UWORLD Practice Questions

Which herbal supplements pose an increased risk for bleeding in surgical clients and should be discontinued prior to major surgery? Select all that apply. 1. Black cohosh 2. Garlic 3. Ginger 4. Ginkgo biloba 5. Hawthorn

2. Garlic 3. Ginger 4. Ginkgo biloba Clients are often aware of the need to discontinue prescription medications such as aspirin and anticoagulants prior to elective surgery, but they may not know that some herbal supplements can increase bleeding risk. The nurse should question the client specifically about the use of herbal supplements. Herbal supplements that can increase risk for bleeding include: Gingko biloba Garlic Ginseng Ginger Feverfew (Option 1) Black cohosh is used for treatment of menopausal symptoms. The main side effect is liver injury. (Option 5) Hawthorn extract is used to control hypertension and mild to moderate heart failure. Hawthorn use does not increase the risk of bleeding. Educational objective:Use of herbal supplements such as ginkgo biloba, garlic, ginseng, ginger, and feverfew should be reported to the health care provider before surgery as they may increase the risk of bleeding.

The practical nurse is collaborating with the registered nurse to create a care plan for a child being admitted with Kawasaki disease. Which nursing intervention is the priority? 1. Apply cool compresses to the skin of the hands and feet(14%) 2. Monitor for a gallop heart rhythm and decreased urine output(46%) 3. Prepare a quiet, non-stimulating, and restful environment(29%) 4. Provide soft foods and liberal amounts of clear liquids(9%)

2. Monitor for a gallop heart rhythm and decreased urine output(46%). Kawasaki disease (KD) is a childhood condition that causes inflammation of arterial walls (vasculitis). The coronary arteries are affected in KD, and some children develop coronary aneurysms. The etiology of KD is unknown; there are no diagnostic tests to confirm the disease, and it is not contagious. KD has the following 3 phases: Acute - sudden onset of high fever that does not respond to antibiotics or antipyretics. The child becomes very irritable and develops swollen red feet and hands. The lips become swollen and cracked, and the tongue can also become red (strawberry tongue). Subacute - skin begins to peel from the hands and feet. The child remains very irritable. Convalescent - symptoms disappear slowly. The child's temperament returns to normal. Initial treatment consists of IV immune globulin (IVIG) and aspirin. IVIG creates high plasma oncotic pressure; signs of fluid overload and pulmonary edema develop if it is given in large quantities. Therefore, the child should be monitored for symptoms of heart failure (eg, decreased urinary output, additional heart sounds, tachycardia, difficulty breathing). (Option 1) During the acute phase (swollen hands and feet), skin discomfort can be eased with cool compresses and lotions. No treatment is needed in the subacute phase (skin peeling), but the new skin might be very tender. (Option 3) The child will be very irritable during the acute phase of KD. A non-stimulating, quiet environment will help to promote rest. After a KD episode, it is important for parents to understand that their child's irritability may last for up to 2 months and that follow-up appointments for cardiac evaluation are important. (Option 4) During the acute phase (painful swollen lips and tongue), the child should be given soft foods and clear liquids as these are tolerated best. Educational objective:Kawasaki disease causes inflammation of the arterial walls and can lead to scarring of the coronary arteries or development of coronary aneurysms. Treatment consists of aspirin and a substantial infusion of IV immune globulin. The affected child must be monitored for signs of heart failure.

The practical nurse (PN) is assisting with care for a 1-day-old client who is irritable, feeding poorly, and only sleeping for very short intervals. The newborn's mother has been taking hydrocodone on a regular basis for several years. When collaborating with the registered nurse to develop the plan of care, which intervention should the PN include? 1. Avoid giving the newborn a pacifier 2. Position the newborn supine after feeding 3. Stimulate the newborn with light regularly 4. Swaddle and gently rock the newborn

​​​​​​​​​​​​​​4. Swaddle and gently rock the newborn The newborn of a mother who is opioid-dependent (eg, heroin, methadone, hydrocodone) is at high risk for neonatal abstinence syndrome (NAS) or drug withdrawal secondary to in utero exposure to maternal substance abuse. Opioid withdrawal typically manifests within 24-48 hours after birth. Clinical manifestations of withdrawal include irritability, jitteriness, high-pitched cry, sneezing, diarrhea, vomiting, and poor feeding. The newborn with NAS is at risk for skin excoriation from excessive movement caused by hyperactivity and restlessness. The nurse should swaddle the newborn with the arms and legs flexed to prevent skin damage from excessive movement and minimize stimulation. If signs of overstimulation (eg, sneezing, arching) continue, then gentle, rhythmic rocking may soothe the newborn (Option 4). (Option 1) Ineffective, unorganized sucking patterns are common in newborns with NAS. Between feedings, a pacifier may soothe the newborn and help establish an organized sucking pattern. (Option 2) Regurgitation is common in newborns with NAS. The parent should hold the newborn upright shortly after feeding to reduce the risk of vomiting and aspiration. (Option 3) The nurse should place the newborn in a quiet, dimly lit area and organize tasks to minimize stimulation (eg, cluster care). Educational objective:The newborn of a mother who is opioid-dependent is at high risk for neonatal abstinence syndrome. Swaddling and gentle, rhythmic rocking can soothe the newborn, minimize stimulation, and prevent skin excoriation from excessive movement caused by hyperactivity and restlessness.

A nurse is reinforcing education to an adolescent client on skin cancer prevention with special focus on melanoma. Which statements should the nurse include? Select all that apply. 1. "Apply a broad-spectrum sunscreen before and during outdoor sports." 2. "Apply sunscreen a few minutes before starting outdoor activities." 3. "Reapply sunscreen after swimming, even if waterproof sunscreen was used earlier." 4. "Serious sunburns occur even on overcast days." 5. "Use tanning beds for ≤15 minutes for a base tan that is less likely to burn."

1. "Apply a broad-spectrum sunscreen before and during outdoor sports." 3. "Reapply sunscreen after swimming, even if waterproof sunscreen was used earlier." 4. "Serious sunburns occur even on overcast days." Skin cancers are most often caused by damage to the skin's DNA. This damage is typically due to exposure to ultraviolet (UV) radiation, primarily from the sun, but also from other sources (eg, tanning beds, sunlamps). The instructions to prevent sunburn and other sun-related damage include: Avoid the sun, if possible, especially between 10 AM and 4 PM. UV rays are not blocked by cloud coverage and can be reflected off water, sand, snow, and concrete. As a result, clients can burn in the shade or even during outdoor winter activities (eg, skiing) (Option 4). Wear protective clothing (eg, long sleeves, wide-brimmed hats, umbrellas) when possible. Apply sunscreen:Use a broad-spectrum sunscreen to block both UVA and UVB rays.Choose a sunscreen with SPF ≥15 for daily use or SPF ≥30 for outdoor activities and sun-sensitive individuals. Sunscreen should be applied 15-30 minutes prior to sun exposure to allow the formation of a protective film on the skin. Regardless of the type of sunscreen used, it should be reapplied at least every 2 hours, or more often if possible (Options 1 and 2).Because sunscreen is washed off with swimming and sweating, it should be reapplied, even for products labeled "water resistant" or "very water resistant" (Option 3). Avoid the use of tanning beds as they emit UV radiation (Option 5). Educational objective:To prevent sunburn, instruct clients to avoid sun exposure from 10 AM to 4 PM, wear protective clothing, use sunscreen properly (daily application; minimum SPF of 15-30; 15-30 minutes before going outside; reapplication after getting wet and every 2 hours), and avoid non-solar exposure to ultraviolet radiation (eg, tanning beds, sunlamps).

The nurse is planning education for clients in group prenatal care who are entering the second trimester of pregnancy. Which of the following are appropriate for the nurse to include in second-trimester teaching? Select all that apply. 1. Anticipate light fetal movements around 16-20 weeks gestation 2. Expect to have an abdominal ultrasound for fetal anatomy evaluation 3. Gain about 1 lb (0.5 kg) per week if pre-pregnancy BMI was normal 4. Increase consumption of iron-rich foods like meat and dried fruit 5. Plan for gestational diabetes screening near the end of the second trimester

.1 Anticipate light fetal movements around 16-20 weeks gestation 2. Expect to have an abdominal ultrasound for fetal anatomy evaluation 3. Gain about 1 lb (0.5 kg) per week if pre-pregnancy BMI was normal 4. Increase consumption of iron-rich foods like meat and dried fruit 5. Plan for gestational diabetes screening near the end of the second trimester. NCLEX® CHANGE AS OF 2017 - Please note that select-all-that-apply (SATA) questions on NCLEX can now include any number of correct responses. Only ONE option or up to ALL options may be correct. UWorld questions now reflect this change. Visit NCSBN® NCLEX FAQs for more information. The second trimester (14 wk 0 d to 27 wk 6 d) is a time of positive changes for many pregnant clients (eg, improved nausea) and when physical evidence of the pregnancy is noted (eg, increased fundal height). The nurse should prepare clients for expected physical changes and discuss prevention of potential complications. Quickening, or a client's first perception of light fetal movement, is expected around 16-20 weeks gestation, depending on parity (Option 1). Weight gain increases by approximately 1 lb (0.5 kg) per week if pre-pregnancy BMI has been normal (Option 3). Increasing intake of iron-rich foods (eg, meat, dried fruit) and continuing prenatal vitamins both help to prevent anemia caused by increased fetal iron requirements after 20 weeks gestation (Option 4). Preterm labor warnings and signs of preeclampsia should be reviewed beginning at 20 weeks gestation. The nurse should also discuss routine screening/diagnostic tests performed during the second trimester. An ultrasound is performed around 18-20 weeks gestation to evaluate fetal anatomy and the placenta (Option 2). Screening for gestational diabetes mellitus (GDM) occurs between 24-28 weeks gestation (ie, 1-hour glucose challenge test) (Option 5). GDM is a complication of pregnancy caused by hormonally related maternal insulin resistance. Educational objective:During the second trimester, the nurse should provide guidance regarding fetal movements, weight gain, screening/diagnostic tests (eg, fetal anatomy ultrasound, 1-hour glucose challenge test), and increased requirements for iron to maintain maternal and fetal health.

The nurse is reinforcing discharge instructions to a 70-year-old client newly diagnosed with heart failure who has a low literacy level. What are some teaching strategies that the nurse can use for this client? Select all that apply. 1. Conduct teaching sessions while a family member is present 2. Discourage the client from using the internet to look up health information 3. Have client watch a DVD about heart failure management 4. Print out pictures of a food label and review where to look for sodium content 5. Speak slowly and loudly so the client can understand you

The nurse needs to consider several factors when selecting teaching strategies; these include client characteristics (eg, age, educational background, language skills, culture), subject matter, and available resources. Learning can be improved as follows: Using pictures and simplified text is beneficial to the older adult with low literacy. Including a family member in the teaching process will assist the client in reinforcement of the material at a later date. Professionally produced programs are beneficial as they contain high quality visual content as well a delivery of auditory content in lay person's language. (Option 2) Older adults are using the internet in increasing numbers as are clients with low literacy. Several organizations are developing and promoting user-friendly websites. Society in general relies heavily on web-based health information. It is important for the nurse to teach the client and possibly supply a list of reputable sites for the client to view. (Option 5) Unless the client is hard of hearing, speaking slowly and loudly is unnecessary and demeaning. Educational objective:For a client with low literacy, the nurse should use multiple teaching strategies including professionally produced educational programs, pictures with simplified text, and inclusion of a family member during teaching sessions. Additional Information Health Promotion and Maintenance NCSBN Client Need

The nurse is caring for a hospitalized 6-month-old client. Which of the following interventions should the nurse implement to provide developmentally appropriate care for this client? Select all that apply. 1. Adhere to the child's home routine when possible during hospitalization 2. Encourage parents to bring the child's favorite toy from home 3. Have the parents step out of the room during procedures 4. Promote a quiet sleep environment with reduced stimuli 5. Provide a parent's shirt for the child to hold during procedures

1. Adhere to the child's home routine when possible during hospitalization 2. Encourage parents to bring the child's favorite toy from home 4. Promote a quiet sleep environment with reduced stimuli 5. Provide a parent's shirt for the child to hold during procedures Around 6 months of age, infants begin to experience separation anxiety. This anxiety may be heightened during hospitalization because of exposure to many unfamiliar stressors. Appropriate nursing care can play a significant role in reducing the infant's physiologic and psychologic stress. Key interventions include: Adhering to the infant's home routine (eg, meal and sleep times) as closely as possible (Option 1) Providing a favorite toy or pacifier (Option 2) Encouraging caregivers to remain whenever possible during hospitalization Providing a quiet sleep environment with reduced stimulation to promote restful sleep (Option 4) Offering a familiar object (eg, caregiver's shirt, blanket, voice recording) during stressful situations (Option 5) (Option 3) The presence of parents or the primary caregiver during hospitalization reduces separation anxiety and decreases the infant's stress response. Therefore, caregivers should remain whenever possible throughout all the client's care (eg, procedures, medication administration, scans). Educational objective:To reduce separation anxiety in infants during hospitalization, the nurse should adhere to the infant's home routine, provide a favorite toy or pacifier, provide a quiet sleep environment, encourage the presence of the primary caregivers, and expose the infant to familiar objects during stressful situations.

The practical nurse is collaborating with the registered nurse to admit a client who will receive general anesthesia in the same-day surgery unit. The client has never had surgery before. Which question is most critical for the nurse to ask the client during preoperative assessment and health history taking? 1. "Has any family member ever had a bad reaction to general anesthesia?"(45%) 2. "Have you ever experienced low back pain?"(5%) 3. "Have you ever had an anaphylactic reaction to a bee sting?"(31%) 4. "Have you ever received opioid pain medications?"(18%)

1. "Has any family member ever had a bad reaction to general anesthesia?"(45%) Malignant hyperthermia (MH) is a rare but life-threatening inherited muscle abnormality that is triggered by specific, inhaled anesthetic agents and succinylcholine (Anectine), a depolarizing muscle relaxant used to induce general anesthesia. In MH-susceptible clients, the triggering agent leads to excessive release of calcium from the muscles, causing sustained muscle contraction and rigidity (usually the jaw and upper body [early sign]), increased oxygen demand and metabolism, and a dangerously high temperature (later sign). Because MH is an inherited condition, proper screening and a thorough preoperative nursing assessment and health history can help minimize the client's risk (Option 1). (Option 2) Cervical spine problems should be assessed before intubation. A history of low back pain is not a deterrent for general anesthesia. (Option 3) It would be appropriate to ask about allergies (eg, drugs, latex). However, asking about an anaphylactic reaction to a bee sting is not the most critical question. (Option 4) Querying the client about prior opioid intake may be helpful, but the most important action is to ask about anesthesia side effects and allergies. Educational objective:Malignant hyperthermia (MH) is a rare, life-threatening inherited muscular abnormality that is triggered by specific drugs used to induce general anesthesia. Therefore, it is critical for the perioperative nurse to screen for MH susceptibility by asking if any of the client's blood relatives have ever experienced an adverse reaction to general anesthesia, including unexplained death.

A client with obesity reports several failed attempts at weight loss. Which client statement best indicates that the client is ready and motivated for successful weight loss? 1. "I have signed up to be a dog walker when I normally would watch television."(55%) 2. "I understand that losing weight would improve my health and well-being."(31%) 3. "I want to lose 8 pounds (3.6 kg) so that my formal gown will fit in 4 weeks."(10%) 4. "My spouse and children are always encouraging me to eat healthier."(2%)

1. "I have signed up to be a dog walker when I normally would watch television."(55%). Successful behavior modification (eg, diet and exercise for effective weight loss) requires client readiness and motivation to change, which can be assessed using the Stages of Change Model. With the appropriate support (eg, listening, not pressuring the client), clients can move from one stage to the next: Precontemplation: The client does not believe a problem exists, although others may point it out (eg, encouraging healthy eating) (Option 4). Contemplation: The client recognizes a change is needed but is undecided whether it would be possible or worthwhile (Option 2). Preparation: The client has decided to change, explores emotions related to the decision, and begins establishing goals (eg, fitting into a dress) (Option 3). Action: The client has firmly committed to changing, has developed a plan (eg, dietary modifications, exercise plans), and actively takes steps toward new behavior (eg, choosing activity over television) (Option 1). Maintenance: The client continues to uphold the new behavior and focuses on preventing relapse. Termination: The client has achieved the desired change. This stage may be theoretical, as relapse to former behaviors is always possible. Educational objective:Successful behavior modification requires client readiness and motivation to change, as evidenced by the client developing and acting on a plan. Clients often do not initially see the need for change, but with the appropriate support they begin contemplating change, preparing to change (eg, goal setting), and then actively changing.

The licensed practical nurse (LPN) assigns the ambulation of a client to unlicensed assistive personnel (UAP). The LPN observes UAP placing the client's Foley bag on the IV pole at the level of the client's chest during client ambulation down the length of the hallway. What action should the LPN take initially? 1. Immediately lower the bag and speak privately to UAP 2. Let UAP complete the assigned tasks and speak to them at the end of the shift 3. Praise UAP fo rencouraging the client to walk the entire hallway 4. Speak with the nurse manager about the need for UAP inservice education.

1. Immediately lower the bag and speak privately to UAP. The Foley bag is too high and needs to be lowered. When observing any provider making an error, the nurse should immediately intervene to stop potential harm to the client. It is important to help ensure that an error is not repeated by timely correcting any staff member who is making a mistake. Correction of staff should always be done privately, not with the client present. (Option 2) It is important for the nurse to attend to the error right away to prevent harm to the client and perpetuation of the error. Correct positioning of the Foley bag (below the level of the bladder) is important to prevent catheter-associated urinary tract infection; therefore, correcting the error is the most important action. (Option 3) The most important issue needing attention is the improper positioning (too high) of the Foley bag, which requires intervention. Positive reinforcement of appropriate actions can also be included (and is beneficial), but first the error should be corrected to prevent harm. (Option 4) Future inservice education is not a timely solution to this immediate need. It is appropriate to carry out teaching first rather than initiate disciplinary actions. According to the Federal Drug Administration's (FDA's) mandate, as no serious harm was caused, the incident does not need to be reported. Educational objective:When observing a member of the health care team making an error, the nurse should correct it immediately to stop any potential of harm caused to the client. Correct the action privately and as soon as possible. Additional Information Coordinated Care NCSBN Client Need

The practical nurse is assisting the registered nurse in preparing the room for a client with new-onset tonic-clonic seizures. It is important to ensure that what equipment is in the room? Select all that apply. 1. Oral bite prevention device 2. Oxygen delivery system 3. Padding on the bed side rails 4. Soft arm and leg restraints 5. Suction equipment

2. Oxygen delivery system 3. Padding on the bed side rails 5. Suction equipment. Client safety is a priority when caring for those with seizure activity. Protecting the airway and improving oxygenation include turning the client on the side and providing oxygen and oral suctioning as needed. Padding the metal bed side rails provides protection and decreases the potential for injury if the client hits the head or extremities during a seizure. (Option 1) During a seizure, nothing should be placed in the client's mouth. Placing objects in the mouth can result in injury to the client or health care provider. Maintaining an open airway is important and can be accomplished by turning the client on the side and providing oral suctioning to the inside of the cheeks as necessary. (Option 4) A client should never be restrained during a seizure. Restraints could cause muscle or tissue injury. Educational objective:Turning the client on the side, providing oxygen and suctioning as needed, and padding the side rails or removing objects that are near the client can decrease the risk for injury during a seizure. Restraints should not be used.

A nurse is caring for a 2-year-old child diagnosed with nephrotic syndrome who is in diapers and has red, edematous genitals. Which collection technique is appropriate for the nurse to obtain daily urine specimens for proteinuria testing with a urine dipstick? 1. Apply adhesive urine collection bag around the genital area and wait for the child to void(44%) 2. Intermittently catheterize the child every morning to avoid contaminating the specimen(17%) 3. Place cotton balls in a dry diaper; when wet, squeeze urine onto dipstick(31%) 4. Place urine dipstick in the child's diaper overnight and check result in the morning(7%)

3. Place cotton balls in a dry diaper; when wet, squeeze urine onto dipstick(31%) Nephrotic syndrome is characterized by massive proteinuria and hypoalbuminemia, which results in severe edema most evident in the abdomen, face, and perineum. Daily dipstick urinalysis determines the presence and pattern of urine protein loss to monitor for exacerbations. To collect a nonsterile urine specimen from a child who is not toilet trained, the nurse can place several cotton balls in a dry diaper and later squeeze urine onto a dipstick. The diaper is checked frequently and the sample collected and tested within 30 minutes of urination for the most accurate result. (Options 1 and 4) Children with nephrotic syndrome often have significant edema of the scrotum or labia. Placing a urine dipstick in the child's diaper or applying a standard adhesive urine collection bag around the genital area would cause further irritation and increased risk for skin breakdown. (Option 2) Children with nephrotic syndrome have a high risk for infection from immunosuppressive effects of corticosteroid therapy. Intermittent or continuous catheterizations are invasive procedures that may cause urinary tract infections. Urine cultures are the only specimen requiring sterile collection techniques (eg, clean catch, catheterization). Educational objective:Children with nephrotic syndrome often require daily urinalysis to monitor for proteinuria. Urine collection bags or dipsticks in the diaper risk breakdown of edematous skin. To collect a nonsterile urine specimen from a child in diapers, the nurse can place cotton balls in a dry diaper and later squeeze urine onto a dipstick.

The nurse precepts a practical nursing student caring for a client with glaucoma and observes the student administer timolol maleate, an ophthalmic medication. Which student action indicates that further instruction is needed? 1. Instructs client to close eyelid and move eye around; applies pressure to the lacrimal duct for 30-60 seconds(15%) 2. Pulls lower eyelid down gently with thumb or forefinger against bony orbit to expose the conjunctival sac(6%) 3. Removes dried secretions with moistened sterile gauze pads by wiping from the outer to inner canthus(68%) 4. Rests hand on client's forehead and holds dropper 1-2 cm (1/2-3/4 in) above the conjunctival sac(8%)

3. Removes dried secretions with moistened sterile gauze pads by wiping from the outer to inner canthus(68%). If applicable, the nurse requests that the client remove contact lenses. The nurse then dons clean gloves and uses aseptic technique to administer ophthalmic medications (eg, eye drops, lubricant) that lubricate the eye and treat eye conditions (eg, glaucoma, infection). The Joint Commission disallows the use of abbreviations for right eye (OD), left eye (OS), and both eyes (OU). The nurse must verify the prescription if the health care provider (HCP) uses these abbreviations. The general procedure for the administration of ophthalmic medications includes the following steps in sequence: Remove dried secretions with moistened (warm water or normal saline) sterile gauze pads by wiping from the inner to outer canthus to keep eyelid and eyelash debris from entering the eye and to prevent transfer of debris into the lacrimal (tear) duct (Option 3) Place client in the supine or sitting position with head tilted back toward side of the affected eye to prevent excess medication from flowing into the lacrimal duct and minimize systemic absorption through the nasal mucosa Rest hand on client's forehead and hold dropper 1-2 cm (1/2-3/4 in) above the conjunctival sac, which keeps the dropper away from the eye globe and avoids contamination (Option 4) Pull lower eyelid down gently with thumb or forefinger against bony orbit to expose the conjunctival sac (Option 2) Instruct client to look upward and then instill drops of medication into the conjunctival sac. This minimizes the blink reflex and retracts the cornea up and away from the conjunctival sac to avoid instillation onto the cornea Instruct client to close the eyelid and move the eye around (if able). Then apply pressure to the lacrimal duct for 30-60 seconds if medication has systemic effects (eg, beta blocker, timolol maleate [Timoptic]). This will distribute the medication, prevent overflow into the lacrimal duct, and reduce possible systemic absorption (Option 1) Remove excess medication from each eye with a new tissue or gauze pad to prevent cross-contamination Wait 5 minutes before instilling a different medication into the same eye Educational objective:To administer ophthalmic medications, follow these steps: (1) Remove secretions from the eyelid by wiping from the inner to outer canthus; (2) pull lower eyelid downward, have client look upward, and instill drops into the conjunctival sac; and (3) apply pressure to the lacrimal duct if medication has systemic effects (eg, beta blocker, timolol maleate).

The practical nurse is assisting the registered nurse in creating a care plan for a client who is intubated, on mechanical ventilation, and receiving continuous enteral tube feedings via a small-bore nasogastric tube. Which interventions should be included to prevent aspiration in this client? Select all that apply. 1. Check gastric residual every 12 hours 2. Keep head of the bed at ≥30 degrees 3. Maintain endotracheal cuff pressure 4. Monitor for abdominal distension every 4 hours 5. Use caution when administering sedatives

The practical nurse is assisting the registered nurse in creating a care plan for a client who is intubated, on mechanical ventilation, and receiving continuous enteral tube feedings via a small-bore nasogastric tube. Which interventions should be included to prevent aspiration in this client? Select all that apply. 1. Check gastric residual every 12 hours 2. Keep head of the bed at ≥30 degrees 3. Maintain endotracheal cuff pressure 4. Monitor for abdominal distension every 4 hours 5. Use caution when administering sedatives Clients who are critically ill are at increased risk for aspiration of oropharyngeal secretions and gastric contents, particularly when they are receiving enteral feedings. Nursing interventions to reduce aspiration risk in clients receiving enteral tube feedings include: Assess client for gastrointestinal intolerance to feedings every 4 hours by monitoring gastric residual and assessing for abdominal distension and pain, bowel movements, and flatus (Option 4). Assess feeding tube placement at regular intervals. Keep head of the bed at ≥30 degrees, with 30-45 degrees being optimal, to reduce gastroesophageal reflux and aspiration risk unless otherwise indicated (Option 2). Keep the endotracheal cuff inflated at appropriate pressure (about 25 cm H2O) for intubated clients as low cuff pressure increases the risk for aspirating oropharyngeal secretions and/or gastric contents (Option 3). Suction any secretions that may have collected above the endotracheal tube before deflating the cuff, if deflation is necessary. Use caution when giving sedatives and frequently monitor for oversedation, which can slow gastric emptying and reduce gag reflex (Option 5). Avoid bolus tube feedings for clients at high risk for aspiration. (Option 1) Gastric residual should be checked at least every 4 hours with continuous feedings. Educational objective:Precautions to prevent aspiration in the client receiving continuous tube feedings include assessing for tube placement regularly and gastric intolerance (eg, residual, distension) every 4 hours, keeping the head of the bed at ≥30 degrees, and using sedation cautiously. If the client is intubated, the nurse should also keep the endotracheal tube cuff inflated and the area above the tube suctioned appropriately.

The practical nurse is collaborating with the registered nurse to create a care plan for a client experiencing exophthalmos as a complication of Graves disease. Which interventions should be included in the client's plan of care? Select all that apply. 1. Administer artificial tears to moisten the conjunctiva 2. Lightly tape eyelids shut if they do not close during sleep 3. Recommend the use of dark glasses to prevent irritation 4. Teach about the importance of smoking cessation 5. Teach avoidance of eye movement to prevent further damage

The practical nurse is collaborating with the registered nurse to create a care plan for a client experiencing exophthalmos as a complication of Graves disease. Which interventions should be included in the client's plan of care? Select all that apply. 1. Administer artificial tears to moisten the conjunctiva 2. Lightly tape eyelids shut if they do not close during sleep 3. Recommend the use of dark glasses to prevent irritation 4. Teach about the importance of smoking cessation 5. Teach avoidance of eye movement to prevent further damage Exophthalmos is a complication of hyperthyroidism (hypermetabolic state due to thyroid hormone overproduction) from Graves disease. It is defined as protrusion of the eyeballs caused by increased orbital tissue (connective, adipose, muscular) expansion and can be irreversible. The exposed cornea is at risk for dryness, injury, and infection. Nursing care for a client with exophthalmos includes the following: Maintaining the head of the bed in a raised position to facilitate fluid drainage from the periorbital area Using artificial tears or similar products to moisten the eyes to prevent corneal drying (causes abrasions/ulcers) (Option 1) Taping the client's eyelids shut during sleep if they do not close on their own (Option 2) Teaching the client the following:Regular visits to the ophthalmologist are necessary to measure eyeball protrusion and evaluate the condition.If recommended, anti-thyroid drugs should be used to prevent further exacerbation of exophthalmos.Smoking cessation is necessary as smoking increases the risk of Graves disease and associated eye problems (Option 4).Restrict salt intake to decrease periorbital edema.Use dark glasses to decrease glare and prevent external irritants and infection (Option 3). (Option 5) The client should perform intraocular muscle exercises (turning the eyes using complete range of motion) to maintain flexibility. Educational objective:Exophthalmos is a complication of hyperthyroidism from Graves disease that leads to increased orbital tissue(connective, adipose, muscular) expansion that can be irreversible. Nursing care to keep the eyes moist and protected is necessary to prevent corneal ulcers and infection.

A client comes to the community mental health clinic seeking treatment for severe anxiety associated with a recent job promotion that requires a 30-minute commute via train. The nurse recognizes that this client most likely suffers from which psychological disorder? 1. Agoraphobia(37%) 2. Generalized anxiety disorder(24%) 3. Social anxiety disorder(35%) 4. Zoophobia(2%)

1. Agoraphobia(37%). Individuals with agoraphobia have fear and anxiety about being in (or anticipating) certain situations or physical spaces. The fear they experience is out of proportion to any actual danger. These individuals are also highly concerned about having trouble escaping or getting help in the event of a panic attack or panic symptoms. The primary psychological need in agoraphobia is to avoid panic, and individuals with this condition will engage in various behaviors to lessen anxiety and avoid specific situations. In severe agoraphobia, the individual may become homebound, not going to public places for fear of experiencing a panic attack that may cause them to become embarrassed or perform an uncontrollable act. The person with agoraphobia will often feel the need to be accompanied by a relative or friend when facing situations. Agoraphobic individuals most typically fear being in the following situations: Outside the home alone In a crowd or standing in line Traveling in a bus, train, car, ship, or airplane On a bridge or in a tunnel Open spaces (eg, parking lots, marketplaces) Enclosed spaces (eg, theaters, concert halls, stores) (Option 2) In generalized anxiety disorder, the anxiety is evident in various situations and can impact all areas of an individual's life (eg, workplace, family/relationships, general well-being). (Option 3) In social anxiety disorder, individuals fear being scrutinized, observed, or embarrassed in social or performance settings (eg, public speaking, eating in public). (Option 4) Zoophobia is fear of animals. Educational objective:Agoraphobia is characterized by intense anxiety about being in a situation from which there may be difficulty escaping in the event of a panic attack. A person with agoraphobia may avoid open spaces, closed spaces, riding in public or private transportation, going outside the home, bridges/tunnels, and crowds.

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 after the infusion is started 3. Edema is observed on the dependent side of the involved arm 4. Intraoperative peripheral IV catheter was placed in the left antecubital region 5. Serous fluid is leaking from the site despite secure connections

1. Area around the insertion site feels cool to the touch 3. Edema is observed on the dependent side of the involved arm 5. Serous fluid is leaking from the site despite secure connections. Peripheral IV (PIV) catheter sites should be changed no more frequently than every 72-96 hours unless signs of complications (eg, phlebitis, infiltration) develop. Signs of phlebitis include erythema, edema, warmth, pain, and a palpable venous cord. Coolness to touch may indicate infiltration (Option 1). The nurse should monitor for infiltration under the involved limb, particularly in the elderly. Infiltrated fluid may leak into loose skin and accumulate in dependent areas with no obvious signs of infiltration at the PIV site (Option 3). If a PIV site leaks 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 specific 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 area dependent from it (ie, edema). Additional Information Reduction of Risk Potential NCSBN Client Need

A nurse in the pulmonology clinic is reinforcing teaching for a college athlete who was recently diagnosed with moderate persistent asthma. Which common asthma trigger should this client avoid? 1. Aspirin and nonsteroidal medications(18%) 2. Latex products(12%) 3. Penicillin group antibiotics(2%) 4. Strenuous physical activity(65%)

1. Aspirin and nonsteroidal medications(18%). In clients with asthma, the airways are chronically inflamed. Clients must be able to identify triggers that cause airway reactions and then avoid them. Maintaining a daily log can also help with detection. Common asthma triggers to avoid include the following: Allergen inhalation (eg, mold, pollen, dust mites, animal dander) Air pollutants (eg, tobacco smoke) Infections - viral upper respiratory infections are the most common Pharmacological agents (eg, beta blockers, aspirin, nonsteroidal anti-inflammatory drugs) (Option 2) Latex products are not a common trigger for asthma. (Option 3) Cephalosporins have some cross-reactivity with penicillin group antibiotics. Asthma exacerbations are unrelated to penicillin allergy. (Option 4) Participating in regular aerobic exercise would be beneficial to this client's health and should be encouraged. Although exercise-induced asthma is common in asthmatics (40%-90%), it occurs typically after exercising in cold, dry air. Using a metered-dose inhaler bronchodilator 20 minutes before exercising is beneficial. Swimming in an indoor heated pool is a good alternative to jogging or skiing. Educational objective:Common asthma triggers to avoid include allergen inhalation (eg, mold, pollen, dust mites, animal dander), air pollutants (eg, tobacco smoke), infection, and pharmacological agents (eg, beta blockers, aspirin, nonsteroidal anti-inflammatory drugs.

The nurse caring for multiple clients on a medical-surgical unit should delegate which action to the nursing assistant? 1. Assist client, post hip fracture repair, to the bathroom(52%) 2. Check the appearance of client's wound(1%) 3. Discontinue nasogastric tube if client tolerates oral liquids(0%) 4. Offer orange juice to client if bedside glucose reading is <70 mg/dL (3.9mmol/L)(45%)

1. Assist client, post hip fracture repair, to the bathroom(52%) Examples of tasks that can be delegated to unlicensed assistive personnel (UAP) include taking vital signs; assisting clients out of bed, to the bathroom, and with activities of daily living; and feeding clients. When a nurse delegates a task to another staff member, the nurse ultimately remains responsible for both the action and its outcome. (Option 2) Checking the wound involves assessment of its appearance. The nurse should perform this assessment as it is not within the scope of practice for the nursing assistant. (Option 3) The nursing assistant can help with feeding. However, the nasogastric tube should be discontinued at the direction of the nurse as this procedure requires client assessment and monitoring. (Option 4) Offering orange juice is an intervention to treat hypoglycemia that is outside the nursing assistant's scope of practice without the client first being assessed by the registered nurse. The client could have accompanying symptoms along with the low glucose result; these would require assessment and interpretation before intervention. Educational objective:The nurse may delegate components of care but does not delegate the nursing process (assessment, planning, evaluation) itself. Skills requiring critical thinking and nursing knowledge cannot be delegated.

The nurse cares for a client who has oral candidiasis. The health care provider has prescribed nystatin oral suspension. Which of the following nursing actions are appropriate? Select all that apply. 1. Assist the client in removing dentures and soaking them in nystatin 2. Inspect the oral mucous membranes thoroughly before administering nystatin 3. Instruct the client to discontinue the medication as soon as symptoms subside 4. Instruct the client to swish the suspension in the mouth for several minutes 5. Shake the bottle of suspension thoroughly before measuring the dose

1. Assist the client in removing dentures and soaking them in nystatin 2. Inspect the oral mucous membranes thoroughly before administering nystatin 4. Instruct the client to swish the suspension in the mouth for several minutes 5. Shake the bottle of suspension thoroughly before measuring the dose Nystatin is an antifungal medication commonly used to treat mucocutaneous candidal infections (ie, oral, intestinal, vaginal, skin). When caring for a client prescribed nystatin, the nurse should: Assist clients with oral candida who wear dentures in removing them and soaking them in nystatin suspension because dentures often become a reservoir for reinfection (Option 1). Assess the appearance of the affected area (eg, oral cavity, skin lesions) frequently throughout nystatin therapy (eg, before administration, during routine assessments) to monitor treatment efficacy and identify potential side effects (eg, mucous membrane irritation) (Option 2). Instruct clients prescribed nystatin liquid suspension for oral thrush to swish the suspension in the mouth for several minutes and then swallow the medication to allow treatment of any esophageal candida (Option 4). Ensure that liquid suspension forms of nystatin are shaken well before being measured for dosing because medication precipitates and causes unequal concentrations within the liquid (Option 5). (Option 3) Clients receiving nystatin should be educated to take the medication as prescribed each day and avoid missing doses; nystatin therapy is continued for at least 48 hours after symptoms subside to prevent recurrence of the infection. Educational objective:Oral nystatin suspension is an antifungal medication used to treat oral thrush caused by candidal infections. Nurses administering nystatin should assist the client in removing and soaking dentures, if present; assess the affected area frequently; educate the client to swish the medication in the mouth before swallowing; and ensure that the suspension is well shaken before dosing.

A client with throat cancer receives radiation therapy to the head and neck. Which strategies are appropriate to increase oral intake? Select all that apply. 1. Avoid irritants such as acidic, spicy foods 2. Discourage the use of topical analgesics 3. Encourage liquid nutritional supplements 4. Perform oral hygiene once a day 5. Use artificial saliva to control dryness

1. Avoid irritants such as acidic, spicy foods 3. Encourage liquid nutritional supplements 5. Use artificial saliva to control dryness. Radiation therapy to the head and neck can decrease a client's oral intake due to the development of mucositis (ie, inflammation of the mouth, esophagus, and oropharynx) and xerostomia (ie, dry mouth). These adverse side effects affect speech, taste, and ability to swallow and can have a significant impact on the client's nutritional status. The nurse teaches the client to: Avoid irritants such as spicy, acidic, dry, or crumbly foods; coffee; and alcohol (Option 1). Consume supplemental nutritional drinks (eg, Ensure), which are often easier to swallow (Option 3). Use artificial saliva to manage xerostomia and the production of thick saliva due to altered salivary gland function (Option 5). Sipping water throughout the day is equally effective and less expensive. (Option 2) Topical anesthetics (eg, lidocaine) have been found to increase comfort and improve oral intake in clients with mucositis due to radiation therapy. (Option 4) Clients on radiation therapy need to maintain more frequent (eg, before and after meals, at bedtime) oral hygiene (eg, using soft toothbrush, rinsing with baking soda solution) due to the drying effects of mucositis. Educational objective:Radiation therapy to the head and neck can cause mucositis (ie, inflammation of the mouth, esophagus, and oropharynx) and xerostomia (ie, dry mouth), leading to decreased nutrition. Care includes avoiding irritants, consuming supplements, using artificial saliva or sipping water, and performing frequent oral hygiene.

The nurse observes a nursing student performing chest compressions on an adult client. Which technique indicates that the student understands how to provide high-quality chest compressions during cardiopulmonary resuscitation? 1. Compressing the chest to a depth of at least 2 in (5 cm) 2. Pausing after each set of 15 compressions to allow for 2 rescue breaths 3. Placing the heel of the hand on the upper half of the client's sternum 4. Providing compressions at a rate of at least 80-100/min

1. Compressing the chest to a depth of at least 2 in (5 cm). The primary goal of cardiopulmonary resuscitation (CPR) is adequate perfusion to the brain and vital organs. High-quality chest compressions for adults are at least 2 in (5 cm) deep to adequately pump blood but no more than 2.4 in (6 cm) deep to prevent unnecessary client injury (Option 1). The chest should recoil completely after each compression to allow complete refilling of the heart chambers, which promotes effective perfusion. (Option 2) Interruption of compressions should be minimized; at least 60% (preferably more) of the total resuscitation time should be made up of compressions. For adults (and in single-rescuer CPR for any age), a cycle of 30 compressionsfollowed by 2 rescue breaths provides the best outcome. If the client has an advanced airway, continuous compressions and 10 breaths/min should be provided. (Option 3) Correct hand placement is in the center of the chest, on the lower half of the sternum (breastbone). Hand placement on the upper half of the sternum does not provide adequate perfusion. (Option 4) Studies have shown better client outcomes due to improved perfusion with a compression rate of 100-120/min. Educational objective:For high-quality adult cardiopulmonary resuscitation, compressions should be in the center of the chest; at a rate of 100-120/min; and at least 2 in (5 cm) but no more than 2.4 in (6 cm) deep for adequate perfusion without unnecessary client injury. Compression interruption should be minimized (eg, 30 compressions to 2 rescue breaths). Additional Information Physiological Adaptation NCSBN Client Need

Which interventions does the nurse perform to promote normal rest and sleep patterns for a critically ill client? Select all that apply. 1. Dimming the lights at night 2. Leaving the television on for diversion at night 3. Opening the window blinds/shades in the morning 4. Scheduling interventions and activities during the day when possible 5. Turning off equipment alarms in the client's room at night

1. Dimming the lights at night 3. Opening the window blinds/shades in the morning 4. Scheduling interventions and activities during the day when possible. It is important to maintain the client's normal circadian rhythms in the intensive care unit (ICU). Interventions that help to maintain the normal sleep-wake cycle include dimming the lights at night, allowing quiet and uninterrupted periods of sleep when possible, scheduling interventions and activities during the day, frequently reorienting the client as necessary, and opening the window shades in the morning. Excessive stimuli and lack of sleep can predispose the client to delirium. (Option 2) Unless the client is awake and chooses to have the television turned on, this extra stimulus is disruptive to sleep. (Option 5) Turning the alarms off in the client's room would pose a risk to safety as the nurse may not be alerted to a change in condition or equipment failure. If possible, alarm parameters should be adjusted according to the client's routine to prevent unnecessary awakening. Educational objective:To prevent disorientation and delirium in the intensive care unit, it is important to provide care that maintains the client's normal circadian rhythm (dimming lights at night, allowing uninterrupted sleep when possible, scheduling interventions and activities during the day, frequent reorientation, and opening window shades in the morning.

A child is brought to the school nurse after having a permanent tooth knocked out during gym class. Which action by the nurse is appropriate? 1. Gently rinse the tooth with sterile saline and reinsert it into the gingival cavity(18%) 2. Gently scrub the root of the tooth to remove any debris, and wrap it in sterile gauze(10%) 3. Place the tooth in water and transport the client to the nearest emergency department(31%) 4. Wrap the tooth in sterile gauze and advise the parent to arrange for a dental appointment(39%)

1. Gently rinse the tooth with sterile saline and reinsert it into the gingival cavity(18%) Dental avulsion (ie, tooth separated from the mouth) of a permanent tooth is a dental emergency. The priority nursing action is to rinse and reinsert the tooth into the gingival socket and hold it in place (eg, with a finger) until stabilized by a dentist (Option 1). Reimplantation within 15 minutes of injury re-establishes blood supply, increasing the probability of tooth survival. If the tooth cannot be reinserted it should be kept moist by submerging it in commercially prepared solution (eg, Hanks Balanced Salt Solution), cold milk, sterile saline, or as a last resort—due to bacteria—saliva (eg, holding it under the tongue). (Option 2) Scrubbing the root would damage it. The tooth should be gently rinsed with sterile saline or clean, running water. (Option 3) Placing the tooth in water (a hypotonic solution) would lyse the cells, killing the tooth. (Option 4) Wrapping the tooth in sterile gauze would dry it out. In addition, the nurse should arrange for immediate transfer to a dentist rather than advise the parent to schedule an appointment that might not be available for days. Educational objective:Dental avulsion is a dental emergency. The nurse should gently rinse off debris and reinsert the tooth into the gingival socket. If reimplantation is not possible, the tooth should be placed in a commercially prepared solution, cold milk, or sterile saline. The client should see a dentist immediately. Additional Information Physiological Adaptation NCSBN Client Need

The practical nurse is assisting the registered nurse to create a care plan for a 3-year-old client admitted with a pertussis infection. Which of the following interventions should be included? Select all that apply. 1. Institute droplet precautions 2. Monitor for signs of airway obstruction 3. Offer small sips of fluid frequently 4. Place the client in a negative-pressure isolation room 5. Request a prescription for cough suppressants

1. Institute droplet precautions 2. Monitor for signs of airway obstruction 3. Offer small sips of fluid frequently Pertussis (whooping cough) is caused by the highly contagious bacterium, Bordetella pertussis, which is spread through close human contact, coughing, and sneezing. Once attached to cilia in the client's upper respiratory tract, this bacterium releases a toxin that causes irritation and swelling. To prevent transmission, the nurse should implement standard (universal) and droplet precautions (Option 1). Pertussis is characterized by a violent, spasmodic cough and a distinctive high-pitched "whooping" sound heard during inhalation. Coughing may continue until the client expectorates a thick mucous plug or vomits (posttussive emesis). Therefore, the nurse should closely monitor for airway obstruction (eg, cyanosis) during coughing episodes, place clients on their sides if vomiting, and suction the airway and provide oxygen as needed (Option 2). Treatment consists of antibiotics and other supportive measures (eg, humidified oxygen, oral fluids). Small amounts of oral fluids help loosen mucus so that it can be expectorated (Option 3). (Option 4) Airborne precautions (ie, negative-pressure isolation room) are appropriate for clients with measles, tuberculosis, and varicella-zoster infections (mnemonic - airing MTV). (Option 5) Cough suppressants interfere with the expectoration of mucous plugs that develop in the airway and are not recommended for pertussis because they are usually ineffective. Educational objective:Pertussis is characterized by violent, spasmodic coughing; a high-pitched "whooping" sound on inhalation; and posttussive emesis. The plan of care includes droplet precautions, airway monitoring, antibiotics, and supportive measures (eg, humidified oxygen, oral fluids).

The practical nurse is collaborating with the registered nurse to create a teaching plan for a client rehabilitating after a tibial fracture. Which instructions should be included 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. Keep a clear path to the bathroom 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 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 client with a history of heart failure calls the clinic and reports a 3-lb (1.4-kg) weight gain over the past 2 days and increased ankle swelling. The nurse reviews the client's medications and anticipates the immediate need for dosage adjustment of which medication? 1. Bumetanide (38%) 2. Candesartan (13%) 3. Carvedilol (29%) 4. Isosorbide (18%)

1. Bumetanide Most clients with heart failure are prescribed a loop diuretic (eg, furosemide, torsemide, bumetanide) to reduce fluid retention. If the client has signs and symptoms of excessive fluid accumulation, the nurse will need to assess the situation by asking the client about dietary and fluid intake, adherence to prescribed medications, and the presence of any other associated symptoms (eg, shortness of breath). If the client is stable, the nurse may anticipate the need to increase the dosage of the prescribed loop diuretic (eg, bumetanide). (Option 2) Losartan, valsartan, and candesartan (sartans) are the commonly used angiotensin II receptor blockers. They are used in clients who cannot take ACE inhibitors (eg, lisinopril, ramipril). They block the renin-angiotensin-aldosterone system but will not affect the fluid status of the client with acute heart failure. (Option 3) Metoprolol, bisoprolol, and carvedilol (lols) are the commonly used beta blockers for treatment of chronic heart failure. They block the negative effects of the sympathetic nervous system (increased heart rate) and reduce the cardiac workload. However, they can worsen heart failure if used in the acute setting of this condition. (Option 4) Isosorbide (nitrate) and hydralazine are used in African American clients with heart failure; this combination decreases cardiac workload by reducing preload and afterload. However, it does not decrease excess fluid. Educational objective:A client who reports weight gain and edema requires evaluation for additional symptoms of fluid volume overload (eg, shortness of breath) and adherence to the current treatment plan. If the client is stable, an increase in the dosage of loop diuretic (eg, furosemide, torsemide, bumetanide) is anticipated.

A client with asthma was recently prescribed fluticasone/salmeterol. After the client has received instructions about this medication, which statement would require further teaching by the nurse? 1. "After taking this medication, I will rinse my mouth with water."(12%) 2. "At the first sign of an asthma attack, I will tterm-27ake this medication."(59%) 3. "I have been smoking for 12 years, but I just quit a month ago."(11%) 4. "I received the pneumococcal vaccine about a month ago."(16%)

2. "At the first sign of an asthma attack, I will take this medication."(59%). Fluticasone/salmeterol (Advair) is a combination drug containing a corticosteroid (fluticasone) and a bronchodilator (salmeterol). Salmeterol is a long-acting inhaled β2-adrenergic agonist that promotes relaxation of the bronchial smooth muscles over 12 hours. Fluticasone decreases inflammation. This medication is used as part of the treatment plan for prevention and long-term control of asthma. Client instructions include: After inhalation, rinse the mouth with water without swallowing to reduce the risk of oral/esophageal candidiasis Avoid smoking and using tobacco products Receive the pneumococcal and influenza vaccines if there is a risk for infection (Option 2) Fluticasone/salmeterol is not a rescue inhaler and does not treat acute exacerbations of asthma. The client should always have a rescue inhaler (eg, albuterol [short-acting β2-adrenergic agonist] or ipratropium [Atrovent]) for sudden changes in breathing and call 911 if the rescue inhaler does not relieve the breathing problem. Educational objective:Fluticasone/salmeterol (Advair) is a long-acting inhaled β2-adrenergic agonist combination drug containing a corticosteroid (fluticasone) and a bronchodilator (salmeterol). It is used for long-term control of asthma but not for acute attacks.

The nurse reinforces medication teaching to a client prescribed metronidazole. Which client statement indicates a need for further education? 1. "I might have a metallic taste in my mouth when I'm taking this medicine."(12%) 2. "I need to decrease the amount of alcohol I drink while taking this medicine."(45%) 3. "I should not worry if my urine turns a dark color while taking this medication."(30%) 4. "I will immediately call the clinic if I get a new rash or have skin peeling."(11%)

2. "I need to decrease the amount of alcohol I drink while taking this medicine."(45%) Metronidazole is an antibiotic medication used to treat bacterial, parasitic, and protozoal infections. Nurses educating clients about metronidazole should ensure that the client is aware of drug interactions and side effects to watch for and report. The client should be instructed to abstain completely from consuming food, drinks, or products containing alcohol during, and for 3 days after, therapy. The combination of alcohol and metronidazole may cause clients to experience facial flushing, headaches, nausea, vomiting, and abdominal cramping (Option 2). (Options 1 and 3) Metronidazole commonly causes a harmless but unpleasant metallic taste in the mouth and darkening of urine (eg, brown, rust-colored). (Option 4) Although it is rare, metronidazole may cause Stevens-Johnson syndrome (SJS), a life-threateningcomplication characterized by necrosis and sloughing of the skin and mucous membranes. Clients should be educated to immediately report signs of SJS (eg, rash, skin peeling). Educational objective:Clients prescribed metronidazole are instructed to abstain from using alcohol during, and for 3 days after, therapy, as it may cause flushing, headaches, nausea, vomiting, and abdominal cramping. Metronidazole may cause a harmless metallic taste and darkened urine. Clients should immediately report any new rashes, as Stevens-Johnson syndrome can occur. Additional Information Pharmacological Therapies NCSBN Client Need

The nurse is caring for a 7-year-old client diagnosed with nephrotic syndrome who will be discharged soon. Which statement by the parent indicates the need for further teaching? 1. "I'll provide a healthy diet without added salt for my child."(10%) 2. "I'll organize playdates to keep my child's spirits up during relapses."(32%) 3. "I'll restrict my child's fluids if I notice swelling or rapid weight gain."(38%) 4. "I'll test for protein in my child's urine every day."(17%)

2. "I'll organize playdates to keep my child's spirits up during relapses."(32%) Nephrotic syndrome, an autoimmune disease, affects children age 2-7 and is characterized by increased permeability of the glomerulus to proteins (eg, albumin, immunoglobulins, natural anticoagulants). Loss of albumin in urine leads to hypoalbuminemia; this causes decreased plasma oncotic pressure, which allows fluid to leak out of the vascular spaces. Reduced plasma volume (hypovolemia) activates kidneys to retain salt and water (via the renin-angiotensin-aldosterone system). Clients experience generalized edema, weight gain, loss of appetite (from ascites), and decreased urine output. The loss of immunoglobulins causes increased susceptibility to infection. Caregivers should minimize the risk of infection during relapses (eg, limiting visitors) (Option 2). Treatment typically includes: Corticosteroids and other immunosuppressants (eg, cyclosporine) Loss of appetite management (eg, making foods fun and attractive) Infection prevention (eg, limiting social interaction until the child is in remission) (Option 1) A regular diet without added salt is prescribed to prevent edema while in remission. More stringent sodium restrictions are necessary when symptoms are present. (Option 3) Fluid restriction is needed in cases of edema or rapid weight gain. (Option 4) There is a high risk for recurrence after recovery, and relapses may occur several times per year. The parent/caregiver should test daily for proteinuria, weigh the child weekly, and keep a diary of results. Educational objective:Nephrotic syndrome is characterized by massive proteinuria, edema, and hypoalbuminemia. Home management includes a low-sodium diet with attractive foods; infection prevention; fluid restriction for severe edema; and monitoring of weight gain and proteinuria to detect relapse.

The nurse is assigned to care for 4 clients at an outpatient ophthalmology clinic. Which client report would most likely indicate a serious pathology that should be given priority? 1. "I'm having trouble reading the small print on a distant object."(0%) 2. "It's as if a curtain is crossing my field of vision today."(65%) 3. "I've been noticing lately that my central vision is blurry."(10%) 4. "I've had yellow discharge from my eye for the past week."(23%)

2. "It's as if a curtain is crossing my field of vision today."(65%). Retinal detachment is separation of the sensory retina from the underlying pigment epithelium with fluid accumulation. It can be a result of spontaneous atrophic retinal breaks or acute trauma. Common symptoms include a painless loss of vision "like a curtain" coming across the field of vision, lightning flashes, or a gnat/hairnet appearance in the vision field. This report needs emergent evaluation. Untreated symptomatic retinal detachment usually leads to blindness in that eye. In addition, this is the only listed presentation that is acute: the rule for prioritization is acute before chronic. (Option 1) Myopia (nearsightedness) is an inability to accommodate for objects at a distance. It is not emergent and will require refractive correction with glasses/contacts. (Option 3) Macular degeneration is related to retinal aging and causes progressive, irreversible central vision loss. However, it is not an acute condition. (Option 4) Conjunctivitis is an infection or inflammation of the conjunctiva that can be caused by bacteria, viruses, allergens, or chemical irritants. Bacterial infections tend to cause purulent drainage; allergic or viral causes result in serous discharge; and an allergic conjunctivitis usually involves pruritus (itching). The client will probably need eye drops and a reminder about good handwashing technique, but the condition is not emergent. Educational objective:Acute retinal detachment includes the sensation of a curtain coming across the field of vision, lightning flashes, or a gnat/hairnet appearance in the vision field. It requires an emergent evaluation.

A client with a 20-year history of schizophrenia is hospitalized. The client appears visibly upset, approaches the nurse, and says in a shaky voice, "I can't find my headband. I can't find my headband. The oil is going to leak out of the crack in my head." What is the best response by the nurse? 1. "How long has the oil been leaking from your head?"(7%) 2. "Let's go back to your room and look for your headband together."(64%) 3. "There is no oil coming out of your head."(26%) 4. "You are going to miss breakfast if you do not go into the dining room."(2%)

2. "Let's go back to your room and look for your headband together."(64%) The client, while delusional, is exhibiting signs of anxiety. The priority action for the nurse is to intervene in a manner that will assist in reducing the client's unease. The headband is part of the client's delusional system; it is highly likely that the client will continue to be apprehensive until the headband or substitute is found. Offering to help the client look for the headband conveys a sense of caring and helps establish a trusting relationship. Once the client has calmed down, the nurse will minimize any conversation about the "crack" and the "oil" and can direct the client to reality-oriented activities. Delusions are fixed, false beliefs that are accepted by the client as real and cannot be changed by logic, reason, or persuasion. Categories of delusions include the following: Persecutory - client thinks others are "out to get me" Ideas of reference - common events refer specifically to the client Grandiose - client has the perception of special importance or powers that are not realistic Somatic - false ideas about bodily functioning Nursing interventions include the following: Not arguing or challenging the belief Reinforcing reality by talking about and encouraging the client to participate in real events. The nurse should not delve into or have long conversations about the delusional belief system. (Option 1) This response focuses on the delusional content and is not therapeutic. It does not help alleviate the client's anxiety. (Option 3) Challenging the delusional content is not therapeutic and will not change the client's belief. (Option 4) This statement does not help reduce the client's anxiety. Educational objective:The priority nursing action for a client exhibiting anxiety is to intervene in a manner that helps make the client feel more at ease. Delusions are fixed, false beliefs; challenging a client's delusional content system will increase the client's anxiety and will not change the client's beliefs.

A client suffering from chronic kidney disease is scheduled to receive recombinant human erythropoietin and iron sucrose. The client's hemoglobin is 9.7 g/dL (97 g/L) and hematocrit is 29% (0.29). What is the appropriate nursing action? 1. Administer the erythropoietin in the client's ventrogluteal muscle(32%) 2. Check blood pressure prior to administering the erythropoietin(35%) 3. Hold the client's next scheduled iron sucrose dose(4%) 4. Hold the erythropoietin and inform the health care provider(28%)

2. Check blood pressure prior to administering the erythropoietin(35%). Anemia associated with chronic kidney disease is treated with recombinant human erythropoietin (Epogen/Procrit, epoetin). Therapy is initiated when hemoglobin is <10 g/dL (100 g/L) to alleviate the symptoms of anemia (eg, fatigue) and the need for blood transfusions. Therapy should be discontinued or the dose reduced for hemoglobin >11 g/dL (110 g/L) to prevent venous thromboembolism and adverse cardiovascular outcomes from blood thickened by high concentrations of RBCs. Hypertension is a major adverse effect of erythropoietin administration. Therefore, uncontrolled hypertension is a contraindication to recombinant erythropoietin therapy. Blood pressure should be well controlled prior to administering erythropoietin (Option 2). (Option 1) Erythropoietin is administered intravenously or in any subcutaneous area (not intramuscularly). (Option 3) Iron in the form of iron sucrose (Venofer) or ferric gluconate (Ferrlecit) may be prescribed to promote an adequate response to erythropoietin. Adequate stores of iron, vitamin B12, and folic acid are required for the erythropoietin to work. (Option 4) The dose should be held if the client has a hemoglobin level >11 g/dL (110 g/L) or uncontrolled hypertension. Educational objective:Anemia of chronic kidney disease is treated with recombinant human erythropoietin for hemoglobin <10 g/dL (100 g/L). Hemoglobin levels >11 g/dL (110 g/L) are associated with thromboembolic and cardiovascular events. Uncontrolled hypertension is a contraindication to recombinant human erythropoietin therapy.

A postoperative client who is receiving continuous enteral feedings via a nasoenteric tube becomes dyspneic with a productive cough, and the nurse auscultates crackles and diminished breath sounds in lung bases. Which action is appropriate at this time? 1. Administer an inhaled bronchodilator(16%) 2. Check marked insertion depth of the tube(61%) 3. Request a prescription for a diuretic(4%) 4. Start the client on incentive spirometry(16%)

2. Check marked insertion depth of the tube(61%). A nasoenteric tube is passed through the nares into the duodenum or jejunum when it is necessary to bypass the esophagus and stomach. Nasoenteric tubes have a decreased risk of aspiration compared with nasogastric tubes; however, a nasoenteric tube can become dislodged to the lungs, causing aspiration of enteral feedings. If a client with a feeding tube develops signs of aspiration pneumonia (diminished or adventitious lung sounds [eg, crackles, wheezing], dyspnea, productive cough), the feeding should be stopped immediately and tube placement checked (eg, measure insertion depth, obtain x-ray, assess aspirate pH) (Option 2). Some facilities use capnography to determine placement; if a sensor detects exhaled CO2 from the tube, it is in the client's airway and must be removed immediately. (Option 1) An inhaled bronchodilator may be prescribed to treat aspiration pneumonia, but the priority is to stop the feeding and check tube placement to prevent additional aspiration. (Option 3) Crackles may be heard with fluid overload, aspiration, or pneumonia. A diuretic would be appropriate if a client is experiencing pulmonary edema from fluid overload. If a client receiving enteral feedings develops signs of aspiration, the nurse should initially hold feedings and assess tube placement. (Option 4) Incentive spirometry promotes expansion of the lungs and resolves atelectasis; however, the priority for this client is assessing for and preventing aspiration. Educational objective:Nasoenteric tubes can become dislodged, causing the tube to enter the stomach or lungs. Feedings should be stopped immediately and tube placement checked if the client develops signs of aspiration.

The nurse has just received report on 4 clients. Which reported information is the most concerning? 1. Client on a heparin drip with an activated partial thromboplastin time of 60 seconds(31%) 2. Client reporting back pain 1 hour following coronary angiography(34%) 3. Client with a head injury and a Glasgow Coma Scale score of 14(20%) 4. Client with incisional pain rated 6/10 on day 2 post coronary artery bypass graft(13%)

2. Client reporting back pain 1 hour following coronary angiography(34%) Postprocedure care of a client who has undergone cardiac catheterization should focus on monitoring hemodynamics (eg, blood pressure, heart rate, strength of distal pulses, temperature of extremities). The client should be also assessed several times per hour (eg, approximately every 15 minutes) for active bleeding or hematoma formation at the incision. Any report of back or flank pain should be investigated for possible retroperitoneal bleeding. Back pain, tachycardia, and hypotension may be the only indications of bleeding as it can take up to 12 hours before a significant drop in hematocrit can be measured. Hemorrhage after cardiac catheterization is particularly dangerous due to the frequent use of anticoagulant prescriptions in these clients. (Option 1) A heparin infusion is used to treat deep venous thrombosis. An activated partial thromboplastin time of 60 seconds is a therapeutic value. The therapeutic range for a client on anticoagulation is usually 46-70 seconds (1½ -2 times the normal value). (Option 3) A client with a head injury should be evaluated hourly for any change in neurological status. However, the highest possible score on the Glasgow Coma Scale is 15 for a fully alert person; a client with a score of 14 does not require urgent attention. (Option 4) The report of incisional pain on postoperative day 2 would take second priority for further assessment, but evaluating a client with possible internal bleeding is the priority. Educational objective:Clients with any indication of compromised airway, breathing, or circulation always take priority. The onset of back pain after angiography always requires further assessment to monitor for retroperitoneal bleeding.

One month ago, a client was prescribed phenytoin 100 mg orally 3 times daily. The client's current serum phenytoin level is 32 mcg/mL (127 µmol/L). Which action by the health care provider does the nurse anticipate? 1. Administer phenytoin as prescribed(27%) 2. Decrease phenytoin daily dose(48%) 3. Increase phenytoin daily dose(3%) 4. Repeat serum phenytoin level in 2 hours(19%)

2. Decrease phenytoin daily dose(48%) Phenytoin (Dilantin), an anticonvulsant drug, is used to treat generalized tonic-clonic seizures. The therapeutic serum phenytoin reference range is 10-20 mcg/mL (40-79 µmol/L). In the presence of an elevated reference range (32 mcg/mL [127 µmol/L]), if no seizure activity is observed, the nurse would anticipate the health care provider prescribing a decreased daily dose. The nurse will continue to monitor for signs of toxicity (eg, ataxia, nystagmus, slurred speech, decreased mentation). (Options 1 and 3) The serum phenytoin level is elevated, so administering the prescribed dose or increasing the dose can raise the level and further increase the risk for drug-induced toxicity. (Option 4) Repeating the serum phenytoin level in 2 hours will not result in a significant change as the average half-life of the drug is 22 hours. Educational objective:Phenytoin (Dilantin) is used to treat generalized tonic-clonic seizures. Common symptoms of phenytoin-induced toxicity involve the central nervous system (eg, nystagmus, ataxia, slurred speech, decreased mentation) and can occur when phenytoin plasma levels exceed the therapeutic reference range (10-20 mcg/mL [40-79 µmol/L]).

A client is receiving scheduled doses of carbidopa-levodopa. The nurse evaluates the medication as having the intended effect if which finding is noted? 1. Improvement in short-term memory(18%) 2. Improvement in spontaneous activity(52%) 3. Reduction in number of visual hallucinations(14%) 4. Reduction of dizziness with standing(15%)

2. Improvement in spontaneous activity(52%) Parkinson disease is caused by low levels of dopamine in the brain. Levodopa is converted to dopamine in the brain, but much of this drug is metabolized before reaching the brain. Carbidopa helps prevent the breakdown of levodopa before it can reach the brain and take effect. This combination medication is particularly effective in treating bradykinesia (generalized slowing of movement). Tremor and rigidity may also improve to some extent. Carbidopa-levodopa (Sinemet) once started should never be stopped suddenly as this can lead to akinetic crisis (complete loss of movement). However, prolonged use can also result in dyskinesias (spontaneous involuntary movements) and on/off periods when the medication will start or stop working unpredictably. (Option 1) Carbidopa-levodopa does not improve memory. Medications for the treatment of Alzheimer disease, such as donepezil and rivastigmine, are used to improve cognition and memory. (Options 3 and 4) Orthostatic hypotension and neuropsychiatric disturbances (eg, confusion, hallucinations, delusions, agitation, psychosis) are serious and important adverse effects of carbidopa-levodopa. Health care providers usually start the medications at low doses and gradually increase them to prevent these effects. Educational objective:The combination medication carbidopa-levodopa is most helpful for treating bradykinesia in Parkinson disease and can also improve tremor and rigidity to some extent. It is started in low doses to prevent orthostatic hypotension and neuropsychiatric adverse effects. Carbidopa-levodopa once started should never be stopped suddenly as doing so can lead to akinetic crisis (complete loss of movement).

The nurse is caring for a newborn with patent ductus arteriosus. Which assessment finding should the nurse expect? 1. Harsh systolic murmur(19%) 2. Loud machine-like murmur(39%) 3. Soft diastolic murmur(23%) 4. Systolic ejection murmur(17%)

2. Loud machine-like murmur(39%). Patent ductus arteriosus (PDA) is an acyanotic congenital defect more common in premature infants. When fetal circulation changes to pulmonary circulation outside the womb, the ductus arteriosus should close spontaneously. This closure is caused by increased oxygenation after birth. If a PDA is present, blood will shunt from the aorta back to the pulmonary arteries via the opened ductus arteriosus. Many newborns are asymptomatic except for a loud, machine-like systolic and diastolic murmur. The PDA will be treated with surgical ligation or IV indomethacin to stimulate duct closure. (Option 1) A harsh systolic murmur is heard in the setting of ventricular septal defect, an opening between the ventricles of the heart. Ventricular septal defect is an acyanotic defect. (Option 3) A diastolic murmur is heard in mitral stenosis and aortic regurgitation but not in PDA. (Option 4) A systolic ejection murmur is heard in pulmonic stenosis. Right ventricular hypertrophy will develop if this defect is not repaired. In adults, systolic ejection murmur is usually due to aortic stenosis. Educational objective:The ductus arteriosus of a newborn should close spontaneously when fetal circulation changes to pulmonary circulation. If the ductus arteriosus remains open, blood will shunt from the aorta to the pulmonary arteries. The child will be acyanotic but will have a machine-like murmur heard on both systole and diastole.

The nurse is monitoring a newborn with skin discoloration in the lumbar area. Which action by the nurse is appropriate? Click the exhibit button for additional information. 1. Check the infant's hemoglobin, hematocrit, and platelet levels(8%) 2. Measure and document the size and location of the markings(72%) 3. Notify the registered nurse of the markings immediately(10%) 4. Review the delivery record for evidence of a traumatic birth(8%)

2. Measure and document the size and location of the markings(72%). Congenital dermal melanocytosis (Mongolian spots) is a benign skin discoloration most often seen in newborns of ethnicities with darker skin tones (eg, African American, Native American, Hispanic, Asian). Mongolian spots are usually bluish-gray, typically found on the back or buttocks, and fade over the first 1-2 years of life. Because they are easily misidentified as bruises, it is important for the nurse to measure and document the area for reference during future health care assessments (Option 2). (Option 1) Mongolian spots are common birthmarks not associated with abnormal laboratory work. (Option 3) Mongolian spots are benign, and notifying the registered nurse immediately is not indicated. (Option 4) Although often mistaken for bruises, Mongolian spots are normal skin variations and are not due to trauma. Educational objective:Congenital dermal melanocytosis (Mongolian spots) is a benign skin discoloration (ie, bluish-gray) typically found on the back or buttocks. It is more common in newborns of ethnicities with darker skin tones. The spots may be misidentified as bruising in future assessments and should be documented to avoid misinterpretation of findings.

A 2-year-old at an outpatient clinic stops breathing and does not have a pulse. CPR is initiated. When the automated external defibrillator (AED) arrives, the nurse notes that it has only adult AED pads. What is the appropriate action at this time? 1. Continue CPR without using the automated external defibrillator (AED) until paramedics arrive(36%) 2. Place one AED pad on the chest and the other on the back(38%) 3. Place one AED pad on the upper right chest and the other on the lower left side(12%) 4. Place one AED pad on the upper right chest and dispose of the other(12%)

2. Place one AED pad on the chest and the other on the back(38%) An automated external defibrillator (AED) should be used as soon as it is available. Pediatric AED pads or a pediatric dose attenuator should be used for children age birth to 8 years if available. Standard adult pads can be used as long as they do not overlap or touch. If adult AED pads are used, one should be placed on the chest and the other on the back("sandwiching the heart"). (Option 1) If an AED is available, it should be placed on the client as soon as possible. Research shows that survival rates increase when CPR and defibrillation occur within 3-5 minutes of arrest. (Option 3) Standard placement of adult AED pads on a 2-year-old would cause the pads to touch or overlap. Touching or overlapping of pads allows the shock to move directly from one pad to the other without traveling through the heart. (Option 4) Both AED pads are necessary for the defibrillator to work effectively. Educational objective:An automated external defibrillator (AED) should be used as soon as it is available. Adult AED pads can be used on a pediatric client if pediatric pads are unavailable. One pad is placed on the chest and the other is placed on the back ("sandwiching the heart").

A child is scheduled to have an electroencephalogram (EEG). Which statement by the parent indicates understanding of the teaching? 1. "I will let my child drink cocoa as usual the morning of the procedure."(5%) 2. "I will wash my child's hair using shampoo the morning of the procedure."(47%) 3. "My child may have scalp tenderness where the electrodes were applied."(38%) 4. "My child will not remember the procedure."(8%)

2. "I will wash my child's hair using shampoo the morning of the procedure."(47%) An electroencephalogram (EEG) is a diagnostic procedure used to evaluate the presence of abnormal electrical discharges in the brain, which may result in a seizure disorder. The EEG can be done in a variety of ways, such as with the child asleep or awake with or without stimulation. Teaching for the parent includes the following: Hair should be washed to remove oils and hair care products, and accessories such as ribbons or barrettes should be removed. Hair may need to be washed after the procedure to remove electrode gel. Avoid caffeine, stimulants, and central nervous system depressants prior to the test. The test is not painful, and no analgesia is required. (Option 1) Food and liquids are not restricted prior to an EEG except for caffeinated beverages. Cocoa contains caffeine. (Option 3) This test (EEG) is not painful as it only records brain electrical activity. Electrode gel is nonirritating to the skin. (Option 4) A routine EEG is not performed under sedation, and so the child should remember the procedure. Educational objective:An EEG is used to diagnose the presence of a seizure disorder. Electrodes are secured to the scalp to observe for abnormal electrical discharges in the brain. Preprocedure teaching includes avoiding stimulants and CNS depressants and washing the hair.

The nurse is caring for a client with an exacerbation of chronic obstructive pulmonary disease and pneumonia. The nurse notes that the client has become disoriented and restless and becomes concerned that the client may have impaired oxygenation due to poor secretion clearance. Which is the nurse's priority action? 1. Administer lorazepam 1 mg IM(1%) 2. Administer oxygen using venturi mask(34%) 3. Maintain IV normal saline infusion at prescribed rate of 125 mL/hr(1%) 4. Place the head of the bed in semi-Fowler position(62%)

2. Administer oxygen using venturi mask(34%) Chronic obstructive pulmonary disease (COPD) is a progressive, inflammatory lung disease that causes hypersecretion of mucus and airway structure changes that reduce expiratory airflow and impair oxygen and carbon dioxide (CO2) exchange. Clients with COPD have chronic hypoxia and hypercarbia, which alters the sensitivity of chemical receptors in the brain and causesbreathing to be triggered by low oxygen levels (ie, hypoxic drive) rather than high CO2 levels. Clients with COPD who develop symptomatic hypoxia (eg, altered mental status, restlessness, respiratory distress) require prompt administration of supplemental oxygen to prevent progression to respiratory failure and arrest (Option 2). Controlled-flow devices (eg, venturi mask) are preferred as they allow delivery of precise oxygen levels, reducing the risk of delivering too much oxygen and suppressing the respiratory drive. (Option 1) Anxiety and restlessness in clients with COPD often relate to worsening hypoxia. If the client remains anxious after resolving hypoxia, low-dose anxiolytic medications (eg, lorazepam) may be used. (Options 3 and 4) Administering fluids and elevating the head of the bed (eg, semi-Fowler position) promote mobilization of secretions and improve work of breathing. However, clients with symptomatic hypoxia require immediate interventions (eg, supplemental oxygen) first. Educational objective:Clients with chronic obstructive pulmonary disease who develop symptomatic hypoxia (eg, altered mentation, restlessness) require prompt oxygen administration with a controlled-flow device (eg, venturi mask) to prevent respiratory failure and arrest.

A nurse is reinforcing teaching to a breastfeeding client who has been diagnosed with mastitis of the right breast. Which instructions should be included? Select all that apply. 1. Cease breastfeeding from right breast 2. Increase oral fluid intake 3. Reduce frequency of feeds to every 8 hours in right breast 4. Take ibuprofen as needed for pain 5. Use underwire bra 24 hours a day for support

2. Increase oral fluid intake 4. Take ibuprofen as needed for pain Mastitis is a common infection in postpartum women due to multiple risk factors leading to inadequate milk duct drainage (eg, poor latch). Bacteria are transmitted from the infant's nasopharynx or the mother's skin through the nipple and multiply in stagnant milk. Staphylococcus aureus is the most common offending organism. Symptoms of mastitis include fever, breast pain, and focal inflammation (redness, edema). In addition to antistaphylococcal antibiotics (dicloxacillin or cephalexin) and analgesics (eg, ibuprofen), treatment of lactational mastitis requires effective and frequent milk drainage. Milk ducts are most efficiently drained by direct breastfeeding while ensuring a proper latch. Adequate rest and increased oral fluid intake are also recommended. (Options 1 and 3) Breastfeeding should be continued every 2-3 hours to relieve milk duct obstruction. Mothers should be reassured that the infant can feed safely from the infected breast as the newborn is already colonized with the mother's skin flora. (Option 5) Underwire bras (tight bras) are not recommended with breastfeeding or mastitis as milk flow is impeded, worsening engorgement. Soft cup bras are recommended for support and to encourage milk flow. Educational objective:Treatment of lactational mastitis includes antibiotic therapy, breast support, adequate hydration, analgesics, and frequent (every 2-3 hours) continued breastfeeding.

The nurse is reinforcing teaching to the parents of a 6-month-old child who has been given a new prescription for a liquid iron supplement. Which statements by the parents indicate a need for further teaching? Select all that apply. 1. "Our child might become constipated while taking this medication." 2. "Our child's stools might become black and tarry." 3. "We can give the dose with milk to prevent gastric irritation." 4. "We will administer the dose into the back of our child's cheek." 5. "We will administer the dose with meals to increase absorption."

3. "We can give the dose with milk to prevent gastric irritation." 5. "We will administer the dose with meals to increase absorption." At birth, a newborn has enough iron (received during the last trimester of pregnancy) to last until approximately age 4 months. After this age, formula-fed infants usually receive adequate iron intake from iron-fortified formula, whereas breastfed infants may require supplementation until they begin eating iron-rich foods. Iron supplements should be given on an empty stomach between meals for best absorption (Option 5). If gastric irritation occurs, iron may be given with meals; however, this decreases absorption. If the child is old enough, supplements with citrus fruit juice should be offered as an abundance of vitamin C increases absorption. Milk products and antacids should be avoided for 2 hours following oral iron administration as these will decrease absorption (Option 3). (Options 1 and 2) Iron supplements may cause constipation and black or dark green, tarry stools; therefore, parents should be taught not to be alarmed if these expected findings occur. (Option 4) Liquid iron supplements can stain teeth; to reduce this risk, parents should use a medicine dropper to administer the dose at the back of the infant's cheek. The dose may also be diluted with water or juice to prevent staining and improve flavor. An older child should use a straw to take the supplement and drink water or juice after each dose. Educational objective:Liquid iron supplements are best absorbed on an empty stomach. Consuming vitamin C with iron supplements increases iron absorption. Milk products and antacids should be avoided for 2 hours following oral iron administration. Iron may be given with meals to reduce gastric irritation; however, this will decrease absorption.

A client with atrial fibrillation has just been placed on warfarin therapy. The nurse preceptor overhears the student nurse reinforcing teaching to the client about potential food-drug interactions. Which statement made by the student nurse requires the nurse preceptor to intervene? 1. "Do you take any nutritional supplements?"(10%) 2. "You will need to monitor your intake of foods containing vitamin K."(24%) 3. "You will not be able to eat green leafy vegetables while taking warfarin."(57%) 4. "Your blood will be tested at regular intervals."(7%)

3. "You will not be able to eat green leafy vegetables while taking warfarin."(57%). Warfarin (Coumadin) works by blocking the availability of vitamin K, which is essential for blood clotting. As a result, the clotting mechanism is disrupted, reducing the risk of stroke, venous thrombosis, and pulmonary embolism. Clients who are on warfarin therapy must monitor their dietary intake of vitamin K (Option 2). Rather than avoid vitamin K-rich foods, the client should maintain consistent vitamin K intake (eg, kale, broccoli, spinach, Brussels sprout) to keep prothrombin time (PT) and International Normalized Ratio (INR) stabilized within the recommended therapeutic range (Option 3). Sudden changes in consumption of vitamin K-rich foods should be avoided as they alter the effectiveness of warfarin. An increase in vitamin K levels places the client at increased risk of blood clot formation, whereas a decrease places the client at increased risk for bleeding. There is some recent evidence that a very low intake of vitamin K may decrease the overall effectiveness of warfarin. (Option 1) Many medications can interfere with warfarin metabolism. Nutritional supplements may contain vitamin K, and any new medication or nutritional supplement should first be approved by the health care provider. Cranberry juice, grapefruit, green tea, and alcohol may also interfere with the effectiveness of warfarin. (Option 4) PT/INR is monitored on an ongoing basis to determine the safest, most therapeutic warfarin dosage. Educational objective:A sudden increase or decrease in consumption of vitamin K-rich foods (green leafy vegetables) alters the effectiveness of warfarin. Rather than avoid vitamin K-rich foods, the client should maintain consistent daily vitamin K intake to keep PT/INR stable and within the recommended therapeutic range. PT/INR is monitored at regular intervals.

A nurse is caring for a group of clients on a medical surgical unit. Which client is most at risk for contracting a nosocomial infection? 1. 51-year-old client who received a permanent pacemaker 48 hours ago(5%) 2. 60-year-old client who had a myocardial infarction 24 hours ago(4%) 3. 74-year-old client with stroke and an indwelling urinary catheter for 3 days(79%) 4. 75-year-old client with dementia and dehydration who is on IV fluids(10%)

3. 74-year-old client with stroke and an indwelling urinary catheter for 3 days(79%). A nosocomial infection occurs in a hospital (hospital-acquired) or other health care setting and is not the reason for the client's admission. Many nosocomial infections are caused by multidrug resistant organisms. These infections occur 48 hours or more after admission or up to 90 days after discharge. Clients at greater risk include young children, the elderly, and those with compromised immune systems. Other risk factors include long hospital stays, being in the intensive care unit, the use of indwelling catheters, failure of health care workers to wash their hands, and the overuse of antibiotics. The most common nosocomial infection is urinary tract infection, followed by surgical site infections, pneumonia, and bloodstream infections. The 74-year-old client is most at risk due to age and the presence of the urinary catheter. The nurse will need to be on high alert for this complication and should follow infection control procedures diligently. (Option 1) This client does have a surgical incision, which poses a risk for infection. However, this client is younger and does not have any underlying chronic condition to compromise the immune system. (Option 2) This client does not fall in the category of elderly and has no surgical incision or indwelling catheters other than a possible IV site. (Option 4) This client is at risk due to age and presence of an IV catheter. However, the risk is not as high as the client with the urinary catheter. Educational objective:The nurse should be aware of the risk for nosocomial infections in young children, elderly, and immunocompromised clients, especially those with long hospital stays, indwelling catheters, and surgical incisions.

The nurse is caring for an assigned team of clients. Which client is the priority for the nurse at this time? 1. Client admitted with Guillain-Barré syndrome yesterday is paralyzed to the knees(8%) 2. Client admitted with multiple sclerosis exacerbation has scanning speech(8%) 3. Client with epilepsy puts on call light and reports having an aura(66%) 4. Client with fibromyalgia reports pain in the neck and shoulders(16%)

3. Client with epilepsy puts on call light and reports having an aura(66%). An aura is a sensory perception that occurs prior to a complex or generalized seizure. The client will most likely have a tonic-clonic seizure soon, and the nurse should attend to this client first to ensure safety measures (ie, seizure precautions) are in place. (Option 1) Guillain-Barré syndrome is an ascending symmetrical paralysis. It can move upward rapidly or relatively slowly (over days/weeks). Respiratory compromise is the worst complication. A client with paralysis at the level of the knee after 24 hours would not take priority over a client who will have a seizure in few minutes. (Option 2) Scanning speech is a dysarthria in which there are noticeable pauses between syllables and/or emphasis on unusual syllables. It is an expected finding with multiple sclerosis. (Option 4) Fibromyalgia involves neuroendocrine/neurotransmitter dysregulation. Clients experience widespread pain with point tenderness at multiple sites, including the neck and shoulders. This client is not a priority. Educational objective:An aura is a sensory warning that a complex or generalized seizure will occur. It is a priority over stable or expected findings such as point tenderness in fibromyalgia, low-level location of paralysis in Guillain-Barré syndrome, or scanning speech in multiple sclerosis. Additional Information Coordinated Care NCSBN Client Need

A client has been admitted to the acute inpatient psychiatric unit with a diagnosis of major depressive disorder (unipolar depression). The nurse understands that this diagnosis was made because the client has been exhibiting at least 1 of which of the 2 key clinical findings daily for at least 2 weeks? 1. Daily sleep disturbance or significant weight loss(6%) 2. Decreased ability to think or low energy(4%) 3. Depressed mood or loss of interest or pleasure(43%) 4. Thoughts of worthlessness or recurrent thoughts of death(45%)

3. Depressed mood or loss of interest or pleasure(43%) Major depressive disorder (also known as unipolar depression) is a subtype of depressive disorder, classified by specific symptoms that interfere with the ability to perform activities of daily living, work, sleep, and enjoy activities that are usually pleasurable to the client. For the diagnosis to be made, 5 or more of the following symptoms must be present almost every day for at least 2 weeks, and 1 of the symptoms must be depressed mood or loss of interest or pleasure. Signs & symptoms of major depression - SIGECAPS Sleep (increased or decreased) Interest deficit (anhedonia) Guilt (worthless, hopeless) Energy deficit Concentration deficit Appetite (increased or decreased) Psychomotor retardation or agitation Suicidality (Option 1) Daily sleep disturbance or significant weight loss is a symptom of depressive disorders; these are not key clinical features necessary for diagnosis. (Option 2) Decreased ability to think or low energy is a symptom of depressive disorders; these are not key clinical features necessary for diagnosis. (Option 4) Thoughts of worthlessness or recurrent thoughts of death are symptoms of depressive disorders; these are not key clinical features necessary for diagnosis. Educational objective:The 2 key clinical features of major depressive disorder (unipolar depression) are depressed mood and loss of interest or pleasure. One of these symptoms must be present daily for at least 2 weeks for the diagnosis of major depressive disorder to be made. Additional Information Psychosocial Integrity NCSBN Client Need

The nurse is providing care to a client experiencing posttraumatic stress disorder following a terrorist attack at the client's place of worship. What is the priority nursing action? 1. Acknowledge the client's feelings of anger(30%) 2. Assess the client's support system(23%) 3. Encourage the client to talk about the trauma(44%) 4. Offer the client a PRN sleep medication(1%)

3. Encourage the client to talk about the trauma(44%). The first step toward resolution of posttraumatic stress disorder (PTSD) is the client's readiness (ability and willingness) to discuss the details of the traumatic event without experiencing high levels of anxiety. The nurse must assess clients with PTSD for their readiness to talk about the experience and encourage them to discuss the trauma at their own pace. The nurse should also use active listening as a therapeutic approach to build trust and allow clients to vent. This will assist in decreasing their feelings of isolation. The nurse can also guide the client in identifying event details that are most troubling and trigger a sense of loss of control. The effectiveness of the client's coping mechanisms can be identified, and alternate strategies to replace maladaptive ones can be explored. (Option 1) It is important to acknowledge any feelings that the client may have about the trauma; the priority nursing action is to encourage the client to talk about the event. (Option 2) Assessing the client's support system is an appropriate nursing intervention; however, it is not the priority. (Option 4) Sleep aids are used for clients with PTSD and insomnia; however, this is only a temporary solution to one aspect of PTSD clinical presentation. Educational objective:The nurse should encourage clients with posttraumatic stress disorder to talk about the experience at their own pace, listen actively to build trust, and allow clients to vent. This will assist in decreasing their feelings of isolation. Additional Information Psychosocial Integrity NCSBN Client Need

The nurse is administering medications to a client who is being evaluated for a brain malignancy. The client is scheduled for a CT scan with IV iodinated contrast the next morning. Which medication should the nurse clarify with the health care provider? 1. Amlodipine(12%) 2. Gabapentin(11%) 3. Metformin(48%) 4. Phenytoin(26%)

3. Metformin(48%) A computed tomography (CT) scan is a noninvasive procedure that provides detailed x-ray images of the body. In some cases, iodinated contrast (eg, IV, PO) is administered during the CT scan to enhance visualization of blood vessels or certain organs. For clients with renal impairment, a potential complication of IV iodinated contrast is acute kidney injury (ie, contrast-induced nephropathy). Lactic acidosis is a severe complication of metformin, an antidiabetic medication. Administration of IV iodinated contrast to a client who takes metformin can cause an accumulation of metformin in the bloodstream, which increases the risk for lactic acidosis. As a result, many health care providers will discontinue metformin 24-48 hours before administration of IV contrast and restart the medication after 48 hours, when stable renal function is confirmed (Option 3). (Options 1, 2, and 4) Amlodipine is a calcium channel blocker commonly used to treat hypertension. Gabapentin is an anticonvulsant that is also used for neuropathic pain. Phenytoin is an anticonvulsant. None of these medications are known to interact with the iodinated contrast or worsen kidney injury. Therefore, these medications can be safely administered to the client who is scheduled to receive IV iodinated contrast. Educational objective:Iodinated contrast is commonly administered during computed tomography (CT) scans to enhance visualization of certain body structures. Clients who receive IV iodinated contrast while taking metformin are at increased risk for lactic acidosis; therefore, the health care provider may discontinue metformin 24-48 hours before administration of IV contrast and restart the medication after 48 hours.

The nurse monitors a child who has been treated for an acute asthma exacerbation. Which finding is the best indicator that treatment has been effective? 1. Episodes of spasmodic coughing have decreased(5%) 2. No wheezes are audible on chest auscultation(45%) 3. Oxygen saturation has increased from 88% to 93%(38%) 4. Peak expiratory flow rate has dropped from 212 L/min to 127 L/min(10%)

3. Oxygen saturation has increased from 88% to 93%(38%) Asthma is a chronic condition characterized by inflammation, swelling, and narrowing of the airways in the lungs. The client having an acute attack will experience chest tightness, wheezing, uncontrollable coughing, rapid respirations, retractions, and anxiety and panic. Treatment of an acute attack can include nebulized breathing treatment with a short-acting beta-agonist medication such as albuterol, and oral or IV corticosteroids. Oxygen saturation is the best indicator of treatment effectiveness as it reflects gas exchange. (Option 1) Decreased coughing may indicate improvement, but it is more subjective than measurement of oxygen saturation. In addition, it may be a sign of client exhaustion and worsening asthma. (Option 2) The absence of wheezes may indicate resolution of the attack or progression of airway swelling to the point of little air flowing through the lungs. (Option 4) Peak expiratory flow rate, by measuring how much air a person can exhale, indicates the amount of airway obstruction. Following treatment for an acute asthma attack, an increase, not a decrease, in peak expiratory flow would be expected. Educational objective:Improvements in oxygen saturation and peak expiratory flow are the best indicators of treatment effectiveness during an acute asthma attack.

The licensed practical nurse is working with a registered nurse to care for a client who has just returned to the cardiac unit after having a percutaneous coronary intervention. Which actions assigned by the registered nurse should the practical nurse question as outside of the practical nurse's scope of practice? Select all that apply. 1. Administering oral pain medication if client reports low back pain 2. Checking for bleeding at the catheter insertion site every 15 minutes 3. Performing post-procedure vital sign measurements 4. Reinforcing instructions to keep the involved extremity straight 5. Reviewing ECG for dysrhythmias

3. Performing post-procedure vital sign measurements 5. Reviewing ECG for dysrhythmias The registered nurse (RN), not the licensed practical nurse (LPN), should perform initial assessments (including vital signs), review the ECG for any dysrhythmias, monitor the client for chest pain, and monitor any infusions of anticoagulants or antiplatelet drugs (Options 3 and 5). If the client is stable after the initial assessment, the RN may delegate routine vital sign measurements. After performing the initial assessment of the client post-procedure and comparing it to the pre-procedure baseline, the RN may assign the following tasks to the LPN: Administer medications (Option 1) Monitor neurovascular status of involved extremity Check for bleeding at catheter site every 15 minutes for the first hour, then according to institution policy (Option 2) Report any changes in neurovascular status or bleeding to the RN Reinforce important teaching (eg, keep affected extremity straight, maintain bedrest) (Option 4) Educational objective:In the client who has had a percutaneous coronary intervention, after the initial assessment and its comparison to pre-procedure baseline, the registered nurse may assign the following tasks to the practical nurse: medication administration, monitoring of neurovascular status of the involved extremity, checking for bleeding at the catheter insertion site, and reinforcing important teaching.

A client with coronary artery disease was discharged home with a prescription for sublingual nitroglycerin (NTG) to treat angina. Which statement by the client indicates that further teaching is required? 1. "I may experience flushing but will continue to take the medication as prescribed."(20%) 2. "I should lie down before taking the medication."(26%) 3. "I should not swallow the tablet."(4%) 4. "I will wait to call 911 if I don't experience relief after the third tablet."(48%)

4. "I will wait to call 911 if I don't experience relief after the third tablet."(48%). Current evidence indicates that up to 50% of clients lack knowledge about administration procedures, storage, and side effects of NTG. Proper teaching can prevent many hospital visits for chest pain from stable angina. The client should be instructed to take 1 pill (or 1 spray) every 5 minutes for up to 3 doses, but emergency medical services (EMS) should be called if pain is unimproved or worsening 5 minutes after the first tablet. Previously, clients were taught to call EMS after the third dose, but newer studies suggest that this causes a significant delay in treatment (Option 4). NTG should cause a slight tingling sensation under the tongue if it is potent; otherwise, the medication is likely outdated. The oral mucosa needs to be moist for adequate absorption of NTG, and clients should be instructed to take a drink of water before administration if needed for dry mouth. Sublingual tablets should never be swallowed (Option 3). If using a spray, the client should not inhale it but direct it onto/under the tongue instead. (Option 1) Headache and flushing are common side effects of NTG due to systemic vasodilation. (Option 2) The client should lie down before taking the pill as it can cause dizziness from possible orthostatic hypotension. Educational objective:The nurse should instruct clients taking sublingual NTG that they should call EMS if their chest pain is unrelieved or worsening 5 minutes after the first tablet. The tablet should be allowed to dissolve under the tongue to allow for adequate absorption and should never be swallowed.

The nurse is working with a client admitted with delirium and reduced level of consciousness due to pneumonia and respiratory failure. The nurse anticipates that the client may need to be intubated soon. The client is not able to make decisions. Who will make decisions for the client? 1. The client's sibling(0%) 2. The client's spouse(20%) 3. The health care provider (HCP)(10%) 4. The health care proxy(68%)

4. The health care proxy(68%). When a client is unable to make decisions, the health care proxy is legally able to make decisions for the client. In the event that the health care proxy is unable to fulfill this role, the responsibility goes to the alternate proxies identified on the advance directive. If the client does not have a health care proxy, the family members would make decisions for the client. Occasionally, there is no family and no proxy. If this happens, a proxy may be appointed, an ethics board may make the decision, or the HCP may be responsible for making the decision. (Options 1, 2, and 3) The health care proxy would be the legally appointed primary decision maker. Educational objective:The role of the health care proxy is to make decisions for a client who is unable to do so. Ideally, the proxy will have a good understanding of the client's wishes and will be emotionally capable of fulfilling this important role. Additional Information Coordinated Care NCSBN Client Need

The nurse is reinforcing health promotion education to the parents of a toddler. Which statement by a parent requires the nurse to clarify teaching? 1. "I will offer my child options rather than asking yes or no questions."(13%) 2. "I will wait at least 15 minutes after a play period to offer a meal to my child."(8%) 3. "If my child is having a tantrum, I will have them sit in a quiet area for a short time-out."(8%) 4. "If my child refuses a meal, I will have them stay at the table until they eat half the food."(69%)

4. "If my child refuses a meal, I will have them stay at the table until they eat half the food."(69%). Physiologic anorexia (ie, decreased nutritional need and appetite) occurs when the very high metabolic demands of infancy slow down to keep pace with moderate growth during toddlerhood. During this phase, toddlers are increasingly picky about their food choices and eating schedules. Parents sometimes fear the child is not consuming enough calories, but over several days intake usually meets nutritional and energy needs. Parents should avoid forcing food or pressuringthe toddler to eat more, which can lead to poor eating habits in the future (Option 4). Strategies to promote intake for toddlers include: Offering 2 or 3 high-quality food choices Keeping food portions small (1-2 tablespoons per serving) Exposing the child to new foods repeatedly Avoiding distractions (eg, television, toys) during meals/snacks (Option 1) Parents can help the toddler gain a sense of control by providing options (eg, corn or peas) rather than asking yes or no questions. (Option 2) Toddlers may have difficulty sitting still at the table immediately after physical activity. Offering a 15-minute period to calm down promotes better eating habits. (Option 3) Tantrums are common as toddlers seek more independence. Parents can consider using time-outs in a quiet, controlled environment to help the child calm down. Educational objective:Toddlers may develop a physiologic decrease in appetite due to reduced nutritional and metabolic demands. The nurse should reassure parents that intake over several days usually meets nutritional and energy needs and encourage parents not to force or pressure the toddler to eat more.

The nurse in the pediatric clinic is planning to reinforce postoperative teaching to parents. The nurse should talk with the parent of which child first? 1. 2-year-old with bilateral tympanostomy tubes who has a small piece of plastic in the right outer ear(16%) 2. 4-year-old post adenotonsillectomy who is now reporting ear pain(51%) 3. 6-year-old with strep throat who needs a note to return to school 24 hours after starting antibiotics(6%) 4. 7-year-old 5 days post tonsillectomy who wants to return to soccer practice tomorrow(26%)

4. 7-year-old 5 days post tonsillectomy who wants to return to soccer practice tomorrow(26%) The child with a recent tonsillectomy is at highest safety risk. Postoperative hemorrhage from tonsillectomy is uncommon but may occur up to 14 days after surgery. During the healing process, white scabs will form at the surgical sites. Sloughing then occurs approximately 7 days after the procedure, increasing the risk for bleeding. Caregivers should be taught to observe for signs of bleeding (eg, frequent swallowing, throat clearing). The child may also experience increased pain. The nurse should instruct the parent that the child should not resume strenuous activity or contact sports for at least 7-14 days post surgery. (Option 1) Tympanostomy tubes or grommets are pressure-equalizing tubes placed in the tympanic membrane to facilitate drainage of middle ear fluid (eg, for eustachian tube dysfunction or recurrent otitis media with effusion). One of this child's tubes has most likely fallen out of the eardrum. No immediate intervention is required; however, the health care provider should be notified. (Option 2) Clients often report ear pain (otalgia) following adenotonsillectomy due to irritation of the ninth cranial nerve (glossopharyngeal) in the throat, causing referred pain to the ears. This is a normal, expected finding. (Option 3) The contagious period for strep throat starts at the onset of symptoms and lasts through the first 24 hours of antibiotic treatment. This client is able to return to activities and does not require an immediate callback. Educational objective:The risk of post-tonsillectomy hemorrhage persists for up to 14 days after surgery, and resuming strenuous activity too early increases this risk. The potential for bleeding is higher 7-10 days postoperatively while sloughing occurs.

The nurse working on a medical-surgical unit receives change-of-shift report on several clients. Which client should the nurse see first? 1. Client after a colonoscopic polypectomy today with abdominal cramping and a small amount of rectal bleeding(11%) 2. Client after a laparoscopic inguinal hernia repair yesterday who reports urinary hesitancy while voiding(7%) 3. Client after a lumbar laminectomy with spinal fusion 3 days ago who reports straining to have a bowel movement(25%) 4. Client after a placement of an arteriovenous graft 3 days ago with a temperature of 100.9 F (38.3 C)(54%)

4. Client after a placement of an arteriovenous graft 3 days ago with a temperature of 100.9 F (38.3 C)(54%). Arteriovenous (AV) graft placement involves surgical connection of an artery to a vein using a synthetic material to graft a hemodialysis access site. Postoperative infection usually manifests approximately 3-5 days after surgery (eg, fever, purulent drainage, swelling) and may cause thrombosis (clotting), graft failure, or systemic infection (Option 4). The health care provider (HCP) should be notified, as this client may require antibiotics and surgical revision or removal of the graft. (Option 1) A small amount of rectal bleeding and abdominal cramping are expected following a colonoscopy. Abdominal cramping occurs as the bowel contracts to expel air that was blown into the colon (insufflated) during the procedure. The HCP should be notified if the client experiences symptoms of bowel perforation (eg, severe abdominal pain, distension, excessive rectal bleeding). (Option 2) Anesthesia and opioid analgesics may cause postoperative urinary hesitancy and retention for up to 3 days following surgery, especially abdominal or pelvic surgery. This client should be instructed on measures to improve voiding (eg, standing) and may ultimately require urinary catheterization. (Option 3) Following surgery, constipation can occur due to narcotic pain medications and decreased ambulation. The client may require a stool softener to reduce straining. Educational objective:Postoperative infection of an arteriovenous graft may result in thrombosis (clotting), graft failure, or systemic infection. The nurse should immediately assess the client with signs of postoperative infection (eg, fever) and notify the health care provider. Additional Information Coordinated Care NCSBN Client Need

A 2-month-old infant has been admitted to the hospital with suspected shaken baby syndrome (abusive head trauma). In reviewing the infant's chart, the nurse expects to encounter which of these clinical findings? 1. A reported history of recent trauma(16%) 2. Abdominal bruising(6%) 3. External signs of trauma(13%) 4. Irritability and vomiting(62%)

4. Irritability and vomiting(62%) Shaken baby syndrome (SBS) is a type of abusive head injury and is defined by the Centers for Disease Control and Prevention (CDC) as severe physical child abuse resulting from violent shaking of an infant by the arms, legs, or shoulders. The impact of the shaking causes bleeding within the brain or the eyes. It is not uncommon for the diagnosis of SBS to be missed as the clinical findings are often vague and nonspecific—vomiting, irritability, lethargy, inability to suck or eat, seizures, and inconsolable crying. Usually, there are no external signs of trauma except for occasional small bruises on the chest or upper arms where the child was held during the shaking episode. The most common reasons that caregivers seek medical attention for children with SBS are breathing difficulty, apnea, seizures, and lifelessness. Caregivers typically do not offer a history of trauma nor do they report the episodes of shaking. By contrast, children who have sustained unintentional head injury are typically brought for treatment out of concern by their caregivers even when the children are asymptomatic. (Option 1) Typically, a history of physical trauma is not reported by the parent or caregiver. (Option 2) Abdominal bruising is not an expected clinical finding of SBS. (Option 3) External signs of trauma are usually absent on physical examination of an infant with SBS. Minimal bruising on the extremities or chest may be present. Educational objective:Shaken baby syndrome is a form of child physical abuse resulting from violent shaking of an infant by the extremities or shoulder that causes bleeding within the brain and/or eyes. The clinical findings of shaken baby syndrome are nonspecific and include lethargy, vomiting, seizures, irritability, inability to eat, and inconsolable crying. Multiple and severe shaking episodes can result in breathing difficulty and lifelessness. Caregivers typically do not report a history of trauma.

While collecting data from pregnant clients in the obstetric clinic, the nurse should alert the health care provider to see which client first? 1. First-trimester client who reports frequent nausea and vomiting(1%) 2. Second-trimester client with dysuria and urinary frequency(5%) 3. Second-trimester client with obesity who reports decrease in fetal movement(49%) 4. Third-trimester client with right upper quadrant pain and nausea(44%)

4. Third-trimester client with right upper quadrant pain and nausea(44%) Right upper quadrant (RUQ) or epigastric pain can be an indicator of HELLP syndrome, a severe form of preeclampsia. HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelet count) is often mistaken for viral gastroenteritis due to its variable and nonspecific presentation. Misdiagnosis may lead to severe complications (eg, placental abruption, liver failure, stroke) and maternal/fetal death. Clients may have RUQ pain, nausea, vomiting, and malaise. Headache, visual changes, proteinuria, and hypertension may or may not be present. (Option 1) Nausea and vomiting during the first trimester are normal, expected findings. Vomiting that continues past the first trimester or that is accompanied by fever, pain, or weight loss is considered abnormal and requires intervention. (Option 2) Although urinary frequency is common in pregnancy, dysuria could indicate a urinary tract infection. This client should be evaluated but does not take priority over a client with symptoms of HELLP. (Option 3) Maternal perception of fetal movement can be altered by obesity, maternal position, fetal sleep cycle, fetal position, anterior placenta, and amniotic fluid volume (increased or decreased). This client should be evaluated to determine the cause of decreased fetal movement; however, this is not the priority. Educational objective:HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelet count) is a severe form of preeclampsia. Its clinical presentation can be quite variable and may include nonspecific symptoms such as right upper quadrant/epigastric pain, nausea, vomiting, and malaise. Complications, including placental abruption, stroke, and death, may occur if HELLP syndrome is not treated immediately.

The nurse is measuring the uterine fundal height of a client at 36 weeks gestation lying in a supine position. The client suddenly reports dizziness, and the nurse observes pallor and damp, cool skin. What should the nurse do first? 1. Alert the supervising registered nurse(1%) 2. Check the client's blood pressure and pulse(17%) 3. Listen to the fetal heart rate(5%) 4. Turn the client to a lateral position(75%)

4. Turn the client to a lateral position(75%) Supine hypotension occurs most commonly in the third trimester when the weight of the gravid uterus compresses the vena cava. This results in decreased venous return to the heart, reducing cardiac output and causing maternal hypotension and reflex tachycardia. Clients may experience dizziness and nausea; other signs may include pallor and cold, clammy skin. If a pregnant client becomes symptomatic (eg, dizzy, nauseated) while lying supine, immediate repositioning to the left side is necessary to relieve vena caval compression (Option 4). Placing a wedge under the client's right hip while lying supine helps prevent supine hypotension. (Option 1) The practical nurse should notify the supervising registered nurse after placing the client in a lateral position. (Option 2) Hypotension should resolve quickly after repositioning; therefore, the nurse should check the client's blood pressure and pulse soon after to ensure vital signs are stable. (Option 3) Decreased maternal cardiac output can result in impaired placental blood flow and fetal heart rate (FHR) abnormalities. Once the nurse tilts the client to a left lateral position, the nurse should verify that the FHR is normal. Educational objective:Supine hypotension occurs commonly in the third trimester when the gravid uterus compresses the vena cava, resulting in decreased venous return to the heart and maternal hypotension. If a pregnant client becomes symptomatic (eg, dizzy, nauseated) while lying supine, the nurse should immediately reposition the client to the left side.