained because suctioning can introduce bacteria into the lower airway and lungs. 1. Place the client in semi-Fowler's position, if not contraindicated, to promote lung expansion and oxygenation. 2. Preoxygenate with 100% oxygen (hyper-oxygenate) to prevent hypoxemia and microatelectasis. Alternately, if the client is breathing room air independently, ask the client to take 3-4 deep breaths. 3. Insert the catheter gently the length of the airway without applying suction to prevent mucosal tissue damage. The distance can be premeasured (0.4-0.8 in [1-2 cm] past the distal end of the tube). 4. Withdraw the catheter slightly (0.4-0.8 in [1-2 cm]) if resistance is felt at the carina (bifurcation of the left and right mainstem) to prevent mucosal tissue damage. 5. Apply intermittent suction while rotating the suction catheter during withdrawal to prevent mucosal tissue damage. Limit suction time to 5-10 seconds with each suction pass to prevent mucosal tissue damage and limit hypoxia. Educational objective: Suctioning removes secretions from the airway. The nurse should minimize risks associated with suctioning by using correct aspiration technique and client positioning. Semi-Fowler's position promotes lung expansion. Preoxygenation and limit of suction time to 5-10 seconds reduces hypoxia and trauma.

A nurse is caring for a homeless client who is moderately malnourished and suffering from pneumonia. The client needs a peripheral IV line for fluid administration. Which IV site should the nurse select to reduce the risk for infection? 1. Antecubital fossa 2. Dorsal surface of hand 3. Dorsum of foot 4. Lateral surface of wrist

2 Clients most at risk for catheter-related bloodstream infections are those with compromised immune systems; therefore, this client is at high risk. The IV site chosen for catheter insertion can influence the infection risk. The risk is higher using the lower extremities compared to the upper extremities and using the wrist or upper arm compared to the hand. Unless the client is very old or very young, the hand is a good site as it is most distal, allowing future sites to be selected higher on the arm if needed. (Option 1) The antecubital fossa is commonly selected in emergency situations due to its size and ease of cannulation but is problem prone for longer-term needs as it is in the bend of the elbow. Bending of the arm can move the catheter, causing irritation at the insertion site and increasing infection risk. (Option 3) The foot is not typically accessed in adults without a specific health care provider prescription. It is occasionally used in emergency situations; however, veins in the legs and feet may have decreased venous return, and complications can lead to thrombophlebitis or deep vein thrombosis. (Option 4) The radial vein is present on the lateral side of the wrist but is in close proximity to several nerves, which could cause severe pain or nerve damage. Educational objective: Peripheral IV sites should be selected in the hand or forearm to reduce the risk of catheter-related bloodstream infections. Sites on the upper extremities located at flexion sites (eg, wrist, bend of arm) and the lower extremities should be avoided.

The nurse prepares to insert an indwelling urinary catheter for a female client. The nurse assesses for allergies, explains the procedure to the client, gathers equipment, and then performs perineal care. Place in order the steps the nurse should take when inserting the urinary catheter. All options must be used. 1. Apply sterile gloves and place sterile drape under the client's buttocks 2. Perform hand hygiene and open a sterile urinary catheterization kit 3. Use the dominant hand to cleanse the labial folds with antiseptic swabs 4. Use the dominant hand to cleanse the urethral meatus with antiseptic swabs 5. Use the dominant hand to insert the catheter until urine return is observed 6. Use the nondominant hand to gently spread the labial folds

2, 1, 6, 3, 4, 5 Steps for indwelling urinary catheter insertion for the female client include: - Position the client supine with knees flexed and hips slightly externally rotated. - Perform hand hygiene and open a sterile catheterization kit (Option 2). - Apply sterile gloves and place a sterile drape underneath the client's buttocks (Option 1). - Remove the protective covering from the catheter, lubricate the catheter tip, and pour antiseptic solution over cotton balls or swab sticks while maintaining sterility of gloves and sterile field. - Use the nondominant hand to gently spread the labia. The nondominant hand is now contaminated (Option 6). - Use the dominant (sterile) hand to cleanse the labia and urinary meatus with antiseptic-soaked cotton balls or swab sticks. Cleanse in an anteroposterior direction (from the clitoris toward the anus). Use a new swab for each swipe to avoid transferring bacteria between areas. Cleanse the labia majora first, then the labia minora, and lastly the urinary meatus (Options 3 and 4). - Use the dominant hand to insert the catheter until urine return is visualized in the tubing (usually 2-3 inch [5-7.6 cm]), and then advance it an additional 1-2 inch (2.5-5 cm) (Option 5). - Hold the catheter in place with the nondominant hand, and then use the dominant hand to inflate the balloon. Educational objective: To insert an indwelling urinary catheter in a female client: perform hand hygiene; apply sterile gloves and place a sterile drape under the client; arrange supplies on a sterile field; gently spread the labia with the nondominant hand; cleanse the labia majora, then the labia minora, and lastly the urinary meatus; insert the catheter until urine return is visualized; advance an additional 1-2 inch (2.5-5 cm); and inflate the balloon.

While preparing to insert a peripheral IV line, the nurse notices scarring near the client's left axilla. The client confirms a history of left breast cancer and modified radical mastectomy. Which actions should the nurse take? Select all that apply. 1. Advance the entire stylet into the vein upon venipuncture 2. Insert the IV line into the most distal site of the right arm 3. Place an appropriate precaution sign above the bed 4. Review the medical record for history of mastectomy 5. Teach the client to keep the left arm in a dependent position

2, 3, 4 A modified radical mastectomy includes removal of axillary lymph nodes that are involved in lymphatic drainage of the arm. Any trauma (eg, IV extravasation) to the arm on the operative side can result in lymphedema, characterized by painful and lengthy swelling, as normal lymphatic circulation is impaired by scarring. Therefore, starting an IV line in this arm is contraindicated. The nurse should insert the IV line into the most distal site of the unaffected side (Option 2). For client safety, it is also important to ensure documentation of the mastectomy history, place a restricted extremity armband on the affected arm, and place a sign above the client's bed notifying hospital staff of necessary mastectomy precautions (eg, no blood pressure measurements, venipuncture, or IV lines) (Options 3 and 4). In general, venipuncture is contraindicated in upper extremities affected by: - Weakness - Paralysis - Infection - Arteriovenous fistula or graft (used for hemodialysis) - Impaired lymphatic drainage (prior mastectomy) (Option 1) The stylet should be advanced until blood return is seen (approximately ¼ inch). If advanced fully, the stylet may penetrate the posterior wall of the vein and cause a hematoma. (Option 5) Keeping the affected arm in a dependent position for a long time can increase lymphedema. The client should be reminded that raising the limb helps drainage. Educational objective: IV line insertion is contraindicated on the operative side of clients with a prior mastectomy. Additional contraindications for IV line insertion include weakness, paralysis, or infection of the arm; or presence of an arteriovenous fistula. Pharmacological and Parenteral Therapies

A comatose client in the intensive care unit has an indwelling urinary catheter. Which action(s) should the nurse implement to reduce the incidence of catheter-associated urinary tract infections (UTIs)? Select all that apply. 1. Cleanse periurethral area with antiseptics every shift 2. Ensure each client has a separate container to empty collection bag 3. Keep catheter bag below the level of the bladder 4. Routinely irrigate the catheter with antimicrobial solution 5. Use sterile technique when collecting a urine specimen

2, 3, 5 Health care catheter-associated UTIs are prevalent among hospitalized clients with indwelling urinary catheters. Steps to prevent infections in clients with urinary catheters include the following: - Wash hands thoroughly and regularly - Perform routine perineal hygiene with soap and water each shift and after bowel movements - Keep drainage system off the floor or contaminated surfaces - Keep the catheter bag below the level of the bladder - Ensure each client has a separate, clean container to empty collection bag and measure urine - Use sterile technique when collecting a urine specimen - Facilitate drainage of urine from tube to bag to prevent pooling of urine in the tube or backflow into the bladder - Avoid prolonged kinking, clamping, or obstruction of the catheter tubing - Encourage oral fluid intake in clients who are awake and if not contraindicated - Secure the catheter in accordance with hospital policy (tape or Velcro device) - Inspect the catheter and tubing for integrity, secure connections, and possible kinks (Option 1) Perineal hygiene is performed using soap and water only every shift and as needed. Routine use of antiseptic cleansers is not shown to prevent infection and may lead to the development of drug-resistant bacteria. (Option 4) Routine irrigation with antimicrobial solution or systemic administration of antimicrobials is not recommended for routine catheter care and infection prevention. Educational objective: Routine catheter care to prevent health care catheter-associated UTIs includes routine hand hygiene, cleansing the perineal area with soap and water routinely, keeping the catheter bag below the bladder and off the ground, keeping the catheter and tubing free of kinks and facilitating urine into the bag, and using sterile technique when collecting urine specimens.

The nurse is preparing to transfer a client from the bed to the chair for the first time. The client has generalized weakness and is unable to follow instructions. Which would be the most appropriate method for the nurse to use to transfer this client safely? (photos) 1. using a gait belt and walking behind/beside patient 2. patient on edge of bed with gait belt and pivoting to chair 3. using a standing-assist transfer device 4. using a full-body sling with mechanical lift

4 To determine the most appropriate method to transfer a client safely for the first time, the nurse should assess 2 factors: - Whether the client can bear weight:Neurological deficits (eg, paralysis, paresis [weakness])Decreased muscle strength (eg, prolonged immobility, multiple sclerosis, muscular dystrophy)Trauma (eg, amputee, hip fracture) - Whether the client is cooperative and able to follow instructions:Altered mental status (eg, delirium, drug intoxication)Decreased cognitive ability (eg, dementia, head injury) Given this client's weakness and inability to cooperate with instructions during the transfer, a pivot transfer would be unsafe. A standing-assist lift may also be unsafe as it also requires the client to follow directions. Therefore, a full-body sling with mechanical lift should be used to safely transfer this client (Option 4). This prevents musculoskeletal injuries to the health care worker and provides the safest method of transfer for this client. (Option 1) A 1-person standby assistance is appropriate for a client with full weight-bearing ability who is either uncooperative or at high risk for falls. (Options 2 and 3) A pivot transfer or standing-assist lift transfer requires client cooperation with instructions to promote safety during the transfer. Educational objective: A client who can bear weight partially but is unable to cooperate with instructions requires a full-body sling with mechanical lift and 2 caregivers for safe transfer.

Which client is most at risk for hospital-acquired methicillin-resistant Staphylococcus aureus (MRSA)? 1. 15-year-old student athlete in the emergency department with a fractured femur 2. 46-year-old with a large abdominal incision and 2 peripheral IV lines 3. 72-year-old who received a permanent pacemaker 24 hours ago 4. 80-year-old with chronic obstructive pulmonary disease (COPD) who is on a ventilator

4 Clients at highest risk for hospital-acquired MRSA are older adults and those with suppressed immunity, long history of antibiotic use, or invasive tubes or lines (hemodialysis clients). Clients in the intensive care unit (ICU) are especially at risk for MRSA. The 80-year-old client with COPD in the ICU on the ventilator has several of these risk factors. COPD is a chronic illness that can affect the immune system, and clients experience exacerbations that may require frequent antibiotic and corticosteroid use. This client is elderly and also has an invasive tube from the ventilator. (Option 1) A student athlete could be colonized with MRSA from time spent in locker rooms and around athletic equipment. MRSA more often appears as skin infections in this age group. Unless this client has an open fracture, there is no break in skin integrity. (Option 2) This client does have an incision (portal of entry) and invasive lines but is younger and has no evidence of suppressed immunity. (Option 3) This client is older and does have a small surgical incision but is not as high risk as the client with COPD. All clients undergoing pacemaker placement will receive a prophylactic antibiotic to prevent surgical site infection just before surgery. Educational objective: Clients at highest risk for developing hospital-acquired MRSA are older adults and those with suppressed immunity, long history of antibiotic use, invasive tubes or lines, or in the ICU. Nurses should follow infection control procedures diligently with these clients.

The nurse is caring for a client who weighs 450 lb (204.1 kg) 2 days after bariatric surgery. The client is pleasant, cooperative, and able to fully bear weight. What would be the most appropriate method for transferring this client safely? 1. 1-person safety standby with walker 2. 2-person full-body sling lift 3. 2-person standing-assist lift 4. 4-person full-body sling lift

1 When determining the most appropriate method to transfer a client safely, the nurse should assess: - Whether the client can bear weight - Whether the client is cooperative This client is able to bear full weight despite having a heavy body and can cooperate during the transfer. Therefore, such clients should be encouraged to do as much as they can for themselves, anticipating discharge in the near future. It is appropriate to transfer this client with 1 person standing by for safety. If the client was unable to bear full weight, more assistance would be needed. The number of caregivers providing assistance during the transfer of a heavier client should be increased to promote safety for the client and staff. When working with bariatric clients, equipment that has the capacity to bear the client's full weight and accommodate their size should be used while maintaining the client's dignity throughout the process. (Options 2 and 3) These would not be necessary as this client can fully bear weight and cooperate with caregiver instructions during the transfer. (Option 4) A 4-person sling lift transfer is appropriate for the bariatric client who cannot bear weight or cooperate with the transfer. Educational objective: A client who is able to fully bear weight and cooperate can transfer independently with standby assistance for safety. If there is any concern for caregiver or client safety during the transfer of a bariatric client, the type of equipment should be reconsidered and the number of caregivers should be increased.

The charge nurse observes a new staff nurse collecting a urine sample for urinalysis and culture as pictured. What is the charge nurse's best action? Click on the exhibit button for additional information. Obtaining urine from collection bag 1. Advise the staff nurse to discard the collected urine specimen and record the output 2. Advise the staff nurse to put the lid on the cup and immediately transfer it to a biohazard bag 3. Instruct the staff nurse to discard the first small amount of urine before collecting the sample 4. Remind the staff nurse that the specimen should be kept cool until it is sent to the laboratory

1 Urine specimens must be collected aseptically from the port located on the catheter tubing of an indwelling urinary catheter. Obtaining urine from a collection bag is improper technique, and it would not be considered a viable specimen (Option 2). In this case, the collected urine should be measured and discarded (Option 1). Colonization and multiplication of bacteria within the stagnant urine in the collection bag may occur and cause incorrect results. In addition, some urinary drainage bags are impregnated with an antimicrobial agent to help prevent catheter-associated urinary tract infections; these agents can also negatively affect the results of a urinalysis or culture. To collect a urine specimen: > Clean the collection port with an alcohol swab > Aspirate urine with a sterile syringe > Use aseptic technique to transfer the specimen to a sterile specimen cup (Option 3) The urine sample should be collected aseptically from the port on the catheter; therefore, the current specimen should be discarded as it was collected incorrectly. (Option 4) Specimens should be kept cool until transported to the laboratory; however, this sample was collected incorrectly and should be discarded. Educational objective: A urine specimen is collected aseptically from the specimen port in an indwelling urinary catheter. Urine that has been collected from the collection bag does not yield accurate urinalysis and culture results.

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

1, 2, 3 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 decrease 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 is reconstituting methylprednisolone sodium succinate for IM injection. Place in order the steps that the nurse should perform to appropriately prepare the medication. All options must be used. - Perform hand hygiene and don clean gloves - Roll vial between the palms of the hands to mix - Withdraw air from the vial - Withdraw reconstituted medication from the vial - Inject diluent into the vial - Label syringe with medication name and dosage

1. Perform hand hygiene and don clean gloves 2. Withdraw air from the vial 3. Inject diluent into the vial 4. Roll vial between the palms of the hands to mix 5. Withdraw reconstituted medication from the vial 6. Label syringe with medication name and dosage When reconstituting a powdered medication for parenteral administration, the nurse should: 1. Perform hand hygiene and don clean gloves prior to handling medication (Option 3). This is a universal practice for aseptic handling of any medication. Cleanse the vial top with alcohol and let it dry to prevent possible microbial contamination. 2. Withdraw an amount of air from the vial equal to the prescribed amount of diluent to create negative pressure that will be equalized when the diluent is injected into the vial. The medication manufacturer will specify the needed amount and type of diluent (Option 5). 3. Inject the appropriate diluent (eg, sterile saline, sterile water) into the vial. The diluent reconstitutes the medication by dissolving the powder (Option 1). 4. Roll the vial between the palms of the hands to gently mix the solution. Avoid shaking the vial as bubbles may develop, making withdrawal of the reconstituted medication difficult (Option 4). 5. Withdraw the reconstituted medication from the vial into a sterile syringe for administration (Option 6). Verify the dosage by checking the prepared medication against the medication administration record and medication label. 6. Label the syringe with the medication name and dosage to prevent medication errors at the bedside (Option 2). Educational objective: To reconstitute powdered medication from a vial, the nurse should perform hand hygiene and don gloves; withdraw air; inject the prescribed amount/type of diluent; mix by rolling the vial between the palms of the hands; withdraw the reconstituted medication into a syringe; and label the syringe with the medication name and dosage. Pharmacological and Parenteral Therapies

The emergency department nurse receives report on 4 clients. Which client will the nurse prioritize for placement in an isolation room? 1. 4-year-old diagnosed with scabies who has red burrows and bumps along the neckline and inner elbows 2. 7-year-old diagnosed with measles who has a fever, conjunctivitis, cough, and maculopapular rash 3. 12-year-old with a positive rapid influenza test who has a fever, cough, and runny nose 4. 14-year-old with 4-inch wound on inner aspect of thigh with a positive culture for methicillin-resistant Staphylococcus aureus

2 Infectious agents that are spread by air currents are among the most contagious of pathogens. Therefore, clients with airborne infections (measles, tuberculosis, varicella, severe acute respiratory syndrome) should be isolated first using airborne precautions. These infections are spread via very small particles that circulate in the air. Clients with airborne infections are placed in an isolation room with negative pressure that provides air exchange or with a high-efficiency particulate air filtration system. (Option 1) Clients with scabies will be placed in contact isolation. The 4-year-old is contagious, but only if direct contact is made. Therefore, isolating the client with airborne precautions is the priority. (Option 3) Clients with influenza are placed on droplet precautions. The 12-year-old can spread pathogens via large droplets released into the air when coughing, sneezing, or talking. The client would be the second priority for isolation. (Option 4) Clients with methicillin-resistant Staphylococcus aureus infection are placed on contact precautions. The 14-year-old is contagious, but only if direct contact is made. The client requires isolation but is not a priority over the client whose pathogens are airborne. Educational objective: Airborne infections (eg, measles, tuberculosis, varicella) are spread by air currents and are among the most contagious of diseases. Clients with these infections require airborne precautions and should be isolated first.

The primary health care provider prescribes a 24-hour urine collection for a client with suspected Cushing syndrome. Which instructions should the nurse give the client regarding this test? Select all that apply. 1. "A continuous urinary catheter must be inserted for this test and the urine will collect in an attached bag." 2. "Keep the urine collection container in the refrigerator or a cooled ice chest when it is not in use." 3. "Only daytime urine should be collected in the container as cortisol levels are higher in the morning." 4. "Record the time the urine collection is started and then empty the bladder into the toilet so that the start time coincides with an empty bladder." 5. "You will be given a dark plastic jug containing a powder that absorbs into the urine that you will collect in the jug."

2, 4, 5 A 24-hour urine is collected to evaluate Cushing syndrome (a condition that results from chronic increased corticosteroids). The urine is tested for free cortisol, and results >80-120 mcg/24 hr (220-330 nmol/day) indicate that Cushing syndrome is present. Instructions for collecting a 24-hour urine are as follows: - Use a dark jug containing a special powder (obtained from the lab) to protect the urine from light during collection. The powder helps preserve the urine and adjusts its acidity (Options 1 and 5). - Collection of the 24-hour urine should span over exactly 24 hours. It is important to first record the time and empty the bladder into the toilet so that the start time coincides with an empty bladder. At that exact time the next day, the bladder should be emptied for a final time and collected into the jug. All urine between the start time and end time should be collected into the container. The time for each urination between start and end does not need to be recorded (Options 3 and 4). - Keep the urine in a refrigerator or a cooled ice chest with the lid tightly screwed on for preservation (Option 2). Educational objective: A 24-hour urine is collected to test for increased cortisol levels when evaluating for Cushing syndrome. The client should be taught to collect the urine in a dark jug issued by the lab, start time and then empty the bladder and discard the 1st urine, and collect all the urine for 24 hours; it is kept in the refrigerator or ice chest with a secure lid. Exactly 24 hours after start time, empty bladder once more into the collection container.

The nurse initiates a norepinephrine infusion through a client's only IV access into a large peripheral vein. The client reports severe pain at the IV site shortly after the infusion is started, and blanching is visible along the vein pathway. Which nursing interventions are appropriate? Select all that apply. 1. Administer morphine IV PRN for pain after flushing the line 2. Elevate the affected extremity above the level of the heart 3. Establish a new IV access proximal to the affected site 4. Notify the health care provider and prepare phentolamine 5. Stop the infusion immediately and disconnect the IV tubing

2, 4, 5 Extravasation is the infiltration of a drug into the tissue surrounding the vein. Norepinephrine (Levophed) is a vasoconstrictor and vesicant that can cause skin breakdown and/or necrosis if absorbed into the tissue. Pain, blanching, swelling, and redness are signs of extravasation. Norepinephrine should be infused through a central line when possible. However, it may be infused at lower concentrations via a large peripheral vein for up to 12 hours until central venous access is established. The nurse should implement the following interventions to manage norepinephrine extravasation: > Stop the infusion immediately and disconnect the IV tubing (Option 5). > Use a syringe to aspirate the drug from the IV catheter; remove the IV catheter while aspirating. Elevate the extremity above the heart to reduce edema (Option 2). > Notify the health care provider and obtain a prescription for the antidote phentolamine (Regitine), a vasodilator that is injected subcutaneously to counteract the effects of some adrenergic agonists (eg, norepinephrine, dopamine) (Option 4). (Options 1 and 3) The nurse should not flush the infiltrated IV site or use it for further drug administration. Although new IV access must be obtained, access should be established ideally through a central line or on an unaffected extremity. Educational objective: If extravasation of IV norepinephrine occurs, the nurse should stop the infusion immediately, aspirate the drug, remove the IV catheter, elevate the extremity, and administer the antidote phentolamine into affected tissues as prescribed. IV access is reestablished on an unaffected extremity or through a central line.

A client with a tracheostomy is alert and oriented and able to tolerate oral intake. Which action would be appropriate to reduce the client's risk of aspiration pneumonia? 1. Fully inflate the cuff before feeding 2. Have the client sit in an upright position with the neck hyperextended 3. Partially or fully deflate the cuff 4. Provide a modified diet of pureed foods

3 A tracheostomy tube with inflated cuff is used in clients who are at risk for aspiration (eg, who are unconscious or on mechanical ventilation). However, an inflated cuff is uncomfortable for clients who are awake because it is difficult to swallow or talk. The cuff is deflated when the client is improving, is determined not to be at risk of aspiration, and is awake. Before the cuff is deflated, the client is asked to cough (if possible) to expectorate the oropharyngeal secretions that have built up above the inflated cuff. In addition, suction is applied through the tracheostomy tube and then the mouth; the cuff is then deflated. Additional interventions to decrease the risk of aspiration include the following: - Having the client sit upright with the chin flexed slightly toward the chest - Monitoring for a wet or garbled-sounding voice - Monitoring for signs of fever (Option 1) Inflating the cuff makes it difficult for a client who is awake to swallow and talk. In addition, more secretions can accumulate above the inflated cuff due to difficulty swallowing. The inflated cuff may not provide a 100% seal and the accumulated secretions can slide through it, causing aspiration. For these reasons, the deflated cuff is beneficial in awake clients with no risk of aspiration. (Option 2) Having the client sit upright will help reduce the risk of aspiration. However, the chin should be flexed toward the chest; hyperextension of the neck increases the risk of aspiration. (Option 4) There is no reason to give pureed foods just because the client has a tracheostomy. The client's diet should be determined by a swallowing evaluation. Educational objective: The risk of aspiration in a conscious, alert, and oriented client with a tracheostomy can be reduced by partially or fully deflating the tracheostomy cuff, having the client in an upright position, monitoring for a wet cough or voice quality, and monitoring vital signs.

A nurse is reviewing the most recent laboratory results of a client on the telemetry floor. The client is currently asymptomatic, and the telemetry monitor indicates sinus rhythm. Which of the following critical values is most likely due to laboratory error? 1. Blood urea nitrogen (BUN) of 60 mg/dL (21.4 mmol/L) 2. Creatinine of 4.0 mg/dL (354 µmol/L) 3. Potassium of 7.0 mEq/L (7.0 mmol/L) 4. Sodium of 155 mEq/L (155 mmol/L)

3 With the exception of clients in end-stage renal disease, a serum potassium value >6.5 mEq/L (6.5 mmol/L) in any client who is walking and talking should raise the suspicion of an erroneously elevated serum potassium (pseudohyperkalemia) from poor hematology technique, hemolysis, or clotting. A serum potassium level of 7.0 mEq/L (7.0 mmol/L) would normally constitute a life-threatening electrolyte imbalance that would cause severe weakness or paralysis, unstable arrhythmias, and eventual cardiac arrest. An assessment would focus on evaluating cardiac symptoms and muscle strength and be reported to the health care provider (HCP). In this case, it is likely that a repeat blood draw would be prescribed. Pseudohyperkalemia can be avoided on the repeat blood draw by using heparin-impregnated hematology vials to prevent clotting, minimal use of a tourniquet and fist clenching, and use of a larger gauge needle for the sample. (Option 1) This blood urea nitrogen (BUN) value is elevated (normal 6-20 mg/dL [2.1-7.1 mmol/L]) and could be related to kidney damage or dehydration. Therefore, it is not the most likely erroneous result. (Option 2) Similar to the BUN level, this creatinine value is significantly elevated (normal 0.6-1.3 mg/dL [53-115 µmol/L]). Further nursing assessment is indicated, with documentation and involvement of the HCP in evaluating the impact of this kidney damage on the client's health. (Option 4) This sodium value is high (normal 135-145 mEq/L [135-145 mmol/L]) and requires further exploration. The nursing assessment should be documented and reported to the HCP. Educational objective: High serum potassium levels could be due to hemolysis or clotting during the blood draw. If a clinical assessment does not correlate with the laboratory values, repeat testing is needed. Reduction of Risk Potential

The health care provider writes a prescription for hydromorphone 10 mg intravenous push every 2 hours prn for the post-operative client. The usual recommended dose is 0.2-1 mg every 2-3 hours prn. What action should the nurse initially take? 1. Administer the medication and monitor client frequently 2. Ask a nursing colleague if this drug amount is used 3. Check hydromorphone dose that the client had previously 4. Question the prescription with the prescriber

4 The nurse needs to have appropriate knowledge about a medication prior to administering it. Hydromorphone (Dilaudid) is a potent narcotic that has 5-10 times the strength of morphine. This client was prescribed a hydromorphone dose that is too high given that the typical maximum dose is 2 mg. As the drug prescription is outside a safe range, it must be questioned and cannot be administered automatically. (Option 1) A prescription that greatly exceeds the safety range should not be given without questioning/clarification. However, anytime the outer limit of drug dosing of a potent narcotic is administered, the client should be monitored frequently for adverse effects. This includes the sedation scale and arousability as sedation precedes respiratory depression for narcotics. (Option 2) When there is a medication dosing question, authoritative resources (eg, the pharmacist, current drug literature) should be consulted rather than relying on a nursing colleague who could be mistaken. (Option 3) Even if the client is opiate-tolerant, the dosage is significantly outside the safety range and the prescription should be questioned or clarified. Educational objective: When a medication prescription is outside the safety range, the nurse must question/clarify the prescription with the prescriber and not administer the drug automatically.

A charge nurse is monitoring a newly licensed registered nurse. What action by the new nurse would warrant intervention by the charge nurse? 1. Administers hydromorphone 1 mg to a client who rates pain at 7 on a 1 to 10 scale 2. Notifies physician of occasional premature ventricular beats in a client with myocardial infarction 3. Positions a postoperative pneumonectomy client on the affected side 4. Prepares to administer IVPB potassium chloride via gravity infusion for a client with hypokalemia

4 Treatment of hypokalemia may require an IV infusion of potassium chloride (KCL). The infusion rate should not exceed 10 mEq/hr (10 mmol/hr). Therefore, IVPB KCL must be given via an infusion pump so the rate can be regulated. IV KCL should be diluted and never given in a concentrated amount. Furthermore, too rapid infusion can cause cardiac arrest. The charge nurse would need to intervene if the new nurse was attempting to administer IVPB KCL via gravity infusion instead of a pump. (Option 1) Hydromorphone is indicated for moderate to severe pain. A pain rating of 7 would warrant its administration. (Option 2) Occasional premature ventricular contractions (PVCs) in the normal heart are not significant. PVCs in the client with coronary artery disease or myocardial infarction indicate ventricular irritability and may lead to life-threatening dysrhythmia such as ventricular tachycardia. (Option 3) With the complete removal of the lung in a pneumonectomy, the client should be positioned on the surgical side to promote adequate expansion and ventilation of the remaining lung. Educational objective: IV infusion of potassium must be administered via a pump to prevent too rapid infusion, which could cause cardiac arrest. Pharmacological and Parenteral Therapies

A nurse prepares to administer an intermittent enteral feeding via nasogastric tube to a client with a prescription for gastric residual checks before each feeding. The nurse obtains a gastric residual volume of 80 mL. Which action should the nurse perform next? 1. Collect gastric pH measurement 2. Delay feeding for at least 1 hour 3. Discard the gastric residual 4. Return residual and administer feeding

1 Before administering intermittent (bolus) enteral feedings, the nurse must verify tube placement, such as with x-ray confirmation or gastric pH measurement. Ensuring that the tip of the feeding tube is correctly placed in the stomach or small intestine is essential because administration of enteral feeding through a misplaced tube may result in life-threatening aspiration (Option 1). (Option 2) Gastric residual volume (GRV) is one indicator of how well the client is tolerating enteral feedings. High GRV (eg, >500 mL) may indicate delayed gastric emptying and poor intestinal motility (ie, feeding intolerance), which is traditionally considered a risk factor for aspiration. The nurse should follow facility policy or contact the health care provider (HCP) to determine if feedings should be delayed for high GRV or other symptoms of intolerance (eg, gastric distension, nausea/vomiting). GRVs are traditionally checked every 4 hours with continuous feeding or before each intermittent feeding. However, some facilities no longer routinely check GRVs because recent evidence shows that this practice impairs calorie delivery and may be ineffective for predicting aspiration risk. (Option 3) Repeatedly discarding gastric contents can cause hypokalemia and metabolic alkalosis. If GRV is excessively high, contents may be discarded to relieve abdominal distension (per facility policy or HCP prescription). However, GRV of 80 mL is not excessive and should be returned to the stomach. (Option 4) Tube placement must be verified before enteral feedings. Educational objective: Before administering enteral feedings, the nurse must verify tube placement (eg, gastric pH measurement). Administration of enteral feeding through a misplaced feeding tube may result in life-threatening aspiration.

The nurse is preparing to administer digoxin to a client. Prior to giving the medication, the nurse should assess the apical pulse rate. Select the best location to auscultate the apical pulse.

The apical pulse is best assessed by placing the stethoscope diaphragm at the apex of the heart/mitral area. This is located at the fifth intercostal space on the midclavicular line. For a client receiving digoxin, the apical heart rate should be assessed for 1 full minute. If the heart rate is <60/min, the nurse should consider holding the dose based on the health care provider's instructions. In addition to the apical heart rate, digoxin and potassium levels should be assessed if available. Digoxin has a very narrow therapeutic range (0.5-2.0 ng/mL), and hypokalemia can potentiate digoxin toxicity (>2.0 ng/mL). Educational objective: To assess the apical heart rate, the nurse needs to place the stethoscope diaphragm on the chest at the apex/mitral area (fifth intercostal space on the midclavicular line).

The nurse is preparing to suction secretions from the airway of an unconscious client whose lungs are mechanically ventilated with an endotracheal tube. Place the steps for suctioning the endotracheal tube in the correct order. All options must be used. - Perform hand hygiene and don clean gloves - Hyperoxygenate the lungs (100% FiO2) - Advance catheter into the trachea - Suction the oropharynx and perform oral care - Gently rotate the catheter while suctioning - Evaluate client tolerance and document

The steps for suctioning an ETT include: 1. Perform hand hygiene and don clean gloves (Option 5). 2. Suction the oropharynx and perform oral care (Option 6). 3. Ensure that the system is connected to appropriate wall suction (<120 mm Hg). 4. Hyperoxygenate the lungs (100% FiO2) (Option 4). 5. Advance the catheter into the trachea just until resistance is met (level of the carina) (Option 1). Do not suction while advancing the catheter. 6. Gently remove the catheter while suctioning and rotating it. Do not suction for more than 10 seconds (Option 3). 7. Evaluate client tolerance; if further secretions remain, suctioning can be repeated 1 or 2 times. Document the procedure when complete (Option 2). 8. Resume oxygenation and ventilation settings as prescribed. Clients with endotracheal tubes (ETTs) have impaired cough and gag reflexes and require suction to clear retained bronchial secretions and promote ventilatory efficacy. Ventilator circuits for ETTs typically have a reusable in-line endotracheal suction device, which remains sterile, in a flexible plastic sleeve. Oral secretions may pool near the base of the ETT and drip into the trachea; therefore, oropharyngeal suctioning and oral care are performed before ETT suctioning to prevent introduction of oral bacteria into the lungs. Educational objective: Tracheal suctioning through an endotracheal tube helps clear retained bronchial secretions and increases ventilatory efficacy. The nurse must follow strict asepsis to prevent the introduction of bacteria into the lungs, hyperoxygenate the lungs to prevent hypoxia, and use appropriate technique to prevent airway trauma.